EMS Education, Outdated Ideals and "Common Sense"

[usalsfyre]

I'm going to ramble/rant a bit so bear with me.

We discuss EMS education a lot on this board, mainly in the context of curriculum. While I think we pretty universally agree the curriculum is deficient, what if the primary issue is not the curriculum but rather the instructors/educators delivering it?

My shop hires a lot of fresh out of school providers. Pretty regularly they come across with ideas that are either long out of date and/or never appeared in any EMT curriculum. This is not stuff they're coming up with, someone's got to be repeating it to them ("COPD sats should never be above 90%, code three transport saves lives, the more paramedics around the better, ect). If educators refuse to update their education and/or training why do we continue to let these individuals deliver instruction? I have started to decide "those who can't do, teach" rings just a little bit too true in EMS (which is hopelessly frustrating to those of us who can do and teach). What's the solution for getting rid of the turds in the punch bowl?

Which brings me to my next thought. We are slaves to the cult of "common sense" in EMS. I was talking with one of my newer providers who is a college educated and reasonably intelligent young lady. She relayed to me she has been told (to the point of her believing it) she couldn't operate as a medic (she is a basic) because she has no common sense. A point I strain to believe a bit. How much of the "common sense" and "book smart" accusations leveled at newer, younger, more educated providers are simple bullying? I remember getting accused of this daily as a newer medic by an "old hand" 400 hour votech medic...looking back the guy was an idiot and a blowhard who couldn't paramedic his way out of a wet paper bag. He had me so convinced I lacked common sense I looked into giving up EMS completely. Is the reliance on "common sense" simply a way to let older, less educated providers make newer ones feel inferior rather than help teach them to make up for their lack of experience?

Sorry this post is a bit disjointed, I've been playing around with these thoughts for a few days and I'm just wanting to see what others think.

 

[NomadicMedic]

I see this happening a lot. Especially the demeaning put downs from the "more experienced" medics. I'm a reasonably well educated paramedic with a fair amount of life experience under my belt. I am constantly accused of being "too aggressive" and "too much of a go getter" because I am trying to better myself and the system.

I always hear "that's the way it is because we've always done it that way". I was told by a very senior guy that we shouldn't bother with 12 leads on patients with a pacemaker, then when I do a presentation on STEMI mimics, including Sgarboasa's Criteria I'm accused of being a suck up.

We need to fix the education. Somedays I feel like I work with a bunch of union pipe fitters. :/

 

[VFlutter]

It seems that many EMS instructors are given their position based on experience over education. Field experience is great for positions such as FTO but should it be the deciding factor for a teaching position?

My EMT instructor was great and had a lot of useful, practical, and real world information but was highly inadequate in his understanding of even basic anatomy, physiology, or chemistry.

In a perfect world teachers should hold a degree higher than what they are teaching. An associate teaching vocational, bachelors teaching associate, masters teaching bachelors and so on. If you are getting a psychology degree you are not being taught by a guy who got a bachelors in psychology then worked for a few years and decided to come back to teach, you are being taught by masters or doctorally prepared experts.

Improve the level of instructors and you will improve the quality of students. It won't be cheap but we need to encourage instructors to hold advanced degrees and pay them adequately for it.

It is crazy that it takes more education to teach kindergarten than it does to teach a paramedic program.

 

[Summit]

A nearby CC decided that Paramedics, not EMTs, should be the lead instructor for EMTs... there were some hurt feelings. It is a start in the right direction. But who will teach the Paramedics?

 

[medicsb]

If I recall, paramedics were once trained by physicians and nurses when there were no paramedics and then the reigns were passed to medics who had gained experience. Since then there hasn't been much in the way of standards for paramedic instructors. I think more physicians should be involved with medic training, but you can't rely on docs to carry the profession along, which EMS has basically been doing since the beginning. Very few advances in EMS have been medic led. Medics like to bail out to other professions instead of sticking around and making EMS better. Instead of thinking "our education sucks, I'm going in to EMS education to make it better" most think "our education sucks, I'm going into [nursing or firefighting]". This is the "brain drain" of EMS.

There is a small advance in the works requiring program directors (via CoEMSP) to have a bachelor's degree. It's a baby step for sure, but a step nonetheless. Hopefully, the baby steps don't stop there and hopefully they turn into big-kid steps and then into adult steps.

 

[Veneficus]

I'm going to ramble/rant a bit so bear with me.

We discuss EMS education a lot on this board, mainly in the context of curriculum. While I think we pretty universally agree the curriculum is deficient, what if the primary issue is not the curriculum but rather the instructors/educators delivering it?.

That is much of the problem.

There seems to only be one way to become an instructor. That is to know an instructor. So who will be hired? People you know, which is to say "like minded" people.

This creates a viscious cycle.

Even when you try to quietly bring these instructors up to speed, by privately letting them know things like a "coma cocktail" is no longer part of ACLS or reasonable medical practice, they smile very nicely, tell you that you are too smart to be a paramedic, then they go and find some way to discredit you with the students. (Usually on a smoke break)

Their statements are always the same:

"You don't know how it works in the field."

"That's not what REAL paramedics do."

"We don't have all that diagnostic equipment."

My favorites are things that have nothing to do with medicine or EMS.

"I am a fire captain."

"This is not a thinking man's game, it's all about action"

If educators refuse to update their education and/or training why do we continue to let these individuals deliver instruction?

We don't. The snake oil medic programs that are just in it for the money do.

Firstly, program directors will not hire somebody more educated than themselves. They are a threat to their position as director, lead instructor, etc.

Secondly, it costs a lot of money to get qualified people. In my home, you could hire a firemedic, pay him $20 an hour, and he would be the most loyal employee you ever bought. Plus he will pass out the same kool-aid to all of your students. (who never having seen a quality EMS instructor before, will heap praise on these morons, so even if there is student feedback in the program, it always comes out positive)

Thirdly, most educators in EMS are part-time. The full time ones usually do have some sort of degree, but they are very few. Those people with degrees are expensive. I am not showing up for $20 an hour. Certainly I am not showing up for only 1 hour. The guy (not me) with a master's in adult education isn't going to "pay his dues" as the lab instructor, before becomming the lead instructor.

What's the solution for getting rid of the turds in the punch bowl?

Legislative action would be ideal.

But the only realistic way I can see is community outreach to potential students. You hae got to have quality people spend time in high schools or job fairs, etc. You have to eat the cost of some free seminars for the community or interested parties before they sign up for class.

You mus also aggresively report substandard programs and practices to state authorities. It is my experience that when subpar educators are put under the microscope, they crack. Their perfect on paper programs unravel very fast when regulators take a closer look.

I was even paid by one program administrator to act as a new student and report on what was really happening in the night class and present my findings to the dean of science for the college. (multiple people lost their jobs) an outside auditor can go a long way too.

Which brings me to my next thought. We are slaves to the cult of "common sense" in EMS. I was talking with one of my newer providers who is a college educated and reasonably intelligent young lady. She relayed to me she has been told (to the point of her believing it) she couldn't operate as a medic (she is a basic) because she has no common sense. A point I strain to believe a bit. How much of the "common sense" and "book smart" accusations leveled at newer, younger, more educated providers are simple bullying? I remember getting accused of this daily as a newer medic by an "old hand" 400 hour votech medic...looking back the guy was an idiot and a blowhard who couldn't paramedic his way out of a wet paper bag. He had me so convinced I lacked common sense I looked into giving up EMS completely. Is the reliance on "common sense" simply a way to let older, less educated providers make newer ones feel inferior rather than help teach them to make up for their lack of experience?.

Been through this numerous times myself. Now that you mention it, it is bullying. (I never considered that before)

I think there is a lot of psychology to it though. Many providers, new and old, cope with the stress of the emergency environment by convincing themselves they did the right thing even when there is a bad outcome. Admitting that based on new information today, what they did in the past didn't help or may have harmed is simply too psychologically stressing. So they double down so to speak, and begin to espouse an extremist position that everyone must do what they have done, because somebody must be wrong and they do not want to admit it may be them.

I think the only way to fix this is medical director involvement, but 99% of medical directors are either absentee landlords, cowards who are afraid of change, outdated themselves, or absolutely impotent.

This thread is a really great point, but without easy solutions.

 

[med51fl]

I think the underlying issue here is have we lost the original intent of paramedics? The original paramedics were brought into being with the idea of providing immediate "life saving" interventions and rapid transport to the ER. Much of what todays EMTs do (AED, epi-pen, LMAs) is what the original paramedics did. We as a society have decidied that we needed to expand on that role and use EMS as an outreach of the ER and public health. Our skills have advanced as well as our responsibilties, but the education has lagged behind. Perhaps the time has come to retire the paramedic. It is a concept that seems to be along the lines of the steam engine and the airline stewardess. Perhaps the answer is a 4 year education along the lines of a PA program that specializes in emergency medicine or a specialized emergency nursing program. Perhaps we need to add a heavy dose of community medicine to allow for outreach to at risk populations. These changes will be hard and come with heavy resistance and a lot of broken pride. I do not have all the answers for sure. I am a "vo-tech" medic who tries hard to keep up with the advancement of our profession. I have no interest in nursing school or becoming a PA. I realize that as I wrote above, the times are passing me by. I will gladly step aside and let those with more knowledge and ability step up. Evolution is the nature of everything.

 

[Medic Tim]

I see this happening a lot. Especially the demeaning put downs from the "more experienced" medics. I'm a reasonably well educated paramedic with a fair amount of life experience under my belt. I am constantly accused of being "too aggressive" and "too much of a go getter" because I am trying to better myself and the system.

I always hear "that's the way it is because we've always done it that way". I was told by a very senior guy that we shouldn't bother with 12 leads on patients with a pacemaker, then when I do a presentation on STEMI mimics, including Sgarboasa's Criteria I'm accused of being a suck up.

We need to fix the education. Somedays I feel like I work with a bunch of union pipe fitters. :/

I was told by my manager yesterday that getting a degree in Public Safety Administration with a concentration in EMS was not something the company was interested in (doing my internship now, they denied my LOA request) and that I was wasting my time. I was also told, why should the company help me get this if I am just going to use it somewhere else( my plan was to go back and make a career there.....and they know that. With that kind of attitude of course i am going to go elsewhere. It is just a shame that myself and others in my position are being forced out. I already have more education than most of the managers. But to them i am an over educated parapup who is gunning for their job so at every chance they let it be known that I don't have the experience they do. When I bring up studies and question why we are doing something I am told that we have always done it this way or that with all my schooling I should know why they do it that way. Even when standards change they are resistant because they dont understand why and revert back to the , we have always done it this way.
the kicker is the big wigs can't understand why they are having trouble keeping medics.

 

[Trashtruck]

It's the good ol' boys club!

 

[WolfmanHarris]

Among my colleagues I find what is actually meant when they say common sense is a poorly articulated combination of clinical judgement and mastery of the logistics of managing a call. While they may say "common sense" when they elaborate what is actually said includes:
- They can't seem to make a decision.
- The student isn't able to anticipate what they may need to do next or complications that may arise.
- They can't manage the equipment
- They can't formulate and move forward with a plan (transport? Mode of conveyance? What equipment do they need?)

Certainly I still meet some medics who are behind the times or spout the old "we don't need that book learning" but where I work they are few and fewer each year and with the direction the profession is going I think this trend will continue to improve.

 

[Brandon O]

Among my colleagues I find what is actually meant when they say common sense is a poorly articulated combination of clinical judgement and mastery of the logistics of managing a call. While they may say "common sense" when they elaborate what is actually said includes:
- They can't seem to make a decision.
- The student isn't able to anticipate what they may need to do next or complications that may arise.
- They can't manage the equipment
- They can't formulate and move forward with a plan (transport? Mode of conveyance? What equipment do they need?)

Adding to this and to the original point, I think it was someone on this board (maybe not) who observed that many of these "difficult students," who seem to take forever to master the basics of the job, end up as the eventual rockstars -- indeed as your boss. (Your medical director, the attending you hand off to, etc.)

I don't know if that's necessarily true, but there may be some correlation, and I think it lies in this: these people are usually young. They're college students or recent graduates, often planning on future careers in medicine and working in EMS while they gather experience or decide on their specific path. They're smart, which is why they have potential. But they're also young, so they lack certain core skills. Functioning as an employee, talking to people in distress, looking out for their own safety and that of those around them, problem-solving and prioritizing, covering their butts, and so forth. This is a very "real-world" job in the sense that we deal with complex and muddled circumstances, and dealing with such things is a life skill, not something you learn in EMT class. Someone who graduated from school two months ago and is working their first real job is still in the process of developing these skills and their overall mindset and toolbox for life -- abilities you take for granted, so it can be baffling to watch them fumble with certain things. (It's a side effect of working in a job whose prerequisites are entry-level.)

Contrariwise, the folks who seem to pick up the job much more quickly -- the sharp new hires who just seem to "get it" -- are often older. They may be new to EMS or to medicine, but they've had jobs or whole other careers, dealt with crisis, fought, loved, lost, triumphed, served, blah blah. (As Thom **** says, you probably have to suffer a little before you can understand suffering in others.) They still have to learn how to be medical professionals, and in fact, if they don't they'll never be particularly good EMTs, but heck -- half of the veterans of this job are in the same position (canny but medically ignorant). And mastering the flow of a call and scene management still requires experience, but it may be similar to other tasks they've learned before.

In case it's not obvious, I've been on both sides of this situation. I was hired in my senior year of college and thrown into the mix of an all-emergency system; I rode with my FTO for something like 15 12-hour shifts and was approved somewhat hesitantly even after that. I was more or less useless for a long time, the stories of some of my idiocies are legend, and the company eventually got tired of me and we parted ways.

Nowadays, I work almost exclusively with brand-new hires, and end up in a teaching role to whatever extent they (and I) have an appetite for. And my patience gets pretty thin sometimes. I do wonder if some people just aren't cut from the right mold for this job. But I also try to remember how useless I was at the beginning, and that it's the wrong approach to think, "How could somebody not get this?" Because I'm imagining a learner like myself, yet the extent of what they have to learn is so vast, they're coming from a totally different place.

 

[EpiEMS]

Brandon, that's a fascinating take on this. I think the educational background and age factors are hugely important. I, for one, have found that more educated providers with life experience have been the people I look up to the most. Generally, I feel like it's the life experience that really helps with developing a rapport and managing a scene, but education that helps most for the provision of medical care, unsurprisingly.

 

[silver]

Adding to this and to the original point, I think it was someone on this board (maybe not) who observed that many of these "difficult students," who seem to take forever to master the basics of the job, end up as the eventual rockstars -- indeed as your boss. (Your medical director, the attending you hand off to, etc.)

I don't know if that's necessarily true, but there may be some correlation, and I think it lies in this: these people are usually young. They're college students or recent graduates, often planning on future careers in medicine and working in EMS while they gather experience or decide on their specific path. They're smart, which is why they have potential. But they're also young, so they lack certain core skills. Functioning as an employee, talking to people in distress, looking out for their own safety and that of those around them, problem-solving and prioritizing, covering their butts, and so forth. This is a very "real-world" job in the sense that we deal with complex and muddled circumstances, and dealing with such things is a life skill, not something you learn in EMT class. Someone who graduated from school two months ago and is working their first real job is still in the process of developing these skills and their overall mindset and toolbox for life -- abilities you take for granted, so it can be baffling to watch them fumble with certain things. (It's a side effect of working in a job whose prerequisites are entry-level.)

Contrariwise, the folks who seem to pick up the job much more quickly -- the sharp new hires who just seem to "get it" -- are often older. They may be new to EMS or to medicine, but they've had jobs or whole other careers, dealt with crisis, fought, loved, lost, triumphed, served, blah blah. (As Thom **** says, you probably have to suffer a little before you can understand suffering in others.) They still have to learn how to be medical professionals, and in fact, if they don't they'll never be particularly good EMTs, but heck -- half of the veterans of this job are in the same position (canny but medically ignorant). And mastering the flow of a call and scene management still requires experience, but it may be similar to other tasks they've learned before.

In case it's not obvious, I've been on both sides of this situation. I was hired in my senior year of college and thrown into the mix of an all-emergency system; I rode with my FTO for something like 15 12-hour shifts and was approved somewhat hesitantly even after that. I was more or less useless for a long time, the stories of some of my idiocies are legend, and the company eventually got tired of me and we parted ways.

Nowadays, I work almost exclusively with brand-new hires, and end up in a teaching role to whatever extent they (and I) have an appetite for. And my patience gets pretty thin sometimes. I do wonder if some people just aren't cut from the right mold for this job. But I also try to remember how useless I was at the beginning, and that it's the wrong approach to think, "How could somebody not get this?" Because I'm imagining a learner like myself, yet the extent of what they have to learn is so vast, they're coming from a totally different place.

Wow talk about generalizations there.

 

[Brandon O]

Brandon, that's a fascinating take on this. I think the educational background and age factors are hugely important. I, for one, have found that more educated providers with life experience have been the people I look up to the most. Generally, I feel like it's the life experience that really helps with developing a rapport and managing a scene, but education that helps most for the provision of medical care, unsurprisingly.

Yes, no doubt. And one of the reasons that crusty old farts with a ton of experience have been able to do relatively well in this field is that, especially at the BLS level, you can do most of our job with almost no medical acumen. And frankly, if you can manage a chaotic situation, connect with patients as human beings, and not make anything worse, you can actually do it pretty well.

Obviously I don't think that's enough, but it's where we're at. That may change.

An interesting parallel: my girlfriend is currently in medical school, and I'll be starting at a PA program soon. One of the differences that's struck me is that in the traditional model, most med students come directly from their undergrad, so they're well-educated but with little experience actually working; conversely, PA programs usually recruit students with at least some experience taking care of people. The idea seems to be that in the former situation, you teach the medicine and then let them figure out how to function (hence the stereotypical naive intern), whereas in the latter you take people who've already been through that crucible and teach them how to practice medicine.

Wow talk about generalizations there.

Sure, insert "YMMV" and "clinical correlation recommended" as appropriate. Hard to talk about anything without generalizing.

 

[EpiEMS]

The MD/PA model parallel seems pretty valid. The problem in EMS, from what I've seen thus far, is when the crusty old farts are ALS providers with a wide array of therapeutic modalities but underutilize them (as in pain management) or misuse them or just don't know the relevant changes in evidence, etc. But that could just be my whining about ALS.

But BLS, sure, can basically be managed with a good rapport, not causing iatrogenic harm, and keeping things safe on scene. Hence why there's no lengthy BLS programs, I suppose.

 

[Brandon O]

Yes, exactly. And as others have observed, particularly as we move increasingly in the direction of more education, there's a conflict. The really astute operational captain (think fire chief) and the clinical wizard who reads every journal (think MD/PhD) are not often the same person; they select for and reinforce difference personality types. So if we want both in the same pair of boots, we usually have to pick one and try to train the other traits as much as possible.

Right now most of the clash comes from trying to teach fire chiefs to be doctors (as it were) but if you tried to teach a doctor to be a fire chief, they'd probably be similarly unimpressed.

(As an addendum, I think that the experience-dominant approach really reinforces reliance on anecdotal knowledge versus evidence-based medicine. That's why the veteran instructors usalsfyre described often teach what's worked for them and have a hard time changing their practice based on a study. "I've seen it work" and "We've done this forever" has real traction for these people; it's how they learned their most important skills.)

 

[JPINFV]

I think the other issue with the "bright" youngster is there's an issue of picking out the wheat from the chaff from the scene and the history and physical. It's much easier to do if you're either experienced, or simply don't care about anything not specially taught in EMT school.

Sure, insert "YMMV" and "clinical correlation recommended" as appropriate. Hard to talk about anything without generalizing.

Planning on being a PA in radiology?

 

[Brandon O]

I think the other issue with the "bright" youngster is there's an issue of picking out the wheat from the chaff from the scene and the history and physical. It's much easier to do if you're either experienced, or simply don't care about anything not specially taught in EMT school.

I think "wheat from chaff" is one of the core skills of the job, but it's combination of both schools. It means, for instance, being able to recognize the important phrase in "Ms. Smith says she's tired, and hasn't eaten, and can't move her left side," but also realizing that the drunk who starts complaining of chest pain when the triage line is long may not need three hits of nitro.

Planning on being a PA in radiology?

Eh.

 

[MrJones]

...
- They can't seem to make a decision.
- The student isn't able to anticipate what they may need to do next or complications that may arise.
- They can't manage the equipment
- They can't formulate and move forward with a plan (transport? Mode of conveyance? What equipment do they need?)

That, in my opinion, is one of the most valuable take-aways from a high-quality Wilderness EMT program; the ability to plan, anticipate, decide and execute. Something about being isolated from the usual "comforts" of pre-hospital emergency medicine seems to reinforce the importance of those traits.

 

[JPINFV]

I think "wheat from chaff" is one of the core skills of the job, but it's combination of both schools. It means, for instance, being able to recognize the important phrase in "Ms. Smith says she's tired, and hasn't eaten, and can't move her left side," but also realizing that the drunk who starts complaining of chest pain when the triage line is long may not need three hits of nitro.

I was going more for the deeper issues. Looking at things like pitting vs non-pitting edema or doing an actual neuro exam past just looking for pupils, CN 7 and hand squeezes. There's a difference between trying to get all of the wheat and just getting enough of the wheat.