The People, Process, & Progress Podcast - Lessons Learned from the 2018 EMS Trend Report | BTS34A

Episode Date: August 9, 2019

In this episode, I provide my perspective on issues raised in the 2018 EMS Trend Report and how I've seen these issues firsthand as a field provider and EMS Planning Captain.Full write-up at https://kevtalkspod.com/bts-ep34-a-addressing-critical-issues-in-emergency-medical-services-ems/

Please silence your cell phones, hold all sidebar conversations to a minimum, and we'll get started with Between the Slides in 3, 2, 1. Welcome to Between the Slides, Episode 34. I'm your host, Kevin Pinnell. This episode is Critical Issues in EMS, and it is based on the 15 key areas or critical areas issues that the 2018 EMS Trend Report identified. And that report was put together by Fitch & Associates with EMS1.com, sponsored by Pulsara and in partnership with the National Emergency Medical Services or EMS Management Association.

And I was a student of the Ambulance Service Manager course that Fitch & Associates puts on each year or a couple times a year. It's great for emergency medical services leaders. I was a planning captain in the city of Richmond and still got to do some field provider stuff. But I wanted to give my feedback on these critical issues and some perspective, kind of like we do on this podcast, of some ground truth. The report is very good. It has great information on how to shore up EMS systems and awareness of a lot of these critical issues.

But I really wanted to speak to what I saw supervising folks, leading folks, even folks I didn't have direct supervision over. And then contrast with in a previous episode where I talked about my time as a volunteer firefighter, the differences that I saw both when I was a professional or a career EMS captain compared to my time as a volunteer firefighter, the differences that I saw both when I was a professional or a career rather EMS captain compared to my time as a volunteer firefighter and then working for many years with career or fire EMS and law enforcement folks. And we'll go through these 15 things as well in this episode. So that previous episode was episode 32 on professional volunteer firefighting, where I talk about some of the things that volunteer departments can do to step up the game, or if they're already doing great work. You talk about some of the things that volunteer departments can do to step up the game, or if they're already doing great work, you'll see some of those trends continue for the emergency medical services field.

So my perspective is coming into, I got into career EMS, and I was there for just under two years. So not a really long time, but as an older employee, I will say, and the supervisor staff, I was in my 40s, as I am now. And so that's a big contrast from a lot of providers. There's a few folks that stay in it for a long time, and a lot that don't. And my perspective from having been a corpsman in the military, I mentioned a volunteer firefighter from also being someone that worked in the information technology sector, healthcare sector. So bringing my perspective of all those and how that fit into EMS down to, you know, being in the field and driving the medic unit or the ambulance and being, you know, a pair of hands carrying stuff like

that. So the first thing that this report, the first critical issue that's identified is retention. For anyone that has spent any amount of time in the emergency medical services, this is not surprising. It's unfortunate though, cause it's always on the list for any kind of study like this. I've seen, um, the study even mentions that it's, you know, keeping folks in emergency medical services is very hard. It is hard on the mind, on the body, on the soul and the spirit. Um, you're treated horribly when you're trying to take care of folks that are on their worst day. So for many, many reasons that the public or folks that haven't done this before will never understand. And so what is retention? It's keeping your EMS employees. It's keeping your

emergency medical technicians. It's keeping your paramedics for longer than a couple years because they want to go be at a fire department or they want to become a nurse or a doctor. And those are all great. But how do we keep the folks that want to do emergency medical services as a career? And I know of some folks who would have stayed as career emergency medical services providers if they had some of the other opportunities we'll touch on later, but they went to a fire department, right? So that's a lost opportunity for star employees, for great people to keep them within your organization. And so how? So that's the format we're going to do today is I'm going to talk

about the critical issue. I'm going to say what it is, which is keeping MS employees for this retention. And then how my two cents on how, right. I'll give some references. The first thing is from day one, treat your people, right. Set the tone where every level of the organization is treating folks right from the, you know, first time they see the job advertised, it should be a quality looking, right from the whole process of bringing them into interview, if they make it through screening, that should be, you know, relatively seamless to everyone's professionalism, when folks come in watching their comments, you know, screening the new folks, and, you know, emergency medical

services is part of public safety. It's an environment where folks, you know, say all sorts of things. We'll just keep it at that. But their whole experience needs to be like, wow, this organization is top notch. I want to stay here for a while. And that's the impression folks should get from the time they see the posting online through whenever they do decide to leave or don't they get through the training, their orientation, or whatever. The other thing that I think goes hand-in-hand in that is to be real from day one. I mentioned this is a hard job. It can be a horrible job at times.

So you need to tell them what they may see. Some folks will come into this having had some volunteer experience, and then they'll try and go to a career department, emergency medical services department. So they they already have some exposure on what it's like. Some folks have never done any medical things at all. And they heard of this organization, your organization. It looks cool when ambulances are going down the road and it's loud and all that kind of stuff. Most folks come for the emergency stuff, not the non-emergency stuff. So you need to tell them what they're going to see. You're going to see people

die. You're going to not be able to help some people. You're going to see folks that aren't sick, but you're going to see their parents abuse the child to get medication for them to take because they say they have a problem. All these different things. And you need to really be real. And I know some folks that do that at different agencies and kudos to you all. I think of particular interest is the mental health awareness that we are going to be looking after you. We are going to, you know, evaluate and we have resources for you. Just like in episode 28 with Ben Gomes, when we talked about, you know, mental health awareness and peer support, get those resources in front of your people as soon as you can in their indoctrination period. The other effect this may have is it may have some folks decide,

you know what, I do not wanna hold a child that's dead. And the good thing about that through a horrible situation to relate to someone that's gonna get into this business is that one, it helps them realize this isn't for me before they're actually in a situation that gets stuck in their head. And it also practically saves the organization money from putting in a bunch of training and a bunch of time and a bunch of effort to get that person either trained. Some organizations train EMTs and paramedics as part of kind of an academy-like thing.

Other folks, when they come in, they do an orientation and do some driver training and that kind of stuff, whatever mix it is. If you're real with folks up front and you really let them know, okay, are you ready to buckle up for the ride, then that's a good screener as well. And how people may be affected, as I mentioned. And that you're going to be there for them. So really, your retention, I think, starts with your recruitment, which is the second critical issue on this list.

And your recruitment starts before they even see anybody that works in your organization. So recruitment is bringing on new EMS workers, new staff. It didn't have to just be field folks. There's accounting folks. There's special event folks, like I was a planning captain, so field cleared and did some field work, but mostly I did special event incident management, that kind of stuff. There's also maintenance, vehicles, folks, supplies, folks, all those things.

So EMS workers isn't just EMTs and paramedics. For the career stuff, we'll focus more on that a bit later. So recruitment, how do we get folks? You know, some of it falls under the standard human resource kind of models of go to career fairs, local ones, state level ones, if they have like emergency medical service kind of organizations for your state. And then the national conferences, there's so many big conferences for emergency medical services, or even public safety. If you're EMS, go to the fire ones, go to the police ones, get some cross thread points, you know, with your brothers and sisters from public safety. And you never know who's going to be like, you know what,

maybe I do want to just focus on EMS. And, of course, that's probably sacrilege to say for all the firefighters listening out there because, you know, everybody wants to fight fire. But we all know the reality about 80% of calls are EMS anyway. But that's, I think, a bold and a good way to recruit is don't just go to EMS only stuff. Go to other things, particularly fire. Online, I have used for this podcast, Facebook advertisements, Instagram ads, Twitter campaigns,

those kind of things to kind of spread the word. And I think it's helped a little bit. You've seen upticks. So imagine a funded company. That's me on my dime. So imagine an emergency medical services company that's really pushing Facebook ads and Instagram and Twitter campaigns and those online job boards. But you could have so much reach for minimal amounts of money. And I'm going to give a shout out to Gary Vaynerchuk, Gary V. He has great strategies in his podcast as well, talking about the value you get for just the ads

that you can put out there. So if you want to, if you want to reach new folks, particularly the new generation of folks that are on the socials, you got to get in there. You have to use those social media programs for recruitment, not just to push out all the good stuff that you're doing, but Hey, we want to get you in here and, and, and really get that interaction.

Billboards. I don't, you know, I don't think they're dead, especially now a lot of are converted to electronic, you know, so you can have variable message ones and have them all around your region or your city or your county. You know, still have the print ones, all that kind of stuff and feature your employees in them, right? You can tell there's

some billboards that are totally kind of doctored up actors. I've seen some organizations that have their folks in their ads, which is fantastic. You know, that's, that's as real as you can get. And then old school, you can, you can print local newspaper, local magazines, industry magazines. So there's probably cost a bit more if you want to get, you know, in the Journal of Emergency Medicine or GEMS and some other big magazines for like EMS World, you know, aren't free. But if you really need the recruitment so that you can retain those folks, then you're going to have to put some money out. And there's many studies on return on investment or ROI of all those different types of things.

So just do your market research, but consider the whole gamut of it if you really have a recruitment issue. So retention, let's keep our folks recruitment. That's how we're going to get them in the door. The third critical issue that the study talks about is reimbursement. This is not my bailiwick. I didn't do a whole lot of finance. The finance I had to worry about was, hey, here's a budget. So how many shifts do we need to cover the demand and work some of those numbers and things like that? But it's a huge deal, particularly with

payment for services rendered, right? So how are emergency medical service organizations, whether they're part of a locality, third service, private, there's all these different models. Again, you can Google those. I'm not going to break all those down. But I looked at a great reference that is from GEMS or the Journal of Emergency Medical Services from January 2018 reimbursement, what does the future look like and great feedback, great information, you know, there's fee for service. So things to consider there. And some of this is in there. Some of this is just, you know, for me, my perspective and knowing of different systems.

So how do you reinforce collection, right? Do you have kind of forgiveness after you've sent a couple notes and go, okay, well, let's just build into the budget kind of this throwaway, so to speak, funds because we're not going to get paid a certain percentage of certain calls from folks that don't have coverage. You've got to consider that. And, you know, most progressive or mature agencies do, but not everybody does. Do you prorate based on income? You know, healthcare organizations do that. I know Medicare, Medicaid has some things like that. If you have a direct

fee for service, do you do that also? The other big consideration in this area of reimbursement is air quote medical necessity, right, which is a big issue because CMS, or the Center for Medicare and Medicaid Services, that's part of Health and Human Services, oversees a lot of the federal health care programs. And so there's standards that organizations have to meet when they charge for reimbursement from CMS if the person doesn't have private insurance. And so that's medical necessity CMS is looking at because they've paid a lot of money over the years. Was this medically necessary? The rub is, for EMS organizations, that's not your call, right?

Someone called and needed help. You went. You have to try and get the money back to keep the lights on or even progress to buy new things. But you know, when you submit the bill, and it's going to be scrutinized, so your billing office and reimbursement, all your folks certainly will know a lot more than me talking about this right now. But that's a huge thing when it comes to organizations concerned about reimbursement, probably provider level, not concerned about reimbursement, right? If the checks on time, if they can go to some classes, if they can do some

things, but if you're in leadership in an EMS organization, this is a huge deal. Some nice trends, I guess I'll say is treat and release, if that was an option, would be cool. So essentially, someone calls, but you say, Oh, you just had a fishhook in your finger, and I'm going to talk to you practically and convince you that we could cut that, pull it out, clean it, and you'll be okay and have some sort of approval. And so that could be an alternative. And some of this, too, again, from that reimbursement, what does the future look like by Vincent D. Robbins from GEMS January 2018, would be great.

Because there's a lot of calls like that where folks don't have an alternative or they abuse the system, either one, as the emergency department, as their primary care physician. Well, and we'll get into some integration and community paramedicine here in a second. But for now, you know, if folks could show up and, you know, do minor care and then have someone sign a release, you know, liability kind of stuff, because certainly we have to have that because someone's going to get sued for something they shouldn't get sued for, then that would be a good alternative. So a payment model that Health and Human Services is looking at is the ET3, or Emergency Triage Treat and Transport model. So, you know, that could be

if someone calls 911, you get their similar situation, it's not an emergency room stabilize, you're really hurt kind of thing. And you can transport that person to their primary care physician or an urgent care facility, then that would be an option. And right now, based on an article from EMS1 from February of this year, where CMS announced Medicare reimbursement for certain non-transport treatment, it may be in early 2020 for 911 agencies only, though. But that's a game changer, too, as far as system efficiencies, not getting stuck in the emergency department. Because when you go to the emergency department and they have both emergency, real emergency

patients there, plus non-emergency patients there, plus your frequent flyers that are just chalking up the system, whether they abuse it on purpose, they're addicted to something, or they have no alternative because they can't afford insurance for whatever reason it is. If you could divert and take someone directly, you know, call their physician that they have the number two or know who they are, we can help them find that out, or an urgent care center, that would help the system tremendously. So it's really cool to learn about and see that alternative. So we're working from the very start to recruit great people, keep them there with retention to get a reimbursement.

And the fourth thing on the list of critical issues in AM mess from that 2018 a mess trend report is healthcare integration so a couple factors that I can see in here is community paramedicine so this is the concept of similar to what I talked about what kind of treatment release or you know alternative but this is we know ahead of time there's appointments we can pre-screen folks, go do blood tests, collect labs. So really, you're sending paramedics that are training community paramedicine out to preempt 911 calls and stop that ER overcrowding and abuse or out of necessity through proactive screenings too. So this is the proactive, you know, arm of emergency medical services partnered very closely with healthcare. So we are making connection one personally, right with potential patients or

people that won't be because we've helped them screen for diabetes or for high cholesterol or whatever else is going on, do a physical, you know, EMTs, even in paramedics, they can do physicals great, that that's the great core skill set of being able to do a really good physical, and do it in the comfort of someone's own home is a huge thing. And then be able to connect that person, you know, and send that information to their primary care physician, I'll get into that kind of that kind of technology piece of that in a second, but that's just a great opportunity. And there's, there are definitely programs out there. Looking at that a little further, there's not a lot of standardization though, across states or healthcare organizations on what are the standards? What are those standard operating procedures? And there's a state

regulation of community paramedicine programs and national analysis from pre-hospital care by Glenn Widenar, Barraza, Jenkins, Greco, and Fisher from 2018 that looks at that. And so it was a look at, yes, there's this cool program. Community paramedicine is good. There's not a tight kind of standard that says, here's the assessments that we're all going to do all as a standard. They're pretty close. And I don't know that every state has to be exactly tight kind of standard that says, here's the assessments that we're all going to do, all as a standard. They're pretty close. And I don't know that every state has to be exactly the same, although it would be nice because that could also lead to part of, there's this weird thing where you can be a paramedic doing all this high-speed stuff like in Virginia, and you can go to another state and you can't do the same stuff. And it doesn't make any sense because paramedic

classes and EMT classes really don't vary that much and certainly medicine doesn't but anywho that's a whole nother really episode so to that some some great references they had there so if you're interested in community paramedicine and how to get into the proactive arm if you're not already the rural health information hub community paramedicine 2018 health and human services community paramedicine evaluation tool which human services community of paramedicine evaluation tool which is pretty good kind of checklist approach to it and then community paramedicine a simple approach to increasing access to care with tangible results so if you play this in slow motion while you're googling then you should be able to get there's there's or just put community

paramedicine in google there's tons of resources the other thing to me especially with my you, being an IT project manager and I'm blending that with my healthcare experience, is the information technology component, right? So imagine a real health information exchange, not just for healthcare organizations, hospitals, and healthcare, but that includes emergency medical services. The first contact with patients, second, I guess, sorry, 911 communicators, the first hands-on will say contact with patients in the field. So I'll say this. From my time and information technology, the barrier to that are the businesses and the competing logos of organizations. The technology exists for sure.

That's not what's holding things up. Connecting systems is actually pretty easy. It's, you know, all the minutiae, we'll say, to kind of wrap up a whole bunch of different things that are around getting systems connected that is holding up why we don't have a national grid of emergency medical services, EPCRs, or electronic patient care records, and electronic health records. You know, the thing is that each organization has to then give electronic health record access to another organization with a different logo. Crazy.

Which, you know, is this huge legal battle. And, you know, folks listening to this, some, depending on where you stand, are going to say, well, what about HIPAA and HIPAA and security? Well, HIPAA one is not a trump card. And if you're around healthcare in any capacity, whether it's EMS or in hospital or urgent care, whatever folks like to use HIPAA as like a barrier, but sometimes they use it and they don't understand that if, you know, if you're in the continuity of the care of the same patient and you're not like spilling the beans about your part, you know, your coworkers health record, like they don't understand that, you know,

HIPAA when it's contained in the continuity of care for a patient is not a hindrance. It's actually helpful. And really let's be realistic. What system is safe? Banks, big retail, everyone's been hacked, everyone's information has been shared. Not that I want everybody to know every medical procedure I've ever had. But you know, if we can connect them do the best we can security wise, because that's all that's happening out there in the information technology world. Anyway, everybody's just doing their best, but there's always somebody that's going to figure something out and hack it, then we can make it happen.

And so the other thing similar is there are many different electronic patient care records or EPCR systems, right? So the pie in the sky of one big electronic patient care record system, whether it's a bunch of different vendors that are just connected, also technically not hard to do unless it's in some super old language, which some systems are. But even then, there are very, very, very smart technology folks out there. And I work with many of them and have in the past that can make systems talk to each other all day long. The organizations that are in charge of their systems, that sell the products, on and on, are the ones that have to decide that, yep, you know what, this is in the best interest of everybody. And so, again, that's Kevin Pennell's personal two cents with some technical know-how in there.

So I think that would be a huge game changer in calling reports, syncing up your tablet wirelessly when you're at the hospital or whatever else. If everyone was connected and were, you know, Wi-Fi networked and the information could just very smoothly, it would never take away the face-to-face handoff, right? Because there's nuances and, you know, that handoff is a very important time too between the EMS providers and the hospital staff. Sometimes it's, you know you know contentious time but you got to have that face-to-face still so the fifth in this list of critical issues is sustainability um keeping the lights on providing the service um so much goes into this as well um that really for my two cents and there's again there's experts that on a much

higher level than me uh that what can break down many of what I'm going to say, plus add 20, 30 more, whatever there is. But I think what systems should do and leaders in the emergency medical system field of whatever flavor they are is evaluate and optimize your costs. And that's really just a good, highly reliable organization and just doing good business sense. Where's your waste? Do you monitor your waste? Do you track your supplies when people check them out, when they return them? Where I was in Richmond, they had a fantastic system that included everyone else, even barcode skaters and things like that.

Pretty awesome. So do you even have pencil and paper, and then you're going to go electronic or something like that? Are you looking at your workflows? Are your workflows efficient so that they save time, which equals less cost in people or lost equipment, devices? What technology do you use? Do you use the latest, most efficient energy saving?

Are there some cool energy saving tips? Richmond Ambulances is no secret. It has solar panels on top of their ambulances. So talking about energy savings is a fantastic idea. But that's something to look at. tips richmond ambulances is no secret has solar panels on top of their ambulances so talk about energy savings is a fantastic idea but that's something to look at you know and the types of vehicles that you're running and you know you're doing diesel or gas and all these different things lost gear and equipment how much are you writing off and lost gear that then leads to the accountability that you are not holding your people to you you know, even perishable items add up when they're, you know,

not optimized, or is it a training issue that someone keeps opening the wrong IV or the wrong, you know, tubing or something like that. So really sustainability, you just got to really look at funding sources and how you're optimizing, I think, the spend that you already have in your system or that you're gonna have have? Or are you you know, partnering? Is there some supplemental funds or something like that? So just really looking at how you keep the lights on and then not just keep the lights on, but how do we get to the next level with the newer equipment with the investments and things like that. So number six, and the critical issues from the 2018 reporter EMS trend is quality of care. So how well do providers provide care? To me, this just screams,

you know, leadership, training, onboarding, what is our process? You know, do we ensure that everyone from the most basic first responder to the critical care paramedic has the strongest foundation of the basics, right? There's a great saying that my preceptor, I precepted with an EMT, happened to be a Marine, I don't hold it against them, just sending love since I was a corpsman. So that was pretty cool. BLS before ALS, right? So basic life support before advanced life support. So does everybody have that really strong foundation and I can do these basics, which is a lot of all you need depending on the call other than, you know, critical airway stuff and maybe some meds with some funky heart things and a few other things. But that the power of really good BLS is huge.

And there's some systems like Boston is primarily BLS, right? It's get there, stabilize, get into the hospital. So making sure when we do our training, when we sign off on folks, when we do periodic quality assurance of skill sets, do we bring folks in and say, hey, we're going to run through an emergency and a non-emergency scenario every quarter with every provider, right? So we can see it, not just looking over their call sheets or looking at how long they're at the hospital or looking at, you know, their turnaround times. But I wouldn't, I want, you know, my training folks and my clinical folks to see them in action. I want to do it with strangers to see

how they react to folks that they don't know, um, which more simulates or shadow them, right? Do ride alongs, get out there on the street with them. That, that pays huge value one and the experience. It's fantastic. Uh, two, it builds teamwork, right? If you are there carrying stuff for your people, if you are helping, and if you happen to be able to, you know, help give advice or just drive the ambulance on a call where it's critical and you're holding someone down in the background that has a head injury, huge, right? Makes a big difference in it, not just in the patient, but with your employees too, with your partners. The other thing I would say is patient satisfaction surveys. So I know surveys are kind of low reward, low percentage response, but you know,

we have to ask, right? So what's the quality of our care? What did you receive? Just like, you know, satisfaction surveys you've gotten from probably any business you've been to, whether it's an electronic follow-up, you know, if they happen to have their email in that system, when we've got the pie in the sky exchange going, or it's an electronic follow-up, you know, if they happen to have their email in that system when we've got the pie-in-the-sky exchange going, or it's a mailer or something like that. There's a lot of services and surveys that exist out there, so, you know, pretty easy to find. And the other thing I would say is do partner satisfaction surveys. So do you ask your public health department how their interactions have been with your people or with you or with your department.

Same with your public safety partners and with the healthcare organizations that your folks transport patients to and from all the time. So you can get kind of that, you know, 360 evaluation of your organization. And again, you can look up 360 evaluation. You look at all the different angles, but these, I want to hear from the people that my boots on the ground, my supervisors are out in the field with on a regular basis. I want to know how we're doing beyond when I see them at a meeting or, you know, a council meeting or a planning meeting for an event or something like that. I want regular feedback on a regular basis. I think, I think can help us set the higher standard for quality of care. Number seven, workforce education. So what requirements do we want the workforce to have emergency medical technicians and paramedics? The good thing is

for requirements to be an emergency medical technician or a paramedic, and I know there's intermediates, so they just can't do a few things that paramedics can do. There are pretty straightforward requirements and scopes of practice or work that they can do. So the good thing is that's there. A lot of the questions in both this survey and other reports are about formal education like GED, high school, associates, bachelors. There's some discussion. For an EMT, typically you have to have at least a GED or high school not necessarily any college really bonus maybe if you took an EMT course through like a community college you know some credits for it paramedic a little bit longer right year year and a half programs so certainly you know there's there's some paramedicine associates degrees

I would say there is value in when you get up into asking or wanting a bachelor's when folks move into leadership positions. Now, time and money wise, that's a lot to ask, but that's another benefit organizations could consider is, you know, tuition reimbursement. And I know some that have that for sure. But it's not necessarily so that I know you can do college algebra while you're out there on the street at a car accident. It's really, you know, my degree is in Homeland Security and Emergency Preparedness, and I'm an IT project manager, right? So the fact that I went to college, I started and finished something is, I think, more what that shows, unless you're in a specific discipline that uses your specific, you know, training. And I used some of that when I was in emergency management and public health as well.

But, you know, when you get up into leadership, do you, did you take accounting? Do you know how to do some financing? Because those also have value outside of the emergency medical system. So services. And so I think that's a, that's a big deal, but you know, a lot there. I don't really have a lot to say about that. I don't think you need a college degree to be a good paramedic for sure. I think when you get up into leadership, more formal education that can be practically applied is helpful. So we've recruited, we've retained, we're working on how our reimbursement model, we're integrating our healthcare with both going out to the community with information technology, we're sustaining, keeping the lights on by optimizing our spend and reducing waste, looking at our quality of care,

which was number six, talking about workforce education, number seven, and number eight is professionalism. How do our folks act in private and public? Do we create or have we created enforced standards from day one? So just like we want folks to know what they're getting into when they get out in the world and what they see, we want them to know what they're getting into when they get out in the world and what they see. We want them to know what they're getting into and what the expectations are for them as a person and them as a provider in our system and the system of the residents that they will be serving. That to me and professionalism and respect and stuff, and we'll talk about a couple of the other ones.

A big part of that starts with how our folks look in the field. Are we holding folks to the same uniform standard that our partners are? Largely law enforcement and the fire departments who often, when they are out and about, not on a call, or even sometimes on a call for sure sure, have button-front shirts. Their shirts are tucked in. They look pretty squared away. There are exceptions.

But there's a big disparity between fire, police, and EMS when it comes to first impressions and uniform standards, and that should absolutely change. That is a total reflection on leadership. That doesn't mean that they're in the military, but I think EMS, emergency medical services, should be treated more like a paramilitary organization like police and fire do. And I think it would up the professionalism significantly if it was also then enforced. Included in the uniform standards are things to me like, you don't need to wear a fixed blade knife anywhere on you ever when you're out in the field for protection because you're not a knife fighter.

And the likelihood that you're going to have to fight someone with a knife or that you're going to cut tubing with that knife is pretty low. But I've seen tons of them. People quote protection for the same reason that they want to carry guns. Um, and as we talk about provider safety and a little bit, there's ways to be safe without having to have a bunch of weapons strapped on your waist that also real bad guys that know how to handle themselves could just take from you and use against you. So, you know, trauma shears, awesome, great. Um, and you know, there's some cool fold up ones that fit in a thing on your waist, a tourniquet that's easily accessible. That's cool, but we don't need weapons, weapons, you know, tactical key chains and all that hanging out.

One, it's just not safe to have that stuff. Like in addition to that kind of jewelry, right? Like facial rings, rings that are sticking out, those kinds of things. Be who you want to be. But when you show up to work as a provider, you're going to be a representative of this agency. And that includes looking professional. Um, and no, it doesn't look professional when you've got piercings everywhere. Um, it's your lifestyle choice, but it was also your choice to sign up for the organization. And it was our choice to hire you. And I would make that apparent in the verbiage in the contract that they sign and hold everyone to it. You know, I'm a pretty progressive guy. I have a tattoo.

I still run into, you know, I have to wear long sleeves. So in some places I go and meet with folks. But, you know, it definitely makes a difference. So that first impression that professionalism should be in everything. And that's in how our folks act too, right? So those surveys, that feedback, what do we do with that information that we got from our partners in particular? Because those are the folks that are going to see a lot like the patient surveys expect a low percentage return, I would say a

partner surveys, they know us and we're going to see them. So we'll probably get feedback. And I mean, beyond the feedback we get, because something went way bad. You know, we usually at the ground level or kind of mid level supervisor are talking to each other anyway, so we know what's happening. But I think we need to up the ante. I think the emergency medical service should adopt a bit more where it can of the paramilitary setup lifestyle and, if possible, academy. I know that's very funding dependent, but I think, you know, the academy, the bonding you get when you go through an experience where you all have to line up, you have to muster, you raise the flag, or even if you don't go to that extreme, but you muster, you report, you check in, you go sit down, you do orientation, whatever that is. Something like that creates a bond with your class beyond just sitting in the classroom and taking smoke breaks or even if folks don't even do that, if you just get to start. So I think beat that horse for a while, but it's very important to me, that one.

And I think an area that is easily fixable because it is completely controlled by the leadership of the organization. Number nine, career path. So I mentioned great folks leave emergency medical services. That's no surprise. They leave for different reasons. They want to be a higher level provider. Awesome. They want to be a firefighter because it's sexier.

Great. It is pretty cool. But what about the folks that want to be EMTs, want to be paramedics, like, and that's what they want to do. There are a handful of folks that stay in it for a long time and a lot that do not. But so what progression for EMTs and paramedics or intermediates as well have organizations set up, right? What is the career path? And there's a lot of variables.

There was a kind of a discussion proposal that I had of having steps very similar to the fire service, which shouldn't be a surprise. You know, whatever you call it, I called it. So let's look at an emergency medical technician, like EMT1. Basic, that means you're not fired, you got out of orientation, you're an EMT, that's what you're at. Or rather, you're hired, and you're kind of probationary, so to speak. And then when you've passed your orientation period, whatever it is, whether it's a period of field responses and checkoffs.

And again, I was fortunate to go through a really good program like that. Or it's a period of that plus time, six months, a year, whatever, that you can be clear as an EMT too. Then we'll have a senior EMT. And with that, it'll be time and grade. And then also, what other education have you taken beyond the basics? Have you done tactical emergency casualty care? Have you done pre-hospital trauma life support or advanced medical life support class? Consider what's going to have the most value.

If you have a basic life support only kind of division, has that person, you know, have they become a preceptor? And do you give rank for that? And there's variations of this, but you really need to put the extra time in, not just sit in your position and grade and just get checked off, but you need to have some additional competencies. And then really for an emergency medical technician, I think it wouldn't hurt to have an EMT sergeant.

I know in Richmond we had that in other places they do that are preceptors, so they're the folks that are training the new EMTs. But I think with a senior EMT, you could do that. But with an EMT sergeant, I think another level that could be provided that also gives that career progression, not just the feeling of it, but real is they have a patrol vehicle, right? So, you know, your emergency medical technician, could they show up to code and be helpful

if they're experienced to that level? Yeah, 100%, right? And so they could show up and help with that. They could help guide a lot of it. Medic, yes, is going to be in charge of the call. They're the highest provider there, so that's the deal. They could also, if you do have a basic life support division, they could respond to other issues at the hospital

or at the home where your patient's getting picked up, something like that, administrative in the hospital. They can go free up somebody or pick them up and help out. But it's another opportunity to help emergency medical technicians advance and get some leadership without having to go to paramedic school, right? If they don't have the inclination, the time or the money, this is a great, I think, career opportunity. And for paramedic, it's very similar, you know, paramedic one, senior medic, medic sergeant with a vehicle. So this can be your augmentee paramedic that can go around and can first respond to the cardiac arrest and get there before with the fire department as your medic unit gets there and help run things

and be an extra set of hands. And then EMS officers, and again, this model I saw in Richmond and it's other places. So you have your field lieutenant, a field captain, and then a planning captain. That's what I was. So I went through the orientation. It was cleared. I was an EMT as well. I was never a paramedic.

I did advanced life support stuff in the Navy, but never in the field and public safety. And so the thing I think that helps there is if you're in a locality that has a lot of special events, having someone that does some street stuff, but primarily they're focused on the system, on the scheduling, on the special events, on the incident management. Of course, a bias, right? Because that's what I did. I was fortunate I was the first one in that position, which was pretty awesome. But I think it's a good augment and a great partnership opportunity with the field ops folks to get their perspective. It's just like incident management teams.

Me as a plan chief, I'm hip to hip with the ops chief because I'm going to put together the plan that they know best as the experts. So same thing. I may know some stuff about emergency medical, but not like the paramedic lieutenant that's been there for six years or captain. And so that's huge. And then on up through the ranks,

officers, major colonel, whatever you want to call them. But there needs to be a career path, whether you have a glitter patch, meaning a nationally certified paramedic, or you're an EMT. Because, you know, that's going to help circle back to retention to where you may then can, you know, through giving that EMT in particular, I'm harboring them because typically paramedics have more career paths. But they also need valid and tangible things too, right? With rank, with increased pay, of course, comes with each of these. And goals, clear goals, clear checklists, clear competencies, and you see that a lot in the fire departments. And it's a great model that I think emergency medical services should adapt for sure.

Number 10 of critical issues, ambulance safety, right? This could, could be the ambulance itself, but you know, ambulances are there in the city, in the highway. Um, you know, it was the danger of the public not paying attention because we're on the side of the highway, which unfortunately we see, um, a lot of has hit close to home where I'm from, uh, back in Hanover and you know, just, just day to day folks, either the public not paying attention and blasting through lights or EMS workers doing the same thing. And you know, that a lot of that we can control with training and stuff, but at the, when the adrenaline's pumping at the, you know, point of impact, you can't control it so much, but what we can do is create an enforced

driving standards. And, and and again i was part of a great model that had this and then i think there's also some other things we could add is so you know do you screen driving records pretty um strictly where you know you can have zero negative you know zero is the lowest you could be on on your dmv record or you know maybe even higher since we're going to be driving other people at high rates of speed or at least elevated adrenaline levels because really we shouldn't be drag racing down there. So does that recruitment initiative include a strong driving record review, right, which can help screen out some folks that don't do well?

Do we do emergency vehicle operator courses of the levels where folks get a lot of hands-on time in the vehicles of different types that they may be asked to drive? And once we get them driving and they're cleared, do we track either electronically, which is really great, and there's so many different systems to do that, track how folks brake too hard or accelerate too fast, and even with audible alarms? And do we post them to create kind of some pure competition?

You know, hey, you know, safest driving of the month gets whatever, a gift card or something like that. And then, of course, you know, horrible driving. Hopefully before anything happens, we'd have a chit-chat with those folks. And do we factor that into their performance review? I had a great partner where I was there that put together a matrix on a spreadsheet of performance reviews and included in that were driving scores, which is great because it's, you know, it's a complete picture of how long you're at the hospital, what's your driving score, what's your turnaround time, how are you from people that have interacted with you, just different factors. But, you know, that makes a big difference just because, you know,

and if you all are in this industry and other emergency services, you know, just because you got lights and sirens on doesn't mean everyone moves out of the way perfectly. And it's a clean, you know, drive down the road, the small road, the big road or whatever. So ambulance safety starts with us and our people with the right training and the right enforcement of the rules and the right observation. And at some point, frankly, folks that just can't get it and keep bumping signs and blasting curbs and doing whatever, they're not cut out to drive an ambulance. And that's part of the enforcement of and the tough call of, well, we want to retain these folks. But how many times do we retrain them and they keep increasing our costs by bumping up our medic units and, you know, wasting our time of having to get out there and make it a teachable moment a few times.

And at some point, then the cost savings is from that person that's not driving safely before they actually do hurt or kill somebody or themselves. Number 11, public perception. I think this has a lot to do with the professional piece that I mentioned earlier in how EMS providers look out there and what is the perception. And maybe it's an understanding. Folks know what firefighters do. They know they do fire and medical things. Although some folks have questions about why firefighters show up when there's a heart attack. And law enforcement, pretty straightforward generally. EMS workers, you know, folks that use them know who they are,

but I think it comes back to the first impressions, right? Do our folks look like they know what they're doing, that their uniforms are squared away, that they're not going to pass out from carrying a couple things because they don't exercise ever. That's a huge factor. There's a huge disparity when you look at folks in uniform between police, fire, and EMS. And it's the ugly truth. It just is. I will tell you for sure as a fact that if you exercise more often, you will both fit better in your uniform, look better in your uniform, but more importantly, be healthier mentally and physically. And you'll be able to do your job better. And that's hard to do on shift work.

I got horribly out of shape when I was on day work with some shift work and, you know, found the excuse. There's exercise bands you can put in the rig. You can do push pushups and air squats and stuff, you know, at post or at the station, particularly if you're at a station based kind of thing. But, you know, the gist of it is it pays to be healthy in many, many ways. Driving, you know, we just talked about ambulance safety. So the way that AMS drives, whether you're in a non-emergent vehicle, taking somebody to dialysis, or you're running lights and sirens, you know, folks don't want to see you with your foot up on the dashboard, or rather you driving

and your partner's foot up on the dashboard surfing on their phone, that looks horrible, it looks unprofessional what it is, or, you know, driving and the passengers vaping down the road, or the drivers, or whatever, you know drivers or whatever, it shouldn't be happening. And when you see folks, you shouldn't be the disgruntled EMS worker. You should be friendly to them because they, in many cases, are paying for the stuff that you drive and your paycheck and augmenting and all that. But more importantly, that's your job is to care for people. I get burnout, no doubt, 100%. That's a large part of why I'm not in emergency services anymore.

But we have to detach. And if you're at the point where you need to take a break or go on vacation, then you need to do it. And if you're at the point where you need to switch careers, then you need to do it for sure. Being friendly to folks has a lot to do with public perception, good customer service. I'm pretty sure that's probably in everybody's documentation that they have when they go through orientation with their organizations about customer service.

And, you know, we'll do good things to good people. But it's hard to remember that when you're exhausted and almost done with your shifts. But you have to. You've got to, to borrow Jocko Willink's term, detach and step back and do the best that you can. The 12th thing on the list of critical issues per the 2018 EMS trend report is violent patients. So attacks on EMS workers, right? From the patients, from the public. Nowadays you see stories where even emergency medical services workers are getting denied coffee because of folks that don't like police, which is stupid on all fronts. But some folks just don't like police, which is stupid on all fronts.

But, you know, some folks just don't like authority or they're just mean, right? So we need to teach providers how to defend themselves. Many firefighters that I know get defensive tactics. Certainly law enforcement does. Why does emergency medical services not? Like EMS is going to be exposed to the same people that the firefighters are. Right. So this, to me, again, goes back to leadership.

Why are we not investing in that? And one thing I'll say, well, I'm going to say more than one thing, I guess, really. But in this stance is if you're an EMS provider out there, watch the Secret Service when they're near a crowd with a high profile person with the president or a secretary of something, their hands are always up, they're always in front of them. They're always looking around. When you're an EMS provider on the field, you need to be the same way. And now it's hard to do when you're focusing on a patient, their families to your left or right, or whoever's the crowds around you, and it's stressful. But you need to always be ready to roll, right? I mean, ready to get in a big MMA match, but always kind of ready to react paying attention don't get complacent pay attention to where your things are there are plenty of courses

and providers and trainers on learning practical situation awareness one opportunity i had which was fantastic partnership we had with the police department in richmond was to go through their milo system and that's the shooter don't shoot simulation with the screen and the light gun. You don't even need the gun part, because that'll get into the whole, okay, we should be issued guns and go out and all that. But just do the part where you talk through a scenario where you're talking to people,

you're going to treat patients, and you just have to evaluate what's going on. It's very easy to overlook that there's a revolver sitting on the table when you're have to evaluate what's going on. It's very easy to overlook that there's a revolver sitting on the table when you're talking to somebody that's smoking, but they called you and their wife can't breathe and they're sitting there in the smoky house. It's a very good system. It's a very great opportunity. The other thing, probably not surprising, is that I think with those defensive tactics,

and what I would suggest if you're in emergency services at all, is jujitsu and I'll circle back to exercise regular, right? It's, you know, fantastic physically, mentally. It's great for self-defense, go figure. And it will get you used to dealing in uncomfortable things. And, you know, there's a lot of folks in general, which is good, that aren't used to confrontation, whether it's physical or verbal. And, you know, going there, fending off chokes and breaks and things like that helps inoculate. It won't turn you into Conor McGregor overnight, unless you're young and you have time to do all that training kind of stuff. But, you know, I would definitely suggest training in something realistic. Let's say that. So defensive tactics for sure.

Pay attention to situational awareness is a great way to stop it. Will it stop all of it? No. Another thing is make sure you have security with you or law enforcement. So if the scene is not safe, right, you'll fail just like on your test, scene safe BSI, and you don't say that you fail. It's worse to fail in the real world when you're in not the greatest neighborhood. And you're like, you know what, let's just go in. It's, you know,

don't do it. Number 13 out of the 15 critical issues facing EMS according to that 2018 report is demonstrating value, right? So how do we show the importance or the value of this system? Another great reference is measuring and sharing the value of EMS systems. So there's a new EMS imperative demonstrating value by Jay Fitch and Steve Knight, PhD, and in their paper, unit hour utilization. So there's some systems, or that's a good standard, which is transports divided by the number of unit hours. And there's different variables there. So basically, you can calculate how efficient is our system, a 0.3 to a 0.5. And you can, there's UHU stuff all over the internet.

A heavy emphasis of that though is on emergency calls. So if you do non-emergent plus emergent, then that's not a 100% true value, but it's better than nothing, right? It's a good calculation that a lot of folks use to see, you know, how efficiently are our units responding, taking the call, taking the patient, dropping the patient off, getting back in service. And again, Google UHU or unit hour utilization, you'll see that. But that's one

measure to look at. Looking at response times, right? So how long does it take us? Does it meet thresholds that we have in agreements for funding or something like that? The variance in shift models, right? So what's the value to our people? How do we balance covering the needs of the system, right? If we're doing a needs analysis by call volume and where calls are and those kind of things with burnout and safety issues, do you cap the number of shifts in a row or hours in a row that your folks can work? And I will say you absolutely should. Or do you not? So, you know, when we're demonstrating

the value of our systems, these are all factors that go into when we go back to scheduling a system, you know, that's money, right? So that's a pot of money that the people plug into the schedule. So, hey, here's a budget. Figure out how all these providers can cover the system while also not burning them out, while also meeting the obligation we need to to keep the money coming that's going to keep them paid. So if you want to talk about pressure on leadership and perspective for ground-level folks that I hope are listening to this, that's the truth of what's happening in the office, various offices. And so that's a big deal.

And there absolutely should, from the leadership, be an emphasis on first, how do we give value to our folks and let them have a life with their families, with whatever they do outside of here? But we have to meet the bottom line. So that's a very tough thing. And, you know, you have to discover what the most kind of quantifiable method that works for your system is because you're going to have to have some hard data. And there's great references, like I mentioned out there, like UHU and other things that you can balance your schedules and systems.

Number 14 was volunteer reliance. So certainly in areas that have a heavy volunteer component that provide the emergency medical services, you know, the heyday of volunteer fire or volunteer emergency medical services is, I don't say completely gone, but it's certainly diminished. And, you know, calls don't stop just because we can't get volunteers to sign up or run duty. So, you know, eventually I think all volunteer, meaning not all of them in existence, but a locality or an organization that is 100% staffed by a volunteer and that locality relies on them is going to kind of go the way of the dodo. I don't think it's sustainable forever at all.

There will have to be combination systems where there's some career-hired folks that work with volunteers as they phase out. And in some places, it may be so bad or getting so bad that you just have to have all career. The good thing is that there are grants. So if it's a fire-based CMS, there's the Staffing for Adequate Fire and Emergency Response or SAFER grants. I've seen a lot of great things happen to smaller departments as they build up with these grants. And that's a way to get staffing to bring folks on to meet the needs of the people, which is the bottom line in all this emergency medical services, right? Someone calls 911, they have to get help. And egos to just hold on to volunteer

only should not be a factor in this decision at all. In Virginia, which is awesome, there's also a rescue squad assistance fund or RESF. And so that's another opportunity for EMS only things. And it's great to help augment with equipment and training and other costs with emergency medical and a good resource that has a list and you do have to sign up in there. So just caveat is EMS grants help.com is a good site that lists all these different EMS specific grants. So like I mentioned, safer is Firebase, but there's other EMS-specific grants. So like I mentioned, Safer is Firebase, but there's other EMS-focused ones.

So if you're a volunteer organization, if you know of one that's struggling, check out some of those resources. Even I'm sure the Safer folks could point you towards if you're EMS-only, so to speak, or not kind of embedded there. What you don't have to sign up for is the previous episodes of Between the Slides, which you can go to BetweenTheSlides.com, listen on iTunes, Spotify, iHeartRadio, and Stitcher.

You could check out what I'm up to on at PenelKG on Instagram and Twitter. And we do have a Between the Slides Facebook page. So I put the show notes, announcements, those kind of things like that. Reach out to me. I've had some folks recently reach out, which is pretty awesome, particularly with the project management professional tips, with the volunteers, somebody that just started volunteer firefighting at 60, which is fantastic. So thank you to the folks that are listening that reached out,

connected on LinkedIn. That's awesome. And so the last thing is succession planning. That's number 15. So are we preparing the next generation of EMS workers? And who in your organization is going to be the next CEO? Are you planning to, with your recruitment and retention, to keep folks in your system to the point where they want to take over? Again, you see this more in fire and police where at least folks stay into higher ranks because there's a ladder.

There's a step. There's some of those structures in place that we talked about earlier. So this isn't just for emergency medical services that this is the topic. But as leaders, we should always be training our folks, particularly our folks that are coming up or are in leadership positions, to be your successor. I should train you to put me out of a job, right? And so what does that mean when you're a brand new emergency medical technician or paramedic? To me, that means that we're going to provide in-house leadership training, both EMS specific, right? How to run a scene and folks can run a scene, whether you're BLS or ALS, the specifics of what drug do I push and what size tube do I use is the paramedicine part, not how do I organize people and how can I have command and presence. So we should provide in-house CMS specific leadership training to

all levels of providers and even our administrative folks. And then general leadership training, right? So we want these people to be leaders, whether they're wearing cargo pants on the street or they're out in the community or they do end up leaving us and they help. We want them to be able to lead people and lead themselves. And there's many different ways and trainings for that. We want to do cross training with partner agencies, right? Ride alongs with partner agencies. And that was another great example I saw in Richmond. Hey, go ride with the battalion or go ride on the engine. That doesn't mean you get to suit up and wear turnout gear even if you've gone through fire one, two and all that kind of stuff. But you get to see a day in the life of your partners in the fire station and they get to ride a medic unit with you. Right. And so that at the ground level, that's great. I think it should also happen at the bid management level. So between the battalion chiefs and the lieutenants and captains from EMS and the safety officers and those kind of things, get some cross-exposure.

And then with even higher levels, they get some exposure with meetings and those kind of high administrative things. And create regional leadership academies with cross-disciplines. And this one's direct from my buddy Mike Fibbs from episode 31, Air Ops and Drone Deployment. That concept of let's teach each other leadership, whether you're a cop, whether you're a medic, whether you're an EMT or a firefighter or a firefighter and EMT,

is that leadership is good leadership. And you're going to wear the leadership hat, not necessarily your discipline hat. And when we do scenario specific stuff, sure, you should, you know, if I need law enforcement expertise, that's what you're going to do. But, you know, it gets folks that shared experience of kind of a, you know, a career path, leadership organization and shared experience, which is pretty awesome having the same cohort. So it's pretty awesome. The other thing is send rising leaders to formal EMS training. So I mentioned the Ambulance Service Manager Program or ASM with Fitch & Associates. I went

to Kansas City for that. It's been hosted in a few other areas. It's great. It's two one-week sessions. They also have it for emergency communicators, actually. So that's pretty awesome. But you learn a lot of what I mentioned in this episode, but you learn some general leadership, some finance, some funding, personal evaluation skills, which is great. You do the DISC evaluation. When I went through, it was kind of in the part where I was getting burnout in general from being on call and a tough spot, some other things that happened in my life. And so it was actually tough for me. And I have some contacts from there still that have been great. But when I look back on it, I still have the list that I did it myself of things that I want to do to get better.

And this is largely personally focused, right? Because we're not going to be better leaders and we're not going to succession plan well if we're not doing that for ourselves. The other thing, leadership training in Virginia is formal. There's an EMS officer one course. So, you know, that's EMS specific. And again, firing police have these, these, you know, officer courses, officer one, two for fire in Virginia, Department of Fire Programs in other states, I'm sure. But in Virginia, they have an EMS officer-specific course, which is pretty awesome. The last thing I would say for succession planning

is to not limit the training to just white shirts and collar brass. And I mean any kind of training. Now, am I going to teach the new EMT what it's like to be on a steering committee for a multimillion dollar project right off the bat? No. Does that mean that every now and then, kind of like an intern, we couldn't have them sit in on a big meeting or a board meeting? It's pretty good.

It's pretty good exposure, right? So remember that picture of me in the office or me meeting with the colonel or the major or the CEO or the COO talking about, here's the pot of money. Here's the call volume we have to meet. Here's the schedule we have to make, but let's not burn our people out. Let's keep them safe. All that kind of stuff. People don't see that. They see, I didn't get my shift. I wanted my custom shift that way. I'm exhausted. All these factors. So if we can peel back the onion, peel back the layers and show them the organization, there's really no secrets, right?

Because we want to know that we have recruited the best folks that we can, that we are doing everything we can to retain them from day one, that when they're out there, they are integrated as part of the overall healthcare system, they are safe, they know how to drive that ambulance, they are documenting well, and we are using whatever model we need to for reimbursement. We can sustain our system, our organization, that our folks are providing the highest level of care because from day one, again, we've built them up on the basics, and now they're just out there working it. We are making sure they're educated. They act and look professional and are healthy for themselves and for the organization

and for the profession, that they have a career path to know that, hey, you can stay here. We are going to help you with education. We're going to, here's a checklist. We're going to work through these competencies with you and the public when they see this and as you're growing and you're professionals and their perception is going to increase, We're going to teach you how to deal with violent patients, how to stay away from them if it's not safe for you to, because it goes you, your partner, anybody else in the ambulance and the public's last after that. So we're going to teach you how to handle yourself or how to stay out of places where you don't need to or wait for that security. We're going to demonstrate value by showing how efficient you are,

by balancing your work life for yourself and for the system. We are going to augment this volunteer force by getting grant money or talking to our locality and saying, look, we need some help, and we're going to tear down that wall if there is one just to hold on to the volunteer, you know, old schoolness. Um, and we are going to plan to train our successor so that we can hand off the organization and the industry to the next generation of folks that are hungry to do good work out on the street to provide the best care they can and to help the public in their worst hour.

Thank you. Fitch & Associates, EMS1.com, Pulsara, National EMS Management Association for the great trend report that I referenced a lot in here and built this episode off of. From my family and friends, partners in public safety that helped me, shaped me, you know, held me up when I was down and helped us I was down and helped me work through a bunch of stuff. And help expand my knowledge base in this area and give me a big picture on what systems involve. And I'm certainly not the be-all, end-all expert, but I hope this maybe helps one system that improves, that keeps one person a little bit longer and is a little bit safer. Thanks for listening to this podcast. Reach me on the socials, Penel KG, Instagram, and Twitter, betweentheslides.com, iTunes, Spotify,

Stitcher, iHeart. Stay safe out there, everyone, and Godspeed.