Reply from Gorrillamedic on Improving EMS part 2

EMS systems are still primarily paid for transport. So long as this is the case, we will continue to be the bastard step-children of healthcare. We need to be clinicians, treating patients, but to do this (on an industry-wide scale) we need to be paid as clinicians primarily. Now, this is not as simple as going to the powers-that-be and saying, “Hey, I diagnosed an anaphylactic reaction and treated it with epinephrine, albuterol, Benadryl, famotidine, and Solu-Medrol. I did everything the ER would do, so pay me what you’d pay the ER.” We need to prove our worth to the healthcare system first, and this means that we, as an industry, need to be able to point to how EMS clinical care in the field saves money overall. Mobile integrated healthcare and community paramedicine programs are popping up in progressive services across the country and are a good step in that direction.

We also need to stop being technicians and start being clinicians. If you don’t read medical journals—why not? If you’re not seeking out advanced knowledge—why not? What we learned in paramedic school is a starting point but I’m convinced it’s not enough. Hell, in my school we really didn’t even talk about 12-leads, only learned how to place them and transmit them (admittedly this was a WHILE ago and a lot has changed). Now, We should be able to identify which vessel has a lesion from a STEMI 12-lead. We need to know how to differentiate sepsis from pneumonia and pneumonia from CHF. We should know why CPAP works for asthma and how it works for CHF (and how the two are different). We need to be comfortable with using PEEP on your patients. We should know what Early Goal Directed Therapy is and how it is relevant for our patients and their transport destination. We should know what dobutamine and Levophed and dopamine are and how they work (and what they work for). 

And this goes for EMS systems too—they need to be developing and encouraging clinicians. If the clinical director doesn’t know the above things, they shouldn’t be leading. EMS systems need to be doing research. Continuing education ought to be a focus. QI/QA shouldn’t focus on how closely protocol was followed but on whether or not care provided was clinically sound and beneficial to the patient.

Part of becoming a profession of clinicians means we need to focus in on how our delivery of service affects our quality of care provider. The biggest 911 EMS provider in my regional trauma council happens to be the worst. They routinely will transport patients to the hospital without getting a set of vital signs or doing even a rudimentary assessment. They (with a few exceptions) simply do not provide patient care, only transport. Why? Because they are a large city fire service, one of the top five in the nation. Most of their ambulance crews are firefighters first, and EMTs a distant second. Most (that I’ve talked to) don’t have a passion for EMS and don’t particularly care for. It would be like having an ER physician whose passion is law, and who got his MD just so he could get a job in a hospital to practice law. That environment—which is common to most of the combined Fire/EMS services I’ve seen—won’t lead to a system of clinical excellence and won’t encourage those who do care about EMS to develop into the clinicians we need to become.

A similar thing can be said about non-critical-care transfer work: the dialysis runs, discharging patients from hospital, and the like. I’ve done it, and I know how boring and inane it can be. It doesn’t encourage growth or even good morale most the time. And around here, private services are more than likely small, pretty unorganized companies that invest nothing in their employees and discourage them from finding a career in EMS.

We have to create environments that encourage that growth in EMTs and that expect clinical excellence. Only then will the public begin to see real value in the care we provide.

I remain optimistic that we will see, in our lifetimes, EMS take a more prominent role in healthcare. I think we will see pay increase some; probably not as some would hope.


(I found these points very well said and an important aspect of improving EMS. I will touch on some of these in the upcoming parts of Improving EMS. This response can be found on his blog at )

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