Paramedic vs. Nurse. The doctor’s definitive edition.


Last night and this morning my Facebook page exploded with articles about The California nurses’ unions and association opposition to a community paramedic program. Not surprisingly the EMS group thinkers got together and have a million reasons why nurses are wrong. The usual utterly misinformed statements appeared, “we don’t need a written order like nurses do”, “nurses cannot handle being on the front lines”, and even EMS leaders chimed in with “we have overlapping training so we can do nursing too; I have nurse friends that say so!”
For those of you who do not know about me what is important for this article is, I started my career as a firefighter who did not want to do EMS, ever. I was forced to become an EMT, I was forced to become a paramedic to work on the fire department. At no point in time did I ever want to do those things. What I wanted was to rescue people. I did however seem to possess a special talent for medicine which was noticed by my peers and superiors alike. After a couple years of being a paramedic I had a “eureka” moment. (My strictly EMS colleagues have said I had seen the light and repented.) Rescue is all about a patient. When it is not about a patient, it is no longer rescue, it is a recovery. You cannot possibly be expert at rescue unless you can take care of the person you are rescuing. (Some fire departments try to separate this into a team task in much the same way as surgery and anesthesia with varying degrees of success) My career has never been driven by what I should do. It has been driven by what I have had to do and what I want to do. After some years of being a paramedic I was encouraged to go to medical school, which I did; with the desire to be both a surgeon and intensivist. Much like rescue, I have discovered you cannot be truly great at trauma or resuscitation without the skills of both. You can get by, many places have a team approach with varying degrees of success, but my unrelenting goal is to be the very best. I take the time to explain all of this to qualify, having “worked my way up” from the bottom, I know, have seen, and have done every part of every step on the way. I have spent holidays, nights, weekends, and blood with every level of healthcare provider and allied health professional there is. I have not only friends, but the best friends anyone could ever hope for among all of them.

Therefore I state:

In the matter of community paramedic programs, I think community paramedicine is the future of EMS, whether any of us like it or not is inconsequential. Everyone knows it is better to prevent emergencies both for the potential patient and for the economics. There are so many calls for help all over the world, that no EMS agency in any country (I have cared for patients in 5 different ones) can possibly be successful as responding after the fact. There must be “preemption.”

Now then, having covered all of that, I agree with the position of the CA nursing bodies 100%. US paramedics are not ready or capable of taking up the role of community healthcare provider.

I must single out US paramedics because unlike their colleagues (“peer” is definitely not accurate) in the rest of the world, they are trained without being educated (to varying levels) and therefore cannot be effectively licensed as independent providers responsible for their own actions. Some states have taken to “licensing” paramedics but it is what my lawyer and paramedic friend Skip calls “differentiation without distinction.” US paramedics function under written standing orders. (You can see where the common paramedic argument of we don’t need a doctor’s permission is blatantly misinformed.) Part of making US paramedics ready is the ability to “cut the cord” and permit them to practice without a doctor ultimately being responsible for them. Doctors are not responsible for nurses like they are for medics. Nurses can practice nursing without the oversight of a doctor. US Medics cannot.

The next major hurdle is education. US paramedics as I have stated before do not possess the education required to be a healthcare provider, neither at home nor in the emergent setting. They have a rudimentary understanding of information that permits the use of various interventions under the orders of a physician. A fair few of them take it upon themselves to go beyond this, but that is the decision and ambition of individuals, not the industry as a whole. In most first world nations and many developing nations, a US paramedic does not have enough education to get reciprocity. This is not true of doctors and nurses. (and in some countries even chiropractors)

In order to become more than a technician, US paramedics must get a formal education. Society demands it, other healthcare professionals demand it, and the very act of taking care of patients demand it. It is more than just about money. US paramedics don’t know what they do not know. That is fine when all of your decisions end with “call medical control or drive to the hospital.” It is not ok when deciding who and when patients need to go where for further healthcare. There have been actual studies that show US paramedics cannot effectively decide who needs to be admitted to the hospital and who does not. That is a critical skill when it comes to taking care of people at home. It is perhaps the most critical skill. Another major part of healthcare education is learning the rare cases and “what if’s?” This is where nursing is actually weakest compared to medicine. But nursing is far ahead in this area compared to US medics. This is another essential skill for home healthcare. Finally one of the reasons “additional training” for paramedics is not adequate to set paramedics loose on home healthcare are the questions of how and why?

During my time as a doctor in Afghanistan I saw many patients who were in worse condition than was reasonable or severely mistreated by medics at remote locations who were given extra “training” and tried to care for the non-emergent patient. This is not a negative judgment about providers who were doing their best under the most extreme of conditions. This is acknowledging the fact that such a system does not effectively work. Giving patients ibuprofen until they have nephrotic syndrome in war is an accident and a risk of the environment. In the civilian world in a modern western country, it is criminal. That is but one example but I could write a book on the failures I have witnessed.

Some systems in the US have already instituted community paramedicine and are having success with it. So how does this affect my position and opinion?

All of the programs I have been familiarized with are not actually providing healthcare. They are filling a needed role for certain, and being successful and preventing the need for EMS and hospitalization by doing things that people without training could do, things that people without training do on a regular basis; things that some patients even do themselves. These paramedics are however doing these things for patients and family who are not doing them.

When you start talking about  addressing medical issues or seeking out care as opposed to routine tasks like taking a blood pressure, making sure people have medication or are taking as instructed, getting to dialysis or the doctor on time, you have entered a whole new world. Nurses are educated and must receive specialized training to do this. Medics taking what amounts to a few more hours of school reminiscent of a merit badge course like CCEMT, ACLS, etc, simply are not going to have all the information they need. In order to have any level of purposeful success and not just get lucky with the occasional tragedy, one must possess a basic underlying knowledge that they can apply to all aspects of patient care. This is the knowledge gained in degree programs like nursing and medicine. It takes years to effectively gain and understand that knowledge.

Permit me a personal example? When I was in medical school, one of the most respected anesthesiologists I ever met and whom I still hold in highest regard, flat out stated to our class during an operation “I could not pass medical school today.” He went on to explain to us that when he was in medical school (he is an old guy) biochemistry and molecular biology were not even considered science. They had no idea what it was or how it worked. Back in the day he knew “enough” to practice his specialty. He learned on the job as he went as he needed. His generation is almost gone from the earth.

Today, that level of knowledge with on-the-job training is inadequate; for doctors, for nurses, for paramedics in every country outside the US. Imitating what one sees (similar to US paramedics doing “research”) is not the same as knowing what one is doing. It is not acceptable in any industry. If a person was able to imitate all the skill requirements for a US Marine to pass basic training but does not actually enlist in the Corps or complete basic training is he permitted to function as a Marine? To call himself one? Obviously the answer is “no.” That is the exact same thing other healthcare providers are trying to tell paramedics. That is exactly why they rightfully oppose community paramedicine in this day and age. Until paramedics go through the same “enlistment” and “basic training” aka accredited official college or university which confers a degree attesting to having learned the basic material and met the minimum requirements to get their piece of paper, paramedics are imitating other healthcare providers like in my marine example above. They are expecting to essentially call themselves “marines” and function in the field without really doing it the official way. The internet today is full of examples of paramedics and even their leaders trying to justify this. Many have convinced themselves it is ok because they are somehow “special.” (I guess it could be called “special education”, but in the most derogatory way possible.)

I am not anti-medic, actually, myself and many would claim I am quite ready and able to help medics. US paramedics should be doing community medicine. They must be doing it in the future. But as the CA nurses pointed out, they are not ready yet. They do not have what it takes. But the only thing stopping them is their useless groupthink and lack of desire to do what it takes to be recognized as a peer of other healthcare providers. There are no secrets. It takes education. Everyone has been telling US medics that for decades. No exception will be made. Quit being laborers masquerading as healthcare professionals and then bitching when recognized healthcare professionals call you out on it or tell you that you don’t measure up. Quit telling yourselves that somehow you are special and do not have to do the same exact basic things everyone else did. I am tired of listening to all of the US EMS windbags. Step up and do what it takes or shut up and sit down. Then we will talk about money and respect and all of those other things. If I have done it, you can do it.

It is not nurses or firefighter or doctors holding back US EMS. The only thing holding US EMS providers back are themselves. Being great is like the ultimate Teflon. People can sling shit at you all day, but nothing sticks. With demonstrated capability, greatness stands on its own merit. Nobody can take it from you. Nobody can reasonably challenge you. Nobody can hold you back.

110 thoughts on “Paramedic vs. Nurse. The doctor’s definitive edition.

  1. Vincent Cisternino

    Can you please tell me from which part if the country you come from? Having been to paramedic school and nursing school there was no difference in education, just focus, medical model vs nursing model. So either both are technical training or both are an education. My experience is from the northeast.

    • Vincent, I originally am from Northeast Ohio, however, as I said, I have been involved in direct patient care in 5 countries and taught medicine in another 2 (7 total) on a total of 3 continents, and I have worked with providers from all over the Earth. I at least tell myself I have a fair understanding of what the general trends are. I am often called out by people who wish to let me know there are exceptions to my statements, and I admit there are. But I have no intention of typing out what amounts to a list of exceptions for egos when making observations of an entire industry.

      • Gillian Cox

        I have schooled as both and the education is vastly different! I am currently completing my matters of nursing and I am interested in participating in an EMS based Community outreach program. My colleges think I’m a bit crazy but it combines my old love with my new education, a perfect combination in my view. Excellent article.

      • Patrick Guziewicz

        I think that EMS will not have respect and will not be able to effectively move into the home health realm until degrees are required. I am pursuing my AAS in paramedicine and I am planning to pursue my bachelor’s degree in nursing or EMS after the fact. I love EMS, but I certainly wish an associates degree was required. It’s the minimum for almost any other health care professional and should be for ems as well. My hope is that some day we will see a requirement for associates degree and options for higher degrees similar to nursing.

      • Josh

        I just read your response to my comment today. In an effort to be the adult here I felt I should point a few things out to you. First, you published your blog for everyone to see AND comment on. Although some comments may not have been appropriate, the vast majority gave you their personal opinions. Instead of letting the opinions be just that, and respectfully replying, you felt the need to be immature and attack those who commented. If this was a way for you to communicate with your friends, I suggest you keep it private and your opinions to yourself. There is no room in this already disaster of a world for someone who seems to enjoy confrontation.

  2. For the most part I do agree with you. Its one of the reasons I’m finally finishing my AAS in EMS this coming spring and also am taking further education in other aspects of EMS. I want my BS in EMS offered by our local university too. We have to be the roll models of this.vocation and keep striving forward until the fsct that cjanges are coming is inevitable

  3. For the most part I do agree with you. Its one of the reasons I’m finally finishing my AAS in EMS this coming spring and also am taking further education in other aspects of EMS. I want my BS in EMS offered by our local university too. We have to be the roll models of this.vocation and keep striving forward until the fact that changes are coming is inevitable

  4. This was my response to a facebook reply to this article. I thought it was worth posting here:

    If you would permit me to expand a bit on my perspective? When I was doing my undergrad prior to medical school, I was in basic science classes like biology. general chemistry, physics, etc. There were fellow students in those exact same classes who were taking prerequisites for nursing, physical therapy, medicine, respiratory therapy, radiology, and perfusionist programs. There were no paramedics or pre-paramedics in those classes except for me at a major university. Today all of the people I kept in touch with from those classes are working in their respective fields. We all have the same or similar base. For many years I was an EMS educator, at both a community college and hospital based programs. One of the things I was tasked with was giving the lecture on metabolic pathways. Since I was almost finished with medical school at the time I had a fairly good understanding of the material. I made my own Powerpoint, gave my very best effort to explain not only the material, but why it was important to medics and how to apply it in the field. I was really impressed with my job until the end of the lecture, one of the students meekly raised her hand and asked “what is that shape you keep drawing?” and pointed to the glucose diagram. After 4 hours I realized that not one of them had ever seen it before and none of them knew what I spent 4 hours talking about. While it seems trivial, that is the kind of thing you learn in basic science education that permits you to understand more advanced work. Without that base, it doesn’t matter what facts you memorize, or try to, because there is too much to medicine to memorize. In order to practice it, you must be able to understand material presented to you. As I said in my post, otherwise, your treatments are just lucky until something fails. If you want others to respect you, sit in the same classes we all do.

    • Mike Goyette

      My B.S. from 1995 required a year of general and biochem. My understanding is that chemistry has been removed as a requirement. Personally, I have found an understanding of organic and biochemistry essential in understanding physiology. Frankly, even calculus has a place in medicine. I agree that fundamental understanding of medicine requires a solid base in general sciences. In this regard, nursing holds a solid edge over EMS. We need to evolve.

    • Christopher

      As an EMT-B currently on my way to a Bachelors in EMS and licensed paramedic what are ways to improve EMS as a community. More importantly for me, what classes in and out of college can I enroll in that will help give me that understanding of what nurses and MD’s have over us. My degree plan only requires 2 biology classes. I am planning on taking A&P 1 and 2 in my future though after I take a Micro bio for my second biology. All of my core classes for EMS outside the EMT-Medic courses are focused on EMS management and supervisor skills, which I think hinders the degree greatly because these are skills you can acquire with OJT, or should be covered in grad school.

      I have been debating Nursing or PA school after working as a Medic but would love to stay in my field to help it advance and grow into an established community. I just don’t know where to start.

    • bblue

      You have horrible grammar and punctuation. With your claimed superior level of education coupled with your boasted international teaching experience, I am shocked and embarrassed for you. I suggest if you continue to berate the courageous men and women of this country comprising our much needed group of first responders, you should at least do so in a more professional way. Or better yet, instead of putting them down due to their limited required by law practical training you yourself could do something more positive. Like maybe working towards lobbying to increase the education requirement for paramedics national and call out the U.S. DOT on this oversight; it truly would be a better use of your time rather than ranting away on a sad unknown blog, which is clearly not calling for action or searching for global justice.

  5. Justin Sleffel

    The problem with this view point is that it will stifle community paramedic initiatives and replace them with community nursing initiatives, and then community paramedicine will vanish once and for all.

    What people seem to be forgetting is that community paramedicine is pushing EMS further toward increasing our educational standards and advancing our care overall more than probably any other initiative in the last decade. If you take that out of our hands, what will happen to that momentum?

    Need is the mother of invention. If you want EMS to advance, you have to give us a need to strive for. Take that away, and you’ll see another decade of “business as usual”.

    • Justin, the problem I see is that these community paramedicine programs are great in theory, but the actual practice has 2 major issues, the 1st is by being merit badge training it basically becomes extra work and responsibility without a corresponding pay and respect increase. the 2nd is it reinforces the very mentality that holds EMS back, “We don’t need no stinking education.” Every measure of employment statistics shows that degreed people earn more and have more mobility than the non-degreed. I am not saying that is fair or just, but it is a fact. I see what you are saying, but it is a Faustian bargain. You “advance” the scope a bit, but in exchange for doing business as usual. How will it turn out any different from things like CCEMT?

      • Justin Sleffel

        I agree with everything you’re saying, Mike. And coming from a state that mandates degrees for paramedics, I see how the rest of the country’s refusal to “degree up” hurts us here too in terms of pay.

        That said, the argument is always “which comes first, degree or pay”, and while I agree that the degree ought to come before the pay increase, I don’t think we will convince people to get the degree and change the requirements until we can articulate how it will change the job. While in principle it may be more “just” to say that if they don’t want the degree that shouldn’t expect either more responsibility or more pay, in practice we’re dealing with herd behavior and that requires a little bit of give on both sides or nothing will change.

        Will the early stages of CP, run by non-degree paramedics, be exactly what they could or should be? No. But will it set us on the path toward improving both educational standards AND toward making CP everything it can be.

        The point I’m making is that if we say “you lack the education, therefore, you should not do it” then neither of those things (CP or improved educational standards) will happen. Not ever. If the system builders refuse to give CP to paramedics over other health care providers, the paramedics will have no incentive to improve their educational standards; and if the paramedics refuse to improve their educational standards, the system will never pay them a livable wage.

        These kinds of discussions help, when they’re phrased the right way. But the phrasing shouldn’t be “you lack the education, therefore, you should not do it and we’re not going to continue pursuing paramedic-based CP”–it should be “you lack the education to do this at the level it could be, but we will let you do the ‘watered down’ version until you either prove you will start taking education seriously or prove that you are unwilling to”.

        It’s the fine line between motivation and giving up on a profession that will determine whether or not paramedics advance or remain right where we have been for the last four decades.

      • Justin, I understand your position. It was already tried. That is exactly the thinking that created a bunch of endorsements like EMT-IV, EMT-Monitor, EMT defib, EMT-I with skill or drug X, etc. It got so bad that it took a bunch of political will and a massive curriculum overhaul to revamp it into EMT, AEMT, and paramedic. Enticement doesn’t work in EMS, I don’t know why. It defies all logic. But what this issue points out exactly is: If EMS does not increase education, it will not only fail to advance, it will start losing to other vested interests. A percentage of my pay goes to the physicians association automatically. They have an army of lawyers and lobbyists making sure my interests are protected. Not only does US EMS not have that, if you took out the percentage of pay I am required to contribute many in US EMS would be on food stamps. Most work 2 or 3 jobs now to make ends meet. That may seem cool in your 20s. Might be a pain in your 30s. But when you are in the 40s making poverty wages, suffering through back pain, with basically no retirement to speak of, and your wife is tired of living such life and your kids are going to college on student loans if at all, it may not be so “ok” anymore. It may also be challenging at that age to go back to say nursing school in order to get a real job. Morality and altruism doesn’t pay bills, secure a job, or stop your family from suffering.

        Doing the exact same enticement strategy that didn’t work before is not going to produce a different effect. It is time to start culling the herd or at least looking out for yourself.

  6. Pete

    Oh yeah! Thank god for the legit education in nursing school, their far reaching knowledge of the history of nursing learned in their history of nursing classes make them much better providers then medics. Or maybe it’s their “in depth” microbiology classes: simple. Have taken all of the classes nurses take, that are actually classes, and most info they learn is covered in an ok paramedic class. So as far as Faustian deals go: the only one that I see is nurses trading their money for a title and thinking that makes them better providers.

    • Brian

      “An ad hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument.”

      You missed the point so hard it hurts. Maybe open your eyes and see the progress nursing has made in the past few decades. Notice how the BSN degree has spread like wildfire? Make any proposal to take jobs away from nurses and give them to another healthcare provider and watch the political backlash.

      We could take a lesson from the nursing lobby.

  7. Vincent Cisternino

    Thank you. I too have been around the world and in some god-awful places. I ask not because of ego and exceptions, although I think you underestimate much. I ask because without a frame of reference your point is lost. I have read more than one post you have made on this topic but I wish you would offer examples of solutions. To say education is not enough. I was very fortunate and eternally grateful that my program required certain classes like A&P and medical physiology (Guyton still haunts me). Being a degree prepared paramedic has served me well. So I ask you, if you could design the curriculum, what would you want?

  8. Steve Chait

    Yes education is the answer, to chime in with some other NJ Paramedics here. Some of us have persued an Associates, Bachelors, Masters. The sad reality is the minimum requirement is a H.S. diploma, also most states paramedic is a certification, not a license. RN’s at minimum receive a 2 year national curriculum education and so should paramedics. Recently, 2 EMS bills were vetoed by the Governor, would have licensed paramedics and EMT’s, largely blocked by the volunteer EMS community. Difficult to make progress.

    • Brian

      We will continue to have great difficulty advancing as EMS professionals if we continue to allow volunteer agencies (NJ seems to be one of the worst states in this regard) and fire-based systems whine about raising minimum standards. If you can’t be trained up to a reasonable standard, you should be replaced by someone who can.

  9. …to add, I would love it if every program had prerequisites and co-requisites in bio and chem (even the watered down nursing kind) as well as social sciences and humanities. Few programs do and I have had more trouble convincing academia that this is the way to go than convincing paramedics. Also, the merit badge classes are a duel edge sword. “In the old days” you were expected to know basic cardio pulmonary physiology before you walked into an ACLS class (just an example). Today the course is structured around JCHO and hospital check boxes that almost anyone can pass without real understanding. Just memorize an algorithm and you are golden. Silly really.

  10. I think the complaints being raised by the nurses would be valid…if they actually wanted to help. Instead we’ve got whining from a group who would not touch these patients with a 100 ft pole. Why? No money in serving the underserved. Unfortunately, that means it falls upon the 911 system.

    EMS has finally awoken to the realization that they have a handful of patients comprising the majority of their workload. Hospitals are also trying to solve their new mission of cost avoidance from patient readmissions. Turns out a lot of these are the same patients! Enter the CP, mutually beneficial to both parties.

    These patients do not have home health nurses, or when they do they just call 911. Honestly, if the rest of the healthcare system was already serving these patients adequately, there wouldn’t be a need for CP’s. Besides, current CP systems already integrate with the nursing community so again these complaints ring hollow. It would be nice to hear the nursing community in CA step up and say, “we’d like to help you fill this gap.”

    CP’s may not have the education to truly fill the role these patients need, not going to argue there, but they do have the education needed to act as a coordinator. The crazy thing is, that’s all most of these patients need: a coordinator.

    Is that healthcare? Perhaps not by a strict definition, but it is fundamental to the efficient usage of the healthcare system.

    (I’m saying all of this as someone who vehemently demands degrees for paramedics and feels we’ve been given far too much responsibility with embarrassingly little education)

    • Joe Medic

      First guy that gets it. The community program is about $$$$. It is cheaper for hospitals to pay paramedics to go babysit readmission risks than it is to readmit these patients and take the financial hit. And because the paramedic is cheap and uneducated labor, it is cheaper to use them and pretend or bestow qualifications upon them than it is to use nurses. Argue merit and qualifications and abilities and intelligence all you want, but the bottom line is $.

  11. In discussing this on another site, I offered this, perhaps this is what you are trying to get across….IMHO we are (supposed to be) the top of the heap. Public health providers in a public safety role. It’s easy to make a medic into a cop or fireman (provided they make physical standards), but it’s very hard to do the reverse, because not all cops and fireman have the interest and ability to master biology, chemistry, and A&P. I have been saying this since 1998 that the very minimum to
    practice should be an AS or AAS and I would prefer BA or BS. We “get by” very well under the bell curve. But there is 10% on either side of the curve that we are not prepared for and should be. This is where he makes a point if we are expanding our role. Let me offer a real life example.

    We all know or at least you should know that if you give 10 mg of a drug that 10 mg is not what actually works on the body, the number is actually quite less as a result of first pass metabolism and break down by the liver or close to the original 10mg due to inhibition of metabolism. Some drugs require breakdown by the liver before they become biologically active and can work. While dealing with a cardiac patient with multiple tachy dysrhythmias my partner and I after using medication had to resort to cardioversion with sedation. Medications are largely based on lean bodyweight and not gross bodyweight. This sometimes results in us overdosing a patient. This patient also had a recent breakfast, one of the reasons why we always ask for last meal and what they ate, in addition to was taking Cimetedine. Shortly after a successful cardioversion our patient became unconscious. My partner was confused and panicked about this and immediately moved to bag valve mask in preparation for intubation. It took a great deal for me to stop him. The reason for this was because he did not understand protein binding sites and competitive protein binding. He also did not understand the metabolism with CYP450 and CYP2D6 set and how both the antiulcer drug and large glass of grapefruit juice works. The result was a relative overdose of benzodiazepine because the body was inhibited from breaking down the benzo. My solution to the patient management was to reevaluate the blood pressure, if safe sit the patient up with a non-rebreather mask and if tolerable, a nasopharyngeal airway. The benzodiazepine will wear off all on its own with no Ill effect. My partner who is a very good paramedic never had the benefit of biology, chemistry, anatomy and physiology, and pharmacology as formal classes. His only exposure to the subjects were drug sheets handed out in paramedic school or lectures taught by paramedics in anatomy and physiology. While I understand that this is not a run-of-the-mill case, when we expect the same level of respect as other healthcare providers they can only come from a proper education. The monkey skills while very critical do not replace basic medical science. If we want a seat at the big table then we need to step up our game even though there is no financial incentive to do so. We need to make our own luck. If we were better educated and universally so then we would have an argument for increased recognition and better salary. It’s perfectly fine for EMTs to be relegated to a technical designation much like a fireman because it’s a technical program with a finite amount of hours. This is not fine for the paramedic whose responsibility and education should be orders of magnitude greater than that of the basic EMT. By the way this is why I do not like the designation EMT – P (too confusing outside of the profession) and prefer paramedic or mobile intensive care paramedic. Of all of the public services, paramedics are (or should be) the best and brightest because our ability to learn and adapt is second to nobody. Unfortunately we need to step up out game and improve if we want to prove it. End of song :-)

    • Vincent, You basically summarized what I was trying to say. Perhaps I neglected to type out solutions because they seem so obvious and have been around for years. It really upsets me that EMS is still having the exact same conversation they were having more than 20 years ago.

      It upsets me when so called “EMS leaders” are comparing paramedics to nurses based on performed skills with no emphasis on the education that came before those skills.

      I made this post after a long discussion on a few other FB pages because I was tired of typing the exact same things on different pages.

      Not surprisingly, most of the hate mail I get is from medics and most of the love letters from nurses.

      I have noticed medics do not like to look critically at themselves, they just want to be told they are great all the time.

      But back to solutions, there need to be academic prereqs to medic, not EMT. When I was in undergrad I sat in the same biology, general chemistry, and physics classes as pre-nursing, pre-radiology, perfusionist, and pre-PT/OT. That basic science is what permits the ability to integrate not only clinical science, but also to evaluate and apply new knowledge when presented in papers, conferences, etc. In my experience, a majority of paramedic programs just attempt to have students memorize an massive amount of discordant facts. Anyone with an advanced degree in just about any industry knows that is impossible. It is especially impossible in medicine, making the basic background essential.

      While prereqs would be a good place to start, in the past I have suggested that continuing education be changed from hours in clinical topics to credit hours at university. Perhaps as little as 6 a year. In roughly 10 years that would essentially get every medic an associates degree. I would prefer a bachelor’s but I think that is simply unrealistic. Eventually a bachelor’s or post-bach similar to many other nations would be ideal.

      Another reason I am so adamant about a degree requirement is because I understand the overall value society places on it. Let’s face it, the point of a degree is to get you something. Many medics I talk to seem to think because once you get a degree everything doesn’t magically change for the better, it is not worth doing. You can see from the labor statistics, just how powerful a degree can be in terms of earning. On average an ADN makes more than double a medic. (who everyone claims has near equal education)

      In discussing this issue with a CA nurse, it was also pointed out that nurses work considerably less hours than medics, employers fight for them, and their credentials are portable anywhere in the world. If an employer starts treating them poorly, they simply move. BSNs and higher degrees have even better options and prospects.

      Meanwhile medics are trying to demonstrate their value with simple skills. Despite no other industry does that. Even the fire service has accepted degrees.

      I mentioned in the comments about the power of professional associations and sarcastically the lack of EMS associations. But until medics can make a livable wage, giving up part of their salary to essentially lobbyists is not possible.

      Fire has the same effect with unions. EMS providers complain about fire and nursing all the time because of their political action, but what will it take to get EMS providers to play the same game. It is working for fire and nursing! Don’t fight it, copy it.

      Employers don’t want EMS degrees because they will have to pay providers more. They are not going to support it. But when a vast majority of degreed EMS providers start looking for work in the established “non-traditional” EMS jobs, such as hospitals, remote medicine, etc, those same employers are going to have to do something to get bodies back in the seat.

      I have said many times, a degree will not suddenly solve all problems in EMS. But without a degree none of the problems can be solved.

      I also think EMS providers with various degrees need to stop telling people they do not matter and to start treating the non-degreed as second class providers who are having a negative impact on the industry and everyone’s pay and benefits. Peer pressure is not always a bad thing,

  12. Derek Noll

    I agree with much of what you’re saying but I do not agree with the main point of US Paramedics not being ready to undertake Community Paramedicine initiatives.

    You have referred numerous times to Paramedics being “technician level” providers and that they do not sit through the same general education classes as nurses. I disagree. Most US Paramedic programs today are two year college based programs. Paramedics take A&P I&II, chemistry, advances math, psych, and sociology just to name a few. The credit requirements for RN are identical to the Paramedic program I attended. Both are associates degrees.

    • Derek, I disagree with your statement that most paramedic classes are 2 year degree granting courses with basic science prereqs. Less than 10% of all states require a degree and while there are many degree granting programs, students may still get their medic education through a non-degreed route in the very same centers.

      Various state and accrediting bodies permit prereqs to be “included as part of the paramedic course”. If you have not seen how that works out, basically the school spends a few weeks going over a very basic A&P book and has students memorize some powerpoints specially designed by publishers to make up for lack of instructor knowledge in the topics.

      I have been a part of designing those projects and it is absolutely laughable that the footnotes on the PPTs are often the only coursework in the topics that the instructors are teaching.

  13. Harold Zwanepol

    Consider this. The average entry level EMS practitioner in Canada has spent more time in the classroom than many US EMT-Ps. They return to become ‘ALS’ practitioners with another 1-2 years of education. UK and Australian paramedics require full academic degrees to practice.

    Many of the ‘advancements’ that US paramedics are now exploring were pioneered 5-10 years (or more) ago in other areas of the world.

    I spent more time in my Canadian classroom during my distributed learning program (where students were expected to do most of their studies independently at home) than many US paramedic programs have in their full time curriculum.

    In short, much of what is said here about the paucity of paramedic education is correct. Having said that, nursing and physician training is often of the same form as is being criticized here as insufficient. ER docs and nurses also take many canned courses, be they ACLS, ATLS or how to do a FAST exam with a scanner.

    Once upon a time nursing was in the same position as paramedicine is now, with little in the way of formal skills or professional recognition. With a century or two of progress things have changed for them. Individuals, then institutions, then systems pushing the envelope is a natural way of progress. There was considerable push back from physicians when nurses began to creep into their domain of practice. Paramedics can and should expect the same.

    Having said that, we now have a century or two of experience since nurses set out developing their profession. Paramedics must learn to organize at national and state level and push for higher standards for their own profession.

    Expressions of bravado or tales of incompetence among other health care professions mean nothing to high level policy makers. They deal with abstracts such as levels of education, levels of expected due diligence and liability exposure. When paramedics put this in place for their own profession, things can progress very quickly. To do this, paramedics must take control of their own profession.

    When levels of education and professional accountability raise to a higher standard, wages and professional esteem will indeed follow upward. Australia, Canada, and the UK are proof that this is so. America will have to find it’s own way to this goal, but the examples are already there.

  14. Derek Noll

    I don’t know how much time you’ve spent in nursing homes, but these super educated nursing “clinicians” are clueless 90% of the time and cannot make an appropriate disposition of when to call 911. They also have no idea what is physiologically wrong with the patient when most often it’s very obvious. And this determination comes from 18yrs experience working in multiple EMS systems in four different states.

    I’ve also responded to calls where a home health nurse was onscene and was not impressed most of the time. Even the patients frequently complain about their care from home health.

    So, categorizing nurses as best suited for the job I think is flawed.

  15. Brian Spencer

    A degree is worthless. Current EMS degrees are a joke, period end of story. It means nothing and does no one any good. Now that I have everyones attention and the pitch forks are coming out let me specify what i mean. Paramedics are not accountants, we are mechanics. What we need is not necessarily more time spend in text books, but rather more and certainly better hands on experiance and in depth explanation of actual patients. I am a district manager and deal with new out of school medics somewhat regularly. The problem is seldom that they can’t tell you about something, but ratherbthat they don’t know what it looks like in the real world. That is something that can not be learned from a power point. We need to revamp the internship portion of our training far worse than we need to change the class room requirements.

    • Rather than pitchfork you, I would just ask a question.

      Why do you think a degree and increased clinical competency are mutually exclusive?

      I will not explain why your mentality is out of touch, that is the responsibility of your peers.

    • Brian

      I don’t even know where to begin with this.

      A mechanic? Congratulations, you really are doing a great job of selling yourself as a technician instead of a clinician. You’re advocating less time in the classroom and more time on the street, which just leads to keeping the amount of instruction time suppressed at embarrassingly low levels. I think that we can all agree that both the classroom AND clinical portions of most EMS programs are woefully insufficient.

      You’re basically saying we need less of that fancy book learnin’ and more time on “tha streets”, and that paramedics are spending too much time learning things in the classroom. Completely out of touch.

  16. Al

    There is a complete distinction between role of the RN, PA, Doctor and Paramedic. I do agree with increasing education levels of Paramedics to a Degree level in anticipation of the year 2020 community Paramedic program mandate. But, unfortunately it is Academia who is at fault for under educated Paramedics. There is no criteria or want to develop a curriculum to support a license of Paramedics. In addition, if one was to develop such a program, the time required to bring all potential Paramedics to that standard would reduce Paramedics to almost a non-existent level in this country. Who is going to go to school for a college degree to volunteer and who is going to want to be paid 22-35 dollars an hour to have similar education requirements as Nurses or PA’s. Who will foot the additional billing for all of these degree Paramedics across the country, Paramedics would have to be under a Federal agency to ensure that every community could afford the additional costs of Para-medicine. The country cannot afford these types of economic burdens nor, with they support them. If you are going to educate Paramedics to the level of a BS they why would you need nurses or PA’s or Emergency room physicians. Paramedic would be able to fill all roles, but not the reverse. In hospitals today, every health care provider is a specialist in a particular area of medicine, that’s why they do internships and none will cross the line into anyone else area of expertise. Emergency room Doctors are the closest thing to a Paramedic, they stabilize the patient and call in a specialist to handle the patients care from that point on, just like we do when we treat our patients. Unfortunately, Nurses and what ever other group can fight all they want, this is going to become a reality, the only thing I see changing is that Paramedics will become licensed and that will only be so that can operate with the same latitudes and nurses, PA’s and Doctors with the addition of mandatory malpractice insurance so some lawyer can make money when something goes wrong. On a personal note, I never wanted to do nursing because I have seen how disenchanted many become with their role in the hospital once they realize its the SSDD health care. Ill keep my 30-45 minute patient contacts and move on to the next one.

  17. Josh

    I truly don’t know what to think of this article. I know of many paramedics that are happy with their current career (although I am not one of them). Many of whom stay in the industry full time even after obtaining degrees in nursing. One friend of mine (who is an ICU nurse) told me his worst day as a medic was still better than his best day as a nurse. I agree that education needs to be improved. But by bashing publicly what some consider an honest, meaningful career, shows how disconnected you are. You also seem to forget that EMS is a different animal. That, as medics, we operate in environments that many of the nurses, and doctors I know can’t handle. Go ahead, diminish the fact that many in EMS give it their all, often times to the detriment to their psychological and physical well being. Nevermind that the “laborer” just had to deal with trying save someone’s child, and immediately after responding to a situation where a grown son beats his fathers head in with a hammer. Many people who entered EMS were idealist, who wanted to help others. Although reality hits hard, and that soon fades, the essence of the job is to help those in need. We may have chosen that path, but that doesn’t mean the profession as a whole is ignorent or uneducated. I plan on getting out of EMS someday soon. Unfortunately making ends meet trumps med school. You can say this rant was off topic. It wasn’t. You did a disservice to EMS, the men and women who put their lives on the line everyday, and the public. What will the public think when they read your post?

    • Josh, I do not think the purpose of this blog was to bash EMS, rather, to provide an explanation for why the EMS community is not prepared for an undertaking that nurses are specifically trained for in most instances… EMS is a necessary service in our society, designed to provide life support techniques quickly and efficiently. We deal with awful social problems and life or death situations often, but we are FAR from definitive care. If medics will be expected to act more autonomously as community paramedics without protocol driven medicine, we need more education. Plain and simple. I believe the author is identifying that EMS often reaches out and says, “Oh we can do that”, when they simply aren’t ready and haven’t been ready. EMS should push to be a more respected profession beyond the blood and guts that we see. We should push for better, more comprehensive education. Then perhaps we will be ready to take on some of the responsibility of community medicine.

    • As a quick lesson in medical ethics, if you are afraid of what the public might think of one of my posts, then the people who are the subject of them might actually be doing something wrong or not doing something they should…

      I am not impressed with your “we put our life on the line, to save somebody’s child hoorah EMS!”

      Apparently you are oblivious to the facts that there are paramedics in every other country that do the same thing everyday that have more education than a few hundred hours.

      You are oblivious to the fact there are doctors and nurses serving in not only EMS, but in austere medicine all over the world. I have heard of doctors without borders and agencies like the IRC sending nurses and doctors to West Africa to treat Ebola patients. I haven’t heard too much about paramedics without borders doing all that much.

      You are oblivious to the fact that ER and ICU providers (Usually nurses and doctors) are on the same front line you are. That they see every EMS patient, you see only your handful. They face many of the same threats. Granted motor vehicle collisions are not high on the list, but most EMS collisions are preventable and often the fault of the EMS provider.

      Please, spare me and the world your hero status. You are not doing anything the rest of us in medicine and healthcare are not and some of us will still be doing for the rest of our lives.

      I am willing to bet most of your protocol driven care isn’t even responsible for saving peoples lives. But if your hero complex is what you need to justify your abysmally low pay and non-existent benefits, particularly since most US EMS providers have to work 2-3 jobs to stay just above the federal poverty line, then I guess you have to do what you must.

      Starbuck’s and McDonalds is honest work, they pay better than most US EMS employers, better benefits, more time off, less physical and psychological damage.

      Perhaps you are right, EMS is just fine how it is. Somehow I don’t think so. I also suspect US EMS would benefit a lot more from active public involvement than providers trying to segregate themselves out of society.

      • I think the subject of the article was drowned out by the arrogance and conceit of the author. What an ass. Yes education needs to be beefed up but damn, that article was just meant to bash EMS. Having an opinion is great. Wanting to see paramedics advance is great. Wanting to see more education for paramedics is great. Your opinion seems to be that paramedics lack education and intelligence. That we are no more than a passing phase, not worth polishing your high and mighty shoes. Your article is poorly written. It is full of accusations and opinions but no facts. Your replies are self righteous and indignant. I concede that we have more progress to make. Unlike you though, I look back, see the miles of advancement already made and am certain that we are heading in the right direction. You are entitled to your judgement but that is all that you have written.

      • Fraser

        “You are oblivious to the fact that ER and ICU providers (Usually nurses and doctors) are on the same front line you are”, and other comments…

        This is the oblivious thinking the other is oblivious. You have either forgotten what it was like to work out of an ambulance, or you never did enough calls to truly know.

        No, actually ER and ICU are not on the same front lines. The following anecdote illustrates why…

        When a 7 year old drops dead on her living room floor in front of her parents, grandparents and brother in diapers, and I arrive, it is just me and my partner. There she lies in her favourite pyjamas, soaked in pee, still holding her favourite teddy, with her favourite movie still on the television, and it is just me and my partner. Her dad is desperately doing CPR, while the rest of the family cries, and it is just me and my partner and a little case of equipment.

        In contrast, in the ER and ICU, you have all the latest equipment plus a team of multiple nurses and doctors. You have telephones to call other doctors with specialities while frequently paramedics like me step in to help. Your patient is in a sterile hospital gown in a sterile white room elevated on highly functional sterile bed with massive lights over head so you can see. There are few personal effects to play with your emotions. Your patient has an IV and central lines hooked up and ready to go. You can step out of the room at any moment if you need a breather. You have computers to look up any information you want. You have multiple people with deep depth of training, unlimited medications, and all the equipment.

        When I walked into that scene, with my little case in hand, it was just me and my partner. We had none of what you have. NONE. But to the family, we were EVERYTHING that you have. We were the nurses, the doctors, the anesthesiologists, the paediatricians, and our little case was the whole trauma bay and the ICU combined. That is what we are to the family, and most importantly to the little girl who lost her life that day. I’ll never forget her name, ever.

        It is just me and my partner and our little case of equipment walking into someone’s home alone on every single call we do.

        So no, you are NOT on the same front lines as us. Not even close.

        Incidentally, that little girl who had newly started chemo a week before had complained three times that she was feeling short of breath that evening. Three times her family called the specialists at our Children’s Hospital about the shortness of breath. And, three times your highly “edjumakated” nurses and doctors at the hospital advised the family to put her to bed, and that she’ll be fine.

        So you can insult us by saying we have a hero complex, or by continuing to call us names in rambling vitriolic diatribes, but that is factually the job we do. The insults don’t reflect badly on us, but on you.

        Factually, PTSD rates are far higher in emergency service employees than ICU nurses and doctors. They are that way for a very good reason, and the story above illustrates why.

        So please, try to be less oblivious and more thoughtful in the future.

      • Fraser, I thought quite long today on how to reply to your post.

        I must say I find a lot of what you wrote troubling. Not so much for the argument, but the details you decided to write look a bit like obsessing to me.

        I truly hope that you will find some help for your distress, several of my friends are involved with this:

        but in any event, please contact somebody.

  18. Dreiski

    An interesting debate… I struggle with much of this and I found myself taking it personally in some areas. However, as I read along in the comments at the bottom I did find the author pointed out that paramedics would be prone to taking this discussion personally, because we like being told we are awesome all the time, no matter what. That is true for the majority of us no doubt, and it is a quality that stifles our desire to change and grow as clinicians. Why shouldn’t paramedicine be a bachelor’s? It could be a degree just like nursing, we could expand our scope, and we could earn a higher wage for it. I see the trouble in this thought process. The way the system is built today, we are relatively effective at what we do and a majority of medics, much like the author expressed, want to do EMS and nothing else-i.e. implement protocols and transport-but if we were to expand to become practicing clinicians in people’s homes (community medicine), medics may need more education. In an age where genetics and biochemistry is the basis for medicine, why would paramedics shy away from more education? We should be keeping up and exceeding the expectations of doctors and nurses if we want to take on more responsibility. Expand the education, make better medics, earn more respect in the medical community, and implement community paramedics nation wide. This will be a long process, but one that is well worth the effort.

  19. Andrew

    This is the first time I’ve ever read one of your blog posts. I appreciate and agree with the fact that PARAMEDICS are not immediately prepared for the world of community paramedicine. With that said, how long ago did you get your PARAmedic? Are you aware that ALL paramedic programs now have to meet CAAHEP and National Registry standards in order to allow students to test? You are going to be hard to find a program currently being taught that is not part of a college, and is a degree program. I think you really need to do some research (true research – not just statements based on past experiences) before making claims that all paramedics in the US as a whole are uneducated. Also, you mention Afganastan and medics – are you referencing Army medics, or true certified Paramedics? The highest level of medical training required for Army medics is EMT. My partner at work is in the Guard and she gets mad at me often because I refuse to agree that Army medics are the same as Paramedics.

    I initially took this post a little personal, but – based on how things were done in the past, I can agree – a large number of paramedics are practicing that do not have the education base. As a doctor, if you wish to see community paramedicine take off properly, and paramedics get better education – help us get it. We need the doctors standing beside us and helping push us along.

    Thank you for your prior Fire/EMS service, and your views.

    – Andrew

    • Rbeau

      Actually Military medics are more highly trained than paramedics. I could have slept through my entire paramedic course and still passed.

  20. Shawn

    As an EMT for over 10 years who has worked closely with paramedics, and also as a nurse, I feel compelled to respond, not so much to the actual post, Mike, but to the responses listed here.

    First off, I do agree with Mike’s opinion. Yes, there is a significant issue with the availability of physicians and nurses in the community setting (most especially evident in home health care), and a large part of that does have to do with funding by insurance companies and salary demands. However, nurses and physicians are specifically trained in providing patient education, both in the classroom and in clinical settings. Paramedics and EMTs in the US do not generally receive the same type of training to provide patient education. Those paramedics I’ve known who could provide education to patients and providers on the fly or in a more formal setting have earned (surprise, surprise) a formal degree that qualifies them to do so. As patient education is at the very heart of community medicine, and healthcare as a whole, it’s clear that the current state of the EMS system in this country is not prepared to effectively provide this care on a regular basis. Someday, perhaps when full undergraduate education is mandated for US paramedics, US EMS may change and be able to better provide such care.

    As for the naysayers out there, what’s wrong with more education? Sure, not every healthcare educational institution is going to be perfect, but the argument that getting a formal education will do nothing for an entire healthcare system is ludicrous. The biggest reason I went to nursing school (I do hold a BSN, and I plan to pursue my education through my PhD) is because I wanted to be better, not only for myself but for my patients. Not to toot my own horn, but shouldn’t that be the aspiration of every healthcare professional? As fir the assertion that learning about the history of a profession is useless, I would point out that becoming an effective healthcare provider does involve knowing how far your profession has come. Ignorance to history in healthcare is the same as ignorance of world history; you’re then doomed to repeat it.

    I do owe a lot to my time in EMS. As an EMT, I learned about different healthcare professions, learned to become confident in providing patient care, and I was able to become proficient in assessment skills. However, nursing taught me a bedside manner, critical thinking, and how to be an autonomous provider. Those skills I’ve picked up in my nursing career are essential skills in providing community healthcare; as US EMS is protocol-driven, the majority of EMS professionals do not currently have the skill sets to practice effectively in the community.

    Lastly, I do agree that EMS is an essential part of the healthcare model in any country. It’s a tough job in every way imaginable and EMS professionals are unappreciated. That being said, you are not gods. You are not infallible. Just like every other healthcare profession, you save lives…and you are human. The most ridiculous part of becoming a nurse for me had nothing to do with the work, which was challenging. It had to do with the unwarranted barbs from EMTs and paramedics that somehow relegated me to the status of third-class citizen. Yes, there are bad nurses out there, but that doesn’t justify the unbelievable arrogance exhibited by those in EMS.

    • Sorry you have had that experience. Where I work (ATCEMS), the ER nurses and paramedics are pretty tight. With very few exceptions (specific people), we are cohesive and appreciative of each other. No, we are not gods. Yes we are fallible. Yes there are those who don’t know their ass from a hole in the ground who believe they are but they exist as RNs and doctors also. These people (and seems to include the author of this blog) are dangerous and hard to be around. I see it in all three professions and don’t appreciate the generalization that it is only a prob;em in EMS and that EMS at large is that way. Your experience shapes your view and you apparently have been around the wrong people. The author is the only one here who has referred to EMS as gods.

  21. John

    You are severely misinformed. EMS education has come a long way since the “short course” you took 30 years ago. And quit lumping military medics (which are EMT-B level) in with degreed (AAS) paramedics. To many inconsistencies to what you though was a well thought out argument. Maybe you should take a couple of writing for research classes.

    • I wasn’t actually going to qualify this post, but I have a few minutes…

      First, if you read my about disclaimer, I write my opinions on this blog, I do not use cult of personality to change practices like most bloggers. I actually do research for that.

      Since research is one of my 2 full time occupations, this is where I offer my observations and personal conclusions without having to take the time to cite every source, etc. Honestly I think it is a complete waste of time to do any type of EMS research because no matter what is discovered or proved, the politics of EMS dictate it will be decades before any of it is put into effect. By that time this “new” information will be just as out of date.

      EMS education has come a long way in 30 years? I am afraid I am going to have to disagree. Maybe some day I will actually post my resume here (I have to update it rather frequently so it is a bit impractical to have it more than one place) but until roughly 3 years ago I still taught US EMS.

      I know all of the inns and outs, latest curriculums, teaching materials, etc. I even helped write some of them. The only thing that has changed in EMS education in the last 30 years is the addition of a few more hours of class memorizing discordant facts.

      As for military medics, I submit you did not understand what I wrote.

      Using military medics as an example, I indirectly compared a system where providers with a broad base of education like nurses, though not specifically nurses, can laterally transfer into related disciplines. I did specifically mention that systems where providers learn a very specific skill set do not readily transfer to other environments. (like paramedics trained in limited emergency procedures into primary care).

      If that is too difficult a concept, go back to reading EMS websites where all they talk about is how great medics are without addressing any real issues.

      • Apparently the poster is unaware that military medics also receive nursing education during their training. In many states a military medic can challenge the exam for an LPN or LVN license. Keep up the pressure, most medics have thick skulls.

  22. Alex

    Many paramedic programs are becoming accredited 2-year degree programs, same as nursing degrees. EMS is definitely taking steps in the right direction to become a better educated system. I will say this though, in my personal experiences, I do not believe that a majority of nurses could handle front line emergency medicine. just the same as a majority of paramedics could not handle clinical emergency medicine. Nurses and paramedics are two different breeds, and I find it difficult to compare the two that closely. There are a lot of paramedics that are “protocol medics”, meaning that they treat patients like recipies. If a patient states a certain complaint, the medic will treat them verbatim from the protocol book. They are not trained enough to understand why they are administering the treatments that they are administering, and are not able to think outside the box and see that each patient is their own unique case, and treat as such. Without taking the initiative to do extra curricular learning, both during class, and throughout their careers, they will never be more than that. On the opposite side of that coin, though, there are nurses that are just as poor at administering care, and critical thinking. I’ve been involved in EMS for 5 1/2 years, and i’ve seen my share of bad medics, and bad nurses, as i’m sure you have too. I respect the “good” nurses, because there is a lot more education and information that goes into clincal care than EMS care. My personal belief is that EMS professionals are better at the physical aspect in the spectrum of care. Being the initial hands on of a patient inside a mangled vehicle at 4 in the morning, or dragging a burned victim from a house fire is what seperates that paramedics from nurses. I absolutely believe that both parties could learn a lot from each other, if the age old argument of who’s better could be left in the past. As you said, community paramedicine is the future of healthcare, and I 100% agree. I look forward to the future, especially community paramedicine. Being able to keep patients at home, rather than burden them with a needless trip to the hospital or doctor’s office will be beneficial in a multitude of ways. Healthcare costs would lower, hospitals and doctor’s offices would be more efficient, and most importantly the stress on the patient and family, in not making an hours long process for a medication adjustment. Oh, and to add, i’m a paramedic from Pennsylvania. I was an EMT/Paramedic in PA for 5 years, and am now practicing as a Firefighter/Paramedic for a career fire company in South Carolina. Thank You.

  23. Steve Whitehead

    Take your average ER RN and place her in the supply closet with the next critical patient that walks through the door and tell her she needs to manage the patient autonomously for the first 15 minutes of care. Most will perform very poorly. Field EMS is a unique skill set. So is nursing. All medical providers fall somewhere on a bell curve of talent, knowledge, training and experience. The skill set of community paramedicine doesn’t fall on either of these bell curves. It is unique to itself.

    The fact that you met a few bad paramedics is anecdotal and no more useful to this discussion than the fact that I’ve met a few bad nurses as well.

    What would be really useful would be to team up AP Paramedics with AP nurses and have them perform community paramedicine as a team while we work out the new and unique skill set required, then fine tune the education to match the job.. To do this we will need to stop fighting like it’s some kind of turf war and work together, recognizing that each entity has value to contribute.

    My two main issues with your argument are first that you seem to be failing to recognize the unique nature of the field EMS skill set and its value to the community paramedic initiative. Second, you’re failing to differentiate between the value of education and the value of learning. Regardless of the practitioner that you choose to put in this new position, they will need new education, new skills, new experience and (most importantly) new learning. And all of us will need patience, which we often lack in emergency service.

    Overall your piece is an excellent contribution to this discussion.

    • Steve, it is not that I don’t recognize there is a unique field skill set, it is that in my experience the best field providers are also excellent in-hospital providers too.

      Medicine does not change whether it is in the hospital or out. Some of the techniques need to be modified, but that is the extent of it.

      Moreover, the more I am involved with cutting edge resuscitation, the more I realize and profess the idea of “initial steps of resuscitation” as practiced by EMS and many emergency departments is flawed to the very core.

      The research is ongoing, but the modern understanding of the effect the inflammatory process and digressing into irreversible apoptosis cascades from systemic activation, is really making the whole “heart, brain, kidney” thing obsolete.

      • “The research is ongoing, but the modern understanding of the effect the inflammatory process and digressing into irreversible apoptosis cascades from systemic activation, is really making the whole “heart, brain, kidney” thing obsolete.”

        Could NOT agree more.

  24. Patrick Garrett

    I see many of your points. I am a retired Fire/Medic (transporting ambulance) and now I teach health and first responder to high school students. Help me out here; there is a need to teach everyone basic first aid CPR/AED and little wilderness and disaster survival, stuff everyone should know. We also need people to respond to emergencies and transport pt.s to the ER who need more than basic training ie. emt, emt-p. My question is where is the break-over point, the cost to benefit, the realization of the proposed extra schooling above the current requirements, will an English class really affect my ability to preform basic and field level care? Of course why stop at nurse, wouldn’t it be better to have a MD on every unit?

    Maybe we (medics) don’t deserve a seat at the big boy table. Maybe ambulances and 911 are not being used as designed. Maybe we need to change and adapt to the new school of thinking but I ran many calls with many smart doctor types and it never really affected the care.

    Some parts of this country would be greatly served, in fact in some locations a paramedic may be the first and only person available for 100+ miles.

    • Patrick,

      I think you maybe combining multiple issues into one question, but I will do my best to dissect what you are asking.

      First, everyone with any respect in the EMS industry world wide knows that having too many advanced providers is a problem. Things like skill degradation, experience, etc. has been well established.

      Everyone involved in some form of resuscitation education or policy making knows it is neither economical nor practical to put a highly educated provider on every corner. Bystander CPR is going to be the biggest contributor to survival.

      From the perspective of life saving, “early advanced care” should not mean a higher educated provider showing up and doing the same things that lesser educated providers were effectively doing. After all, an AED works just as well as a manual defibrillator. A bystander or EMT is just as capable of doing quality CPR as a medic, and probably puts more focus on it. The purpose of having a higher educated resuscitation provider is to provide the next and ongoing steps, with a seamless transition.

      From the perspective of EMS, most providers agree that only 5-10% of calls are life threatening. Could you imagine if McDonalds or the like only focused on 5-10% of their customers? It would be a business disaster! What if the police only dealt with the most severe 5-10% of crimes? The whole purpose, and consequently economic benefit of community paramedicine is to address the other 90+% The 3am toe pain. The kid with a fever. The old fall down and go boom. These are the calls where simple prevention saves a crazy amount of money down the line. Money that comes out of your pocket indirectly. An example I like to use is making sure an elderly person is taking their medicine as prescribed. They are often home bound and on limited income. What amounts to somebody dropping off a $3 bottle of furosemide can prevent the need for an ALS ambulance (several hundred dollars) followed by an ED (several thousand dollars) and sometimes culminating in a few days in the ICU. (tens of thousands of dollars) Do you think paying somebody with enough education to help some of these people without resorting to the emergency medical system does not have considerable economic benefit?

      At the very least it reduces the amount of ambulances you need driving around and staffed. I could write pages on the ineffectiveness of the ED for treating non-emergent patients.

      Prevention is always cheaper than response. But the people supplying the prevention need to be expert at it, not just guessing and hoping things don’t go wrong.

  25. Thank you, well said. There are many problems with the Paramedic level that most do not see. As a Paramedic Educator I have seen the quality of the students decline, and the basic education they received dumbed down. Part of the problem is that many enter the industry as EMTs then work full time while the go to Paramedic School part time (more or less). The system was set up to make it that way and it is a set up for failure. EMS should be like nursing and many other healthcare paths, you make a decision to go into it and you go to a college and get the basic foundation education like, math, biology, A&P I&II, Microbiology, psychology, pharmacology, pathophysiology and so on. Then learn what you need to function as a Paramedic. I left Nursing school to be a Paramedic and that education didn’t go to waste. It is too bad, there was no degree program for Paramedic. Our future is going to be in preventive (community based paramedics), but we need to start down that path with an education that will match the responsibilities that will accompany the change.

  26. Chris

    EMS is a strange animal. We serve two masters. Public safety and the medical community . It’s hard being the red headed step child in the room. The public safety side dose not want to do what we do. Police and Fire want to do , well Policing and Firefighting. We stick around because they need us to do the grunt work. The medical community needs us only to get people to more definitive care. I know most of you are aware EMS is very fragmented. Each state has different rules based on very loose and outdated guidelines from the Feds. I have been an EMT (Basic) for 17 years. I can say without a bit of doubt , we need better education. It’s not enough just to show us something and say it works. We need to learn why it works. How can we ever call our selfs medical professionals if we don’t have the education to back it up. I think EMS has to wake up and understand we are working with rules spelled out by people who ARE pros. I saw some in this thread say ,why don’t doctors and nurses help us. Well , I have that answer. No one will help us if we don’t help ourselves. The push has to come from within . We need to demand the changes. We have to push for a Federal agency to help with change. We have to demand the states to push for higher standards . I have to push each other to be better. Then and only then we can stop being technicians and become clinicians. We have to put our self inflated egos aside. Pride is a hard thing to over come. Yes , we have a stressful job. It effects our mental and physical well being. Our hours are long and our pay is little. We as a profession can do so much more. EMS is a young profession. We have have only been around for 40 or so years. How dose that compare with Nursing and Doctors? It dose not even come close. EMS is like a teenager who thinks they know everything . Look, I don’t like lamb basting the profession that I love. I just think we can be better. I agree with the article above in the most part. I believe that with better training and education, we can be better medical providers. It will be then we will really be professionals. Stay safe everyone.

  27. Chris

    EMS is a strange animal. We serve two masters. Public safety and the medical community . It’s hard being the red headed step child in the room. The public safety side dose not want to do what we do. Police and Fire want to do , well Policing and Firefighting. We stick around because they need us to do the grunt work. The medical community needs us only to get people to more definitive care. I know most of you are aware EMS is very fragmented. Each state has different rules based on very loose and outdated guidelines from the Feds. I have been an EMT (Basic) for 17 years. I can say without a bit of doubt , we need better education. It’s not enough just to show us something and say it works. We need to learn why it works. How can we ever call our selfs medical professionals if we don’t have the education to back it up. I think EMS has to wake up and understand we are working with rules spelled out by people who ARE pros. I saw some in this thread say ,why don’t doctors and nurses help us. Well , I have that answer. No one will help us if we don’t help ourselves. The push has to come from within . We need to demand the changes. We have to push for a Federal agency to help with change. We have to demand the states to push for higher standards . I have to push each other to be better. Then and only then we can stop being technicians and become clinicians. We have to put our self inflated egos aside. Pride is a hard thing to over come. Yes , we have a stressful job. It effects our mental and physical well being. Our hours are long and our pay is little. We as a profession can do so much more. EMS is a young profession. We have have only been around for 40 or so years. How dose that compare with Nursing and Doctors? It dose not even come close. EMS is like a teenager who thinks they know everything . Look, I don’t like lamb basting the profession that I love. I just think we can be better. I agree with the article above in the most part. I believe that with better training and education, we can be better medical providers. It will be then we will really be professionals. Stay safe everyone

    • I have no intention of posting my resume on my blog. Seems too much like narcissism to me…(considered that most of my posts are read only by my friends, it hardly seems necessary anyway)

      I posted the relevant information to this post in the body of the post and added to it in a reply.

      Am I just out of school would depend on your point of reference. I have been a doctor for a couple of years. Is that just out? I am sure some would say “yes.”

      I have since earned another degree and I am working on yet a third, so I guess some would say I am still in school. (I have accepted school is forever, I embrace it rather than fight it.)

      What do I do? What I love to do. I have a couple of jobs actually, all are connected to medicine.

      My comments are under my name, but the question of: “who am I?” Is one I have not yet found the answer to yet. I have no doubt I will post the answer here if I find it.

  28. Cameron

    Wow…just wow! You can say what you want but your bashing Medics. Your bashing the profession you never wanted to take part of in the first place but now that your at the highest level you think you can do that. You talk about the education part and how nurses are much more educated than Medics. Where I’m from I can take a course on-line and become a nurse in six months with very little in class time so I don’t think its that much of a difference in education. Its been plenty of times where we would take in a patient and the doc say “well there is nothing for me to do. The medics done it all”. The ER stabilizes what we have already saved and brought back. I think you need to remember where you came from. I’ve seen doctors I would not let work on my dog but I’ve seen medics and nurses to don’t get me wrong. Any medic I’m sure will agree that we don’t do it for the money. Most of the time the money is not even worth what we go through. You know. You been there right? I wouldn’t bash medics. One day you might need one. And for all of you agreeing with the doctor….please ride a truck and see how things work besides going off what little time you interact with us during transferring care. We all need to be a team and have a understanding of each other and our roles. I’m sure doctors have protocols to follow just like us medics. I know Medics don’t mean anything to anyone unless where needed…then we are everything.

    • I think this deserves a special reply…

      “Wow…just wow! You can say what you want but your bashing Medics. Your bashing the profession you never wanted to take part of in the first place but now that your at the highest level you think you can do that. You talk about the education part and how nurses are much more educated than Medics. Where I’m from I can take a course on-line and become a nurse in six months with very little in class time so I don’t think its that much of a difference in education.”

      “And if a frog had wings it wouldn’t bump its ass.”

      You may find this arrogant and bashing, but my offering criticism of something I have done actually carries far more weight than your stipulation of something you have not done.

      I stipulate your assertion to the equality of education is without merit.

      “Its been plenty of times where we would take in a patient and the doc say “well there is nothing for me to do. The medics done it all”.

      So what?
      My wife has no medical education or experience, when my daughter gets hurt, my wife takes care of her and then asks me to look at her. In most cases, my wife has done everything that can be done and there is nothing for me to do. Perhaps my medical ability is suspect? Just because there is so little to do for a patient and it has all been done does not affirm the provider as capable.

      “The ER stabilizes what we have already saved and brought back.”

      What?! I suspect you do not know what the ED does or that most patients are brought back in the ICU after some sort of surgical intervention like PCI.

      I would suggest you spend some time with services outside of EMS and learn who does what rather than make stuff up.

      ” I think you need to remember where you came from.”

      It is not that I forgot where I came from, it is that my telling medics how great they are when in fact it is just delusional propaganda does not actually help the industry become a profession in the US on par with many of its international colleagues.

      Incomplete ranting thought not addressed.

      ” I’m sure will agree that we don’t do it for the money. Most of the time the money is not even worth what we go through. You know. You been there right?”

      You think that is ok? Because I don’t. I think that people who are a vital part of and a growing player in the healthcare community should be justly compensated for their sacrifice. Pounding your chest destroying yourself mentally and physically with the expense paid by your friends and family is not something to be proud of. It means that somebody is using you and feeding you BS in order to get you to play along.

      “I wouldn’t bash medics. One day you might need one. ”

      There is a difference between legitimate criticism and bashing. If I wanted to actually bash medics I could do far better than this.

      Chances are good that one day I will need a medic, but I have chosen to live in a place where a medic needs a degree to get on the truck and many of the field supervisors have advanced degrees. With both knowledge and a scope of practice to match, I have every confidence in them. If I am really in need, there are still doctors on ambulances here and if the call sounds bad, the doctor (who are most often either anesthesiologists or surgeons) will be dispatched too. If I am that bad, I will not even see the ED, except perhaps to watch them wave goodbye.

      “And for all of you agreeing with the doctor….please ride a truck and see how things work besides going off what little time you interact with us during transferring care.”

      More senseless ranting? Many of the people here have spent a good many years on the truck. A few more (including nurses) are EMS educators and leaders. Perhaps you should spend some time learning what everyone else does?

      Just a thought.

  29. I’ve figured it out. A rookie doctor from another country full up to his head with images of how he is finally important. Bashing American paramedics who are “obviously” inferior to those in his country. You’re not worth the effort. I’m out.

  30. Mary Lynn

    After reading original text and all the replies here, I am disheartened. I am both an “old-school” ‘medic, my original cert was in 1991 and a “new” ‘medic. Having let my cert expire by choosing not to renew in 2002, for personal reasons. 3 years ago, I went back to school to be a medic again. Back in 1991 it was a certificate program and while some got their patch and went to work, many of us continued on to get the degree. 20+ years later, the certificate program wasn’t even an option so I have the distinction of having TWO Paramedicine degrees. I also have degrees in Biology and Chemistry, which are relevant here, no? As well as degrees in genetics, history, and English, and am 7 credits away from a degree in engineering. I believe the real issue with education and US medics is that the compensation doesn’t equal the education. Chicken and Egg debate, for sure. If we had more education the compensation would be increased as well, right? I have tons of education and a ream of pretty papers from institutions of higher education and I still make less than the kid making my sandwich at Subway. I have more “education” than many of the nurses that I work with, of whom I have great respect, yet I make less than 50% of what they do. (In truth, it would be generous even to say that I make 30% of what they do.) I would love to get a Masters or a PhD in Paramedicine, however, at my current pay rate, my great-great-great-grandchildren would still be paying off my student loans. To be honest, I’m guessing that medics don’t make a “good risk” to loan officers. How many medics do you know that really want to be, or plan to ONLY be medics? It often seems to be a stepping-stone to something “bigger and better.” Why invest in training a paramedic that has limited intentions of being a medic. (ie. Just a job until: that position on the engine/rescue squad opens, their name moves to the top of the nursing school waiting list or they finally get into medical school? Do I have a solution? No, I wish that I did, but I would like to say that it is NOT that we as medics are happily undereducated. It is more a “nature of the beast” with the beast being the system in which we function. Let it be known, many of us take every opportunity that we can get, or make, to improve our understanding and further our education; frequently at a financial cost greater than our current compensation.

    • It is not the degree of the individual that raises pay, it is the degree of the industry. Nursing all have degrees. Some medics have degrees. The job is still listed officially as vocational labor. It is your peers dragging you down, I would move to a different industry with those credentials.

    • redskullmedic

      Not to attack you personally, but you just listed 6 degrees if i read right. Some are related: chemistry, biology, genetics -others not so much. Why would anyone choose to get all these unrelated degrees and still continue to be a medic making crappy money that is not sufficient to support yourself. It’s not that i don’t think that you have some degrees is just that i don’t believe that you possess all the credentials that you claim to have.

  31. Micah

    I have been a US Paramedic for almost 25 years and been through many levels of extra training. I have to agree with most of what you say, but one thing has been left out. Paramedics fill a unique roll that RNs and other providers have not been trained for and are far to expensive to be utilized for. Unless the people proposing community healthcare are ready to double (or more) what Paramedics are paid, it’s just not reasonable to expect them to get that level of education.

    I don’t believe it would be a good utilization of a RN, but at the same time I agree the base level US Paramedic is not qualified to provide the level of care that real community medicine deserves. Maybe we need to be looking at a new roll, one with new expectations on both sides.

  32. TS

    You have valid point about education. No matter what field you are in furthering education will be beneficial in the long run. However you attitude could not be better designed to put people off. You state that you believe community para-medicine is the future and then you turn around and belittle the people who will be filling the role.

    Your bedside manner sucks doc.

    When you see a patient with a problem do you sit there and tell him he is an idiot and incompetent, or do you educate him on what he could do better?

    I read all the responses here by others, I agreed with many of them. Then you inevitably respond to someone and I stop thinking about what the article is trying to state and start thinking about what and arrogant jerk you are.

    You actually have some REALLY good points. To bad you present them with all the diplomacy of an internet troll. Instead of getting people to think about what you are trying to say, you end up coming across as a complete ass and people end up disregarding all you have to say.

    Education is very important and should be sought out, you sir need to educate yourself on communication because you are your own worst enemy to your own argument.

    • Sorry I missed this before, but I would just like to ask how you can draw a conclusion about bedside manner with patients being similar to having a candid discussion about weaknesses in a system.

      I must respectfully disagree that I am my own worse enemy. I am not trying to advance my position, I am stating my position. Advancing an agenda is the responsibility of those involved in it.

      The agenda was community paramedicine. My statement is US medics are not ready for it and it will take education similar to their international counterparts, not a bunch of comparisons of psychomotor skills and complaining that “street smarts” is good enough.

  33. Marc Peek

    “You are a moron. You ate the only one who has used the word “hero.” Several times even. I think that means you have a perception issue based on faulty information.”

    That’s funny I was going to say the same thing about you. I posted the google link that showed several Civil Service EMS agencies.

    I think you buy your own BS.

    “American TV show portrayal of EMS perhaps. That would explain your poor understanding.

    Actually, if you watch Emergency and Mother Jugs and Speed, they still accurately portray US EMS in a majority of places. Truth is stranger than fiction.

    I guess my contact and involvement with so many US EMS persons leaves me grossly wanting for the accurate picture, after all, 50 or so of the US EMS people I communicate with regularly must be wrong or inaccurately portraying the circumstances to me.

    ” I’m insulting you because I don’t like you and I think your a douche with a superiority complex. No better than the hero complex you refer to.”

    Of course I could just be calling things as I see them? But you will never think that way because you must drink the Kool-aid.

    I must be wrong and stupid, because the only other possibility is you are pretty much an ambulance driver who doesn’t make much of a difference. At least not anything worth paying more than medicare transport wages for.

    If I could ask? Are you on a “tactical team” or some other EMS group that views yourselves as the elite?

    I mean other than your basic agency, which is more political action and propaganda than actual substance?

    I think many agree there is a difference between a superiority complex and simply not pretending people are greater than they are simply so they can feel good about their miserable lot.

    I will suggest you get a trophy for playing though. Everyone who is in EMS should get one. Just like the little kids who play soccer.

    “You talk about American EMS being a failure. Its not a failure. Its changing and growing. Then you don’t provide anything but assumptions.”

    This is laughable, I don’t know what your measure of success is, but it is plain for everyone to see in the last 40 years EMS not only has not made the same progress nursing has, it hasn’t even kept pace with the fire service! Which changes about once every 200 or so years.

    Most US EMS would be lucky to be practicing medicine as it was known in the 1980s. EMS students are not only told, but tested on such concepts like high flow oxygen for every patient. If you read websites like EMS1, their authors are designing scenarios talking about the analgesic properties of oxygen! A few services are now starting to make spinal immobilization either optional or realistic. Forget my word! Look at the national curriculum! Open up the textbooks and read what is inside (If you can read at such a high level) I know what is in them because I review them for publishers. I know the politics behind what is in them. I know doctors who have quit reviewing them because they cannot stomach the nonsense in them.

    Are you suggesting the EMS training agencies are not teaching that curriculum? Because not only could they be closed down, they would be held liable for any damages that their students incurred practicing outside of it! Any instructor who doesn’t know that might want to actually get some advice from a real attorney.

    I am not an attorney, but i can think of several instances like “bash’em with the O2 bottle” that is taught on the street that can land providers in prison.

    If anyone is out of touch, it is you cowboy.

    “You totally ignore the fact that European EMS has as many faults and that there are just as many examples of nurses not knowing what their doing.”

    I don’t ignore the troubles with EMS in any nation I speak of. The big difference is in all of the European and Australasian EMS circles you can actually have a candid discussion about the issues without hurting somebody’s feelings because you didn’t say how great they are.

    Tell me? How much are US paramedic reimbursed for their medical knowledge? If they are not transporting how much does medicare, medicade, and insurance companies pay?

    You know the other industries who are paid for only transport? Livery and shipping.

    The policy makers paying the bills for all of US EMS believe you are a taxi service or a trucking company! (I will accept some local agencies may bill beyond this, but they are not a majority and the ability to actually collect is somewhat limited)

    Honestly you know what I would do if your agency sent me a bill for $1 over what medicare pays? I would hire a lawyer and dispute the debt. Even if I lost, your agency would pay more in legal bills then they would ever collect. I would actually encourage all people to do that until US EMS provides more.

    “You cur are the one with a superiority/hero complex. Just stay upstairs on the floor and read your charts. Out of the media and public eye.”

    I hear there is a $100 bill in the chart! It was a lie there was one under the dressing…

    I am not really in the public eye. Granted sometimes a few thousand people read my opinion here, but smiling for the camera or papers is not my strong suit. My media presence is largely limited to scientific journals, but somebody must be reading them because they keep citing them.

    Truthfully though, it just a bit or elitism I will indulge in, I can’t wait for the academic year to start again, because the discussion are with much smarter and more in touch people than you.

    “Hey maybe that’s your problem. you became a doctor and everyone forgot about you. You are no longer the “hero” on TV and news.”

    That could well be. Somehow I doubt it.

    “Whatever your problem, clearly your institution time leaves much to be desired.”

    The only thing it leaves you to desire is for me to tell you that you are an important and able member of the healthcare community. It is not going to happen.

    I agree EMS is an important part of healthcare, but US EMS is so behind and wanting that it just cannot step up to things like community paramedicine in any large scale capacity or recognize its full value.

    Did you know in Columbus, Ohio, it was recently suggested by a politician that because transport times for the Fire based EMS were so short that they should do away with paramedics entirely because he had some Canadian studies that showed there was not a mortality difference with ALS?

    Do you, as a civil service employee, think that could be troubling in a political climate where the public views government workers as over-paid and entitled?

    Because I would worry about that. Especially if I worked for a service with less political involvement or it became the trend.

    Of course, what do I know, my educated world view clearly impairs my judgment.

    • I’m not even sure what all that rambling was. I corrected you. I never said the only EMS service that was civil service. I said the only service that isn’t fire based.

  34. Dave Mendoza

    There are some salient points; yet I have to agree with the general consensus; doctor, although your points are well articulated, you have this air of having ‘been there, did that. And therefore I speak with constructive objectivity.’ I have been a paramedic for over 23 years; and an EMS provider/professional for 27 – starting on the streets of the Bronx and working throughout NJ as a paramedic and an EMS Educator. However, I’m not making this post to give you my resume. I am making this post to respectfully agree with your overall point of educational foundation in EMS. However, I can’t help to feel the slightest bit offended at your generalizations. As you posted, you began your medical academic pursuits foundational through the fire department that “started my career as a firefighter who did not want to do EMS, ever. I was forced to become an EMT, I was forced to become a paramedic to work on the fire department. At no point in time did I ever want to do those things.” So, your assessment of EMS in general is out of a sort of disillusionment, maybe even regret to have been forced to do something that you didn’t want to. However, and I can only speak for myself. I pursued and educated myself in a career in EMS by my own volition. I don’t want to loose site of the over all topic which is professionalism in EMS which should be rooted with an academic foundation. This whole discussion was predicated on the idea that the community paramedicine concept is flawed because of a variety of reasons; the most obvious is the undereducation of paramedics to adequately perform this form of patient care. Albeit, this idea was founded on the idea of a needs assessment of a patient to decrease readmission to the hospital; and with assistance and additional education (being provided at the college level, taught by masters level and PhD educators). Myself and other ‘EMS professionals, tirelessly work to educate other ‘medical professionals’ and ourselves through a variety of venues. And we, who continue to professionalize EMS through education are hopeful that our campaign continues to have EMS/mobile health care recognized to stand shoulder to shoulder with our nursing, medical and other allied health partners. Excuse the rhetoric, but this should not be a shit slinging match. But at the same time, please don’t try to sell me that snake oil that ‘I am not anti-medic, actually, myself and many would claim I am quite ready and able to help medics.’ On the contrary; your statements are not only antimedic, but anti EMS with the sentiment that we are self important, disillusioned uneducated glorified taxi and bus drivers . This eureka moment that you had that prompted you to pursue medicine, I would argue is predicated on your getting into the EMS aspect of your job to begin with. But as your said, it wasn’t your choice. If it were not for as your claim, your superiors indenturing you to learn the EMS aspect in order to keep your job in the fire department, and you moving on to bigger and better things with EMS as your spring board, I would take your assertions about EMS professionalism with a little more credibility. Many of us true EMS professionals that keep the march of our betterment going would be better suited to comment. I think we all can agree that there are disparities in training for EMS professionals. And perhaps it is time that the uniformity of the mobile health care (as we continue to professionalize and rebrand ourselves) training gains more traction and is formalized through the a degree process throughout the country. There are many supporting, and mitigating circumstances to this. Maybe we should stop pointing at the flaws and start ‘enacting’ the solutions – I’m sure doing my part.

    • Mr. Mendoza,

      Perhaps I did not focus on the articulation nor articulate it properly, but at some point I did recognize the significance and value of EMS.

      I can appreciate your call to action, but I must confess that after many years of attempting to do my part, both in the field and in the classroom, the “we can do no wrong” mentality of many of the rank and file, in my observation particularly evident of providers who started after 9/11, is the major thing that needs to change to effect any other changes.

  35. Dave Mendoza

    Again, let’s not make this a shit slinging match. You and many of us have passion for what we do; irrespective of how we got there to begin with, or where we ended up, the associations we have made, the experiences that we have, the people whom we’ve taught. You make some very valid points. I sell my own form of snake oil, I suppose. Maybe the truth that stares us in the face for which we ignore, stings all the more when pointed out to us by other others.

    Best of luck in your endeavors

  36. Dave Mendoza


    again my friend, you are right. The pre-requisite educational pendulum swings very wide for EMS. There should be formalization; there should be grounded pre-requisites. our profession will only be [that], if it is formalized and cultivated academically. Other professions around us are raising the bar to have academic foundation as a prerequisite to even apply (i.e., police departments). And I would like to think that the basis of some of these courses is not only to have a scientific understanding of process, but to have an understanding of how to problem solve. I had an idea that when I took higher level course in college such as organic and molecular chem, that it was not only to have an understanding of how certain process occur, but to be faced with a product and trace the mechanisms how they occurred. EMS in many regards is like that. You are faced with a acuity and you have to know fundamentally about the problem in order to address it.

    Doctor, please take no offence in my original post. I would love to speak to you personally. You seem like a dynamic and passionate individual.

    Again, all the best and thank you for your thoughts.

  37. Micheal H. McCabe

    “Community Paramedic Program.”

    What the fuck is that?

    Oh, I’ve read the published papers. We’re going out into the community and try to divert some of these folks that are using the ER for primary care. We’ll try and hook them up with appropriate community resources so they aren’t dialing 911 for every sniffle. We’ll make sure that granny is taking her medications as directed and won’t end up back in the hospital when her blood sugar soars. Maybe we’ll go around taking blood pressures and make some referrals based on what we observe. Throw in a few “well baby” visits, some patient education, and some “free” flu shots for whichever group is especially at risk this year.

    There might be some “expanded scope.” Medics might be able to order some basic lab tests. Maybe those classes I took thirty years ago in basic wound repair will come in handy after all!

    I doubt it.

    Hell, most physicians won’t even put in a few stitches any more. They hand that off to whichever surgery resident drew the short straw today. Likewise, with everybody playing legal defense these days, any labs or tests I might perform, order, or interpret will (at best) get repeated when I kick the problem “upstairs.” Just like the 12-leads. Just like the “stroke kits.” Just like the trauma-scores.

    On the plus side, I can’t think of any red-blooded American paramedic that really wants to tackle patient education out in the ghetto, or the trailer parks, or the rural sticks. The nurses don’t like it? Great! I didn’t want to waste my time PREVENTING illness; I’m here for the cardiac arrests and the multiple traumas, and those calls “worthy” of my advanced training!

    At one of the services I work at, we can’t even get medics to take inter-facility transfers without complaining about being a “transport bitch.” We’re going to ask these same prima-donnas to counsel a diabetic about foot care?

    Any argument about the qualifications of an American paramedic to provide these services ignores the fact that we’ve created a culture that believes its own press. We’re “life savers” – racing to the scene in our shiny medical chariots and providing top-notch technical interventions to people who are already dead or dying. It doesn’t make much difference in the end. People who are dead tend to remain so, despite the occasional return of spontaneous circulation.

    Folks, I AM an educated man. I’ve got the degree. I took the same undergraduate classes as the doctors and nurses. I graduated with honors. I took the paramedic classes when Reagan was president. I’ve worked non-stop in EMS for almost three decades. What it still comes down to is that the best thing we do for our patients, regardless of circumstance, is simply “TAKE THEM TO THE HOSPITAL.” I’ll do some of what I call “advanced first aid” in the meantime, but definitive care isn’t something I’m equipped to do in the back of a van.

    If we’re going to change the very nature of what EMS does, we need to start by changing the culture. That means different educational requirements, different training priorities, and different public expectations. Quit beating up the messengers.

  38. Medicinenz

    In New Zealand Paramedicine has moved to an education based process: volunteers generally complete a diploma in ambulance practice that givens them the scope to practice as an EMT. Paramedics are now generally only paid staff or ex staff. This level requires a BHSc of Health Science in Paramedicine. Once completing the degree you will usually spend 1-2years as an EMT before challenging to Practice as as Paramedeic. Beyond that Intensive care paramedics complete a post grad certificate in critical care. For Intensive care paramedics with more than 18months experience they can complete a post grad cert in advanced resuscitation a that allows them to use RSI. In the post grad frame work their is also a community medicine paper that is 12 months long all of these post grad papers work towards a Master in Heath Practice: Paramedic Practitioner it is likely in the future that this may be the level of an ICP. NZ is awaiting for the government to register paramedics. Paramedics currently practice with no medical contact just using clinical practice guidelines. The scope currently extends to a number of procedures that can be done such as shoulder relocations using fentanyl / midazolam or ketamine and are not required to transport in an ambulance post some procedures but can reffer to medical clinics for or to the patients own gp. Although still using standing orders there is a great deal autonomy especially to ICPs. I agree that paramedics need formal education especially as the future direction will be in providing treatment with out transport.

  39. Vicki Jones

    I honestly did not read through all of the 90 some posts above, I did read through some. Forgive me if restate anything from above.

    As a paramedic in Michigan, who is also working on a my MPH, I agree that the mindset of EMS is the holdup. We complain about the lack of loop closure, whine about wanting to know how the patient turned out, and loathe physicians who will not bother to even look our way. But the truth is, we can do so much more than what we are doing.

    We can close the loops by getting off our own butts and requesting the information from the hospitals and calling the PCP. We can do our own research and our own follow up to find out what it is that we need to improve upon. We should be bombarding insurance companies to be paid appropriately for what we do, and actually give the community the services they deserve. We should demand that EMS degrees and move into the professional world.

    And we should have more respect for physicians. We should start out by NOT making physicians suffer EMS “professionals” who do not speak using appropriate medical language and who do not know how to give report. I wish the words “um” and “I was so close that I didn’t want to do it”, should be banned from the ER.

    I couldn’t agree with you more, EMS would move forward if we would just get out of our own way.

  40. John

    The “Medics vs Nurses” debate is a futile one, for the simple reason that the roles are entirely different as they relate to patient care. First, lets get one thing out of the way. If you, Sir, are indeed a physician, I must say that I am a bit surprised at the grossly rudimentary grammatical cadence that your blog carries over to the occasional visitor to your blog. One would think that an MD would be capable of crafting not only a methodical, systematic flow to bolster his take, but an intelligently worded and punctuated one at that! But I digress. What you fail to comprehend is that anyone can spend the time going through the motions to achieve the so called prestige of that slip of paper known as a “Degree.” Anyone can sign up at the local community college and smash through a few semesters of field-relevant course content, and anyone can pull up a chair in front of a few Bunsen burners in a Bio-Chem classroom and perhaps sneak a few occasional wayward glances at their classmate’s Scantron during Finals to ensure matriculation onto the next portion of their journey through education. And anyone with a set of parents willing to lay down the 60 grand a year for a few years of Med school will ultimately persevere, if they possess the dedication. But, indeed, the old adage rings true: “C’s get Degrees.”
    The true core of this discussion can simply be boiled down to the very elementary fact that, regardless of purported status, the skill level of any medical professional is only as good as the common sense, intellect, and continuing education behind the badge, scrubs, or white coat that they wear everyday. I am a Medic, as you may have assumed, and I hold Doctors and Nurses in the highest regard. Again, however: That all depends on which particular Doctor or Nurse I happen to be dealing with at the moment! There are those Nurses who absolutely will put me to shame in regards to their vast understanding of patho-phys. And then there are Nurses who are Nurses simply because they made it through Nursing school. The same is true for Physicians, and there are some absolutely horrendous Paramedics currently practicing. I could spend hours highlighting topics such as the fact that almost all Nurses cannot intubate, and that alot of Docs couldn’t perform the skill themselves without the Glidescope. I could point out that Nurses can give Antibiotics on a drip, but they’ve never drilled an IO into a patient’s tibial tuberosity on their living room floor. I could spend time touching on the fact that Nurses are simply an extension of a physician, and work as a Team, instead of solely operating as the Leader on scene, before any cleanup or packaging has occurred. That would be counterproductive. EMS is a team effort. Its about the patient, period! Regardless of “status,” an individual is only as good as their passion for patient care, and their inherent common sense. The entire basis for this discussion is meaningless, and surprising, coming from an alleged physician. Perhaps the reasoning stems from some deep seeded insecurities. Perhaps my spending 20 minutes typing this stems from the same. Regardless: its about the patient, and these three professional roles can work beautifully together for the patient’s sake. Thats all that matters.

    • Let me just address the whole grammatical/logical flow issue here, since it seems to be the most important aspect of the comments.

      1. This blog is for my thoughts. If you don’t like my thoughts or the way I think them, you don’t have to read it.

      2. In order to give some rudimentary level of proofing, I actually write it in word, with both the grammar and spell check on. Because I don’t have all day to worry about what I write here, if the line turns green, I just accept whatever change is suggested. As a personal writing style, I like to liberally use asides.

      3. Thoughts are written in the order I think them, I spend a lot of time with technical writing and I am just not remotely interested in making this an exercise in technical writing. That defeats the whole purpose of relaxing.

      4. Sometimes I am typing on a computer which is not set to English as the primary language. That really messes with the spelling and grammar, but I do try to make major corrections as time permits.

      5. It was recently brought to my attention there is a major formatting error when I copy and paste things from word to here. I have tried to rectify this in later posts.

      6. If you find my thoughts too complex and hard to follow, I suggest something along the lines of “see spot jump.”

      7. I don’t even remotely consider this post the most important post I have made. What I write here is certainly not the most important contribution I make on a given day. If this is the only post you read because you want to hear how great paramedics are or are not, there must be a 1000 or so blogs and webpages you might like better.

      8. The number one thing I hear about my published works is “that is so detailed I have no idea what you are talking about…” If order and complexity is your thing, I suggest you start reading those instead.

      9. The software here tracks the IP address as well as the nation and posts that were viewed as well as how many and what posts were viewed by various viewers. So when you come here and rant on one post, I know that you have no clue and the only reason you probably offered a reply is because you feel somehow slighted I did not tell you how wonderful and important you are.

      News flash, you are not wonderful and important. I am not wonderful and important. We are just drops in the ocean of humanity. If you want to be told how wonderful and special you are, I strongly suggest calling your mom.

      10. The only replies I do not approve are imposters and I do my best to respond to everyone who makes a comment, but I am rapidly considering changing that guideline to only approving posts which I deem intelligent. That means most of you spending time writing about how hurt your feelings are will not only be wasting your own time, nobody will be reading your dribble here either.

      Feel free to run this through your grammar and spell check to make sure it meets your standards.

  41. M.D.

    As a emergency room physician who worked in EMS throughout my university years, I sympathize and understand your perspective to a degree. However, I would NEVER degrade any replies from fellow human beings (let alone use the term-dare I say-AHPs) in the belittling manner you have. I actually conduct myself in the manner that those initials M.D. attest to-professionalism, scholarly debate, and the ability to be above senseless name calling.

    That all aside. EMS is ingrained with the idea that all calls will be Priority 1, and anything other than that is a waste of time-just as many of my colleagues in the ED regardless of training or scope will scoff at the obese patient with stage 4 saccral ulcers. The culture of entitlement runs rampant in every aspect of healthcare: I can only think of a handful of instances where nurses treated even the custodial staff as little less than automatons. I have seen Endocrinologists verbally destroy their dedicated nursing staff for not putting the correct pink hearts above their “i’s” (so to speak) and quite frankly the disrespect and arrogance in healthcare is the bane of my existence.

    Like yourself, I agree that the ideal model of Paramedicine in today’s changing healthcare field is being hindered by the public service side of EMS. In addition to meager wages and a culture that promotes “street smarts” over concepts as definitive care or academic pursuit. Quite frankly, there are more than a few “whackers” that would prefer to throw the lights on and save the day as opposed to an IFT. But come to one of the many EDs I have worked in and you will see the same attitude in nurses as well. The same can be said of lawyers-the law degree is the end sum, not the beginning of the career. Hence we have those rather colorful ads on television espousing various attorneys-at-law. The fact of the matter is BOTH Registered Nurses and Paramedics are woefully stuck in very cliquey mindsets-and why I always look for the ED Technician, Nurse Practitioner or Physician’s Aide when it is time to speak about the human being we are treating-or as the RN’s say “patient” and Medics say “victim.”

    I think an agency with PA’s/NP’s as supervisors, Degree Paramedics and Registered Nurses in an integrated system would do wonders for preventative care within a community. Even better would be a “BLS” variant within such agency with Basics and CNA’s under an RN’s direction. The two aspects of care have alot more to learn from each other than they realize-and I have encouraged that team building every place I have gone since medical school saw it fit to issue little old me that coveted coat. And, if the nurses could talk the EMS folks into getting a degree that would be wonderful-so many brilliant and driven young men and women settle for so much less than they are capable of simply because they are trapped within a very confused career-just look at the evolution of our radiology technicians within the past 50 years.

    Thank all of you for reading this long-winded and doctor approved PSA. Please remember to have an apple a day, it truly is our repellant.

  42. I appreciate your perspective, and unfortunately must admit that my patience for “providers” who claim how little I know and how incapable I am is at an end. If this is the only post you have read, you may not have found what had prompted this rant, but it basically comes down to “paramedics are the true masters of resuscitation and doctors outside of emergency, including anesthesia, don’t know as much and are therefore less capable.”

    Attempting to educate this view with scholarly debate proved to be futile.

    While I take great pains not to manipulate people or make them feel inferior in most cases, I do have my limits and I think the problem you describe as the bane of your existence is going to be the status quo in medicine and healthcare for the foreseeable future, particularly in the US, where there is a pervasiveness of believing everyone is equally knowledgeable and capable, sometimes even more so than experts.

    It all goes back to the golden rule. If (collective) you do not want me to tell you how inferior you are, don’t do it to me. Perhaps even a bit of “if you cannot take it, don’t dish it out.”

    Without undue modesty, I am fairly skilled in my undertakings and that does include reminding people exactly where they stand. If that makes me less doctor like, or less of one, then I must be counted as one of many. (particularly among surgeons). Strangely enough, the only place I find such behavior is with the internet’s keyboard commandos.

    From an introspective point of view, maybe working in a system where doctors who are also scientists are held in the highest esteem, I have subconsciously come to expect a higher level of respect despite my best efforts to get people to not do things like bow before speaking to me or being afraid to speak to me. I will put more thought into this.

  43. Without apology.

    I gave the comment some more thought this morning and have decided I am not really inclined to be concerned with admonitions from anonymous physicians about what it means to be a physician and the values there of.

    Furthermore, I do not recognize people with less education than a barber, no matter what sort of medical procedures they provide, as an advanced healthcare provider in any sense of the word.

    Moreover, I took the responsibility for my opinions and positions signing my name, If you cannot do the same, I stipulate your credentials and opinion are without merit.

    • No, no they aren’t. SOCOM guys are, but your normal run of the mill Army medic is lucky to be issued a NREMT Basic when being returned to civilian life.

      They cant manage a medical patient for shit, much less geriatrics or peds.

      When you take care of young people who are in the best shape of their life, its not really a challenge.

  44. Jenna

    I completely agree with this post. The main factor Is lack of education; a premedic/ EMT can tell you the facts but not the “why” behind it. The “why” is something you learn when you engage in higher education, not just technical school. As a practicing nurse, my judgement always comes down to what I learned in nursing school. In nursing school we learn about the “why” behind it and thats why we are able to follow doctors orders because it makes sense to us RNs. This whole debate is more than knowing the macro of it, it’s about knowing micro of it.

    It’s simple.

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