EMT Before Paramedic? How Much Education is Enough?

On the last EMS Educast, Mike “Fossil Medic” Ward discussed his EMS 1 article with Greg Friese, Rob Theriault, and Bill Toon about why he believes experience as an EMT is not necessary to become a paramedic.  Last Sunday on EMS Office Hours, Jim Hoffman, Josh Knapp, Tim Noonan, and I discussed when EMS people at each level are ready to work on their own after certification.   These discussions reminded me of my experience as a new EMS provider, and stimulated me to think about better ways to educate and mentor new people.

I had an excellent EMT instructor at a community college, who developed his own curriculum and truly cared about his students.  As Mike pointed out on the Educast, not every EMT class is like this.  Still, I am a visual learner.  I can read about something,  hear about it, and practice it in a skill station, but it does not click until I watch someone do it in a real situation. The 8 hours of ED observation time in EMT class did not prepare me to work by myself.  The services I started with, one as a volunteer and one with a private company, had short orientations.  In his post about our discussion on Office Hours, Tim writes about how we throw new people to the wolves.  I was almost eaten.

As a visual learner, I would not have passed in paramedic school without having experience as an EMT.   I needed the mental library of sick patients that I assisted my paramedic partners manage.  After paramedic school, I worked as an ED tech at a busy, urban level 1 trauma center.  I saw a ton of really sick patients, and and learned from watching other people in charge of managing them.  This made the transition to working on my own as a paramedic a little less rocky.  Many people do fine without any experience, though, and others don’t learn from the experience they get.  I would not consider it a requirement for everyone to become a paramedic.

On the Educast, Greg asked if requirements for EMT experience are meant to compensate for inadequate education.  I believe it is.  Other healthcare and public safety professions do not require experience at one level before moving to another.  Instead of requiring work experience, either as an EMT or in a healthcare setting, how about incorporating better clinical experience into initial education?  I like Rob’s description of a four-year paramedic program on the Educast, where an entire third year is spent doing clinical rotations.

Bill also mentioned that few paramedic programs send preceptors along with students on their hospital clinical rotations. I actually do this with the paramedic program I teach with, and I believe it is a huge help for students.  That program has been accredited for many years and has a very high first-pass rate on the National Registry exam.  There is still a big learning curve for many new graduates when they start working.  Many certified paramedics spend months in additional field training, and some don’t make it. Experience as an EMT is not required for admission, and some blame the learning curve on that.  I think the reasons are more complicated than just lack of experience.

I recently finished my 10th year as a paramedic.  I was not taught about 12-lead ECGs or CPAP in school, and learned about them when I started working.  About four years ago we rolled out RSI, and two years ago we rolled out a sepsis protocol and lactate meters.  All of these are complicated topics that the program I teach with must now cover, and that new paramedics are expected to be proficient with, in roughly the same amount of time as the program I went through. Deciding how much time should be devoted to each topic has become an exercise in triage, and this is only going to get worse.

The topic of Office Hours focused on what happens immediately after certification.  When are people ready, and when should people be directed to another career field? Many organizations send new people into situations they are not prepared for, or feed them to hostile  seasoned providers.  Good people end up leaving the field, and patient care suffers along the way.  Skip Kirkwood’s wrote about the FTEP program in September’s JEMS.  This program was adopted from the law enforcement model of field training, and the article is well worth reading.

So my question is, if newly certified people are not prepared to work independently, why do our education programs allow them to become certified in the first place?  If new people can’t cut it, shouldn’t that be figured out before they graduate?  How are new EMT’s declared to be minimally competent when they have not demonstrated any skills on live patients? How much more material will paramedic programs be required to cover before more time is added to do it?

I do not know the answers, but am happy so many smart EMS people acknowledge these are problems.  So what do you think?

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