# Delete American paramedics.



## mycrofft (Feb 1, 2012)

How about cutting to the chase and abolishing paramedics and replacing them with physician assistants and maybe nurse practitioners? Keep the much lesser-trained EMT-B and first responder for areas which need a filler between first-aid and ACLS and won't otherwise get some, but in other areas go right to a really well-educated and qualified partitioner who is cheaper than a doc and oriented/indoctrinated for prehospital situations?  Darned good step into the field of emergency medicine for an aspiring full-on MD too, if they stay long enough "on the street" to learn about it before they dive back into the ivory towers.

Our Australian and New Zealand associates may be saying "Just give the paramedics more power; works here!".

Let's toss it around!


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## BEorP (Feb 1, 2012)

Why not just make paramedicine a real profession through education, which will lead to empowerment of paramedics?


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## Veneficus (Feb 1, 2012)

I support the European idea of using a physician (particulary an anesthesiologist) but I think that empowering paramedics is a reasonable alternative.


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## EpiEMS (Feb 1, 2012)

Isn't Load and Go vs. Stay and Play the primary distinction between the American and European (e.g. SAMU in France) models? High level practitioners on scene may be more inclined to stay and play, even though they don't have the same level of equipment that they would in a hospital, no?


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## Aidey (Feb 1, 2012)

Well, considering I think that having both PA and NP in this country is an absurdity I can't really pick one. I'm personally a fan of the Oz/Nz systems, and of all the options I think those would be the most feasible to adapt to the current US system.


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## Veneficus (Feb 1, 2012)

EpiEMS said:


> Isn't Load and Go vs. Stay and Play the primary distinction between the American and European (e.g. SAMU in France) models? High level practitioners on scene may be more inclined to stay and play, even though they don't have the same level of equipment that they would in a hospital, no?



I would wager you don't know what kind of equipment those types of units carry. I have seen European units with scrub sinks, a full complement of surgical tools, and every medication used in emergency medicine. (all neatly packed away on a Mercedes sprinter)

As well, I have not witnessed a "stay and play mentality," rather a treat and release or stabilize and transfer.

"The load and go" mentality, I would think came more from the US EMS origin of needing to rapidly train and field providers to work out of hospital, as the US medical establishment purposefully limits the number of physicians it trains or accepts to manipulate market forces.

If you design an imperfect system, propaganda is the perfect way to justify it.

What is quite puzzling to me is since US Emergency Medicine docs are proud of their ability to decide who needs to be admitted vs. who can be treated and released, it seems more appropriate for them to increase their numbers and get involved in EMS prevention, treat and release, etc, then actually work in an emergency room.

After all, when a really sick patient comes to the ED, it is surgery or one of the intensive medicine disciplines that are called to handle those "critical" patients.

Unless you count the glorified paramedic role of hyperoxygenation and fluid resuscitation.


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## medicdan (Feb 1, 2012)

Isn't it commonly agreed upon that less than 10% of 911 call volume truly requires ALS-level skills (ignoring simple cannulation/fluid administration), or at least can honestly be billed for as ALS-2?


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## Smash (Feb 1, 2012)

Veneficus said:


> Unless you count the glorified paramedic role of hyperoxygenation and fluid resuscitation.



Hey now!  What patient doesn't benefit from an absence of clotting factors and a PaO2 of 400, I ask you!


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## Hunter (Feb 1, 2012)

mycrofft said:


> How about cutting to the chase and abolishing paramedics and replacing them with physician assistants and maybe nurse practitioners? Keep the much lesser-trained EMT-B and first responder for areas which need a filler between first-aid and ACLS and won't otherwise get some, but in other areas go right to a really well-educated and qualified partitioner who is cheaper than a doc and oriented/indoctrinated for prehospital situations?  Darned good step into the field of emergency medicine for an aspiring full-on MD too, if they stay long enough "on the street" to learn about it before they dive back into the ivory towers.
> 
> Our Australian and New Zealand associates may be saying "Just give the paramedics more power; works here!".
> 
> Let's toss it around!



How about PAs get paid about $30-40/hour and medics barely get half of that in some areas, if you think people complain about how much we get paid/charge them now imagine if they were paying for PA's and LPN


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## usalsfyre (Feb 1, 2012)

Actually it's usually closer to $70-80hr...

The point is the cost savings of not taking everyone to the ungodly high cost center of the ED would more than make up the difference. I imagine ambulance RVUs would be worth a good deal less than ED RVUs.


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## BF2BC EMT (Feb 1, 2012)

NP no, PA yes or increase the paramedic education degree only. 

and cut the cord between fire and EMS


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## EpiEMS (Feb 1, 2012)

Venificus said:
			
		

> I would wager you don't know what kind of equipment those types of units carry. I have seen European units with scrub sinks, a full complement of surgical tools, and every medication used in emergency medicine. (all neatly packed away on a Mercedes sprinter)



True, I honestly don't know — I just, I dunno, one ER doc can't nearly do the job of a trauma team. I'm curious about this. Maybe there's some good research about trauma survival rates in US vs. Europe. I founds some stuff on scoop and go in the US trauma setting. Cool natural experiment in this article: "Prehospital procedures before emergency department thoracotomy: 'scoop and run' saves lives" (http://www.ncbi.nlm.nih.gov/pubmed/17622878).
Another interesting one: http://www.anesthesiologie.nl/uploads/150/635/mmt_les.Siegers__Frassdorf.pdf

I would just love love love to run controlled experiments instead of natural ones. Take ten cities, make them set up several levels of care and see what happens.



BF2BC EMT said:


> and cut the cord between fire and EMS



In the area where I am, it's EMS and Police, with Fire on its own. I can't shake the feeling that EMS/Police combo makes just as much (or more) sense


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## Medic Tim (Feb 1, 2012)

Hunter said:


> How about PAs get paid about $30-40/hour and medics barely get half of that in some areas, if you think people complain about how much we get paid/charge them now imagine if they were paying for PA's and LPN



That is the medic pay range most places in Canada.


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## EpiEMS (Feb 1, 2012)

Medic Tim said:


> That is the medic pay range most places in Canada.



Canadian $ or US$?


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## rescue1 (Feb 1, 2012)

Canadian and US dollars are basically worth the same these days. I think there's like a .5 cent difference right now.

EDIT: In fact, as it stands, the Canadian dollar is worth more


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## Medic Tim (Feb 1, 2012)

EpiEMS said:


> Canadian $ or US$?


Cdn but the exchange is only a few cents on the dollar


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## EpiEMS (Feb 1, 2012)

Maybe a new class of practitioner could be added. Or, say, let PAs supervise medics?

What with all the "degree creep" that there is these days, why not just make EMT-B an associate degree level, paramedics a baccalaureate level? That'd keep it in line with PAs being masters level and physicians being, well, doctorate-level.


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## Aidey (Feb 1, 2012)

That doesn't address the issue of RN having both AS and BS level degrees. Seems a little bizarre of someone could be an RN with an AS but only an EMT B with an AS.


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## EpiEMS (Feb 1, 2012)

Aidey said:


> That doesn't address the issue of RN having both AS and BS level degrees. Seems a little bizarre of someone could be an RN with an AS but only an EMT B with an AS.



I remember reading somewhere about a proposal to make RN require a baccalaureate degree. All equivalent professions, like PT and OT require at the very minimum a bachelor's degree, and PT is now, for example, at the doctoral level for practice, so I've read.


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## Martyn (Feb 1, 2012)

Absolutely NOTHING would be achieved by the United States of America towards having a nationally recognised 'paramedical doctor' until the United States of America actually became the United States of America. With each state having it's own certification and licensure etc this will never happen. Even the National Registry is not really national. There are still some states that don't recognise it. Coming to the USA from the UK it wasn't until I had lived here for a while that I realised just how screwy this country really is. On a smaller scale it would be like each county in the UK advocating for its own licensure etc. It would not be a viable option. Until ALL of the states learn to pull together and adopt a national recognition program something like this would never be accomplished. The overall state of health care in the USA is, without a doubt, world class, however, the actual provision of this healthcare to the masses is absolutely ridiculous. One of the main problems that I have seen is that there are way too many big money companies involved. Something has to change, something is going to break but until the big medical companies are reined in nothing will get done. OPEN MESSAGE TO THE UNITED STATES OF AMERICA: STOP FAILING YOUR PEOPLE AND PULL TOGETHER.


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## Martyn (Feb 1, 2012)

Just read out my above post to my wife (US citizen). Her reply? 'I'm sorry but nurse practitioners and physician assistants would NOT work for $10 an hour'


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## triemal04 (Feb 1, 2012)

usalsfyre said:


> Actually it's usually closer to $70-80hr...


No.  Let's keep thing's honest here without any embellishment.  Average for PA's and NP's is more around 50 per hour; NP's generally seem to average more, though that may be skewed by the number of CRNA's out there.  Feel free to check that if you like.

It wouldn't neccasarily be a bad idea to put a true midlevel provider in the field in some form, but a better idea, especially before that is even considered would be to:
1) create a true national standard for what a paramedic is, and what the requirements are to become one
2) enforce those standards by tying medicare/medicaid reimbursement to following along
3) increase the educational requirements for both EMT's and paramedics
4) get rid of the idea that every single person needs to be seen by a paramedic and that every person going to/from a healthcare center needs to be in the "care" of medical personell.
5) create a state and federal group that actually monitors and enforces regulations harshly

That would be a start.  After that was done (ha!) maybe it would be time to look at what else could be done.  

Having a limited number of PA's doing field responces would appear to be a good idea at face value; though aside from the funding issue similar problems to what is going on currently would probably pop up: instead of being used and reserved for the types of cases where they are actually needed, I bet PA's would end up being sent on EVERY call; after all, everyone should be seen by the highest provider, right?  The issues of oversaturation and skill/knowledge degredation could also very well come into play.  I'd say the educational curriculum might also be dumbed down as the demand increased, but I think (hope) that the PA profession is well enough established and grounded that it wouldn't be an issue.

In short, no, PA's shouldn't replace all paramedics.  There could be a place and use for them, acutally I'll go further and say there IS a place/use, but there are many other problems that need to be resolved first.


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## Tigger (Feb 1, 2012)

Martyn said:


> Absolutely NOTHING would be achieved by the United States of America towards having a nationally recognised 'paramedical doctor' until the United States of America actually became the United States of America. With each state having it's own certification and licensure etc this will never happen. Even the National Registry is not really national. There are still some states that don't recognise it. Coming to the USA from the UK it wasn't until I had lived here for a while that I realised just how screwy this country really is. On a smaller scale it would be like each county in the UK advocating for its own licensure etc. It would not be a viable option. Until ALL of the states learn to pull together and adopt a national recognition program something like this would never be accomplished. The overall state of health care in the USA is, without a doubt, world class, however, the actual provision of this healthcare to the masses is absolutely ridiculous. One of the main problems that I have seen is that there are way too many big money companies involved. Something has to change, something is going to break but until the big medical companies are reined in nothing will get done. OPEN MESSAGE TO THE UNITED STATES OF AMERICA: STOP FAILING YOUR PEOPLE AND PULL TOGETHER.



I disagree, there is no reason why individual states cannot provide for having physicians working the field. Why do we need a national standard? Many agencies have they Medical Directors respond to calls and there are some areas of the country that already maintain "Physician Response Vehicles." Every doctor needs a state license to practice anyway. 

The issue I see with implementing a program like this is finding doctors willing to work in such a program, as most specialties are going to pay better. 

I think a universally recognized set of provider standards would be useful, but that's kind of the least of this country's EMS woes. I see no issue with statewide licensure, especially considering the unique challenges faced by individual states.


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## Tigger (Feb 1, 2012)

BF2BC EMT said:


> NP no, PA yes or increase the paramedic education degree only.
> 
> and cut the cord between fire and EMS



Why no to NP and yes to PA? If I'm not mistaken there are a few HEMS agencies that use NPs already.


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## Tigger (Feb 1, 2012)

Martyn said:


> Just read out my above post to my wife (US citizen). Her reply? 'I'm sorry but nurse practitioners and physician assistants would NOT work for $10 an hour'



I don't think anyone imagines they would. Their education far exceeds that of EMS providers, so they already deserve better compensation.


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## Medic Tim (Feb 1, 2012)

Tigger said:


> I don't think anyone imagines they would. Their education far exceeds that of EMS providers, so they already deserve better compensation.



HS students working at mcdonalds make more than that.

It amazes me how low the wages are in the US.


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## triemal04 (Feb 1, 2012)

Tigger said:


> I think a universally recognized set of provider standards would be useful, but that's kind of the least of this country's EMS woes. I see no issue with statewide licensure, especially considering the unique challenges faced by individual states.


In a way the complete lack of a nationwide standard for what a paramedic is (or EMT for that matter, though not to the same extent) really is the root of the problem; how can you change and fix a system when there is no reason for everyone to abide by your changes, and no standard for what the system should be?

The new NREMT standards are a perfect example; so many people tout them as the best thing since sliced bread, when, in reality, if a state decided to not follow them, they wouldn't need to.  Contrary to what some may think, the NREMT is a TESTING AGENCY; it is not a government agency that has any standing with anyone who doesn't feel like playing with them.  If Oregon (to pick a random state) decided that their standard for what a paramedic is would now be less than what the NREMT requires, then that is their choice.  It would just mean that paramedics there couldn't get "nationally" certified.  

How paramedics and EMT's are taught needs to change; but how can you change that and ENFORCE those changes if there is no national standard?  Recommendations are fine, but at the end of the day it's still a recommendation, not a requirement.

The EMS system in the US doesn't need to be rebuilt from the ground up, but it does need to be overhauled from the ground up; and that starts with deciding exactly what a paramedic is and isn't and forcing everyone to play by the same rules.

Far as the "unique challenges" faced by different states...medicine is medicine.  You might see different aspects in different places (probably not a lot of frostbite in West Texas) but that is a problem for individual services to deal with, not a statewide licensure issue.


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## Tigger (Feb 1, 2012)

triemal04 said:


> In a way the complete lack of a nationwide standard for what a paramedic is (or EMT for that matter, though not to the same extent) really is the root of the problem; how can you change and fix a system when there is no reason for everyone to abide by your changes, and no standard for what the system should be?
> 
> The new NREMT standards are a perfect example; so many people tout them as the best thing since sliced bread, when, in reality, if a state decided to not follow them, they wouldn't need to.  Contrary to what some may think, the NREMT is a TESTING AGENCY; it is not a government agency that has any standing with anyone who doesn't feel like playing with them.  If Oregon (to pick a random state) decided that their standard for what a paramedic is would now be less than what the NREMT requires, then that is their choice.  It would just mean that paramedics there couldn't get "nationally" certified.
> 
> ...



Ok I'll retract my statement to a degree. I agree with what your saying, but I think the true root problem is the lack of education at all levels, and no state is presently immune from this. If the national standards are no different than what they are now, how much improvement in terms of care delivery are we going to see?


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## mycrofft (Feb 1, 2012)

Wow, thanks for the response! Keep going.

A person can become a nurse with NO degree, just a certificate. Good luck finding a job above condo or corrections or some such. During Vietnam the Army commissioned nurses with certificates for a while; later, if they stayed, they had to finish a study course and get the degree  if they wanted to get past Captain. Some were promoted to Major, then had to drop back and were docked the difference/overpay they received! (Happened to my chief nurse once!).

Oh, and as for creating yet anther type of prehosptial EMS (PEMS) worker, hold out for hands and feel the ruler! One more way to dilute the pay pool.

People complain PA's and FNP's make so much more money than paramedics, they ought to suck it up and go get their degree! Step out of the tech ghetto.


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## triemal04 (Feb 1, 2012)

Tigger said:


> Ok I'll retract my statement to a degree. I agree with what your saying, but I think the true root problem is the lack of education at all levels, and no state is presently immune from this. If the national standards are no different than what they are now, how much improvement in terms of care delivery are we going to see?


Oh sure, that is absolutely part of the problem too, a huge part of it in fact.  What I'm saying is that until there is one true national standard for what a paramedic and EMT is, and until that standard is rigidly enforced, then it doesn't matter what the educational level is, because each individual state can opt out.

First determine what a paramedic is, and what it takes to become one.

Then mandate that each state fall into line.

Then start increasing the requirements.

If the requirements are "too hard" or "not needed" and there is no incentive for every state to use them...many won't.


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## tacitblue (Feb 1, 2012)

emt.dan said:


> Isn't it commonly agreed upon that less than 10% of 911 call volume truly requires ALS-level skills (ignoring simple cannulation/fluid administration), or at least can honestly be billed for as ALS-2?



I have heard of this too, but you have to ask yourself, who did this study? What did the investigators of this study consider ALS? did they have a bias when publishing these data? 

I find that a majority of my patients get a better assessment tha. They would if EMTs were the sole responders. Also, I have the ability to give analgesics and antiemtics to patients who may not be critical, but it goes a long way in relieving suffering. These people benefit more from paramedics than traumatic arrests do, even though a traumatic arrest will be considered ALS and gastroenteritis BLS in many systems. You can frame call data to support almost any conclusion you come up with.


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## bigbaldguy (Feb 1, 2012)

Where's the money going to come from?


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## BF2BC EMT (Feb 1, 2012)

Tigger said:


> Why no to NP and yes to PA? If I'm not mistaken there are a few HEMS agencies that use NPs already.



because there has been enough encroachment from "doctor" nurses and the BON. I wouldn't want someone who took their masters programme online and has a year of CCMed working me up in a medical emergency, sorry. PA or degree medic and no more I got my medic to be a FF types.

In fact ask a lot of PA's what they were before PA school and a lot were EMT-B/I/P's who already have a working knowledge of being on the ambo.


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## medicdan (Feb 2, 2012)

tacitblue said:


> I have heard of this too, but you have to ask yourself, who did this study? What did the investigators of this study consider ALS? did they have a bias when publishing these data?
> 
> I find that a majority of my patients get a better assessment tha. They would if EMTs were the sole responders. Also, I have the ability to give analgesics and antiemtics to patients who may not be critical, but it goes a long way in relieving suffering. These people benefit more from paramedics than traumatic arrests do, even though a traumatic arrest will be considered ALS and gastroenteritis BLS in many systems. You can frame call data to support almost any conclusion you come up with.



I hear you. Just because many calls CAN go BLS doesn't mean they should, but also that not every call needs to be upgraded to ALS skills, although having the assessment is absolutely crucial. This data comes from private service billings-- and the realization that they were billing BLS for medic truck transports a fair amount. I really wish I could cite something more scientific... let me do some research.


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## FourLoko (Feb 2, 2012)

Does LA Fire ever downgrade to BLS, I think they actually have BLS ambulances. And I'm agreeing with emt.dan on this one. 

One of the busiest ERs we frequent gets a pretty steady flow once the sun goes down. Most patients roll out of the back just sitting nice and calm as can be. Lights and sirens though, be sure of that.

911, stubbed toe, etc


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## DPM (Feb 2, 2012)

In my opinion EMT-B is too easy / simplified. HS students can pass this is 14 days. I don't know the EMT-I scope but I've always felt that EMT-B was too basic. It doesn't have to be an AA degree but I think we can all agree that there are a lot of ALS calls that don't require much actual ALS. Expanding the scope to 3 Lead and a handful if IM meds could allow EMT-Bs to be more hands on and, more important, more useful.


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## Jon (Feb 2, 2012)

I think the idea of the Austrian / NZ system appeals to me. A 4 year degree to be a paramedic. If we made that step, we might then be able to look nurses in the eye and be considered their equals.

Problem with this? Fire. Fire Departments, Fire Unions, and Fire Fighters. More training will cost more, and salaries will cost more.


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## RocketMedic (Feb 2, 2012)

I strongly disagree with the general direction of this thread, and here's why.

1. Paramedics are currently the highest common prehospital provider, and we're barely paid with respect to what we do. There is no economic incentive for a PA or NP to work for our wages- even high-end jobs.

2. There isn't really much to be gained by putting a PA on every truck- probably nothing that wouldn't be gained with the (much cheaper) empowerment of paramedics. A few PAs for advanced preventive medicine makes sense- a PA on every truck in a 911 system is going to be prohibitively expensive and won't make a lick of difference.

3. Staffing will be a huge issue. Pay as well. How is a service supposed to employ several _hundred_ PAs on budgets even remotely feasible in this economy?

4. What really changes in terms of practical interventions? Without changing our deployment models to stay-and-play-and-release, there's really not much more indicated in the field, and if we were to act as some European systems do, we now need many more physicians and trucks to cover all of those calls that a crew is now spending an hour or two on. 

5. Again, what's the medical benefit to our patients? A PA is, at their core, simply a well-trained paramedic with wide protocols. Granted, they've got more training and a wider set of 'best-guess' ruleouts, but without labs and imagery, their assessments are _the exact same_ as a paramedic assessment, and they're going to say basically the same thing. What is gained by putting a very expensive mid-level provider on a truck when that exact role could be filled by a seasoned paramedic?

There are places for PAs in EMS, but those roles are niche roles in community paramedicine, not a wholesale replacement of paramedics. By the logic of the OP, why not replace every RN with an NP?


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## RocketMedic (Feb 2, 2012)

Jon said:


> I think the idea of the Austrian / NZ system appeals to me. A 4 year degree to be a paramedic. If we made that step, we might then be able to look nurses in the eye and be considered their equals.
> 
> Problem with this? Fire. Fire Departments, Fire Unions, and Fire Fighters. More training will cost more, and salaries will cost more.



We are, role-wise, their equals. I've sunk the last five years into becoming the best paramedic I could be, and I've picked up quite a bit of knowledge along the way. Granted, I haven't been to college or learned the ins and outs of changing bedsheets or building a nursing care plan, but I have learned tactical medicine, triage, and a host of other skills. 

If a nurse ever wants to get uppity with me about my "lack of education", I tune them out. I know my job very well, and although I love learning and learn new things every day, I really don't need a paper diploma from a college to do my job and learn new things. I'm pretty sure that a year strolling around Iraq seeing and treating everything from sprains to crazy Third-World bacterial infections is at least the equal of college English. 

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. 

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

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.


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## Veneficus (Feb 2, 2012)

*did you read these studies?*



EpiEMS said:


> True, I honestly don't know — I just, I dunno, one ER doc can't nearly do the job of a trauma team. I'm curious about this. Maybe there's some good research about trauma survival rates in US vs. Europe. I founds some stuff on scoop and go in the US trauma setting. Cool natural experiment in this article: "Prehospital procedures before emergency department thoracotomy: 'scoop and run' saves lives" (http://www.ncbi.nlm.nih.gov/pubmed/17622878).
> Another interesting one: http://www.anesthesiologie.nl/uploads/150/635/mmt_les.Siegers__Frassdorf.pdf



The first one is whether or not paramedics provide "care on scene" which in no way equates to that of a doctor and concludes with: paramedics should scoop and run trauma patients.

The second one shows a clear demonstration of superiority in physician intervention to brain function in the critically ill. Additionally it demonstrates that better care is superior to faster response times, and in critically ill patients.

As mentioned, the major benefit of a doctor on an ambulance is so as not to transport everyone to an exceeding expensive and unhelpful ED.


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## systemet (Feb 2, 2012)

Rocketmedic40 said:


> 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.


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## RocketMedic (Feb 2, 2012)

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


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## RocketMedic (Feb 2, 2012)

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?


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## systemet (Feb 2, 2012)

Rocketmedic40 said:


> 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.


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## sir.shocksalot (Feb 2, 2012)

Rocketmedic40 said:


> 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.


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## systemet (Feb 2, 2012)

systemet said:


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



Fail...

"they're"


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## DPM (Feb 2, 2012)

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.


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## Veneficus (Feb 2, 2012)

Rocketmedic40 said:


> 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.


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## Veneficus (Feb 2, 2012)

Rocketmedic40 said:


> 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?


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## Level1pedstech (Feb 2, 2012)

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.


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## RocketMedic (Feb 2, 2012)

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?


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## systemet (Feb 2, 2012)

Level1pedstech said:


> 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.


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## Foxbat (Feb 2, 2012)

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.


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## systemet (Feb 2, 2012)

Rocketmedic40 said:


> 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.


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## mycrofft (Feb 2, 2012)

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.


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## Maine iac (Feb 2, 2012)

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.


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## systemet (Feb 2, 2012)

mycrofft said:


> 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%.


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## systemet (Feb 2, 2012)

Maine iac said:


> 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.


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## EpiEMS (Feb 2, 2012)

systemet said:


> 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.


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## Sandog (Feb 2, 2012)

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:


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## Veneficus (Feb 2, 2012)

Level1pedstech said:


> 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.



I don't think you are fully appreciating the situation. 

Malpractice rates or not, the transport all patients to the ED for a battery of mostly useless testing is not economically sustainable. It hasn't been for some time.

So when healthcare spending collapses, and it is just a matter of years, some sort of reasonable and sustainable alternative will have to be found.

I think that is what all the discussion on what should or needs to be done is based on.

When people start finding out that a BLS ambulance in an urban area is just as useful as ALS, which has been discovered by a major city council in OH, paramedic positions are going to go faster than fire jobs. 

Some systems around the country, notably Wake County, has taken the initiative, and is actually about to present data I understand, demonstrating how much money is saved by making EMS proactive as opposed to reactive. (and I might add they had to increase education to do it)

So while it is easy to say say dinosaurs rule the earth and always will, because that is what you see today, some of us actually acknowledge the incoming meteor instead of burying our head in the sand and pretending it will go away on its own.

If you do not participate in shaping your future, then you will just have to accept whatever happens to you.


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## EpiEMS (Feb 2, 2012)

Veneficus said:


> When people start finding out that a BLS ambulance in an urban area is just as useful as ALS, which has been discovered by a major city council in OH, paramedic positions are going to go faster than fire jobs.



How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?


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## Level1pedstech (Feb 2, 2012)

Veneficus said:


> I don't think you are fully appreciating the situation.
> 
> Malpractice rates or not, the transport all patients to the ED for a battery of mostly useless testing is not economically sustainable. It hasn't been for some time.
> 
> ...



 I agree with the need to prticipate in shaping your future I have spent my life setting goals then woking towards obtaing those goals. Sady most people are more talk than action.


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## Level1pedstech (Feb 2, 2012)

Obviously I dont have the multi quote thing down sorry all.


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## Veneficus (Feb 2, 2012)

Level1pedstech said:


> Obviously I dont have the multi quote thing down sorry all.



No worries,

Actually I have been involved in the conversations of healthcare costs for a number of years now. I am party to two professional associations where healthcare spending is their focus.

I understand the requirement from the organizational standpoint of defensive medicine. 

However, as I said, sooner, rather than later, the level of healthcare spending will need to be drastically reduced. 

Just as medicare stopped paying for treatment resulting from "preventable" complications(which I agree their definition of preventable is rather unrealistic), I forsee they will stop paying for diagnostics that are indicated to prevent monetary loss to the hospital, rather than medical necessity to dx or treat the patient condition.

Not paying for exams or treatments not related to a reasonable suspicion has been used to control the healthcare costs of several nations.

It is fair to say these nations do not have the malpractice liability issues the US does, but as that is unsustainable and driving up the cost of care to the point of pricing healthcare out of the market, eventually it will be changed. 

Logically, when it takes lawyers more effort to get money than the value of spending that time, the issue will likely self resolve. 

One of the major contributors to this situation is the malpractice insurance company. As long as they feel it is cheaper to settle than fight, it really benefits plantifs to bring cases. 

The short sightedness of the insurance companies is that if they did regularly fight, it would remove the easy money and likely lawyers would be less likely to spend time on cases that were not likely winners.

The much simpler solution would be to remove a jury from the process in favor of an arbitor of 3 judge panel.

But the long and short is, defensive medicine is not going to pay well forever.


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## Level1pedstech (Feb 2, 2012)

Veneficus said:


> No worries,
> 
> Actually I have been involved in the conversations of healthcare costs for a number of years now. I am party to two professional associations where healthcare spending is their focus.
> 
> ...



 Nice to see someone that can offer a clear,concise and experience based opinion. To many people like to spew out opinions one way or the other without even taking time to learn both sides of the arguement. To be honest I have done it and now always try and post only what I can source.

 There are others in this community that have inside hospital experience or a the least some first hand knowledge of what goes on behind the scenes. Howeverr the majority is made up of young less thanwell informed people who love to take a side sometimes not even knowing that sides arguement. Thats okay we all were young and less than informed at one time.

  Sometimes I think the hospitals and health care sytems in general take an unfair beating.All the stories I have heard are most likely the same as you and do with out a doubt point to the need for change. On the other hand I know of millions of dollars in charity provided to those without resources by my former employer.


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## systemet (Feb 2, 2012)

EpiEMS said:


> How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?



For cardiac arrest, and trauma, take a look for OPALS, it's a study of progressive introduction of ALS into the Ontario provincial system in Canada.  It's the best data for that.

There's also a paper somewhere in Quebec comparing a pure BLS system with a physician-ALS system and a paramedic-ALS system for trauma.  The BLS system had the best outcome, though I suspect there was some selection bias in there.

If I feel energetic I'll grab the references, but this should be a different thread.

--------------

I think for ALS, we know that it improves outcomes in medical patients not in arrest, specifically respiratory and cardiac patients.  There's good data for 12-lead, pre-alert, and some data for prehospital thrombolysis and ER bypass to PCI.

There's not good data for pain control, but it's intuitive that ALS is beneficial here.


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## EpiEMS (Feb 2, 2012)

I'd definitely buy ALS > BLS for pain control. Morphine + splints beats splints alone any day.

I just pulled up the Quebec study and your intuition is on target, they indicate quite clearly that the "injury severity scores" were higher for paramedics and MDs than for BLS. However, when you hold ISS levels constant, BLS still comes out ahead.


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## Veneficus (Feb 2, 2012)

Level1pedstech said:


> I have done it and now always try and post only what I can source..



There are not too many sources to what is discussed in private and not in public




Level1pedstech said:


> Sometimes I think the hospitals and health care sytems in general take an unfair beating.All the stories I have heard are most likely the same as you and do with out a doubt point to the need for change. On the other hand I know of millions of dollars in charity provided to those without resources by my former employer.



Nobody should doubt hospitals provide charity. Not just in care but also community programs and support.

There will always be disaffected people.

But I see no way that a strictly for profit healthcare system can sustain itself. Particularly when it is constantly under attack by the tort system.

As I said, various factors increase cost. That cost has been unsustainable.

Because of ideology being the driving force, total collapse will likely be what it takes for meaningful reform. 

I think all of the interests involved know that, but they are all hell bent on bleeding every last drop and letting it collapse, rather than make sacrifice for sustainability. 

No single group bears more responsibility than the rest. That includes physicians and their professional associations.


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## Veneficus (Feb 2, 2012)

*sorry, missed this in all the type*



EpiEMS said:


> How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?



OPALS was the most damning study to ALS.

However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.

While there are instances where ALS onscene treatment are beneficial, I think anyone who has worked in an urban system can attest that so few patients require ALS intervention, that from an economic standpoint, as well as using the response time benchmark that has so long been touted to the public by EMS agencies as the benchmark of effectiveness, how many BLS rigs could you field if you cut ALS rigs (and all the associated costs from initial training to equipment and recertification) out of the budget?

A strong case was made and it was only political lobby by the interested party (aka self serving greedy party) that stopped it.


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## EpiEMS (Feb 2, 2012)

Gotta say, this sounds like a great dissertation topic for an epidemiologist or health policy/management PhD.


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## Veneficus (Feb 2, 2012)

EpiEMS said:


> Gotta say, this sounds like a great dissertation topic for an epidemiologist or health policy/management PhD.



it's all yours, i'll stick with pathophys.


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## EpiEMS (Feb 2, 2012)

I just wish a major city would let me run a controlled experiment on this. Oh man...


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## Veneficus (Feb 2, 2012)

EpiEMS said:


> I just wish a major city would let me run a controlled experiment on this. Oh man...



I have a sneaky suspicion you would have to be put into protective custody after publishing your findings. 

I also suspect the smear campaign funded by organized labor and private EMS against you and your results will reach a fever never before seen.


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## RocketMedic (Feb 2, 2012)

Veneficus said:


> OPALS was the most damning study to ALS.
> 
> However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.
> 
> ...


The flaw with dropping ALS is that those rare patients who need it are out of luck and you place even more of a burden on the ER to triage patients.


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## Maine iac (Feb 2, 2012)

How about we get rid of certain elements in our government which seem to slow down any advancements in EMS, then change the system so every truck has either dual ALS or BLS + ALS. THEN place an emphasis on quick care type locations so that the public does not have to wait 8 hours for an ear infection, or so that I can transport my ear infection that called 911 to the quick care instead of the ER.


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## Tigger (Feb 2, 2012)

Rocketmedic40 said:


> 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?



Degrees objectively quantify someone's knowledge base. A certification obviously does the same thing, but a bachelor's degree includes a knowledge base not just limited to the subject at hand. The thing with 4+ year degrees is they teach one to learn and research, not just the knowledge needed to preform a job. My upcoming political science degree has not provided me with a meaningful technical education for politics, far from it in fact. But it has provided be with the tools to be an effective researcher as well as the ability to succinctly state my findings in a compelling way. This is one way for a trade to advance into a profession, it's members need to be able to learn how to improve their profession's quality independently. It's tough for other medical professions to take any EMS providers' research seriously since they simply do not have the background in academics that lends authenticity to their findings.


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## Tigger (Feb 2, 2012)

Veneficus said:


> OPALS was the most damning study to ALS.
> 
> However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.
> 
> ...



Using the commonly cited metric of cardiac arrest survival rates, the city of Boston's EMS system is generally rated as excellent. Yet the city is served by (on average) 19 BLS and 5 ALS trucks with a relatively small amount of calls seeing ALS on the initial dispatch. Realistically, in the Boston system non-cardiac arrests are saved by the close proximity of hospitals and cardiac arrests are saved my early CPR and AED administration. With most transports under 10 minutes, the question of whether ALS being actually needed comes into play. The patients transported by BLS may not arrive in better shape on arrival to the hospital, but they aren't dead either. It's tough to prove that ALS does lead to a decrease in mortality as far as I can see. 

However, mortality rates are not the only metric of systemic effectiveness. Providing pain and nausea control will not improve patient outcomes in a measurable way but they do improve outcomes in a meaningful way. So therein lies a question, how do we measure the effectiveness of EMS systems besides on who lives and who dies? There's so much more to EMS than just saving lives.


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## Veneficus (Feb 3, 2012)

Tigger said:


> However, mortality rates are not the only metric of systemic effectiveness. Providing pain and nausea control will not improve patient outcomes in a measurable way but they do improve outcomes in a meaningful way. So therein lies a question, how do we measure the effectiveness of EMS systems besides on who lives and who dies? There's so much more to EMS than just saving lives.



I agree with this, however, EMS systems in order to easily demonstrate their effectiveness to the public (erroneously and without much forethought, but look at the caliber of people who came up with it) have long spouted about saving lives and response times.

Those are therefore what the public knows and expects. It has been drilled into their heads over a decades. (easy little tag lne for the masses, saving lives/response times)

If you try to go on TV and lobby for pain/nausea control, some right wing anti tax nut job is going to counter with not wanting to pay for drug seeking ambulance abusers. 

That metric will not work either.

If you want to show effectiveness, the metric needs to be cost savings. With the increase in demands for EMS service,as both the population and those with disease increases, response and a ride to the ED is not only going to be logistically impossible to keep up with, the public will demand it is done as cheap as possible.

We are left only with the alternative that in order to be of value to society, paramedics and EMS providers in general will have to provide more and more valuable service.

As I keep stating, that service is logically, education, prevention, alternate destination, and treat and release.

It will require more resources, but when the public actually sees and feels it is getting something for its money, it is more inclined to spend money on it. No reasonable person doubts that roads are a good use of tax dollars. But EMS is largely only seen when an individual needs it. That largely inhibits any quality/cost comparison outside of responsetime and lives saved.

As with any job, if you want more, you will be expected to do more and show you are worth more.


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## Tigger (Feb 3, 2012)

As usual, well said Vene.


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## EMRRx (Feb 3, 2012)

I have been checking out EMTLIFE and have really enjoyed the discussions.

I wanted to make a few comments about this topic.

For those that go though a MD, Pharm.D., DDS program, it is not required to have a BS/BA degree first. I do not know the percentages but my guess is that a very large percent do not have a bachelors.
Infact, many of the above mentioned programs do not require A&P to be accepted, very similar to Paramedic School, however highly recommended.

NP and PA programs are typicallly 16-18 months. PA programs are not considered master level programs. For the NP program, you must 1st be an RN, other than that, the NP/PA programs are nearly identical.

Most nurses out there are RN's from typical Junior College or private nursing programs that run from 3 to 4 semesters. Today, many more are getting their BSN(Bachelors of Science in Nursing) as these programs have become more and more avaialble. Hopefully Paramedic schools with begin to do the same.

The typical RN would not be at the same EMS level as a Paramedic and infact most NP, PA, and BSN's would not be considered equal level providers as Paramedics unless they had additional specialized training in EMS.
Most RN's are not ALS trained unless they work in ICU, ER, or another department that has it as a requirement unlike all Paramedics which are all ALS.

Most RN's will never intubate, needle decompress a tension pneumothorax, etc, during their entire training and career.

Nurses work extremely demanding shifts, put up with a lot of "crap",from patients and higher level providers, etc so they must be compensated well or few would do this job.

I think the idea of moving from Paramedics to MD's, NP's, PA's does not make sense, mainly because all these providers(less and ER/EMS physican), would have to go through a lot of additional EMS training to be an equal of a Paramedic in the Pre hospital setting.

I know if something happened to me or my family that required EMS, I would want a Paramedic to care for me or my family in the field over a general practioner(MD,NP,PA,or RN) any day. Most of them have very little to no EMS training and if they do, they rarely ever, or never get to use the training as to be proficient. Now, if it is a ER/EMS physicain, or NP,PA,RN that I knew had the additonal EMS training, that might be ok, but how would I know that if I did not know the provider personally.


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## systemet (Feb 3, 2012)

EMRRx said:


> For those that go though a MD, Pharm.D., DDS program, it is not required to have a BS/BA degree first. I do not know the percentages but my guess is that a very large percent do not have a bachelors.



This varies widely depending on geographic location.  In the US/Canada, most MD / DDS applicants have an undergraduate degree.  The numbers I've heard are somewhere around 15% have Master's or PhD's, about the same amount just have 2 years of undergraduate.  

In other countries medicine may be an undergraduate program that you enter out of high school.

I have never heard of a PharmD program that doesn't require a Bachelor's or Master's degree to enter.  That doesn't mean they don't exist, but I haven't encountered them.



> Infact, many of the above mentioned programs do not require A&P to be accepted, very similar to Paramedic School, however highly recommended.



Prerequisites vary by school.  Most US/Canadian med schools require you to write the MCAT, and most usually want a minimum selection of science courses, equivalent to two years study.

There are some alternative entry programs that don't require an MCAT or a science background, but most of these require a completed undergraduate degree.  These are the minority of programs.



> NP and PA programs are typicallly 16-18 months. PA programs are not considered master level programs. For the NP program, you must 1st be an RN, other than that, the NP/PA programs are nearly identical.



Depends on the program.  Most Bachelor's PA programs are either a full program or require you to already have a degree.  There's an increasing number of Master's programs for entry.  Most NPs programs require that you have a BScN/BSN.



> Most nurses out there are RN's from typical Junior College or private nursing programs that run from 3 to 4 semesters.



This depends very much on where you are.  Some places are setting a Bachelor's degree for entry to practice.  Where I used to work, even with a medic cert and a science degree, I was looking at 22 months to get a BScN.  (I didn't do it).




> Today, many more are getting their BSN(Bachelors of Science in Nursing) as these programs have become more and more avaialble. Hopefully Paramedic schools with begin to do the same.
> 
> The *typical RN would not be at the same EMS level* as a Paramedic and infact most NP, PA, and BSN's would not be considered equal level providers as Paramedics unless they had additional specialized training in EMS.
> Most RN's are not ALS trained unless they work in ICU, ER, or another department that has it as a requirement unlike all Paramedics which are all ALS.



Of course not!  They're not trained to do EMS, but it's also not like a medic is trained to be an RN.  Granted, there's a lot of overlap, but it makes no sense to expect to train for a completely different role, and then be competent at someone else's job.



> Most RN's will never intubate, needle decompress a tension pneumothorax, etc, during their entire training and career.



Why would they?  

A needle decompression is something you do before you put in a chest tube.  When is an RN going to be in a position to need to do this, when a doctor isn't going to be present?

Same thing with intubation.  Most of the situations where this is likely to happen you have a physician present.  This is their responsibility.  In the settings where RNs do intubate, usually they're nurse anesthetists, or they've receive training in prehospital medicine to work flight / EMS, etc.

This is a typical logical flaw in paramedic thinking.  We assume because we ram plastic down someone's trachea that because usually only doctors do (or nowadays, PAs, a few RRTs, nurse anesthetists, etc.) that we're somehow better than providers working in a controlled setting with better resources.  Our scope of practice is broad because we work in an environment without physicians, dealing episodically with sick people in whom the risk of us performing the technique in an unskilled manner is generally outweighed by the potential benefit, or the anticipated deterioration that will happen if treatment is deferred to a more suitable environment.  [An even this is very much in question, see RSI in closed head injury].



> Nurses work extremely demanding shifts, put up with a lot of "crap",from patients and higher level providers, etc so they must be compensated well or few would do this job.
> 
> I think the idea of moving from Paramedics to MD's, NP's, PA's does not make sense, mainly because all these providers(less and ER/EMS physican), would have to go through a lot of additional EMS training to be an equal of a Paramedic in the Pre hospital setting.



I think an MD from a suitable specialty would need very little extra training to function in the prehospital environment.  See: any good flight program.

If you look at the overlaps between nursing and EMS, you're probably not looking at more than a year to cover the difference, if the nurse has acute care experience.  Many of the countries that have nurse-based EMS have providers with a Bachelor's degree, a year or two of ICU / ER experience, and then a postgraduate diploma or Master's degree in prehospital care.



> I know if something happened to me or my family that required EMS, I would want a Paramedic to care for me or my family in the field over a general practioner(MD,NP,PA,or RN) any day.



Depends on the provider, and their experience with emergency medicine.  No fellowship trained EM doc is going to have more than minor teething problems if you throw them in an ambulance.  Another specialty, e.g a rheumatologist might be a different story.

If you take an RN from a medical ward and throw them in an ambulance without any training, they're going to drown.  But so's a paramedic if you throw them on a medical ward without any training.

Other countries have managed to train RNs to work as paramedics, and MDs  to work in ambulances.  It is possible.  The question is more, whether it's desirable.


----------



## systemet (Feb 3, 2012)

EMRRx said:


> For those that go though a MD, Pharm.D., DDS program, it is not required to have a BS/BA degree first. I do not know the percentages but my guess is that a very large percent do not have a bachelors.



This varies widely depending on geographic location.  In the US/Canada, most MD / DDS applicants have an undergraduate degree.  The numbers I've heard are somewhere around 15% have Master's or PhD's, about the same amount just have 2 years of undergraduate.  

In other countries medicine may be an undergraduate program that you enter out of high school.

I have never heard of a PharmD program that doesn't require a Bachelor's or Master's degree to enter.  That doesn't mean they don't exist, but I haven't encountered them.



> Infact, many of the above mentioned programs do not require A&P to be accepted, very similar to Paramedic School, however highly recommended.



Prerequisites vary by school.  Most US/Canadian med schools require you to write the MCAT, and most usually want a minimum selection of science courses, equivalent to two years study.

There are some alternative entry programs that don't require an MCAT or a science background, but most of these require a completed undergraduate degree.  These are the minority of programs.



> NP and PA programs are typicallly 16-18 months. PA programs are not considered master level programs. For the NP program, you must 1st be an RN, other than that, the NP/PA programs are nearly identical.



Depends on the program.  Most Bachelor's PA programs are either a full program or require you to already have a degree.  There's an increasing number of Master's programs for entry.  Most NPs programs require that you have a BScN/BSN.



> Most nurses out there are RN's from typical Junior College or private nursing programs that run from 3 to 4 semesters.



This depends very much on where you are.  Some places are setting a Bachelor's degree for entry to practice.  Where I used to work, even with a medic cert and a science degree, I was looking at 22 months to get a BScN.  (I didn't do it).




> Today, many more are getting their BSN(Bachelors of Science in Nursing) as these programs have become more and more avaialble. Hopefully Paramedic schools with begin to do the same.
> 
> The *typical RN would not be at the same EMS level* as a Paramedic and infact most NP, PA, and BSN's would not be considered equal level providers as Paramedics unless they had additional specialized training in EMS.
> Most RN's are not ALS trained unless they work in ICU, ER, or another department that has it as a requirement unlike all Paramedics which are all ALS.



Of course not!  They're not trained to do EMS, but it's also not like a medic is trained to be an RN.  Granted, there's a lot of overlap, but it makes no sense to expect to train for a completely different role, and then be competent at someone else's job.



> Most RN's will never intubate, needle decompress a tension pneumothorax, etc, during their entire training and career.



Why would they?  

A needle decompression is something you do before you put in a chest tube.  When is an RN going to be in a position to need to do this, when a doctor isn't going to be present?

Same thing with intubation.  Most of the situations where this is likely to happen you have a physician present.  This is their responsibility.  In the settings where RNs do intubate, usually they're nurse anesthetists, or they've receive training in prehospital medicine to work flight / EMS, etc.

This is a typical logical flaw in paramedic thinking.  We assume because we ram plastic down someone's trachea that because usually only doctors do (or nowadays, PAs, a few RRTs, nurse anesthetists, etc.) that we're somehow better than providers working in a controlled setting with better resources.  Our scope of practice is broad because we work in an environment without physicians, dealing episodically with sick people in whom the risk of us performing the technique in an unskilled manner is generally outweighed by the potential benefit, or the anticipated deterioration that will happen if treatment is deferred to a more suitable environment.  [An even this is very much in question, see RSI in closed head injury].



> Nurses work extremely demanding shifts, put up with a lot of "crap",from patients and higher level providers, etc so they must be compensated well or few would do this job.
> 
> I think the idea of moving from Paramedics to MD's, NP's, PA's does not make sense, mainly because all these providers(less and ER/EMS physican), would have to go through a lot of additional EMS training to be an equal of a Paramedic in the Pre hospital setting.



I think an MD from a suitable specialty would need very little extra training to function in the prehospital environment.  See: any good flight program.

If you look at the overlaps between nursing and EMS, you're probably not looking at more than a year to cover the difference, if the nurse has acute care experience.  Many of the countries that have nurse-based EMS have providers with a Bachelor's degree, a year or two of ICU / ER experience, and then a postgraduate diploma or Master's degree in prehospital care.



> I know if something happened to me or my family that required EMS, I would want a Paramedic to care for me or my family in the field over a general practioner(MD,NP,PA,or RN) any day.



Depends on the provider, and their experience with emergency medicine.  No fellowship trained EM doc is going to have more than minor teething problems if you throw them in an ambulance.  Another specialty, e.g a rheumatologist might be a different story.

If you take an RN from a medical ward and throw them in an ambulance without any training, they're going to drown.  But so's a paramedic if you throw them on a medical ward without any training.

Other countries have managed to train RNs to work as paramedics, and MDs  to work in ambulances.  It is possible.  The question is more, whether it's desirable.


----------



## Veneficus (Feb 3, 2012)

EMRRx said:


> For those that go though a MD, Pharm.D., DDS program, it is not required to have a BS/BA degree first. I do not know the percentages but my guess is that a very large percent do not have a bachelors.



Guess again...

Even 6 year medical programs in countries outside the US and Canada, upon completion of the 2nd year are considered a bachelor's of basic science or bachelor's of basic medicine. (I don't know anyone who actually asked for one of these diplomas that actually finished a medical program.

I have never met a US doctor who didn't have a bachelor's prior to matriculation to medical school. 



EMRRx said:


> Infact, many of the above mentioned programs do not require A&P to be accepted, very similar to Paramedic School, however highly recommended.



This is because Anatomy and physiology are seperate disciplines and therefore classes.

The depth of the graduate medical education is far more than what is taught in these basic a/p classes. In terms of time, my anatomy class alone is over 700 hours in class and lab. (not including time spent pulling my brains out at home) 

For physiology we used 3 texts, the primary being Guyton's medical physiology, for anatomy, I used 2 texts (primary daley and moore's clinical oriented anatomy) and 5 atlases. (sabota 2 volume set being the primary) 



EMRRx said:


> Most RN's will never intubate, needle decompress a tension pneumothorax, etc, during their entire training and career.



Neither will most medics or most doctors, what is your point? The ones who do will actually be really good at it.



EMRRx said:


> I think the idea of moving from Paramedics to MD's, NP's, PA's does not make sense, mainly because all these providers(less and ER/EMS physican), would have to go through a lot of additional EMS training to be an equal of a Paramedic in the Pre hospital setting.



:rofl: :rofl: :rofl:

I can't decide if you are trolling or just do not understand medial education. In most European nations, most ED directors as well as ambulance docs are anesthesiologists. Even in America, prehospital and emergency medicine is part of their curriculum.

I have never met a surgeon who could not intubate or defibrillate. Emergency procedures, both field and in hospital are part of the surgical curriculum.

Did you know the airway procedures for trauma patients in EMS were drawn up by the American College of Surgeons?

But wait, there's more...

OB/GYN is the only medical specialty outside the US that is a combination of surgery and medicine. Whether they are removing your appendix, delivering a baby, or using pharmacology to manipulate hormones in a brain and thyroid, these are some of the most capable and underestimated providers anywhere. (the first 2 years of their residency is learning general surgery)

I can't speak for skills outside of Europe, but not only do we have a semester of what amounts to 10 months of paramedic class, we have multiple clinical rotations that require us to get signed off on more skills than any paramedic. (Including intubation)

Ortho surgery are also the original trauma experts. They also still learn all of those "paramedic" skills as part of their curriculum.  




EMRRx said:


> I know if something happened to me or my family that required EMS, I would want a Paramedic to care for me or my family in the field over a general practioner(MD,NP,PA,or RN) any day.



No thanks, I'll take the doctor. Particularly any who went through the same curriculum I did. I don't care if they specialized later in diagnostic radiology.



EMRRx said:


> Most of them have very little to no EMS training and if they do, they rarely ever, or never get to use the training as to be proficient..



:rofl: guess again.



EMRRx said:


> Now, if it is a ER/EMS physicain, or NP,PA,RN that I knew had the additonal EMS training, that might be ok, but how would I know that if I did not know the provider personally.



I really think you have no idea what exactly a doctor is or can do.

As for the rest, I have never met a competent PA whos ability was equal the ego.

I know a handful of NPs, none in the emergency field, but if I was having a cardiac problem, or my wife/daughter having an OB/Gyn problem, I would be happy to see the ones I know anyday and twice on sunday.

I know several RN/medics, flight RNs, CCRNs, and Emergency RNs that I would likewise trust anyday. It is readily apparent when they begin acting who works in a discipline equally as valuable as a medic.


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## tacitblue (Feb 3, 2012)

EMRRx said:


> I have been checking out EMTLIFE and have really enjoyed the discussions.
> 
> I wanted to make a few comments about this topic.
> 
> ...



There are some medical schools that in theory only require 90 units prior to acceptance. 90 units is still 90 units of college and includes the pre-req science courses in general biology, chemistry, and organic chemistry. These three core series classes far exceed the basic science background one would learn in an undergrad anatomy/physiology course. Medical students go into graduate level anatomy and physiology in med school, after having been through 3-4 years of college level science.

That being said, it is a _de facto_ requirement to obtain a BA/BS prior to applying to medical school; the overwhelming majority if not every medical student accepted will have at least an undergraduate degree. 

PA schools are required by their accrediting body (ARC-PA) to have a curriculum that meets their minimum standards, which is graduate level material. No matter what degree the PA program awards, it will teach to this minimum national standard. Also, PA programs require a pre-clinical year that teaches medical science followed by a clinical year in which the students rotate in every major medical discipline (medicine, surgery, OB/GYN, psych, pedi). On graduation, every PA will have completed this. Contrasted to NP programs where the students are required to only do one or two rotations in their specific area of specialization....


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## St George (Feb 5, 2012)

Dont delete them. Just replace them with degree educated, state registered healthcare professionals with complete clinical autonomy and legal authorisation to prescribe a range of medication (currently 29 different drugs in the UK). Works very well (albiet not perfectly) in countries with such a system.


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## RocketMedic (Feb 5, 2012)

Agree with St. George, but why are we hating the "medical director" concept?


Also, I need to go back to school. What's a useful degree to aim for?


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## Veneficus (Feb 5, 2012)

Rocketmedic40 said:


> Agree with St. George, but why are we hating the "medical director" concept??



I voted for upskill the medics, I just prefer the MD better because of the current diversity available in treatment.

As for hating on a medical director, most are only an official signiture, of the ones left, many lack the anatomy/ability to actually provide direction outside of consensus from 40 years ago. Very few are actually useful for understanding/implementing current medicine at all.




Rocketmedic40 said:


> Also, I need to go back to school. What's a useful degree to aim for?



MD

(For future reference MD and DO are synonymous and I am not typing both out everytime.)


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## Maine iac (Feb 5, 2012)

I think some services have pretty stellar med directors and some have lousy at best med directors, which is where the dislike comes from. The few that I've worked with have been super helpful, but I have heard stories just like everybody I'm sure has.

Rocketmedic, what interests you? If you are good you can spin almost any degree to your advantage. If you are looking to upgrade to mangt at some point, I am sure any of the Business degrees would be good, or the actual EMS BS degree. If you are gung-ho get an MBA or MHA. All really just depends on what you are interested in.


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## jjesusfreak01 (Feb 5, 2012)

Veneficus said:


> No thanks, I'll take the doctor. Particularly any who went through the same curriculum I did. I don't care if they specialized later in diagnostic radiology.



Ehh, for a few years. I don't expect the diagnostic radiologists to remember everything from med school forever, but I do expect paramedics to increase in knowledge the longer they work in the field. 


Another thing to note is that there is one really really big problem with moving medics towards 2 and 4 year degrees. Almost all paramedic certs and degrees in the US come from either cert mills, or at best, 2 year degree schools. For us to move towards 4 year degrees as the standard, we need a huge increase in the number of Bachelors in Emergency Medicine programs at our 4 year colleges. The NREMT is going to rid us of the medic mills for the most part by requiring degrees for medics, but its going to take a sea change in the system to allow medics to advance beyond that. Making it a 2 year post-bac program puts it equivalent to PAs, or a bachelors level program puts it at the same level as BSNs. The question really is whether its even necessary for paramedics to have a higher level degree (above associates), and even if they do move to that how are they going to achieve the higher level of responsibility and scope that they will want at that point. 

It just seems to me that there are a lot of really strong impediments to the advancement of EMS in the US, from education, to nursing, to fire, to the climate of litigation. I don't know how EMS is going to be able to move past them.


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## Veneficus (Feb 5, 2012)

jjesusfreak01 said:


> Ehh, for a few years. I don't expect the diagnostic radiologists to remember everything from med school forever,.



I'll take my chances.




jjesusfreak01 said:


> but I do expect paramedics to increase in knowledge the longer they work in the field.,.



You expect a lot.

Next time I am in the US, I invite you to come and see what I do teaching. 

clipped for brevity



jjesusfreak01 said:


> It just seems to me that there are a lot of really strong impediments to the advancement of EMS in the US, from education, to nursing, to fire, to the climate of litigation. I don't know how EMS is going to be able to move past them.



Never fear, when the system goes broke, change will come. The only question will be whether or not EMS providers position themselves for success prior to the collapse or it becomes an even less sustainable career option because they didn't after.

I made a suggestion to a respected EMS leader that an easy way to change the amount of medics with degrees was simply to require all active medics without one to take specific college courses as continuing ed. 

This exact strategy was successful for the fire science degrees in the fire service.

Why reinvent something that already works?


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## EpiEMS (Feb 5, 2012)

The BSN was/is a logical change for the nursing field. A Bachelor's degree focused on emergency care would professionalize the EMT-P further. Makes sense to do it.


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## St George (Feb 5, 2012)

EpiEMS said:


> The BSN was/is a logical change for the nursing field. A Bachelor's degree focused on emergency care would professionalize the EMT-P further. Makes sense to do it.



 It does, and we did.


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## medicsb (Feb 5, 2012)

Veneficus said:


> Guess again...
> I can't decide if you are trolling or just do not understand medial education. In most European nations, most ED directors as well as ambulance docs are anesthesiologists. Even in America, prehospital and emergency medicine is part of their curriculum.



I was unsure, but on a cursory search, EM is a very small component of anesthesia training, if at all incorporated.  My school indicates no requirement for anesthesia residents to rotate through the ED.  They may be present on trauma or when summoned for the unusually difficult airway, but overall the ED is NOT part of anesthesia's primary domain in the academic setting.  And of any physicians that get out into the prehospital setting, almost all are EM trained.



> I have never met a surgeon who could not intubate or defibrillate. Emergency procedures, both field and in hospital are part of the surgical curriculum.



In my neck of the woods, it is quite rare for a surgeon to intubate.  Actually, I've never heard of it (outside of surgical airways).



Veneficus said:


> No thanks, I'll take the doctor. Particularly any who went through the same curriculum I did. I don't care if they specialized later in diagnostic radiology.



Maybe you were being hyperbolic with the diagnostic radiologist part, but I would disagree with the notion that any physician is better than any paramedic in an emergency.  Though I would "take a doctor", I'd probably be VERY careful about which type of doctor.  Despite the intense curriculum of medical school, the didactic years cover very little about emergency management of patients.  And though I have yet to start my clinical years, from all my interactions with medical students and residents is that though there is exposure to emergency care in the clinical years, it is no where enough to be proficient.

Seeing as we are on other sides of the pond, there are clearly some big differences between medical training in the US and abroad.  My medical curriculum has minimal emphasis on clinical procedures.  While we will do certain procedures during our clinical years, I don't know of having to be signed off on anything other than CPR and history and physical exam (of which the most invasive would be pelvic and rectal exams).


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## Veneficus (Feb 5, 2012)

medicsb said:


> I was unsure, but on a cursory search, EM is a very small component of anesthesia training, if at all incorporated.  My school indicates no requirement for anesthesia residents to rotate through the ED.  They may be present on trauma or when summoned for the unusually difficult airway, but overall the ED is NOT part of anesthesia's primary domain in the academic setting.  And of any physicians that get out into the prehospital setting, almost all are EM trained.



I do not suggest they have to rotate through the ED in the US. I also don't think it is beneficial. 

I am talking about emergency resuscitation, which is only slightly different than what is done every day in a unit or surgery.

Sure they won't really know how to splint a fx, but nothing an ATLS course will not solve.

Actual emergencies are a very small component of EM. Just like EMS. Anesthesia has no need to determine who gets admitted or treated and released, they need only to be able to take care of a very sick patient. 





medicsb said:


> In my neck of the woods, it is quite rare for a surgeon to intubate.  Actually, I've never heard of it (outside of surgical airways).



Not many actually do, they are still trained. Without paralytics. (Sounds rather like many in EMS doesn't it?)



medicsb said:


> Maybe you were being hyperbolic with the diagnostic radiologist part, but I would disagree with the notion that any physician is better than any paramedic in an emergency.



Not better than any, better than what I experienced as the mean. Radiologists still have to know about anatomy and pathology, the basic medical education (at least here) is more than enough to give them a decent chance to help in an emergency.

For certain not at the level of a highly competent paramedic, but, there is an important adjective there.



medicsb said:


> Though I would "take a doctor", I'd probably be VERY careful about which type of doctor.  Despite the intense curriculum of medical school, the didactic years cover very little about emergency management of patients.  And though I have yet to start my clinical years, from all my interactions with medical students and residents is that though there is exposure to emergency care in the clinical years, it is no where enough to be proficient.



That is unfortunate.



medicsb said:


> Seeing as we are on other sides of the pond, there are clearly some big differences between medical training in the US and abroad.  My medical curriculum has minimal emphasis on clinical procedures.  While we will do certain procedures during our clinical years, I don't know of having to be signed off on anything other than CPR and history and physical exam (of which the most invasive would be pelvic and rectal exams).



I have a 13 page list I have to perform at an acceptable level and had to get signed off by the respective departments. It does not cover everything I have done though.

I'll spare us both the typing, suffice to say everything a nurse or paramedic does, and some of the more notable ones:

fixation of fx limb
assist in surgery
wound care and suturing
colposcopy
just about every type of exam imaginable (ophtho, psych, pelvic, etc.)
various "first aid" skills,(tube thoracostomy, intubation, surgical cric, burn care and patient ambulance transport)
pleurocentesis
peritoneocentisis

definately I am not an expert at all these things, but I can do the whole list to an "acceptable" level today.


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## medicsb (Feb 5, 2012)

Veneficus said:


> I am talking about emergency resuscitation, which is only slightly different than what is done every day in a unit or surgery.



I think there is a level of complexity added to the resuscitation when the patient is undifferentiated, especially when the patient is wheeled through the doors already circling the drain.  By the time the patient is in the ICU or OR, there is a general diagnosis made, which certainly can serve to stream-line further resuscitative efforts (obviously, I'm not speaking of strictly cardiac arrests), especially considering that many of the ICU patients have IV access, hemodynamic monitoring, radiology reports, and blood work to help guide the physician no matter their flavor.  Now, certainly, that is not always the case, but as I know it, it is much less common.  



> Actual emergencies are a very small component of EM. Just like EMS.



I don't disagree with this, but with many EM physicians averaging 1-2 patient contacts per hour, they are sure to encounter critical patients and resuscitation more frequently than those in EMS and more so than most other specialties.  



> Not many actually do, they are still trained. Without paralytics. (Sounds rather like many in EMS doesn't it?)



I'll Agree.



> Not better than any, better than what I experienced as the mean. Radiologists still have to know about anatomy and pathology, the basic medical education (at least here) is more than enough to give them a decent chance to help in an emergency.



Yeah, but how long does that schooling maintain over the long term.  If one has spent 20 years in a dimly lit cave, rarely interacting with real patients, I'm not too confident that they'll be of much help other than doing what they're told. But, again this is my American-centric view.  Your radiologists may function much differently.  



> That is unfortunate.



Largely, I agree.  This difference may be why EM HAD to become a specialty in the US when it did.  Maybe had emergency care been covered better covered in medical training, EM would not have been necessary as we know it now, and maybe it would have taken a route similar to that in Europe (i.e. a subspecialty or anesthesia or another).  



> I have a 13 page list I have to perform at an acceptable level and had to get signed off by the respective departments. It does not cover everything I have done though.
> 
> I'll spare us both the typing, suffice to say everything a nurse or paramedic does, and some of the more notable ones:
> 
> ...



I know there are general requirements for clinical rotations, but a lot of the procedures are "do them if you get a chance", because of the competition with residents, who are mandated to get X number of Y procedures.  Most of the procedural training comes with residency, where there are specific specialty requirements for which a resident must be signed off on.  Our 4th year will likely provide great procedural exposure during sub-internships in the our prospective specialty.  Basically our 3rd and 4th year are focused on us developing our skills in performing H&Ps, learning tests to order, interpret lab work and radiographs, forming differential diagnoses, working as part of a team, developing patient-physician relation ships, etc. Anyhow, I could be wrong, it will be another 5 months before I'm doing my clerkships, so I'll be able to provide a far better insight a year from now.


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## Veneficus (Feb 6, 2012)

medicsb said:


> I think there is a level of complexity added to the resuscitation when the patient is undifferentiated, especially when the patient is wheeled through the doors already circling the drain.  By the time the patient is in the ICU or OR, there is a general diagnosis made, which certainly can serve to stream-line further resuscitative efforts (obviously, I'm not speaking of strictly cardiac arrests), especially considering that many of the ICU patients have IV access, hemodynamic monitoring, radiology reports, and blood work to help guide the physician no matter their flavor.  Now, certainly, that is not always the case, but as I know it, it is much less common.



I think in your near future you will find that the principles of resuscitation are actually very similar whether the pt is previously DXed or not.

What it really comes down to is supporting vital functions and managing the physiologic response of the body while searching for the underlying pathological process.

In my US experience, on critical patients, the ED tries to provide enough supportive care to get the pt to the required specialist. Which on a critical patient is likely to be surgery, some kind of interventional angio, or an ICU.

Otherwise they are usually using a simplified intensivist formula of maximizing Do2.

Just my thinking, but if a person can do the complex, it often takes them less effort for the simple.     




medicsb said:


> I don't disagree with this, but with many EM physicians averaging 1-2 patient contacts per hour, they are sure to encounter critical patients and resuscitation more frequently than those in EMS and more so than most other specialties.



I'll Agree way more than EMS. Otherwise it depends on the specialist. Surprisingly, nephrology does considerable consults on post op and ICU patients. Ophtho is a near constant presence in NeoICUs.I would hope that intensivists and even surgeons see a large number of critical patients. 

BUt I get your point, but I think location plays a big role in that. Since here many docs see their first job in the ED or on an ambulance, they carry that experience/knowledge with them when they move on from it.

Many still pick up ambulance or urgent care work as an easy part time gig.  



medicsb said:


> Yeah, but how long does that schooling maintain over the long term.  If one has spent 20 years in a dimly lit cave, rarely interacting with real patients, I'm not too confident that they'll be of much help other than doing what they're told. But, again this is my American-centric view.  Your radiologists may function much differently.



In principle I agree with this. But in America being in that cave is likely the only thing that practicioner ever did, from residency on. Definately not much help in an emergency I'd wager.

But it is a bit different for a doctor who spent at least 7-8 months in med school emergency education, who might still work on an ambulance, ed, urgent care, austere environment, in addition to spending 40 hours in a dark cave.

As I mentioned, if the radiologist was educated with the curriculum here, I'll take them. I don't see much difference in a guy who hasn't done something in 20 years and has to recall than a guy (like many US medics) who may never have done something at all. (like intubate something other than Fred the head)




medicsb said:


> Largely, I agree.  This difference may be why EM HAD to become a specialty in the US when it did.  Maybe had emergency care been covered better covered in medical training, EM would not have been necessary as we know it now, and maybe it would have taken a route similar to that in Europe (i.e. a subspecialty or anesthesia or another).



I don't think the US system could function without EM for many reasons. like being too hyperspecialized and the ED being the major gateway as access to the medical system. (mostly because of how healthcare is funded.) 

The US ED has become the health provider of first resort to many in America. Unfortunately its ability to handle this mission is moving rather slow.

One of the "wow" moments I had in rotations here was a few years ago when the pediatric surgeon (the only doctor) on duty in the ED (and she worked in both the ED and did residency in plastic surgery before becomming a peds surgeon) was scheduling her outpatient follow ups (from plastics and peds)to stop by the ED when she was working there.    

I have seen many of the other specialists who work in the ED do the same thing since.

Can you imagine?

"I'll take care of your problem in my specialty clinic today and you can just drop by for your follow up in the ED after you get off work on friday or sunday, whatever works best for you."

Imagine how it would play out in the US if a kid  came into the ED for a follow up from peds surgery.

It would probably take hours, maybe an admission, and a host of diagnostic tests to repel potential litigation.

That is why I get so agitated over how US EDs operate. It is a complete waste of time and money in most cases. If the radiologist here can work on an ambulance, an EM doc can certainly learn to do a little more primary care and follow it up.



medicsb said:


> Basically our 3rd and 4th year are focused on us developing our skills in performing H&Ps, learning tests to order, interpret lab work and radiographs, forming differential diagnoses, working as part of a team, developing patient-physician relation ships, etc. Anyhow, I could be wrong, it will be another 5 months before I'm doing my clerkships, so I'll be able to provide a far better insight a year from now.



That is my understanding of it. In 5 months I will be counting down the days on my fingers until I am done  The end is near!!!


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## RocketMedic (Feb 6, 2012)

People come to American ERs for follow ups all the time. Its generally pretity smooth.


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## Veneficus (Feb 6, 2012)

Rocketmedic40 said:


> People come to American ERs for follow ups all the time. Its generally pretity smooth.



For what and where?

I spent 4 years in an Urban ED in the US, in nearly 100K patients a year, I never saw somebody who came in for a follow up.


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## RocketMedic (Feb 6, 2012)

Here in El Paso (granted, at an Army hospital), we see follow ups all the time.


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## Tigger (Feb 6, 2012)

By follow ups do you mean "the doctor said to come back if anything changes, and it did," or "the doctor told me to come back so he could check me out on this date and time?"


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## Veneficus (Feb 6, 2012)

Tigger said:


> "the doctor told me to come back so he could check me out on this date and time?"



this


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## Tigger (Feb 6, 2012)

Veneficus said:


> this



I figured that's what you meant, I was asking RocketMedic that. Forgot to hit that quite button.


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## mycrofft (Feb 22, 2012)

During my brief ER orientation and probation, we had people come in for f/up's...all were street people.

The current system will continue because the crushing deficits caused by sinkholes the money goes down is not a real one, it is an imbalance of profits (not inflated claims of amortization) being made from billing for care, then applied to non-care, such as buying adjacent real estate, building a "pavilion" for fundraising, better executive compensation, increasing stockholder profits, etc. You simply suck each needy pt.'s savings and insurance dry, then go to another; they/we are a renewable resource, and incapable of collectively responding because once they go through the wringer, they are poor, maybe homeless, maybe dead.


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## mycrofft (Feb 22, 2012)

*So, the answer is go faster on the current path, per the poll.*

Ok..........


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## Hunter (Feb 23, 2012)

I say empower Medics, however we wanna be empowered but don't hold ourselves to a higher standard. If we wanna be "empowered" then we need to behave like professionals in ALL branches of EMS, Fire/Rescue departments, Private (Not just 911, but even the [lizard slingers,transport jockey] IFT Ambulance transports.) These act like just because they don't work for a 911 system their job doesn't matter, and the ones that do work for 911 seem to have the same attitude towards them. Hospital based (i don't think there's too many of these left.)


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## TatuICU (Feb 23, 2012)

Start requiring at the very least an AAS to get on a truck and get rid of these idiotic 2 week RN to Paramedic programs.


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## mycrofft (Feb 23, 2012)

So paramedic is the epitome of PEMS?


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## ah2388 (Feb 24, 2012)

The consensus that I am developing from this thread, is that more or less it's time for American Paramedics, and American EMS in general to either step up, or step off.

I am hopeful that it is only a matter of time before we "step up."


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## TatuICU (Feb 24, 2012)

ah2388 said:


> The consensus that I am developing from this thread, is that more or less it's time for American Paramedics, and American EMS in general to either step up, or step off.
> 
> I am hopeful that it is only a matter of time before we "step up."



I agree with this sentiment.  Everyone wants the money and credibility of being a healthcare professional but a lot of people don't want to put in the work.  EMS has to start requiring a degree if it stands a chance.  Sadly, in our area probably 5/10 medics do have at least one degree but still top out at about $11 an hour.  Its very very sad but honestly if EMS did require a degree we'd lose half of our people and we can't afford that in this area.  Double-edged sword.  What doesn't help is our local paramedic training school's vehement arguments to state legislators (who don't really give a :censored::censored::censored::censored: anyway) that EMS training should not require a degree to protect their bottom line.


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## TatuICU (Feb 24, 2012)

emt.dan said:


> Isn't it commonly agreed upon that less than 10% of 911 call volume truly requires ALS-level skills (ignoring simple cannulation/fluid administration), or at least can honestly be billed for as ALS-2?



I would agree with this. In fact I wouldn't argue against the number being closer to 5%


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## TatuICU (Feb 24, 2012)

Aidey said:


> That doesn't address the issue of RN having both AS and BS level degrees. Seems a little bizarre of someone could be an RN with an AS but only an EMT B with an AS.



An EMT-B should not require an AS, just as a CNA or LPN does not  receive an AS. Both are certificate programs and should remain that way.

As an aside, in my experience its best to have the BSN or BS in something relevant (cell biology, chemistry, etc) if you want serious recommendation for hire these days as a nurse, especially in the critical care arena.  I will say though that frankly, a BSN program's contents do not in any way better prepare a nurse to handle critical patients.


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## TatuICU (Feb 24, 2012)

sir.shocksalot said:


> 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.



Wow, someone here has an actual grasp of supply side economics.


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## mycrofft (Feb 24, 2012)

EMT's, and that DOES include paramedics as defined by NHTSA who fathered them, were intended to be a low-price, widely disseminated technical group. Interfacility transfer was not even planned on, injury by car crash was their primary objective of preparation.

Do we strip rural and frontier areas of their EMS because vollies and certified (versus degreed) techs are downgraded and degree-prepared techs mandatory but not a realistic option out there (unless paid for by federal grants)?,

Do we artificially limit the supply? Many (mostly young) people want to be heroes, and this is one avenue, so the supply of cheap young labor is very large. Also, with low entry thresholds to certification and employment, PEMS offers a means to get a decently paying job, sort-of.

Do we prune off all the superfluous varieties of tech which various states and etc. have created since the inception?

And who is "We"? Who will bell this cat?


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## triemal04 (Feb 24, 2012)

mycrofft said:


> EMT's, and that DOES include paramedics as defined by NHTSA who fathered them, were intended to be a low-price, widely disseminated technical group. Interfacility transfer was not even planned on, injury by car crash was their primary objective of preparation.
> But medicine changes; that's just the nature of the beast.  Just because something was initially designed as one thing does not mean that it shouldn't change to fit the current needs.  Look at nursing now compared to what it used to be (don't anyone take that as an endorsement of what's happening in nursing please).
> 
> Do we strip rural and frontier areas of their EMS because vollies and certified (versus degreed) techs are downgraded and degree-prepared techs mandatory but not a realistic option out there (unless paid for by federal grants)?,
> ...


"We" is people who are actually in this profession and vested in it.  Unfortunately, getting "we" to speak with one voice and come up with, and then implement a coherent plan is likely next to impossible.


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## EFDUnit823 (Feb 26, 2012)

BEorP said:


> Why not just make paramedicine a real profession through education, which will lead to empowerment of paramedics?



There was a real attempt for this in Indiana only to be staunchly opposed (and eventually won) by the Nursing Union


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## RocketMedic (Feb 26, 2012)

Job threat.

Another concern is how will this affect fire EMS? Many of us are firefighters or looking at becoming firefighters, and their priorities may differ.


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## systemet (Feb 26, 2012)

mycrofft said:


> Do we strip rural and frontier areas of their EMS because vollies and certified (versus degreed) techs are downgraded and degree-prepared techs mandatory but not a realistic option out there (unless paid for by federal grants)?



I think you have to grandfather in the currently certified providers, and provide some sort of distance-delivery upgrade program.  

Nursing had to deal with this with the advent of the BScN (and is still dealing with it).  There are lots of angry diploma-RNs who don't like that their upward mobility has been restricted by the advent of the BScN, but haven't upgraded to a higher level.  There are also plenty of diploma-trained RNs who now have BScN or higher degrees.

To a certain extent, a new wave of more educated providers will drive the profession forwards and bring the rest of us with them.  To the same degree, those currently operating in the field that aren't degree-educated will provide years of experience and mentorship and help develop these new paramedics.  The learning should be a two-way street.  

This was often my experience working as a new medic with some of the veterans.  The guys that had trained in the 80's had had no initial exposure to 12-lead, for example, but had received piecemeal training over the last 10-15 years to catch up.  There were instances there when even when I was a new medic, that I could help them.  Just as working with someone who'd run a few hundred cardiac arrests greatly benefited me.



> Do we artificially limit the supply? Many (mostly young) people want to be heroes, and this is one avenue, so the supply of cheap young labor is very large. Also, with low entry thresholds to certification and employment, PEMS offers a means to get a decently paying job, sort-of.



Yes.  It can't continue to be acceptable to work on an ambulance and deal with life-threatening injury and illness on the basis of a few months of school.



> Do we prune off all the superfluous varieties of tech which various states and etc. have created since the inception?



I think so.  If you train an EMT for 2 years, they're going to have some sort of pharmacology/traditionally non-BLS skills anyway.  So it's probably a net move towards increasing the "BLS" scope of practice.



> And who is "We"? Who will bell this cat?



I don't know.  How did the RNs do this? Or the RTs (they're definitely moving in this direction too).  Even a lot of the lab tech / diagnostic imaging is moving this way.


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## Tigger (Feb 26, 2012)

TatuICU said:


> As an aside, in my experience its best to have the BSN or BS in something relevant (cell biology, chemistry, etc) if you want serious recommendation for hire these days as a nurse, especially in the critical care arena.  I will say though that frankly, a BSN program's contents do not in any way better prepare a nurse to handle critical patients.



By the nature of nursing, it's initial degrees have to be very broad in their curriculum. A BSN is directly useful and needed in many areas of healthcare, a paramedic's certificate or degree is obviously not. EMS is lucky in that it is a bit of a "niche role" within in healthcare, meaning that the initial degree process can be quite specific and directly train providers for their role. This eliminates the myriad of add on course that are found in the nursing field and will hopefully make the transition process somewhat less painful when it comes.


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## triemal04 (Mar 1, 2012)

systemet said:


> I don't know.  How did the RNs do this? Or the RTs (they're definitely moving in this direction too).  Even a lot of the lab tech / diagnostic imaging is moving this way.





Rocketmedic40 said:


> Another concern is how will this affect fire EMS? Many of us are firefighters or looking at becoming firefighters, and their priorities may differ.


Unfortunately, that says it all right there.  Not fire departments being involved in EMS, but people using their time and involvement in EMS just so they can move on to something else.

You don't see that with many other medical fields.  A RN may choose to specialize in one thing or another, or only work in certain places, but they are still an RN.  Same with an RT.  Or PA, or radiology tech, or MD.  

Not always the case with EMS.


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