# How to fix EMS



## thegreypilgrim (Sep 8, 2011)

In the United States, that is.

(1) Transfer federal oversight of EMS from NHTSA to the Department of Health and Human Services (HHS).

(2) Convert all privately owned, for-profit ambulance companies to not-for-profit status. Compensate any investors for past investment.

(3) Convert all fire department operated EMS programs to an independent state (preferably), regional, or municipal agency. Downgrade FDs to CFR level.

(4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).

(5) Change the Medicare ambulance billing scheme by requiring patients to be seen by providers trained to new NAEMSP/ACEP standards in order for non-transport to still be covered. Also replace the mileage-based structure with one based on clinical time usage.

(6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.

(7) Staff all ambulances with two AEMTs which will be able to handle the majority of calls. Place Paramedics in rapid response vehicles with a driver (non-medically trained) for intercept - only auto-dispatched in limited set of calls.

(8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.


Man...that's a lot of stuff to do.


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## JPINFV (Sep 8, 2011)

9. Separate non-emergent medical transport from EMS both in terms of education and licensure.


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## thegreypilgrim (Sep 8, 2011)

JPINFV said:


> 9. Separate non-emergent medical transport from EMS both in terms of education and licensure.


Indeed. The majority of IFT does not require medically trained personnel, but merely the means of physically moving patients and possibly some oxygen.

It would also be nice if we could consolidate our health insurance system into a single-payer model which would effectively eliminate the need for out-of-network repatriation.


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## looker (Sep 8, 2011)

All I can say is keep dreaming as it will never happen and i am very thankfull for that.


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## thegreypilgrim (Sep 8, 2011)

looker said:


> All I can say is keep dreaming as it will never happen and i am very thankfull for that.


 What does it feel like to be an exploitative leech that contributes nothing of any real value to anyone? How many people have experienced adverse medical outcomes because of delays/obstructions in care due in large part to organizations such as yours? Do you ever think about that?


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## fast65 (Sep 8, 2011)

looker said:


> All I can say is keep dreaming as it will never happen and i am very thankfull for that.



Come now Pilgrim, let us hear his side of the story. Tell us looker, why would you be thankful for such a thing? 

I personally agree wholeheartedly with you GreyPilgrim.

Sent from my mobile command center


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## Sasha (Sep 8, 2011)

fast65 said:


> Come now Pilgrim, let us hear his side of the story. Tell us looker, why would you be thankful for such a thing?
> 
> I personally agree wholeheartedly with you GreyPilgrim.
> 
> Sent from my mobile command center



Because he owns a private company, if memory serves, in CA?

Sent from LuLu using Tapatalk


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## fast65 (Sep 8, 2011)

Sasha said:


> Because he owns a private company, if memory serves, in CA?
> 
> Sent from LuLu using Tapatalk



I thought that was someone else? Either way, I'm sure you're correct

Sent from my mobile command center


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## looker (Sep 8, 2011)

thegreypilgrim said:


> What does it feel like to be an exploitative leech that contributes nothing of any real value to anyone? How many people have experienced adverse medical outcomes because of delays/obstructions in care due in large part to organizations such as yours? Do you ever think about that?



Can you explain how private ambulance company cause delays/obstruction in care ? All bls company employee 2 certified emt. How is that different from any other bls ambulance? All ALS ambulance employee at minimum one emt and one medic, again how is that much different compare to other als ambulance company?


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## looker (Sep 8, 2011)

fast65 said:


> Come now Pilgrim, let us hear his side of the story. Tell us looker, why would you be thankful for such a thing?
> 
> I personally agree wholeheartedly with you GreyPilgrim.
> 
> Sent from my mobile command center



I own for profit ambulance company in CA


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## fast65 (Sep 8, 2011)

looker said:


> I own for profit ambulance company in CA



I see, so basically, your disdain for EMS progression is solely based on the fact it would subtract from your profits?

Sent from my mobile command center


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## firetender (Sep 8, 2011)

*Get back on track*

The initial post was a good start but now is getting perilously close to being fixated on one small aspect of the larger picture presented.

Let's continue to look at the Big Picture without getting hung up on one aspect. My understanding was it's a call to re-vamp the whole Enchilada, not just eliminate one part.

...and keep it polite folks!


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## CAOX3 (Sep 8, 2011)

fast65 said:


> I see, so basically, your disdain for EMS progression is solely based on the fact it would subtract from your profits?
> 
> Sent from my mobile command center



Yeah why would he be concerned with something that would take away the ability to financially provide for his family. Ridiculous.

Would you be thrilled if they made paramedic school  a masters degree education level after you finished medic school and forced you to work as an EMT for eight dollars an hour, im sure you wouldn't.

 EMS is a job, if they didnt pay me I wouldn't do it.

You want to fix it, someone needs ultimate control of it.  Lets start there, until that happens you don't have a shot.


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## thegreypilgrim (Sep 8, 2011)

looker said:


> Can you explain how private ambulance company cause delays/obstruction in care ? All bls company employee 2 certified emt. How is that different from any other bls ambulance? All ALS ambulance employee at minimum one emt and one medic, again how is that much different compare to other als ambulance company?


 Well, it's really simple, looker, but you don't seem to understand so I'll explain it to you.

Many SNFs and urgent care centers have a financial and legal interest in circumventing the 911 system as much as they can, often to the point of inappropriateness. I don't think I have to go into the motivational basis for this as it's fairly clear that it exists; and, when there is uncertainty they will err on the side of non-emergent workup.

They use organizations like yours to perpetuate this process, and seeing as private ambulance companies are always willing to partake in these endeavors it makes them complicit in these grossly unethical practices. See how that works? You don't do anything to redirect that patient to a more appropriate care pathway, and indeed profit from not doing so! See where the problem is?

*Note:* as the author of this thread I endorse an off-topic direction of conversation.


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## Sasha (Sep 8, 2011)

In all fairness, my company at least will ask the caller to consider calling 911 but due to contracts cant turn down a call.

Sent from LuLu using Tapatalk


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## thegreypilgrim (Sep 8, 2011)

CAOX3 said:


> Yeah why would he be concerned with something that would take away the ability to financially provide for his family. Ridiculous.


 I have little sympathy for those who exploit the sick and elderly, sorry. This language of it being a necessity for familial support is emotive and enabling. 



> Would you be thrilled if they made paramedic school  a masters degree education level after you finished medic school and forced you to work as an EMT for eight dollars an hour, im sure you wouldn't.


 I don't know where you're getting master's degree as all I suggested was a bachelor's (you know, the entry-level requirement for basically every other career in existence), but as it happens I would. The reason EMTs are barely above minimum wage is because there are essentially no barriers of entry, leaving the market flooded with potential candidates. Requiring some semblance of a modern education would add a much needed element of professionalism to the  field and transform it from a wage-slave job into a sustainable career.



> EMS is a job, if they didnt pay me I wouldn't do it.


 Compensation for most in EMS will never be livable as long as the status quo remains. I wouldn't do it for free either, and the fact that I have to continue to do it for such meager pay is largely due to the mentality of your reply.


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## looker (Sep 8, 2011)

> =thegreypilgrim;334872]In the United States, that is.
> 
> (1) Transfer federal oversight of EMS from NHTSA to the Department of Health and Human Services (HHS).



This would be fine by me



> (2) Convert all privately owned, for-profit ambulance companies to not-for-profit status. Compensate any investors for past investment.



If people can't make much money why would they stay in this business? At the end of the day it's about profit.



> (3) Convert all fire department operated EMS programs to an independent state (preferably), regional, or municipal agency. Downgrade FDs to CFR level.



Something tells me city would object to this



> (4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).


 Couple of issue with this. 1) Will all current emt/medic be grandfathered? Also how much more would it cost to become emt/medic, how long etc? That would make big difference if people would go in to this field or not. Especially if all ambulance company become non profit. 


> (5) Change the Medicare ambulance billing scheme by requiring patients to be seen by providers trained to new NAEMSP/ACEP standards in order for non-transport to still be covered. Also replace the mileage-based structure with one based on clinical time usage.


 Big problem if current emt/medic are not grandfathered in to this plan. Pay will also be bigi problem. Everything cost money to run ambulance company, lets not forget that.



> (6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.


 This would eliminate big pool of people being how low emt are being paid. If you need to get bs to be a medic you might as well get some good bs degree and work in that field.


> (7) Staff all ambulances with two AEMTs which will be able to handle the majority of calls. Place Paramedics in rapid response vehicles with a driver (non-medically trained) for intercept - only auto-dispatched in limited set of calls.


 extra cost that is just not needed.



> (8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.


 Why not make gurney vehicle paid by medicare and eliminate majority of the industry which is what will happened eitherway. 


 Replying so as to get discussion going a bit more on topic


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## looker (Sep 8, 2011)

thegreypilgrim said:


> Well, it's really simple, looker, but you don't seem to understand so I'll explain it to you.
> 
> Many SNFs and urgent care centers have a financial and legal interest in circumventing the 911 system as much as they can, often to the point of inappropriateness. I don't think I have to go into the motivational basis for this as it's fairly clear that it exists; and, when there is uncertainty they will err on the side of non-emergent workup.
> 
> ...



If we come to SNF and find patient needs ALS, we call 911 and advice. Depending on how close als unit is available we either go l &s to nearest er. Get intercepted by als or just wait for them.  Yes some company do not do that and they should be fined for that.


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## fast65 (Sep 8, 2011)

CAOX3 said:


> Would you be thrilled if they made paramedic school  a masters degree education level after you finished medic school and forced you to work as an EMT for eight dollars an hour, im sure you wouldn't.



I would be thrilled, education is awesome 


Sent from my mobile command center


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## firetender (Sep 8, 2011)

thegreypilgrim said:


> *Note:* as the author of this thread I endorse an off-topic direction of conversation.


 
As CL, I say start another thread, keep it polite and really look at the issues rather than react.


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## thegreypilgrim (Sep 8, 2011)

> If people can't make much money why would they stay in this business? At the end of the day it's about profit.


 It isn't a business. It's a professional social service where the profit motive has no place. This is why it is the responsibility of government and possibly philanthropic organizations. Not the market.



> Something tells me city would object to this


 It would be a tough fight, but I'm confident that with growing public awareness of the unsustainability of fire-based EMS they will ultimately have to concede.



> 1) Will all current emt/medic be grandfathered?


 If I had my way I'd create a retraining and job placement program that they can choose to take part in to upgrade to the new standards or apply towards another career.


> Also how much more would it cost to become emt/medic, how long etc? That would make big difference if people would go in to this field or not.


 It's not going to carry any different costs than would be faced in the pursuit of any other academic study. Unfortunately, education to the tertiary level is not free in this country as it is in many other industrialized nations so people will have to get by as they currently are for anything else. And this will help limit the entry of candidates into the field, thereby driving the supply/demand curve to the right and improve the quality of life for its members.


> Especially if all ambulance company become non profit.


 Getting rid of for-profit care in all aspects of healthcare (not just ambulance service) is part of the process of making said programs more efficient. 


> Big problem if current emt/medic are not grandfathered in to this plan. Pay will also be bigi problem. Everything cost money to run ambulance company, lets not forget that.


 There would be pathways open for them to remain in the field. And this would actually save significant amounts of money as the majority of calls do not require transport. 



> extra cost that is just not needed.


 What extra costs? Do you have any figures? 



> Why not make gurney vehicle paid by medicare and eliminate majority of the industry which is what will happened eitherway.


 I'm not understanding what you're saying here.


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## thegreypilgrim (Sep 8, 2011)

looker said:


> If we come to SNF and find patient needs ALS, we call 911 and advice. Depending on how close als unit is available we either go l &s to nearest er. Get intercepted by als or just wait for them.  Yes some company do not do that and they should be fined for that.


 You do realize in LA County you're not supposed to take that call at all right? You're actually supposed to do some degree of caller interrogation, and find out why this patient needs to go to the ED when there's supposedly a physician on the premises. Then you're supposed to advise them to call 911 and not accept the call.


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## looker (Sep 8, 2011)

thegreypilgrim said:


> You do realize in LA County you're not supposed to take that call at all right? You're actually supposed to do some degree of caller interrogation, and find out why this patient needs to go to the ED when there's supposedly a physician on the premises. Then you're supposed to advise them to call 911 and not accept the call.



Yes, but have you ever try to get much info from RN?


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## thegreypilgrim (Sep 8, 2011)

looker said:


> Yes, but have you ever try to get much info from RN?


 If they're unwilling to provide you with the necessary information, then you can't in good conscience do business with them. This is also in your own self-interest, looker as I'm sure you wouldn't want to appear in court one day with just this as your defense. In LA County (and pretty much anywhere else) it's a dispatching issue, you simply cannot accept calls from these facilities that should be 911 activations.


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## looker (Sep 8, 2011)

thegreypilgrim said:


> > Why not make gurney vehicle paid by medicare and eliminate majority of the industry which is what will happened eitherway.
> 
> 
> 
> I'm not understanding what you're saying here.



You're saying eliminate ift from ems industry. So why not just use gurney vehicles. If it is just iFT and no need for emt then it's just plain gurney transp. So why even use ambulance to transport? 

The fact is ambulance association and other profession will never let the industry go to non profit. It's just not how this country works.


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## VCEMT (Sep 8, 2011)

L.A. County, what a joke.


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## looker (Sep 8, 2011)

thegreypilgrim said:


> If they're unwilling to provide you with the necessary information, then you can't in good conscience do business with them. This is also in your own self-interest, looker as I'm sure you wouldn't want to appear in court one day with just this as your defense. In LA County (and pretty much anywhere else) it's a dispatching issue, you simply cannot accept calls from these facilities that should be 911 activations.



Part of is the contract, start refusing and another provider will take the call. Soon will be out of business. Second part rn will say some random bs thing that makes it straight BLS only to find out it's not when you come.


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## JPINFV (Sep 8, 2011)

I think a lot of Looker's issues are a non-issue if (when) non-emergent transport was completely disassociated with the emergency medical system outside of an MCI/disaster surge capacity role. 



looker said:


> If people can't make much money why would they stay in this business? At the end of the day it's about profit.


The question isn't whether a profit is being made or not, but what is done with the profit. How much is being reinvested into the company vs going into the owners pocket, especially for something that should, at worst, be treated like a natural monopoly like water service or power (prior to deregulation in California). 




> Something tells me city would object to this


Depends. Plenty of cities run great non-fire EMS systems, and a lot of the recent mergers aren't going well. Ultimately, the success of fire based EMS revolves around the attitude involved. Is fire suppression and EMS equals? Is EMS just something that the fire department has to do during their down time? Is it more of a behind the scenes ("fire department administered EMS), which can go either good (Seattle) or bad (New York City)? 



> Couple of issue with this. 1) Will all current emt/medic be grandfathered? Also how much more would it cost to become emt/medic, how long etc? That would make big difference if people would go in to this field or not. Especially if all ambulance company become non profit.


I have no problem with grandfathered status provided that the grandfathered applicants can meet the new standards (i.e. can they at least pass the test). There will always be a transition period. As a perfect example, when Emergency Medicine became a medical specialty, there was a practice track to essentially grandfather emergency physicians into board certification without going through a residency. That track has been closed for a while and the only way to become a board certified (through ABEM and AOBEM) is by completing a residency. However, the practice track wasn't a simple, "Oh, you worked in an emergency room? Here's your card."

As far as cost, what about it? Ideally, as education level increases, so does usefulness and scope of practice (including things like community paramedicine, research, etc), which will ultimately lead to increased reimbursement. The current path, however, is not sustainable especially as Medicare continues to cut reimbursement. 



> Big problem if current emt/medic are not grandfathered in to this plan.  Pay will also be bigi problem. Everything cost money to run ambulance  company, lets not forget that.



Where's the problem? If EMS providers were reimbursed for providing care besides transport, then reimbursement will go up, even as transports go down. The problem is that currently it's fee for service, and the only service recognized by Medicare is transport. Is the only potential value for EMS is as a glorified taxi driver? 



> This would eliminate big pool of people being how low emt are being paid. If you need to get bs to be a medic you might as well get some good bs degree and work in that field.



1. I don't think the assumption that reimbursement would not increase when EMS can begin to do something other than transport every patient to the ED is not a valid assumption. 

2. Why can't paramedicine be good work? Work worthy of requiring a proper education? 




> extra cost that is just not needed.


Yet having a bajillion and a half paramedics sitting around fire stations is a justified extra cost? 



> Why not make gurney vehicle paid by medicare and eliminate majority of the industry which is what will happened eitherway.




For non-emergent medical transport? Sure. For pre-hospital emergency medicine? The better path is to integrate it better into the health care system as something other than a medical taxi service. 


Looker, how do you ultimately view your company? Is it a medical taxi company? Is it, in any part, providing prehospital emergency medicine? Do you provide, in some fashion health care?

If you're ultimately coming from a medical taxi service view point, I can understand your argument completely. That portion of "EMS" (it should have never been a part of EMS due to different demands and different needs, not a "one side is better than the other" view) has a legitimate stake at keeping the trade as it currently is. Unfortunately, the demands of the 911 service is moving towards being able to do more than be a medical taxi service. Ultimately how do we ensure that paramedics are capable of taking on the roles that the health care system needs them to take on?


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## thegreypilgrim (Sep 8, 2011)

looker said:


> You're saying eliminate ift from ems industry. So why not just use gurney vehicles. If it is just iFT and no need for emt then it's just plain gurney transp. So why even use ambulance to transport?


 I would be fine with that.



> The fact is ambulance association and other profession will never let the industry go to non profit. It's just not how this country works.


 Whether or not there's a political will to do so isn't really the point, although I agree with you there would be significant opposition (not from the NAEMT which has essentially no lobbying power, but definitely from peripheral organizations with like interests).

Regardless, I suggest this is among those things which are necessary to improve our EMS system.


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## thegreypilgrim (Sep 8, 2011)

looker said:


> Part of is the contract, start refusing and another provider will take the call. Soon will be out of business.


 I guess that's why this isn't a business right? It's just not designed for market principles to function.


> Second part rn will say some random bs thing that makes it straight BLS only to find out it's not when you come.


 If they lie to you about the nature of the patients you're supposed to care for why continue to do business with them? You might even have grounds for a lawsuit against them.


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## CAOX3 (Sep 8, 2011)

thegreypilgrim said:


> I have little sympathy for those who exploit the sick and elderly, sorry. This language of it being a necessity for familial support is emotive and enabling. .




Then you should be pissed at the entire medical profession, they have been using the sick snd elderly as a meal ticket for years.



thegreypilgrim said:


> I don't know where you're getting master's degree as all I suggested was a bachelor's (you know, the entry-level requirement for basically every other career in existence), but as it happens I would. The reason EMTs are barely above minimum wage is because there are essentially no barriers of entry, leaving the market flooded with potential candidates. Requiring some semblance of a modern education would add a much needed element of professionalism to the  field and transform it from a wage-slave job into a sustainable career..



I was speaking to Fast65, everyone wants to "fix EMS" until it affects them personally, then not so much.




thegreypilgrim said:


> Compensation for most in EMS will never be livable as long as the status quo remains. I wouldn't do it for free either, and the fact that I have to continue to do it for such meager pay is largely due to the mentality of your reply.



I make a livable wage, the problem is you have people that will do it for free thats your biggest issue. I wouldnt work for eight dollars an hour, Im educated and Im not leading a charge into a losing battle, I have a wife and children that I would rather spend my free time with, by all means if your willing go ahead I wish you luck but your attempting to change a profession that doesnt want to change, Im going to sit on my deck with a beer and throw a stick to my dog, Ill see more results with that.

And go ahead say I dont care or Im in it for me, you could be right, after alot of years I have given to much to EMS all ready.


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## thegreypilgrim (Sep 8, 2011)

CAOX3 said:


> Then you should be pissed at the entire medical profession, they have been using the sick snd elderly as a meal ticket for years.


 I'm well aware of this. The entire healthcare system needs reform.



> I was speaking to Fast65, everyone wants to "fix EMS" until it affects them personally, then not so much.


 Because they're short-sighted. Raising the standards of the profession will require short-term sacrifices which will be easily offset by long-term gains.


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## looker (Sep 8, 2011)

JPINFV said:


> Looker, how do you ultimately view your company? Is it a medical taxi company? Is it, in any part, providing prehospital emergency medicine? Do you provide, in some fashion health care?
> 
> If you're ultimately coming from a medical taxi service view point, I can understand your argument completely. That portion of "EMS" (it should have never been a part of EMS due to different demands and different needs, not a "one side is better than the other" view) has a legitimate stake at keeping the trade as it currently is. Unfortunately, the demands of the 911 service is moving towards being able to do more than be a medical taxi service. Ultimately how do we ensure that paramedics are capable of taking on the roles that the health care system needs them to take on?



If medicare paid for medical taxi I would have no problem calling it that. Yes big part of IFT is just transport and nothing else. However ever once in a while something happens while in route and rapid transport to local ER  is needed....


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## JPINFV (Sep 8, 2011)

looker said:


> You're saying eliminate ift from ems industry. So why not just use gurney vehicles. If it is just iFT and no need for emt then it's just plain gurney transp. So why even use ambulance to transport?
> 
> The fact is ambulance association and other profession will never let the industry go to non profit. It's just not how this country works.



Looker, assuming that reimbursement was proportional, what would you say would be the value added for using two EMTs and an ambulance, in contrast to 2 orderlies and a gurney van, for the average hospital discharge? 

If you could, both legally and with appropriate reimbursement, run a gurney van service, how would your overhead change?


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## looker (Sep 8, 2011)

JPINFV said:


> Looker, assuming that reimbursement was proportional, what would you say would be the value added for using two EMTs and an ambulance, in contrast to 2 orderlies and a gurney van, for the average hospital discharge?
> 
> If you could, both legally and with appropriate reimbursement, run a gurney van service, how would your overhead change?



Overhead would drop when using gurney van. Vehicle cost would be much less compare to ambulance. No need for any supplies in the vehicle except for gurney, oxygen , first aid kit etc, no requirement currently to have it operated 24/7etc. Currently BLS is used instead of gurney because medicare do not pay for it. Pay out of pocket vs use an ambulance and have medicare pay, always ends up with medicare pay.


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## the_negro_puppy (Sep 8, 2011)

Sounds like a system we have here, except you guys would need socialised medicine for it to work-


We have-

One ambulance service run by the state. 4 levels of training-

Patient transport officer- does non acute IFTs etc
Student paramedic
Advanced Care Paramedic
Intensive Care Paramedic

Our patient transfer service for non acute IFTs also have buses with seats etc for those not requiring a stretcher.

Our fire department is state run and does fire and rescue, not pre-hospital care.

Our ambulances are 'free'' for all state residences

Our Intensive Care Paramedics (ALS) are in fly-cars for intercept.

We manage OK with 750,000 + calls a year


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## JPINFV (Sep 8, 2011)

looker said:


> Overhead would drop when using gurney van. Vehicle  cost would be much less compare to ambulance. No need for any supplies  in the vehicle except for gurney, oxygen , first aid kit etc, no  requirement currently to have it operated 24/7etc. Currently BLS is used  instead of gurney because medicare do not pay for it. Pay out of pocket  vs use an ambulance and have medicare pay, always ends up with medicare  pay.




So, in the end the system becomes much more efficient?


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## looker (Sep 9, 2011)

JPINFV said:


> So, in the end the system becomes much more efficient?



Yes and no. 

Yes it would be cheaper for medicare to pay for gurney van compare to ambulance . From patient standpoint the care will go down. If you need to get to ER, even bls can go l & s and get there quickly compare to gurney van calling 911, waiting for ambulance to come etc. Basically majority of BLS ambulance would be replaced by gurney van.


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## JPINFV (Sep 9, 2011)

looker said:


> Yes and no.
> 
> Yes it would be cheaper for medicare to pay for gurney van compare to ambulance . From patient standpoint the care will go down. If you need to get to ER, even bls can go l & s and get there quickly compare to gurney van calling 911, waiting for ambulance to come etc. Basically majority of BLS ambulance would be replaced by gurney van.



In my ideal world, something higher than a provider with 150 hours (being generous and using the new standard here) who can give, at best, oxygen and oral glucose, would be required to take someone to the emergency department, regardless of site of origin. So such patients would be routed through the 911 system.


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## Farmer2DO (Sep 9, 2011)

thegreypilgrim said:


> (6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.



I think a more reasonable option would be to make the BLS provider a 1 year, vocational program, like the practical nursing program, and the ALS provider an associate's degree, with a bachelor's degree as an option for upword mobility.  Most areas of allied health are an associate's degree for licensure/certification.  But I agree with the increased educational standards.



thegreypilgrim said:


> (8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.



I work in a state where any patient who is going to the ED is considered a 911 patient.  Now, nursing homes are still able to contract with private companies, but all the ambulances are certified to the same level with the same level of provider, and can stop and pick up the patient from the MVA that happened in front of them just as well as take grandma to the hospital to get her PEG tube replaced.  California seems like a bloody mess.


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## Trevor (Sep 9, 2011)

I whole heartedly agree with Pilgrim... Private ambulance systems are preventing the progression of EMS as a profession. They keep people overworked, underappreciated and underpaid... People are willing to do it for free, or for peanuts and so places have a constant influx of undereducated, underpaid, and underappreciated workers... "Hey, I can walk off the streets and take a 6 week EMT course and then be on an ambulance?!?! Awesome!!!" This "Lack of educational standards" propogates the problem of having underqualified TECHNICIANS (as opposed to clinicians, which is what we should be)... And you're never going to have adequately educated (*read Bachelor's degree*{which as pointed out earlier is the entry level requirements for most careers, and ALL "professions"}) without paying them more. Privately owned companies are the second most common system model, and you're never going to get a decent amount of pay, when your supervisors main focus being making money! 

The majority of EMS (nationwide {next to volunteer}) are being run by Fire Departments... And no offense to you fire medics, but when i call a plumber, i want a plumber to show up... Not an electrician who does plumbing on the side... Whats the problem with this? Its apples and oranges, just because you have trucks placed around the city, and have lights on them, doesnt mean you can do Prehospital Medicine. The other problem is that the majority of your time, effort, and money is spent supporting your primary mission... Fire Suppression... 

AS A GENERAL RULE U.S. HEALTHCARE SUCKS! It totally needs overhauled... Its way overpriced, is not nearly as progressive as we think (especially in the prehospital arena), and in some of our major benchmarks, we lag way behind countries like... CUBA?!?!?!? 

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html


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## firemedic132903 (Sep 10, 2011)

*Another idea...*

All those are great suggestions, however suggestions like staffing ambulances w/ two paramedics is in theory great;however it means nothing if some educational facilities around the U.S do not start raising standards and really focusing on teaching the entire curriculum, and stop using the excuse "you won't have to know that, because...".  You could put 4 paramedics or EMTs on a truck and still get subpar care and results or you could staff it w/ one quality paramedic/EMT and get a better result.  As a paramedic/firefighter and EMS Instructor for almost 8 years I have seen too many EMS educational facilities gear more towards the monetary rewards of pushing as many students through as possible, regardless of their skill and ability.


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## Ramel40 (Sep 10, 2011)

So then we extend the program by a few months and maintain the EMT's scope of practice? Basically, you want a longer training period to do the exact same thing. I am good with increasing education, but the scope of practice must increase as well. Spending a year learning to administer oxygen and a few assisted meds seems quite much. If the scope of the practice increased, as well as the educational requirement, maybe EMT's would be recognized differently and possibly become a career field that the entry level pay DOES NOT qualify you for State Public Assistance.


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## JPINFV (Sep 10, 2011)

Ramel40 said:


> So then we extend the program by a few months and maintain the EMT's scope of practice? Basically, you want a longer training period to do the exact same thing. I am good with increasing education, but the scope of practice must increase as well. Spending a year learning to administer oxygen and a few assisted meds seems quite much. If the scope of the practice increased, as well as the educational requirement, maybe EMT's would be recognized differently and possibly become a career field that the entry level pay DOES NOT qualify you for State Public Assistance.




At a year, full time, sure increase the scope. However the level of education needs to increase (and I'm not sure if going from 110 to 150 is enough to be honest) to justify the current scope by ensuring that providers have enough foundation to think.


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## thegreypilgrim (Sep 11, 2011)

Ramel40 said:


> So then we extend the program by a few months and maintain the EMT's scope of practice? Basically, you want a longer training period to do the exact same thing. I am good with increasing education, but the scope of practice must increase as well. Spending a year learning to administer oxygen and a few assisted meds seems quite much. If the scope of the practice increased, as well as the educational requirement, maybe EMT's would be recognized differently and possibly become a career field that the entry level pay DOES NOT qualify you for State Public Assistance.


Under the scheme I suggested there would no longer be EMTs. All existing EMTs would have to upgrade to something more or less equivalent to what is currently referred to as 
AEMT (formerly EMT-Intermediate) which would itself then require an AS degree and carry some corresponding scope of practice changes.


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## Melclin (Sep 11, 2011)

While I agree with a lot of what you've said, you've described our system reasonably well and well still have many problems. For the sake of comparison:



thegreypilgrim said:


> (1) Transfer federal oversight of EMS from NHTSA to the Department of Health and Human Services (HHS).



We exist as part of the health system, not the emergency services or any other body. Unfortunately, this doesn't seem to help us when it comes to funding. If we spend x million dollars improving TBI outcomes, saving the health system 20x million in lifetime care for TBI pts, we don't see a cent of that 20x and we simply end being x million over budget. Management is trying to change this but there isn't a lot of free money floating around the healthcare system at the moment. 



thegreypilgrim said:


> (2) Convert all privately owned, for-profit ambulance companies to not-for-profit status. Compensate any investors for past investment.



There is no for-profit emergency response, unless you count the non-emerg companies covering some of the very low acuity 000 (911) work occasionally, at the request of the state ambulance service. This seems to work reasonably well. In fact, I'd argue that expanding the private role would take some of the strain of emergency system, as long as it all runs through and is regulated by the state ambulance service. 



thegreypilgrim said:


> (3) Convert all fire department operated EMS programs to an independent state (preferably), regional, or municipal agency. Downgrade FDs to CFR level.



This just seems like a no brainer. We're actually going the other way, in that we're expanding medical training for fire fighters to bring everyone from nothing up to first response, and I think its a great idea. Its improves disaster coping capacity, its great for cardiac arrest response times, it means FD can do some basics like put oxygen, clear airways. This was initiated, controlled and overseen by the state ambulance service. To suggest the FD should be competing with ambulance services just seems absurd to me. 




thegreypilgrim said:


> (4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).



The universities that offer paramedic programs here are struggling with this idea too. No easy when there are so many regional differences in scope and general approach.



> (5) Change the Medicare ambulance billing scheme by requiring patients to be seen by providers trained to new NAEMSP/ACEP standards in order for non-transport to still be covered. Also replace the mileage-based structure with one based on clinical time usage.



Ambulance attendance is billed here, not transport. Again this seems like a no brainer. 



> (6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.



Similar, as you know, to our system. Bachelors (3 years at uni) for paramedic (ILS), Graduate study for Intensive care paramedic (ALS). I think putting the bulk of the education behind the basic provider such that all paramedics share a basic standard of education that can then be built on, is the way to go.



> (7) Staff all ambulances with two AEMTs which will be able to handle the majority of calls. Place Paramedics in rapid response vehicles with a driver (non-medically trained) for intercept - only auto-dispatched in limited set of calls.



As we've discussed in the past we do a lot of this. Its important to have enough scope at the basic provider level such that you can have a smaller number of ALS providers seeing a lot more sick people. ALS for pain relief or for a pulse >100 is just absurd. ALS for RSI, inotropic support, chest decompression and general complex management. That's the way to go.

The fly car model has issues though. They see more patients, do more work, get more tired, do more driving and end up responding to jobs alone a lot which is both dangerous and stressful. The occupational health and safety issues here are clear. Tired, overworked, stressed paramedics driving more without being able to split the load with your partner is causing issues. Additionally, our fly car medics have been having a disproportionately large number of nasty crashes, which is currently being addressed by our driving standards department. 

When a job requires two intensive care paramedics, the single responder can be left with a lot a work to do, if the basics on the back ILS car aren't the sharpest tools in the shed.

Overall I think its a positive model that needs to be tweaked a little.



> (8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.



In general I agree. We do have some ability to utilize non-emerg and IFT guys for over flow. I think its a good option to have. Its reasonably common to get jobs here where a person has called a specialist or a doctor has arranged a direct admission and we get called, knowing with reasonable certainty that we're not going to be doing anything a taxi driver couldn't do. It would be nice for the non-emerg sector to be able to deal with this type of patient as well. People who have essentially already received some form of medical assessment and really just need a lift to hospital for non-emergent admission. 



JPINFV said:


> 9. Separate non-emergent medical transport from EMS both in terms of education and licensure.



We have this. On account of our non-emerg and emerg sectors being reasonable separate.


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## Tigger (Sep 12, 2011)

Melclin said:


> The fly car model has issues though. They see more patients, do more work, get more tired, do more driving and end up responding to jobs alone a lot which is both dangerous and stressful. The occupational health and safety issues here are clear. Tired, overworked, stressed paramedics driving more without being able to split the load with your partner is causing issues. Additionally, our fly car medics have been having a disproportionately large number of nasty crashes, which is currently being addressed by our driving standards department.
> 
> When a job requires two intensive care paramedics, the single responder can be left with a lot a work to do, if the basics on the back ILS car aren't the sharpest tools in the shed.
> 
> Overall I think its a positive model that needs to be tweaked a little.



Has there been any thought put towards having double ICP fly cars?

There are still a few non-transporting ALS services around in my area, and all of them I believe utilize two paramedics with two sets of ALS gear. Obviously this has the benefit of being able to split the workload and driving, along with the added advantage of having two medics for very sick patients or 2 medics on scene at multi-patient MVC. I still think that these medics are seeing plenty of sick patients though, despite the perceived splitting of workload. If the patient is a mess, both medics are taking the call and an EMT from the transporting service will drive the fly car.

Assuming that the ICP car is not responding to a call alone, will they ever be dispatched simultaneously with an ILS truck? Around here the medics are almost never dispatched with the ambulance, the BLS crews just request them. The police, who beat the ambulance every time since the ambulance is not staffed in-station, can also call ALS if it's clear they will be needed (arrest, major trauma, etc.)


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## Melclin (Sep 12, 2011)

Tigger said:


> Has there been any thought put towards having double ICP fly cars?
> 
> There are still a few non-transporting ALS services around in my area, and all of them I believe utilize two paramedics with two sets of ALS gear. Obviously this has the benefit of being able to split the workload and driving, along with the added advantage of having two medics for very sick patients or 2 medics on scene at multi-patient MVC. I still think that these medics are seeing plenty of sick patients though, despite the perceived splitting of workload. If the patient is a mess, both medics are taking the call and an EMT from the transporting service will drive the fly car.
> 
> Assuming that the ICP car is not responding to a call alone, will they ever be dispatched simultaneously with an ILS truck? Around here the medics are almost never dispatched with the ambulance, the BLS crews just request them. The police, who beat the ambulance every time since the ambulance is not staffed in-station, can also call ALS if it's clear they will be needed (arrest, major trauma, etc.)



I don't know if they've considered dual ICP cars. If you were ganna staff it like that, why not just put them on an ambulance and have an extra stretcher resource? 

We dispatch ICP and ILS simultaneously for certain job codes. Most of the time this means the ILS will cancel ICPs back up pretty quickly after the ILS truck arrives (if you don't, you risk getting a dodgy reputation). Unless there are resourcing issues (which is often) at which time they cancel the dual response and its simply closest car goes and if you need ICPs then you call.

Fly cars are always backed by ILS though.


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## Tigger (Sep 12, 2011)

Melclin said:


> I don't know if they've considered dual ICP cars. If you were ganna staff it like that, why not just put them on an ambulance and have an extra stretcher resource?
> 
> We dispatch ICP and ILS simultaneously for certain job codes. Most of the time this means the ILS will cancel ICPs back up pretty quickly after the ILS truck arrives (if you don't, you risk getting a dodgy reputation). Unless there are resourcing issues (which is often) at which time they cancel the dual response and its simply closest car goes and if you need ICPs then you call.
> 
> Fly cars are always backed by ILS though.



Part of theory behind fly cars is that they cost less to purchase and operate than an ambulance. Ideally staffing allows the fly car to operate in an intercept only role, which happens neither here nor where you are apparently, sadly. I guess the thinking is if all you are doing is intercepting other ambulances it's just wasteful to run an ambulance that will never see a patient.

Plus, if you put the ICP guys on an ambulance, they then become an overflow resource for when all the ILS trucks are out, and that's not really the goal of the ICP program I'd imagine?


Sent from my out of area communications device.


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## Katy (Sep 12, 2011)

Ramel40 said:


> So then we extend the program by a few months and maintain the EMT's scope of practice? Basically, you want a longer training period to do the exact same thing. I am good with increasing education, but the scope of practice must increase as well. Spending a year learning to administer oxygen and a few assisted meds seems quite much. If the scope of the practice increased, as well as the educational requirement, maybe EMT's would be recognized differently and possibly become a career field that the entry level pay DOES NOT qualify you for State Public Assistance.


The education level would have to be expanded a good bit before you can even consider expanding the scope of practice, EMT's need more education doing what they do now before moving on to anything more complex.


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## Jon (Sep 19, 2011)

thegreypilgrim said:


> (4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).



Why NAEMSP / ACEP?

Shouldn't NAEMSE be involved? In charge?

I think that setting it up with the docs in charge will always limit the scope of our highest providers.


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## jjesusfreak01 (Sep 19, 2011)

Happy said:


> The education level would have to be expanded a good bit before you can even consider expanding the scope of practice, EMT's need more education doing what they do now before moving on to anything more complex.



Due to the current regional system where medical directors, counties, or states determine scope of practice for each provider, EMS classes can do little more than establish a baseline of education for a provider. It is the responsibility of the EMS system to complete each providers education to allow them to work within that systems protocols and with their equipment. 

My EMT-B field training period is going to be far far longer than my EMT-B class, and I think that's really how it should be, because when they finally put the rubber stamp on my file, it doesn't say that i'm trained to be an EMT, it says that they trust me with the lives of the citizens of my county. 

What i'm getting at here is that while the EMT basic training may not be very long or in depth, EMTs are usually not definitive prehospital care, and in most places they undergo at least some additional training before being given additional responsibilities or skills to use.


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## traumaluv2011 (Sep 19, 2011)

The United States is screwed up in general. It doesn't make sense to have 10 different ambulance companies in one area, it just makes all this competition. If the privatized ambulances merged and kept their ALS units (and maybe a few backup BLS), we'd be much better off. 

Let the government fire companies, first aid/rescue squads, etc. handle BLS. If ALS is absolutely necessary, in places with long drives to the hospital especially, dispatch medics to. It would be much easier on the patients because they shouldn't need to spend $500-2000 for the ambulance alone. The medical bills will already kill them. I have about a 10 minute ride to the hospital and I'd say 9 times of of 10 we won't need the medics.


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## atropine (Sep 20, 2011)

How to fix ems?, well first who are we asking?, I know on this fourm the people who work ems will always have an opinion, but who is really going to fix it and from what level of the government. Until I retire I think ems is just fine in my area, but if you ask some private guy making eight bucks an hour he will have a different answer.


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## Tigger (Sep 20, 2011)

traumaluv2011 said:


> I have about a 10 minute ride to the hospital and I'd say 9 times of of 10 we won't need the medics.



If we want to fix EMS we need to make sure that every patient is seen by a provider that can thoroughly assess them. You and I both know that our assessment skills are lacking compared to everyone with our degree of autonomy. Sure we can document signs and symptoms, but how often can we make anything close to a differential dx. Obviously with something like anaphylaxis it's different, but those are exceptions to the rule. 

How much does it suck to sit in back with a little old lady with a UTI that is in so much pain she can barely move and know that you can do pretty much nothing? I'm all about keeping patients as comfortable as possible and reassuring them, but these people need real medicine, not kind words. Can a BLS truck deal with a sick lady 10 minutes from the hospital? Yes, undoubtedly. But those are 10 more minutes that your patient is suffering and we can't do anything about it. Medics aren't just for crazy traumas and arrests, they can actually alleviate pain and suffering, which is what a lot of medicine is about.


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## 46Young (Sep 21, 2011)

Tigger said:


> If we want to fix EMS we need to make sure that every patient is seen by a provider that can thoroughly assess them. You and I both know that our assessment skills are lacking compared to everyone with our degree of autonomy. Sure we can document signs and symptoms, but how often can we make anything close to a differential dx. Obviously with something like anaphylaxis it's different, but those are exceptions to the rule.
> 
> How much does it suck to sit in back with a little old lady with a UTI that is in so much pain she can barely move and know that you can do pretty much nothing? I'm all about keeping patients as comfortable as possible and reassuring them, but these people need real medicine, not kind words. Can a BLS truck deal with a sick lady 10 minutes from the hospital? Yes, undoubtedly. But those are 10 more minutes that your patient is suffering and we can't do anything about it. Medics aren't just for crazy traumas and arrests, they can actually alleviate pain and suffering, which is what a lot of medicine is about.



I like being able to practice pain management, even though it's only for musculoskeletal injuries, cx pain, or kidney stones at the moment. 

What I think you're talking about is being able to practice independent thinking. When you move towards independent thinking, you're moving away from the role of prehospital EMS and moving towards that of a physician.

The question is, what is the practical limit of what we should be capable of in our prehospital role? Perhaps we should be able to triage out at the scene, and direct the pt to a more appropriate destination than the ED where applicable, and preferably by alternate means than an ambulance if appropriate. I could see the practicality of doing sutures in the field, for example. 

But there's a limit to what's appropriate and practical in the prehospital realm. We're not doing blood work, other than possibly an I-stat. We're not doing X-Rays and CT scans. We're not doing surgical procedures in the field. We don't have the additional necessary staff, the space to store the equipment and supplies, and we don't have an X-ray tech or ultrasound tech degree, for example. If we were capable of these procedures, the time spent could be better spent transporting to the hospital. The hospital is called definitive care for a reason.

Many of us choose to improve our medical education beyond the minimum standard for the EMT-P in our country (the U.S.). The thing is, much of it isn't useable in prehospital EMS. Those who realize this, and long to be capable of more, may choose to leave EMS and enter PA school or medical school.

As each shift goes by, I realize that we're really just treating signs and symptoms, and making provisional diagnoses (maybe) for the purpose of giving treatment according to protocol or guidelines. It still boils down to "see A, do B, transport," just like in EMT school. It's just that our education allows us to better quantify "A." We're not making a definitive diagnosis. We're not prescribing meds or performing surgery. We're not writing a discharge plan for the pt. The meds we do give are pre-determined by the OMD, so we're really pushing meds as an extension of the OMD, based on "see A," as above. We're not doctors. There's an upper limit to what is appropriate for EMS to do in the field.

Do we need a four year degree to properly quantify "A"? Since upwards of 90% of our patients are not time sensitive, I'm going to say no. A two year degree to provide the basics of a medical education (no ride hours, just the classroom), and then a one year field internship? That sounds about right, IMO. Patch factory? That would have been adequate maybe 15 or 20 years ago, but not now.

Edit: Go to court, go on the stand, and see what happens when you say "I diagnosed "X." You'll need to say "I saw A, and treated for A with B,C, and D, according to protocol."


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## 46Young (Sep 21, 2011)

As far as minimum educational requirements, I can agree that the paramedic ought to have a two year degree. I understand how nurses, RT's, etc. organized, established a minimum eduactional standard, and were able to negotiate more generous reimbursement by convincing the powers that be that the degrees were for the patients' benefit.

In American EMS, I don't envision the majority of medics being willing to fall on their swords by incurring the financial and time expense to earn a degree, when it won't increase their bottom line. Another demotivational factor to that end is that the opportunities for career development (promotions, managerial positions) are severely limited. I don't know about you, but if I'm going to get a degree, especially a four year one, there had better be an attainable career ladder as an incentive. I don't know of too many people who will get the two year degree, then the four, when the chances are quite high that they're going to be on the street for most if not all of their career, making the same anemic salary.

The fire service has been villianized for it's role in EMS, particularly the takeovers and resistance to educational advancements. In some cases it's very true, in other cases it's not. It's on a department to department basis, a region to region basis. But I ask you this, what are the hospital based EMS organizations, the municipal Third Services, the private Third Services, and IFT only companies doing to either advocate or outright require degrees as a condition of hire? I haven't seen much. Think about it, if every hospital based EMS organization, and every municipal system required a degree, then that would become the new standard. The privates generally don't give as much as the munis and hospitals, so they would simply get the leftovers. But this doesn't happen. 

In short, everyone's to blame. 

On other threads, I've said that the fire service at least compensates those with degrees with hiring preference in some cases, but certainly with career development points which help with the promotional process. Now, the fire service, as a whole is moving to the National Professional Development Models. There's one for EMS, and one for the fire service. My department is dual role, so naturally, we're doing a combination of the two. I know, the EMS model doesn't require a degree for entry, but it does require a degree at some point. The effect of this is that I've seen more and more of our ALS hires coming in with an EMS AAS in hand. Others, such as myself, have used the P-card as time served, only having to earn 31 more credits for that same degree. Our classes are paid for by the county as well. THe county sends it's incumbents to  ALS (currently EMT-I) school. The classes are credit courses, and those interested need NAS 150 Human Biology and HLT 250 Pharmacology as pre-reqs. When the "I" program goes away, it'll be the degree program for all future incumbent ALS hopefuls.

What's everyone else's employers doing?

Edit: Here's the model:

http://www.usfa.fema.gov/nfa/higher_ed/feshe/feshe_strategic.shtm


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## thegreypilgrim (Sep 21, 2011)

Jon said:


> Why NAEMSP / ACEP?
> 
> Shouldn't NAEMSE be involved? In charge?


 Why should they be? What have they done that demonstrates a willingness and/or capability to implement such an agenda? At least the NAEMSP and NASEMSD were the ones who actually developed the EMS Education Agenda for the Future...way back in 1996. Fifteen years later, we're only just now barely seeing shadows of that plan being implemented and to my knowledge NAEMSE hasn't been all that active in getting this accomplished.



> I think that setting it up with the docs in charge will always limit the scope of our highest providers.


 What makes you say that?


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## JPINFV (Sep 21, 2011)

Jon said:


> I think that setting it up with the docs in charge will always limit the scope of our highest providers.



How often are physicians looking to limit the scope of EMS providers for reasons outside of education and capability?


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## thegreypilgrim (Sep 21, 2011)

46Young said:


> The question is, what is the practical limit of what we should be capable of in our prehospital role?
> 
> As each shift goes by, I realize that we're really just treating signs and symptoms, and making provisional diagnoses (maybe) for the purpose of giving treatment according to protocol or guidelines. It still boils down to "see A, do B, transport," just like in EMT school...We're not doctors. There's an upper limit to what is appropriate for EMS to do in the field.


 It's this mentality right here that totally takes the wind out of the sails of any movement to turn EMS into some semblance of a profession. I have difficulty understanding the notion that any suggestion of increasing education standards is fruitless because even after that "we're still not doctors". I do not understand this objection. Are you suggesting that in order to increase our autonomy and/or functions to a meaningful degree we'd have to attain an education level equivalent to physicians and anything less than that would be redundant? Surely, there are many options between where we currently are and that of doctors that are worth pursuing. 

Also, the ED is not definitive. The ED physician doesn't make a "definitive diagnosis", so by the same logic we shouldn't require such a thing as an Emergency Physician. The point is "See A, do B, transport" is not a sustainable model from neither a medical or economic standpoint, and policymakers will eventually come to understand this. The system will be changed in a way which can be beneficial to EMS providers or not as much.



> Do we need a four year degree to properly quantify "A"? Since upwards of 90% of our patients are not time sensitive, I'm going to say no. A two year degree to provide the basics of a medical education (no ride hours, just the classroom), and then a one year field internship? That sounds about right, IMO.


 (1) An undergraduate degree is the standard for _any_ professional career, let alone one in healthcare. If a BA/BS is required to be an HR Representative, CPA, engineer, etc. than why shouldn't it be necessary for something as critical as emergency care?

(2) It is precisely because 90% of our patients are not only not time-sensitive, but not even acutely ill that our education needs to provide us with the tools to handle this. EMS literally has nothing to offer the vast majority of people who access it beyond a cardiac monitor, a line of saline, and a ride to the hospital. That is not worth the ambulance fee. We should adapt our capabilities and services to the public, not try to adapt the public to what we think we should limit ourselves to.

(3) Our decisions need to be justified, and if options such as provider-initiated non-transport, alternative clinical pathways, treat-and-release, etc. are going to be incorporated into EMS the providers must have the cognitive abilities to justifiably apply them. If we're going to make such demands on paramedics then they have to be provided the tools to properly and safely fulfill those demands. It isn't prudent from a logistical standpoint to think that an 18 month AS degree is sufficient education to achieve that level of performance. Especially when Nursing, Respiratory Therapy, Occupational Therapy, etc. have all long ago determined a BS degree is required for their functions.



> Another demotivational factor to that end is that the opportunities for career development (promotions, managerial positions) are severely limited. I don't know about you, but if I'm going to get a degree, especially a four year one, there had better be an attainable career ladder as an incentive. I don't know of too many people who will get the two year degree, then the four, when the chances are quite high that they're going to be on the street for most if not all of their career, making the same anemic salary.


 This is myopic thinking. Sure, it will require short-term sacrifice, but will result in long-term gains. Raising the bar for entry into the field will significantly limit the number of employable candidates and desaturate the market. Demand for paramedics will increase, and with that a better negotiating position for said paramedics. Career development will also open up once it is understood by the rest of society that a "Paramedic" is an educated person. I don't see why, following this, paramedics won't be able to move into management/administration, academia, or other clinical roles (e.g. CCT, primary care, etc.).


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## pa132399 (Sep 23, 2011)

i didnt have the ambition to read through everything in here way too late still cant fall asleep but everything began to blur as i read it so if it was said in here im sorry...

ELIMINATE NREMT it is nothing but a money making gimmic and at 130 a pop for the medic test and basic i think in the 70's they sure make a killing on it.

Make states create there test to accomodate their approved protocols and meet the NHSTA guidline or better yet make the standards nationwide and then we could keep the godforsaken NREMT and actually use the drugs and protocols we are taught that in most cases are thrown out the window the day after you find out you passed the class. no havent taken the test but i think that it would either cut down on confusion or make it that we were a universal and wouldnt be governed by multiple redunant levels. my state PA has approved protocols then it kicks down to ems councils which cover different regions, and then different medical directors for each unit. If only it was universal it would be simple. but who would have thought of that. 

Also if we were universal we might not be looked at as the very bottom of the totem pole by everyone else in the medical field. hey we might make a few extra bucks and be looked at as professionals.

Wow that was a mouthful must be my long lenghty post kind of night


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## TheyCallMeNasty (Sep 23, 2011)

This thread is nothing but a pipe dream.....I lol'd when i read the AS degree for emt thats a good one, I think i've come across pieces of thin paper in the depths of LA County bathrooms that would be worth more than that degree....compared to others...

also I would be good with the jobs requiring degrees if they came with a salary to match it.


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## Smash (Sep 23, 2011)

Callen909 said:


> This thread is nothing but a pipe dream.....I lol'd when i read the AS degree for emt thats a good one, I think i've come across pieces of thin paper in the depths of LA County bathrooms that would be worth more than that degree....compared to others...
> 
> also I would be good with the jobs requiring degrees if they came with a salary to match it.



So which is it, the chicken or the egg?

Every other country in the world has come to grips with the requirement for a degree as an entry into EMS. Some places require a full degree as a _minimum_ level, and that won't even let you operate at an "ALS" level.  Mostly this education is done in the pre-employment sector, and paid for by the hopeful EMT.  Funnily enough, this is exactly the same as every other profession, and lo and behold! EMS is seen as a profession as a result. 

American EMS, however, seems mired in a lazy, self absorbed, anti-education,   trade mentality that it seems unable (or unwilling) to change. 

Now, before everyone climbs up me, yes I realise that there are exceptions, and most of those exceptions post here. However, the people who post here are arguably atypical of US EMS.  So long as the above attitude prevails, unfortunately I believe that the poster is right, and this thread is a pipedream. If a few more people pulled their fingers out and stopped accepting that attitude, maybe things can change.


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## FirstInTac'dOut (Sep 23, 2011)

"How to fix EMS"

I guess that depends on how you see EMS, and by extension, yourself. 

To point, do you see yourself as a link in the chain of MD-PA-NP-RN-ERT-(EMS)? If you do, I suppose that you are of the mind that EMT-B certification should be done away with entirely, and that Paramedic certification (or, dare-i-say, licensure) require a Bachelors degree, and thus, I bet you think, more respect and higher pay. 

Or... Do you see EMS as part of the Emergency Response system, ie Police, Fire. If you do, I bet you would prefer a high intensity, high-immersion, boot-camp style program for EMT/Paramedic training.

Full disclosure: I am a graduate of 4 year University, and I also fall into the latter model, or perhaps a hybrid of the two. 

Ever wonder why in an ER, or a Nursing Home, paramedics, and to a lesser extent, EMTs, walk away muttering under their breath about the incompetence of the nurses? In my observation, it's because nursing TRAINING is non-tactical, it is care based; or, if they are more advanced, and this includes MDs, it is diagnostically based. 

EMS, however, is different. EMS is based on differential treatment algorithms, and a tactical approach to medicine. The role of EMS, in its purest form, is to identify life threats, treat and stabilize them, and get the patient to a hospital. EMS is, in my eyes, a Emergency Medical Corps, if you will. You are the soldier of medicine, on the front lines. Police get called for Crime. Fire Dept gets called for Fire. EMS gets called for Medical Emergencies. Simply put, unless you are going to turn the ambulance into a rolling OR, you are not a doctor; unless you are going to manage a pt's condition for 12 hours at a time, you are not a nurse. You are something else.

A thought on Paramedic education: 
A four year degree requires approximately 1200 hours of classroom time (15hr/wk x 10 wk semester x 2 semesters/yr x 4 yrs = 1200hrs). You could do boot camp-style training (5day/week x 12 hr day = 60/hr wk) in 20 weeks, or less than 6 months, and acheive the same goal. I know there are some out there who will say that the information load would be too intense in such a short time, and certainly that is an argument, but some studies show that intensive learning can not only encourage retention, but can also force dramatic change in the WAY you think; which, I believe, is most important when you are training someone in a new field; or, for example, turning someone from a civilian into a type of soldier. A Tactical Medical Responder. Para-medicine necessitates para-military style training.

Sorry if this got rant-y; it has been a long week. I'm sure there will be more who disagree than agree, so please, let me know what you think. Here we go... 

Oh, and look: Most people I've come across who'd rather see themselves on the same level as a nurse, or other hospital staff, seem to regret their career path more than anything. If you want to be an RN, be an RN. If you want to play doctor, you should've gone to medical school. Treat the life threats, treat the symptoms, gather the information and the evidence for the Doc. Don't try to BE the doc. Let them all do their jobs, and understand what yours is, and what it could be.


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## usalsfyre (Sep 23, 2011)

Yeah...no....

Medicine. That's what we do. We don't ensure the safety of large groups of people, we don't protect property, we treat the individual patient, one at a time.


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## thegreypilgrim (Sep 23, 2011)

Callen909 said:


> This thread is nothing but a pipe dream.....I lol'd when i read the AS degree for emt thats a good one, I think i've come across pieces of thin paper in the depths of LA County bathrooms that would be worth more than that degree....compared to others...
> 
> also I would be good with the jobs requiring degrees if they came with a salary to match it.


 This is precious. Like the august Smash asked, what comes first? How is the proportionate salary increase supposed to unfold? Do you expect someone else to just magically force employers to start paying their providers more if they have a degree? It doesn't work that way, unfortunately. It requires self-initiation, organization en masse, and sacrifice to rise to the professional level.


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## thegreypilgrim (Sep 23, 2011)

FirstInTac'dOut said:


> Or... Do you see EMS as part of the Emergency Response system, ie Police, Fire. If you do, I bet you would prefer a high intensity, high-immersion, boot-camp style program for EMT/Paramedic training.


 This is what EMS has been for years. It has not succeeded transitioning EMS into an actual profession.



> Ever wonder why in an ER, or a Nursing Home, paramedics, and to a lesser extent, EMTs, walk away muttering under their breath about the incompetence of the nurses? In my observation, it's because nursing TRAINING is non-tactical, it is care based; or, if they are more advanced, and this includes MDs, it is diagnostically based.


 This is an incredibly arrogant statement to make, based on flawed thinking and hasty generalizations. Sure, there are incompetent nurses but I would be loath to apply that descriptor to nurses as a whole. And I have no idea what you mean by "non-tactical" or "care-based" or "diagnosticlly-based" training. You're going to have to explicitly define those concepts and explain why the the complexities of nurse or physician training can be distilled down to these single concepts.



> EMS is, in my eyes, a Emergency Medical Corps, if you will. You are the soldier of medicine, on the front lines. Police get called for Crime. Fire Dept gets called for Fire. EMS gets called for Medical Emergencies. Simply put, unless you are going to turn the ambulance into a rolling OR, you are not a doctor; unless you are going to manage a pt's condition for 12 hours at a time, you are not a nurse. You are something else.


 I am not a soldier. I am not some Public Safety guru. I am a health care professional who practices medicine of a defined scope. I like to think that paramedicine is more than some adaptation of combat-style first aid and rescue. No, that isn't what I do.



> A thought on Paramedic education:
> A four year degree requires approximately 1200 hours of classroom time (15hr/wk x 10 wk semester x 2 semesters/yr x 4 yrs = 1200hrs). You could do boot camp-style training (5day/week x 12 hr day = 60/hr wk) in 20 weeks, or less than 6 months, and acheive the same goal.


 This is by all known evidence a terrible educational model. Time spent at your desk in the classroom is not at all where the magic of learning happens. Many additional hours outside the classroom are necessary to augment and solidify what was gleaned from the lecture material which is why the pace of the course needs to account for that (and you ought to know that 10 week quarters go by rather quickly). Furthermore you have access to an excellent faculty that is dedicated to learning (not the espousal of war stories) and the resources of a university in this setting which can be invaluable. This 6 month "boot-camp style" model is a great way to ensure students have a flawed understanding that is basically just rote-learning and higher-order naturalistic understanding is absent.



> If you want to be an RN, be an RN. If you want to play doctor, you should've gone to medical school. Treat the life threats, treat the symptoms, gather the information and the evidence for the Doc. Don't try to BE the doc. Let them all do their jobs, and understand what yours is, and what it could be.


 I'm having a tremendously difficult time understanding why so many people have equated the suggestion for something as meager as a baccalaureate degree with wanting to turn medics into doctors. I really think that is absurd. What I want is for paramedics to become professionals who can exercise critical thinking, be autonomous, accept responsibility, and play a greater role on the health care continuum than a manual laborer who brings people to the hospital after minimal intervention.


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## DrParasite (Sep 23, 2011)

thegreypilgrim said:


> This is by all known evidence a terrible educational model. Time spent at your desk in the classroom is not at all where the magic of learning happens. Many additional hours outside the classroom are necessary to augment and solidify what was gleaned from the lecture material which is why the pace of the course needs to account for that (and you ought to know that 10 week quarters go by rather quickly). Furthermore you have access to an excellent faculty that is dedicated to learning (not the espousal of war stories) and the resources of a university in this setting which can be invaluable. This 6 month "boot-camp style" model is a great way to ensure students have a flawed understanding that is basically just rote-learning and higher-order naturalistic understanding is absent.


I respectfully disagree.  While I don't discount the value of the work done outside of the classroom, I do think that classroom time is time for learning, and when you leave classroom, you should be permitted to be off the clock.  

Speaking for myself only, I hate homework.  in high school, I hate homework.  in grammer, I hated homeworking.  in college, I hated homework.  I did stuff outside of school, and while I gave 100% while I was in class, outside of class I did have other priorities.  

I've also taken 4 and 5 credit classes over the summer, cramming 9 credits of schooling into a 8 week time frame.  plus working full time.  it sucked.  We did the same work as a a regular 4 month just super condensed.  but the work was the same.

It can be done, and I do think that a good instructor/professor can teach what is needed during the time frame, and if you can't, than it's either time to restructure the course or utilize the time better.  Outside of some outside reading, you should be able to teach what you need to within the timeframes give.  and yes, I did have many upper level course that were able to do just that.

Class is for learning.  let people have lives outside of class, as well as time to unwind from a mentally difficult day


thegreypilgrim said:


> I'm having a tremendously difficult time understanding why so many people have equated the suggestion for something as meager as a baccalaureate degree with wanting to turn medics into doctors. I really think that is absurd. What I want is for paramedics to become professionals who can exercise critical thinking, be autonomous, accept responsibility, and play a greater role on the health care continuum than a manual laborer who brings people to the hospital after minimal intervention.


because more of your baccalaureate degrees are crap.  no wait, that's not accurate; most of your  baccalaureate degree are diverse, and are not focused on a single area.

I have said it before, and I will say it again: you show me a  baccalaureate degree that is completely 100% focused on paramedicine, and prehospital emergency care, and I will support it 100%.  no electives, no side focus on health services management, no side focus on emergency management, no courses that are designed to give you a "well rounded education", everything is about become a good paramedic.

when you go to a trade school, or a current paramedic or EMT program, everything is 100% focused on the skill.  grad schools are like this too, where everything is focused on the overall goal.  I can't tell you how many courses in college I took were a huge waste of time, some because I learned nothing from them, others because they weren't at all applicable to my area of study.

I think Australia actually does something like this.  Sadly, I haven't seen anything in the US like this, nor do I forsee it happening anytime soon.


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## JPINFV (Sep 23, 2011)

Damn, I wish I wouldn't have needed to study outside of class.


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## usalsfyre (Sep 23, 2011)

The expectation of any higher education program that I've ever been aware of is that you study outside of class.


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## medicswag (Sep 23, 2011)

Why doesn't nursing take over EMS? They have done remarkably well advancing their profession.


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## Handsome Robb (Sep 23, 2011)

medicswag said:


> Why doesn't nursing take over EMS? They have done remarkably well advancing their profession.




Go back under your bridge.


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## JPINFV (Sep 23, 2011)

medicswag said:


> Why doesn't nursing take over EMS? They have done remarkably well advancing their profession.




...because it's not nursing. Why doesn't medicine take over nursing? After all, advanced practice nurses are just wanna-be physicians that couldn't hack medical school.  

/See, I can play this game too!


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## medicswag (Sep 23, 2011)

JPINFV said:


> ...because it's not nursing. Why doesn't medicine take over nursing? After all, advanced practice nurses are just wanna-be physicians that couldn't hack medical school.
> 
> /See, I can play this game too!



Are you implying that " [paramedics]  are just  just wanna-be [nurses] that couldn't hack [nursing] school."?


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## 46Young (Sep 23, 2011)

thegreypilgrim said:


> It's this mentality right here that totally takes the wind out of the sails of any movement to turn EMS into some semblance of a profession. I have difficulty understanding the notion that any suggestion of increasing education standards is fruitless because even after that "we're still not doctors". I do not understand this objection. Are you suggesting that in order to increase our autonomy and/or functions to a meaningful degree we'd have to attain an education level equivalent to physicians and anything less than that would be redundant? Surely, there are many options between where we currently are and that of doctors that are worth pursuing.
> 
> Also, the ED is not definitive. The ED physician doesn't make a "definitive diagnosis", so by the same logic we shouldn't require such a thing as an Emergency Physician. The point is "See A, do B, transport" is not a sustainable model from neither a medical or economic standpoint, and policymakers will eventually come to understand this. The system will be changed in a way which can be beneficial to EMS providers or not as much.
> 
> ...



1 - An RN and an RRT treat patients without a 4 year degree. The progression to BSN doesn't really include any further medical education. I suspect that the same holds true for respiratory therapy. In EMS, it's the same thing. Going to school for two more years won't make me a better paramedic; it's for career development, Rather, it would be if there was a career ladder to speak of. Those opportunities are few and far between in single role EMS.

2 - In the role of prehospital EMS, how much more can realistically be done? Our role is to assess, treat if necessary, and transport to a hospital. It would be nice if we could transport the pt to a more appropriate destination, or perform more treat and release functions, but we're not performing field surgery, field CT's and X-Rays, nor are we capable of performing blood work or diagnosing and writing a treatment plan based on any of the above results.

If you want to talk about expanded scope and functions outside of 911, then we're getting away from EMS, and transitioning into roles that PA's, BSN's, and NP's are better suited for.

3 - OLMD consult can address that. Many, if not most systems here will be too litigation phobic to enable provider initiated refusals and anthing past minor treat and release. We have urgent care facilities that can do treat and release.

In EMS, I suppose that an Attending Physician in Emergency Medicine would be the top level of the profession. We're at the bottom. What liberties and level of autonomy are you looking for, exactly? Without Medical Direction, I would say that we need a lot more than four years of medical education to pracitce independently. I don't know of any medical professions in the U.S. that can practice with true autonomy that have only four years of medical education.

CCT and specialty transport is done by nurses in many places. Good luck taking that over with our extent of disorganization.


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## 46Young (Sep 23, 2011)

thegreypilgrim said:


> This is precious. Like the august Smash asked, what comes first? How is the proportionate salary increase supposed to unfold? Do you expect someone else to just magically force employers to start paying their providers more if they have a degree? It doesn't work that way, unfortunately. It requires self-initiation, organization en masse, and sacrifice to rise to the professional level.



I agree with Callen. If I'm going to sacrifice my time, money, and opportunity cost by earning a degree, it is not unreasonable to expect to be compensated appropriately. I realize that this created a catch-22, but I am unwilling to wait things out for 10-20 years for an uncertain future at best/ I  also have a family to support and a mortgage to pay. I'm not going to screw myself out of a gainfully employed lifestyle just to fight the good fight. Just the opportunity cost of the loss in retirement savings, the inability to save for a home, or even pay off student loans and other debt bears mentioning. I suspect that many others feel the same. 

If we could get nationally organized, truly nationally organized, then we could talk about everything else you're advocating. I expect a decent ROI for any education I choose to complete.

Me, the only reason that I'm completing the EMS-AAS is so that I have the best chance of promoting to Lieutenant. After that, it's going to be a degree in Emergency Management. A few people at my old hospital based EMS job did the Emergency Management thing, and they all left that department to work in other areas of the Health System for much more money, and a real career track. I prefer to use education in a way that is profitable. After all, that time invested is time away from my family, and also time that I could spend building my business or working OT.

Until employers require degrees for employment, or at least heavily incentivize them, an EMS degree is going to be only a "joke degree" for purposes of compensation and career advancement (they have automotive Assosciates degrees now), unless you parlay that into another degree program.


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## 46Young (Sep 23, 2011)

medicswag said:


> Why doesn't nursing take over EMS? They have done remarkably well advancing their profession.



EMS should partner with their organization and seek to benefit from their strength and influence. What's the alternative, the IAFF?


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## JPINFV (Sep 23, 2011)

medicswag said:


> Are you implying that " [paramedics]  are just  just wanna-be [nurses] that couldn't hack [nursing] school."?




No, because EMS is not nursing no more than RT or AAs, or perfusionists are wanna-be nurses. On the other hand, the NPs are fighting to be called "doctor" (because "doctor" doesn't have a specific connotation in US health care) and have unrestricted practice rights.


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## 46Young (Sep 23, 2011)

DrParasite said:


> I respectfully disagree.  While I don't discount the value of the work done outside of the classroom, I do think that classroom time is time for learning, and when you leave classroom, you should be permitted to be off the clock.
> 
> Speaking for myself only, I hate homework.  in high school, I hate homework.  in grammer, I hated homeworking.  in college, I hated homework.  I did stuff outside of school, and while I gave 100% while I was in class, outside of class I did have other priorities.
> 
> ...



We're seeing this problem in the fire service. Weight is given to those holding degrees for promotions, which is fine, but it's too much weight. Those with practical experience are being left behind while we now have officers that had the education points, regurgitated the operations manuals and did well on the written, but are a train wreck on the fireground. These are usually the EMS people who went up the EMS career ladder then made a lateral move to All-Hazards officer (medic/fire officer). Practical skills and knowledge are being de-emphasized in favor of education points in sometimes loosely related fields and the ability to memorize a manual.

In my personal experience, I can advocate for a mandatory pre-req of college level A&P and pharm prior to admission to a non degree paramedic program. A general aptitude test would also be wise. Other than that, I've seen nothing in the college curriculum that would have made me a better medic than the program I went through previously (NY Methodist Paramedic Program, accredited). The time spent with the fluff classes could have been better used on field rotations, or perhaps additional education on any number of subjects within the core curriculum.


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## usalsfyre (Sep 23, 2011)

I've seen several post implying specific field diagnosis is impossible because we lack diagnostic imaging. Do we suck that bad at H&PE? Can we not assess and if the findings are ambiguous transport for further diagnostics?


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## JPINFV (Sep 24, 2011)

46Young said:


> 1 - An RN and an RRT treat patients without a 4 year degree. The progression to BSN doesn't really include any further medical education. I suspect that the same holds true for respiratory therapy. In EMS, it's the same thing. Going to school for two more years won't make me a better paramedic; it's for career development, Rather, it would be if there was a career ladder to speak of. Those opportunities are few and far between in single role EMS.



In part because, at least in California, nurses have assumed roles that should be ran by paramedics. Fox had a TV series called "The Academy," and did their third season with Orange County Fire Authority. Why was an RN and not a paramedic the one who was critiquing the medical aid scenario near the end of the academy? (link to episode) Especially when were talking about EMTs handling a diabetic case?



> 2 - In the role of prehospital EMS, how much more can realistically be done? Our role is to assess, treat if necessary, and transport to a hospital. It would be nice if we could transport the pt to a more appropriate destination, or perform more treat and release functions, but we're not performing field surgery, field CT's and X-Rays, nor are we capable of performing blood work or diagnosing and writing a treatment plan based on any of the above results.


Is the only role for EMS forever simply assess, treat, transport? Why would it not be possible to treat/release or initiate alternative pathways? While most agencies aren't doing blood work, as technologies like iStat mature, would that be always true? Additionally, is there a difference between the needs of an agency with a 30 minute average transport and a 5 minute average transport? Should EMS split into a rural medic and urban medic designation if the needs of the different environments don't mesh enough? 



> If you want to talk about expanded scope and functions outside of 911, then we're getting away from EMS, and transitioning into roles that PA's, BSN's, and NP's are better suited for.



Aren't EMS already functioning in some of those roles simply because of the needs of the agency, regardless of if the training, education, and agency support are available? 

To go to a fire department analogy, aren't civil engineers and building inspectors more apt at building inspection than fire fighters? By transitioning into a prevention mode, aren't fire departments getting away from fire suppression? More importantly, isn't that a good thing?



> 3 - OLMD consult can address that. Many, if not most systems here will be too litigation phobic to enable provider initiated refusals and anthing past minor treat and release. We have urgent care facilities that can do treat and release.



Too many systems employ technicians and not professionals. Too many providers in those systems have no problem acting like technicians. Too many providers who act like technicians demand to be treated like professionals. Why should other health care professionals treat someone who acts like a technician treat the technician like a professional?  



> In EMS, I suppose that an Attending Physician in Emergency Medicine would be the top level of the profession. We're at the bottom. What liberties and level of autonomy are you looking for, exactly? Without Medical Direction, I would say that we need a lot more than four years of medical education to pracitce independently. I don't know of any medical professions in the U.S. that can practice with true autonomy that have only four years of medical education.



There's a difference between acting without a safety net and requiring providers to throw themselves into the safety net. There a huge difference when it comes to requiring providers to throw themselves into a safety net in a perceived chance to shed off liability. Being a professional requires taking on an appropriate level of liability. 



> CCT and specialty transport is done by nurses in many places. Good luck taking that over with our extent of disorganization.



So EMS providers are, once again, their own worse enemy?


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## JPINFV (Sep 24, 2011)

usalsfyre said:


> I've seen several post implying specific field diagnosis is impossible because we lack diagnostic imaging. Do we suck that bad at H&PE? Can we not assess and if the findings are ambiguous transport for further diagnostics?


I think the bigger issue is the concept that a diagnosis is final. It's not.


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## medicswag (Sep 24, 2011)

46Young said:


> EMS should partner with their organization and seek to benefit from their strength and influence. What's the alternative, the IAFF?



I agree with this. why do paramedics and nurses have to serve in separate and distinct roles? To what extend does the paramedic and the nursing knowledge/skill base overlap? How much reform would be neccessary to overcome the downfalls of each profession? Could it be that healthcare could benefit from a "hybrid" provider?

Lurking on this forum (among others), I have seen many Paramedics wanting to be nurses, many nurses wanting to be paramedics. I believe there are programs that allow clinicians to "bridge" from one discipline to the other. 

I feel EMS may have much to gain if not being absolved into nursing, atleast forging a much stronger association, mutually beneficial relationship.


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## medicswag (Sep 24, 2011)

repost


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## 46Young (Sep 25, 2011)

How to fix EMS? It's apparent to me that many who first get into EMS, and even many medics, mainly have an interest in prehospital 911 EMS. There aren't too many that have their main interest in interfacility txp, let alone community outreach, home visits and wellness checks, and other expansions of scope in that direction. 

I say, have two seperate education tracks. The first could be "EMS Speciaist," and the other could be "Paramedic." The former could be educated and trained for 911 prehospital EMS only. The latter could encompass all manners of IFT, as well as the expanded scopes many here are advocating. Really, I don't feel I need a four year degree to do what I'm doing in the field. It's really not that challenging, 911 EMS. IFT EMS would be challenging if we were collectively doing more than babysitting nurses, RT's, and Fellows for most of the "real" calls. 

Alternatively, make 911 EMS an Assosciate's, make it a Bachelors for IFT and flight, and a Master's for anything above and beyond that. As far as independent thinking, I feel that we need a lot more than four years of medical education to have any real autonomy, write our own guidelines, divorce ourselves of the need for a medical director, and the risk or liability that comes with that responsibility. A Masters and above are overkill to function as a 911 medic, no?

With either scenario, I feel that 911 EMS should be 100% municipal. Many are saying that 911 EMS results in a negative cash flow, so going municipal makes sense. If it's a positive cash flow situation, then the local gov't makes out. 

The current trend seems to have FD's assuming EMS txp resonsibilities. Since the fire service the mandate of being a catch-all for whatever the locality cannot handle, EMS has fallen into the fire service's hands in certain cases as a result. In other regions, it has been a hostile takeover for the wrong reasons. Regardless, you don't really need anything above a 911 medics with two years of medical education to do the job effectively. If you can't get enough medics to apply for dual role positions, then consider hiring EMS only recruits. If you want treat and release capabilities, if you need the capability for provider initiated refusals, or for txp to more appropriate destinations than an ED, the solution is simple - as a requirement to sit for the test for EMS Supervisor, you'll need to have the additional education as above, one of those two examples. No need for everyone to be overeducated for the position. If a new procedure or capability or procedure comes out, these supervisors train the rest of the department.

The reason I say fire based municipal EMS is that this is the only EMS model that provides a real, attainable career ladder for EMS personnel, with several areas of specialty to focus on to keep motivation high, prevent burnout, provide positions other than in the field or dispatch, provide superior pay, benefits and retirement, and also as a superior resume builder for a post EMS career. In my department alone, besides there being the career ladder with 10 rungs, you can move into fire prevention, the Fire Marshall's office, the Peer Fitness Program, be in EMS Admin, teaching recruits and also CEU's alongside our PA's, and BSN's. There are numerous "off the road" positions, unlike single role EMS, which is basically running calls in the bus, or dispatch for nearly everyone. 

Those that feel restricted by 911 EMS would be better served going into the areas that advocates of advanced scope in EMS would like to see. You can work in clinics, do community outreach, do real, independent IFT, etc. Most in EMS have no interest in doing any of these things, however. Or, if you like 911 EMS and also all those other things, get a FT job in 911, and work PT in those other areas.


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## JPINFV (Sep 25, 2011)

46Young said:


> Alternatively, make 911 EMS an Assosciate's, make it a Bachelors for IFT and flight, and a Master's for anything above and beyond that. As far as independent thinking, I feel that we need a lot more than four years of medical education to have any real autonomy, write our own guidelines, divorce ourselves of the need for a medical director, and the risk or liability that comes with that responsibility. A Masters and above are overkill to function as a 911 medic, no?



I don't think independent thinking or judgement is necessarily the same as independent practice. Using a current example from California, California is introducing a critical care paramedic level and an advanced practice paramedic level. One of those levels explicitly includes digital intubation. It honestly never occurred to me that methods of intubation would be limited by scope of practice. In my mind, if paramedics were professionals (in contrast to technicians), then the intervention of "intubation" would be the scope of practice. It would be up to the paramedic, based on his or her education, training, available tools, and patient assessment, to choose which method (laryngoscope, digital, use of a gum bougie, etc) would be best for that individual paramedic for that individual patient. That is independent judgement at its core.  



> With either scenario, I feel that 911 EMS should be 100% municipal. Many are saying that 911 EMS results in a negative cash flow, so going municipal makes sense. If it's a positive cash flow situation, then the local gov't makes out.



I think, depending on the area, that a regional approach would be more efficient. Be it a county agency or a quasi-government non-profit entity. In Orange County, CA (which is characterized by many small to moderate sized cities), a bunch of the cities are looking at giving up their fire departments and contracting with the county fire agency (Orange County Fire Authority). 

I also think that we're going to switch from an emergency medical care system to a prehospital care system that integrates more fully with the local hospitals and health care providers for alternatives to both funding* and the 'everyone goes to the ED' issue. 

*This was discussed at EMS World when dealing with issues like funding to introduce CPAP to EMS. Devices like that are saving the hospitals a ton of money by reducing ICU days, and given the cost saving, some of the systems represented were reporting success with having the hospitals help offset introducing new treatment modalities.


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## 46Young (Sep 25, 2011)

JPINFV said:


> I don't think independent thinking or judgement is necessarily the same as independent practice. Using a current example from California, California is introducing a critical care paramedic level and an advanced practice paramedic level. One of those levels explicitly includes digital intubation. It honestly never occurred to me that methods of intubation would be limited by scope of practice. In my mind, if paramedics were professionals (in contrast to technicians), then the intervention of "intubation" would be the scope of practice. It would be up to the paramedic, based on his or her education, training, available tools, and patient assessment, to choose which method (laryngoscope, digital, use of a gum bougie, etc) would be best for that individual paramedic for that individual patient. That is independent judgement at its core.
> 
> 
> 
> ...



Now I understand the difference between independent thinking and independent practice. Independent thinking/judgment still require medical oversight, but much more lattitude is given when making clinical decisions. This requires more than two years of medical education, depending on what degree of lattitude you're looking for. I, like others, would like to see billing in skills hours rather than by the mile and category of txp.

A prehospital care system that integrates with local hospitals would be a wonderful thing as you describe it. Are there any systems currently working to that end? I'd like to present this idea to my department and the region at large, and it would help to have an example of how this can work, or at least some working ideas.

Edit: Could someone explain to me how to use quote tags to break up someones post and reply to each specific point?


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## JPINFV (Sep 25, 2011)

46Young said:


> Now I understand the difference between independent thinking and independent practice. Independent thinking/judgment still require medical oversight, but much more lattitude is given when making clinical decisions. This requires more than two years of medical education, depending on what degree of lattitude you're looking for. I, like others, would like to see billing in skills hours rather than by the mile and category of txp.



I too agree that billing should be based off of interventions provided (and transport would be included as an intervention when appropriate). 


With that, I think I've found the best way to illustrate what I'm personally talking about. It's not about cutting out medical directors, or necessarily protocols. It's about insuring that paramedics have the education, training, tools, and institutional support to make good decisions. That includes the ability (both mental ability and institutional ability) to deviate when appropriate without requiring hand holding. Medical directors would still be involved to help monitor education, training, and providing support. Online medical control would be for when providers honestly need help with something. Not as a helicopter parent or method to shift responsibility for a hard decision. 

It means things like having the ability to preclear evidence based deviations (like, say, a paramedic as an individual introducing D10 into his personal practice before protocols are changed) with the medical director.

The cookbook type mentality and one size fits all approach is responsible for so much damage to EMS as a profession that it's not funny. I imagine the fire service would have significant issues too with a career ladder if the line officers had to call the fire chief for every difficult on scene decision or deviation from SOP like paramedics have to with the medical director. 





> A prehospital care system that integrates with local hospitals would be a wonderful thing as you describe it. Are there any systems currently working to that end? I'd like to present this idea to my department and the region at large, and it would help to have an example of how this can work, or at least some working ideas.



I think it's necessary for any system seriously considering alternative transport options. I don't see how showing up without warning or preplanning to the local urgent care center would work out well... for anyone. It was mentioned also that one of the community paramedic programs saved some ungodly (several thousand) bed hours. I just emailed the person who gave that presentation (I think it was that one where the CPAP funding issue was discussed. I really should have taken notes) and I'll pass on what he replied with. 





> Edit: Could someone explain to me how to use quote tags to break up someones post and reply to each specific point?



[_quote]  message [_/quote]

No underscores. Also, if you remove the first and last tags, you can highlight and click the 
	

	
	
		
		

		
			





 and it will add them automatically.


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## firecoins (Sep 26, 2011)

> (1) Transfer federal oversight of EMS from NHTSA to the Department of Health and Human Services (HHS).


fine



> (2) Convert all privately owned, for-profit ambulance companies to not-for-profit status. Compensate any investors for past investment.


Meaningless.  Companies still have to cover costs. Its an overstep of government authority anyway.  

(





> 3) Convert all fire department operated EMS programs to an independent state (preferably), regional, or municipal agency. Downgrade FDs to CFR level


Who will pay for this?  It costs billions.  Fire Depts run EMS to save municipalities money. So we are going to force cities to pay for this. Major tax increase.  



> (4) Commission the NAEMSP and/or ACEP to draft new principles and standards of EMS education, and introduce legislation granting HHS the authority to issue federal grants to accredited educational institutions to develop curricula based on said principles (i.e. community colleges and universities only).


Sounds great. I support higher standards. Volunteer agencies are now unable to train members. Now who will cover the loss of these agencies?  The for profit companies are gone in your proposal. We need more billions of dollars to create more independant municipal EMS agencies. 




> (6) Eliminate the EMT provider level. Upgrade the AEMT to require an AS degree and Paramedic to BS degree.


No more EMS volunteers. Why would we train FDs responding to EMS calls as first responders only to the current CFR level?  If increasing education, why not the current EMT?

Couldn't people trained the EMT-B level handle the non emergency calls?    



> (7) Staff all ambulances with two AEMTs which will be able to handle the majority of calls. Place Paramedics in rapid response vehicles with a driver (non-medically trained) for intercept - only auto-dispatched in limited set of calls.


 So we will have 4 people in 2 response vehicles?  Why not put the AEMT and a Medic in the ambulance, forget the untrained driver and the extra vehicle.  Save money and get the better trained people to the calls. 



> (8) Restrict IFT services to non-emergent discharges, repatriations, or other routine pre-arranged transports for bed-ridden people (i.e. dialysis, PCP or specialist appointments, etc.). No SNF or urgent care to ED "non-emergent" transports from privately owned IFT organizations without referral from the primary emergency response agency.


Why not have EMT-Bs for this?  And why must they be non profit to do this?  





]


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## usalsfyre (Sep 26, 2011)

Firecoins, your living inside the paradigm. Yes the number of ambulances and paramedics would be reduced. The thought being AEMTs could handle 80% of calls appropriately. The other thought is does NJ really need 400 EMS providers for 200 municipalities? Does every tiny borough and township in PA need an ambulance? Does the city of Houston need 300+ "EMS" (i.e. dialysis derby) providers?

Finally, show me a fire-based system that actually saves money....


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## firecoins (Sep 26, 2011)

The whole point of fire based ems is to not have 2 separate services and give an excuse to having a large stand by fire service. It isn't a good thing for EMS but forcing municipalities to separate them is a fantasy that costs billions of dollars. 

Many municipalities in NY and NJ rely on unreliable volunteer services. Entire counties in many cases. Sure there are the private for profit companies that do the non emergencies. Since we are eliminating both in the process of properly educated providers, the counties will now be uncovered by anyone. Your solution is they don't need a service? 


---
I am here: http://maps.google.com/maps?ll=41.098631,-73.923563


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## firecoins (Sep 26, 2011)

Fewer ambulance run by indepndant municipal agencies with properly trained personnel. Sounds good of everyone is covered. There is no money for it though. 


---
I am here: http://maps.google.com/maps?ll=41.098631,-73.923563


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## usalsfyre (Sep 26, 2011)

firecoins said:


> The whole point of fire based ems is to not have 2 separate services and give an excuse to having a large stand by fire service.


Why do we need as large a standby fire service, excepting certain large cities? Typical suburban FDs (where fire-based EMS is strongest) don't staff enough people and don't have the fire load and building construction to make interior firefighting practical anyway. Fires that are any larger than incipient stage in these areas often end up being defensive anyway, and defensive tactics don't need a large standby fire service. Not to mention, who's covering EMS while the ambulance is involved in firefighting operations/the ambulance is unavailable for firefighting while doing it's primary job.



firecoins said:


> It isn't a good thing for EMS but forcing municipalities to separate them is a fantasy that costs billions of dollars.


Your assuming FD staffing staying the same. Separate EMS, you've mainly simply moved money around, in the above plan often to lower paying positions (no need to have an engineer or LT on an ambulance like many FDs do). Cutting FD jobs though has been made out by the IAFF to be un-American, even though post 9/11 they often grew to bloated proportions.


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## firecoins (Sep 26, 2011)

usalsfyre said:


> Why do we need as large a standby fire service, excepting certain large cities? Typical suburban FDs (where fire-based EMS is strongest) don't staff enough people and don't have the fire load and building construction to make interior firefighting practical anyway. Fires that are any larger than incipient stage in these areas often end up being defensive anyway, and defensive tactics don't need a large standby fire service. Not to mention, who's covering EMS while the ambulance is involved in firefighting operations/the ambulance is unavailable for firefighting while doing it's primary job.


You dont need large firefighting stand by crews but they aren't going to change for EMS.  




> Your assuming FD staffing staying the same.


Come to NYC  and tell the FD your closing down fire houses. They fight tooth and nail for every job and every house.   FDNY is already running EMS as a separte unit but it props up the FD. It would cost millions of dollars NYC doesn't have to return EMS back to NYC health and hospitals.  



> Separate EMS, you've mainly simply moved money around, in the above plan often to lower paying positions (no need to have an engineer or LT on an ambulance like many FDs do).


FDNY EMS is already a separate division.  No LTs to cut. 



> Cutting FD jobs though has been made out by the IAFF to be un-American, even though post 9/11 they often grew to bloated proportions.


Right!  And they will out lobby any change to FD based EMS because it cuts FF union dues.


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## usalsfyre (Sep 26, 2011)

firecoins said:


> You dont need large firefighting stand by crews but they aren't going to change for EMS.


It's not really the FDs choice in the end. We're already seeing some backlash over funding levels here, despite being in the middle of the worst fire season in the state in 50+ years.  



firecoins said:


> Come to NYC  and tell the FD your closing down fire houses. They fight tooth and nail for every job and every house.


NYC is probably one if the few places that does need a large standby firefighting force due to the proximity of construction, however, everyone is going to fight tooth and nail. Why? Because a refusal to look at their operations and "200 years of tradition unimpeded by process". The beginning of the end of my last fire-service job was when I mentioned to the chief and a coworker the idea of interior firefighting to protect already destroyed property was stupid to me.



firecoins said:


> FDNY is already running EMS as a separte unit but it props up the FD. It would cost millions of dollars NYC doesn't have to return EMS back to NYC health and hospitals.


Can't speak intelligently to this. But the fact that going from an autonomously acting position with responsibility similar to a unit officer (paramedic) to a bucket FF is a "promotion" to me shows how jacked the system is up there.



firecoins said:


> FDNY EMS is already a separate division.  No LTs to cut.


Not really FDNY specific but how many FDs run dual medic trucks and all ALS engines? How much money are we saving putting two AEMTs in an ambulance and say one paramedic per three or four ambulances?



firecoins said:


> Right!  And they will out lobby any change to FD based EMS because it cuts FF union dues.


Public unions aren't very popular at the moment, and if they continue screaming about "heroes", "9/11" and "people will die" I predict they will get less so.


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## firecoins (Sep 26, 2011)

FDNY EMS is one of the few dual medic systems I know and it isn't well reguarded outside of NYC.  Of course you also have the advantage of so many hospitals being so close. BLS can be just as good here sue to the short transports with the ERs providing quick and effective ALS themselves.

Getting rid of for profits?  I don't think its necessary. Not in NYC at least.  

Nursing homes calling me instead of 911 is a problem but its the nursing homes that are the problem. Its not my fault the RNs at nursing home are either incompetant, complacent or overworked but I get set serious emergencies out of them.  It weird showing up to an emergency and FDNY EMS is present for a less emergent situation than I am getting.  The nurses clearly don't know what constitutes an emergency.  Than I have to fight them on destination.


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## Bullets (Sep 26, 2011)

We talked about this today at work, and ive got it

Everyone who calls 911 and get transport gets 2 things...

1) Trauma Naked
     If you get admited you changing into a hospital gown anyway, so lets help the hospitals by stripping our patients prior to arrival at the Hospital


2) Rectal thermometer
     Diagnostic vital sign, critically important for accurate diagnosis


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## 46Young (Sep 26, 2011)

JPINFV said:


> I too agree that billing should be based off of interventions provided (and transport would be included as an intervention when appropriate).
> 
> 
> With that, I think I've found the best way to illustrate what I'm personally talking about. It's not about cutting out medical directors, or necessarily protocols. It's about insuring that paramedics have the education, training, tools, and institutional support to make good decisions. That includes the ability (both mental ability and institutional ability) to deviate when appropriate without requiring hand holding. Medical directors would still be involved to help monitor education, training, and providing support. Online medical control would be for when providers honestly need help with something. Not as a helicopter parent or method to shift responsibility for a hard decision.
> ...



Thank you.


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## thegreypilgrim (Sep 26, 2011)

firecoins said:
			
		

> Meaningless.  Companies still have to cover costs. Its an overstep of government authority anyway.


 NPOs are more efficient in that there's less administrative overhead, and the burden of executive salaries is virtually nonexistent. All revenue generated above base operating costs is reinvested into the community/organization and not put in somebody's investment portfolio. 

And the US government has nationalized or partially nationalized industries in the past. What I proposed would not even go as far as that.



			
				firecoins said:
			
		

> (Who will pay for this?  It costs billions.  Fire Depts run EMS to save municipalities money. So we are going to force cities to pay for this. Major tax increase.


 I challenge the notion that FD-based EMS is more cost-efficient for local governments.

And you're not really going to see much in the way of additional expense in setting up the new agency - just a lot of transferring funds from one organization to another. 



			
				firecoins said:
			
		

> Sounds great. I support higher standards. Volunteer agencies are now unable to train members. Now who will cover the loss of these agencies?  The for profit companies are gone in your proposal. We need more billions of dollars to create more independant municipal EMS agencies.


There will be some added expense here, but it wouldn't necessarily have to be at the municipal level. It can be done at the state or regional level to capture sufficient funds in cash-strapped areas so the burden isn't entirely leveled on individual communities.

So, sure it's going to result in more taxes, but these are taxes that are more than offset by savings in out-of-pocket expense to the typical consumer/citizen and to the system as a whole. An EMS service as advanced as the one I propose could significantly reduce hospital admissions, length of admissions, and the number of unnecessary transports. Furthermore, wouldn't you rather pay a small levee tacked onto your property tax or utility bill that covers you for the whole fiscal year as opposed to hundreds (or even thousands) of dollars in ambulance fees used on a case-by-case basis? Or are you just objecting to it simply because it's a tax?



			
				firecoins said:
			
		

> No more EMS volunteers. Why would we train FDs responding to EMS calls as first responders only to the current CFR level?  If increasing education, why not the current EMT?
> 
> Couldn't people trained the EMT-B level handle the non emergency calls?


 There's no advantage of the EMT-B over CFR plus AED. In my opinion EMT-B's cannot provide much to the typical 911 request for medical aid. The training just isn't up to the challenge of an appropriately detailed HP&E nor can they provide much therapeutics beyond high-flow 02 and hemorrhage control.

A better approach is to send two "enhanced" (under the new training I proposed) AEMTs to every call who can screen out non-urgent runs. Non-emergent patients don't get transported. Problem solved.



			
				firecoins said:
			
		

> So we will have 4 people in 2 response vehicles?  Why not put the AEMT and a Medic in the ambulance, forget the untrained driver and the extra vehicle.  Save money and get the better trained people to the calls.


 Most calls will just have 2 AEMTs in an ambulance (the new BLS) with ALS available for intercept upon request (auto-dispatched in only select cases).

Frees up ALS to treat most critical patients, therefore most efficient use of resources. 



			
				firecoins said:
			
		

> Why not have EMT-Bs for this?  And why must they be non profit to do this?


 Explained above.


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## Harvey (Sep 26, 2011)

There are similar situations in other professions, an example would be Security in relation to Law Enforcement. In my opinion I do not agree with your decision to push more regulation on the private sector. 
(change all for-profit to non-profit) If I want to pay a private company to transport me to a medical facility thats my decision. Who are you to take that away from me? Its called consumer based capitalism, which drives supply and demand. Besides wont obama care fix all of this in 2014 when it goes into effect? (sarcasm)


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## thegreypilgrim (Sep 26, 2011)

46Young said:
			
		

> Going to school for two more years won't make me a better paramedic; it's for career development, Rather, it would be if there was a career ladder to speak of. Those opportunities are few and far between in single role EMS.


 I think the paramedic curriculum could accommodate significant expansion if it were spread out over an additional 2 academic years. Beyond that a broader foundational education could turn the role of Paramedic into a much more versatile one.



			
				46Young said:
			
		

> 2 - In the role of prehospital EMS, how much more can realistically be done? Our role is to assess, treat if necessary, and transport to a hospital. It would be nice if we could transport the pt to a more appropriate destination, or perform more treat and release functions, but we're not performing field surgery, field CT's and X-Rays, nor are we capable of performing blood work or diagnosing and writing a treatment plan based on any of the above results.


 As POC diagnostic technology continues to progress this will become less of a concern. And diagnostic imaging studies are over-rated. In other parts of the world (namely Europe) they are used much less frequently than they are here and European healthcare systems consistently outperform the US in terms of medical outcomes and cost-efficiency. A lot can be done with a solid clinical history and physical exam.



			
				46Young said:
			
		

> If you want to talk about expanded scope and functions outside of 911, then we're getting away from EMS, and transitioning into roles that PA's, BSN's, and NP's are better suited for.


 I think it's the other way around, actually. Roles that are better suited for paramedics are being filled by BSNs and mid-level providers simply because there is a lack of properly educated paramedics. Why should nurses be doing prehospital QA/QI? or disaster/CBRNE planning? Why are there nurses on school campuses or serving as industrial HSE Officers? 



			
				46Young said:
			
		

> 3 - OLMD consult can address that. Many, if not most systems here will be too litigation phobic to enable provider initiated refusals and anthing past minor treat and release. We have urgent care facilities that can do treat and release.


 There's actually little to no evidence that OLMD improves paramedic decision making or clinical outcomes of patients. I did my senior research project on OLMD and, of the dearth of literature addressing the subject (most of which dates from the 80s and 90s) OLMD is associated with delays, miscommunication, and redundant reiteration of orders already covered by protocol (very few "novel" OLMD orders actually occur). Furthermore, it's enormously expensive for hospitals to maintain the facilities necessary for OLMD operations. The far better option would be to send a provider to the scene that's actually capable of making an appropriate decision in the first place.



			
				46Young said:
			
		

> Without Medical Direction, I would say that we need a lot more than four years of medical education to pracitce independently. I don't know of any medical professions in the U.S. that can practice with true autonomy that have only four years of medical education.


 There will always be Medical Direction, but what I propose is Medical Directors serve primarily as consultants to oversea the ongoing education of the agency's providers and to manage the QA/QI processes. In other countries, paramedics are independently licensed, so why can't American medics do the same? Furthermore, other countries don't use "protocols" to govern paramedics actions in the field. They simply have a defined scope of practice, and then the agency adopts evidence-based guidelines to serve as just that - guides for practicing within your scope.


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## thegreypilgrim (Sep 26, 2011)

Harvey said:


> There are similar situations in other professions, an example would be Security in relation to Law Enforcement.


 An example of what? I'm not understanding what you're trying to say here.


> In my opinion I do not agree with your decision to push more regulation on the private sector.
> (change all for-profit to non-profit) If I want to pay a private company to transport me to a medical facility thats my decision. Who are you to take that away from me?


 For the same reason you aren't allowed to call a private security firm if someone rapes you or you're not allowed to call a private fire suppression company if your house is on fire. Such services are part of the public infrastructure, and undermining them compromises public safety/health. Think about the consequences of market liberalization on services like those. Those who can afford them will procure their services well enough, leaving the most vulnerable and least well-off of society dependent on a now fiscally gutted public program. It's a gross affront to social justice to have such disparities in programs that address basic social necessities.

Now, if you're already in a hospital, and you've completed your course there and are being discharged home but still aren't well enough to ambulate without assistance I have no problem with you wanting a private company that will cater to your needs to transport you home.


			
				Harvey said:
			
		

> Its called consumer based capitalism, which drives supply and demand.


 That's all well and good, but unfortunately market principles don't apply to things like healthcare. Demand for healthcare isn't a function of consumerism. I don't choose to undergo PCI in the same sense that I choose to buy a new TV. There just isn't an equivalency there. In fact, the commercialization of healthcare is the primary reason why the American healthcare system is completely unsustainable.


			
				Harvey said:
			
		

> Besides wont obama care fix all of this in 2014 when it goes into effect? (sarcasm)


 (1) It's not "Obamacare". It's the Patient Protection and Affordable Care Act (PPACA). Let's discuss this like rational adults and avoid the Fox News pejoratives, please.

(2) Many provisions of PPACA have already been implemented. For instance, if you're under 26 you can now thank PPACA that you can remain on your parents' health plan.

(3) No, it won't solve America's health policy problems because despite intense misinformation campaigns by interest groups and the media, PPACA is not a single-payer insurance program (i.e. the dreaded "socialized medicine" people talk about and what every other industrialized nation in the world has). It still uses the same privatized system of insurance networks which are the very things causing our problems. They are defective products (much the same way private ambulance companies are), which needs to be replaced with a publicly funded program.


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## looker (Sep 26, 2011)

thegreypilgrim, 

I hope I do not get slammed by mods for discussing PPACA so here it goes.

Yes you can stay under your parents plan until you're 26 and all of other nice stuff, so lets get in to the ugly stuff.

Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money. The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.


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## JPINFV (Sep 26, 2011)

looker said:


> Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money. The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.



Would being an insurance salesmen and an EMT be worthy of a raise, or a commission?


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## thegreypilgrim (Sep 26, 2011)

looker said:


> Starting in 2014 precondition goes away. You know that one thing that made people really buy insurance in case you got sick so you would have health coverage. If you could afford it, you would buy it. With precondition going away, people will wait till they are sick and only then will they buy insurance. Basically it will be buying insurance in the back of ambulance. I know what some will say, that is why there is penalty for not buying it. Yes but penalty is a) A joke b) IRS can't force you to pay it, they can only withhold tax return if they owe you money.


 Well color me shocked, but I actually agree with you Looker. Albeit, for entirely different reasons. Guaranteed issue is not going to drive up adverse selection to unsustainable levels. Sure, a large segment of the population are estimated to not comply with the new law, but so what? That's the least of our problems. The real problem is a mandate completely throws off the constraints placed on enrollment into insurance programs that used to be imposed by risk aversion. People used to weigh the costs of premiums against their expected risk, which limited how much they were willing to pay. Now that constraint is gone, and insurance companies can charge whatever they want.


> The only thing PPACA will do is bankrupt health insurance company in about 5-10 years being only sick will buy insurance.


 Lolz, in this day and age of "too big to fail" I am slow to believe this. What's going happen is the government will subsidize low-income groups which will shift costs to taxpayers as opposed to the market players, effectively negating any cost savings from enrolling more people into the insurance system (which wasn't even the primary problem to begin with).

What we need is a single-payer system that eliminates the private market except for supplemental and/or elective procedures (and is completely self-sustaining and non-eligible for federal reimbursement).


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## looker (Sep 26, 2011)

thegreypilgrim said:


> Well color me shocked, but I actually agree with you Looker. Albeit, for entirely different reasons. Guaranteed issue is not going to drive up adverse selection to unsustainable levels. Sure, a large segment of the population are estimated to not comply with the new law, but so what? That's the least of our problems. The real problem is a mandate completely throws off the constraints placed on enrollment into insurance programs that used to be imposed by risk aversion. People used to weigh the costs of premiums against their expected risk, which limited how much they were willing to pay. Now that constraint is gone, and insurance companies can charge whatever they want.
> Lolz, in this day and age of "too big to fail" I am slow to believe this. What's going happen is the government will subsidize low-income groups which will shift costs to taxpayers as opposed to the market players, effectively negating any cost savings from enrolling more people into the insurance system (which wasn't even the primary problem to begin with).
> 
> What we need is a single-payer system that eliminates the private market except for supplemental and/or elective procedures (and is completely self-sustaining and non-eligible for federal reimbursement).



I am going to reply to both of your statement. Lets take the first one regarding control of how much insurance charge.

 Insurance company will be required to charge an age group same price. So 55 year old smoker, cancer survivor, cva, chf will pay same thing as 55 year old that is non smoker, never had cancer, in great shape etc. Not only that but that 55 year old that is very healthy will not buy insurance because well he do not need it. He will buy it only if and when he gets sick. On the other hand the sick person will buy insurance and insurance company will be required to pay out thousands, maybe even millions if the person gets hospitalized in ICU for a while. 

 What will basically happen at the end is we will have single payer system because health insurance company's will go out of business. This business model is not sustainable.


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## looker (Sep 26, 2011)

JPINFV said:


> Would being an insurance salesmen and an EMT be worthy of a raise, or a commission?



Sure for every health insurance you sell you get x% cut.


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## RocketMedic (Sep 27, 2011)

looker said:


> I am going to reply to both of your statement. Lets take the first one regarding control of how much insurance charge.
> 
> Insurance company will be required to charge an age group same price. So 55 year old smoker, cancer survivor, cva, chf will pay same thing as 55 year old that is non smoker, never had cancer, in great shape etc. Not only that but that 55 year old that is very healthy will not buy insurance because well he do not need it. He will buy it only if and when he gets sick. On the other hand the sick person will buy insurance and insurance company will be required to pay out thousands, maybe even millions if the person gets hospitalized in ICU for a while.
> 
> What will basically happen at the end is we will have single payer system because health insurance company's will go out of business. This business model is not sustainable.



We've already been seeing this for years. My employer _exists_ because of Medicare's funding. If you go and take any incentive to purchase insurance beforehand away (which will happen in 2014), people will stop buying insurance policies (after all, you can get one later, once you start feeling bad), and an even larger portion of funding will come from Medicare and government subsidies.

Looker, your company primarily is funded by Medicare reimbursements, yes? 
PS- are you hiring?


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## looker (Sep 27, 2011)

Rocketmedic said:


> Looker, your company primarily is funded by Medicare reimbursements, yes?
> PS- are you hiring?


Yes, no.


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## RocketMedic (Sep 29, 2011)

That's OK. I have no desire to work in SoCal or strictly IFT


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