How to fix EMS

[Trevor]

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

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

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

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

 

[firemedic132903]

Another idea...

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

 

[Ramel40]

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

 

[JPINFV]

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

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

 

[thegreypilgrim]

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

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

 

[Melclin]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

[Tigger]

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

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

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

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

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

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

 

[Melclin]

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

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

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

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

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

Fly cars are always backed by ILS though.

 

[Tigger]

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

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

Fly cars are always backed by ILS though.

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

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


Sent from my out of area communications device.

 

[Katy]

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

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

 

[Jon]

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

Why NAEMSP / ACEP?

Shouldn't NAEMSE be involved? In charge?

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

 

[jjesusfreak01]

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

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

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

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

 

[traumaluv2011]

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

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

 

[atropine]

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

 

[Tigger]

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

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

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

 

[46Young]

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

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

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

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

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

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

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

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

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

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

 

[46Young]

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

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

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

In short, everyone's to blame.

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

What's everyone else's employers doing?

Edit: Here's the model:

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

 

[thegreypilgrim]

Why NAEMSP / ACEP?

Shouldn't NAEMSE be involved? In charge?

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

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

What makes you say that?

 

[JPINFV]

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

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

 

[thegreypilgrim]

The question is, what is the practical limit of what we should be capable of in our prehospital role?

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

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

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

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

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

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

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

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

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