EMS then and NOW .........

[Ridryder 911]

I don't know where "Crochtity" worked at but I started in the late 70's in a small poor rural town. We had MRL monitors (LP was not invented for prehospital yet) no strips but we carried about 30 medications and performed intracardiac sticks as well. We as well performed intubations and yes we had to mix medications which was a bummer but at least Paramedics knew how to perform medication admixtures.

As well, I performed RSI when I worked in a small oil town about 8,000 people and had protocols to do central lines and yes even in the late 80's Fibrolytics (TpA). No 12 leads, but we did perform multi leads and yes even a pacemaker that attached to the LP5 with a 9 volt battery in it. So yes, there was such a thing.

In retrospective my protocols were much more advanced than now. We had albumin, and even had Troopers transport O- to us to start on patient with a long extrication or for scene to interfacility transfers. Prehospital Dilantin & Phenobarb.. so in patient care I was able to provide more care.

Now, I have to admit as well that the majority of Paramedics I worked with between 1982 and 1992 Paramedics had a degree as well. I will admit the units were primarily van and at one service suburbans and unfortunately were not well taken care of. Yeah, I have sawed more than one LSB to cover a hole in the floor and the wind going through the trailer was so strong it would literally blow out the gas heater. One night alone all trucks were shut down do to poor maintenance. So yes, it definitely had it bad points.

What I did notice though was the personal at the time usually did the job because they really wanted to. The pay sucked (more so than it does now).

Now, I will admit that the units is nicer, the pay is better, and the living conditions are tremendously are much better than they used to be. Also working hours is much better as well such as most do not work in ER and field at 48 hours at a time. So there is a pay off.

As much as there were good times, I would not want to go back to the past. I miss the personalities and the dedication of those in the past. Rarely, I see such of this anymore. It is much more about the "me" than the patient. I am glad though that some of that attitude is there (usually from us old medics) enough to want EMS to change into a profession. Making it a better profession than when we started.

R/r 911

[Christopher.Collins]

and there was nothing like the pucker factor you experienced when you lifted a large patient and heard the board "crack".

[Dustdevil]

I'm with Rid on this one. Crotch's recollection sounds more like 1975 to me than 1985. We had all of those things by 1985. CID's, KEDs, LP5, cellphones, updraft meds, three narcotics, two antiemetics, two steroids, six different meds administered by titrated drip, special paediatric kit, surgical crichs, central lines, venous cutdowns, Paramedic/RN crews with the medic in charge, and no orders ever required for ANY drug or procedure. In fact, if you called a doc to ask what to do, for a patient, that was the same as resigning, lol. If they didn't think you were capable of competent independent practice, they didn't hire you in the first place. All these things were in the better systems by 1980. It seems the further east of the Mississippi River, or north of the Mason-Dixon line you went though (as well as the closer you got to California), the less likely you were to have any of it.

We were still using wooden backboards, but they sure weren't homemade, lol. They were the high quality Bound Tree's or the folding aluminium Fernos ever since the late 1970s. You did, however, hit the salary average spot-on. The rural hospital-based system I was in was making more than twice that. The sheriff's department complained because their deputies (which I was also) were barely making half of what the medics were. But we were certainly the exception to the rule in EMS.

What this thread very much shows is that really, EMS has not grown a bit in the last twenty-five years. Sure, things have changed, but none of those things represent EMS progress. They represent progress in the fields of medicine, biomedical technology, communications, etc... But not even education has improved in EMS since then. It is disingenuous to claim advances in other fields as our own when, in reality, we had nothing to do with them. They were just trickled down to us.

[crotchitymedic1986]

Great point dustdevil, as i typed the line about "the driver only had to be trained in CPR", it immediately hit me that we have come full circle with EMTBs being allowed on the bus. And you are right about the trickle down effect, but i would say that is true in all of medicine. Everything "new" is usually driven by a new invention, gadget, or drug. What is really "new" in hospital care over the past 20 years ? Thrombolytics, heart caths, CABG, stroke treatment, implantible defibrillators/pacemakers -- we still cant cure the cold, blindness, diabetes, CRF, or met. cancer. For all of JCAHO's involvement in improving hospital care, I would say you have twice the likelyhood of being killed by a medical mistake or getting an infection during your hospital stay.

They say if you arent part of the solution, you are part of the problem, so how do we solve this. I have read suggestions regarding "national standards", but what if the new national standard is set at the minimal level -- we would like to think it would be a higher standard, but typically government sets low thresholds. I have read suggestions about more education and four year degrees, but I am not sure that will improve EMS or its pay, because our pay is proportional to reimbursement. Medicaid typically pays a hospital the same amount for a child birth whether it is done by a midwife or a doctor. Medicare changed to a reimbursement rate for ems that was based on georgraphy a few years ago. Are we to assume that they will pay more for an ALS transport because the medics on the truck had a degree, especially when the current insurance model is to hold/reduce cost and payouts ? If there is no increase in reimbursement, can our employers afford to pay you more (my answer to that is yes -- just as we have seen with recent fuel prices, they found a way to pay it, but if you asked them 3 years ago what they would have done if fuel prices went above $4.00/gallon, their kneejerk response would have been, we would have to go out of business.

So what is the answer ? How do we take EMS to the plateau that is talked about in this forum ?

[fiznat]

So what is the answer ? How do we take EMS to the plateau that is talked about in this forum ?

The answer in my opinion is to do a few things:

1. A national lobby with these ideals and a vision for the future that we can be proud of.

2. National standardization requiring an associate's degree at the minimum for a Paramedic.

3. Doctors and researchers that believe in EMS and are willing to work for it. More EMS specific peer-reviewed literature.

4. A financial incentive for both EMS employers and employees so that any of this can be viable.

5. Street level respect for the job. Increase standards, and decrease tolerance of those unable to perform this job well.

[Ridryder 911]

The first thing is medics have to be involved. Apathy is our real killer, the problems is because of our lack of actions. In review, if we were dependent on todays medics to start EMS again, we would be in bad shape. Thank God there were those before those of today.

Lip service is cheap, action(s) are not.

R/r 911

[zzyzx]

Is there an EMS lobby that is pushing for a national standard that would include all medics having an associate's degree? Wouldn't the firefighter lobby oppose it?

[firedoc5]

The first thing is medics have to be involved. Apathy is our real killer, the problems is because of our lack of actions. In review, if we were dependent on todays medics to start EMS again, we would be in bad shape. Thank God there were those before those of today.

Lip service is cheap, action(s) are not.

R/r 911

Apathy goes hand-in-hand with burn out. I know that for a fact.

I could go on and on regarding have and have not's back in the early days compared to now. I can't decide to write them down first then post them later, or just do a few at a time wasting posting space. I'd say up to '89 we were finally getting up to 1985 standards in some areas.

[VentMedic]

Is there an EMS lobby that is pushing for a national standard that would include all medics having an associate's degree? Wouldn't the firefighter lobby oppose it?

There are different ways to approach this. It can be done at a state level as Oregon has mandated the equivalent of a 2 year degree for licensure. Texas has added an extra patch as Licensed Paramedic for a degree. Another way would be an agreement on the national exam and make a national requirement for a degree for licensing. The NREMT has at least made the effort to have schools accredited to make the graduates eligible for testing. Educators would have to be on the same page and states that are greatly lacking in college based education centers would be at a disadvantage.

However, it seems that some states that previously had higher educational standards to at least keep the programs college based are buckling to FDs as the recent Memphis thread showed. Removing the programs farther from standardized education fragments the system and muddies the potential for unity under the college oversight boards to regulate an across the board standard if there was to ever be one proposed.

The FDs in some states believe even a 500 or 700 hour paramedic program is too long. Medic mills that contract to these departments must guarantee the program will not be 501 or 701 hours. These states, like Florida, would maintain their own exam to stay in control although the actual control is from the special interests groups.

Some states can not even agree on what to call their providers and end up with 5 - 8 different levels. Some do not even use the terms EMT or Paramedic. This has also frustrated legislators who have tried to help EMS but have had 50+ different titles presented with only a skill or two making the difference between levels. This form of identity confusion or "patch craze" also makes any unity impossible.

There are lobbyists from EMS educators and a few other groups with a common interest but the lacking support is from the providers themselves. There is not a strong national organization with enough members to support any cause. It is too easy for special interest groups to take control and get their own agendas pushed through while EMS lags.

Organizations for other professions already have their educational and professional goals mapped out for 15 years with plans of action ready to impliment as well as the anticipation for the length of time for each step to take effect. Any time there is a proposed change in legislation to be annouced at one of their conferences, thousands show up in the general assembly hall. When there are legislators and/or industry representatives available to discuss changes in EMS, maybe 20 show up out of thousands. It is embarrassing to see such a poor interest in one's profession and the message it sends to those controlling the purse strings for reimbursement or legislative issues.

Other professions have also been successful because they do look at where they are in relation to others and the quality or worth of their contribution to healthcare. Healthcare is a business and each member or profession must have a plan to make itself more marketable and come up with reimbursible stategies. EMS has made itself into an island with pissing matches instead of constructive analysis of others. The "we so different" attitude has severely damaged the profession when it started to cause alienation from the world of medicine. Some providers prefer not to be thought of as medical professionals and still want to be known as public safety officers of some type.

In summary, there are too many factors for the EMS communities to agree on. Some states will struggle to remain control because of their Fire based EMS status. Others will use the poor volunteer reasons. Finding enough college educated instructors to replace the Bubbas at medic mills and the back rooms of FDs or ambulance companies would be yet another issue.

[Christopher.Collins]

5. Street level respect for the job. Increase standards, and decrease tolerance of those unable to perform this job well.

Hopefully putting out of business, agencies that hire people that others wont (for a reason). This could be both benneficial and bad at once though... if I never put on the cranberry uniform Id never have gained the experience I have now... on the same token, Ive seen people there who shouldnt have a drivers license much less a public health one.