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The Legal Guardian
by David Givot

How EMS changes will weed out the worst providers

EMS will only ever be as good as you make it; if you remain silent, you forfeit the right to complain when it crumbles around you

By David Givot

As EMS evolves — almost by the day — many of the “ways of the past” are being replaced by new, more efficient and effective “ways of the now.”

Hyperventilating head injuries has gone the way of MAST trousers; the flow meter on oxygen has been turned down and there are even new contrary opinions about Narcan.

One particularly dramatic change seems to be the shift from strict medical control to standing orders and protocols. Going, if not gone, are the days of calling Rampart for IV and defibrillation orders.

Paramedics are becoming more and more autonomous and less and less dependent on Dixie and Dr. Bracket for handholding. Previously difficult and complex decisions, once made by base hospital physicians and specialty nurses, are now in the hands of the providers on scene.

You guessed it: I have mixed feelings.

First, I am thrilled that paramedics are finally getting the respect they deserve for being the professionals they can be. The scope of practice is expanding and patient care modalities are improving, seemingly by the minute. Patient outcomes are also improving as a result, and EMS is passing through puberty and forging into adulthood.

On the other hand, autonomy in the hands of the … lesser-motivated, can be a very dangerous thing. You know as well as I do that there are still plenty of providers who operate from a subjective, complacent, and downright lazy place.

Combined with the ever-expanding autonomy, that provider just became more dangerous than he or she ever has been – to the patients and to you.

Working without a safety net

Autonomy in patient care places more pressure for excellence on the provider charged with delivering it, and also on the partner and crew members on scene. Since the base hospital is not involved like it once was, they are likewise less responsible for the errors and omissions of the medics on the scene.

Now more than ever, crew members are being held to answer for the mistakes and follies of their coworkers; now more than ever, EMS providers are working without a net.

What’s next? I predict (and hope) emergency medical Darwinism is going to force some painful and necessary changes. First, increasing autonomy is going to result in the better and best providing superior patient care.

More personal ownership of the results is going to manifest in outcomes such as increased cardiac arrest survival rates, faster and more complete stroke recovery, and significantly better outcomes for STEMI patients, all leading to the brass ring: EMS as a profession, not just a job.

On the flip side of that coin, you will see consequences for the not-so-good and completely awful providers. There will be higher instances of licensure action, internal discipline, and wash-out. Unfortunately, all of those things will stem from preventable negative patient outcomes.

Weeding out the worst

The danger for the better provider will be in the penumbra; the murky, gray area of time when providers are self-categorizing. Specifically, the better provider who is aware of the dangerously poor provider, but does nothing to fix or flush him or her, is almost certain to be caught up in a bad situation caused by sloppy, complacent, or ultimately negligent patient care that should have been corrected or stopped.

The answer is as simple as it is difficult. If you are reading this, it is more likely because you are one of the better, more committed, more professional providers. This transition is up to you.

You have to muster the strength necessary to face the issue and force the change; you have to demand more from yourself and of those around you. You must have the willingness to help those providers who want it -and respond to those who need it, but don’t want it - with tough love by showing them the door.

In the end, EMS will only ever be as good as you make it. If you lay silent through its evolution, you forfeit the right to complain when it crumbles around you.

About the author

David Givot, Esq., graduated from the UCLA Center for Prehospital Care (formerly DFH) in June 1989 and spent most of the next decade working as a Paramedic responding to 911 in Glendale, CA, with the (then BLS only) fire department. By the end of 1998, he was traveling around the country working with distressed EMS agencies teaching improved field provider performance through better communication and leadership practices. David then moved into the position of director of operations for the largest ambulance provider in the Maryland. Now, back in Los Angeles, he has earned his law degree and is a practicing Defense Attorney still looking to the future of EMS. In addition to defending EMS Providers, both on the job and off, he has created as a vital step toward improving the state of EMS through information and education designed to protect EMS professionals - and agencies - nationwide. David can be contacted via e-mail at
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Peggie Hicks Knight Peggie Hicks Knight Thursday, April 03, 2014 5:25:40 PM This would be a fabulous opportunity for dedicated improvement in EMS. It should give us the desire to take a hard look at those providers who are unwilling or unable to move forward as this modality matures. Civilian EMS services have the ability to encourage those lesser providers to seek opportunities elsewhere. Making those tough career decisions are uncomfortable. "Because we've always done it that way" is no longer acceptable. Welcome to the uncomfortable aspect of growing pains. It brings up the even tougher questions of how this can be encouraged. In the times of nationwide budget crunching, obtaining education and hosting training evolutions becomes an exercise in futility. More and more EMS providers are finding that while the desire to learn is present, the funding is not. As we don't make the money of some of our less autonomous counterparts, this can be disheartening.
Rick Fikes Rick Fikes Friday, April 04, 2014 5:43:32 AM We must all strive for excellence in our profession. Our patients depend on it.
Thomas Landers Thomas Landers Saturday, April 05, 2014 2:26:52 PM Good to see that there is, At Least, one of us, awake at the "WHEEL! Many Thanks...
Tami D. Bulik Tami D. Bulik Saturday, April 05, 2014 2:47:09 PM While I agree with the majority of your post Peggie, I believe there needs to be less and less comparisons and emphasis made between wages and education. When you allow those thought processes to continue, we enable the subpar provider to think that it's okay to say "they don't pay me enough to do/know/learn that." Until EMS quits accepting "minimal training" as the gold standard to complete and receive a license, we will not see much of an increase in wages or respect. If the desire is there to learn and improve self knowledge there is a way to obtain it without it becoming an issue of cost. Unrelated to your statement, another problem I feel that contributes to the publics lack of respect for EMS are the FB sites that are predominantly EMS related which continue to post stupid pictures/sayings that portray the general public as idiots and EMS as those who are there to "save your stupid ass" or something to that effect....until we respect ourselves enough to not put up with derogatory images towards us or the public, we cannot expect the public to consider us as anything other than "ambulance drivers".......
Chris Mancuso Chris Mancuso Saturday, April 05, 2014 2:56:51 PM I find that hard to understand. We have been doing it this way for 25 years. It works just fine. Most know no other way.
Chris Mancuso Chris Mancuso Saturday, April 05, 2014 3:00:22 PM SE Texas. Most of the medical directors expect you to know what to do.
Jeremy Lauseng Jeremy Lauseng Saturday, April 05, 2014 3:23:23 PM I began in a service that operated autonomously in 1997. Our medical director firmly believed we as Paramedics should not waste time trying to call for direction, but have vast amounts of knowledge in the medical field and apply it to every patient care situation. I have been unable to understand so many places in the country allowing the lowest common person to work in EMS by giving them a recipe book to work with, and someone to call and ask what ingredients to use. The service that I refer to originally excepted nothing less than the best. You had to know what you were doing at all times. Document well, and understand your documentation, to back yourself against complaints of the receiving facilities. Only the best, or move on. You learned to seek out vast amounts of education, and keep yourself knowledgeable in the newest therapies and medicine. I believe this has been coming for quite some time. The faster the country is able to move to this type of EMS model, the faster we as a community or profession gain the respect we deserve.
Jeff Huffman Jeff Huffman Saturday, April 05, 2014 5:25:27 PM i feel that we may not have to worry about it in the very near future. the way the government is making simple things such as transporting to the nearest facility a priority even though your patient may need a cath lab that is 25 miles compared to a band aid station that is 5 miles away. we are fortunate to be able to make that decision in my service. but how long will that continue? if medicare etc... will not cover this cost? i also have a concern lately about national registry, so many great emt-b's that can not seem to pass the national registry computerized test just give up. the seasoned medics that are not national registered are going to have to become national registered, for what reason i do not know other then national registry see's a chance to make more money at getting them registered, but these more seasoned medics are saying "screw you i'll retire or just look for another line of work. in pennsylvania there are under 800 practicing paramedics right now and i see it going below 700 soon. where is it going to end? all the new changes in the ems act of Pa. are really putting alot of bad ideas in our heads like just giving up. I on the other hand will not stop complaining. i love this profession and i wish i got treated like it was a profession instead of a job. i struggled and worked harder then any one i know at getting my paramedic cert. i was in the late 40's when this happened and i will not give up. i sure dont want to loose what i worked so hard to get, but i cant see it continueing if the government keeps on messing with a good thing.
Sheila Moore Sheila Moore Saturday, April 05, 2014 6:15:16 PM Your so right Jeff... very sad situation.
Brett Nathan Gillet Brett Nathan Gillet Saturday, April 05, 2014 8:34:01 PM Rural EMS and urban or city EMS are two entirely different animals. I think more attention needs to be paid to rural EMS, where the nearest hospital or facility is sometimes 30+ minutes drive
Joe Cellucci Joe Cellucci Sunday, April 06, 2014 5:09:52 AM I understand lazy but don't forget the medic that cants or don't even know how to do a proper assessment they treat every pt the same way 4 lead 12 lead oxygen Iv and vitals no clue why they are doing just doing it all day long and then they only way they can read a 12 lead is when the monitor tells them there pt is having a Mi!
Alan Hubbard Alan Hubbard Sunday, April 06, 2014 2:35:13 PM Brett Nathan Gillet very good point. I run not only rural ems but also volunteer. Its easy to say you have to have national registry and so many hours ce every year when your getting paid and it is your profession. For some of us though its a service to the community that if we didn't do would not get done. (no paid ems in my county) Not saying we shouldn't be well trained just saying when the call is over I still have to go to a real job to earn money to eat. How you earn a living will dictate how much time you can spend training.
Brian Fox Brian Fox Sunday, April 06, 2014 2:40:13 PM It's about patient care. I remember when paramedics was new. I saw a lot of errors back then. I thought we should have been better then. We need people who care enough about patient care and they should be responsible. In the long run the. Changs will be good, but there will be some pain along the way.
Skip Kirkwood Skip Kirkwood Sunday, April 06, 2014 7:28:54 PM Medicare WILL cover the cost of transport to the nearest APPROPRIATE facility, like that cath lab hospital. We've got to stop making reimbursement limitations play a role in emergent care decisions - let the front office sort that stuff out! It's just part of the cost of doing business. The NR's tests evaluate whether the candidate has the MINIMUM knowledge necessary to function as an EMT. If they don't have the minimum, they don't belong on the street - period! Sometimes things have to get worse before they get better - and I am both optimistic and willing to work on the needed improvements. I hope the others here will re-commit to a future of excellence in EMS!
Skip Kirkwood Skip Kirkwood Sunday, April 06, 2014 7:30:05 PM Another outstanding article, David! Keep them coming!
David Shrader David Shrader Sunday, April 06, 2014 7:36:15 PM Good Work dude! On target!
Dan Greenhaus Dan Greenhaus Sunday, April 06, 2014 7:39:26 PM currently the most potential liability is with the MD who is overseeing the paramedic (as you are acting under their license, and they need to sign your orders), but with more autonomy, will paramedics take more of the blame when something goes wrong and they don't consult with the doctor? While I like the concept, how will it affect malpractice insurance costs? will they skyrocket for the paramedic since they are the highest level of care, as has happened to the occupational therapists that no longer need to work under an MD?
David Givot David Givot Monday, April 07, 2014 11:48:58 AM Thanks, Skip!
Cory T. Spankowski Cory T. Spankowski Wednesday, April 09, 2014 3:09:33 PM Wow...very well said.
Cory T. Spankowski Cory T. Spankowski Wednesday, April 09, 2014 3:11:51 PM LOL...yeah, I know some medics that do that very thing.
David Givot David Givot Monday, April 14, 2014 12:15:32 PM Be careful about assuming that the MD has more liability than the field provider; it's not necessarily true. If the MD acts reasonably in the course of his or her duties of medical control, then the bulk of the liability rests squarely on the shoulders of the provider. It's too soon to know the impact on insurance rates for providers, but you can expect everything to get more expensive. Lastly, if you are worrying about blame, your concern is misplaced; the biggest concern should be for providing the very best care possible and insisting that your co-workers do the same.
David Givot David Givot Monday, April 14, 2014 12:19:03 PM I have traveled all across the country speaking with every kind of EMS provider there is...and there is no doubt that the rural EMS provider has the toughest job. I thought I was bad ass because I could work a trauma and get it to the trauma center within 10 minutes...I never imagined the difficulty and complexity of having to work a critically ill or injured patient - alone - for hours at a time. Rural EMS does not get nearly the respect it deserves!
Kenneth Churning Kenneth Churning Wednesday, October 29, 2014 9:16:17 PM Watching a fellow caregiver do bad patient care and doing nothing about it, might as well be you doing the bad patient care. Take action and educate those around you.
Jeff Bandalo Jeff Bandalo Thursday, October 30, 2014 4:12:54 AM This article is nothing but hot air being blown up medics and emts butts we have not had to call a doctor for orders for more than 20 years now you cannot get poor sloppy ems care workers just like careless drivers or bad attitude nurses. I've also seen terrible attitude medics provide awesome life saving care when the shit hits the fan. We work in a tough field environment. Most of us have thick skin and a twisted sense of humor. But like all jobs you have the good and the bad usually your service and co workers will be the ones who either mold you in the right direction when your standards are to low. or ship you out the door.
Branden Sellers Branden Sellers Thursday, October 30, 2014 4:15:08 PM going against a whole Village…. to the point of, the best care for the patient will consist of dissolving the current Board and Government.. wasting $ killing budgets, and not moving forward with the EMS scope of practice. An IV Tech Ambulance crew has handcuffed a Village with scare tactics and bullying of a select few. Scaring townspeople into believing that they, as a non paramedic unit can handle anything that comes their way!! well any Cardiac, or Respiratory patients they cannot treat leads to precious time lost with a Paramedic Intercept. instead of a direct route to Hospital.. they have even put on the November Ballot a referendum to NOT contract with the Intercepting Fire Rescue Squad… just insane .. Please ant suggestions would be greatly appreciated..
Bob Henderson Bob Henderson Saturday, November 01, 2014 5:03:33 AM That's what I was thinking.

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