With much ballyhoo and publicity, we’ve heard a ton about increasing educational requirements for EMS.  The National Registry now requires a paramedic candidate to have graduated from an accredited paramedic program.   What does accreditation mean?  Speaking cynically, it means that an education program has gone through a process where it has created a big ol’ (Yep, “big ol'” is a Texas colloquialism, so deal with it…) policies and procedures process that may or may not have anything to do with academics and/or successfully creating baby paramedics.

And at least some of the EMS world is clamoring for a degree requirement for paramedics.  They’re convinced that a degree for paramedicine will enhance both pay and professionalism.  They point to nursing as an example where this has happened. Perhaps.  Maybe.  Respiratory therapy now has degree programs and, if I remember correctly, its pay hasn’t skyrocketed like nursing.  Correct me if I’m wrong.

What concerns me about the EMS education trend is this.  We are continuing to look at an EMS degree as a technical thing.  More hours in the hospital.  More hours in the classroom learning what paramedics already know how to do.

What EMS hasn’t done is grow a future generation of EMS leaders and thinkers.  We need paramedics who know public health, public policy, management, the political and regulatory processes, and dare I say it, the legal realm. EMS is a business, whether it’s publicly run or a private enterprise.  Johnny and Roy may know how to intubate, but if Johnny and Roy can’t make a budget, deal with HR, and deal with Capitol Hill, Johnny and Roy are going to remain the bastard stepchildren of healthcare.

If we’re going to have a debate about a paramedicine degree, let’s be sure that we know what a paramedicine degree should contain.  And let’s start growing a cadre and a core of EMS subject matter experts in all of the fields that touch EMS — not just experts in EMS.

So many people have complained about the lowest common denominator (or “low information voter” AKA LIV) tendencies in EMS and EMS management (both clinically and operationally) ad nauseum. What we haven’t done is begun to fix it. The path is deceptively simple. Infiltrate. Infiltrate. Infiltrate. There are tons of committees, focus groups, etc. out there. Imagine if each of these committees had a strong advocate for higher EMS standards on them advocating for change or at least showing the way.

Currently, I’m up at NREMT helping review EMT exam questions. Watching a medic’s eyes pop out at reading a sepsis protocol that involves more than fluid resuscitation has been worth the trip alone.  I don’t blame him.  I blame his regional system for maintaining a lowest common denominator EMS system.  I blame the fire departments and private services that want a lowest common denominator system for the express purposes of lower wages and/or ease of training.

I’ve noticed two interesting discussions going on simultaneously on EMS social media.  One discussion, which started on the National EMS Management Association list on Google Groups initially started out as a medical director trying to update his protocols.  It has since evolved (or perhaps, devolved) into a discussion about keeping endotracheal intubation as a paramedic skill.   The usual positions are being hashed out.  Again.  In short — one position is that EMS, as a whole, doesn’t do a good job at intubation — either in initial education and skills mastery or in skills retention.  The other side is the argument of “That may well be true, but things are different at the XYZ EMS System where we absolutely excel at intubation.  Here’s why and take a look at our numbers.”

Another discussion has been brought up by friend and fellow blogger Chris Kaiser.  He’s raised some very good concerns about the current American Heart Association Advanced Cardiac Life Support program sinking to the level of a merit badge course that every advanced life support EMS provider has and that most hospital staff have.

I see both of these discussions as a symptom of what I call the McDonald-ization of EMS.  In other words, we want to ensure a similar experience wherever you get EMS, regardless of previous excellence (or incompetence).  Face it, when we travel, we stop at Mickey D’s because we know what we’re getting, not because it’s the best burger anywhere.

EMS seems to be trending towards this as well.  The statistical gurus and the usual crowd of professional committee members and buzzword repeaters all bloviate (sorry for the Bill O’Reilly word there) about the need to have a common standard.  Two problems there.  First, the common standard doesn’t take into account the variations throughout the entire United States.  To me, it’s unreasonable and illogical to presume that Cut Bank, Montana and Boston, Massachusetts have the same needs for EMS, much less the same populations and sources of funding.  Second, like McDonald’s, when your chief concern is consistency, your product or service easily becomes the lowest common denominator.  What you end up with is a consensus model where pit crew CPR, good airway management (both including and excluding intubation), and even more cutting edge advances like dual defibrillation and transporting certain cardiac arrest patients straight to the cath lab end up sacrificed because “we all need to be delivering the same care everywhere.”

As for me, I’ll take the occasionally singed porterhouse in recognition that even that is better than the uniformly average Big Mac, which for the record, isn’t even prepared the way I like my burgers to begin with.  It’s time that we quit punishing the EMS services that try to deliver excellent patient care just so that everyone receives the same, consistent, AVERAGE care.

Of course, the statistician will tell me that there’s always going to be an average.  We just need to keep IMPROVING what we do so that the average keeps advancing too.