This is my first posting ever so, please be gentile. Let me introduce myself. I am a Paramedic with twenty years of professional service. I work in a high volume 911 system. I have been a firefighter paramedic for the last ten years. I have held many titles in the industry Dispatcher, FTO, Field Supervisor and I have worked for the small “mom and pops” and Corporate EMS. I have worked, in areas that I call rural (30 minutes transport time to the hospital) and inner city.

Now that the entire introduction is out of the way I wanted to discuss a problem that I am struggling with. I am finding it hard to do my job due to the stress that I compete with on a daily basis that stems from my Managment. I feel my supervisors are out of touch, lack the necessary training and personality to instill motivation. I would guess that I am not the only one dealing with this. The issues at hand are not the small little whinny issues that I totally understand happen in a day- to – day operation. The issues I have leap out and hit me in the gut.

Medical supplies, continuously out of twenty gauge catheters, saline flushes, INT caps. Protocols: Our monitors at one time were equipped to transmit 12-Lead EKG’s however now the program has fallen by the way side. The equipment we have will not transmit them anymore. Even when they did we would call a STEMI alert only to have the “real” STEMI alert called ten minutes after arrival. Aggressive (not even) meds like Nitro Paste, Zofran, and I could go on.

Policy and Procedure: Example my wife and I are trying to have a baby. We were doing IVF. The schedule was kind of unpredictable and I explained this to my Supervisors (which really I should not have to do) to prepare them in case I had to call out sick. I have plenty of sick time and I don’t abuse it. I missed two shifts. Had a Doctor note (because I know how they are). She had a miscarriage a few months latter and yep missed a shift and a half. Everyone at my station was supportive. Four months latter management wants to know if I had a Dr note for one of the days I missed. Yep, brought all the bad memories back.

With all of that said, I am required to go out to the field and make a difference. Looking at my patient having a STEMI, begging an ER Physician to call a STEMI alert and he/she is giving me hell for not being able to send it and flat out refuses to call a STEMI alert only to watch my patient die in the ER fifth-teen minutes after arrival. Beg borrow and steel for supplies, all while I’m thinking about my Supervisors who can’t even manage attendance correctly much less handle a complaint about a problems as complex as a patient dying in the ER because a STEMI alert wasn’t called. In the fire service my supervisor may or may not be a Paramedic.

I realize the EMS / Fire Supervisors position is difficult but come on. Should there not be a little professionalism in their area of practice. I’m looking for solutions because I cant work like this much longer. I love the job and always will. Writing letters and incident reports up the chain of command is not an option because its not going to do any good. It will only bring attention upon myself and that will put me in a position to do nothing without a job.

I feel like in this date and time we are moving backwards and it frustrates me because we have more technology today than we did twenty years ago. I feel we don't get the support needed from the medical community nor government officials. Our state agency is for lack of better words non exsistent. We have ambulances in my state that most third world countries would not except and the only new thing on them is a sticker from the state certifying the ambulance to be used in the arena of prehospital care. I look forward to your comments and possible solutions.

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"The equipment we have will not transmit them anymore. Even when they did we would call a STEMI alert only to have the “real” STEMI alert called ten minutes after arrival."

 

"Looking at my patient having a STEMI, begging an ER Physician to call a STEMI alert and he/she is giving me hell for not being able to send it and flat out refuses to call a STEMI alert only to watch my patient die in the ER fifth-teen minutes after arrival."

 

A sad state of affairs to be sure. Usually this is "politics above patient care" but there's plenty of blame to go around. However, and this may come as a surprise to some, I do put the majority of the blame on EMS Management and Medical Direction.

 

But I also blame "us" as a profession. We demand respect without commanding respect.

 

Our failure to embrace the role of becoming experts at 12-lead ECG interpretation so that we can accurately activate the cardiac cath lab from the field will go down as one of our biggest failures and a missed opportunity the likes of which we will probably not see again in our lifetimes.

 

Quite a boon to the medical device industry, though.

 

For the sake of solving this issue of ED physicians not activating the cath lab while you are in the field, I would suggest contacting the chapter of AHA Mission: Lifeline in your state and see if there's anything they can do to help.

 

It's their raison d'etre.

 

Tom

You've hit on much of what is wrong in many EMS agencies and communities today.  We've thought it so important to be "independent" that we have failed to build any sort of political or economic power base so that we could address these issues.  We have no power because we will take no risk; we have no strength because we are small.  We have no character so we generally won't say what needs to be said, because we are afraid that if we do, someone will take our stuff away.  We would rather be under-funded, weak, and (as Mike describes) miserable than stand up for what we know to be right and take the chance that someone will take our franchise away.

 

First, I've got to say though - motivation is what you bring with you to work in your gear bag.  It's an internal, personal thing.  Bosses don't motivate workers - workers are either motivated or they are not.  Bosses surely can DE-MOTIVATE workers, and it sounds like Mike's are doing a darn good job.

 

Short answer - you need a new employer.  If the organization is as bad as you describe, it may be that others are looking to veterans like you for an example.  And if a few of you said "We're not standing for this" and left, the agency would either change for the better or fail and go away.  You gain nothing by holding together a failing organization.

 

We've got to start saying this, in communities where it is not true already:

 

  1. You can't run a decent EMS system based on "transport revenue" alone.  Something has to give - either response performance, quality of patient care, human resources.  The community has to contribute something, most likely in the form of local tax dollars.
  2. Your people have to have the supplies, equipment, etc. to do the job.
  3. If one of your hospitals has the ability to provide proper care, but won't (for example, won't activate the cath lab when EMS calls a STEMI), go elsewhere.  Have evidence-based destination protocols that call for patients to go only to hospitals that agree to activate the cath lab, give TPA, have the trauma surgeon waiting, continue hypothermia, or whatever.
  4. Help get your medical director the authority and responsibility to address all of this.  Too many EMS agencies only want a figurehead medical director to sign off on administrative and certification stuff.  Get a real EMS physician who can stand up to his/her professional colleagues whose decisions are being driven by something other than patients' best interest, and maybe the hospital issues can be resolved.

 

I can't give advice about how to fix an organization that is terminally broken.  Changes to those come either from outside (like, the citizens or the medical community demand change) or from the inside (when employees say "We won't do this any more").  Change is not possible without risk, and you have to evaluate the level of risk that you're willing to take.  Make sure that you have little debt and a pile of savings, so that you can sustain if you need to make a change in job or geography.  Good luck!

This is very well said.  I wish more people in leadership positions (not to be confused with leaders) said and believed this as well.  

 

The biggest problem with agencies like Mike's (Maryland is over-saturated with them) is that they see absolutely no problem with the way they're doing things.  Regarding some things Mike mentioned, they think their issues are rooted in medical reimbursement, competition, regulatory agencies and material costs.  Their only human resource efforts (besides not getting caught up in EEO and sexual harassment quagmires) seem limited to "I'm tired of people not wanting to do their jobs" and "EMT's are a dime a dozen.  If you don't like it here, go somewhere else, I can fill your spot tomorrow."  I've heard all three.   Not a single provider I've ever worked for has ever looked at the non-tangible costs in their field operations or looked at the consequences of human resource mismanagement.  As an aside, what ever happened to that great wave of human resource management that hit the US from Japan back in the '80s?  Was that just a fad? Did we decide that that stuff didn't hold any water or did we just elect to stop and go no further than the "Mission Vision Values" hotel yard sale picture in the front lobby?  

 

Hmmmm.......


Skip Kirkwood said:

You've hit on much of what is wrong in many EMS agencies and communities today.  We've thought it so important to be "independent" that we have failed to build any sort of political or economic power base so that we could address these issues.  We have no power because we will take no risk; we have no strength because we are small.  We have no character so we generally won't say what needs to be said, because we are afraid that if we do, someone will take our stuff away.  We would rather be under-funded, weak, and (as Mike describes) miserable than stand up for what we know to be right and take the chance that someone will take our franchise away.

 

First, I've got to say though - motivation is what you bring with you to work in your gear bag.  It's an internal, personal thing.  Bosses don't motivate workers - workers are either motivated or they are not.  Bosses surely can DE-MOTIVATE workers, and it sounds like Mike's are doing a darn good job.

 

Short answer - you need a new employer.  If the organization is as bad as you describe, it may be that others are looking to veterans like you for an example.  And if a few of you said "We're not standing for this" and left, the agency would either change for the better or fail and go away.  You gain nothing by holding together a failing organization.

 

We've got to start saying this, in communities where it is not true already:

 

  1. You can't run a decent EMS system based on "transport revenue" alone.  Something has to give - either response performance, quality of patient care, human resources.  The community has to contribute something, most likely in the form of local tax dollars.
  2. Your people have to have the supplies, equipment, etc. to do the job.
  3. If one of your hospitals has the ability to provide proper care, but won't (for example, won't activate the cath lab when EMS calls a STEMI), go elsewhere.  Have evidence-based destination protocols that call for patients to go only to hospitals that agree to activate the cath lab, give TPA, have the trauma surgeon waiting, continue hypothermia, or whatever.
  4. Help get your medical director the authority and responsibility to address all of this.  Too many EMS agencies only want a figurehead medical director to sign off on administrative and certification stuff.  Get a real EMS physician who can stand up to his/her professional colleagues whose decisions are being driven by something other than patients' best interest, and maybe the hospital issues can be resolved.

 

I can't give advice about how to fix an organization that is terminally broken.  Changes to those come either from outside (like, the citizens or the medical community demand change) or from the inside (when employees say "We won't do this any more").  Change is not possible without risk, and you have to evaluate the level of risk that you're willing to take.  Make sure that you have little debt and a pile of savings, so that you can sustain if you need to make a change in job or geography.  Good luck!

Chris, is the economy in Maryland so bad, or are there so many Rescue-Randy wanna-bes out there, that there is in fact an endless supply of EMTs willing to work in crappy organizations for peanut wages?

     Not only is this the situation in Maryland, but look immediatly south to the great Commonwealth and you will find much of the same.

     It is unfortunate that I find myself choking back shame when I am asked where I work. Surrounded by EMT's who would be better suited working at the local garage, fast food joint or box store is a morale buster for any professional minded provider. So, why do we have these sorts in our mist? Because they are the the ones who will do a job as they are told, without question, because if they had to get a real job, it would require effort on their part to keep it.

     Transport ambulance companies exist for one reason...to make money. How do they do it? By manipulating people to weave the rules and regulations into a workable scheme to access the reimbursable rates allocated by Medicare, Medicade and third party insurance companies. They need employees who can not and will not think critically. They need employees who will go to managed care facilities (aka, nursing homes) and take residents who protest transport after a fall all under the guise of "altered mental status". They need employees who will write call reports to reflect the necessity of ambulance transport when none exist or when wheelchair transport is sufficient. They need people who will convince the ED to sign off for a BLS discharge because Medicare does not reimburse for a wheelchair trip.

    To answer your question, yes; not only is the economy that bad to allow for this to continue, but there exist an endless supply of people who convinced a group of evaluators that they were compitant enough to care for another human being with their on self interest removed. They exhibited an acceptable skill level and a mastery of cookbook medicine and patient assessment. There are people who are willing to work in this industry because for one reason or another they find it a noble profession, yet they lack the ethical and moral standards of a professional.

     Alas, there are those of us who dare not speak up and challenge the in-house system because we too are caught up in this economy. We too have bills to pay and mouths to feed within our homes. Relocation to another city or region is the only option for some who find themselves employed by a monopoly in their clity.

     It's a dog eat dog world out here Skip and I'm fed up with it! I find myself with a bit in my mouth every day on my job, connected to the reins of capitalism on one side and democracy on the other. I love my profession and hold my head high as a Paramedic, but until there is a national standard and a system of governance in place to police this sector of "EMS", we will be grouped in with the Rescue-Randy wanna bes and we will continue to work for peanuts in these crappy organizations. These forums are our only outlet, but I wonder if our voice will ever be heard outside of these cyberwalls.
Skip Kirkwood said:

Chris, is the economy in Maryland so bad, or are there so many Rescue-Randy wanna-bes out there, that there is in fact an endless supply of EMTs willing to work in crappy organizations for peanut wages?

The problem with EMS Management is multi-faceted... Everyone above is absolutely correct, but it goes even deeper. EMS is young, but it is already in desperate need of a near complete overhaul! This profession has the potential to be a very effective, and integral part of the health care system. However, in its current state (as a whole) its not nearly as effective as it should/could be...

 

One solution is to increase education requirements, so those "Rescue Randys" arent able to meet the qualifications. Our inconsistant requirements and general lack of education is one of the fundamental issues with EMS, and is one that is holding us back from TRUELY being a profession.  Our education requirements are so fragmented, its REDICULOUS! So lemme get this straight, i can be Joe Schmo off the street, and I go to A TWELVE WEEK PARAMEDIC "Program", then i can be "qualified" to work in a high stress level MEDICAL job, giving drugs, pronouncing people dead, running red lights, WITH VERY LITTLE oversight??? And all I have to do is pass some bull-#&$t exam? (and even that requirement is inconsistant state to state. I.E. "National" Registry that isnt accepted in every state...) ARE YOU KIDDING ME!!!!!!!!! However improving this, in rural America, will be very slow and difficult. But the NAEMT is working on it... But it will take years...

 

The next solution is to put leaders in leadership positions. Let me explain. Historically, EMS has promoted people who have been on the job a long time...

 

Two problems with this,

1) Just because you've done this job for a long time, DOESN'T mean you're good at it. It's no longer "Push the purple box Roy..." Its becoming a true evidence based medical PRACTICE. And (unfortunately) a lot of current providers should not, and wont, be able to "hang" with the change... (I wont let say anything else about that, for fear of being burned in effogy...)

2) Just because you've done this job for a long time, DOESNT mean you know how to lead people (and i use the word lead as oppose to manage), or educate people... EMS does this frequently and has for a long time. "Oh look, we need a... (*insert any management type position here, PIO/"commander"/Chief/training officer/etc). Johnny, you've been here a while, why dont you take over that position." So in this situation the education issue is compounded. Now we've got someone (potentially) with VERY little education, doing a job that he/she has no real training/experience/education in. Why cant we hire people that ARE PIOs? Why cant we hire "Leaders" as opposed to promoting people? Why dont we send training officers/educators to classes (and i mean more then the couple for "Adult education") on how to educate? In the private sector, a Master's Degree is pretty much the accepted level of education for people in "Management" type positions. Will this weed out all bad leaders? No, but it'll help.

 

Why have we done it this way for so long? Because The Fire Service does it this way. Again, we are compared to/are part of the Fire Service... In a subordinate based, task oriented "profession" like Fire Supression, they need people who "do things because they are told to". They need you to follow directions without thought, much like the military. And as long as you have competent people in "power" they lead effectively... With, Fire, Civil Service testing (for promotions) theoretically you have competent people in leadership positions... However, in a "free thinking" type, autonomous environment like EMS, this DOESNT WORK as well! People need a reason to do what they do. They need it to make sense. They need leaders who are able to give them direction, but then are "relatively hands off". They need to be supporting, and empowering, not directing...

 

These reasons are SOME of the root causes for EMS's other problems, like lack of pay/benefits, employee retention, job satisfaction etc...

 

How about just applying the same requirements to the "Rescue Randys" as the rest of us?

Trevor said:

One solution is to increase education requirements, so those "Rescue Randys" arent able to meet the qualifications.

Well, as the sheer numbers go, it seems they are right and there are, indeed, plenty enough bodies to fill newly opened slots. So, the answer to that question is an undeniable 'Yes' on the Rescue-Randy wannabes.  However, the bodies are new, unscarred and plenty elastic. Like anything, though, they wear in short enough time and they themselves move along, only to be replaced by the newest EMT card.  They are so new, though, they really don't know any better and so young that they really don't care.  If they don't like it they can quit and walk down the street and work somewhere else the same day.  What's to sweat?  The ones that do care leave and go to RN or PA school, or move to Pawtucket, so there you go.  The ones that care and don't leave....are stuck and can't. 

 

Skip Kirkwood said:

Chris, is the economy in Maryland so bad, or are there so many Rescue-Randy wanna-bes out there, that there is in fact an endless supply of EMTs willing to work in crappy organizations for peanut wages?

Mike,

I would agree with you, if i felt like "the rest of us" had worthwhile and stringent enough education requirements... Unfortunately, they arent... As a whole, the education "required" for our profession is GROSSLY under what is should be... BUT our profession is new, and Rome wasnt built overnight... Like i said above, there are many, many, issues that will come into play with increasing our educational requirements. And while Im a HUGE proponent of education, Im now naive enough to overlook the problems it will create. However, in the span of my career, i KNOW that the educational requirements will be changed. (and they already have started to be)...

 

Example: Look at nursing... They used to only require a certificate and vocational training (LVN), then they started unofficially requiring an RN. Most places RN is AT LEAST an associates degree. Now days, its hard to find work (outside of a nursing home) if you're a LVN. To be competetive in a job search as a nurse you need to have an RN. Many schools (and most decent sized universities) now offer BSN, or MSN programs, so many people are getting those. Its changes like this (and many others) that have allowed the nursing profession to come so far... ALSO, the more time you invest in training, the lless likely you arae to leave that profession.

In EMS its difficult to find a 4 year degree program. Most are only offered online, and there are even fewer graduate programs (which again, are mostly online)... I cant imagine being able to "competently" do my job after completing one of these "Medic Mill" programs...

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