10 Reasons Why Modern EMS is Broken
In 1989, my neighbor invited my wife and I over for dinner. It was that evening that I learned he was an EMT, and I was fascinated by what he told me about his job. At the time, I was working in a factory, and had never really felt it was my calling.
During my conversation with him, I found out that even I could get involved with EMS, even though I had no training. He said that the county 911 service he worked for would allow volunteers to come in and drive, while be reimbursed .97 cents for their time. The idea of getting involved in this thrilled me, and I immediately took him up on it. The next day, I was at the station, filling out paperwork to become a volunteer driver, and was shocked to find out that all I had to do was pass a written test that they had created. Before I left I had completed all paperwork and passed the written test, and was now cleared to put my name on the schedule to drive as often as I like.
For the next year I volunteered my time. On almost every shift I volunteered, I was placed on a truck with just myself and a tech. I loved it, and learned the ropes of EMS along the way. It did not take long to realize what I wanted to do for the rest of my life, and I enrolled in the first EMT course I could find.
Becoming an EMT
In late 1990, I completed my EMT-Basic course. Although I did not immediately get hired into the department I had been volunteering at, I had no problems finding work at other departments. It seemed that almost every EMS department around was in dire need of EMTs, and having any kind of experience was something that none of them cared about. I took a full time position and without any type of “warming up” period, I was now beginning my new career.
The new service I was working for was much like the previous. I had a certification, and that was enough. Despite my lack of experience as an EMT, my partners often had even less. While no issues ever came up, I knew even then that something in the system was flawed.
Becoming a Paramedic
Just 1 year after becoming an EMT, I began to look for any Paramedic programs that had openings. In 1992, I was accepted, and by mid 1993, I was a full-fledged Paramedic that was ready to jump into my new position.
I was immediately hired back on to the county 911 service I had originally volunteered at. The training process was little more than riding a few hours with an experienced Paramedic to prove I was capable of handling things on my own. In fact, I had only ridden a total of 24 hours, when an emergency came in while we were short staffed. I was immediately cleared to function on my own, and was now cleared for “solo” duty.
I spent many of my adult years working as a Paramedic. Along the way, I met some really brilliant Paramedics and EMTs. However, I also met many more than I knew really had no business working on their own. The problem is that guidelines must be followed, and until someone makes a serious mistake, there really is not anything that can be done.
A mistake: What does that mean when dealing with the lives of patients?
Why I feel modern EMS is broken
I retired from EMS in 2006. I have to say that I truly loved the career, and to this day, I am still pro-active in supporting EMS. However, I do believe that changes need to be made, as NOTHING seems to have changed since I first started driving ambulances in 1989. Here are some examples of my views and opinions.
- Training processes at all levels of EMS need some serious reconsideration: Every instructor I ever had or met was brilliant. The problem with EMS training lies in the requirements for completion, and even more, the requirements of various providers on releasing EMTs and Paramedics onto the streets. At every stage in the process, there are entirely too many people that have the ability to make subjective decisions on whether or not an EMT or Paramedic is capable of being released to work on their own. It leaves too much room for error, and even worse, it leaves too much of a margin of error. It also leaves too much leniency for liability.What needs done: Training requirements need to be more standardized. A person should NEVER be released to perform patient care without being fully trained and proven to be able to provide it in a more prudent manner.
- Liability: If a cleared Paramedic is right out of school and is working the streets, then who is liable for his/her actions? During my career, I never met, or heard of, a Paramedic carrying liability insurance. It was just assumed that we would either never be held liable, or the service we worked for carried it for us. This is not the case. In fact there are some gray areas in laws that are taken advantage of when it comes to liability. Sure, the service we worked for carried liability insurance, but only to protect them. Had I ever made a serious mistake, I would have been held liable for my actions without having any type of malpractice insurance coverage to protect me. There is no requirement for it, and there should be.What needs done: There needs to be clarity on liability of EMS professionals. There should not be any gray area around this topic. We live in a world that includes people who are willing to sue, just to try and get rich. With the current situation, a frivolous lawsuit upon a Paramedic or EMT would not make anyone rich, but would perhaps ruin the career and financial security of a great person.
- There was a time when I thought I might like to work in another state. Surprised to find out that the state I wanted to work in required licensure for their Paramedics. This meant that my current Paramedic certification was nearly useless, if I wanted to move. The reciprocity procedure would have required me to pay some money, take some tests, and then take an additional course to become “updated.” Huh? I thought I had already taken all the tests needed to be a Paramedic. Am I to believe that a sick person in Tennessee gets different treatments than a sick person in Indiana?What needs done: training of all EMTs and Paramedics in the nation needs to be more standardized. It also needs to be governed by a single body that outlines proper procedures. This is something that is detrimental to patient care, and should be a top priority in insuring that ALL EMS professionals are trained in the same patient care techniques and receive the same updates, across the country.
- There is a National Registry of Emergency Medical Technicians, but why? If you ask them who they are, they will absolutely deny that they set any kind of standards or regulations. All they will claim to be is a group that does testing. Many states require a NREMT certification to become certified in their state, but yet they do not require you to keep the NREMT cert updated. In the state I worked in, I carried 2 certifications: One for the state, and one for the NREMT. After I was tired of paying the $45 re-certification fee to the NREMT, I stopped re-certifying it. There was no need. It was not a requirement to maintain in my state, and it did not really help in reciprocity to another state, so why even bother with it? Also, a Paramedic or EMT can let their cert expire for many years, yet only be required to take a very short refresher course to become certified again. There is no way that a person can retain enough information after such a long downtime that a ‘refresher’ course can get them back up to speed.What needs done: I feel that the current situation regarding the National Registry is a joke. There really is no other way for me to say it. I do not think we need an entity like the NREMT to “just do testing”. I think what we need is someone like the NREMT to handle teaching, testing, and governing, all done by one single entity. For lack of better words, EMS needs to have fewer “hoops” to jump, so that the focus can be primarily on training, and not on legalities.
- While talking to a Paramedic from another state, I was shocked to find out that Paramedics in their state were not allowed to intubate. What? Isn’t intubation a staple in the Paramedic’s lifesaving care that is the top priority of all Paramedics? After all, the first thing they teach you is the ABC’s: airway, breathing, and circulation. Intubation is often required to maintain a clear airway. Why is it that some states allow Paramedics to do some skills they have been trained to do, while other states do not? Should a paramedic be a Paramedic, regardless of where they are?What needs done: Treatment of patients by EMTs and Paramedics across the country should only change when it is necessary for environment or region. In other words, providing oxygen to a patient in Alabama is no different to providing it to a patient in Missouri, so why do the treatments vary so much?
- Documentation is extremely flawed. While chatting with a Paramedic from another department, after a mutual aid run, I was shocked to see that their paperwork was a mere 3 forms to fill out. The service I worked for had a whole bundle of paperwork that needed completed after each run. Why is it that requirements for details and patient information are different, depending on the service and location? Also, it is my belief that documentation protocols are directly related to how easy we can make it on the billing secretary of the provider. The most time consuming part of paperwork is done for billing purposes, and has nothing to do with the transfer of important patient information between health care professionals.What needs done: Paperwork and documentation procedures need to be the same across all EMS platforms. One service should not be required to gather different information than another. Too many times, we see that a volunteer service that does not bill patients are required to only document patient care, yet other services spend thousands of dollars a year on documents that help billing purposes.
- Protocols are something that are created in tandem between the sponsoring hospital and the service provider. However, protocols vary widely between one service and another. This is wrong, and we have known it for years. Obviously certain treatment protocols are bound to vary a little, depending on the treatment guidelines of each hospital, but why are Paramedics in some services given the “go ahead” for multi-dose Epinephrine, while others are required to use bare minimums. Why do some services promote the “stay and play” philosophy, while others emphasize “load and go”?What needs done: the way protocols are currently in place, leaves too much variance between providers. When involved in a mutual aid run, there should not EVER be a reason for the two departments to argue “My protocols say we get to sit on the scene and stabilize the patient”, while the other states “our protocols say we have to load the patient and get them to the hospital quickly”. The idea of scene time is only the beginning of the arguments on why protocol procedures need changed, but in my opinion, it is a good start.
- Supporting certifications are additional certifications that can be obtained by EMTs and Paramedics. Examples are, ACLS, BTLS, PhTLS, PALS, etc… Not all services require the same supporting certifications. In fact, many only require their state’s minimum. In the state I worked, the only supporting cert. we were required to carry were CPR and ACLS. However, many other providers required a whole different set.What needs done: All EMS providers should require the same set of supporting certifications among EMTs and Paramedics. The only variance on this would be to suit environmental or regional needs. An example would be that if a Paramedic is working for a pediatric hospital, then PALS would be required. However, in my opinion, there is no reason why the basic supporting certifications should not already be included in a Paramedic program, and re-certified automatically by completing re-certification for your Paramedic cert. Examples of the basic supporting certifications would be: CPR, ACLS, and PALS. Having all of the current supporting certifying bodies does nothing but offer a means for those governing bodies to make money from courses and re-certification processes. A Paramedic should know how to perform CPR, and it should be the most basic requirement for Paramedic certification each year. We do not need the American Heart Association or the American Red Cross to be separate certification options. Pick one as the standard for a Paramedic cert. include it in the EMT or Paramedic program, and include the re-certification in the annual or bi-annual re-certification or licensure for the Paramedic, not a separate cert.
- If you really stop to think about it, the job of a Paramedic is really a “dead-end” job. Because of the extreme differences between states in requirements, there is no real way for a Paramedic to insure his/her future in medicine. Some states require certification, others require licensure. Some states require NREMT certification, while others do not. Some providers are beginning to require college level education, while other never will. All this does if blur the lines of whether or not an EMT or Paramedic is a legitimate profession, and offers no real means for a Paramedic to advance. Because of this, pay rates for EMS are nearly frozen in time, as providers know that there are so few choices.What needs done: Currently, the only viable options for EMTs and Paramedics are: Using their experience to get one of the few jobs at a fire department, which may offer more alternatives in the future. Taking advantage of the few actual college programs, such as the EMT to EMS Management or the Paramedic to RN. EMS training needs revamped to give EMS professionals a long standing future. The current design, for lack of better words, is designed for young people that can afford to spend some time in EMS before moving on to a new career which would provide for a family. Training needs to be designed so that it provides a means for EMS professionals to advance.
- Lastly, let’s discuss patient care. Patient care is the single most important factor in why we are even on the streets. Why is it that there has never been a standard in how QA is performed among providers? QA/A&R is an integral part in ensuring that proper patient care is always being performed. It COULD be a way that EMTs and Paramedics learn from medical directors and peers. Instead, in many providers, it is simply a way that other EMTs and Paramedics can subjectively pick apart another’s patient care or documentation. Rarely do Paramedics and EMTs get “Official” treatments that are new. In other words, I cannot recall a single time in my career where my certifying body contacted all Paramedics to say “We have discovered something new that all EMTs and Paramedics need to learn.” Instead, once you receive a certification, the knowledge you gain from then on is left up to you and your sponsoring hospital. This makes it difficult to stay up to date on new patient care techniques, and to maintain the ability to provide the very best care to our patients.What needs to be done: QA/A&R should be a requirement across all providers, and not just an option. It should also be redeveloped into a standard format that is provided as a learning tool, and not as a tool that can be used as a contest between EMS crews. I once overheard the crew from one shift bragging about how only 2 of their run reports had been pulled for A&R; while the crew from another shift had 4 of theirs pulled. This is a detriment to patient care, and it only serves to either boost the egos of some or derail the confidence of others.
The rest of the story
In 2006, I not only retired from EMS, but I also allowed my certification to expire. I have since remained active in the EMS community. I love the career I had. In fact, I would say that I am extremely passionate about it. I loved every aspect of it, including the people I worked with, the patients I had the pleasure of meeting, and even the training I had to undergo. However, it saddens me to see that nothing really changes. Many brilliant people fought so hard to carry EMS from the 1960s to what it is today, yet nothing has really changed in the past 20 years. Sure, new equipment, new trucks, better radios, better ways to diagnose (oops, did I just use the “D” word while talking about EMS?), but has anything really changed?
I will forever be happy that I had the opportunity to be involved in such a remarkable career. It taught me things about myself, and about “the ways of the world” that many people live sheltered from. I had the opportunity to be part of a “brotherhood” that will forever remain in my heart. I love what I was able to do for patients, and how I may have affected the lives of countless people in the world. But most of all, I like knowing that I may have saved the life of someone who may someday save the life of another.
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