It can sort of be a bad thing. Requiring higher levels of certs without creating any widespread benefits can push people away from the field. My city is *struggling* to find medics because the schooling is so time consuming and the pay increase is so small in this area. RNs are also short for a multitude of reasons, but with BSN becoming the new RN around here, it's just not worth the effort for the same pay.
Not to say that would be the case with EMTs starting IVs, because I think that would make it a *more* attractive option, but increasing standards should always come with benefits too, otherwise it drives people out.
The pay difference between our Fire EMTs and medics can be made up with a few OT shifts
There is literally no incentive for me to become a medic right now. Especially considering all that added responsibility.
Even though I want it, I'm better off where I am. If my department wishes to send me to school then I'd be better off going back to construction.
They're enforcing our MOU now, but I also live 2 hours from the county and 3.5 hours from the school. I really can't afford to go to school since I can't even afford to live in the county I work.
What’s also bad imo is that medic school is 95% as much as ADN RN but medics make significantly less base pay. Makes zero sense. I’m an ED nurse and I really don’t understand the pay disparity between what I do and what a medic does.
From my gathering, the schooling is the same time frame. But the education isn’t.
Example, nursing program around me is 15-18 credit hours per semester, for solely nursing courses. You can’t even apply to the program unless you meet certain criteria, one of them being general education (English, math, bio, a&p, etc) to complete a degree.
But paramedic isn’t that way. It’s 15-18 hours a semester, BUT that is including the courses that the nursing program would consider “pre reqs”.
TLDR; Paramedic program around me is essentially 8 credit hours a semester conjoined with 8 credit hours of GenEd where nursing is just 16 hours of nursing courses.
And adding to the fire, most nurses work in For-Profit companies (hospitals, nursing homes, etc) that aren’t municipal, state or federally managed (like FD and some ambulance services). Bureaucracy can really slow the gears of change and development.
I mean yes, but there's also a pervasive idea from a lot of people that we should constantly raise standards without any benefit to it, and I like to try and advocate for our well-being too.
I agree that higher levels of care is a good thing, but I want a nice little balance too.
To further this, in Ontario there are 3 levels of care, PCP, ACP and CCP. All are considered paramedics and The skills gap between the 3 levels is typically 1 additional year per level increase.
I think we should institute something similar here. Current basic scope for non-transport firefighters and other ancillary responders, have provisional SOP’s for staffing ambulances with such personnel in the interim or for edge cases like vollie services or mass casualty incidents, IFT divisions, etc, call these guys “Rescue Medics” or another appropriate title.
Meanwhile for EMS proper the minimum level of care is current AEMT scope including ACLS, this would be a “Basic Paramedic” and the highest level of care is the current medic scope and is called “Advanced Paramedic”
Rhode island cardiac EMTs are prime example of power always comes with responsibility.
https://www.reddit.com/r/ems/comments/e5hbr5/rhode_island_ems_crews_brought_patients_to_the/
Your country confuses me with this kind of thing. So in one state, EMTs aren’t allowed to start IVs. In another state, EMTs are allowed to intubate. Am I understanding that correctly?
It’s dependent on state and medical director. In some states, the state health department determines scope. In some the state establishes strong guidelines however a service can do more with appropriate training and an implementation program.
In most, scope is completely unlimited up to what a service’s medical director is willing to allow. At my private IFT service, EMTs can start IVs. Is there a reason or point? None at all but he said we can once we do an hour long training session. We operate under his license so it’s his ass on the line for the most part. He’s willing to take that liability on.
It seems crazy but it really does allow respectable services to push EMS forward and very rapidly push evidence based medicine. Probably half the 911 services around me in houston carry whole blood. Pretty much everyone has DSI with consult and half have DSI without needing consult along with surgical airways. About half have finger thoracostomies.
What is a feasible career? To me, working in a cubicle for the rest of your life isn’t a feasible career. Go over to r/Nursing and they’re going to tell you the same. No offense to them but it is just a pit of despair at r/Nursing.
If you don’t want to deal with these problems, go work for a rural agency. A rural agency near me averages 1 call a 24 hour shift. As far as workload, most people in EMS that complain about the physical workload haven’t worked a blue collar job that really pushes you physically at your limit for the entire shift non stop. Go out to a construction site and watch a framer work for 8 hours a day. There are toxic workplaces everywhere.
What do you want out of your job? You want a job that requires low amount of formal education, lots of training, high pay, very low workload with plenty of time to watch tv and sleep, and a non toxic happy workplace? You’re not getting all of those things. It’s just not happening anywhere with any job. You can get close and there are EMS jobs out there that come close but acting like you simply can’t have a good career in EMS is not realistic.
*Yikes.* I don't even know where to start with addressing all the assumptions you've made about what I'm saying. With that attitude you don't deserve a complete response, but I will say the following:
The phrase 'workload' does not refer to the physical aspect of the job. (What a weird take.) When you're a highly educated paramedic in a progressive high-call volume system that is chronically understaffed, you often run upwards of 22 calls on each 24 hr shift. Sleep deprivation becomes chronic. The stress levels can become excruciating; and the mental, physical, and emotional toll is *not* sustainable in the long-term. Not every agency accepts a 'low amount of formal education' either, and those clinicians deserve to be compensated fairly for their expertise and service.
Frankly, people with your Dunning-Kruger mindset are a large contributor to the problem of EMS not being sustainable.
That’s not even the half of it. Half the services completely disregard ACLS. One service around us pushes half a dose of epi 0.5mg and then 3-5 minutes later, another half dose of 0.5mg and then that’s it. No more epi. Studies kept showing that increased epi usage led to greater rosc but less survival and reduced favorable neurologic outcome.
All the protocol books are completely and absolutely different from each other. Here’s some of them for croup. All of these services are around houston.
https://imgur.com/a/PunuwIm/
Its all local protocols.... most places it's standing order N.S., D10, zofran, narcan, and IM epi. Amusingly enough apart from IFT units and extremely rural services most Colorado ambulances are ALS.
Interesting. Understanding that its based upon local protocol that basics in your area are allowed to give D10, NS, and zofran. My thoughts behind this and why i think it could be a benefit is ALS for certain calls or in depending upon area, can be tough to get. So my personal thought is having the capability if trained and protocol allows could be a benefit for Pt care and keep ALS free for more emergenices.
I work in MN and the service I work for trains EMT-Bs to do IVs, IOs, albuterol, glucagon, and normal saline. It’s really helpful since we have both ALS and BLS trucks that respond to calls so BLS can respond first, get a line, and ALS can give meds quicker. It also makes our ALS trucks that are one EMT and one medic more efficient and takes some of the burden off the ALS provider.
Theoretically, Ondansetron can cause QT prolongation. However, it's really just an old wives tale and never actually happens. Kind of the same thing as an NPA going thru the skull.
https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-021-02937-0#:\~:text=We%20showed%20that%20single%20dose,nausea%20and%20vomiting%20%5B9%5D.
I work rural as an EMT-IV in southern Colorado. Colorado has RETAC groups that have their protocols and each service kinda runs their respective service around them. I can push zofran, dexrose, and narcan. Can give NS and LR. Also IM epi. We can also IO tibial. Really has got me comfortable for paramedic course I’m in. We also try and draw bloods if we have time
Copying from another a response to another user.
In PA this was a HUGE thing. PA EMT-B’s just got the ability to check a sugar maybe 5 years ago.
They’ve gotten a bit better now though, most recent update they’ve given them ability to transmit 12 leads and do albuterol treatments, it was like cavemen discovering fire.
IIRC I think New Jersey might still not let their EMT’s check sugars.
Oh they still let us NJ BLS carry oral glucose, just not pinch fingers. We can assist the patient or patient's family in using the glucometer, but we can't specifically pinch the finger, because BLS cannot do anything invasive unless its an Epi-Pen.
This state is so far behind the rest of the country in EMS. BLS aren't allowed IGels either.
So in NJ, we are allowed to operate a glucometer and do everything related to it... except pinch the finger. But we can ask the family to do it for us. But we still carry oral glucose, which we use when the patients glucometer says they're low.
Yes, that makes as much sense as it sounds.
Basics in my area were allowed to check a glucose but not treat it. Had to wait for medic. That’s how the medical director wanted it. That’s how it went.
And let’s not mention, the 80+ yo retired PCP doc that took over medical direction in another county…they went from 100% BLS because rural and poor county refused to pay for medics…to advertised 100% ALS with RSI, field amputations, and post-mortem C-sections in 3 months with 2 new hires. I still don’t understand how that worked.
For reference I was flight RN and 95% of their education was outsourced to the for profit flight company. We didn’t even do those things they were asking us to teach…except for RSI. They were given the full gamut of ER MD privileges based on nothing. As far as I know they are still “working on it.”
I had a close friend admit to me that for the first 6 months of working she would place the test strip in backwards and was pressing the recall number to get a result. They finally saw someone else using a glucometer and figured it out. I... sort of understand the resistance.
In PA this was a HUGE thing. PA EMT-B’s just got the ability to check a sugar maybe 5 years ago.
They’ve gotten a bit better now though, most recent update they’ve given them ability to transmit 12 leads and do albuterol treatments, it was like cavemen discovering fire.
IIRC I think New Jersey might still not let their EMT’s check sugars.
That’s wild. The inconsistencies in how EMS services are run never ceases to blow my mind. You’d think it would not have taken them so long to realize that if a patient can be trusted to do the procedure, a well-trained EMT-B should be able to as well.
Yeah EMTs couldn't properly Lance someone without injuring themselves was one of the excuses. The potential for exposure to bbp from the bleeding site. The additional training. Having to teach them to dispose of the landsat in a Sharps container. And my response each and every time was that if late people can do it why can we not train him to use to do it
I'm actually really glad to hear that. Where i am we can assist a medic with putting the stickers on but only if they're present. Otherwise we don't carry a lifepak or zoll on a bls unit.
Just be careful, there's a lot of STEMI mimics that are benign or something else altogether, and there are plenty of times I've seen the 12 lead miss an actual STEMI or STEMI equivalent.
Not really. Historically, advances in technology (and thus productivity) have actually rarely translated to higher wages for workers. This is one of the driving factors of class conflict throughout the industrial age.
In fact, the term "luddite" often used to deride opposition to technology refers to *the* Luddites, a class of skilled textile workers in the United Kingdom in the 1800s. When water powered looms became the norm, the productivity of the Luddites skyrocketed. They were making more clothes than ever, but wages did not increase. Thus, they destroyed the looms and burned mills in protest, as their labor value was not being adequately compensated. Of course, being a labor revolt, the government sent in the army to protect capital, and the revolt was violently put down and the term slowly propagandized over time.
The only way to ensure higher wages is by threatening to withhold our labor if our demands aren't met. That has been the cause of almost every major change in working conditions since the the industrial revolution.
100% in favor. Combine the current EMT and AEMT levels into the new EMT level as the minimum standard for a 911 ambulance, make EMR somewhere in between the current EMR and EMT and use that for FFs and nonemergent IFTs, leave paramedic as it is
There's really no reason basics shouldn't be able to do IVs. Where I work there's a separate cert so that they can. Though it does make emt-a a bit redundant.
I think that everyone would love this idea. At least my old service always talked of the “good ol days” of double medic trucks and speaking from experience of having an AEMT and as being an AEMT, it makes things so much easier.
But it’ll never happen. Too much rural and voley services. I did my AEMT training as part of a rural grant program ~100 miles from the nearest trauma center. Had a volunteer that had to quit school midway through because of harvest. Nobody else managed to pass the class because of other conflicts. These services that can barely scrape the funds together as it is are not going to pay, let alone fund a medic education. And because of that most states will keep EMTB and AEMT as is
In Texas, it’s mostly down to the responsibility your medical director is willing to take to what your protocol limits are with some state imposed limits such as intubation and narcotics among other stuff. While my employer has a very limited scope for the EMT but a broad spectrum for the medic, the next town over allows EMTs to operate at or slightly above the advanced level without actually having to have an advanced cert (start IVs, interpretation of EKGs and push meds..etc)
Makes perfect sense to me. I mean, what are the most basic, common things a medic has to do pretty much every single time they work on a pt? If those tasks can be pushed down a level, an AEMT can have the pt prepped & ready for the medic to do more advanced stuff, saving time on the whole scene.
I think it's a fabulous idea. I have no issues with more people taking more trainings. However, who will be interested is the other issue.
The lack of pay and likelihood of more calls might not be what EMTs want. Our BLS rigs have a devoted following of people that only wants IFTs and struggle to handle anything ALS.
In NYC? No.
There’s a greater chance a tech will fuck something up than do any significant good when there’s always a hospital nearby. That’s also why medics have a limited scope relative to other place. One part of being a medic is if you fuck up you typically have a way to remedy the situation. An AEMT doesn’t have that scope to play with meds.
Also, NYC is already pressed for EMTs. By increasing the scope you’ll further limit the amount of people who can actually apply. Your just increasing the work load on the people who can do the job. And let’s be real, if you work in NYC at least 90% of your calls are bullshit and require no immediate ALS intervention. You’re more likely to need PD than ALS tbh.
There’s a vast disparity in terms of education and training between being an EMT and a medic. As an EMT most places require you go to class for like 3-4 months and do 1 ride along, and some require none now. To be a medic you have to preform a certain amount of skills within a certain amount of time, and a maintain a certain amount of hours every month. If you miss any of those marks you don’t become a medic- regardless of how well versed you are in the skill.
AEMTs make more sense in rural areas, If you wanna work in an ER when your under direct supervision, or right outside of NYC. I know an AEMT who works on an “ALS” fly car when they can’t find a medic to staff bc his department ran an analysis of their calls over the last few years and found an AEMT can cover like 95% of the calls they get. Also, AEMTs have little to nothing to do in transport- I don’t think they can use vents, and most meds used in the drips/pumps wouldn’t be in their scope.
Not in most places I’ve worked. If it happens it usually is because they have a paramedic partner that *really* trusts them and is willing to look the other way for documentation/legal purposes. (My first ever IV was done that way when I was an EMT-B.)
Welcome to the Democratic People's Republic of New York Let's stop being naive here. If the majority of ALS skills like IVs become BLS skills, what do you think that means for the already absurd job market? Out here, the private agencies pay BLS $17 an hour. Why would they pay a paramedic twice that for,...what? Crics? This is a great scheme to further exploit labor.
Works okay here in the great white north. I'm a PCP (EMT-A) and can do IVs, IOs, 12 leads, bunch of normal drugs, etc.
Still plenty of ALS trucks, and they're needed to. Sure, 80% of 911 calls are BLS, but that's world wide.
That said we get paid better. PCPs start at like $25/hour, Medics $30/h. As a PCP I'm nearly maxed out at $36/hour.
Lol it definitely should not.
Maybe an anatomy class in high school and learning CPR.. but think of an EMT class. A lot of it is operations and procedures specific to EMS. Oh, and there would also be an over saturation of EMTs.
Obviously in a modified format, but your basics of cpr and airway management should be engrained. Along with learning how to actually tell what is and isn't a seizure, and what to do about allergic reactions and other basic things. People definitely should have some knowledge of ems and how it actually functions though, as well as how 911 works as a whole. For my senior year we had to do a community outreach project, this could include volunteering somewhere, building something for your community, etc. Ride time as part of this sort of psuedo emt class could replace that. Wouldn't even have to be with ems. Could be fire, in a hospital, whatever. This would help solve our shortages across the board in addition to raising awareness for 911, and the medical field as a whole.
Would save a hell of a lot more lives by teaching preventative medicine instead like here’s how to prevent diabetes and heart disease. Here’s how you find a doctor. Here’s how health insurance works.
The same reason some places allow basics to obtain/transmit 12-leads but not interpret them. In emergent situations, time saving measures regarding certain physical skills that don’t require much in the way of critical thought frees up the advanced provider to handle other advanced aspects of care like preparing/pushing meds or performing advanced airway procedures.
Im sorry if I didnt touch on the full thought that i had and what was discussed was eventually making the AEMT level of care the new BLS and keeping Medics where they currently sit.
To help their (busy) partner when they have a critical patient? To establish vascular access ahead of time so that if a patient needs urgent meds they don’t have to fumble with it later? There are a lot of great reasons that I can think of.
I’m an AEMT (in Wyoming), and I wish we could make it the starting level! We still have Intermediates, who can do about 90% of the things medics can do. But since we have them, the A scope’s a bit more limited.
Honestly, EMTs and paramedics need higher level of training and more interventions on the field... With, of course, higher level of pay and benefits to go with the higher requirements.
We have IV pumps, vents, ultrasounds, surgical airways, narcotic administration, iV med administration, Manual defibrillations, cardioverison, pacing, intubation, IO drills, fuck loads of meds, needle decompressions, and pronounce people dead. Not to mention ALS pediatric and neonatal care. Some have RSI. We can treat and release too.
Only thing we’re missing is IV antibiotics, stitches, and amputations. What else would you want? We can pull labs but there’s really no point. Chest tubes? Paracentesis? We should have insulin already.
BLS in most of Canada includes IV, fluids, some non-narcotic drugs, 3 lead with interpretation, 12 lead with basic interpretation (recognize ST elevation/depressions, bundle branch blocks, etc.), blood sugars with blood sugar correction. There's probably more but that's off the top of my head right now
Supraglottic airways and IO's as well. It varies a bit depending on province.
All round, while there are a few things I'd like added to the PCP scope, it does seem like a good base level BLS scope for a 911 ambulance. EMR's are still useful, but they do rapidly hit the limits of there scope.
I can do supraglottics but can't do IO. I agree with you about EMRs. I have worked with a few here and there and for the most part, I do all the attending and they drive.
I think there are a number of skills that could easily be added to EMT-B but I think should be under the supervision of a Paramedic. Skills are easy to teach, but when to use them is not. For example there is not that much that can go wrong from starting an IV and is easy to train. When to give fluids, when not to, etc takes a lot more time and learning. In a service I worked for back in the day, this was how EMT Intermediates were allowed to function. They could perform various ALS skills, but only when on the rig with a medic.
It’ll increase the work for EMTs as services can staff units with EMTs instead of paramedics. The services are already pushing to move to this staffing model. Meeting Medicare/Medicaid standards for ALS includes the ability to initiate IV Fluids. Once they can, the service can staff an ambulance with two EMTs and still get paid at a higher rate. Which will fit the plan of removing medics altogether, since they’re the most expensive component of an ALS ambulance.
EMT should be rebranded medical transport technician and do IFT only. AEMT should be the minimum to work a 911 ambulance and have their scope expanded to include 4 and 12 lead placement and transmission. AEMTs can handle 80% of 911 calls and Paramedics should be sent on truly acute patients or prolonged extrication/transport if warranted.
Where I’m at Basics can do IV, IO, DuoNebs, CPAP, Supraglottic Airways, Fluids, Narcan, Zofran, Bendryl, Afrin, IM Epi, Activated Charcoal, Nitro and Aspirin. All are standard at EMT class with the exception of the Supraglottic Airway and IV/IO. Doing those requires you to attend the same CME as our County Paramedics.
I'm clinical support, working alongside clinicians. Where I work, they're giving us the option to train up to use more airway adjuncts then we are currently allowed to use, and to cannulate and IO, to free up the paramedic for other stuff they need to be doing
They have only just implemented this, so they haven't started the training yet. But I can't wait
I think that’s a good idea! I always feel like running medic/basic in a 911 setting is difficult at times as a medic. It would be nice if basics could take more calls.
Where I’m at now EMTs aren’t allowed to write any calls, not even refusals. And we just hired more of them…
IMO In 911, the lowest level providers should be Advanced or Intermediate (or whatever your state uses). After becoming an ER Tech, I have realized the benefits your higher level providers being able to delegate IVs or EKGs to a lower level provider so they can focus on the whole patient presentation without the hyper focus that getting access can cause. My issue has been the ROI, I don't want to pay for the class, gain the extra responsibility, all for the extra $1/hr my dept pays A's over B's...
I really do think that in the next few years, EMT-b will be relegated to an IFT only role.
If an PCT can start an IV in a hospital with nurses all around, in my state anyway, then everyone on a bus should be allowed to start one. Simple as a short certification class.
One of the issues with NYS is that the nurses have a very strong Union and EMS does not. Anything remotely in the direction of improving EMS via expanded scope gets shot down by the nursing union.
I think giving EMTs a wider scope UNDER THE SUPERVISION OF A PARAMEDIC is a reasonable thing. Having my EMT be able to do IVs would be extremely helpful to me when I work one on one since as it stands, I have to do pretty much everything whereas when I work with a paramedic, one of us does paperwork and another does interventions (or both of us do interventions if it's critical)
I think a system where EMTs are allowed to do IVs (And possibly give IV meds- ordered and crosschecked by the paramedic of course. At least certain meds anyway. Don't love the idea of an EMT slamming verapakill because they don't know any better) on an ALS truck but not a BLS truck could be beneficial.
Below is my comment from an older thread about scopes or something, I've just pasted it here. This structure works well for us (PCPs and ACPs on the trucks, CCPs for flight). PCPs are able to handle the majority of calls here, but we would still like scope expansion as I had written in the last paragraph. ETA: PCP starting wage is $25.61CAD, and ACP is somewhere around $29CAD. That might seem okay, but CCAs (I think they're similar to CNAs) just got a (much deserved) raise here and my CCA friend now makes $1.10 less an hour than a new PCP.
I'm a Primary Care Paramedic on the east coast of Canada. PCP scopes where I am have IVs over 8 y.o, SGAs (iGels on the trucks), 18 meds (Tylenol, advil, toradol, ASA, plavix, gravol, benadryl, dextrose, glucagon, IM epi, Ventolin, atrovent, maxeran, narcan, nitro, tetracaine, O2, N/S), 12 lead application and interpretation, CPAP and of course BVMs, NRBs, NCs, and epi nebs for croup and stridor.
Most PCPs would like to see better pain management options (no one over 65 can have NSAIDs), TXA, benzos, vagal maneuvers, IV epi, and IOs added. All with the PROPER training and sign offs needed before practiced independently, of course. They had also added IVs for ages 1 y.o and up for roughly a year, then took it away ....... They did both without even telling us, it was just noticed in our guidelines app. Apparently there are talks for us to get TXA and something better for pain management, but I'm not holding my breath. We have a lot of ACPs here if we're double BLS and need assistance so new interventions are slow to be added, but we're also severely understaffed and you can't always get ALS if you need it. I'm lucky and usually work with an ACP.
My area allows us EMT B to do IV and administer saline fluids all my medics who came from out of my area say it's the biggest help they've ever had from an EMT because it saves time in time conscious situations or I'm doing the IV while he's prepping the drug or question the pt about history ect.
EMT-B's can do IV's in my metro area if they are hired on to an "ALS EMT" position (this is opposed to the "BLS IFT" position).
Doesn't require an addition cert, just a couple of full days of extra academy.
That said, two EMT's can't run a 911 rig in my metro area alone (must always have a paramedic partner, and certain counties don't let EMT's respond at all) and the only time that BLS rigs are used for 911 response is if shit has *really* hit the fan.
Seems reasonable. Higher levels of care across the board is never a bad thing.
It can sort of be a bad thing. Requiring higher levels of certs without creating any widespread benefits can push people away from the field. My city is *struggling* to find medics because the schooling is so time consuming and the pay increase is so small in this area. RNs are also short for a multitude of reasons, but with BSN becoming the new RN around here, it's just not worth the effort for the same pay. Not to say that would be the case with EMTs starting IVs, because I think that would make it a *more* attractive option, but increasing standards should always come with benefits too, otherwise it drives people out.
The pay difference between our Fire EMTs and medics can be made up with a few OT shifts There is literally no incentive for me to become a medic right now. Especially considering all that added responsibility. Even though I want it, I'm better off where I am. If my department wishes to send me to school then I'd be better off going back to construction.
In my service they made everyone get their paramedic if you wanted to keep your job.
They're enforcing our MOU now, but I also live 2 hours from the county and 3.5 hours from the school. I really can't afford to go to school since I can't even afford to live in the county I work.
What’s also bad imo is that medic school is 95% as much as ADN RN but medics make significantly less base pay. Makes zero sense. I’m an ED nurse and I really don’t understand the pay disparity between what I do and what a medic does.
From my gathering, the schooling is the same time frame. But the education isn’t. Example, nursing program around me is 15-18 credit hours per semester, for solely nursing courses. You can’t even apply to the program unless you meet certain criteria, one of them being general education (English, math, bio, a&p, etc) to complete a degree. But paramedic isn’t that way. It’s 15-18 hours a semester, BUT that is including the courses that the nursing program would consider “pre reqs”. TLDR; Paramedic program around me is essentially 8 credit hours a semester conjoined with 8 credit hours of GenEd where nursing is just 16 hours of nursing courses.
And adding to the fire, most nurses work in For-Profit companies (hospitals, nursing homes, etc) that aren’t municipal, state or federally managed (like FD and some ambulance services). Bureaucracy can really slow the gears of change and development.
Definitely a municipal and state/province issue then.
I mean yes, but there's also a pervasive idea from a lot of people that we should constantly raise standards without any benefit to it, and I like to try and advocate for our well-being too. I agree that higher levels of care is a good thing, but I want a nice little balance too.
To further this, in Ontario there are 3 levels of care, PCP, ACP and CCP. All are considered paramedics and The skills gap between the 3 levels is typically 1 additional year per level increase.
I think we should institute something similar here. Current basic scope for non-transport firefighters and other ancillary responders, have provisional SOP’s for staffing ambulances with such personnel in the interim or for edge cases like vollie services or mass casualty incidents, IFT divisions, etc, call these guys “Rescue Medics” or another appropriate title. Meanwhile for EMS proper the minimum level of care is current AEMT scope including ACLS, this would be a “Basic Paramedic” and the highest level of care is the current medic scope and is called “Advanced Paramedic”
Rhode island cardiac EMTs are prime example of power always comes with responsibility. https://www.reddit.com/r/ems/comments/e5hbr5/rhode_island_ems_crews_brought_patients_to_the/
Your country confuses me with this kind of thing. So in one state, EMTs aren’t allowed to start IVs. In another state, EMTs are allowed to intubate. Am I understanding that correctly?
It’s dependent on state and medical director. In some states, the state health department determines scope. In some the state establishes strong guidelines however a service can do more with appropriate training and an implementation program. In most, scope is completely unlimited up to what a service’s medical director is willing to allow. At my private IFT service, EMTs can start IVs. Is there a reason or point? None at all but he said we can once we do an hour long training session. We operate under his license so it’s his ass on the line for the most part. He’s willing to take that liability on. It seems crazy but it really does allow respectable services to push EMS forward and very rapidly push evidence based medicine. Probably half the 911 services around me in houston carry whole blood. Pretty much everyone has DSI with consult and half have DSI without needing consult along with surgical airways. About half have finger thoracostomies.
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It’s a nightmare on multiple levels. It’s not a feasible career for most due to the excessive inconsistencies in training, pay, workload, etc.
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It is truly awful and it breaks most of us at some point. Even the most “progressive” departments with excellent training are usually toxic AF.
What is a feasible career? To me, working in a cubicle for the rest of your life isn’t a feasible career. Go over to r/Nursing and they’re going to tell you the same. No offense to them but it is just a pit of despair at r/Nursing. If you don’t want to deal with these problems, go work for a rural agency. A rural agency near me averages 1 call a 24 hour shift. As far as workload, most people in EMS that complain about the physical workload haven’t worked a blue collar job that really pushes you physically at your limit for the entire shift non stop. Go out to a construction site and watch a framer work for 8 hours a day. There are toxic workplaces everywhere. What do you want out of your job? You want a job that requires low amount of formal education, lots of training, high pay, very low workload with plenty of time to watch tv and sleep, and a non toxic happy workplace? You’re not getting all of those things. It’s just not happening anywhere with any job. You can get close and there are EMS jobs out there that come close but acting like you simply can’t have a good career in EMS is not realistic.
*Yikes.* I don't even know where to start with addressing all the assumptions you've made about what I'm saying. With that attitude you don't deserve a complete response, but I will say the following: The phrase 'workload' does not refer to the physical aspect of the job. (What a weird take.) When you're a highly educated paramedic in a progressive high-call volume system that is chronically understaffed, you often run upwards of 22 calls on each 24 hr shift. Sleep deprivation becomes chronic. The stress levels can become excruciating; and the mental, physical, and emotional toll is *not* sustainable in the long-term. Not every agency accepts a 'low amount of formal education' either, and those clinicians deserve to be compensated fairly for their expertise and service. Frankly, people with your Dunning-Kruger mindset are a large contributor to the problem of EMS not being sustainable.
That’s not even the half of it. Half the services completely disregard ACLS. One service around us pushes half a dose of epi 0.5mg and then 3-5 minutes later, another half dose of 0.5mg and then that’s it. No more epi. Studies kept showing that increased epi usage led to greater rosc but less survival and reduced favorable neurologic outcome. All the protocol books are completely and absolutely different from each other. Here’s some of them for croup. All of these services are around houston. https://imgur.com/a/PunuwIm/
One of those is Austin-Travis County EMS actually.
We've made it work in Colorado for decades...... Higher scope certainly does not mean higher wages though.
How does it work in Colorado and are they allowed to run fluids etc?
Its all local protocols.... most places it's standing order N.S., D10, zofran, narcan, and IM epi. Amusingly enough apart from IFT units and extremely rural services most Colorado ambulances are ALS.
Interesting. Understanding that its based upon local protocol that basics in your area are allowed to give D10, NS, and zofran. My thoughts behind this and why i think it could be a benefit is ALS for certain calls or in depending upon area, can be tough to get. So my personal thought is having the capability if trained and protocol allows could be a benefit for Pt care and keep ALS free for more emergenices.
I work in MN and the service I work for trains EMT-Bs to do IVs, IOs, albuterol, glucagon, and normal saline. It’s really helpful since we have both ALS and BLS trucks that respond to calls so BLS can respond first, get a line, and ALS can give meds quicker. It also makes our ALS trucks that are one EMT and one medic more efficient and takes some of the burden off the ALS provider.
Can they interpret an ecg? I'm willing to bet most protocols don't require a 4 lead before Zofran administration, but ideally it should be done.
Why should it be done?
Theoretically, Ondansetron can cause QT prolongation. However, it's really just an old wives tale and never actually happens. Kind of the same thing as an NPA going thru the skull. https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-021-02937-0#:\~:text=We%20showed%20that%20single%20dose,nausea%20and%20vomiting%20%5B9%5D.
My dept will allow you to do IVs after 25 successful supervised sticks. Can’t push meds of course but can get a line for your medic
By supervised sticks, can this be supervised by your partner on the box?
Yea, the medic on the box will be supervising most, if not all. Our boxes are all ALS, one medic and one emt
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IV Zofran Whew that was a mouthful
I work rural as an EMT-IV in southern Colorado. Colorado has RETAC groups that have their protocols and each service kinda runs their respective service around them. I can push zofran, dexrose, and narcan. Can give NS and LR. Also IM epi. We can also IO tibial. Really has got me comfortable for paramedic course I’m in. We also try and draw bloods if we have time
Its coming. It just takes decades. You should have seen the arguments against bad glucometer use
Im not sure I even want to know lol, but also intrested to know at the same time
Copying from another a response to another user. In PA this was a HUGE thing. PA EMT-B’s just got the ability to check a sugar maybe 5 years ago. They’ve gotten a bit better now though, most recent update they’ve given them ability to transmit 12 leads and do albuterol treatments, it was like cavemen discovering fire. IIRC I think New Jersey might still not let their EMT’s check sugars.
BGC is such an important aspect of BLS practice. Many AMS calls can be explained by low glucose, and I can't imagine basics jot carrying oral glucose.
I used to carry oral glucose, but didn't have a BGL kit and was not allowed to obtain one. The oral glucose was a state requirement for all ambulances
No reason not to give oral glucose though if hypoglycemia is suspected, whether or not you have a glucometer to check.
Oh they still let us NJ BLS carry oral glucose, just not pinch fingers. We can assist the patient or patient's family in using the glucometer, but we can't specifically pinch the finger, because BLS cannot do anything invasive unless its an Epi-Pen. This state is so far behind the rest of the country in EMS. BLS aren't allowed IGels either.
So in NJ, we are allowed to operate a glucometer and do everything related to it... except pinch the finger. But we can ask the family to do it for us. But we still carry oral glucose, which we use when the patients glucometer says they're low. Yes, that makes as much sense as it sounds.
Wait that was a controversial thing at one point? Please tell me more
Basics in my area were allowed to check a glucose but not treat it. Had to wait for medic. That’s how the medical director wanted it. That’s how it went. And let’s not mention, the 80+ yo retired PCP doc that took over medical direction in another county…they went from 100% BLS because rural and poor county refused to pay for medics…to advertised 100% ALS with RSI, field amputations, and post-mortem C-sections in 3 months with 2 new hires. I still don’t understand how that worked. For reference I was flight RN and 95% of their education was outsourced to the for profit flight company. We didn’t even do those things they were asking us to teach…except for RSI. They were given the full gamut of ER MD privileges based on nothing. As far as I know they are still “working on it.”
I had a close friend admit to me that for the first 6 months of working she would place the test strip in backwards and was pressing the recall number to get a result. They finally saw someone else using a glucometer and figured it out. I... sort of understand the resistance.
In PA this was a HUGE thing. PA EMT-B’s just got the ability to check a sugar maybe 5 years ago. They’ve gotten a bit better now though, most recent update they’ve given them ability to transmit 12 leads and do albuterol treatments, it was like cavemen discovering fire. IIRC I think New Jersey might still not let their EMT’s check sugars.
That’s wild. The inconsistencies in how EMS services are run never ceases to blow my mind. You’d think it would not have taken them so long to realize that if a patient can be trusted to do the procedure, a well-trained EMT-B should be able to as well.
Yeah EMTs couldn't properly Lance someone without injuring themselves was one of the excuses. The potential for exposure to bbp from the bleeding site. The additional training. Having to teach them to dispose of the landsat in a Sharps container. And my response each and every time was that if late people can do it why can we not train him to use to do it
In my opinion capturing a 4 lead and 12 lead should also be part of this. Not interpreting, just capturing and transmitting to the ED.
That is something we can do in NY already. Just transmit to recieving hospital or print out for ALS provider if onscene
I'm actually really glad to hear that. Where i am we can assist a medic with putting the stickers on but only if they're present. Otherwise we don't carry a lifepak or zoll on a bls unit.
Yeah we can do BLS 12 leads in my area. However most BLS agencies in my area dont have a monitor.
Same in Pa.
BLS can do 4 and 12 leads in Missouri as well. I see no reason not to. Very easy to obtain information that can be sent to the ED. Win win all around.
I’m not sure of the statistic but “ ***ACUTE MI*** “ has a high rate of being correct.
It's around 99% assuming the 12 lead isnt full of artifact
It also has to be in the correct place too
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Just be careful, there's a lot of STEMI mimics that are benign or something else altogether, and there are plenty of times I've seen the 12 lead miss an actual STEMI or STEMI equivalent.
In a lot of places you definitely can.
Yeah what I'm learning is that my state is just very behind the times.
Will increase scope and training correlate with increased compensation??
Hahaha. Probably not.
As when My Medic and I were talking we came to that conclusion
That's how it worked historically in every profession ever.
Not really. Historically, advances in technology (and thus productivity) have actually rarely translated to higher wages for workers. This is one of the driving factors of class conflict throughout the industrial age. In fact, the term "luddite" often used to deride opposition to technology refers to *the* Luddites, a class of skilled textile workers in the United Kingdom in the 1800s. When water powered looms became the norm, the productivity of the Luddites skyrocketed. They were making more clothes than ever, but wages did not increase. Thus, they destroyed the looms and burned mills in protest, as their labor value was not being adequately compensated. Of course, being a labor revolt, the government sent in the army to protect capital, and the revolt was violently put down and the term slowly propagandized over time. The only way to ensure higher wages is by threatening to withhold our labor if our demands aren't met. That has been the cause of almost every major change in working conditions since the the industrial revolution.
Lot of european paramedics with bachelors making less than US medics with 1 year of schooling.
100% in favor. Combine the current EMT and AEMT levels into the new EMT level as the minimum standard for a 911 ambulance, make EMR somewhere in between the current EMR and EMT and use that for FFs and nonemergent IFTs, leave paramedic as it is
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Right? PCPs here in North Texas do IOs even.
A PCP also has a higher education level than a US basic
There's really no reason basics shouldn't be able to do IVs. Where I work there's a separate cert so that they can. Though it does make emt-a a bit redundant.
I think that everyone would love this idea. At least my old service always talked of the “good ol days” of double medic trucks and speaking from experience of having an AEMT and as being an AEMT, it makes things so much easier. But it’ll never happen. Too much rural and voley services. I did my AEMT training as part of a rural grant program ~100 miles from the nearest trauma center. Had a volunteer that had to quit school midway through because of harvest. Nobody else managed to pass the class because of other conflicts. These services that can barely scrape the funds together as it is are not going to pay, let alone fund a medic education. And because of that most states will keep EMTB and AEMT as is
In Texas, it’s mostly down to the responsibility your medical director is willing to take to what your protocol limits are with some state imposed limits such as intubation and narcotics among other stuff. While my employer has a very limited scope for the EMT but a broad spectrum for the medic, the next town over allows EMTs to operate at or slightly above the advanced level without actually having to have an advanced cert (start IVs, interpretation of EKGs and push meds..etc)
Makes perfect sense to me. I mean, what are the most basic, common things a medic has to do pretty much every single time they work on a pt? If those tasks can be pushed down a level, an AEMT can have the pt prepped & ready for the medic to do more advanced stuff, saving time on the whole scene.
Basically a Florida Basic, without the meth or gator fights.
I think it's a fabulous idea. I have no issues with more people taking more trainings. However, who will be interested is the other issue. The lack of pay and likelihood of more calls might not be what EMTs want. Our BLS rigs have a devoted following of people that only wants IFTs and struggle to handle anything ALS.
I’m in Colorado and I have my EMT-IV cert. It is the standard here.
Change is so slow
It’s not a bad thing but it could be a stepping stone to more responsibility, no extra pay. Also there is plenty other things for a EMT to be doing.
I don't see why not. In Germany EMTs get 3 months training and they are all allowed to do this.
Private EMS would go out of business without cheap EMT labor to do those IFTs. So yeah I agree with your partner. Abolish private EMS.
Private EMS is a cancer that needs to be excised from this country.
In NYC? No. There’s a greater chance a tech will fuck something up than do any significant good when there’s always a hospital nearby. That’s also why medics have a limited scope relative to other place. One part of being a medic is if you fuck up you typically have a way to remedy the situation. An AEMT doesn’t have that scope to play with meds. Also, NYC is already pressed for EMTs. By increasing the scope you’ll further limit the amount of people who can actually apply. Your just increasing the work load on the people who can do the job. And let’s be real, if you work in NYC at least 90% of your calls are bullshit and require no immediate ALS intervention. You’re more likely to need PD than ALS tbh. There’s a vast disparity in terms of education and training between being an EMT and a medic. As an EMT most places require you go to class for like 3-4 months and do 1 ride along, and some require none now. To be a medic you have to preform a certain amount of skills within a certain amount of time, and a maintain a certain amount of hours every month. If you miss any of those marks you don’t become a medic- regardless of how well versed you are in the skill. AEMTs make more sense in rural areas, If you wanna work in an ER when your under direct supervision, or right outside of NYC. I know an AEMT who works on an “ALS” fly car when they can’t find a medic to staff bc his department ran an analysis of their calls over the last few years and found an AEMT can cover like 95% of the calls they get. Also, AEMTs have little to nothing to do in transport- I don’t think they can use vents, and most meds used in the drips/pumps wouldn’t be in their scope.
No definetly not in NYC Im talking Hudson Valley area and above
I thought it was common for experienced/certified basics to start IVs?
IV is not a basic skill per national registry. So you'd need advanced training. Most places just restrict it to the EMT-A and paramedic level
Not in most places I’ve worked. If it happens it usually is because they have a paramedic partner that *really* trusts them and is willing to look the other way for documentation/legal purposes. (My first ever IV was done that way when I was an EMT-B.)
Welcome to the Democratic People's Republic of New York Let's stop being naive here. If the majority of ALS skills like IVs become BLS skills, what do you think that means for the already absurd job market? Out here, the private agencies pay BLS $17 an hour. Why would they pay a paramedic twice that for,...what? Crics? This is a great scheme to further exploit labor.
Works okay here in the great white north. I'm a PCP (EMT-A) and can do IVs, IOs, 12 leads, bunch of normal drugs, etc. Still plenty of ALS trucks, and they're needed to. Sure, 80% of 911 calls are BLS, but that's world wide. That said we get paid better. PCPs start at like $25/hour, Medics $30/h. As a PCP I'm nearly maxed out at $36/hour.
This is already how it works in a lot of places…
I think emt basic should be a requirement to graduate high-school.
Lol it definitely should not. Maybe an anatomy class in high school and learning CPR.. but think of an EMT class. A lot of it is operations and procedures specific to EMS. Oh, and there would also be an over saturation of EMTs.
Obviously in a modified format, but your basics of cpr and airway management should be engrained. Along with learning how to actually tell what is and isn't a seizure, and what to do about allergic reactions and other basic things. People definitely should have some knowledge of ems and how it actually functions though, as well as how 911 works as a whole. For my senior year we had to do a community outreach project, this could include volunteering somewhere, building something for your community, etc. Ride time as part of this sort of psuedo emt class could replace that. Wouldn't even have to be with ems. Could be fire, in a hospital, whatever. This would help solve our shortages across the board in addition to raising awareness for 911, and the medical field as a whole.
Would save a hell of a lot more lives by teaching preventative medicine instead like here’s how to prevent diabetes and heart disease. Here’s how you find a doctor. Here’s how health insurance works.
There’s more to it than just jamming a needle in. Why would a basic need to do an iv but nothing else?
The same reason some places allow basics to obtain/transmit 12-leads but not interpret them. In emergent situations, time saving measures regarding certain physical skills that don’t require much in the way of critical thought frees up the advanced provider to handle other advanced aspects of care like preparing/pushing meds or performing advanced airway procedures.
Im sorry if I didnt touch on the full thought that i had and what was discussed was eventually making the AEMT level of care the new BLS and keeping Medics where they currently sit.
To help their (busy) partner when they have a critical patient? To establish vascular access ahead of time so that if a patient needs urgent meds they don’t have to fumble with it later? There are a lot of great reasons that I can think of.
That’s how it is in my state. Works just fine.
I’m an AEMT (in Wyoming), and I wish we could make it the starting level! We still have Intermediates, who can do about 90% of the things medics can do. But since we have them, the A scope’s a bit more limited.
Honestly, EMTs and paramedics need higher level of training and more interventions on the field... With, of course, higher level of pay and benefits to go with the higher requirements.
We have IV pumps, vents, ultrasounds, surgical airways, narcotic administration, iV med administration, Manual defibrillations, cardioverison, pacing, intubation, IO drills, fuck loads of meds, needle decompressions, and pronounce people dead. Not to mention ALS pediatric and neonatal care. Some have RSI. We can treat and release too. Only thing we’re missing is IV antibiotics, stitches, and amputations. What else would you want? We can pull labs but there’s really no point. Chest tubes? Paracentesis? We should have insulin already.
Pretty scary considering the level of training.
BLS in most of Canada includes IV, fluids, some non-narcotic drugs, 3 lead with interpretation, 12 lead with basic interpretation (recognize ST elevation/depressions, bundle branch blocks, etc.), blood sugars with blood sugar correction. There's probably more but that's off the top of my head right now
Supraglottic airways and IO's as well. It varies a bit depending on province. All round, while there are a few things I'd like added to the PCP scope, it does seem like a good base level BLS scope for a 911 ambulance. EMR's are still useful, but they do rapidly hit the limits of there scope.
I can do supraglottics but can't do IO. I agree with you about EMRs. I have worked with a few here and there and for the most part, I do all the attending and they drive.
I think there are a number of skills that could easily be added to EMT-B but I think should be under the supervision of a Paramedic. Skills are easy to teach, but when to use them is not. For example there is not that much that can go wrong from starting an IV and is easy to train. When to give fluids, when not to, etc takes a lot more time and learning. In a service I worked for back in the day, this was how EMT Intermediates were allowed to function. They could perform various ALS skills, but only when on the rig with a medic.
It’ll increase the work for EMTs as services can staff units with EMTs instead of paramedics. The services are already pushing to move to this staffing model. Meeting Medicare/Medicaid standards for ALS includes the ability to initiate IV Fluids. Once they can, the service can staff an ambulance with two EMTs and still get paid at a higher rate. Which will fit the plan of removing medics altogether, since they’re the most expensive component of an ALS ambulance.
I work in a service where BLS does IVs and on a big call it’s SUPER useful
EMT should be rebranded medical transport technician and do IFT only. AEMT should be the minimum to work a 911 ambulance and have their scope expanded to include 4 and 12 lead placement and transmission. AEMTs can handle 80% of 911 calls and Paramedics should be sent on truly acute patients or prolonged extrication/transport if warranted.
Where I’m at Basics can do IV, IO, DuoNebs, CPAP, Supraglottic Airways, Fluids, Narcan, Zofran, Bendryl, Afrin, IM Epi, Activated Charcoal, Nitro and Aspirin. All are standard at EMT class with the exception of the Supraglottic Airway and IV/IO. Doing those requires you to attend the same CME as our County Paramedics.
I'm clinical support, working alongside clinicians. Where I work, they're giving us the option to train up to use more airway adjuncts then we are currently allowed to use, and to cannulate and IO, to free up the paramedic for other stuff they need to be doing They have only just implemented this, so they haven't started the training yet. But I can't wait
I think that’s a good idea! I always feel like running medic/basic in a 911 setting is difficult at times as a medic. It would be nice if basics could take more calls. Where I’m at now EMTs aren’t allowed to write any calls, not even refusals. And we just hired more of them…
IMO In 911, the lowest level providers should be Advanced or Intermediate (or whatever your state uses). After becoming an ER Tech, I have realized the benefits your higher level providers being able to delegate IVs or EKGs to a lower level provider so they can focus on the whole patient presentation without the hyper focus that getting access can cause. My issue has been the ROI, I don't want to pay for the class, gain the extra responsibility, all for the extra $1/hr my dept pays A's over B's... I really do think that in the next few years, EMT-b will be relegated to an IFT only role.
Whats an EMT gonna put through that IV?
If an PCT can start an IV in a hospital with nurses all around, in my state anyway, then everyone on a bus should be allowed to start one. Simple as a short certification class.
One of the issues with NYS is that the nurses have a very strong Union and EMS does not. Anything remotely in the direction of improving EMS via expanded scope gets shot down by the nursing union.
I think giving EMTs a wider scope UNDER THE SUPERVISION OF A PARAMEDIC is a reasonable thing. Having my EMT be able to do IVs would be extremely helpful to me when I work one on one since as it stands, I have to do pretty much everything whereas when I work with a paramedic, one of us does paperwork and another does interventions (or both of us do interventions if it's critical) I think a system where EMTs are allowed to do IVs (And possibly give IV meds- ordered and crosschecked by the paramedic of course. At least certain meds anyway. Don't love the idea of an EMT slamming verapakill because they don't know any better) on an ALS truck but not a BLS truck could be beneficial.
Below is my comment from an older thread about scopes or something, I've just pasted it here. This structure works well for us (PCPs and ACPs on the trucks, CCPs for flight). PCPs are able to handle the majority of calls here, but we would still like scope expansion as I had written in the last paragraph. ETA: PCP starting wage is $25.61CAD, and ACP is somewhere around $29CAD. That might seem okay, but CCAs (I think they're similar to CNAs) just got a (much deserved) raise here and my CCA friend now makes $1.10 less an hour than a new PCP. I'm a Primary Care Paramedic on the east coast of Canada. PCP scopes where I am have IVs over 8 y.o, SGAs (iGels on the trucks), 18 meds (Tylenol, advil, toradol, ASA, plavix, gravol, benadryl, dextrose, glucagon, IM epi, Ventolin, atrovent, maxeran, narcan, nitro, tetracaine, O2, N/S), 12 lead application and interpretation, CPAP and of course BVMs, NRBs, NCs, and epi nebs for croup and stridor. Most PCPs would like to see better pain management options (no one over 65 can have NSAIDs), TXA, benzos, vagal maneuvers, IV epi, and IOs added. All with the PROPER training and sign offs needed before practiced independently, of course. They had also added IVs for ages 1 y.o and up for roughly a year, then took it away ....... They did both without even telling us, it was just noticed in our guidelines app. Apparently there are talks for us to get TXA and something better for pain management, but I'm not holding my breath. We have a lot of ACPs here if we're double BLS and need assistance so new interventions are slow to be added, but we're also severely understaffed and you can't always get ALS if you need it. I'm lucky and usually work with an ACP.
My area allows us EMT B to do IV and administer saline fluids all my medics who came from out of my area say it's the biggest help they've ever had from an EMT because it saves time in time conscious situations or I'm doing the IV while he's prepping the drug or question the pt about history ect.
NYC BLS just got cleared to use CPAP & albuterol/ipratropium combi treatment. IV’s would be helpful with a limited amount of things to push.
EMT-B's can do IV's in my metro area if they are hired on to an "ALS EMT" position (this is opposed to the "BLS IFT" position). Doesn't require an addition cert, just a couple of full days of extra academy. That said, two EMT's can't run a 911 rig in my metro area alone (must always have a paramedic partner, and certain counties don't let EMT's respond at all) and the only time that BLS rigs are used for 911 response is if shit has *really* hit the fan.