Attend any EMS conference or gathering around the nation or across the border and you will no doubt hear a discussion about the nature of the paramedic profession. Paramedicine, as an industry and a profession, has come a long way since Johnny and Roy fixed the paradigm in the 70s. Or, has it?

Many of the methodologies that were current at the time have fallen out of favour. One obvious example is MAST; or, as it was frequently called, “MAST Pants”. MAST, or Military Anti-Shock Trousers, seemed like a good idea at the time. But several studies helped to debunk the myth of MAST over time . The device did not contribute to an increase in survival of trauma patients by helping to shunt blood to vital systems and core organs, as was hoped. MAST, in fact, was likely to increase morbidity and mortality rates, or at best, have no effect.

Early EMS systems used cumbersome radio-telephones to link paramedics to delegating physicians and emergency rooms. As the technology improved, the industry switched to portable radios. Cellular then took the forefront in the late 80s and early 90s, as increased portability and reliability made this emerging technology a more viable option. Today, with improved trunk radio capabilities, portable radios are again beginning to emerge as the pre-eminent choice for communications from the field, as EMS agencies take advantage of newer privacy features offered by these systems.

We have become increasingly aware of how quickly we adopt new technologies and treatment modalities. We now realize that this is not always a good thing. Nowadays, there is a greater insistence on awaiting the results of research to back up the movement towards new medical treatments. This trend towards evidence-based medicine in EMS is a positive shift for the profession. But there is another influence starting to show itself around our industry. And that is that some labour unions are suggesting to their members that they incorporate fee-for-service or pay-per-skill schemes into their collective agreements. This introduces a whole new slant on controlling the pace at which treatments become available to the consuming public—our patients.

Ours is a profession that by its very nature needs to embrace change. The myth of the labour movement that we can anchor ourselves to past practices—and not to best practices—is a threat to our profession. The notion that we should be paid on a skill-by-skill basis flies in the face of any profession, let alone one based in medicine. It is totally a labour-minded, blue collar concept that may serve the auto industry well enough, but not the taking-care-of-people industry. To demand a change in pay when a new skill is taught—which is often only a variation of an old skill—limits our ability to provide the best care to our patients.

Paramedics need to tread very carefully in these areas, because this practice can easily work against us. There is a movement of sorts afoot in the United States to perhaps begin eliminating skills or practices from the cadre of the paramedic. An example is pediatric intubation. For that matter, intubation of severe trauma patients by paramedics in the field is also falling out of favour, as some retrospective studies have shown that the efficacy of these interventions—not to mention their poor success rates—are having a negative impact on outcomes.

Here in Ontario some EMS agencies allow the advanced care paramedic (ACP) to perform surgical airways. Although clearly this is potentially a life-saving skill, the frequency of its use is rare. Is it worthwhile then for a service and base hospital to not only continue to train paramedics in this skill, and to keep them current on the performance of the technique, but also to pay them a set amount of money specifically for the inclusion of this skill within their scope of practice? The answer is no. If an agency were to find itself in a position where it was required to pay every paramedic for a skill rarely used, that skill would soon vanish. And, if one toys with the idea for a moment of paying the paramedic only when the paramedic uses this (or any other) skill, then I have serious concerns regarding the ethical dilemma or questions that this raises.

Another example is needle decompression of the chest. While this is a core skill taught to ACPs, it is a treatment that is receiving greater scrutiny by trauma physicians and the medical community as a whole, as its value as a life-saving tool has come into question. So, why would an ambulance service continue to pay its paramedics for a skill whose efficacy is under question? The answer is they won’t.

If these skills are eliminated, or the incidence of such treatments is decreased, are we as a profession willing to accept a commensurate decrease in our salaries to reflect this lessened workload; this decrease in the application of medical skills? I suspect that we are not.

I, for one, believe that it is a slippery slope and one we must tread upon very carefully. While it is true that physicians are compensated via a schedule of fees, it is also true that this schedule is largely based on a calculation and estimation of the time required to perform these skills. The longer a physician requires to perform a given skill, the less time he has to see other patients. In most instances, he is not—like us—paid by the hour. He is paid according to the number of patients he sees. We are not physicians. We are a smaller body politic, not likely to find any sympathetic ears within the rest of the medical community—not from nurses and not from any other group, I presume, who all must adapt to new treatment protocols as a matter of rote.

We have struggled for years to increase our scope of practice and to become recognized as professionals. Demanding pay for piece work will detract from that image and, as I have stated, is rife with risk. Moving from one category or core set of skills to another requires an appropriate change in monetary compensation. It is easy to argue that an Advanced Care Paramedic has a significant increase in his training and level of responsibility and accountability over a Primary Care Paramedic. And a Critical Care Paramedic has even more training and greater responsibility. Again, therefore, a commensurate pay increase is warranted.

A Luddite can be defined as someone who opposes technological innovation. We must be careful to not cast ourselves in this light. We must strive not to hold back medical progress for want of a few dollars more. Nor should we expect that the pendulum won’t swing back in the other direction when skills begin to fall away. All we have fought so hard for will be lost and we will once again become “ambulance drivers.”