# Progression of EMS



## VentMedic (Oct 3, 2007)

Where has EMS been? Where is EMS going? Will the National EMS Educators (NAEMSE) proposals make a difference?


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## Ridryder911 (Oct 3, 2007)

Well, Vent you are one of the few that can answer this as much anyone here.

I realize many do not care where EMS has been. I can understand that, but unless one realizes where you have been then you definitely cannot ever understand how you became as a profession where you are, or where you might go. 

We became to we are by a strange group of people. In the 70's many post Vietnam era youth that had grown up under the influence of watching _ Emergency_ every week. Yes, I hate to admit it, but it was for not for that television show EMS would had never got off the ground. Uniquely, we had to struggle and fight just to be able to perform any tasks. 

In the earlier days we always had to "justify" anything we did. I actually seen physical altercations, and poor behavior because everything we performed was belittled, scrutinized, and put down. As well, I had seen medics deliver a child, or treat a raped female, resuscitate a patient, only to be denied to even enter the ER. The nurse and physician would actually take the stretcher from the medic at the door and whisk it away, not allowing the medics past the door. Maybe, this is why we developed such a "cocky" attitude of why we have to feel we must act like there is a chip on our shoulders. 

Fortunately, it was not much later in the 80's that those in field felt we must be recognized as a professional. Observing nursing and how they were previously treated, many endorsed collegiate level programs. It was at this time the NREMT finally developed the Paramedic level. Yes, until that time most Paramedics were authorized  by local sources only. The 80's actually, was one of the best times for EMS. Special grants, and foundations had been started in the 70's was finally being spent for education and equipment. People entering the field were actually considering this occupation as a potential career. We were finally beginning to be recognized as a peer in the medical profession. 

Alas, this would only last for a short period. Apparently, many did not want to continue the trend. Multiple levels were developed. Where small communities once had Paramedics, now cried that they could no longer afford such luxuries, as well as communities that once were progressing towards full ALS coverage now resorted to excusable levels such as the Intermediate or multiple developed levels in partial comparison to the Paramedic level. Part of the blame can be placed on the AED device. Albeit, it is a wonderful device, it was purchased by many communities with the false intentions that by having EMT/D's they would provide ALS similar to Paramedic care. Unfortunately, many EMS personal rather attend a week-end course than a two year Paramedic program, but portraying themselves as "delivering the same care" with the ability to "defib" someone if needed. Thus, the false presentations began, which still continues today with multiple levels. 

We have seen EMS climb, then plateau out and now decline. 

Other than a few skills such as twelve lead and CPAP, RSI there has not been much movement. Many now enter the EMS with NO intentions to ever work in this profession, thus having apathetic feelings on the longevity of this profession. Fire Departments that had earlier refused to participate in EMS activities now realize their profession is danger, see EMS as a "security blanket" for productivity, and public relations. Unfortunately, we have began to see that EMS again is at the bottom of the pole. These Fire Services are degrading EMS personal by only hiring them as "non-uniformed" thus; they do not obtain benefits, pay structure, etc.. however; may someday be able to be honored to be a "real firefighter" if they are real good... again the step-child syndrome. 

So this lead us to today. We have a few that enter EMS for multiple reasons. Thus part of the problem. If one was to ask why they entered medicine, nursing, or any other health career, the general consensus would be to deliver patient care and to work in that profession by doing so. Unfortunately, not EMS. There are those in EMS because they had no choice. FD requiring them to participate, those that feel it can be used as a stepping stone, and those that performing in EMS makes them feel good about themselves and perform it as a charity, or community service. 

There are very few that enter EMS to actually participate in direct patient care, that want to stay the longevity and participate in professional development. Not that there are not any... just are the minority. 

EMS is one of the few health care professions that has to fight each other to progress. This is why other medical careers, scratch their head looking upon us. Where others rallied together and fought obstacles among the way, EMS continue to fight within each other. With the division of those that want to move forward and those that want to dilute and keep status quo. Excuses are generally made in comparison as to the location of geography (rural, urban, metro) to employment ( be it paid or volunteer). Thus again, those in the health career do not seem to understand. They realize it does not matter whom, where patient care is delivered there has to consistency with standards. That the respiratory therapist in a town of 5,000 is just as qualified as the ones in 500,000 and the RN working the rural clinic has the same level of entry education working in the Indian Reservation has the same degree as the one in downtown Chicago, the same based equal education. There cannot be multiple entry levels, everyone starts off on the same place, without professional standards and work the profession will NEVER advance. 

So what now.. ? 

Yes, I believe we will see a tear and a division in EMS. Unfortunately, FD and large corporations will be there to pick up the remains in attempt to control it. I do believe there has to be a final fight to see where we will go. The population that is becoming the consumers will have too much demand on the current system. Yes, volunteers will want to "hold on" but will have to let go due to the demand. Run volumes will be increasing by triple volumes, as well as the responsibility will be increased. It has to. 

According to many world and national health organizations, there will not be enough hospital beds, ER facilities to ever meet the demands of the public. Look at the current trend, even within the past ten years. The population has increased more than the facilities that deliver the care. Yes, it is scary.. and yes it will be MUCH worse in the future. 

So how will our role change...? 

Either we will attempt for maintain as it is... (which will lead to failure), continue to dilute programs and produce EMT's by the hundreds of thousands that have no function or job, or we can look at our neighbors up north. View that they are placing the EMS personal more than in a transporting unit. Utilizing EMS as out of hospital treatment and delivery of care. Yes, our role will change, but it will have to, or we will be replaced. It is too costly for Medicare and other payers to continue paying for high dollar taxi rides. 
The decision will be yours what the future of EMS will be like.. either be part of the change, or do nothing and see what comes along.


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## Jon (Oct 3, 2007)

Wow, Rid... Tell us how you REALLY feel!

What is the NAEMSE proposal, anyway?


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## Ridryder911 (Oct 3, 2007)

In general paraphrase to remove all the ABCDEFG and the other 132 acronyms after the EMT title. There would be an EMT Basic, Advanced EMT and then EMT Paramedic. That's it.. 

As well, as increase the hours required for each level and increase the anatomy and physiology in the Paramedic level. Of course, we know that this is desperately needed. A mere 120 hour course, is just past the advanced first aid level, and the Paramedic requirements are a sham. 

Unfortunately, the ugly heads of lobby groups of the IAFC and Volunteer groups are beginning to object changes that might actually increase our professions knowledge... citing they would loose members, (oh well to he*l, with the patient, as long they feel good about themselves). 

Here is the link to the site, review the changes. ( www.nemses.org - "right click on related docs" to view ). 

It's time for EMS to grow up, if we don't do it ourselves, someone else will. 

R/r 911


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## firecoins (Oct 4, 2007)

I would hope EMS is going to the closest approriate medical facility, wellness clinic or hospital.


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## Ridryder911 (Oct 4, 2007)

firecoins said:


> I would hope EMS is going to the closest *approriate* medical facility, wellness clinic or hospital.



Wellness clinic? What can they do? Most of them do not perform any major medications, or even IV's .. We are banned from transporting any patient to such, in actuality we do more for the patient than they do. They call us to treat emergency patients. 

I am glad to see you acknowledged *appropriate* instead of just closest. This may mean bypassing two other hospitals while doing so, and increasing transportation time, but saving time in the long run. 

R/r 911


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## triemal04 (Oct 4, 2007)

Rid...while sometimes you come across as a rather pious and pompous medic, right now all I want to do is shake your hand.  It is always very heartening to see other people out there acknowledge that EMS is in trouble and that changes need to be made.  Thank you sir.

If nothing changes, in another 30 years, EMS will be almost unrecognizable to todays system.  My guess would be that there would be some local areas that had well trained people and well run systems, but EMS on a national scale would be very scaled back, poorly trained, and not used in many areas.  A big reason for this would be the complete lack of education and training that is required to become a nationally certified EMT, and way to many places base their programs on the national model.  So, change the training requirements.  The medic course should be a 2 year associates degree program (while some of the classes required are somewhat pointless, having a degree would help paramedics become more accepted into the "professional" medical world); no more 90 day wonders or shake and bake medics.  This course would include an approximately 1000 hour medic course, full year of A&P, pharmacology course, medical terminology, biology, chemistry courses, psychology, hx of EMS, CISM, chart writing, and basic rescue courses plus whatever else was needed for a degree.  And this should be the bare MINIMUM that all states are REQUIRED to follow.  If they refuse, then the schools should not be accredited (which means that only accredited schools are allowed to train medics) and the people there would not be allowed to be called paramedics.  For anyone out there that complains that this is to long...shut your mouth right now.  Paramedicine has been around for about 30 years now, and that is way to long to be content with having the monkey skills without the knowledge to back it up.  If you want to call yourself a professional EMT-Paramedic, then you need to be prepared to spend some time learning how to do it.

The same should apply for any lower levels of EMT.  (for starters, there should only be 1 or maybe 2 lower; all the states with 4 different versions of an EMT-I...tough).  The standards for education and training must be rigorously followed, and if that means that there will be rural areas that loose their "EMT-IV with meds and combitube and defib and...that's tough.  The way to solve it would be...

Private ambulance services need to go away.  It's been 30 years of the dash for the cash, and now it's time for something different.  Begin a push (a very strong push) for third service EMS.  Local gov't agencies (from city to county) should start being responsible for running an EMS program; in rural areas this would actually help as it would more than likely let them maintain some paid medics for the area.  Get federal money out there when neccasary to help, and advance the use of fixed wing and helicopter transports for the very rural areas.  It'll take time and money, but it can be done.

Volunteers need to stop wanting all the fancy toys and skills without the training.  The arguement that they need them because of the distance to a hospital doesn't cut it.  There are ways to get ALS units into the area, it'll just take work.  

A national voice for EMS needs to be created; best way for that would be to have a union, either national or international that represents EMTS ONLY and isn't afraid to flex it's muscle.  Unfortunately, this is a slow process that should have started decades ago but didn't (privates), and I can't say with a straight face that it's biggest competitor wouldn't be IAFF.  (and private services, but we allready covered that)  But, if the public was made aware, and I mean really made aware of how EMS works, and how it's supposed to work, a lot of support could be raised.  That is one of the biggest issue; the public for the most part has no clue how EMS is run, what an EMT is, and what a paramedic is.  That must change for any postive change to come about.

Now, some of this is sort of being done; I don't have a whole lot of faith in the new standards for paramedic, advanced EMT etc, because really, what has changed?  EMS is no longer part of the DOT, but the skill set for the medic has gotten smaller if anything, the training requirements aren't that much improved, and states can still pretty much do what they want.  Really, I think the single thing that would have the biggest impact would be having a national voice/union for EMS personell.  When someone is willing to fight for you and can make good on any threats, things will get done in a much more timely fashion.

EMS is still a very young thing compared to the rest of the medical field, and I don't think it's bad that there are "growing pains."  What is wrong is that people don't want to recognize the problems or do anything to fix them.

Edit:  Forgot this part.  The final testing that is done to certify people must be changed.  A bigger emphasise needs to be placed on how the person performs in the oral stations and trauma/medical scenarios than on the skills they perform.  (not to say that those should be rigourously tested)  And the internship program needs to be a bit different as well; stop basing it on getting X calls in X area and XXX hours (normally 10 resp', 10 cardiac, 10 med, and 10 trauma and 200 hours minimum) and instead base it on if the person knows what they are doing and can function as a medic ALONE.  There is something of a push to do that here, which I think is great, but the problem will be in finding enough preceptors that are really qualified to make that judgement.  Still, it can, and should be done.


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## firecoins (Oct 4, 2007)

Ridryder911 said:


> Wellness clinic? What can they do? Most of them do not perform any major medications, or even IV's .. We are banned from transporting any patient to such, in actuality we do more for the patient than they do. They call us to treat emergency patients.
> 
> I am glad to see you acknowledged *appropriate* instead of just closest. This may mean bypassing two other hospitals while doing so, and increasing transportation time, but saving time in the long run.
> 
> R/r 911



don't take the wellness clinic too seriously.  It was a joke. The OP was clearly not asking about the transport of patients.  But yes appropriate medical facility. For some patients who seem to not understand the term emergency, a wellness clinic might be the appropriate facility.


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## disassociative (Oct 4, 2007)

It's kind of funny that this topic showed up today, as I just completed a presentation in my communications class in regards to the ever-increasing role of emergency medical personnel in prehospital and post-hospital medicine. 

The main focus was on how as a profession, we have moved from prehospital medicine into emergency departments, and even I.C.U.'s in some places. 

I think, in order for us to grow as a profession; we must introduce a formal structure, as Rid said. We must implement a system in which the levels of the EMS provider are consolidated to one simple framework and the skills set forth for this framework are clearly defined.

We should really take notes from nursing in regards to how the profession has grown since the medicine of the World Wars and has adopted collegiate level credentialing in order to provide a more informed care with a multi-system approach to medicine. I believe the beginning of this process is currently taking place with degree programs in EMS. I feel in many ways, that the EMS provider should have the same basic curriculum as the nursing student, substituting the nursing core coursework with the paramedic curriculum. 

This way the provider would be well versed in Anatomy & Physiology, Pathophysiology, Microbiology, as well as the over-all human condition as it relates to medicine and changes in the bodies homeostatic mechanisms. 

In summation, I feel that formal education along with formal licensure and consolidation of EMS levels as a whole would prove beneficial to emergency medical services as a profession. Of course, this is just my opinion.


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## VentMedic (Oct 4, 2007)

The majority of the 2 year degrees for EMS were started prior to 1983.  I graduated in 1979 while I believe Rid got his degree in EMS around that time also. Everybody was excited about the new "profession". Then the PDQ marts appeared fueled by the demand of both the students and employers for immediate satisfaction. It also allowed many people to enter the field that otherwise may have been weeded out or quit when they realized there's alittle more to EMS than lights and sirens.  

It was disheartening to see people who strived to increase their education and make the field a profession be over shadowed by the skills jock who has little knowledge of the BASICS as Rid eloquently described in another thread. The BASICS are not to be confused with EMT skills.

Unions are also not the answer to representation. They will just bring another divide to the already divided and fragmented field. I still can not see how a group of people that work predominantly in prehospital (regardless of public or private) and have similar skills be in such disagreement about their future.  While there is variance in education, it still comes down to approx 1000 hrs for paramedic and 120 for EMT. There lies the problem.

Unions are paid representatives that negotiate for many differents types of workers ranging from welders to paramedics. Many have no idea of what skills the "laborers" actually perform. They are just focused on contractual agreement.  Many professionals chose not to belong to unions but rather build a strong professional national organization.  This is what the allied health professions have done.  Nurses also have some of the strongest national organizations.

Nurses do have unions in many states and they are strong. But, they are strictly unions for nurses. There is not another branch out of the same office for welders.  Even then they have their problems especially on education issues. However, many of this country's nurses are not covered by a union. Some find more satification with the different clinical ladders available to them via education rather than senority.  More hospitals are recognizing that pay for education is an incentive for retention of more motivated and educated employees. 

More skill certifications should never have been used as the answer for a patch to a leaky state system.  A solid foundation of education is necessary.  The biggest difference between EMS and other healthcare professionals is the realization by the other professionals that more education was needed to perform their basic duties. Nurses and RTs especially saw that the techs (LVNs and Resp Tech) could not keep up with the changing patient environment and technology.  They realized that a minimum of 2 years in basic health education was a must while months or years would be spent specializing in their chosen specialties after the college education finished.  I still can not see how new parmedics are put in the field with little more than 2 weeks of being precepted.  

People criticize Florida for allowing RNs (and just about everybody else) to challenge the EMT-P.  More often than not, the RNs that do challenge the test are already involved in some aspect of transport.  Some challenge it with the idea that it is not that hard. And, they are right, the written test is written in such a way that very few practitioners fail.  The written tests are generally not very impressive in a field that promotes itself by skills. 

It is just by the nature of the training that RNs and RTs do not accept assignments that they have not had an orientation to.  At least with the PHRN certification, it is a training certification that comes with 80 - 130 hours of hands on skills as mandated by some of the states promoting this certification.  This more hours than most EMS "skills" certification plus the nurse has a solid education foundation. It is not to replace the paramedic, but to meet a growing need to transport sicker patients to various facilities. Healthcare has created a distribution situation where hospitals owned by the same company must channel their resources to the most appropriate facility. It is not feasible to have a cath lab on every corner.  The transfer liability is also enormous for any hospital. 

While hospitals are supposed maintain ICUs, often times the company says only ICU can do CVVH or other advanced procedures.  The patients requiring CVVH are very sick. I'm using this as an example because I just finished packaging a patient for transport to a sister hospital. The hospital sprung for another ICU nurse to accompany our dedicated Critical Care transport nurse (used a float or procedure nurse when not transporting) because of the ventilator and numerous med pumps.  No matter how well the CC Paramedic perceives their introductory course prepared them for ICU transport it would be arrogant to get in over your head or expect an on the scene inservice at the hospital. This would also not instill much confidence in the transfer of care to someone that is supposed be an equal caregiver.  Without some serious hands on training and knowledge of the ICU patient, it could be very easy to make a fatal mistake.  

Will there be more paramedics in the hospital environment? Possibly. The ED is more of a reality now.  Of course, then what would be the reasoning of "prehospital training" if you want to work in the hospital?  To see it from the hospital's view as it stands now; they would be bringing back in the minimally educated technicians, regardless of your skills, that they thought they got rid of with the LVN and Resp Tech.  There are many professionals around the ICUs now that can do all the "skills" a paramedic can plus they have the education and internships to back them up. 

There are paramedics who have made critical care transport a reality, but they must have intense support from their medical directors for continuing education. The most successful have been part of flight medicine. But, the applicant process, as discussed in another thread, is intense. However, again, without a solid educational foundation, it is difficult to build in areas that require a mastering of the BASICS.


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## reaper (Oct 4, 2007)

I agree with everyone that we need better education in the paramedic field. The one thing I do not agree with is the comparison to RN's, like they are the top of the line. I have been around RN's my whole life. Mother,sisters,wife, and in laws, All RN's. There are great RN's and :censored::censored::censored::censored:ty RN's. Not all RN programs are BSN. Most are two year programs. They do require more prereq's, Which I think medics should have too. 

My point is that a good percentage of RN's out there are not that great and some are down right a disgrace to the system. Does this mean that all RN's should now have MSN to do their job. ICU RN's are a top notch group,(I know, my wife is one) but they are a select few.

So yes, let's fight for better education in EMS, but stop comparing us to RN's. That is apples to oranges. ICU RN's may know our skills, but very few use them or are proficient in them. So lets keep this education deal about ems. That is the only way we will ever project ems to the future.


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## VentMedic (Oct 4, 2007)

reaper said:


> My point is that a good percentage of RN's out there are not that great and some are down right a disgrace to the system. Does this mean that all RN's should now have MSN to do their job. ICU RN's are a top notch group,(I know, my wife is one) but they are a select few..



The same could be said for many in the EMS profession. 

Actually there are many hospitals that do prefer the BSN as well as professions such as Public Health.  The BSN will eventually be a reality for nursing licenses. They are finding it hard to be now considered the lesser of the entry level degrees in the hospital.  See where I'm going with this? I could compare EMS to just about any health care professional ( or just about any other profession including welders) that saw a need to keep up in education to provide better health care for the patient as a whole. 

I was astonished to learn of the education levels and certifications as well as continuing education that our hospital maintenance workers must have.  Yeah, I could compare the 90 day Medic Mart wonders that "fix" patients to them also. 



reaper said:


> So yes, let's fight for better education in EMS, but stop comparing us to RN's. That is apples to oranges. ICU RN's may know our skills, but very few use them or are proficient in them. So lets keep this education deal about ems. That is the only way we will ever project ems to the future.



I am not comparing EMS to Nursing. Rather, I am stating how the changing patient environment and technology has opened up a need for highly educated and skilled practitioners.  

And actually, the nurses that do Critical Care transport in the facilities that I a personally familar with are very proficient with intubation, central lines, defib/cardioversion and numerous medications as well as being very capable of autonomy. They have proven this both inside and outside of the hospital.  These nurses participate in both ground and flight. The hospital is their lab. They must do a mandatory set amount of procedures each month to stay an active member. They, too, must pass several verbal tests and observation in the Critical Care situations by the Medical Directors before even being invited to apply for the team.  This standard is not heard of in EMS.   

Maybe it is a comparison in the fact that we no longer monitor the skills or knowledge of our EMS crews until some article is published and then everyone is shocked at the findings. Intubation is one such topic that is controversial. Why?  Because, as a whole EMS has failed to set standards to police themselves. EMS has continued to lower the bar to allow lower credentialed people the privilege of intubating. 

As EMS has already proven, skills can be taught to just about anyone. So, why not teach them to nurses who have already have a strong educational background?   

If the paramedic had some resemblance of a national educational standard then there may not be any discussion or question about how to bring them into other patient care areas.  The question might be "when can they start to work?."

Of course, there will be exceptions and there are some fantastic professional EMS providers out there and some very proficient systems.   But, given as a whole, there's a lot of work to be done.


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## triemal04 (Oct 4, 2007)

I'm curious why someone would say that a national/international union for EMS providers would be detrimental to it.  A union that only represents a certain type of job and is willing to go to bat for them and has the clout to do it...that's bad because...why?  A national organization with a backbone would be great too, but so far we don't have that today.  About the closest there is is NAEMT which get's about zip done.  Really, both would be very helpful in the future of EMS, but a union would have the advantage of being able to be more involved with contracts, ie getting medic's and EMT's paid appropriate wages.  I'm at a loss why you would think that this is a bad thing.  Look at IAFF (union) and NFPA (national organization); both have done very good things for the fire service.  Why is it wrong to want the same for EMS?  Of course getting these going would be a long, slow process that should have started long ago, but it's not to late.

Since you brought it up in this thread as well, my problem with Florida isn't RN's challenging to get their paramedic cert (as long as the process is run well I'm ok with it) but with the whole idea of a "pre-hospital registered nurse."  Now, like I've allready said, a nurse from an ICU or other specialty unit is probably better suited to run an interfacility transfer with a pt from that unit than a medic, and I think that is a perfectly acceptable use for RN's. (this isn't to say that medic's (in some areas I suppose) can't be used for the same role or won't be able to provide adequate care, but, admittedly, there will be a difference in knowledge when it comes to some meds/equipment, so an RN who's familair with those AND the pt is probably better)  But, with this being the case, where is the need for a PHRN certification?  Why not just use an ICU, or Critical Care or whatever the name happens to be nurse with more autonomous protocolls?  Pre-hospital means just that; care given BEFORE reaching a hospital, all this sounds like is a backdoor way for RN's to get on an ambulance as RN's and not paramedics.  I've allready said why this is a bad idea so I won't go into that here, but I will say this again:  I can see why this could be an attractive option for some places with the state that some areas EMS system is in.  But, that is exactly the kind of situation that we should be working to prevent by increasing the education and training of EMT and medics and increasing understanding of EMS.  Those of us who are medics should not be advocating for another group to step in to do our job, we should be advocating to change things so that is not needed.  I hate repeating myself.

Oh, and you may want to always remember that your system is not everyone's system; requirements for specialty RN's in your area are not the requirements for specialty RN's somewhere else.  (and yeah, that goes for me too)

I'm kind of at a loss here.  You really don't think very highly of EMS anymore do you?  That's fine, you've moved on, but like I've said, this is where you started...why not try and improve the system instead of looking to take it down?


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## reaper (Oct 4, 2007)

Very well stated Triemal04!

 Vent,
I agree with you on all you are saying about the need for better education. I just hate seeing EMS compared to nursing. Yes, they both have the same problems, but we need to find our own fix for EMS. Every time this is brought up someone starts comparing us to RN's. What if a lay person is reading these. They say well if EMS has problems and nursing is so great, then lets just put RN's on the ambulance. This is one thing I do not want. I am a medic, I have no desire to be a nurse or a firefighter. 

Ems has a lot of things that need fixed. Like you said, until we get the masses on one page, where do we start. I agree that a union is not the answer. They have been around and get nothing done for EMS. Like you said, we need a national org. that will get it done at the legislative level. I heard a supervisor of one place say that unions didn't scare them. What leverage did they have. They could not strike, it was illegal. So they had no leverage. The bean counters could not fight it, if it came from the legislative level.

So lets keep up the fight for improvements, but lets keep it geared toward EMS.


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## VentMedic (Oct 4, 2007)

triemal04 said:


> I'm kind of at a loss here.  You really don't think very highly of EMS anymore do you?  That's fine, you've moved on, but like I've said, this is where you started...why not try and improve the system instead of looking to take it down?



No disrespect to your personally triemal04, but you must look at 50 states and healthcare as it has evolved in legislative issues. EMS has isolated itself by saying "it's different". "We're not like them."  But if you are about patient care, then you must include your position in the bigger scheme of things.  It's time stop blaming FF, nurses and John Q Public who can't tell an EMT or Paramedic by the way they walk.  Paramedics say they want to work inside the hosptials yet don't want to be compared to nurses. "We are prehospital". You can't have it both ways unless you understand the roles. Are you in or out. If you're in, well too bad because your job description may overlap with other professionals.  If you are basing your argument purely on the skills you can do, the profession with the most education along with those skills will win out. 

I guess you haven't read my posts closely. I haven't moved on entirely. I am still active in HEMS. I've just broaden my opportunities to better keep up my skills and knowledge. My RT job definitely has added a level of education, skills and autonomy that being a Paramedic didn't in many ways. My co-workers who are nurses and I both do this inside of the hospital.  I recognized my paramedic training was going to limit what I could do even with the A.A.S. in EMS.  As I said, I have watched my education take a slap by co-workers who were just happy to have the 6 month certificate.  I chose to go toward Flight medicine because of its competitiveness and education did matter to most companies.

There's a lot more to the wage thing than just negotiating for better wages. EMS providers must establish professionalism to lobby for better reimbursement at the government levels. That is another reason why so many allied health professionals increased their education standards. They can now lobby as professsionals for recognition of their services.  With the 46 different certifications throughout the country, legislatures don't know what or how to classify any standards for the profession. 

I actually even haven't mentioned what skills and knowledge the specialty nurses and RTs possess. I've only discussed CC and prehospital (and yes, HEMS is prehospital also as are nurses that transport from various clinics to the hospitals). The various agencies that employ PICU and NICU specialists follow NATIONAL guidelines.  There are certain criteria that must be maintained for these specialty units to be accredited.  It doesn't matter who possesses the qualifications as long as they are met. 

The vision of a nurse in starched whites should be vanished. Nurses are the largest group healthcare professionals in the world. Underestimating what they can be capable of is where EMS has made some mistakes. Also, it has been nurses who have supported the paramedics in their education when there were few others qualified to teach them in the early days. Nurses are also on almost every states EMS boards and paramedic licensing committees.  A lot can be learned from them.  They are also serving in our Armed Forces. Do you also think they should "know their place also"?   I admit that is hitting below the belt, but I find these nurses to also be extremely well trained and professional.  The sterotyping can go right back to the paramedic in so many ways that, too, has been discussed at great length on the forums. 

I've participated in almost every EMS function possible and have been on various committees as well as educational boards.  The plans have been laid out a hundred times. But, it has been the EMTs and Paramedics themselves that have not be willing to accept change.  They are afraid of giving up their "identity" which they have yet to define. 

There is vast world out there. Very few people take the opportunity to look past their own backyard and most of them don't recognize when its time to clean up their own backyard.


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## Hastings (Oct 4, 2007)

EMS has a bright future.

EMTs are more than Ambulance drivers these days, and people are starting to expect ER-quality care when the paramedics arrive on scene. Paramedics are learning how to do more in the field, and how to provide a higher level of care, and - to put it bluntly - are becoming better recognized as serious medical providers. With the progression, care in the field is going to become even more in demand.

Edit: Here in Lansing, Paramedics receive the same level of training as RNs.


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## Ridryder911 (Oct 5, 2007)

A few things.. 

First, I have yet seen a nurse that would actually want to go to the field full time that was not a Paramedic previously. Actually, most nurses view EMS and out of hospital care as needed but not really health care.  Their view on the subject is why would they want to go in the trenches, to get dirty, puked upon and sweaty,  glass- hazardous materials ? Usually, they reply .. "you got to be kidding!" 

It is even hard to get them to work in critical areas such as ICU, ER, CCU etc.. I realize it is hard for medics to understand, but in comparison those areas are not the "best" areas. The profession is MUCH different than medics. They much rather have more time with the patient, much rather be in a controlled environment with no exposures to the element, not work 24 hour shifts and only get paid for partial, or have to have 2-3 jobs to survive.. otherwise they would had been EMT's. 

I know it may seem hard to believe that I had a hard time recruiting Flight Nurses. Again, why be exposed to possible death, dangerous situation for the same amount of money?

I do agree, we should be in charge of ourselves... definitely.  The reason we compare is because the first time a medic wants more money guess who they compare themselves too ?.... Again, we want the same money, respect and all the extras (as we should be able to obtain) but we do not want the same requirements in education or professional responsibility. This does mean, no more free gratis for services, entry level requirements, and of course at the least an associate degree level for entry level. 

Unfortunately, those in EMS has seen the typical behavior of we want, want, b*tch and moan.. but when it is time to dig in and to change things.. no one has the time, financial support, or participation to ever get things done. We much rather complain than to ever really be progressive. Heck, we can't even get people to quit complaining about increasing the current level of our poor training requirements. 

Again, you are correct, we should be able to monitor ourselves. Our boards should be governed by EMT's for EMT's... no one else except maybe a medical representative (M.D.) for clarification. No special consideration for FD, volunteer, paid, nurse representative, etc.. Just EMT's. Then again, look around and see what and whom you would have to represent you. Do you really want to have these person being responsible for our profession? Most no nothing about curriculum development, EMS systems development, or EMS more than just field medicine and cannot read above the 10'th grade level. Hopefully, if our profession does mature and become more educated we can have individuals represent us in a better light. 

R/r 911


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## Summit (Oct 5, 2007)

*Some thoughts from an EMT-B*

After I took my 180hr EMT-B course with an A+ grade, completed my 40hrs of clinicals, and upon my certification I wondered what the hell I had gotten into. I mostly knew what I was supposed to do how to do it, but understood so little. My first day on a 911 ambulance felt like the first day of a telemarketing job I had once where, after 4 hours of listening to other people making cold calls, I was informed that my training was complete and that I was expected to start generating sales. "This is sink or swim, kid." I swam... but sometimes I didn't understand how...

By the time I recertified my NREMT, I had over 300 eligable CE hours.

I also completed the following relevant college classes (out of ~115 credit hours):
2 semesters of college Biology /w lab
2 semesters of college Anatomy and Physiology /w lab
Microbiology
Pathophysiology
Public Speaking
Human Nutrition
Human Growth and Development
Medical Terminology
IV Therapy
3-lead EKG interpretation
Wilderness EMT

Other relevant classes I'd had prior:
2 semesters of college Chemistry /w lab
2 semesters of college Psychology
2 semesters of college Physics /w lab
1 semester of college English

*MY POINT:*

POINT 1: NOW, after completing all of that additional education, I finally feel like I have a sufficient understanding that *I SHOULD have had before I was let my far-too-short EMT-B clinicals.*

POINT 2: I will probably go to P school, but Paramedicine will not be my life's career. There isn't the progressiveness nor the compensation to make paramedicine my sole career.

POINT 3: If I lived in Canada, or if the US had the Canadian EMS system, I'd know right now that my career for life would be prehospital medicine.

POINT 4: Within one week of starting that telemarketing job, I was the best telemarketer in the entire office and I held that status until I quit four months later. (oh the irony) I made more money as a telemarketer than 95% of paramedics. I had better benefits too.


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## VentMedic (Oct 5, 2007)

Excellent points.

Rid,
We don't have the problems getting applicants for Flight. For nurses, we raise our own and it is competitive. The pay is excellent for Flight Nurses as it compares with the hospital pay. Yes, some of the privates and a couple county services don't pay that well but the county has great benefits.  

AMR and a couple of private ambulance companies hire nurses for CCT and their pay is not quite what it is in the hospital, but it is not too shabby either. It is definitely more then the paramedics. 

As for as the Flight Paramedics, we will get easily 200 - 300 applicants. We can quickly eliminate down to about 10 immediately. Most will have only the bare minimum requirements to be a paramedic. Very few have taken the initiative toward a career in Flight Medicine as far as getting more formal education or seminars. Skills are easy to teach but we would like the person to know something about the science behind it. The community college offers classes in Flight medicine but there is a catch; prerequisities.  They require college level sciences and math. The majority of the applicants, even though we have many reasonably priced Community Colleges most of which also offer a degree in EMS, do not have even college A&P. 

Our ER nurses would probably also disagree about your "sissy-fied" description of them. They are the ones who are stuck for 12 hours taking care  of the patients that ambulance crews can not wait to unload. Who do you think has to clean up this patients for admission? Nursing Assistants are even harder to come by for those working conditions.  And then there's the isolation patients for whatever diseases and bacteria who the nurses must care for all 12 hours with many actual contact hours increasing their risk of exposure. 

There has been an overall acceptance of prehospital professionals by hospital employees where EMS services provide well trained staff with a team player attitude. But, when the attitude of "poor me" you don't know what I have to do on the streets, one can only say, go back to school if you don't like it or if you are whining about working conditions and the demands of the job.  The whining makes one think you got into the profession for the wrong reasons and patient care is not your priority.   Too many people fall for the "you too can do all this" Medic mart commercials.  The training is too short to actually give a student a chance to experience some aspects of patient care that we now hear people constantly whine about on the forums.


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## reaper (Oct 5, 2007)

Vent,
I agree with you. Our education requirements need to be alot higher. I can not stand the whiners and *****ers in EMS. I want to see medics that are doing this, because they want to be medics. If it is to hard for them in the street and they can't handle the pay, then they need to go get their RN degree. 
Yes, we do need better pay and more advancement in EMS. This will come, if we can get the quality people in the field. Then you can have all flight medics and not need flight nurses. I agree that you should weed out any flight medics that do not want to further their education. If this is the career you want, then you dam well better prepare for it.
The ones that :censored::censored::censored::censored::censored: about CEU's, that there are too much required. I say, too bad!! You should gladly be doing these, to further your education. I usually have 2-3 times the amount of CEU's required, in the first year.
The ones that :censored::censored::censored::censored::censored: about bad services and no pay, need to move. The nice thing about being a medic is you can pretty much find a job any where in the country. I agree that rural EMS is hard, but it can be made better. Don't volley! If the citizens want the service, then they will pony up to pay for it. If they don't then they don't need the service. Remember, nothing in life is free. Once we start demanding better pay and respect for our service, it will come. We all have to band together, to get this done. If not, it will never happen.


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## Ridryder911 (Oct 5, 2007)

Vent, I agree there are some interested parties to be a flight nurse, however; the service I worked at was 24 hr shifts.... which many did not want to participate. As well, the services in my area do not have any pay differential for flight crews as those that are med-surg nurses. 

My point, was more to emphasize that most nurses do NOT enter health care for the adrenline type scenarious like medics. Many and majority are very pleased with providing compassionate, intensive care, without any drama. For example many prefer nursery and L & D or even case manager social services. 

ICU and ER's in my area are always short. Yes, they prefer to have experienced applicants, but like anyone else.. happy to get what they can get. 

What I do get angered about is medics should not have to make the choice to leave the profession for better pay and working conditions. About the time we finally get a medic with some real clinical experience to perform well (>5 yrs.) they go to another profession. This leaves a void in the profession and patient care. If administration was really wise, they would observe that they loose about $5000* for every employee that quits. (*costs of hiring, physical, drug tests, orientation, over time for empty shifts, etc) 

I do disagree with job vacancies for Paramedics. We crank out about 200 Paramedics every 16 weeks for about 10 openings in that area, and this is rural state. I know of at least one Wal-Mart greeter that wears their NREMT/P lapel pin on their vest.

Yes, nationally there are openings, usually because there is a reason for vacancies. As long as there are schools that can produce them in <16 weeks and every 10 months, then there will never be a shortage. Thus supply and demand will never work and pay will never increase. Why should they?.. just wait in a month or two, and new batch comes out that will work for pennies. Unfortuntely, there are few collegiate level and many Vo-Tech (trade) in my area. Which the Vo-Tech does not require any entry requirements.. straight through from basic to Paramedic in < 1 yr... hard to compare education levels.. in which the LPN has the exact same hours (actually more clinical hours). 

Hopefully, the NEMSE will reform at least anatomy and physiology ata collegiate level requirement.. this desparately needs to be performed. 

Well, I off for a state meeting. They are attempting to make Paramedic an on-line program from start to finish.. with observation & eval of skills at a site. Now, this type of program will present some type of credibility huh ?

R/r 911


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## triemal04 (Oct 5, 2007)

Again vent, you need to remember that your system is not the nations.  EMS has isolated itself, extremely so in some places, but in others it hasn't.  In some it's an accepted field in the state health dept.  And there is nobody to blame about the lack of understanding about what a paramedic is and does other than us.  Yes, us medic's.  Not anyone else.  Don't know anyone would think otherwise.  EMS is so fragmented and split among different states, providers, skill sets, services etc etc that it really isn't surprising that the public doesn't have a good picture of what goes on.  (this is where having a national group behind is would help fix the problem.)

Where are you hearing so much about medics wanting to work in the hospital?  That may be more of a local problem; I can tell you that here it's the exact opposite, and I've never heard a lot (a little though) about medics wanting to move indoors anywhere.  Personally I don't see the point.  There are allready multiple different types of providers that are trained to work in house.  We get trained to work in the field, which is very different.  Far as I'm concerned the place for a medic is in the field, not a hospital.  That being said, there are multiple services I've seen/heard of that are hospital based and, when not on calls, or sometimes as part of a rotation, the medics work in the ER.  For most of those they work essentially as an ER nurse using the same protocols they have for the field with some additional meds and the ability to call for labs, x-ray, etc etc.  It works for those places which is great, but, if you become a medic, you should go into it knowing that your workplace will be in the field.  If you want to go indoors, get your RN, or RT, hell, even a CNA.  

Increasing education would help with wages sure, and like I've said, that should be one of the first changes made in EMS.  But don't for a minute think that a private company would be willing to pay someone $20/hr unless something forced them to.  A union is a decent way to do it, as long as they have the mucle to get it done.  It is long past the time when medic's should be able to work a single job as a medic and get paid a decent living wage with decent benefits. This won't happen easily though.  (be really hard in privates anyway; part of the reason that for-profit services should go away) And there are benefits to it that I've mentioned allready.

I don't know that many people who underestimate nurses.  While I'm all to happy to call some floor nurses bed pan changers to thier faces when they deserve it, I (and everyone I've ever talked to) still recognizes that there are very talented nurses out there (just like medics) and some crappy ones (just like medics).  Still doesn't change the fact that the place for a nurse is in the hospital, and the place for a medic is in the field.

I still can't figure out where you're coming from.  EMS training and educational standards need to be improved, we both agree on that.  But beyond that...this isn't an insult in anyway but curiosity more than anything;  when did you last work in the field as a medic responding to 911 emergencies?  Not transfers, no flight medic work, but working for a FD, third service, private, whatever as a garden-variety street medic?  You seem to be more of the mind that bringing hospital personell outside instead of improving paramediciene is the way to go.


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## skyemt (Oct 5, 2007)

"Volunteers need to stop wanting all the fancy toys and skills without the training. The arguement that they need them because of the distance to a hospital doesn't cut it."

Wow... triemal04... you say this and you call Rid pious and pompous??
we are a volunteer agency, including volunteer ALS and Paramedic service...
We bust our butts for 1200 calls per year, and we are advocates for increased education.  We work for free, and have no benefits.  But we do it because we want to help our patients. we don't need unions, and we don't :censored::censored::censored::censored::censored: and moan about hours or pay, because there isn't any.

yet, you belittle volunteers...

either you have forgotten the reason you got involved in EMS in the first place, or you really don't quite have a handle on what you are talking about.

if you want to be helpful, triemal04, tone down the judgements and be part of a solution, it would be a little more helpful.

nothing personal, of course.


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## triemal04 (Oct 6, 2007)

skyemt said:


> "Volunteers need to stop wanting all the fancy toys and skills without the training. The arguement that they need them because of the distance to a hospital doesn't cut it."
> 
> Wow... triemal04... you say this and you call Rid pious and pompous??
> we are a volunteer agency, including volunteer ALS and Paramedic service...
> ...


Actually I usually call myself a belligerent sometimes arrogant @#$hole.  

But, if you look at what I wrote, I'm not sure why it's a problem for you.  If you maintain a high level of training and standards, then that is great.  To many don't though, and to many want the extra skills without the extra training and education that is required.  I figured that was pretty clear in that quote.  Now, this does not need to be turned into a volunteer vs career thread, so leave it at that.


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## VentMedic (Oct 6, 2007)

triemal04 said:


> I still can't figure out where you're coming from.  EMS training and educational standards need to be improved, we both agree on that.  But beyond that...this isn't an insult in anyway but curiosity more than anything;  when did you last work in the field as a medic responding to 911 emergencies?  Not transfers, no flight medic work, but working for a FD, third service, private, whatever as a garden-variety street medic?  You seem to be more of the mind that bringing hospital personell outside instead of improving paramediciene is the way to go.



*triemal04*
HEMS:  Helicopter Emergency Medical Service  
As a paramedic on a helicopter that also responds to 911 scenes as well as interfacility, am I less of a Paramedic than you?  Where are you coming from? Should all paramedics only work for your perception of normal to be "street wise"?  You need to get out more. Maybe attend a national conference or something to see just how many different EMS systems there are. 

I prefer to also work in a hospital as an RRT on my off days to stay current in the hospital. There are several of us on this forum who hold several credentials in the medical professions as well as other professions. 



> Where are you hearing so much about medics wanting to work in the hospital? That may be more of a local problem; I can tell you that here it's the exact opposite, and I've never heard a lot (a little though) about medics wanting to move indoors anywhere.


I take it you are also new to EMS and forums.  Search any forum and you will find extensive threads on Paramedics questioning what they can and can not do in the ER and why they can and can not do.  I also hear this a just about every recert class, seminars as well as the FD picnics. 

Some of the skills and knowledge of the paramedic can be used in areas besides the street. Don't criticize someone that may have found a great opportunity working oil rigs, industrial, prisons, jails, theme parks or college campus medic jobs as well as hospitals.  This is a free country and should be a land of opportunity for those who want to work hard and maybe be creative in finding a great job that fits well into their life. 

National standards will definitely increase opportunites for employment if various agencies can petition for reimbursement. 



> Still doesn't change the fact that the place for a nurse is in the hospital, and the place for a medic is in the field.



There are many paramedics that do work in the hospitals for various reasons: hours, family, injury, benefits etc. Don't criticize someone who may have taken the opportunity to do something different with their paramedic training.  You are way too quick to criticize those who do not fit your stereotype.  

If paramedics have a future in public health as described in several recent articles, attitudes that lack flexibility will definitely hinder the progression into a new territory.   

The laws of economics, reimbursement and professional recognition will determine many of wages in healthcare and this includes EMS.  Muscle? Forcing an employer to pay? Would you be the first to abandon a patient to walk a picket line?  The vastness of healthcare, politics and the many types of EMS systems to fund present more variables than one can imagine. One must understand how legislation and reimbursement is obtained. 

Volunteers are not the reason for problems in the EMS community as a whole. Chances are if you lack professionalism as a volunteer, you probably will not change your ways as a paid employee.  Even in the paid services you have the haves and the have nots. That goes for both public and private. 

quote from triemal04


> While I'm all to happy to call some floor nurses bed pan changers to thier faces when they deserve it,


I can not believe someone who is preaching professionalism would do this.  
Showing disrespect to others that you probably do not know is not the way to promote your own profession.  If you want to bash nurses and other paramedics, I can point you to a couple of forums and their threads.  Calling another healthcare professional names of disrepect in the work place is just wrong. Nobody deserves to be treated like that no matter how much they screw up.  Again, we have extensive threads in various forums about the paramedic who thought he/she got disrespected in the ED. Yet, it is okay for a paramedic to do the same?  Someone has to be the example of  professionalism.


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## Ridryder911 (Oct 6, 2007)

triemal04
Obvious your a union man... and we see how much that has helped EMS....no where! Look at AMR's dilemma. No EMS union has made any progression except in their own pocket books. 

We can not get more money from Medicare who then pays administration, until we increase the reimbursement rates.. no matter if your union or not! Union wil not increase payers rates.. 

Go union, I love them ! I definitely love working for hospitals and services when they strike.. the best pay possible, and guess what.. they always have to settle out, plus pay the old union dues. 

Read any EMS journals lately?... hmm... let's see _ Get your RN!_ .. oh here's another one _ Paramedic to RN_... wow! Now, if there was not an interest, do you really beleive they would spend the amount of money advertising. As well, the bridge courses are in high demand, we have 5 in our state with 2 year waiting list. I don't see become a Paramedic in any my nursing journals... then again, it's too easy to be one, just go to most trade schools for a couple nights a week & in a few weeks, your one!  Heck, there is even a "boot camp" Paramedic school in < than 6 weeks, with guaranteed passing NREMT. 

Sorry, I teach Paramedics at various institutions, over 60% of the students only take the course because they think it will improve their chances of getting on at a FD or promotion for FD, the other 40% want to get into nursing school. 

Don't know where you work, but I travel and lecture abroad, and this is a general topic nationwide. Like Vent said, just read the forums... very few want to make the field their home.. 

For Paramedics to survive, the will have to get the "EMS" mentalility out of their head. Emergencies (shootings and stabbings) do not pay.. no one (insuers and Medicare) is going to pay high bucks for a taxi ride with an IV. Again, I suggest to read this months JEMS, and observe what is occuring north of us. Await, the new national health care reform, and see what all you will be doing in the future. People, expect more bang for their buck, albeit Fire Service, private, hospital, or third party. 

As many national EMS educators and those that deal with EMS more than ditch medicine, say .."Look outside the box, if one does not, they will be passed by". 

R/r 911


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## Canoeman (Oct 6, 2007)

*Progression*

This is a great thread. 

Actually I am impressed with all the responses, but as I look at the thread I can see the the opinions on where we have been and what has been the EMS progression are different as seen through a prizm according to the individual. 

I see many various topics that you all see as hot potatoes tossing it around, yet no one seems to what to take the heat and stance to solve the various components. Can we expand our thought process a bit more and divide the issues into catagories and come up with a brainstorming session that can deal with the items. 

All of the multiple topics are issues for all of us and yes things are diffent regions to regions. 

Above all to me is the unification:

This has been brushed on a bit here but one othe most criticical things that I here in almost every seminar I go to, every EMS management tree, and every EMS station I visit, is the unification of all the providers under one department, association, union or what ever you want to call it and that we have no national representation for EMS in general. We need this ----and we all know it -----but we sit and fuss wringing our hands. Why can't we seem to get this accomplished?
I for one do not want to be represented by IFFA or NAEMT or the like. I would like an EMS Federal Boss and a department who can tackle (all) of things that we are mentioning here.

Canoeman


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## VentMedic (Oct 7, 2007)

I have got to reference a thread Ridryder started a few months ago. There were some excellent points made about skills, knowledge and education of both past and presesnt. 

Basics before Advanced
http://www.emtlife.com/showthread.php?t=4830


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## medicprof (Oct 7, 2007)

Its great to see the thoughts flying around about making our profession just that, a profession. I'm doing the research and will be presenting the facts about paramedic degrees. The minimum should be the Associate Degree.


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## disassociative (Oct 8, 2007)

medicprof said:


> Its great to see the thoughts flying around about making our profession just that, a profession. I'm doing the research and will be presenting the facts about paramedic degrees. The minimum should be the Associate Degree.



You should also compare your findings with the advent of formal credentialing for nurses. I believe the degree process holds the key to our future. This way, the provider is proficient in College level composition, Collegiate mathematics, psychology, etc. If only Paramedic degree programs would have the same gen ed as nursing: A & P, Microbiology, Patho, etc. 

For those of you who are wondering why the comparison to nursing is even in this thread, I would suggest to you to research Post-War nursing and how these providers fought for formal licensure, and credentialing. As for the process, we are all involved in continuation of care. Neither one of us(EMT/Paramedic or Nurse) can be defined a definitive care of any patient.

Our job is to get them to the hospital under a physician's care. The nurses job is to care for the patient during the duration of their stay.


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## triemal04 (Oct 8, 2007)

Whoa there ventmedic...I told you, I didn't mean the question to be insulting in any way, I'm honestly curious.  (still am if you don't mind, when did you last work on a car?)  I'm not sure why that question upset you so much, flight medics here are required to go above and beyond the normal medic requirements, and that holds true for several out of state services I've heard of, and hopefully holds true nationally.  So no, it doesn't make anyone less of a medic.  What it might do is change someones perspective of EMS; not always bad, but how you see EMS at the bottom tier may be different than someone working in a car.  Think about it, most flight services I've seen are generally well run with highly educated, well paid employees.  They usually only run on critical pt's and have a lower call volume than a lot of street-level services.  A lot of the work may be done in a more clinical environment; picking someone up from an ER/ICU/hospital, you'll have a lot more info (hopefully) than someone walking into a house, and certain treatements may allready be done (again, not bad, and if you respond to the scene sometimes not always true)  Now, none of that is bad, but it may lead to a different perspective, which is what it seems to have done for you.  Now one last time:  that isn't neccasarily a bad thing.  My only problem with some of what you've said is that you seem to be turning your back on EMS and advocating more for bringing hospital based personell outside and not improving the level of paramediciene.  

No, I stand by what I've said about medics working in hospitals.  I know of people who have tried to get jobs as ER Techs or something like that because they could not find a job on an ambulance, but I still have never heard of anyone going through medic school so that they could work in a hospital.  There is no push that I've seen or heard of to create a role for a paramedic in the hospital as a replacement for, or equivalent to, a RN.  There's no push to create a role for a paramedic in the hospital period.

Now I'm sorry, but when have I critisized someone for working in a prison, oil rig, industrial site?  You need to pay more attention and not get so angy at comments.  Working at a place like that is still different than working in a hospital.  For a lot of oil rig work, given that the medic may be the ONLY medical care around...nothing wrong with that, and my hat's off to people who do it.  Doing that is no different than doing what your average paramedic does, except they need to know a lot more clinical mediciene.  Which is a good thing.  Bottom line:  the place of a paramedic is not in the hospital.  It is not what we get trained for, and hospitals are allready well staffed with people with different levels of training.  There is not a need for another.  If people do, they do, fine, but it isn't the primary spot that we belong in.  

The comment about volunteers was specifically aimed at people wanting a skill without the required knowledge.  They aren't the main problem with EMS, but they can contribute.  Just like many paid providers can also contribute.

Now look, I don't care if you call it a union, national organization, or a breakfast club, EMS needs a voice on a national scale that will speak for us and us alone.  Since you're so fond of pointing it out, changing legislation and the way that we get reimbursed (especially through medicare) will take a lot of work.  Who is doing that now?  Who's working on that at a national level?  See the problem?  There are a miriad of problems with EMS and changes to be made, but nobody is pushing for them to be done nationally, and pushing hard.  For the pay...you can be happy with what you make and not care about anyone else, but personally I am sick of seeing medics make 10-12 dollars an hour with no benefits while the owners/directors/trustees of the company they work for walk away with 4 times that.  Private sector EMS sucks...the compensation won't increase unless someone makes it happen.  The same could happen with fire or third service.  Paramedics will not be paid an appropriate wage until we are recognized as a true medical professional, people know what we do, we are well trained in all areas, and someone is look out for us.  Again, I don't care if you call it a breakfast club, but something needs to be there.

I think I made the analogy once before.  Look at IAFF (union) and NFPA (nat'l org).  Together they have done great things for the fire service in almost all areas.  Why shouldn't we have 2 groups like that for EMS?  Unions can, and should be doing more than just working for better wages, and I've said as much.  Please, tell me what the problem is with having someone advocating for EMS?  

Actually, my comment about bed pan changers was mostly a joke.  I've never said that to someones face...wanted to several times, but haven't, mostly for the reasons you listed.  Plus I really like my job.  And it's not nurse bashing, like every profession, including EMS, there will be good ones, and bad ones.  Does that mean that you should never point out the bad ones?  

Rid...I have no ideas where your "medic to RN" comments are coming from.  Someone wants to become a nurse?  Ok, good for them.  What's the problem?  The bootcamp medic school...that is a huge problem and one of the things I'd like to see go away.  

I'm going to go out on a limb and say that your 60/40 split is completely false.  Unless the only ambulances in your area are FD run, and then I suppose it could be possible.  On the off chance that it is true...shouldn't we, or some group anyway, be helping to inform people of what paramedics do so that people go through medic school with the express goal of being a paramedic, FD based or otherwise?

I know about what Canada is doing.  I think it's great, and I think there are definetly applications for it down here.  Definetly in rural areas, but with a few tweaks and changes it could even have some use in more urban areas.  Probably won't have any complaints on that from me.


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## triemal04 (Oct 8, 2007)

1.  EMS needs a voice at the national and local level to advocate for us, be it union or otherwise.

2.  EMS needs an organization that will work for change in the system.

3.  Pay paramedics an appropriate wage.  

4.  Increase the training requirements for paramedics.

These are the 4 things that I've harped on in almost every post in this thread.  Why are any of them a bad idea?


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## skyemt (Oct 8, 2007)

Triemal04, you seem to have many criticisms, and of course, you seem to "inadvertantly" offend some people along the way... so as to offer an opportunity for you to clarify something for me, would you mind creating a reply outlining what you think is "good" about ems...

surely, while debates on areas to improve are important, it is also important to keep a balance between what works, and what doesn't... perhaps you come across as too weighted on the negative side...

so, triemal04, what works for you in ems?


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## disassociative (Oct 8, 2007)

You know, this sounds like a good group project: Define a better EMS.


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## triemal04 (Oct 8, 2007)

skyemt said:


> Triemal04, you seem to have many criticisms, and of course, you seem to "inadvertantly" offend some people along the way... so as to offer an opportunity for you to clarify something for me, would you mind creating a reply outlining what you think is "good" about ems...
> 
> surely, while debates on areas to improve are important, it is also important to keep a balance between what works, and what doesn't... perhaps you come across as too weighted on the negative side...
> 
> so, triemal04, what works for you in ems?


Sure.  In a nutshell: the entire concept of EMS.  Of all the changes made to medical professions over the last 30 years, of all the new fields created, personally I see EMS as the most important one and the one that has had the most impact and helped, and can continue to have the most impact and help the general public at large.  The ability to have hospital level care at your door within a few minutes is an absolutely wonderful thing.

A tiered level of training is very appropriate.

The fact that many advances in mediciene and equipment come from field work; EMS is a great way to improve mediciene as a whole and try new things.

I can go on, but the first part really says it all.  EMS works.  I love it.  End of story.  If I come across as "weighted on the negative side" it's because there are problems with EMS at the national level and changes must be made.  Anyone who thinks otherwise isn't paying attention.  My problem is that if nothing changes I can see EMS spiralling downwards until, in another 30 years, there will be some good local agencies, but on a national level EMS will be much more basic and not always used.  Like I said several pages ago.  

Most of the things that bother me are happening beyond the local level; we've been around for 30 years now, it's time for EMS to grow up and start acting like a true medical profession.  

Now, what are all these critisims that I have?  The lack of mandatory quality education?  The lack of a strong nat'l body working for improving EMS?  Poor pay for medics?  Are these things not true?  Should we just ignore the problems and hope they go away?  Hell no.  Part of improving things is looking at the problem and acknowledging it, not downplaying it.  And if doing that means that I offend some people...I'm not going to lose any sleep over it if that means that people will start wanting to make a difference and make some changes.

Now you tell me:  look beyond your own service at what EMS is like throughout the US.  What are the problems you see, and how should they be resolved?


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## skyemt (Oct 8, 2007)

triemal04, thank you for your answer and your candor...
it wouldn't be fair for me to comment on hours or pay, since i work for a fully volunteer agency...

however, lack of a national body is a concern... better education is a concern... i am hopeful with the advent of cme, that very good, informative, educational classes will be coming down the pike...

i see lack of standardization in levels as an issue... it seems like a mess sometimes when some counties have emt-i, some don't... some have three levels, emt-b,cc and emt-p, and some have five... first responder, emt's b,i,cc,p...

i also would like to see more standardization among protocols for different levels... some b's can administer certain meds, and some can't administer any... while puzzling for the emt's it also creates confusion for patients who have been treated by a bls crew who could administer meds, and then is treated by one who can't... i have run into that before...

but to me, these issues are more about "quality control", and not about a faulty product... like you, i believe that EMS works, and if improvements can be made in these areas, it will only continue to work and grow...

those are some of my thoughts... any comments?


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## triemal04 (Oct 8, 2007)

See?  Look at that, we pretty much agree completely.  

I guess you could call some of the problems "quality control" issues, but that leads back to...who is responsible for fixing those issues?  It can, and is fixed at the local level in many places, which is a great start, but it needs to go further.  I agree with all the things you pointed out, but now that the problems are known about, we need to be asking ourselves "how do we fix this for EVERYONE, not just our local service?"

EMS definetly works and is not a faulty product, and it is most definetly NOT broken.  But it is cracked, and I don't want to see it go any further than that.


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## VentMedic (Oct 9, 2007)

So, how many people here talking up education have at least a two year degree in EMS? or the health sciences?

For those that have 2 year degrees in EMS:  How many obtained their degrees before 1990?  

How many were encouraged by their instructors to continue on to a two year degree? 

How many were told "you'll get every thing you need to know about being a Paramedic without wasting time on other classes"?

How many believed it then and still believe it? 

How many are planning to get a two year degree in EMS or the health sciences even it doesn't become a standard?

How many have encouraged your co-workers to get a degree in EMS or the health sciences?

I know there are many people on this forum who also hold degrees in other areas of medicine and people who hold degrees not related to medicine.  In each class, were you encouraged to go further in your education?  How many were encouraged to get a Bachelors or go on to graduate school? 

Did anyone have a mentor in the profession (any profession) to encourage them to go further?

How many have belonged or do belong to a state or national professional organization (NOT UNIONS) that promotes EMS?   Or a specialty EMS organization?


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## triemal04 (Oct 9, 2007)

VentMedic said:


> So, how many people here talking up education have at least a two year degree in EMS? or the health sciences?Yes.
> 
> For those that have 2 year degrees in EMS:  How many obtained their degrees before 1990?  No.  Not sure why that's relevant, unless you're checking to see how long someone has been a medic.
> 
> ...



Look.  You can get angry and upset if you want.  That's ok.  Please though, before you do I do honestly want to get a couple of answers from you.  This isn't from spite, but I really want to know, I'm curious.  I can repeat the questions, but they should be clear by now, given the number of times I've asked them in this thread, and others.


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## VentMedic (Oct 9, 2007)

triemal04 said:


> For those that have 2 year degrees in EMS: How many obtained their degrees before 1990?  No. Not sure why that's relevant, unless you're checking to see how long someone has been a medic.



The majority of the more than 300 two year paramedic degree programs were started well before 1985. Students were encouraged from 1975 to 1985 to get a degree in EMS because that was the future. So if you entered a program in 1985, you probably graduated prior to 1990.  We were preparing for something bigger and it came close to happening.


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## Guardian (Oct 9, 2007)

Great discussion!  I'm going to try and stay out of it because I don't want to ruin it.  I'm impressed with a lot of the comments though


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## Guardian (Oct 9, 2007)

triemal04 said:


> Private ambulance services need to go away.  It's been 30 years of the dash for the cash, and now it's time for something different.  Begin a push (a very strong push) for third service EMS.  Local gov't agencies (from city to county) should start being responsible for running an EMS program; in rural areas this would actually help as it would more than likely let them maintain some paid medics for the area.  Get federal money out there when neccasary to help, and advance the use of fixed wing and helicopter transports for the very rural areas.  It'll take time and money, but it can be done.




Ah screw it; I can't stay out of this discussion.

This is a big can of worms right here.  I used to feel like you until I argued with rid about it on this site and now my attitude is changing.  There's a link somewhere...


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## medicprof (Oct 9, 2007)

I can see some really great thoughts about the future of our profession. Join the NAEMSE, and any of the other associations to lobby for where we need to go. The "Agenda for the Future" should be on every desk of every medic and medic educator.


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## firecoins (Oct 9, 2007)

What exactly should go into an associate's degree in Paramedicine contain?  I ask this because I choose to go to a hospital based paramedic program and not a Community College based program.  I did this because I felt in the end the hospital based paramedic program was much better.  Rotations were done in a learning hospital and rotations on a FDNY participating hospital rig.  

The classes taken in excess of the medic program at the comminty college included math and english, a diversity class, medical terminology, an into to allied health class and A&P I & II. Some of these classes I already had in my BA degree.


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## skyemt (Oct 9, 2007)

so many good points out here, from many different contributers...
firstly, as i am not a paramedic, it wouldn't be fair for me to comment on the educational standards of paramedics...
but i am a proponent of better education, and i think it starts from the bottom up... the way basic ems is taught, at least in my state, is geared toward passing a separate "practical skills" exam, and the the written "knowledge" exam... however, as we all know, many students, als and bls, pass the skills exam without the applicational knowledge we would desire them to have...
case in point: you can pass a skills exam on CPR... get all your critical points checked off on rate of compressions, ventilations, etc... BUT if you are not sharp on your physiology, and you do not know WHY is is important to compress at least 1 3/4 to 2 inches, or WHY it is so important not to overventilate, you are much more likely to make a mistake here in the field than someone who does... yet both would have "passed" their skills exam...we were not really taught to really apply the physiological lessons learned to the skills being performed...
i believe this is one of Rid's earlier points about really knowing more physiology on even the basic level...

an obvious solution is to blend knowledge comprehension into the skills exam... to stop someone rattling off the hypoperfusion protocol, and see what they really know about hypoperfusion... i know from my own class, it would make the exam far more difficult...
the problem with this, as far as the state is concerned, is that it brings too much of a "subjective" element into the testing, which they want to be "objective"... the problem, of course, is that our job is very "subjective"... we have to choose a protocol, and much is based on our history taking, which can be very subjective, and referred to as the "art" in our job.

to me, that is a big problem... new emt's and i've even seen it at the ALS level, are being taught in an "objective" way, tested by and objective list of boxes to check, and our sent out to practice subjective thinking and decision making witout a good understanding of how the physiology really applies to what we do... we all see what the results of this are...

now, for the more motivated emt's this won't really be a problem... they will learn on there own... they will come to forum's such as this to stimulate thought, and learn some more... to marry the subjective to the objective...

the problem lies with all the emt's who don't visit this or other sites... who don't look for extra education... and they are the majority... all they have to rely on their prior education and testing methodology in place... and this is where a major bump up in the educational process is needed, in my humble opinion.


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## VentMedic (Oct 9, 2007)

Healthcare as a whole as seen the evolution of new jobs, job titles, licensing, re-credentialing, departments (in hospital and prehospital) reorganize, jobs eliminated, jobs created and colleges constantly changing curriculums to meet the demand.  

EMS as a SYSTEM has changed. Unfortunately not all components of the system have changed equally.  Has prehospital care changed enough to warrant a re-evaluation of the standard? Has the perception of prehospital care by the providers themselves changed? 

Hospitals have re-organized their care centers and resources which now require more critically ill patients to be transported between facilities. Twenty years ago, it was the occasional balloon pump patient that needed transport by the local ALS ambulance and it usually was no big deal. The balloon pump training was provided by the hospital classes with a little hands on. I have been criticized for mentioning that many hospitals saw a need to train nurses to do the transports where paramedics once ruled in that area. Hospitals unfortunately found that prehospital providers could not keep up with the changing inhospital technology. Also, not every crew, even though they were in a truck that said CRITICAL CARE TRANSPORT was equally prepared.  It has nothing to do with who's turf or who should stay in the hospital or out of it.  It's about being educated and skilled enough to provide the necessary care or at least know enough when you are not the most qualified to provide the care.  For some, it is difficult for them to admit that their overall education is not as up to par as they would have one believe.  

PHRNs, yes, in some areas there might be a need depending on that type of EMS system. Remember an EMS system consists of more than ambulances and fire fighters.  If there was a need that could not be filled by other EMS providers of whatever title, than another title is created to fill the void. Eventually, the strongest survive as we have seen throughout the last 30+ years.  EMS has practiced this patchwork of titles with 46 different certifications in the U.S.  

So, when considering what must be done, the SYSTEM and how all the components fit must be examined. Many times the funding is for SYSTEM. Individual components then compete for their share.


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## skyemt (Oct 9, 2007)

vent, i have to think it is a question of not seeing the forest through the trees...

in reality, there is no real "system"... there is no national standard, no national governing board...perhaps you could say that national ems is made up of all the thousands of "mini-systems" made up by different counties and localities across the country...some are better, some are worse... some more advanced, some less... you get my drift...

i believe the solution starts "grass roots", from the ground up...get the basic level more organized, and standardized, and you have a common surface to start building blocks from...

as it is now, it is too chaotic from state to state, even municipality to municipality, paid to voluntieer, etc... the majority of ems calls are bls, so it is a good place to start.


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## VentMedic (Oct 9, 2007)

Now for the bottom up to happen, funding and authority from the top down must be recognized.  

Start with you state's EMS page. See how your EMS system is organized. Where does your trauma funds come from and go to?  Where is FD in the hierarchy of the scheme?  What legislators are sympathetic to the cause? 

Find out what grant writing is being done.  What taxation issues are being proposed? Which agency is benefiting from legislative pork? Why do some areas have volunteers, some have paid and some have municipal or county.  How have the county systems evolved? A lot can be learned from our history. Many counties have gone from having 10 - 20 individual providers to one county system or a half a dozen municipal systems. Then, you see headlines about funding or lack of. Who has the better plan? There are college degrees based on just pondering this question.  

An idealistic view of "grass roots" is fine, but, it is better to have an understanding of the government entities and how they factor into change. 

Of course, if radical changes are made in healthcare, everybody may be scrambling back to the battle field for their cause.  Those who read the legislative pages on their home EMS websites will be the most informed. 

Does your state have its own EMT or Paramedic organization? Have you checked your state's EMS board for regional meetings?  Until you actually start acquiring knowledge from the people or legislators that are supporting you, it is difficult to see what has been done to bring about change.  Until EMS people do start taking part in what is available, the cause is will struggle.  

Remember even for the education standards to change, colleges will have to be on board with it. Most have the same basic EMT or Paramedic curriculums but the degree may vary from college to college.  Check out the organization that is rewriting the education curriculum. See what and who they have petitioned for change.


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## medicprof (Oct 10, 2007)

VentMedic said:


> So, how many people here talking up education have at least a two year degree in EMS? or the health sciences?
> 
> For those that have 2 year degrees in EMS:  How many obtained their degrees before 1990?
> 
> ...



VentMedic, 
I have my degree since the 1980's and I also have my Bachelor and master's. The masters is in adult education. I am convinced that a degree will help with patient care, the main issue, and will help to bring the profession up in status. We need to get to the state Department of Education and let them mandate the level of education needed to become a paramedic. The individuals I talked to from the DOE have told me they just need to become involved. The cost of education will work out on its own as student will find the money for school. The fact of the matter there should not be a choice but rather it should just be a mater of fact.


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## VentMedic (Oct 10, 2007)

Good article from JEMS published May 2007.
http://www.jems.com/news_and_articles/articles/EMS_Needs_a_National_Brand_Identity.html

*EMS Needs a National Brand Identity*
Matt Zavadsky 
EMS Insider May 2007 Vol. 25 Issue 5 
May 1, 2007 
Editor's Note: In May EMS Insider , we promised you more from Matt Zavadsky on the topic of branding EMS. In a special Web exclusive, here's his take on how to create a national brand for EMS.   


As a profession, EMS has a lot of work to do to create a respected image or "brand identity" on a state and national level. Perhaps the most poignant comment to illustrate this point came from an elected official in the Florida Senate when several of us were lobbying for an innovative change to the statutes that would dramatically improve patient care. One senator said, "We cannot vote to pave a road for you EMS people when you all want to take different roads." Painful. But you know, she was right. The measure failed.  

We've been so busy pursuing the public vs. private agenda that we've lost credibility on a national front. We've invested so many resources battling each other that we've almost lost the war.   

There seemed to be a glimmer of hope when the lobbying group Advocates for EMS appeared to be making progress pursuing a truly cross-representative and singular voice for EMS on a national level. However, now as the April  EMS Insider reported (in "Fire Service Groups Create EMS Coalition"), one sector has created its own advocacy group specifically geared toward promoting its own agenda for one type of service-delivery model.  

So it's back to square one.  

In the fog of this public vs. private war, EMS has lost its identity. We can ill-afford to invest our resources arguing which EMS "brand" is better. Instead, we must focus nationally on elevating the  profession , working in unison toward common goals. 
http://www.jems.com/news_and_articles/articles/EMS_Needs_a_National_Brand_Identity.html




> So many issues affect all of us in EMS, whether the name of our agency ends in "Inc." or starts with "City of." There's scope of practice, workforce development, funding and reimbursement, vehicle design standards, liability reform, treat-and-refer programs and a host of other challenges.


http://www.jems.com/news_and_articles/articles/EMS_Needs_a_National_Brand_Identity.html


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## Ridryder911 (Oct 10, 2007)

As a member of Advocates for EMS, I realize what their goal is. Albeit, somewhat generic and watered down, it is at least a start building a coalition. Without large member participation and active members, we will NEVER get the legislation's attention. Remember, for every $1.00 there is about 3 million groups that want it as well. All with valid points and needs. 

The difficult part comes with the "hidden agenda" each player brings with them in a coalition setting. There is no escaping it. Hopefully, we can place those behind us and actually agree that we are there for one ultimate goal.. that being for the patient. 

Now it appears fire dogs, want to go and be sure that nothing changes to severe .. especially in regards of education. Since most FD's are geared for training rather than educating. The old saying FD's hire below the neck is unfortunately being more stressed and stressed instead of attempting to change their image. Unfortunately, since they have numbers.. we may have a large fight on our hand. 

R/r 911


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## firetender (Oct 11, 2007)

*The nature of the beast!*

Before I went into EMS in 1973 I was one of the first males in an RN program in New York (Queens Hospital Center). Nursing was at a turning point. RNs were in the midst of a transition and that was all about legitimizing themselves as other than just a doctors’ prosthesis. They began taking control of their own internal standards and along the way showing us how what they did was important enough to help them better their working conditions. They started by establishing local, and then regional professional organizations.

Flash forward and I was an MICU paramedic in California with ten years under my belt working on building legitimacy for that profession. This included issues of equipment, modalities employed, hours (96 hr. work weeks), coverage areas (this address gets ALS: across the street; Basic), remuneration as compared to other vital protection agencies ($900/month vs. $1,300 for fire), response time, and on and on; you know the drill.

Neither local government nor the companies were listening. What we were saying pretty much had to do with raising the standards of the profession in that particular county. After five years beating our heads against the wall -- county and private company pretty much working hand in hand to keep all levels of service and care at a marginal level, while medics were burning out left and right -- myself and a couple other medics looked at what the RNs had done and saw the model.

We developed a professional organization, (that went on to be called the California Paramedic’s Association) and began developing a twofold program of becoming a “voice” to publicize the value of paramedic services to raise overall community standards and organizing to lobby for better working conditions.

We put together a platform that placed emphasis on standards of care first…just like the Nurses had done. After a couple years we were making headway in that direction but registering zero on the equitable professional treatment level. Backs against the wall, we turned to the SEIU (AFL-CIO) for support.

What we did was to develop a unique charter where there was separation between labor organizing and professional development. The Union was contracted to represent us solely in labor negotiations, while the CPA was assigned with the responsibility to lobby for setting higher standards in emergency care. 

The union was voted in by better than 80% of the medics involved. The CPA was the first union for EMS West of the Mississippi. That’s where it ended though. Within a couple years, the union trucked along (don’t know today’s status) but the aspect of a medic-driven pursuit of higher standards for the profession pretty much dribbled away.

What happened?

Only a few of us held a greater vision at any one time. Medics would come in, participate, and when it got rough, drop out. We had the ears of the medics on the working conditions, but still, 99% of the work had to be done by those of us who were willing (or dumb enough!) to dedicate most of our off-hours to the task. We knew the union was only a vehicle of stability to help us do what we really wanted to do – legitimize the profession and put it on an even level with fire and police protection so we’d have a future in it.

Herding cats is one way to put it. But, for the most part – and this after at least five years personally dedicated to organizing (I was “Communications Officer” for at least four precursors of the union, almost without a break) – what I found was that the medics themselves viewed the position as transitory. They were interested in pay and benefits and hours, but they lost the vision for the future because they did not see themselves as having a future in EMS unless they went to management

In my experience, most of the medics who did stay in the job beyond ten years just wanted to do their shifts and go home. It’s about the job, not the profession. Why? Because all the other stuff is related to politics, uphill battles and a burnout that feels even more debilitating than call-related trauma. Personally, I never burned out on the work. I burned out on the politics.

Most medics then and now know that they are just a few bad calls in a row from throwing in the towel. No one, not the medics themselves, not their employers, and not the governmental institutions that regulate the industry have taken steps to build  outlets so those in the field are encouraged to stay in the field. This includes acknowledging the high-stress of the job and developing “safety-nets” for the medics. Just like always, the primary issue is keeping warm bodies in the rigs by taking advantage of the rookie’s altruistic impulses.

I would say there’s a coming together of influences: the high specificity of the job, the economics of actually supporting a high turnover rate to keep salaries and benefits in check, and maybe most important, the fact that it does take a lot of psychic energy to do the job and there just isn’t that much reserve left for the medic to enter political battles against people who still see medics as Ambulance Drivers, aka, glorified civil servants.

Look at this site alone. It’s rife with older medics tempering Newbies with sage advice, while warning, warning, warning about how it’ll be nothing like what they envision. This is twenty-five years later in each of the areas we were appalled at back then!

As long as there are young men and women doing out in the field what most doctors can’t do in the hospital there will be issues of power and responsibility  dependent on local standards. At any point in its development, if the right person (with power) gets tweaked, it’s back to the drawing board and modification of what levels of care can and cannot be delivered. A lot more people react when something goes wrong in the back of an ambulance than when something goes wrong in the hospital. Why? Once again, these snot-nosed kids are not supposed to be doctors.

Nursing as a whole has many, many specialty career outlets and opportunities to cross over to from wherever you’re at. It also has a better-defined system of reciprocity from state to state. Standardization in pay, benefits and opportunities has come about through local professional nursing organizations bonding with others nearby and establishing unified, therefore effective, voices that eventually went National. In that respect nursing had the numbers to expand the web of their affiliations and support. This doesn't exist in EMS.

In conclusion (for this part, anyway), I think the odds are stacked against the medic to make this a bonafide profession like Nursing. 

First comes the way medics view the profession as a no more than a stepping-stone to something with more stability. The agencies that render the service support this. I think there’s no plot there, they’re just working with what is. What is is that for the most part, medics are a transient work force. 

Second is the high specificity of the job, which really limits flexibility and outlets for cross-training and placement. Besides, most medics just want to run calls, and “good” ones at that. 

Yet Fire and Police departments have, within the context of high specificity, integrated themselves into the fabric of society as ESSENTIAL services. They have built avenues that support internal movement and opportunity such that they can maintain relatively stable work forces. 

Could that be because you can pretty much eliminate fires and crime, and Firemen die in fires and Cops get shot, but for the most part the medic is in a losing battle against death and the only thing that dies in the medic is his or her soul which doesn’t make good copy? 

The final (and perhaps unifying) factor is that there are very few people built for the onslaught that is emergency medicine. It takes a certain kind of person to deal with the territory, and usually, there is a prime time in life when that can happen. It is a limited period of time where the attraction to the field is sustainable only during one’s vital second and third decades. And then, for the most part, the cumulative pressures wear you out.

Next round, I want to talk about the way things are and potential avenues for expanding the job description to meet the changing face of medical care.


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## triemal04 (Oct 11, 2007)

Ventmedic-  I'm still not sure what you're getting at with the year the degree was given, other than pointing out that initially EMS was concerned with the amount of knowledge/training required and tried to make it a good system.  And failed unfortunately.  It does bring up a good point though:  look at what a paramedic can do and must know compared to what could be done in the beginning.  If people 30 years ago recognized the need for a long, extensive training program...what the hell is going through people's heads today!?

Now, be honest.  I haven't critisized you for wanting RN's to do transports, far from it.  I have, and will continue to critisize you for wanting to introduce PHRN's, a certification that could, and very likely would be used to compete with paramedics in systems that respond to emergency calls instead of improving the training given.  Now we've gone over that ad infinitum, don't know why you'd try and misrepresent what was said.

EMS is not really a unified system nationally.  If you want that to change, why not advocate for it?  Why sit back and let it continue instead of trying to get some group or another involved to help fix the problem?

Now, is there anyway I can convince you to answer any of the questions I've brought up and refute anything I've said, or will you just continue to ignore it?  I'm ok with either one at this point.  

Gaurdian-  it is a big can of words, and I'd be happy to open up that can, but in a different thread.  

firecoins-  the program I went through required A&P 1,2,3, chemistry, biology, Intro to EMS (hx, CISM, ethics, etc) EMT-Rescue, communication/transport (how to write a chart basically), math, speech, english, basic health course, medical terminology, psychology, a couple of electives, computer course and maybe one or two other core classes, I can't recall.  Plus the EMT-basic course.  I'd like to see a pharmocology class added, but that isn't bad for the minimum standards as I see it.  With a system like that the paramedic course itself is focused ONLY on paramedicine; the rest has allready been covered.

skyemt-  yes, changing the testing process for all new EMT's is definetly a must.  The same with the internship.  Look back a couple of posts for more.

Rid-  got anymore info on Advocates for EMS?  Never heard of it before.  

firetender-  my hat is off to you and I'll shake your hand if we ever meet.  What you tried to do back in the 80's is what is needed today, but on a larger scale.  Unfortunately, the problems that you experienced would probably pop up again today.  You tried though, and for having the vison and drive to do that...thank you, it sets an example for everyone to follow.

I think that there are more people now who are getting into this field because it is what they want to do and not just to use it as a stepping stone.  I realize that may not hold true everywhere; a lot depends on how difficult it is to become a medic I think; if it's a 2-3 year commitment vs 1 year or less, the people who just want to cert as an extra merit badge will (hopefully) be scared off from trying it.

Fire and police definetly do have their niche carved out for them.  But, that has taken place over 200 years, wheras EMS has only been around for 30 odd years.  Hopefully we can get there ourselves.  But, to do that, we need to be unified, and we need a voice.  Like you've allready tried, but bigger, if that is at all possible.

Curious, when you had the union and CPA going, how did it work initially?  Did they work together?  Did they need to?  Were any advances made in training, education, working conditions, eet etc?  Or did it fall apart immedietly?


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## Ridryder911 (Oct 11, 2007)

Firetender, you brought some very interesting points. I agree, the "politics" of the business is what usually "burns" out the professionals. The eager Johnny Go Rescuer, usually exits much sooner. You will have some that attempt to change things, and finally after years of hitting a brick wall, and their head, they finally leave EMS dissatisfied. 

The problem is, that those that serve (like yourself) make progress and then it stops when no one else will replace the fallen. Then years later another poor soul will attempt, then the cycle continuous. 

I was fortunate to meet with an EMS professional in the education department of a university. I was impressed (as I believe she was as well) on our similarity of views and visions of EMS. I have to admit it was refreshing to meet another one, whom wants to remove the "good ole boys" system in EMS. Education actually matters, that improving entry requirements to screen those that are  really interested in EMS as a profession, that actually are willing to prepare themselves mentally and physically for the profession. 

I have to admit it is shameful; when most colleges will not recognize EMS textbooks due to the lower level it is written at. When the whole profession can be placed into one text, one must realize there is something wrong. 

In regards to PHRN's I am not worried, nor should anyone in EMS feel threatened. In fact instead of worrying about them, we need to focus on ourselves. If we become replaced, it will by our own doing.

Let's focus on subject(s) at hand : 
> Poor to no education, rather trained at any building that can store CPR dummies. 

> EMS instructors only education in teaching is a week long lecture. EMS administrators that endorse multiple levels and poor training for many reasons: ability to charge for higher rates & maintain poor pay scale, limit possibility of employees leaving for diverse positions. 

> Fire Chiefs that finally realized that EMS is the best PR tool. They can demonstrate productivity, allow EMS to wear the FD logo (although technically they are not really F/F) and pay them cheaper salary and no benefits.

> EMT's that have a apathetic attitude, as long as the check clears.. who care.. then there are the ones whom will even fight any advancement in education improvements secondary of worrying about volunteerism. 

> Poor pay and no career ladder all lateral movement, no matter what position is obtained. 

We can not approach law makers (locally or federally) if we do not come in unionization (not union) presenting our case. Lawmakers do not presume anyone (organizations) represents their profession if they are made up of > 25% of the number of their profession. This is why active participation is so crucial from multiple organizations in agreement so a coalition can be made. This is what make me so disgruntled. About the time we advance to upward, special interest groups (IAFC, Volunteers) pull the card of being worried to advance, protecting themselves rather than having interest of the patient in mind. 

Hopefully, with forums such as this we can educate  all members of EMS to participate and improve EMS standards. 

Info: http://www.advocatesforems.org/

R/r 911


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## firetender (Oct 12, 2007)

Two points for triemal04:

I think very few of the people who come into EMS come in with the intent that being a paramedic is a stepping stone. There are some who consciously do this (i.e. to get higher priority for Fire Service hire), but most enter because they want to provide EMS. Once they're in and see the nature of the (monkey) business, however, THEN they decide it is just a stepping stone.

and...

Haven't thought about this in a long, long time.

The truth is within a week (or so?) of the successful vote of the company paramedics for union affiliation, me and my partner got fired by the private provider for a minor infraction. They fired me, talked the county (Santa Barbara) into revoking my paramedic certification, got California to revoke my ambulance driver's certificate, and denied me unemployment benefits based on "Gross negligence in the performance of your duties"!

I spent the next 9 months of my life challenging them at every turn at hearing after hearing after hearing, until I got everything reinstated. Everything, that is, except a favorable ruling from the (Reagan-directed) National Labor Relations Board showing that the firing was a direct result of my union activity.

From what I understand, the transition went smoothly, though I didn't get to see how it developed. The union did not come to my defense in other than a marginal way. I suspect I was a sacrificial lamb, like my company saying: "Let's not start off by fighting. He's always been a rabble-rouser. You got what you want (spelled d-u-e-s ? ) so let's move cooperatively from here."

AirwayGoddess is still in touch with a couple of my co-conspirators. At this late date, I, too, would like to hear how things unfolded or unravelled as the case may be.

After I got everything reinstated, I decided I had enough, wrote a screenplay and spent the next nine years of my life trying to get it made as I explored more of the incredible world of the healing arts. I suppose I was bitter for a while, but that's really not who I am.

I've been much too busy -- and this is no joke -- spending the last twenty-five years of my life assimilating the precious things I learned in the back of an ambulance.

Without that spin, I wouldn't be here, and I can't tell you how happy I am to be here!

...Oh, and don't squirm when you reach out your hand for a shake and get a hug back!


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## Guardian (Oct 12, 2007)

firetender said:


> Two points for triemal04:
> 
> I think very few of the people who come into EMS come in with the intent that being a paramedic is a stepping stone.




Every time I start agreeing with you, you write something like this.  Have you worked on an ambulance in the last 15 years?  I would say the vast majority of people knowingly see ems as a stepping stone before they even take emt-b.  Stepping stone to FD, RN, MD, PD, STD, and the ever sickening "Flight Medic."  I can't stand these people who decide they want to be "flight medics" before they even take emt-b.  Worst yet are the people who want to be "flight medics" simply for the "prestige" and "excitement", and not the authentic desire to provide great paramedical care.  That's a lot of quotation marks, but they are there to point out the idiotic delusions that piss me off the most.  Largest still, are the people who use ems as a stepping stone for excitement, and have no real interest in helping people.  Anyway, I’m digressing.


I’m doing college research on theories involving sociological commodification (mass manipulation).  One of the great lines is “to offer and to deprive them of something is one in the same.”  So Zavadsky’s article was right up my alley; thanks for posting vent.  When I get some free time, I hope to combine some of these theories and apply them to ems in relation to its national brand and/or lack thereof.  Stay tuned.


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## Ridryder911 (Oct 12, 2007)

I agree. This is some of the points me and this college EMS coordinator was discussing. Even many of those that are entering an associate degree no longer have intentions of working in the field, rather immediately to leave into another profession. 

Collegiate level courses usually have lower number of applicants than some other traditional programs. Even with the number of applicants in other programs it is estimated that only about 1:10 to 1:12 have any intention of working in the field. This of course leads us into having one to two students that have any intention of working in the EMS profession. This is not even accounting the points that "if" they pass or "if" they are desirable to be employable. 

Most of the programs I have seen, (not just in my area) are now breeding grounds for pre-fire employment, pre-nursing, other medical occupation to hobbyist. 
With FD's increasing the number of Paramedics on their staff, many will even enter and complete the Paramedic program in hopes this will increase their chances of employment with a FD. Even though, they have no intention, or desire to ever to work in that capacity. 

The same true for those wanting to enter or are on hold for a nursing program. Many feel this will increase their chances, or will be able to accomplish "bridge" programs.

These are some of the major problems we have seen in multiple areas. In fact I am consulting some peers today in to attempt to form a coalation addressing this very problem. 

There are EMS services that pay decent comparable salary within the region  however; are loosing any potential interested candidates and even experienced Paramedics. Metro cities that are located across the state border (approx 1 hr) that having starting salaries that are double to almost triple what any EMS can pay. Due to the region the EMS is in, Medicare will never pay reimbursement rates enough to be competitive enough. 

As well, we need to be objective and honest. Why would anyone really consider entering EMS? Very few services offer competitive wages, as well as retirement, full medical and dental benefits, and retirement? Even my EMS, which the second highest paid in my state, caps out the salary after just 10 years.. so yes, we have many "lifers" leave due to no more expectations and growth. 

As well, why should anyone ever enter a profession that is dead end? Seriously, after the Paramedic level there is no where for a person to go. They either enter education or management level... that's it. Some will still perform in the field, but after years of trivial pay increases become discouraged. 

How do you approach a young person to enter EMS with those facts? Knowing, within five years they have hit the high point of their career. That within ten yrs or so, they have reached their full career ladder. 

We need to explore other avenues and develop career opportunities. Expand the role of the Paramedic, and not limit ourselves. Promote programs instead of fighting educational development. Participate in local, state, and national organizations that promote EMS development. 

R/r 911


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## skyemt (Oct 12, 2007)

One thing that has not really been touched upon is the fact that the EMS system, if you want to call it that, is predicated on having sufficient numbers... this is a major reason that states are not eager to increase the educational standards... it will come at a cost of decreasing numbers of emt applicants, as well as those who pass the exams, and the states do not want to risk losing too many numbers...while we can agree or disagree on that, we do know that it is a concern on the administrative level...

the other thing, reading between the lines, is that there is no glamour in EMS... in fact, many view EMS as a "taxi ride" to the hospital, where they can get real care...of course, i disagree with this, but there is a generally poor public perception of EMS, which is a hurdle to achieving what you all want...

public perception can not be underestimated... in fact, the 70s tv show "emergency", did a lot to further the cause of Paramedicine, and while unlikely, this type of mass media glamourization would do the same thing today...

i know even in my system, which i believe works very well, there is a general lack of knowledge of what EMS really does... it is a challenge to educate the public, and perhaps, some of you have had positive experiences with this... any thoughts?


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## VentMedic (Oct 12, 2007)

skyemt said:


> i know even in my system, which i believe works very well, there is a general lack of knowledge of what EMS really does... it is a challenge to educate the public, and perhaps, some of you have had positive experiences with this... any thoughts?



The public gets mixed messages about EMS from both the media and the EMS systems.  Since there are so many different systems that each vary in everything from skills to retirement benefits as well as the education level, it is hard to put anything other than a generic definition on the many aspects of EMS.   

While the paramedic can go out and talk about what great education and skills they prossess, there will be a TV ad in the background for a Medic Mart school  that says "in just a few weeks you too can do all this". 

In Florida, some of the county and municipal EMS systems are excellent for employees to grow and move throughout the system as they continue their education. The medical and retirement benefits are excellent also.  But, then we also have large and small private or municipal companies that may be the exact opposite.   

Someone wanting to go into EMS may get mixed messages depending on who they choose to ask for advise. The questions I posted earlier were meant to discover if there were roles models that pointed out the need for further education in one's career path.  

As Guardian pointed out:


> I would say the vast majority of people knowingly see ems as a stepping stone before they even take emt-b. Stepping stone to FD, RN, MD, PD, STD, and the ever sickening "Flight Medic."



This may be the advice one receives in their career infancy and thus, that is the direction they go because someone has discouraged them from discovering any positive aspects of a career in EMS. 

Maybe once Paramedics and EMTs define themselves through a national organization and standards and not the agency they work for, then we can offer a better explaination to the legislators and the public.


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## triemal04 (Oct 13, 2007)

Firetender/Gaurdian-  ok, I can agree with that, up to a point anyway.  First, depending on the dept, I wouldn't call getting on a FD leaving EMS or moving on; in this part of the country the majority of ambulances are FD run, and in all honesty, if someone wants to work on an ambulance run by a FD vs a private, does that make them less of a medic or a copout?  No.  (I do agree though that people who become medic's with the sole intention of riding on an engine and never on a medic unit are not doing anyone any favors, including themselves).  But, I can see people working in EMS for a few years and then moving on to other medical work; this is where increasing wages and benefits to an appropriate level comes in; if medics are getting paid what they should, then I think that less (not all) would want to move on.  And if someone is willing to spend 2-3 years getting that degree, they may be more inclined to use it.  The rest of your post...that sucks.  It looks like you've come out ok in the end though and are back at it, so congratulations.

A couple of half-truths have been floated here that need to be addressed.  First, not every fire department that runs an ambulance uses civillian employess like FDNY does; some of the larger ones do, but look at the country as a whole and it is absolutely false that medics working for a FD are "not really FF's" and are getting paid less.  The majority of dept's crosstrain their personell, and often the medic get's EXTRA pay for being a paramedic, not less.  Second, if the educational requirements are changed, if it is MANDATED AT THE NATIONAL LEVEL that a AAS degree is required, and that states may not go below this education and still certify paramedics, it won't matter if ANY service wants to train medic's faster...there won't be a way to do it.  Of course this won't happen unless some group steps up to the plate, but hopefully that will happen.  If EMS is to survive, it needs to.


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## Ridryder911 (Oct 13, 2007)

triemal04 said:


> A couple of half-truths have been floated here that need to be addressed.  First, not every fire department that runs an ambulance uses civillian employess like FDNY does; some of the larger ones do, but look at the country as a whole and it is absolutely false that medics working for a FD are "not really FF's" and are getting paid less.  The majority of dept's crosstrain their personell, and often the medic get's EXTRA pay for being a paramedic, not less.  Second, if the educational requirements are changed, if it is MANDATED AT THE NATIONAL LEVEL that a AAS degree is required, and that states may not go below this education and still certify paramedics, it won't matter if ANY service wants to train medic's faster...there won't be a way to do it.  Of course this won't happen unless some group steps up to the plate, but hopefully that will happen.  If EMS is to survive, it needs to.



Actually, if you were to read IAFC ten year plan you will see them endorsing   Fire Departments to attempt to change systems internally. Emphasis in to be able to still meet the demand of FF and then to have EMS as a different department. This is not just large FD's but moderate size as well. There is a reason IAFC and other fire department organizations did not want EMS to go to Project Homeland.. less funding for FD's.  

Just as part of the problem, we have too many FD/Paramedics in large metro areas, where skill attribution has been noted. Enough, that intubation has been questioned if it should be even part of the curriculum? I know of some Paramedics that get to intubate about once a year (even in a high call volume area) because there are 5 Paramedics on each call, that are eagerly awaiting to perform the skill. Overkill needs to be addressed. 

I do agree some there are some departments that have financial pay raises for Paramedics, which is great!  Then there are some that it has became a requirement to be even be employed, (although many describe you do not have to keep current after a period of time). I have yet seen very many aggressive F.D.'s in EMS, especially those of being cross trained. Fire Science within itself is a full time study and profession. Specialities such haz-mat, prevention, investigation, etc. makes it a continuous study and profession within itself. EMS is medical and needs to be addressed as such. I do agree having the F.D. act as a first response, but past that point EMS should be placed as a independent agency. Medical not rescue, nor public service. 

You will never see IAFC, IAFF support the AAS as entry for Paramedics. Heck, they won't require an A.S. or such for their own profession, do you really think they would endorse for a side line?  I know this at a personal level with a degree in Fire Science and Safety Engineering. 

Again, until we are on our own, we will never be recognized for our own endeavours. 

The main point is get at least the ground level of the need of education, and removal of training programs, at least at the Paramedic level. Just like the remainder of the medical community, and its peers. 

R/r 911


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## triemal04 (Oct 13, 2007)

Ridryder911 said:


> Actually, if you were to read IAFC ten year plan you will see them endorsing   Fire Departments to attempt to change systems internally. Emphasis in to be able to still meet the demand of FF and then to have EMS as a different department. This is not just large FD's but moderate size as well. There is a reason IAFC and other fire department organizations did not want EMS to go to Project Homeland.. less funding for FD's.
> 
> Just as part of the problem, we have too many FD/Paramedics in large metro areas, where skill attribution has been noted. Enough, that intubation has been questioned if it should be even part of the curriculum? I know of some Paramedics that get to intubate about once a year (even in a high call volume area) because there are 5 Paramedics on each call, that are eagerly awaiting to perform the skill. Overkill needs to be addressed.
> 
> ...


Yeah...the International Association of Fire Chief's is a funny bunch...luckily they don't set policy for everyone.  That's left up to the local department.  It doesn't change the fact that the majority of departments have cross-trained FF/paramedics in their department, not straight civillian medics.  Granted, some do, and I think there are some with both.

To be honest, I agree with the over saturation of medic's.  It is a problem, and it will admittedly happen more with some (not all by any means) fire departments because of the nature of the organization.  But, if the problem is recognized, it can be keep in check somewhat, it just needs to be recognized.  Unfortunately, this is a problem that goes beyond the fire vs private medic debate; there are too many medics out there in all different kinds of services period.  

Never say never; look beyond the east coast when it comes to FD's and EMS systems.  Seattle is the easiest to point out, but they aren't the only one.

Much as it means that I'm shooting myself in the foot, I would like to see more ambulance services being run as city/county/region/whatever third services with ALS first responce done by the local fire department.  EMS can be done, and be done well by a fire department, and the two go together well, but a service that is only concerned with EMS would have a bit of an edge.  And yeah, it would be opposed by IAFF.  No brainer on that one.  But, if EMS had it's own big voice....

The same goes for requiring a degree for a paramedic.  If EMS get's enough people together, then it won't matter who opposes it.  Getting the people together will be the hard part though.

And don't be so sure about FD's not requiring degress...for entry level sure, but look at the requirements for promotion to Lt, Capt, BC, DV, ***, etc etc.


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## reaper (Oct 13, 2007)

Our service is a county third service, EMS only. City fire does run ALS first response. We have no problem with it.

I don't want to see the FD taking over transports. That is where the problems start. Right now the fire/medics are happy,  they get to play medic until we show up and takeover care.


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## chfite (Oct 16, 2007)

*Contrast of Paramedic Preparation*

I feel that I have gained a broader perspective, having read all these posts.

Looking at the education of a Paramedic in the state where I attended school wherein the program grants an AA degree as the base for Paramedics versus the educational requirements in this state left me incredulous.

The instructors of my school were required to have a Master's degree.  Here the EMT-P and an instructor's course are all that are needed.  The course here is a couple of days a week for a few months with some slapdash clinical and field time, then test.  The only text for the course is the Paramedic text we all have seen.  The Intermediate course for my school was longer and more intense than the entire Paramedic program here.

I have heard the administrative grumbling here about the time when the program was lengthened to its current state being that the increased time for the course would create a perpetual shortage of Paramedics.  I had to ask the obvious rhetorical question, “You mean it used to be less?”

What I have seen in the past 7 years here is a lack of depth of knowledge in EMS at the Paramedic level coupled with a lack of perspicacity.   I have met some broadly credentialed instructors here who lack understanding.  They know the drill and the checklists, but don't understand why or why not.

Operationally, nothing is done to better this situation.  When departmental training is conducted for re-certification, the same, old, tired boiler-plate is trotted out.  Repetition of this over time numbs the mind, making training weak.

Consequently, the view of the Paramedic here is that of an automaton, something to be directed and controlled, not someone to be guided and encouraged.  This is borne out most clearly in the state standing orders and protocols.  

Hence, the notion of warm bodies on trucks prevails over quality.


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## reaper (Oct 16, 2007)

What state are you in?


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## chfite (Oct 17, 2007)

South Carolina


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