Simple dumb question: Why not make everyone a paramedic?

[mycrofft]

Earlier I suggested we do way with paramedics, force them to all upgrade to PA or higher.
Now I'm proposing the idea that, since ACLS can treat BLS AND ACLS, we do away with EMT-B entirely and require all PEMS workers to be at least paramedics.
What do you think of that? What would the impacts be?

 

[Christopher]

Earlier I suggested we do way with paramedics, force them to all upgrade to PA or higher.
Now I'm proposing the idea that, since ACLS can treat BLS AND ACLS, we do away with EMT-B entirely and require all PEMS workers to be at least paramedics.
What do you think of that? What would the impacts be?

I think we're on the same page, just with a slightly different end result. We should all be Paramedics!

My druthers would be the Paramedic level of education is the minimum, with an expanded scope EMT-B level of skills (3-lead/12-lead interpretation, etc). This would be 1000 hours of classroom/clinical time.

You'd add a 2 year or 4 year degree to be a Paramedic with IV starts and a generous list of meds. Another 1000 hours of classroom/clinical.

The last bunch would be an APP medic with a masters level of education, intubation, Rx med refills, suturing, etc. Another 500-1000 hours of classroom/clinical time.

The impacts would be the silly notion that ALS saves lives or that every first responder needs to be an EMT would be thrown right out. CPR/First Aid would be the focus for all non-clinical EMS types. Skill dilution would be less of a problem as the recognition that ALS skills don't save lives would be baked right into the first two levels of providers. The focus on solid clinical understand with solid BLS providers would allow a cost effective means of providing EMS.

 

[Veneficus]

Earlier I suggested we do way with paramedics, force them to all upgrade to PA or higher.
Now I'm proposing the idea that, since ACLS can treat BLS AND ACLS, we do away with EMT-B entirely and require all PEMS workers to be at least paramedics.
What do you think of that? What would the impacts be?

That is a giant can of worms my friend.

While on the surface it sounds like a great idea, there are several issues that would have to be worked out.

Cost. Who is going to pay for this upgrade? How?

One of the reasons FDs want paramedics prior to application is because of the cost of sending somebody to school. You have to pay them their wage while in class, on clinical, cover their shifts with OT for another, plus the cost of their instruction, testing, and materials.

That is a fine chunk of change. 10's of thousands in costs per person. (Last I heard from my former FD many years ago, nearly $60K a person.)

Once you have people with a higher cert, they are rightfully going to demand more money. This will exponentiate human resource costs. A basic might accept $8.00/hour, but the day I graduated medic school, I wouldn't day a penny under $16/hour. After a couple years of experience, with benefits and wages, I was quite expensive compared to a basic.

You are talking about replacing every basic/basic or basic/medic truck with somebody who costs more than double. In IFT, this would be particluarly devastating to budgets.

When you upgrade every basic unit to medic, you are now buying cardiac monitors and other expensive stuff that must be on the vehicle in order to make it ALS.

Because reliably more than 90% of all EMS calls don't actually need this, you really might waste a lot fo money.

Next, there is that skills problem. In order to maintain skills, you must practice them. MOre medics means less going around for all. It is already a problem in many systems.

Now you have to invest in simulators, continuing education, etc, just to keep rudamentary ability (not even proficency) in many more porviders.

From the operational standpoint, I think there needs to be less medics, not more.

At the same time, there needs to be more basic only units if we are going to continue the transport everyone mentality. Maybe even a few cars, because many EMS patients have no reason they cannot sit in a passenger seat.

 

[Christopher]

From the operational standpoint, I think there needs to be less medics, not more.

Agreed! Instead you make the minimum educational standards the same as a Paramedic's.

 

[mycrofft]

Costs for personnel: if everyone was a paramedic the wages would fall, as would benefits and maybe the percentage of full time positions versus part time, because of inflation of labor supply, presuming a majority of the people currently becoming EMT-B's could/would get their paramedic (EMT-P).

Equipment for units would climb, somewhat.

Insurance for employers ...?

 

[EpiEMS]

I have yet to see conclusive evidence that more medics means better outcomes. If anything, the skill dilution that occurs is more harmful. Plus, having three or four medics on a single call is fairly useless – you don't need a medic doing compressions, bagging, bandaging, splinting, etc.

I would much rather make all levels of education more rigorous without necessarily adding skills - except for letting paramedics decide that certain patients probably don't need an ED, just an urgent care clinic, say.

Regarding increasing educational requirements, make medics associates' degree at a minimum (or a BA/BS in any other subject with the same coursework as the associate's trained medics). That'll drive wages up, surely, by reducing the labor supply. Would it improve patient care? I am unsure...

 

[mycrofft]

But my premise is that there is no more EMT-B rating, not how to improve them. Make everyone get a paramedic cert as the baseline above first aid. If you want to be a hero, you can't take EMT-B (or whatever mutation your state offers), it's EMT-P or stay home and watch "Rescue Rangers".

How would this affect rural and frontier areas? Inner city? IFT? Private versus civil service? Patient care? IS there enough of a skill gradient that we would not be able to field enough bodies, or could we? Would this dilute further the EMT-P (Paramedic) rating?

 

[Veneficus]

I think it would dilute the paramedic rating to near uselessness.

 

[mycrofft]

Due to more medic mills sliding out shiny new Paragods?

 

[EpiEMS]

How would this affect rural and frontier areas? Inner city? IFT? Private versus civil service? Patient care? IS there enough of a skill gradient that we would not be able to field enough bodies, or could we? Would this dilute further the EMT-P (Paramedic) rating?

Places with volunteer services would end up gutted. Places that use EMT/EMT-Bs to provide a placeholder/quick response until ALS transporting units show up would end up with nobody to hold the line and provide the immediate, first line assessment and treatment as needed to determine priority.

There would be a lot fewer providers: the difference between a 1 semester course that can be delivered in as little as two weeks straight and a two year course that is or nears an associate's degree level of training is massive as far as time commitment goes. And yet, despite that, you can teach most of the interventions we know make a difference in outcomes in an EMT course alone. Yes, ALS helps, but we often don't know either how much or whether it's cost effective.

This proposal would also raise a number of questions:

What level of training would firefighters and police officers have (unless you're retaining EMR/FR), and how would we verify it on a national level?

Would EMT-P as we know it be the only level of training? Nothing higher?

Where would the nascent paramedics be able to learn their BLS skills?

How would you ensure that these EMT-Ps have enough experience at tubes, IVs, and similar skills that require lots of practice?

If the reduction in the total number of providers occurs, how in the heck are we going to have enough providers to respond to the current call volume?

Who would handle the low acuity calls? Who would handle the IFTs that require only assessment and diesel? It wouldn't be cost effective?

How much does it cost in terms of dollar per life saved in an ALS system vs. one that only has BLS?

 

[mycrofft]

Places with volunteer services would end up gutted. Places that use EMT/EMT-Bs to provide a placeholder/quick response until ALS transporting units show up would end up with nobody to hold the line and provide the immediate, first line assessment and treatment as needed to determine priority.

There would be a lot fewer providers: the difference between a 1 semester course that can be delivered in as little as two weeks straight and a two year course that is or nears an associate's degree level of training is massive as far as time commitment goes. And yet, despite that, you can teach most of the interventions we know make a difference in outcomes in an EMT course alone. Yes, ALS helps, but we often don't know either how much or whether it's cost effective.

This proposal would also raise a number of questions:

What level of training would firefighters and police officers have (unless you're retaining EMR/FR), and how would we verify it on a national level?
FIRST AID. OK, MAYBE FIRST RESPONDER

Would EMT-P as we know it be the only level of training? Nothing higher? NO

Where would the nascent paramedics be able to learn their BLS skills? AS PARAMEDICS, IN CLINICALS AND RIDEALONGS. MAYBE AN ARTICULATED PROGRAM? WHY NOT JUST AS THEY DO NOW?

How would you ensure that these EMT-Ps have enough experience at tubes, IVs, and similar skills that require lots of practice? HOW DO WE NOW?

If the reduction in the total number of providers occurs, how in the heck are we going to have enough providers to respond to the current call volume? WILL THERE BE THAT BIG A DROP, IF ANY, OR WILL THE HEROES STEP UP AND PASS THE PARAMEDIC MILLS?

Who would handle the low acuity calls? Who would handle the IFTs that require only assessment and diesel? It wouldn't be cost effective? PARAMEDICS, THAT'S IT. UNLESS STATES PASSED LAWS TO ALLOW FIRST AIDERS (OKAY, MAYBE EFRs).

How much does it cost in terms of dollar per life saved in an ALS system vs. one that only has BLS? IF COST OF PARAMEDICS DROPS BECAUSE THEY BECOME MORE NUMEROUS, WOULD IT MAKE ANY DIFFERENCE?

I hear mental gears grinding!!!
(Oops, their mine!).

 

[EpiEMS]

I guess my overarching question is: Are paramedics really worth the added cost?

My thought is that paramedics are useful on the high acuity calls: real dyspnea, cardiac complaints, and major trauma. Is it really necessary to have a paramedic on every call? Do we have better outcomes for patients on the low and moderate acuity calls with paramedic-level treatment and management?

 

[mycrofft]

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?

 

[EpiEMS]

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.

That's a substantial assumption to make, considering the relative costs of B vs. P programs. They're not forced – they could exit the industry and make use of their skills elsewhere. A higher barrier to entry (i.e. more education) will, ceteris paribus, reduce the number of persons in the field. Also, I take issue with the claim that costs of educating paramedics would decrease: unlike for law school (where the marginal cost of adding a student is low: you only need one more chair), medic school has a high marginal cost per student. After all, to train one more paramedic, you've gotta have more equipment, more ambulances for internship hours, etc.

This all adds up to minimal, if any, savings from increased scale.

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?

While I am unaware of any current system vs. all ALS system study, there is good research that has shown the relative inefficacy of many ALS skills, while upholding the use of BLS interventions. Take, for example, the research showing that ETT placement rates are quite poor. Heck, there's research out there showing that ACLS IV medications don't improve the rates of neurologically intact outcomes or even survival to discharge. Now, that being said, as an EMT, I am usually glad when the medic shows up on a severe call, whether or not they make an empirically demonstrated difference.

 

[Bullets]

From a NJ point of view

Any area that still relies on volunteer EMS at the EMT level would get slaughtered financially. We have areas of the state that run 100% volunteer, or hybrid type squads that still lean heavily on volunteer EMS. Hybrid squads are appearing in the populated areas, Middlesex, Monmouth, Ocean, but the rural areas of the state, North- and South- West provide EMS to the municipality for free. Turning everyone into a paramedic would

A.) Force municipalities to pay for what they got for free, this would not be acceptable for the municipalities, they are hard up as it is, and the call volume would not warrant that. Areas like Sussex, Cumberland, Gloucester, have large coverage areas but small populations and small call volume, less then one call a day, paying a Medic to sit in a building or truck and do nothing most of the time would not be accepted

B.) You would have increase response time, which looks bad publicly, which would not be accepted by the municipalities. Medics in NJ come from hospitals, as opposed to EMTs which come from stations in the municipality.

C.) Some squads might be able to upgrade their current system, but many would not be able to afford the increased cost of ALS supplies and would fold. Closing EMS stations does not look good to the public. Most EMS agencies are not publicly funded like Fire Departments, they private non-profits

 

[Bullets]

From a NJ point of view

and because i cant edit my previous post

D.) My town handles roughly 5000 calls per year. 9sq miles, 40k people
We get ALS service from MONOC, who provides the service based on need or when requested by BLS on scene. We REQUEST ALS for approx 23% of calls, either automatically by dispatch or after assessment. ALS treats approx 12% of those requests. According to MONOC, about 5% of those actually NEED ALS. So my mayor is going to ask why they need to now pay for a service that is only needed 5% of the time all the time, when the volunteers provide free service for 95% of our calls.

The League of Municipalities is strong and they will fight this

 

[NYMedic828]

Terrible idea.

EMT serves its purpose absolutely for 90% of calls.

Injuries especially, don't need medics.

As a medic, my emplodemanded is in higher demand. Why would I want that to change drastically?

Not everyone is capable of the further education. Some people just can't cut it academically. Others can't afford it or don't have time for it.

The biggest issue I see is the countless volunteer services. My own department has probably 40 EMTs and 8 "CCs" which is like an AEMT. We only have 4 actual medics. By eliminating EMTs you essentially shut down EMS systems countrywide.

 

[Frozennoodle]

At the same time, there needs to be more basic only units if we are going to continue the transport everyone mentality. Maybe even a few cars, because many EMS patients have no reason they cannot sit in a passenger seat.

Do you think that expanding EMS to include mid-level providers would solve that situation in the US? Seeing a PA or NP in a hospital counts as having received a medical screening at the hospital so would a PA in the field resolve some of those transport issues?

I also think attempting to expand medicaid and medicare payments to pre-hospital non-transports is something huge to push for if we want to go down this road. I know the suburban hospital-based EMS service bills the patient directly for refusals about 100-150 bucks a pop so that's another option to get around insurance non-payment.

Thoughts?

 

[EpiEMS]

Do you think that expanding EMS to include mid-level providers would solve that situation in the US?
Thoughts?

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.

 

[Veneficus]

Do you think that expanding EMS to include mid-level providers would solve that situation in the US?

I do not think it requires a midlevel provider. Services such as Wake County have demonstrated the economic effectiveness of using specially uptrained and experienced paramedics.

As I understand these medics also function with more advanced emergency capabilities as well.

So it is really benefiting in all respects.

I also think attempting to expand medicaid and medicare payments to pre-hospital non-transports is something huge to push for if we want to go down this road.

This is going to be the key to success of any future EMS efforts.

But there are many people who have a strong financial incentive to make sure EMS transports to an ED, not least of which are doctors and hospitals.