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.

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

  1. Mike P.

    As long as the EMS model for delivery of care stays as it is currently in the U.S. (Specifically protocol based with on/offline medical direction) then there truly is no benefit to having higher/better educated medics. In all reality, nurses really don’t need all their education either when functioning under immediate direction of a doctor. Why? Because it doesn’t matter what we know or don’t know, macro or micro. What matters is a doc wrote an order and it’s the nurse or medics responsibility to carry it out. For that, all you need is technical proficiency in skills performance.

    Everyone that’s written a comment on this has one thing in common. That is that we all take our jobs and ourselves way too seriously. The overwhelming majority of patients need nothing more than some pain meds and antibiotics. Whoopty-freaking-do. I’m not certain, but I’m pretty sure my 4 year old could manage the dolling out of pain meds to people who have ouchies. Not sure how having 4 years of higher education turns that into such a grandiose medical procedure. Spare me the “what-ifs” and the “this one time” stories. That’s true to any trade regardless of level of education.

    EMS folk want higher pay…for doing what exactly? How many patients receive “ALS” treatment on any give shift? And of those, how many actually show a demonstrable improvement in outcome that wouldn’t have otherwise occurred had they not received it in the field, 10 minutes sooner than it would have taken them to drive themselves to the hospital? Probably less than 1% of our patients. We truly are a taxi service. We just can provide medical stuff that other cabs cannot. Again, not sure how a BS equates to deserving more pay for driving a taxi.

    Would more education benefit patients? Yup! But only if the patients are the ones being educated! No amount of education is going to change the way IVs are started or make a breathing treatment more beneficial. And regardless of how highly educated we are, we’re still following the protocol. Back to my original point, the model for delivery of care has to change. For all the higher educated medics posting here, every single one of them render the same treatment following the same protocols as the lower educated medics. And they do it for the same lousy pay. Sorry nurses but you all aren’t any better. And you too ER docs. No life threatening emergencies=management of symptoms and discharge with orders to follow up with a primary care doc, which none of them do resulting in return trips to the ER via ambulance. Hooray for making a difference. Anyone capable of reading can look at discharge paperwork and see what someone was diagnosed with and ask, oh it feels exactly like it did yesterday?

    Does higher education have a purpose? Yes. Absolutely. But until the delivery model changes its purpose is not in EMS. Mr. New Zealand…sounds like they’ve got it right over there.

    As for CPs, you said yourself that they don’t do anything families members couldn’t do themselves. Remind me how our higher level of care/education makes us less competent to do BP checks than family or caretakers? Make sure meds are dosed and administered properly? Refer them to PCPs vs EDs for chronic/dx problems? That’s just plain common sense. And for all the “special and specific education” nurses and doctors, according to you, receive…y’all do an absolutely crap job at informing and educating your patients on what meds they’re supposed to be taking, why they’re supposed to be taking them, what will happen if they don’t, when they’re supposed to be taking them, and making sure they realize that antihypertensives are not like antibiotics that, ideally, once are finished the problem is gone. Yet here all you higher-ups are sneering down on medics for being undereducated but doing the work that should be done by the higher educated who want nothing to do with the work that falls to the medics. We do the best with what we’ve got. Had there been a degree option for my training I’d have absolutely chosen it. But there wasn’t.

    We want change, higher pay with better benefits and more respect within the healthcare field. It will come. But it’s going to take decades to get medics the higher education necessary to achieve it. We can’t all of a sudden require all medics to have X-degree. There would be an immediate cease-to-exist of EMS if that happened. It’s going to be changing the education standards for all new trainees, and then waiting patiently for all the more senior medics to go away for there to be any chance at change.

    That brings about a whole new beast which has also been touched on. All our most current research and treatment that was implemented yesterday is already years out of date by the time we implement it in the field. Makes that fancy degree pretty moot 30 years later when all you learned is in an antique store.

    Quite literally, every aspect of EMS has to change before we get what we want. No amount of typing online is going to bring about change. Mr. Doc Author of this blog is correct. Mr. Doc Author may also be a fantastically cool dude, but dude…your writing portrays you as a pompous ass.

    Along with EMS changing, the rest of the healthcare community needs to have an attitude adjustment towards EMS. We’re not advanced clinicians and I wouldn’t expect you to treat us as such. But what we are trained and educated in we know as good as anyone else. Don’t mistake education for intelligence and don’t mistake the uneducated as unintelligent. An almighty RN told me just two nights ago that my patient couldn’t have an arterial bleed in his hand because there are no arteries in the hand. So much for a nursing degree producing superior clinicians. I’m sure she can place a foley and read labs better than I can though. Granted, when the normal values are listed right next to the patients values that really isn’t a skill anymore and doesn’t require education beyond basic reading. And don’t try to tell me how you know what all the values mean and what to do about it. I know you are educated in that. My point is that it doesn’t matter that you know it because it’s ultimately a docs responsibility and decision what to do about it.

    As for the hero complex… It’s not just EMS that holds themselves in high regard. It’s everyone in anything emergency. As far as I’m concerned, heroes don’t exist. I’m not a hero and anyone who tries to tell me otherwise will promptly be shot down. We chose to do our job and when we actually do it is not heroic. Quite frankly the situations from which “heroes” are made are fucked up and nothing any human should ever have to endure. That doesn’t equal heroic. That said, the way you smeared the guy talking about the 7 y/o female who coded is so fucked up you should be publicly bitch-slapped and humiliated by the masses. His emotional response and anguish of that situation is perfectly normal. Shame on you for that! How quickly you’ve forgotten what it’s like to deal with such tragedy. Must be nice to write snide remarks from high up in your lab amongst the educated elites while looking down your nose at us poor, uneducated and pitiful lower-middle class. Keep your involvement about textbooks and published works to yourself. It means jack shit when you’ve long-forgotten what it’s like to be spit on by the very group you joined. I hold no animosity to the title or position, only to those who hold those positions and consider themselves better than the rest.

    I’m well aware that this is your blog and your opinion and I can read elsewhere to find people who will praise EMS. You’ve made that quite clear in damn near every comment. You can do no wrong and you’ll likely have some chiding remarks for all I’ve written and will probably mention how you never claim to be omniscient yet in the subsequent paragraphs will outline how and why you are, in fact, all-knowing. Save it. Had you kept your damned mouth shut after your original post you’d have much more respect from many more people. Now everyone just finds you a narcissistic prick. Check your ego. That’s all I hear you telling everyone else to do yet you surely haven’t left yours at the door. You stand on the platform of “telling it like it is” and “if you don’t like then leave” yet heaven forbid someone do the same to you! For claiming to be favorable to medics and trying to have a scholarly discussion you sure spent a fuck of a lot more time making us feel like idiots. Counterproductive hypocrisy.

    I don’t need a pat on the back for doing a good job so leave your remarks about that out of it too. I’m well aware we don’t know jack shit and I’m apparently more aware than you that until the mantra changes from “you call we haul” there’s zero benefit to upgrading our education standards. Better to start it now so we’re ready to adapt when that change comes? Yes. But until then, don’t pretend like being higher educated is going to better serve our patients. So what if we know the chem and bio and patho phys behind it all? It won’t change what we do in the here and now until we get away from automatically transporting every patient.

  2. JamesS

    Mike P, you preach the truth brother. As a lowly Critical Care Paramedic of 15 years I debated for awhile about being a nurse for higher pay. Instead i am pursuing my Bachelors in Emergency Medicine because i still enjoy the challenges of Street Medicine and I want to see Licensure for the Paramedic profession. Any good seasoned medic in a high volume system can tell you in a truly life threatening situation there is no time to consult a Doctor. Thats why we need Paramedics to have BSP(Batchelor of Science in Paramedicine). This is the future. Performing sutures in the field and prescribing medications will be routine. I wonder if the Doc is aware that Iatrogenic death is the 3rd leading cause of death in the US behind heart attacks and strokes? Medicine is Dynamic not Static. Alot of the “education” recieved by most MDs in Alopathic medicine is not only outdated, its straight up killing patients.

  3. Andrew

    This article is fascinating and we are discussing it in my professional orientation and legal foundation class that I am taking for my B.S. degree. Can I get your name and credentials as my classmates would like to know who wrote this article.
    Andrew (AJ) Paulson NRP, LP

  4. Marvin

    I got enrolled in an EMT program after getting a B.A. in Biology. My final goal is to get my masters in Epidemiology, but I still want to have the knowledge on how to treat patients. I’ve seriously considered switching over to nursing instead of finishing as a paramedic. This article was very informative but if any knowledgable person on these professions has any good advice for me I would be more then happy to receive.

  5. Caleb Morris, NRP

    This post really needs no addendum but I do feel it is worth adding that the US paramedic is NOT homologous. There are several university based bachelors programs that DO produce practitioner level educated paramedics. I graduated from one and I absolutely can tell a difference in my interaction with physicians and nurses vs those graduating from certificate programs. Unfortunately, my state makes no differentiation in practice between degree holding and non-degree holding paramedics so my clinical practice is thus restricted. My degree included all but 2 courses required to attend medical school (I took them as a post bacc. along with a couple electives) and goes far beyond a BSN’s basic science, physiological, and anatomical material. That said, even quality B.S. paramedic programs need more clinical experience and we need it in two places:
    1. On HIGH VOLUME ambulances with vetted quality preceptors.
    2. Paired with a physician in the ED, ICU, and OR.

    I don’t see those resources being available to many programs and where available, I see them fought for with great difficulty. Paramedics as a whole in the US need to get aggressive and persistent representation in D.C. to ensure quality education becomes mandatory.

    To any physician reading this in the US: YOU are capable of assisting in this needed development as medical directors. If you don’t like the quality you see in prehospital providers then do something about it!

  6. Randal

    I recognize that this is an older post but I would be remiss if I were not to point out the gross error in casting such a wide net when referencing programs beyond the States and colouring them negatively. What is an even more egregious oversight is to have not looked to the north- paramedics in Canada have been going through degree programs for decades. A BSc in Paramedicine is offered across the country. They have their own license and many provinces are moving towards complete autonomy. Those that have yet to move beyond this have only done so because of stalled union negotiations. They also have their own professional associations. The remark regarding Critical Care accreditation was out of line- to reach the point of being eligible for CC training one has spent between 3 and 5 years in the classroom, and two years in the field for a total of 5 – 7 when entering a 5 year critical care licensing program. Ten to twelve years of study is surely not something deserving dismissal! In the grander scheme, I posit the following: why is it that Americans are far more preoccupied competing and necessitating the placing of one into rank and file–only to bitch ad nauseam–to determine “the best / who’s better”? Rather better to do ones chosen job admirably without feeling inadequate, without belittling another certification / degree / licensure / uni vs college- isn’t it then…? And leave the petty obsession with the totem pole to politicians. Not like your’s get anything done, ‘eh?! Hopefully that latter bit garnered a chuckle. Cheers, friends!

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