Nearly 50 years ago, W. Ann “Winnie” Maggiore and two friends from Brooklyn squeezed bodies and belongings into a dented, high-mileage, pacific-blue Karmann Ghia and headed west.
“It was the summer of love,” says Maggiore. “Like so many young people back then, I wanted to see what else the world had to offer. We went from national park to national park. New Mexico caught my eye and I never came back.”
Maggiore joined a commune in Placitas, just outside Albuquerque, where organized firefighting and EMS were foreign concepts. “It was a very rural area,” Maggiore recalls. “When I got there, we didn’t even have electricity or running water. We were on our own.”
A consequence of that isolation – a fatal house fire – prompted Maggiore and her neighbors to seek improved emergency services for their community.
“I was one of the founding mothers of the local volunteer fire department,” Maggiore says. “We were just 25 hippies and a fire truck. We lived up in the mountains and would come down when we were needed. There were no radios or beepers back then – just a funky, red telephone where the initial call would come in.” Members would call each other to respond.
“I remember going down to the freeway in ‘73 for a terrible wreck: An 18-wheeler had rear-ended a small sedan and the patient was very much dead,” Maggiore says. “The gearshift – on the steering column in those days – had penetrated his skull. I was on the nozzle and had never seen anything like it. Afterwards I thought, well, I didn’t throw up or pass out, so I guess I could do EMS, too.”
A preoccupation with EMS legislation
Maggiore became an EMT in 1978, then upgraded to paramedic in 1981 while working for Albuquerque Ambulance. Following a stint at Bernalillo County’s fire department, she joined New Mexico’s EMS office. “At the time, there was no enabling legislation for EMS providers; we were pretty much paramedics at large,” she explains. “We were told by local doctors to just do whatever we could because there weren’t protocols or anything defining our practice. Meanwhile, I got very interested in the legal framework of paramedicine.”
So Maggiore went to law school after completing her undergraduate studies at the University of New Mexico. “My very first project as a lawyer was to revise and update New Mexico’s EMS legislation,” she says of that 1992 job. Soon after, she challenged the health department’s stand on licensure versus certification.
“The state told us we [EMS providers] were certified,” she reports. “When I found out the difference, I realized no, we’re licensed. We take a test and the state gives us the privilege to practice. That’s a license. I think that disparity has helped keep EMS down for years, even though the people who do my nails and groom my dog are licensed, too.”
Whose license is it, anyway?
A related concept that’s often misunderstood, according to Maggiore, is delegated practice – among EMS providers, the notion we work under physicians’ licenses. There’s a good reason for that belief: it’s what we’re taught as EMTs.
“I’ve taken great pains to clarify delegated practice,” says Maggiore, who’s on the faculty of UNM’s Department of Emergency Medicine. “There may be one or two states working that way, but most don’t.
“I have a license. I don’t practice under the license of a physician; I’m supervised by physicians who can’t just tell me to do anything they want. If a doctor ordered me to put in a chest tube, I’d have to decline.
“Scope of practice is how we roll. Our medical directors are free to embrace that scope or make it narrower.”
Maggiore adds that the word “protocols,” implying mandatory actions, is falling out of favor. “We’re moving toward ‘treatment guidelines’ because it’s been discovered that EMTs and paramedics are actually capable of thinking, as opposed to just following cookbook recipes.
“Plaintiffs’ attorneys love to get ahold of a protocol that says you must do A, B, C, D and E so they can jam us for not doing D, which may have been completely inappropriate under the circumstances. You can’t write a protocol that covers all situations.”
EMS: Trade or profession?
Standards of care help define EMS, but they don’t address one topic often debated by caregivers: Is EMS a profession like the law, or more of a trade, like carpentry? Maggiore thinks EMS is trying to be a profession, but it’s not there yet.
“Obviously, advanced education is one of the hallmarks of professionalism,” she says. “So is self-regulation. That’s something the medical field hasn’t done well overall, which is one of the reasons we have so many malpractice suits. I think we need to be better at policing our ranks rather than waiting until something bad happens.”
Not all of the impetus toward professionalism needs to be institutional, though. “Each of us has a lot to do with how our industry is perceived by others,” says Maggiore, who encourages individual EMS providers to, “try to do something no one’s done before.”
“Be an innovator,” she suggests. “There are phenomenal public-health problems out there. Find some solutions.”
