Should EMS wages be call based?

[tniuqs]

Well quite an entertaining thread, especially concerning the AB the Rural vs Metro, and replying out of a personal request

Just may have a little experience in: rural, remote, urban, suburban, turban and tepee, both ground and air in AB but that is not the point at all, moreover the historical perspective in the development of EMS in Alberta and just attempting to establish I have seen many sides of these fences, but now I am observing some concertina wire getting strung up <sheesh guys>

One point is they are all very unique in their own ways and all challenging providing care. If was asked and the amount of ass time, comparableness and one to another it would be that of comparing apples to oranges meh a waste of breath quite literally.

One should be paid for what you KNOW, as opposed to what type of service one chooses to work in. The entire concept of pay based on call volume or types of calls or length of shifts is way counter productive, it is a blue shirt mentality, quite frankly.

Secondly the point is when there is any controversy or any "in" fighting about job equity, pay checks or work conditions (whatever) The Prime "employer" is very pleased and happy when that situation occurs, as without solidarity in any union or association your hooped for any success in negotiations even before one sits down at the big round table.

In fact this is a prime example of the Divide and Conquer Technique applied to labour negotiations. Its far more systematic related in the bigger political picture of folks living in Urban AB to Rural, just the area of Health Care to start scraping the surface, and will I predict with the "super board" type controversies will be a topic for discussion with the upcoming election, Wild Rose go get em I say !

Now facts as I perceive them of the pay equalization are a direct result of when the Conservatives in the "take over to perfection and bigger is better er unmanageable phylosophy' and taking over a entire system (that actually worked fairly well before) so if at the municipality level funding had increased this entire cluster would have been nipped in the bud. Without any actual tangible plan, just a concept applied and lets just see how many migraines we can generate and reinvent the wagon wheel .

Yes one can see the huge improvement LMFAO ! New chezzy uniforms made in Thailand by child labour and new generic paint jobs on the sides of the most of trucks, then generating protocols that DO NOT address the very different needs of the communities, not purely evidence based just "expert opinions' of the government chosen trio, the good the bad and the fossil I call them. Protocols established but no new drugs or equipment on the truck to acually follow them ..epic failure.

From the initial budget of 110 million for "take over" well its closer to 480 million now and its not yet anywhere completed, any government involvement results in exorbitant costs with VERY little change to the quality of actual delivery of said services.

Thirdly: AB Employment Standards dictating what Union (the lesser of 2 evils CUPE vs HSAA for the government perspective) to represent that entire "group of labours" oddly enough because your actual rights in Canada to "organize labour" were stomped on.. plain and simple. We got "controlled" by big brother Alberta Conservatives ... that move was fundamentally a blatant contravention of the Canadian Constitution .. if that happened with our brother and sisters south of us it would have become a civil war.

Remember that the entire reason for this was because Calgary took a Strike Vote in 2008 and at that time, the Minister of Health dodged a bullet and claimed that EMS in Calgary was not an essential service but a lockout would result in a "local emergency" .. then curiously within a year the Essential Services Act forced through the legislature .... hmmmm .

Siff:

In fact, I've give you my next paycheque if you walk up to one of the STARS medics and tell them their critical care skills are shit. You appear to know it all so it shouldn't be an issue for you.

My Dearest Siffalass:

Can I take you up on that offer ? PLEASE .. and just which rock STARs Paramedic would you like me to do a snap quiz with first ? LOL. Although I would prefer a few home made bottles of wine and hand delivered in lou of your pay-check that is. <insert wink>

Just to be very clear there is no Critical Care Level established in Alberta, yet the starboys have developed their own independent in house standards of supreme excellence better than all the rest of we lowly grunts in the ditches, but awesome PR once again.

If ANYONE "represents oneself" as a CCP-Flight in AB no matter what their real credentials may be, they could be subject to investigation for unauthorised use of that title by the College ... just saying it there was a release of that to the registered members on a group email a year ago.

cheers

multiple edits due the fact I was abducted by aliens in a limo last pm and was forced against my will to go bar hopping and getting asked to leave 3 bars .. a personal best for this group of aliens but unfortunate still feeling the after effects ... oh my aching head

Edited October 23, 2011 by tniuqs

[JPINFV]

JP, the problem I see with that theory is, first, you begin to have medical decision significantly influenced my monetary concerns, and next you have Bob and Leroy fighting over Ms whoever's call because she always turns into a transport.

That is worst case scenario of course, but as humans, particularly where money is concerned, we seem to take the low road too often.

Dwayne

I'm not sure if your response is meant seriously, because if it was then you took my post seriously, which was not the intent of my post. My post was meant more of a poke than a serous alternative.

Serious note: Keep what you kill works for some emergency medicine physician practice groups because physicians can treat more than 1 patient at a time, unlike EMS. As such, it's easier to get a mix of the higher paying, more complex patients, as well as the higher volume quicker patients. Similarly, issues with one patient and billing isn't nearly as bad if the other 5 patients you're seeing at that time pay.

[DwayneEMTP]

I'm not sure if your response is meant seriously, because if it was then you took my post seriously, which was not the intent of my post. My post was meant more of a poke than a serous alternative.

Serious note: Keep what you kill works for some emergency medicine physician practice groups because physicians can treat more than 1 patient at a time, unlike EMS. As such, it's easier to get a mix of the higher paying, more complex patients, as well as the higher volume quicker patients. Similarly, issues with one patient and billing isn't nearly as bad if the other 5 patients you're seeing at that time pay.

Yeah man, the tongue/cheek went right over my head...

Dwayne

[Siffaliss]

I wonder if Mother, Jugs, and Speed is on Netflix?

I have it on DVD. It's certainly not on crappy Canadian netflix ...

[Tactical Spork]

I guess there is a way view US Netflix in Canada. I should look that one up online. I bet it would cost extra but if you get a ton of extra content then perhaps it would be worth it.

Kind of related, but have you ever noticed how EMS is featured in movies? Sometimes it is less than favorable. As mentioned Mother, Jugs, and Speed come to mind. Bringing out the Dead comes to mind also. Not sure my feelings on that one, as I thought the book was quite good.

Dwayne do you get Mongolian Netflix?

[Siffaliss]

I guess there is a way view US Netflix in Canada. I should look that one up online. I bet it would cost extra but if you get a ton of extra content then perhaps it would be worth it.

You need a US IP address and yeah the content is WAY better.

[mobey]

questions for the people who think we should be payed less in the rural, although I am short on tiime:

1. If we are justifying lower wages in the rural setting by saying skills are weaker because of low call volumes, aren't we showing a level of acceptance for the crappier patient care?
   
2. Is every provider in a rural setting weaker at specific "skills" than thier metro counterpart?
   
3. Is there any data/studies showing minimum repetition numbers to keep ones skills in the "competent" column?
   
4. If Metro workers come out to the rural, are they entitled to a higher wage based on the "superiority" of having a history of multiple short emerg calls compared to the rural counterparts?
   
5. Can a city EMT (especially on an ALS car) be "weak" as far as skillset of competence is concerned?
   

BTW Siff: Rather than tell off a STARS medic, I have a few on Fb. I'll ask them if Metro medics are superior to Rural medics, being sure to mention things like infusions, transport vents, antibiotics, blood transfusions, chest tube complications, you know..... that stuff we see during our long critical transports here in the remote setting.

Again, not saying we are superior out here..... just sayin we all have our strengths/specialties.

Dwayne: As per your Salary post.

Seems as though you are punishing the whole for the actions of a few.

Check out this model.

Every Medic starts at $25/hr and tops out at $35/hr.

There are incriments or "steps" that a practitioner moves up usually annually based on job performance and continuing education attendance. If one does not qualify for his anuall "step" increment, they are given 90 days to correct the deficiency then reviewed and or disaplined as necessary. Yes, this depends on quality management... that is another thread.

In this model, those shitty employees get left behind, while others excel. Also, it is fair for all based on education/attitude/competence.

[systemet]

Let me start by saying that I don't have recent experience in this system. I don't want to post my identity on the forum, but if anyone wants to pm me, I'll be happy to chat more candidly.

I agree with squint that there's an element of "divide and conquer" here. As long as providers are fighting each other, they're not organising for the common good. Whatever inequities exist in the system, they won't be solved by one rural line medic and one city line medic arguing over who's got the better skills. Just as the various FD and EMS system clashes in the past were never fixed by two front-line providers getting in each other's way on a call.

I think that the rural providers have been historically underpaid. It's good to see their wages brought up to par. If this has had to happen at the cost of stagnation in the bigger centers, then that's a shame, and obviously undesirable. I imagine a positive with this change is that it must now be possible to leave the city after 10 years, go to a quieter rural service, and not have to take a huge pay cut. In the past a lot of the senior guys would have had to take a huge hit to do this.

I'm a little biased towards the urban providers, I have to admit. I also agree with squint where he suggests that there's a lack of a real critical care level in AB. It seems a little silly to have AOCPs including Swan-Ganz monitoring, ABG analysis and x-ray interpretation when very very few providers have had more than a few hours of training in these areas, have more than a cursory understanding, and are unlikely to be exposed to them on anything approaching a regular basis.

Is running a transfer to the city with an intubated patient and a pressor running critical care? Maybe. But then, is doing a 12-lead, and giving tenecteplase, plavix and enoxaparin critical care? Perhaps. Because that's been done in the big city for 10 years now. My experience has been that any system has it's five percenters. This even includes STARS. I can't argue if the average rural medic is better, or the average city medic (I could accept the argument that the average STARS medic might be). They're different roles. I can understand the frustration of flexing all over Planet Earth, doing hallway nursing and running inner city calls. I can also see how working rural, doing LDTs for patients with antibiotics hung, and being on call when you get home can be pretty tiring too.

It will be interesting to see how AHS manages to attract providers to the less desirable services / positions, now that they can't simply raise the wage for a given region.

I'm woefully out of touch with the current situation, however my suggestion would be that the best thing for EMS in AB would be to increase educational hours, and extend the training for both EMTs and paramedics. Move to a Bachelor's degree program, as the RNs did, and provide a more solid basis for clinical practice. If I recall, paramedic training has been 2 years since the early 80s. And despite all the scope of practice changes, and increasing responsibility, it hasn't been extended a day since. This would seem to be a critical issue to address.

As an aside, regarding the skills argument. Obviously competency is a range. It's not a binary outcome. Some people are more competent than others, and will find themselves at different places within that continuum. There's been studies suggesting that cardiac arrest survival is higher when patients are intubated by providers with > 25 ETIs in the last 5 years [1]. This is obviously subject to a lot of confounders, and some of the odds ratios are a little sketchy There data showing that paramedic students success rate improves as they intubate more patients, and they suggest a minimum number of ETIs for initial training is ~ 25 intubations / student [2]. This is probably fairly intuitive. It's also been shown that paramedics that intubate more frequently have higher success rates [3]. There have also been many reported studies discussing the effects of restricting intubations for paramedics who perform less than 6-12/year [4][5]. A decay in intubation skills following paramedic training has also been described [6]. It's not like this hasn't been investigated, although obviously it could use some further study.

Without straying too far off topic, skill decay and retention may be a particular problem for the rural paramedic [7], but is also an issue in the urban setting. I'm sure there are city medics who aren't intubating 6 times a year (and six times a year might not be enough, especially if the success rate is 0%, or the patients are traumatised / subject to excessive hypoxia / hypercapnia, etc.). This is why there should be a good quality control and continuing education program in place to meet the needs of providers that aren't getting sufficient exposure to skill practice.

All the best.

[1] Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.Out-of-hospital endotracheal intubation experience and patient outcomes. Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14. Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071147/?tool=pubmed

[2] Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR.Paramedic training for proficient prehospital endotracheal intubation.Prehosp Emerg Care. 2010 Jan-Mar;14(1):103-8.

[3]Garza AG, Gratton MC, Coontz D, Noble E, Ma OJ. Effects of paramedic experience on orotracheal intubation success rates JEM (2003) 25(3):251-256

[4] Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE. Endotracheal intubation in a rural EMS state: procedure utilization and impact of skills maintenance guidelines.Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6.

[5] Wang HE, Abo BN, Lave JR, Yealy DM.How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations? Ann Emerg Med. 2007 Sep;50(3):246-52. Epub 2007 Jun 27.

[6] Zautcke JL, Lee RW, Ethington NA. Paramedic skill decay. J Emerg Med. 1987 Nov-Dec;5(6):505-12.

[7] Youngquist ST, Henderson DP, Gausche-Hill M, Goodrich SM, Poore PD, Lewis RJ. Paramedic self-efficacy and skill retention in pediatric airway management. Acad Emerg Med. 2008 Dec;15(12):1295-303. Epub 2008 Oct 25.

[ERDoc]

I used to assume that rural providers were weaker providers due to lack of experience, but after some discussion on here over the years, my opinion may have changed. Sure, more urban providers run more calls, but how much do they get to do in the time they have? When I was a volley we were 7 minutes from the ER, 12 minutes during rush hour. Treatment was started on scene but the pt was quickly moved to the ER. I did 1 ride along with NYC EMS (I know, huge n of 1) and it seemed like that cardiac arrests were worked on the scene and everyone else was worked in the ambulance enroute to the ER. Rural providers may not have the volume of calls but they spend a lot more time with the pt. When they get a critical pt, they have to be able to manage them for longer periods of time. So, which is more important, volume of calls or time spent managing pts? I don't think I have an aswer.

[BushyFromOz]

in reality, the whole metro/rural EMS is just an extension of the whole city v's country shite that runs in every day life, usually propgated by people who have either lived in or worked in only one of those environments yet has a "solid" opinion absed on conjecture and what a friend of a friend told them