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Provider Levels (Controversial Discussion)

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What is about to follow is a hot button topic, but I think its worthy of philosophical debate:

I would propose the idea that there should only be one level of EMS provider and offer the following as a starting point for discussion:

1. The public does not know or care about various EMS provider levels. They think that everyone is a "Paramedic" and an "Ambulance Driver". EMT vs EMT-Intermediate vs AEMT vs Paramedic may mean a lot to people in the industry, but has no significance to the general public. How can we establish a professional identity when our different levels of certification are just plain confusing?

2. Most people probably assume that if they call 911, then the ambulance will be staffed with the highest level of provider possible. Would most people appreciate how varied the training of the person on the ambulance might be?

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This may sound good in theory, but it's simply not practical. I don't know where you work, but there are many places that simply cannot afford to have ALS providers. In less populous areas, you may only have a couple advanced level providers for an entire county. In my state, there are more than double the number of EMTB's as there are paramedics, and we have several large cities. I would imagine in the more rural states and areas with a lower tax base, that disparity is even higher.

Unless federal funding is secured to upgrade all services- from training, to equipping the providers, to upgrading the hospitals with needed supplies and equipment, updating telemetry and radio equipment and personnel, I don't think- especially in this economy- it's a feasible concept.

Hell- in many places, there is even a shortage of certain doctors because there is no money to pay them, and the cost of malpractice insurance makes it not worth it for them to provide their services in these areas. In our state, other than the major cities, it used to be you could count on one hand the number of neurosurgeons and OB/GYN's practicing. To my knowledge, it's still a problem.

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I can't agree entirely with the concept of a single-provider system, however I agree with you on point number 1 and will say that I believe, for the sake of the public's ease and to help establish a professional identity, that all EMS providers from the EMT level up to Paramedic should be renamed simply paramedic for ease of use. For industry reasons, I would advocate for affixes that indicate their particular level of education (i.e. Basic Paramedic, Advanced Paramedic).

As for your second point, I can't venture to guess what the public's perception would be if they knew more about ambulance staffing models, but I will say that our principle job is not to appease the public's perception of what adequate medical staffing is (because, in all honesty, the layman does not know what an adequate medical staffing model is), but rather to actually provide adequate medical staffing. There is little to no evidence that an all ALS system improves patient outcomes and in fact evidence that suggests that a paramedic/EMT staffing model provides just as adequate (and possibly better) outcomes than dual medic units.

In my humble opinion, I think that we should adopt an EMS educational system similar to that of some of the commonwealth countries, with a Basic Paramedic (2 year Associates degree) and an Advanced Paramedic (4 year Bachelors degree). And maybe something like a Critical Care/Community Health/Advanced Practice Paramedic (Masters degree) as well.

Edited by Bieber

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I still see the need for two levels, because for high risk/low frequency/high acuity type situations you need experienced, educated people who run these calls often. Not something your going to get from every crew.

What needs to go away is the EMT-Basic level and 700hr medic courses. I personally think AUS and NZ have well thought out systems.

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To be honest with you I am not sure why we have so many levels of EMS providers in the US. To the best of my knowledge there have never been any studies done that show that "Intermediate" life support or ILS improves patient care or outcomes. Instead of spending money on things like ILS why don't we focus on better educating the EMT's & Paramedics we have.

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Interesting topic. Presumably you're suggesting that all ambulance personnel should be trained to medic level. Do you consider NREMT-P certification high enough or would you prefer a setup more similar to that of some other countries which require 4 year degrees? Additionally, have you considered the logistics? Given the (approximate number according to the best estimates I could find online) 40,000 ambulances operating in the US we would have to open up some more paramedic schools certainly. I'm honestly unsure of the percentages involved basics vs medics, but I think it's a safe assumption that basics are a significant majority given the faster (and much much cheaper) education required. The numbers I saw most frequently were 40000 ambulances and half a million 911 calls per day. Not sure if that's including services like mine in which 80% of our calls are medical and/or scheduled transfers for testing or treatments.

Regarding 1: I agree to an extent. The public is certainly unaware of the variances between our certs. I'm not entirely sure that it matters to the majority of them though. I don't bother telling people outside the business anymore since doing so typically generates a blank stare and a shrug. I'm not sure about establishing a professional identity though. I need to give it some more thought, I honestly haven't considered the issue in any depth.

Regarding 2: I'm sure the average joe(sephine) on the street doesn't appreciate our extremely varied levels of training but I'm also not sure how much it would matter to them. I understand that an ALS crew is able to provide a lot of treatments BLS crews can't, and certainly if I'm in serious trouble medically I'd be real happy to see that paramedic patch. I really prefer to avoid medical care altogether whenever possible, barring serious injury or a worse illness than I've ever had I will avoid hospitals at all costs. For myself obviously, not my patients. I have a couple regulars who call us once or twice a week for a ride to the ER. (Like triage much? *sad headshake*) Anyway, I've never been on a call in which the patient said or implied that I oughtta be a medic instead of a basic. I grant that it could happen though, particularly in pain management situations. "Morphine? Sorry, no can do. II have...errr... Baby aspirin and a bite stick?" :devil:

Anyway, I once again need to crash, hopefully sleep will prove less elusive for me tonight. This is a great topic and I look forward to the lively debate that will doubtless ensue. I'd like to add as well, one of the reasons I'm getting prepared for medic school this fall is that I ~do~ feel my patients would be better served if I had a deeper medical background and education. Would I like to see everyone on the rigs a certified medic? Sure! Would I like to see everyone on the rigs granted the same level of autonomy as a New Zealand medic? Given proper education then absolutely! I'm just not sure how practical that would be given the current (and expected) call volume in the US. Again, great topic!

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I think that EMS could benefit from klcking up the levels a notch. What the United States needs is a national mandate. There needs to be a mandate that every population of a certain size needs to have advanced level providers able to respond in a timely fashion. And before anyone gives me this socialism-states-rights-the-south-will-rise-again bullshit, I have three replies for you, Medicare, Medicaid, and Highway funds. You don't want the federal government telling you what to do, give back your federal money.

New Jersey is my example of what EMS looks like under local control. Backwards, over-funded, sometimes outright corrupt little fiefdoms where blowjob politics* rules the roost. If you put things like heath care out there under the span of local control, it will turn into a nightmare. People with a high-school education and 120 hours of first aid training will be in charge of multi-million dollar organizations and I cannot begin to tell you what that opens up.

My ideal system would be this. You have three levels. Transport-technician, Paramedic 1 and Paramedic 2.

Transport-technician would be responsible for attending to simple IFT's and dialysis runs. It would be the very basics you need to know to be reasonably successful doing simple IFT's, discharges to home or rehab, or dialysis runs. Think of what we could do if we didn't use EMT-B's for this role, rather, we had an actual course dedicated to transport. We could do things lessons like reading charts, geography lessons, who to call if the patient stops breathing. It could be customer service driven and just make for such a more enjoyable experience than two EMT-B's who hate doing it.

Paramedic 1 would be the equivalent of EMT-I, plus some sciency stuff. You would need English, A&P, basic math, and some sort of elective as prerequisites. It would be a year long, not necessarily paramilitary, but regimented like a good private school is, with regular physical activity and have clinical and field time interwoven with didactics. You would still be a moron when you graduate but hopefully you're a little better prepared for the field.

Paramedic 2 would build on paramedic one, and add advanced airway, cardiology, neonatology (like the NNRP, not like one chapter in the book and five questions on the cumulative exam), pharmacology, pathophysiology, and in depth learning of the respiratory system, PEEP, I:E ratios, hypoxic hypoxemia, hypercapnia, all that fun stuff. The entrance would be open, and based on previous academic and physical scores coupled with MMI style interviews.

Plus any 911 receiving ER that did not have a cath lab or CAT scan on premises would be mandated to have a fully operation CCTU truck on premises, ready to transport, with a paid 24/7 crew to standby. I think you could get away with having an ER nurse with special training who works the floor until it's ready to go coupled with a paramedic who operates as an ER tech if you were worried about people sitting on their keisters.

That would be my system, and it would be great. It would also piss off, in order, the IAFF, the NAEMT, every volunteer squad in the nation, probably the nurses unions, and some good ol' boys who do things thar way round 'thar parts. Which is why it will never happen.

*blowjob politics is my neologism for the petty interpersonal goings on that run EMS systems to a large degree. Many times it comes down to who received, did not receive, procured for, or failed to procure, oral sex upon or from another person. Contracts, promotions, hirings, firings, write-ups and test scores many times fall into blowjob politics land. When I come up with a less crude way of saying it, I will be sure to post it.

Edited by Asysin2leads

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I did have a huge reply but the basic 20 is that no it wouldnt work as you simply rob people of the already slim opportunities to use such high risk interventions as chest decompression, RSI, cricothyrotomy etc

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One level, what would you do with all the EMT's currently? How would you mandate moving them into the new standard that you propose to make required? How will you pay for all those EMT's to get those classes? Surely you don't expect them to foot the bill when they don't want to advance any further?

They have no intention of furthering their education and they should not be penalized by a system that now says that in order for them to continue working in their chosen career where they have always driven the ambulance and they never want to do anything else, you are going to require them to now become that new level of provider and only be a driver. The cost to them will be very high for NO increase in return of investment. That will force many out of work unless the companies they work for to pay for their increased training.

Are you going to grandfather these folks in?

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One level, what would you do with all the EMT's currently? How would you mandate moving them into the new standard that you propose to make required? How will you pay for all those EMT's to get those classes? Surely you don't expect them to foot the bill when they don't want to advance any further?

They have no intention of furthering their education and they should not be penalized by a system that now says that in order for them to continue working in their chosen career where they have always driven the ambulance and they never want to do anything else, you are going to require them to now become that new level of provider and only be a driver. The cost to them will be very high for NO increase in return of investment. That will force many out of work unless the companies they work for to pay for their increased training.

Are you going to grandfather these folks in?

No one payed to reeducate blacksmiths or typewriter repairmen.

Stay up with the times or move on. If you want to continue to work in EMS you have to be useful. The basic level is dangerously close to obsolescence. Tell us where the current level EMT-Basic really helps.

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