how to fix EMS

[firetender]

EMS is a System Complex

Eliminating Medical Control is bad medicine; it's tackling a symptom and saying the patient is healed.

The system needs to be re-structured from the ground up to reflect the services that are REALLY provided and designed with enough safety-nets so that its practitioners have what they need to actually make it a career..

 

[Anjel]

As for the first bolded area, how did I imply that an Bachelor's was to be the minimum? I just said that we need to get more education. The government has already attempted to solve problems elsewhere by chunking money at them, hoping they'll go away, but it does not seem to be working. And continuing along that line, how does it create/worsen problems? Having more education only benefits, and never hurts.....

That was me that implied that. And that was me just dreaming of a perfect world. If you have a higher education, you get paid more money. That really isn't an option at the moment when they are shutting down police and fire departments (here at least).

Or maybe the education that we do get needs to be a little more than memorization and follow the leader and a little more the patient is this this and this. Treat your PATIENT.

Is that something that was voted on, but can be repealed if they want? ALS is only 40 years old or so; I'm sure your county has existed for longer than that. Someone had to propose that mandate, and get it voted on. I'm sure they would reconsider the measure if $$$ were at stake.

Alternatively, are you referring to a contract that a private 911 EMS provider has with the county, or is your county 100% municipal EMS?

I am not sure about the voting part. And we have 2 contract 911 private companies I believe. Maybe 3. And some cities handle their own 911. Or the city responds and uses a private to transport. Or where I live. Auburn Hills contracts with a private company to use 2 of their rigss, and 1 medic.

But in here it has to be 2 medics on a rig. A medic-basic rigg doesn't run. 15miles down the expressway in the other county Medic-basic is fine.

I think EMS needs to be more uniformed in the way things work. County to County to state to state.

I think Australia, UK etc have a pretty good system going on.

 

[HotelCo]

No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.

Detroit.

Not due to progressive protocols, but mismanagement of money.

 

[Sasha]

Duct tape.

 

[46Young]

Although i'm just regurgitating what Brown has been saying- Aus, NZ England etc are all examples of this. We have no medical control and generally an education level of diploma or degree.

I guess the problem is that the US EMS is largely privatised with different companies having different drugs, guidelines, skills etc. Here as with the UK and NZ, Ambulance services are state or region run and funded.

This means that the services can afford to educate, train and employ people.

I am doing the Diploma method, where I work full-time for 2.5 years, complete papers and study in my own time, have assessments (CME's + exams) and skill training every 6 months and receive mentoring.

The other method is attend university, obtain a bachelors degree (3-4 years) and apply for employment.

Both the degree and diploma method both allow practice as paramedic witht he same skills.

What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.

 

[46Young]

There's an area that covers a couple hundred square miles not too far from here that has no fire or EMS coverage because they don't want to pay for it (via taxes, etc...). There's about 15 homes in that area so there are some out there.

I'm not sure if an ambulance would respond if they were called to a home in that area (same for fire).

I figured that some unincorporated areas would be w/o guaranteed coverage.

 

[46Young]

Detroit.

Not due to progressive protocols, but mismanagement of money.

And then they try to throw the empoyees under the bus for having 20 min+ response times.

 

[MrBrown]

What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.

Not true, in Australia and NZ we get paid a student allowance to study in order to cover living costs. Its not a great amount but its enough for a bunch of guys sharing an apartment or living at home with mum and dad to get by on especially considering programs like HECS HELP and Studylink pay the total amount of our books and tuition for us while we are studying and we do not pay it back until we earn enough to afford the repayments.

There is a program of significant cross-crediting for qualified Paramedics to enable them to earn the Bachelors Degree.

Remember our Bachelors Degrees are only three years long and we do not have "general education" or "liberal arts" and that tertiary education is significantly cheaper than in the US, we pay about half of what you do for a University degree.

The simple thing is that the Bachelors Degree is mandatory for employment in all but a few States in Australia and is almost mandatory in NZ.

Brown has said that replicating the requirement in the US is not the answer because the system is so radically different; however a massive increase in education is required and having Paramedic (ALS) as the entry to practice standard is also not the answer.

 

[the_negro_puppy]

What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.

The difference is that there are only limited intakes of the Diploma program, perhaps 100 positions a year for the whole state. Diploma students tend to be older, ex military/police/nurses and may already have uni degrees.

Once you complete the diploma you can convert it to a degree with 3 years part time study. As Brown said, most states here now require a degree- If i wanted to work in another state I would need a degree. Also in a few years it will be degree only, much like RN's here went from on the job training to degree.

 

[rescue99]

Except no one has even attempted to "sort out the details" in the 10 years I've been around. National Scope of Practice came out with the thought of establishing uniform levels, and it was derided because (gasp!) we might have to go back to school. It was watered down to the point of being basically the same thing we have now. We've had enough time. It's time to stop making excuses and DO SOMETHING.

The excuses are pushing me closer and closer to leaving the field entirely.

The education standards are slowly increasing however, there is so much influence by states to remain in control of their own EMS systems. Only D.C. can change it. Fact is, under a federal program, with regulations and various other details to work out (and fund), it's easier (and cheaper) to avoid change than to actually enact anything new. The DOT sets the minimum and each state either stays at that minimum or, they can add to the initial and recertification objectives. Unless all 50 states and D.C. agree to work cooperatively, EMS education will continue down the same slow path. States do not put EMS legislation very high on their list of priorities.

 

[Melclin]

No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.

We have a system called 'refcom' that tries to organise more appropriate care pathways for people identified over the phone as not needing an ambulance. It seems to have been very successful, however, its not a large enough operation to cover all the jobs its should. There is often a disappointed tone to a paramedic's response when they see on their pager that the job was marked as 'refcom' but 'timed out' because refcom was busy with other stuff. It generally means you're going to a pretty ridiculous job.

What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.

Firstly, I some cases you don't get a choice. The vocational method has been phased out in some states and as far as I know, most states a moving towards university only.

Secondly, as Brown mentioned, university doesn't work the same way here. You don't really add credits until you've got a degree. Its more like that with the arts and science degrees, but with the professional degrees, it tends to just be all at once or nothing. The paramedic degree especially is all or nothing. They did at one stage have an upskilling program just after they created the bachelors so that people with diplomas could upgrade easily, but it was just a bridging program and no-longer exists. So a vocational diploma is worth almost nothing if you move to another industry, a bachelors degree, however, is still a bachelors degree. If I want to go do medicine, I can. If I want a masters in nursing, an MPH or I want change focus entirely and do an MBA, I can. If I want to apply for a job that simply requires a bachelors degree, I can. Healthcare administration? Research? Yep.

Thirdly, the older vocational method has both ups and downs. Certainly, one learns to tick the basic boxes of how to be a paramedic far more quickly than a university student. You won't find to many vocational students fumbling with the O2 or dropping patients after 3 years, as uni students will. Uni students often struggle with many of the more practical aspects of being a paramedic; things that you can't learn from a book. However, you don't seem to have the same depth of education from a theoretical point of view, and the nature of your education can be very dependent on the group of clinical instructors you have been allotted over your time. Also, from what I've seen, the vocational stuff is very 'cook-book'. It doesn't seem to encourage quite the same deeper understanding of whats going on. So you get the problems that kind of thinking entails. Just a personal observation though.

 

[HappyParamedicRN]

That only makes you ahead of the game if your standing orders are good.

Oh they are! We are allowed to do more medication wise than most EMS systems in surrounding states. We even have IV Nitro! Heparin as already stated for STEMI.

If your curious check out the NH bureau of EMS website...


Happy

 

[MrBrown]

Thirdly, the older vocational method has both ups and downs. Certainly, one learns to tick the basic boxes of how to be a paramedic far more quickly than a university student. You won't find to many vocational students fumbling with the O2 or dropping patients after 3 years, as uni students will. Uni students often struggle with many of the more practical aspects of being a paramedic; things that you can't learn from a book. However, you don't seem to have the same depth of education from a theoretical point of view, and the nature of your education can be very dependent on the group of clinical instructors you have been allotted over your time. Also, from what I've seen, the vocational stuff is very 'cook-book'. It doesn't seem to encourage quite the same deeper understanding of whats going on. So you get the problems that kind of thinking entails. Just a personal observation though.

Brown went through the old vocational method of training but should declare that Brown also has a Bachelors Degree, although not in EMS so is reasonably familiar enough with both methods of instruction and you are correct in your observation.

While Brown would not call those vocationally trained more "cook book" than Uni ambos the Uni ambos have a much deeper appreciation for the larger context of ambulance practice and theoretical knowledge than their vocational counterparts.

 

[JJR512]

As for the first bolded area, how did I imply that an Bachelor's was to be the minimum? I just said that we need to get more education. The government has already attempted to solve problems elsewhere by chunking money at them, hoping they'll go away, but it does not seem to be working. And continuing along that line, how does it create/worsen problems? Having more education only benefits, and never hurts.....

There have been a lot of replies in this thread prior to my first. I didn't even reply directly after you. Why are you assuming that anything I said was in direct response to anything that you said? The bit about the bachelor's degree came from another reply, not by you:

I think a Bachelors degree should be the absolute minimum.

As for how does it create or worsen problems...If people who desire to be EMS providers are required to get degrees, even if only at the Associate's level, and they are required to pay for it themselves, there will be fewer providers in the industry because not everyone can afford to pay for higher education, and not everyone will want to go through it even if they can afford it. So that's a problem. If they are required to get a higher degree but the cost of this is going to be paid for either directly by the employer or the community, or reimbursed later, then that's money the employer or community is going to have to get from somewhere, which will probably be the people who are treated. So that's the start of billing patients, or billing at higher rates if billing already happens.

Basically, any time you talk about changing something, you're talking about creating new and/or worsening existing problems, at least on a temporary basis if not longer. That's not to say that nothing is not also getting improved, though.

 

[JJR512]

Actually, it seemed a rather inexpensive idea when I thought of it.

I didn't even suggest mandating education.

I did suggest that if they were held personally accountable for thier decisions, individuals might seek out further education on their own.

The rest of it is basically cutting costs.

Sure, eliminating medical control, in and of itself, is not only an inexpensive idea, it's probably a money-saving idea.

But nobody who is on duty provides EMS on their own. They do it while working for another entity, whether a private EMS company or a municipal fire department, whether being paid or volunteering. When the system changes to "when in doubt, contact medical control" to "when in doubt, use your best judgement", any smart employer is going to make sure their providers have the intelligence and education to actually have and use their own judgement. I would imagine that most, if not all, employers will mandate the "further education" you mention.

So whether the prospective provider decides on his own to seek out further or higher education, or if he or she is mandated to by local law or policy, one way or another further or higher education is going to be practically required, which means all the cost issues I mentioned come back into play. Are the cost issues prohibitive? I don't know. It may not be as bad as I'm imagining. It could be a lot worse.

 

[ffemt8978]

When the system changes to "when in doubt, contact medical control" to "when in doubt, use your best judgement", any smart employer is going to make sure their providers have the intelligence and education to actually have and use their own judgement. I would imagine that most, if not all, employers will mandate the "further education" you mention.

Malpractice attorneys would probably love this type of scenario. Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense. The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.

 

[46Young]

Malpractice attorneys would probably love this type of scenario. Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense. The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.

Annnnnnnnnd that's likely the end of this thread.

 

[Anjel]

Malpractice attorneys would probably love this type of scenario. Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense. The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgment" caused harm to a patient.

Wow... ^^ THIS TIMES A MILLION.

I really didn't think about that. But that is the most valid point in this entire thread. EMS workers would be the first to be sued and the first to loose if we didn't have something to protect us.

 

[JJR512]

For an EMS provider to be found guilty of negligence, the EMS provider must have had a duty to provide care, must not have performed the duty to the standard of care, and damages must have occurred. It is the second part that is most especially relevant here. The standard of care is that which would have been done by a reasonably prudent person in the same line of work. Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?

 

[ffemt8978]

For an EMS provider to be found guilty of negligence, the EMS provider must have had a duty to provide care, must not have performed the duty to the standard of care, and damages must have occurred. It is the second part that is most especially relevant here. The standard of care is that which would have been done by a reasonably prudent person in the same line of work. Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?

That covers negligence, but what about malpractice? As to the second part of your question about doctors commenting on out of hospital treatment, they do it now. An expert witness is somebody with education and credentials after their name, not a random lay person picked off the street (that's reserved for juries).

My personal feeling is that we need tort reform before we can really reform EMS in any meaningful manner.