Paramedicine is not Fire Suppression: a response to Chief Ludwig

Fire Chief Gary Ludwig’s September Firehouse column is “EMS: Do You Need a College Degree to Be Paramedic?” His column is in response to an anticipated position paper by the National EMS Management Association advocating that the paramedic candidate should have earned an associate’s degree before sitting for the National Registry examination. I think requiring an associate degree before taking the initial paramedic credential exam is appropriate, here is why:

Initial Fire Fighter Credentialling is Task-Focused Vocational training

Chief Engineer Ralph J. Scott of the Los Angeles Fire Department (LAFD) established a fire college in 1925. The LAFD training staff researched and documented every task a firefighter might be required to perform. The list of almost 2000 entries evolved into The Trade Analysis of Fire Engineering.

While president of the IAFC in 1928, Scott convinced the U.S. Department of Vocational Education to accept this list as an official definition of firefighter tasks. Most of those tasks still exist in NFPA 1001 Standard for Fire Fighter Professional Qualifications. Firefighter training material is written at a 6th to 7th-grade reading level.

Initial Paramedic Credentialling Requires Demonstration of Clinical Judgment.

The 2009 National EMS Educational Standards included a significant change in scope and educational material from the original National Standard Curriculum. The Standards provide a general framework to support individual programs for developing specific curricula to meet identified training and educational needs in particular regions. The format also allows for ongoing revision when research supports practice changes based on scientific evidence or when standards of care change.

The Standards are made up of four components:

• Competencies
• The knowledge required to achieve the competencies
• Clinical behaviors/judgments
• Educational infrastructure

The paramedic level has the highest depth and breadth of medical information, this graphic is from the National Association of State EMS Officials Education Agenda Implementation Team presentation “2014: A New Day in EMS Education”

• Breadth is the number of topics a student needs to know about a content area.
• Depth is the amount of detail a student needs to know about a particular topic.

Paramedic textbooks that meet the 2009 curricula are written at the lower division college reading comprehension level (grades 13 to 14). Paramedic candidates are expected to initiate a patient care plan after assessing a patient.

“(The Standards) define the competencies, clinical behaviors, and judgments that must be met by entry-level EMS personnel to meet practice guidelines defined in the National EMS Scope of Practice Model.” (NHTSA p. 7)

The implementation of these educational standards took five years with input from all stakeholders, including representatives from the IAFC.

National EMS Educational Standards Meant the End of 9-month Paramedic Programs

The original National Standard Curriculum at the paramedic level was task focused. We would take firefighter/EMTs and run them through 9 months of a daywork paramedic school (3 days of lecture and 2 days of rotations),  followed by three months of functioning as the lead paramedic under preceptor supervision. That’s how I was trained in the 1970s, so it must be a good model, right?

The Consortium Conundrum 

A significant impact of implementing the National EMS Educational Standards was a decision by the National Registry of Emergency Medical Technicians (NREMT) Board of Directors in November 2007. They established a requirement that paramedic applicants graduate from a nationally accredited paramedic program effective January 1, 2013.

This decision impacted the 30-some fire department based paramedic programs. They needed to establish a consortium agreement with a sponsoring educational institution. A key change is that the consortium board runs the paramedic program.

A September 2018 survey of the 607 paramedic programs credentialed by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) showed 22 fire departments offering paramedic certification training, including the Memphis program established by Chief Ludwig.

NEMSMA Associate Degree Recommendation has a Larger Impact

Requiring completion of an associate degree before taking the National Registry exam will create a larger challenge than the 2007 requirement that a candidate graduate from a nationally accredited paramedic program. The National Registry is required for initial paramedic certification in 45 states.

 

In addition to the fire department run paramedic certification programs, there are another 221 of the 607 accredited programs that only offer a paramedic certification program. They will need to develop a process, through an expanded relationship with their current sponsoring educational institution or a restructure of their programs, to meet the associate degree requirement.

That is going to take heavy administrative lifting and will be disruptive. But we need to do this. Retired NREMT Director Bill Brown made this observation on social media in response to Chief Ludwig’s column:

EMS is one of only 3 “health care professionals” tracked by the United States Department of Labor that does not require at least an associate degree. We are tracked beside pharmacy technicians, “ok, that’s 10 pills. Let me count them for you!”

Paramedicine is not fire suppression. While fire departments are heavily involved in 911 EMS services, paramedic caregivers are found in a wider variety of work settings. The anticipated impact of EMS Agenda 2050 will further expand the role of paramedics.

This requires paramedics to join the rest of the health industry professional caregivers. We need to raise the educational minimum for initial paramedics.

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I have a few conflicts of interest with this issue:

• National EMS Management Association executive director from 2014 – 2016.
• Joined the IAFC EMS Section when it was new and continue to be an IAFC member.
• Was a full-time academic: 4 years running a community college fire science program and 8 years as an assistant professor of emergency medicine at a university medical center.
• Over 3 years as an EMS director at hospital-based paramedic/911/medical transportation division.

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Gowell, Joseph L., William W. Tebbetts, and John F. Baker. (1932) The Trade Analysis of Fire Engineering. Los Angeles, CA: Los Angeles Fire Department, Fire College.

National Highway Traffic Safety Administration (2009) National Emergency Medical Services Educational Standards. Washington DC: U.S. Department of Transportation.

Tritt, Patricia (no date) “What is a Consortium Anyway?” Rowlett, TX: Committee on Accreditation of Educational Programs for the EMS profession. Accessed September 8, 2018, from https://coaemsp.org/Documents/WhatIsAConsortium.pdf

Logan, J. Harold (2014 January 10) “The Cinderella Story of the Memphis Fire Department’s EMS System.” Journal of Emergency Medical Services, Volume 39, Issue 1. Accessed September 9, 2018, from https://www.jems.com/articles/print/volume-39/issue-1/features/cinderella-story-memphis-fire-department.html  The article describes the growth of Memphis EMS under Chief Ludwig and is the source of the opening image.

Related articles, revised March 5, 2019:

(2016 November 10) Are we working EMS providers to death? Excessive work hours, compassion fatigue and violence are contributing to an alarming increase in EMS caregiver suicide. 

(2018 May 29) EMS Turnover and compensation reports

(2018 June 5) It took 18 years and two attempts before EMS was recognized as an Emergency Medicine physician subspecialty

(2018 June 12) The unreasonable expectations of an Associate Degree in Paramedicine.

(2018 September 17) Chicken, Egg, and Angst; the Challenge of Moving EMS Forward

(2019 February 4) A reaction to EMS Agenda 2050 and a suggestion for fire-based EMS in 2020