EMS Artifact

Not me, but EMS as a profession certainly seems to be.

Here are a few data points from here and there.

One private service is offering up to $40.00/hour for paramedics based on years of experience. They are still unable to fill empty slots.

Fire based services are also having trouble filling slots despite the generally better schedule, pay, benefits, and working conditions. In my state anyone who wants to be a fire fighter pretty much only has to become a paramedic, take the fire exam, and they will be offered a job, probably several.

Once hired, these brand new, ink still wet, paramedics are being placed on ambulances with little to no field mentoring. That’s good for me because I get to spend a lot of time teaching them what paramedics generally learn after they start treating patients under the guidance of an experienced medic.

These days, few departments have the time or money to do that, so the new hires are sent right to the ambulance. This is not particularly good for either the provider or the patient.

As I’ve said many times before, getting a paramedic license is just getting a ticket to actually learn how to treat patients. For you downhill skiers, it’s the Bunny Slope of EMS if you get my meaning.

At that, fewer people are taking the fire exam overall.

Some fire departments are hiring people who are basic EMTs and paying for them to go to paramedic school.

Traditionally, a person stayed with his fire department for an entire 30 or so year career. No more. As one chief officer described it, “It’s like musical chairs, only there are more chairs than players.”

A good number of experienced paramedics are transferring to other fire departments that do not have ambulances. They are getting an annual stipend because they are paramedics, but don’t actually do more than first responder duties.

At least one fire district has added ambulance availability to it’s morning radio/availability checks. Traditionally that only included engines and ladder trucks, but now some departments are reporting that they can not send an ambulance for mutual aid on medical calls. They are just too busy trying to cover their own cities or towns.

There is some talk of starting up regional non transporting “fly car” systems. Which used to be common in my state, but died out through the 1990s into the early 2000s as fire based services started to provide ALS care.

Everything goes in cycles, I guess.

Some areas of my state have reverted to the long discarded staffing system of one medically trained crew member and an first aid trained ambulance driver. That system started to die in the mid 1970s just before I became a full time EMS provider. Now, it’s coming back to help relieve staffing shortages.

As a result, there is more stress and work load on the single provider as what the driver can do in terms of care is strictly limited.

Some private services have taken advantage of the emergency regulation changes and are trying to convince the state regulatory agency that this should be a permanent change. Which will of course drive more people out of EMS as they get burned like an electric vehicle under salt water.

My former employer is now reporting zero available ambulances at various times during the day. The private services that used to provide back up 9-1-1 service are no longer doing so because they are too overwhelmed with their own emergency and Inter Facility Transfer (IFT) calls.

Patients are being held additional days in Emergency Departments because the hospital has no available beds and the private services that do their transfers are booked solid days in advance.

One large non profit teaching hospital has started it’s own ambulance service at two of it’s larger facilities.

Why did this happen? There are a few reasons.

1. COVID. Since the pandemic started requests for ambulances have gone up. No one is quite sure of why since COVID transports aren’t a huge part of either emergency or IFT calls. Of course if providers test positive they are barred from working for some period of days. Early one, that was two weeks, but now it’s often less time. The additional work load has driven some providers to just leave the field entirely.
2. No one seems to want to work. At least not in EMS. When fast food restaurants are paying as much to start as an EMT would make, why take the harder job.
3. The population is aging. Baby Boomers are all approaching or at retirement age. Which means that a lot of providers are no longer working in EMS. Like me. I’m in good physical condition for my age, have minor ailments, and could theoretically work on an ambulance. But I don’t have to and do want to. I’ve done my service and now perform easier EMS related tasks.
4. People are living much longer and using EMS more often. It’s now fairly routine to see patients over 100 years old. When I started in EMS I might see one or two a year. Now, services are seeing that number every week if not more often.
5. Ironically electronic Patient Care Report  (ePCR) systems take longer than the old pen and paper reports to write. That often increases at hospital time. They are great data collection tools, but in addition to more time, they provide far less useful clinical data.

I’m pretty pessimistic right now as are people who work in the field and the managers who have to try to find and retain EMS providers.

I’d like to think that maybe this will get better, but I can’t see how or when.

Japan is starting to use robots to provide care in nursing homes. Is there a role for robotic EMS providers?

We may well find out.

There has always been some violence in EMS, but the levels are much higher today than during my active years.

Back in the early days of what I call modern EMS in Sorta Big City it wasn’t unusual for EMTs to have to respond to calls without the police. The police weren’t dispatched to all ambulance calls, but certain call types and locations were supposed to get the police. Sometimes no police were available and some times they were dispatched, but somehow just didn’t manage to get to the scene until after the ambulance arrived.

During that time period just about every EMT on the night shift carried a gun. That, of course, we strictly against the rules, but people did it anyway since they couldn’t rely on a police response. To my knowledge no one ever fired there gun, but there were rumors. In at least a few instances guns were drawn and “suggestions” were made.

As EMS progressed that became less necessary since the police also progressed and were more vigilant in the responses.

Still, there were times when a violent patient had to be restrained and other times when a family member decided that attacking the people trying to help their loved one was a viable way to improve patient care.

Over the years most of us became more adept at defusing a situation by talking the patient down, but of course that didn’t always work.

In the years since I retired, I’ve noticed both in the news and from talking with still active former co workers that patients have turned more violent. That became even more prevalent from mid 2020 on as various nitwits decided that attacking anyone in uniform was okay. Fire fighters have also seen an increase in attacks.

It’s a hopefully temporary devolution of American society. If it’s permanent we are a really screwed as a country.

Which brings me to the end of last week. An EMS supervisor working for the New York City Fire Department EMS service was stabbed to death.

Lt. Alison Russo-Elling who was a 61 year old EMS supervisor was stabbed to death while walking down the street to get some food. The attack was unprovoked and the suspect arrested for the murder was not part of the call and had never seen Lt. Russo-Elling.

Just another crazy homeless person in New York City, which is full of homeless people many with mental health issues.

We were taught to be wary when dealing with homeless people. Many of them have some combination of having served prison terms, have drug abuse problems, and mental illness. Some have all three. One of the first things we always did was check the patient for weapons. Not really our job, but if the police weren’t there it was a prudent precaution.

I collected enough steak knives to start my own restaurant. For some reason the homeless in Sorta Big City favored steak knives. Maybe the stole them from restaurants, I don’t know.

Here is the story from Fox News,

FDNY paramedic, 9/11 responder fatally stabbed in the line of duty in Queens: ‘Heartbreaking and enraging’

Lots of high ranking city officials have said a lot of things about this, but what will really matter is how seriously they take not only this kind of violence, but the unprosecuted violence increasingly seen in cities all over the country.

Unless something is done, this is just going to get worse and no one will be safe from attack.

This is not the first New York City EMT to be killed in the line of duty,

FDNY EMT KILLED BY AMBULANCE HIJACKER REMEMBERED, MOURNED BY THOUSANDS

There are others as well, but that doesn’t mean it’s acceptable. Quite the contrary, but as long as city leaders tolerate it they will continue to happen.

Words are easy, action is hard.

Not just COVID alone, but a lot of other factors as well.

As I’ve mentioned in the past my post EMS second career is doing Quality Improvement work with various EMS systems under contract. Most of our clients are fire based systems with dual roll providers.

I get to know not only the providers, but most of the their officers as well. In all but one agency I’m on a first name basis with everyone in the agency.

As a result, I hear a lot of things not directly related to my work. First, a lot of people are retiring and in some cases just quitting the profession. Which used to be unheard of in the fire service. Once on a a department just about everyone spent their entire career there. Now, people are just leaving because they are burned out from doing EMS.

It’s not so much responding to COVID calls per se, but responding to calls from people who want to go to the hospital, but think that their risk will be minimized by going via ambulance. Makes no sense, but there it is.

Other providers are transferring from agencies that provide EMS with transport to agencies that restrict their EMS  role to first response until the private contract service arrives to show up.

Every couple of months one of my clients loses an experienced provider to another department that doesn’t transport. Or they’ll lose a provider to a larger department where providers get respite from the constant flow of EMS calls.

There is what I call a “generational change in EMS and fire service EMS in particular. A lot of the providers who were hired in the early to mid 1990s have now reached retirement age. Many are leaving the minute that they hit the magic numbers for a full pension.

In order to replace those providers, fire departments and even private services are forced to hire new medics with little or even NO EMS experience. One of my clients as a brand new firefighter/paramedic who was hired because he is certified as a paramedic. Other than the ride time he had during his paramedic program he has never worked in an ambulance until he was hired.

The results are predictable and I’m frequently out to his department to review a call with him and provide education (that’s our approach to QI) on what errors he made and how to better treat patients in the future. This is an agency with a very good in house mentorship, but that can only go on so long because their is a slot to be filled on their roster and it becomes prohibitively expensive to keep paying overtime.

I don’t know how this will work out for him and his department, but I’m not optimistic.

Even at that, agencies are having trouble recruiting new providers. The state civil service fire exam used to draw 15,000 applicants. The last exam drew 2,500 with about 10% of them being paramedics. EVERY paramedic that passed the exam was offered a job, sometimes from multiple departments.

As I commented to a Deputy Chief I work with “It’s like musical chairs, only with more chairs than players.”

All of this has lead to a measurable decrease in the quality of patient care. We work with about a dozen agencies and it’s persistent among all of them. It’s also traceable for the most part to the new providers although there are a few more experienced “Valued Repeat Customers” in the mix as well. Some of them would have been removed from providing cares, but agencies can’t find replacements that they are confident would be an improvement.

It’s worse among out one big private service client. During the height of COVID the state EMS office issued a waiver to allow ambulance services to staff with one EMT or paramedic and one “first responder” driver. A first responder has to have taken a first aid course and be certified in CPR. They can’t be the primary care provider and there are limits to what they can do.

As I learned in my years working for a government agency, there is nothing more permanent than a temporary rule or procedure. I fear that the state will continue this waiver for the foreseeable future.

This private service has no mentorship program at all, so it’s not unusual to see a provider working as an EMT on Monday, have a day off on Tuesday, and then be working as a newly minted paramedic on Wednesday with no mentor or paramedic partner.

This is a formula for disaster as these providers know only what they were taught in paramedic school with bad practices that they observed over their ride time or when working with a paramedic partner when they were EMTs.

I’ve seen a lot of serious medical errors that definitely harmed the patients and had a high risk of a bad outcome for them. We do what we can to better educate these new providers and help them become better, but there are more calls than we can handle.

I jokingly refer to it as the “EMS Artifact Full Employment Act of 2022”, but it’s really not funny.

If EMS can’t fix this, we are plunging headlong back to the bad old days of “throw and go” when an ambulance was little more than a horizontal taxi.

In case anyone wonders why I don’t jump back into the fray, the answer is that I’m just too old for that.  Even with things like power stretchers and lift systems, stair chairs with track rollers to make moving patients down stairs, and even better ride quality for ambulances EMS is not a job for older people. At least not high volume emergency responses.