Your Internship in EMS

Some of my best ideas for discussion fodder come from EMS social media.  Both the great insights and the “what was that guy thinking” moments get me to thinking about EMS and how we can “Make EMS Great Again.”

Today, several discussions led me to the topic of today’s blog entry for y’all.  A good friend of mine was bemoaning the lack of critical thinking in EMS providers of all levels, particularly after reading yet another “experienced” paramedic say the worn out, discredited, incorrect cliché of “BLS before ALS” yet again.  He suggested a need for an assessment and scenario based class on critical decision making, especially in relationship to airway management.  Another smart paramedic commented on a need for a course in scene management.  A few short moments later, I got an email advertising a textbook for a new NAEMT “card course” on “EMS Vehicle Operator Safety.”  And several days prior, people were bemoaning the current state of EMS continuing education where mandatory “card courses” like CPR and ACLS are virtually impossible to fail, yet also devoid of much educational value.  Then, there are all the new “tactical” classes for incidents unlikely to occur in your jurisdiction. Meanwhile EMS continuing education fails to keep providers current on the science and treatment of “bread and butter” EMS calls like respiratory distress, chest pain, abdominal pain, and routine trauma.  But there are certifications for critical care medicine, flight medicine, tactical medicine, and community paramedicine.  Before we reboot into EMS 3.0, let’s try to make sure that EMS 1.0 isn’t a completely flawed platform.

And then, all of these thoughts combined as I realized that they all, in part, address the same challenge. Namely, the idea of a “street ready” paramedic doesn’t exist. The National Registry exam, by its own admission, measures minimal entry level competence to safely practice.  Most organizations have some sort of field training process.  In these organizations, they usually run between one of two extremes. Some sort of quick orientation process that exists solely to say the new hire was “checked off” or some sort of extremely long process that is a virtual repeat of your EMS educational program’s clinicals where you are evaluated on clinical proficiency in each and every skill.  And in all too many programs, the FTO process becomes a legalized hazing process where you perform to your FTO’s prejudices, biases, and whims. Having been through a variety of field training programs, I can say that what doesn’t exist is an orientation to things you might experience daily — how to use the two way radio, how to troubleshoot various pieces of equipment, how to get supplies, etc. And depending on where you’re employed, you may go weeks — or years — without being exposed to certain types of calls and patients to put in your personal library of encounters that you can call upon for the next patient care challenge.

As a new lawyer, I experienced many of the same frustrations.  I came out of law school and the bar exam supposedly “ready to practice law.”  But my first few years as a lawyer, I was really learning how to practice law. And I began to recall something that was discussed in law school – namely, there is no internship or residency for lawyers like there are for physicians.

As a paramedic who didn’t have to rely on a paycheck as a paramedic, I got lucky.  I worked part-time for a while for a suburban service as I realized how little I actually knew.  I then got VERY lucky to find a volunteer position with the service that made me the paramedic that I am today — Harris County Emergency Services District 1 (now called Harris County Emergency Corps).  I walked into a perfect situation.  At the time, the District utilized their volunteers primarily as third crew members on a truck.  The paid staff usually appreciated an extra crew member to help.  And there were plenty of crew members who were willing to take the time to teach and pass on lessons.  It also didn’t hurt that the District was like the Bermuda Triangle of EMS.  Calls happened at HCESD-1 that simply didn’t happen anywhere else. High acuity calls in an economically depressed inner city combined with access to the best hospital systems in Texas made this an ideal learning environment for a motivated paramedic wanting to truly learn their craft.

In other words, I walked into, without realizing it at the time, a virtual internship and residency in urban EMS.  I remain convinced that my three years there made me a competent, motivated paramedic.  I actually even remain in contact with several of my former colleagues.

I realize that the funding issues and operational issues remain out there, but don’t we owe it to our patients, and even more to our professional identity, to create paid internships and residencies in EMS where a new paramedic has a safety net of experienced providers to work with in the right environment to truly become a master clinician?  Clearly, what we’re doing now is window dressing.

An internship program for EMS would create truly “street ready” paramedics.  Having an opportunity to truly learn medicine, both clinically and operationally, functioning as a third crew member with an experienced mentor (NOT a FTO “checking you off”) in a high volume system would be a perfect transition from student to employee.  If we can continue to tilt at windmills in EMS, like the quixotic quest to declare EMS an “essential government service,” why can’t we decide that we want providers who are truly ready to practice?

Let’s make the commitment for some high volume systems to serve as true training grounds for new paramedics to earn their spurs.  It’s time.


  1. If you’re not familiar with Sussex County Delaware’s EMS system, it’s worth taking a look. One of the more unique systems, they staff paramedic squads (or QRVs) with two paramedics that respond to high acuity calls with 21 volunteer BLS level agencies to provide comprehensive ALS service for a diverse mix of rural/suburban/beach and farmland spread over close to 1000 square miles.

    They could easily fall into the good old boy routine of bare bones ALS in an economically depressed community, but instead they chose to innovate and practice progressive EMS, with a strong focus on education and QI. Their paramedic internship is one of the most grueling and intense processes I’ve seen. It’s made many experienced paramedics question their knowledge and skillset and it’s not uncommon for new paramedics to wash out of the internship phase due to a lack of base knowledge or a lack of experience. It’s not a beat down, instead the process, as it’s colloquially known, is a true education and the medics that make it are arguably some of the finest paramedics in the country. If you’d like to experience a great system and learn more about their paramedic education and credentialing process, I highly recommend a ride along and a meeting with the senior staff. It’s a fantastic system that has few equals in the EMS world, at least in the US. And, I think they’re hiring.

  2. Stephanie Jordan says:

    As usual, very well written. This is thought provoking, and implementation worthy.

  3. Colleen Heinsohn says:

    Served me well.

  4. Great articulation of a solid idea. There is a reason that physicians have required residency time before they are really ready for independent practice. Many high-functioning EMS systems have a similar model, where a newly graduated or newly hired paramedic enters an extended period as a “P1” or something similar before being cleared to function on their own.

    EMS as a profession would be well served if we made this approach a consistent requirement and recognized that a newly graduated paramedic needs a structured internship like you describe to really reach their potential as a clinician.

Speak Your Mind