degrees for all paramedics 10 year plan

[tacitblue]

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...

 

[Handsome Robb]

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.

 

[Melclin]

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.

"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.

 

[JPINFV]

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?

 

[MedicBrew]

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.

 

[Veneficus]

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.

 

[MedicBrew]

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.

 

[systemet]

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.

 

[systemet]

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?

 

[MedicBrew]

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.

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.

 

[Veneficus]

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.

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.

I have friends that made more than that per hour as a manager at taco bell during that same period.

If I had a paramedic cert then, I would drop that area like...

...a sack of bricks.

 

[MedicBrew]

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

 

[RocketMedic]

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.

 

[systemet]

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.

 

[Veneficus]

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.

 

[systemet]

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.

 

[RocketMedic]

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.




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.

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.

 

[RocketMedic]

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.

 

[Veneficus]

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.

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?

 

[RocketMedic]

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.