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Guest Editorial: If I Were the Zeus of Prehospital Care

As a prehospital healthcare professional, I sometimes wonder if we are not our own worst enemies. 

We say we want to be recognized as professionals and paid appropriately, but we argue vehemently about requiring a college degree for entry into the profession. 

We demand to be recognized as equals by our healthcare colleagues, yet we insist on clinging to a public-safety operational model rather than embracing one of public health. 

We embrace specialty certifications—community paramedic, critical care paramedic, flight paramedic, tactical paramedic—yet we whine about the need for and importance of lifelong learning and continuing education requirements to maintain our licenses and certifications.

Over my 42 years as a prehospital healthcare professional, I have been an active and sometimes even obnoxious proponent of the need for a process for the professionalism of prehospital healthcare providers. 

If I were the Zeus of prehospital healthcare, I would decree that process to be:

1) An associate degree as a minimum requirement to sit for the National Registry paramedic exam. 

2) Passage and maintenance of certification as a nationally registered paramedic to obtain and maintain state licensure.

3) A bachelor’s degree as the required pathway to advanced clinical certifications (community paramedic, critical care paramedic, flight paramedic, tactical paramedic, etc.).

4) A bachelor’s degree as the required pathway for all supervisory, education/training, and administrative certifications.

5) A bachelor’s degree as a minimum for all supervisory, education/training, and administrative positions. 

6) A national standardized lifelong learning and continuing education requirements program for the maintenance of national paramedic certification and state licensure across all U.S. states, territories, and the military. 

7) The implementation of a public-health model for providing prehospital healthcare and its full integration as a component of the healthcare continuum. 

8) Implementation of standardized national health, wellness, and safety standards for prehospital healthcare providers.

9) The implementation of 8–12-hour work shifts with restrictions on back-to-back shifts (mandatory holdover and call-in).

10) The implementation of a salary scale compensatory with the education, certification, licensure, and competencies of prehospital healthcare professionals.

11) The elimination of all ridiculous and demeaning EMS t-shirt slogans, e.g., I Race the Reaper for a Living; As a Paramedic My Job Is to Save Your Ass, Not Kiss It; and Drive Safe or I Get to See You Naked. 

I know what you’re thinking: This is all well and good, but we have a national paramedic shortage, and these education and operational changes will make it worse. People will die! 

Really? People will die if we require degrees? Enough with the fearmongering! People will not die, because as a profession we will establish a plan that will provide an appropriate, controlled, step-by-step process to enact a Zeus plan. 

Years of inaction while wringing our hands and whining about being the redheaded stepchild, getting no respect, and infighting has gotten us nowhere. I am close to retirement, and I want to know—check that, I need to know—that the sweat, blood, tears, and vomit I’ve endured as a prehospital healthcare professional have not been in vain. 

As Norman Vincent Peale said, “Action is a great restorer and builder of confidence. Inaction is not only the result, but the cause of fear. Perhaps the action you take will be successful; perhaps different action or adjustments will have to follow. But any action is better than no action at all.” 

I am asking the young guns, the true mavericks of prehospital healthcare (you know who you are), to stand up, take action, and continue the positive progress of the prehospital healthcare profession.

John Todaro, BA, NRP, RN, TNS, NCEE, is assistant director in the College of Nursing at the University of South Florida in Tampa. He is a member of the EMS World editorial advisory board.


Submitted bydenverdive on 11/02/2018

I just finished reading the article in the November's issue, "If I were the Zeus of Prehospital Care." First and foremost I agree 100%. Not a single day goes by, I see or hear one of my colleagues complain about our wages, wearing some type of asinine and/or derogatory T-shirt. As far as the Education, I have always been on board with higher education (Any education for that matter). It can only make this profession better.

Submitted bymedicabcinstru… on 11/13/2018

Mr. Todaro:

Thank you. Thank you. Thank you.
Thank you for saying the things I have been saying for some time. Although your years are double mine, I too see the incongruence with the way we want to be treated and the way we act.

I say this to my students all the time-- I fear what will happen to EMS when the people that care and want to do better are gone.

Thank you.

Submitted byJTodaro on 11/14/2018

I would like to thank those of you who have taken the time to send me e-mails regarding my November 2018 EMS World Editorial. The responses have been interesting and thought provoking.
It is always fascinating to me when people with multiple degrees expresses their support of degrees, then denounces the importance of other people having degrees. “Knowledge is Power” not sure who first said it but it certainly provokes some thought to the motive of the naysayers.

Submitted bycprtracey on 11/15/2018

Thank you, Sir, for your point of view. I agree completely with every aspect of your article. These are the goals that we should aim for. Now, how do we build the ladder to reach them?

Submitted byMarkSelf on 11/15/2018

While I have nothing against degrees for EMS professionals, I have one major question, Who is going to pay for it? Having 43 years in EMS (most of them on the street and the rest in the classroom) I have seen EMS evolve and prosper until someone started pushing the accreditation and NREMT line of increasing the profession by adding a pile of requirements. Now it takes twice as long to train EMS professionals in the life saving skills they perform and nearly four times the cost due to all of the requirements now placed on educational institutions (whether colleges, or vocational schools) by COAEMSP, NREMT, and NAEMSE. John's call for AD paramedics and BS advanced providers is a recipe for disaster. I recognize that I am the "lone wolf in the wilderness" on this subject but enough is more than enough! Paramedics are part of the health care field and are recognized for their professional delivery of quality care. A degree does not make a person a professional. Most EMS services operate off of county tax bases, just like police and fire. So long as that is true, pay will be low and generating future paramedics and EMT's will continue to be a challenge, especially in the "me first" society we live in. EMS is filled with technicians-an expert in the practical application of a science. It is time to put some sense back into EMS education and recognize that just because everyone else is doing something does not make it right for everyone. For those who say degrees are the way to go, why is the degree driven nursing profession looking at a nursing shortage in the next few years? Quite a difference between $15.00/hour paramedics and $35.00/hour RNs! In a recent survey of 65 respondents in a compensation survey for Program Directors over 80% were performing more jobs than Program Director at salary ranges from $35,000-$105,000.00 and fully 30% were considering leaving the position and only 5% were extremely satisfied with their positions. Remember these are the heads of programs! For the future of EMS perhaps we better find out just what is happening before we go jumping into the fire from the frying pan.

Mark, as you know I have worked in rural areas and have experienced first-hand students struggling to find the time and money to attend a Paramedic program.

The one thing that keeps coming up in the “to degree or not to degree” conversation is how it is ok for EMS providers to be technicians.

If we research the definition of a technician, we find that the Merriam-Webster Dictionary defines technician as “a specialist in the technical details of a subject or occupation”. Where the Merriam-Webster Dictionary defines a clinician as “a person qualified in the clinical practice of medicine, psychiatry, or psychology as distinguished from one specializing in laboratory or research techniques or in theory”.

If we are all about the patient care shouldn’t we endeavor to provided high level clinical care rather than good technical care. It is in the process to evolve from technicians to clinicians that I believe as a profession we (paramedicine) need the to have a degree (for Paramedics) entry point such as the associates degree and an advanced path as bachelor’s degree etc.

As for the requirement of CoAEMSP accreditation, it is through standards, guidelines and an accreditation process that a profession assures the quality of its body of academics and its professional services.

Regarding the question of “who is going to pay for it”, the answer to that can be complicated however the bottom line is if you chose to enter a profession then you chose to pay the cost of the academic preparation for that profession. A choice that you and I as well as many others have made to better ourselves and our profession.

Submitted bysmedly9921 on 11/15/2018

I have no problem with number 1, I have no problem with number 2, but you will never get all the states to agree on common paramedic training level, I have no problem with number 3, but good luck getting number 1 let alone number 3, number 4 already exists in the education realm, number 5 is similar to number 4 but I assume you mean in work life, fat chance of that ever happening, the fire and ems world cares not for higher education. Number 6 again is up to each state, i have no problem with it, but that is too broad of control, 9 i disagree with big time, number 10, you have no idea what you are saying with that, 11 you will never stop that, and honestly why even comment on it.
How are you going to mandate a salary scale, my municipality can afford only what they can, I do not agree with it, but you cannot squeeze blood from a rock. Big cities like Cleveland can barley pay what they pay now, now you want paramedics to have 50 - 80 worth of education to make 20 bucks an hour, its never going to happen.
I am not against better education, the key right now is how are you going to pay for it, medicaid and medicare are tapped, municipalities and taxes are tapped, this is just no affordable at this time. The way this is presented to me via my paramedic programs directors group was clear in site that most of us agree, I paid 3,000 for my paramedic class, i make 47,500 as a paramedic firefighter, today students will pay 8,500 for paramedic school and you guessed it make 47,500. Fix that first before requiring higher education. I am not against higher education by any means, for me or for others, but first compensation for money spent must be in place.

Submitted byJTodaro on 11/19/2018

“I am not against higher education by any means, for me or for others, but first compensation for money spent must be in place.” Is an interesting thought.

This pay me first then I will get a degree process just makes no sense to me. If we want to elevate the profession and earn better pay you have to start by moving from the technician approach to the clinician approach.

This shift from technician to clinician is based in education and is what provides healthcare professions the means to enhance their professional status and in turn produces an upward curve in their salary bases.

Submitted byDale.currier@o… on 11/23/2018

I read this article with great interest as MANY of these items have been discussed since I started in the EMS business in 1974. That said, in the past 5 years I have been amazed at what the public does not know about our EMS providers. Recently some state level Dept. of Labor training folks were amazed that Paramedics, providing ALS medical treatment, were not 4 year college grads. They just assumed, based on what people are actually doing in the field that they have advanced education.

Salaries are a HUGE ISSUE. They likely will be for a long time as the public has come to expect EMS care on par with other public safety services - most of which are mandated by law as "Essential Services." Until EMS has that status everywhere, and the government and insurance reimbursement actually covers the true cost of service, provider pay will be problematic.

Over my 40+ year working career I have been through the transition from a "technical field to a profession" in a number of different fields. It takes time for the public and the workers to come into sync on how this will work out for everyone's benefit.

There are specific definitions in the training and performance fields (Refs.: International Society for Performance Improvement and ATD] - in which I have worked for decades - for "Training" and "Education." For nearly 50 years EMS has relied on "Training" - learning the skills to do the job basics. Current EMS work - especially in the ALS and Community Paramedicine realms - require more general thinking, not only in the science and EMS technical skills but in broader critical thinking, psychology and business acumen, to name a few. If one has the time to 'stick-it-out' they will learn much of this information via on-the- job experience. Yet, with turnover in the filed at about 4-5 years after certification one needs the additional education and thinking skills coming in the door. This is where more formal education of any sort, as preparation for entering and staying in the EMS fields, is critically important. Lest we forget that a million mile journey begins with a single step.
EMS, as a field-of-practice trying to reach the status of a profession in many areas, needs to take a hard look at how they present themselves to the public. I still see ambulances that say "John Q. Public Volunteer Ambulance Corps" on the side - the same name as when they started in 1973. They have NO VOLUNTEER EMS PROVIDERS ANYMORE!!! All of their EMS providers are paid - some through tax payer subsidies to keep them financially viable. Yet I recently heard people balk at calling them "because they are just volunteers!" Reality - they are paid, professional Paramedics but they resist doing any public outreach to improve public understanding and awareness of what EMS does and what is now involved to get certified. So, I ask openly, why would/should we expect a different response in terms of acceptance and higher pay from an uninformed public that we are prepared to serve?

If we don't work together to do something ourselves to change our field, someone else will do it to us - and that could get nasty. It's time to think like business people and public officials - not just technicians - and work to change public image. Then we can have some expectation of better support.

"If you think you can, or you think you can't, either way you are correct" Henry Ford

Submitted byJTodaro on 11/29/2018

The joint position statement on degree requirements for Paramedics from the National Association of EMS Educators, the National EMS Management Association and the International Association of Flight and Critical Care Paramedics has been published in the Prehospital Care Journal online:

Sean M. Caffrey, Leaugeay C. Barnes & David J. Olvera (2018): Joint Position Statement on Degree Requirements for Paramedics, Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1519006…

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