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It’s no secret – the EMS community is hemorrhaging people. As the economy improves, more and more opportunities, with better compensation, are available. Credentials such as registered nurse, physician assistant and several allied health professions – all of which typically pay 30-50 percent more than paramedic salaries in most communities – are within reach of motivated paramedics.

I don’t see becoming a nurse or a physician assistant as part of EMS career development. Those professions, however noble and important, are different from EMS. My goal is, and always has been, for the EMS community to provide vehicles for career professional paramedics to earn a decent living – to be able to raise a family, buy a home and enjoy a decent standard of living – without having to work unreasonable amounts of overtime at multiple EMS organizations.

There is pretty good evidence that experience matters [2,3,4,5]. Think of your workforce – and who might show up at your house in response to a 911 call. Do you want that to be a brand-new paramedic, with the ink barely dry on their state license? Or a paramedic who is well-seasoned, who enjoys clinical medicine, and who has been successfully caring for patients in your system for 10 years?

If we are to provide excellent clinical care, we need to keep experienced practitioners working on our ambulances, and that means challenging them, providing them advancement opportunities and compensating them reasonably for the work that they do.

EMS career options dilemma

For too long, career advancement in EMS has meant becoming a supervisor or manager. It has meant getting away from patient care, not delving more deeply in to it. It has meant moving off of the ambulance, away from the calls, away from patient care. This has been a limiting proposition, because most agencies only need, or can support, a limited number of bosses – particularly those bosses whose daily activities do not involve patient care delivered from an ambulance.

Even in EMS agencies where supervisors have reasonable span of control, and six to 12 subordinates, only 10-15 percent of the total staff occupies supervisory or management positions. Those who don’t want to become bosses, or for whom no supervisory positions were available – more than 80 percent of the workforce – are left with only two career choices – the back of the ambulance, or the front of the ambulance. Or, leave EMS and go find something else that is more fulfilling, professionally and economically.

Paramedic replacement cost

Replacing paramedics is a costly proposition. Several agencies with I have worked with have studied the cost of replacing a full-time career paramedic. The costs, ranging from $56,000 to $105,000 per replacement, include:

• Overtime while the vacancy exists.
• Classroom orientation or academy.
• Field training.
• Uniforms and equipment.

That is money which could be well-spent retaining experienced paramedics. If you replaced eight paramedics last year, you could have spent $750,000 or more keeping your experienced people on the street, in your ambulances, serving your community.

Accept responsibility instead of assigning blame

Before we can move forward, we’ve got to get some excuses out of the way. Blaming the problem on poor reimbursement from Medicare simply reflects a lack of imagination. There are other sources of money to run EMS operations, if leadership has the courage to go out and develop them.

Greed is another. When money is available, it is often not spent on increasing salaries and benefits or developing employees – sadly, sometimes with the excuse that personnel will leave soon, regardless of development programs.

Our own leadership failures are part of the problem. Our failure to involve ourselves in good, ongoing leadership education means that many of us are unaware of the root causes of our problems. We revert to doing to treating subordinates the way we were treated, with predictable results.

We also have to recognize that what we lump together today as EMS is really two (or maybe three) separate businesses, all based on trucks with stretchers in the rear, with very different economic models. Those businesses are:

1. Scheduled inter-facility medical transportation.
2. 911 emergency medical care.
3. Specialty/critical care transportation.

While some of the principles in this article may apply to all of these, this article is specifically directed to the 911 emergency response component, which I refer to as EMS.

Goals for an EMS career ladder

Here are four goals for an EMS career ladder:

1. We want to retain experienced paramedics in the organization who are primarily engaged in direct patient care, working aboard our ambulances.
2. We want to allow paramedics to achieve meaningful levels of compensation, just as though they had elected to move up the supervisory chain.
3. We want the paramedic and the organization to develop a greater breadth of knowledge and skills, beyond running ambulance calls and providing clinical care during transportation.
4. We want to encourage continuing professional development and higher education because it’s a good thing to do and the right thing to do for the paramedic, the organization and the profession.

New position and rank structure

This model was designed for implementation in a county EMS department of approximately 175 personnel. Before the new model was implemented, the supervisory rank structure looked like this:

The organization had 12 supervising EMS officers, three program managers and 16 FTOs, along with four assistant chiefs and the chief/director. There were 36 advancement opportunities (20 percent) for 175 staff members. Turnover was common, with good paramedics leaving often at three to six years’ experience, which was just when they were becoming expert paramedics.

The EMS Career Ladder proposal was developed after looking at other large organizations, including local hospitals which had a robust clinical ladder for nurses performing primary patient care, law enforcement and fire service agencies, and the armed forces [1]. The idea that emerged was to create a non-supervisory career ladder to allow paramedics to expand their roles and add value to the EMS agency, at the same time increasing compensation commensurate with the compensation of similarly experienced supervisors.

These position levels conveniently aligned with the clinical ladder familiar as a result of interacting with the local nursing population [6].

(Specific hourly salary is determined based on starting salary, annual merit increases, and periodic salary adjustments.)

Multiple EMS career ladders

Having agreed upon the position levels, the next task was to define what the levels meant, the options available at each level and the requirement to attain or promote to the next rung on the EMS Career Ladder.

A brainstorming session produced six different career ladders or options:

1. Clinical.
2. Instructional.
3. Public Information and Education.
4. Special Operations.
5. Administration and Finance.
6. Special Events and Mass Gatherings.

There are probably additional options that could be considered, depending on the roles and functions of different agencies. A service that provides frequent ambulance transportation for longer-term care facilities might have a ladder for the customer service and business development staff.

To begin climbing the ladder, paramedics must meet these prerequisites:

• Two years cleared in the local EMS system; no significant disciplinary actions in the last year.
• MS Office proficiency (Word, Excel, PowerPoint) or completion of online courses.
• In good standing with the Medical Director.
• Passed the EMS Physical Abilities Test within the last year.
• Complete Basic FTO and Basic Preceptor course.
• Complete the NAEMT Principles of Ethics and Personal Leadership course and the NAEMT Safety course.
• Complete the DT4EMS® Escaping Violent Encounters course.

Rungs on the EMS career ladder

Looking across several organizations, ambulance paramedics with varying degrees of education were identified, ranging from no academic credential (certificate paramedics) to associate, baccalaureate and master’s degrees. As there was a desire to encourage academic development, those levels were adopted and attached to the ladder. Also, instead of using numbers, a series of titles evolved.

Those academic requirements and titles were applied to each of the six EMS Career Ladders.

In addition to their salary enhancements, career ladder participants are paid for a number of shifts per month off the ambulance to participate in activities related to their career ladder (e.g., specialists get two days per month and program leaders get five days per month). An Instructional Senior Specialist might spend three days planning and delivering a monthly education program or completing a special outside certification program.

Position marking and insignia

After discussing several marking and insignia concepts, it was decided to utilize the small silver rank bars worn as collar insignia by U.S. Army warrant officers, which are silver in color. All of the other services use gold or some combination of gold, which – in the public safety world – connotes a supervisory officer. Conveniently, the bars correspond to the career ladder levels P2-P5.

In this way, individuals with recognized special expertise can be identified by others, and initiate conversations about the EMS career ladder with those who ask about their distinctive insignia.

EMS Career Ladder requires leadership commitment

If we’re going to keep people in EMS for a career, we must give those people meaningful career options. That means not just occasional different things to do, but something that provides them career-level compensation, along with the incentives to gain additional education and professional qualifications that add value to both the employee and the organization. It is not unduly expensive to build and provide that ladder, and the cost of the involved salary enhancements should be more than offset by the reduction in turnover the agency will enjoy.

References

1. Persse DE, Resuscitation 59 (2003) 97-104.
2. Sayre MR et al. Cardiac Arrest Survival Rates Depend on Paramedic Experience. Academic Emergency Medicine May 2006;13(5) Suppl 1: S55-56
4. David, G. et al. Retention, Learning by Doing, and Performance in Emergency Medical Services. Health Serv Res. 2009 Jun; 44(3): 902–925.

This article, originally posted in February 2018, has been updated.