Reform Paramedic Education!
Once upon a time I had a critical care paramedic as a trainee. This individual had been in EMS for approximately two years, and was an FTO at another local service. I was very surprised to learn of the providers complete lack of knowledge base and experience. Get ready for my list. It's scary. They had never run a code, never performed CPR, never intubated in the field, never seen an RSI performed, never used an ART line, never physically touched a ventilator, did not know any ventilator strategies, could not calculate medication dosages, was very ignorant of correct medication dosages and indications, had no idea of what normal CBC or CMP values were, and could not interpret blood gas values - just to name a few things. Was this complete lack of knowledge their fault? They had recently graduated from "CC" school and informed me that most of their exams were open book, and that their critical care course did not even have a final exam - all they had to do was show up. The educational system had completely failed them. The technical colleges got their money, and they were fine with pumping out an awful product - a "critical care paramedic" who would surely kill someone. When will enough finally be enough? We have to reform paramedic education from the ground up and finally gain the respect that so many of us desire from our colleagues in healthcare. We not only owe it to our profession, we owe it to our patients.
"Zero to Hero"
We have colleges that put on "zero to hero" courses (a term that was actually used by a college) in as little as a year. This included one semester for EMT, a one semester "accelerated" paramedic course, and then capped off by a two week critical care paramedic course. The individuals that came out of this program were anything but "accelerated" (I know because I trained a lot of them after graduation). They were robbed of an education and had no idea. The problem with paramedic education, is that there is barely any education to be had. Even the regular two semester paramedic course is not nearly enough time to gain the type of experience a paramedic should have when they leave school. Technical colleges are not trying to advance the educational experience, so it is up to us as providers to stand up and call for reform! If we stand by and do nothing, nothing will change. There are two groups of people in this case. The first group is screaming that we need more education, and the other group thinks what we have now is good enough. If you are of the latter opinion, my hope is to get you screaming that we need more education by the end of this blog. First I will talk about what type of education we need, and then I will talk about what this education will do for us as a profession.
Prior to enrolling in a paramedic course, it should be required to take EMT and AEMT first. EMT teaches the basics of patient assessment, scene management, patient populations, several medications, basic trauma skills, basic airway management, and CPR. Important stuff! There is not nearly enough clinical time in EMT, but the skills that are learned there are the foundation of EMS. In all, the EMT curriculum it probably adequate for the learning curve it takes to go from knowing nothing about EMS, to being able to care for patients at a fundamental level.
In AEMT you learn so start an IV and an IO, you hit on fluids 101, add a couple more medications to your scope, learn IV medication administration, and a little more anatomy and physiology. This program is good, but it's not used to its full potential. If it were a prerequisite to paramedic, paramedics would not have to focus on getting IV sticks during their clinical time. This would allow them to focus on assessment and treatment. A lot of classroom time in AEMT is spent refreshing on things learned in EMT. And then we repeat again when we go to paramedic school? Once skills like IV/IO insertion and medication administration and learned at a lower level, they should be left out of testing and clinical evaluations in paramedic school to make room for new information and forming the provider into a better clinician. I hear the following type of situation over and over again from paramedic students:
Student: We had a really sick cardiac patient in the ED today during my clinicals!
Me: Really? What did the ECG look like?
Student: I'm not really sure, but I started the IV and put the 12 lead on. The doctor said it was a STEMI.
This paramedic should have been learning about the ECG from the doctor, discussing the doctor's thoughts on treatment, and the logistics of care - not doing the work of a nurse/tech. Placing an ECG and IV should be second nature to the paramedic student (if they were required to take AEMT). Requiring the paramedic to complete both of these courses before starting paramedic school would build a much needed fundamental knowledge, and give the basics some time to settle in. Since testing would not be done on IV/IO in paramedic school (since it wastes valuable clinical time), more IV/IO practice should be required from the AEMT to ensure mastery. It would also be ideal if the EMT and AEMT would receive more clinical time, and therefore, patient contacts. Now that EMT and AEMT are completed, what's next?
Prior to starting paramedic core classes, the paramedic should take the associates degree core classes. These would include:
Gen Anatomy & Physiology
Advanced Anatomy & Physiology
Life Science Chemistry
And any needed electives (if they were needed for degree completion). If you stop and think about what we are saying by allowing paramedics to graduate without these classes, we are saying that these classes do not apply to the paramedics job. We are saying that it is not necessary for paramedics to fully understand anatomy, physiology, microbiology, chemistry, math, english, critical thinking, psychology, or medical terminology. We are not ambulance drivers! We need to understand these things! These are skills that a paramedic must use in their job, so why are we allowing them to graduate without the necessary tools? Why it is even a choice? Imagine how much more a paramedic would get out of their class and clinical time if they already had these prerequisites completed. I'm going to repeat that. Imagine how much more a paramedic would get out of their class and clinical time if they already had these prerequisites completed. It would be like night and day. They would understand procedures, medications, and disease processes much better. They would be able to communicate and understand medical terms from other healthcare providers with ease. They wouldn't struggle with medication math. They would develop critical thinking and psychology skills to not only deal with people better but patients as well. Microbiology would prepare them for their future. Think this sounds like too much work so far? Just remember that nurses, respiratory therapists, and even medical assistants have to take these courses before their core medical courses. How much more so should a paramedic - who works with a great deal of autonomy - understand these things?
In year three the paramedic should be heavily involved in classroom learning. This would include simulation and practical skills relevant solely to the paramedic curriculum. The paramedic would learn from a paramedic textbook like they do now, but more information would need to be added to the curriculum. Paramedics are still being taught as if all we do is run 911 calls. When I was in paramedic school, I barely knew what an interfacility transport was. Then I came to find out that interfacility transports would be a huge part of my job! I had to learn lab values and all kinds of medications that I never even heard of in paramedic school. EMS is coming to a point where everyone will be doing interfacility transports. How much longer until this is included into the schooling? Paramedics should know lab values and be able to treat their patients based off of these interpretations. EMS is evolving. Our scenes are not just people's houses or ditches by the roadside. Often our scene is a hospital ED that can no longer handle the patient. A scene is a scene. Every call is a scene call. Paramedics need to be taught to interact and communicate with doctors who stress to them critical lab values and should know how to treat the patient accordingly. iStat analyzers are also being more common on the ambulance. Soon, paramedics will be routinely drawing labs in the field to help guide treatment. There are also skills that are being added to ambulances all the time. Think of the strong push for point of care ultrasound (POCUS). These things take time to learn, and right now the paramedic class time doesn't allow for it. Why? Because we are wasting time covering things from AEMT and things we should have learned in associate degree prerequisites. We are also trying to cram our clinical time in over the same year as well! How absurd! How can we fix this?
After all classroom time is completed, ACLS, PALS, NRP, and a trauma certification have all been obtained, the paramedic should now start clinicals. Our clinicals need a complete overhaul. The current way of doing things is not working! Right now, paramedics spend their time trying to get a certain number of each patient population. X number of peds, geriatrics, OB, psychiatric, respiratory, cardiac, etc. They mostly do this in the ED, doing the absolute minimum to count an "assessment" (going in and asking the patient a few questions so that the nurse will sign off on their paperwork at the end of the shift). Paramedics also chase skills like IV, IO, and medication pushes. I have talked to many paramedics about their experience in clinicals, and the VAST majority tell me that it turned into number punching and skill chasing, and that they were hoping for something much more from the whole experience. What can be done to resurrect this dead pastime?
First of all, extend the amount of time the paramedic is in clinicals. There should be a one year minimum where the paramedic just focuses on clinicals. They would meet in class once a week to study the subject of the clinicals they are involved in that month (if in OB rotations, study OB), and spend the rest of the time in clinicals. It is important to note that the paramedic would in these extended clinicals to learn how to make patient care decisions, not just perform skills. The paramedic, therefore, must shadow a clinician who is willing to teach them the pathophysiology behind making decisions. Since nurses are usually mired in skill work, I am not sure if shadowing nurses is best for the paramedic student. They would most likely benefit from being with either a mid-level provider or a physician. I have heard endless complaints from EMS students who say that nurses are not willing to teach them the pathophysiology behind treatments modalities. I must admit that when I was in clinicals, the nurses made me feel like a huge burden. The doctors, however, were always willing to teach me and talk about treatment and pathophysiology. I learned much more from watching the doctors assess patients and explain their methods of treatment than I did in any other part of my clinicals. The paramedic model of clinicals should more closely mirror PA clinicals. The paramedic needs to spend the most amount of time with providers who work with a high level of autonomy, since we expect paramedics to operate at this level as well. Paramedic education focuses heavily on cardiology and respiratory/airway care. Paramedics must learn practical application of these skills from practitioners who are well versed in these areas. Check out this self check list to see if you should be guiding a paramedic in the clinical setting:
- Can you explain every detail of 12 lead abnormalities? This would include things like the importance of axis, r wave progression, Wellens sign, De Winter's T waves, S1Q3T3, subtle inferior MI, (smith modified) Sgarbossa criteria, etc.
- Can you explain mechanism of action of all the medications in the paramedic scope of practice backwards and forwards?
- Do you have excellent airway management practices and skills (based on evidence based medicine and recent literature)? Can you instruct them through an intubation, help them recognize landmarks, and assist them in different methods of managing a difficult airway?
- Can you instruct them in setting up a ventilator with ARDSNET setting and troubleshooting specific alarms? Many paramedics use ventilators even at the non-critical care level. A vast understanding of ventilation and oxygenation is needed to teach them.
- Can you explain the details of oxygen and ventilation of the non-intubated patient? This would include things like the NRB, NC, CPAP, BIPAP, and other forms of non-invasive oxygenation and ventilation.
- Can you help them learn anatomical landmarks for IV and IO access?
- Can you explain how all the different forms of shock work, and how each is treated?
- Are you up-to-date on recent literature about sepsis management?
- Can you teach them how to calculate infusions using a calculator? They will need to know several different calculations by heart since the pumps they use on the ambulance may not have medications programed into them (mcg/min, mcg/kg/min, fluid over time, units/kg/hour).
- Can you teach them hands on assessment?
- Can you help them calculate acid-base disorders with not only a blood gas, but help them calculate an anion gap and guide treatment through the CMP as well? Can you guide them in treatment of MUDPILES?
- Do you have a lot of experience being the leader on codes?
These are just a few of the basic items you should have a good handle on. If you have any doubt about the things above, perhaps teaching a paramedic in clinicals is not for you. Now that we have that out of the way, here is how the clinicals would be laid out:
Month 1: Operating room. Month one should be used to get intubation out of the way. This is a skill that must be taught so that the paramedic can use it whenever the opportunity comes up in the rest of clinicals. Right now, the amount of intubations keeps getting lower. When I went through school, you only needed 5! A recent graduate told me that they needed 2, and that others could be simulated! Outrageous! Paramedics should be somewhat comfortable with this skill, but right now they don't have time to get acclimated. They only get a few OR rotations to get a couple intubations, and then they are done. No wonder most paramedics are so scared to perform an intubation! Paramedics should be spending an entire month in the OR, getting hundreds of intubations. Three shifts in the OR at 8 hours a piece would give the paramedic 96 hours to perform intubations. With good planning and a good clinical site, the paramedic should be able to get in 200-300 intubations in a month. They will no doubt also learn a lot about ventilation, airway equipment, sedation, paralysis, and procedures from the anesthesiologists and nurse anesthetists. What a far cry from the training they get now! Shouldn't paramedics get the most airway training? They get the least amount of help when they have to perform an intubation in the field. OR time could be so much more than 'getting tubes.' It could be an entire airway, ventilation, anatomy, respiratory, and equipment module taught by doctors.
Month 2: Neurological ICU. The paramedic would learn to perform neurocheck, learn the NIHSS, practice the CSS, and be exposed to all types of neurological deficits that they could observe and study. They would shadow a neurologist that could teach them management of these acutely ill patients. Neuroanatomy would be stressed in study groups and how certain types of ischemic and hemorrhagic strokes present and how they are detected and treated. The students would no doubt also get exposure to many different types of medication infusions, and get to care for intubated patients.
Month 3: Trauma center/ trauma surgery. This is where paramedics would get their hands on trauma victims. They could see them in the ED, and then follow them up to surgery. Paramedics would practice their trauma management skills from not only watching a trauma team work, but actually being part of that team. This would give paramedics the chance to practice needle decompression, chest tubes, and pericardiocentesis, hemorrhage control, application of tourniquets, and blood product administration. They would also get to practice reduction of fractures and dislocations, and learn a little about treading x-rays and CT scans of injuries.
Month 4: Cardiac cath lab and cardiac ICU. This is where paramedics would hone their cardiology skills and have a chance to see interventional cardiology in action. In this split month, the paramedic would start in the cath lab where they would discuss cases with the cardiologist and watch caths being performed. Once they understand the operations of the cath lab, it would be time to spend the rest of the month in the cardiac ICU. The paramedic would get exposed to a lot of different rhythms and 12 lead abnormalities. They would also see pressors in use and get a chance to titrate them and see the effects.
Month 5: Medical ICU. This will give the paramedics a chance to see septic and as very sick medical patients. Sepsis is another killer that paramedics must be vigilant for in the field. They will have a chance to identify abnormal WBC counts and figure out bands, watch lactate levels, and learn about infection (building on their microbiology class). This is another instance where pressor titration would be used, and lab values would further become more relevant. Included in this rotation would most likely be seeing many sick abdominal and diabetic patients (usual criteria for paramedic curriculum).
Month 6: Obstetric and Pediatric. Many paramedics never get the experience of assisting in childbirth. Why don't we send them to an OB unit where they have multiple births a day? Two weeks in OB would give the paramedic the basic understanding of the process. The paramedic would of also had simulation on this, and taken the NRP class by this time. The second two weeks of month 6 would be spent at a childrens ED. This would give the paramedic plenty of exposure to pediatric assessment. Picking the brains of the pediatricians and nurses who deal with pediatrics would be an experience the paramedic would not soon forget.
Months 7-9: These three months would be spend in the ED, shadowing different ED physicians. They would do this in a similar to the way a PA student performs their clinicals. Again, it makes the most amount of sense to have paramedics with other providers who work with a high level of autonomy (MD/DO, PA, NP). Paramedics need to learn how to think critically, make patient care decisions independently, and understand the way a physician thinks. With this much time in the ED, paramedics will naturally pick up the skills nurses carry out and learn from them as well.
Months 10-12: These final three months would be spent on the ambulance. Since the paramedic would not need any skills or specific types of patient contacts at this point, they could focus on their practice of leading calls, directing the other providers, and putting their knowledge base to the test. This would also give time to learn from experienced providers. This 'ambulance' time should include specialty transport teams (children) and flight services. The prehospital services that the paramedic rides along with should be progressive services, not the typical 'diesel therapy' - 'let the hospital figure it out' - 'load and go' - type of toxic services.
Every paramedic I tell about this layout of clinicals wishes they had these kinds of opportunities. Paramedics are hungry for education and clinical experience. Why do the colleges deny them? And should the paramedic education stop there?
A 4 Year Opportunity
The four year colleges should be more willing to work with paramedics who want to obtain a four year degree in EMS. There are plenty of 'emergency management' degrees out there, but that's not what I'm talking about at all. I am talking about a biology focused degree that accepts paramedic credits. This completion of a 4 year degree would be the new standard for a critical care paramedic. No more of this ultra-short CC courses that are popping up everywhere. I can hear the complainers now... 'What is a paramedic going to do with a four year degree?!' Let me explain. As EMS continues to advance, we will need providers with biology backgrounds, and providers who have done specialty fellowships to lead the way. If you cannot see the need for educated providers to take the lead in EMS, you are ignorant and shortsighted. This degree would also fulfill the prerequisites to PA school, and open us up to other post-prehospital options.
Transfer to a 4 year university would allow providers to take a real critical care course. Two years at university would focus on any biology classes required for the degree, and classes specific to critical care. Paramedics would also be placed the in ICU clinicals where they would be spending their time learning from intensivists and respiratory therapists. The hands-on experience with things like ventilators, IVP monitoring, central lines, and other items they will see on critical care transport would be priceless (and a far cry from the lackluster critical care courses that are available to paramedics right now).
Let's be honest... The "critical care paramedic" means absolutely nothing right now. There are courses pumping out these providers with almost no education at all. Near where I live there was a "critical care" course that was 4 classes long. 4 classes! And the 4th day was a poor excuse for a test. Why even have class? Pretty soon you will be able to test out of these classes without any time spend on the curriculum at all. We are going in the opposite direction of where we need to go. EMS is running away from education when it needs to be demanding more! Why else should we obtain 4 year degrees?
If these reasons aren't enough to convince you, then how about the problem of nurses taking paramedic jobs? Nurses are hired for critical care transport positions (ground and air) because paramedics supposedly do not have the education to fill these spots. Paramedics, who are supposed to be the experts on interfacility and prehospital medicine, are losing jobs to nurses because paramedics lack formal education. In other countries, nurses are not employed in these roles. Why? Because in countries outside of the USA, paramedics have 4 year educations, and a masters degree if they are considered critical care paramedics. This makes them qualified to fill any prehospital job, so there is no need for nurses (whose education focuses on care that takes place inside the hospital). There is also the issue of financial compensation while in these roles (in the USA). A paramedic on a helicopter makes much less than a nurse. Why? Because the paramedic often lacks formal education. For pay equality to happen, education equality has to happen first. What else does a 4 year degree buy us an opportunity for?
PA, NP, Paramedic?
Let's consider the education of a mid-level provider like a PA. A PA can obtain a bachelor's degree any discipline, as long as they have a few specific classes under their belt. Here are a set of pretty basic requirements for PA school acceptance:
Baccalaureate degree from an accredited institution
Minimum science and cumulative GPA of 3.20 is required for all applicants.
Mammalian Biology w/ lab
Microbiology w/ lab
Human Anatomy and Physiology (1 and 2)
Statistics (1 sem)
Intro/General/Abnormal or Developmental Psychology (1 sem)
1000 hours direct patient care required at the time of application submission
This means that the PA school applicant could be a CNA with a bachelor's in business. This would leave pretty much all of their medical education up to a two year program, where they spend one year in class, and one year doing clinicals. Yet, a PA can apply for a job in an emergency department and receive on the job training. That's not a whole lot of education if you think about it... By this logic, a paramedic with a bachelor's degree should be able to apply to PA school no problem! And they do, we have plenty of paramedics who go to PA school. After all, the original PA program was made up of paramedics, so this makes sense. PA school is a much more logical progression for a paramedic than nursing school. If you have any doubt in what I just said, or take offense to it, just look at the curriculum for all these disciplines. You will see my point. I am not knocking nursing, nurses have their own educational model and path which is different from the medical model followed by other health care professions. So what medical model should paramedics follow?