Fiddling While Rome Burns – The “Ambulance Industry”

Allow me if you will to allude to some Roman history here. I know that it’s a little heavy for an EMS blog but if you would please search the dusty recesses of your memories to think of the Roman Emperor Nero, it would help this post. You know, the one who “fiddled while Rome burned”

I am way oversimplifying this, but the way that I remember the story was that Rome was being swept by the “Great Fire of Rome” that burned for days and decimated the city. Popular legend has it that Nero, unconcerned with the plight of his citizenry, played the fiddle while the city was burning.

 (Although, the MOST TRUSTWORTHY SITE ON THE INTERNET *Other than Mine* has this on the subject: http://en.wikipedia.org/wiki/Great_Fire_of_Rome)

Recent events and some things that I’ve been reading lately have brought some EMS issues to light in my mind, and thoughts about good ol’ Nero have popped into my head.

Are we Fiddling while Rome Burns?

There’s a few competing EMS system design models out there that have various people in their camps. Mention the virtues of one over another and you will get passionate and snarky responses from the various members of these camps. Trash Fire Based EMS and you’ll get a ton of people that will take a break from lifting weights and will bombard you with reasons while Fire Based EMS is awesome while wearing their T-Shirts emblazoned with “FIRE RULES!!”. Mention that 3rd service and not-for-profit EMS may have their downfalls and the EMS Chess Club will bring forth obscure research that shows how much better they are for the patients than everyone else is. Trash Private-for-profit EMS and um, the employees thereof will trash it right along with you and their management will be too busy putting out fires to care.

Try as you might to convince me that one is better than the other and I’ll agree with you on some points and disagree with you on others. I will only endorse what I call “EMS based EMS”, which is EMS provided by truly dedicated caregivers who base their decisions and actions simply upon what is best for their patients and their communities. I have my beef with fire based services that place protecting firefighter jobs and the “fun” stuff involving spraying water on things that happen to be on fire over solid patient care. I have my beef with private-for-profit services that always default to the bottom line, and admittedly, I have a bias towards third service and not-for-profit EMS agencies. However, no one system has ever proven to be a good fit for every community, none are inherently evil, and other professions find their fit within lots of configurations.

If the system design models out there are really locked into a competition for the soul of EMS then they’ve all got a lot of work to do. In this piece, I’m going to ignore patient outcomes, efficient use of tax money, and all of the stuff that I usually talk about… and focus on one thing and one thing only.

The way EMS people are treated by the competing systems will probably decide this debate we’ve got going on here. The model that treats the paramedics the best will win and will take over the industry. Why wouldn’t it? What paramedic with half of a brain would continue to work in a service model that didn’t pay and treat them the best?

Here in Northern Illinois, there are very few options for a paramedic that doesn’t want to do Fire Based EMS for one reason or another. The few options that there are don’t pay nearly as well as the fire-based groups and this creates an endless revolving door of young paramedics entering the system, working the “privates” for a while, while trying to get a “real job” with a fire department. The private services suffer for it, and the fire based services reap the benefits while fostering a system that (gulp, here it comes) focuses less on the healthcare and more on the fun stuff.

So I challenge the private, third-service, and not-for-profit services out there with my next statement.

You’re fiddling while Rome burns.

If you aren’t out there doing your absolute damndest to treat your employees well and pay them what they deserve, you’re failing. You push your employees away. You push the best and brightest into other professions and into fire-based EMS which hands down has the best pay and benefit structure. Your lack of interest in caring for your caregivers is killing our profession. You fiddle whilst complaining about decreased reimbursements and failing to do anything about it. You fiddle whilst focusing on minutia like stupid rules and regulations that degrade the dignity of the adults who work for you. You fiddle while worrying about protecting your jurisdictional boundaries and contracts while they’re eroded away by the constant stream of departing employees.

Nero could have been an ambulance manager in some of the services I’ve been to, worked for, and observed from the outside. Could he be you?

You have got to find a way to pay your people better. I don’t know exactly how it’s going to happen either, but it has to be priority #1 for every ambulance manager out there. Trust me, if you don’t do it you will find that your capital city has burned to the ground. You will lose your empire and it will not come back. If you aren’t out there doing every possible thing you can to keep your employees as happy as you can get them, you’re fiddling, and you’re failing our profession.

This blog has a lot of content on it that explores new revenue sources for ambulance organizations already. Coming soon: Ways for each individual EMS professional to take control of our own income potential, own our profession, and improve our care to our patients. I’ve said it before and I’ll say it again folks, hang on cuz it’s going to get fun.

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  • http://notesfrommosquitohill.com mack505

    CK, I'd love to agree with you, but:

    “The way EMS people are treated by the competing systems will probably decide this debate we’ve got going on here. The model that treats the paramedics the best will win and will take over the industry.”

    Sadly, I doubt it. In this era of tight municipal budgets and threatened reimbursements, the system that will win is the one which provides the minimum level of service demanded by the community at the cheapest cost.

    New EMTs and paramedics keep coming into the system willing to work for low wages. There's no incentive to treat or pay us better if the employers know they can get another warm body with a quick online ad.

    And there's no incentive to demand better performance from any model unless/until it becomes a political issue. When the mayor's mother dies, you might hear something. Otherwise the politicians in charge will look at the bottom line only.

    Sorry to be a cynic, but I've lived too close to small municipal politics for too long.

  • http://www.lifeunderthelights.com Ckemtp

    If the system as a whole continues like it is, then sadly you may be right Mack. However, allow me to hold out some optimism here that one day in the future EMTs and Paramedics may get some self esteem directed at real things like pay, respect, and education. Your vision, while completely correct, will play out if indeed we continue on the path that we've always continued on which allows our profession to bend to the whims of the petty politics, backhanded control from behind the scenes groups, and low barriers to entry that allow the lowest common denominator to set our price.

    In my version of the future, we've had these hard conversations and we've all decided that EMS is actually worth something… and we've demanded that we get it.

    I figure that it's the point of this here blog here to cause controversy and raise issues. I think that this post did it. Now I've just got to get everyone as fired up as I am. We can beat the odds, we just have to redefine the game.

  • http://notesfrommosquitohill.com mack505

    CK, I'd love to agree with you, but:

    “The way EMS people are treated by the competing systems will probably decide this debate we’ve got going on here. The model that treats the paramedics the best will win and will take over the industry.”

    Sadly, I doubt it. In this era of tight municipal budgets and threatened reimbursements, the system that will win is the one which provides the minimum level of service demanded by the community at the cheapest cost.

    New EMTs and paramedics keep coming into the system willing to work for low wages. There's no incentive to treat or pay us better if the employers know they can get another warm body with a quick online ad.

    And there's no incentive to demand better performance from any model unless/until it becomes a political issue. When the mayor's mother dies, you might hear something. Otherwise the politicians in charge will look at the bottom line only.

    Sorry to be a cynic, but I've lived too close to small municipal politics for too long.

  • http://www.lifeunderthelights.com Ckemtp

    If the system as a whole continues like it is, then sadly you may be right Mack. However, allow me to hold out some optimism here that one day in the future EMTs and Paramedics may get some self esteem directed at real things like pay, respect, and education. Your vision, while completely correct, will play out if indeed we continue on the path that we've always continued on which allows our profession to bend to the whims of the petty politics, backhanded control from behind the scenes groups, and low barriers to entry that allow the lowest common denominator to set our price.

    In my version of the future, we've had these hard conversations and we've all decided that EMS is actually worth something… and we've demanded that we get it.

    I figure that it's the point of this here blog here to cause controversy and raise issues. I think that this post did it. Now I've just got to get everyone as fired up as I am. We can beat the odds, we just have to redefine the game.

  • http://twitter.com/in_the_city Angelo

    There will never be any change to EMS until medics and emts realize how powerful they are and start standing up for themselves. We should be the ones who control our own lives. Until we get a system designed by medics/emts for medics/emts we'll always just be someone elses slaves. And that will never happen until we all organize and stand up for ourselves.

    Down here every company that's not the FD treats their field employees like they are whinny children and most people take it, they take that lack of respect and just smile and are happy to have a job.

    People who ask questions or question policy or god forbid have ideas are treated like lepers.

    The problems are two fold:
    1. The owners have no respect for the people who's blood sweat and tears have built their company and allowed them to build a second house in glenco with a gold plated toilet.
    2. The workers (mostly) accept the change is impossible, in fact change is bad, if we change we might end up in a worse situation… OH MY GOD PLEASE DONT MAKE US ASK TO BE TREATED LIKE HUMAN BEINGS… or something.

    We need to change the who system by starting with the young people. The 18 year old emt straight out of highschool needs to be taught that this isnt a game, its serious work and serious work demands serious pay/treatment. If you make the youngest least trained of us take themselves seriously and have so much pride that they stand up and fight for what is fair it will eventually trickle upward.

    Soon you have a system full of angry, hard fighting bastards who know what they are worth and will try to get it.

    Or maybe all those people get fired… and the one who managed to hold onto his job gets sent to critical care school gets segregated from the normal employees and forgets how angry he is altogether…. until he reads a blog on the internet.

  • http://www.firedaily.com Fire Daily

    “This blog has a lot of content on it that explores new revenue sources for ambulance organizations already. Coming soon: Ways for each individual EMS professional to take control of our own income potential, own our profession, and improve our care to our patients. I’ve said it before and I’ll say it again folks, hang on cuz it’s going to get fun.”

    The cynical me is eagerly awaiting the next phase. Mehopes (!) that the ideas you can put forth will be practical enough and make sense enough to get hard-working EMS professionals out there fired up enough to put them into play.

    Great job so far, and a huge effort ahead. Keep your eyes on the prize!

  • http://notesfrommosquitohill.com mack505

    Wow, I sounded like more of a cynic than I thought. I don’t hold out much hope, but if we can change things from the ground up I’m all for trying.

  • Robby

    I feel we don't get the recognition we deserve. Where I am from in NC we have closed down one of the county's 3 rescue bases and have started using fire based rescue. I think that is a shame. To be a volunteer EMT you shouldn't have to get fire fighting skills too. All anyone hears is Fire or Police when it comes to honoring the ones out on the front line.

  • John

    CK, your right on the money! I have been a volunteer in the EMS society for over 18 years starting off in the ranks of first responder and worked my way up to a Paramedic. I did try to work for a for profit organization that was very blunt and demanded all skills be used (even if not needed) so they can bill the maximum to the patient. WHY? so they can make more money? it wasn’t for me to get paid more, be trained better, or new equipment. no it was for their bottom line only. as a volunteer we do what we have to to deliver the pt to the ER safely and hopefully in a condition better than we found them.

    I thoughts have been heavy on this subject for a few years now, health reform has been a big subject and I have been thinking, if we can make lawmakers realize that pre-hospital care is just as important as hospital care than maybe insurance companies would realize maybe they need to pay out better. but as long as we are seen as the stepchildren of medical care I don’t think we will ever see or get the respect that we are well deserved. if there is anything I or we can do to help start that debate in the house or senate let me know.

  • justmeKC

    I am in Kansas City MO where we have run a not for profit third service for thirty years. It has been wonderful but our Nero is the Mayor and City Council, who have voted to destroy our form of EMS delivery and make us fire based, who have no regard for the citizenry either patient care wise or tax wise. All they care about is the large PAC contributors for the next election. We get paid VERY well, have great benefits and have not had a medic or emt die of natural causes in the many years I have been here. The FD cannot say the same and we run more than twice as many calls as they do! Politics is a dirty business and it is a shame that it plays such a large role in your future health!

  • justmeKC

    I am in Kansas City MO where we have run a not for profit third service for thirty years. It has been wonderful but our Nero is the Mayor and City Council, who have voted to destroy our form of EMS delivery and make us fire based, who have no regard for the citizenry either patient care wise or tax wise. All they care about is the large PAC contributors for the next election. We get paid VERY well, have great benefits and have not had a medic or emt die of natural causes in the many years I have been here. The FD cannot say the same and we run more than twice as many calls as they do! Politics is a dirty business and it is a shame that it plays such a large role in your future health!

  • CarlM

    Is it possible for those locations that feel for political and or financial reasons develop the fire based ems by having the medics/emts be just that and not fire fighters also. I would think this would satiisfy both camps since so many firefighters want NOTHING to do with the EMS side of the house and vice versa. Why MAKE people do a job they have no interest in and punish those that do? I know it sounds simple, but could it work. Same pay, same benefits, same union, same retirement? Who knows, the public/taxpayor might actually get the proper person to the proper call and benefit from someone who really wants to be and is a professional in the field of pre-hospital medicine instead of “I have to be here cause they make me come”. In the military, a soldier is a basic rifleman first and then gets specialized training usually based on interest and capability (remember I used the word 'usually') and that makes for a better soldier. So whether fired-based, for profit, volunteer or government run, if you are truly a medic/emt career person, really get down with your job, then it shouldn't matter the mode of delivery of the expertise of your service. Some systems work well one way or the other or as a mixture. We see all the negative comments here about one being worse than another. How about some of the succss stories out there? I know there are some. And yes, until higher standards for training, certification and licensing are REQUIRED by law across the board, we will continue to suffer low pay, low respect and high turn over. You cannot hold people in a career that feel as though they are not part of the 'system', get demeaned by peers and superiors, get paid less than the garbage collector or secretary whose responsibilities and daily routines do not entail saving lives and lessening pain. Each of us is responsible for putting out the very best image of ourselves, our company/agency and our profession. I was taught that respect is not something you are owed, it is something you earn. Lets' try and make a difference by not disrespecting each other first, then work to elevate ourselves in whatever system we work in to the highest possible level. It isn't going to happen overnight. We are a 'young profession' of about 30 years old. To some we are still the 'teenagers' in the medical profession block. Let's grow up and be adults here and band together by putting the unimportant aspects of which model is the best and present a united front for EDUCATION, HIGH STANDARDS, NATIONAL STANDARDS (law), PAY SCALES and ACT LIKE WE CAN ACTUALLY BE ADULT ENOUGH AND EARN THAT RESPECT.

  • CarlM

    Is it possible for those locations that feel for political and or financial reasons develop the fire based ems by having the medics/emts be just that and not fire fighters also. I would think this would satiisfy both camps since so many firefighters want NOTHING to do with the EMS side of the house and vice versa. Why MAKE people do a job they have no interest in and punish those that do? I know it sounds simple, but could it work. Same pay, same benefits, same union, same retirement? Who knows, the public/taxpayor might actually get the proper person to the proper call and benefit from someone who really wants to be and is a professional in the field of pre-hospital medicine instead of “I have to be here cause they make me come”. In the military, a soldier is a basic rifleman first and then gets specialized training usually based on interest and capability (remember I used the word 'usually') and that makes for a better soldier. So whether fired-based, for profit, volunteer or government run, if you are truly a medic/emt career person, really get down with your job, then it shouldn't matter the mode of delivery of the expertise of your service. Some systems work well one way or the other or as a mixture. We see all the negative comments here about one being worse than another. How about some of the succss stories out there? I know there are some. And yes, until higher standards for training, certification and licensing are REQUIRED by law across the board, we will continue to suffer low pay, low respect and high turn over. You cannot hold people in a career that feel as though they are not part of the 'system', get demeaned by peers and superiors, get paid less than the garbage collector or secretary whose responsibilities and daily routines do not entail saving lives and lessening pain. Each of us is responsible for putting out the very best image of ourselves, our company/agency and our profession. I was taught that respect is not something you are owed, it is something you earn. Lets' try and make a difference by not disrespecting each other first, then work to elevate ourselves in whatever system we work in to the highest possible level. It isn't going to happen overnight. We are a 'young profession' of about 30 years old. To some we are still the 'teenagers' in the medical profession block. Let's grow up and be adults here and band together by putting the unimportant aspects of which model is the best and present a united front for EDUCATION, HIGH STANDARDS, NATIONAL STANDARDS (law), PAY SCALES and ACT LIKE WE CAN ACTUALLY BE ADULT ENOUGH AND EARN THAT RESPECT.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    mr618
    Welcome to the Club
    Well said, Chris. We can't save everybody, but the ones we don't save tend to stick around a lot longer than the ones we do save.
    2014-10-18 14:40:00
    Steel City Medic
    Welcome to the Club
    Particularly appropriate for me this week. Thanks.
    2014-09-23 21:46:00
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00
    DiverMedic
    My Blogroll
    One of these days you'll figure out where my blog is... :)
    2014-09-17 22:11:00
    emtterri123
    Six Tricks You Can Use Today to Improve Your EMS Narrative Report
    The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. - Me thinks this should have been restructured as it does not flow and caused me to reread it several times. lol :)
    2014-09-17 08:27:00

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