# degrees for all paramedics 10 year plan



## Veneficus (Feb 5, 2012)

Here it is, as simple as it gets.

First, we legally set a date. Call it Jan 1, 2024.

Next we extort states to comply by tying medicare reimbursement for ALS service only to agencies that have 100% degreed paramedics.

So if your agency has 1 paramedic without a 4 year degree, you can only get the BLS rate for your whole agency.

When this happens, seeing a need and a market, 4 year universities will open programs left and right.

That is the only major hurdle, and since it isn't an unreasonable time frame, resistance will be lower.

Since most state EMS authorities decide what con ed requirement need to be met, instead of some arbitrary hours like 48 or 96 every 2 years, depending on what state you are from, call it 12 credit hours a year at an accredited university for all with a 2 year degree and 15 a year to those without.

With the average credit for EMT and paramedic class counted, that should get everyone to 120 credits in 10 years.

It will also allow employers to shift the money they currently spend for coned and allow them to negotiate group tuition rates with the unis in the area.

It will not be overly burdonsome for individuals who must pay their own way.  Not to mention depending on what your coned fees are, you may be paying less than you do now. Additionally since this coned will be recognized university healthcare courses, it will provide lateral transfer opportunity to other degrees. So when you hurt your back, you can go into being an ultrasound tech.

It then becomes beneficial for employers to hire people who come with a degree because it protects their revenue stream, reduces agency coned costs, and scheduling problems.

If you go to an agency with a degree in hand, you have the bargaining power of coming ready made, which means you can demand a higher pay, since your agency will spend less on you over time and have a provider at the level they will need. 

At the end of these 10 years, since providers will be much more educated than now, you could drop the recert con ed back to hours and make it minimal. Say: 20 every 2 years. Make it really enticing and give credit for teaching public classes. (like CPR, first aid, etc.)

Now with a large body of equally educated providers, they can form a real professional organization (not like the pityful NAEMT) and start lobbying for increased pay, etc. with the world accepted bargaining chip.

Now this is not without problem, for example, if you fail your coned classes, you could really be in a bind. Not only would you probably take a financial hit, most likely being forced to pay again out of your own pocket for this conEd, you very easily could fall out of compliance with the necessary credit hours. Which means you could not work in EMS until you made it right.

But this would give every provider a fair shot. I suspect it would eliminate a fair few. (But honestly, is it really a loss?) 

Now this could really put a hurt on volunteer agencies. But, it is so far in the future, and the advancements right now considerabe, chances are, an EMT-B will have enough gadgets in hand (like an AED that could recognize any rhtym and apply the appropriate electrical therapy, epipen, etc) to help any life threatening emergency.  

Hopefully by then the AHA will have its $hit together on ACLS and PALS medications and all the useless ones (aka most of them) will be gone.

The degree also positions for the future EMS revenue streams, like prevention, education, and public health. As you raise the value of service you provide, you raise your pay.

It also opens up the possibility of making being an instructor a master's degree. Less teachers = less providers. (proven by medical and nursing professions)

Less providers = higher demand = pay bargaining chip.

HIgher paid providers = less fly by night minimalist services = better pay and working conditions for all. Especially when employers are invested in your education.

It can be done, but it is not realistic to say "paramedics need a 4 year degree next year."


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## Tigger (Feb 5, 2012)

Considering what is starting shortly, I'm not going to respond directly to your plan, which I like.

But, this is what EMS needs. If all we keep doing is talking about the problems but, we get nowhere. Even a solution that is purely theoretical is better than whining. I applaud you for taking the time and thinking things out. Obviously there are holes in the above plan, but there is no such thing as a perfect plan. This where the real discussion comes from.


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## Amberlamps916 (Feb 5, 2012)

If only schools offered Paramedic Bachelors programs like Loma Linda University....


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## Shishkabob (Feb 5, 2012)

I don't see a jump from most states requiring just a cert to all requiring a bachelors that quickly.  It will have to start at an associates first.

Simply stated, the average salary does not warrant a bachelors, therefor people will not go to school for 4 years to get the average paltry wages, just for the 'hope', that it will be increased in the future. 


Starting at an associates, then increasing the pay somewhat, THEN moving to a bachelors is a lot more feasible.


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## Veneficus (Feb 5, 2012)

Tigger said:


> Obviously there are holes in the above plan, but there is no such thing as a perfect plan.



Exactly


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## tacitblue (Feb 5, 2012)

We can start by requiring paramedics to have at least an associates degree from a regionally accredited college/university and tie that to reimbursement. Then we can lobby CMS to reimburse paramedic services for CCT and community medicine if the service employs BA/BS prepared medics.

I think Oregeon requires an AS for licensure already.


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## fast65 (Feb 5, 2012)

tacitblue said:


> We can start by requiring paramedics to have at least an associates degree from a regionally accredited college/university and tie that to reimbursement. Then we can lobby CMS to reimburse paramedic services for CCT and community medicine if the service employs BA/BS prepared medics.
> 
> I think Oregeon requires an AS for licensure already.



Yup, we do; I believe Washington is the only other state to require it as well.


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## BandageBrigade (Feb 5, 2012)

With RT and RN still only requiring a associates, I don't see this happening. But one can dream.


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## jjesusfreak01 (Feb 5, 2012)

So, how do we go about getting reimbursement changed? You need EMS people in high positions in the government to get that passed, and probably people in HHS. Not going to be easy.


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## Jon (Feb 5, 2012)

I think this is one of many things that could help drive EMS forward.


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## NYMedic828 (Feb 6, 2012)

EMS wont go anywhere until we have a Nationally recognized board that governs what we all do to begin with.

The government of our nation works the way it does because it is unified. The states can make federal law stricter, but they cannot make them more lenient.

The same should go for EMS. We need a unified, governing federal body for the entire country to bring us all together as a recognized professional group.

The National Registry is an option, not a requirement. For me here in NY for example, its just a merit badge. It serves me 0 purpose and isn't recognized anywhere by me. It is simply a complete waste.

Nurses have a national board.
Doctors have a national board.
PAs and NPs have a national board.

We may be lower on the food chain, but we are still a big part of it and should fit into it just the same.

In pieces like we are, we are weak. Together we would be strong.


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## Tigger (Feb 6, 2012)

NYMedic828 said:


> EMS wont go anywhere until we have a Nationally recognized board that governs what we all do to begin with.


This is an important point. Without a national unification of EMS, there will be no change at any government level because there will be no unified voice asking for it.


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## RocketMedic (Feb 6, 2012)

Associate's is probably more realistic, at least now.

Agree that we need an associate's, but in what? Army-style "anything goes" degrees, nursing, medical, or specific Paramedic degrees?

Also, and more importantly, who is going to lobby for this, pay for the effort to get it passed, and enforce it. Remember that the resistance to this will be very, very strong, and the current system "works" well enough for now that it's going to be hard to change.

Arguments that will be used against it:
1. Why? Studies still haven't shown a difference in patient outcomes between US and degree-mandated systems.
2. Who pays? _Really_ relevant to volunteers, who do need to go- but there's going to be a lot of resistance. _Especially_ relevant to municipal departments- how do you convince cities that they should support increased salaries for the same job?

3. What should be mandated? Do firefighters need degrees too?
4. Where will the standard of care end up? 

My greatest fear is that we end up like the UK, where paramedics are "independent", but they're essentially Intermediates. Here, paramedics legitimately _need_ to be able to perform a lot of techniques that our European counterparts don't, simply due to our nation's size, population, and health-care system. While Veneficus raises excellent points, I really don't think that we need PAs or doctors on ambulances when we could empower paramedics to do the same thing with proper education and protocols.


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## Tigger (Feb 6, 2012)

Rocketmedic40 said:


> Also, and more importantly, who is going to lobby for this, pay for the effort to get it passed, and enforce it. Remember that the resistance to this will be very, very strong, and the current system "works" well enough for now that it's going to be hard to change.



Another key point, few outside of EMS are aware of how broken the system really is, especially since quality and delivery methods vary so much from place to place. Just another reason that a national "EMS voice" is needed. In a way we have that now with the NAEMT and NREMT, but I'm not sure many people outside of the industry know what those organizations do, or even who they are.


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## JPINFV (Feb 6, 2012)

In regards to a national board, it should be noted that those are private institutions that the state governments defer to much in the same fashion as they do with the NREMT. The National Board of Medical Examiners (NBME), which runs the USMLE (MD licensing exam) is not a Federal agency.


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## RocketMedic (Feb 6, 2012)

Tigger said:


> Another key point, few outside of EMS are aware of how broken the system really is, especially since quality and delivery methods vary so much from place to place. Just another reason that a national "EMS voice" is needed. In a way we have that now with the NAEMT and NREMT, but I'm not sure many people outside of the industry know what those organizations do, or even who they are.




We can take a page from the IAFF, who (within my lifetime) have quite successfully painted the "you'll burn to death without a paid FD" scenario. Kids love firemen because Fire is marketed hard, early, and often. Police as well. When your average elementary kid thinks of a paramedic, chances are that the truck is red and helmets are involved somehow- MARKETING! Few of them will say "paramedics are not firefighters, they're a third service or a private contractor." 

Another thing we really need to focus on is EMS's service model. All the private-worker or third-service complaints on the Internet, regardless of the validity of their point, mean nothing when they're cancelled out by firefighter-paramedics who do the same job and view the _appropriate_ educational pathway as a tradesman- and they've got some good points.


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## Smash (Feb 6, 2012)

Rocketmedic40 said:


> Arguments that will be used against it:
> 1. Why? Studies still haven't shown a difference in patient outcomes between US and degree-mandated systems.



What studies?



Rocketmedic40 said:


> 2. Who pays? _Really_ relevant to volunteers, who do need to go- but there's going to be a lot of resistance. _Especially_ relevant to municipal departments- how do you convince cities that they should support increased salaries for the same job?



Every other country with degree minimum paramedics has managed to pay for it.



Rocketmedic40 said:


> 3. What should be mandated? Do firefighters need degrees too?



Who cares?  The discussion is about paramedics.



Rocketmedic40 said:


> 4. Where will the standard of care end up?



Higher. 



Rocketmedic40 said:


> My greatest fear is that we end up like the UK, where paramedics are "independent", but they're essentially Intermediates. Here, paramedics legitimately _need_ to be able to perform a lot of techniques that our European counterparts don't, simply due to our nation's size, population, and health-care system.



What is that you think UK paramedics can't do that US paramedics can?


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## Pavehawk (Feb 6, 2012)

When EMS has a professional lobby spending millions of dollars to influance legsislation at a national and then a state level we might see that kind of program. Fire spends money, private ambulance spends money, nurses spend money, doctors spend money EMS sorry Charlie...

We can rant and plan and speculate all we want on this and other forums but EMS is still unorganized at a national level. We can't even get agreement on which federal agency should be lead for us. 

Like it or not what drives change in America is MONEY or massive public reaction, which for the most part takes money. When we have a "Super PAC" and big lobbists working for us perhaps we can grow. Sorry to sound so cynical but our system of government works that way and until we do too we are doomed to be the rented mule of the farm.


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## Veneficus (Feb 6, 2012)

jjesusfreak01 said:


> So, how do we go about getting reimbursement changed? You need EMS people in high positions in the government to get that passed, and probably people in HHS. Not going to be easy.



But nobody in EMS is going to get to one of those positions without a degree.


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## alphatrauma (Feb 6, 2012)

BandageBrigade said:


> With RT and *RN still only requiring a associates*, I don't see this happening. But one can dream.



With many health systems nationwide striving to achieve magnet status... the 2 year RN is soon to be going the way of the LPN. BSN is quickly becoming the gold standard.


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## Commonsavage (Feb 6, 2012)

Linuss said:


> I don't see a jump from most states requiring just a cert to all requiring a bachelors that quickly.  It will have to start at an associates first.
> 
> Simply stated, the average salary does not warrant a bachelors, therefor people will not go to school for 4 years to get the average paltry wages, just for the 'hope', that it will be increased in the future.
> 
> ...



That's fine with me.  If the number of qualified medics drops, the market forces will raise their compensation.  Right now we have a dirth of minimally qualified and undercompensated medics.  Requiring higher educational standards is a win-win for all.


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## Melclin (Feb 6, 2012)

I don't think you can jump from a completely disparate array of glorified first aid courses, back room fire brigade add ons and perhaps more importantly,a general attitude that all of this is okay, and go all the way to uniform 4 year degrees. I think it would be almost impossible, even if you had the promise of much better wages right from the beginning. 

We went from a basically state wide associates degree (or at least what might be called an *** in the US), to a bachelors involving a few universities and 3 government mandated services (that then became one services) with some advancements in scope etc. Vastly simpler than what has been suggested here. Ten years later, we're still struggling with some of the broader brush strokes let alone the details. Wages are a very big part of that.


All that systemic upheaval, people being left without jobs, different systems in different areas with different cultures struggling to conform to a one size fits all approach.... without any promise of improved pay. Not ganna happen.


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## Smash (Feb 6, 2012)

Melclin said:


> I don't think you can jump from a completely disparate array of glorified first aid courses, back room fire brigade add ons and perhaps more importantly,a general attitude that all of this is okay, and go all the way to uniform 4 year degrees. I think it would be almost impossible, even if you had the promise of much better wages right from the beginning.
> 
> We went from a basically state wide associates degree (or at least what might be called an *** in the US), to a bachelors involving a few universities and 3 government mandated services (that then became one services) with some advancements in scope etc. Vastly simpler than what has been suggested here. Ten years later, we're still struggling with some of the broader brush strokes let alone the details. Wages are a very big part of that.
> 
> ...



You are conflating the merger of the services with the change to pre-employment degree based education.  Changing to degree based education happened well before the merger occurred.  It also didn't really change anything from an organisational culture perspective, except possibly to introduce another layer of belligerence from those who feel threatened by advancement.  The merger of course did change things, most notably due to the crippling debt taken on when the rural service came into the fold, and it is this to which you refer with different systems, approaches, cultures and redundancies.  That is nothing to do with degree-based education.

However, prior to degree based education in Victoria there was very much a "one size fits all" approach, with everyone taking the same course at the same place.  Now there are 6 universities within Victoria alone offering under-graduate, conversion and post-graduate courses, and all the small variations that come with that: hardly one size fits all.

Indeed, it could be argued that in the US there already is a "one size fits all" approach, as the curriculum for EMT, EMT-P, whatever, is standardised by the DOT as well.

Of course there will be some education providers that are better, some that are worse.  There will be some areas that require further education, some that are happy with the baseline.  This is the status quo already; true for whatever industry you care to discuss; and not particularly important when considered in the context of an overall raising of that baseline.

I agree that the strange attitude of some parts of US EMS where poor education is not only accepted, but somehow glorified and actively pursued will be a very difficult thing to manage.


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## VFlutter (Feb 7, 2012)

alphatrauma said:


> With many health systems nationwide striving to achieve magnet status... the 2 year RN is soon to be going the way of the LPN. BSN is quickly becoming the gold standard.



+1000 Most hospitals are moving towards exclusively hiring BSN new grads and making their current AD RNs go back to school if they want to keep their charge nurse positions.


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## triemal04 (Feb 7, 2012)

fast65 said:


> Yup, we do; I believe Washington is the only other state to require it as well.


It's actually Iowa of all places; Washington doesn't, but they at least do require the school (no matter what state it was in) to be accredited by a national body; generally CAAHEP.  And thanks to that worthless mother:censored:ing piece of :censored: state rep who should be taken out behind the barn and shot (not that I'm advocating that in any way, shape, or form) from Gresham, Oregon no longer strictly requires a degree, or that you be working on it during your initial temporary certification.  Thanks to the above :censored:heel, now as long as you have "worked" for 4 out of the last 5 years in another state as a parawannabe you can pop right in.

Yeah.  I'm still bitter about that.


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## Maine iac (Feb 7, 2012)

Iowa does not require their medics to have an AAS.


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## triemal04 (Feb 7, 2012)

Smash said:


> Every other country with degree minimum paramedics has managed to pay for it.?


Yes, and not to say that it can't or shouldn't be done, but generally the countries that have done that have a very different way of running their healthcare system.  The difference in size really isn't as big a hurdle as this.


Smash said:


> Higher.


Probably, though that really isn't a sure thing.  Speaking from personal experience in an area where a degree has (had now) been required for some years, it doesn't always improve the level of care, or at least not by that much.  Even if there were only small gains it would still be worth it, and the care may be better here than elsewhere, but just having the degree is not an automatic fix.


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## triemal04 (Feb 7, 2012)

Maine iac said:


> Iowa does not require their medics to have an AAS.


I though the paramedic specialist level required an Associates.  That not correct?


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## JPINFV (Feb 7, 2012)

Iowa doesn't require paramedics to be a paramedic.


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## Maine iac (Feb 7, 2012)

triemal04 said:


> I though the paramedic specialist level required an Associates.  That not correct?



Nope. You just have to be 18 to take the class, and have a GED/HS Diploma.


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## BandageBrigade (Feb 7, 2012)

JPINFV said:


> Iowa doesn't require paramedics to be a paramedic.



Ouch..  Come on JP that was low. After much headaches iemsa got the ' iowa paramedics' (or I99's to the rest of the world) to be phased out in the transitions to the new NREMT classifications. Eventually (next 6 years I believe) only recognize four levers. First responder, emt, aemt and paramedic.. With the CCP endorsment still recognized for paramedics


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## JPINFV (Feb 7, 2012)

The problem is that it's true. It would be like a state saying, "We need more physicians, so we're going to license PAs and NPs as physicians and give them an unrestricted license to practice medicine too!" It's why, despite being an "EMT-I" for 4 years, I never used that designation because it would be misinterpreted as "EMT-Intermediate" and not as "EMT-One." Similarly, even the handful of times I've seen employers or counties use an "EMT-I" designation, they would normally substitute the Roman numeral for a "1."


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## BandageBrigade (Feb 7, 2012)

Oh I agree with you completely. Thankfully they did not allow them to practice as full medics, only called them medics. Which arguably could be worse, telling the public they are getting a medic when in reality you are getting an intermediate 99.


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## Maine iac (Feb 7, 2012)

Yes... some might call themselves medics, but in Iowa it has the same connotation as somebody elsewhere saying I'm an intermediate. For example, I am not a "medic", I am a Paramedic Specialist, and my equal would not be a medic, they would be a PS.

The public has no idea anyway of what they are getting. But the EMSers here know the levels and use the Iowa-specific vocab.


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## Fish (Feb 7, 2012)

UT San Antonio offers B.S in Emergency Medical Services


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## JPINFV (Feb 8, 2012)

Maine iac said:


> Yes... some might call themselves medics, but in Iowa it has the same connotation as somebody elsewhere saying I'm an intermediate. For example, I am not a "medic", I am a Paramedic Specialist, and my equal would not be a medic, they would be a PS.
> 
> The public has no idea anyway of what they are getting. But the EMSers here know the levels and use the Iowa-specific vocab.



The problem is when those people go someplace outside of Iowa and continue to call themselves a paramedic when they aren't.


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## Handsome Robb (Feb 8, 2012)

JPINFV said:


> The problem is that it's true. It would be like a state saying, "We need more physicians, so we're going to license PAs and NPs as physicians and give them an unrestricted license to practice medicine too!" It's why, despite being an "EMT-I" for 4 years, I never used that designation because it would be misinterpreted as "EMT-Intermediate" and not as "EMT-One." Similarly, even the handful of times I've seen employers or counties use an "EMT-I" designation, they would normally substitute the Roman numeral for a "1."



I love the new guys from Cali that have EMT-II on their uniforms then they see mine with just EMT-I and think I'm a basic. "Sorry guys, you lose, I'm the same thing as you and I don't look like a goober with two I's on my shirt.


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## JPINFV (Feb 8, 2012)

Thank God California went to the EMR/EMT/AEMT/Paramedic nomenclature a year and a half ago.


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## ffemt8978 (Feb 8, 2012)

JPINFV said:


> Thank God California went to the EMR/EMT/AEMT/Paramedic nomenclature a year and a half ago.



Never thought I'd see the day that JPINFV had something good to say about California EMS.  Maybe the Mayans were correct.

Sent from my Android Tablet using Tapatalk


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## JPINFV (Feb 8, 2012)

I think California generally has a good top level (statutes, state level EMS Authority, etc) with terrible ground level operations (the worst of fire based EMS, restrictive protocols, etc).


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## tacitblue (Feb 8, 2012)

JPINFV said:


> I think California generally has a good top level (statutes, state level EMS Authority, etc) with terrible ground level operations (the worst of fire based EMS, restrictive protocols, etc).



I agree; too bad it generally doesn't translate down...


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## Handsome Robb (Feb 8, 2012)

JPINFV said:


> I think California generally has a good top level (statutes, state level EMS Authority, etc) with terrible ground level operations (the worst of fire based EMS, restrictive protocols, etc).



I liked their OT laws when I was working 16s for a company contracted by Union Pacific for railway maintenance.


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## Melclin (Feb 8, 2012)

Smash said:


> You are conflating the merger of the services with the change to pre-employment degree based education.  Changing to degree based education happened well before the merger occurred.  It also didn't really change anything from an organisational culture perspective, except possibly to introduce another layer of belligerence from those who feel threatened by advancement.  The merger of course did change things, most notably due to the crippling debt taken on when the rural service came into the fold, and it is this to which you refer with different systems, approaches, cultures and redundancies.  That is nothing to do with degree-based education.
> 
> However, prior to degree based education in Victoria there was very much a "one size fits all" approach, with everyone taking the same course at the same place.  Now there are 6 universities within Victoria alone offering under-graduate, conversion and post-graduate courses, and all the small variations that come with that: hardly one size fits all.
> 
> ...



"You are conflating the merger of the services" - No I don't think I am. Or at least I didn't intend too. In the second paragraph, I only mentioned the merger as a matter of accuracy. To address the fact that there were three and is now one service. Only relevant because it (3 or 1 service) is far fewer than in the US and as such, easier to shift educational requirements. I know that there are ongoing cultural and organisational issues associated with the merger (a bit of an understatement) and that they happened at quite different times. But those weren't what I was getting at. I was talking more about adapting paramedic education to the university model, the quality of graduate and the acceptance of said graduate into the existing system. As always I'm certain open to objections or corrections but I think you would agree that there have been and continue to be some issues with graduates. Perhaps not issues with as big an impact as the merger, but I was never really comparing them. 

In the third paragraph I probably confused things by talking about jobs losses etc, but that part was in regards to an American future not a Victorian past.


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## JPINFV (Feb 8, 2012)

NVRob said:


> I liked their OT laws when I was working 16s for a company contracted by Union Pacific for railway maintenance.




4 hours of time and a half and 4 hours of double time a shift? Awesome. It's why I never had a problem being asked to be held over. At $20 an hour? How long do you need me?


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## MedicBrew (Feb 14, 2012)

Let me first say that I agree that in order to elevate EMS and to be recognized as the profession we know it as, a degree should be mandatory.

We must first look at the reason why medics (EMT’s, NRP’s, MICP’s or whatever you’re called in your locale) are not compensated proportionately to others with the same amount of training time in healthdcare. Currently in my state to achieve the Paramedic level, you are required to complete 1800 hrs, and that’s just to set for the test. To enter the course, you are required to be an EMT in good standing (approx 200 hrs), have a college level A&P course, EVOC, and CPR etc. Now compare that to the hours that the typical RN needs to set for their board, approx 60-65 credit hours. Including clinical hours, the paramedic candidate has the heavier load. No I’m not degrading nurses! When everything is done, tests taken, license received, and job obtained, there is almost an 85-100% increase for the nurse compared to the paramedic, in regards to starting salary. So why is this?  

This is a complex subject but to put it simple, Hospitals, Dr’s offices, Clinic’s have the ability to bill more for their services. This equates to more capital in, resulting in higher wages. Now EMS on the other hand, in Oklahoma (that’s were I am), an average bill for a transport is approx. $1500 plus $12 per mile. Now let’s say that this is a Medicare patient. Medicare will pay $154.63 base, plus $12 per mile for the 1st 12 miles. Everything else, by law, must be written off and you cannot peruse the patient or family for further compensation. So in short, yes this is the short explanation, there is simply not enough money to increase salaries in EMS even with an increase demand AND keep the doors open. There has to be a tax base to pull from, and in many areas across the country that’s not going to happen. 
I say this because this is a conversation that I’ve heard for several years. I my humble opinion, we must first unite to increase funding to EMS across the nation, then we can delve into elevated education, costs and salaries because that is what’s going to motivate individuals to seek undergrad degrees. But don’t fool yourself thinking that just because you have a BS, you will be paid accordingly. You have to crawl before you walk kinda thing.


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## Veneficus (Feb 14, 2012)

I have had this conversation for many years as well.

Until there are people with a university degree, organization, lobbying, etc. are impossible. 

It just doesn't work to demand more and promise to increase your standards if you get it.


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## MedicBrew (Feb 14, 2012)

I don’t disagree with what you’re saying; I didn’t intend to suggest that. My apologies if I did. 

I merely suggest that it will be extremely difficult, if not impossible to impose increased educational requirements for a yearly salary that’s less than $24,000, which is only a few thousand above poverty level if you have a family. Not when you can get a degree in the same amount of time with the potential to double that as a nurse. 

I would love to see a national degree requirement.


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## systemet (Feb 14, 2012)

MedicBrew said:


> I merely suggest that it will be extremely difficult, if not impossible to impose increased educational requirements for a yearly salary that’s less than $24,000, which is only a few thousand above poverty level if you have a family. Not when you can get a degree in the same amount of time with the potential to double that as a nurse.



This is supply and demand.  Increase the educational requirements and the pool of eligible applicants decreases.  When this happes the compensation has to go up.

I do agree that $24,000 / year is a terrible wage for a paramedic.  Anyone making that full-time doing EMS has my respect.


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## systemet (Feb 14, 2012)

Rocketmedic40 said:


> My greatest fear is that we end up like the UK, where paramedics are "independent", but they're essentially Intermediates.



Tell me where in the US intermediates are doing field thrombolysis.  Or paramedics for that matter.  I don't think you'll have too many places.  (I admit this may be partly due to the PCI capabilities you have there).

Is it better to have less education and a wider scope, or less tools, but the education to use them effectively?


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## MedicBrew (Feb 14, 2012)

systemet said:


> This is supply and demand.  Increase the educational requirements and the pool of eligible applicants decreases.  When this happes the compensation has to go up.



True, in theory that should happen. However, at least in my area, there is currently a severe shortage of upper level medics. The overwhelming response by far is that the services are simply dropping their level of response. What once was a paramedic unit, is now an intermediate unit, if not a basic unit, or simply downing units completely. As for elevating existing salaries, that has been below marginal. 



systemet said:


> I do agree that $24,000 / year is a terrible wage for a paramedic.  Anyone making that full-time doing EMS has my respect.



Thats a pretty average starting salary around here. When I recieved my blue and gold, I was being paid $9/hr($18,000/yr), of course that was back in the 90's when minimum wage was $4/hr. 

Don't get me wrong, I FULLY support greater education, not trying to be argumentative.


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## Veneficus (Feb 14, 2012)

MedicBrew said:


> True, in theory that should happen. However, at least in my area, there is currently a severe shortage of upper level medics. The overwhelming response by far is that the services are simply dropping their level of response. What once was a paramedic unit, is now an intermediate unit, if not a basic unit, or simply downing units completely. As for elevating existing salaries, that has been below marginal.
> 
> 
> 
> ...


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## MedicBrew (Feb 14, 2012)

What can I say, I was young and dumb. I do a little better than that now of course.


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## RocketMedic (Feb 15, 2012)

systemet said:


> Tell me where in the US intermediates are doing field thrombolysis.  Or paramedics for that matter.  I don't think you'll have too many places.  (I admit this may be partly due to the PCI capabilities you have there).
> 
> Is it better to have less education and a wider scope, or less tools, but the education to use them effectively?



Two sides of the same solution. What good does a doctor-level education do if you can't do anything other than take them to the ER due to tool/legal limitations? Likewise, what good does the Army answer (extremely wide and aggressive toolset on virtually no training) do in the absence of the education to use it?

The best answer is to educate paramedics (and EMTs), _and_ give them the tools and scope of practice to actually use that education in a relevant and safe manner (with aggressive QA/QI, continuing education that has a purpose, and compensate EMS workers accordingly to retain them.


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## systemet (Feb 16, 2012)

Rocketmedic40 said:


> Two sides of the same solution. What good does a doctor-level education do if you can't do anything other than take them to the ER due to tool/legal limitations? Likewise, what good does the Army answer (extremely wide and aggressive toolset on virtually no training) do in the absence of the education to use it?



I would argue that the physician group would be less likely to actively harm their patients by doing something stupid, even if their abilities would be limited by the equipment available.

The UK EMS system is impressive.  They're making huge leaps forward.  Consider the Bachelor's degree paramedic programs, and paramedic practitioner program.  I think they're actively pushing to develop EMS into a profession.  I'm not sure why you feel so negatively about it.



> The best answer is to educate paramedics (and EMTs), _and_ give them the tools and scope of practice to actually use that education in a relevant and safe manner (with aggressive QA/QI, continuing education that has a purpose, and compensate EMS workers accordingly to retain them.



Agreed. I think we're on the same page here.

We have to increase the length of training, because right now our scope is outstripping our understanding of how to apply it properly.  Our development as a profession is also being limited by our lack of ability to do things like treat and release, which is partially an educational issue.  The time has come for the Bachelor's degree paramedic.


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## Veneficus (Feb 16, 2012)

systemet said:


> We have to increase the length of training, because right now our scope is outstripping our understanding of how to apply it properly.  Our development as a profession is also being limited by our lack of ability to do things like treat and release, which is partially an educational issue.  The time has come for the Bachelor's degree paramedic.



It is the same story it has always been.

US providers see EMS a a labor based trade. They measure value by psychomotor skills. 

They attempt to make up for the lack of education with cookbook protocols that keep getting more and more outrageous or by iimplementing state/regional protocols that so limit the skill as to reduce the value of the service.

I agree that the research is showing that skills need to be reined in, but I think the manner in which it is being done is doing a disservice to turning EMS into a profession. 

It is my conclusion that until EMS providers as a larger percentage of their population embrace education, the skills will continue to be removed as the research showing they are ineffectively applied continues to grow.

One of the major issues zmedic very accurately pointed out. Everytime a study comes out showing something like ETI is not effective or performed appropriately, instead of providers uniting and taking responsibility for the weak links in the profession and addressing the issue with global system recommendations, they make up reasons why the research doesn't apply to them.

Followed by the excuses: "it's the best we can do" or "it is better than we had."

Then, rather than issuing a strong condemnation of performance and issue decisive recommendations, groups like the NAEMT and IAFF just come up with pathetic nonstatements or sweep it under the rug and beat their chest about saving lives.


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## systemet (Feb 16, 2012)

Veneficus said:


> One of the major issues zmedic very accurately pointed out. Everytime a study comes out showing something like ETI is not effective or performed appropriately, instead of providers uniting and taking responsibility for the weak links in the profession and addressing the issue with global system recommendations, they make up reasons why the research doesn't apply to them.



Yeah.  I could rant for a while about this.  It's disheartening.

The ETI debate is troublesome.  The San Diego trial suggests harm, and there's a bunch of scarey data out of California in general.  It's tempting to dismiss that as a training / paramedic saturation issue.  But even the Australian data is only weakly supporting paramedic RSI in what sounds like a pretty optimised environment.

I'm not sure what the answer is.  It would be nice if we could look at the San Diego trial and say this is an exception, this is just poorly-trained providers without capnography unintentionally hyperventilating a bunch of patients.  I don't think it's that simple.  

I think part of the problem is that EMS has a lot of pride when it comes to intubation.  It's one of those skills that are normally reserved for physicians that make us feel very special.  This is part of the whole defining ourselves as a collection of skills / protocols / medication list sort of thinking that's also holding us back.  It would be nice to hear more voices at least acknowledging the possibility that perhaps current training and exposure to ETI is lacking, and that in some settings our attention might be better focused on less aggressive intubation, alternative airway use, and getting decent bilevel ventilation on the ambulance.

There's this "cargo cult" mentality where we seem to want to imitate the physicians without actually completing a fraction of the educational requirements that they do.




> Followed by the excuses: "it's the best we can do" or "it is better than we had."



I hear you.  But I will say that sometimes physicians lose sight of the idea that the goal of EMS is not to provide care at the same level as the hospital, but to "provide the best care that non-physician paramedic providers can perform in a technology and information poor environment".  What's done on the ambulance doesn't have to be done as well as in hospital, just better than not doing it on the ambulance.


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## RocketMedic (Feb 16, 2012)

systemet said:


> Yeah.  I could rant for a while about this.  It's disheartening.
> 
> The ETI debate is troublesome.  The San Diego trial suggests harm, and there's a bunch of scarey data out of California in general.  It's tempting to dismiss that as a training / paramedic saturation issue.  But even the Australian data is only weakly supporting paramedic RSI in what sounds like a pretty optimised environment.
> 
> ...



A lot of the problems we see in these studies seems to be influenced by the fact that many of the people we tube are already either critically ill/injured or dead. 

I, for one, think that the largest problem with ETI in EMS is that we don't have good education. Many paramedic students simply can't get tubes in ORs, ERs, or on ambulances due to liability.


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## RocketMedic (Feb 16, 2012)

http://www.youtube.com/watch?v=nxpYuVr53zQ

I watched this, and was surprised at the difference and similarities between UK and US cardiac-arrest responses, and what works.

First, I think we can all agree that compressions work. Really well. There may be semantics in rate, number, and ratios, but compressions work.

I was surprised that the UK paramedics did not have a Lifepack or other manual monitor-defibrillator. Although an AED delivers similar capabilities in a full arrest, current AEDs don't allow us to treat things like SVT or perfusing V-tach, and I was surprised by that. I was also really surprised by the delayed IV.


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## Veneficus (Feb 16, 2012)

Rocketmedic40 said:


> A lot of the problems we see in these studies seems to be influenced by the fact that many of the people we tube are already either critically ill/injured or dead..



I agree there are some flaws in the individual studies, however, despite the various flaws, most of the studies show that there is a problem wityh failed intubation or lack of improvement in outcome.

In my interpretation it seems more like a lack of skill combined with an inappropriate identification of when the skill is important.

In the services that have aggresive oversight of intubation (usually because it is attached to RSI protocols) there are  common components that these services all have.

1.Not least of which is an active medical director.

2.Another is increased knowledge based training. Identifying who benefits and when, as well as hyperacute awareness of what constitutes poor practice and common mistakes demonstrates these providers are actually educated higher than the mean.

3.These services usually have enough patients that get intubated and/or the support of local medical facilities for ongoing practice and training.



Rocketmedic40 said:


> I, for one, think that the largest problem with ETI in EMS is that we don't have good education. Many paramedic students simply can't get tubes in ORs, ERs, or on ambulances due to liability.



These two ideas are not the same. 

Education is knowledge based. 

Training is the actual hands on practice.

Liability is only one aspect of the problem. 

Various medical advances have decreased the need for ETI in various patient populations.

Various medical providers like anesthesia and emergency medicine have higher priority in ET training and practice because they have greater need in order to benefit the most patients.

Pathologies that were once thought to benefit from ETI as well as the complications of mechanical ventilation have demonstrated it is not as beneficial globally as once thought.

Regional anesthesia techniques and supraglottic airways like the LMA have further reduced the amount of ETI performed.

Liability is an issue as is who will pay for the cost of complications in training.

But this response illustrates exactly my point. EMS should not be coming to the defense of the skill. As a group it should be issuing what is considered minimally acceptable training and proficency guidlines. Along with this it should recommend that services unable to meet these standards should not be performing ETI.

Like all other healthcare providers outside of EMS, EMS providers, especially paramedics, need to seperate skills and knowledge as what defines their identity.

As something to think about...

Are you not a paramedic if you didn't have ETI equipment on your unit? (like on a bls transport, fire unit, clinic etc.)

If you have ETI equipment but never see a patient that needs it are you not a paramedic?


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## RocketMedic (Feb 16, 2012)

Me being a paramedic has very little to do with the tools on the rig. When I'm in the (near-useless) Stryker MEV or on my feet, or with a full MICU unit, I'm still a paramedic.

That being said, I can do my job _better_ in many cases with more equipment. Can't really help a CHFer or a cardiac patient with the contents of a trauma kit, and I really can't do anything for someone suffering from anaphylaxis with a chest needle- you get the point.

Mindset-skillset-toolset. Mindsets are on the individual. Skillsets and toolsets are delegated- we're responsible for learning the skills, but without authorization to perform a procedure, a paramedic will get fired in a hurry, regardless of whether or not it is correct. The tools are the least important of the three, but taking away our tools hurts patients who many need them.

You brought up ETI. Granted, there's a lot of situations it's overused in. But there are definite times when it is needed. Should we let those people die? What about pain management? Is it _really_ needed? What about seizure control?

One gigantic flaw I see in the current "let's make EMS more educated" campaign is that, in many ways, EMS is getting _simpler_. I understand the logic behind more education, and so do you. But it's not us (the choir) that we need to convince. It's the firefighters who are paramedics because they have to be, the private corporations who are quite profitable on current results, and most importantly, it's the public. To Joe Average, why should his city pay $100,000/year for a paramedic whose job is to put on a Lucas, toss on an AED, squeeze a bag a few times, and maybe start an IV in the classic cardiac arrest? _I_ understand that that's pretty good care- but _he_ doesn't. Heck, he makes it look easy! So why pay them? Volunteers can do that, man! We don't need no _college_!"

EMS needs to move away from this to really become a profession. I'm a paramedic no matter what I'm carrying- mindset. However, allowing our peers in the medical professions to strip tools from our kits and ban skills with justifications like "y'all can't do these perfectly all the time" or "you only need it sometimes" or "I'm a doctor and I should be the only one to do this" is just as flawed as handing those authorizations and tools to a bystander. As long as we have 'paramedics' who are only that on paper, who think that EMT-I/85 is "advanced" life support, and a professional image of ourselves that is defined by our skillsets and not our mindsets, we're tradesmen.


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## Veneficus (Feb 17, 2012)

Rocketmedic40 said:


> You brought up ETI. Granted, there's a lot of situations it's overused in. But there are definite times when it is needed. Should we let those people die?



If more people are dying or being harmed than would die if it wasn't available. Then yes. Those unfortunate people will die.




Rocketmedic40 said:


> One gigantic flaw I see in the current "let's make EMS more educated" campaign is that, in many ways, EMS is getting _simpler_.



This is not a flaw.

EMS is getting simpler because many of the treatments that were thought to help are being discovered not to help. 

As well, there has been a shift in the mindset of the medical community from the 80s. Death is no longer the enemy. Not everyone benefits from aggresive resuscitations.

I have spoken before on the evolution of disease. That hold true again here. Because of more advanced medical care, safety standards, etc. there is a shift towards chronic disease which need to be managed, away from acute emergency. 

The purpose of advanced education is to retool EMS providers to this new reality so they have a job.

I have really given up trying to convince people. I just type this stuff to try and help those who want to be better.


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## RocketMedic (Feb 17, 2012)

I understand that, Veneficus, but I don't think that we should entirely focus our education, training, and most importantly our _scopes of practice_ on chronic disease care.

Emergencies, real legitimate emergencies, still happen all the time. There's no reason to throw our capabilities to deal with those away.


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## RocketMedic (Feb 17, 2012)

http://www.youtube.com/watch?v=nxpYuVr53zQ

I watched this, and was surprised at the difference and similarities between UK and US cardiac-arrest responses, and what works.

First, I think we can all agree that compressions work. Really well. There may be semantics in rate, number, and ratios, but compressions work.

I was surprised that the UK paramedics did not have a Lifepack or other manual monitor-defibrillator. Although an AED delivers similar capabilities in a full arrest, current AEDs don't allow us to treat things like SVT or perfusing V-tach, and I was surprised by that. I was also really surprised by the delayed IV. Also surprised by the OPA- here, it would have been at least a Combitube, likely an ETI. 

Clearly, that crew did a great job. It's just interesting looking at the standards of care.

And yes, I do believe that pressors aren't super-effective. I do, however, think that American EMS may have an advantage in periarrest management, especially in rural or suburban areas.


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## systemet (Feb 17, 2012)

Rocketmedic40 said:


> I watched this, and was surprised at the difference and similarities between UK and US cardiac-arrest responses, and what works.



Me too.  It's easy to criticise, but I'm surprised they chose to work the code between the bike racks like that.  It seems like it would have been easier to drag the patient a couple of meters out.  But it's difficult to judge how many people were crowded around, and I can understand why they might not want to interrupt the code to move the patient.  I still think I would have.



> Although an AED delivers similar capabilities in a full arrest, current AEDs don't allow us to treat things like SVT or perfusing V-tach, and I was surprised by that. I was also really surprised by the delayed IV. Also surprised by the OPA- here, it would have been at least a Combitube, likely an ETI.



Yet they clearly had decent ventilation.  The patient didn't aspirate -- although this would have concerned me too.  And though they report the patient as GCS3 in their radio patch, with the increasing level of consciousness during a (presumably) short transport, it might have been that drugs would be required to intubate.  

With a longer transport, and in other systems, the patient might have been intubated +/- drugs post-arrest, hypothermia begun, and a post-arrest 12-lead done during transport.  But it's hard to get a sense of how much time elapsed.

I'll admit to having been on a few scenes where the paramedic has had tunnelled in on intubating to the exclusion of all else.  That mistake was avoided here.




> And yes, I do believe that pressors aren't super-effective. I do, however, think that American EMS may have an advantage in periarrest management, especially in rural or suburban areas.



Maybe.  It depends if the dopamine is being used properly and safely, which often it isn't.  There's also a lack of prehospital research in this area.


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