Simple dumb question: Why not make everyone a paramedic?

EpiEMS and all, good discussion so far.

What I'm not hearing addressed are intrinsic capabilities in the employment pool (how many potential paramedics are qualified emotionally and cognitively, or would some be better as paid or even volunteer EMT-B's, or even EFR's), and the hero/recruitment aspect (how many people who now would become an EMT-B would go ahead , take out a loan and try to get the paramedic because it is their calling, realistic or not).

Given a potential employment pool of X, a smaller set of potential candidates would be capable balanced by one intrinsically incapable (learning deficits, poor education, physically challenged, criminal background, etc). Another set, overlapping both, would be willing. The set being capable but not willing would be the ones off-put by low earnings or other factors. The set being willing but not capable would include those who might have been good EMT-B's or EFR's, but would get in over their heads either during or after they pass school.

Could they still fill the needed slots in all geographic areas?
 
mycrofft said:
Could they still fill the needed slots in all geographic areas?
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Short answer: Yes.

But it would require a retooling of how the system operates and what the measures of effectiveness are.

If you take response time out of the equation, you could do a lot more with much less.
 
So lower the bar and declare victory? Sort of like my last full-time employer, and the ARC.
 
mycrofft said:
So lower the bar and declare victory? Sort of like my last full-time employer, and the ARC.
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As I recall it is Josef Stalin who is credited with the phrase:

"Quantity is a quality all of its own."

It is diametrically opposed to my philosophy, but many people in the modern world do subscribe to it.
 
mycrofft said:
Again, if EMT-B's are eliminated, the number of paramedics would rise since many current B's would be forced to upgrade to P, and new grads would just DO it and not shilly-shally around. Paramedic costs other than tools and supplies might fall in relation to current costs.

An ambulance operator from 1965 would be saying the same about emergency medical techs of any sort; why hire them when Wilbur and Enis will do it as part of their job as garage mechanics next door to the funeral parlor?
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And the reward for someone that is willing to put in so much time and effort is a job that in most cases pays a wage that has many providers working second and sometimes third jobs to make ends meet especially if they are working on higher education goals.

This seems to come up from time to time and as much as I like the idea of a better educated provider one has to wonder where are the jobs going to come from?

If you took all the paid positions now available both medic and basic and over time phased out basics where do you think the additional revenue is going to come from to make current medic wages available to all?

If you look at what any given agency has in its operating budget for its current mix of medics and basics and average it out which way do you think wages are likely to go?

Maybe your thinking that there are people that are so into providing emergency care that they will take on the education challenge and all the time involved just for the heck of it. There are such people we call them volunteers and most of them have jobs outside EMS,jobs that pay well for a persons education and experience.

The resorce pool for most agencies is only so deep and whats available for operating expenses now is most likely all their is or at least all current revenue will allow. Most private agency budgets dont provide decent wages for the current mix of providers which correct me if Im wrong is more basic than medic.

Employers know there will be a segment of this new all medic group that will accept substandard wages so Im sure they will continue to operate just like they do now. The combination of those willing to accept the poor wages and those that have no choice because of the lack of jobs will make for such a wonderful work environment,much like now.

Higher levels of education and an increase in the certification level for entry into the field is a great idea but as usual its really only applicable in theory at this point in time. We will revisit the idea again down the line but unless there are big changes in the economy I think we will continue to hold our present course.
 
I think a lot of people envision the future of EMS to be something a long the lines of mobile urgent care clinics. I don't think that that's a reasonable expectation for the future. The only capacity I see mid-level providers serving is in medical clearance and possibly a treat and release with a follow up order written for a PCP followup. The issue for me is you're not able to not transport a patient based on your clinical judgment legally. This causes problems especially for hospital based EMS services with regards to EMTALA automatically triggering a required medical screening once pt contact is made unless the pt refuses. The only exception to this would be if the EMS service was operating under a regional protocol that selected destination based on acuity or condition. In those instances a medical screening exam must take place a paramedic can absolutely not clear a patient with a referral. The patient must be evaluated by a mid-level provider or physician. How would you solve that problem?

I'm all for increasing education and having a 4th B.S./M.S. degreed pre-hospital provider. Many countries do it. They would be limited to areas that could afford them though and depending on the level of care they were providing it would be difficult to find a way to properly utilize their skills in out current system.
 
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Frozennoodle said:
I think a lot of people envision the future of EMS to be something a long the lines of mobile urgent care clinics. I don't think that that's a reasonable expectation for the future. The only capacity I see mid-level providers serving is in medical clearance and possibly a treat and release with a follow up order written for a PCP followup. The issue for me is you're not able to not transport a patient based on your clinical judgment legally. This causes problems especially for hospital based EMS services with regards to EMTALA automatically triggering a required medical screening once pt contact is made unless the pt refuses. The only exception to this would be if the EMS service was operating under a regional protocol that selected destination based on acuity or condition. In those instances a medical screening exam must take place a paramedic can absolutely not clear a patient with a referral. The patient must be evaluated by a mid-level provider or physician. How would you solve that problem?

I'm all for increasing education and having a 4th B.S./M.S. degreed pre-hospital provider. Many countries do it. They would be limited to areas that could afford them though and depending on the level of care they were providing it would be difficult to find a way to properly utilize their skills in out current system.
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I think this question is really putting the cart before the horse.

All other healthcare providers, including surgeons at one time, had to increase their minimum education level prior to demanding changes in legislation or renumeration.

medical screenings and what constitutes one, alternate transport decisions, etc. all come after demonstrating knowledge and competence. Not before.
 
I dont buy the argument that making everyone medics would reduce the pay of medics. While i love EMS and emergency medicine is truly a passion, even as a Paramedic i know that i would not be able to afford living in NJ, unless i do what most others do and work for multiple agencies. So i became a police officer, where the money is good and i still get to work out in the field

In NJ we have three levels of law enforcement officer, each having their own pay rate and abilities which increase based on education time.
Class I officers do not carry and can not make arrests, they primarily do traffic enforcement and work on beach and boardwalks issuing ordinance violations, 2 weeks of academy

Class II officers carry on duty and have full police powers when working, but have no powers off duty and can not take their sidearm home, about 400 hours of education

Class A officers are regular patrolmen who have full enforcement powers at all times, 800 hours of education, full pension and benefits

So if i am going to go to 2 years of education to become a Paramedic, get an AS or BS, i expect to be paid like a cop, who may not even have a AS. and start at 40k a year and retire in 25 years at 120k
 
Bullets said:
I dont buy the argument that making everyone medics would reduce the pay of medics. While i love EMS and emergency medicine is truly a passion, even as a Paramedic i know that i would not be able to afford living in NJ, unless i do what most others do and work for multiple agencies. So i became a police officer, where the money is good and i still get to work out in the field

In NJ we have three levels of law enforcement officer, each having their own pay rate and abilities which increase based on education time.
Class I officers do not carry and can not make arrests, they primarily do traffic enforcement and work on beach and boardwalks issuing ordinance violations, 2 weeks of academy

Class II officers carry on duty and have full police powers when working, but have no powers off duty and can not take their sidearm home, about 400 hours of education

Class A officers are regular patrolmen who have full enforcement powers at all times, 800 hours of education, full pension and benefits

So if i am going to go to 2 years of education to become a Paramedic, get an AS or BS, i expect to be paid like a cop, who may not even have a AS. and start at 40k a year and retire in 25 years at 120k
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Im in it to be a firefighter.

My pay is $44,000 base at the moment and the only potential i have is $60,000 after 5 years.

For 5 years of work I gain a whopping $16,000. No thank you. And, I am in NY. You wanna complain about NJ, gas alone is $0.20 more when you cross the state line to NY.
 
Then who would drive the truck!??

Seriously though, from a purely selfish standpoint... It's hard enough to get a job, I wouldn't want to compete with even more medics for a position.
 
Veneficus said:
I think this question is really putting the cart before the horse.

All other healthcare providers, including surgeons at one time, had to increase their minimum education level prior to demanding changes in legislation or renumeration.

medical screenings and what constitutes one, alternate transport decisions, etc. all come after demonstrating knowledge and competence. Not before.
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This is very true. We can't rely on NREMT or the NHTSA to create our profession for us. We need to educate ourselves, start performing our own studies and research, and prove that we're providing a valuable service. Research would also help to prove that EMS can be used in new and unique ways to help prop up under served and urban communities by reducing strain on hospitals and cutting patients lose after a field MSE with a referral to an urgent care clinic.

If we get enough of us with advanced degrees we can create and expand our own degree programs in the future. EMS is a recognized sub-specialty of medicine. We need to utilize that to forward the profession.
 
EpiEMS said:
It would certainly help – having an advanced practice paramedic, with a master's level education (preferably – so they'd be equivalent to NPs and PAs) able to refill rx as needed, provide rx for minor things, do some suturing even, among other things, would be quite useful. It'd be like a "visiting doctor" service minus the cost of a doctor.

Billing should change, though, too, preferably to fee-for-service plus mileage.
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Absolutely pointless. You don't need another provider "equivalent" to a PA or NP. Visiting doctor? Seriously? Suturing? Writing scripts? This is not what paramedics do. Be proud of what you already do, because there is a huge need for it. You can't be all things to all people. The concept you describe essentially already exists with PA's and NP's, but the cost of using them in that environment is prohibitive.

Clearly you have no concept of the costs of what you propose. A master's level education (soon to be a doctorate for NP's, a truly stupid idea, but that's for another forum) is megabucks. Graduate level degrees from universities, even state schools, cost 10's of thousands of dollars, and that's on top of the undergraduate education that has to come first. Compare that to a paramedic with an AS degree that can easily be had for well under $10k. It makes zero economic sense. Maybe you're oblivious to the cost of the care you provide, but reimbursement/payment for any and all medical care is going down, not up.
 
jwk said:
A master's level education (soon to be a doctorate for NP's, a truly stupid idea, but that's for another forum) is megabucks.
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So make the EMT-P an associate's degree (mandatory), and make Advanced Practice Paramedics do a bachelors. Same sort of thing as the RNs have been doing.


mycrofft said:
What I'm not hearing addressed are intrinsic capabilities in the employment pool (how many potential paramedics are qualified emotionally and cognitively, or would some be better as paid or even volunteer EMT-B's, or even EFR's), and the hero/recruitment aspect (how many people who now would become an EMT-B would go ahead , take out a loan and try to get the paramedic because it is their calling, realistic or not).
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You've got plenty of people who are competent and would love to do EMS as a career, but the low levels of pay make it undesirable. Add more requirements (barriers to entry), so supply drops and wages must rise. If you were to, say, make EMT-Ps have a mandatory associates degree in EMS or have medic school plus a Bachelor's degree in any subject, you'd get better medics - and more career medics at that (assuming that wages rise due to an endogenous change in supply, ceteris paribus). Myself, I'd consider getting my medic cert if I could pull down, say, $25 an hour and work some per diems.

I'd wager that most EMTs and AEMTs who have a college degree in a science or quantitative discipline (think biology, physics, chemistry, economics) could manage medic school. Then again, they may not want to, due to the relatively low wages for paramedics in many areas.

mycrofft said:
Could they still fill the needed slots in all geographic areas?
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Probably not. Certainly not in rural areas or low income regions.
 
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With a four year degree I started my last full time nurse job at $20/hr...in 1987 dollars.
 
ummmm, why????

haven't their been studies that ACLS doesn't save any lives? so why are we still pushing it?

it's like the whole ETT idea of airway maintenance, if the king is just as good, but requires less education, why are we insisting on using the ETT?

There is also the whole funding issue. the majority of EMS agencies in the US are either private, 3rd party non-profit, or volunteer, and as such, not tax funded. where are you going to get the funding for it? it's not like you can get more tax money to make up the balance.

and that's not even counting the fact that only 5% of EMS calls need ALS (using Bullet's numbers). Lets say it's closer to 25%. That means 75% of the time the patient doesn't need ALS care. So you have a highly skilled and highly educated provider whose skills end up degrading because he (or she) spends most of his time dealing with BS, and never using his high skills.

It's a great concept, in theory, having more highly educated and skilled providers handling all the emergencies. but their several more problems that come along with it, and I don't know what scientific evidence backs up how it benefits the patients.
 
DrParasite said:
Not specifically aimed at you parasite, butive seen = these arguments in your post, and i have read them dozens of times by different people in different forums, and they still get up my nose.

ummmm, why????

haven't their been studies that ACLS doesn't save any lives? so why are we still pushing it?

Perhaps in your country where :censored::censored::censored::censored:ty systems and :censored::censored::censored::censored:ty education and :censored::censored::censored::censored:ty requirements produce :censored::censored::censored::censored:ty results. Its not even about "saving lives" An allALS system outstrips any BLS system every day of the week because they are able t provide the basic humane intervention of pain relief. This job isn't about saving lives, its about relieving suffering, improving outcomes and occasionally saving a few along the way. The myopic idea that this is entirely about saving lives is short sighted at best. IF oyur system is not also focused on reducing morbidity and mortality then it sucks.

But if you want to compare saving lives, ACLS, RSI, therapeutic hypothermia has our survival to discharge rates of 30%, not survival to hospital. We get ROSC over 55% of the time at the moment - ACLS brought us that, will you find that in any BLS only system? I doubt it, its worlds best practice, and it includes VF/VT arrests rural areas.

Significant inroads are being mad einto reducing mortality and improving functional neurologic outcomes of which RSI is a part of

it's like the whole ETT idea of airway maintenance, if the king is just as good, but requires less education, why are we insisting on using the ETT?

Thats because you have an education problem...... when the RSI package was being introduced here it was preceeded by an extensive education and assessment package, then the randomised trial and then introduced state wide. The short answer reason for the massive levels of governance is that any RSI / intubation study,trial whatever form the states was deemed to be non reliable in terms of data. To put it simply, we thought we do it better than the states and data says that we do

undetected oesephegeal is unheard of
tracheal intubation is achieved 96% of the time
the other 4% are then managed through the failed intubation drill

The studies (especially that horrible one out of southern california) that say Paramedics cant pot a tube putting a big black X on the profession



There is also the whole funding issue. the majority of EMS agencies in the US are either private, 3rd party non-profit, or volunteer, and as such, not tax funded. where are you going to get the funding for it? it's not like you can get more tax money to make up the balance.

short answer, your system sucks and your public is ill informed, scared of change and would rather stick with the status quo. Has US -EMS ever looked at the rest of the world and figured out that you actually are not the norm??

and that's not even counting the fact that only 5% of EMS calls need ALS (using Bullet's numbers). Lets say it's closer to 25%. That means 75% of the time the patient doesn't need ALS care. So you have a highly skilled and highly educated provider whose skills end up degrading because he (or she) spends most of his time dealing with BS, and never using his high skills.

And yet your patients still suffer from lack of humane management. Every patient i have recieves an ALS level of assessment. Assessment and gathering information is the single most important function we have. We assess, gather information, decide how crook they are and then transport to an appropriate facility. I dont need to put in IV, push drugs etc to do the most important part of my job as a paramedic

It's a great concept, in theory, having more highly educated and skilled providers handling all the emergencies. but their several more problems that come along with it, and I don't know what scientific evidence backs up how it benefits the patients.

Reams of information, youve just got to sart looking outside of your own borders.
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Point in case, the US is lagging behind the rest of the world. your basic level of care is substandard in most other third world country, it doesn;t even cover the basic needs of your patients, and the systm still rages against the need for change

How can the country who invented modern EMS (go freedom house and that eugene guy) get it so wrong?
 
OzAmbo said:
Point in case, the US is lagging behind the rest of the world. your basic level of care is substandard in most other third world country, it doesn;t even cover the basic needs of your patients, and the systm still rages against the need for change

How can the country who invented modern EMS (go freedom house and that eugene guy) get it so wrong?
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Well said. Perhaps never better.

The issues though are not medical, they are social and economic.

There are a lot of people making a lot of money keeping the status quo. The people making that money, from the medic mills/educational institutions, to the NR testing service, to hospitals who recieve transports, doctors who evaluate them, medical/pharm companies, and every other needless hand in the till fights tooth and nail to make sure things stay the same.

Many leaders of US EMS are such not because of ability, but seniority. They not only want to relive the glory days, but their very self value is based not around good patient care, but mastery of the system they "grew up in"

US EMS has nothing to do with doing what is needed or right, it has to do with perfecting the system that is. The whole industry revolves around it.

There would be no need of all the different supraglottic airways if US EMS providers as a whole didn't suck at ETI.

Hang around this forum, you see the "bury my head in the sand" mentality rampant in US EMS providers. They think EMS is for "emergencies" and refuse to see the elephant oin the room.

Most are spineless cowards who cannot or will not accept responsibility for their actions. That is why protocols and medical direction still exist...

So somebody else is always responsible.

ACLS, it is a fancy name, sounds impressive. But it is not for resuscitation experts, it is for people who rarely resuscitate. Nobody I know in any discipline who has any decision making capacity follows it. Not because they don't know it, because it is too elementary, doesn't reflect the realities of their environment, and for all intents and purposes is obsolete.

But from instructors, to training centers, to the AHA itself, it generates money. Lots and lots of money. Infact I make more than double my best street salary as a TCF.

I even preface my classes with: "This is probably what you will do, but certainly not what I will."

The USA is ethnocentric, not only do they believe as a society they do everything better than everyone else without equal, they vilianize what others do.

Sometimes doing the opposite of what is right or even logical not to copy somebody else.

The US is a declining society. In my lifetime it will likely look like the Russian republic after the fall of communism. It is well on the way in all respects. The oligarchs are just stripping away every last bit of wealth they can before it collapes while the common people demand they be permitted without interference.

Fools and their money are soon parted.

Look at the issue of EMS education, but it permiates society. What society in the world other than the US, actually sees education as derogatory or invaluable?

Your points here and wisdom while accurate and great are simply as valuable as pearls to swine.

My attempts at change are as useful as bailing water on the titanic.

I just hope I can get one or two more off the ship before it goes down or at the very least, get them to realize they are sinking and may need to change what they are doing.
 
OzAmbo said:
Point in case, the US is lagging behind the rest of the world. your basic level of care is substandard in most other third world country, it doesn;t even cover the basic needs of your patients, and the systm still rages against the need for change

How can the country who invented modern EMS (go freedom house and that eugene guy) get it so wrong?
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Amen. The big difference is we focus on skills rather than education. If we front-ended the process with education and let the skills fall out later, we'd see a much better level of care.

Make a 40-60 hour BLS/CPR class, expanding to include splinting and more first aid. Use this first responder class to focus on a good initial assessment for an effective hand-off. Teach 12-Lead application, and hopefully by then Physio or Zoll or Philips will have an AED/12-Lead all in one that's in the same form factor as an AED. Yep, that's right, I'm bringing back Ambulance Attendants (really though this is geared towards FD's. Most don't need EMT-B). ~20% of EMS providers would be at this level, however, mostly in the patient transport arena.

Then you'd use the current US Paramedic level of education, either 1000 hour cert or 2yr AA, with a slightly expanded EMT-B scope. I think this would be perfect for most of the US. 3-lead/12-lead interpretation, IV's, maybe narcs and benzos. Ultimately something between EMT-I and EMT-P. These would be your mainstay of transport units. I envision this level being ~40% of providers across the US (1 per 5k capita). Median salary 35-45k.

Get rid of EMT-I, expand EMT-P's education and clinical requirements, perhaps another 2 years or 1000 hours. These guys would mostly ride trucks, some would ride fly-cars/QRV's. I envision this level being ~30% of providers (1 per 10k capita). Median salary 45-55k.

Make Advanced Practice Paramedics a MS or BSc with RSI, suturing, etc. Likely these folks would be fly-car only, or perhaps on transports in busier ALS areas. I envision this level being ~10% of providers (1 per 50-75k capita?). Median salary 65k+.

Who knows, pipe dreams are nice.
 
EMS is the least of our worries here in the US.

At the rate we are sinking I'd bet the farm on a full scale economic collapse within my lifetime. (most likely sooner than later)

All of these self proclaimed expert financial and economic advisors wanna tell us "it can't happen" but the reality is, it has happened in the past and will happen again. Those who don't learn from their history are destined to repeat it.

Granted, healthcare as a whole is broken beyond repair at this point and costs more than anything else currently present in the economy.

At this point it's not about finding means to repair a broken machine it's about building a whole new machine altogether.


I am all for having a sense of patriotism but honestly, America sucks. As already stated we think we are so awesome at everything and even when we are wrong we find a way to belittle the other guy and make ourselves the dominant party.
 
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