New Standards/Levels

[Jwade]

To the first comment - I'll state let pilots do their jobs, medics do their and while I can definitely appreciate your input from both sides of the fence I have no qualms about telling a pilot I'm not going anywhere if they are pushing weather minimums or I feel my safety jeopardized. I'm sure the vast majority feel the same way. Safety issues addressed, it's their aircraft, and their job to fly it, just as it is my patient, and my job to treat it. I am definitely in agreement though in that the more advanced certifications the better educated you are the more it helps. I have absolutely no argument with that at all. I know it helped me.

Second point - when released from class the first thing I was told - "you know just enough now to kill somebody"...didn't think it at the time, but later realized how very, very true it was.

I fully agree let people do their jobs, the inherent problem is, how many non-pilots can tell the difference between an 800ft & 500 ft ceiling? 3 or 5 mile visibility? Temp / dew point spread? How many of you can look at Nexrad weather and decipher the radar picture in depth? How many people know how to tune in the ILS or Localizer, or read an approach plate properly?

I am all about keeping my a$$ on the ground if weather is closing in, or could deteriorate in route, but too many times people jump the gun and start quoting something they know minimal about, and this includes flying, medicine, sports whatever..... This is what really irritates me to no end.....

VentMedic,

Nice to see you are still ruffling feathers on Flightweb! LOL......Same old crap over there i see! Hope you are well...

Respectfully,

JW

[fireflymedic]

I fully agree let people do their jobs, the inherent problem is, how many non-pilots can tell the difference between an 800ft & 500 ft ceiling? 3 or 5 mile visibility? Temp / dew point spread? How many of you can look at Nexrad weather and decipher the radar picture in depth? How many people know how to tune in the ILS or Localizer, or read an approach plate properly?

I am all about keeping my a$$ on the ground if weather is closing in, or could deteriorate in route, but too many times people jump the gun and start quoting something they know minimal about, and this includes flying, medicine, sports whatever..... This is what really irritates me to no end.....

Respectfully,

JW

JW - I will not speak as to what I don't know. However, the one incident that stands out in my mind was the desire to accept a flight when the particular county requesting had just had a tornado spotted in their county. Do I think it was inappropriate to accept that? Very much so. It was sheer ignorance to begin with and yes, on an instance like that I am all for putting my foot down. You are trusting the pilots with your life, and yes, if there is a valid concern as to accepting the flight, then I would express my concerns. Though I agree the ultimate decision lies with them and they are the ones that will be scrutinized even harder should something go wrong. I am far from a weather expert and as previously stated, I respect your input as you can speak from both sides of the fence.

However, this discussion is not on flight medicine, so I'll apologize for hijacking a thread here. If you care to continue the discussion JW - feel free to PM me about it.

Now back to your regularly scheduled discussion.

[paramedicmike]

Fix education (read that as change the minimum standards to a four year degree for entry level paramedicine) and everything else will follow.

It might not follow overnight. It might not follow in a month or even a year.

If you fix the embarrassing educational requirements, everything, and I mean *everything*, else will follow.

We are not only fighting ourselves within the profession about this. We are fighting for respect of the rest of the healthcare community...the rest of the healthcare community that requires a four year degree to enter the field. We are being judged on their standards (standards, by the way, which apply to every other field as well.) Failure to live up to these standards will continue to see us left in the dust.

It doesn't matter if you like it or not. This is the way it is.

Fix education and everything else will follow. It really is that simple.

-be safe

[Fox800]

I disagree. EMT-I's in some states, such as Maryland, have just about the same protocol as an EMT-P. I understand the I-85 protocol is vastly different than the I-99 but to say that the EMT-I level is essentially a "filler" is somewhat of an insult.

While I agree that EMT-I may be considered a stop-gap and that ALS should be a 2-year degree, it isn't fair to just say they are a filler and a way to bill for monitoring a lock. EMT-I/99's in most places can do a hellova lot more than monitor a lock.

I think EMT-I/85 should be removed, and I/99 be the new basic level and the scope of practice to include IV's, 3-lead ECG, advanced airway, and code drugs (plus a few more but that's more to debate). EMT-B should be done with, they are valuable members so don't get me on "bashing basics", but they should be I/99's. EMT-P scope should remain the same but be required to be a 2 year or 4 year degree and have the ability to do more diagnosing in the field...

Just my $0.02 worth...

EMT-I(99) seems to me like Paramedic Lite . 80% of the skills, with only some the education. Same great taste, 50% less calories. How is that not a stop-gap measure?

I'm not meaning it to be an insult. I've been an Intermediate myself (although an I-85...Texas doesn't recognize I-99). I'm not implying that someone would "settle" for I-99 because they couldn't make it through paramedic school. I do however have issue with states that use I-99's to compensate for lack of paramedics...or in Iowa's case, calling an Intermediate-99 a paramedic and an NREMT-Paramedic a "paramedic specialist".

I've also found that in most 911 systems, the powers that be aren't quite sure what to do with EMT-I's. Their scopes vary, in some systems they may be the lead provider on an ILS truck or first response unit, in others their ILS skills are sharply restricted. Our intermediates (85) are allowed to perform fluid resuscitation, administer D50%, naloxone, establish intraosseous access, and place rescue airways (King LTS-D). They are not permitted to perform endo/nasotracheal intubation or start E.J.'s, for example.

Your suggestion to make I-99 the minimum may hold some merit. That model is very similiar to Australia/New Zealand's. Their entry-level paramedics are capable of 3-lead interpretation, manual defibrilliation (and in some cases cardioversion/pacing), IV access, ACLS medications, naloxone, dextrose solutions, antiemetics, analgesia, rescue airway placement (usually LMA), etc.

The advanced/intensive care paramedics are trained to interpret 12-lead ECG's, perform oro/nasotracheal intubation, perform cricothyrotomies and needle thoracostomies, administer fibrinolyitics, perform rapid sequence intubation, etc.

I really don't think that oro/nasotracheal intubation should be authroized at the ILS level. You need to have other tools/procedures to fall back on. Surgical cricothyrotomy if efforts fail. Benzodiazepines to sedate the patient post-intubation if needed. Waveform capnography and the necessary skill in its interpretation. Needle thoracostomy if you inadvertently create a pneumothorax. Rapid sequence intubation if your medical director authorizes it. Just having a laryngoscope, some blades and a set of tubes isn't enough.

Edited October 16, 2009 by Fox800

[P_Instructor]

I do however have issue with states that use I-99's to compensate for lack of paramedics...or in Iowa's case, calling an Intermediate-99 a paramedic and an NREMT-Paramedic a "paramedic specialist".

Whoa pardner.....Since I originated this post concerning the different levels and new standards, I was very interested in other opinions. Concerning this statement you made above, just what 'issue' do you have? I am from Iowa, was an 85-I, then took the paramedic course a long time ago and saw the progression of the 99I. Do not pen the phrase 'for lack of paramedics'. There were many other factors why Iowa provided this level, and the term 'Iowa Paramedic' for the 99I was because of the specific topics taught within this curriculum aligned with Iowa's scope of practice. Did I completely agree with this.....no.....but there are numerous other items to consider. This has created a nightmare for some of these individuals currently at the 99I or 85I level on whether to move up or down to the forecasted EMT, AEMT, or Paramedic level. It's a dilema that this post was originally started to see how others within the nation felt about the changes.

[HERBIE1]

Why do you put so little faith into education? Do you think all the professions I mentioned were wrong and they just got their nice salaries out of the blue for no good reason? Their education made them marketable. Once more EMS professionals start taking their own careers seriously, the IAFF will not be able to keep their strong stance. The more you use the IAFF as an excuse for not continuing your own education or discouraging others, the longer they will have a say in YOUR career. If you have not gotten higher education, it is difficult to sell this concept you. If you have never attended a committee meeting at the state or national level, it would be difficult for you to understand how professions are evaluated. For RT at a national level, we can say all RTs entering the profession must have an Associates with a large percentage now having a Bachelors. This is the push we have made for a Bill that puts the RTs with a Bachelors or Masters as an Independent Practitioner realm for reimbursement for certain services. That bill in now its final stages of reimbursement. For EMS at the national level, "we have 50 plus different certs and for the Paramedic level the training starts at 500 hours and one state does require a degree". Now which one sounds better? Yes it is about marketing but only if you allow lobbyists like the IAFF to rule YOUR own destiny. The more in EMS that realize the IAFF does not control what education they get, the sooner the educated can gain some ground. Once RTs took control of their own destiny, all that was left was signing the paperwork at the state and national levels for the Associates degree. The RTs themselves did all the preparation prior by getting their education as they saw a benefit to it for the profession and to their patients. Now, most see how lacking we are with just a mere 2 year degree in the world of medicine.

There are multiple issues here- education, politics, promoting the profession, money, and providing care.

I would also say that all allied health professions are not created equal, so comparing an RT vs a medic is probably disingenuous. EMS is unique in the sense that we operate independently from a traditional hospital setting. We make decisions- guided by established protocols, but essentially on our own. Xrays, ultrasound, MRI's physical therapists, nuclear med techs- all provide a service based on a specific order from a physician. Someone does not seek out radiation therapy on their own, but someone can request and receive EMS based only on their desire. Ultimately a person requests EMS as a means to get treatment from a doctor, but we act as the first line of treatment for that doctor. It's not simply about the level of training, although obviously the argument could be made that more education is vital since we do operate outside the norm of most medical care.

First, I have been an urban medic for most of my career, although I did receive my initial EMT training in a rural setting, and even was trained in Wilderness techniques. That said, I am no longer in that rural setting, but based on what I saw, there is a real need for medical providers in these rural settings. Not only are they lacking in prehospital providers, but they also have very limited options for any medical care. If a volunteer crew is all they can get, then yes, it IS better than nothing. After all, isn't that what this is all about- caring for people who need it most? Once you mandate a certain level of care, along with a mandated level of education, tell me how a small, rural, financially strapped city or county can afford to have their area compliant with these standards? It costs big money to fund an advanced care system, and in many areas, people are hurting. There is a very limited pool of money and resources in these areas and an initiative to ask for more money to expand EMS means another area suffers. At least they have a basic level of service AND that extra money can be used to help a farmer, subsidize a local industry that is struggling, establish a food pantry, or provide social services to needy folks. In a larger area, there are many more options for increasing a revenue stream.

I'm the first to advocate education- Even after grad school I have continued my education, and am even considering pursuing a Phd. That doesn't mean this education makes me a better provider. Minimum standards are the answer, not a bunch of letters piled up at the end of our names on a business card.

The problem with our profession is that we do NOT determine or control our own destiny. The standards we use, the protocols we comply with- are ultimately determined by a doctor, who's license we work under. Mandated national standards are the key.

I've been involved in high level planning and policy drafting- but not in the strictly EMS setting. The single most important thing to be successful at promoting an agenda is politics(also known as clout or power). Unless you have the backing/blessing of an established presence in your arena, even a good idea may die an untimely death.

Yes, in our case the IAFF is probably the biggest deterrent to EMS getting the recognition/respect/pay we deserve, and education certainly is a plus, but don't fool yourself.

Do you really think that all we need to do is throw up some folks with college educations against the IAFF, they will cower in fear, and agree to our agenda? This is about a long established organizational culture, and we are the young upstarts who are threatening their stranglehold on our progress. Most fire services are funded by tax revenues, and EMS is generally a fee for service so each.

I don't know all the answers here, but I do know the trend is for fire service to absorb EMS- NOT the other way around. I do think we need to be realistic as to what we intend to accomplish, especially since our future is not entirely up to us.

[VentMedic]

There are multiple issues here- education, politics, promoting the profession, money, and providing care.

I would also say that all allied health professions are not created equal, so comparing an RT vs a medic is probably disingenuous. EMS is unique in the sense that we operate independently from a traditional hospital setting. We make decisions- guided by established protocols, but essentially on our own. Xrays, ultrasound, MRI's physical therapists, nuclear med techs- all provide a service based on a specific order from a physician. Someone does not seek out radiation therapy on their own, but someone can request and receive EMS based only on their desire. Ultimately a person requests EMS as a means to get treatment from a doctor, but we act as the first line of treatment for that doctor. It's not simply about the level of training, although obviously the argument could be made that more education is vital since we do operate outside the norm of most medical care.

So are you saying that those working in the hospital don't need none of that there book learnin' stuff? Your paragraph here makes absolutely no sense. RNs, RRTs, PAs and NPs already saw their need for advanced education to work outside of an ED or ICU. This could also bring us to the Paramedics that attempt to do CCT half-arsed with a pathetic 80 hour overview of a few basic concepts that pertain to ICU. No Paramedic should be allowed such responsibility without more education. At least that is one thing CA did do right by having predominantly RNs on CCTs and Flight. That state at least knows its Paramedics are not educated to accept that responsibility.

First, I have been an urban medic for most of my career, although I did receive my initial EMT training in a rural setting, and even was trained in Wilderness techniques. That said, I am no longer in that rural setting, but based on what I saw, there is a real need for medical providers in these rural settings. Not only are they lacking in prehospital providers, but they also have very limited options for any medical care. If a volunteer crew is all they can get, then yes, it IS better than nothing. After all, isn't that what this is all about- caring for people who need it most? Once you mandate a certain level of care, along with a mandated level of education, tell me how a small, rural, financially strapped city or county can afford to have their area compliant with these standards? It costs big money to fund an advanced care system, and in many areas, people are hurting. There is a very limited pool of money and resources in these areas and an initiative to ask for more money to expand EMS means another area suffers. At least they have a basic level of service AND that extra money can be used to help a farmer, subsidize a local industry that is struggling, establish a food pantry, or provide social services to needy folks. In a larger area, there are many more options for increasing a revenue stream.

RRTs, Radiology Techologists, RNs and a whole list of health care providers in rural areas have managed to get their 2, 4 and 6 year degrees while living in rural areas. Why is it that EMS seems to attract those that are so incapable of seeking education and use everything they can as an excuse. Believe it or not, education might just bring a change to some of that volunteer stuff. Florida has very rural areas also that were once covered by volunteer. Now it is an all paid ALS state for 911.

I'm the first to advocate education- Even after grad school I have continued my education, and am even considering pursuing a Phd. That doesn't mean this education makes me a better provider. Minimum standards are the answer, not a bunch of letters piled up at the end of our names on a business card.

If you ever get a college degree, it is something to be proud of. Those who have yet to obtain that accomplishment usually make statements like yours. Nobody is asking EMTs to get a Ph.D. Although, if a few did they wouldn't have to use the nurse educators for their academic leaders.

The problem with our profession is that we do NOT determine or control our own destiny. The standards we use, the protocols we comply with- are ultimately determined by a doctor, who's license we work under. Mandated national standards are the key.

An Associates degree is not going to make you an independent practitioner. Why should doctors extend advanced privileges to those with so little education? You are also not going to force a doctor to grant privileges to Paramedics who are not capable of advanced protocols. The type of system, oversight and area will also play a role. Not all Paramedic ALS systems should be doing RSI regardless of the national standard. But, those who are capable can be given great responsibility. Flight Paramedics and some CCTs do have expanded protocols but also have closer oversight and are often extensively trained. Others may just be given 2 hours of orientation in the back room of an ambulance service and that is all. The basic education of a two year degree should be there so the PRIVILEGE of advanced protocols can be granted to the Paramedics by their medical directors. Just because you can does not always mean you or everybody should.

Another example: look at what the RNs and RRTs can do on transport for patients of all ages that most Paramedics have never heard of. They also aren't just responsible for that patient in a truck, plane or helicopter for 10 minutes but may be with that patient for 12 hours. They were able to build upon their basic 2 or 4 year degree to be clinicians that can function anywhere.

I've been involved in high level planning and policy drafting- but not in the strictly EMS setting. The single most important thing to be successful at promoting an agenda is politics(also known as clout or power). Unless you have the backing/blessing of an established presence in your arena, even a good idea may die an untimely death.

Yes, in our case the IAFF is probably the biggest deterrent to EMS getting the recognition/respect/pay we deserve, and education certainly is a plus, but don't fool yourself.

Do you really think that all we need to do is throw up some folks with college educations against the IAFF, they will cower in fear, and agree to our agenda? This is about a long established organizational culture, and we are the young upstarts who are threatening their stranglehold on our progress. Most fire services are funded by tax revenues, and EMS is generally a fee for service so each.

I don't know all the answers here, but I do know the trend is for fire service to absorb EMS- NOT the other way around. I do think we need to be realistic as to what we intend to accomplish, especially since our future is not entirely up to us.

Again, does the IAFF come to you personally and forbid you to go to college? You are using them as an excuse. Once more saw the importance of an education and quality did improve, the 3 month wonders might be scrutinized closer. You need to get past your attitude againt the FDs.

And no it is not the IAFF that is keeping your wages low. For the amount of education it takes some to become a Paramedic, you should be happy with what you are paid as those making minimum wage at other jobs involving more hours of training. You might complain about how bad your working conditions or how much responsibility you have but if you even looked at some of the others jobs out there, you might have a different opinion. If you want to try the argument about responsibility for the patient that is invalid also as you don't see it as enough of a responsibility to see that yourself and those around you should have a decent baseline education to see what type of quality care that can be provided.

I don't know what it is going to take for EMS to see it is about health care and medicine. It is NOT "so different" as some would like to believe. The only thing that makes it different is all the labels EMS uses for avoid the word "medicine". Thus, all we get is excuses for some to not take responsibility for their own destiny. Waiting for someone (or IAFF) to make you get an education is not the correct attitude or path.

[HERBIE1]

Vent, I think you are naive about the IAFF, and also are applying standards from a hospital setting here. Inappropriate.

You also misconstrue and misinterpret what I said. First, simply getting a degree will NOT change the problems in EMS. You need to understand the underlying reasons why EMS is struggling for respectability and recognition. The vast majority of IAFF members have nothing more than a high school education or a GED. They may have multiple classes in HazMat, technical rescue, but their baseline education is the same. Some places require various levels of college education to advance within their ranks, but in most areas, an entry level FF does not NEED a college education.

Why? Because what they do does not REQUIRE advanced training or education. The vast majority of what they learn is technical instruction in a fire academy, and the rest is on the job training.

So, why are they able to dictate and determine the future of EMS in many areas?

It's about established culture. They, along with LEO's are the dominant force in public safety.

Why? History, numbers, and tradition- NOT the level of their education.

More education will certainly benefit the provider, but not necessarily EMS in general.

A college degree or advanced education is not like a magic wand that will cure what ails EMS. It's far more complicated than that and education is only one piece of the puzzle.

We are at a crossroads in EMS, and I think we need to be very careful how we proceed here.

If you are suggesting(as is the current trend) that we transform EMS into something new- ie advanced care providers with multiple certifications and competencies- that's fine, but it's also a fundamental shift in prehospital care. Like I said, I think you are neglecting the impact this would have in smaller areas who would be unable to pay the salaries someone who has these competencies and education would demand.

[paramedicmike]

A college degree or advanced education is not like a magic wand that will cure what ails EMS. It's far more complicated than that and education is only one piece of the puzzle.

Actually, it's not. Education will fix everything that ails EMS. It really is that simple. Fix education and you fix the problems facing the industry today. As I mentioned previously, the fixes won't happen overnight. But they will happen and they will only happen after our backward and damaging attitude towards education is fixed.

-be safe

[JakeEMTP]

The vast majority of IAFF members have nothing more than a high school education or a GED. They may have multiple classes in HazMat, technical rescue, but their baseline education is the same. Some places require various levels of college education to advance within their ranks, but in most areas, an entry level FF does not NEED a college education.

Why? Because what they do does not REQUIRE advanced training or education. The vast majority of what they learn is technical instruction in a fire academy, and the rest is on the job training.

.

This is exactly why EMS needs to be a stand alone part of Public Safety to work along side of the FD and PD and not be some afterthought or source of revenue for the FD.

I do not hesitate to say that a good number of the membership on this board DO have further education beyond the traditional high school and academies. I know that most, if not all commenting in this thread do.

I can not speak for the others but my jest of what Ventmedic and Paramedicmike are saying is, with further education including a AAS for entry into the profession of prehospital medicine, we will become a separate entity because the majority of FD's won't send there recruits to college for 2 years, or attract paramedics to the FD because they have just invested 2 years of their lives minimum, obtaining a EMS degree.

The onus of course, is on the individual to step up and make the commitment. I think we all agree on that. The only thing the IAFF will do is fight such a entry level of education tooth and nail! It takes a lot of commitment to want to do prehospital medicine. My education did not end when they handed me my diploma. Con-ed requirements must be met, there are classes on just about any topic you want to know about if you just search for them. Currently I am working on my BS in Emergency Medical Science. I have a degree in Biology albeit I'd have to blow the dust off it. The education process is continuous. The point is, we as a profession MUST progress to a AAS degree minimum to move forward and try and catch up to the rest of the world when it comes to EMS.

In my home Country of Canada, a EMT-B wouldn't even be allowed on a emergency ambulance. The entry level Paramedic which has a skill set akin to the EMT-I here has 2 years of full-time college education! Somehow, 120 hrs doesn't really compare.

Edited October 16, 2009 by JakeEMTP