The Flawed Logic of EMT Before Paramedic

This morning I caught Chris Cebollero debate Kelly Grayson on the Inside EMS podcast about whether experience as an EMT should be required before entry into paramedic school.   Chris’s position is that it should be required, and is necessary to have experience interacting with patients before paramedic school.  Kelly believes it does not, and that our education system is flawed.  I agree with Kelly, and believe that providers at all certification levels should get experience in supervised clinical settings, not on the job and alone with patients.

Thom Dick also believes that EMT experience should be required before paramedic school, and he wrote about this last year in his EMS Reruns Column in EMS World. Here he answers a question from a frustrated preceptor:

Q. See, there ought to be a screening test for common sense. It’s hard enough doing your own job, without having to compensate for people who have the same certs you do, but seem so clueless about the basics of the work. Isn’t there some way to fix that?

A. I think there’s just such a test, and it’s called EMT experience. I think when we don’t insist on that prior to paramedic school, we accept more responsibility than we can handle. I think we should stop precepting paramedic students who have never been full-time street EMTs. In fact, I think we should do that right now, today. Next time a school asks you to take one, inquire about their experience. If they haven’t spent at least two years as a full-time working ambulance EMT, you’re going to have to teach them how be an EMT and a paramedic simultaneously. (You’re also going to have to teach them some humility.) If you think you can do it, knock yourself out. But if not, I think you should politely decline.

I believe we should screen for common sense before we certify EMT’s. Compare this approach to law enforcement’s.  Police academies have a rigid screening process before entry and drill situational awareness and driving skills into their initial training.  Why do we allow it to be so much easier to work on an ambulance than a police car? Even with the new education standards, only about 150 hours is required to become an EMT.  EMT students are not required to demonstrate skill competence on any live patients, have no required field internship, are only required to observe patients in some healthcare setting – not necessarily even an emergency department.  Now many education programs do more than what is required, and many services have an extensive field internship for new graduates, but many do not.  On the podcast, Chris stated that the first time a paramedic is handed a child who is not breathing, they would wish that they had experience first.  I could easily have been in that situation as 20-year-old brand new EMT, with a driver-only partner, because we were the only ones at our volunteer ambulance station.  Thank God that I wasn’t, and had I been my career path may have gone much differently.  The fact that EMT class is so short, and that we expect services to assess for competence after EMT’s are certified is ridiculous.

The amount of time working on an ambulance is also a poor gauge of experience.  EMT’s in rural areas may see as many patients in a year as urban EMT’s see in a week.  EMT’s may function as a lead caregiver on an ambulance, only go on nonemergent transfers, do first response on a firetruck, or drive and assist a paramedic.  Many EMT’s are young and easily influenced by senior people, which may be good or bad.  One of my paramedic students is an EMT who was taught that if chest pain gets worse on palpation, it is not a cardiac problem and that he should cancel paramedics.  He did that for some time, and who knows what the damage was to his patients.  In order to make the experience before paramedic school argument, you need to examine the type and quality of experience instead of just time.  I would rather have a clean slate to work with and mold.

Requiring EMT experience before paramedic school has harmful implications to the career field as well.  Many services pay EMT’s close to minimum wage, and EMT’s work 60 or more hours each week.  Those who wish to become paramedics must then balance paramedic school with working for an additional year or two.  This makes things like marriage, buying a house, and having children even more challenging.  Nursing, by the way, has no such requirement and pays more.

The paramedic program I teach with does not require EMT experience.  That decision was made in the 90’s when the state’s paramedic programs were moved from hospitals to a community college.  At the time almost all of the state’s EMT’s were volunteers, and the advisory board wanted to make a career as a paramedic open to people outside of the volunteer fire service.  Because of this our program was designed to include much more than the minimum requirements.  For three semester, students spend about 10 hours each week in class, 10 hours in a simulation lab, and sixteen hours each in clinical sites with a faculty preceptor.  Students then go through a field internship with a training officer, where they must demonstrate successful management of a variety of patient types – not just ride on a paramedic unit for a set number of hours.  There is still a learning curve after they graduate, but I think providing supervised clinical experience during paramedic school is  better approach than hoping paramedic students have good experience as EMT’s before entry.

In my class I frequently show videos from the Australian show Recruits: Paramedics, and I think that the New South Whales Ambulance Service has a much better education model.  There are a variety of ways to become a paramedic in Australia, and most require a bachelor’s degree before you are ever by yourself on an ambulance.   After graduation from the program, NSW Ambulance has a three year internship program where new paramedics work with an experienced partner.  Compare that with what we expect EMT’s to do after 150 hours in class.

Sorry Chris, but I’m with Kelly on this.  We need to provide paramedic students with the experience in school, not on the job as EMT’s.


  1. In an ideal world our whole system would be radically revisited with substantially more training at the BLS level; I’m sure we agree on that. But one of the interesting silver linings of the current system is that a motivated EMT is forced to learn excellent BLS skills because that’s all he has available. Those are absolutely applicable at all levels of care, and I think it’s hit or miss trying to acquire them when you start out with more tools and toys available. (This doesn’t just apply to medics, of course.)

    Do you ever learn to be quite so good at understanding a palpated pulse or obtaining a manual BP if you have a monitor available from day 1 — and you’re busy trying not to forget your meds? If so, how long does it take? Is it even necessary? Will you ever care?

    There’s something a bit magical when you take a smart person and force them to practice purely clinical medicine for a while. It’s not worth accepting a dysfunctional system, but it’s something.

  2. Jon Kavanagh says:

    Perhaps the problem isn’t a one-or-the-other. Perhaps we need to bolster our EMT programs–the status quo (competing schools/programs don’t want to be the only ones in town with a 200 hr program, etc.) is a huge problem. We know one of the solutions is to improve the EMT curriculum. We know our EMTs are (generally speaking) not well prepared for their jobs; some programs have ridiculously low clinical time built in. Yet, what is being changed?

    These poorly trained EMTs then come to a Paramedic program, yet cannot pass an EMT-level written test. The candidate may minimally pass a minimum competency practical exam. These are the minds we want to be shaping? But, despite this uphill battle, the Paramedic programs in a given area are all the same–no one recognizes the issue and rocks the boat with a program that goes way above and beyond. Why? Because we have bred a class of citizens that don’t care about the goal, only the first step. Why pay an extra few thousand dollars and stay in class a few extra months, when these guys will get me in and out cheaply, and still have me pass the NR exam?

    Bottom line, we need to fix the entire EMS educational structure. Only then will the “Thou shalt have X years experience/X patient encounters” argument go away…

    • emspatientperspective says:

      Thanks Jon. I agree. We have the lowest education standards of any first world country at all provider levels. I believe that students should be competent enough to function independently upon graduation, and am not sure that is possible in time frame we have to work with in this country.

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