Many departments struggle to keep qualified paramedics on the front line. This need facilitates paramedics moving from department to department for better wages or working conditions. It's a sellers' market for paramedic recruits, and the old adage, buyer beware, rings true.

Many departments hire personnel whose experience may not have been appropriately screened, who may not be certified or who may be erroneously qualified. A careful method of hiring practices that includes adequate screening will benefit any organization. Adequate screening ought to include credential verification, medical knowledge assessment, physical agility test, psychological screening, background checks, and oral board analysis by peers or management.

Inadequate screening can lead to embarrassing, expensive and often serious consequences. For example, a private ambulance organization employed serial killer John Wayne Gacy for more than six months before they found out that he didn't have a valid EMT certificate. There have been cases where fire service personnel have either embellished or falsified credentials. Recently we have seen officer candidates submit purchased professional papers as original pieces of work. In another example a firefighter/paramedic presented falsified college degrees while testifying to Congress on behalf of the fire service.

In November 2002, NBC reported that hundreds of employed paramedics and EMTs had violent criminal histories and were committed sex offenders. More recently the Denver Post reported that several paramedics may have been issued licenses without passing their certification. Every time a situation develops because of inadequate screenings, credibility is diminished and not easily repaired.

The demand for paramedics on every piece of equipment creates similar problems. Service providers must persuade firefighters to attend paramedic classes, even when they have no enthusiasm for the field. This often results in mediocre paramedics and average patient care. The system tolerates this and allows for further deterioration of the level of care by not supporting those paramedics through teambuilding and skills improvement.

Most paramedics aren't held responsible for the quality of emergency medicine, and a majority of quality improvement programs are focused on retrospective chart review, not on performance. Recently a non-profit community organization circumvented a regional training program to educate economically disadvantaged people in emergency medicine, which would ultimately make them eligible for employment in the fire service. This group failed to have the students insured, properly vaccinated, and screened for drug use or criminal activity. These people should not have been eligible for hiring but appeared on the surface to be suitable.

Again, a full screening process would ensure that we get the best and brightest. One of the most thorough and comprehensive screening programs comes from the Austin — Travis County (Texas) EMS Department. Their multi-step program provides an excellent framework for a standard on hiring paramedics. Using multiple techniques helps eliminate bias and screening errors and allows for the candidate to be measured thoroughly.

It's important to consider the process by which we screen paramedics when entering the fire service. The first step in this process should be to establish and verify that the applicant does in fact have the proper certifications and credentials. The National Registry of Emergency Medical Technicians now has a page on its Web site that confirms the status of a person holding registry credentials. In the future this system could act as a national certification clearinghouse to verify the status of new applicants or lateral hires. Most state EMS departments have records and verification standards and clerical staff to conduct state-to-state checks.

Second, a written evaluation of knowledge would be appropriate. Many standardized-test banks used in paramedic training programs are available to screen new hires, and it's more appropriate to use a test bank because it's the standard that most new paramedics and EMTs are trained to. There often are debates about what a passing grade is, and most organizations look for at least a 70% or higher. An argument can be made for 80% or higher — would you want someone who is not above average in medical knowledge responding to and treating one of your loved ones? Agencies using a written exam usually provide the source, reference material and study guides.

Third should be an assessment of medical knowledge with a medical and trauma scenario similar to the NREMT stations for patient assessment. While this is an excellent screening tool, often one candidate passes the scenario to another at the end of the testing schedule, skewing the results. One strategy to combat that is to keep the same general patient but rotate the cause and the treatment. For example, the patient can present with pulmonary edema and have one of several different causes for the condition. Pulmonary edema can cause some cardiac conditions, and some cardiac conditions can cause pulmonary edema. This forces the student to know medications, physiology and cardiology.

One agency implemented a troubleshooting scenario in which the candidate needed to deal with a monitor malfunction, laryngoscope failure or another critical equipment failure. The rotating options allowed the evaluators to present a scenario that assessed the same job task but in a different way for every third candidate.

Fourth, a physical assessment related to a job-task analysis is needed to determine if the candidate can physically do the job. The Candidate Physical Abilities Test remains the gold standard, as it has been crafted in partnership by the IAFF and IAFC. For those agencies in which the EMS is a third service, a different physical agility exam may be more appropriate. Some agencies have started using isometric evaluations to identify previous injuries.

Fifth, psychological evaluations are becoming more and more commonplace, and some Web sites proclaim at least a 40% failure rate during the psychological test. Often this screening can have consequences under the Americans with Disabilities Act. Several consulting firms offer psychological evaluations. Pearson Assessments has a large selection of training programs to effectively and responsibly use a psychological test. The Minnesota Multiphasic Personality Inventory and Myers-Briggs are well-accepted national standardized tests. A more specific test has been created to look at firefighters and police officers. Identifying candidates with hostile or aggressive traits can prevent problems and customer complaints.

Sixth should be the oral board interview. There has been a lot of criticism of the process for its cattle-call resemblance. Often the oral board sees several hundred candidates, and environmental factors or inter-rater reliability become a problem. Many of the questions have subjective answers, and standard questions get generic, well-rehearsed answers. Often résumés are not allowed.

One way to help remember candidates would be to allow résumés and give the evaluators a chance to connect faces and qualifications. Southwest Airlines invites the entire company to an oral board in auditorium fashion. The thought is that the employee will be working with everyone, so everyone should have a say in the hiring process. As the chief rarely works with a line employee, maybe those who must rely in them should be consulted.

Lastly, a complete and thorough background evaluation must be completed, especially as security and terrorism have become major concerns. The latest trend is conducting a credit check, as some feel poor credit is a reflection of compulsive behavior. For public safety agencies trying to ensure the public trust and reduce employee theft, poor credit presents a risk.

While theft seems to be unimaginable, 30 students who participated in mock oral boards last semester showed some surprises. When asked what they would do if they noticed that their ambulance partner had stolen a candy from a convenience store, almost a third neglected the significance of that event and stated, “It's only candy bar.” Background investigators often contact family, employers and neighbors to provide information on candidates. But the backgrounds conducted by human resources, when done at all, lack the capacity to really evaluate a candidate's medicine or EMS skills are.

The competition for paramedics may force fire departments to attend career fairs and recruit from college campuses like Fortune 500 firms. The fire department needs a corporate approach, which should include requesting a structured résumé. Agencies may need to provide verification through a committee of peers and not human resources when a background investigation is related to medicine, while human resources should conduct and confirm certifications through a national or state system. Consider a group of paramedics from within the organization to evaluate the medical written and practical exams to ensure you are bringing on a person who believes in your organization's way of doing business.

Fire chiefs should not overlook raising their own paramedics after a period of mentorship and evaluation of their skills and abilities in the field. The fire service may very well be the last role model for the country, and we owe it to the public to ensure the best and brightest are there to answer the call.

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Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has a master's degree in public administration and an associate's degree in fire management.

Online Tools

www.ci.austin.tx.us/ems/hp-paramedic.htm explains Austin — Travis County's extensive screening process to hire paramedics.

www.pearsonassessments.com/top/psafetyws.htm details the public safety workshops and information on industry standards for public safety use of psychological test and pre-employment screening.

www.chabotfire.com/Bground.htm gives some guidance and information about background investigations in the fire service.

www.nremt.org/about/checkEMTStatus.asp provides certificate verification for emergency medical personnel.