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Wanting It Both Ways

My long-time friend and colleague, Dr. Keith Wrenn, says most people want it "both ways." I rarely listen to him (a whole other potential column), but I was thinking that he may be right this time. That is, we in emergency medicine, emergency nursing and EMS sometimes want it both ways.

Some emergency physicians complain about how the "specialists upstairs" bad mouth emergency medicine, but then not five minutes after an "elitist specialist" leaves the ED, that very same ED doctor will make similar disparaging comments about the other specialist. Thus, some ED doctors want it both ways: They want to complain about others for criticizing them but then do the same thing to another specialty or physician.

As emergency medicine has evolved, so, too, has emergency nursing. Emergency nurses do so much more today than in the past, some now even work as nurse practitioners. With their advanced training, they evaluate patients and write prescriptions and discharge instructions. Other ED RNs are credentialed to do advanced procedures, including the insertion of PICC lines. However, some of these very same nurses will become indignant if you talk about an EMT or paramedic working in the ED and performing "nursing duties," such as starting IVs, doing an ECG or-one of the biggest sins-performing triage of patients on ED entry. Thus, some ED nurses want it both ways: They want to be able to be credentialed to do "doctor stuff" yet balk at allowing EMS personnel to do "nurse stuff."

Which brings me to my main point (finally): EMTs and paramedics want it both ways, too. Almost every EMT and paramedic feels they should be allowed to do more procedures, use more drugs, provide advanced airway management, including rapid sequence induction. Many paramedics are disappointed or angry that their EMS medical director doesn't allow prehospital RSI protocols, the administration of thrombolytics or the non-transport of "non-emergency" patients. But these same paramedics will say that, although many other EMS agencies aren't competent to perform these tasks, they are competent to do so.

Many of you are true experts in prehospital care. Many of you work in EDs and perform superbly. EDs across the country now depend on you to provide invaluable staffing services 24 hours per day. However, it's time for us to admit that we want it both ways in EMS.

Specifically, few of us-doctors or EMS providers-demand regular performance-based certification, allowing some EMTs and paramedics to stay in the system who aren't true professionals. All of us know someone who doesn't deserve their "certification." I know that some doctors and nurses don't deserve their jobs, either; but the difference is that EMS is in the lead for variability. To counter this variability, we must establish objective national performance standards.

It's time for us to say "enough is enough. I'm mad, and I'm not going to take it anymore." We as EMS providers, leaders, administrators and physicians need to agree on minimum standards for at least: core factual knowledge, ECG reading, pharmacology, airway management and procedural performance. These areas should be routinely evaluated in performance-based skill labs. We should demand and comply with regular state, regional or county testing that obtains objective, unbiased results. If someone "fails" a station, they can repeat it. If they're truly not competent, then they shouldn't go back into the field until they have been re-trained. [Editor's note: "Whose Tube Is It?" in March JEMS presents a unique assessment and re-training program for airway management implemented by San Diego Fire-Rescue Department.]

Our patients in emergency medicine, emergency nursing and EMS are so dependent on us to be experts that we can no longer have it both ways. Be competent, be tested, be certified, and let's no longer accept variability in our abilities to deal with life-and-death situations. All of us in emergency care -- doctors, nurses and EMS providers -- must be able to routinely prove we have the minimum required abilities to cheat death. Our reputations and our patients depend on it.

Corey M. Slovis, MD, FACP, FACEP, is professor and chair of the Department of Emergency Medicine at Vanderbilt University Medical Center, Nashville, Tenn., and serves as the medical director for Nashville Fire EMS. Slovis is also a member of the JEMS editorial board. Throughout the 1980s, he served as medical director for the Grady Hospital EMS program and as the fire surgeon for the city of Atlanta.


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