Allows Fire/Volly squads to keep their relevance and call volume, while at the same time cutting expense on ALS. Paramedics can have real career prospects and train the job they want. Can create real education standards for paramedics and could even tier it. CC for transfers, ALS for typical ALS stuff. All intercept based, dual medic. Allows for a tremendously reduced pool of personnel so oversight is better.
This is basically how Jersey works to my knowledge, aside from ALS being hospital based as opposed to third service
Hospital based would honestly probably be a logical approach as well. The resources are already there to scale like the pharmacy, medical oversight, etc.. Instead of having to do everything organically.
The major downside of having hospital based for ALS is you'll likely end up with nurses as your leadership that have no clue about EMS but insist theyre qualified to run it because their licensure and degree are 'higher' (its not).
Saw many hospital based services run into that issue of unqualified people insisting they know how to run the system better than the EMS people, and can't fathom why what works for a hospital does not work for EMS.
That's a big issue as well. Nursing sticking their grubby hands into everything. This is why I also am a heavy advocate of EMS professionalizing. As in Bachelors of EMS for CC. Masters for leadership/advanced roles, etc. More education = less providers = more bargaining power.
One of my hot takes is Nursing actually probably needs less overall education than EMS to get into. Could get away with like a 6-9 month course and probably get the exact same results.
That's correct. Only issue we have is at least in the North, it's very volunteer based. And I think the squads are having more an more trouble keeping up.
Jersey the island, or New Jersey?
You’ve described my actual system! Minus the CCT stuff which is separate, but close enough.
This is literally the only way it should be done IMO. The more I learn about EMS, medicine, logistics, agencies, fire, etc.. The more I realize that true ALS needs to be treated completely as it's own thing. Fire obviously will not give up it's grip on EMS as a whole, but I think this would be a good compromise.
EDIT: To add, FFS I wish it was more common in my area. The only places that REALLY do it never have openings or are CCIFT based, and you have to suck up hard to make area supervisor, no thanks.
This is pretty close to the best way to do it, except that paramedic level care should really be hospital based (even if the government is funding it as a 3rd service). The systems with the best, smartest, most skilled, and dare I say overall the most satisfied paramedics I’ve ever seen have pretty much all been hospital-based, with the paramedics rotating between working in the hospital and in the field.
When paramedics work in a hospital in addition to the field, it’s almost like being in constant clinicals. You’re seeing, treating, and working with so many patients for so much longer than you do in the field, and you’re doing it as part of a care team instead of by yourself. Every day you get to learn from the doctors and nurses, and they get to learn from you. You develop a deep understanding of how the hospital works, what they do, and why. You develop a level of trust with the physicians and nurses that is really hard to do without working alongside them. Then, when you are out in the field, the continuity of care is so much better and smoother.
I have been screaming this for years and years. I've advocated for exchange programs between Paramedics and ED/ICU nurses for years too. Get Paramedics exposure to longer term and more advanced care and pull through, and let ED/ICU nurses get exposure to acute emergencies they have to manage with little to no background information or history on their own.
But alas it has all fallen on deaf ears because no Admins wants to take the time and money to actually expand their providers' knowledge.
I think this really comes down to whether you think the paramedic level of prehospital care should really be a public safety service or a healthcare service.
I believe that BLS/AEMT level care should be in the public safety realm (with private agencies, FDs, rescue squads, etc leading the charge), but that paramedic/cc level care needs to be integrated into the healthcare service. To fully realize its potential, and to provide the best, most efficient level of care possible, this level needs to be a much more seamless bridge between prehospital and hospital environments than it is now.
High acuity prehospital critical care requires focus and experience in a variety of clinical settings to maintain both good judgment and high skill levels. It does our patients a disservice if the people providing that level of care have their focus split by other things like fighting fires and doing rescues.
This is where my issues lie. Prehospital medicine isn't treated as medicine, WHEN IT IS. It's treated as a "trade". It's severely watered down and often times bad for patients.
Some agencies still use Dopamine ffs. That gets thrown in the trash as soon as you arrive, the MD gets pissed, and Levophed is started.
Vast majority of agencies still don't have blood. What do they get as soon as they get to the hospital? Blood. I have had a couple patients that likely would have lived with blood in the field.
Vast majority of agencies don't have Bipap/Vents, and what do they get when they get to the hospital? CPAP ripped off and thrown in the trash, Bipap placed. Vents placed after having a patient bagged at who knows what efficiency for 20+ minutes.
I could go on and on about antibiotics, pressors, vents, RSI, blood, ultrasound, etc.... Why do we make some weird compromise that prehospital medicine is grossly inferior to in hospital? Oh yeah, money.....
Sorry, rant over. You just hit my sensitive point.
The big issue is this can lead to "scope creep", which is a big non-starter for the AMA. They ONLY want Physicians performing medicine and everyone in the hospital, regardless of their "stance". As soon as we start really taking Paramedic education seriously, and treat in place protocols become more and more common, that means less people in the hospital, which is bad for hospitals, but good for the public and taxpayers. This is the biggest issue with for profit healthcare.
What role do medics play in hospitals? I ask as a medic that went RN lol.
I've only seen medic be labeled "advance techs" in an ER so they could do IVs but nothing like what you describe.
Depends on the hospital and the state and what they’re allowed to do. In some places, they can function similar to nurses. In others, they can’t do much beyond a regular tech.
For instance, I’m in MA. Here, our OEMS has recently taken the position that paramedics can do nothing in hospitals except function as ordinary techs or act at the first responder (not even EMR) level. They’re not permitted under OEMS’s interpretation of the state EMS regs to administer any drugs or perform any advanced skills like starting IVs or defibrillating or intubating unless they’re working as part of a licensed ambulance service.
In NH, in contrast, the laws are a little different, so some hospitals use paramedics in a role similar to RNs, but with a slightly different scope. So for instance, they might be assigned ER patients to handle essentially as a nurse, but they might only be allowed to administer drugs that are in their state formulary. They might be assigned to rapid response teams to work codes or to help stabilize crashing patients because they might be credentialed to intubate or defibrillate in cases where RNs are not. They might also be assigned to a trauma team or to transport STEMI patients to the cath lab so they can intervene right away if the patient arrests or develops a lethal arrhythmia. Some hospitals up there have a paramedic working alongside RNs in the cath lab. They might even be assigned to ER triage or to float up to the ICU to help the RNs on very busy days. It really depends on what the hospital is comfortable with, what they can get away with under their existing staffing contracts, and what the state will allow.
I actually agree with this, with the caveat that third service departments that handle BLS calls tend to have a lot of bloat and low morale. And I’m not opposed to having privates help out with the BLS transports to keep the fire squads in service. Honestly pretty ideal service.
I have been doing a large amount of system research, reading threads, watching documentaries on other nations, chatting to people I know in other departments, and looking at other system protocols. The big thing that hurts is burnout, having paramedics on ambos 24/7 is just a burnout machine. The same stands for EMT's, but they are far easier to train and these days a dime a dozen.
Could have the BLS trucks staffed in the fire service as "stepping stones" to paramedic school. X amount of years required.
You might be the only person I’ve ever fully agreed with on this subreddit
Appreciate that. I have an interest in getting involved in my states OEMS, but unfortunately fire holds almost all of the power, and I don't see that changing anytime soon without something really drastic changing. No interest in arguing with them.
Would be cool if they paid us more. Highest paying job I've ever had was as a phlebotomist lmao
We really need to have an EMS focused job forum. Where people can anonymously post their job, location, YOE, and pay. To my knowledge, there really isn’t one central website created for that.
Screw it maybe I’ll make one
I’ve thought about doing that for a long time. For all healthcare, but a focus on EMS.
Shoot me a DM with some of your ideas, I’ll actually work on making it
I've been a health system based medic for pretty much my whole career, and the perks I get working for health systems makes it worthwhile. I learn a lot of medicine, I'm in constant contact with our medical directors, Clinical Quality Improvement is mandatory so we actually get to follow up on calls. One of the systems I work for gives us access to the patient charting system used in hospital (Epic), so we can look up our patients and see what the hospital ended up diagnosing/treating. It's been mentioned already, but I think New Jersey made a great call requiring all ALS to be hospital based, which I think is the better move. You can keep ALS third service, but hook it up to the municipal hospital systems.
This is probably the correct way to do it tbh. Third service would work, but if you really want REAL high quality and efficient Prehospital ALS, hospital based ALS is the way to go. QA/QI would shoot through the roof, you can see patient outcomes more easily, you could do some clinical rotation to get some really good experience and skill sustainment.
Hospitals wouldn't, for the most part, willingly take this on without being forced, so hospital based with third service government funding, is probably the way to go.
This is the way. I don’t like fire doing really anything medical, but that’s not going to change. They are too powerful and need it to justify their call volume.
My question is how does a pt pay? How are calls upgraded? So I call 911. Local fire dept / volley shows up, they assess me determine I’m ALS. 3rd service ALS transports. Who does the insurance pay? Do I get billed for both? Is there now a financial incentive not to upgrade calls to ALS?