Why US EMS will never get to sit at the adult table.

Standard

Here is the bottom line, at the top of the page, they have too little education, do not understand science, and are too simple minded.

I was recently in a discussion with another doctor about using or adding anesthesiologists to emergency department resuscitation. It was an extremely good conversation, very civil, despite opposing ideas, and in the end, a very agreeable conclusion with each admitting that the other had some good points. But this was a conversation between physicians.

Enter in some cretin who is believed to be an EMT at some level. Yea I know that National Registry changed EMT-P to paramedic, but that is just lipstick on a pig. Paramedics are still trained like technicians. They still act like technicians, and worst of all, still think like technicians.

Right about now somebody chimes in with “our service…” and “not the people I know…” but I am just going to state the obvious for you. Your “service” is probably not as great as you think, because if it was, we would all know and have already have heard of it, because good services are so small in number anyone who has been around for 5 or more years knows them all.

The people you know are good… Ok, how many of them have even an associate’s education? The States that have made an associate’s degree the minimum as laudable, but they are few, if I count the 2 states I know of, 2 out of 50 is 4% of all states.

This is where somebody chimes in with a comment like “well we can give fentanyl and RSI. We have an advanced scope of practice.” Sad news friend, you have a medication you can administer and a technical procedure. That doesn’t make you advanced. Maybe you were even one of those services that “forced” your local hospital to institute the now questionable practice of hypothermia based on “science?” More sad news, you were duped.

The reason you do not succeed and are so easy to make a sucker out of is because you do not understand medical research. There is more to it than being able to read and convince yourself it is irrefutable data and no amount of opinion can dislodge it.

 You should do yourself a favor and go read some of the many websites on science based medicine compared to “evidence based medicine.” One of the things they all talk about it the serious (fatal) flaw in EBM. You see it most often in the form of a clinical study. “treatment X was tried N times on Population Z, and compared to Y. our conclusion is…” (let me fill in the blank) A. More study is needed. B. Our hypothesis is confirmed. This is where unsuspecting EMS providers seize this published document as evidence and the answer to all mysteries. But in this attempt to use the scientific method to answer all riddles, (The same exact behavior of religious people who spout their deity knows and controls all without fail.) simple minded EMS folk don’t want to believe that this evidence is actually pretty circumstantial. I have yet to see an EMS provider pick up a study they like and try to reproduce it. Well, you know, it takes time and money and effort, and…Education!

You see, EBM is a system. Like any system, there are those who have mastered the ability to use that system. It may seem innocuous. That everyone has the best intentions. But what intentions are those? Sell a product? Get your name on a published paper? Publish a paper in order to get/use grant money? Make a new breakthrough discovery and save the world? Change medical practice to what you believe is correct?

Permit me to pose another question? If it was possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation, why would we need healthcare providers at all? It is 2014, kid sick? Just get out your smart phone and google up some answers! The evidence is clear and incontrovertible. You could solve your kid’s sickness yourself, effectively and accurately. Drug companies would love it, they could massively slash their R&D budgets because they would almost never make a mistake. A simple clinical study easily would demonstrate the value of their medicine. No doctors or pharmacists injecting their villainous “expert opinion” in on the true and benevolent god of EBM.

But here is the heresy called the truth. All medical publications are based on expert opinion. How they start is an expert gets an idea, we call it a hypothesis. Said expert got this idea because they need to publish/sell something, or because they believe in their position. So they decide to create a study. (For our purposes we will assume that this expert has every benevolent intention and is not corrupt in any way, intentional bias is very easy to insert into a “study” and also very easy, but time consuming to disprove and is a criminal act in many places.) So, our expert needs to do a few things. 1. They need to convince somebody to pay for this research. It takes peoples time, you use consumable resources, etc. So you have to present your idea in such a way it seems like it matters. (Even if it is ketchup flow rates) Having competed against others seeking these same resources and having won, you now get to decide how you are going to study this topic. 1st, it must be possible to study. Meaning the technology and materials need to exist. 2nd, you must be able to measure it, if you cannot you must devise a way (this is more expert opinion) to extrapolate such data from something you can measure. 3rd, and probably most important to the critical care environment, you must be able to do it within ethical and legal limitations.

That’s right, no double blind random placebo controlled studies on the validity of CPR. No prospective treatment studies on unconscious people who cannot be advised on and consent to the risks. No deviating from “the standards” or “commonly accepted” modalities of care. Sometimes you can get a waiver, but it is easier to walk on water and part seas. Those waivers are extraordinarily rare. Nazi Germany is the closest anyone has come to unbiased human experimentation. Have a look at some of those studies (and the pictures). EMS exists in this environment; direct correlation studies are simply inconsequential, ethically impossible, or expertly extrapolated. Sure you can do a retrospective chart review study. But in terms of accuracy, precision, and conclusions, they don’t really provide much. Since one of the limits of these studies is documentation, a lot is assumed, missing, inconsistent, or just outright made up. (In very “reasonable ways” like filling in blank spots in your spread sheet with average values from those you have or asking your stat software to do it for you.)

What all that means is that your all knowing all powerful Evidence Based study isn’t really all knowing or all powerful. That big giant hole is filled in by, wait for it… Expert opinion.

This is where I will talk about another major issue with EBM in general. The peer review and consensus. In my )expert)opinion peer review is absolutely a must for any study. It needs to start during the study, to look for unintentional bias and perhaps keep excitement under control and force you to constantly re-verify your findings. But when submitting for publication, your experiment is not repeated, some “experts” look over the work, make sure there are no glaring errors, and often ask you to answer a question, soften the language of your conclusions, or add or delete something they believe is important. Once you do this, you are published.

The system of EBM is easily corrupted by the exact same trick creationists use to insert the idea of intelligent design as scientifically credible for more “reasonable” purposes. Teach the controversy! You see, if I do not like something you have to say, I can immediately give credibility to my position, by demanding evidence from you. In many cases the evidence does not exist, and as we have seen here, because of things like ethics and the publication requirements, may never exist. Simply, if you cannot produce a published study, you must be wrong or your position has no credibility. On one of the SBM websites, this was very well illustrated by an example the author (I forget who, but it was all his/her idea) parodied called “stick in the eye to cure blindness treatment.” Many years ago, the (correction)BMJ published a similar example claiming “There is no randomly controlled, double blinded, evidence that parachutes work.” It is all simply expert opinion. If you track it down, it is quite funny to read.

Science based medicine in a nutshell. The long and short of it is, in order for a study to have credibility, in order to nullify the giant flaw in the EBM system, the basic science, biology, chemistry, physics, etc. must be viable. If these basic elements are unaccounted for or a study does not account for them, then that study is suspect.

I’ll tell you, as a researcher, this prospect is painful. You have to track down and read all kinds of publications totally unrelated to your specialty or research. A personal example is when I had to prove a molecule could physically fit through the space between glomerular cells. Eventually, I was able to establish this basic fact with credible research, but it took time and was definitely not fun.

Ask a homeopath to do something like that with eye of toad or whatever they are selling today. Does the molecule actually fit where it supposedly works? Do the chemical properties of the atoms permit bonding to their target? This is the basic science that proves the value of an evidence based study. It is why clinical studies without it are garbage, even if they enroll ½ the population of the entire earth and come out with numbers needed to treat and harm. It has to be accounted for at every level of measurement too. Not just atomically, or molecular receptor cite, as well as other basics like transport, volume of distribution, etc.

Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff. They read a study, and assume this evidence has been met. Here is a hint, after I take the time and effort to research all that stuff, I write about it and cite it in the publication as evidence, so if you are not reading about it in the publication in front of you, it is because it has not been done.

EMS providers, especially ones who call themselves “advocates of evidence based medicine” really latch onto clinical studies. They are on every website demanding you cite proof that parachutes work in order to give credibility to their pathetic positions for stick in the eye treatment. They believe so desperately and completely in the all-knowing, all powerful deity of the published study, that they label anyone who does not share their acceptance of the one true faith as uninformed, unscientific, biased, and simply an unsubstantiated opinion. Yet they haven’t the education, resources, or experience, in research perhaps other than retrospective studies or reviews of research. (Among the lowest levels of publication, just above case report) They create websites and blogs (which are not peer reviewed) to pontificate their opinions citing this incomplete “research” and the masses of EMS buy into this dogma and call it “evidence” as clear to see, read, and accept as fact as the King James Bible or the Quran.

No critical care provider will ever be able in the Western and even Modern World to ethically and legally conduct definitive studies to treatments or diagnostics. All of that information is “expertly extrapolated.” EMS providers are simply not expert enough to do it. So you will repeat the cycle of backboards, fluid boluses, etc. with treatments and procedures that will one day ultimately be disproven because our knowledge of basic and clinical science changes with time. The “expert opinions” that brought you those treatments actually used EMB and studies to come up with them. They were not sitting around drawing on bar napkins when they decided a fractured spine should be stabilized. They had actual patients and created studies. Based on this “evidence” they instituted what they could demonstrate was best, based on what they knew. Today’s EMS providers vilify these people as just making shit up. (Expert opinion) Some of these people are still alive today. You can talk to them. Meet them. Ask them what evidence they used. They will tell you and show you. They are not meat headed villains. They spent their lives caring for people, not selling snake oil. 10 or 20 years from now, the evidence we create will be written off as expert opinion, unless we check our basic science credibility and publish studies based on it rather than random clinical trials. The dogma you buy into today based on “evidence” will one day be vilified and ridiculed as expert opinion. You can “teach the controversy” and demand evidence all you like. But you will never have the true answers.

Because of all of this, US EMS providers, and in fact many providers at all levels around the world, will never be more than sheep, singing the choruses created by the experts with more knowledge, while indisputably believing in their evidence, and labeling as a heretic anyone who cannot prove another god exists.

It is sort of ironic they use the same methods to attempt to discredit others that homeopaths and creationists use to discredit them. “Where is your evidence God did not create the earth in 6 days? You cannot cite one study as proof!”

EMS providers really sound that stupid when they do it too.            

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93 thoughts on “Why US EMS will never get to sit at the adult table.

  1. Vincent Cisternino

    Interesting timing of this blog. Just two days ago this came up in a NJ circle. I find myself shouting at the rain on education. Paramedics should be BS or BA prepared and AS or AAS be the very minimum for practice. Not just because I am but because having tested critical thinking skills, an understanding of cell/molec, solid A&P with Pathology, and research design are tools that have served me and my patients well. As for EBM I will cut and copy here my previous thoughts on that. “That’s another term I love (and by that I mean hate), evidence based medicine. It’s the PC term for conjecture by those unfamiliar with the law of numerical probability of large and small numbers while suffering from selective amnesia and washing the “data” through your statistical software of choice. Jane Goodall had better “evidence” with a bound notebook and pencil.”

  2. Rick Valesko

    You sir, need to get your head out of your ass!!! It’s pompous assholes, like you, who think that everything revolves around you!!! Quit being egotistical… We are all here to do the same thing…. HELP PEOPLE! I may be, just a technician, but you are also a TECNICIAN!!! You have a license to PRACTICE medicine… You don’t know everything…that is why it’s a license to PRACTICE. Until egotistical idiots like you get it through their heads that everyone needs to work together… People are not going to benefit….

  3. S. Benson, EMT-P

    Wow.
    You may have some valid points in there but they get lost in between your condescension and lack of focus. As a veteran paramedic (one of the pigs with lip stick), I am well aware of the limitations of EMS training.
    However, I don’t know whether your screed is directed at the individual EMTs and Paramedics, the various EMS systems, the numerous medical control/medical oversight systems, Evidence Based Medicine, or the practice of Emergency Medicine (unstated but I think implied).

    One thing for sure, though, is that cretins are not limited to ambulances.

  4. Vincent Cisternino

    The one place I disagree with is where knowledge is derived. While probably greater than 85% of the time there is a sourcible group, the study designs are not always what they appear. Physicians I have worked with have taken the one study approach as gospel more times than I care to illustrate. There is also a sort of medical cultural oppression when mid level providers or low level providers identify avenues for study and are dismissed by physicians only to come back years later. Backboards were though useless if not harmful in the wilderness rescue world in the 80’s but physicians by and large spoke otherwise. Anyway, EMS can surely step up their game.

  5. sdadam

    Hi, I’m a Paramedic. You couldn’t be more correct. US EMS is a joke in 90% of places, but we could be more than that. Here are some starting steps:

    1. Separate Paramedics from everything else. RN’s and CNA’s don’t have much to do with each other, nor do EMT’s and Paramedics. (You are right about the lipstick on a pig, it needs to be a real separation.)

    2. Require a minimum of a bachelors degree to be a Paramedic.

    3. Get the fire department out of any decision making having to do with prehospital emergency medical care.

    4. Have more doctors that understand what EMS is and are willing to get involved in serious discussion of what could help end outcomes of patients in the prehospital environment. Additionally, MD’s who are willing to take action against the poor care of Paramedics and services instead of accepting the system as it is. When it comes down to it it’s the MD that has the authority, you have to demand a change to this as much as we need to internally regulate ourselves.

    5. Remove the nursing influence keeping Paramedics from being able to practice in a meaningful way in institutionalized clinical medicine. I know the nursing profession sees another licensed ancillary healthcare professional as a threat to nursing jobs, but it’s a fight we are going to have to have.

    6. Finally, let people be firefighters without being Paramedics. Stop the constant flow of uneducated, non-academically inclined people looking for a tick mark towards dragging hoses into Paramedicine.

    We also need a national, organized, ALS level only organization that is a serious player in making these things happen.

    The education issue is by far the most important though, until being a Paramedic is at LEAST a bachelors level education then the rest doesn’t matter.

    It’s not complicated; regulate entry into the profession by increasing educational standards thereby decreasing the workforce by eliminating less desirable candidates and THEN we can talk about some of the other issues. When Paramedics aren’t a dime a dozen and the ones that are around are thinking clinicians, the power shifts to the profession.

    Thanks for calling out all the BS, it’s nice to hear from a Doctor who actually understands the true state of EMS. As a Paramedic I beg you to nail us to the wall every chance you get.

    -Adam

    • Jim

      Sober take off of an emotional entry. I think these are good suggestions, but the political environment — party-politics and practical politics both — probably militate against these things. Specifically, the need for more caregivers is plain and elevating the bar to entry for technician-level operators isn’t likely. In fact, it seems to be trending downward even among the nursing organizations.

      That isn’t to say we shouldn’t push. I’ll be wrapping up my EMT-B pretty quick, and looking for a paramedic course. Have my BA and will be pursuing basic science beyond the p-school requirements, but with the idea of going further, rather than perfecting my role as a first responder. And part of what is motivating that is the knowledge that my scope of practice will always be limited…in large part because of the institutional attitudes and habits you point out.

      Part of what makes the commentary accurate is the author’s having been in EMS to begin with.

      • 1. I actually think ALS (MEDIC) level services doing 911 should be hospital-based. Yes, there are very good EMS-Fire Services out there, this is not against fire. In your #6 point you stated we go to the same calls; extrapolate that out and PD should do EMS as well? That’s a slippery slope, FDs got into EMS for manpower and budgets in many cases. EMS should be a dedicated service, not an add-on to another, in my opinion. There have been many studies about being a subject matter expert, and the great difficulty in mastery of more then one area. Fire fighters are experts at what they do; if EMS is 80% of your calls, is your training 80% medical based? In my experience, it’s about 75% fire fighting / Hazmat / Rescue and 25% EMS. Having them hospital-based allows for better oversight and training, clear lines of communication with the doctors, and increased respect in the healthcare community. New Jersey actually does this very well, and could be used as a model.

        2. I respectfully disagree with you on this one. The rest of the western world (think commonwealth countries) have come to the realization the college-level education should be mandatory to those doing medicine, the US is way behind on this. I would agree with an associate level entry though, with a BS as an add-on. Does the education make you a better “paramedic”? That is unclear, it does make you a better critical thinker, better writer, communicator, and every other allied health provider in the industry needs a degree – so should Paramedics.

        Just my thoughts.
        Scott

    • J Carson, Fire Lt. and Paramedic

      1. Separate Paramedics from everything else.

      EMTs can be effective in ALS ambulances. Providing compressions, airway support or driving the ambulance do not require a P license. Not all services run B/P or even P/P. My agency is a fire based jump company which provides P/P/P on most days but can reduce one to a B.

      2. Require a minimum of a bachelors degree to be a Paramedic.

      No. There is a theory that once you have a bachelor’s degree, everyone at your level should have one. I have 9 years of post secondary education. I have a desire to learn. The most I learned about paramedicine was in the army, and through EMT and P school. Those who equate EMTs to CNAs are ignorant. There are plenty of doctors who cannot pass a CPR class taught by a “lowly scummy technician”. Education makes you no better than the guy next to you. Willingness to learn and adapt to new standards and methods is the key.

      3. Get the fire department out of any decision making having to do with prehospital emergency medical care.

      Again, no. Fire based EMS is just as good as solo EMS. The burnout rate in fire based systems are lower. And believe it or not, there are smart hose jockeys. In addition to my firefighting duties, I am also a paramedic (primarily as we run 80 pct EMS), structural collapse, hazmat tech, diver, arson investigator, instructor and tech rescue/extrication specialist. Being those things does not hamper my effectivity as a paramedic. A volunteer EMS chief nearby once said that firemen make horrible medics and that the only ones who are competent medics were their ems only vollies. He failed to realize that those ems vollies also had jobs outside of ems, negating his argument. Fire based ems has background checks and standards. I’ve seen hospital based and private ems providers that treat their employees poorly as they are for profit, and hire anyone with a license. You have some career “unhireables” that bounce from private to private until the echelon changes enough that they are forgotten for their previous screwups. Now fire based is not perfect, but it works.

      4. Have more doctors that understand what EMS is and are willing to get involved

      Here we agree 100%

      5. Remove the nursing influence keeping Paramedics from being able to practice in a meaningful way in institutionalized clinical medicine.

      Our medics are required to work in ER annually as part of CE. They function as “super techs” because they operate at their skill level and build the relationship between the nurses and medics. Program is actually successful. We work well with our docs and they are very involved in QA. We actually operate under their license and as their field extension.

      6. Finally, let people be firefighters without being Paramedics. Stop the constant flow of uneducated, non-academically inclined people looking for a tick mark towards dragging hoses into Paramedicine.

      Again, get over it. You obviously were rubbed wrong by a firefighter or a fire department. We’re not all uneducated. Some of us actually teach for our state universities and fire /ems academies. Firefighters are great problem solvers. Fire based EMS is a better use of money, and cross training the willing is huge. We respond to the same incidents it only makes sense. You dont see people who work at subway who only slice bread or only work the register. What happens when they go on break? Close the store?

      I think the author of the original blog raises some interesting ideas. No we are not doctors. I do not claim to be a doctor. If doctors wanted to come along more often to see our joys on the street, great. They are welcome in my box any time. My postsecondary education does not help me one bit in the ambulance. What does help me are CE, my training and education to complete EMT and Paramedic and our annual clinicals. I don’t claim to be a life saver or a hero or a know it all. There’s plenty of those out there. I do know that in real emergencies our hands are pretty tied by our lack of equipment and meds that we could have but are cost prohibitive due to low frequency of use. Our best treatment we have is sometimes copious amounts of diesel. I have no problem getting a patient to definitive care, where the experts can do their job where my job ends. I’m not breaking ground or doing studies in my ambulance, sorry it isnt happening. But I am using my knowledge, skills and abilities along with my tools and equipment to try snd make things better for our patients. I love my job, I am proud of what we do -EMS wide. Can we be more progressive? Sure. But that’s up to the doc’s not the medics.

      • Don

        Great reply. I think we should be really good at those things we can actually affect pre-hospital and accept that fact. This advocating for thing that go beyond emergent situations is nonsense in my eyes. Definitive care is the ER, I’m good with that, Docs should be good with that, and nurses should be good with that and we should be good with that. Not sure why folks are losing sight of why we were brought into existence.

      • Don,

        This has been an argument for many years. There are basically 2 schools of thought on EMS in the world, one is not surprisingly known as the American view, which is exactly what you described. The other is the Franco-German view, which is to bring definitive care outside the hospital. There have actually been a few studies which showed neither was superior, however, as I recall, they were measuring primarily mortality. (That would make the level of illness or injury a confounder as there is a possibility that these people were going to die no matter what.)

        But back to your point. US EMS was founded in the late 60’s and 70’s. During that time it was accepted that many “emergencies” had a sudden and unforeseeable onset. The “white paper” everyone who ever sat in an EMS class has heard of specifically addressed trauma injuries in car accidents. As we can still see, prehospital trauma management in the US has barely changed at all, despite an almost paradigm shift in the hospital. Trauma care occupies almost no time in EMS education, especially when compared to cardiac care?

        While the obvious solution may be “who cares, the hospital will fix it,” the problem is really a question of managing volume. In today’s medicine, unlike in the 70’s we now know that most “emergencies” like MIs are actually acute exacerbations of chronic disease. As the population ages and life expectancy increases, the prevalence chronic diseases is becoming so great there simply are not enough hospital resources or money in any nation in the world to shuttle all of these people to the ED and hospitalize them. That is why you see other nations like Britain and Australia attempting to create other “outpatient” avenues. The US will have to do the same. PAs and NPs were supposed to fill this role, but due to basically greed (politics and economics) they have failed in that respect of their “mission,” and basically just add a middleman to already existing healthcare facilities. As has been the case since US paramedics were “invented”, they will become the default “bandage” to this problem. But because our understanding and therefore effective treatment of disease is more advanced, the paramedic will also have to become more advanced to cope with it. Use your own life experience as the example. I imagine if you are like most healthcare providers, when somebody you are close to is sick they call you for advice right? Why? Because they know you, you are accessible, they trust your knowledge and judgment. Now there is such a need “strangers” are calling 911 to find a knowledgeable, trusted person (aka paramedics) to seek help for their chronic conditions. Think about how much COPD, slip/trip, and other calls deemed “not really emergencies” you see compared to actual emergencies. These are the emergency calls of today and the future. Not as glamorous as a GSW or an MI, but it is evolution. EMS needs to evolve in order to be functional and effective. Consider all the times or stories you hear of EMS resources not being able to meet public demand, calls waiting, serious calls waiting. In the modern age, you have to be able to help modern “emergencies.” Because the knowledge to do that is more advanced and there is no realistic script to just “tell you what to do” in every eventuality, particularly with multiple concurrent diseases, it means you will have to learn more. That means education. That means effective clinical application of scientific knowledge. Otherwise you will not be able to help, will not be trusted, and the people you serve will demand you become so or they will stop paying you. It was already suggested in Columbus, Ohio that because of short transport times, ALS was probably not money well spent as it does not equate to lives saved. (you learn CPR and AED as part of BLS, there is also a preponderance of evidence from Well done Canadian studies showing that. It is very likely that one of the most valuable and accurate measures of modern EMS is in how they reduce hospitals stays and morbidity. (Also pointed out by the same studies) But basically, the world has changed, knowledge has changed, and so must US EMS.

  6. JSH

    who are you? i came to this website out of curiosity, following a link on a friend’s Facebook page. I am an MD/PHD neurosurgeon who worked my way through college and medical school as a paramedic. I find your statements inflammatory and your arguments ad hominem. I would never single out a group of professionals for ridicule like this. I seriously question whether you are indeed a physician. And if you are, you should be ashamed of yourself.

    • Actually I am not ashamed of myself at all. The behavior of a vast majority of US EMS providers is that they are “doing what doctors do at 60MPH” and this post was inspired by an EMT who claimed there is no evidence that anesthesiologists are better at resuscitation than EMTs. Everyone has a story about themselves or somebody they knew who was somehow better than the average, which I think sounds a bit egotistical too. But when you look at the group as a whole, certain facts remain. Not least of which is the general education requirement for US paramedics still revolves around a trade school mentality while other healthcare professionals from RTs to nurses have increased their educational rates at a constant pace. These same providers attempt to actually do research as a profession before they try to interpret outside research and changing it to practice. When you take the population of the US protected by the “average paramedic, it is well into the 10s of millions. When you look at the EMS protection in the capital of DC and compare it to other capitals like London, Sydney, Warsaw, Paris, etc. The representation of US EMS provider is outright embarrassing. Regretfully, telling themselves how they are just as capable as specialist doctors, “real life savers” as you can see from these comments, or experts at research, it is all empty chest beating.

      • GGdoc

        So you made this whole blog post because 1 EMT claimed there is no evidence that anesthesiologists are better at resuscitation than EMTs? /SMH

      • No I made the post because Multiple EMS providers I have encountered over time have grossly misused EBM to justify their positions. It was this “one” that was simply the straw that broke the camel’s back and in no small measure the lack of his peers from more delicately policing their own.

      • teresa johnson

        Doctor, in addressing this one emt’s stance, you lambasted the entire profession. You made good points about EBM, but it seems you failed to take into account the fact that many medical directors base protocols on EBM. We have no control over that. Our scope of practice is prescribed to us. If you feel so strongly about our lack of education, why are you not at the forefront changing the system? Instead of denigrating hundreds of thousands of people who chose to try and make a boots on the ground difference, why are you not grabbing the bull by the horns to set the bar higher not just for us, but for physicians who want to be medical directors? Part of the reason we cannot sit at “the adult table” lies in the very tone of your article. For all your good points, you perpetuated the assertion held by some in the medical community that ems personnel are somehow less than….become part of the solution.

      • No, I lambasted an entire work group. EMS in the US has not reached the professional status it has in other nations. I didn’t fail to take into account anything, I am not new to EMS and have done my very best to help it for many years, both as a part of it (as a paramedic and EMS instructor) and after becoming a physician. I am frustrated that despite the many efforts of not only myself, but other notable people, the overwhelming population of US EMS providers are basically hell bent on being glorified taxi drivers who think nobody can do what they do and they have no reason to improve or even recognize there are people more capable at doing what they do. If a majority of were like you, posts like this would never be written, but they are not. They are what on EMS pages are commonly called LIVs. (Perhaps the greatest insult I ever heard was when a popular EMS blogger called them “monosynaptic fucktards”) But as you can see from the comments here, these people fire off their mouths without even bothering to read the about page before they do. If you ask around, I have been around for quite some time, but I have lost all hope that the US persons like you will ever measure up to your international colleagues because of these LIVs, and I don’t plan to be a part of the failure anymore.

      • teresa johnson

        Doc, who are these international colleques of whom you speak?
        You spent a great deal of time pointing out flaws in the system; Those flaws, admittedly, have merit. You speak, though, in absolutes. You say you don’t try to better the system anymore because it is a failure. You believe a great number of us wish to stay “glorified taxi drivers.” Generally, I disagree.
        during my career, I’ve seen doctors say and do some stupid things. I would never suggest that American doctors, as a whole, should “step away from science” because of the actions of a few. Science is as fallible as the humans who use it, sir. That fallible science gave us thalidomide, and hosts upon hosts of other drugs and procedures that men and women of medicine were certain, with their studies, data, and graphs told us with certainty were the next best thing to sliced bread…..no…the failings you speak of are not limited to ems. I believe your stance suggests you’ve thrown the baby out with the bathwater.maybe if we expect to consort with the sacred god of science, we should all dine on a little humility and humble pie at that “adult table.”

      • I never said science was a god, I said several times it is a tool. I compared how people use science as a god the same way people use gods in religion.

        I also suggested at least once in this post, and several others of mine that others, and doctors in particular, have a habit of putting a falsely high value on clinical study. You listed a few, but we could probably put together a list hundreds of lines long.

        The reason I suggest that US EMS in particular needs to step away from science is because other nations have embraced an educated EMS provider who also have science as part of their education and as such are largely self governing, with physician input. (Like AU as one example)

        I don’t doubt, there are a few good people in US EMS even on the fire side. MY contention is they are the exception, not the rule.

        Why do we pay architects and engineers? Have you ever seen them on a construction site? They don’t do very much manual work. Why doesn’t the guy who has been pouring concrete on bridges for 20 years design them?

        It is the same thing with EMS, sure there is the occasional paramedic/lawyer, paramedic/engineer, paramedic/politician, paramedic/journalist, etc., but they are relatively few compared to the masses.

        What the uneducated masses in EMS are doing is trying to use science in the same way they use a laryngoscope. Most have no idea of the why’s and wherefores, they are just doing as they are told and like it. If you don’t believe me, peruse many of the comments here.

        I don’t see it as throwing the baby out with the bathwater, I see it as dumping out the garbage, that unfortunately has some valuables in it. My humble suggestion is you focus less on calling me an asshole for being the messenger and direct that towards your coworkers who are causing the actual problem.

        You think I am the only former EMS doc that thinks this? You think non-EMS docs who are nice to you really always believe what they say? How about nurses? Not everyone who is nice to you is your friend.

        How many of my posts have you read? Anyone can see most of them are based on shortcomings of the medicine. You don’t see the handful of doctors and about 10 others who regularly read my posts with a list of comments about what an unknowing, unkind, person I am. You will also see that I almost always offer a possible solution. But for US EMS, there is no solution. There is simply too few pearls and too much swine. I believe it was Dr. Bledsoe who once wrote a piece about the best and brightest move on. Look at how many other healthcare providers are “former” medics. Look at the people who have “real” jobs in other industries and are part-time or volunteer medics.

        How many EMS leaders put out a help wanted sign that says “degree required”? Very few, because those leaders who have no longer have that job, and the ones who would like to know they cannot if they don’t want to face the same fate. Your problems will only be solved by the rank and file culling the herd. Even the fire service has embraced formal education for its officers. They have dedicated career persons at all levels. Higher pay, better benefits, and prestige. They also use peer pressure to influence the behavior of their coworkers. Perhaps it is time for EMS to take a leaf out of their book?

        Much easier to tell me what I don’t know than for people to fix what is wrong with themselves. I posted some recent stats on this blog to make a point. My normal readership is 30-35 people per post. Most of them I know in “real life.” This post goes viral, and the only possible reason is people got upset because I didn’t write about what great heroes they are for racing the reaper, and they would rather I talked about how awesome they are. Like most of US EMS, there are a few intelligent posts, but the majority are not. That is why I limited my comments to US EMS, because the rest of the world actually try to be great, not just call themselves such.

        Res ipsa loquitur.

      • teresa johnson

        The thing DOES speak for itself. By your definition we are heros for even attempting to do what we do as we apparently are all failures from the get go. If you can’t fix it, don’t step on it….

      • Garrett

        In part I agree. One thing I would like to see a lot more of is EMS research lead and done by EMS providers.
        I’m an EMT (also a software engineer), and I’ve bullied a local medical director into letting me do some research (IRB approval and everything). It’s not much – it’s a multi-service, multi-year retrospective chart analysis on pre-hospital DKA treatment. It isn’t “sexy”, but there’s a lack of good data of even what’s happening in the field. So I try to fill some of that in.

    • dennodog

      Kudos, Doctor. As a police officer I had hundreds of interactions with EMT(s), parameds,and so on. They were doing their jobs on the street, in cramped slums, speeding ambulances and other difficult locations. They are some of the BEST and most dedicated people you’ll ever meet. The author of that long winded screed seems to be trying to impress someone with his alleged “knowlege”. It didn’t work. He came off as a complete nitwit.

  7. Thomas

    You may be a doctor, an investor , a waiter , or a paramedic but eventually you end up in the same box, some fancier than others, but if you claim or see yourself better than another individual your arrogance is how you will be remembered, and you will be hated for generations. not everyone was dealt the same cards. There are rich- parent drug addicts , just as their poor-family doctors and vice versa. Provided the FACT that whoever wrote this is an arrogant generalizing big-headed scumbag seems to convey the entitled snobby demeanor and therefore i will gladly stoop to your low generalizing you as the “my parents were rich, i became a doctor, im better than everyone” type of person. You as a “Doctor” should know that the human body is comprised of water , oxygen and various other elements. Meaning you are no different than anyone else. just a vessel with a very shitty personality that not even a mother would miss.

    – Please do have a terrible remainder of your existence with an abundance of sincerity from a guy who brings you patients to treat , a paramedic, a generally kind soul, Someone who will be remembered for their good deeds not their self obsession you fucking cretin!

  8. Patrick Nance

    This sheep says you can stick your opinion up your snooty, snotty ass. I am educated (three degrees), keep up with the latest studies and have been doing my job as Paramedic (I am not a technician. I don’t work on cars or machines. I am a clinician. I work with people) probably since you were shitting in your diapers. I have seen it all change a dozen times. And I don’t chime in with an opinion until someone like you comes along and manages to say some pretty demeaning shit without being able to back it up. Next time one of your kids has an allergic reaction, or you have an heart attack, or your wife has a serious MVC, I hope to God the providers that show up never saw your opinionated blog. You might be in a real world of hurt if they did… oh wait, we put our biases aside and treat everyone the same. Too bad, the same can’t be said about you!

      • S. Benson, EMT-P

        I doubt that you are “keenly introspective.”
        You may think of yourself as having keen insight into issues but that is not the same as introspection.

        If your communication style leads others to think of you as a pompous ass on a regular basis (“happens to me all the time”), then there is something about your behavior that is dysfunctional. You need to look into that.

        You want to fix EMS? Insulting the people doing the job, who frequently have little power to change they system, won’t work.

      • Scott Ratheal

        Oh please master of all rightious research and and digger of perfect knowledge, show me again where you just sited wikipedia! This jackass is just another rebel rouser with a large vocabulary! You just did the main thing that you are calling stupid!

  9. danny densmore

    Can we not say that we in ems world, that we receive training which is centered around the issue of saving a life and not long term medicine, Although I am not a medic I would just say that we are all on the same team we just operate at different levels. Often times we in ems are in environments which would make most doctors turn green and many experts would stand there in a daze. Does there need to be change in the world of ems? Yes there needs be change, So remember when talking of ems of course many in the field don’t really care what the studies or what ever say they just want something that will help them do their job of helping someone, because most cases we encounter major and minor requires a course of treatment without the benefit of a fully staff hospital and that is the difference,

    • There is a difference between being trained and being educated.

      It is a little unfair to say that “most doctors” would turn green or be in a daze, because while it may seem like the whole world, the US does not lay claim to “the most doctors.” In several countries, doctors function on ambulances, aircraft, and chase cars. They function in austere conditions such as field hospitals and tents serving as clinics. They even operate in those conditions and have textbooks on doing it.

      Moreover, Anesthesia is often the specialty tasked with not only emergency care, but also pre-hospital care. If your only exposure is the US, then it may understandably seem that way to you.

      Those doctors do not have the benefit of a fully staffed hospital either, and they have only 2 options, do something or do nothing.

      Claiming to not be a medic is not a sin. In Britain, and probably some other countries, a “medic” is the term used for a non-surgeon doctor.

      I don’t know, but I would stipulate since the original members of the Red Cross were doctors, the moniker of “medic” may actually trace back to there.

  10. Mike Tragesser

    His offensive presentation did include a few salient points that speak to the non-professional status of Paramedics. Unfortunately his rambling essay swung from scathing critiques of evidence based-medicine, the frustration of research ethics, the difficulty of establishing scientific support for hypotheses, a disdain for religious faith. His vitriol stems, I suspect, from naked jealousy toward technicians who are given the opportunity to perform far more immensely satisfying and dramatic life-saving procedures than him. We operate under medical control, so I don’t see his problem. As far as raising the academic bar for the basic line paramedic, it doesn’t appear to be necessary. The world needs technicians, warm bodies, trained rapidly to do what needs to be done. Physician Assistants and Nurse Practitioners also do excellent work with the medical profession’s cookbook. Research is for PhDs. Ain’t nobody got time for that! Just tell us what you want us to do.

    • Actually it was connected in that paramedics do not effectively use evidence based medicine because they do not understand and account for it’s intricacies, which perhaps may seem disconnected to you, but is a rather logical progression to me. Improperly using a tool usually causes a bad result. You learn to use tools by being educated. BTW, you don’t have any dramatic life saving procedures or we have a very different idea what comprises one. Since you can’t discharge people home after your life saving treatments, I am inclined to the latter possibility.

      • Scott Ratheal

        You have just proved that you are not a doctor or more to the point, an ER doctor that has worked with any EMS systems. I have discharged to home many pts that I have given life saving treatment to. Hypoglycemia….D50….right back home. You keep saying that you should not be a paramedic until you have a higher education, who do you know of that has a masters degree will do the job that I do for the pay that I get? Our EMS system is military based! Trial and error based medicine in unforgiving environments! You sir are out of your league in our playground!

      • I am not an emergency medical specialist. I will never be an emergency medical specialist.

        You see I don’t actually like the specialty.

        But to somehow ascertain I have no experience working in an ED is a rather bold statement you cannot possibly substantiate, because it is not factual.

        I have also worked with EMS systems in multiple countries, so if I were you I would be a bit more careful and the accusations.

        Who do I know? Well, for starters I know several countries where paramedics need a bachelor’s or a post Bac. I know a few countries where providers working on a truck actually have a PhD in “Rescue medicine.” They probably earn much less a month than you do.

        Also if you would tell me? How many US EMS agencies are permitted to discharge a patient as opposed to not transporting a refusal, or refusing to transport somebody by ambulance? 2? 3? In the country of 300 million? How many are doing it in NYC? Chicago? Houston? DC? LA? SF? Atlanta? Dallas? Baltimore? Philly? What is the population of your response area?

      • Scott Ratheal

        You missed one very big point in your argument, are any of those PhD emergency medics that are working for less than my yearly pay….. in the United States? You titled your article US EMS!

  11. Joyce Berry

    I am a retired professor of physics who also happens to be a paramedic. Now I understand why the medical director at one time accused me of thinking too much.

  12. Micheal H. McCabe

    Well, as far as your assessment of EMS workers goes, you seem to have been “spot on.” The limited education and scientific training of EMT’s and Paramedics is part and parcel of a systemic problem. Like you, I question the recent move towards “evidence based medicine” and suspect that the fatal flaw in EBM is its reliance on uncontrolled, unreproducible, retrospective studies of highly-subjective patient care reports.

    While my own educational background is limited to a four year degree in general science with a few graduate school classes thrown into the mix, I believe my 30 year involvement in the Emergency Medical Services can also provide some insight. I’ve seen the EMS “fads” come and go: MAST, lidocaine prophylaxis, “Scoop and Run”, “Stay and Play”, thumpers, auto-vents, routine pacing of asystole, various drug regimens, innumberable changes to CPR and ACLS guidelines; you name it! The distressing fact is that patient outcomes change very little.

    My own approach to EMS is very basic: try and get people to definative care in a safe and expeditious fashion without causing further harm. While doing this, I try and obtain as much information about the patient’s condition as possible and relay that to the receiving facility. When possible, I attempt to address critical life-threats: uncontrolled bleeding, hypoxia, unstable cardiac rhythms, low blood sugar, etc. Although trained to perform certain “advanced” procedures, I find that they are only rarely necessary and, in truth, are far beyond my modest skills, knowledge and equipment.

    There are frustrations I have to deal with working in a rural area that is 30 minutes from the nearest physician on a good day: I’ve watched people bleed out and die from relatively minor wounds; I’ve gotten “spanked” by medical control for using things like tourniquets and vascular clamps; I’ve been sorely tempted to perform field amputations and peri-mortum caesarian sections, but haven’t — not out of any real respect for the rules of medical practice, but out of a dearth of appropriate supplies, equipment, and training.

    My “Wish List” for EMS is pretty short and simple: First, physicians can’t have it both ways — if they expect EMT’s and Paramedics to take responsibility for patient care, the EMT’s and Paramedics have to enjoy the requisite authority to act within their scope-of-practice. Second, emergency physicians need to be familiar with the EMS system. They need to know the people, the equipment, the protocols, and most importantly the limitations. Finally, they need to appreciate that they are not dealing with fellow clinicians; they are dealing with rescue workers whose “trade school” education entails not only a smattering of medicine but things like fire suppression, building construction, technical rescue, hazardous materials, and traffic control. I would not expect a physician to weild a Hurst Tool, nor would I expect a paramedic to use an electron microscope.

    Thank you for your opinions and insight, I look forward to reading more in the future.

    Sincerely,

    Micheal H. McCabe

      • Patrick Nance

        I don’t know about you, Michael but I have three college degrees and not a “trade school education”. My EMS education program was run by one of the Level Two trauma centers in Dallas and that is where we did our clinical rotations. I never studied one day about building construction, traffic control of hazmat. Those all came later in Continuing Education which, in any state is required of EMS personnel for relicensing (I am LICENSED in four states, not certified). Don’t bag on me for a lack of education or not caring about “EBM”. I attend my CEU’s not because I have to but because I want to better myself. I do pretend to be pompous but I do what is considered my calling. I think that fact that people keep dying means we save the ones who can be saved and that simple, some people just die. By the way, I am not a “technician”; I am by definition of most medical personnel a “clinician”. I work with people not machines. And the NREMT has dropped the moniker “technician” in an effort to recognize that fact.

      • You pretend to be pompous?

        Could I just point something out?

        You did your paramedic education at a hospital. That has distinguished itself as a trauma center. Does being a trauma center measure the overall quality of the facility or the breadth of medical services?

        If I am not mistaken, Baltimore Shock/Trauma does not have ACS accreditation. Are they lesser of a hospital? Should you not take trauma patients there?

        Your testing organization dropped the moniker and that somehow legitimizes it’s position? I am not convinced of that.

      • Scott Ratheal

        I just love when you guys jump up and down that you are licensed and not certified! In my state, TX, NREMT-P is the exact same education in medicine that I received but you have a college degree in underwater basket weaving that I don’t have! There is no rule that says your higher education is in emergency medicine! Tell me how a degree in electronics makes you a better paramedic than me!

  13. Scott

    You missed the point entirely, sir. You also did so in an embarrassingly ignorant manner.

    I, nor any other similarly licensed and trained colleagues of mine, fancy ourselves as doctors or research experts. Our issue with being perceived as less than professionals is a little lower on the totem pole.

    The police officers and firefighters I interact with every day are considered professionals. Why them and not us? The educational requirements for fire and law are usually the same as mine, often less.

    I don’t want to be a doctor. I only want the public at large and the other professionals I interact with to recognize the professionalism transport EMS brings to the table.

    Now go back to your hole.

  14. Patrick Nance

    You would think a former Paramedic would stand up for his brethren more but no, this guy (who doesn’t even post his name with his blog) becomes a doctor and starts talking crap about what we do and what we know? Well you know what, Mr. Blogger… we as Paramedics don’t go around and change protocols because we read an article which is what you seem to be saying. We act on the protocols established by guess who? That’s right, moron… DOCTORS! WE don’t chime in with opinions on evidence based medicine, not because we don’t know what it is but because it is not relevant. We do what you tell us when it comes to patient care. I don’t have the luxury of deciding to stop backboarding or initiating RSI. We do as we are instructed hence the term Paramedic which means, according to Latin “alongside the doctor.” So back off…

    • Actually, I sign my name to everything I do. Even when I have administrator privileges. I like to call it “taking responsibility.”

      I don’t stick up for EMS, because when I have, they turn right around and embarrass me by doing exactly what I tell other doctors they don’t do.

      Furthermore, read the comments here, look at the numerous EMS blogs, even the trade publications. You most certainly do advertise as people who know best and tell others what to do.

      I would be curious to hear an explanation as to why other modern nations require degrees but you don’t need one?

      Have you seen articles on EMS systems that forced hospitals to implement hypothermia therapy? Have you seen the recent studies on it’s effectiveness?

      There was an article on EMS 1 the other day, and when I checked the citations, they didn’t say what the author claimed they said. He drew his own conclusions and cited the sources. Nobody else noticed that?

      Tell me? How many paramedics teach ACLS and PALS classes to doctors? (Quite a few that I am aware of) They are teaching guidelines that they do not even know the basis of? That is not going to win hearts and minds.

    • I am not sure my opinion counts as plagiarism, when I was not aware of the existence of a similar opinion.

      I am also not sure a widely accepted belief can be counted as plagiarism. There are several websites that have said something similar I have found recently.

      If you read through my posts you will notice that I always have given credit where I had the ability, even if it was to admit I did not know who said it, but it was not me.

      Would it be considered plagiarism if somebody else writes a blog post saying US EMS does not have enough education, but I have been saying that for many years, and I am sure somebody copied it from me…

      I must say, that was a pretty good attack, but in actuality, still not effective.

  15. Todd

    Keep patting yourself on the shoulder and telling yourself and everybody around you how good and educated you are as a MD. I can promise you that you could not do our job even on the best of your days.

      • Todd

        I have over 20 yrs experience as a paramedic, I have yet to ever meet a Dr or nurse who was capable of doing my job. We don’t have the luxury of working in a controlled environment. You obviously have never ventured your green ass into a gang infested, drug riddled neighborhood to interact with the irate locals all who are circled around a child who has been shot in the chest twice. You don’t know the first thing about my job nor could you ever do it. When’s the last time you saved an infants life or held a dead child in your arms? The correct answer would be “NEVER.” Don’t sit there and act as if you know what our job entails of because you don’t have the slightest idea. So take yourself and your silver spoon and bounce.

      • Thanks for this, I am going to show all of my friends, we will have a good laugh. I have done all of those things and a few more. I don’t know where your impression that nobody else can do you job comes from, but you really need to get out more.

  16. Bryek

    Ah gotta love the rage posts. Not the best vehicle for your idea eh?

    As a Canadian PCP I cant say much on the American system but it needs some revamping and you as a doctor (im assuming an anesthesthestist) and having training in all of this EBM vs Expert Opinion are really in an opportune position to change the problems you see.
    You will need to speak with your political party leader who is a part of the level of government who regulates health care (in canada that is our MLA) and convince them that there should be an advance in paramedic training.
    Next you need to form a board and figure out exactly what courses will be required to obtain a bachelors in paramedicine. Also you need to start a legal movement to move paramedicine into a health profession.
    Of course since we have gotten this far we have to reexamine how much a paramedic makes and make all the little companies out there change the way they do things to fit this.

    And that is really barely scratching the surface of the changes needed. Personally they need to move away from volunteer services and pay their employees wages they can live on. But that itself is difficult. Especially with the law being what it is.

    Tbh buddy, unless you want to help fix it, go whine to people who care. You had a bad experience with an EMT-B. We’ve all had that experience on all sides of the fence.

    As my mom would say “Pull up your big girl panties and grow up!”

    Step up or step out.

    • Bryek,

      What you are suggesting here has been tried. Not only by myself, but by greater minds. US EMS will continue to remain just better than nothing because of the abundance of providers with the perspectives you have witnessed here. It is really not worth wasting anymore time on them, and I plan my next post to be back to the regularly scheduled program of medicine. I’ll keep approving the many “you are an asshole” “You don’t really know” comments, for those who feel the need to vent their anger, but I have read all of the ones I am going to. It is not that I don’t want to help them, it is that they cannot be helped. (and no, I am not an anesthesiologist, I am just close enough to them to realize they are the experts at what they do.)

      • Bryek

        Interesting. Honestly I dont really believe you have tried but in your own post you mention them needing to change it but now you admit to how difficult that is.

  17. Jim

    I had to go away and come back. First read-through was disheartening. I’m just starting out, and I’m trying to be a good clinician (technician if you prefer), and I’m trying to remain excited by the role I hope to assume in the field. It was hard to read that diatribe from a person who “came up” in EMS.

    My first response is that if what you say about the practice of medicine is true — not just in the US, but world-wide — then there are plenty of children already entrenched around the “adult table.” I’m not sure that I’m in a hurry to join them.

    Perhaps you’re right — probably you’re right — that EBM is misused in the EMS field. And probably the SBM folks are right about the emphasis EBM erroneously places on anecdotal outcomes, field reports, and consistent narrative in lieu of deeper scientific analysis of practices that appear to be work for reasons that seem, well, apparent.

    But I also get the sense that you’re meeting passion with passion, without context for many of your readers. I think this does your thinking a disservice.

    EMS is in its adolescence in the US, and it is bounded by small political realities and large ones. Small ones include the provision of public services at the local level. I live in Connecticut, which is by comparison a wealthy state. But one third of the geography is covered by one paramedic. Another 1/4 of the geography is covered by four.

    Whatever the profession may want to establish as an entry standard — at least in an upward direction — is not going to help that problem. Those areas of the state have the coverage they do (or don’t) because that is what those areas are willing to pay to support. Writ larger, there isn’t likely to be a market for better educated paramedics until either a) the price of advanced education goes down dramatically or b) the desire of communities to forgo things like roads, public education, snowplowing, etc., in exchange for a better level of medical services increases, or more likely, both.

    It may well be that there are places in the world with the luxury of well-educated (in medicine and/or science) first-responders. My guess would be that those places also enjoy a higher level of underwriting for advanced public education.

    Lacking that, our poor US EMS community is groping toward respectability and grasping at whatever tools lay closest to hand — in the instant case, so-called EBM. This probably appeals to many in that community because it is accessible to them. This, it should be noted, is probably what inspires their bettors (MDs, e.g.) to find it attractive as well. In both cases, these groups find their experience in practice conflicts (or at least aligns imperfectly) with received wisdom — whether that be the practice of the ages or the tablets of genius most lately minted by the high priests of the research academy. They find in EBM a narrative that supports their experience — they find that their experience aligns more perfectly with that of other practitioners and the assembled evidence (imperfect though it may be) confirms them in their work.

    The only intellectual problem I have with your piece is that, having identified a lack of science training in EMS and excoriating that benighted class for availing itself of imperfect tools and drawing (therefore) unstable conclusions, you leave the blame at their feet. But they (we) are equipped for little else.

    Who is? Why, the MDs and PhDs of the academy and the teaching hospitals. They are the ones who can design research to test the EBM theories (or call them suppositions). The medical establishment could, if it chose, increase dramatically the attention it pays to the first level of care. I have a hunch that vastly improved investment by academic science researchers in the work that we do would be welcomed by most of the best EMS professionals in the US — particularly those who you seem to direct your beat-down. The EMS 2.0 types, etc., for example.

    To close I offer a plea: Please remember that just as you implore your fellow residents/surgeons/docs to remember that teaching is part of knowing, I would ask you to remember that the best of us see ourselves not as medical cops or firefighters with bandaids, but as caregivers, and that at that root level we are engaged in the same work as you are. The very people who annoy you most with trumpets of EBM in EMS are probably the ones who care the most, too.

    • Bryek

      I think many of the issues the US has is due to its unerring need to be as far away from socialism as it can. The US is the only industrialized country without socialized health care and the hirt that has dont to the US is plain for all to see.
      EMS personnel should be state or federal employees and their wages should be paid by the state. But I doubt that will happen until a drastic change in the US ideology changes.

  18. The problem EMS has is twofold. We have providers, well represented above I see, who take any criticism as a reason to respond in a childish manner, thereby proving that Paramedics are not capable of being part of the discussion. The other problem it that we allow others to define, control, and police our profession. From belittling education and defending bad treatment modalities to protecting those who refuse to be part of the solution, we have to change and push each other to be better. It isn’t a lack of ability to learn, adapt, and grow, it is a lack of desire. These same people are more concerned about salary than they are proper treatment. We have allowed the profession to be dominated by Fire Service. We are defined by doctors and nurses. You have to be better. But if swear words, flaming skulls, and UHH BLS BEFORE ALS defines your career, then we cannot ever change.

  19. S.D.

    Yuck, I am disgusted. Yes you are 100% right, but you are also very hateful and arrogant. Politics, arrogant and impatient people and the need for people to constantly need affirmation and praise for their credentials is just a few reasons why I fled from my job as an RN.

  20. Doug H

    I’m glad that my medical director and several of the emergency room doctors and PAs at the primary hospital I transport to are former paramedics. This guy had never known anything other than being an arrogant doctor. I’m sure he’s probably the type who doesn’t bother to get to know the names of his patients or the nurses/techs with whom he works.

    I’m also in the process of applying to medical school. I did my BA (at an ivy) with the intention of going to law school but decided against it, as my interest changed to medicine. Being an EMT already, I chose to become a medic first for the experience.

    I’m realizing that a lot of the medical experience won’t translate over, but the life experience and knowing how to treat people without being condescending will.

    Thank you, Doc, for reminding me pompous doctors like you still exist.

  21. teresa johnson

    Wow….oh, wait…let this pig wipe the lipstick from her teeth…..you really are quite enamored of yourself, aren’t you, herr doctor….? You missed one rather important point. No matter how well educated I may be as a paramedic, my scope of practice is dictated by the state, and by my medical director….yep, a DOCTOR!!! So, you see, it matters not what I actually know or understand….what I do in any given situation is dictated to me. I work under delegated authority…. maybe you should condescend the system instead of the good people who have no choice but to operate within it. As for your adult table, you may shove that straight up your tight, snooty ass! My fellow pigs and I will just sit here and admire all our various shades of lipstick.

  22. Micheal H. McCabe

    Hello, again.

    I just wanted to follow up with a few of my colleagues that questioned the value of post-secondary education to EMS practice. One simply stated that his four-year degree had not been of any value to him in EMS, another commented that a degree in basket-weaving or electronics would not make someone a better paramedic.

    I will respectfully disagree on all counts.

    First, I believe that a well-rounded education has been of enormous benefit to me personally as well as to those that I have been able to help over the years. I’ll admit to never having taken a course in basket-weaving, but I can imagine that those who create rescue slings and deal directly with composite materials might find the techniques of basket-weaving applicable to their daily work. I’m sure the textile engineers that created Nomex, Kevlar, and Ballistic Nylon can trace a portion of their work to this most ancient of crafts.

    My own curriculum included courses in Physics, Chemistry, and Biology that directly applied to subjects in the “standard” Paramedic Curriculum. I cannot imagine anyone claiming a functional understanding of anatomy, physiology, pharmacology, or pathophysiology without some understanding of these basic subjects. Other college classes that have been directly helpful included Sociology, Anthropology, French, Latin and History.

    The most general of subjects, English (including the freshman courses in basic research and writing skills), Mathematics, Rhetoric, Logic, Philosophy, and Ethics provide the very foundations for organized thought, communication, and action. These subjects might be somewhat elementary in nature, but in an era when “No child left behind” and “teaching to the test” have replaced real education in America’s public schools, it has fallen to the post-secondary institutions to fill the void.

    The original author made several good points about what passes for “research” in EMS. I submit that by willfully failing to read, understand, and consider his argument (regardless of its “tone”), the EMS community has demonstrated a lack of maturity that proved his point — we are not yet entitled to a seat at the “adults table.”

    Those of you who are passionate about providing good patient care should take the time to re-read the original post, ignore what you consider his “condescending tone” and consider the meaningful content. Simply engaging in ad hominem attacks against the author accomplishes nothing and diminishes the “professional” status of EMS.

    Sincerely,

    Micheal H. McCabe

    • teresa johnson

      Michael, I understand your contention. The author does have salient points, however his educationally elitist attitudes and his confrontational stance against ems personnel elicits much ire frome people such as myself. I am one of those lipstick wearing pigs he speaks of. I have spent thirty plus years in this field perfecting more than my lipstick application not because I could not do anything else, but because I loved the job and believe in the proffession. Iconoclastic though I may be, I believe I’ve earned the right to tell the author he comes across as a douche canoe.

      • Micheal H. McCabe

        There’s no question that you have a right to disagree with the author, his thesis, or his chosen form of expression. I do not advocate any form of censorship here: it’s just a blog post. I actually admire your rather whimsical turn of phrase (“douche canoe!”) and willingness to express yourself in a public forum without resorting to some alias. The world is far too over-populated with trolls willing to hide behind the anonymity of the Internet.

        Like you, I have spent three decades in EMS. I have degrees in other subject areas and could probably find a job doing something else, but I enjoy the work and find personal satisfaction in helping people. Perhaps I have unusually thick skin or a severe case of cluelessness, but I found little offensive in his original post.

        In particular, I didn’t find him exceptionally “elitist” or “against EMS.” He is an advocate of education and the scientific method. A quick examination of his other writings reveals that he is a former paramedic, he has conducted “primary” research in basic science, and is active in both clinical medicine and medical education. Attitudes aside, I would argue that he has also “paid his dues” in both academic circles and in the EMS community. I’m planning on cutting him some slack and following anything else he writes that I can access.

        Sincerely,

        Micheal H. McCabe

  23. Todd

    Let me start by saying i’m a Firefighter / Paramedic. I’ve been in the medical field for 22 years, 17 as a Paramedic.
    Now…. YOUR A DIVOT !! In my mind you walk around with 3-4 pages on your belt along with a radio waiting for the next call with 6 pairs of trauma scissors secured in your pockets.
    To put it simple “my friend” (yes, sarcastic voice) stop masterbating as people post to your article as this is your only pleasure in life.
    If you want to make a change, trying showing compassion to your next customer instead of being a divot !!

  24. Peri Duncan

    Wow. You are a real jerk.

    Sincerely,

    Medic with Master’s Degree from The George Washington University.

  25. So what was your intention writing this? Are you interested in training paramedics like professionals instead of technicians, or just anonymously pointing out well known problems in a condescending tone? Are nurses and respiratory therapists also sheep singing the praises of people with more knowledge (like you?)

    I happen to agree with most of what you wrote, but there’s a big distinction between EMS education standards, practice, and oversight and the SBM/EBM debate. A lot of your physician colleagues got duped by hypothermia too.

    • My intention in writing this was effectively voicing my frustration at the ineffective way medics try to use EBM to demonstrate competence, without knowing or admitting to it’s limitations.

      I spent considerable time and effort trying to improve US EMS. (Generally EMS as a whole wherever I found it)

      But I am at my wit’s end and really think anymore attempts would just be a waste of time.

      When EMS providers start using the argument “there is no evidence anesthesia is better at resuscitating people than EMTs” it is time for those providers to step away from science.

      There was also a sentence in there that mentioned other providers don’t use EBM correctly either, and a rather long discussion on the limitations of clinical study.

      To just address some of the comments also, despite saying that there are a few educated medics in the US and a majority are not, both in the post and in the comments, there are still idiots posting “fuck you I have a degree!” Certainly not in reading comprehension, that is for sure.

      • I really wanted to disagree with your whole premise when I read the title, but, being an educated and mature person, I read the whole thing (and most of the comments) and came to the following conclusion: You appear to be a passionate person who is frustrated with the status quo of US EMS.

        Oh, and there are ass-hats in every profession, but they come out of the woodwork when their “home” is apparently attacked. Those “fuk yoo!” posters go a long way to proving the title of the post.

        I am recently licensed as an EMT-B, and am trying to get into the field. I am also completing a bachelors degree in emergency management, which has led me to more than a few research papers and reading peer-reviewed and vetted documents. I’ll be the first to admit that I was not aware of the issue with EBM, but that’s because I hadn’t looked into it. I’m not a trained researcher, merely self-taught and pretty good at ferreting out interesting tidbits.

        US EMS seems to have always been the proverbial “red-headed stepchild” of medicine and first response, from what I’ve read. We’re neither fish nor fowl, and tend to get stuck in the corner by the so-called adults (both medicine and public service), who are too busy or too disinterested to teach the child to grow.

        Rather than lambasting the whole field (which admittedly has many issues, including god- and hero-complexes in a large number of cases), I ask you this with actual interest: Have you worked with individual EMS systems (even to the level of provider organizations) how they can mature the field? Obviously, local politics can be a problem, but as the saying goes, it is better to light a candle than curse the darkness.

        Where would you suggest I start looking to go beyond EBM and into SBM, particularly as a single individual? After all, if you can’t get the head of the organization to come in line, it is good practice to under-cut the problem and start with willing and interested people who want to improve.

      • Mr. VanTassle,

        Your last question is actually the easiest to answer, so if you will permit me, I will start with that?

        SBM is not different from EBM, it is simply a reminder for a part of EBM which has been lost. Historically it is people like PhDs who did research. At the time this “relatively” small group demanded the highest quality of idea, especially for would be research projects. These ideas had to first be theoretically compliant with the known science of the time. Eventually, and unfortunately for no small part pointing to “proving” they were doing something worth paying for, medical doctors also started doing research. Naturally, all doctors are positioned to provide reputable research, but in many cases they opted for “clinical studies,” which admittedly could be more than what they currently are. This method of “proving what you were doing was right” was later adopted by other healthcare providers, and largely explains why it often faces a major bias in acceptance in the general scientific community. (I honestly cannot cite a source other than an MD or PhD and get my boss’s approval, no matter how great the study is, unfortunately, this is the norm in medicine in most of the world.) But all this leads to the same point, most researchers are not experts at the basic science (chemistry, physics, biology, physiology, etc.) that original researchers simply took for granted. SBM (as I recently learned it is called, despite personally preaching it for years) is just a reminder that the basic science cannot be over looked or dismissed by clinical study. There is no secret to learning it. The easy way is to go to school and take a bunch of science courses. Not only is it easiest, but you actually get credit for it, and one day get a piece of paper attesting to your expertise. (School is also the easiest way to get involved in research, and like all of life, experience counts) The alternative is to be self taught. Unfortunately, while this is possible, without the piece of paper, a researcher will not be recognized outside of their very small clique. In other words, still a second class citizen. Researchers who follow the tenant of SBM simply require the corroboration of basic science knowledge in their research. This is especially important when researching the cutting edge (my next post) compared to the bleeding edge. After all, there will be few if any studies supporting you, for all intents and purposes, your basic science theory is “proof of concept.” Like I said, when I track that stuff down, I put it in the paper. It is a lot of work. Many “SBM researchers” publish one or more papers on the basic science behind a potential clinical study before undertaking the actual study. Personally I would love to do that, but currently I am too low on the totem pole to requisition those kinds of resources, but it is a work in progress. (generally there is an index for the quality and capability of a pro researcher. The bottom line is to enter that upper echelon, your 10th published paper of original research has to be cited 10 times.)

        Do I try to engage EMS persons and systems? The simple answer is “yes, I do”, around the world, formally in 7 countries. I was part of the US EMS system at one time. for many more years than what I do now. It’s problems are unique to it. As time passes, the frustration of dealing with it causes me to engage in it less and less. Usually just when I am re-convinced I can do something for it, some meat head comes out and destroys that desire again one way or another. In fact that is the exact thing that prompted this post. How do you fix it? Beats me. There are many great minds that have tried. But not much has changed in 30+ years despite all the efforts. A few of those people I communicate with regularly, and while we do not always agree, our conversations are very candid and a common recurrent theme is most EMS providers suck. As you can see, when you say that publically, everyone gets upset and states “not me,” but we also said the same thing when we were the rank and file. I mentioned to a blog post on my post, a mandatory educational degree will not magically solve the problems facing US EMS. But without it, there is simply no opportunity to start.

      • Thank you for taking the time to both read my comment and respond in kind. I appreciate your willingness to engage with those who try to meet you at least part way.

        I understand all too well about the “second class” nature of amateur (as opposed to professional) efforts, both in research and in emergency response. I spent several years as a member of a historical recreation group that had, as one of the popular aspects, subject matter research and “experimental archaeology” by which I mean the willingness to learn about a thing then trying to create said thing in a manner that would be consistent with historical methods. While there was a lot of good (and no small amount of bad) work done, the academic community tended to distrust (at best) or discount (at worst) the investigations just because there was no piece of paper. However, the community continued (and continues) to do their avocational research and even, on occasion, surprise academics with new analyses.

        I choose to think that the same thing could (not necessarily *will* but could) happen with EMS, if more providers were willing to get their head out of their collective pockets. However, as you intimate, there are more than a few meatheads in the field that make it hard on everybody. I hold out hope (and will do my part, once I break into the field) that the newer providers will tend to want to be viewed as more than tradesmen.

  26. Micheal H. McCabe

    “Evidence Based Medicine” is merely the new dogma. Just like every other “good” idea, it will be misapplied, reinterpreted, watered-down, and adulterated to the point where any good it does gets lost in the shuffle. When “science based medicine” becomes the banner, it too will suffer these same indignities.

    “Common sense” will never be part of the equation. It can’t be defined and there are no standards to determine that which should be common.

    “Oxygen Therapy” is a good example of the dogmatic approach to EMS:

    When I started, we administered oxygen to folks who reported they were “short of breath.” Soon, we began giving oxygen to those who exhibited the signs and symptoms of “shock” — anxiety, tachypnea, tachycardia, pallor, and diaphoresis; altered mental status and evident metabolic derangement. Next, it was anyone who complained of chest discomfort. Before too long, we were instructed to give oxygen to folks with abdominal pain, headaches, and “significant” bleeding. What is “significant bleeding?” Who the hell knows? I’ve personally seen oxygen therapy used as a first-line treatment for hemorrhoids!

    Techniques for oxygen administration changed as well. We started with nasal cannulae, simple face-masks, tracheostomy masks, venturi masks, partial rebreathers, non-rebreathers, and the demand-valve mask. The demand-valve was first to go — despite its evident effectiveness in congestive heart failure. We were told to remove it from our arsenal. Legend says you could “blow somebody’s lungs out with it.” Slightly more temperate reasons cited were “gastric insufflation” and “pneumothorax.” Next to go were the venturi masks — no need for a “low flow” oxygen device when all we were doing was “high flow” oxygen. Simple face masks and partial re-breathers went away. Nasal Cannulae were retained in case someone couldn’t tolerate a facemask.

    Sometime around Y2K the trend peaked, and nearly everybody was getting high-flow oxygen through a non-rebreather facemask. Then the pendulum started swinging the other way. Now in 2014 you have to remind some EMT’s that maybe that grey, gasping, COPD patient with an SPO2 of 74% needs a little oxygen. The dogma has now gone against routine oxygen administration.

    As I said in my first reply, you hit the nail on the head. Until people start to THINK about what they are doing and WHY they are doing it, there won’t be any significant changes in EMS.

  27. OK… So I have issues with the tone of piece, and I have expressed that opinion both online and to the author personally. For those questioning his background – he is an MD, former EMT, has worked in the field both in civilian EMS and in war zones as a doc.

    Unfortunately, I think the tone of many of the responses on here only validate is thoughts in some manner. First, what is a “Divot”? Profanity laced responses? Really? “I’ve been doing this for x number of years, I know…” Come on – anecdotal and anonymous posts are supposed to further the discussion?

    It’s fair to question the tone of the piece, even have an honest disagreement with the content, but do it professionally for the love of all things holy! Many people call themselves professionals, but you have to behave like one to be treated as one.

    • S. Benson, EMT-P

      Let’s not pretend that this article was a professional attempt at prompting an important discussion about EMS.
      The tone and the insulting descriptions of EMTs and Paramedics went beyond any sort professional dialogue.

      If the author actually desires a collegial discussion then he needs to write at that level. In effect, he trolled EMS and got blow-back.

      As for being called professionals: this is the web and not the best place to judge behavior. Unless, of course, you want to bait people and then have a self-fulfilling prophecy that they went for the bait.

      • No, it was not meant to prompt a discussion at all. It was me voicing my opinion on EMS’s misuse of EBM and extremely narrow-mindedness to a small group of people who regularly are interested in my opinion. None of my prior opinions even saw 50 views, I had no reason to think this would be any different. I had no intention of trolling anyone, ever. I think trolling is a behavior of children. The responses here are that of people’s own doing, not my soliciting anything from anyone. Probably better if a majority of respondents here stick to more self gratifying and simple discussions though, do you diagnose, faulty legal ethical advice, incomplete understanding of medicine and scientific method, EMTs save medics and that sort of thing. Oh, don’t forget to buy a t-shirt.

      • S. Benson, EMT-P

        LOL: good try but I reject your changing the premise of my argument.
        An article was posted that was insulting towards EMS. The response to the insults is used as evidence that EMS people aren’t professionals and therefore, in effect, deserving the disrespectful treatment in the article.

        The respondents are not using this forum as evidence for anything. You stated that their responses may validate the position the author took. I disagree.

        As for MSMERTKAs reply, I’ll accept your statement that you weren’t trolling. Your article got sent out to a number of EMS forums and generated a fair amount of interest (although maybe not to the point of “trending” as a lead story on the internet.
        Still, and yet again, it’s simply not necessary to be insulting and condescending towards the EMTs and Medics. EBM was not brought into EMS by some EMTs who read about it someplace. EBM is an issue many places including, but certainly not limited to, Emergency Medicine. Kudos to EMTs who go to lectures and want to improve EMS. However, if they are misguided then help them out. Rumor has it that you were an EMT some time ago.
        What would you have thought then if someone talked to you that way? What would you have thought, as an EMT, if a doctor berated you that way? What would the old you think of the new you?

      • Truly, I hope the old me would be very proud of the new me.

        When I was an EMT and medic I found it quite disheartening that I was told by not only doctors, but other healthcare providers that if I was ever to be able to sit in the meetings and be credible as something more than an experienced technician I would have to get an education.

        When I was in medical school I was told that in order to actually have credibility questioning dogma I had to be a scientist.

        In the endeavor to do that I learned that it is simply not enough to review the research of others, you actually have to do your own. For better or worse, the research I am involved in doesn’t have many studies, if any at all. To be credible at it, the mastery of basic scientific knowledge is a must.

        I would endeavor to save younger providers the grief I experienced by doing the same thing they do now and trumpeting I was a life saving hero who already knew what I needed and did not have to have formal education.

        As a personal value, I am embarrassed by failures especially when I am trying to demonstrate to superiors my value. When they point out my inadequacy I make it a point to get better, not to tell them they are being mean or assholes. I also question my knowledge, not theirs when they do it.

        They got to be where they are by proving themselves.

        It is an age old question, is it better to be the junior of the elite or the king of amateurs?

        Perhaps when I am a professor, I will look back at the mistakes I make now and try to help people not make the same ones again.

  28. Due to some cretin over at the rogue medic site very deftly trying to impersonate me, I have unapproved all comments from aliases of people not known to me.

    For those of you have chosen to comment, even it was to insult me, I respect you signing for your own work and will continue to approve such comments unless I find out you are or attempting to impersonate somebody else.

  29. mpatk Paramedic, M.S. Chemistry

    First off, there are some very valid points made here. Unfortunately, they’re hard to find in all the condescending self-justifications within.

    If your purpose is to encourage EMS to bring itself up to the level it needs to be in the 21st century, you’ve failed miserably. Essentially all your article is stating is “don’t get thoughts above your station and go back to driving your big red taxi.” Only people with the right letters after their name get to talk at the Big People’s Table about research. Too bad many of the people with M.D. after their name follow the same poor practice you decry in EMS: cherry-picking studies to support their biases rather than the other way around.

    Hell, you even SUPPORT that sort of pseudo-science by overstating the importance of “expert opinion”. To take an example from a field where I’ve done original, peer-reviewed and published research (chemistry), the idiocy over “cold fusion” in the 1990s is a prime example of what happens when “expert opinion” is substituted for scientific method and well-crafted studies.

    It would be nice if you really did want to help EMS improve and become a more valuable part of healthcare; since you yourself have pointed out that hospitals will not be able to accommodate the growing cases of acute exacerbation of chronic conditions. Frankly, EMS could use the support to help convince the public to make it a full-fledged public safety service; and the red-headed stepchild of the fire departments or the cheap labor for private ambulance services. I suppose you just need to decide whether you want to have paramedics become more professional partners (not equals, but valued helpers); or you just want to kick EMS around so you have someone to feel superior to.

    • No, my point by this post was not to encourage EMS, it was to point out how minimal a part of the team it is.

      If you have not been following along, it stems from me trying to be nice and help and EMS people responding by claiming I don’t know what I am talking about, cannot cite a study that doctors who specialize in resuscitation are not better at it than EMTs, and your “peers” supporting that position.

      So I made my own post on how pitiful US EMS is. Every idiot and their brother then comments on my post on how mean and condescending I am. Look at yourself, look at the comments. “I have never met a doctor who can do what I do.” “Doctors turn green.”

      You are not great, you are not a part of the team, you are glorified taxi drivers.

      If you want respect you have to give it in return. That means policing the behavior of your peers. What do you think the reaction of my peers would be if I demanded a study showing Anesthesia was more capable than an EMT? Even if the person was a troll, what do you think the reaction of my peers would be if I trolled a physician’s webpage?

      You are no different than when I was in EMS. A few good people being dragged to the bottom by the ignorant masses. You might as well get used to it, because until they are a minority, they are what represents you to the rest of healthcare.

      I would suggest in the future if you want to help yourself out of that mess, jump all over them. Because I can assure you, what I wrote here is kind compared to what I hear from doctors about US EMS providers.

      • mpatk

        “No, my point by this post was not to encourage EMS, it was to point out how minimal a part of the team it is.

        If you have not been following along, it stems from me trying to be nice and help and EMS people responding by claiming I don’t know what I am talking about, cannot cite a study that doctors who specialize in resuscitation are not better at it than EMTs, and your “peers” supporting that position. ”

        Fair enough, and I’ve cringed while reading a lot of the replies you’ve gotten here.

        Some of the defensiveness (at least from me) is frustration at wondering where to start in “pulling ourselves up by our bootstraps” and improving as a whole. The impetus for higher standards won’t come from the majority of EMS management (too much vested interest in keeping paramedics low education and easily replaced). We’ll never get improved salary/benefits/etc… without that improved education; but it’s hard to encourage people to get a formal degree (even an A.S.) when they’re treated the same as the guy who went to a “certificate mill”. On the educational side, it’s discouraging to try and emphasize professionalism and learning the WHY of the pathophysiology and treatments, when we know significant numbers of FTOs will start their training by saying, “Forget that crap you learned in class; we’ll teach you REAL ambulance medicine.”

  30. Charles

    “Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff.”

    First, it appears that BASIC education is weaker in the US. Your highly, are highly educated, Kudos. America loves winners. But it hates losers, it does not much care for them (need I elaborate?) Your lowly, are lowly educated are a notch below many other developed nations (Many studies point to this) So… you have got yourself a poor foundation to start with… not good. Eliminating the “lowlys” from the EMT through higher Education requirement is but a trumped up strategy. First fix your (inner city) education this is of National strategic importance. EMS has more to do with what you do than what you know. Quality EMS does not depend on Bachelors degree (Beefed up Initial Education) It has all to do with MD involvement, Strong RE$OURFUL Medical Command, non punitive QA/QC Peer review (8 X 3 hour$ a year), Generous Compulsory CME, (re)credentialisation (testing),ALL THIS generating a positive quality care environment beats all your University degrees.,

    Resources ! America doesn’t like loser. Patients are losers, Patients in inner city are real losers. NOBODY want’s to spend the (extra) money. EMTs (Paramedics are EMTs) are poor people (generally) Being an EMT is a “working poor” job (A revolting reality, especially if you are conservative and value hard work)(Working poor: Is having a full time job and not being able to generate enough revenue to support yourself/family).
    Why are EMTs badly paid? They are a dime a dozen. As long as the course is only 120 hour DOT. Loads of (bad) EMTs lot’s of offer drives down salaries. Basic Economics 101. You are not sure about this, check out Québec, Ontario, British Colombia, Australia, and you will understand.
    You do not get what you deserve, you get what you are able to extirpate from your employer (Bargaining power) .

    Make the EMT-P a stepping stone to PA
    and on to… MD

    And you have got yourself a real hardy road to better Patient care… and your place at whatever table you want to go

    Charles

  31. Corky

    I agree with some of his statements but this is a prime example of too much college and not enough preschool.

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