This fall I welcomed a class of new recruits into the Austin-Travis County EMS System. I was impressed by the excitement in the room and the enthusiasm for the positions these folks were about to take on. Some were newly minted EMTs, some seasoned paramedics, but all were motivated to be a part of this great system.
Then I asked the question that has been burning within me regarding the future of this industry: “How many of you are interested in going to nursing school?” Half of the room raised their hands. Half of the newest recruits had the desire as a career goal to do something else.
Perhaps my gloomy interpretation of that show of hands is misplaced. Perhaps they just want to augment their EMS education with a nursing education, be both a nurse and a paramedic and work on a helicopter service, or moonlight in the ED. Regardless of the motivation or intention, whatever it was they sought, EMS couldn’t provide for them. It reminded me that, despite the fact 25 years have passed since I started in this field and the mountains of advances we’ve made clinically, EMS still remains a stepping stone to doing something else.
Of my close friends in EMS back in the 1990s, those who haven’t moved up the administrative ladder within EMS have largely moved out of the field.
We see over and over again EMS providers coming in the door with certificates or associates degrees and we work hard to encourage them to get more formal education. Then, sometimes as leaders, we’re guilty of telling our promising clinicians who embrace that challenge that they should go to nursing school or medical school.
Why would we do this? Why trade our star quarterback? Perhaps it’s because we don’t believe we have an industry that allows enough opportunity for them to grow.
This “brain drain” in EMS is crippling our present and our future. The lack of clinical career pathways within EMS relegates our paramedics to reaching their clinical peak within a couple of years of starting in a service.
For most, the “in-charge paramedic” position is the top tier of clinical positions. Some services offer coveted and rarely vacated EMS supervisor positions. Some offer community health paramedic positions to grant the paramedic more continuity in managing patients.
The problem is that, regardless of the clinical milieu, there’s no significant increase in autonomy of practice. Although we have paramedics capable of being competitive in advanced formal education such as physician assistant school, there’s currently no place for them in EMS.
EMS must work hard to create opportunities for advanced EMS providers in the field. Like nurse practitioners, the “paramedic practitioner” is a level of paramedic that’s desperately needed to create a career path for our industry that combines increased education with increased autonomy and pay.
Having the pinnacle of clinical care that involves a salary that’s higher than livable wage without working 80 hours a week increases the prestige of the entire field. This will in turn improve perceived career longevity and will help recruit and retain talent. This is the process that nursing began in the 1950s, which resulted in vast improvements in their workforce.
The paramedic practitioner model also helps to fill a very costly healthcare gap. We’re all acutely aware that we have a relatively small number of patients in EMS who have a true life-threatening emergency where seconds or minutes count. We have some others that need the services of an ED to do advanced laboratory testing, CT scanning or specialty care. Then we have the large mass of patients who could be dispositioned in the field at the point of contact if we had paramedics who were trained to the level of physician-extenders.
The patient could avoid the $1,000 transport to the ED, followed by the often larger ED bill. With the advent of portable diagnostic testing as well as the improvements in telemedicine, the paramedic practitioner is now a realistic model that may prove to be a cost-effective solution to the very costly “you call, we haul” mentality in EMS.
As EMS redefines itself and transitions from a public safety mentality to a healthcare delivery service mentality, it’s going to be increasingly important that we help to more broadly address the healthcare needs in our communities. Through increased formal education and development of advanced clinical practice that’s consistent with the rest of the house of medicine, we’ll be better equipped to meet those needs and we’ll be more successful at recruiting and retaining talented individuals in this exciting field of emergency medicine.