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Where Is EMS Going?


And how do we get there?

Recently there has been debate about an education requirement for paramedics beyond just having a paramedic certification. Some, maybe many, people want to require at least a bachelors degree in “Emergency Medical Services” for someone to work as a paramedic.

There are different opinions as to exactly what courses should be required. More biology, more anatomy and physiology, more chemistry, all seem to be popular ideas.

Many people see nursing as the model to which EMS should aspire. After all, they ask, isn’t better education how nurses became recognized as a profession and how pay for nurses improved?

Yes, but that has nothing to do with how EMS is going to advance, if EMS is going to advance.

There are many differences between nursing and EMS. First, the work venue and opportunities. If you work in EMS, in most areas that means you work in an ambulance. Or maybe you’re a supervisor or lower level manager. Sure, there are some systems where there are Community Paramedics, but that’s not wide spread and isn’t likely to become widespread unless and until there is a funding mechanism. Right now, most of the Community Paramedic programs are funded by grants of one sort or another.

Once that funding runs out, if it’s not replaced by another source, we’re likely to see Community Paramedicine disappear once more.

Nursing, on the other hand has a lot of different work venues available. Even within a hospital there are different types of nursing. Some of those don’t even involve direct patient care. There are nurses who do research or work with doctors who do research. There are nurse managers, who do management and administration.

I have a cousin who has a PhD is nursing. She does research into Stroke care and a very small amount of direct patient contact. She works at a major teaching hospital and is well paid. I don’t see that sort of thing happening in EMS. Not that it can’t, just that it won’t.

By the way, there are two different types of Doctorates available for nursing.  This post isn’t about that topic, interested readers can read the short article at the link.

In addition to working in hospitals, there are all sorts of nursing jobs outside of hospitals. Again, many of them don’t involve patient care.

In contrast, being a paramedic mostly involves working in an ambulance doing direct patient care. That’s not likely to change.

Also, in contrast to EMS, nursing in many areas is unionized. I won’t get into that debate here, but it should be noted that EMS systems that are uniionized generally have better pay, benefits, and working conditions.

Nursing also has far more control over who is a nurse than EMS has over who is a paramedic. Which is a problem for EMS. A lot of people who are paramedics identify primarily as something “and” a paramedic. It’s even more prevalent with EMTs. There are a lot of people who have gone through EMT courses and taken the test to get certified. Many of them have no intent or interest in working in EMS, but wanted or needed the certification for some reason.

Even people who are paramedics look at that certification as a means to an end and not as a career itself. Many of them are good paramedics, but they don’t see being a paramedic as their primary career.

I’m up to almost 600 words and still haven’t gotten to the biggest problem with a college degree requirement for paramedics.

Cost. More specifically cost and return on investment.

A Bachelors degree is not inexpensive no matter where you go. A person is going to have to lay out X amount of dollars to get that degree , if indeed one does exist.

Does anyone expect that ambulance services, especially privately owned for profit services, are going grant wage increases just because a person has a degree?

“Ahh,” you say, “When every paramedic has a degree, services are going to have to raise wages.”

Would you like to bet on that? Since paramedics have limited job opportunities, there is no incentive to give raises to them.

If I were to be asked by a young paramedic what type of college degree he should get, my advice would be to either get a Bachelors of Science in something like biology or chemistry OR a degree in business administration. Both are far more portable than a specific degree in EMS. Both give a paramedic a route on to professions outside of EMS. There is far more likelihood of a good return on investment with those degrees.

This is not to say that better education is needed in EMS, at both the BLS and ALS levels. That’s not going to happen at the BLS level for reasons I won’t go into. It should and might happen at the ALS level.

As long time readers will know, post retirement I make money in the Quality Improvement end of EMS. A big part of that job involves reading Patient Care Reports. My company rules don’t allow us to score the quality of writing other than as it relates directly to patient care. That is, we can’t correct spelling, grammar, syntax, or anything related to them.

If we were allowed to, I’d be far busier than I already am.

Which is to say that many of the reports are horrendous when it comes to how they are written. I wince at some of what I read in those reports, even if the clinical care is fine. I can only only imagine what the doctors and nurses who read those reports think about EMS providers. Not to mention what the lawyers think when they are reviewing reports for possible litigation.

If I were building a paramedic program, or rather if I were responsible for setting the requirements, remedial English and Mathematics would be added as well as better Chemistry, A&P, and Biology classes. That would be the first part of the program, before we even got to the medicine part. I’d probably add a basic business course as well, so the students could understand the economics of EMS.

That’s the biggest need in paramedic education right now. Produce paramedics that know what they are doing and why, can write a coherent sentence in a report, and understand why EMS operates as it does, then you can talk about making EMS a profession.

As it stands now, EMS on it’s best days is a trade, but spends most of it’s time as a skill set that can be used in a variety of other trades and even a couple of professions.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.


  1. My daughter has grumbled about the ‘lack’ of quality in PCRs for a few years now… And questioned the ‘literacy’ of some of the medics and EMTs…

    • She and I could probably start a blog called “Horrifically Funny Paramedic Misspellings”.

      You really have to wonder about public school education in the US.

    • Let me just say that I once did a QA of a report that said “The patient has an open sore on his leg that appears pussy,” with ‘pussy’ meaning purulent.

      There was also this gem: “Dude be cooking pizza, and he be burned on the stove. We be taking him to the hospital.”

      Then there was the medic who was complaining that his supervisor was not doing his job in reviewing reports, and proved it by typing the same narrative in every report for three months before anyone noticed: “Patient called 911, we arrived, treated them, and transported to the hospital.”

      • Way, way, way, back early in my career a fellow dispatcher put the comments “pussy show” in for an OB-Gyn call. Since this was in the computer, the comment stayed there. I forget who it was in management that saw it, but the result was a three day suspension. He claimed that it was the proper way to describe the vaginal infection that the caller was talking about. To this day, I don’t know if he was right or wrong, but he still served the suspension.

  2. Well-reasoned arguments all, but two quibbles:

    1. The current position paper on degree requirements for paramedics specifies an associates degree, not bachelors. Most of those courses are provided at the community college level, at significantly lower tuition rates than 4-year universities. Grandfathering of existing paramedis is also specified, with a 5-10 year implementation plan. Right now, certificate paramedic programs are roughly equal in hours to an associate degree, minus a few gen ed credits. The cost is going to be much less significant than you think.

    2. Many major insurers and several states are now reimbursing on a non- transport billing code that will fund community paramedicine. Anthem Blue Cross insures millions across 11 states, and now reimburses community paramedic services. A number of other major insurers are rumored to be following suit in the near future, and even CMS is looking at feasibility.

    • The question is not so much the cost, but the Return on Investment. Of course the other issue is that the number of paramedic programs may well drop, which will necessarily drive up the cost.

      The insurers will only be interested in paying if this drops hospital admissions and thus transports. We both know that if it doesn’t end up saving them money, they won’t sustain their financial support for long. If CMS comes on board, that will help a lot. That being said, I read a study the other day that said that using Quality of Care as a benchmark for payment has resulted in more deaths, not fewer. That was within the context of CMS and other insurers refusing to pay if a patient was readmitted within 48 hours for the same problem. Different topic, of course, but the point is that CMS is somewhat stingy.

      You can make a good case that better paramedic education can result in better patient care. Certainly we need a better education model for paramedics (and EMTs for that matter), but what exactly that should be is still open to question.

      One of the problems is that there are a few dozen different models of EMS delivery in the United States, but we’ve discussed that in the past, haven’t we?

  3. If I were building a paramedic program, or rather if I were responsible for setting the requirements, remedial English and Mathematics would be added as well as better Chemistry, A&P, and Biology classes. That would be the first part of the program, before we even got to the medicine part. I’d probably add a basic business course as well, so the students could understand the economics of EMS.

    Don’t look now, but you pretty much just designed an Associates Degree, which is all we’re looking for at the moent.

    • I don’t disagree with a better paramedic program, degree or not. I do disagree that a program designed to make paramedics competent is the key to improving wages.

  4. Well, as to bad spelling, grammar and basic language skills, just try reading a report by a Bachelors in Social Work (yes, a real thing) and you’ll weep.

    An advanced degree isn’t and shouldn’t be where EMS goes.

    Think more trades school. Or what the Navy does with Corpsmen.

    Trust me, start requiring degrees and you’ll get many much more levels of idiocy than what you experience right now. Seen it hit the ‘Administrative Assistant’ field, as degree requirement to be an office worker creep into that field. For staff assistants. Who type. And answer phones. Yeah, 4 year degree sounds like a good idea…

    • A Bachelors in Social Work is, uh, pretty useless. My daughter is a Social Worker and before she could even start she needed to have a MSW. Her writing has always been good, so she had no issues in that regard.

  5. My hazy (from 30-years ago, when I looked at it) understanding is that paramedic certification is closer to 6 months training full-time, not anything close to a 2-year Associate’s degree.
    Clinical rotations may almost approach a year total from start to finish, but I doubt it, at least anywhere hereabouts.
    (Obviously, individual companies/agencies my have other requirements.)

    You might could expand paramedic to the level of LVN training, which is a solid year.

    Two years is frankly overkill, on so many levels, and a bachelor’s degree, while admirable, is ridiculous to even suggest.
    (I’m biased there: I was told twenty-five years ago that in 10 years, all RNs would be BA/BS degrees. Over 25 years later, and I’m still working as many shifts a week as I want with my humble associate’s degree, including at the magnet hospitals that require most staff to hold a BSN, and there are only three of those out of about 40, locally. Double Bonus: they all pay less than the hospitals that accept anyone even without a BSN, even with the BSN pay bump. And they can’t figure out why they’re always short-handed. Hmm. I wonder…)

    If you have 2 or 4 years to work for your paramedic degree, which was suddenly required, why on God’s green earth wouldn’t you either get a nursing degree at either ADN or BSN level, tripling your pay and expanding your work opportunities a thousand-fold, or just gut it out a few more years after a bachelor’s, to become a P.A. or M.D.?

    Is more training a good idea? Sure. For anyone, from EMT to board-certified neurosurgeon.
    Is it necessary for paramedics? Probably not. At least not initially, for entry-level. (What you do as CE is your business, but smarter and more trained is better, certainly.)
    Is it cost-effective, or sensible, to turn a 6-month (or 9-month) cert into one that takes a year, or two, or four, just to ante in? Highly unlikely, unless someone else (other than the paramedic) is paying for it, and even then, every year you’re in school, you’re not working to feed yourself and keep a roof over your head.

    And non-governmental agencies (which is most of them outside Megopolis) will go the other way: they’d rather have cheaper, less-qualified workers, and if they have to pay more, they’ll just upgrade to LVNs/ RNs/etc., and paramedic will become a dinosaur profession, except for firefighters on the civil payroll.

    Exactly like live-in indentured servitude diplomate-nursing has all but disappeared.
    (That will also exacerbate the perennial nursing shortage, and/or provide a new pipeline from LVN to RN, LVN being a similarly limited-end job category.)

    And as a subtle hint, there’s not a lot of crossover between guys who want to put out fires, and guys who’ll sit still for an ADN/BSN. They are pretty fundamentally different groups, overall. I like what I do in the ER, but slinging ladders and hosepacks, and chopping cars open, wasn’t the sort of thing I was into, then or now. I got my fill of heavy lifting in the Marines, thanks, and if I were in a firehouse, I’d be a captain or higher royalty by now, or retired, as my back and knees remind me daily.

    FWIW, the three biggest limits on nurses now is lack of qualified instructors, lack of program seats to train more, and lack of places for them to train.
    All of those things cost even more money, by the metric buttload. If you see the J.C.s and state colleges firing their Victim Studies programs to expand their faculty in nursing, EMS, and the pre-reqs for either, or anything else worthwhile, give a holler. Out here, it’s hard enough to get them to even teach college-level English and math, and find students who can pass the pre-test to enter the courses, let alone successfully get a degree.

    How anyone’s going to leap all three of those hurdles by significantly ramping up paramedic training is probably ten more thoughts than anyone inside EMS has thought through, IMHO.

    • I work with a number of fire based EMS systems. The all have significant problems recruiting paramedics. It seems that, for reasons that baffle me, young paramedics would rather stay with private ambulance services than go to work for fire departments. One department I know of has lifted it’s maximum age for hiring and has new firefighters in their late 40s or early 50s. I can’t imagine going to the fire academy at that age, but people are doing it.

      Young medics don’t want to be fire fighters and would prefer to stay on the “renal round up” at lower page, with crappy work conditions, and of course System Status Management posting.

      Yeah, give me some more of that.

    • The problem is not education. Let me illustrate using Central Florida as an example. A paramedic certificate program at Valencia College in Orlando, Florida is a 54 credit hour course.
      EMT: 3 classes for a total of 12 credit hours.
      Prerequisite of a basic A&P class: 4 credit hours
      Paramedic: 39 credit hours.
      Add in a bunch of three credit hour classes: 2 classes of English composition, Algebra, Statistics, Psychology, US Government, and Public Speaking. There is your AS, which is exactly how I got mine. Those 76 credit hours cost about $7,000 and took 6 semesters (two calendar years). The problem here is this: you do all of that work, and still only make $13 or $14 an hour. Bus drivers at Disney World start at $20 an hour. Let’s say you are a kid coming out of school. Which career would look better to you?

      • This was more or less my point. Students are going to have to spend a significant amount of money, but have no commensurate increase in salary.

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