UMSTUDENT

Dust, as you know I can speak first hand for one of these programs. At least here, I think there is definitely an issue between between available supply of qualified applicants and the demand for such educational programs. Primary Reasons: A) In the four years that I completed by undergraduate education, tuition soared at state colleges. When I started college, it was actually very affordable. I think my first year my total bill was somewhere in the region of 14k (tuition, room, and board). During my senior year the costs had risen to almost 19k. This is even in a state that has a well established tuition reimbursement program for those students who pursue associates or bachelor's level education in clinical or managerial EMS! I think most of these costs can be directly attributed to our previous governor's short four years in office. He cut higher education funding tremendously in order to achieve his BS $1 billion surplus. He just never explained where he got it. The value of the education seems to have diminished. When I first started I was told about all the "great opportunities" there would be for me when I graduated. And to be truthful, they weren't lying. During the 80's and 90's the program did seem to produce an extremely well-rounded group of successful graduates. State directors, numerous physicians, scores of EMS managers, physician assistants, researchers, etc. For some reason though, and it may be entirely a perception, these great outcomes seemed to stop showing up. I blame a couple of reasons: 1) My school completed an institutional realignment in order to make itself one of the top research universities in the region, if not the country. Our university president, who saw opportunity to place the school on the national stage, began pushing the science education of "disenfranchised" populations as a way to get magazine headlines. When I began my basic sciences during my freshmen and sophomore years it was practically impossible to get anyone to pay attention to a white, middle-class student trying to actually understand chemistry, biology, math, etc. Class sizes were too large for a mid-sized school (I had almost 250-300 students in my Chem lectures) and the professors, who were imports from places like Harvard, Berkeley, Stanford, etc, were focused much more on research than on actual education. I passed and did well, but it costs me my entire first two years of a college (no partying, no social development, and definitely no shenanigans!). 2) The paramedic program is extremely credit intensive. Whereas many majors require 30-40 upper division credits (300 and 400 level courses), the paramedic program consist of 67 by itself to graduate. When you add in the lower division prerequisite requirements to even be admitted to the program , you'll take 117 required credits while at the university for completion of the Bachelor of Science in Emergency Health Services. This leaves no room for a minor or exploration of other classes or enrichment. Many students specifically enter the paramedic program with the intention of eventually matriculating to professional schools (medicine, physician assistant, nursing, etc), but you can't. Not in four years at least. While much of the prerequisite science education overlaps with the premedical students, we are still left without Organic Chemistry, Physics, and Calculus in order to complete more specific course work in Anatomy, Physiology, Statistics, and Psychology that is specific to our major. This is particularly important as you come to finish your senior year and realize you're about to enter a workforce that may be intellectually unfullfilling. 3) Local departments are almost all fire-based. Very few seem to care where you get your paramedic, so long as your have it. Education doesn't seem to be valued. You're taught socially to just keep your mouth shut. Professional development takes a back seat to professional survival. C) Lack of direct economic support. When you're a department of barely 300 undergraduate and graduate students fighting for funding against departments like chemistry, biology, and computer science your budget takes a definite back seat to everyone else. You struggle to pay for the equipment you need, let alone provide direct scholarships or grants for tuition or research opportunities. This is especially important if you're trying to lure qualified students who may have an interest in EMS, but may shy away from the high costs of tuition and large clinical time commitments in favor of a major that may provide a larger payoff in the long run. Don't get me wrong. I got a good education and the people there do look out for you, but its hard. The people who decide to take this route, in my opinion, make a lot of sacrifices in order to do what they think is right. I felt like I was much better prepared than much of my peers when I entered the workforce. I had hundreds of more hours of patient contact experience in an educational setting than every other person I competed with and I was taught by a cadre of different medical professionals. The good thing about acquiring the training in a true "academic" setting is that you get to see, on a much grander scale, how the things you do directly effect the patients you see. I was taught patient assessment by a physician assistant, pharmacology by physicians and pharmacologist, behavioral and crisis intervention by a social worker, EMS management by an actual experienced EMS manager, etc. We were constantly reminded of how we differed and interacted with our peers (nurses, doctors, etc). Is there a demand? I guess. If you want to be a clinically sophisticated, well educated paramedic. These programs, be it Maryland, Pittsburgh, Western Carolina, etc definitely offer that to you. I think the problem is that you then have to find employers who will nourish that commitment to clinically sophisticated paramedicine. Otherwise you just get bored or complacent. What good does that do?

I was recently reading the following article in EMS Magazine during a very slow shift... http://www.emsresponder.com/print/Emergenc...pectives/1$8404 Focus specifically on the section entitled "Esteem Power: How Respect Benefits EMS Recruitment Down Under." The article talks about how in Australia, EMS is considered a respected health profession. At one university in particular I read the following: "Its bachelor's-level paramedic course was the university's fourth most popular choice among prospective students in 2007." This is amazing. How did this happen? What did the land down under do to push EMS into the hearts and minds of its population? Can anyone who works in Australia elaborate as to how this happened? What's the history of the advancement of EMS in the country?

Definitely correct there. Without elaborating further I'm waiting to acquire enough professional/vacation time to start school again on the side. It's a fire department. What else can I say?

Best quote ever.

Thats the attitude that gets people killed. Honestly, I'm not held down by this current employer, but it is a good paycheck and a fairly progressive department. I'd like to think that I'm a fairly valuable asset. If someone wants to have that attitude, and many employers do, they won't keep good people very long. These are the places with high turnover and constant ads in the paper.

Yeah, I'm not joking. The Washington Post Reports the following: Scotch Tape Can Emit X-Rays U.S. researchers have discovered that Scotch tape emits X-rays if it's peeled off its roll in a vacuum, a finding that may lead to the development of inexpensive, portable X-ray machines for paramedics or for use in remote locations. For the study, a machine was used to peel Scotch tape off a role in a vacuum chamber at a rate of about 3 centimeters per second. This produced rapid pulses of X-rays, each about a billionth second long, from the area where the tape was coming off the role, theAssociated Pressreported. The researchers even managed to make an X-ray image of a finger. The study was published Thursday in the journalNature. "We were very surprised," researcher Juan Escobar, a graduate student at the University of California, Los Angeles, told theAP. "The power you could get from just peeling tape was enormous." Escobar noted that Scotch tape only produces X-rays in a vacuum, so normal use of the tape poses no health hazard. http://www.washingtonpost.com/wp-dyn/conte...02301585_2.html Ah, the future is coming. From such unlikely places.

Yeah, I had another bad night. Got one good hour of sleep right before I got off. Was up all day, and right as we dozed off we got a call for a MVC with reported rollover. Got canceled, came back, finished documentation, and right as I was getting in bed we got a call in the outskirts of our area for chest pain. Totally BS. I'm also being told that I may get reassigned to a station with a more consistent, steady call volume during the entire shift!

How is what you just said any different that what I said? Dentists/Surgeons made strides to separate themselves from centuries of failed practice such as blood letting, leaching, etc that seemed to "make sense" but really just did a great deal of harm. Oh, and killed our first president... I'm saying that most of what we do is based on this same premise. Just because a certain intervention has a benefit in the hospital environment does not mean that those same skill sets, when implemented by the majority of providers in the field, will produce those same benefits. People realize this. Doctors...the people who control what we do are starting to catch on. Inevitably what I'm saying is that there are thousands of paramedics in the United States. The majority, I would imagine, aren't you Dust. I've found that successfully determining when to use certain invasive skills or push certain medications often relies on a careful mix of education, observation, and talent. By the very nature of our profession we often only get one shot at doing it right and we have far fewer options to reverse course if our decisions are faulty. When you're operating in a world like we are, under the conditions we are, with the workforce currently available, you're 'bound to get research results that point to reform. We don't disagree that the current problems need fixed. I just don't think you're going to achieve meaningful results by beating the same drum.

Damn you're bitter. That's why I love you Dust. I've never disagreed with you. I think, minus the rhetoric, that you're 90% correct. I really do deeply agree with you. I think you should really scrap EMS all together Dust. It's done. It's failed you. That's where we differ. You can't undo what's been done to it. You just have to manuever around it. Make giant leaps in order to preserve a dream. As for Cowley's Ghost Comment: You know a lot about us...a lot actually. BUT, I should be the first to tell you that a lot of people messed up that dream. It's not like that anymore and I wasn't taught that way. The stuff you hear is mine alone, not someone else preaching. I love these arguments because somewhere I believe that it'll be these arguments, one day, that will be had in conferences. Stats, tables, PowerPoints. Yep. Some day people like you and me won't be confined to message boards. Same vision. Different experiences. Different outlooks.

I'm not talking about You or We, or Our. We'll be extinct in 40 years...at least in the form we see today. Stop worrying about "we" and worry about "them." The future...those guys and gals who will be educated and trained well enough to do the job. My whole point is that prehospital emergency care as we see it today is a joke. It is 50% science and 50% nonsense that gets destroyed by hundreds of years of fire-oriented tradition. For every amazing innovation that our forefathers brought to our industry we diluted our mission with countless more "interventions" that probably don't make much of a difference in survivability when implemented in their current fashion. Everything we do is good...just often not in the hands of the people we choose, or at the time we choose, or the place we choose. Look where our profession is going. Advanced interventions like intubation and needle decompression, when placed in the hands of this generation's paramedics, are harming more people than helping. First line ACLS drugs may be of little benefit if not delivered earlier than what we can currently achieve. Good, consistent CPR along with induced hypothermia is leading the way in cardiac arrest survival. ALS interventions that focus more on weighing the risk vs. simply doing. Acting prudently instead of acting quickly. Research is suggesting that we better implement ourselves in the overall disease process. 1.Preventing disease through proper preventive care...wherever it can be administered. 2.Educating the public to initiate EMS services when they are most useful. 3.Responding in a timely manner. 4.Initiating interventions that can be safely performed in our setting with maximal benefit. That means weighing the cost of doing it in the field vs. doing it in a controlled setting. If time is really essential, then research and develop a means to safely eliminate and mitigate the risk in the field. 5. Developing new diagnostic technologies that can be deployed to the field. 6. DEMANDING higher professional standards. Higher education. Entry-level competencies.

Agreed. I can see very few needs for such invasive skills in EMS. Looking at the APP as a glamor position is wrong. It should be more of a bridge between emergency interventionalist/primary care in the home.

Chest tubes are definitely not a DOT curriculum skill...

Dust, seriously. I've never known you to be politically correct or anything on this forum, but damn. I respect Dr. Myers for many reasons. I respect that he is a medical director who was trained in an EMS fellowship first and foremost. Second, I respect what he is trying to do. You're absolutely right. You and I both know that skills like drug assisted intubation and transport decision making are things taught in a good paramedic program. My thinking is that Dr. Myers needs to sell this idea to the public. Whether you agree with it or not, the home is where the paramedic's future is. The current system doesn't work. We spend more money annually on health care than any other western nation with continually disappointing results. My idea, at least from I was taught about public health, is that there is probably a deep socioeconomic and cultural divide between our version of Western Medicine and what will really work given our diverse, American population. The future will be about mitigating injury and illness and about approaching illness during it's most infant phases...where it first happens. Call it stupid. You may be right. Call it misguided. You might be right. BUT, there has to be some sort of professional preservation, or our profession, the "largest hoax ever foisted on the American People", will be erased into history as nothing more than an experiment. The Ontario Prehospital Study was the beginning. More and more research will begin debunking our practice. Our fall will be a combination of poor intuition (skills that don't work, but made sense) and poor professional standards (idiots making us all look stupid). Our profession is full of unprofessional fools and fire monkeys who are degrading the meaning of being a paramedic every day and nursing, with its far more elaborate professional representation, is simultaneously assisting us in this goal. Someone is going to get smart and start doing research into the efficacy of every, tiny thing we do. And one day, while we were all sitting on a couch in a station, someone's going to publish our end. Someone is going to prove that 85% of what we do offers no decrease in mortality or morbidity when done in the prehospital environment. Not because it is categorically true, but because when these skills are given to the majority of providers...people die faster/have worse outcomes. It will be a world of BLS... APPs with advanced education for an advanced health care solution. I hope they do have Master's Degrees. Hell, I hope they're fully licensed PAs. Whatever that means...it means more education. It means producing a future of kids who grow-up, go to college, and become professional, educated paramedics. Somewhere I believe there will be better health care. If we keep drinking our Koolaid, we'll be pushed under the rug. Nurses started out as nothing more than assistants to physicians and now represent one of the most respected professions in the world. Hm, somewhere they even convinced the world to let them have individual practice. I'm not suggesting such grand things, but I am suggesting advancement.

I recently started a new career with a fairly large municipal service as a paramedic. It's not my first job as an ALS provider, but my first "structured" career-oriented job. Not exactly certain how long I plan on staying with this department, but the following is worth asking: In our service we run a intercept car/chase car system. This is a large metro department and the paramedics function similarly to police officers in that we have a cruiser/SUV that we and only we are responsible for during the day. The SUV is set-up to provide full ALS upgrade to career and volunteer BLS ambulances throughout the county. We are assigned to stations, either fire or EMS only, but essentially operate under our own guise...in most places even independent of career firefighters that are within the station (even though it is an integrated department). We're really just asked to be paramedics, which is extremely nice. My problem is this: My current station is extremely slow during much of the day and picks up tremendously at night as satellite commuters return home from work, get liquored up, and crash crap or realize they're suddenly sick. We work 24 hour shifts. The upper echelons pretty much mandate that we remain conscious, alert, and in full Class-B uniform during most of the entire work day (0600-2200 hours). Uniform code is extremely rigid as are pretty much all SOPs. We're only allowed out of uniform and into PT clothes during physical training. The issue is that we spend much of the day doing nothing, finding busy work, or just staring at a TV waiting for stuff to happen and then at night, when we're exhausted, sh*t hits the fan. I know some buddies who work for several large metro fire departments and/or flight services where they are allowed, usually under union contract, to engage in "safety naps" during the day. Some of these services even allow their crews to put the unit entirely out-of-service should they feel "tired" or "unsafe" without repercussion. My issue is that as of lately I've felt like I've been on the verge of "unsafe" in regards to sleep. Not there yet, but given the wrong day or a bad nights sleep before, I could be. I've been getting calls almost every night as we go to wind down and then in the early morning right as I'm approaching a deep sleep. I wake up disoriented and exhausted. I've even noticed what I believe to be a declining IV success rate during these hours. My question is this: Does your service have these "safety naps" or does it have a liberal policy regarding sleeping during the day? Is this unreasonable? Keep in mind that we often respond miles out of our immediate area, alone, and without significant cover units (back-up or supervision). At night, especially, we work almost entirely with volunteer ambulances that often get out late or fail entirely. Sometimes you can seriously be on scene for quite sometime without any additional personnel. Typical call turn around, including reporting, can be as long as three hours.

I agree with everyone regarding one short fall of the Wake County experiment. I think providing a paramedic with advanced intubation skills is probably a bad idea. If every time you, as a "regular" paramedic, try to intubate and some guy or gal shows up and steals it, how will you ever develop a skill level? If Wake only means to provide a chase car-based paramedic with some experience, I'd be disappointed. My system already does this: we call them EMS Lieutenants/EMS Supervisors. Furthermore the idea of being in a chase car/SUV looses its luster if you're like me and the paramedics I work with and your entire system is designed that way.

Because not all of us have shortfalls. I think I'm more than capable of doing my job to a high standard-on a daily basis. There are plenty of paramedics out there who are at levels of profeciency. Yep, I said that. I agree with it. Like I said, I'm not opposed to them simply being prehospital physician assistants. If it makes you feel better, take the word "paramedic" out of the entire equation. I think this is a big downfall for a lot of people. The whole idea of having to get a Master's Degree is just petrifying. At least if it got boring you could move into a hospital.

While I generally agree with much of what you say, I do disagree with the narrow focus of "sticking to one thing and going it well." Unfortunately I think as more and more research becomes available there will be data coming out suggesting that much of what we do and respond for is of little benefit to some patients. More importantly that the conventional interventions we engage in today really, in most cases, does not significantly decrease the morbidity and mortality of many diseases. I think what we'll find in the coming years is that most disease processes are best fought with time honored prevention and maintenance of disease. This is where the paramedic, where the profession, has the opportunity to progress and advance. From what I've gathered about Wake, they're going to have more than just the gambit of skills that paramedics should be educated to do. Trust me, I understand that things like DAI (RSI) and prevention issues should be found in current paramedic programs, but I've also heard that Wake and other jurisdictions are attempting to pass through refusal of services, home medication maintenance, basic scripts (heard third-hand), and diagnostic referrals. What I'm worried about is the idea of simply giving current paramedics, who may or may not have the education in physiology to back these skills, the capability with just a couple months of "extra" training. The idea for the APP works. The Brits have implemented it with initial success. Financially is where it shows the most promise. As I've said, and they are now discovering, keeping people from costly hospitals for basic illnesses is simply the best fiscal decision and the best option for the patient and family. I'm totally in your camp. I'd prefer the program to require a Master's Degree. For that matter I wouldn't be against it being a PA program with a speciality in prehospital medicine. I just simply think there is a place for this. I appreciate the response though. This is the stuff I want to hear.

The theory is correct, but several underlying factors destroy the really awesome idea that the PUM is. The most successful systems that I've seen (from the perspective of a paramedic) seem to utilize a hybrid version of the public utility model system, generally adopting its principals and virtues and leaving behind the nitty-gritty contract requirements and technical details of a true public utility model system. The first flaw in this argument is that it is wrong to charge the "insurance companies" and poor "patients" for the service. PUMs really take advantage of a free market economy by trying to place the burden for service in the hands of the people who are actually using the service. When you take into account the cost-of-readiness, staggering cost of inflation on medical practice, and really crappy Medicare/Medicaid reimbursement policies, a thousand dollars for ambulance transport is probably a reality. The only reason most services get by with charging typical Medicare Schedule fees is because they are offset by local tax revenue. Even worse is the organization that refuses to bill thinking they are providing a valuable "community service" to their constituents. The only people they're helping is the insurance companies for whom the "real customer" pays premiums. Stout, Finch, Dean, etc were all famous for bringing to light the real problem with health care in general...especially in EMS. "The User is not the customer, is not the payer." As Stout is famous for saying, "Emergency victims make poor shoppers." EMS is an example of a fragmented economy. The PUM simply looked to reduce costs and increase quality of service by making the industry somewhat competitive to a consumer base. By creating an oversight authority (a central theme within the PUM), Stout wanted to create accountability for the people while trusting elected officials to continually reevaluate competitive private firms. Important to Note: 1.EMS Systems function best when there is only one provider (Natural Monopoly) 2.The goals of any system are to provide response time reliability, provide a quality service, and do this at the lowest costs to the consumer. 3. Like a utility company, powerful economies of scale exist. The more people, the cheaper it becomes to provide a service. PUMS work best with large populations which is why regionalizing services beyond simple geopolitical areas works so well (Ex: Oklahoma-Tulsa). When was the last time you saw a power company provide a service to just one county? The largest problem with PUMs seems to have occurred when nobody got in the business. Without a plethora of private firms bouncing around the country competing with each other, communities, with their well-established ambulance authorities, lack a true choice. I think that when you really look at the contribution of the PUM, you're forced to look at number 2 above: 2.The goals of any system are to provide response time reliability, provide a quality service, and do this at the lowest costs to the consumer. Stout and friends introduced our world to accountability and effective, patient care oriented businesses. In essence the PUM became relatively extinct because people couldn't come together to really make it work. I think this is why when you find systems that did it the right way, all of the time, you see great success. Places like EMSA and Pinnellas County, FL. You must also look at the PUM from the perspective of a manager-not a paramedic. When forced to provide a quality service to the public in a feasible, cheap way, while still retaining enough revenue to provide for continued development and reinvestment...the PUM works. Look at any large, successful company from Wal Mart to Starbucks and you will see some of Stout's basic economic principles at work.

When voting in this poll please only vote if you can contribute with a response. I want serious answers as to why or why not. A recent post sparked my interest in this thread. Apparently there are several jurisdictions across the United States that are toying with this idea, including several states that are seeking approval from their relevant State Medical Boards to begin implementing paramedics with expanded "critical" and "primary" care roles. I find this interesting after the idea was so quickly shot down in the first round of discussions regarding the new National Scope of Practice Model. I personally, as some of the regulars here know, believe this is the future of our profession. I thought it was at least 5-10 years away, but apparently there are some progressive jurisdictions who are starting to seriously consider the concept even earlier. For those who are not familiar, our British cousins have already developed such a program in the form of their Emergency Care Practitioner. References: http://www.gatheringofeagles.us/Presentati...20EaglesAPP.pdf http://www.wakeems.com/blog/?p=57

I would hope that your service does routine training on RSI. Most services that I've heard of have quarterly requirements to maintain the skill. Either so many documented intubations using paralytics or so much time in an OR. Any handout or pocket card should probably be customized to your department's procedures. I mean it would depend on the type of sedative, paralytic, etc depending on the situation. Some services use different drugs for different situations or pre-dose with certain medications.

If Wake is starting a true Advanced Practice Paramedic...I'll move, hell, I'd probably take a pay cut. So long as it stays true to the concept of high educational standards, increased capabilities, and a focus on more primary care practice. I want to hear more...

I think Dust brings up a valid point. EMS, at least where I'm from, is a very cliquey organization. I know several people whose job placement I can attribute simply to the people they know or don't know. In fact, there are more than a couple organizations within EMS/Fire Depts that act more like frats or political steering committees than anything else. Not everyone will always have an "in" with these types of organizations, but you may simply know someone who does and not even know it. Put people on your application who are respected in the field and who you have developed a good relationship with. A supervisor might say, "Hm...I went to college with Richard. If he'll vouch for this guy then he can't be all that bad."

We're not in disagreeance. The "system" I was referring to was the trauma decision tree, not the entire Maryland system which is plagued with problems. Maryland has plenty of rules in place already about flying stuff, but as you've said, people make poor decisions. As for your comment about inappropriately flying category C and D trauma patients, perhaps I'm unclear. Absolutely it is wrong to be flying these paients and absolutely this is a poor choice by ground providers, but my point is that some have justified it by the poor performance of area hospitals. I'm simply saying that there are multiple psychosocial factors in why providers fail to follow protocol and make these decisions. I mean we both understand that the majority of the individuals out there making decisions are not always making those decisions based on hard medicine. When a provider takes a level III trauma center a simple femur fracture and that center then turns around, calls a private helicopter, and then sends that patient to Shock Trauma anyway you begin to wonder about the overal competence of the hospital. The reality is often not so simple...we both understand this. Level III trauma centers must often call in orthopods or trauma surgeons from home, generally with a 30 minute ETA. Occassionally these surgeons are either out-of-range or simply unavailable to respond to the hospital, thus an otherwise "simple" trauma will get a private helicopter bill to fly someplace they could have already been sent. Providers start working around the system. Is it right? No, but it happens. The problem can be fixed from multiple angles. Category C and D patients do occassionally have life threatening issues, although a more competent clinician will generaly pick-up on these things and either advance their category or make a more appropriate transport decision. The problem here is the word "competent."