



Pre-Hospital Providers are expected to make critical decisions that significantly affect the outcome of the patients that they treat. They must quickly assess for life threating conditions, perform highly technical skills that in any other situation would only be performed by a physician, and often on more than one patient at a time without the full staff and resources of a hospital. We trust that the Paramedics and EMTS are adequately prepared mentally, physically, and emotionally to treat us and our families. The reality is, that couldn't be farther from the truth. Increases in call volumes over the last two decades coupled with the " Laissez-faire” status, that allows for both public and private ambulance services to run both emergency and non-emergency calls, when many of the employees have not slept, and in some cases, have not stopped treating patients for 24+ hours. has created a paradigm of pre-hospital care that is damaging to the provider, the public, and the patients.

The shifts worked by Pre-Hospital providers vary greatly due to variations in the call volumes of the systems in which they work. In General, most Paramedics & EMTs work an average of at least 60 hours a week for one service and many work for multiple services where the combined hours worked per week can routinely exceed 100 hours a week. Most schedules are 24/48 where an employee works for 24 hours and then has 48 hours off. Low wages, many at or near minimum wage force many Employees to work 24 hours and then to pick up another 12 or 24 hours at their part time Employer. This results in an already tired provider beginning their shift exhausted. A study from the national institute of health (http://www.ncbi.nlm.nih.gov/ books/NBK19961/) shows that the Chronic fatigue and irregular sleeping patterns created by the scheduling in EMS, leads to many short term and long term Physical and mental health problems such as those listed below:

• Obesity

• Diabetes and impaired glucose tolerance

• Cardiovascular disease and hypertension

• Anxiety symptoms

• Depressed mood

• Alcohol use

The negative repercussions on the health and well-being of pre-hospital providers are not limited to the provider. On every call, a provider is tasked with an infinite amount of possible treatments all of which have the potential to negatively impact not only the final outcome of the patient, but also the duration of recovery. Interventions performed, such as airway management, medication calculation and administration, and many others can prolong hospital stays and in many cases lead to the permanent disability or death of a patient. There is a risk-benefit assessment associated with every intervention. Impaired judgement due to provider fatigue has a lasting physical and emotional toll on the patient. The Fiscal burden of preventable death and disability is ultimately passed on to the public through increased costs from loss of work, increased payout of social benefits, increased hospital stays and many other factors. Prehospital providers are also more likely to be disabled at an earlier age and require more expensive medical care. This burden is generally paid for by the counties or city governments that employ them.

Increased fatigue does not only affect the patient’s care directly, but through the means in which they assess the patient. Providers must respond to calls with urgency but also with a regard to other motorists. Driving at increased speeds and the disregard of general traffic laws carries with it an increased risk, doing so while barely able to keep one’s eyes open is comparable and at times worse than driving under the influence of drugs and or alcohol. This problem can be highlighted especially in the private sector where providers may transport patients from one facility to another that is hundreds of miles away. It is not uncommon for a provider to transport a Patient from Chattanooga to Knoxville or Nashville. Interstate transfers are also common as many specialty centers are located across state lines. Currently, EMS organizations are excluded from restrictions placed on the number of hours that an individual can drive. In an effort to reduce costs, most private services operate with one EMT and one Paramedic. Because Paramedics (ALS) have a larger scope of practice, this creates a dilemma where the EMT (BLS) may have to drive 100% of the time.

It is taken for granted that the practice of medicine is both a science and an Art. The science being the principals, the art... implementation. The current model creates a culture with unprecedented turnover, as experienced providers leave for other fields or to work in hospitals. This Experience vacuum decreases the standard of patient care with some services operating with 80% of their providers having less than six months of experience, and only 5% with more than two years.

We recognize that the current system is not designed on a basis to maximize revenue, rather that it is to minimize expenses. The distinction is important, as we understand there is a narrow profit margin in pre-hospital care and that in order to decrease hours worked, more jobs must be created. It is without naivety and with humility that we understand that the burden of changing the scheduling practices of EMS would, for the most part, be carried in the short term by Private Ambulance services and by the public. However, the system as it exists now is unsustainable. We also recognize that a sustainable legislative solution can only be accomplished by working with the Ambulance services and that a solution must be multi-faceted, focused at the root causes with respect to public that we serve. Sustainability must start with a means of funding, and that requires a directed effort by the government of Tennessee to work with all levels of governments from federal to community to:

• Legislate stricter definitions of Emergency, Non-Emergency to prevent administrative manipulation of the intent of the law.

• legally protect providers right to refuse calls if they feel they are to exhausted to adequately provide care as is common practice in air medical industries.

• Diversify The flow of income to ambulance services by allowing EMS organizations to bill for preventive care services provided in home and to pressure Medicare, and private insurance companies to reimburse for services other than transport. Especially those services that decrease the cost to the community.

• Increase the depth and breadth of the field of Para-medicine by working with universities to create Paramedic Practitioner Degrees that allow Paramedics greater autonomy and the ability to treat without transport for non life threatening conditions, as already has been done in Australia and the U.K.

• Provide stricter oversight by independent agencies to the working conditions of pre-hospital providers

Regardless of the ultimate means by which we take care of all citizens in the great state of Tennessee, it must start now with our Paramedics and EMTs. We Petition you, our state representatives, to diligently enact legislation that places limits on the hours that Paramedics and EMTs are allowed to work, not only for our sake, but for those we have taken an oath to serve.