As I’ve probably mentioned a few times, in my post active EMS career I read a lot of Patient Care Reports. I’ve been doing this since shortly before I retired, so it’s close to thirteen years.

As a result of the thousands of PCRs I’ve read I’ve observed some trends. Most medics and EMTs try to do their job well. They don’t take inappropriate shortcuts, perform treatments and procedures competently, and mostly get the diagnosis of their patient correct.

Yes, there are still lazy paramedics out there. The ones I call “line and ride” paramedics who will start an IV and ride in with the patient, but not do anything else. Sometimes they shouldn’t have started the IV and sometimes they should have done a lot more than just start an IV.

I worked with a medic like that. Anything even vaguely, might be, cardiac he’d give them aspirin, IV, NTG and a ride to the hospital. He logic was that while he was on this call, dispatch couldn’t send him on another call.

He also referred to patients as “sausages” for reasons I never understood and never cared to understand. His reward for being such a lazy medic was that he was promoted to management.

Another kind of medic is the “Throw the drug box at the patient” medic. I worked with a few and I could never tell if they were super smart or just throwing medication at the patient in the hope that something worked.

Along with the clinically astute paramedic who exams the patient, looks at the medical history, medication and allergy lists and decides what the diagnosis is. He also directs the work of the rest of the crew and monitors the entire call. In some systems that have two medics per ambulance with good BLS providers, he may not actually touch the patient at all during the call. A couple I knew rarely put on gloves when they were the “tech” or “primary.”

Sadly the second two types of medics seem to be disappearing. Mostly that’s because they are retiring or moving on to other career fields. I suspect that volunteer services have similar or maybe worse retention problems. I have no direct experience with any volunteer services, so that’s just a guess.

I started to see what I call a “generational  change” in EMS providers sometime in the 20 teen years. As more people became paramedics the quality of EMS education and training seemed to decline.

There were, and I think still are a few programs run by the training divisions of ambulance services. From talking to medics that went through those programs it seems that academically they were “taught to the test.” Which meant that they could pass the certification exams. but didn’t have the theoretical underpinnings to understand why they were performing the skills and giving the treatments for patients.

An example is that if the patient’s heart rate was fast or slow, they’d start an IV and give a large bolus of fluid. Unless the underlying cause was hypotension, it was unlikely to change the patient condition for the better. They failed to understand that IV fluid is and should be treated as a medication. As with all medications there are indications, contraindications, and the potential for adverse effects.

When I had occasion to sit down and review a case like this I’d try to explain the anatomy and physiology of what had occurred on the call. This is knowledge that they should have been given during paramedic school and maybe had been so taught. Sadly, the looks on their faces told me that they either forgot or never comprehended that information.

All of this was happening in services of all types private or public. Some public services were somewhat better because they had training programs for new paramedics. Some were not better and would take a new paramedic and throw them to the wolves. Most of the private services I dealt with had a one or two day orientation intended to show the new medic where equipment and medications were kept in the ambulance. There was little to no oversight of new medics.

I will note at this point that this was personally good for me because it meant more work hours spent doing re education. It was decidedly not good for their patients because if I was meeting with a medic to review a call there was at least the possibility of some harm to the patient.

Many of the medics were receptive and appreciated the knowledge I passed along to them and based on our evaluation process they started doing better patient care. That’s why I do this work and use my very good EMS education and experience to help medics be better.

Then came COVID. EMS systems were overwhelmed by the call demand plus the isolation requirements that were adopted. This included being confined to their stations between calls and not being able to even watch TV, eat, or even just talk about calls together.

COVID drove a lot of the experienced medics and EMTs out of the field. Those who could retire did so in large numbers. Others just quit and it was almost impossible hire new providers. Providers that test positive, even if they were asymptomatic were sent home for two weeks. A manager I knew told me that if ten percent of his systems providers were out per day it would be impossible to maintain proper staffing levels.

EMS regulatory agencies started to approve “expediencies” that ended up being practices that had been abandoned years before as EMS grew up. Providers in some states were allowed to decide that a patient didn’t need to go to the hospital. This wasn’t so much to help with EMS overload, but was an effort to relieve the same kind of issues that hospitals were having. Staff were overworked for the same reasons as EMS.

Another was a temporary waiver to allow systems to work with one EMT or paramedic on the ambulance and a none certified vehicle operator who had little to no medical training.

Hospitals were tacitly allowed to hold the ambulance and patient outside the building for hours until a bed was available in the ED. More stress on providers and systems for the benefit of hospitals.

COVID is now in the rear view mirror, but the damage still lingers. If spend any time on Facebook you will see that all types of EMS systems are looking for paramedics and EMTs, especially paramedics. An EMT course can be anywhere from a minimum of 120 hours to 190 hours. The 190 hour courses have more information and usually cost more. A 120 hour course can be crammed into about three weeks of full time instruction. Someone can take that course, pass the exam and be hired within a bit more than a month.

An Advanced EMT course is somewhere between 30 to 350 hours of additional training. AEMTs can do some of the things that a paramedic can, but not most of them.

A paramedic program is six months to two years depending on where it is taken. It’s also much more expensive. The two year programs are usually paired with an Associates Degree.

Which is why the demand for paramedics is much higher than for either of the other levels.

That temporary waiver for ambulance staffing? In many areas it’s now become permanent. EMT and Ambulance Driver or worse Paramedic and Ambulance Driver.

How bad is the staffing crisis? I know several other retired paramedics who have been offered jobs by ambulance services. I’m talking about people in their mid 60s or even older.

As if.

At this point there is no way to know when or even if EMS will recover. Based on what I’m seeing, I am not very optimistic. EMS is a hard way to earn a living no matter where one works. There are far easier ways to earn more money and many people are taking those jobs instead.

I hope I’m wrong and that EMS will rebound because patients deserve the best care possible in or out of a hospital.