Grand Rounds is a new monthly blog series developed by EMS World and FlightBridgeED that will feature top EMS medical directors exploring the intricacies of critical care in EMS practice. In this installment FlightBridgeED Medical Director Ritu Sahni, MD, reviews political advocacy.
Usually this column covers clinical issues that appeal to critical care-minded individuals. At FlightBridgeED we focus on the emergency care provider who is interested in knowing more and being more. However, we are also interested in those who want to lead.
As many of you know, on the SecondShift podcast cohost Mike Verkest and I like to discuss the news of the day in EMS. The news of the day has been, of course, COVID-19. As EMS, emergency department, and critical care workers, we are on the frontlines of this war. We not only see the human impact, but we can see how policy at the federal, state, and local levels impacts our ability to care for our community. Now more than ever is the time for advocacy.
In our context advocacy means efforts to influence the introduction, enactment, and modification of legislation and proposed rulemaking. These policies can impact funding for EMS as well as how EMS practices. While some people worry about “politics,” the reality is that most decisions that affect EMS are apolitical and not driven by party or ideology. Instead, these decisions are based on specific knowledge available to the decision-maker. As an EMS provider, what if I asked you about regulations around proper interstate trucking? We ask our policymakers to make decisions that affect patient care with a minimum of knowledge. Responsible advocacy can fill that gap.
History of EMS Advocacy
Following the attacks of September 11, 2001, the federal government focused on funding for preparedness. Law enforcement and fire services received specific funding lines. Medical readiness focused on hospitals, which controlled the local distribution of federal funds. Emergency medical services were not included in the definitions and therefore not eligible for many of these funds.
Then-NAEMSP President Richard Hunt, MD, identified this problem and reached out to his congressional representative. When he spoke with that member’s staff, the response was clear: EMS had no one at the table, and without anyone around there was no one to ask. NAEMSP realized we could not adequately care for our patients without a policy voice. Unfortunately this required more resources than NAEMSP had by itself. As a result, Advocates for EMS (AEMS) was born.
AEMS emerged from a desire to provide a “generic” EMS advocacy arm. NAEMSP’s goal was to bring the “alphabet soup” of EMS organizations together into an advocacy outlet that was patient-focused and separate from other issues that may divide EMS. Early on the National Association of State EMS Officials (NASEMSO) was a key partner. Later the National Association of EMTs (NAEMT) became the primary partner. These partnerships allowed the organizations to pool resources and invest in professional lobbying along with a more strategic legislative focus.
Advocates for EMS adopted many strategies in pursuit of its mission. Early on it sought to ensure “report language” and grant requirements included EMS. It was successful in these endeavors, and some small victories were helpful to the EMS community. Ultimately AEMS became more aggressive and developed the EMS Field Bill. This bill was substantial, calling for a formal federal “home” for EMS within Health and Human Services (not NHTSA, which is part of the Department of Transportation). It led to significant discussion and even controversy in the EMS community but did not achieve passage.
Ultimately trying to run an “association of associations” can be difficult. Each association has a slightly different twist on EMS issues and, more important, different processes when it comes to setting legislative goals. As this became more difficult, AEMS came to an end.
Its demise does not mean AEMS was a failure, however—quite the opposite. EMS associations realized “you must be present to win.” Having a presence in Washington, D.C., is imperative, or national policy will roll right over us. Based on this experience, both NAEMSP and NAEMT decided they needed to invest their members’ resources into a permanent presence in Washington. As a result, both organizations now have active advocacy programs. These programs work with other EMS partners, such as the American College of Emergency Physicians, American Ambulance Association, International Association of Fire Fighters, and International Association of Fire Chiefs.
Amending the Controlled Substances Act
In January 2015 I was completing my term as president of NAEMSP. We had been discussing issues regarding the management of controlled substances in EMS for years. The only consistency was inconsistency. In some locales EMS medical directors were required to get separate DEA licenses for every location that stored controlled substances of any variety. Some EMS agencies were required to get a distribution license because they “distributed” controlled substances among their various rigs and stations.
It was in this context that the DEA’s policy/regulatory section approached the EMS community proposing to create a set of rules specific to EMS. We were pleased there would be some consistency and excited to hear the DEA was reaching out. During that year’s NAEMSP meeting in New Orleans, we met with the DEA’s policy personnel. As we talked it became increasingly clear we had a problem.
The DEA’s authority comes from the Controlled Substances Act (CSA). The CSA was written two years before Johnny and Roy premiered on television. The law didn’t anticipate the use of controlled substances in a mobile environment and without a physician present. Ultimately the DEA decided the CSA had specific guidelines as to when controlled substances could be delivered. The crux was this: All orders for controlled substances had to be “patient-specific.” There couldn’t be a “standing order” that allowed nonphysicians to deliver controlled substances without an order given to them directly by a physician in real time. When we suggested the new EMS rules could allow this, the DEA pointed out it could not write a rule counter to the requirements of the statute. The only way to get rules that made sense was to change the law.
At the same time NAEMSP had invested in a government relations firm. Because of the lobbying experience available to us from our Holland & Knight partners, we were able to identify a member of Congress willing to listen to us and take up our fight.
Rep. Richard Hudson from North Carolina heard us and as a result introduced the Protecting Patient Access to Emergency Medications Act. We tried our hand at advocacy, and NAEMSP members started contacting Congress. We quickly partnered with ACEP and NAEMT, both of which activated their membership on the issue. NAEMT agreed to make the bill a priority for EMS On the Hill Day, and members of the EMS community walked the halls of Congress to advocate for it.
Our issue was almost complete in 2016, which would have been amazing, but politics prevailed, and the bill didn’t pass. Hudson reintroduced the bill in the House. Sen. Bill Cassidy introduced a version in the Senate. This time everything fell into place, and both chambers passed them. The president then signed the legislation. To some it was a small thing, but using protocols or standing orders for EMS to deliver controlled substances was now legal.
How Can I Help?
It is not hard to guess the key issues today: preparedness, preparedness, and preparedness. Once again EMS mustn’t be left out as funding becomes available to manage the current crisis and beyond. Problems in supply chains, whether for personal protective equipment or medications, must be identified and proper stopgaps applied to make sure these items are available. EMS must be funded to a readiness level and not by a just-in-time model. Our workforce must remain protected from physical and mental harm. Finally, we muse emphasize quality of care. EMS should not be considered just a ride to the hospital but a vital component of the healthcare and security of any community.
Get involved locally and nationally. National organizations such as the NAEMSP, NAEMT, and IAFF all have active advocacy components.
Participate in a national fly-in. NAEMT’s EMS On the Hill event was canceled this year, but it will be back, and you should attend.
Donate to a political action committee (PAC). Members of an organization can donate to their PAC. The PAC then donates money to the political campaigns of those legislators with records of leading and supporting preferred legislation.
Get involved in local politics. Be present at local and state meetings, especially when EMS issues arise. Serve on local and state policy committees that impact EMS.
Here’s the crazy one: Run for office. Imagine a world in which your county commissioner is an actual paramedic, nurse, or EMS physician. It could be a game-changer. We can provide information, but only when holding the levers of power can you truly make a change.
Ritu Sahni, MD, MPH, FAEMS, is medical director of the podcast division and cohost of the SecondShift podcast for FlightBridgeED. He is an active EMS medical director with multiple agencies in two counties outside Portland, Ore. He has been president of NAEMSP and now chairs its Advocacy Committee.