Why are Paramedics paid so little?

[SandpitMedic]

Agreed, but how do you account for the 80%+ of EMS services that rely on volunteers? The time requirements and lack of incentives for training & CE would preclude lots of people who may be able to practice as a Paramedic on ambulances that would otherwise be downgraded to BLS service.

First, watch your tone.

Second, in reply to your comment, then bye bye volley EMS. You don't see volunteer cops, nurses, doctors, teachers, retailers, etc en masse...
Personally I wouldn't volunteer even as an EMT, although, given the human element.... sure... you can have volunteer EMRs or something. (For the childrennnnn )

No other profession has the number of volunteers that EMS does, and quite frankly 95% of the time it is for people who really don't need an ambulance anyways.

To be objective about it as someone put it, a paramedic is a professional paid career (or is intended to be). Should we hold ourselves down for communities that refuse to pay for such services? No, they must adapt and pay to play like they do for utilities, police services, hospital services, etc... this is the first world. We're not in Botswana or Liberia where pandemics are raging and folks are constantly ill and underserviced medically. They are underserved because they choose to live in places in America without adequate services... and America is pretty darn big.

I'll give you two examples; one is police services. Even rural folks have access to local and state law enforcement- paid professionals subsidized by tax dollars. They risk long response times, although city folk would also argue about long response times.

Another is living in a rural forest with little access to fire protection. If there is a fire you're probably going to lose everything. It's a risk.

Therefore if you live in an area where there are no medical services.... then that is a personal choice. Those communities need to come together and figure out a way to pay for such services. You want a BLS crew taking you 100 miles to the nearest town? Fine, but if you want access to ALS/CCT services then you need to pay.

I'll just say it... volunteer EMS beyond EMRs needs to go away. And yes I am fully aware that I may be in an accident in a rural area... chopper is coming, and I'm going to pay for it. Quite frankly I wouldn't let most of the volunteers I've seen touch me with my own stethoscope. Many have no clue what they are doing in my experience, and that is not to bash them. They simply don't have the actual experience and hours necessary to be good at applying the skills they are supposed to be competent in.

Barriers to entry need to be raised... and you will see less coo-coo for co-co puff ricky rescue volunteers. Communities will be forced to pay for EMS services, as they do for clean running water and modern day alternating current.

I'd like to see the NREMT implement a degree requirement. The apparatus is in place, all they need to do is make the change and enforce it. Those without currently get two recert cycles to get it done.

 

[ExpatMedic0]

1. Entry education/training requirements.
2. Reimbursement methods.
There are others, but in my opinion, these may be the two largest.

 

[EpiEMS]

For what it's worth....there's a lot of good data on how much of the EMS workforce is volunteer-dependent. And yes, it is very high in rural areas, see the chart below, taken from the National Academies' 2007 paper "Emergency Medical Services: At the Crossroads".

For the above, though, keep in mind the composition of provider types!

Volunteer NREMT registrants, United States, 2003 (below):

Paid NREMT registrants, United States, 2003. (below):

See: https://www.nap.edu/read/11629/chapter/6#137 and page 45 of this document (http://www.nasemso.org/documents/EMSWorkforceReport.pdf)


What can we infer?

Volunteer services are much more BLS-heavy, and tend to be in areas that are less-population dense.

So, what does that mean for wages? Well, I'd bet that it is probably a non-issue in places where there isn't paid EMS...but if we were to see paid EMS in areas that were formerly all or mostly volunteer, BLS wages would be low, but ALS wages shouldn't be (relative to similarly skilled professions in the region).

 

[NomadicMedic]

This is the perfect case for a hospital or community consortium ALS fly car service. If you have to have volunteer BLS or low-paid BLS, staff a fly car or two with a single paramedic and have them respond to the rural areas to provide ALS when it's needed. I don't know why this is such a foreign concept to so many services. Only send paramedics where you need them, rather than put one on every street corner "just in case".

 

[EpiEMS]

@NomadicMedic, I absolutely agree. One or two fly car medics is a much more effective use of resources.

 

[ExpatMedic0]

Does anyone know of any other modern western country in the world which can train their EMT's in 3 weeks to respond to emergency calls? Zero to hero in 3 weeks... This is the minimum standard of staffing an ambulance and the majority of our countries EMS providers.

 

[EpiEMS]

Does anyone know of any other modern western country in the world which can train their EMT's in 3 weeks to respond to emergency calls? Zero to hero in 3 weeks... This is the minimum standard of staffing an ambulance and the majority of our countries EMS providers.

U.S. EMT course - being a bit liberal, let's call it 200 hours.

South Africa (considered, potentially, a developing country)- Basic Ambulance Assistant, similar length to U.S. EMT course (160-200 hours, based on some quick Google-Fu - example 1, example 2)

Ireland - EMT courses are 20 days

Israel - the "Hovesh" (EMT equivalent) level is circa 200 hours (based on personal conversations with MDA providers)

However, this is *not* the case in NZ, AUS, the UK, Germany, etc.

 

[ExpatMedic0]

I am surprised the Basic Ambulance Assistant in SA and the EMT in Ireland have such low training. I know that their U.S. Paramedic equivalent requires a Bachelor (BTech) degree in SA.

 

[SandpitMedic]

Your post and data.

That is all good info, yet it is dated. The majority of that information is from 2003... 14 years ago. The other from 2007 (10 years old) is more relevant, but just to put it in perspective... I got my initial NREMT in 2008.

That data predates my entrance to EMS... I've been in the game for nine years. Is there any newer relevant data? A lot has changed in that many years.

I still think other than BLS/EMR volunteer should go the way of the dodo. The majority of EMS folks work in the urban and suburban areas, and therefore the focus (regarding workforce and professional standing) should be on them.

The EMTs in those countries you talked about are more like EMRs in equivalency, but with access to oxygen and nitrous oxide... and quite frankly I'm not concerned with other countries.

An associates degree for US Paramedics is my main point and focus. And the Bachelors degrees from most commonwealth countries are more or less equivalent to that. It is not the same 4 year Bachelors tract/concept we are used to. Most are ~2-3 years.

Regardless, I think that most of us share the same idea on raising the bar to an Associate's degree (to start with) here in the US. That is the only way to curb the unending supply of low barrier Paramedics. It would also change the dynamic of Fire based EMS... you just might be surprised.

 

[EpiEMS]

@SandpitMedic I totally agree with you that the data is dated (see what I did there ), but such is the state of EMS with its fractious municipal, state, and federal (non-)coordinated governance. Absent good data, which I have yet to be able to find (other than making inferences around Bureau of Labor Statistics and NREMT data), I can't make an evidence-based conclusion. That said, I would agree that we have likely had some change since then, insofar as that there is a general consensus among state EMS officials that, as stated in the, the 2011 National EMS Assessment, "it appears that purely volunteer EMS services are declining" and being replaced by "mixed, paid volunteer, and/or call pay services" (which I would, collectively, deem a type of career/volunteer mixed staffing).

Also, similarly to earlier studies, the 2011 National EMS Assessment found that:

"Over 50% of the States providing data, indicated that the majority of the First Responder and EMT-Basic level EMS professionals in their State could be considered volunteer. This is consistent with a 2004 LEADS survey completed by the National Registry of Emergency Medical Technicians that identified 49.8% of EMT-Basic level professionals as volunteer. It is noted that as the educational requirements associated with an EMS professional increase (with EMT-Paramedic having the greatest requirements) the percentage that serve in volunteer roles decrease. Over 90% of the States indicated that less than 50% of the EMT-Paramedics in their State could be considered volunteer. The 2004 LEADS survey identified 21.8% of EMT-Paramedic level professionals as volunteer."

If you look at the maps provided by the report, you can sort of infer that it's going to be in places that are more rural where volunteerism is dominant, at least, for now.

The majority of EMS folks work in the urban and suburban areas, and therefore the focus (regarding workforce and professional standing) should be on them.

I am not sure if this is true - I don't have any evidence available to me. I would agree, but, I would agree with your conclusion mainly based on the fact that *more people* live in urban/suburban areas than anywhere else, thus we should focus on them.

I love the idea of first response volunteer EMS - it works in Israel (and very nicely in some U.S. areas where it is being tried or has been tried...think Hatzolah!). However, while I think EMR is probably fine, I'd like to see the levels restructured like so:
New EMR = Old EMT
New EMT = Old AEMT
Paramedic = Stays the same, add a mandatory associates degree (phase in over 10 years, say)

 

[Summit]

U.S. EMT course - being a bit liberal, let's call it 200 hours.

That is pretty darn generous... I think the average is in the 130-140 range after the NREMT curriculum updates.
150 is a lot. Not that long ago 180 was a lot to get your EMT an WEMT at the same time. 200 hours would be an outlier.
Not that 200 is a lot, but is it is roughly 150% of average.

 

[EpiEMS]

@Summit, that's a fair point. I was being as generous as I could be. That said, NYS says the range is typically150-190 hours, and UCLA (I'm taking it as representative of California) says 120-150 hours. So, you're probably right. Still, I don't think this changes the story very much - it's not really very much education, but it does have some international comparisons.

FWIW, my WEMT course (EMT + WEMT, which is basically WFR) was 20 days of 8 to 10 hours plus ~20 hours in hospital/on the ambulance, if I recall correctly - plus my (overkill) 4 hours studying a night.

 

[Flying]

This is the perfect case for a hospital or community consortium ALS fly car service. If you have to have volunteer BLS or low-paid BLS, staff a fly car or two with a single paramedic and have them respond to the rural areas to provide ALS when it's needed. I don't know why this is such a foreign concept to so many services. Only send paramedics where you need them, rather than put one on every street corner "just in case".

But, but, but response times! We have these heat maps!

 

[SpecialK]

@SpecialK, aren't your folks required to have a bachelors' degree (or something along those lines)?

Yes.

EMT: One year of study
Paramedic: Three years study (or two for EMTs)
Intensive Care Paramedic: Four years study (Paramedic plus one extra year)

It's the same in Australia as well except they do not have the equivalent of EMT level from what I understand. When I looked at the LAS they said the UK College of Paramedics will require a BHSc by 2020 (so three-year degree as the entry standard). I don't know about the rest of the world but would hazard a reasonable guess that it's pretty similar.

I don't really think the degree is enough to be honest; the types of patients being seen are increasingly complex; requiring a much greater understanding particularly of general medicine and mental health. I would really like the degree to be extended to four years or run for three full years (not the standard 26 university weeks) and include placements and learning in general medicine, geriatrics, psychiatry and community. At the moment there's exactly zero exposure to general medicine or geriatrics and only perhaps two placements in psychiatric and maybe one in rest home?

The level of clinical decision making regarding community management and referral now is almost more than is required of the emergent patient who is going to be transported to ED.

 

[EpiEMS]

But, but, but response times! We have these heat maps!

They need a (science-based) smackdown, sir!

I don't really think the degree is enough to be honest; the types of patients being seen are increasingly complex; requiring a much greater understanding particularly of general medicine and mental health. I would really like the degree to be extended to four years or run for three full years (not the standard 26 university weeks) and include placements and learning in general medicine, geriatrics, psychiatry and community. At the moment there's exactly zero exposure to general medicine or geriatrics and only perhaps two placements in psychiatric and maybe one in rest home?

The level of clinical decision making regarding community management and referral now is almost more than is required of the emergent patient who is going to be transported to ED.

You guys are in a much better state than we are in the U.S., that's for sure!

How much in the way of rotation time in the ED, OR, etc. do your folks get during their undergraduate training? Any minimum numbers of, say, intubations?

 

[MikeC]

@SandpitMedic I totally agree with you that the data is dated (see what I did there ), but such is the state of EMS with its fractious municipal, state, and federal (non-)coordinated governance. Absent good data, which I have yet to be able to find (other than making inferences around Bureau of Labor Statistics and NREMT data), I can't make an evidence-based conclusion. That said, I would agree that we have likely had some change since then, insofar as that there is a general consensus among state EMS officials that, as stated in the, the 2011 National EMS Assessment, "it appears that purely volunteer EMS services are declining" and being replaced by "mixed, paid volunteer, and/or call pay services" (which I would, collectively, deem a type of career/volunteer mixed staffing).

Also, similarly to earlier studies, the 2011 National EMS Assessment found that:

"Over 50% of the States providing data, indicated that the majority of the First Responder and EMT-Basic level EMS professionals in their State could be considered volunteer. This is consistent with a 2004 LEADS survey completed by the National Registry of Emergency Medical Technicians that identified 49.8% of EMT-Basic level professionals as volunteer. It is noted that as the educational requirements associated with an EMS professional increase (with EMT-Paramedic having the greatest requirements) the percentage that serve in volunteer roles decrease. Over 90% of the States indicated that less than 50% of the EMT-Paramedics in their State could be considered volunteer. The 2004 LEADS survey identified 21.8% of EMT-Paramedic level professionals as volunteer."

If you look at the maps provided by the report, you can sort of infer that it's going to be in places that are more rural where volunteerism is dominant, at least, for now.



I am not sure if this is true - I don't have any evidence available to me. I would agree, but, I would agree with your conclusion mainly based on the fact that *more people* live in urban/suburban areas than anywhere else, thus we should focus on them.

I love the idea of first response volunteer EMS - it works in Israel (and very nicely in some U.S. areas where it is being tried or has been tried...think Hatzolah!). However, while I think EMR is probably fine, I'd like to see the levels restructured like so:
New EMR = Old EMT
New EMT = Old AEMT
Paramedic = Stays the same, add a mandatory associates degree (phase in over 10 years, say)

From what I've seen, they could definitely expand the EMT-B program a couple months to include many interventions that would decrease the need for calling ALS assistance such as starting IVs, Cardiac Monitoring, etc.

Put those that are getting the EMR in the driver seat of the ambulance and use the resources one has better.

In our area, ALS is called out for many things a BLS crew can handle.

 

[VentMonkey]

From what I've seen, they could definitely expand the EMT-B program a couple months to include many interventions that would decrease the need for calling ALS assistance such as starting IVs, Cardiac Monitoring, etc.

What good do you do anyone having a monitor with a "couple of months" training and nothing to treat the patient with after your primary dx?Even a lot paramedic programs are lacking on how in depth cardiology modules should be.

I have no qualms with an EMT starting IV's, but again what good are you doing gam-gam with a lock in place and a hip fx? To me you need more rhyme and reason (and experience).

All of these ideas may sound well and good, but the goal for all of us (including experienced providers) is increasing educational standards. This often dictates an increase in critical thinking abilities, which in turn may decrease (the need for) multiple providers with similar skillsets, rightfully so.

In our area, ALS is called out for many things a BLS crew can handle.

This is hardly endemical. I do agree major tweaks need to be made, as well as a nationally recognized standardized approach.

I could care less who the sanctioning body is---if there is one at all---over it so long as from one coast to the other we're all held to the same uniform standards and policies.

 

[EpiEMS]

From what I've seen, they could definitely expand the EMT-B program a couple months to include many interventions that would decrease the need for calling ALS assistance such as starting IVs, Cardiac Monitoring, etc.

Put those that are getting the EMR in the driver seat of the ambulance and use the resources one has better.

In our area, ALS is called out for many things a BLS crew can handle.

So what you've suggested is basically AEMT (less the cardiac monitoring). This level exists, but it is not the base level for (911) EMS responses in most of the country (excluding Georgia, I believe?). Many of us on these forums would agree with increasing baseline educational standards (i.e. make a new EMT standard that is equivalent to AEMT, or perhaps make AEMT the base level for 911 response). That said, to add too many skills to the undereducated provider (I include myself in this) is liability ridden and worse - possibly harmful to patients (or just more costly without any benefits). Many of us have discussed problems with the EMT-I '99 or the EMT-CC that NYS had to make this point.

 

[NomadicMedic]

From what I've seen, they could definitely expand the EMT-B program a couple months to include many interventions that would decrease the need for calling ALS assistance such as starting IVs, Cardiac Monitoring, etc.

Put those that are getting the EMR in the driver seat of the ambulance and use the resources one has better.

In our area, ALS is called out for many things a BLS crew can handle.

The problem is, by expanding the EMT program a few months, you'd only teach the skills and wouldn't provide enough education to actually do anything with them. (This is my biggest problem with AEMT.)

For example, starting an IV by itself is usually pointless, unless you're working as an assistant to a paramedic. Obtaining a cardiac rhythm is pointless unless you have the education to actually interpret a rhythm and have drugs (or other modalities) to treat what you see.

In my dream world, the entry point for staffing a 911 truck would be a crew of 2 AEMTs with an expanded education model, equiped with some standard medications, like Narcan, Benadryl, Zofran, D50/Glucagon and Albuterol and CPAP and SGA and with the caveat that anytime an 'advanced' procedure is initiated, a paramedic in a fly car is dispatched to evaluate and, if needed, assume care.

Also, the EMT basic level should be retooled to focus on inter-facility and non emergency transports, borrowing pieces of the CNA curriculum. To reflect this, the name should be changed to ATT, Ambulance Transport Technician.

 

[EpiEMS]

@NomadicMedic, this is basically what other Anglophone countries have - I think. Their first level of paramedics are our AEMTs (as far as scope, but have much more education) and EMT-equivalents (if they exist at all) focus on IFT, supporting paramedics, or are volunteers.

That said, @NomadicMedic, wouldn't you agree that AEMT as it exists today, would be better for baseline 911 providers than EMT is?