Some People Will Be Offended


As a former co worker was fond of saying “The truth only hurts who it is about.”

The post I am commenting on is going to hurt a lot of feelings, but it needed to be said.

I don’t know who this guy is or even if I’ll link to him, but I found this post via Facebook,

Why US EMS will never get to sit at the adult table.

I started to write a comment on his blog, but realized that my comment was of blog post length and so decided to get an easy post out of my comments.

I don’t agree with him 100%, but he’s about 80% correct. The part about EBM versus SBM is priceless and will make some EMS heads explode.

Here are my comments,

You bring up some good points, although a couple of your seques are on the head spinning side.

The problem with EMS is that it has not yet decided whether it wants to be a profession, a trade, or a skill set. If it is a profession, then, and I’m sure someone will jump in to object, it has to become a self regulating body that sets and keeps minimum standards. Which might just end volunteer EMS, at least as we know it.

If it’s to be a trade, then volunteers are definitely out, and while it might be self regulating, it will not have the educational requirements to be a profession.

Which leads a skill set. Fire Fighter/Paramedics think of themselves as fire fighters who do EMS on the side. That despite the fact that most of their work load (70-80%) is EMS and not fire suppression. They’ll read all about “fighting the dragon”, but many of them won’t pick up an EMS magazine or book until it’s time to recertify.

It may well come down to paramedicine becoming a profession or trade and EMT being a skill set.

I come from one of “those” systems where we maintain higher standards than the norm. I won’t identify it, but suffice it to say we have a research division, have published studies, our recently retired medical director was well regarded on a national level, etc…

The key to upgrading EMS is not related to some phony baloney EMS degree. It’s related to improving medical education for paramedics, improving pay, benefits, and working conditions to the point that people will stay in the filed for longer than it takes to get hired by a fire department, police department, or admission to a nursing program.

Since there is a seemingly never ending supply of minimally qualified paramedics ready to go to work for chump change, that will likely never change other than in a few systems. The one thing that those systems will share is that their work force is unionized. Which of course most people in EMS that are not working in fire based or third service systems will never do because it’s easy to break the unions in the private sector.

I also agree with you about EBM versus SBM. Although too much of what we do is based on anecdote, too much of what we do is based on the foggy evidence of EBM and not enough is based on SBM. Sadly Emergency Medicine shares that problem as well.


    • No, not really. When people talk about EMS 2.0, Community Paramedics, and other proposed advances, I just remind them that we need to make sure that every EMT can take a blood pressure first. Sigh indeed.

  1. I think your analysis is right on. However, I don’t know where the money will come from. There’s a huge effort to squeeze the costs out of medical everything, and increasing the pay for EMS is unlikely to happen unless we can show that there will be benefits to the patients or cost savings overall. I’m not certain where that’s going to come from, however.

    • Which is exactly the problem. I’ve been told that CMS has reduced ambulance reimbursement rates, which won’t help things.

      • The only reason why CMS gets to pay us whatever they feel like is because they know that they can get away with it. We will gladly take whatever peanuts they choose to pay us, and make up the difference by selling cookies, lemon cake or whatever other BS fundraiser we can think of. Small governments don’t care because nobody is making them care. We purposely hide bad response times and outcomes to stay afloat, instead of exposing the problems that we are facing to obligate the governments to do something about it.
        Everyone knows that the way we bill for our services is antiquated. How can you run a bill-per-service business when the service is required to be available and fully staffed 24/7?

        I, personally don’t think that everyone needs to go to college and get a degree, but I do strongly believe that if you’re going to practice medicine at any level you should at least have an associate degree. I must also admit that i have 3 undergraduates, and I’m considering beginning an MPH program in the next year or so. Academia is a big part of my life, but college is not for everyone

        Why is everyone measuring the value of a college degree by it’s weight in paper? Having a college degree doesn’t mean that you have a piece a paper that everyone needs to respect; having a degree means that you didn’t only focus on the technical portions of your chosen career; it means that you also had a chance to develop other complementary skills as well. Everyone seems to think that the only good thing about getting degrees is the the ability to conduct studies. Here’s the thing, there is already a group of people to do that research portion: epidemiologist,bio- statisticians, Medical doctors with PhDs, etc.

        Math and English are paramount and a given , however I think the average field provider would also greatly benefit from college level courses in abnormal psychology, medical ethics, cultural competency, sociology, even basic chemistry and economics can be valuable. Let us be honest -how many of the patients that we see on a weekly basis fall under the “EDP” (emotionally disturbed person) category, and how does a vast knowledge about cardiology benefit them? We might not be able to give them a proper psychological assessment with one or two psychology courses under our belt, but we could definitely have a stronger impact in their treatment, if we actually understood a little bit more about their illness.

        • And who is going to pay for those degrees you value so much?

          Prove to me that a college degree is of any benefit to a field provider. Keep in mind that I have a BA and a Master’s Degree, so I have direct experience.

          Explain to me how a couple of courses in psychology (I’ve had those too) make us better able to affect EDP patient’s treatment.
          CMS pays everyone what they pay because they figure that is what the service is worth. It’s not just EMS that gets below market rates, it’s everyone. That’s why some doctors are no longer accepting new Medicaid patients. The rates that CMS will authorize just don’t make it worth their time. Another benefit of the so called Affordable Care Act.

          • Half the medics I know cannot compose a decent paper, have no idea how to do non-academic research much less academic. The little that we learn in Medic school about psych is barely enough to comfort an EDP (which can go a long way if you ever try it).
            A BS would eliminate the need to be an EMT before going to Medic school by giving providers enough supervised clinic practice to learn the job while in school. I’ve always found it ridiculous that there is no real direct entrance into a paramedic role. Under the current scheme you have to be one before you can be the other because there’s simply not enough time to learn the ropes in class.
            We’ve already position ourselves in a place where the community expects our services, but we have not asked them anything in return besides whatever we can scrape up in revenue through billing and fundraising. There’s a need for the job to be done. I think we can both agree on that. The problem is that there’s too many people lined up to do the job, and why wouldn’t there be. Medic Mills are pumping out 1000s of EMTs and 100s of medics every year. EMS is one of the easiest jobs to get into, there’s no need to raise the pay because there’s tons of people who are willing to do the job. Wouldn’t it be a good thing if we could restrict the market? It works for oil and diamonds why can’t it work for EMS. The best paid regions are usually the ones that are hurting the most for medics

    • Where does the money come from for fire / PD / DPW / snow removal / trash pick-up, or the like? If EMS is thought of as a profit center, then you are correct, there isn’t that much money to go around. If it’s thought of as an essential service, and tax-funded, there is. It just dependent on ‘what’ of the public.

      • All of these services are able to get money based on availability and the results delivered. If it routinely takes too long for the fire department to respond to calls because they are busy elsewhere, they can get for more funding to increase their numbers. If they are unable to fight fires at certain locations (eg. chemical plants) due to a lack of training or equipment, they can get funding for more training or equipment.

        On either a government-funded or fee-for-service model, it is possible to increase the number of EMS providers. More billing = more revenue. However, getting more money for more training for EMS is hard. Who can’t be treated or transported under the current scheme? This is why I mentioned that there has to be a demonstrated benefit.

        In the system I volunteer with (hybrid system mostly staffed by full-time paid employees), most of our calls are BLS or just above BLS. BLS, a little Zofran or dextrose addresses most of our patients. We’re a full ALS service, though. On occasion we’ll do an interfacility transport with a dedicated team for patients who require a higher level of care, or we’ll request a doctor in the field. I’ve been on two transports which have required this (one which was cancelled).

        In medical speak, what is the Number Needed to Treat? That is, how many 911 calls would a typical service need to handle to run into a single call where a higher level of care would be needed? Even more, how many of those would suffer permanent harm for lack of it in the field? I don’t know. Given that the costs exist for every call, but the benefits only exist for those calls where needed, you end up with rapidly-deminishing returns.

        Anecdotally, I suspect that those communities which are most likely to routinely need a higher level of care are going to be those which are least likely to be able to afford them.

        • Any model that relies upon increased funding, especially government funding, is doomed to fail. The money is just not there and never will be.

  2. I wrote that article and came here to read your reply.

    I think that you are right on about the elusive “EMS degree” will not suddenly change the realities of the industry in the US. I would stipulate that without one, none of the problems will be solved.

    In the comments here, there is talk about reimbursement, particularly for ambulance transport. One of the reasons US EMS needs that degree is so they can demonstrate a measurable body of knowledge in order to do what other US healthcare providers have done, and have reimbursement tied to actual patient care as opposed to a taxi fee.

    I would also point out that a degree is a barrier to entry, which lowers the amount of cheap labor.

    There are some recent blog opinions that labor and management, legal, and political education be part of that degree, and I support that idea fully.

    Many providers claim that I degree will not change their scope of practice or ability to write their own protocols. I also agree with that. It takes a volume of knowledge far beyond what can be taught in a 2 or 4 year degree. But having that degree will get you not only a seat, but a vote, which is really something you need, if for no other reason than to protect your own interests, like reimbursement.

    I would say that such a degree, while not changing your scope, should have enough information in order to change how you practice.

    But based on the majority representing your industry now, you are losing support from outside, not gaining it.

    • Mike, I’m glad to see you come here to address a response, it demonstrates (to me, at least) that you care about the issue and want to see the situation improved.

      I’ll be the first to say that I don’t have all (many? any?) of the answer/s. However, I want to help the public, which is also why I’m finishing a BA in emergency and disaster management while I am, at 41, currently working retail.

      There is a need for a certain amount of cheap labor, which is what the EMT-B training currently provides.

      I think of EMT-B as an entry-level job into the prehospital care field. In my area, we don’t use EMR or EMT-I, just basics and paramedics. EMT-B should be an entry- and vo-tech (do people still use that term?) job.

      From what I’ve seen in some aspects of EMS, there is more than a little “eating our young” that goes on, and a LOT of “I got mine, screw you” as well. Some people want an earned seat at the table. I know that I’m one of them, and I suspect that there are more than a few out there. But until the EMS industry starts to police itself from the inside, there will not be much support from the outside. Someone on the original page suggested that we federalize EMS, or at least take it out of the hands of the economy, like we did with fire many decades ago. We now have a fire service that will respond to anybody, rather than just people who pay appropriate subscription fees before hand. We fund police and fire out of the public coffers, for the public good. Without doing any research about it, I don’t see much wrong with that idea.

      Other than the fact that we already have FF/EMS and not all of the FF want to do EMS, but are rather “forced” into it. FOr me, I would not want to have to do FF. I have no desire for that vainglory.

    • Unfortunately, most people will not be able to afford that degree to which you attribute such magical power. More so at the BLS level, but for the vast majority of ALS providers as well. And even more so for the people who work for private services. Private services count on a constant supply of new medics to off set the loss of the medics that go to the fire service, third service, or just get out of EMS all together. The major reason for that is money, or lack there of.

      The service I worked for had a higher than average percentage of EMTs and medics with college degrees. Most of those came from people who went to college before getting in to EMS, not after. For reasons which varied widely, those people left other careers to work in EMS. It had a lot of advantages to the service and the patients in a myriad of ways. I don’t know how many of them would have gone to college if they had gotten into EMS first.

      • This has always been a chicken and egg argument.

        “I am not going to get the degree because it costs so much and I will not get a raise.”

        Yes that is absolutely true beyond any doubt. I don’t think any sane person disputes that. Having said that though, nursing said the same thing not too many years back. I actually know nurses still practicing that went to hospital nursing programs prior to it even being an ADN.

        When you consider that in the last 50 years, nursing has gone from no degree, to an associates degree, and now is well into making a bachelor’s the minimum, when in 40 years ems has not even come close to that on a national level, it is no wonder the pay hasn’t come up for EMS.

        But consider in nearly the exact same time span, nursing went from EMS level wages to well over double and many places triple what an EMS provider makes. Sure it took 50 years, and mistakes were made by nursing, but by looking long term they helped untold generations to come.

        I would also humbly point out the pay for positions such as rad techs and other healthcare techs pay considerably more than EMS. All of them require at least a 2 year degree to even start.

        Is there a need for a entry level vo-tech in EMS? That is debatable and I don’t think anyone will ever agree. It is also true that no other profession makes you spend time at a vo-tech entry level. Look at what all of them have compared to EMS.

        It is all about long term goals.

        • And I would point out that there are more nurses than EMTs and paramedics, and that they are highly unionized. I will also point out that there are no volunteer nurses, and that fire fighters don’t provide nursing services between the very rare fire calls. Which is my way of saying that you analogy won’t hold up. Rad techs require two years of school because that’s how long it takes to learn how to be a rad tech. Physical and Occupational Therapists go to school for five years (I think). And of course there are no volunteer physical therapists and the fire service doesn’t provide PT between the very rare fire calls to which they respond.

          Which is to say that unless we fundamentally change how we deliver EMS in this country, there are going to be no great advances in pay, benefits, and working conditions.

          • “Which is to say that unless we fundamentally change how we deliver EMS in this country, there are going to be no great advances in pay, benefits, and working conditions.”

            and that is the fact that is common to all the arguments we have over how to change.

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