Administration and Leadership, Columns

EMS Physicians Must Promote Greater Expectations for Paramedics

Issue 2 and Volume 40.

EMS quality improvement (QI) in the age of the physician subspecialty of EMS needs to look much different than in the past.

Classically, QI has focused on administrative indicators as a symbol of efficiency and on gross clinical metrics to determine if our technicians were technically proficient. This must transition to clinician-based metrics focused on qualitative measures, as well as strategies directed at practice improvement.

Some folks will unquestionably argue paramedics aren’t practicing medicine, they’re just following protocols. I understand we’ve been trying to use some sort of Jedi mind trick to convince folks they’re following a prescribed set of protocols and not using independent judgment. But as one of my great mentors Col. Sherman T. Potter would say: “Horse hockey!” The concept of paramedics as protocol followers was outdated at the entry of ALS, and the maintenance of that position is untenable.

We’ve hidden behind this juxtaposition for ages because our industry needed a way to defend the great divide between education and expectations. I’m often criticized by referring to paramedics as “practitioners” or “clinicians” with the retort of, “They don’t diagnose, they just treat.”

I certainly appreciate the difference between a physician and a paramedic—I’m both—but the problem with the retort is that the disagreement is in the wrong place. There’s no question in my mind paramedics are and must be practitioners and clinicians.

To take the position that paramedics are simple technicians is disrespectful to the hard work and difficult decision-making they face every day.

When you see that squiggly line on the monitor and there isn’t a pulse, what leads you to the decision to defibrillate? A diagnosis of v fib!

So why, if we have clinicians or practitioners, don’t we treat them as such?

The Role of Formal Education

I was blessed to train in medicine in Adelaide, Australia, at a time when there was a great shift in the role of paramedics. In the late ‘90s there was an organized push for paramedics to be paid better than nurses. The argument? Paramedics are working independently with limited resources and managing highly complex patients in austere environments. The thing which made me most proud was that the collective bargaining for higher wages was also based on a commitment to provide paramedics with bachelor’s degrees and an additional service-based internship after completion for another 18 months. The push was successful and as a result, paramedics in the South Australian Ambulance Service were making exactly double what I made as a paramedic in Texas the year before.

That was more than a decade ago, so why hasn’t this happened in the United States? First, according to the U.S. Bureau of Labor Statistics (BLS), there are an estimated 237,660 EMTs and paramedics in the U.S. Taking into consideration the median salary of $31,270, a doubling of that would increase the cost for EMS by $7.4 billion. Of course, this isn’t an accurate number because the assertion about the need for increased formal education applies to paramedics and not EMTs. The problem is that the BLS data doesn’t distinguish between the two even though their roles, responsibilities and education requirements are clearly different.

There are significant concerns from employers regarding the ability to double the pay of all paramedics within a jurisdiction. The problem we’ve created in this workforce is an unsustainable delivery model. In many jurisdictions we have ALS ambulances running with two paramedics and paramedic firebased first responders. This dramatic growth in the perception that every apparatus needs a paramedic (or two) is in stark contrast to the evidence that for the significant majority of pathologies, BLS care is best.
This overgrowth of paramedicbased services serves two major disservices to the industry: It ensures the finite number of critical skills and critical decision-making is distributed in such a way that degrades individual paramedic abilities to do both, and ensures salaries stay artificially low to accommodate larger numbers of paramedics within each system.

As a new subspecialty, EMS physicians must be the champions of the effort to reduce the number of paramedics where appropriate in our jurisdictions while we dramatically raise the education and pay for our practitioners. Our evidence demonstrates over and over again for many of our “bread and butter” EMS runs that BLS is superior to ALS. We have to go back to our roots of having smaller numbers of highly trained and maintained paramedics. We’ll still need a large number of EMTs and AEMTs to provide critical services to our communities, but the designation of paramedic or, better yet, “paramedic practitioner,” needs to be reserved for those who’ve passed through the gauntlet of college education.

Until this ideal is reached, we have to be committed to building our current paramedic workforce to meet the expectations now placed before us. The expectation as a subspecialty is that our paramedics will operate like physician extenders despite the current differences.

EMS physicians have an opportunity to engage our paramedic clinicians like never before. In order to do that, we have to first believe they can make tough, critical decisions and then convince them they’re capable of doing so while providing increased oversight. There are many ways to meet this objective, but they have to start from the position of improvement based upon the “standard of care,” not on adherence to a protocol.

The protocol should be a starting point for the paramedic entry into EMS. These clinical guidelines are scaffolding on which to develop one’s practice. Like our newly minted doctors, our new paramedics should operate within strict boundaries and with direct oversight.

As they develop their clinical acumen and procedural skills, they should be given graduated responsibilities and more independence to interpret and move among the guidelines while maintaining a standard of care.

Development is different from experience. We’ve relied heavily on experiential learning, which may be beneficial or harmful based upon the experience and the outcome. Without focused development, our paramedics are in danger of developing flawed decisionmaking based solely on experience.

The dangers of experiential learning and the development of cognitive biases are well documented in medicine. Anchoring bias, confirmation bias, and availability bias are just a few errors we commonly see in our experienced medics.

The EMS physician is uniquely positioned to provide this development due to their education and experience in hospital-based medical education. The professional development of paramedics should mirror those of physicians, physician assistants and nurse practitioners. Concepts of case reviews, journal clubs, and bedside Socratic teaching should not be the exception, they should be the norm.

The industrial revolution for EMS is happening right now and the bar has been raised. We’ll continue to fall short unless we recognize that the way we educate, operate and provide oversight must change.