EMS doesn't have an actual paramedic shortage....

[DrParasite]

EMS doesn't have an actual paramedic shortage; instead, EMS has a shortage of paramedics willing to work for low wages in terrible working conditions

By Kelly Grayson

WE HAVE TOO MUCH EMS
Over the years, I’ve come to realize he wasn’t unusual at all. The entire profession of EMS has a skewed concept of resource allocation. We fall prey to the conceit that new technology trumps better education, and like much of the health care consumers in our country, believe that more equals better.

read the whole article here:

https://www.ems1.com/ems-advocacy/articles/202741048-Re-inventing-EMS-with-a-BLS-intercept/

 

[EpiEMS]

So, "shortage" is a technical word that gets thrown around in this sort of haphazard fashion.

A shortage only exists when you cannot get enough X at *any price*. That is so not the case here.

Mr. Grayson's ideas are fun, but so often half-baked like many EMS ideas, insofar as that they lack (a) data and (b) cost-benefit analysis. I can't blame folks for the first - there is not good EMS data available, and as a corollary, it's hard to calculate things without good macro data.

That said, his idea in this case IS sound. Heavy BLS in urban systems makes sense (see: OPALS studies) - as do medic fly units in rural areas. However, I balk at the concept of dual medic units for anything - it is not evidence based. Yes, for cardiac arrest, one medic might not be enough (two is ideal), but it should suffice for the first couple of minutes until you can get another medic to join.

But back to my point on research - we should study these things before/as we do them. Studies can and must be done.

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[hometownmedic5]

Once again, my opinions are limited to Massachusetts.

I feel like the medic shortage here is quite real, and is almost entirely the fault of the fire departments. Many departments in this state only hire paramedics, well beyond their daily need to staff the ambulance(s) in the town. So the engineer is a medic. The pipe man, medic; and so on. Entire groups made up of medics to staff one or two ambulances.

Now I get the idea of having your entire dept cross trained so anybody can work any piece, but it eats up a lot of trained paramedics.

A municipal third service system would remove the medics from the fire side and, over time, would result in a plethora of paramedics with the same staffing.

 

[EpiEMS]

@hometownmedic5 This isn't a shortage - this is just demand. Obviously, it is thoroughly ridiculous to have 5 medics on a fire engine, truck, rescue, or, heck, at any call. However, a municipal third service system, if they paid competitive (higher?) wages, could certainly get away with hiring away some of these guys - all else equal.

Let's be real, the supply constraints in this industry are pretty minimal - 24 months (max) to train up a medic, and a fourth of that (on the high end) to train up an EMT. Indeed, more realistically, you can go EMT to Medic in 12 months, and zero to hero (EMT ) in a month. Wages are dictated by these factors and the demand side factors...which, we all know too well.

 

[DrParasite]

Once again, my opinions are limited to Massachusetts.

I feel like the medic shortage here is quite real, and is almost entirely the fault of the fire departments. Many departments in this state only hire paramedics, well beyond their daily need to staff the ambulance(s) in the town. So the engineer is a medic. The pipe man, medic; and so on. Entire groups made up of medics to staff one or two ambulances.

Now I get the idea of having your entire dept cross trained so anybody can work any piece, but it eats up a lot of trained paramedics.

A municipal third service system would remove the medics from the fire side and, over time, would result in a plethora of paramedics with the same staffing.

I respectfully disagree with your opinion, and the conclusion you are drawing.

If the FD runs the EMS system, and does EMS on the suppression units, than it makes sense to have everyone be a medic. further, requiring firefighters to maintain their medic cert to get promoted ensure that the people in supervisory roles are keeping up with the latest EMS treatments, due to continuing education requirements (at least in theory). In fact, if I was a paramedic on the ambulance, I'd had trouble taking orders from a non-paramedic captain who was giving me order on how to treat the patient.

as @EpidEMS said, maybe if the EMS agencies paid and treated their paramedics better, their would be more of an incentive for FD medics to leave the FD to be full time on the ambulance.

Think of it this way... would you rather make $14 an hour as a non-fire medic, or 60k a year as a fire medic? which would you chose? Can you see why the non-fire medics are experiencing a paramedic shortage?

 

[Summit]

as @EpidEMS said, maybe if the EMS agencies paid and treated their paramedics better, their would be more of an incentive for FD medics to leave the FD to be full time on the ambulance.

If EMS agencies were funded by property taxes (like FDs) and still were allowed to bill for their service on top of it (like FDs) maybe they could afford to pay professional middle class wages to peeps who just have vocational training (like FDs do).

 

[EpiEMS]

If the FD runs the EMS system, and does EMS on the suppression units, than it makes sense to have everyone be a medic.

Yes and no. From an "ease of staffing" perspective, sure, it makes sense. But if well administrated, you could do with fewer medics. And, obviously, you need to rationalize staffing - you need one (maybe 2) medic(s) per ALS unit, that's all.

In fact, if I was a paramedic on the ambulance, I'd had trouble taking orders from a non-paramedic captain who was giving me order on how to treat the patient.

Of course - but in many places, the highest cert'ed provider dictates patient care, by *law*.

as @EpidEMS said, maybe if the EMS agencies paid and treated their paramedics better, their would be more of an incentive for FD medics to leave the FD to be full time on the ambulance.

I think this is the only answer - you have got to have competitive wages. Of course, that's hard to do, because, as @Summit states:

If EMS agencies were funded by property taxes (like FDs) and still were allowed to bill for their service on top of it (like FDs) maybe they could afford to pay professional middle class wages to peeps who just have vocational training (like FDs do).

Of course, they aren't, and can't, so there we go.

 

[NomadicMedic]

I've said it over and over, if this model sounds appealing, take a good look at Delaware's ALS system. County paramedics in fly cars, funded by county taxes. They are dispatched with BLS simultaneously to respond to higher acuity calls and downgrade the BLS calls to BLS units when appropriate. I've not been in DE for a few years, but I hear that community paramedicine is on the near horizon.

Oh yeah, they pay a more than liveable wage, have very good benefits and all of the goodies you'd get as a fire medic, without the sample eating.

It's about as close to a ideal system as you can get.

 

[EpiEMS]

@NomadicMedic (almost typed DEMedic), they run dual medic, right?


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[DrParasite]

hey @NomadicMedic , I think NJ was doing it first ;-)

 

[NomadicMedic]

They do, but that is a function of state code. The rule says something like, "two paramedics must be dispatched to each call for assistance". Some run a medic unit split, with a single guy either as a power unit or when one medic is on an ambulance transporting. A supervisor or another medic unit may respond as back up, and get cancelled quickly. As long as two medics respond, all is good. Of course, 2 medics are needed for an RSI and another medic will come in handy on high priority calls.

There had been talk of single medic units as the norm, but that hasn't gone anywhere.

 

[Summit]

Living in NJ or DE... wah wah wahhhhhhhhhhh

 

[EpiEMS]

@NomadicMedic Interesting - I know staffing is often dictated by statute or billing, curious if this 2 medics to every (ALS?) call is done elsewhere.

So, here's a follow-up question: If we really don't have enough medics around, shouldn't we just be staffing single medic units?

 

[DrParasite]

NJ does the same thing DE does; all paramedics are in 2 person flycars (with the exception of 4 agencies, which have them in ambulances). This, too, is dictated by state statute.

The thing to remember is in a tiered system (like NJ and DE), in theory paramedics are only going to ALS calls, so they are only dealing with sick people. If you switch to a single medic, than they will probably end up on an ambulance (with an EMT partner, or if on a flycar, a lowly paid taxi driver). If they are on the ambulance, they will end up going on many calls that don't require ALS interventions, and will be tied up on those BLS level calls.

The other logistical concern is, if you are in a rural or suburban environment, in a single person flycar, and you transport the patient ALS, that medic is unavailable for any other calls from the time they leave the scene until the time they are returned to their scene, because they need to leave their vehicle parked in front of the house. that can be 15 minutes, or over an hour depending on how far you go or how much cleanup the ambulance needs. not only that, but that ambulance is OOS until they have dropped the paramedic back off at his vehicle (assuming it's in their primary).

 

[NomadicMedic]

@NomadicMedic Interesting - I know staffing is often dictated by statute or billing, curious if this 2 medics to every (ALS?) call is done elsewhere.

So, here's a follow-up question: If we really don't have enough medics around, shouldn't we just be staffing single medic units?

I guess, in areas where there's actual medic shortage. I guess, in areas where there's actual medic shortage. I think if a specific service is bemoaning a medic shortage, they need to work on internal policies to keep the medics they have, rather than lose them to other allied health care jobs or nursing.

We also, as an industry, do a pretty lousy job of getting new people interested, we do a pisspoor job of recruiting and then once we get them in, retention is lousy too.

We keep talking about how we'd like to do a systemic reform of EMS, but it's all tied together. In reality, there should never be a paramedic shortage. Entry-level EMTs should be encouraged to move up to the paramedic level and then once they're there, be encouraged to obtain additional education and have a compensation plan that suits.

Is it the fact that we don't have enough paramedic education? I see the paramedic programs around me chock full of students. Where did they all go? How come we can never find enough paramedics to staff our trucks?

 

[EpiEMS]

The thing to remember is in a tiered system (like NJ and DE), in theory paramedics are only going to ALS calls, so they are only dealing with sick people. If you switch to a single medic, than they will probably end up on an ambulance (with an EMT partner, or if on a flycar, a lowly paid taxi driver). If they are on the ambulance, they will end up going on many calls that don't require ALS interventions, and will be tied up on those BLS level calls.

That is not necessarily true. Staffing medics in fly cars, as you address below, is easily possible. There isn't a need to have a driver on a fly car, as far as I am aware.

The other logistical concern is, if you are in a rural or suburban environment, in a single person flycar, and you transport the patient ALS, that medic is unavailable for any other calls from the time they leave the scene until the time they are returned to their scene, because they need to leave their vehicle parked in front of the house. that can be 15 minutes, or over an hour depending on how far you go or how much cleanup the ambulance needs. not only that, but that ambulance is OOS until they have dropped the paramedic back off at his vehicle (assuming it's in their primary).

I do disagree - with good system design, this is a non-issue. It is axiomatic that the medic is unavailable for that ALS transport time - that is the case no matter what. They don't need to leave their vehicle parked at the house - the second EMT on the BLS unit they intercepted/responded with can follow the ambulance back to the receiving facility (I do this regularly). Or, the EMT can return to the station with the medic fly car (I also do this regularly). Or, if you really need the second EMT in the back, you can have Fire drop it off somewhere more convenient. Heck, fire can drive and you can have one EMT return with the fly car. Simple operational enhancements prevent this issue.

I guess, in areas where there's actual medic shortage. I guess, in areas where there's actual medic shortage. I think if a specific service is bemoaning a medic shortage, they need to work on internal policies to keep the medics they have, rather than lose them to other allied health care jobs or nursing.

I would posit to you that there is no shortage - because there is some wage that would induce people to move. In actuality, people move less than they used to. I totally agree with your points on retention, though.

 

[VentMonkey]

And so it all circles back to the same issues we bring up over, and over again: less wages, poor working conditions, higher paying jobs at other levels (e.g., RN, PA, fire, LE, etc.) and the list goes on and on. I honestly don't know for sure that there is or isn't a paramedic shortage. I do like Grayson's article piece. Is it reality? Who knows, but for now to me it's just more "what I would do if..." nothing more, nothing less. So at face value, yes, it sounds practical; that's all it is to me, yet another suggestion of how one would run a system, or like a system to be ran.

The area I am in is hurting for paramedics, and all I can do is speculate they're either leaving for a similar position closer to where they came from, getting hired on with public service departments, perhaps they're not happy here, or are moving on to school like the flight paramedic who I replaced. Again, I know my fate, I made my choice, so I personally can't keep complaining about what I would like to see. Is it wrong to dream of a unicorn system where paramedics are used on truly emergent calls while the soon-to-be paramedic EMT's get to transport the lower acuity calls while the intercept goes back in service? No.

FWIW, like it or not LA County is a fly-car system...in a densely populated urban setting. I have seen---on more than one occasion---where the squad is coming from so far out of their jurisdiction that it would have been better to take the patient in BLS with a fire rider. Obviously, the system itself has issues that prevent logical thinking which I won't get into here, but the point remains fly cars seem logical, but aren't a fix all. They also don't fit every system well if they aren't adopted properly with items such as proficient EMD triage, public education, sufficient BLS transport, and willing and adequate staffing of the fly cars (You know? Paramedics actually wanting to "just be" paramedics).

I cringe at having to repeat this, but personally our first step needs to be re-educating the public, community outreach, offering other services in an environment outside of the hospital aside from just transportation. When the public begins to realize that we are a vital part of not only the public service system, but a necessity to the community they'll begin to have a better understanding of what exactly we can offer them. For now all we seem to do is say what we want done with no actions taken; it gets old.

@NomadicMedic made a good point about getting people interested, perhaps he can elaborate. My personal opinion on that matter is that we're focusing on the wrong things to entice the wrong kind of people. That's not to say we still shouldn't, or wouldn't teach the treatment of "common" prehospital emergencies, nor is it a slam at people that get into this field and find out they actually really enjoy it; it's how I found it, dumb luck. I think my point here is that we're still focusing on "juicy calls", and cool decals, the latest gadgets, etc. How, if at all, are any of these things indicators of progress, or higher education?

I'll throw this out there for the hell of it. I was perusing through "Nightwatch" Tampa and saw one of the fire medics singing to his patient, was it cheesy? Maybe to some, but it put a smile on the patients face. Honestly? It was kind of refreshing to see someone take the time do that, and kudos to the producers for showing that on prime time. Patient care, even in the out of hospital environment goes way beyond what any of us were taught, it's time we truly teach that, and not gloss it over to get a nod, but actual comprehension from any would-be EMT or paramedic. There's nothing wrong with any of that. We're very much in a business of humanity, and I think that has definitely gotten lost in translation over many years of "racing to an emergency".

 

[EpiEMS]

Is it wrong to dream of a unicorn system where paramedics are used on truly emergent calls while the soon-to-be paramedic EMT's get to transport the lower acuity calls while the intercept goes back in service? No.

I don't think this is a unicorn - I think it exists in a number of places throughout the country and is a viable model for most areas.

When the public begins to realize that we are a vital part of not only the public service system, but a necessity to the community they'll begin to have a better understanding of what exactly we can offer them.

This is a PR story that is tough to sell, sadly. We could use more research to substantiate (or, you know, not) our value.

 

[DrParasite]

I do disagree - with good system design, this is a non-issue. It is axiomatic that the medic is unavailable for that ALS transport time - that is the case no matter what. They don't need to leave their vehicle parked at the house - the second EMT on the BLS unit they intercepted/responded with can follow the ambulance back to the receiving facility (I do this regularly). Or, the EMT can return to the station with the medic fly car (I also do this regularly). Or, if you really need the second EMT in the back, you can have Fire drop it off somewhere more convenient. Heck, fire can drive and you can have one EMT return with the fly car. Simple operational enhancements prevent this issue.

That's all well and good, if you all work for the same agency. When I moved down to NC, I was told that firefighters are not allowed to drive the county ambulances; insurance liability was the main reason. So they couldn't just drive the flycar car back. Again, not my call, the powers above me made that decision. Ditto having the EMT hop out and the paramedic hop in, works great if you are the same agency, not so much if you are different ones. So it's it's LA county, when everyone is part of the LA county fire system, sure, why not?

But if fireman bill crashes the ambulance or fly car when he's driving it home, whose insurance gets to cover it? the agency, who has a non-employee driving the vehicle, or the fire department, who has an employee driving a vehicle that he wasn't insured to be driving.

And I agree the medic is unavailable during the transport time, but not from the hospital back to his or her vehicle. my former agency would routinely take calls right out of the hospital, often not in their primary response area, but because they happen to be closer.

Back to the original topic, to modify the old phrase, "if you don't fund it, then they will not come."

 

[EpiEMS]

@DrParasite, operational issues like that are interesting but ultimately why system design differs by location (i.e. state law).

but not from the hospital back to his or her vehicle.

Not true if the EMT off the ambulance (driving the fly car) follows the ambulance to the hospital, no?

But yes, of course - without $, nothing good can happen.