EMS Educational Standards

[edpmedic]

[QUOTE=L-Webb;1254166]

How is it a shame to become a paramedic for a pay raise? I thought about what I would like to do that pays well, and being a paramedic was what fit the bill. If the pay was lousy, I would have had to go into another career, as my family prefers to be clothed and fed.

If you like doing it and it pays better... That's good. Thats not quite what I meant.

There are 2 students in my class that have openly stated that the only reason that they are here is that they will get 5-6000 more a year and just want to get enough to pass the test.

There are two things that are beyond me:

First, why do certain depts insist on making everyone become a medic? It costs for the class, the increased compensation, and also for CME's and such. ALS isn't for everyone, either. Pushing drugs and providing electrical therapy, and the education that comes with that is serious business. If you carry an apathetic attitude toward that side of the job, people are going to get hurt and killed.

Second, in medic saturated regions such as FL and OH, why don't these depts require that their applicants, who typically have to be medics to even apply, have EMS degrees as a hiring condition? In these regions, the competition for fire jobs are like the competition for non-ALS fire positions elsewhere. If the applicant has the EMS degree, that would imply a certain amount of proficiency in EMS, and they'll be less likely to drop their cert after getting on as well.

[BoxAlarm187]

Are Canadians sicker than Americans? Are the Dutch? Or do they just know something that we don't? Or, is it because they don't have national-level special interest groups with a vested interest in keeping standards as low as possible and a lot of money to be spent making that happen?

Can you expand on your meaning of the above statement?

I come from a state that doesn't have medic mills either - our programs are no less than a year, generally 18+ months. The programs are associated with a college (generally a community college), so the student is eligible for a AAS in EMS at the end of the program should so they so choose. A&P? You're getting two full semesters of it.

However, I don't care what country you're in, taking actions to restrict paramedicine to someone with ICU experience is a bit extreme. While I don't condone a 6-month EMT-P canned program, I don't see that getting a graduate-level education is paramount to treatment & diagnosis of what we encounter daily.

[edpmedic]

Can you expand on your meaning of the above statement?

What emt161 is getting at is that some blame the IAFF for keeping EMS educational standards low, the reason being that it would lower the supply of medics. In reality, we can blame most private, hospital based, and third service EMS employers of the same thing. How many of these employers require degrees to apply? How many even give preference to someone with a degree? Usually to get hired it's just a P-card or I-card, a pulse, a couple of alphabet cards, a good driving record, no felonies, and you're good. These non fire based EMS employers far outnumber the fire based services. I don't see them making any noticeable push for increasing EMS educational standards.

Edit: Who either requires or gives weight towards promotional scores for having degrees? The fire service does. What's the easiest degree for a medic to get? The EMS AAS. It only takes a year if you have the P-card. Who sends their medic students to college (NVCC)? Fairfax County does. Just sayin'

[tree68]

In our area there aren't enough P's that a degree makes a big difference. In fact, most of the P's are working at several agencies, because there is the need.

[FireMedic049]

I was under the impression that the core courses within the EMS AAS curriculum could only be taken if you're in the program, similar to the RN classes.

Can't speak to that in general, nor what the exact degree discipline that is offered. I just know that this particular has long offered a stand-alone paramedic program that was very highly regarded in the industry. This program is integrated into the degree program such that you spend a year doing the paramedic program, then the next finishing the other requirements for the degree, however you are able to practice as a paramedic upon completion of that portion and the applicable certification hoops.

[BoxAlarm187]

What emt161 is getting at is that some blame the IAFF for keeping EMS educational standards low, the reason being that it would lower the supply of medics.

I assumed that what he was getting at, as I known he's had issues with the IAFF in the past. However, I've yet to hear any IAFF-based rhetoric about EMS education standards. Perhaps in collective bargaining states this has been brought up? I don't know, but I've personally never heard of the IAFF seeking to lower educational standards.

Edit: Who either requires or gives weight towards promotional scores for having degrees? The fire service does. What's the easiest degree for a medic to get? The EMS AAS. It only takes a year if you have the P-card. Who sends their medic students to college (NVCC)? Fairfax County does. Just sayin'

I can see where you're drawing a parallel, but as a line officer who has been intimately involved in training and education in a progressive department I can confidently say that I don't know ANY of our employees that have sought an EMS AAS degree for the purposes of promotion. Perhaps there's someone out there that has, but it would certainly be the exception, not the norm.

The previous discussion about pay incentives is interesting. I work with some excellent medics that I would want treating my family if they were ever sick. However, some of them have clearly stated that if they lost their 15% pay incentive tomorrow, they'd give up their ALS certification. The blurred line between "doing it for the money" and "doing it because you want to" blurs a little more....

[FireMedic049]

What emt161 is getting at is that some blame the IAFF for keeping EMS educational standards low, the reason being that it would lower the supply of medics. In reality, we can blame most private, hospital based, and third service EMS employers of the same thing. How many of these employers require degrees to apply? How many even give preference to someone with a degree? Usually to get hired it's just a P-card or I-card, a pulse, a couple of alphabet cards, a good driving record, no felonies, and you're good. These non fire based EMS employers far outnumber the fire based services. I don't see them making any noticeable push for increasing EMS educational standards.

You probably won't and for many of the very reasons you favor it. Most of the EMS agencies in my area (and probably a lot more across the country) are pretty much hanging on by a thread to break even every year and keep operating. A lot of them pay pretty crappy for their medics, have fair to average benefits at best (EE only) and for the most part no retirement benefits or true career ladder.

The theory that increased educational requirements will drive down the supply and drive up the wages isn't very a very attractive prospect for these employers. It's tough enough finding employees now plus economically they aren't in a position to support any significant wage increases a degree paramedic would theoretically command. So why would they push for something like this even if it could be "better" clinically?

Until the overall funding issue for EMS is fixed or the non-degree paramedic is legislated into extinction, you likely won't see a significant movement towards degree paramedics outside the larger systems that are already at the forefront of EMS delivery now.

[emt161]

What emt161 is getting at is that some blame the IAFF for keeping EMS educational standards low, the reason being that it would lower the supply of medics.

I said "groups," as in plural, and I meant it. The IAFF is only one leg of the IAFF/IAFC/NVFC triangle that have played a huge role in preventing EMS from progressing.

However, I've yet to hear any IAFF-based rhetoric about EMS education standards.

The Interational's role is a little more indirect, or was at least until the last National Convention. The usual agenda is to promote all-ALS systems, the theory being that if two paramedics on an ambulance at an EMS call are good, 4 more on a fire truck must be better. This leads to paramedic requirements for hire, which induces young people looking for work as firefighters to want a Paramedic card not for the love of pre-hospital care, but for the dream of riding a big red truck. If given the option, most of them will take the path of least resistance towards this goal, like 6 and 9-month patch factories whose owners are only too happy to supply the demand.

At the 2010 Convention, a resolution was passed calling for the International to seek two seats on the board of CAAHEP, which is the body whose accreditation will be required for the program's graduates to test at the NREMT. The purpose of these members, per the Resolution, would be to ensure that fire departments who run their own in-house programs would be accredited. Hmm, instead of just encouraging these department to meet the CAAHEP requirements for the good of the program, its students, and their patients, we'll just take a slot on the board and vote to keep the status quo. Nice.

The previous discussion about pay incentives is interesting. I work with some excellent medics that I would want treating my family if they were ever sick. However, some of them have clearly stated that if they lost their 15% pay incentive tomorrow, they'd give up their ALS certification. The blurred line between "doing it for the money" and "doing it because you want to" blurs a little more....

Happened at a department near me, almost to the T. Department was shorthanded, and was (and still is) running half as many transport units as they needed. They began taking ALS-licensed guys off their fire companies for months-long details to the EMS side.

What happened next? Dozens and dozens fewer ALS-licensed firefighters- they can't go to the EMS division as Basics.

Next contract comes up, the stipend for an ALS license was increased significantly.

What happened next? Dozens of formerly ALS-licensed firefighters recerting.

Blurred? Damn near opaque.

[edpmedic]

You probably won't and for many of the very reasons you favor it. Most of the EMS agencies in my area (and probably a lot more across the country) are pretty much hanging on by a thread to break even every year and keep operating. A lot of them pay pretty crappy for their medics, have fair to average benefits at best (EE only) and for the most part no retirement benefits or true career ladder.

The theory that increased educational requirements will drive down the supply and drive up the wages isn't very a very attractive prospect for these employers. It's tough enough finding employees now plus economically they aren't in a position to support any significant wage increases a degree paramedic would theoretically command. So why would they push for something like this even if it could be "better" clinically?

Until the overall funding issue for EMS is fixed or the non-degree paramedic is legislated into extinction, you likely won't see a significant movement towards degree paramedics outside the larger systems that are already at the forefront of EMS delivery now.

I agree. These agencies and companies thrive on the plentiful supply of medics. They hire new medics with little experience for the bare minimum (because they're happy just to get the work experience until they get a better job) work them to the bone, and then replace them with other new medics for the same low salary. It's even better if it's for a municipal employer. You get a lot of 1-3 year people who leave before they're vested for defined benefit. You can tell which places just want bodies to staff their rigs - they typically have just a one day orientation, maybe three ride alongs, and then you're thrown to the wolves. It costs them very little to hire and train, as opposed to companies and depts that run academies, or at least have FTO programs that may last months.

[edpmedic]

I said "groups," as in plural, and I meant it. The IAFF is only one leg of the IAFF/IAFC/NVFC triangle that have played a huge role in preventing EMS from progressing.



The Interational's role is a little more indirect, or was at least until the last National Convention. The usual agenda is to promote all-ALS systems, the theory being that if two paramedics on an ambulance at an EMS call are good, 4 more on a fire truck must be better. This leads to paramedic requirements for hire, which induces young people looking for work as firefighters to want a Paramedic card not for the love of pre-hospital care, but for the dream of riding a big red truck. If given the option, most of them will take the path of least resistance towards this goal, like 6 and 9-month patch factories whose owners are only too happy to supply the demand.

At the 2010 Convention, a resolution was passed calling for the International to seek two seats on the board of CAAHEP, which is the body whose accreditation will be required for the program's graduates to test at the NREMT. The purpose of these members, per the Resolution, would be to ensure that fire departments who run their own in-house programs would be accredited. Hmm, instead of just encouraging these department to meet the CAAHEP requirements for the good of the program, its students, and their patients, we'll just take a slot on the board and vote to keep the status quo. Nice.



Happened at a department near me, almost to the T. Department was shorthanded, and was (and still is) running half as many transport units as they needed. They began taking ALS-licensed guys off their fire companies for months-long details to the EMS side.

What happened next? Dozens and dozens fewer ALS-licensed firefighters- they can't go to the EMS division as Basics.

Next contract comes up, the stipend for an ALS license was increased significantly.

What happened next? Dozens of formerly ALS-licensed firefighters recerting.

Blurred? Damn near opaque.

Okay, I'll change "IAFF" to "Fire Service" in general.

See my above reply to FM049. The numerous private companies, hospital based EMS depts, and municipal/PUM EMS agencies have a vested interest in keeping the supply of medics high to keep payroll down. They also benefit from the 6-9 month patch factories. I've interviewed for one FD, two municipal third service agencies, four hospital based systems, and four privates throughout my career. I've spoken to others that have also applied to different types of EMS delivery systems. None of these places cared if you had an EMS degree or just a card. Go on to any paremedic job posting, fire based or not. They only ask that you have a GED, a valid cert, no felonies, a decent driving record, your alphabet cards, or the ability to get them, and to between 18-21 y/o depending.

You can say that it's the fire service's fault directly or inderectly for keeping EMS educational standards down, but the non fire based employers have the power to change that. For the most part, they choose not to. Key word "choose." They could collectively choose to only hire medics with EMS degrees, give hiring preference to them, or at least compensate at a significantly higher rate than cert only medics. But they don't. That's for the same reasons that you say the FD seeks to keep the standards down - cheap, replaceable, abundant labor. Let's not single out the fire service when there are other major players in EMS employment that have just as much of a part in the big picture of EMS educational standards. If these non fire based employers required degrees for employment, or at least compensated significantly higher for one, you would see the medic mills go out of business, and more colege EMS programs open up.

I don't blame the IAFF for seeking out seats on the board of the CAAHEP. The fire service is a large enough employer of EMS professionals, so they ought to seek positions of influence, rather than have others make their decisions for them. They don't run the board, but their opinions can be voiced.

I don't see the point of having an all ALS FD, either. That seems to be a FL thing, though. I haven't seen that from the NE down to SC as far as I know.

Speaking from experience, I can't say I blame medics for dropping their cert if they're made to ride the box all the time. I know FF's that have no interest in EMS, I also know many who enjoy the EMS side. That's was the half the appeal for me applying to a FD with ALS txp. The other half was the salary and benefits. The typical burnout in EMS is 5-7 years, or maybe 7-10 depending on who you talk to. I don't know many 25-30 year street medics or EMT's. With a FD, you can move from a suppression assignment on one day, and ride the box the next. It keeps you fresh, and it definitely keeps me interested in EMS. I don't blame those for dropping their certs in the example you gave because they're probably running a high call call volume, missing drills, PT, meals, sleep, etc. They may also enjoy fire suppression, and are being deprived of that. They don't get that break from the EMS volume and time consumption. It's nice to get back to dinner or PT 20 minutes after a call in many cases, instead of an hour to two hours each run, if you don't get hit for another while going back to the station. If they did EMS only, they would also be subject to that 5-10 year burnout range.

Edit: Opaque: Hell yeah! I left a decent paying, urban hospital based EMS system to go fire based. My family and I would never have been able to own a home, have a secure retirement, and have a sustainable career if I didn't make the move to the fire service. Why would these FF/medics stay on the box 100% of the time and be out of the station all day and night running skells? How long do you want to do that before you burn out? If you pay well enough, the call volume, along with the drama in EMS becomes worth it. Where I work, I'm getting at least $25k more than a basic FF to also be a medic. I think I can do this 30+ years w/o a problem. I've been in EMS for nine years - 6 outside of the FD, and three in the fire service. I sure as hell wouldn't be in EMS FT any more had I stayed. I'd be an RN/BSN, and maybe be a per diem medic for that hospital (too old for FDNY).

[edpmedic]

I assumed that what he was getting at, as I known he's had issues with the IAFF in the past. However, I've yet to hear any IAFF-based rhetoric about EMS education standards. Perhaps in collective bargaining states this has been brought up? I don't know, but I've personally never heard of the IAFF seeking to lower educational standards.



I can see where you're drawing a parallel, but as a line officer who has been intimately involved in training and education in a progressive department I can confidently say that I don't know ANY of our employees that have sought an EMS AAS degree for the purposes of promotion. Perhaps there's someone out there that has, but it would certainly be the exception, not the norm.

The previous discussion about pay incentives is interesting. I work with some excellent medics that I would want treating my family if they were ever sick. However, some of them have clearly stated that if they lost their 15% pay incentive tomorrow, they'd give up their ALS certification. The blurred line between "doing it for the money" and "doing it because you want to" blurs a little more....

I mentioned the EMS AAS because some of our newly hired FF/medics already have this degree. Others are taking it because it's the quickest degree to get for promotional purposes, as you get a free year just for having the P-card.

As far as pay incentives, consider that the paramedic cert is not merely an add-on specialty such as TROT, Hazmat, and such. Our Hazmat school is two weeks long, or 80 hours. You can promote to Technician off of that. For Apparatus Tech, you only need to know how to pump, drive, know your way around the engine, and pass the exam. EMS can and is a career in it's own right in many places. Compensating the same as a TROT cert (training around the year, but it equals around six FT weeks if you add it up, IIRC), or as an A-Tech or HM-Tech is not adequate for the amount of education, training, hundreds of hours of (uncompensated) ride alongs and hospital rotations, not to mention the continuing education requirements, and let's not forget that the paramedic also uses their education and training on a regular basis, numerous times a day in a busy system. Take the example of the engine medic. They're supposed to be on the bus half the time, and on the engine half the time, until they can promote out of the position. On the engine, they're still an ALS provider. On the ambulance, they may need to do rehab in the fire building on an high rise, or perhaps get dressed to pull a line or function as RIT in the event of delayed units. A decent salary for a fairly new medic is around 50k/yr in NOVA or NYC. I'm getting an additional 25k or so a year on top of the FF job. That's half of a single role medic's salary, and I'm on an engine half the time. That seems like fair compensation to me.

[BoxAlarm187]

EDP,

It sounds like your experience with your department is much like mine is with my department, having nothing to do with your current chief/our past chief. Unfortunately, we don't have a Tech or Tech II position, nor do our TROT, water rescue, or HM team members get a stipend - that's reserved solely for the ALS providers.

I have an ALS provider on my shift who did 16 years of full-time EMS for a very progressive third party service with a very high call volume. He loved being a street doc (and still does) but was getting burned out on it. Like you, he entered the fire service, where he's only subjected to the ambulance between 30% and 50% of the time. It allows him to keep his excellent skill set while learning the intricacies of being a firefighter also.

I also see NO need for a fully ALS system. About 200 of our 525 members are ALS providers, which gives us an ALS provider on every ambulance (with a BLS driver/attendant depending on the call; we don't run any BLS ambulances either), plus we generally have an ALS provider on every engine as well. This was worked exceptionally well for us, without over-saturating the system with medics.

There are likely some places in which the fire-based EMS system isn't all it's made out to be. There are other places that it's working - quite well, at that. The same can be said for private or municipal EMS systems. The barrier here isn't whether it's fire-based or not, it's about how the system is structured to demand high performance from the members.

[headoutdaplane]

To answer your original question: No, P's should not be required to have a two year degree. A degree would not substantially make a difference in the long term outcome of the vast majority of pre-hospital care patients. You are correct though, a mandated two year degree will create a barrier to entry and indeed eventually raise P's salaries, that is true, but would it really affect patient care in a positive way? probably not.

The fact is that the vast majority of pre-hospital care is done with standing orders and company/department SOPs: If A then do B and check for outcome.

It would be interesting to see numbers-wise the change in overall px outcome by a degreed P versus non-degreed P. In other words: how many px have a different/better outcome because the P that attended them pre-hospital did something different than a non-degreed P would have done, which, in turn led to better care and outcome. I don't believe that number would be significant (except for that individual Px and his family of course).

Really, what difference would it make if the medic had an additional year of classroom schooling with classes like EMS Management? Not that much.

If patient care was the priority, I just don't see an arbitrary goal of an AA would really make the difference. I would suggest that instead of a degree just make the ride along time requirement in school, or, pre-program BLS experience more stringent.

Your arguments for the pro using Candada and the Netherlands just because their healthcare systems are very different than ours, different funding and a lot less lawyers. I have a friend that is a P in Australia and she diagnoses PX and refuses transport in many cases, I can't imagine that happening for long here. I would like to see data that PX outcome is higher for similar maladies in those countries.

[edpmedic]

To answer your original question: No, P's should not be required to have a two year degree. A degree would not substantially make a difference in the long term outcome of the vast majority of pre-hospital care patients. You are correct though, a mandated two year degree will create a barrier to entry and indeed eventually raise P's salaries, that is true, but would it really affect patient care in a positive way? probably not.

The fact is that the vast majority of pre-hospital care is done with standing orders and company/department SOPs: If A then do B and check for outcome.

It would be interesting to see numbers-wise the change in overall px outcome by a degreed P versus non-degreed P. In other words: how many px have a different/better outcome because the P that attended them pre-hospital did something different than a non-degreed P would have done, which, in turn led to better care and outcome. I don't believe that number would be significant (except for that individual Px and his family of course).

Really, what difference would it make if the medic had an additional year of classroom schooling with classes like EMS Management? Not that much.

If patient care was the priority, I just don't see an arbitrary goal of an AA would really make the difference. I would suggest that instead of a degree just make the ride along time requirement in school, or, pre-program BLS experience more stringent.

Your arguments for the pro using Candada and the Netherlands just because their healthcare systems are very different than ours, different funding and a lot less lawyers. I have a friend that is a P in Australia and she diagnoses PX and refuses transport in many cases, I can't imagine that happening for long here. I would like to see data that PX outcome is higher for similar maladies in those countries.

"If A then do B and check for outcome," huh? Your what's commonly referred to as a cookbook medic. Not every pt fits into a neat little textbook presentation. For example, consider that many CHF pts developed that CHF secondary to their COPD (emphysema) over the years. Pulmonary HTN is a common contributing factor. They have dyspnea, and they're fairly tight, too tight to hear rales. Do you think they're having a COPD exacerbation? Are they developing APE? Is it both? What do you do first? How do you manage both conditions, and how do you go about that? That requires using at least two protocols. Take a good look at Wake Co, NC's EMS clinical guidelines. Their medics use guidelines, as in best judgment, rather than the simplistic "see A, do B."

Do you understand the mechanism with which succinylcholine (one of the RSI meds) can cause hyperkalemia, and how that can lead to malignant hyperthermia? I'll bet the in house "pharmacology for EMS" that waters down a college pharm course into a week, and only covers the thirty meds or so didn't teach you that.

Do you understand how to use the ETCO2 capnoline (nasal ETCO2 for non-intubated pts) for applications other than verifying tube placement? I'm guessing that the two week watered down "A&P" for EMS that the medic mill gives in lieu of requiring college A&P didn't give you the education to fully understand capnography and capnometry. Can you tell me how to diagnose a STEMI with a pt that has a LBBB or paced rhythm?

To take NVCC's EMS AAS program as an example, you get human biology (A&P), general pharmacology, pathophysiology, advanced patho, a class dedicated to just 12 leads. EMS management is what you study when you progress past the AAS and go for an EMS Bachelors, BTW.

When over 90% of pts in EMS are non-acute, or non-time sensitive, I wouldn't expect the numbers to differ much from the degree medics to non degree medics. We're talking about maybe 5-10% of the pt population that would fare worse if they weren't given more than an O2 NRB and txp. Part of that 10% would be cardiac arrests, who typically stay dead regardless. That opens a whole other can of worms regarding the importance of ALS response and pt outcomes. Consider that a dept's current protocols reflect the medic's lack of education. That's why your friend in Australia, who is likely an Advanced Care Paramedic, which is above the Primary Care Paramedic, can treat and release. In NYC, you can't even give an albuterol in-line neb for an APE pt. Even if you could, that would be jumping protocols, and you would have to spend a few minutes on the phone with the doc-in-the-box giving a complete head to toe while your pt deteriorates.

[headoutdaplane]

All very good points, but again, I don't see the AA as fixing all the above mentioned examples. This would be a fairly easy question to answer if the studies are available, do countries that require university degrees for their paramedics have better pt outcome for similar injuries or maladies than the US? My gut level instinct says no, but I have no factual data to back it up.

The standards to acquire the P could be increased to address your concerns, I just don't believe that the added expense and time of the other core classes e.g. humanities or social sciences, needed to get an AA are really necessary and/or would benefit px outcome. And again, if the AA req is put in place as a barrier to entry to increase wages, that is another subject, I am only speaking of pt longterm outcome.