Tracey Loscar is a featured speaker at the 2012 EMS World Expo, scheduled for October 29–November 2 in New Orleans, LA. For more information, visit EMSWorldExpo.com.

“Remember upon the conduct of each depends the fate of all.”

—Alexander the Great

On April 23 of this year, popular EMS author Kelly Grayson posted this on his blog:

Your Homework Assignment for the Day:

“Nobody in EMS is paid what they’re worth. 25% are paid far less than what they’re worth, and 75% are paid far more than what they’re worth.”

—Kelly Grayson

If you happen to agree with the statement, tell us what we as a profession should do about the 75%. If you disagree, tell us why.

This referenced a quote Grayson had made in a social media thread discussing why EMS is so underpaid as a profession. Like many of those who read it, it gave me significant food for thought. Though you do not want to come out and say the percentage is that skewed, in all reality and based on personal experience, that statistic is probably dead-on when you look at prehospital providers on the whole.

I am not talking about small clusters or departments that work constantly on performance improvement or those who don’t just have CQI as an acronym on a piece of paper to maintain a certification. I am talking about the breadth of providers, EMTs and paramedics as they practice across the country. People get into this field for vastly different reasons, and it is reflected in the type of care they deliver and perpetuated in a professional culture as a result.

EMS is a minimum competency field, and whether you graduated with honors or squeaked in by the skin of your teeth, the patch on your arm will look precisely the same and carry with it the same life-threatening responsibility—regardless of whether you barely passed pharmacology or can read a 12-lead ECG with any accuracy.

With those of us for whom this is a career choice, our livelihoods rest on maintaining those slips of paper. To do that, we rely on continuing education, which really has a twofold purpose: It is meant to refresh us in those low-volume topics and skills that happen infrequently but are critical when they do, and also to teach us emerging trends and treatment modalities. Changes in protocols (one hopes) reflect evidence-based practice and a foundation in sound research.

Yet there is a problem with a lot of continuing education out there: You are required to attend, but you are not required to pay attention. You must demonstrate that your body sat in that seat for the prescribed amount of time, but in many cases there is no parameter that proves you’ve processed the material and can now incorporate it into your clinical practice. If you can manage to stay vertical, be polite and manage the basic life functions such as gas exchange for a few hours at a shot, you too can have a certificate that says you’re entitled to those CEUs.

In short, you are required to metabolize, but nowhere does it say you must evolve.

We know you do not have to evolve. We have all worked with (or are) those members of the prehospital Cretaceous period whose basic evolutionary design allows them to arrive on scene and put forth the minimum amount of care required—who have mastered those techniques that allow them to proceed unimpeded by either protocols or progress. They meander forth, enjoying relative job security and employing the mantra of, “This is the way we’ve always done it.”

It is not always a matter of age; the dinosaurs are only part of the EMS ecosystem. Much like baby ducks, the brand-new EMT or paramedic will imprint from their first partner, the first service they come to. With no sound work habits of their own, they look to their peers and elders to develop their professional processes. They will imitate what you do, so the question is, what are you teaching them to be without even realizing it?

The newest generation comes out raring to go, with heads crammed full of knowledge and hands and feet out of which they cannot get out of the way. Once imprinted, the younger provider can demonstrate those decidedly learned behaviors, so why aren’t we making sure they are prepared to evolve and succeed versus merely survive? In a realm where tenure is too often equated to knowledge or ability, where are the role models that demonstrate to the world that we are a profession, not a hobby? That we are a third service, a valuable and independent cog in the wheel of medicine, and should be recognized not only for service but for skill sets as well?

I think to a degree, we are all culpable and should be taking responsibility from the ground up. It is not the fault of a generation, a system, an economy or a government that we do not get the compensation we feel is warranted. Nobody owes us anything, and if you think a couple hundred hours of classes and a third-grade-level reading assignment entitle you to something more, I’m afraid you have deeper issues than pay disparity.

There is no sweeping legislation that is going to move through the U.S. and grant you professional stature; there are no plans in the Vatican to canonize any of us as saints for managing to show up for work on time. To demonstrate value, then, you must consider yourself valuable to begin with and show your peers and the public just what a resource EMS truly is. Stop being a minimally competent provider, and stop fostering frameworks that equally encourage and reward those who do nothing and those who consistently do more.

Make sure you’re not one of the 75%, and be the change you wish to see in others.

How to Do That

Wikipedia defines the Occupy movement as an international protest movement against social and economic inequality, its primary goal being to make the economic structure and power relations in society fairer. Isn’t that what you’re asking for? To be on an equal footing with police and fire in the public’s eyes? To be recognized by the medical community as clinicians and not ambulance drivers? To be acknowledged as technical experts in your chosen field and given respect as a professional? Then do it—occupy EMS.

What does that mean?

Be present—That is what occupy means, isn’t it? Show up on time, in uniform, prepared to work and not with your blankie in hand expecting you’ll be toes-up with a remote in hand 10 minutes after you punch in. Your job is not only about the 9-1-1 call, it’s about preparation—making sure you have the equipment you need when you need it, in working order. It’s about making sure you’re up to date on policies, procedures, changes in SOPs and mandatory education items. These are all behaviors you can and should demonstrate.

Do more—Stop being satisfied with the minimum. Yes, it will let you keep your certification, but it will never make you any better at your job. Just because you’ve always done something one way does not mean it is right or the best care you can provide for your patient. If you’re comfortable with your skills, then extend yourself, even if it’s just in one area. Approach a topic or skill from a new vantage point. If you have an area that interests you, go ahead and “specialize” in it—invest yourself in your field.

Shop around—Not all classes are created equal. Why not get the most bang for your buck? Ask around, contact instructors or course coordinators, do your homework and see the quality of programs they’re providing. What is the experience level of instructors? Are there practical stations? What materials represent the source of the program? Talk to people who have taken the same program in other locations and compare notes. Even if it’s a few extra dollars, it might be more worth your time to be immersed in new material with experienced presenters than to sit staring at a screen and having slides read to you.

Write a review—Most CEU programs come with evaluation forms, and you will come across hundreds of them during your career. Here’s the funny thing: Most speakers actually do read them. They rely on that feedback, both positive and negative, to improve their performance. Checking off good class and running out the door is good for instructors’ stats but lousy for improving performance. Notice a nervous tic? Mention it. Enjoy a smattering of relevant war stories? Say so. Quality education is a reciprocal relationship, with the instructor and student working together toward a goal. By cutting corners here you are cheating the instructor. It results in a lot of bad instructors continuing exactly what they’re doing…because that’s the way they’ve always done it.

Hold auditions—Coordinators and employers are accountable too. Stop letting people teach or train just because they 1) feel like it, 2) ran out and got an instructor card just to have or so they wouldn’t have to take the class anymore, or 3) have been around a while so therefore must know what they’re talking about. Instructors and FTOs should in fact know what they’re talking about; they are not above reproach, and if they cannot demonstrate a working knowledge of their material, they do not need to be up there perpetuating bad information. Test your trainers, make sure they’re prepared, and if they aren’t, don’t use them. Good educators want to teach and will improve their skills to stay in the game.

Learn to swim—Baby ducks need to learn to swim before they can fly. It is an unfortunate mark of later generations that they can go out and instruct at a peer or higher level before they’ve had any practical experience as a field provider. It’s a lousy practice, not well-received by peers, and likely causes the new instructor to struggle more than if they’d simply waited to get some mileage or begun with topics suited to new providers or even lay people.

The Internet is forever—This is the age of communication, and there is nothing you do that could not go almost instantly viral with the right set of circumstances. Get out of that truck with the assumption that your next action will be on YouTube within 10 minutes. Be mindful of your social media presence—like it or not, you are a public figure, and once something is out there, it is not going away.

I subscribe to several EMS-based groups on Facebook, and the range of activity is amazing. Some are truly aboveboard—they’re classy and show us as intelligent, funny, sensitive-when-we-should-be/tougher-when-we-must-be people. Others do nothing but spew poorly spelled sarcasm and nasty jokes about patients, nurses and other providers. And while they may think they’re a “private” group, it takes about three clicks to see all their dirty underwear and all the people laughing right along with it.

Be sensible, people. The internet is the abyss—don’t get lost in it. It’s not worth your career, and it’s easily avoided.

P.S.: Spelling and grammar count. Showing an inability to capitalize, use punctuation or at least spell-check your rant about why we don’t all have Master’s degree equivalents illustrates the point without further discussion.

Stop saying “It’s OK”—Guess what: It’s not OK when someone behaves poorly or inappropriately with other providers, family members, bystanders or patients. It’s not OK when people are unable to provide basic care or make grievous clinical errors due to lack of knowledge. Yet we all historically cover for these actions, and as a result there are terrible providers and instructors of all levels who go out there year after year, engaging in the same bad behaviors. Maybe they’re nice people, or we say it’s because they are just tired or have been around too long. Whatever the reason, we excuse it and are thus brought to the lowest common denominator in the eyes of the public.

The peer wall only stands as long as there is a brother- and sisterhood behind it to hold it up. If nobody steps up and corrects these people, then it is quite simply a reflection on all of us. After all, they are dressed exactly like you, so whom do they represent?

So I suppose that’s my response, Mr. Grayson. If we want to affect the 75%, then it is that remaining one in four who picks up the bar and holds it up. After seeing it long enough, someone will take the other end, and then hopefully those standards can spread until we reach a true measure of fraternity and can step forward as a service.

We are not individuals in the eyes of the public. We are a patch, a presence, a trade. You may think you are not your brother’s keeper, and you’re right—you’re not. You’re his mirror.

How do you like the way you look?

Tracey A. Loscar, NREMT-P, is the training supervisor in charge of QA at University Hospital EMS in Newark, NJ. Contact her at taloscar@gmail.com. She is also a member of the EMS World editorial advisory board.