The ideal paramedic program -- how would you do it?

[46Young]

I love the curriculum, but I won't put myself into educational debt and make the same amount that I do now. If there were some guarantee that I'd make substantially more than I do now, I'd be all for it.

That looks like a great curriculum, but I'd have to agree with you. For that time investment, I could be a PA, have a BSN, or an EMS AAS and be halfway through an RN program. It's a catch 22 like we've been saying all along. How many are going to sacrifice themselves by getting going the four years, making only mediocre money afterwards, and maybe, if they're lucky, get enough others to do the same, and improve their financial compensation.

 

[Veneficus]

That looks like a great curriculum, but I'd have to agree with you. For that time investment, I could be a PA, have a BSN, or an EMS AAS and be halfway through an RN program. It's a catch 22 like we've been saying all along. How many are going to sacrifice themselves by getting going the four years, making only mediocre money afterwards, and maybe, if they're lucky, get enough others to do the same, and improve their financial compensation.

Somebody is going to have to do it.

I hate to say, but there is an unhealthy focus on "what's in it for me" today than in generations past. What if the people who were in the First waves of Normandy or Iwo Jima were looking out what was best for them instead of what was best for their country?

What if nurses were looking out for what was best for the individuals instead of the profession?

Not picking on you specifically, but if you don't make some kind of sacrifice, then who?

 

[firetender]

This ain't Kansas any more!

(Couldn't resist!)

Metaphorically, we should be entering OZ. Maybe literally!

Brown offers a curriculum and standards of care for a clearly defined, tiered system that some instructional institutions in the US are approaching. But it's going to take a while for us to get there because we here in the U.S. STILL think EMS is about emergency intervention.

Until we recognize that our patients have evolved into a large segment of the general populace that really doesn't know where to go to fix what ails them OTHER THAN the Emergency Room, we're going to continue to train medics to do things that they only get to do a small percentage of the time.

It appears to me that Brown's system makes use of interventions that can be broadly described as "referral services". Would I be crazy, Brown, to say that a significant part of your day includes making sure people get to where they need to go rather than everyone getting shunted off to an ER?

Rather than calling for MORE technical/theoretical depth in emergency interventions I suggest that EMS needs restructuring from the ground up which means spending a couple years (Associate's degree here) training EMT's in emergency stabilization and referral, with significant emphasis placed on more of the sociological problems that cause people to dial 9-1-1, the development of effective communication/connection with patients, and proper psychological and emotional care of oneself.

Technically, getting this first level to a point where they can effectively manage the scene (especially of a TRUE emergency) and assist a more medically trained partner (Paramedic, BS education) would suffice and also prepare the practitioner for the next, more medically interventionist oriented tier.

The stumbling block is that EVERYBODY goes to the ER or they don't get to go anywhere else. That's a systemic sickness that must be addressed. We, here in the US, need to create more places to go than the ER for help.

 

[medicRob]

That looks like a great curriculum, but I'd have to agree with you. For that time investment, I could be a PA, have a BSN, or an EMS AAS and be halfway through an RN program. It's a catch 22 like we've been saying all along. How many are going to sacrifice themselves by getting going the four years, making only mediocre money afterwards, and maybe, if they're lucky, get enough others to do the same, and improve their financial compensation.

That kind of thinking is exactly why EMS is never going to progress to a profession. Someone has to take the initiative to lead the way in furthering EMS education, what better way than to lead by example? If EMS does make it to the status of profession, I guarantee you that a degree will be the MINIMUM requirement to practice. I like to imagine a future EMS where paramedic care is billed as Skill hours rather than mileage. Once this happens, then you will see the salary increases. All of the other allied health fields had to deal with it to become professions, it is time for EMS to step up. If individuals in EMS want to be taken seriously by their peers in healthcare, then they need to step up to the plate with the rest of us who have gone through formal collegiate education to get to where we are as opposed to a 1 year, here are your skills and a little background behind them course.

A BSN spends twice the time in clinicals alone than a paramedic spends in their entire program, and you never hear RNs or any other allied health professions define themselves by a skill set. There is much more to the practice of medicine than a flashy skill set. I commend UNM for creating a respectable EMS curriculum that will no doubt turn out well-rounded providers who will use their clinical knowledge as well as their formal education to bring a more informed care to the patients, that is what there is to gain.

I hope this doesn't turn into another Certificate vs Degree paramedic, who is better debate because that is not the point I am trying to make, as a matter of fact, I can think of medics with degrees who plain suck.. and certificate medics I would trust my life with and vice versa.

The point I am trying to make is that having a solid foundation in the areas of biology, chemistry, pharmacology, communication, research, psychology, etc is going to make for a well-rounded provider who doesn't just rely on what a protocol calls for, but one who understands from his Anatomy & Physiology, Pathophysiology, and Microbiology classes the underlying mechanisms responsible for a patient's presentation and can come to a more informed decision on how to treat that particular alteration in that patient's physiology. Not only that, but medics in general (Not all, of course) could really benefit from a course or two on English Composition and Expository writing. Moreover, we need more individuals in the field doing write ups and conducting research that is applicable to the prehospital environment as opposed to us relying solely on research that has been conducted in ED's and circumstances that are less than ideal for our purposes.

Education is never a bad thing. If EMS wants to be taken seriously, it is time to suck it up and get a real education.

 

[MrBrown]

Perhaps if production of barely homeostasasing, loser cookbook skill monkey medics with poor cerberal perfusion, nonexistant critical thinking and bad English skills who are more interested in engraved badges, putting a 14ga drip into everybody and that new siren on the ambulance than the conversion of angiotensin I to angiotensin II and pharmokenetics ceased then Medical Directors would trust you, standing orders would expand, that ambophone to the Medical Control Physician in the back pocket would go away, analgesia and scopes of practice wouldn't look like what New Zealand and Australia were practicing in 1993 and amazing things like increased pay, Medicaid reimbursment and leaving people at home would happen!

Perhaps ....

 

[abckidsmom]

I love the curriculum, but I won't put myself into educational debt and make the same amount that I do now. If there were some guarantee that I'd make substantially more than I do now, I'd be all for it.

You could always do it without debt. Some people still operate with saving, working extra and busting their butt to do the educational thing.

I agree with the others that if enough people treated this like a profession with eduation to have just for the sake of being smarter and more able to think through issues, we might just get somewhere.

 

[John E]

I'm curious...

Mr. Brown, who pays for EMS services in NZ these days?

 

[MrBrown]

Mr. Brown, who pays for EMS services in NZ these days?

Ambulance is funded through contracts with the Ministry of Health and Accident Compensation Commission, part-charges to patients and some community based funding

 

[John E]

Thanks...

could you expand on that a bit more, where does your national health care system enter into EMS?

I'm asking because there are such distinct differences between how EMS is paid for and administered here in the U.S. vs how it's done in NZ and other commonwealth and former commonwealth countries that it seems a bit silly comparing the educational standards without some qualification.

 

[systemet]

That looks like a great curriculum, but I'd have to agree with you. For that time investment, I could be a PA, have a BSN, or an EMS AAS and be halfway through an RN program. It's a catch 22 like we've been saying all along. How many are going to sacrifice themselves by getting going the four years, making only mediocre money afterwards, and maybe, if they're lucky, get enough others to do the same, and improve their financial compensation.

I think this becomes a chicken-and-the-egg situation. Which comes first?

[standard caveat: I haven't been in an ambulance for several years, there's a distinct possibility I'm an idiot]. When I started EMS, few services in my area were doing 12-lead. It was considered to be a fancy skill, that added no value. "What's the point?", people would say, "when we get to the hospital they just do their own and throw our's away. They don't even want to see it?".

Then after a while, more and more services started getting 12-lead capability. Telemetry became more widespread. Some of the services started sending 12-leads to the ERs, and the doctors and nurses became more used to the idea.

As an EMT and as a new medic, I was involved in some of the first thrombolytic trials in the region (around 2001). We showed that we could identify infarcts in the field, fax them to a cardiologist, give this new drug, tenecteplase, and actually have people reperfuse (occasionally) in the back of the ambulance. We also started doing the ER bypass direct to cathlab thing.

This evolved to the point that when I left EMS, it was considered unacceptable not to have done an ECG on pretty much any one with any sort of potential anginal pain/equivalent. The ERs had become so reliant on this being done, that if you brought in an elderly female diabetic patient with vague malaise, and couldn't produce as 12-lead, it caused real problems.

But all that time, paramedic training was 2 years. Had been for 20 years. Over 20 years, new skills, new procedures, more responsibility, and no one had increased the educational requirements.

I've heard for years now that paramedics want to have more responsibility, and they want to direct more patients away from the ER. But no one wants to take more training in order to do this. And this holds the profession back.

For example, we were trained to suture. This was/is part of our scope of practice. But very few paramedics in my area had sutured anyone outside of their hospital practicum. There was a small group of people working in remote locations suturing minor wounds to keep rig workers working. But really, no one else was doing it. Yet I'd hear people talking about how we should be able to assess minor wounds, clean them, suture, dispense antibiotics, and refer them to a minor clinic for assessment in a few days. But for the most part, few people felt they should have to have university level microbiology to do this. The idea seemed to be, that a technical school diploma was enough background to do this on. After all, we'd all sutured random pieces of meat during class labs. A few of us had sutured real people, a couple of times. How hard could it be? It's these attitudes that prevent us from moving forwards.

 

[MrBrown]

could you expand on that a bit more, where does your national health care system enter into EMS?

I'm asking because there are such distinct differences between how EMS is paid for and administered here in the U.S. vs how it's done in NZ and other commonwealth and former commonwealth countries that it seems a bit silly comparing the educational standards without some qualification.

Ambulance recieves the bulk of its funding from contracts for service with the Ministry of Health, ie the moneybags and brains our public health and disability system and ACC (accident compensation corporation).

We have three service providers; two are private, not for profit entities (sort of like MDA in Israel) and one is hospital based covering a small geographic area, although there are doubts as to how long they will survive.

Every two years the Ministry of Health and ACC put out tenders for the Ambulance contract, of which there are only three bidders and every cycle, the same three tenderees are chosen; it's a bit silly really and its in the works to either have a permanent contract or one that is valid for five years.

ACC pays a fee for service if Ambulance transport somebody who has had an accident, so basically somebody with trauma. This creates a variable level of funding which is unsustainable and the subject of a review at the moment.

The Ministry of Health bulk funds Ambulance (ie gives us money to disperse as we see fit) so the service providers can carry out the contractual requirements we have with them. Because this same money comes out of the national health budget there is always contention as to how much we get and Ambulance has historically been required to justify a request for increase in funding by proving positive patient outcomes, this has been rather difficult and perpetuated budgetary problems. The problem with the Ministry of Health funding is that it is there to provide a level of service ie fund core operating costs and up until recent years has not really been any specific allocation of money for building capacity and resillance.

As well as Government funding the Service also relies on part-charges for medical emergencies (although this has a dubious benefit) and community funding.

From December 2012 when the new contract comes out we will have a single funding stream from Central Government with seperate funding allocated for capacity and resillance building although we will still rely on part-charges and community funding for sometime yet.

 

[systemet]

I think the key difference in places like the UK or NZ, is that the ambulance system is part of the health care system. The funding dollars come from the same place as the money for hospitals and nursing / physician services.

In North America EMS is often regulated at the state/provincial level, then each county / municipality has a responsibility to fund EMS out of their own budget. This leads to a patchwork mess of systems, a duplication of resources, and a lot of unnecessary bureaucracy.

Not to mention the problem that in North America it's seen as acceptable for private institutions to teach EMT / paramedic. This creates a group of stakeholders who have little incentive to increase the length of training, and will oppose movement towards a degree-granting system.

 

[MrBrown]

I think the key difference in places like the UK or NZ, is that the ambulance system is part of the health care system. The funding dollars come from the same place as the money for hospitals and nursing / physician services.

Ambulance is provided by private, not for profit entities who are mainly funded by the health system. There is increasing moves to make Ambulance part of the health system by registering Ambulance Officers as health providers and make them answerable to the same standards as doctors, nurses, physios, dieticians etc as well as give us access to the National Health Index (healthcare records) through new electronic PRF system which is coming.

Just to be clear, Ambulance is not directly provided or owned by the healthcare system except the one small service which is hospital based, which ironically leads to more problems than good.

Not to mention the problem that in North America it's seen as acceptable for private institutions to teach EMT / paramedic. This creates a group of stakeholders who have little incentive to increase the length of training, and will oppose movement towards a degree-granting system.

Very true, and lets not forget the influence of Big Red.

 

[Emma]

I love the curriculum, but I won't put myself into educational debt and make the same amount that I do now. If there were some guarantee that I'd make substantially more than I do now, I'd be all for it.

Just curious, what's the average starting salary for an EMT or a paramedic? I mean the full time sorts of jobs, with health insurance.

For what it's worth, to be a teacher, you need a 4 year bachelors degree and then to keep your license you need your masters degree. Right now teachers start out at around $25k (full time, with health insurance). When I started, after my masters in ecology, I made 18K. Yay, food stamps! You can make more or less, depending on the district you work for. I was in a poor rural area when I started.

Having a bachelors and a graduate degree on a very small salary works out alright. I was sort of assuming that people who choose professions that are there to serve other people are not in it for money. Not saying that wanting money is bad, just that if you're choosing a profession like this I don't think you can ever expect to be paid six figures.

 

[TransportJockey]

Just curious, what's the average starting salary for an EMT or a paramedic? I mean the full time sorts of jobs, with health insurance.

For what it's worth, to be a teacher, you need a 4 year bachelors degree and then to keep your license you need your masters degree. Right now teachers start out at around $25k (full time, with health insurance). When I started, after my masters in ecology, I made 18K. Yay, food stamps! You can make more or less, depending on the district you work for. I was in a poor rural area when I started.

Having a bachelors and a graduate degree on a very small salary works out alright. I was sort of assuming that people who choose professions that are there to serve other people are not in it for money. Not saying that wanting money is bad, just that if you're choosing a profession like this I don't think you can ever expect to be paid six figures.

EMS is probably close to the same. I make in the low 30s right now as an EMT-I, and I get city benefits. But I've seen EMT-Bs making just over minimum wage, and some that make more than I do.
If teachers make that little and require more education than EMS does, it helps kick the legs out from under the argument that we need to see higher pay before we require advanced degrees for EMS.