Lately, on Facebook, there’s been some debate. (Or what passes for debate on Facebook — AKA, monkeys flinging poo.) The Facebook EMS forums have been all abuzz about the idea that some EMS systems don’t hire you in as a paramedic and that you have to work as an EMT for a couple of years before promoting into a paramedic position, regardless of your state certification level.
Let me say that I think this is a flawed model. Do I have the science behind ALS skills retention and the number of ALS interventions out there? Nope, I don’t. I won’t even deny that there’s only a few patients who really need the whiz-bang ALS stuff such as intubation, but that’s not all there is to being a paramedic. But, I think the way to learn being a paramedic is by being a paramedic. And a good paramedic assessment is something you can perform on every patient. Symptom relief, whether pain management or nausea management is one of those ALS skills as well. Good BLS skills are definitely the foundation of competent paramedic care, but at some point, the “everyone is an EMT for X number of years” model is going to turn away experienced providers. The BLS skills model also works really well when you have short transport times to definitive care as is the case in Boston and most parts of Austin. (Heck, the Houston Fire Department even recognizes this and tells their EMT crews to initiate emergency transport for any trauma patient they encounter in inner Houston.)
As for me, I was very fortunate to have the opportunity to “grow” as a medic in a very high volume, high acuity EMS system with exceptionally broad and aggressive protocols developed and implemented by a full time medical director. New full-time medics went through a FTO process before being released as a second crew member. To be the lead (AKA in-charge) paramedic took an additional FTO process. As for volunteers, you rode as a third crew member while retaining the ability to practice virtually any skill available to your certification level and, after a period of time, could challenge the FTO process. For me, that process worked. It worked quite well. While I’m no longer with that service, I appreciate my experience and routinely refer back to it with almost every call I run.
There’s no secret about these places (most notably Boston and Austin) that hire paramedics into the role of a basic. They tell you in advance that’s what it’s going to be. There’s full disclosure. If you don’t like that process, you don’t have to apply. And while I don’t have the numbers, my supposition is that a lot of experienced providers aren’t interested in such a process. Sadly, many of the younger, inexperienced medics who’d benefit from an extended skills development process and FTO program because of a lack of maturity, both as a person and a provider, also lack the maturity to recognize that they need such processes. Civil service produces a lot of good benefits for medics — namely a well-defined process for HR issues. What it also produces is a relatively static culture that promotes from within, and without careful attention from management, promotes an insular groupthink.
In conclusion, I’d say that the model that Austin and Boston use is the model they’ve decided on. If you don’t like it, don’t apply. But to those services, when you have an extended FTO and promotional process, you have to recognize that you’re unlikely to attract experienced medics. It becomes a self-fulfilling prophecy. You can’t attract experienced medics to such a system, so the system becomes even more rigid to adapt for inexperienced medics requiring more initial training and mentoring.
Yep, when the only tool you have is a hammer, everything starts looking like a nail.
A/TC EMS used to be on my short list of places I wanted to work. Once they left the all-paramedic model and went to this laughably inefficient system they quickly were scratched off. I might be a newer medic (just over two years) but I have worked in high acuity, progressively aggressive systems and can’t justify taking three steps backwards to work as a BLS provider while my ALS skills and practices atrophy.
Pretty much exactly what I just said, in fewer words and with less vitriol.
As someone who is starting to see himself as a reasonably experienced and good paramedic, I don’t think that mandating me to be an EMT-B is a positive professional maturation.
Would you become a paralegal for two years if you went to another law job?
I think the idea, at least in part, is to emphasize the importance and foundational role of BLS care in the system, with the ALS scope being “added on” rather than a replacement or the gold standard. This is the best defense of the “work as an EMT for x duration before going to medic school” argument, as well. Systems like Boston really do believe in that model, and it’s fundamentally different from the approach that says you have to base your system around medics just to get competent basic care.
In other words, the “good paramedic assessment” you describe, aside from “add-ons” like electrocardiography, should be performed by everyone… but in many cases it’s presumed you need a paramedic for that. I don’t necessarily dispute that this is often the case due to the sad level of initial EMT training, and that’s why these BLS-focused systems usually do their own retraining to strengthen their BLS base. But it’s certainly not how it should be, in an ideal world.
Whether starting everyone as a basic before you let them play with tubes is the answer, I have no real opinion on, but insofar as it supports the above philosophy, I can understand and endorse the thought process.
I was once of the same mentality. And I still think that good basic skills make a good medic. But once you start paramedic education and begin to grow as a medic, you learn it’s a continuum of care. As such, I can’t really endorse such a model. But until you’ve gone through the paramedic education process, it’s hard to understand.
But this also calls into question why we require you to be an EMT before you’re a paramedic. We don’t require lawyers to be paralegals first. Nor do you have to be a PA before becoming a physician. EMS will always be a trade so long as we create these apprentice levels — including functioning at the BLS level before someone deems you worthy enough to be a paramedic in their system.
I would have no problem with EMT education that involved the same level of A&P, pathophys, and so forth as paramedic school, merely without requiring the same training in ALS “skills” like drugs and therapeutics. That is the type of foundational knowledge that should come first for everyone.
But the fact is that when you take someone with no clinical experience and drop them in the field as a new paramedic, they’re not only going to need to master their tricky ALS skills, they’ll be doing it at the same time they learn their core BLS skillset. And those BLS skills are the absolute foundational tools that are essential to all levels of medicine: a well-formulated diagnostic process, rational and patient-centered decision-making, excellent history-taking and physical exam skills, basic life support like bleeding and airway control, scene management, patient rapport and advocacy, etc etc.
I would want a provider every day of the week who had mastered those skills and couldn’t intubate or push a med to save their life over the alternative, and that applies whether they’re an EMT, a paramedic, or an emergency physician. (Okay, maybe not a surgeon…) The difference is that the EMT has ONLY those things in his toolbox, which means if he wants to be good — which admittedly not everyone does, and with the low barrier to entry, they certainly won’t be forced to — he’ll need to master them without anything else to fall back upon. The paramedic who never has to solely rely upon those skills will take longer to develop them, and may never fully do so, because he’ll always have other crutches and distractions. At the very least, he’ll have a hell of a learning curve, and at the worst, he’ll never truly have the ability to connect with patients, evaluate their problem using the history and physical exam, figure out what the patient needs, and make a plan for them to get it.
If there’s a parallel to other educational models, and I think it’s tricky to draw one, it might be to the declining skillset of these same bedside skills in the current generation of practitioners in the US. The fact that every patient has a CT, MRI, and laboratory available not only means there are powerful diagnostic tools that can be brought to bear, it means it’s almost impossible for a new provider to develop his ability to make decisions WITHOUT those tools, without spending a while in Ghana or something where they’re absent. Good luck finding a doc in most hospitals who really knows how to percuss a chest… but they’re still the norm in places like India.
Another parallel is that you don’t need to be a nurse to go to med school… but you mostly DO need experience with the aforementioned core skills to go to PA or NP school, for exactly these reasons. Medical programs get around it with their prolonged training time (two clinical years plus residency), which allows for you to start as an idiot and still come out with all your ducks in a row. Medics have much less and will end up practicing with almost no help or oversight except their partner.
My thing is if they are going to make this the way they hire, why not just hire basics to begin with and then put them throught they’re paramedic training? Why make someone pay for 2 years of school, get that fancy EMT-P patch and then pay them basic wages for 2 years? I sure wouldn’t want to be getting screwed like that!
Over the years, I saw a lot of experienced paramedics who came from both private services and municipal services fail out of our basic EMT training process. The clinical standards of those services were for reasons I’m not sure I understand, well below what we expected even from EMTs.
In many systems, paramedic is a promotional position. There are a myriad of reasons for that, but one of them is to have a career ladder. Those systems don’t hire paramedics from outside, nor do they hire supervisors from the outside.
Maybe that doesn’t fit your definition of professionalism, but it fits mine.