# 911 versus IFT for NEW paramedics



## CentralCalEMT (Mar 15, 2014)

I realize this may offend people. This is not my intention. I want to get people thinking, especially new paramedics looking for their first job.

Especially in SoCal, we all know IFT companies pay more for medics and are closer to the population centers. A lot of new medics will take jobs that pay, say $17 an hour as a medic running transfers all day that has a short commute rather than the $14 an hour job that runs first in 911 calls but requires a longer commute or relocation and is not located in as cosmopolitan of an area. While the money and convenience may seem great, there is not a lot of opportunity to develop your paramedic skills running solely IFTs. Now it that is what you want as a new medic, that is completely your choice. But I am tired of hearing IFT medics put down rural 911 providers because we make less money and work in the middle of nowhere.

Now before someone jumps all over me, I do realize that you can learn something on ANY call and IFTs are no exception. Those patients often do have serious and unique disease processes going on. However you are mainly assessing a patient in an acute care setting, where they have been reasonably stabilized and their history, allergies, meds etc. are in the paperwork, they all ready have IV access, and you have a reasonable idea of what is going on. Yes there are critical care transports of life and death patients, but the truth is most ALS transfers are patients who require someone to take vitals and stare at the cardiac monitor during the transport and nothing else. 

 There has never and will never be a substitute for real life emergency calls. You can do CE units all you want and reread your book every day. However there is no substitute for the calls that stretch you as a medic and as a person. The calls that cause you to develop into a thinking paramedic and a competent care provider. For instance, there is the 0200 call where the patient is in respiratory distress, you can hear wheezing from outside the house, does not know their own medical history, can't find their meds, has crappy veins that can barely take a 22 on a good day, who is cyonatic and crashing in the living room of their pack rat home. There is no substitute for actually setting up in line albuterol with CPAP or a mag drip or any other ALS procedure. With IFT companies, you can attend MCI training or even be on your company's "strike team" all you want, but there is no substitute for being first on of a MCI with multiple red tags and your next in unit at least 15 minutes out and have to manage it with limited resources. 

In conclusion, personally, I believe that as a new medic, you should try and get into a system that truly lets you develop your paramedic skills, assessment skills, and critical thinking skills. Yes the pay might be less and the scenery not as good, but as a new medic you are in danger of losing your knowledge and skill set if you do not practice what you just learned. Do not be one of those medics who all they talk about is the calls they ran during internship since they haven't run a real emergency since then. Remember, it is a lot easier to go from running 911 to running IFTs than vice versa. Especially several years out of school. I personally have worked with some medics who did the IFT route for several years and then decided to work 911 and it was an uphill battle for them from the start because they lost their skill set. Anyway, this is just my opinion for those seeking employment as a new paramedic.


----------



## blachatch (Mar 15, 2014)

Great post. I am in the same situation I have been out of school for a few months now and where I live all we have is IFT all 911 is done through fire. All the companies have a terrible reputation and I don't even want to get involved with them and learn there bad habits. At the same time I am already forgetting quite a bit of info I learned in school. At the same time it is not that easy to pick up and relocate as it seems.


----------



## TRSpeed (Mar 15, 2014)

Totally agree. Experience is invaluable! 

Yes going from a Los Angeles atmosphere to a rural area is a huge difference but there are lots of things to do still. It just takes some getting used to.

That being said after many years of experience, working 911 in OC, LA, ICEMA, mostly Riverside, and now Kern County. There is nothing even compared in California especially SoCal to a system like Kern County. As for services we got Hall ambulance which is absolutely amazing. Amazing equipment always with the bells and whistles and cleaned by a ambulance detailing crew everyday. As for pay we just got 19% raises(over two yrs) 9% in 07/14 and 10% in 01/16. from an already competative pay!!! Fully paid for Kaiser benefits with no monthly premiums and a pre paid card for deductibles and Rxs of $1300/3500 single/family.  Priority dispatching, bls fire. Company 100-200 gift cards for Christmas. Etc. 

We got Liberty in ridgecrest and lake Isabella area that runs in great type1s as well with stat packs and lp15s. Pay is a little less but they work 72/96 so it makes up for it.


If you want to make EMS a career only 100mi away from Los Angeles then this is the place to be. We have a low turnover, great working moral. 

Gosh I sound like a recruiter but what can you say. When you love EMS and the service takes pride in the there employees and equipment the employees speaks for its self.


----------



## Akulahawk (Mar 15, 2014)

I would have to somewhat agree. It all really depends upon the type of IFT you do as a Paramedic. If you're doing runs that are basically CCT or other high acuity call, then that's fine. You'll spend a lot of time learning the _other_ end of being a Paramedic. You'll do lots of thinking, considering, titrating, and so on. Those are skills you rarely learn in school. As a 911 medic,  you do lots of the same things over and over. You become very good at starting IV lines, running codes, doing those in-line nebs on your patient that's on a CPAP while considering starting a mag drip. If you run in an urban area, your skillset also decreases because you can only get just so far down the protocols before you reach the hospital. If you're in a "mother may I" system where you must call for orders, you don't really even have to know the protocols because the specific orders for your patient will be given to you. 

On the one hand, 911 keeps you busy and you do get to do quite a few skills, but most patients you'll see aren't very sick. There's often a few Paramedics on scene with you, and only one of you gets to do the intubation so you only get maybe one or 4 per year. On the other hand, if you're doing IFT work _and_ it's more CCT stuff, sometimes the whole protocol manual is open to you without OLMC. It's often just YOU in the back with the patient so if anything goes sideways, it's all YOU. You may have to become proficient in ventilator use that's more involved than just setting volume and rate. The patients you see will usually be sicker and you'll get to read the patient's H&P, progress notes, meds and so on and correlate that with what you see in front of  you. You become proficient at reading the monitors, dealing with other meds that you might have in your cabinet but rarely, if ever, get to pull them out. You get good at noticing the small things. 

I'm not knocking the 911 Paramedic, quite the opposite. They're really good at what they do. The IFT medic is put at a disadvantage, just as the EMT is. We train them for 911 and then expect them to thrive in the IFT environment. Then we wonder why they have problems providing adequate care for their patients, why hospitals think that Paramedics are knuckle-draggers, why there's a high turn-over rate, even if they're paid better than they'd be at the local 911 service. 

The point is really that if you want to be an IFT Paramedic, really learn how to be one. If you really want to be a 911 Paramedic, really learn to be one. Yes, you might be able to "float" over to the other role from time to time, but the people that run those calls are really the experts at it. So, newbie Paramedics, do yourself a HUGE favor and decide which kind of Paramedic you want to be and become that kind of Paramedic. 

Just don't become _that_ Paramedic that's there to become a Firefighter that doesn't want to be a Paramedic but wants the extra stipend anyway...


----------



## TransportJockey (Mar 15, 2014)

I have to admit, doing rural 911 as a transporting provider helped me in my practice to a large extent. As did doing CCT-ish IFT. I was doing both (2 full time jobs) almost my entire first two years as a medic (which is a month from yesteday (4-14-14 is my anniversary date)


----------



## UnkiEMT (Mar 15, 2014)

CentralCalEMT said:


> But I am tired of hearing IFT medics put down rural 911 providers because we make less money and work in the middle of nowhere.



I find that utterly boggling. I've worked in 4 different areas, and with the exception of Honduras where I was the ONLY medic, the IFT medics both make less than the 911 medics do, and are looked down upon by the 911 medics.


----------



## TransportJockey (Mar 15, 2014)

UnkiEMT said:


> I find that utterly boggling. I've worked in 4 different areas, and with the exception of Honduras where I was the ONLY medic, the IFT medics both make less than the 911 medics do, and are looked down upon by the 911 medics.



It's a California thing I think. I've never seen an IFT medic make more just cause he's a transfer medic, other than true critical care teams


----------



## Akulahawk (Mar 15, 2014)

UnkiEMT said:


> I find that utterly boggling. I've worked in 4 different areas, and with the exception of Honduras where I was the ONLY medic, the IFT medics both make less than the 911 medics do, and are looked down upon by the 911 medics.


My experience with 911 vs IFT medics mirrors yours. IFT is usually paid less and is looked down upon by the 911 folks. Most of my work as a medic was doing IFT. Back when I got started, our medical control was almost entirely off-line. We used the same protocol manual as the 911 medics however, as long as we were actually _doing_ IFT work, all directives in the protocols to contact OLMC did not apply. This is no longer the case. Some years ago, the EMS system decided (probably to make something simple or a medic goofed) that the off-line option is no longer available. Instead, they decided that the availability of direct medical oversight would be extended to all Paramedics working or terminating transport in the County, if they contacted a base hospital for patient care orders. Indirect Medical Oversight by the Sacramento EMS Agency would apply only to those working in the system. Non-Sacramento EMS personnel would/could function under their usual oversight/protocol system. 

At least they made things a LOT simpler...

The good news, so to speak, is that all ground EMS in the County functions under identical protocols, and in an entirely identical manner, 911 or not. Flight EMS is a whole different ball of weird.


----------



## CentralCalEMT (Mar 15, 2014)

I should probably have qualified my remarks. Yes it is mainly a Southern California thing. (Mainly LA/OC) for the IFT medics making way more than the 911 medics in the surrounding county. I have friends who are new IFT medics who make 10-15K a year more than me. Also, the rural system I work in and the surrounding ones, there is only 1 medic on scene, so I do start all the lines, push all the meds, and get all the tubes. 

Also, I have tremendous respect for medics who do CCT work. But in Southern California, most ALS transfers are stable patients going between hospitals for insurance reasons. (such as Kaiser) With so many specialty centers readily available, most patients end up at the correct hospital in the first place and are transferred for insurance reasons. I do personally know medics who have not pushed a single medication in 6 months of ALS IFT in LA County. Now I realize California is in the dark ages of EMS and it is not the same elsewhere in the country so I should have qualified my remarks, but a significant portion of the people on these boards are from SoCal so I wanted to give them food for thought.


----------



## UnkiEMT (Mar 16, 2014)

Well, if I were to guess, the pay thing is just a cost of living issue, it costs more to live in LA, so you have to pay people more.

As to the nature of the work, I would say that's again probably largely a big city thing. As you say, it's pretty easy for the primary response to get pt to the right resources in the first place. I've never worked in a big city, however, so when you say PIFT, what I think of is the type I do, which is almost exclusively level of care transfers, from the outlying small hospitals (band-aid stations), to the medium hospital located in the city my service is based in, and then from the medium hospital to the big hospitals located in the "big city", or direct from the small ones to the big ones, depending. The only time I ever do insurance status transfers is (rarely) for the VA (Who, after demanding that the hospital transfer the pt to them for insurance reasons, then won't pay us for the transfer, since it wasn't medically necessary...Yay, VA.).

Now, I absolutely transfer pts who are effectively stable, but just require EKG monitoring or an antibiotic drip (Or one of any number of other things), leaving me lots of time to chat with the pt, do paperwork or read a book, whatever is appropriate. Even on those, it doesn't do to get complacent, I've have pts who the nurse assured me were just as stable as could be code on me before.

However I also regularly transport pts who are vented, being monitored 11 ways from Sunday and have 6 drips running (Which, incidentally, still don't qualify as CCTs, they're ALS-2s). Even with those pts, I rarely push my own drugs, usually what I do is tweak the drips that the hospital started, which means that I have to know every last detail of those drugs, and how they all interact with each other...and the PIFT formulary is a LOT larger than the primary response fomulary is (at least here).



> We used the same protocol manual as the 911 medics however, as long as we were actually doing IFT work, all directives in the protocols to contact OLMC did not apply.



That kinda sucks. Here, protocols are service/medical director specific, and can bend (though not break) the state scope to a large degree. The protocols I work under are hands down the broadest I've ever hand, and they are almost exclusively offline, I've called for OLMC exactly once in the year and a half I've been working here...though I'll admit I've called a few more times for advice. At first it was scary as all hell to work like that, but I've really come to like it. It lets me be a practitioner rather than a set of remote hands for a doc.


----------



## DesertMedic66 (Mar 16, 2014)

TransportJockey said:


> It's a California thing I think. I've never seen an IFT medic make more just cause he's a transfer medic, other than true critical care teams



It's not all of CA. 911 payes better than IFT in my neck of the woods.


----------



## mycrofft (Mar 16, 2014)

Great question and a quandary.

I wish paramedics could work in a primary care clinic like a County clinic and or a doc in the box (freestanding emergency clinic).

I think IFt is good especially for some, but as you said, you have to keep striving to learn more and keep what you have. And keep an eye open for better jobs higher up the food chain.

Doing vollie work occurs to me, but I am ignorant as to how good a choice that is to sharpen and maintain new skills.


----------



## Akulahawk (Mar 16, 2014)

mycrofft said:


> Great question and a quandary.
> 
> I wish paramedics could work in a primary care clinic like a County clinic and or a doc in the box (freestanding emergency clinic).
> 
> ...


Around here, the local volunteer FD does do primary 911 responses, however, their medics rarely ride in with the patient. Consequently they get good at managing the first 5-10 minutes of patient contact time and hand-off the patient to the transport crew as they don't have their own transport capability. Given the choice of occasionally working vs not doing any... I'd do the vollie thing. I'll lose more skills proficiency by NOT working...


----------



## mycrofft (Mar 17, 2014)

Akulahawk said:


> Around here, the local volunteer FD does do primary 911 responses, however, their medics rarely ride in with the patient. Consequently they get good at managing the first 5-10 minutes of patient contact time and hand-off the patient to the transport crew as they don't have their own transport capability. Given the choice of occasionally working vs not doing any... I'd do the vollie thing. I'll lose more skills proficiency by NOT working...



I was thinking about the aspect of the control and feedback or even collaboration with a good doctor. Exposure to cases is the first third of learning and maturing, doing the right or wrong thing then learning from and about it are the other thirds.

I did "nurse sick call", as well as "man downs", with up to fifty cases a day expected of me, for close to twenty years, and learned much more about emergency and general medical care from the MD's I referred to and sometimes assisted than I did from my EMT class in 1977 and nurse college other than the basic groundings in A&P, Rx, labs, ethics...


----------

