The FAILURE of EMS in the US ?

[tniuqs]

This cut copy paste from a forward to myself:

[align=center:716f564b9a]The FAILURE of EMS[/align:716f564b9a]

In order to survive, the system must first collapse By Scot Phelps, JD, MPH, EMT-P, CEM, CBCP, MEP

The concept of an EMS system has failed. After 40 years, it is time to admit defeat. The concept of an EMS system has failed. After 40 years, it is time to admit defeat. While the idea of providing an organized system of advanced out-of-hospital care was a good one, internal and external forces have led to the imminent failure of the EMS system in America. I, for one, am glad, because the system as it is currently structured cannot work.

This collapse was about 20 years in coming. When I started EMS in the 1980s, there was a lot of hope for the industry. I grew up in an era when BLS ambulances were nearly 100% volunteer outside of large cities, when first aiders were transitioning into EMTs, and when statewide paramedic coverage was an almost-realized dream in New Jersey. It was also an era of mobile intensive care nurses (holy cow!

a decently paid career track with options), a strong tradition of volunteer crew chiefs with a decade of experience mentoring new cadets, and a billing system that let paramedics bill enough to cover the costs of operating the paramedic system. It was far from perfect, but it seemed to be moving ahead.

Twenty-three years later, when I talk to colleagues from my era about their experiences, I hear a common refrain: "I thought being a paramedic was going to be a real job." Instead, we have regressed into an EMS system that is only interested in cost, not quality; that equates certification with competency, with no field training and supervision; EMS providers (both career and volunteer) who work an endless series of 60-hour work weeks; no upward career mobility; and McJobs (no pension, no benefits) instead of careers. How did things go so wrong? I have a few ideas:

The Public Has Never Understood What We Do.

Until we jettison the acronyms that mean nothing to the public (EMT, BLS, etc.) and focus on using the term "medic" for all ambulance providers, we will never have a consistent public image. A SWAT police officer is still called "officer." We also need to be the ones who talk to the press about accidents involving injuries and fatalities. The police are not the ones who cared for the patients-- we are.

We Let Medicare Pay for Calls, But Not the EMS System.

When Medicare changed its payment rules seven years ago, we let them fundamentally change from paying for patients' pro rata share of system costs to paying for the actual cost of the transport, stranding a huge percentage of overhead costs if your agency has a normal level of utilization. We did not make it clear to our elected officials that they would need to pay the rest. We also accepted mandatory coverage from Medicare, which meant that systems had no reason to compete on quality, only cost, since their payment remained fixed.

We Let Other Disciplines Do Our Jobs.

Where I worked, I constantly heard the EMT crews complaining about the career fire department, yet on the scene, they always let the firefighter/ EMTs carry the patient. I will say it in no uncertain

terms: Do your own job. Fire takes care of fire and rescue, police take care of law enforcement. If it involves injury prevention, safety or health, it is EMS' job. Carrying patients, teaching injury- prevention programs in schools, installing child car seats and decontamination are all patient safety-related issues and clearly the role of EMS.

We Never Asserted Control Over Emergency Medical Care.

It is great that your community firefighters and police are EMTs and respond quickly, but providing care is our profession and we have a right to regulate it. Generally, communities should have sufficient EMS resources to be able to respond anywhere in the community within minutes. But where EMS permits fire or police to provide emergency medical care, it should be only under our direct control for care, oversight and quality assurance.

We Never Stood Up and Said "No More McJobs."

In the Northeast, the volunteer EMS ethic is that "this job is so important, I'll do it for free," yet inexplicably, when they begin to transition to a career system, they do not think that EMS is important enough to pay career staff a fair living wage (with benefits and pension) to do it. To be fair, this is also prevalent in the private ambulance sector, but at least they can point to a profit motive. The reason paramedics have to work a 60-hour week is that you need 60 hours to pay your rent, and nobody in EMS thinks that's crazy. If we all quit our per-diem jobs tomorrow, salaries would correct themselves within six months.

We Need to Admit That Paramedics and EMTs Are Not the Same.

EMTs are technicians with less than five weeks of full-time training (significantly less than the police or fire academy) who treat symptoms. Paramedics are professionals with at least 50 weeks of full-time training who treat a diagnosis. With the new curriculum, there is no longer even a continuum of education from EMT to paramedic. This is important for one key reason: It artificially depresses paramedic wages, because there are so many more EMTs in any bargaining group. This undermines a graduated pay scale that would pay paramedics significantly more and pay for their experience.

Without it, how can we ever expect to retain good paramedics when their long-term wages are depressed by EMTs? The primary reason we lose so many great EMTs, who choose not to become paramedics, is because the money just isn't there in the long-term.

We Abandoned the Concept of the Mobile Intensive Care Nurse.

I've never understood why we created paramedics in the first place in an era that also saw the development of specialized critical- care nursing. In New Jersey, and in many states across the country, almost every paramedic program had nurse preceptors for years. Nurses specializing in out-of-hospital care were quite common until the early 1990s. I never actually saw a paramedic work in the field until I began my clinical rotations. If we shifted to a three-year community college MICN program, we could ensure both a decent wage scale and true career path for medics (and it would solve #6).

Volunteers Are Fine, But the Year-to-Year Mind-Set Is Not.

EMS is a complex business, with eight-minute response times within your community, a stock that is both critical and time- and

temperature- based, burdensome regulatory requirements and continuing education for your staff. Who the hell told you that you can manage all this without a business plan? Without short- and long-term multi- year goals? Without strong management support for a volunteer labor force? Volunteer EMS organizations, even more than career organizations, need career managers with a multi-year business plan mind-set or your organization is going to fail. Even the Red Cross has career people who manage volunteer staff.

Regardless of Our Employer, When We Do 9-1-1 Response, We Have Not Said That We Are Public Safety.

After 9/11, I had the privilege of working with George Contreras and Richard Fox to try to secure federal line-of-duty Public Safety Officer Benefits for all of the municipal, hospital, private and volunteer paramedics and EMTs who died during that event. That experience really opened my eyes to the inequality faced by medics across the country. We are not public safety because of who our employer is; we are public safety because we respond to the public's calls to a public emergency number. That is a critically important distinction.

Summary

In summary, the problem is us. While we have become very good at

blaming everybody else for our troubles, in our hearts, we must think

that EMS is not all that important. If we did, we would be fighting

like hell, working together and pounding our fists on the table.

As it stands now, most of the talented paramedics I started with

20 years ago are no longer paramedics. Some got hurt, some died, some

burned out, and many of the rest work part time, because they love

EMS, but need careers to make livings for their families. It is

painful for me to say that EMS is not a career, but it is not. It is

also painful to see the EMS system, which I do value and once had

great hope for, collapse, but it is. While many of the problems I

have identified have fixes that could be implemented now, I

understand that most will only be implemented when the system

collapses. And that can't happen too soon for me.

Scot Phelps, JD, MPH, EMT-P, CEM, CBCP, MEP, is an associate

professor for the Emergency and Disaster Management MPA in the School

of Public Affairs and Administration at Metropolitan College of New

York. He has served as assistant commissioner for Emergency

Management at the NYC Department of Health and Mental Hygiene, as a

hospital emergency manager and as a professor of emergency medicine

at George Washington University School of Medicine.

[JPINFV]

Sounds like someone has read Atlas Shurgged. I guess it's too bad he wasn't named John Galt.

[JakeEMTP]

Good article. I happen to agree with the majority of what Scot Phelps talks about.

If you doubt what he is talking about, look at our neighbours to the North where EMS is a career and a has some stability.

[somedic]

Good article. I dont think nurses belong in the field and I dont see the need to be "precepted" by a nurse but I agree with what he is saying.

Ive said before that EMS people are their own worst enemy when it comes to public perception. After nearly 20 years of Combined civilian and military EMS experience, I see no real progress.

[itku2er]

Somedic what is wrong with NURSES in the feild?

Terr

[somedic]

Terri: Whats wrong with Paramedics in an ER?

[itku2er]

I never said there was anything wrong with that dear.

[somedic]

Terri: It's just different forms of medicine really. Nurses recieve no education in prehospital medicine in nursing school but some seem to think that they can inject themselves into a Paramedics world just because they are nurses.

With Love, Somedic

[tniuqs]

Good article. I happen to agree with the majority of what Scot Phelps talks about.

If you doubt what he is talking about, look at our neighbours to the North where EMS is a career and a has some stability.

Well:

I personally would not give that much credit just yet, the summary that Phelps is quite indicative of the actual reality in Canada as well.

Yes, I agree that the access to Health Care system here is a "bit" better and as it is more focused on the Care of the Patients instead of billing.

Realistically the pubic system we all seam to jump up and down about is NOT exclusively "PUBLIC" just in really a different billing process, start talking the reality (that has been forever a blend ) or Public vs. Private delivery then everyone gets their poop in a knot....and polarizing (sp) everyone, well this was quite clearly explained to me last November by Preston Manning, It is most likely the biggest problem to over come... stanch idealism.

The fact remains that the US HAS established the REMT-P nationally (lets NOT get into standards OK, Please) We here in Kanukistan have NOT, and we even a bill called "The Interprovincial agreement on Mobility of Labour" but no one yet has used this to an advantage some provinces have actually put in place barriers that should be kicked over in my view. Yet even though the lobby group PAC or Paramedics of Canada have made great strides very little change has come about just yet!

The difference is the typical apathy of Canadians and some sticks in the mud like ACoP in Alberta (thinking that the National Competency Based Objectives) needs to be revaluated based on the Alberta standards...good grief BATMAN...move forward, accept then modify!

Now here is a kicker too....most Alberta registered members have NOT a farking idea that they too are members of PAC!

Is it true that "ignorance is bliss?" tell me it isn't so...PLEASE.

cheers

ps The most discussion I see is on US based Website (s)....sheesh,

We do have our own but no one goes there to communicate these issues "North of the Border" and why I will never know.

I do know that a single entity lobbing federal government with solidarity in "support" could change things positively.

[AZCEP]

tniuqs, I'm trying really I am, but I don't see how this is "Funny Stuff".

Truth be told, the "system" is beginning to collapse on itself without much effort from anyone.

Detroit, Philadelphia, Washington D.C., and recently Los Angeles, to name a few, have had to make some major changes just to continue with operations. Things will have to get much worse before they begin to show any sign of improvement.