EMS

People signing up for EMT and Paramedic schools are at an all time high. The economy is so bad, that people are trying to gain job skills to be employable. Employers are taking advantage of this, and things are getting tight. In the peninsula of Florida, there are a few choices for EMT or Paramedic jobs:

1- Fire Department. This is a decent job with good pay, but the hours are long. You go to EMT school, and then Fire school. This takes about 7 months to complete. You take a certifying exam for both, and then start looking for work. Paramedic takes an additional year. Starting pay is $10-12 an hour for a Firefighter-EMT with no experience. Paramedics get around $13-16 an hour. Firefighters work 48-56 hours a week on average, so take home starts near $30,000 a year for EMTs, and $40,000 for Paramedics. Pensions are nor what they once were, but they are still better than most other professions. The real downside is that the competition is fierce. Even a “stepping stone” department, where many new firefighters get a job, earn experience, and them move on has a lot of applicants. Departments with a job opening are getting 200-300 applicants for each position. For that reason, there are so many unemployed people with firefighter certifications, that the state has largely shut down funding for the training of new firefighters. Unless you have experience or are a minority, getting a job as a firefighter is a long shot.

2- Hospitals, Doctor’s offices, and clinics: These usually have decent hours, good working conditions, and pay varies widely. Hospitals pay well, and you usually work the Emergency Department in 3-12 hour shifts per week. Starting pay is usually $12 for EMTs and $16-$17 for Paramedics. Again, hard to come by, but not as hard as firefighter or theme park spots. You are restricted in what you can do by many places, so the work is not very exciting or challenging.

3- Theme parks: Even more difficult to get into than a firefighting spot, but the hours are great and flexible, and the starting pay is $14-16 an hour. Benefits are outstanding, if you can get a full time spot, but those are becoming as rare as unicorn sightings.

4- So you are then left with private ambulances. In this area, all these companies do is haul non-emergency medical patients between nursing homes, hospitals, and dialysis clinics. No 911 or emergency calls. In fact, in many counties, if the patient is emergent the ambulance is REQUIRED to pull over and wait for a 911 unit from the fire department to take over the patient. Starting pay is $9-10 for EMTs, and $13-14 for paramedics. Benefits are poor. Shifts are long, normally 12-14 hours each. You do not get a station to sit in on those times where you wait for your next call. You sit in the truck and wait. No reading, eating, sleeping, watching movies on your electronic devices, no texting, no phone use, and no drinking of anything except water. (Not even coffee) These jobs are easy to get, but turnover is high, and most people don’t stay for long, using this place to get experience and move on. A person that stays at one of these places for more than 2 years becomes unemployable anywhere else, because many employers assume that you are stuck there for a reason.

One manager at a private ambulance company told me that his crews were not allowed to eat during shift, because he doesn’t pay them to eat. Another told me that patient care is secondary to keeping the customer (nursing home, hospital, etc) happy, and that the patient was just cargo, and no one cares what cargo thinks. One of my former EMT students was told by an employer when he complained about working conditions, that for every EMT that was working there, there were 7 more looking for a job, and if he didn’t like it, he could be replaced tomorrow.

Compare that to other jobs in the area: Fast food pays $8.50-9 an hour, or about as much as an EMT, and without the exposure to diseases that comes with EMT. Paramedic jobs that started at $14 an hour ten years ago are starting at $13.23 now. In comparison, my son went to nursing school after only three years as a paramedic, and his pay is now $32 an hour. Nursing school is the same length as paramedic, but more than double the pay.

There is a reason why the average EMT or paramedic spends less than 5 years in this job: injuries, poor working conditions, a lack of appreciation for hard work, and low pay all too frequently make the best and most talented leave. My advice to people that are thinking about a career in this field changed about two years ago: stay away.

There is an interesting case in New York involving an EMT and a pregnant woman with asthma. The asthma patient had been seen earlier in the day by paramedics for her condition and had refused to be transported for evaluation. The EMT, who was working in dispatch for FDNY, was on a coffee break when the woman nearby began having an asthma attack. Bystanders, frantically looking for help, saw the dispatcher in uniform and asked her for help. The dispatcher called 911, but refused to get up and evaluate the patient. The women died.
FDNY Was sued by the dead woman’s family, and the EMT was charged with the crime of negligence. To protect itself from the lawsuit, the FDNY claimed that dispatchers on break do not have a duty to act, and asked that criminal charges against the EMT be dropped.
My personal feeling is that when you are on the clock and in uniform, you do your job, even if you are on a coffee break. This EMT should have tried to do something. Even without equipment, she could have performed CPR.
Off the clock, I agree that you don’t have a duty to act. Heck, I quit stopping at car accidents about ten years ago when a paramedic in Central Florida who stopped at a car accident was struck and killed by oncoming traffic, and the State of Florida refused to pay the widow his death benefits
because he was not on duty.
In this case, this EMT got lucky that her employer needed to avoid legal liability more than they wanted to prosecute her.

I work a second job at a large central Florida theme park. (There are only a few, you can guess which one.) During my last shift there, I was called to evaluate a man who was “having a seizure.” When I arrived, I found a 59 year old man who was sitting upright in a chair and only verbally responsive.  He has a history of cardiac, HTN, hyperlipidemia, and diabetes. A local hospital owned ambulance service was called. While waiting for them to arrive, we got the following vitals: HR 88, BP 92/54, RR 18, Temp 97.8, BGL 140. It was over 100 degrees in the park, and the patient’s skin was flushed. We initiated active cooling, and he was again responsive within ten minutes.

The unit arrived, and in walks the EMT. Alone. Then he began talking the patient into signing a refusal. The medic never even got out of the truck. They took no vitals and did not even put him on the monitor. I pitched a fit and threatened to call their supervisor. The medic came in, ran a strip and they collected their refusal and left. Here are my questions:

How does the medic know that this was not a seizure?
How does the medic know that this was not a cardiac problem?
Why did the medic send his EMT in to get a refusal without even evaluating the patient?
Why do some medics still insist that medics who work for EMS only agencies are automatically better than fire based medics? Is it possible that my position, that it doesn’t matter who signs the paychecks, it is what lies in the heart of the medic that counts, is the correct one?

I think the real problem is that some medics are unable to get a fire medic job for a variety of reasons (too fat, out of shape, can’t pass the test, whatever) and spend their time bashing the fire department. I do everything that an EMS only paramedic does, and I fight fires and perform rescues as well.

A 69 year old male with an implantable defibrillator calls EMS because it shocked him. A medic who was on the call with me was assuming that the defibrillator was malfunctioning. That is usually not the case. In fact, I cannot think of a single time when an implantable defibrillator shocked a patient unnecessarily. This patient told me that he got lightheaded at about the same time as he was shocked, so I was running off the assumption that the patient had been in Ventricular Tachycardia, and the ICD shocked him. We put the patient on the monitor, and the patient was in a first degree AV block with frequent (15 per minute or so) PVCs.

The best treatment for PVCs is oxygen, so we started the patient on 4 liters, and obtained IV access. By this time, the patient was in ventricular trigeminy, and it wasn’t long before we started seeing couplets. Vitals: HR 88, BP 152/88, RR 18, SaO2 100%, EtCO2 34, and he weighs 193 pounds.  Of the five of us on scene, there were three medics, and the other two medics wanted to give him a cordarone drip.

I told them to give 100mg of lidocaine, and follow that with a maintenance drip of 2mg/ minute. The PVCs were almost completely resolved (less than 4 per minute) within 3 minutes, and we took our ride to the hospital.

When we returned to quarters, we had a discussion on the benefits of lidocaine versus cordarone, and turned it into a training session. I must admit that other medics may have different feelings on this, but here are the reasons why I prefer lidocaine over amiodarone for conscious patients:

1. Amiodarone causes too much hypotension for my comfort
2. Amiodarone frequently causes bradycardia
3. Amiodarone has a long half-life, so in the event that 1 or 2 occurs, the patient is going to be screwed for a long time
4. Although lidocaine toxicity is theoretically a worry, I have never seen it on any of my patients.

So that is why I go with lidocaine. Any other readers have different opinions? If so, why?

This is another one of those EMS related posts. For those of you who are not in the medical field, I am sorry if this post makes your eyes glaze over a bit.

We have been taught to backboard every trauma patient. My protocols have us routinely backboarding patients who have been in car accidents, falls, penetrating trauma to the neck or torso, and a host of other accidents. Even when there is no sign of damage to the spine, we backboard. This is a result of the practice of defensive medicine. That is, we do this under the theory that we could be sued by the ambulance chasing “if I don’t get you a big payoff, I don’t collect a fee” lawyers that are always on the television during the day. The belief goes that if the patient needed to be immobilized and wasn’t, there is a chance we could lose, but throwing someone who isn’t really injured on a backboard doesn’t hurt the patient, so we cover our collective butts by doing it to everyone.

Studies are starting to show that immobilizing patients is not a benign treatment. In fact, this 2010 study of over 45,000 trauma patients shows that patients who are victims of penetrating trauma to the torso, but do not present with any specific neurological deficit, experience a higher mortality rate when immobilized than similar patients who are not immobilized. We need to cease backboarding everyone. We are killing people. The lawyers are killing people. This needs to stop.