Any Random Person

I love Dave Barry, he has been called the most influential humor writer since Mark Twain. If you haven’t read any of his stuff, you really should. In fact, I’ll even provide a link to his web site here: Yes, I’m providing that before what I’m sure will be my well-written, extremely interesting content below. He’s that good.

I put that up there because I am going to use a quote of his that he put into one of his columns; he asks his readers if they are saying to themselves “Hey, I can do this! *Any* random person can do this!” And he counters that they are wrong, because “It takes a very special kind of random person to do this”.

And that’s how I’m tying this into EMS.

I work with a few EMT-Intermediates (I-99 curriculum) and some EMT-IV Techs (WI has a version of a basic that can start IVs with NS and give a few IV meds) that are very sour on the fact that they aren’t paramedics yet. They’re not sour on the fact that they do not yet wish to sit through the required education to become paramedics, but they’re sour that there are skills that they can’t do that they see their ALS counterparts doing. They see us “paragods” performing ALS skills and say, “Hey, I can do that”.

And it may indeed be true. I see these days that they keep pushing skills that were once only the domain of paramedics down to the BLS providers. Heck, that’s what EMS is entirely built upon. In the far beginnings of our profession (and we’re still really in the beginning phases) the skills that Paramedics and EMTs perform were once only the domain of physicians. If you would have asked a physician in the 70’s whether a non-physician could interpret an EKG and give relevant medications and treatment as well as he could, you probably would have gotten a very incredulous answer. EMS is all about proving to the medical profession that treatments once firmly entrenched as only for use in the hospital have a demonstrated benefit to the patient when used quickly at the patient’s side close to the onset of symptoms. EMS personnel were trained for that most probably because it just isn’t cost effective to have doctors sitting around manning ambulances.

However, the question that has come up in my mind is where the bottom of that lowering of educational requirements for advanced skill performance ends. I have seen in my career a paradoxical movement in educational standards for paramedics and EMTs. There are a smattering of disparate and yet somehow complimentary certifications in some states, but while some educational standards have improved, most of them have decreased. While a good argument can be made for EMS levels between the Paramedic and the EMT-Basic, such as the I-99 and the IV tech in WI or the Iowa Intermediate in Iowa in the sense that they allow rural communities to be able to perform some advanced skills without having to shoulder the full breadth of costs and responsibilities associated with full paramedics, they also don’t take into account that a lot of those skills require a whole heck of education to be safely performed in the outlying patient that can be harmed by inexperienced providers.

The debate that I got into with an EMT-IV Tech over breakfast the other morning went something like this. He brought up the fact that EMT-IVTs could administer Narcan to reverse heroin OD’s or other narcotic overdoses. His statement to that was that they ought to be then able to give Morphine for pain control “since we already carry the reversing agent” (in case they give the patient too much or the patient has a reaction). My thoughts are that they should not be able to, because the administration of a narcotic for anything requires a requisite knowledge of the pharmacologic, physiological, and social actions of the drug. And while yes, that could be covered in a module I could assume, why should it be? I brought up that it takes physicians years of experience to be able to tell how to identify drug seekers who want to get a high from the legal, medically prescribed narcotic. Contemporary medical journals in family practice and emergency medicine have written volumes on the topic, and still physicians can be fooled. The extrapyramidal reactions possible with morphine, including respiratory and other Central-Nervous-System (CNS) depressing features of the drug have other treatments and symptoms that can be hard to recognize for an inexperienced provider. An EMT-IVT just doesn’t have the breadth of background knowledge needed in order to judiciously use the drug safely in all cases. The fact that most of the time it would work out fine does not withstand the certain percentage of patients that could and would be harmed. I ended the argument with him by bringing up something that I’ve always remembered from paramedic school. Our lead instructor told us that our drug bag was nothing but “A big bag full of poison” if you didn’t know how to use it.

Remember, every single time any medical care provider performs any treatment of any kind on a patient they’re making the statement that “Right now, I know better than your body does. I know better than your brain, your nervous system, and better than all of your body’s self healing systems do what you need to keep living and get better”. Any time you put on a bandage, you’re telling that patient that you know better than their body does that they need to stop bleeding. Every time a paramedic or other provider uses an airway management technique they’re saying that they know how to breathe better for the patient than the patient’s own body does. Every time you give a medication to a patient you’re telling them that you know how best to control their body’s systems. Think about it. Every treatment, every time. It is a HUGE deal to be able to do this stuff, and you dang well better know your stuff.

Physicians are rooted in the quest for knowledge. Their reputation as learned individuals goes back to prehistory in one form or another. They’ve earned their vaulted place in society due to their quest for knowledge and reason and their caring for others above all else. EMS people came from physicians. I can think of no other medical profession that has a downward pressure on their educational standards. I’m saying that, because I think that EMS does. We have elements in our own ranks, and external forces that are continuously working to make us into skills monkeys that can be paid very little and know very little.

This is a big statement: Not everyone can be a good paramedic or EMT. It takes a certain intellect, sound ethical reasoning skills, and a level of professionalism that not everyone can attain.

This is another big statement: There are groups in our society that want to make it so that any random idiot can become a basically qualified one. This keeps us all down and lowers the quality of patient care… a lot.

Yet another: Us good EMS people should be really ticked off that educational standards are so dang low these days. Fight for excellence. Respect ourselves.

If you and or your service want to be able to perform advanced skills, earn the requisite knowledge through your studies and earn the level that it takes to do them. Enough is enough. I don’t believe that we should lower any more educational standards. No other group would do this, not the nurses, not the PA’s, and certainly not the physicians. Why should we? Yes, I understand that with the advent of Urban Fire Based EMS the IAFF and IAFC want to put more paramedics on the streets to increase their influence and their revenues, and that in order to do this they need to match the intellectual skills of medics with the intellectual skills needed to be a good grunt firefighter, but EMS is a MEDICAL profession built from the quest for knowledge. It should not be relegated to the technical performance of skills if X equals Y.

Heck, I think that the current level of Paramedic should be the basic level, and that Paramedics should be as independent as Physician Assistants. In fact, I’d like to see that in the future.