As a rookie emergency medical technician, Jeffrey Brown went to work his first day on the job both excited and nervous. He was starting work for a private service in Oklahoma. However, it was not a typical first day on the job. It was September 11, 2001, and fire departments, ambulance services and hospitals across the country were being warned by authorities that there had been threats of terrorists loading up ambulances with explosives and blowing them up at hospital doors. In the next days and weeks that followed, Brown and his fellow EMTs and paramedics received frantic calls from paranoid citizens who saw anthrax in every letter and small pox in every child coming down with a common case of chicken pox.

Most EMTs have easier starts to their job. EMTs and paramedics say they’ve had so much textbook and clinical training by the time they begin their careers, that they feel ready to treat patients in any number of unpredictable conditions. Still the first year is a crucial, steep learning curve for those embarking on such a tough job.

“The hardest part is realizing that you can’t help everyone,” says Brown, who now lives in New Orleans. He recalls patients such as an elderly man who refused help despite his children’s worried pleas. Beyond the patients who cannot be helped medically, there are also those whom EMTs cannot help for legal reasons, such as a man who insisted he was fine even though EMS and his own children could see that he was not.

Trial by Fire

Fortunately for students who might not be cut out for dealing with patients in often-difficult circumstances, EMT and paramedic programs require clinical training. The education of EMTs and paramedics (who are also EMTs but have additional classroom and clinical training beyond the EMT-basic or -intermediate level) includes clinical experience, such as following and assisting real EMTs on the job. Usually a percentage of students drop out at this stage, realizing the work isn’t right for them.

Susan Schmele, director of the Oregon Health and Science University (OHSU) Paramedic Program in Portland, Ore., says paramedics-in-training have a lot to learn in that one crucial year of studying and internships. “Students have to learn how to step out onto a scene and take control,” says Schmele. “It’s not like you’re in a controlled environment like a hospital or doctor’s office. You could be anywhere from in the middle of a cow field to a million-dollar home.”
Despite the rigors of unpredictable work in the field, many students are hooked early on and stick with the hours of studying and internships with hospitals, fire departments or ambulance services because they love the work.

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Take Peter Lehmann a paramedic and firefighter for Tualatin Valley Fire and Rescue in Portland, Ore., who completed the paramedic program at OHSU. He left an unfulfilling job in corporate sales with an eye toward a career change.

Lehmann, who had a bachelor of arts in business from the University of Vermont, used his new freedom to have some fun and became a rafting guide in Montana. He had to learn first aid for the job, which he found intriguing. Later, he did some ride-alongs in ambulances and knew that he had found his calling.
“It involves teamwork and serving your community,” he says now. “You feel a sense of comfort working with your crews. You have people looking out for you and you’re looking out for them.”

Because Lehmann already had a bachelor’s degree, he was able to skip a lot of the required courses in the associate’s degree program at OHSU and focus almost entirely on emergency medicine. After he received his EMT basic training at another college, he spent four months in classroom instruction at OHSU, another four months doing clinical rotations in the emergency room, operating room and in the obstetrics ward of a local hospital, and the final four months at an internship working on an ambulance with experienced paramedics.

Lehmann, who was one of 1,600 firefighter applicants for 24 openings at Tualatin Valley, is one of the fortunate paramedic grads who found a job that not only pays fairly well, but also offers continuing training. His first days on the job were spent in a three-month fire and paramedic training program in which participants are faced with scenarios-including live fires-to practice what they’ve learned.

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Still, even for those with extensive training and the support of fellow paramedics and firefighters, the first year of actually working on an ambulance can be rough.

“Some calls are really hard in your first year,” says Lehmann. “Like bad car wrecks. Those are difficult calls because the patients are so critical. But you’re working with people who are experienced and who can offer another opinion or advice.”

Lehmann adds, “After a call I’ll ask, ‘How could that call have been done better? What could I have done differently?'”

Salaries Out of Step

Not only does Lehmann appreciate the training opportunities and enjoy the camaraderie that comes with being in a fire station, he also enjoys the better pay that is part of his position. In fact, on average firefighters earn higher wages than paramedics.

Training and coursework standards depend on state standards and vary by program, but requirements for paramedics are extensive compared to their EMT-basic counterparts. However their pay is typically lower than that of other allied health professionals with similar levels of medical training. Basic EMTs are versed in first aid techniques, such as CPR, but intermediate EMTs and paramedics can perform more invasive procedures and administer certain drugs.
Low pay has been a frequent topic of discussion and complaint among EMT circles for years. Now a shortage of EMTs is bringing greater attention to the issue.

According to an April 2004 article in the Journal of EMS, most states have seen a decrease in the number of newly certified EMTs and licensed paramedics. Some speculate that declining numbers are due to new curriculum guidelines that are adding hours to many training programs. Pay and attrition are also potential culprits, and many believe that a combination of all three is to blame.

“Paramedics are making a living now, but they often have more than one job,” says Ken Bouvier, president of the National Association of EMTs. “But the ultimate goal is to get salaries up comparable to other jobs in America where you can afford to put food on your family’s table without having to work two or three jobs.”

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According to Bouvier and others, pay depends a lot on geography. An EMT in a rural area could make barely more than minimum wage-and that is for non-volunteer EMS. Those who volunteer, however, make as little as $12 a run. That means on a slow day, you might only make $12-if anything. Bouvier says paramedic pay typically ranges anywhere from $10 to $17 an hour, but again, it’s difficult to generalize typical pay because standards and funding vary dramatically from state to state and from county to county. Still, it’s clear that in a profession in which it takes years to become properly trained, and, in the case of paramedics, includes hours of additional classroom and clinical study, salaries are out of step with the level of expertise demanded by the job.

“You pay more money to the lady who would groom your pet than you would a paramedic to save your life,” says Bouvier. “She would spend about an hour grooming your dog and charge you $25; a paramedic might get paid $17 in an hour to save your life.”

The shortage could be good news for those who are considering a career in EMS. In many states, it will mean that jobs will be more plentiful and in some cases may be paying better to attract new talent. Bouvier says many ambulance services and other employers are losing paramedics to competing services that offer sign-on bonuses. As a result, job-hopping is adding to the retention problem. Other trends are less hopeful for future paramedics, like services and government departments replacing two-paramedic teams with one EMT and one paramedic.

Still, for EMTs such as Lehmann and Brown, passion for the work more than makes up for the profession’s drawbacks. Before he decided to go into EMS, Brown was diagnosed with Hodgkins Lymphoma and forced to quit his job as a professional diver, a career he loved. “I’m actually glad I’m not a diver anymore because I never would have found this job,” he says. “I love to do this so much.”

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Observing the Experts

Both Brown and Lehmann advise new EMTs to spend their first few years on the job expanding their knowledge outside the classroom, especially by observing experienced colleagues. Lehmann says that working with other paramedics was one of his primary learning tools in his early months on the job. Rookie paramedics often underestimate how much they still have to learn once they are licensed or certified. Both Lehmann and Brown say that new EMTs and paramedics typically encounter cases that are not only difficult to deal with but tough to diagnose, as well.

“When I first got out of school as an EMT-basic, I thought, ‘I’m ready to go. I could be a paramedic now’,” says Brown.

Months later, after a move to New Orleans and a new job at the health department, Brown remembers going on a call to a nursing home with an “old-hand” EMT with several years of experience under his belt. The home had called EMS because one of its patients, an elderly woman, was acting strangely. Brown’s partner took one look at the woman and said to Brown, “Load and go.” Brown, used to the usual protocol of talking to the patient and asking basic questions, didn’t understand but followed his more experienced partner’s lead. As soon as the woman was loaded on to the ambulance, her heart stopped beating regularly, and the two EMTs had to use electric paddles to regain a regular rhythm. Brown’s partner recognized the symptoms, including the familiar pallor that he’d seen on a handful of patients over the many years he had worked in EMS.

Zero to Hero?

While new EMTs are often surprised by life-or-death cases that challenge what they think they already know, they are also equally surprised to find that much of an EMT’s typical day can be slow and quiet. Schmele says sometimes new paramedics are disappointed by the lack of excitement. “Especially younger people,” she says. “They’re a little disappointed that it’s not all car wrecks and gun shot wounds. They’re all geared up for this excitement and then it’s sit around and wait.”

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“When I first started,” says Brown, “I thought every call was going to be life and death.” Instead he found his first job working for a private service to involve a lot of transporting patients from nursing homes to hospitals. Bouvier says that typically 90% of EMS work doesn’t involve life or death cases.

Some have used this reality to bolster the notion of “zero to hero” programs that reduce the number of classroom and clinical hours required to earn EMT certification. Looking at the profession more as one of ambulance driving than one of patient care also supports the argument that fewer paramedics are needed on ambulance crews. But EMT advocates think this view is shortsighted.

“Rarely are you going to have the opportunity to save a life,” says Bouvier, conceding that inexperienced, basic EMTs can handle the majority of these non-emergency cases. “Most of the calls are routine. The other seven or eight percent are going to be crisis, life-threatening calls without a well-trained, experienced EMT or paramedic, that patient won’t have a second chance at life.”

Bob Luftus is a retired paramedic in Carbondale, Ill., with decades of experience as a military and civilian paramedic who has worked all over the country and witnessed first hand the struggle of EMTs to be recognized as full-fledged medical professionals and not just patient transporters. “We’re still trying to grow up and be treated like other first responders,” he says of the profession’s growing movement to demand recognition and better pay. “You’re out there helping people, sometimes saving lives, and in the bigger scope of things that’s better than making money.”

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