Bieber

Well, now that's getting pretty high, isn't it? Do we have a transport ventilator or are we gonna be bagging this guy all the way in? I'm not especially familiar with them, but if I'm not mistaken it's recommended to ventilate with a tidal volume of 6ml/kg to help reduce the incidence of ARDS (though I'm doubtful this kid'll last long enough for it to be a concern). Also, did the doctor at the local ER place a central line or an art line so we can keep an eye on those measurements as well (MAP and JVP)? Did we get any labs or imaging done before initiating transport? I'm interested in knowing the patient's serum osmolality and the location of the bleed, if available. If possible, let's transport with his head elevated at least 30-45 degrees if possible. You said he has a spinal injury, but he obviously still has vasomotor control intact so it's not a complete disruption. Were we able to assess neurologic function in the extremities before RSI'ing the kid? Did he have intact reflexes (+Babinski's)?

You are a member of a dual paramedic county EMS truck stationed inside the limits of a large city dispatched to the far edge of the county thirty minutes outside of the city (that side of the county has been dumped and you're the closest available unit) to respond to a "sick person" in one of the smaller towns of the county. You arrive at a rural house that appears pricey and well kept with no medications/oxygen/other pertinent findings present. The town's volunteer fire department is first on scene (BLS/first responder only) and advises the patient is a 400 lbs male located in the back bedroom of the house who complains of "feeling cruddy" since yesterday. Patient presents alert and oriented x3 lying supine on his bed with no shirt on, a patent airway, unlabored respirations that don't appear brady or tachypneic, with warm, dry skin maybe a little pale in color. You have plenty of firefighters available and the only obstacle to extrication is a five step patio and a "mega-mover" tarp for moving bariatric patients.

Looks like Cushing's response to me. Also with the other RSI drugs can we throw in some lidocaine for that ICP too? Also, what is his ICP? The flight to the hospital is going to be all about that airway, the head injury needs surgical correction. Did we find any other injuries?

All right. I'm not a fire/rescue/anything guy, so to begin with my role is going to be to stand back and let the fire guys do their job. Whatever they need to do to secure the scene for my entry, let 'em do their thing and as soon as it's secure I'll move in. It looks like accessing the truck driver shouldn't be too hard, though I think climbing into the truck might potentially cause the roof of the car to collapse more so ideally I want to get the passengers of the car out first if that's the case. It sounds like the patient in the truck is more critical, however, so if there's any way to safely get the truck driver out without endangering the car occupants (again, this is gonna be fire's call, I don't know about that kind of stuff) I'd prefer that but I'll defer to their judgement. Does fire advise a prolonged extrication? If so, I'm going to consider the air transport but I want to get a better idea of what's going on first. Can we access the patients enough to assess them or at least get a verbal account of the verbal patients' injuries? Also, in this scenario, are we assuming the role of BLS providers or can we input ALS care as well?

Thanks for providing such a warm and friendly atmosphere to come to, and for your guidance, suggestions, and insight. Every day I learn a little bit more about EMS and how to be a paramedic, and it's great to have another route to share stories and learn from people with as much experience as you all. As far as the "youngins" comments, I don't mind. The other day at the ER one of the nurses asked me how old I was and they said, "Eighteen... but only because I assume you have to be at least eighteen to be a paramedic." So I don't mind.

Guten tag! Welcome to the boards, Marius. Nice to meet someone from across the pond, I've heard you guys have a pretty interesting EMS system over there in Deutschland. Hope to learn more about it from you, and see how our two systems are similar and how they differ.

Sorry, the only emergency equipment I keep with me is my phone and a little keychain face shield, haha. Anything more than that and I'd just get myself into trouble. I'd check Amazon, though, I bet they have plenty of rescue bags for you to choose from.

I had a feeling I knew what the diagnosis was after I saw those lesions. I'm very familiar with the disease and I was pleased to find out after I checked the spoiler that I was right. But I won't be a spoilsport and ruin it before everyone else is done. Great scenario though! Hope to see more like it in the future.

I've only seen one possible flail chest segment so far, and it was really, really wild. It was an older patient restrained front seat passenger of a car that went off the road and into the ditch (actually it landed so that the front and back bumpers were suspended on both edges of a drainage ditch with the rest of the car suspended about three or four feet above the ditch itself) with no airbag deployment who was a little banged up and complaining of some difficulty breathing. It actually looked like they had either bilateral flail segments or a floating sternum, they had bilateral paradoxical chest wall motion that moved concurrently and equally with respect to the other side and opposite of the sternum, which itself appeared to be moving anteriorly outward from their chest with each breath. The patient did fine during transport with some minimal relief from the NRB, alert and oriented x3 throughout the trip, clear and equal breath sounds, good pressures, sinus tachycardia with frequent unifocal PVC's, no 12 lead changes. The chest wall motion was about as dramatic as in your video, Dwayne. We boarded them, plus IV, O2 and monitor (switching back and fourth between patient number one and the driver).

Well, after four pages of some very interesting discussion, I think I'll finally weigh in on my own topic! Your friendly disclaimer, as always (or at least till December), I'm just a student (so you already know half of what I say is wrong, haha), and my opinion is always up to revision, but here it is for what it's worth. First of all, yes, I use ammonia inhalants. Second of all, your question of "what is the point of proving someone is faking it?" I think is really at the heart of this issue, so I'm going to respond to that with my views, such as they are. For me, I believe it's absolutely vital to know whether or not a patient is truly alert and oriented and simply non-compliant with the assessment versus truly unresponsive. After all, the level of alertness is right there next to airway in the ABCs. I don't need to tell anyone here that an unresponsive patient is a serious problem, and one that needs to be corrected or attempted to be corrected immediately. So if I have a patient that is truly obtunded, that is a serious pucker factor for me, and tells me that something has gone seriously wrong and needs to be corrected immediately to prevent them from getting any worse. And I am personally going to HAVE a line established on ALL unresponsive patients anyway I can get it, because regardless of what a person's vital signs are, if they are truly unresponsive then we're already behind the ball and I'm not going to be without a means to give them fluid or medications when the rest of their body catches up. Now maybe I'll be able to get an IV, but maybe I won't. Do I really want to do an IO on an unresponsive patient with stable vital signs if I can't get IV access any other way? Well, I don't have too much of a problem with that. Like I said, if something has gone that wrong inside a person's body that they're unresponsive, it's only a question of time until it starts wreaking havoc on other body systems as well. I NEED to have venous access. But do I really want to start an IO on someone who's perfectly fine and just fibbing with me? Hell no. And you know what? Most of the time I'll be able to get venous access with an IV. But if I can't, and they don't really NEED the IO, well, I don't think there's much benefit to the significant risk that accompanies having a needle drilled into their bone. To help direct MY care, I need to know what I'm up against. The other facet of this is how we direct the hospital's care. And I don't know how it works in your guys' system, but here a code red (I think most of the country calls them code III?) unresponsive patient is automatically limited in the number of hospitals they can be taken to. Which is no big deal. However, what IS a big deal is whether or not I'll be dragging away a doctor and a code team from patients who may truly need them not to mention automatically freeing up a portable x-ray and a CT for someone who doesn't need them. Now, I have no problem erring on the side of caution if there's any doubt in my mind, but I'm also not about to expect the folks at the hospital to pull themselves away from folks who may actually need them because I don't want to investigate the matter a little deeper and really find out, for myself AND for them, what we're up against. I don't think highly of those people who decide to shove any amount of inhalants up a patient's nose, but I don't think it's inappropriate to hold one under their nose and pop it to see if that'll elicit a response. As providers, we need to know our patients' status, including their mental status, to help direct our own care, and also to direct the care they get at the hospital.

The hand drop isn't very likely to hurt them, and even the ammonia inhalants have, at least according to the British Journal of Sports Medicine, never caused harm to any patients. Though I must ask, what "non-archaic" methods do you use to assess responsiveness? Is it just the painful response and corneal reflex or do you do something else to differentiate between the truly obtunded and those who are playing possum?

That's a good point, Dwayne. And hopefully, regardless of whether or not anyone or anyone's service is using ammonia inhalants nobody is withholding care from a patient that remains unresponsive following attempts to elicit a response. Unresponsiveness of unknown etiology is just that until it can be ruled out by either eliciting a faker to respond, or by field examination that indicates another cause.

So. Ammonia inhalants. They're controversial, and I've heard everything from "never use them" to "hey, why not?" but I want to know what YOU guys think. For anyone who's not familiar with them, ammonia inhalants are little quarter-size pouches that you squeeze to release "aromatic spirits of ammonia" that irritates the nasal mucosa and stimulates the breathing reflex. They're most commonly used in EMS on apparently unresponsive patients who are presumed to be playing possum, that is, to give a patient faking unresponsive a stimulant so unpleasant that they will react and no longer be much interested in faking unresponsiveness. According to a 2006 article from the British Journal of Sports Medicine, there are no reports of injury as a result from ammonia inhalant use, and though ammonia is toxic, the amounts used in the inhalants are considered too low to result in toxicity. All the same, there is the risk of, say, stimulating a person who is spine boarded and causing them to jerk their head so hard that they exacerbate an existing spinal cord injury. To my knowledge, there hasn't ever been a case of this. So, here's your chance to weigh in. Use them? Ever used them? Do you like 'em, hate 'em, think they're the best thing in the world, loathe their very existence?

Word to the wise, learn your lidocaine and dopamine drip concentrations. And not just enough to get through class, but to commit to memory. Even if you plan on working for a service that carries both premixed. Not only is it truly a vital thing to know, because hey, you may not always have that luxury for any number of reasons, but also because you don't want to be that paramedic student who has to spend a day of internship walking around with a sign on their shirt that says "Ask Me How to Mix Lidocaine" and have your preceptors stop every nurse, doctor and tech in the hospital and make them read the sign and ask the question and then to top it off have them post the image on Facebook for all of your future coworkers to see how royally screwed you are for irking them with your lack of knowledge. Not that I would know anything about that... (Oh, and it's 1 g lidocaine in 250 cc NS for a 4 mg/cc concentration and 200 mg dopamine in 250 cc NS for an 800 mcg/cc concentration or alternatively 400 mg dopamine in 250 cc NS for a 1600 mcg/cc concentration.)

Deleted. Ignore this, please.

Thanks, Lone Star. I appreciate your words, and I wish you good luck in your own education. Are you doing a Bachelors in paramedicine/EMS program?

Welcome to the forums. I'm new here too, and also a paramedic student, though I'm about to graduate in December. Can't say I'm the biggest fan of fire myself, but I can't find a thing wrong with someone who wants to expand their medical knowledge. Good luck in paramedic school and glad to have you here.

Just a student, but I'll share my humble opinion if that's all right. When it comes to not transporting patients, I am perfectly fine with not transporting patients if a certain number of conditions are met. Really, I guess I'm more on the more liberal side of the debate, and I really don't think transport is necessary/should be done with every patient. You have to be careful, though, because like everyone on here has said, it's a huge risk you're taking. Every patient that refuses, we get a signature from and I am very meticulous in my documenting that the patient refused transport, and I also document and tell every patient that if anything changes they need to call us right back. But you know what? A recent court case showed that it doesn't matter IF you have a signed refusal from a patient, you can still be sued and still lose the case if they decide to come back after you. That little refusal of treatment/transport doesn't mean squat in a court of law. It won't protect you one bit. So, in light of that foreboding knowledge, the absolute safest thing to do is to transport all patients. And if you choose not to, you had better be very thorough in your assessment, very thorough in your documentation, and very sure that you can justify yourself in a court of law if they come back after you. On the same hand, someone on here mentioned that we, as providers, shouldn't worry about things like medical necessity and costs. Well, I disagree with you on that. Yeah, patient care should always be our number one priority, and shouldn't ever be compromised for anything, but it was a world full of people each being unconcerned with costs that led to the inflation of health care, and it will take a world of people to bring those costs down. Unfortunately, the notion of defensive medicine makes it very hard for all providers from paramedics to doctors to follow their instinct instead of tacking on a transport or a couple additional tests to cover their asses. And again, I'm not saying that maybe that's not what we should do, only that I don't know of any studies that show an increased benefit to cost--if anyone knows of any, please share. Here's an example to illustrate what I mean, the way my protocols and the protocols at the hospital are set up, all penetrating trauma above the knees or elbows is automatically a code red trauma, and all code red traumas at the hospital immediately get a head CT, chest x-ray, FAST and stat labs and the whole trauma team gets mobilized and an OR prepped. Now, I've had a patient before who DID have penetrating trauma to the leg above the knee, and we DID run them code red, but they really weren't code red. It was an isolated soft-tissue injury, with no other injuries or complaints, know arterial bleeding, no loss of neurovasculars, and no fracture. Did that patient really need a stat head CT, chest x-ray, FAST and stat labs? In my opinion, no. Unfortunately, for whatever reason, they took the "Per paramedic discretion," clause out of the trauma alert protocol, and it's no longer my decision. Yeah, we could have called for orders to downgrade him, and I can't recall why my preceptors chose not to, but this is just a point I make to illustrate that simply following protocol isn't always in the patient's best interest. Like it or not, SOMEONE has to pay for the care we provide and the care the hospital provides, and while we should never compromise patient care for that, that doesn't mean that every patient needs an ER/trauma room/head CT/etc.. In the end, it all comes down to you and how strongly you feel about not transporting every patient to the ER. Does every patient need to go? No, of course not. Nobody here would argue that. But should every patient be taken all the same? Maybe. We don't have the ability to rule out a lot of things outside of the hospital. We can check a 12-lead, take a blood glucose, do a pulse ox and a thorough assessment. Except in a few small cases, we can't do ABGs, we can't do an ultrasound, we can't do much else. So it's going to have to be a judgement call on your part. I know that I won't transport every patient I have, and that I will seek other appropriate avenues for them, but that's my certification to risk. If you want to risk yours too, that's your call to make, but you will be risking it every time you don't transport a patient. As always, I would warn to err on the side of caution and transport if there is any question at ALL about the patient's condition.

Hey, thanks a lot, Mike. I really appreciate that. I know what you mean by the pressure to stay in EMS or otherwise do things that would hinder my ability to get into PA school. I'm happy to hear you've managed to get back into school, my preceptor is actually in a similar boat; he's been a paramedic for like a decade and is going back now to get his Bachelors and NP and I respect the hell out of you both for going back after so long to do that, but I definitely don't want to end up waiting that long myself. I will be graduating with my AAS/Paramedic this december, and I plan on getting right back into classes come spring 2011 to get this taken care of. Good luck to you too, and thanks again.

I had a hard time with IVs for a while, finally realized it was my technique that was screwy. I was holding the needle like a dart or a pencil instead of holding it in two fingers perpendicular to them. Since I've refined my technique, I haven't seemed to have the kind of trouble I was before, I'm happy to say. Not to say I don't still miss them (there's more than one patient I've taken to the ER with several new holes in their arms that's probably still cursing my name to this day), but I don't seem to be missing the average or easy sticks anymore. 'Course now I probably just jinxed myself.

I'm not all that familiar with dobutamine, but to my understanding it's similar to dopamine in that it's a sympathomimetic as well. It does sound like, while it's also used for cardiogenic shock, that it's also used for CHF. So yeah, you should be able to use it for non-hypovolemic hypotensive patients, from what I understand. Don't know of any services that carry dobutamine, though.

Hi, Kyle. I'm just a student, and I haven't seen the number of code blues that probably the majority of people on this board have, but if it's not too presumptuous I'll share my opinions, such as they are. To be honest, I guess I don't. I've had, if I'm recalling correctly, a total of eight codes that I've been involved in. On all but one, I took part in performing CPR at some point, and in the two I've had thus far in my field internship, I intubated both of them, and on the second one was leading the code. I say this just to clarify that I wasn't merely a passive observer (or maybe I was?), but involved in their care in some fashion. Now maybe I'm too green in the job to be affected by it yet, but to be honest they haven't interrupted my day or otherwise affected me emotionally. In the EMS/Police/Fire TV series, Third Watch, there's an episode where one of the new paramedics recounts also feeling nothing for his patient who coded, to which the senior paramedic "Doc" replies something along the lines of, "You didn't know them when they were alive, so it's hard for you to miss them when they're gone." I think this is very true in a lot of ways, at least for me. Now, maybe this will change as I get more experience and run more codes, maybe it won't. In the end, who is it for anyone to decide how we should react to death? We all experience it differently, and hopefully we process it in a healthy way. I don't and haven't, and to be honest I, in my humble student opinion, don't think we should cry in the presence of family. Not that it's inappropriate to be sad, or to cry later in the ambulance or back at station or wherever, but for two reasons. First of all, we are there to be calm and collected when no one else is. Family is there and is freaking out and they need to know and see that we are calm, that we are doing (or have done) everything possible to save their loved one, but were unable to. And secondly, and this is more of my own personal take on things, because I feel like if I were to cry in front of family that I would be stealing something from them. It isn't our tragedy, it's theirs. I don't have any definable reason to feel that way but it's how I feel and maybe it will change someday, but not today. Like I said before, I think that, at least for me, dealing with the death of someone you knew and loved is different from dealing with the death of someone else. Losing someone you were close to is putting the back cover on a book of memories that will never grow any bigger; precious memories that you held dear and had an expectation of adding to. You have no fond memories of the patient (unless you've run them before or otherwise had the opportunity to really enjoy their company before their passing, even the idle happy chit-chat after you've done what you needed to and now have time to kill en route to the hospital), and no expectation to continue to grow upon them. Again, that's just my take for myself. No, thank you. I hope what I've said helps, or at least makes some semblance of sense. As I continue through my internship and later in my career in medicine, I wonder if my opinions will change. I haven't had any peds code on me yet, and I understand that for a lot of people those are the heartbreakers that tear down even the toughest of medics, so I really don't know how I'll react to them. Either way, thinking about death now helps me try to make sense of it and my role in it, both in the death of my patients, my family and friends, and myself.

I'm doing my FI in a county with a large urban city (where all of the posts on my preceptors rotation are located) and a large rural area as well. I've had a little bit of rural experience at some of our posts (we're on a three post rotation) where we respond further out in the county, but most of my experience has been in the city. I'm not a paramedic yet, and I haven't worked in a rural setting (though after I get my paramedic I plan on working both at the service where I'm doing my FI and also at a smaller, rural service as well) but I can offer my limited take on things. Or at least, the reasons why I do most of my treatments in the truck. First of all, because that is the way I've been instructed. Perhaps not the noblest of reasons, but true nonetheless. I have my own quirks to patient care, and I have my own way of doing things, but I was taught to run calls the way my preceptors run them and so I generally follow their template; not solely because they want me to, but also because I agree with their way of doing things. Second, why I agree with my preceptors and also prefer to do my treatments in the back of the truck, is for a number of reasons. Now, I don't withhold all treatment until we get to the truck, for example I like to get an initial 12-lead on cardiac patients on scene, put my patients who need the monitor on the monitor, get a blood sugar (if I think it could be a sugar problem, otherwise I get it off the IV needle) and place them on O2 and get my first breathing treatment in if necessary, but I prefer to do most everything else in the truck. I usually save the on scene IV for code blues or symptomatic tachy/bradyarrhythmias because I don't want the line getting yanked while we're moving the patient, and because most of the time we can get them to the truck within a reasonable amount of time if they really need an IV stat (not a lot of high rises where I am, and those that are around I've never gotten a call at). Also, the vast majority of my patients need three things: an IV, a monitor, and a paramedic to monitor their condition. Most of their conditions are either non-life-threatening, but require vascular access and monitoring, or aren't so acute that I expect their condition to deteriorate in the time it takes me to get them out to the truck. Now, that's not necessarily always the case, my fourth patient on my first day of field internship as a difficulty breather who went from respiratory failure to arrest in about the time it took us to walk all ten feet from the front door to them. In that case, I probably would have preferred to run the code on scene (I'm in favor of not transporting codes, however that's not currently what the service advocates), but we scooped her up, bagged her to the ambulance and took care of things there. Thus far, that has been the only patient I have had who has deteriorated that quickly on me, and even then we were able to manage her long enough to get her into the truck. The final reason, and this is really an operational/administrative issue, but one I (and certainly others as well) have to deal with, is that scene times are closely monitored and it's my perception that dawdling around for too long can attract unwanted attention. And that's not necessarily bad in se, we're a very busy service and there's a lot of pressure for trucks to have a quick turn around, lest we get short on manpower, but all the same, I wish it wasn't necessarily pushed so fervently. Also, along the same lines as the first, is it becomes an issue of both billing and the continuum of patient care if you treat the patient on scene, they decide they feel great and don't want to go to the hospital, and refuse transport. Not to say they can't change their minds en route, but I think there's less of a willingness to do so when we're already going and also when they find out that we're not a taxi service and they only get two destinations: the hospital, or right where we are when we hit the brakes. I'm not a fan of making patient care decisions based on finances, but at the same time, that same policy DOES also help to discourage patients who decide they're fine after they've been converted from their new onset of a-fib from not going in for further eval at the hospital. Anyway, that's my take on it, such as it is. To clarify, I'm not saying either way of doing things is wrong (I'm a student, I have no opinion), and I think what's most important is patient care. To me, it seems more like two different styles of doing things. If anything, I'm kind of surprised it's not reversed. The folks with 30 minute transport times have a plenty long transport to do everything they need en route, while those of us in the city are often scrambling to get everything done in the 10-15 minutes we spend with the patient. I'd almost expect urban EMS'ers to do what they need on scene and for those out in the boonies to be loading and going and getting things done en route.

Because I see how hard it's been from me going from no previous field experience to trying to become an entry level paramedic, and I see the other students in my class who have had that experience and how much more comfortable they were going into field internship and familiar with prehospital care and operations. Also, just from my own experience in field internship, I know how valuable every minute of experience on the truck is and how much of a difference it has made in how I thought calls should go before I got to internship and how I think they should now. I haven't worked previously as an EMT, but I do plan to work as a paramedic while I continue my education. To answer your question about why I am doing paramedic, it's because I don't think it is a waste and because I want to be a paramedic. That's not to say that I don't want to continue my education and eventually finish my Bachelors and get into PA school (I have some gen ed courses and the PA prereqs left to finish my Bachelors and qualify to apply to PA school), but that until that time when I can go to PA school, I want to be a paramedic, and I want to work in EMS. Even after I get my PA, I still want to stay involved in EMS because it is where I got my first taste of medicine, and where I think I can contribute to both as a paramedic and as a PA if I get there.

You know, I did feel better prepared in some things, but I don't know if you can ever really be all that prepared for all that paramedic school entails, no matter where you're coming from. The one thing I do really wish I had done that I think would have made a huge difference especially in FI is to have actually worked a year as an EMT before getting into the paramedic program. Unfortunately it isn't required by my program anymore but I really see now the value of previous experience as a basic before you go on to paramedic school. Didn't even see this question until after I'd answered it! But to expand, experience is everything. I'm what everyone calls "book smart", with no common sense to save my life. But reading about a condition and actually seeing it are two separate things, and one of the hardest things to overcome in internship has been that difficulty in making my brain and my body work at the same time and trying to remember everything I've learned in the heat of the moment, if you will. Well, unfortunately I didn't spend any time working as a basic but rather dicking around, basically, while I tried to figure out whether I wanted to go to paramedic school or not. But like I said, experience as a basic before paramedic is invaluable. Not at all. The things I learned about acid/base balances and fluid shifts and fluid therapy made relearning and expanding on it in paramedic all the easier. I feel like getting my intermediate first helped me in a lot of ways to be a little more ready for paramedic. Well, I'm not quite through yet, I'll be graduating in December assuming I survive the final half of internship, but yeah, I do kind of miss the parts of the program we're already done with; all of the lectures, clinicals. It will probably always feel like there is still so much more I could have learned, but I'm happy with how I've done and where I am and I wouldn't trade the last year and a half for anything. Well, I never did get the chance to work as an intermediate, but I was disappointed in the limitations of how much I would have been able to do had I worked as one. I decided to do paramedic because PA/med school isn't a sure thing (not that paramedic was, not in the least) and I felt like, at the very least, I want to be able to provide the best possible care to patients in the prehospital setting, and at the most I wanted to continue my education after working the streets for a few years and continue to provide the best possible care in the in-hospital setting as well. I feel now like, if I don't ever become anything more than a paramedic, that's something I can be happy with and proud of. Since entering medicine, my goal has always to be able to provide the most and best care I could to my patients in whatever setting I'm in, and I think that in the prehospital arena becoming a paramedic was a requirement for me to be able to offer that to my patients. I would recommend people take it as they work for at least a year on the streets as a basic. Even if you don't intend to practice as an intermediate, the knowledge you gain in the class will "soften the blow", so to speak, in learning some of those things in paramedic school that they don't teach in basic. Ultimately, it's whatever works best for the person, but I can think of no wrong reason to take advantage of more knowledge that will help you or make things a little less foreign in paramedic school. Oh no. Not at all. If your program doesn't require you to work for a year as a basic before entering paramedic school, take a year off beforehand and do it anyway. It is unbelievable just how much experience matters, and you don't want to be spending a lot of time in FI just learning to be a good EMT before you can work on being a good paramedic. Like I said, if I could go back and do it again I would have definitely worked as an EMT before going to paramedic school. Every chance you get to work on a truck with patients is like gold when you go to paramedic school. Its worth simply cannot be understated.