For Love of the Job

I have a few friends I consider extended family. One of them in particular feels like a brother from another mother. We have a similar taste for good food and sarcasm mixed with snark. And like me, he doesn’t do EMS full-time. He’s not paid either. He’s a pretty wicked smart (I think that’s the New England term) MBA who is in the financial sector full time and volunteers as a “paramedic light” and firefighter. He’s also acquired a taste for Texas BBQ. (You’re welcome for that trip to Cooper’s.)

He and I are in a group chat with several other like minded individuals. And yes, we’re probably talking about you.

But here’s what caught my eye this morning.

My friend mentioned the trust that the public places in us. The other night, he gets called for a six week old child with respiratory distress. In his own words, he says “it’s 99% likely panicking parent and 1% potential for ‘oh sh-t.'” Fortunately, the kid turns out to be ok. And I’ll quote his words on the next part, which is the key part. “Here’s the trust part: the other twin was crying so mom says ‘I have to get her’ and just hands me the little one. Has NO idea who these three guys standing in her living room are, never met or seen us before, we’re in a mix of regular clothes and ‘uniform,’ etc. Hands me the kiddo and goes upstairs like it’s nothing.” Exactly, my friend. Exactly.

He did a thorough assessment of the kiddo, then calmed the kiddo — and Mom and Dad. And whatever he was thinking about being woken up for what turned out to be a low acuity call, he made the patient and family feel as if they were all that mattered. (On that note, I’d note that there are more than a few paid EMS providers out there whose attitude is much less “professional” than my fellow volunteer in a small New England state.)

Years ago, a San Marcos cop told me that regardless of how silly it seems, to the person who called 911, it’s the most important thing that’s happened to them that day. It’s a lesson I try to remember when I’m responding and it’s the lesson I try to impart to those who I train and work with.

For those of us in emergency services and emergency medicine, we’re offered a ringside seat to humanity. Those who call us trust us implicitly. Let’s keep earning that trust. Train like it counts. Care for people like they’re your family. And never stop learning.

Earlier this week on Facebook, I said “Do the work. Be nice. Look like a professional. Polish your duty boots.” My friend from New England shared his experience that reminded me exactly why those things count — for both us and the public we’re trusted to care for. I hope I never violate that trust and that you don’t either.

What Does A Paramedic Need To Know?

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.

FirstNet Fails

Anyone who knows me well knows that, outside of my passion for volunteer EMS, I also enjoy good food and sharing my opinions about good (and bad) food with reviews. And more than a few of you know that the job that actually pays my bills is … [Continue reading]

EMS Week Thoughts

Over the last week, which happened to be EMS Week, I tried to do a Facebook post each day with my thoughts on EMS for EMS Week. Here's that collection for y'all... Sunday, May 16 Happy EMS Week to my EMS friends and extended family.To those of … [Continue reading]

EMS – Starting From Scratch

Right now, there's some controversy in Texas EMS circles over a pilot program to combine EMT and paramedic education into a single program where an entry level student wouldn't need to be an EMT before entering paramedic education. I am cautiously … [Continue reading]

The Right EMS Degree

Because I haven't thrown out any EMS dynamite in a while, here we go... I oppose the idea of a mandated associates degree for paramedics. Much of what it will do is to guarantee a monopoly to community college programs. These programs are often … [Continue reading]

The Lawyer Says Enough

Many of you who know me, whether in person or via social media, know that I complain about people expecting free legal advice. Between you, me, and the fencepost, I've actually done quite a bit over the years for the EMS world, whether it's for … [Continue reading]

Where EMS and education collide

This morning, I read an article with great interest about our local EMS system using a physician assistant who's also a paramedic to provide enhanced EMS care -- both for acute patients and to divert non-acute patients from the emergency room. The … [Continue reading]

EMS Education — Some Easy Places To Start

Right now, EMS is being asked to step up its game and take on more of a role in healthcare.  Even before we knew about COVID-19, EMS was being asked to do more in terms of reducing repeat patients and finding alternatives to the "you call, we haul" … [Continue reading]

A Solution to EMS Stagnation?

As I look at EMS's stagnation in comparison to nursing, I have a thought. Nursing has made it where a Registered Nurse is the minimum level of entry to almost any acute care role -- and where an associate's degree is the minimum education level at … [Continue reading]