Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.
As an outsider coming into the field, it baffled me that paramedics complain about low pay rates and little respect when compared to their counterparts in nursing. After all, they must master many of the same medical techniques, including advanced procedures like intubation (placing an airway in the trachea), the calculation and administration of narcotics and paralytics, cricothyrotomy (cutting the larynx to create an artificial airway), or chest decompression (stabbing a patient's chest to relieve pressure from air or blood build-up in the cavity) -- any of which could just as easily end a patient's life as save it, if improperly performed. (See the NC paramedic's scope of practice here.) Furthermore, as many medics point out, they are often expected to perform these procedures without the benefit of the controlled and well-lighted hospital environment that nurses typically enjoy -- and that usually with only one trained partner available to assist them, whereas nurses often have at their availability a myriad of health professionals from doctors to other nurses to aides. I want to emphasize, over and over again, that I believe that nurses deserve every ounce of respect they receive and every cent they earn, and even then, if you ask me, it's not enough. I've worked with them in the ER and I've seen what they have to handle, and it's ungodly. My issue is why paramedics don't receive equal treatment.
Having settled on my topic, I set out to investigate the questions below through a historical lens to see if that would provide any clues as to the evolution of EMS in the US. Obviously, five blog posts can't even begin to thoroughly cover these questions, but it definitely provided a sound enough start for me to begin to understand the EMS situation.
- Why do paramedics receive less pay than nurses? If as paramedics charge, they are respected less than nurses, why is this so?
- Why did paramedicine arise as an independent field from nursing? Why do we use "paramedics" to staff ambulances instead of "nurses"? After all, if medically trained non-physicians already existed, when EMS came into vogue, why not utilize those professionals instead of creating a new field?
As I started my research, I was quickly overwhelmed by the breadth of the topic. For one thing, EMS in the United States is comparatively behind the times when compared to some European countries such as the UK, which employs paramedic practitioners that can diagnose and prescribe without needing to enlist a physician (Canada, too, has a similarly privileged advanced paramedic level); these paramedics are comparable in scope to nurse practitioners in the US. With standardization of education and regulations at the national level, the pay discrepancies in these countries have disappeared, whereas in the US, the DOT has a recommended curriculum, but individual states have the final word on EMT training within their boundaries. Therefore, I found it necessary to narrow my scope to the US only.
Still, every topic, however specific, had a million different pieces in its background, and if I neglected one I felt as though I'd not been completely thorough on presenting the facts to the reader, whom I felt would thus be unable to gain a complete understanding of the subject. Yet, it was logistically impossible to include everything (I had to keep reminding myself I was making a blog, not a novel). This problem didn't extend solely to historical topics; modern EMS has a tangled web of certifications and regulations that even I, as an EMT, do not fully comprehend. Therefore, I assumed that the average reader would be at least somewhat familiar with the way EMS systems function and the people who work in them. Without this basic knowledge, the reader would be unable to appreciate the blog's posts. This wasn't a far stretch, as I feel that mainly EMTs would come to a blog of this type; after all, the problem I have sought to address is one that affects them, and unless one extrapolates that patients will suffer from poor care from EMTs who feel they are mistreated, this problem doesn't really affect many other people. (I've included to the right a glossary of some terms I thought the non-EMT might not understand.)
This brings me to the name of the blog, "The Patch", which refers to the patch usually worn on the sleeve of the EMTs shirt or jacket that identifies the individual as an EMT. However, in EMS culture, the phrase has a deeper meaning that stands for all of the hard work the EMT went through to earn the right to wear it. It is a symbol of everything EMS stands for in that community: sacrifice, service, saving lives. By violating any of those standards, the EMT can lose his patch, a disgrace indeed. Therefore, any visitor with experience in EMS would instantly recognize the meaning of the title, which I've accentuated by using for my logo a patch of the Star of Life. To me, however, "the patch" also stands for the way the blog is formatted: a patchwork of snippets from the history of EMS. Unlike a novel, a blog is not necessarily comprehensively or chronologically ordered, but rather provides relatively brief snapshots of relevant content. I will say that this blog is designed very differently from the typical EMS website, which tends to get a little crowded with exciting images of flashing ambulances and medics in action. However, as this site isn't focused so much on the adrenaline-fueled aspects of EMS treatment, I thought a cleaner design would work better.
First things first: what do EMTs think?
The National Association of EMTs lists among its objectives to secure for their field better recognition and pay.For a more personal insight, I conducted the following questionnaire on a popular EMT Facebook page. People cited lack of education, lack of funding, a background in the morgue, a lack of a defined role, and a lack of visibility -- all parts of the problem, but no the whole problem, which is why a blog like this is needed to help EMTs. Three out of fifteen of the respondents specifically used the "red-headed stepchild" phrase to refer to the field of EMS, a phrase I had already heard many times prior during my experience learning and interning as an EMT.
"I wanted to see if I could get your perspectives, as EMS professionals, on how EMS emerged into its current state as viewed a historical perspective. I'm particularly curious as to what clues that history might provide on why EMS as a field is perceived as being less respected (lower pay, recognition, etc) than other medical professions, such as nursing (and how this could influence the future of the field)."
- "Most of the public still think that we just drive them to the hospital. They have no idea what we can really do. As for pay. A gross number of things work against us. The biggest being history and low payments from insurance. Not to mention EMS is a stepping stone for firefighters." (DK)
- "In the public safety world, especially when it comes to funding, EMS is the adopted red headed step child... "(AG)
- "2 words: meat wagon." (EJH)
- "After spending many years working for a private ambulance company in a busy system, you realize that it's a thankless job most of the time -- but there are a few thanks here and there. It's a difficult field to work in, that's why the average burn out time is 5 years. I lasted 10, finally succumbing to a back injury. People either love you or hate you, that includes other agencies you interact with and even your patients. The advancement of the treatments being provided here in Colorado are mind blowing. We are cutting edge in EMS and always have been. The education requirements and continuing education requirements can be overwhelming. Unfortunately, often times the ambulance crews are the red headed step-children of EMS, which is quite unfortunate. Most often the problem is too many chiefs and not enough Indians." (KV)
- "I may be completely wrong about this but I believe 'back in the day' possibly the 60's and 70's that, orderlies from the hospitals were used to run emergencies. I don't remember where I heard or read that. But they would go pick up patients and take them to the hospital. Little or no treatment was rendered. If the person died en route to the hospital, then they were taken to the morgue. And I completely agree with Sean, compare the 2, no one has a clue. But that may be why we are the red headed step children." (CJG)
- "Most people don't care about emergencies until it's THEIR emergency." (AJC)
- "EMS was run by the morgue long time ago. I have a pic on my page from the EMS conference they has a hearse displayed as an early EMS vehicle." (MJB)
- "It all began during World War 2 as the need for medical assistance was so very prevalent. And sadly to date we are all still viewed as simply ambulance drivers, hence the reason I did PR with the station I worked at as the public simply needs education on what exactly it is that we do, I used to bring the ambulance also to the local school and let the kids do a tour and many public events. Good luck , as many of us do it simply for the love of helping others knowing we will never see the pay we actually deserve. But I would never change my 20 yrs dedicated in the field as they were the best 20 yrs of my life. So many stay in the field when they are burned out and that does no good for the patience and or your partners, it is a rewarding field to be in as long as you consider your reward personal and not monetary. And again in all those years it is simply because people do not know what we do and PR is what is so badly needed." (JM)
- "Take a look at how each state has dipped their hands into it-setting their own standards... for financial gain." (JMH)
- "Doctors, nurses and PA's, although great, aren't worth shit on the streets... WHERE IT COUNTS! We are the ones who stabilize, clean and package their patients. They could NEVER do what we do nor do they think they cant... that's the problem. Why we are treated worse than an alley-dog...I don't know." (RD)
- "We do and see more in a 12 hour shift than most people should in a lifetime. Death is a part of all health care workers occupational undertakings but EMS see the most unfortunate side: in homes (suicides), roadside RTCs, messy domestics, etc... We see what polite society thinks doesn't go on, hence we are invisible and largely unrecognized." (MD)
- "About 25 years ago I applied for a grant for a volunteer ambulance corps. We didn't get it. It went to the volunteer fire dept. When I questioned the decision, I was told that, 'You can put a value on property not on a life.' Thus their decision. So with that belief in mind, EMS is low paid and less respected." (JKD)
- "The first ambulance corps began in the Civil War; they had no medical treatment, basically went around and picked up the injured in the battlefield and transported them to the field hospitals then. It started from there." (MS)
Proving a Pay Divide
In the US, according to the Bureau of Labor Statistics, the average salary for "EMTs/Paramedics" runs around $30,000 while hourly rates were $14.60. Licensed vocational nurses earn $40,000 a year, or almost $20 an hour. Firefighters earn $45,000 a year, or almost $22 an hour. Registered nurses receive over twice that much: almost $65,000 a year, or $31 an hour. The first three require a "postsecondary non-degree award" for entry-level jobs, while the latter lists an associate's degree (although this is not necessarily true, as a few rare places still grant diplomas that lead to the RN license; the BLS site claims 6% of new entrants use this route). Nursing aides were the only allied health profession I found to make less than EMTs: $24,000, or $11.50 an hour.
One issue that comes up with these statistics is that they lump all types of EMT certifications together -- basic, advanced/intermediate, and paramedic -- even though each certification level has very different requirements for education, and accordingly, each level receives a proportionate level of pay. Therefore, a critic could argue that paramedics are actually paid just as much as nurses, but that basic-level EMTs are pulling down the average. While this is true to a degree, further research proves that when we only look at paramedic, the discrepancy is still there. Indeed.com, a popular job listing site that aggregates job postings, lists the average salary posting for various careers, and they do separate regular EMTs from paramedics. According to Indeed.com, paramedics in NC make around $54,000 a year, while EMTs make $34,000 a year, and nurses make $77,000 a year. (According to Indeed, LVNs only earn $44,000 a year). The discrepancy is real.
What about education standards?
Here, a lot of people, will claim that paramedics are paid less because they just have less education. Nurses typically get degrees (although some get diplomas, as I mentioned above) and paramedics typically get certificates (although some have two-year degrees in EMS and a few schools, including Western Carolina, offer a B.S. in emergency medical care), but does this mean paramedics are less qualified? Indeed, many paramedics themselves explain the divide this way (and the NAEMT is petitioning for enforced national education standards).
Again, since there is no federal regulation legislating minimum educational requirements for either field (although there are recommendations), I'll look at NC. In 2011, the National Council of State Boards of Nursing published a survey of the educational requirements that its member states upheld for RN licensure; clinical hours required ranged from 250-900, although some states -- including NC -- did not have a legislated minimum at all. North Carolina follows the DOT guidelines for its EMS curricula; for the paramedic level, this means a minimum of 260 clinical hours in a hospital or related setting plus 300 in the field with an EMS agency (or 500 hours total), a range that makes it on par with most nursing programs as far as real world training goes.
What about theoretical coursework? The NHTSA recommends 1000-1200 hours of instruction time. North Carolina mandates 596 hours of paramedic class, although the student must first attend 196 hours of EMT-Basic class for about 800 hours total. As far as I can tell, the NC State Board of Nursing accredits schools but does not publish the requirements it uses. I used my community college's nursing curriculum to get a rough estimate of the hours that nursing requires for it's ADN. I've subtracted classes like writing and psychology that don't directly apply to nursing. (For direct comparison of degree options, the school also offers an A.A.S. in EMS which requires about the same number of total credit hours.) I've estimated sixteen weeks of school and used the traditional scheme that one credit hour equals one classroom hour; as labs and clinical hours are measured differently but not separated out in the curriculum, this will result in a rough calculation, but one we can nonetheless use for a rough comparison. At 51 credit hours in nursing, this results in around 816 hours of conceptual class time, a number on par with the certificate needed for EMT-Paramedic.
But EMS is young...
This isn't necessarily true, as I showed here. EMS has roots that go back to at least 1792 when Larrey started the first real organized ambulance corps. In the US, one can definitively point to the Civil War. It's true enough that these "EMS systems" were not quite what we think of as EMS today, but the tradition is obvious. By comparison, Florence Nightingale, who is credited with having "started" nursing, did not become active in that respect until the 1850's. Obviously, as with EMS, nursing had existed in one form or another before then, so arguing over its start date is another messy matter. Still, the point stands that EMS didn't miraculously materialize in the 1960's.
So why did this happen?
I see mirrored in the nurse vs. paramedic setup the same that happened with the physician vs. barber surgeon setup. Physicians claimed that barber surgeons were uneducated hacks, yet Gelfand showed that barber surgeons actually underwent a rigorous education. Despite this, barber surgeons remained lower in status, and typically had lower pay to go with it. In a similar way, many medical professionals today perceive that paramedics lack training, yet I've shown this is not the case.
A similar class divide might have influenced the divergent pathways of nursing and paramedicine. While both professions truly came out of war, in America, paramedicine has a dubious birth from the morgue, a place that has never been associated with "nice" people. Nursing, however, has for its face Florence Nightingale, a "proper lady." (Few people seem to know that the earliest "nurses" in hospitals were often prostitutes. On that note, it's funny how nursing and paramedicine have both flipped their origins in a sense -- nursing from prostitute to proper lady, and paramedicine from the morgue-worker to life-saver.) This was obviously not a conscious choice. Paramedicine evolved on what worked at the time using the limited resources available. In the early 1960's, this meant hearses, and that model was re-fitted as needed to meet new demands. Since the early focus was on transport, ambulance attendants just needed to be fast. This could explain why it never became popular to employ nurses for ambulances: their advanced medical training would be wasted. By the time it was discovered that advanced care en route could improve patient outcomes and should become a point of interest, ambulance attendants were already the people who manned ambulances. It was a logical step to simply begin training those people to provide the care. These people, who at least at the beginning had only minimal medical training, would naturally receive lower pay rates.
It's also confounding how a brilliant man like Larrey implemented a functional and apparently quite successful ambulance corps in the late 18th century, yet his innovations were ignored by civilian and military authorities in other countries for decades. The only explanation I can come up with is that civilians simply didn't experience in their everyday lives the same kind of extensive trauma that soldiers would in war, so the need wasn't as obvious or as great. Wars saw many people injured in one nicely concentrated area. In civilian areas, injuries would happen haphazardly and over a much greater geographical area. In other words, over a period of one day, thirty men in one square mile might get hurt in a battle, whereas in a city, only three people might get severely hurt -- with ten square miles between them. This would explain why the widespread use of automobiles would serve as the catalyst for EMS in the United States. Traumatic injuries are unlike some chronic illnesses in that they must be dealt with immediately. The patient doesn't have the luxury of waiting for a drawn out death. What gunpowder did for EMS in wars, motorized vehicles would do for EMS in peacetime.
What can EMTs do about it?
In 2007, the National Academy of Sciences turned its attention to EMS once again, releasing Emergency Medical Services: At the Crossroads, a 200-page document discussing the current state of affairs, and a highly recommended read for anybody seeking a thorough dissection of the topic. “Emergency care has made important advances in recent decades,” it found, applauding universal 9-1-1 coverage that gives access to “advanced lifesaving care within minutes.” However, it charged that “the quality of EMS is highly inconsistent from one town, city, or region to the next” (with rural areas suffering the most) and there is a “lack of clinical evidence to support much of the care that is delivered” (back boarding, for example, has recently come under fire as a typically unnecessary and occasionally even harmful procedure).
EMS, for example, is unlike any other field of medicine -- over one-third of its professional workforce consists of volunteers. Further, EMS has one foot in the public safety realm and one foot in medical care, with nearly half of all services being housed in fire departments. - NAS
As the quote above shows, the divide between an EMT and any member of the public is, often unclear. According to the NAEMT, the 1977 show Emergency! was influential in garnering public support for EMS, stated, "The program suggested to the public that paramedics existed everywhere. In reality, they did not. Additionally, it portrayed paramedics as frequent lifesavers." While it is widely accepted today that paramedics save lives, the work they do must become more visible. EMS must not be viewed as simply an intermediary between fire department and hospital, but must be recognized for the important and distinct role they play. EMS needs a serious PR campaign.
This confusion over the role EMS probably plays a role in its current lack of funding; initially considered a distinct medical field, its funding was eventually rolled into funding for other projects. Throughout the 1960's and 1970's, the government led the way in EMS improvement. The Department of Health, Education, and Welfare allotted $16 million to EMS programs in 1972. In 1973, the Emergency Medical Services Systems Act -- Title XII of the Public Health Service Act -- set up fifteen components of EMS systems and provided states with a total of $300 million in funding to make those components a reality (manpower, training, communications, transportation, facilities, critical care units, public safety agencies, access to care, patient transfer, coordinated patient record keeping, public information and education, review and evaluation, disaster plan, mutual aid). However, that well ran dry in 1981, when the Omnibus Budget Reconciliation Act merged EMS funding into generalized health grants for states. States had greater discretion to spend the money as they wished, and this sometimes led to the neglect of their EMS systems. Since then, federal funding for EMS has never been as comprehensive.
More importantly, standardization, standardization, standardization must be implemented and enforced at the federal level. Both the NAEMT and Crossroads stress the need for nationally accredited programs. The current state-based model not only results in haphazard funding, but also in inconsistent quality in the kinds of care EMTs can provide. One problem this causes for EMTs themselves is trouble moving between states, since the different educational requirements across borders can render one's hard-earned certificate useless. An EMT should still be an EMT whether he is in Florida or in North Carolina.
Included in this new model of education should be a stronger emphasis on history. In my EMT class, for example, we briefly skimmed over the history, but the gist of it was something along the lines of, "People realized EMS techniques saved a lot of lives in the Vietnamese war and decided to bring them home to America." Medics such as myself, who have been taught to think historically, would be much better equipped to analyze their profession across time, and compare its tradition and education to other professions. Insights into evolution of EMS in the United States could provide thoughtful accurate solutions to modern EMS problems. (It's notable that among the fifteen respondents to my survey, only the one in the bachelor's program seemed to have a fairly thorough understanding of the history of EMS in America.) Such training would allow them to combat the false misconceptions that plague EMS, as discussed in this essay, and make a fair bid for increased funding. Everybody, the public included, benefits when EMTs are more well-informed, a goal which this blogs seeks to achieve.
References Frequently Used in this Blog:
- A History of Emergency Medical Services & Medical Transportation Systems in America. Robbins. 2005.
- Accidental Death & Disability: The Neglected Disease of Modern Society. NAS, 1966.
- Emergency Care and Transportation of the Sick and Injured, 9th edition. AAOS, 2005.
- Emergency Medical Services: at the Crossroads. NAS, 2007.
- EMS: A Historical Perspective, EMS Agenda for the Future. National Association of Emergency Medical Technicians. NHTSA, 1996.
- Gestation of the Clinic. Gelfand. Medical History, 1981.
- History of Emergency Medical Services in the United States. Rockwood, Mann, Farrington, Hampton & Motley. The Journal of Trauma, 1976.
- Prehospital Emergency Care, 9th edition. Mistovich, Hafen & Karren, 2009.
- EMS educational standards obtained from the NHTSA and/or the NC Office of EMS.
- Their paramedic instruction guide has a great timeline on the history of EMS.