Different angle: why basic level technicians?

[mycrofft]

I've suggested that Paramedics be forced to upgrade and the category be abolished, as well as other aspects of the skill/scope picture.
How about another slice at it?

Instead of fighting to graft new individual skills onto EMT-B's (and this includes everything between EMT-B and Paramedic), why not just recognize that a basic EMT, with sufficient training and protocols, makes a difference and fills a vital niche (remember more than just paid urban settings here), and propose we sharply draw the line between Basic and Paramedic...as the Feds obviously want to do but don't have the huevos to carry through?

Or is this wrong, and we need to be able to graft and glue/tape on any skill set a basic wants, or create all sorts of hybrids as has been done by many EMSA's and states?

Before we start, I recognize and respect people who want to gain more skills and knowledge, and I know theoretically that more skills OUGHT TO (but largely hasn't) translate(ed) into more pay and security. But WHY NOT a basic level tech, with decent pay and a threshold over which they become paramedics so their training and practice is not fragmented by a non-holistic/global approach? (Do you know what global/holistic approach means?).

Thoughts?

 

[EpiEMS]

Perhaps it's an artifact of the apprentice, journeyman, master system?

The idea of the EMT-B (i.e. the EMT, according to the new nomenclature) is to be able to reduce morbidity and mortality due to traumatic injury and acute medical problems - and to adequately triage them. We all know the basic history of EMS, and Mycrofft, you're certainly more knowledgeable than I, so I hate to "lecture."

As far as the economics and business aspect of it goes, EMTs can provide the most cost-effective life-saving and life-preserving interventions that are shown to have minimal downside risk and maximum benefit. Most of what the EMT can do is fairly uncomplicated and very effective or of such low cost (both financial, opportunity-cost, and in terms of risk to the patient) that it is judged to be appropriate. I'd go as far as to say that the addition of ALS skills, while important and sometimes efficacious (as well as very helpful for alleviating suffering), are not as cost-effective or life saving, on a purely empirical basis.

This lack of cost effectiveness of the ALS provider at the prehospital level means that it makes sense to bolt-on, as needed, ALS skills to the BLS level, both to suit research, cost, the region, and other conditions the medical director deems appropriate. For example, I would most certainly consider blind airway insertion devices to be BLS-appropriate. Not only are they quick, cheap, and fairly easy to use, they are nearly as effective (if not just as effective) as the ETT. Thus, since the cost is low and the skill fairly simple, it makes sense as a bolt-on. Similarly, consider Narcan. Yes, overdose management at the BLS level can be accomplished with a BVM. But if there is an effective way to move from BVM ventilation to solve the underlying problem, why not at least consider it, if it proves to be effective and safe? (And, far as I know, IN naloxone administration is used successfully at the BLS level in some regions).

Let's question all of our assumptions: let's start with evidence and cost efficacy and then build from there.

 

[bahnrokt]

The lines between ALS and BLS should be flexible region to region. What works for FDNY probably isn't going to work for a rural squad in Montana.

I am an EMT with a rural 100% volunteer BLS only squad with no ALS coverage in our CON. 30+ minutes to a hospital, 60+ to level 1 trauma. Most of our members are college educated, many hold advanced degrees...we are not idiots. I can do a lot more with some extra tools than a city emt that rides with a medic and is never more than 10 min from an er door.

I do agree that the requirements need to be changed in general. EMT B should be eliminated and the min to work in EMS should be should be near that of an EMT I or CCT.

 

[TB 3541]

EMT B should be eliminated and the min to work in EMS should be should be near that of an EMT I or CCT.

I think this should be the focus, instead of clarifying the lines between Basic and Paramedic. Maybe it would cause shortages of "ambulance drivers" in other parts of the country, but I know that in Southern California, we need for EMT-B (or whatever we will call entry-level EMS care providers) to be harder to get.

Why not advance society and patient care by raising the bar? I'm probably going to lose my EMT-B certification with having never gotten a job, and not for lack of trying. The only thing I haven't done was start assassinating EMT's to open some positions .

All joking aside, I would gladly take a longer, more expensive, more comprehensive course if I knew that not every Joe and Jane out there who "just felt like trying it" could get hired just as easily as me.

 

[EpiEMS]

Hold on, now. Eliminate EMT? That doesn't make sense. There is a reason we have the EMT. Cost effective life-saving (and IFT).

The AEMT is, more than anything else, an EMT with additional skills training. There's nothing wrong with that. However, most of the additional skills that the AEMT can provide should be at the EMT level to begin with -- namely administration of nitro, BiADs, inhaled beta agonists, Narcan, Nitrous (not like it's widely used), and administration ofIM and SQ epinephrine for anaphylaxis (which most EMT protocols that I've read allow). Oh, and, of course, CPAP.

Is the AEMT useful? Yes. Cost effective? I don't know.

 

[TB 3541]

Eliminate EMT?

I suppose it does say that in my post, but what I meant was something like EMT-B's would be trained at the level of AEMT, and EMT-B, as it is currently known, would cease to exist.

 

[TB 3541]

Cost effective? I don't know.

From my limited understanding of economics, (and also potentially limited to the Southern California market, and others like it) an EMT-B with more training would not cost much more to hire, if any more, than they currently do. The reason being that there are so many EMT-B's currently, that all can't possibly be hired. If you increase the standard by which EMT's are measured, many are bound to fall out. You would just have to find the spot wherein the supply of EMT-B's at the new training level matched, or slightly exceeded the demand.

But who's to say that it would be a bad thing if private EMS wages competed more closely with city or county wages?

 

[the_negro_puppy]

Or maybe have two levels of Paramedic like in Aus?

We have Advanced Care Paramedic (ACP) and the higher Intensive Care Paramedic.

Our ACP is somewhere between your EMT-I and EMT-P

we operate ACP/ACP or ACP/ACP student and have Intensive Care Paramedics on fly cars for intercept.

Just a thought.

 

[EpiEMS]

From my limited understanding of economics, (and also potentially limited to the Southern California market, and others like it) an EMT-B with more training would not cost much more to hire, if any more, than they currently do. The reason being that there are so many EMT-B's currently, that all can't possibly be hired.

Makes good sense. If you bring EMT training up to the AEMT level (for convenience, "New EMTs"), you've automatically removed a large portion of the "supply," that is, workers. So, less labor supply, given the same level of demand for their services, ceteris paribus, means higher wages for the New EMTs.

There's a problem, though. What if, by imposing this additional barrier to entry, we reduce the number of providers to a level where peoples' healthcare needs go unmet?

I'd rather have the status quo (from a system perspective).

But who's to say that it would be a bad thing if private EMS wages competed more closely with city or county wages?

Private companies might not be able to continue to operate, for all I know. Honestly, I don't know much about the business model of private EMS to speak intelligently on that aspect of it.

 

[EpiEMS]

Or maybe have two levels of Paramedic like in Aus?

We have Advanced Care Paramedic (ACP) and the higher Intensive Care Paramedic.

Our ACP is somewhere between your EMT-I and EMT-P

Makes sense to me. Then again, I repeat my objection to eliminating a whole level of provider (especially because of how cost effective and efficacious the EMT level is).

I'd certainly like to see a system like that, where we're all medics (that term has so much more traction with the public, after all). Something like:

Certified Paramedic (EMT-level, with the addition of all AEMT skills except IV and IO, no degree requirement, but encouraged)

Licensed Paramedic (EMT-P level, minimum associates degree level)

Advanced Practice Paramedic (EMT-P, with more medications, more autonomy, etc., minimum bachelors degree level; a physician extender like a PA, with an independent DEA #, etc.)

 

[DPM]

Other EMS systems that I have experience with don't really have this problem, and I think it's mainly down to EMS not being 3rd service.

Many people, especially in CA where I am, take EMT-B because it is now a requirement for Fire, and the same can be said (to a degree) about Paramedics too. And this has had two knock on effects.

One is that the labor market is saturated with EMT-Bs. Not surprisingly, Fire doesn't hire around here very often. And with hundreds of applicants for every 1 position, and with every applicant being an EMT-B, we have a surplus.

Second is that private firms exist. Even though their 'product' is healthcare, they are also, essentially, private companies. They provide 911 and IFT ambulances because they have identified that this is a way to make money.

The normal rules of supply and demand will show you that if you have 1,000s of people to choose from then you don't have to pay a great deal. This pay can then be decreased further when most of the employers are private firms looking to make money. And I don't think that any of this is new to anyone here, but what is a solution?

I think making the entry level harder to obtain is a start. We are currently churning out 'healthcare providers' within a period of weeks. There is a school near me that has an EMT-B school that is 15 days long. This has lead to a situation where EMT-B is not so much a job, but a certificate and something used to fill out your CV for the Fire Department.

I don't want to get rid of EMT-B. I think we all agree that we need them. But I would estimate that probably close to 50% of people in my state that are licensed EMT-Bs do not work in healthcare, be it Fire, AMR, hospital etc. I'd recommend adding more of those grey I-95 / EMT-IV areas, but on a national level.

Basic, Intermediate, Paramedic and then CCT / Paramedic Practitioner. This would allow a county EMS coordinator to cater to the levels that they require, giving you multiple ways to combine the 4 levels of training. The rural service can run Basic / Basic ambulances with a Intermediate or Paramedic cars to supplement their coverage. Also, with degree level trained Practitioners more patients can be treated at home without requiring a lengthy and expensive trip to the ER.

This is a similar to the NHS in the UK and to the Australian model and probably a few others too. Unfortunately I don't see this shift happening in the US without a lot of change. Change in the level of training required and also in the general mentality of pre-hospital providers. EMS in itself needs to be a career choice, not some quasi half private half fire situation. I honestly feel that 3rd service EMS, with several well defined levels of experience and training would be a big step in the right direction.

An interesting JEMS article on Paramedic Practitioners / ACPs

 

[firetender]

What am I hearing?

There's economic justification for providing the Lowest Common Denominator of service to our people?

What I'm looking for is an understanding that we as a society are sophisticated enough and reasonable enough to actually want an EMS system that can handle all the basics AND has the will, desire and willingness to sacrifice so that if someone needs more advanced care, they've got it available to them.

Everybody. Everywhere. At any time.

That means an EMS culture designed for upward mobility, steady continuing education and numbers large enough at every level (with safety-nets built in to protect them) so that no one is left out of receiving superior emergency care.

Anything less is cheating our populace.

This means a service and culture completely independent from other vital protection agencies.

 

[DPM]

There's economic justification for providing the Lowest Common Denominator of service to our people?

There is when the shortfall in coverage is bridged by private agencies.

This means a service and culture completely independent from other vital protection agencies.

^ This is the answer. Either 3rd agency like in other countries, or left ENTIRELY up to Fire. It's the middle ground that we've fallen into that causes this trouble.

 

[DrParasite]

oh, where to start, where to start, where to start.....

Why not just get rid of paramedics? We are always pushing for evidenced based medicine, have any studies been done to say that paramedics save move lives than EMTs?

Or lets make everyone have to be a paramedic.... I'm sure there are studies that will say that all ALS systems have lower mortality rates than tiered systems right?

Lets also consider this, currently Paramedics are specialists (like a cardiologist, pulmonologist, or any other specialist doctor). If you are a specialist, and only see sick people in your specialty, you will be really good at what you do.... but if I have a heart condition, and am experiencing chest pains, should I really be going to a proctologist? So if I'm a paramedic, why am I dealing with an assault victim, or back pain, or abdominal pain, or the guy with a boil on his butt???? Shouldn't I be dealing with people with complaints that I am a specialist in?

Lets also deal with the other groups: 1) volunteers, people who want to help out, are working a full time job, and now you want to send them to an even LONGER course? what about sending them to a 6 month course, but they only go on 20 calls a year, how good will they be? 2) for profit, companies (and their employees) where the almighty dollar rules, as long as the billing paperwork is correct, you will still have a job. not only that, but I don't need a 6 month educated EMT, a 3 month one will do; at least it has for the past 15 years. 3) firefighter, we don't want to be EMTs, we don't want to do EMS, we don't want to be on the ambulance, we are only completing it because it's a job requirements. If it wasn't a job requirements, I wouldn't even have CPR.

I'm sure there is more, but It's 4am and I don't want to make this 3 pages long.

There are a lot of short comings in the current EMT class. complete your 120-140 hour class. than take another 80 hours of training (con edu). and then have 100 patient contacts, 30 of them are sick patients who would benefit from ALS interventions. spend 3-6 months with an FTO, who is constantly evaluating you. Maybe by then you will be ready.

And before anyone calls me any education, I have my degree, and have completed all by one requirement to get into med school (MCATs). Organic Chem was a :censored::censored::censored::censored::censored:, esp when taking it and Bio 2 at the same time, and working 60 hour weeks in two busy EMS systems.

But if we want to be considered equals to others in healthcare, than we need to start playing by their rules, and that means using evidence based medicine to guide our protocols and actions, need to be active in the research area, and realize new items that have shown to be beneficial to patients can be used, not disregarded because "we didn't need them 20 years ago, and we don't need them now!"

 

[mycrofft]

Tiered EMS was initiated so that it could penetrate areas and people who did not have what it takes to field paramedics. Have we solved that? We have areas where you can't even get a doctor much less a base hospital.

Why make job descriptions so fluid they cannot be legislated and you can train someone to within one skill short of a paramedic and pay her/him as an EMT? (The answer to the latter is that EMT's want the skills and don't realize they ought to/need to be paid much more).

If we all need coverage from BLS up through ALS, why not just require everyone doing paid prehospital EMS (PHEMS) become a paramedic? Or require a certain ratio in the smallest and most-rural services?

Can a new service ("The PHEMS Service", say) afford to be started by purchasing all new infrastructure, separate communication system (hardware and frequencies/bandwidth), and hiring (either new hired because current fire EMS don't want to lose their jobs, or pay enough to attract old hires away)?

 

[EpiEMS]

The practice of medicine is state-regulated in this country. That's one aspect we shouldn't forget. (And, I for one, think it makes sense.)

There's economic justification for providing the Lowest Common Denominator of service to our people?

That's not the idea –:censored:the idea is to do what's evidence based and efficient, especially if people are demanding something for free (or low cost).

What I'm looking for is an understanding that we as a society are sophisticated enough and reasonable enough to actually want an EMS system that can handle all the basics AND has the will, desire and willingness to sacrifice so that if someone needs more advanced care, they've got it available to them.
Everybody. Everywhere. At any time.

That's ideal, I agree, but it is both unrealistic and doesn't necessarily jive with the scientific evidence.

This means a service and culture completely independent from other vital protection agencies.

Absolutely. I like the idea of PD and FD responding to life-threatening emergencies on the off chance that they arrive first, but outsourcing medicine to PD and FD is a huge mistake.

 

[mycrofft]

Consider a parallel: get rid of nurses and staff hospitals with only MD's. Aren't there some advantages to tiered coverage ?

 

[thegreypilgrim]

What has to happen is the EMT-B level has to be scrapped altogether and replaced with something else. It simply has no utility in a modern ambulance service (O2 and band aids are not all that useful for much). It has to be upgraded to something like a "Basic Paramedic" level which would have the education and skillset to attend the majority of calls so you can actually have a tiered response system.

Basic Paramedic
BS Degree
Basic airway management: supraglottic/BIAD insertion, NPA/OPA, BVM
CPAP
IV/IO Cannulation
12-lead ECG
Defibrillation/Cardioversion/TCP
Meds: O2, Adenosine, Amiodarone, Albuterol, ASA, Atrovent, Atropine, Benadryl, Dextrose, Epinephrine, Fentanyl, Glucagon, Morphine, Midazolam (or some other benzo), Narcan, NTG, Sodium Chloride, Zofran

Advanced Paramedic
MS Degree
Independent medical license
Advanced airway management: adult & pediatric oral and nasotracheal ET, RSI, surgical cricothyrotomy
Needle thoracostomy
EJ & Central cannulation
Execution of behavioral hold orders
Minor wound debridement and closure
On scene discharge and alternative destination referral
Meds: Calcium Gluconate, Diltiazem, Ceftriaxone, Dobutamine, Ketamine, Dexamethasone (or some other corticosteroid), Levophed, Succinylcholine, Vecuronium, Tetanus toxoid
Scope could be significantly altered for CCT and HEMS operations

There should be a federal mandate for this - no more state-level or (even worse) local determination of provider standards.

Then you unmerge fire and EMS. Fund EMS by taxation or application of levies at state-level. EMS organization should be at state-level as well (so, no more litany of different agencies and companies providing EMS - just one statewide organization). Very important to not codify scope of practice or education into any kind of statutory law though (too difficult to change). All states should defer to a delegated practice model.

 

[mycrofft]

Can and would rural and frontier services be able to do that? WOUld these practitioners need a base hospital? Some areas need to travel over a hundred miles to get to an accredited emergency department.

 

[thegreypilgrim]

Can and would rural and frontier services be able to do that? WOUld these practitioners need a base hospital? Some areas need to travel over a hundred miles to get to an accredited emergency department.

Not if funding and resources are limited to local entities. What we would have in this scenario are statewide ambulance services (eg California Ambulance Service, Wyoming Ambulance Service, North Dakota Ambulance Service, etc.). So resource allocation wouldn't be an issue. This is what Australia does with great success despite significant remote areas.

No more base hospitals either.