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 na├»ve 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.