EMS Aficionado

I would argue that: Expectations (On the part of the student and the program) + Content (Breadth and depth of material) = Outcomes (The knowledge and abilities of the program graduate) Expectations by themselves are useless without content. Its just a group of students wishing that they knew more. Or an educator that wishes that their students knew more. Content alone is meaningless. There are instructors that teach a lot of material, but don't expect their students to truly retain or fully understand it. Some students memorize a great deal without really understanding it, because understanding is not what is expected of them. Physicians are expected to know everything about medicine. Obviously as they specialize their knowledge will expand in some areas and decline in others, but they are expected to learn a lot of content. Physician Assistants are expected to know a great deal about medicine, but they aren't expected to know as much as physicians. So they are taught less content than physicians, but are still taught and expected to know a great deal. Paramedics (in the US) are often not expected to know a great deal about medicine. Many programs attempt to teach it, but it can become an afterthought to skills and ACLS/PALS/PHTLS standards. The content often isn't there. Medical school within the US is very standardized. It is four years long and there is a very solid understanding and expectation about what is expected of graduates. PA programs have more flexibility in length, but the expectations of graduates are very clearly defined. Paramedic education and the expectations of what a Paramedic knows can vary greatly. The profession suffers as a result.

There has been very good debate so far! I am going to push the envelope a little further; hopefully without causing too many hurt feelings. BLS is non-invasive care that could, and hopefully in an emergency would, be performed by anyone that is properly trained. It is a set of skills should be possessed by firefighters, law enforcement, school teachers, and every licensed healthcare provider. But, does it really meet the requirements of an organized ambulance service response? It would be unheard of (by US standards) to have an emergency department without a cardiac monitor and someone capable of interpreting the results. Even in the most rural parts of the country, that is the expected standard of care. Shouldn't ambulance care be at the same level as an emergency department? In many places it is. So how can we justify that in some places it isn't? I acknowledge that some places are very rural and resources extremely limited. Resource scarcity equals longer response times. An ambulance can always come from somewhere, its just a matter of the time involved. Please forgive my coldheartedness, but living an hour or more away from a population center, or even just a community hospital, puts you in a certain category of risk. If anything, the more rural the location of response, the greater the need for a higher level of EMS provider. Let me propose this scenario: An on-duty police officer that is certified as an EMT arrives on the scene of a medical emergency. In his patrol car he has an AED, a face mask for ventilations, and a small kit with some bandages. A BLS ambulance staffed with two certified EMTs arrives at the same time. The patient has a very low blood pressure. It is because of an SVT. No one knows this because no one there has a cardiac monitor. Even if there was a monitor there, none of the three is capable of interpreting ECGs. In this scenario, we have three individuals certified to respond to medical emergencies and none of them can adequately treat the current problem. If this had been a life-threatening event, such as cardiac arrest, choking, or major bleeding, then the police officer could have provided an equal level of care to that of the ambulance crew. To my knowledge there is no other licensed healthcare provider (in the US) with less education or training than in EMS (in the US). How can we hope for anything more when we expect so little of ourselves?

What is about to follow is a hot button topic, but I think its worthy of philosophical debate: I would propose the idea that there should only be one level of EMS provider and offer the following as a starting point for discussion: 1. The public does not know or care about various EMS provider levels. They think that everyone is a "Paramedic" and an "Ambulance Driver". EMT vs EMT-Intermediate vs AEMT vs Paramedic may mean a lot to people in the industry, but has no significance to the general public. How can we establish a professional identity when our different levels of certification are just plain confusing? 2. Most people probably assume that if they call 911, then the ambulance will be staffed with the highest level of provider possible. Would most people appreciate how varied the training of the person on the ambulance might be?

You are correct that many PA programs are now graduate level degrees, but there were still associate degree level PA programs as recently as within the past twenty years. PA programs now also frequently require more pre-requisites than MD/DO programs. PA programs raised their standards for admission by moving towards graduate level education and yet there are currently more interested applicants than available program seats. Increased competition among applicants results in the public gaining a higher level of service from graduates. I disagree with the idea that EMS education should descend to the ability of the student, rather than require the student to rise to the level of the education.

If you want proof that longer programs equal better outcomes, then here it is: Physician Assistant programs in the United States typically last 27 months of full time study. When PAs graduate they are capable of assessing patients, writing prescriptions, and performing minor surgical procedures. The only background prior to their very intensive 27 months of medical training are pre-requisites in the basic sciences. They are competent enough that Physicians take them on as colleagues and compensate them very well. The key component with this example is that Physician Assistant students are in the classroom and clinical settings for more than forty hours per week for the 27 months of their education. They also study a great deal out of class and typically only work part-time, if at all. Paramedic students typically work full time and spend 16-20 hours per week on classroom time and clinical training. Is it any wonder that we learn so little by comparison?

In my experience, in the eyes of the public, we are all "Paramedics" or "Ambulance Drivers". The majority of the public probably can't differentiate between an LPN, RN or NP. By the way, they all refer to themselves as nurses, despite each having a dramatically different scope of practice. Who cares if an EMT-Intermediate calls themselves a "medic"? For that matter, who cares if an EMT calls themselves a "medic"? People in the industry will know the difference in level of training and the general public usually won't.

I contend that the issue with Paramedic education in the United States is that it is a class, rather than a program. In other words, it is a stand alone class that is approved by the state licensing authority. Paramedic Programs will link with colleges, but it is not the same thing as in the rest of healthcare education. In the vast majority of places, degrees are an "add-on", rather than a requirement for licensure. As a result, many Paramedics lack the knowledge that other allied health practitioners with two year degrees typically have. If you wanted to become a Respiratory Therapist, CT Technologist, or a Registered Nurse at a two year college, you would need to take college level mathematics and writing. Many nursing programs require a semester of Microbiology and a semester of Life-Span/Developmental Psychology. All of the aforementioned courses are taught by qualified professors that typically possess a graduate degree in their field of expertise. EMS education is too often centered around the idea that a Paramedic instructor can teach every aspect of knowledge that a Paramedic needs to have. Shouldn't healthcare ethics and medical legal be a semester long course taught by a Lawyer or a healthcare ethicist? We encounter legal and ethical issues on every call, yet more classroom time is typically spent on learning Magnesium Sulfate.

This debate speaks loudly about the culture of EMS. With the exception of in some very rural areas, hospital Emergency Departments have security. Sometimes they are armed. In a really dangerous area, hospital staff have security walk them to their cars at night. Hospital based practitioners work in facilities that are in extremely dangerous neighborhoods. They would never walk outside alone. They would never accept the notion that their safety was entirely in their own hands. EMS providers are too accepting of current practices. Law enforcement should be present on every emergency response. Because, we are healthcare providers. I would be very surprised to see a debate like this in a forum for nurses or respiratory therapists. If their place of work was that dangerous, they would not work there. Why are our expectations for ourselves so low? We, as a profession, should demand that we are safe. We are healthcare providers. If it is dangerous, then we shouldn't be there alone.

AHA is accepted everywhere. Some organizations will not accept ASHI. My advice would be to maintain your CPR through the way your organization provides it. If ever you need an AHA card, you can spend the time and money to obtain one.

I think that rigid ranking systems typically operate with several poor practices: They often equate experience with competence. They assume an organization always has enough qualified individuals for vacancies. They typically won't promote a qualified individual unless a vacancy exists. In my view, the more rigid the ranking system, the less able the organization is to attract and retain talent. I think that newer ALS providers should be partnered with clinically competent ALS providers that have strong mentorship abilities.

I was fortunate enough to attend a CCEMTP during my career. The site at which I attended put together a very impressive cohort of lecturers that were experts in the content upon which they were speaking. The subject matter was current and relevant to clinical practice. One of the benefits of the attending program was interacting with my classmates. The program participants were from all over the nation. Their clinical experiences included 911 response, inter-facility, miltary, aeromedical, and remote medicine. In addition to the content of the program, we were able to gain knowledge from each other about different EMS systems and standards of care. I would highly recommend taking the program. The only caveat I would offer is that the quality of the program will vary based upon the the resources of the host site. An interested individual should thoroughly investigate the program site that they are considering.