EMS – Starting From Scratch

Right now, there’s some controversy in Texas EMS circles over a pilot program to combine EMT and paramedic education into a single program where an entry level student wouldn’t need to be an EMT before entering paramedic education. I am cautiously optimistic for this concept, but I’m also sure it will need tweaking along the way. EMS is the only career field I’m aware of, at least in healthcare, where you have to obtain a lower level certification in order to advance. Registered nurses don’t have to become vocational/practical nurses first. And physicians don’t start out as physician assistants.

In this spirit, I started to wonder what other sacred cows I’d slay. With my squirrel brain, that quickly morphed into how I, your humble scribe, would completely redesign EMS from scratch.

First, get rid of the Emergency Medical Responder certification — or what Texas calls Emergency Care Attendant. EMT becomes the new certification for first responders, whether police officers, firefighters, or other personnel. On that note, aside from politics and inertia, why do we have the fire department doing first response prior to EMS arrival? Why not have law enforcement or even community based organizations doing EMS first response?

AEMT would become the minimum staffing level for a 911 ambulance. Of course, there can and should be a process for rural communities to make the case for EMT level staffing due to unavailability of AEMT and/or paramedic staffing.

Non-emergent transfers would be done by nursing aides and/or vocational/practical nurses with training in operating a van and patient movement. Non-emergent transfers should not be part of the EMS world. EMS resources should be dedicated to 911/emergency calls and critical care transfers only. On that related note, medical facilities, especially skilled nursing facilities, should be required to use the 911 EMS system for emergency calls. These facilities should also be financially sanctioned for using the 911 EMS system when a transfer company is not able to respond to a non-emergent transfer.

To supplement the 911 AEMT/Paramedic crews, advanced practice paramedics with enhanced education and skill sets in critical care and community paramedicine riding in SUVs to supplement and assist on 911 calls. These paramedic clinicians should function as true physician extenders to help patients navigate the healthcare system, engage in alternatives to transport, and considering alternate destinations besides the hospital emergency department. A paramedic clinician with telemedicine capabilities and point of care lab testing could present a huge opportunity for cost savings throughout the healthcare system.

In my ideal EMS world, there would be 3 ways to become a paramedic. Much as some nursing programs have a bridge course for vocational/practical nurses to become registered nurses, EMS needs a paramedic transition curriculum for those who are already AEMTs. Also like nursing has alternative entry BSN programs for those with a bachelor’s degree, we need a route for a paramedic certificate as an add-on for those who already have a bachelor’s degree. In this revised EMS world, most people would get a bachelor’s in EMS that covers the current knowledge base as well as the things we don’t cover, but need to advance in EMS — courses in management, policy, economics of healthcare, and adult education methods. The ideal EMS degree should be preparing graduates not only as paramedics, but as the future managers and leaders of our profession.

The current proposal of creating the associate’s degree as the entry level EMS degree accomplishes little beyond awarding college hours for what is currently, by and large, a technical degree in the career/technical education side of the community college world. EMS is a medical field with more in common with nursing, respiratory therapy, and dare I even say, medicine than it has in common with career/technical education like diesel mechanics or heating and air conditioning repair.

Everyone wants to fix EMS, especially those of us in EMS. All but the most naïve realize that any solution is going to require funding. Funding is a challenge whether the service is directly funded by the government or whether EMS is a private entity. There’s one untapped source of EMS money that most of us aren’t considering. As the more astute in EMS know, the Center for Medicare/Medicaid Services (CMS) only reimburses EMS for transports, not treatment. Until EMS speaks with a united voice and focuses our Federal legislative efforts on this change as opposed to quixotic, feel good legislative initiatives, we are doomed to poor pay, poor equipment, and a seat at the kids’ table of the Thanksgiving dinner that is the American healthcare system.

Am I wrong on this? Maybe. But unlike a lot of the others purporting to speak for EMS, I’m not unwilling to challenge the status quo. Johnny and Roy are but a memory to the newer generation in EMS and it’s time that we stop considering the original model of EMS responding to cardiac events and collisions as what constitutes an EMS system, much less a functional, successful EMS system.

The Right EMS Degree

Because I haven’t thrown out any EMS dynamite in a while, here we go…

I oppose the idea of a mandated associates degree for paramedics. Much of what it will do is to guarantee a monopoly to community college programs. These programs are often judged by completion, not success on the licensing exam. Additionally, these programs are often unavailable in rural communities. Many of the community college programs have shown an unwillingness to provide distance education and/or adjusted schedules for students unable to do a full-time day program.

My solution? Make paramedic a post-bachelor’s certificate. By doing so, you’ve already guaranteed that you will have students who’ve demonstrated an ability to think critically, complete a course of study, and to communicate. In other words, much of the affective domain has already been evaluated and validated. I’d also surmise such a paradigm shift will have lower attrition and have graduates, who by the very nature of their education, have the familiarity with standardized testing to succeed at the National Registry as opposed to viewing it as a mysterious hurdle that represents the pinnacle of professional accomplishment. Whereas, the reality is that the National Registry represents the minimal competence to safely function as an entry level provider.

We’ve all said it’s easy to teach the skills of a paramedic, but it’s much harder to teach someone to think critically and relate to patients. By requiring a college degree before becoming a paramedic, we’ve already found people who know how to think and (hopefully) relate to others.

And before you say that paramedicine doesn’t pay well for someone with a bachelor’s degree, I’d encourage you to look at the salaries for teaching and social work, both of which require a bachelor’s at a minimum. The truth is that EMS can and does pay a decent salary to the motivated individuals who seek employment with the more professional EMS systems as opposed to the employers who operate on a “patch and a pulse” mentality. Eventually, bachelors’ level paramedics will require two things that many EMS systems are unwilling or unable to provide — namely a decent salary and a less toxic work environment.

This won’t (and can’t) happen overnight. I’d argue that we need to look at making this the requirement in the next ten to fifteen years. And to remove one obstacle, let’s agree from the outset to grandfather in everyone who’s licensed as a paramedic before that.

Further, let’s do two more controversial things at the same time. First, we need to demand that paramedic is the ONLY advanced provider in the field. No more “cardiac techs,” “Intermediate-99s,” or the like. Next, like any other real healthcare field, we should not require completion of a lower certification to enter a paramedic program. Paramedicine is a separate profession from the technician level providers and it’s time we recognize this.

In short, paramedicine needs to be a professional education, not a technical education — even if said technical education leads to a terminal level associate of applied arts/sciences with limited mobility into a bachelor’s degree.

If we don’t dream big, EMS professionals are destined to remain viewed as ambulance drivers by those in healthcare, business, and government who act surprised when you tell them there’s a difference between an EMT and a paramedic.

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