What will the future of EMS look like? How do we get there?

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Permalink Reply by Nathan on October 25, 2009 at 3:07am

Mike had some great things to say on moving forward in the profession. In the thread found here http://connect.jems.com/forum/topics/county-fire-district-in so I cited it below.

Skip, Ive seen you talk about things that need to change for us as a profession (dress uniforms, chain of command ideas ect). Your an experienced provider in what appears to be a great EMS system. I like your vision but how do us younger (less powerful) guys help make those changes happen?

Mike said:

ec•o•nom•ics
NOUN: 1. (used with a sing. verb) The social science that deals with the production, distribution, and consumption of goods and services and with the theory and management of economies or economic systems. Throughout the world, and very much so in developed nations, society sets what it finds valuable. In other words what and how much it is willing to pay for something.
In many first world countries, education is among the top 3 values. I have to qualify many, because it seems to be less valuable in the US. From the inability of people to pay for or find enough assistance to pay for higher education to the outright refusal to help pay for the primary education of children. The general populous of the US does not understand the value of education.

Why should they? For generations unions have insured that those without education could earn not only a fair wage, but an upper middle class one. Not only that, but well paying non union jobs were in reach of people with a high school diploma. Times have changed.

Our level of technology, scientific knowledge, and complex economic and social systems now require large amounts of education. The US lifestyle cannot be funded by a position in unskilled labor. Obviously with the national average pay of EMS workers and the high unemployment of machinists and other tradesmen, these vocations are no longer viable for a middleclass income either. The recent and dramatic decrease in material wealth and high standard of living has caused people to vehemently oppose anything that cost what little wealth they have. (The US has one of the lowest tax rates if not the lowest in the Western world yet can’t understand why bridges are falling into rivers)

I bothered to type this so maybe a passerby reading it might be motivated to better themselves.

Volunteers are not the only organizations that lobby to keep EMS education as low as possible. Additionally both EMS and Fire throughout the US seem to think they are only in place for “emergencies” that they have defined themselves. With such low education and narrow roles in responsibility and service, it is no wonder it is becoming increasingly difficult to earn a middleclass income. Even if you have one of those “municipal” jobs, the state of the economy has demonstrated such ultra specialized service is no longer feasible.

The only option to maintain a viable career in Fire or EMS is to increase both the education (to demand society increase your value) as well as expand responsibility so that a service that has global demonstratable value is performed.

It doesn’t matter how important or stressful or necessary you think your job is, it is what society thinks that matters, even if they are mistaken. This particular thread post demonstrates that.

The emergency industry is caught in the erroneous idea that pay needs to increase before education or increased service. The fact is educated people can demand higher pay as well as set the value of service. As examples: physicians, attorneys, accountants, and investment bankers set their fees. (obviously constrained by what can be paid)They have demonstrated the value they provide in terms of service, wealth generation, or preservation.

The nursing industry has caught on to this concept and has over years evolved and strived to do the same. They increased the minimum education for members, they took on more responsibility, they increased their scope of duties well beyond the original and they are well paid for it. Furthermore they continue to build on this success.

As I stated in another thread, if EMS were to increase its responsibilities, it would require an increase in education, such individual would have to be compensated justly, and well meaning volunteers simply could not devote the time nor energy to meeting these demands. Civil servants who could not meet these demands would be phased out as well. Leaders advocating less would be lost to normal attrition or would find their services were no longer required.

You really want to get rid of volunteers? Start an industry watchdog group similar to JCAHO and team up with some malpractice attorneys and a federal budget committee. Such an effort would probably come down hard on anyone that only tried to do the minimum. Unions would definitely not appreciate this.

Like it or not, in this news clip the Fire service of the area provides a tangible value, a reduction in insurance rates. Can the EMS providers who run so few calls demonstrate a reduction in healthcare costs by proactive community participation? A valuable service that makes people’s lives more convenient? A public health component? An educational component? I don’t know, but as most US EMS agencies don’t and actively refuse to take on such responsibility, it is fair to say they may not be demonstrating a value to society.

The question should not be: “Why should I pay for a person with a degree when I could get the same service from a person with a GED and a 750 hour tech school certification for less or free?”

The question needs to be: “Why pay $30K for a person you might need twice in your life when you could pay $60K for person who will be involved and improve your health, safety, and engage in your community everyday who can save you time, money, provide an educational service and a helping hand which will improve the lives of and give security to you and your family?”

“Be the change you want to see in the world”
--Mahatma Gandhi

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Permalink Reply by Skip Kirkwood on October 25, 2009 at 8:53am

This is fodder for long articles, but great to pull together in a thread. Thanks, Nathan. I'm just going to pop out some bullets. Right now, to me, the future looks pretty grim, but only because of the lack of involvement, lack of initiative, and lack of effort on the part of EMS personnel around the country. So my bullets will address what changes I think we, the EMS profession, need to make to keep EMS viable.

1. We've got to stop being afraid of change and struggling to maintain the status quo. The status quo has failed. If your big concern is "My ambulance service might go out of business or merge with somebody else" you can't contribute to success. Courage and risk taking are going to be required.

2. We've got to get educated, organized, and politically active. If we don't do these things we will be squeezed out of existence.

3. We’ve got to firmly commit to being more than a taxi service with a little first aid and resuscitation thrown in. This means expanding our scope of services to include mobile community health, illness and injury prevention and control, health and social services of indigent patients, and to strong support of disaster medicine, evacuation medicine, rescue medicine, etc. This will mean lots of education, training, and hard work.

4. We’ve got to earn the respect of the public (including their elected officials), the health care community, and the public safety community. That means shedding the “Ricky Rescue” and volunteer image, the slovenly appearance, the morbid obesity, the sitting around the station between calls, the invisibility (not being involved in community affairs), and the unwillingness to put effort in to anything except a “billable transport.”

5. We’ve got to develop, support, market, and use a new fiscal model. The concept of taxpayer support as a “bad thing” has to be eliminated – public financial support of EMS is GOOD! You simply CAN’T support a decent EMS system on transportation revenue. Our leadership and our workforce has to be intellectually honest enough to make this case, and courageous enough to say “It can’t be done” when asked to provide services on a shoestring.

That’s a tall order. But we are at a crossroads. We can either work our way in to a future where physically fit, professional-looking, positive attitude-possessing, broadly educated medics provide a bevy of important and socially useful out-of-hospital medical and social services, OR we can watch while other allied health professions figure out how to expand their markets by adding wheels to the services they provide. It’s up to us!

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Permalink Reply by Robert Sullivan on October 25, 2009 at 9:22am

The first thing is to shift our mission from primarily life-saving to one that helps people. Anyone who's spent a month on an ambulance knows that true life-saving is rare, but too many of our people believe that you don't deserve an ambulance unless you're going to die. This attracts people with unrealistic expectations of what we do.

I think one way to get here is from education. Increase the standards up front and weed out some of the wanna-be superheroes. Make EMT students spend 16 hours in a nursing home and 8 hours in a dialysis center, and maybe attitudes towards staff will change when they show up there on an ambulance.

Another thing is for alternative transport destinations, injury prevention, and wellness checks. EMS can be a means of helping ED overcrowding instead of worsening it, and provide better service to our customers. In addition to good PR, how much money would be saved if there were fewer hip fractures in a community after an injury prevention program was started? This requires more education to treat the least-sick people who call us, and field providers who are interested in this.

Last, critical care transfers should be done by the same people who answer 911 calls. The education and experience gained from transfers can be applied to people's homes, and we can increase the number of low-frequency, high risk procedures we do for the sickest people who call us. Not many 911 paramedics know how safely stop pre-term labor, but ones who routinely transfer high-risk manternity patients would. Unfortunately in the US, transfer medics usually aren't the ones called to people's houses. This also creates diverse career paths for EMS.

Any change requires a cultural shift that would meet heavy resistance. We need to get active in NAEMT, NAEMSE, and even NAEMSP (you don't have to be a doctor to join). If you don't like a protocol or procedure, do a study on how to do it better. There is a ton of free stuff on the internet on how to do this.

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Permalink Reply by Ben Waller on October 25, 2009 at 4:45pm

Robert,

Why should EMS system design force systems who want to specialize in interfacility transfers also run scene calls? For starters, systems who specialize in transfers don't need employees who are trained in scene safety, the incident command system, interagency operations, and in operating in uncontrolled environments. Scene systems need all of the above.

The frequency of serious scene calls that can benefit from the skills and abilities of interfacility transfer specialists is so low that in the rare places that do something like you suggest, it uses specialists that work in non-transport vehicles...the antithesis of interfacility transport.

The demonstrated need for EMS to stop pre-term labor is essentially zero.

Alternate transport destinations - interestingly, I've been a member of two different EMS systems that tried this. Both stopped doing it over liability concerns and in one case, pressure from a state EMS agency whose perception is that if the patient is sick enough to be transported by EMS, the patient is sick enough to go to the E.D.

Community health and wellness initiatives, great. Lots of agencies already do this, including my current employer. We don't use critical care medics to deliver the education, however. We use on-duty EMTs and paramedics working with a public education specialist with the educational credentials to design and implement the education.

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Permalink Reply by Duncan Hitchcock on October 25, 2009 at 5:17pm

I think that I have stated my opinion and vision in other threads. Being an grumpy old man I really hate having to repeat myself.

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Permalink Reply by Nathan on October 25, 2009 at 5:28pm

Ben Waller said:

Robert,
Alternate transport destinations - interestingly, I've been a member of two different EMS systems that tried this. Both stopped doing it over liability concerns and in one case, pressure from a state EMS agency whose perception is that if the patient is sick enough to be transported by EMS, the patient is sick enough to go to the E.D. .

Well, I think thats where the "It might not be easy" part comes in. There is a clear need for EMS to be able to do this. I hope with the health care reform that we may get a little more freedom to "treat and street" or to refer to other health care providers. So what are your ideas Ben? Lets try to keep this positive, that way maybe more people will get involved with the discussion.

I think home health care is an area we could easily expand into. Im not saying completely take over the field but becoming more involved with it would only be beneficial. This is essentially whats happening with some of the agencies who do welfare checks or are otherwise proactively involved with the elderly and others who need it.

Skip you hit on something that I think is huge, well a few things actually but the one that Ive encountered is being afraid of change. We are a health care provider and we all know the field of medicine moves with leaps and bounds, we've got to be able to keep up. Education is of course also huge and I really believe this is our biggest hurdle

Robert, I think joining organizations like the NAEMT are very important. Even if I wasn't to agree with every little thing they do its about helping to effect overall positive change on the national level. Its like signing a petition. Besides that they give you free life insurance, discounts on all sorts of things and most recently they are offering some health insurance I believe.
I believe joining the NAEMT is very important. https://www.naemt.org/become_a_member/join_naemt.aspx

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Permalink Reply by Ben Waller on October 25, 2009 at 5:52pm

Nathan,

When you say that there is "a clear need for EMS to do this" in reference to alternate transport destinations, what is that based upon? Your opinion? A study or set of studies? The opinions of others?

I happen to agree that the capability would be nice, but I don't know if we can show a "clear need". If we can show an evidence-based clear need, this would already be an industry standard. It is not - at least not yet.

As far as my thoughts, I'd like to see EMS become specialized, much as medicine is specialized.
We need scene call specialists, whose focus is in responding to 911 calls.
We need critical care specialists, who can supplement the 911 responders. Those specialists don't necessarily need to be paramedics - they could be R.N.s or P.A.s, for example.

We also need interfacility transport specialists - CCEMT-P training is a step in the right direction.

We need to get past the mindset that EMS is provided exclusively in ambulances.

An A.S. should be the minimum standard to practice as a paramedic, but we need to have educated field providers involved in designing the educational system.

We need to include everything about the profession in the training/education. If an EMT or paramedic program doesn't include lifting and moving patients, operating the stretcher, operating the stair chair, driving the ambulance, driving other response vehicles, etc. then that program has a big hole in it. Ditto for handling bariatric patients. Ditto for operating at night, in the rain, in high-noise environments. Ditto for technical rescue and hazmat patients and in avoiding getting killed or seriously injured/exposed in that type of environment.

How about teaching tactical approaches to buildings and vehicles. The cops get this training as one of the basics. How about teaching the mindset that we need PPE that will defeat the hazards in which we work. I still see video of medics working extrications wearing no PPE except a pair of exam gloves around vehicles that are leaking a variety of flammable, toxic, and corrosive chemicals, are minefields of broken glass and jagged metal edges, and which are half a lane from traffic running 50 or 60 MPH.

How about including incident command training, starting with the basic NIMS courses and the NIMS Medical Group model?

How about specific required management/leadership educational training for EMS leaders prior to promotion?

How about education in EMS personnel issues? Hiring practices, retention practices, and employee retention systems that do more than an occasional raise and a 5-year pin would be good starting points.

How about systems design that give the system designers a cafeteria menu of things they want from their EMS system? Forcing a one-size-fits-all system might be more efficient on a national scale, but it has the potential to force inefficiencies on local systems who have geographics, demographics, a lack of local fixed health care resources, or other things that put them outside the norm for which a federal system might be designed. At the end of the day, "all EMS is local" is equally as valid for the U.S. as is "all politics is local". The two are deeply intertwined, and seperating them is likely to be impossible. After all, in the U.S., we have the right to vote for things that might not be in everyone's best interest, based upon our own self-interest. Any system that doesn't recognize that fact while depending upon government funding is doomed to failure. That's just my opinion, of course.

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Permalink Reply by Skip Kirkwood on October 25, 2009 at 6:12pm

How about if we get a consistent, useful baseline before we start specializing? We've already got enough fragmentation, and the specialists that Ben describes already exist, de facto.

Who is to require anything? There is no federal mandate, and nobody is going to give them one any time soon. One could hope that there would be a consistent commitment on the part of state EMS directors toward a standard that is applicable nationwide, but that isn't ever going to happen. They are going to continue to be driven by local politics, toward the lowest common denominator - which is where we find ourselves today.

All politics is local. So is all EMS, all firefighting, and all law enforcement. Yet we don't see this mess in other disciplines. Or do we, and we just don't acknowledge it, or don't care about it?

I see a "clear need" for alternate destination options just in the run reports that I read every day. People needing detox need to go to a detox center, people with sniffles don't need an ED to get that solved, people with mental health problems need to go somewhere with mental health capability,etc. Asking for proof of that is like asking for the randomized controlled double-blind study of a parachute!

The root cause of the mess is a failed financial model - we've got to fix that to get to all that other stuff. Plenty of EMS executives know what needs to be done for personnel, retention, training, etc., but they just plain can't afford to DO it!

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Permalink Reply by Ben Waller on October 25, 2009 at 7:15pm

Skip,

I don't disagree, but I was confining my comments to things that I think are practical realities. As admirable as your dream is, I'm not sure that it will ever become viable, given the nature of EMS funding, the divergent interests and baseline assuptions of the various players, and the local focus on keeping costs low as the limitation for everything else in EMS.

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Permalink Reply by Ben Waller on October 25, 2009 at 8:05pm

Mike,

As long as people call 911 with problems that require a mix of EMS, law enforcement, and fire-rescue resources to handle the problem, there will be an element of public safety in EMS. Every auto accident involves the potential need for all three, for example.

The problem with the public health vs. public safety continued EMS battle is that both are partially correct. EMS involves elements of both public safety and public health. Until we all recognize the reality that EMS doesn't fit neatly into one pigeonhole or the other, there is no hope of resolving either that argument or the bigger picture issues we're discussing here.

We can learn from physicians. We can also learn from police chiefs, fire chiefs, technical rescue specialists, hazmat specialists, vehicle service technicians, pharmacists, nurses, engineers...

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Permalink Reply by Thomas Durkee on October 25, 2009 at 8:34pm

OMG really Nathan? You are going to start another post on the Future of EMS???

WHY??

It is the same old stuff. The same old people are posting the same old opinions on the same old problem.


*********************************************************************************

Let me first say that I AGREE with Ben and Skip that the EMS profession does NOT end when the ambulance is parked.


Now, let me get myself into trouble:

1. The very FIRST thing the EMS field needs to do to modernize is to GET RID of the tired, old, stale people in the profession. You know what I mean? These people who advocate for change yet do NOTHING but sit on their collective butts and collect paychecks week after week after week after week after week. How many times do we have to hear "change" yet nothing gets done??!?!

When is the last time you've even gone to JEMS TODAY? I stopped in April, 2007. It is the same tired old people teaching the same tired old concepts. It's a "Review Of this... or a Review Of that..." Capnography with Bob Page? GREAT STUFF!!!!! when I first heard it in 2002. Seven years later it's a little long-in-the-tooth since very few EMS agencies use the technique as part of their daily protocols. Patient Assessment (the 20 commandments) with Paul Werfel? WONDERFUL STUFF!!!! He has taught patient assessment for sooooo many years now, he has that presentatation widdled down to a fine art.

I guess it's not all bad... Zoll and Medtronic usually have new toys to play with and it IS fun drinking beer with the ALS contest winners at the piano bar in Baltimore. But is it any WONDER why so many other organizations are starting their own rival EMS conferences?

And since we are on the subject of tired, old EMS things, how 'bout that JEMS print magazine?? There is a reason why it sits on the back of my toilet. It's all ads, or "words of wisdom" by tired old EMS workers. What happened to the JEMS I used to know?? God forbid an actual learned research study come out of it. Speaking of EMS research, what's new with the Prehospital Care Research folks at the UCLA David Geffen School of Medicine (founded 1992)? Let's take a moment to see what they've been up to:

http://www.pcrf.mednet.ucla.edu/pcrf/resources.shtml

Well, ok... that's 18 year's worth of work.... At least we HAVE a research arm, right? Let's throw more EMS dollars at it.


Until EMS stops practicing the AMR personnel model (hire newbies fresh outta Medic school, let 'em work for a couple years and when they accumulate enough raises, have them train their replacements who are also fresh outta school). Really - - - have you ever seen another profession that eats its old to such an extent? And of course there are plenty of NCTIs or local community colleges that can crank 'em out while getting fat on student loan dollars.



Even the leaders at the top are oblivious. An opportunity to shine a bright light (Maurice White) on our profession? Swing and a miss. NO, wait... nobody ever even stepped up to the plate. A "national swine flu emergency" freeing up federal dollars to healthcare/public health? Hey Tom, stop posting that crap. EMS doesn't want to hear it.

I could go on and on and on.

The profession is rotten to the core. It's stale. Old. Rigor has set in.

Until we can get rid of the old mentalties, more and more educate.d professionals will walk away". As more of our better colleagues leave for greener pastures, we are stuck with the Mediocre... too afraid of taking risks for fear of losing that steady paycheck. Meanwhile Fire will continue to usurp our profession and the idea of a private not-for-profit ambulance squad will be relegated to the history books.


Now, let me apologize for the bluntness. I love EMS which is why I renew my license every three years and continute to work with my brothers and sisters. But I just simply can't afford to work in the professsion. There is ZERO job security and plenty of other opportunites out there. The only people LEFT in EMS are scared out-of-their-wits that the next round of budget cuts will eliminate their position. Skip? Duncan? Ben? How much longer before your community relegates your office to Fire? When does Moses Lake catch up with you?? Where will you go? What color is your parachute??


Please don't castigate me too much for my bluntness. It's just my .02

-Tom

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Permalink Reply by Nathan on October 25, 2009 at 9:04pm

I agree with much of your post.
Even the leaders at the top are oblivious. An opportunity to shine a bright light (Maurice White) on our profession? Swing and a miss. NO, wait... nobody ever even stepped up to the plate. A "national swine flu emergency" freeing up federal dollars to healthcare/public health? Hey Tom, stop posting that crap. EMS doesn't want to hear it.

Referring to that incident, I sent a letter to the NAEMT and they said it "looked like the situation was being adequately handled at the local level. The NAEMT continues to have a strong voice at the national level". Your right, we are terrible at PR.

The question I posed to Skip speaks to the old guys sitting around doing nothing. Right now Im young and I have the energy and time. Ive been able to relatively easily effect change in the hospital where I work. I try to do things in the EMS world and Im met with lots of either red tape or feet dragging. WHY???????? MAN! its so discouraging and frustrating! Thats the reason Im somewhat concerned by the military model, it seems slow or immobile. If the big man doesnt like it, it doesnt fly. (doesnt matter if the big guy is an idiot or lazy) It doesn't have to be that way its just the way it seems to end up.
I dont think our profession is dying. I do think its definitely not "being all it can be". I want to stay in EMS, there is huge opportunity for us as a profession but its deeply discouraging when we stay mired in the way we've always done it. It does seem that many of our best do leave eventually. I think thats a combo of the physical aspect, the pay, and the very very low level of education that is rampant throughout our field.

I look forward to the JEMS mag and it sometimes has some good stuff in it. (the suspended trauma article comes to mind) It is full of advertisements and I guess if thats what they have to do to survive then whatever but Its evolving away from a real "medical journal".



But Im getting a little off track. We do have the usuals on here posting but its only been one day so lets see if some others speak up.

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