Why are Paramedics paid so little?

[ExpatMedic0]

First and Foremost, we need to be masters of acute emergency situations requiring interventions and recognizing potentially urgent cases that need immediate transport. This concept is the whole reason we were invented and exist; it's our bread and butter. The problem is, this is like 10% of our calls (at least in my experience). The other 90% get responses and/or transports to the ED. If the patient wants to go to the ED, you HAVE to take them. "You call, we haul." This concept is an incredibly outdated and inefficient method. The problem is we need more education and training for things that are not acute emergencies, and the system is set up against us. Additional entry level training to make a proper transport decision and follow-up care plan for the patient is needed. Transporting everyone to the ED is a huge waste of time, money, and resources. Community paramedic training has the right idea in a way, but some of those concepts and ideas need to be passed down for every day paramedics. This knowledge is not something a merit badge NAEMT or AHA course can provide; only higher education can. We also need better phone triage and an entirely re-worked reimbursement and billing plan which is not transport based. We are still being treated like a transport service along the lines of Uber or Dominos delivery. Stakeholders care about response times and billing/reimbursement based on transport, not patient attention and the grand scheme of what's best for the patient's health and the system's sustainability. The whole system needs to move away from looking at this as a transport service or public safety and start looking at it as part of the regular health care system. There is potential even to make EMS the gatekeeper of the entire healthcare system if changes were implemented.

 

[VentMonkey]

I vote changing the name from Emergency Medical Services to something along the lines of Prehospital Medical Services.

It's all encompassing and sounds so much less appealing to those duped so easily by buzzwords.

 

[NomadicMedic]

@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?

Absolutely, but really the education needs to be ramped up and the protocols across the country need to be standardized. Also, we'd need to totally eliminate the EMT-B position as an option for a "emergency response".

 

[TransportJockey]

I vote changing the name from Emergency Medical Services to something along the lines of Prehospital Emergency Services.

It's all encompassing and sounds so much less appealing to those duped so easily by buzzwords.

Prehospital medical services. Take emergency out of the title altogether. We can still do 911, but it would more wholly encompass future rolls. And get some of the adrenaline junkie tools from even getting a start

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[NomadicMedic]

I vote changing the name from Emergency Medical Services to something along the lines of Prehospital Emergency Services.

It's all encompassing and sounds so much less appealing to those duped so easily by buzzwords.

How about "City Name" Medical Services, or "Prehospital Medical Service"? I think we should take the word emergency out of it. Police and Fire don't use the word "emergency' anywhere in their name.

 

[MikeC]

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.

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.

Very interesting perspective from a cardiologist..

"EMS is on the scene minutes later. Yes, the cavalry has arrived. I tell the EMS personnel that I’m a cardiologist and I think this guy is having a heart attack. “We need a 12 lead ECG now.” The EMS personnel respond: “We can’t do an ECG because we are a basic life support ambulance.” Are you kidding me? I think to myself.

An abnormal ECG is the portal to entry for heart attack care and the key to unleashing the fury of modern day medicine to save this guys life. Once the ECG is abnormal, a cath lab team can be activated.

EMS in my county—an urban area–is great and they do a wonderful job. But it turns out there is up to a 50% chance that when an ambulance pulls up on a scene they can’t provide even an ECG. It’s the same in many areas in my state and throughout the country. If a paramedic is on board then an ECG is done at the scene and it is transmitted to the PCI center. However, for a variety of reasons, in most locales, basic EMTs are not allowed to perform ECGs. This means the diagnosis of heart attack has to wait until arrival in the ER. That’s a significant delay–and it makes no sense.

ECGs are cheap to do, easy to perform and confer no risk to the patient. The accompanying computer software correctly recognizes a heart attack the vast majority of the time. The recently released heart attack guidelines for the US have as the second recommendation “performance of a 12-lead ECG by EMS personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI.” Furthermore, just last month in JACC Intervention a study was published showing a greater than 50% reduction in mortality with pre-hospital activation of the cath lab during STEMI care."

for the whole story.. http://www.kevinmd.com/blog/2013/01/allowing-emts-perform-ecg-controversial.html

I disagree that EMT-B can't learn how to apply and interpret the 12 lead. Technology also allows for faxing the results to medical command. I think it would be wise to add it to the EMT-B curriculum.

As for the A-EMT, they should just move the basic level up to that and eliminate it entirely.

It's a vast waste of resources to reduce a NREMT-B to a ambulance driver IMO. Sadly this is what many people believe the capabilities of an EMT-B are limited to.

 

[VentMonkey]

Prehospital medical services. Take emergency out of the title altogether. We can still do 911, but it would more wholly encompass future rolls. And get some of the adrenaline junkie tools from even getting a start

Thanks, TJ. That's what I had meant, and the rest as you've elaborated. I edited it.

 

[MikeC]

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.

The level exists but is not widely practiced, at least in our area. BLS is BLS. If an ALS call is required, they still have to be dispatch to the scene.

In our area, there really isn't a market for the A-EMT. Many think it will be phased out eventually. People looking to advance from basic are encouraged to pursue the Paramedic.

 

[VentMonkey]

The level exists but is not widely practiced. BLS is BLS. If an ALS call is required, they still have to be dispatch to the scene.

In our area, there really isn't a market for the A-EMT. Many think it will be phased out eventually. People looking to advance from basic are encouraged to pursue the Paramedic.

You really need to quit reiterating what the veterans on here already know too well, and/ or have lived. You don't have a dog in the fight, do us all a favor and eat a little humble pie.

 

[EpiEMS]

@VentMonkey @NomadicMedic Along with changing the nomenclature, may as well change the titles, too:
First Responder - Today's EMT + undergraduate certificate
Paramedic Technician - Today's AEMT + associates degree in EMS (or bachelors in another discipline + certificate)
Paramedic - Today's Paramedic scope + bachelors degree (option for accelerated bachelors like ABSNs for those with a degree in another field)
Critical Care Paramedic/Community Paramedic/Tactical Paramedic/[Insert Specialty] Paramedic - Masters' degree

I wish I could get on the National Scope of Practice dealio.

 

[MikeC]

First and Foremost, we need to be masters of acute emergency situations requiring interventions and recognizing potentially urgent cases that need immediate transport. This concept is the whole reason we were invented and exist; it's our bread and butter. The problem is, this is like 10% of our calls (at least in my experience). The other 90% get responses and/or transports to the ED. If the patient wants to go to the ED, you HAVE to take them. "You call, we haul." This concept is an incredibly outdated and inefficient method. The problem is we need more education and training for things that are not acute emergencies, and the system is set up against us. Additional entry level training to make a proper transport decision and follow-up care plan for the patient is needed. Transporting everyone to the ED is a huge waste of time, money, and resources. Community paramedic training has the right idea in a way, but some of those concepts and ideas need to be passed down for every day paramedics. This knowledge is not something a merit badge NAEMT or AHA course can provide; only higher education can. We also need better phone triage and an entirely re-worked reimbursement and billing plan which is not transport based. We are still being treated like a transport service along the lines of Uber or Dominos delivery. Stakeholders care about response times and billing/reimbursement based on transport, not patient attention and the grand scheme of what's best for the patient's health and the system's sustainability. The whole system needs to move away from looking at this as a transport service or public safety and start looking at it as part of the regular health care system. There is potential even to make EMS the gatekeeper of the entire healthcare system if changes were implemented.

I think it's a great idea. EMS could actually play a HUGE part in preventative services, education, etc. Especially how much they deal with cardiology, diabetes, enter other chronic conditions. Hopefully any new healthcare reform concepts actually take in feeback from healthcare providers and not simply be dictated by special interest groups. Not holding my breath on that one.

 

[MikeC]

You really need to quit reiterating what the veterans on here already know too well, and/ or have lived. You don't have a dog in the fight, do us all a favor and eat a little humble pie.

I'm just discussing. You seem to have a problem with that. The discussion was involving advancing the course training of EMT-B to include that of the A-EMT and do away with it. Others suggest making the EMT-B curriculum is sufficient only for an EMR. I disagree with that. It's a vast waste of resources to make an EMT-B a transport technician capable of driving an ambulance with little to no patient contact. The current curriculum is more advanced than that.

 

[STXmedic]

I disagree that EMT-B can't learn how to apply and interpret the 12 lead. Technology also allows for faxing the results to medical command. I think it would be wise to add it to the EMT-B curriculum.

And then when the monitor is wrong, the MI doesn't get recognized, and the patient dies. Or theres no MI, but another condition that may indicate something serious or life-threatening, but since the monitor does not say "STEMI", the condition doesn't get recognized, and the patient dies (or is much worse off if you're not a fan of hyperbole). 12 leads are for much more than just STEMI's, and many paramedics have difficulty being proficient with 12 lead interpretation.

You need to familiarize yourself with the phrase "You don't know what you don't know." Especially since you seem to constantly fall victim to the phrase.

You also seem like a smart guy (edit, corrected, apparently I can't read). One of the things that took me forever to realize is to not expect others to be at the same level as you from an intelligence perspective. While you may very well be capable of learning 12 lead interpretation without much time or difficulty, most of the people you work with will barely be able to spell PCR. The entry requirements and educational standards basically ensure that this field will be inundated with idiots. Don't expect them to be at the same level as you. That won't change until the system changes its standards.

 

[TransportJockey]

The level exists but is not widely practiced, at least in our area. BLS is BLS. If an ALS call is required, they still have to be dispatch to the scene.

In our area, there really isn't a market for the A-EMT. Many think it will be phased out eventually. People looking to advance from basic are encouraged to pursue the Paramedic.

ILS is widely used in New Mexico and Texas, along with a few other rural States.

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[VentMonkey]

I'm just discussing. You seem to have a problem with that. The discussion was involving advancing the course training of EMT-B to include that of the A-EMT and do away with it. Others suggest making the EMT-B curriculum is sufficient only for an EMR. I disagree with that. It's a vast waste of resources to make an EMT-B a transport technician capable of driving an ambulance with little to no patient contact. The current curriculum is more advanced than that.

Nope, discussions are relevant, it's your arrogantly "know it all" demeanor. Plus the fact you're pointing things out we're all pretty much well aware of. Again, do some digging on this forum some more, and you'll find much of this stuff is hardly new, just because it's new to you.

Perhaps pursue higher education if you don't already possess any. You do articulate yourself well, I'll give you that, but trying and pointing things out in the manner that you do usually doesn't yield results in a way conducive to effect change.

@STXmedic his profile pic says the dude is 35.

 

[NysEms2117]

First Responder - Today's EMT + undergraduate certificate
Paramedic Technician - Today's AEMT + associates degree in EMS (or bachelors in another discipline + certificate)
Paramedic - Today's Paramedic scope + bachelors degree (option for accelerated bachelors like ABSNs for those with a degree in another field)
Critical Care Paramedic/Community Paramedic/Tactical Paramedic/[Insert Specialty] Paramedic - Masters' degree

would there be any spot for folks like me? Bachelors in non EMS, but educated(ish) in EMS, or emergency ops in general? Also would you count relevant nursing topics such as A&P and pharmacology at one of them?

My personal 2 cents would be this. Educate everybody. It's my same motto for LE(day job). If you mandate lets say CPR to be learned and certified for each and every high school senior, In a few years time, i'd venture to say that you would see survival rates for cardiac arrests increase due to CPR being started within the first 5 minutes(obviously good). Now i can agree with EPI and most of you out there EMT-B right now isn't all that useful. I think it needs to be a mix of DE... wait @NomadicMedic and @EpiEMS .I fully agree that AEMT is kind of a "we are throwing you to the sharks" category, you know just enough to do some damage. I think ER docs need to get together and say the top 5 things they need done past a BLS scope and list them. Cater to those needs(yes i know they will vary between city life, and country life), Make an EMT-CC or intermediate or whatever name you want to call them. have the BLS and those 5 skills. Then have the paramedics(raise the bar for a B.S in EMS/Paramedicine) have the all encompassing scope saying you can do whatever to those rare patients. At the same time, i think the minimum requirements need to change, I do not think an EMT-B course should be able to be completed in a month-2 months. I understand why it currently is, but i don't think it is helping anybody. To this day i still don't agree with most of the alphabet soup (TCCC and all that stuff),but thats a story for a different day. If they continue to offer the alphabet soup, there should be incentives for providers to get said certifications. For example you get a geriatric specialty cert(whatever it's called GEMS?) you should get a +.75$/hr pay-raise, or whatever they deem that to be.
I completely agree, Emergency should be removed, i'm pretty sure everybody can see the emergency by the obnoxious red blue and white lights, and sirens blaring(which debatably should also be limited/taken away for certain things).
@VentMonkey @ExpatMedic0 @NomadicMedic @STXmedic (or any paramedic+)- Would you guys consider the idea of changing EMR- to paramedic assistant, and teaching them how to set up the paramedics equipment, while your off getting the patient/prelim asses?

 

[NomadicMedic]

I think we do a fair portion of this now. EMTs that work with a paramedic usually do a really good job of providing support to the medic. But I don't believe they should be left alone to provide patient care. Unless, it's a very benign nonemergency transport.

And I also think if you polled emergency room physicians, they would tell you that the top five things that we need to do pre-hospital would be; transmit 12 leads, provide dextrose to hypoglycemics, beta agonists to reactive airways, Narcan to opiate overdose and Epi to anaphylaxis. Most of the rest of it is nice to have but not necessary. 5 items may not be enough. there are a few others that i can think of that would have immediate benefit.

And as far as education goes, I believe it needs to be specialized. Having a doctorate in medieval literature doesn't equal "medical doctor.". And just because you have a doctorate, that doesn't mean you can challenge the test.

 

[Handsome Robb]

@NysEms2117 you'd fall into the "Paramedic Technician" category. That being BS in something other than EMS plus a certificate.

Or you could follow the fancy route with the accelerated Paramedic degree by using your nursing classes.

To go back to the core question of this thread, while supply and demand play a roll as well as low entry requirements, without a restructuring of reimbursement rates/practices it doesn't matter if we all have Master's degrees.

Someone may have said this already, I just skimmed the thread.


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[Giant81]

I think there is nothing wrong with a Basic applying a 12-lead then transmitting the telemetry to the ED and allow the on call DR to look it over while we're en-route. As a basic rig, we don't need to interpret considering there is little we can do in the field aside from O2, ASA, assist with nitro, rapid transport, making interpretation less important. And, most of our medication interventions require online med control approval.

 

[EpiEMS]

It's a vast waste of resources to make an EMT-B a transport technician capable of driving an ambulance with little to no patient contact. The current curriculum is more advanced than that.

That's what EMTs (more or less) do, we show up, treat immediate life threats (which is a rare thing to have to deal with), and (almost always) transport...sounds more or less like patient transfer/IFT to me.

would there be any spot for folks like me?

In my model, absolutely - I don't see why it couldn't help with the certificate or secondary bachelors (like an ABSN type of thing, where if you have a non-science degree, you would need to take some prerequisites).

In a few years time, i'd venture to say that you would see survival rates for cardiac arrests increase due to CPR being started within the first 5 minutes(obviously good).

Totally - and it's cheap!

Would you guys consider the idea of changing EMR- to paramedic assistant

I mean, in an ALS-heavy system like mine, that's basically what I am - I run the BLS side of things (vitals and set up for medic procedures) while they get venous access or get a more detailed history/exam going, then I drive. No reason to not make EMTs --> "EMR" in name.

To go back to the core question of this thread, while supply and demand play a roll as well as low entry requirements, without a restructuring of reimbursement rates/practices it doesn't matter if we all have Master's degrees.

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Absolutely - from the reimbursement side, if we have more education, we can justify charging like a physician or midlevel. That said, the "fee for service" model is going away in many areas, and being replaced by bundled/capitation payments (which, frankly, is kinda like ambulance transport, but aligned to conditions, sometimes).