If you listen to the folks from Boston, Seattle, and, to a lesser extent, Austin, you’ll hear that the secret to good paramedics is to have a small core of paramedics backed up by a larger group of EMTs. The theory is that the paramedics will be at the top of their game as they are reserved for those patients who truly require advanced life support care. In these systems, one promotes into the paramedic position, usually after working several years as an EMT, regardless of the certification level they were hired at. (In other words, in these jurisdictions, you can be a state-certified paramedic, but working only as an EMT.)
Minions, allow me to call BS on this. First, how does working as an EMT for a few years make you a better paramedic? Second, what’s an advanced life support call? I’d be almost willing to bet you that a fractured extremity isn’t considered an ALS call. Want to bet that the patient with a fracture would like a paramedic on scene. If that patient wants pain medications, there’s going to have to be a paramedic there. And yes, while I definitely buy the argument that too many paramedics lead to skills dilution, the skills that a paramedic truly needs, in other words assessment and critical thinking, come in on every call. As for intubation, chest decompression, and other “sexy” skills, they can be compensated for through skills labs and hospital rotations.
If we’re really worried about wanting to produce good, experienced medics, I’ll throw out two suggestions. First, have a good hiring process and a good salary and working environment. That will go a long way towards ensuring that your applicant pool consists of good, experienced paramedics. As for the inexperienced providers who have the potential to become good paramedics, hire them and put them through an extended internship where they work as a third crew member with experienced providers. Give them the opportunity to learn and practice while still having the safety net of experienced providers with them. I had an opportunity to ride as a volunteer medic for several years with Harris County ESD-1 (later Harris County Emergency Corps) as a third crew member, which gave me a ton of experience and confidence dealing with some very sick patients. That time at HCESD-1 and HCEC made me the paramedic I am today. (I can supply the names of partners to blame if you’d like…)
I realize that my experience as a volunteer third medic isn’t the same, but I definitely believe that offering an extended paramedic internship would be an improvement over requiring an arbitrary amount of time spent as a paramedic functioning in an EMT capacity. That model is nothing but a system wide application of the shopworn cliche of “BLS before ALS.” It’s time that emergency medical services approaches career development through an internship paradigm rather than through a “pay your dues” mentality.
Happy Friday, y’all!
There’s no research to guide any best practices in this area. Typically it’s a group of people who believe that their way is the best way or “this is the way we’ve always done it” or “when I was a blah…blah..blah”. The answer is that it depends in the system and more likely the individual. I know that it’s crazy but maybe we should tailor practices based on how an individual learns. Nearly impossible in a large system but just a thought.
As far as paramedics vs EMT’s…having paramedics is a system luxury that is becoming more and more expensive. Think about the vast majority of the nation that relies in volunteers. Maybe pain management is a BLS skill? I rather have a dose of fentanyl by an EMT than nothing. Heretical I know…
Houston and Dallas have good hiring processes, good pay, and good benefits. Are those the systems you want to emulate?
Do you want your paramedics to give analgesia to every orthopedic injury they encounter or do you want them to be proficient in airway management, ACS recognition and treatment and other critical emergencies? From what I’ve seen you can’t have both.
Paramedics don’t become good by reading a lot of books and passing a lot of meaningless tests. They become good by seeing and treating a lot of sick patients. That’s also how EMTs become good and go on to become good paramedics.
Do you even know what the process to get promoted in some of the systems you disdain is?
The proof is in the pudding. The systems you cite have pretty good reputations, despite having a system of which you don’t approve. I’d be willing to be that most of the BLS providers I worked with are better than just about any of the paramedics you’ve worked with.
Too Old, I strongly disagree. Many of the worst medics in my system are the oldest and most experienced. Many of the ones who are actually willing to (and do) help people are the younger, less-experienced ones.
Additionally, it is entirely possible to be good at both essential paramedic care and patient-comfort measures. That is the job, after all.
I think Wake County nailed this with their Advanced Practice Paramedics. Every call gets one paramedic, so extremity fractures get Fentanyl and dizzy patients get 12-leads. APP’s are drawn from the highest performing paramedics, and respond to critical patients who need the high risk, low frequency interventions. They also have a strict selection process and field internship.
And yes, patients with fractures deserve pain medication. I think we will look back at dragging hip fracture patients out of their homes without Fentanyl and Versed on board as barbaric.
That is part of the reason that now Paramedic programs are required to put students through a final field internship program where they are expected to function as Paramedics under the supervision of the Paramedic preceptor on the truck – they are expected to lead the call unless they make a decision or something that would lead to patient harm or incorrect or incomplete care, then the preceptor has to step in but they student shouldn’t get the credit for the “team lead” in that instance. However, many of the EMS education programs (in Texas at least) have run into roadblocks with EMS services and individual preceptors who won’t abide by that process. We had one college tell us that the administration of the EMS service they primarily deal with for rotations (a very large one) has flat refused and said they will not allow their Paramedic preceptors to function in that capacity. Some services are ok with it but the preceptors just cannot grasp the concept because they weren’t taught that way and find it difficult to let go of the reins and guide instead of barking all the orders. If services and preceptors were more open and supportive of the concept overall, Paramedic graduates would come out of their programs much more prepared because at least part of that needed practice orientation to being “in charge”, able to make sound patient care decisions and deliver more experienced patient care at least as a basis would already have been achieved.