This is the second installment in my rant about the interlopers to our profession. As promised, I will attempt to explain how things got like this. It is important to know that it might not be this bad yet in your location. It depends on where you work. I was a guest not long ago on this podcast and found out that there actually are people who get paid to be a paramedic. However, in my part of the country, things are getting ugly. I thought that when things got critical as far as staffing, that the money would follow. I was wrong. Some places have made it abundantly clear that they would rather go BLS then pay a paramedic a salary that is comparable to other fields. I suspect that the new national accreditation model for paramedic education may be the straw that breaks the camel’s back. That is a bold statement that needs explanation which will be the subject of the rest of this post.

Paramedics are in a very precarious position right now. We don’t know it, but we are between a rock and a hard place. We are dangling off the edge of a cliff. We are in -insert metaphor here- kind of bad shape. Let me count the ways that paramedics are threatened:

1. It is almost impossible to make money at an ambulance service, yet we are expected to. I have no idea how any of the places I have worked stay afloat. EMS has so many panic values as far as running a business is concerned that the success of any program is a true brain teaser. If I were a venture capitalist, and someone like AMR or Rural/Metro gave me a pitch on their business model I would laugh in their faces. After I regained my composure I would have such questions as, “How in the hell can you make money when about half of your customers don’t pay for the services you give them? Could a store survive if half of the goods were shoplifted everyday?” I would also ask, “What were you smoking when you dreamed up a business that has more employees than customers? Let me get this straight, you want to have two caregivers for every patient you see? And those guys are going to sit around doing nothing most of the time? Would you run a store that had 20 employees on shift while only 10 customers at a time where in the store? Oh but wait, most of the time no customers are in the store, and only half of them pay you for what they take away.”

EMS is expensive, and the number one expenditure is payroll. So being the most expensive person on that payroll puts us in a precarious position before we even start our career. It wouldn’t be so bad if we got a free ride like the police and fire departments. Are police expected to bill callers and balance income with expenditures? Is the fire department responsible for making money when people call 911?

2. We have created our replacement, the EMT-I. Everyone seems to have an idea of what the EMT-I or the EMT-A is for. I will tell you what it really is. It is the future of paramedicine. If you take an EMT, hand her a KING LTD airway, an AED, and teach her to start IV’s and give fluid, how close is that person to replacing you? Add epi, nitro, albuterol, and a few other drugs to that scope of practice as well. Now look in the mirror and truly ask yourself, “How many calls did I make in the last three months that were truly outside of that scope of practice?” And don’t forget to ask yourself, “How many of those patients would have made it to the hospital just fine under that limited scope of practice?” Technology is quickly making people with less training and lower wages just as functional as we are. Don’t think that when push comes to shove you will not be replaced during a budget crisis. The prospect is just too attractive.

3. There are no advancement opportunities for paramedics. How would you like a job with ZERO upward mobility? If you are a cop, there are many special teams to join and many ways to get promoted. Canine, SWAT, detective, bomb squad…you name it, the police have it. Extra responsibility usually comes with a promotion and a raise as well. And the fire department? Don’t even get me started there. The fire service is the only place I know of that actually has more supervision than front line employees. I once worked for a small fire department that would have eight people in the building on average. The rundown went Chief, Assistant Chief, Captain, Sargeant, and four firefighters. Guess where I was. Guess who worked on the ambulance?  Some departments would have a lieutenant in there as well. If you have worked for a fire department for over five years and you have not been promoted, you need to leave. Something is wrong.  Either that, or you probably work on the ambulance.

In contrast, a good medic can be stuck on a truck for a 20 year tour without any chance for promotion. A service of over 200 people can be run comfortably with about 10 people in the command staff. Every opening that comes up will have 100 internal applicants and 800 external applicants. How do you like those odds? Get used to that truck. You are going to be there for a while.

4. Paramedic school has become more difficult, time consuming, and costly, yet the scope of practice has not changed at all. This is an alarming concept that I have been wanting to articulate for awhile. When I went to paramedic school (many moons ago) I went to class twice a week for four hours. I did about 200 hours worth of clinicals, and then 240 hours of ride time. The training took 12 months and at the end of it I was able to start IV’s and IO’s, intubate, read ECGs, defibrillate, pace, cardiovert, and push a bunch of drugs.

Here is what my last paramedic class looked like: two classes a week for four hours…but get this, the classroom portion alone takes 16 months. There is almost 300 hours of clinical time and almost 500 hours of ride time. The process takes almost two years from start to finish. And what kind of scope of practice do we get for this training? We can start IV’s and IO’s, intubate, read ECGs, defibrillate, pace, cardiovert, and push a bunch of drugs. Hey, wait a minute…

To be honest I am a big proponent of teaching paramedics more about their craft. But in a large service, the educator will be alone in that opinion. The rest of the command staff will be saying, “I want a guy that can start IV’s and IO’s, intubate, read ECGs, defibrillate, pace, cardiovert, and push a bunch of drugs. I want that guy quick. What you are offering me is the same pig in a dress. How can we cut corners here?  Hey, what can an EMT-I do again?”

5. Our predicament is fueled by the fact that there are fewer paramedics every year. Why? Because this economy is rough. It’s all about choices. Imagine that you are a newly minted high school graduate who does not really want to go corporate, feels like doing something exciting, and starts looking at health care and/or public service. Lets see…paramedic…over 1200 hours of instruction with a high fail rate and low starting wage. Hmmmm. Fire fighter…400 hours of instruction, higher starting salary, and everyone kisses your ass and brings food to the station. Cop…a few months of the academy and a higher starting salary…take home car…guns and badge bunnies. Lets see…nurse…about the same kind of education as a paramedic with a higher pass rate and a much higher starting salary and tons of advancement and lateral opportunities.

What would you choose? Honestly.

What we are seeing is the perfect storm. Paramedics have painted themselves into a corner. Insert another depressing metaphor here. Who would enter into a profession with all of this brewing? Terrible pay, long hours, weird shifts, no advancement, and complicated training with a high fail rate. Who would do that to themselves? The answer is, “less and less every year.”

Okay, so lets go back to this interloper subject. I have been spouting off for awhile without answering the question, “Why are so many apathetic people seeking refuge in our profession?”

Because we have very low standards of entry, and we get what we pay for.

Have you ever applied to be a cop? It is a lesson in stamina, but there is a clear reward at the end. Same thing for fire fighter. What about RNs? Have you seen the nursing shortage numbers. There is no such thing as a nurse that can’t find work. However, you have to go to college first. So that gauntlet is there. But what about EMTs? Anyone who can read or write can sign up for an EMT course, and in four to five months they will be on the street killing patients. There is no barrier to work. I have had interviews where I left with a uniform shirt and a schedule. The pay checks are low, and the respect is lower. We let it happen.

Out of all public service, EMS is the easiest entry point and we get the dregs. It’s that simple. But despite this simple fact, one of these EMT’s with a King LTD, and AED, a bag of fluid and some drugs can do 90% of my job at a much lower pay rate. If your service is going broke in a tight economy, what would you do?

So who is the kind of person who applies for a job like this? To be honest, someone who is down on their luck. Someone who needs a job and benefits quick. And we take them, clean them up, pay them little, and train them to be the closest thing to being a paramedic they can be without going to school for 20 months. And when they ask, “Do I really need to know this?” we say, “No. You don’t.”

Most of my paramedic applicants are bored interlopers who are hoping that paramedic school will be easier than it is. “Why shouldn’t it be? Don’t I already do that job?” In a way you do.

So how do we fix this? I have an idea! Lets all go get degrees and make ourselves just as respectable as the other guys!  Okay, so where does that get us?  We just made it even harder to perform that same old scope of practice.  Now we are pigs in an expensive evening gown.  An EMT-I can still do our job, the same as before.  Why don’t you push atropine on a high degree heart block?  Did someone say something about widening the block?

Soon I will post my outragious idea to fix this.  But beware, it isn’t pretty.  There will be wailing and gnashing of teeth, and blood will run in the streets before it is over.  But that pretty picture will have to be in my next blog post.  Until then, keep the faith.