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.