Delete American paramedics.

[systemet]

If a nurse ever wants to get uppity with me about my "lack of education", I tune them out.

Fair enough really. Someone with a BScN shouldn't be acting like their the second coming of Einstein.

Should a bachelor's degree be mandatory to work as a paramedic? If our wages justify the expenditure and we can make the education relevant to our work, absolutely. If wages don't justify the education, there will never be a push towards higher education.

I would argue that almost everyone has this backwards. As a group, we can't argue that we should be paid more so that we can go and get degrees and be more useful. I think we have to approach it the other way, become collectively more educated and organised, then advocate for better pay.

Part of the wage problem is also an overabundant supply of EMTs and Paramedics (depending on your region). If we increase the entry requirements, we reduce the number of qualified applicants and the employers become forced to offer better compensation. The labour market is still a market.

Additionally, what does the evidence say? Do OZ/NZ/UK EMS systems do better by their patients then American "technician" paramedics?

I think it depends on how you measure better. There's some economies of scale. For example, a lot of EMS crews in the UK are set up for prehospital thrombolysis. This isn't done as much in the US. Part of this is undoubtedly that there's a lot of money in doing PCI stateside, and there's lot of cathlab resources. But it's also just very difficult to implement regional systems when you have so many different players.

There is very little "evidence" for higher levels of training -- although this also includes comparing EMT-B to paramedic. Fortunately most of this is due to a lack of interest, and a lack of research than the presence of a large body of negative outcome data. Unfortunately there's a tendency for physicians and other consumers of research data to assume a paramedic = a paramedic = a paramedic. When you read the literature, there's not been much of an attempt to differentiate between a medic from a 12 week program, and a degree paramedic with post-degree training.

Although I'm not the biggest fan of fire-based EMS, it does have some strong points. Departments that do EMS well are every bit as good as many of the private services.

A fire department that does EMS well is as good as an EMS department that does EMS well, at doing EMS? Sure.

 

[RocketMedic]

A doctor on every truck will be retarded expensive. The current model may not provide perfection, but it does provide access to almost everyone.

 

[RocketMedic]

That being said, one could argue that its a good thing we work for peanuts. The first bog groups of "$30/HR for my bachelor's" are going to be disappointed or unemployed right quick. What power, exactly, does a degree confer over, say, military service or prior experience?

 

[systemet]

A doctor on every truck will be retarded expensive. The current model may not provide perfection, but it does provide access to almost everyone.

Yeah, I don't think there's anywhere that can put a physician on every ambulance. It would be very expensive, and it would be difficult to keep the physicians exposed to enough critical patients.

I think pretty much every system using physicians has a lower tier as well, with paramedics or basic EMTs. It is possible to run an ALS response with a couple of physician cars. For some reason I keep thinking of the Netherlands, where their paramedics are Master's degree RNs (I think). I seem to remember that they have a small number of physician ambulances in the bigger centers. But I might be wrong.

I did talk to a pediatric intensivist from somewhere in Germany (Koln?) once, who used to routinely fly out for sick kids, although his complaint was that many of the children weren't sick enough.

Someone's already mentioned London HEMS, which is supported by a very large ALS ambulance service.

 

[sir.shocksalot]

That being said, one could argue that its a good thing we work for peanuts. The first bog groups of "$30/HR for my bachelor's" are going to be disappointed or unemployed right quick. What power, exactly, does a degree confer over, say, military service or prior experience?

The power does not lie in the piece of paper, but rather in what was required to obtain it. A degree has a set of requirements that must be fulfilled by all that wish to get it, military service or prior experience guarantee nothing to employers.

My point is that a degree guarantees a depth of knowledge, something that our current system can't do. Some Paramedics need to learn A+P before they graduate, some don't, but both end up with the same patch even though one paramedic might have a greater appreciation and understanding of what is taking place with their patient.

You might laugh at anyone demanding appropriate pay for their level of education, but it is simple economics. If every paramedic had to get a degree to keep their cert, I promise there will be a lot less paramedics, and those paramedics that can get a BS will get to tell employers what their pay rate will be. Simple supply and demand.

 

[systemet]

Fair enough really. Someone with a BScN shouldn't be acting like their the second coming of Einstein.

Fail...

"they're"

 

[DPM]

I think a lot can be learned from the London Ambulance Service / HEMS setup. They have ALS ambulances, paramedics / Medic supervisors in fast response cars and then HEMS / BASICS Drs in an air ambulance / response car to top it all off. I wouldn't ever say that one system is perfect but LAS deals with a population of over 13 million and they seem to do alright as the city's only ALS providers.

There is a 4 year degree / career path that takes you from EMT up to Paramedic with continual OJT and professional development. For

If EMT-B and Paramedic is made "harder" then the job market wouldn't be flooded and wages would increase. We cannot demand more money as an incentive to improve education, it should be the reward.

 

[Veneficus]

A doctor on every truck will be retarded expensive. The current model may not provide perfection, but it does provide access to almost everyone.

The question is not how much it costs to put a doctor on an ambulance, the question is how much would be saved by not having to pay for the doctor, the ED charge, and the outrageous routine diagnostic tests performed in the ED with no long term care afforded to patients who do not have access to primary care and have turned the ED into their acute palliative care center.

I use for examples inflammatory bowel disease:

Either of the IBDs go to the ED during an acute attack because they are not managed by primary care due to lack of access/ability to pay. Let's cut out the ALS ambulance for a more conservative estimate.

ED facility charge for non emergent care in my home town ~$500, ED physician charge for same ~$500, Chem 13 lab panel +CBC ~$800, xray ~$75, abd CT scan w/contrast ~$1000, IV therapy, ~$650, pain medication ~$100.

Definitive treatment, prescriptiopn for pain meds to go and a referral for a PCP or GI doc that the patient couldn't afford in the first place.

Average cost across the US for a PCP visit? ~$140.

Everytime the pt goes to the ED (for the exact same thing), they will get the exact same thing.

The problem is not managed at all. Despite the previously known DX, because of liability repeat diagnostics reaching the same DX will be performed everytime.

THe ED docs are not stupid, they know what needs to be done, they know these diagnostics are not needed. But because of the system, will be forced to limit their treatment options and repeat DX all the same.

That is for 1 patient on one visit. The same for psych, the same for alcoholism, the same for drug addiction, renal stones, and a host of other primary care problems.

As I mentioned in another thread, the days of the acute emergency where prompt 1 time intervention is the treatment of choice are over. (with the exception of trauma which I just read yesterday is actually on the increase.)

But even still, the treatment performed by a US paramedic for trauma is basically a taxi ride. (remember not all trauma is life threatening) But even in the case where it is requires the intervention of a physician. (not to say it always requires a surgeon, because that is simply not true, EM docs are more than capable of handling all except the most extreme cases.)

Nobody could expect that putting a doctor on an ambulance and responding to 911 calls like is done today would show any cost or patient benefit.

There would have to be a change in the system where these doctor would have primary care visits in between responding to emergency calls and the system would have to reasonably compensate them for such.

Having said that, when you look at the costs above, you could probably pay them a very lucrative wage for saving all that money by treating patients at home or taking them to an appropriate place other than the ED. Especially if you add on the cost of an ALS emergency ambulance for every toe pain etc, that generates a bill even prior to the one the ED is going to charge.

Putting a doctor on an ambulance and equipping them/having them function as a paramedic is a terrible waste of money and the capabilities a doctor brings.

 

[Veneficus]

What power, exactly, does a degree confer over, say, military service or prior experience?

It is a measurable and constant standard recognized by society world wide.

As I am sure you know, 2 people who join the same branch of service with the same initial MOS can have vastly different functions and experiences.

Additionally, military training for enlisted persons is not known for creating independant decision makers but more of "when you see X do Y"

On the nonmilitary side, experience is also nonstandard. You may never see certain patient populations or circumstances in your life/career. If you were to encounter one, it is the minimum level of education you received that applies to it that will determine your level of success.

I read newspaper article last year about a fire captain in a suburb who went to his first structure fire in his 20+ year career. Would you say he has 20+ years of experience or no experience?

 

[Level1pedstech]

Has anyone thought of who is going to pay what would likely be sky high rates for the malpractice insurance these providers would need to carry. Providers already are running as fast as they can from areas in medicine that carry high risk,this MD or PA in the field idea it seems to me would carry a huge amount of liability and risk that most MD's and PA's would not be interested in.

As always the compensation versus education and vice vera comes into play. There is no money in pre hospital EMS fire non fire or any other area of pre hospital medicine. When I think compensation I am thinking no less than 90K a year for advanced providers. People that have put in the time effort and money involved in obtaining education should expect at least something more than slightly above poverty level wages. Right now I see very poor wages that might increase if you climb the ladder into something like an FTO but who needs the stress and headache of mothering a bunch of field cowboys. Most of the fire oriented people know how that end of the industry is going,layoffs and hiring freezes nation wide and starting pay that should you be lucky enough to receive is chump change in most parts of the country.

We see this "doc on the box" idea every so often and then people come to their senses or sober up. Face the facts,it is what it is and trying to make it better by thinking advanced providers are going to come on boad in a nation wide effort to make our pre hospital ssytem look like of an EMS nirvana is just never going to happen.

 

[RocketMedic]

I would also argue that there's nothing a PA or MD can do in the field with reasonable additions that a trained paramedic couldn't do. Isn't this the root of community paramedicine?

 

[systemet]

Has anyone thought of who is going to pay what would likely be sky high rates for the malpractice insurance these providers would need to carry.

Are you sure? How much supplementary insurance are paramedics carrying in the US right now? What's that costing?

People are running around cancelling on STEMIs, intubating esophagi and committing all manner of malpractice. I accept that increasing the responsibilities in the prehospital environment, liability might go up, but by how much?

Is tort law really a barrier to advancing EMS care?

Providers already are running as fast as they can from areas in medicine that carry high risk,this MD or PA in the field idea it seems to me would carry a huge amount of liability and risk that most MD's and PA's would not be interested in.

Maybe you're right, I don't know enough about this area. You're obviously going to have to compensate people enough for any extra risk they're going to carry.

I'd suggest that a better approach to involving PAs in EMS, would be to develop paramedic practitioners like in the UK.

As always the compensation versus education and vice vera comes into play. There is no money in pre hospital EMS fire non fire or any other area of pre hospital medicine.

FD seems to want it pretty bad for there being no money. Same thing with AMR, and any number of other private providers.

I agree this probably is part of the problem. If you can't bill someone (or their insurance), an higher amount for a higher level of care, but you can get that higher level of billing at the ER, there's not much of an incentive to move ER services into the ambulance. The current system is mostly about making money, not saving it. [At least as I see it, as a foreigner, with no direct experience. So I may not know what I'm talking about.]

When I think compensation I am thinking no less than 90K a year for advanced providers.

I think any labour cost would be determined by the realities of the job market, and the perceived value of providing higher service levels on the ambulance.

It's hard to really pull a figure out of the air, and say, $90,000 for a PA. I know senior medics making that sort of money without working OT shifts. But compensation for medics also varies greatly by geographic area.

People that have put in the time effort and money involved in obtaining education should expect at least something more than slightly above poverty level wages.

I agree, but I don't think $90,000 = "slightly above poverty level wages". Nor is a number like $60,000 for a medic. Some places make much less than this, some much more.

The other thing is, how much compensation can you really expect for < 6months of training (EMT), or maybe another 2 years (paramedic) -- with some places being significantly less.

Everyone likes to justify it by comparing the ALS scope of practice with nursing, but it seems like no one wants to spend the equivalent time in school.

Right now I see very poor wages that might increase if you climb the ladder into something like an FTO but who needs the stress and headache of mothering a bunch of field cowboys.

"Mothering a bunch of field cowboys?"

Most of the fire oriented people know how that end of the industry is going,layoffs and hiring freezes nation wide and starting pay that should you be lucky enough to receive is chump change in most parts of the country.

Chump change? Starting firefighter in a lot of places I've seen is $37,000 / year. Pay scale goes up steeply, and a senior firefighter is making more than a senior medic in many settings. Factor in early retirement, and almost being guaranteed to be on a captain's rate for the last two years that set your pension level, with plenty of opportunity to climb the career ladder.

That, and most places you work as a FF, you can have a second job, because you sleep all night.

We see this "doc on the box" idea every so often and then people come to their senses or sober up. Face the facts,it is what it is and trying to make it better by thinking advanced providers are going to come on boad in a nation wide effort to make our pre hospital ssytem look like of an EMS nirvana is just never going to happen.

It may never happen. There's got to be a benefit for it. And maybe you're right, it might require changes to billing or tort law. Perhaps the US would need a more socialised/centralised medical system for this to be worthwhile.

But it is being done in other countries, and seems to work well for them. It's not such a leap to think that there might be some benefits to implementing aspects of those models.

 

[Foxbat]

I can see how having an MD on an ambulance can benefit many patients. From a patient standpoint, European system is awesome.
However...
Whether an intervention is done in the field on in the ER, the medications cost the same, supplies cost the same, and doctor's time costs the same (probably more. If you want physicians to work in more stressful field conditions rather than in a warm, well-lit hospital, you better offer them higher wages). Also, a physician in the field will have more "dead time" (when he is on duty, but not treating a patient), - again, $$$. It is cheaper to put a lot of patients and providers in one building, just like colleges saving money by having large classes instead of small ones.
Europeans can afford physicians and PHPAs on ambulances because their medical system in general is not as outrageously expensive as American one. Russia has physicians (or at least PAs) on every ambulance. Heck, it even has specialized mobile ICUs (pediatric, neurologic, psychiatric, cardiac, etc.). You know why? Because Russia has a large number of physicians per capita, and physicians' wages there are very low.
Until US has more physicians and/or lower physician wages, I don't see the situation changing.

 

[systemet]

I would also argue that there's nothing a PA or MD can do in the field with reasonable additions that a trained paramedic couldn't do. Isn't this the root of community paramedicine?

I wish this was the case, but I think there's too big a deficiency in microbiology, pharmacology, pathophysiology, even basic physical assessment techniques in paramedic training.

Obvious things that come to mind:

* Suturing -- yes, it's in some people's scope, including mine, but very few people have received enough training to do it well.

* Wound care -- what are high risk injuries, what needs to be referred for x-ray, proper debridgement etc.

* Prescribing -- not only can we not do this, but we lack the background to select appropriate antibiotics, identify common medication interactions, and just do this safely.

* Joint reduction -- maybe a few of us have put patellars back in, but most of us don't have it in scope, and most haven't been trained.

* Care of basic ailments.

* Pretty much anything surgical, including proper local anesthesia, ring blocks, foreign body removal etc.

* Mental health assessments.

* Otoscopy, EENT assessments -- most of us have played with these tools but have no real competency.

* Chronic pain management

I'm sure some of the physicians / medical students could extend this list much further.

 

[mycrofft]

It's usually BSN, but the onomatopoeia is a little off-putting.

I knew BSN graduate who had an MBA and worked on an ICU for five years before she came to where I worked. We carry many disguises, as do people with EMT-B's.


I hear some people arguing against upgrading EMT-P's (the runaway favorite) because their training doesn't cover this and that...essentially making them PA's. If there are enough PA's the cost of fielding them will go down too.

 

[Maine iac]

How many people here have degrees? AAS? BS/BA? MS?

Is there a difference between the courses that last 2 years and the ones that have you working 40+ hours a week, but you finish in a year?

I did 4 years of university and have a BS, then did a medic program (at a very competitive medical university/very large teaching hospital), that only lasted 10 months. I wasn't offered an AAS but if I was going to university here I could have gotten 30 credits for the program.

Do I feel that while going through the job application process that my university degree gives me an advantage over somebody with the same training/experience but no degree? Not really..

One thing about the European EMS programs is that all calls are screened to see if a Doc is actually needed on a call. If there is not a suspected need for a doctor then one does not go. With some places I've seen in the US they have fast cars for doctors who are always oncall incase of an MCI or large event where a doctor would be needed for either higher skill level (field amputation comes to mind), or to tell people who don't really need to go to a hospital not to go.

I don't really think it is fair to say it is the medics choice to get more education and then try to bargain for higher wages. If there is to be an increase in the education two things need to happen (and this is starting to be seen with BSN versus AAS): First, paramedic programs need to have higher standards of getting in. Second, the employer needs to only hirer people with hirer educations. If employers only hire people with a BS degree well guess what.... it will force people to get those degrees.

 

[systemet]

It's usually BSN, but the onomatopoeia is a little off-putting.

This depends a little on the geographic location. A lot of countries abbreviate Bachlor of Science to BSc, and their BSN degrees are BScN degrees. I've also seen Bachelor of Nursing (BN) degrees. As far as I can tell there's almost no difference between them, despite some people claiming that the BScN is more sciencey than the BN.

I knew BSN graduate who had an MBA and worked on an ICU for five years before she came to where I worked. We carry many disguises, as do people with EMT-B's.

Yeah, I realised after I wrote that that I was reacting to the general douchieness of someone talking down to someone else based solely on their educational level, instead of making a rational argument, and had then done exactly the same thing.

I hear some people arguing against upgrading EMT-P's (the runaway favorite) because their training doesn't cover this and that...essentially making them PA's. If there are enough PA's the cost of fielding them will go down too.

For my part this might just be not having worked with PAs. They're not that common outside of the US.

It might be that the answer is to just have a couple of PAs on shift driving around in jeeps who can go consult and handle cancellations and referrals.

I think a lot of the efficiency gain in this sort of system would be providing care in the home, not transporting, and consulting and referring to other agencies. A lot of paperwork and cellphone time, and relatively little acute care.

I think this is where we let ourselves down in traditional paramedic training. We devote 90% of our educational time to 10% of our call volume. A very important 10%, but the biggest incremental benefit will probably come from refocusing on the other 90%.

 

[systemet]

One thing about the European EMS programs is that all calls are screened to see if a Doc is actually needed on a call. If there is not a suspected need for a doctor then one does not go. With some places I've seen in the US they have fast cars for doctors who are always oncall incase of an MCI or large event where a doctor would be needed for either higher skill level (field amputation comes to mind), or to tell people who don't really need to go to a hospital not to go.

This is a big difference.

For example, I'm currently living in a European country. My two year old daughter got an ear infection last week. I go to the family doctor, and get a PenV script, and about 24 hours later, she's developing uriticaria. But she's not that sick.

So I call the health guide people. They tell me to call the family doc. I call their office, get voicemail, and book a phone call with an RN, and the next available is 45 minutes. So I talk to them, and this is around 1500 now. She says, well don't give her any more penicillin, see if it gets better, and if you think you want a different antibiotic, maybe you can see the doctor tomorrow.

I tell her, maybe I'd like to get a new antibiotic today, because I don't want this infection getting worse, and she says, we're too busy here, but go to the low acuity ER tonight if you want, they open at 1700. So I call them a couple of hours later, at 1700, and they tell me, come by at 1900, and we'll fit you in.

I arrive at 1900, see the doctor at 1905. Got a script for erythromycin, and everything's good.

Had the same thing happened in North America, and I'd called a health guide line, they'd have told me to call 911, I'd have got an ALS hot response for a potential anaphylaxis, been at a pediatric ER within 30 minutes, and be occupying a bed for a couple of hours minimum while they do general tests. How much would this have cost?

Now the difference where I am right now, perhaps, is that it's not possible to initiate civil suits against the hospital system. So if this had been anaphylaxis, and something terrible had happened, I would have got a general insurance payout from the hospital. This sort of organisation makes it easier for care to be delivered based on medicine instead of litigation management.

 

[EpiEMS]

This sort of organisation makes it easier for care to be delivered based on medicine instead of litigation management.

Could just limit the size of torts.

 

[Sandog]

I have seen some medics that just impressed the hell out of me. Why sell yourselves short guys, Most medics I know do an awesome job?

PA indeed, oh brother... :huh: