# Basics before Advanced



## Ridryder911 (Jun 13, 2007)

I continue to read and hear the old saying...._ "remember basics before advanced... one, should know the basics before ever attempting advance....._"

If this was really the case, one should know the basics of anatomy and physiology and have a complete understanding of shock physiology as well before being taught treatment of shock therapy(i.e. IV therapy, intubation, etc). 

The same as the full understanding of blood pressures and what causes them as well the meaning of differentials, not just bits and peices that is now taught. 

Since these items are not really "advanced" rather are the basics; and one should know the "basics" before allowing or being taught therapy for problems.

As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02  & MR02 and multiple organ shutdowns (MODS)? 

It appears, we want to emphasize the basics of everything, yet when it comes down to really understanding the "basics" most have very little or no knowledgeof such.

R/r 911


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## TKO (Jun 13, 2007)

Isn't that really what you are saying too?  Know the basics before you try the advanced = basics before advanced?

I agree that nobody should be attempting to perform a skill that they do not fully understand.  Just because one manual says to hyperventilate a cerebral herniation doesn't mean a provider should be doing 24-30 RR/min with a BVM.  If that provider doesn't realize that they can increase the cerebral ischemia and is just doing as they are told, then what makes them any more useful to the pt than dumb luck?

That is the dance of the EMT and the paramedic.  EMTs should be paired with a medic, and performing under the direction of the paramedic.  And the paramedic should know very well what it is he/she is doing.


Out of curiosity, what is the education of a paramedic in the US?  Here in Canada, ACPs are *almost* the equivalent of an RN.  If the College of Nursing hadn't welched on their end of the bargain, ACPs would have been able to challenge for an RN degree.  And that wasn't for lack of knowledge, but moreover because of politics.

PCPs do 500 hours of course time, or the equivalent of 1.25 years of fulltime university education.  ACPs go to school 7 hours/day for just over a year.  That's pretty close to the 4 year university RN degree (minus all the practicums for both professions).


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## VentMedic (Jun 13, 2007)

ridryder 911 said:


> Since these items are not really "advanced" rather are the basics; and one should know the "basics" before allowing or being taught therapy for problems.
> 
> As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02  & MR02 and multiple organ shutdowns (MODS)?
> 
> ...



So, essentially what we perceive to be advanced is really less than basic level by many other standards in the healthcare profession.


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## Rattletrap (Jun 13, 2007)

I always start with the simple basics / "old horse medicine" first. It is amazing what can be fixed with simple Oxygen and coached breathing " take nice slow deep breaths".


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## Summit (Jun 13, 2007)

ridryder 911 said:


> I continue to read and hear the old saying...._ "remember basics before advanced... one, should know the basics before ever attempting advance....._"
> 
> If this was really the case, one should know the basics of anatomy and physiology and have a complete understanding of shock physiology as well before being taught treatment of shock therapy(i.e. IV therapy, intubation, etc).
> 
> ...



I AGREE!!!


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## Guardian (Jun 13, 2007)

VentMedic said:


> So, essentially what we perceive to be advanced is really less than basic level by many other standards in the healthcare profession.



I don't think so.  I'm sure rid will correct me if I'm wrong but, I think he meant that people are always harping on the "basics" but really have no concept of what the "basics" really are.  EMT-basics don't have a good basic medical foundation of knowledge.  So it is strange to hear them constantly say basics before advanced care, and I wish they would follow their own advice.

I have yet to see a paramedic intubate a breathing pt without respiratory distress, who is AAO*3.  I've yet to see a paramedic forget to backboard someone (although they might choose not to).  I have yet to see a paramedic worry about starting a 22g in the hand while their pt has an active femoral bleed spraying blood everywhere.  Can someone please tell me where the paramedics are neglecting to perform bls care.  I don't see it.  Bls before als is common sense and doesn't need to said over and over.  I assure you, you can't pass a paramedic exam (practical or written) unless you do bls before als.  It's ingrained into paramedic students from day one.  For example, when paramedics practice at airway stations, we must start off with scene safety, bsi, abc's, etc.  If someone goes and picks up the laryngoscope without saying a word, the instructor/evaluator will immediately say "stop, do it again and this time do it right."  It's like this for every topic, practical station, etc.  There really is no bls and als, only a list of steps that emt-basics stop at around step 5 and paramedics are expected to continue to step 10.  More often than not, it seems that emt-basics use this phrase as a justification for existence.  I think it's unnecessary, dumb, and as some would say "played out."


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## VentMedic (Jun 13, 2007)

Thank you GUARDIAN.  
You've supported *my* statement very well since *I* was referring to Paramedics.  I'm sure Rid will offer a further explanation of his post later. 

EMT-Bs know what they know and make the best use of their basics. 

Paramedics sometimes don't know what they don't know.


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## Guardian (Jun 13, 2007)

well, ok. I see what your saying and I pretty much agree.  I guess it's just a matter of focus between emt and paramedic or ems and other healthcare professions.  I do think we have to be careful not to bog down ems with info they will never use so that we can focus in greater detail on info we will use to save lives.  Where do we draw the line?...that's a complicated issue which should be studied by academics with input from other healthcare providers as well as a large number of the best ems leaders in the country...definitely not cut-and-dry.  I would love however, to learn what specific additional information you would add to the mandatory emt and/or paramedic curriculum.  My personal opinion (as biased as it may be) is that the critical care paramedic's knowledge, while lacking, is relatively far better than the emt-b,I,etc. and so I would flip the emt-b and paramedic in your last two sentences.


ps, I love that rumsfeld quote.


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## VentMedic (Jun 13, 2007)

*The Unknown*
As we know, 
There are known knowns. 
There are things we know we know. 
We also know 
There are known unknowns. 
That is to say 
We know there are some things 
We do not know. 
But there are also unknown unknowns, 
The ones we don't know 
We don't know. 

—Feb. 12, 2002, Department of Defense news briefing


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## Ridryder911 (Jun 14, 2007)

Great dialogue. Yes, I did have more than one meaning and intent. As I had thought, the replies are from posters that have a true understanding of what the true "basics" are.

I find it ironic that many acclaim to state...._ 'basic before advanced"_ and _ one cannot be a good at advanced level, without being a good basic"_ without realizing what the "basics" really are. 

EMS is one of the few medical professions that teaches bass ackwards. We allow one to intubate, perform intravenous therapy, and even administer medications, without having the "basic knowledge". In fact, one that usually really knows and understands the "basics" are really considered to be at an upper level of being advanced... makes sense huh? Again, in comparison of the medical community, it is backwards and odd, then we wonder why.. "they don't understand and appreciate us". 

Worse, it evens starts before any introduction of EMT training. One has to have the "basics" of reading and writing, to be able to understand those so called "basics" that are needed to build the essential foundation to provide adequate health care.  Many EMT courses may require reading and general education tests such as HOBET, Briggs, etc for entrance but very few have standards that eliminate or restrict candidates. 

I find it ironic, there are many that want to state.."basic before advance".. then yet, they themselves may not even understand or have the basics covered. It is hard to compare, when one has nothing to compare it to. 

TKO, unfortunately EMS in the U.S. is very fragmented and antiquated. One can go from the start to finish (Basic to Paramedic) in less than four months. Albeit, many do not and as well many may pursue much longer obtaining an education, the general criteria is the same. 

My points is multiple and I encourage discussion, especially from those that always emphasize the statement of .._ basics before advance_.. 

We all are in agreement, every one should have the "basics" before advance. As I agree, and stated it is definitely needed as a foundation to build upon before proceeding upwards to any advanced levels. This means one should have a thorough knowledge of the basics of the workings and parts of the body, way before procedures such as intubation, intravenous therapy, and of administering of any solutes & medications. 

Since we are all in agreement of that.. Why do we allow and promote not teaching the basics?.. and much more than that, since everyone appears to be in agreement again, .."basics before advance".. Why do we promote such certifications and levels that does not include those much needed "basics"? 

So yes, one does need to know the osmolality and potassium shift, as well as respiratory drives and physiology of why the differences in ventilatory systems, before any thought of altering or even repairing any of those applied systems. The old cliche.. one cannot fix, that they do not what is broke" could not be more true. One has to know normal before abnormal. 

So I open up for discussion and debate, especially those that acclaim .."basics before advance" the following:

Basics are never not really taught the " basics" at all, even then I would predict even that majority of Paramedics are not taught them as well. 

It is hard or even hypocritical to acclaim such statements as "basics before advance", if one does not really have the knowledge of the basics themselves.

The EMS system has to evaluate the current education and training systems. It is appearantly it is not working, and continues to fail. Could this possibly be related to that we are not following proven methodologies from other medical professions, that have been around a lot longer than ours? 

That in providing care to patients, there is really no basic nor advance levels, rather a beginning and continuation, then finally outcome of the patient. 


Discussions ?
R/r 911


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## VentMedic (Jun 15, 2007)

Ridryder911 said:


> This means one should have a thorough knowledge of the basics of the workings and parts of the body, way before procedures such as intubation, intravenous therapy, and of administering of any solutes & medications.
> 
> Since we are all in agreement of that.. Why do we allow and promote not teaching the basics?.. and much more than that, since everyone appears to be in agreement again, .."basics before advance".. Why do we promote such certifications and levels that does not include those much needed "basics"?




Dictionary definition of Skill; 
a. Proficiency, facility, or dexterity that is acquired or developed through training or experience.
b. An art, trade, or technique, particularly one requiring use of the hands or body. 
c. A developed talent or ability

Yes, skills are important. It is what we base our EMS certifications on. Look up almost any state and they will give you a list of skills. 

Yet, how to actually become skilled is not clearly defined. Is it a video, manikin, cadaver, or the living?  How many repetitions?  See one, do one, teach one? 

What are the qualifications of the person teaching the skills?  Are they skilled? Who judges proficiency when a manikin is used?  

Proficiency; The state of being able to do something very well.

Will the skill be reproducible on the living enough to be proficient?

What is "ride time"?  Do students pick the busiest stations?  Is seeing the same as doing?  What makes for good ride time? Who determines quality ride time? Is it a trauma or medical call? How many calls? 

Why aren't the skills taught the same? Who says this way is better than that way?  Why are there more skills in that state than this state. 

Going purely by definition, is it possible for someone of a lower certification to be more proficient and skilled than a higher certification or licensure? They could have performed the skill more times. They could have natural talent or be a quick learner of a skill. What else would there be to set them apart with that skill? Did they watch the same video? Practice on the same manikin?

Of course, to make up for deficiency in proficiency, we get better equipment. Or, so says the sales pitch from the salesperson. We can put a tube into anyone and never miss an IV. 

I was looking at some of the different certifications in a few states.

Example:
Washington: First Responder, EMT-Basic, IV Technician, Airway Technician,  IV/AW Technician, ILS Technician, ILS/Airway Technician, Paramedic.

The EMERGENCY MEDICAL SERVICES THE NATIONAL EMS SCOPE OF PRACTICE MODEL, which Rid mentioned in another post, points out that there are 44 different certifications and 39 different licensure levels between EMT and Paramedic in the U.S. 

http://www.jems.com/data/pdf/SOPFinal4.0.pdf 

Education?  Basics?  

Where to start? 

Wouldn't it be easier if we just make up another certification or licensure and say this one is the right one THIS time?  Wouldn't that be as practical as the patch work of skills certifications we have going on now?


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## Glorified (Jun 15, 2007)

The only solution to this dilemma would be to make it nationally mandatory for all EMS personnel to be associate degree paramedics and the rest of EMS are first responders. But until that happens, you are going to have to endure all of us annoying basics, saying "bls before als."


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## Ridryder911 (Jun 15, 2007)

I think Vent you make some very valid and important points. Educators and EMS officials are quite aware that the ability of performing skills proficiently and having the associated knowledge is two different things. 

The skills of the Basic EMT is considered very simplistic in the terms of hierarchy of skill level and over all rated very easy to repeat and perform with repetitious practice. However; we need to increase the education level, not just to have the basic EMT to be able to perform tasks. In simplistic terms skills are no value, without knowledge behind them. Skills can be improved and the skills of the EMT those can be mastered with clinical exposure. 

As the level of practice increases with the difficulty and intensity of the skill level, many EMS educators and state officials much rather develop multiple levels than to face the task and do it right the first time. In the typical EMS fashion, the old analogy..."_ placing a band-aid on a arterial bleed"_....and then try to "fix" it as we go. We much rather for some reason do things half ***. 

Unfortunately, the questions you ask are not always able to be answered because most of the education is generally set in a "training" environment and most are never reviewed to improve. Ask most EMS educators what teaching model(s) they are using, or if they even know what critical thinking skills are, and see the response. 

For as what validation can be used to assure proficiency, this is why Quality Improvement is so essential. The reason that most states and NREMT asks on re-certification of proficiency level, although I am sure it is checked off by habit instead of being truly reviewed. 

I agree there is discrepancy in clinicals. That is why National Scope of training and practice is essential. Like your RT and as well as other medical models of education, objectives should be required. In lieu of clinical hours, contacts and requirement of clinical objectives should be set and used. This would prevent those "coffee clinicals" and clinical time with most action was playing a video game. In the original clinical agreement of the rough draft of the National Scope, clinical exposures required certain types of calls and medical conditions. I agree, a student should not be released until they have treated certain medical conditions. For example cardiac arrest, chest pains, trauma patients, high risk O.B.'s etc. 

Many may describe one could not be guaranteed to have exposure. I argue that if the clinical site was at a metro or progressive center, the chances would be increased. Yes, this may mean travel time, but like residency and even other medical careers, that is again the represents the dedication and sincerity of the student to be able to obtain exposures 

So with at least 83 multiple levels, how is the medical community supposedly take our profession seriously? When ever there is an area that is more difficult ... develop another EMT level, of course this is always in comparison to the highest level being the Paramedic... sorta....kinda... almost.. not quite. Pull out the band-aid. 

When one investigates on the amount of money is spent developing levels (including tests, studies, curriculum's, etc) and instead of providing grants, tuition wavers.. many Basic EMT's could had been sponsored through the entire Paramedic course.

So how do we improve on such... support and make recommendations on the National Scope, support Advocates of EMS, discuss the education and lack of to you State EMS Director and Directing Board, become active in local, state, and national professional organizations. 

Glorified you are right I will have to tolerate, but I will retaliate with forwarding back to this post every time I read Basics before Advanced. Hopefully, we can educate the Basics what really basics are and not a cliche of basic before Advanced really is. 

R/r 911


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## VentMedic (Jun 16, 2007)

Besides state licensing websites, there are many other sources of information. Although, this too is getting fragmented in focus by different agencies, each with their own issues instead of a true national organization to lobby for legislation. Of course this too will be difficult to get an organized representation of all of the certified and licensed EMS people, each also with their own issues.

Many do not know about the different pieces of legislation that are being or have been considered. Due to this lack of a general interest of the masses, special interest groups are able to push legislation through without being noticed. Many times it is specifically for their gain and not for the greater good of EMS. 

National Conference of State Legislatures
http://www.ncsl.org/programs/health/ems.htm

http://www.ncsl.org/index.htm?tabsel=issues


The National Association of State EMS Officials 
http://www.nasemsd.org/

National EMS Education Standards
http://www.nemsed.org/

These are just a few links that provide some valuable information about this profession.


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## eggshen (Jun 17, 2007)

This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up. 

Egg


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## RichmondMedik (Jun 19, 2007)

eggshen said:


> This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.
> 
> Egg



Try telling a Med control doc that " We take people to the hospital" and I bet you would no longer get orders or respect from them -- My old Med control doc would stress "You start treating patients in the field" and if we were unsure he would point us in the direction to get the education we needed to accomplish treating the patient correctly -


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## MRE (Jun 19, 2007)

Not sure if this is completely appropreate for this thread (only had time to skim it quickly) 

I am  in the 4th week of Basic training and my instructor was complaining recently about the way the class has been dumbed down over the years.  He said that the current Basic curriculum trains us to be assessment based EMT's as opposed to the old one which taught students to be diagnostic EMT's.  He said he will be teaching our course so that we are actually trained as both.  

From what I have seen so far, he has been using a bit more medical terminology than the Brady book we are using, and we have discussed some underlying causes of particular signs and symptoms that are not mentioned in the book (so far at least).  One example of this is "spontaneous pnumothorax" being a problem encountered mostly with tall, thin white males.

Can anyone tell me if this is normal for a Basic course (we have only covered material up to trauma assessment so far) or if my instructor is giving us anything more?  Also, please comment on the assessment vs diagnostic based EMT.

Thanks,
-Blake


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## SMC (Jun 19, 2007)

*My thoughts*

Hello my EMS family !  New to forums.....

Basics before advanced is a popular topic these days !  And, I'm sure I don't know lots of things including...



> As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02 & MR02 and multiple organ shutdowns (MODS)?



But look at EMS training requirements.  In the state of Texas more training hours are required to become a cosmetologists than a NREMT Paramedic. 

If we want our field to have an understanding about these things, we need to look at the requirements for EMS.  I don't think it's our fault we don't know.

And, now I'm going to get a bad rep in here lol.

Why do I need to understand VO2 ?    I see my patient for a short periods of time.  I have my ETCO2 and my SPO2 and I will oxygenate my patient if needed during my short treatment time.  The Dr. and the RN's at the hospital are trained for more long term treatment.  The overwhelming majority of the EMS professionals in the field are not RN/paramedics.  It's good you know and understand those things, but the majority of us don't and I don't think we need to.

I'm going to enjoy discussions in this forum I can tell.  

Little bit about me.

I've been a paramedic for about a year now.  I'm a Call Of Duty UO PC Gamer.  RCA are fun.  Like I said I've got tons to learn !  And I will continue to learn and educate my self on the ever changing EMS field.  I like to keep things very simple in this complicated job.   

SMC.  EMT-P    Sgt US. Marines OIF II vet.  C.Ph.T (pharmacy Tech) 10 years.  lol  that job helped me tons with patient home medications


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## Guardian (Jun 19, 2007)

eggshen said:


> This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.
> 
> Egg



Why do you think ems was invented?  We already had people to drive pts to the hospital.  We were supposed to be more than that.  I guess it's a matter of perspective.  What seems like too much technical imperative to you is just scratching the surface to me.  I don't want us to become doctors; right now, I'm just trying to get back to the level of understanding we had 30 years ago.


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## VentMedic (Jun 19, 2007)

Guardian said:


> I'm just trying to get back to the level of understanding we had 30 years ago.



That is so true. 

The phrase "physcian extender" was coined for us almost 40 years ago. At that time our skills and knowledge were unique to us and physicians. Unfortunately it is used loosely today and holds no legal bearing. PAs and NPs are two of the legal physician extenders.  Their extensive education and clinical hours give them that privilege.  

The skills we possess are no longer unique to just the Paramedic. Many other healthcare professions also practice advanced skills along with protocols and standing orders. For many, their education has to meet certain standards with many hours of clinicals before they are  granted these privileges. They are also required to maintain competencies that is not heard of in many EMS agencies. 

When viewed on a national level as a whole we are now skilled "technicians".  Our varied certifications and licensures make it difficult to give credit to those in the profession who have truly put forth educational and skills betterment. 

In many situations:
"You are only as strong as your weakest link."


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## Bongy (Jun 21, 2007)

VentMedic said:


> That is so true.
> 
> The phrase "physcian extender" was coined for us almost 40 years ago. At that time our skills and knowledge were unique to us and physicians. Unfortunately it is used loosely today and holds no legal bearing. PAs and NPs are two of the legal physician extenders.  Their extensive education and clinical hours give them that privilege.


Hello,to you all...Long time no see... And you know why? Becouse your lazyness,in cases that I asked you to think a little in...
I gave some medical quizes,that ordered to extend you scope of thinking - not practice,but thinking...But you prefer to argue page after page about importance of knowelge,but exept of few forum members,I did see a lot of interest in medical...
You can start to say,that "I'm wrong",that "I dont understand US reality" e.t.c.... But result is here - In this forum you have much more discussion about managment issues that medical... Why that? I don't know...Much easier to talk about " adrenaline in blood" and "sirens in the night"..But when I gave something more complicated that ABC-Evacuation...Most of a forum members prefered to ignore it... Yes... May by you shouldn know that from you college studies,but even no intention for self education??!!
At final... I'm disappoited... Basics...It's not a BLS... It's a CLINICAL (and CRITICAL)THINKING!!


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## ffemt8978 (Jun 22, 2007)

Bongy said:


> Hello,to you all...Long time no see... And you know why? Becouse your lazyness,in cases that I asked you to think a little in...
> I gave some medical quizes,that ordered to extend you scope of thinking - not practice,but thinking...But you prefer to argue page after page about importance of knowelge,but exept of few forum members,I did see a lot of interest in medical...
> You can start to say,that "I'm wrong",that "I dont understand US reality" e.t.c.... But result is here - In this forum you have much more discussion about managment issues that medical... Why that? I don't know...Much easier to talk about " adrenaline in blood" and "sirens in the night"..But when I gave something more complicated that ABC-Evacuation...Most of a forum members prefered to ignore it... Yes... May by you shouldn know that from you college studies,but even no intention for self education??!!
> At final... I'm disappoited... Basics...It's not a BLS... It's a CLINICAL (and CRITICAL)THINKING!!



Not that it matters what you think of me, or what I think of you, but here's the deal...(PLEASE NOTE - these are my personal opinions and do not reflect the opinions of the rest of the Community Leaders or EMTLife.com)

You show up here a few months ago and start talking about the Russian language EMS forum you were a part of.  Your second post is part of your Quiz.  As a matter of fact, over half of your posts to this date have been about your Quizzes.

Without ever giving our forum members a chance to get to know you first, you show up and start acting like Alex Trebek and "order" us to extend our scope of thinking.  I'm sorry, but I don't feel like being quizzed by some self appointed examiner that thinks or acts like they're better than me.  I have no problem being quizzed as a part of my efforts to expand my knowledge base, but around here it's going to have to meet a couple of criteria first.  1) It must be part of a genuine effort to learn on everyone's part and not an effort to make one person appear or feel better than another (and that's as touchy-feely as I get).  2) It must be from someone I respect here, and around here there is only one way to get respect.  You earn it by becoming a productive member of our forum, proving that you are not someone suffering from a Cranial-Rectal Inversion.

You seem to think that all we talk about is the importance of knowledge or management issues.  If you took a couple of minutes to actually think about what is posted here, you'll see that we all agree that knowledge is important.  Where we disagree is the IMPLEMENTATION of that knowledge.

And yes, we talk about management issues because like it or not, it is a HUGE part of EMS - no matter where you are.

In closing, you said 





> It's a CLINICAL (and CRITICAL)THINKING!!


.  That's about the only thing I agree with you about.


To all of our other forum members, I apologize for my soapbox rant but I wanted this to serve as an example to all of our current and future members.


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## Guardian (Jun 22, 2007)

Your stuff seemed a little far out there and beyond my understanding of medicine.  You guys over in Israel must really know you stuff!  Also, your writing ability leaves something to be desired, although I'm very impressed given it's not your native language.  I hope you continue to post here because I'm sure I could learn a thing or two from you.

Oh, and before you go calling us lazy, remember who you're talking about...the richest and most powerful country in the world that invented ems as we know it today


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## Bongy (Jun 22, 2007)

ffemt8978 said:


> Not that it matters what you think of me, or what I think of you, but here's the deal...(PLEASE NOTE - these are my personal opinions and do not reflect the opinions of the rest of the Community Leaders or EMTLife.com)


 Deal...Ok..But should I give my opinion also?


> You show up here a few months ago and start talking about the Russian language EMS forum you were a part of.  Your second post is part of your Quiz.  As a matter of fact, over half of your posts to this date have been about your Quizzes.


...and got "warning" for publishing advertisment(exept of membership I have no finanicial connection..)By the way,it was a call to cooperate..But who cares..


> Without ever giving our forum members a chance to get to know you first, you show up and start acting like Alex Trebek and "order" us to extend our scope of thinking.  I'm sorry, but I don't feel like being quizzed by some self appointed examiner that thinks or acts like they're better than me.  I have no problem being quizzed as a part of my efforts to expand my knowledge base, but around here it's going to have to meet a couple of criteria first.  1) It must be part of a genuine effort to learn on everyone's part and not an effort to make one person appear or feel better than another (and that's as touchy-feely as I get).  2) It must be from someone I respect here, and around here there is only one way to get respect.  You earn it by becoming a productive member of our forum, proving that you are not someone suffering from a Cranial-Rectal Inversion.


Well yee...I don't know who is Alex Trebek.... I order no-one...I gave an option to think about clinical case - that a way to share knowlege in medicine... My ego is well maintaned WITHOUT EMSlife also,so you can be sure,that I don't want to show nothing... I'm not better than you...Ok?
And,I'm sorry...My knowlege in anatomy,not good enough to emagine cranio-rectal inversion


> You seem to think that all we talk about is the importance of knowledge or management issues.  If you took a couple of minutes to actually think about what is posted here, you'll see that we all agree that knowledge is important.  Where we disagree is the IMPLEMENTATION of that knowledge.
> 
> And yes, we talk about management issues because like it or not, it is a HUGE part of EMS - no matter where you are.


Huge...Yes,but not a biggest one..Biggest one is a MEDICINE...
I'm not living in US but I'm generaly familiar with your system-still medicine more important than managment...


> To all of our other forum members, I apologize for my soapbox rant but I wanted this to serve as an example to all of our current and future members.


To scare all others that would like to post a clinical case???

toGuardian....THANKS!!
P.S. Beeng rich and powerful,doesn't mean NOT to be lazy!


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## DocHoliday (Jun 22, 2007)

Rattletrap said:


> I always start with the simple basics / "old horse medicine" first. It is amazing what can be fixed with simple Oxygen and coached breathing " take nice slow deep breaths".



I agree with that.  IF you can't do basic Pt assesment and effective BLS skills you have no buisness doing ALS skills.  There are too many EMTs and go to Medic school without mastering the simple basic and fail out their first day of pratical because they aren't good EMTs.


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## Chimpie (Jun 22, 2007)

Bongy said:


> I order no-one...I gave an option to think about clinical case - that a way to share knowlege in medicine...


And because a limited few chose to respond, you come back and call our members lazy?  You said you gave the option (to particpate or not).  Most chose not to, sorry.

Going along with ffemt8978 said, if you would have came here, earned the respect of being a knowledgable, contributing member, you probably would have received a greater response.

Chimp


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## Flight-LP (Jun 22, 2007)

eggshen said:


> This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.
> 
> Egg





			
				SMC said:
			
		

> Why do I need to understand VO2 ? I see my patient for a short periods of time. I have my ETCO2 and my SPO2 and I will oxygenate my patient if needed during my short treatment time. The Dr. and the RN's at the hospital are trained for more long term treatment. The overwhelming majority of the EMS professionals in the field are not RN/paramedics. It's good you know and understand those things, but the majority of us don't and I don't think we need to.



*sigh*

And we wonder why no one respects us...........People who accept mediocrity are destined to a life of it..............Come on guys, would it really kill you to learn something new about the job you do day in and day out? I mean heaven forbid!


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## RedZone (Jun 26, 2007)

Ahhh!  I was looking for an intelligent debate.

Do you like stories?  I like to tell stories!  

I became an EMT in 1994.  When I was a new EMT, I was excited about my new profession.  I was young, energetic, motivated, willing to learn everything that I could.  Two new friends (a medic and an EMT) were having a conversation and the medic began ranting about how a BLS crew he backed up didn’t know the difference between right sided and left sided heart failure.  I didn’t know either, but I wouldn’t dare ask!  I was too embarrassed after hearing his rant!  As soon as I got home I opened up my EMT book, and thoroughly searched for the answer.  It wasn’t there.

Too bad that medic intimidated me by his complaint.  I could have learned the difference.

Soon after graduating medic school in 1997, I taunted a medic for not knowing what VQ mismatch was.  At the time, I understood it very well, and I explained it to him in detail.  Could I do that today?  Not without reviewing the text first!

I have been hearing about this trend of “dumbing down” the curriculum from the time I was in EMT school, and it still continues to this day.  I hear about it from teachers in other areas as well.  Math teachers used to complain all the time about how students should be required to know “proofs”.  

Yes, I do agree with you that more in-depth detail means a higher quality education.  But a well educated medic/emt doesn’t automatically translate into a good medic/emt.

If I listed all the medics I know whom I would trust with a family member, I doubt many of them would know what VQ mismatch was.  The only two exceptions I can think of are if the medic was also an instructor, or a student of some other medical discipline (RN, PA, etc).

Before the first time I ever drove a car, I had many years of “driving education”.  From early childhood, I was playing driving games, driving go-carts / bumper cars, observing other drivers, and learning all the basic traffic laws.  Before I even shifted the car into drive for the first time, I was quite familiar with all the necessary concepts.  I had a perfect score on my written permit test.  I had high marks on all my written exams in driver’s ed!  But even after I was qualified to drive all by myself, I wouldn’t dare say I was a good driver.  That took plenty of hands-on experience.

Oh, I’d love to go on… but I’ve spent too much time already.  I’ll let others get a few words in first!  Remember, I am not completely disagreeing with your opinion!  I encourage opinions!  I am merely offering some food for thought.


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## Ridryder911 (Jun 26, 2007)

Very good points, application of the knowledge as in clinical skills is essential. Without the knowledge though, one is just "performing" or "acting" without really knowing the reason why and accepts everything as face value. 

This is why so many EMT's & medics are hesitant for any changes. For example trendelenburg to even CISD, even though both have been repeated in several hundred studies and years of research, not to work, we continue. 

Without the knowledge, all we have is performing personnel. Not really knowing the "full picture" can be detrimental. My question is why not give the full picture? 

For example I always taught the full hemodynamic lecture to basic when explaining blood pressures. It proved to be less confusing to learn something right the first time, than to go back to school later and re-learn something. Ironically, basic always had a higher score than most advanced students, because they did not already have preconceived ideas. 

The difference between good medics and half arse ones is the desire and "want" to learn. Instead of stopping at your basic book, maybe if you had researched and looked past, you would had found the answer. Again, we must stop the traditional mentality of describing that everything is found in the basic course and texts. In actuality it is a very poor, poor representation of emergency medicine. You see my Basic EMT book had the pathophysiology of right failure and left, again we did "dumb down" the EMT curriculum in 1993. This was met by resistance of many educators that knew the potential effects that we are now seeing. 

We expect our basics to have the knowledge and skills, but we are not teaching, nor providing avenues to meet those expectations. Yet, again how many instructors are informing students that they must go outside their comfort zone and read other educational materials and demand such? Yes, the basic text is needed as one of the required books, but NOT the sole text. 

Hopefully, with the proposed new curriculum we will see the EMT length increase by 20-30%, requiring more in-depth education. 

R/r 911


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## RedZone (Jun 26, 2007)

Warning: I guess I was bored.. this is long, but I think it is valuable!



Ridryder911 said:


> Very good points, application of the knowledge as in clinical skills is essential. Without the knowledge though, one is just "performing" or "acting" without really knowing the reason why and accepts everything as face value.



Agreed 



> This is why so many EMT's & medics are hesitant for any changes. For example trendelenburg to even CISD, even though both have been repeated in several hundred studies and years of research, not to work, we continue.



Here I disagree.  "This is why": unsubstantiated cause and effect argument.  Sure, change may be met with some degree of resistance, but I find that many EMT's and medics accept change quite well.  Yes, at least in NYC and NYS, my observations give me the impression that many times change only happens after it is long overdue. The responsibility for that doesn't lie with the street level EMT's and medics, it has to do much more with the politicians (those who write the protocols, the policies, the medical directors, the upper level administrators).

I remember reading an abstract of a published study in JEMS evaluating the efficacy of prehospital intubation for APE patients a few years ago.  They compared the eventual outcomes of APE patients intubated in-field with APE patients intubated immediately on arrival at the ED.  There was convincing evidence that prehospital intubation for APE patients was harmful.

So, now I am armed with a piece of knowledge.  But, even to this day, daring to apply that knowledge means risking my certification and the ability to support myself and my family.  

Since then CPAP has been added as an "option" in our protocols.  I don't use it, not because of my hesitance to change, but because none of my employers have even considered providing either the equipment or the training.  I guess that option must be expensive.

When I was in medic school (96-97), there were drastic changes implemented to the citywide protocols.  Calcium was removed from the cardiac arrest protocol.  Versed was added as a sedation option for pacing and intubation.  Ativan was also added as an option for stat-ep.  ASA was added to the MI protocol, and the use of NTG (SL and paste) was emphasized while morphine was de-emphasized.  Transcutaneous pacing and 12 lead EKG's were all added to the protocols. The medic trucks I was riding on carried all the new drugs, and they were all equipped with new lifepak 12's capable of the new technology.  The training was provided by their employer.  

Were the "old-time medics" I worked with hesitant to the change?  HELL NO! They WELCOMED it!  I observed every one of these new implementations during my "observer tours"... except for the Versed and Ativan.  See, it wasn't the medics that were hesitant, telemetry absolutely refused to acknowledge that we even carried the option.

EMT-B's can now carry and administer albuterol, ASA, even epi-pens under certain strict circumstances.  Although required on the 911 units, the commercial service I work for doesn't equip BLS units with these options.  As far as the albuterol, they went as far as offering the training and preparing the equipment for distribution to all the units.  The medical director refused.  Do you really believe that the EMTs would be unwelcome to these new changes?



> Without the knowledge, all we have is performing personnel. Not really knowing the "full picture" can be detrimental. My question is why not give the full picture?



Yes, without knowledge, all we have is performing personnel.  I can't see any harm in giving the full picture.  But I question how "not really knowing the full picture can be detrimental".  Do you have a basis to support this? 



> For example I always taught the full hemodynamic lecture to basic when explaining blood pressures. It proved to be less confusing to learn something right the first time, than to go back to school later and re-learn something. Ironically, basic always had a higher score than most advanced students, because they did not already have preconceived ideas.



Hmmm... not sure I get this.  "It proved to be less confusing to learn something right the first time" as opposed to "relearning it later".  Are you saying that those paramedic students who had previously attended your hemodynamic lecture during EMT-B training had better test scores (for this area of knowledge) than already practicing medics who lacked receiving an equivalent lesson during their EMT-B training?  

Since I'm playing devil's advocate, I'll refrain from forming an opinion to the "because they did not already have preconceived ideas."  Cause and effect statements are tricky to evaluate.



> The difference between good medics and half arse ones is the desire and "want" to learn. Instead of stopping at your basic book, maybe if you had researched and looked past, you would had found the answer. Again, we must stop the traditional mentality of describing that everything is found in the basic course and texts. In actuality it is a very poor, poor representation of emergency medicine. You see my Basic EMT book had the pathophysiology of right failure and left, again we did "dumb down" the EMT curriculum in 1993. This was met by resistance of many educators that knew the potential effects that we are now seeing.



Yes, I agree!  I'll reword it though since I don't think it is "THE" difference, but I think that you are on to something here.

One (of several) important qualities necessary to be a good medic is the desire to learn.  

Later on, I actually did ask some more experienced EMTs about the difference between left/right sided heart failure, but none of them knew the answer either.  Nowadays, I could have easily googled the answer in seconds.  For this reason, I feel it is necessary to teach EMTs about evaluating sources of information.  Back then, I would have been too intimidated to just stop a doctor in the ED and ask.  This was enforced by the medic's rant (I wouldn't dare want to give off the impression I was incompetent for not knowing what a peer felt was "basic knowledge").  Maybe more needs to be done with promoting a good relationship between EMS (especially new EMTs) and the staff of their regional EDs.  

Yes, CME needs to be encouraged.  But, motivation cannot be forced. 



> We expect our basics to have the knowledge and skills, but we are not teaching, nor providing avenues to meet those expectations. Yet, again how many instructors are informing students that they must go outside their comfort zone and read other educational materials and demand such? Yes, the basic text is needed as one of the required books, but NOT the sole text.
> 
> Hopefully, with the proposed new curriculum we will see the EMT length increase by 20-30%, requiring more in-depth education.
> 
> R/r 911



Every CME I have attended has welcomed EMTs, but there has never been a requirement for EMT-Bs in NY.  Even most medics will attend the bare minimum, or even look for ways around attending CMEs.  Again, motivation cannot be forced, and this lack of motivation is sad indeed.  It's a spiraling effect too.  Why should an employer spend their resources organizing CMEs when their personnel lack the interest of attending.  

So more avenues to increase knowledge and skills need to be provided, yes.  But maybe incentive needs to be provided since natural desire lacks.  Some larger organizations may offer compensation (paid time or even $) for attending CME, but good luck encouraging this expensive option to administrators.  Actually union shop stewards for non-profit agencies should find out about government education and training grants.  They can secure the resources to provide all sorts of training programs, including wage compensation, at no cost to the agency.

Encourage competition!  As humans, we love to compete!  Instead of compensating every employee for every CME hour they attend, you could probably get better response for offering some sort of periodic competition with prizes going to the top few.  It can end up promoting a better social working environment as well.

Say, you offer a CME for pediatric trauma.  All those in attendance are allowed to take a written test.  The top 1 or 2 scores can be awarded a gift certificate to a restaurant, an extra personal day, tickets to a local sporting event.  All sorts of options that are certainly cheaper than paying out hourly wages... and I suspect the turnout would be better.  Inter-agency and regional competitions should be promoted as well.


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## RedZone (Jun 26, 2007)

RedZone said:


> Yes, without knowledge, all we have is performing personnel.  I can't see any harm in giving the full picture.  But I question how "not really knowing the full picture can be detrimental".  Do you have a basis to support this?



Doesn't American Heart promote public access defibrillation and teach this in CPR courses offered to lay persons?  How long have CPR classes been available to the general public?  Don't the studies show such efforts as being effective?  And while I am sure a lot of material is covered during these classes besides the actual skill, there has to be plenty of "basics" which are not taught to these people.  And how much of the information thought do you actually believe is retained... and for how long?


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## Guardian (Jun 26, 2007)

Have we dumbed down our curriculum, yes, just read an old emt-a textbook.  Also, another form of dumbing down is being stuck in a rut and not moving your profession forward.  Do you need work experience as an emt-basic before you become a paramedic, no, this is an outdated view that almost all ems experts agree on now.  Should we intimidate other providers, well no, but we shouldn't coddle them like we are doing now.

Now, a word about internet forums.  From a scientific point of view, all of our points are unsubstantiated cause and effect arguments.  We are sharing opinions and forming ideas.  Advanced brainstorming if you will.  We’re not scientists and should not be held to their standard.  I could argue that all of your points are unsubstantiated cause and effect arguments (like that little thing on learning to drive), but I won’t.


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## RedZone (Jun 26, 2007)

Guardian said:


> Have we dumbed down our curriculum, yes, just read an old emt-a textbook.  Also, another form of dumbing down is being stuck in a rut and not moving your profession forward.  Do you need work experience as an emt-basic before you become a paramedic, no, this is an outdated view that almost all ems experts agree on now.  Should we intimidate other providers, well no, but we shouldn't coddle them like we are doing now.
> 
> Now, a word about internet forums.  From a scientific point of view, all of our points are unsubstantiated cause and effect arguments.  We are sharing opinions and forming ideas.  Advanced brainstorming if you will.  We’re not scientists and should not be held to their standard.  I could argue that all of your points are unsubstantiated cause and effect arguments (like that little thing on learning to drive), but I won’t.




Good points indeed.  I shouldn't expect any higher standards than if I was having a similar conversation with coworkers.  After all, I am not a teacher grading an essay!  

I really like the points rid is making, and for the most part, I probably agree with most of them.  I AM playing Devil's Advocate a lot on this one, maybe I am evaluating my own opinions as well.  I would love to see EMS move forward!

Back onto topic.  I like your point guardian.  A rigorous "initiation" process probably doesn't improve the quality of care provided by 'rookies'.  But certain standards should be expected.

As far as the "dumbing down".. I agree that the curriculum has been dumbed down.  I am only questioning whether or not this has a negative effect on patient care.  Should an EMT-B be able to decribe the path of blood flow through each heart chamber from vena cava to aorta, including pulmonary circulation?  My emotions tell me yes, but I doubt many could do this from the top of their head.  Do I think it will have a negative effect on their treatment?  No.  Do I think it should be omitted from the curriculum... absolutely not.  How else can you explain VF/VT, or chronic conditions they may encounter such as A Fib? 

But exactly how much more detail is necessary?  Are the valves important?  Pacemaker locations?


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## RedZone (Jun 26, 2007)

RedZone said:


> Should an EMT-B be able to decribe the path of blood flow through each heart chamber from vena cava to aorta, including pulmonary circulation?  My emotions tell me yes, but I doubt many could do this from the top of their head.




More accurately... I AM sure many EMT-B's CAN do this, but I suspect there are also many who cannot.


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## Guardian (Jun 26, 2007)

Ok, I think you and I are going to agree on a lot of issues.  Now to the specific question...this is a great question and the reason I know it's great is because I can't sum up an easy answer into one sentence.  I think every paramedic should have a minimum of 2 college semesters of A&P.  That way they can read and understand why they are doing what they are doing.  Why is this important you ask?  The vast majority of clinical mistakes are due to a lack of understanding about basic disease processes and/or A&P.  Can you think of many clinical mistakes that were caused by something else?  And after all, what are we put here to do?...we are here to work as skilled clinicians, not taxi drivers.  Where do we draw the line?  Well, we are all going to have our own opinions about where we would draw the line.  With that said, some of us on this site (myself included) think we should push ourselves a little harder.  With more education comes better clinical skills, more money, less riff-raff, and thus a better all around profession.


I'll add, this is an issue for everyone.  Even medical schools have a hard time deciding where to draw the line.  With the constant advancements in medicine and ever increasing subspecialties, they're having a harder and harder time deciding what to cram into the 4 years of medical school.  I think we are a long way off from having this problem.  If we wanted to, we could easily increase our basic level of understanding within a 2 year paramedic program (without cramming) which would make this a bonafide profession just like nursing and vastly improve our clinical care.


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## Guardian (Jun 26, 2007)

I should also add that I'm one who believes that emt-basic training is fine where it is.  In other words, as bls first responders, their level of understanding is fine.  However, when put in the position of primary prehospital care provider (like out in the boondocks without any als providers around) they are doomed to provide mediocre (at best) care because of their lack of education.  To make matters worse, we have some that come on here and say "we can't do no better because bls providers is all we have here in boondockville."  I think if we increase education, then ems will finally become a respectable profession with higher salaries.  Only then will boondockville be able to find paramedics and start providing the level of care its citizens deserve.


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## RedZone (Jun 26, 2007)

Guardian said:


> Ok, I think you and I are going to agree on a lot of issues.  Now to the specific question...this is a great question and the reason I know it's great is because I can't sum up an easy answer into one sentence.  I think every paramedic should have a minimum of 2 college semesters of A&P.  That way they can read and understand why they are doing what they are doing.  Why is this important you ask?  The vast majority of clinical mistakes are due to a lack of understanding about basic disease processes and/or A&P.  Can you think of many clinical mistakes that were caused by something else?  And after all, what are we put here to do?...we are here to work as skilled clinicians, not taxi drivers.  Where do we draw the line?  Well, we are all going to have our own opinions about where we would draw the line.  With that said, some of us on this site (myself included) think we should push ourselves a little harder.  With more education comes better clinical skills, more money, less riff-raff, and thus a better all around profession.
> 
> 
> I'll add, this is an issue for everyone.  Even medical schools have a hard time deciding where to draw the line.  With the constant advancements in medicine and ever increasing subspecialties, they're having a harder and harder time deciding what to cram into the 4 years of medical school.  I think we are a long way off from having this problem.  If we wanted to, we could easily increase our basic level of understanding within a 2 year paramedic program (without cramming) which would make this a bonafide profession just like nursing and vastly improve our clinical care.



Paramedics should have a minimum of 2 semesters of A&P.  Hmmm... let me work on that a bit.  

Myself, rid, and guardian all seem to share the opinion of: An important quality necessary to be a good medic is the desire to learn.  Maybe we should be prescreening for this quality.  

If an EMT had to first pass certain pre-requisite classes before applying to medic school, *maybe* a greater percentage of the applicants would possess that desire to learn.  I would suggest a medical-dosage calculation class myself if that were the case.  A local senior-college offers that class for nursing students, yet it probably would be of great benefit to medic students as well.  

At the very least, the burden of teaching this material (A&P/med-dosage calculation), would be removed from the paramedic program, and the students would be expected to already have comprehension of this material.  A&P was a big barrier for students in my class, and it WAS taught by a college A&P professor (who was also a certified medic/instructor) using a separate A&P text.  I believe this is a similar structure used in my area medic programs today. Why "weed out" those unable to grasp certain concepts when you can just start out with those who have already grasped them?

So, instead of emptying x # of seats, you can BEGIN by offerring those seats to better qualified candidates.  I like that.

And yes, I wholeheartedly agree that higher standards for education would be a great argument to lobby for increased salaries.  I do see problems with implementing this structure, and I also can think of a potential solution... but let me take a break before I write anoter book.


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## RedZone (Jun 28, 2007)

Ok, nobody wants to butt in.  I wonder if anybody is still reading.  I gotta learn to type less.

Keep in mind, I am not a trainer.  I also don't know how Paramedic training works across the country.  Most medic courses here are not affiliated with an accredited college/university.  Is this pretty much a standard?  I will assume it is for this post.

So, should an EMT-B who wants to be a medic be required to apply to college, be accepted, enroll, and pay tuition just to register for and take maybe 2 or 3 pre-requisite classes over a 1 year period?  And that is just to be eligible to apply for paramedic school.  Are enough "community" or "open enrollment" colleges available nationwide that have affordable tuition and no unnecessarily high standards for admittance?  Do they have enough A&P classes available to incoming freshman, or are those classes filled up by juniors before new students and freshmen are even allowed to register?  

Plus, unless this became a state or regional requirement, why should Joe Student go thru all that trouble if he can just apply to a competing, less-restrictive medic program?  

My suggestion is: tier the medic course.

Let's say you now offer: Medic Course 2008: Jan 1, 2008 to Dec 31, 2008...

Instead, maybe it's better to do it this way:

Medic Course, phase 1: Jan 1, 2008 to March 30, 2008.  
     This course emphasizes the "basics" necessary for paramedic students to comprehend.  Emphasis is placed on A&P (taught by a qualified A&P instructor) and mathematics necessary for calculating medical dosages.  This class is required to move on to phase 2.

Medic Course, phase 2: April 1, 2008 to Dec. 31, 2008.  Pre-req: phase 1.

I can think of many advantages to arranging the class this way.  If you usually start out with 30 medic students, you can maybe run two separate phase 1 classes with 20 seats each, expecting 15 from each class to meet the requirements for continuing to phase 2.  That of course would have to be worked out.

Plus... if you charge $6,000 now... maybe charge $2,000 for phase 1 and $4,000 for phase 2.  That seems win-win for both student and class to me.

Thoughts?


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## medic417 (Jan 24, 2009)

Interesting read.


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