Keep tilting at windmills to change EMS

Improving the profession of EMS may seem an impossible dream, but nothing worth achieving is easy

I nearly flunked my senior year of high school.

I had a propensity for skipping class and going hunting. I’d come to school feverish, coughing up a lung, preferring to bank my unexcused absences for something more important than a little illness: the opening day of duck season. Then I’d disappear for a month. My teachers didn’t much mind; my grades were good, even if I rarely showed up for class.

Then, one day at the end of my first semester, I discovered I had miscounted my available unexcused absences, and was one over the limit. So I faked an illness and went to my pediatrician, and while his back was turned, I stole the top sheet from his prescription pad and carefully forged his signature on a doctor’s excuse for 48 hours.

Don Quixote
Don Quixote (Image Biblioteca de la Facultad de Derecho y Ciencias del Trabajo Universidad de Sevilla)

Predictably, I got caught.

Sentenced to study

My senior English teacher was the only one who sniffed out the deception, and he confronted me in private. After I confessed, Marshall Halbrook made me a deal: If I met his terms, he’d keep quiet about the fake excuse, and I could graduate. Defy him, and he’d turn me in, and I’d have to repeat my senior year.

It was the kindest act of blackmail ever committed upon me, and to this day I am grateful for it. For the entire second semester, I had to work for an A in English, forced to develop a level of academic discipline I had never had before, and one that has served me well in the nearly 30 years since.

One of the books he forced me to read was "Don Quixote," and it left quite an impression. For those of you unfamiliar with the story, a Spanish gentleman named Alonso Quijano read one too many fictional chivalric romances, and his cognitive cheese slid off his reality cracker. Convinced he was a knight-errant, he renamed himself Don Quixote and set out in search of the adventures he read about in his novels. In Quixote’s fevered imagination, windmills were fierce giants, flocks of sheep were armies, and humble farm girls were fair and noble ladies.

The book became such a part of the cultural lexicon that “tilting at windmills” became forever synonymous with hopeless quests, and “quixotic” was used to describe anyone who retained their idealism in the face of harsh reality.

There is a little Don Quixote in those of us who advocate for change in EMS. The reality is, most people in EMS are undereducated for the jobs we do. We value rote memorization of algorithms and protocols over critical thinking. We place greater precedence on what we do rather than what we know, placing us in a cage of our own making: a set of psychomotor skills a monkey could master, instead of a body of knowledge unique to out-of-hospital care. We prefer anecdote over evidence.

We bitch mightily, but few of us dare to dream.

The possible dream for modern EMS

Those of us who do dare to dream often see our dreams dashed by the reality of modern EMS. We become jaded and cynical, convinced that EMS will never become the profession we envisioned. We look around us and see little but the low-information voters of health care, and feel hopelessly outnumbered. In the book, Quixote died of despair when he could no longer reconcile his delusions with reality.

But it’s the dreamers who make things happen. Christopher Columbus. Orville and Wilbur Wright. Galileo. Martin Luther. Thomas Edison. Jonas Salk. The founding fathers of our country.

Every one of them dreamed up something radical, and was too naïve, stubborn or angry to realize that what they proposed was impossible according to the conventional wisdom of the day. Had they listened to the low-information voters of their time, what would our world look like today?

The key to retaining your idealism and continuing to advocate for change is the realization that just because an idea has been held by a lot of people for a long time doesn’t make it a good idea.

What you need is the stamina to outlast the naysayers.

Keep the faith

All too many dreamers get into EMS, see all that is wrong with the profession, and throw themselves headlong into their quest to reform EMS, as close to yesterday as possible. When they can’t sustain that passion, their careers die from the same despair that killed Don Quixote, and you will never find so bitter a burnout as a disillusioned idealist.

So when you feel outnumbered by the low-information voters, think of the changes we’ve already seen in EMS. In my career, I’ve seen wholesale shifts in clinical treatment. Twenty years ago, we immobilized everyone and let the radiologists sort ‘em out. Now, not only do most EMS systems practice selective immobilization, an increasing number are abandoning the practice altogether. Cardiopulmonary resuscitation has undergone radical a radical shift toward BLS, and for the better. Even our most sacred of cows, oxygen therapy, is undergoing serious scrutiny.

Elements of system design are no longer immune to scrutiny, either. Forty-eight and 72-hour shifts are becoming rarities. Lights-and-siren response is falling out of favor in many systems. Community paramedicine is gaining a foothold. Everywhere you look, EMS is changing and adapting.

If you don’t see improvements at your agency, perhaps you’re just not casting your gaze broadly enough. And if you can’t affect some degree of change at your agency, perhaps it’s time to leave your comfort zone and seek a place that challenges and inspires you.

And next time someone calls you a malcontent, don’t view it as an epithet. Consider it a badge of honor, and keep on tilting at windmills. Eventually, we’ll knock ‘em down.

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