The Ambulance Chaser

When I was still a relatively new paramedic, I took an EMS instructor class. My instructor had also taught my paramedic course. While I’ve forgotten a lot about drafting lesson plans (which I think may be the educational version of nursing care plans — taught in school and rarely used in practice), I do remember him emphasizing the difference between “need to know” and “nice to know” when teaching.

Yesterday, while talking to an EMS friend, they mentioned that their service does a promotional exam to promote to paramedic. (Yeah, don’t get me started on the idea that paramedic is a promotion. The idea of not using someone’s education and skills to their full potential from the get-go is short sighted, especially while there’s a paramedic shortage.) They then mentioned the extremely low pass rate on this exam. Another thing I remember from my EMS instructor coursework and many other educational settings is that a low pass rate on an exam usually reflects a problem with the education, not with the students.

Then we discussed some of the exam, which included some subtle EKG minutiae about hyperkalemia criteria. That led me to thinking about how EMS education and exams love to focus on EKG details, especially 12 leads. And once I got to thinking about that, I decided to discuss this with some of my network of EMS friends, all of whom are smarter than me. The unanimous conclusion from them was that knowing specific EKG details for hyperkalemia probably wasn’t the best test of a paramedic’s knowledge. In fact, two of them (one an experienced paramedic who’s now an ED charge nurse and the other is a paramedic who’s now an advanced practice nurse) said their expectation was that a paramedic should recognize the peaked T waves on an EKG and report their findings as hyperkalemia should be diagnosed and treated based upon lab values. (By the way, I should mention that many paramedics, including me, have a very limited understanding of lab values in large part because our education doesn’t include that.)

This then led to several of us discussing what a paramedic should know — and what an assessment of said knowledge should look like. This led to a snarky, yet accurate comment from the advanced practice nurse. They said they’d be impressed by a paramedic who does three things.

1. Take a good history.
2. Bring patients to the appropriate hospital.
3. Think beyond the next hour or two of treatment.

These seem to be skills that a paramedic should master and have down but seem to be regularly lacking.

I began to wonder why this is the case and my conclusion is simple. EMS education is heavily focused on solely the “emergency” aspect of healthcare. Most of our clinical rotations are in the emergency department of a hospital or on an ambulance. Needless to say, that makes a ton of sense. The challenge is that such an educational model and mindset leads to clinicians who have tunnel vision and little, if any, understanding of the rest of medicine. And that feeds right back into those three things that would impress the advanced practice nurse (and me, for that matter.)

The question is how to fix EMS education to give students more understanding of medicine and healthcare outside of the “emergency” setting. Not only would this understanding of medicine as a whole benefit our “emergency” patients, it would benefit our less acute patients who call EMS because we are their safety net and/or in their mind is having an emergency. As anyone who’s been in EMS for more than a few minutes recognizes, our patients’ definition of emergency doesn’t always match with our education and skill set of what constitutes an emergency.

First and foremost, every EMS initial education class from EMT on up should have a lesson on how EMS fits into the healthcare system. That lesson should be expanded, especially at the paramedic level, to discuss the different specialties of medicine and the roles of other healthcare practitioners. The lesson should also include discussion of hospital capabilities. And part of the field training and orientation process for an EMS provider MUST include a thorough orientation to the local hospitals that their EMS system transports to.

One other thing. EMS clinical rotations, especially at the paramedic level, need to include exposure to other parts of medicine. In an ideal world, I’d include a rotation with a hospital based internal medicine physician to provide a better understanding of chronic and acute illnesses as well as to provide at least an exposure to the types of medical cases that are routinely admitted. (By the way, there’s study after study showing that EMS clinicians routinely lack the ability to determine which patients who present to EMS are “sick enough” to be admitted to the hospital.)

Until we get EMS to embrace the medicine part of EMS as much as we embrace the emergency part of EMS, we’re going to remain the “ambulance drivers” without a place at the healthcare table. And no amount of discussion about EMS degrees, EMS 2.0, Med Twitter, or obsessing over EKG criteria will fix that.