However, I digress. What I’m trying to say is that the spork, the half-breed malformation of a spoon and a fork, has its place as a substitute for either when it is not economical to provide both. Like its lesser known brother the “knork”, it is a natural idea and a somewhat cool concept. However, there is a very clear reason that the spoon and the fork are separate utensils. There are specific purposes for the design of the spoon and the fork and good reason to have separate tools that are suited to the kind of tasks that they’re used for. The spork is the watered down version of both. It can somewhat perform the tasks of its parents, but not well. It is the “Jack of all trades, Master of none” if you will.
And that is why I’m writing about our humble friend the Spork in my usual rotation of EMS topics. A conversation I had on Twitter the other day with my tweeps @pgsilva and @rescue_monkey brought up the spectre of why exactly ambulances aren’t staffed with nurses and physicians’ assistants and are instead staffed with Paramedics and EMTs. PG and The Rescue Monkey thought that the conversation would make that vein pop out of my forehead like it does sometimes when I get enraged. They were mistaken. It doesn’t make me angry. In fact, I informed everyone that I would write a post on what exactly it makes me think about. This is that post.
The “Why don’t nurses and/or (insert title of healthcare provider here) staff ambulances debate” has a clear answer for me. Here it is:
EMS providers are sporks. We’re also not sporks. We exist in the realm of both the specific and the generalized. We are jacks of all trades and the master of the non-specific. EMS providers are generalized in nature and that generalization is specialized into the random nature of the work in which we perform.
Are you confused? Well that’s understandable. Let’s look at it this way. The ultimate healthcare provider has always been the physician. Since the beginning of western medicine, the physician has always been the healer that people have turned to. Physicians are learned professionals who seek to learn and apply knowledge to the human condition in the name of healing. Physicians are “clinicians” in the fact that they make a clinical diagnosis based upon an examination of a patient and then devise a proper treatment path to treat a patient’s diagnosis. They physician assesses a patient, makes a diagnosis of the patient’s condition based upon their knowledge base and ongoing research, and then uses that same knowledge base and research in order to devise the best treatment possible for the patient. It’s the definition of a clinician.
Nurses, and their modern incarnation as the Registered Professional Nurse (RN) developed as the ultimate assistant to the physician. Their goal was to be the caregiver, the person with enough medical knowledge to continue the care plan and treatment that the physician determined with the compassion and the ability to meet the ongoing needs of the patient. While the physician devoted their efforts to learning and education, the nurse required less education and more compassion. Medical technology and knowledge has expanded greatly and has required the nurse to develop a vast array of knowledge and a myriad of specializations, but their basic function has remained the same. They care for patients in the long term during their convalescence from an illness or injury.
Physicians and nurses have worked in concert. They have developed a system where the sick and injured are brought to them so they may take care of them using the resources they gather together. Each of them performs their role with the goal of making people get better. As knowledge of medicine has increased, different types of physicians and nurses have developed into specialties. The general practitioner acts as a gatekeeper to specialties and treats the most common maladies and is assisted by nurses qualified to care for the largest population of patients. Specialists, such as Cardiologists, Oncologists, and Surgeons, have developed to allow patients the benefit of having people treat them who have sought out to become experts in exactly the illness that the patient may have. The nurses have adapted and have become specialized in their own right, with nursing specialties that complement the specialties of the physician.
However, there is a drawback to all of this specialization. When you have a malady that affects your feet, you would benefit being under the care of the podiatrist. However, you wouldn’t get the best care possible if the only physician available were a cardiologist. The same holds true for the oncologist that attempts to treat your pulmonary condition or for the proctologist who treats your sore throat. While the basic concepts are there, the specialization of focus is not. To be sure, while a person who has graduated from medical school may be able to treat pretty much any condition that you may have at a level that is basically adequate, specialists have devoted their time in the quest of knowledge in their specific area at the possible expense of their knowledge of other areas. This is a good thing, and it’s the reason that pretty much every hospital is full of people with vast arrays of knowledge in singular topics. This system wasn’t designed. Like capitalism the system designed itself. It works and works well, most of the time. However when economics dictate a limited number of available specialties, certain conditions may be left out.
Nurses have done much the same. While the basic concepts are the same pretty much across the board, a School Nurse would have trouble transitioning into the operating theatre as much as the Oncology nurse would have trouble transitioning into public health. Both of them can probably change a bedpan, start an IV, pass medication, or lend a caring smile in the same manner but the oncology nurse would be much more well versed in the management of chemotherapy drugs and chronic pain management than a would be a surgical nurse.
This brings us to Paramedics and EMTs. We are a profession born out of necessity and forged in battle. Really. We can thank Napoleon for bringing forth the first example of the “flying ambulance” which was a brigade of horse-drawn ambulances staffed by medically trained soldiers. They appeared on the battlefield during the Napoleonic wars and boasted that “No soldier lay with undressed wounds for more than a quarter of an hour”. Battlefield “Medics” have always been on the forefront of emergency acute care in the field. While some examples of ambulance care available to the civilian population exist, in the US it wasn’t until after the Vietnam War that civilian emergency ambulance service became popular and seen as a need rather than a nice thing to have. While physicians often made house calls where they travelled to the patient to provide care, in the interest of efficiency they began to confine themselves in clinics and hospitals where they could more efficiently care for larger patient volumes. With the publishing of the “EMS White Paper” entitled “Accidental Death and Disability: The Neglected Disease of Modern Society” in 1966, the attention of the public was focused on the need for an effort to extend care out of the walls of the hospital or clinic. The white paper laid out statistics of trauma, stated the need for injury prevention and education, and stated the need for standardization of emergency medical training. The US. Dept. of Transportation took up the mantle of the new Emergency Medical Services system due to the alarming number of fatalities on the burgeoning highway system and modern EMS was born.
The EMT and the Paramedic are the equivalent of sticking a spork in the problem and calling it done. EMTs were cheap to train, cheap to employ, and could be widely distributed out there in the field. At the time, it was the perfect solution. Train people in how to perform in the first few moments of a severe injury or acute illness and give them the ability to safely transport a patient to a hospital where the physicians could work in concert to help heal the patient. The nurses, in their role as the assistants to the physicians, stayed in the walls of the hospital or clinic and developed within their specialties. The system grew and developed as the innovators in the field saw more and more acute treatments that could be performed by these new breed of healthcare providers and as the EMTs and Paramedics proved themselves in service.
EMTs and Paramedics are clinicians in the sense that we evaluate a patient and develop a treatment plan that we follow to help them. Our specialty is in the acute, the treatment of disease in the here and now. If it’s happening to a patient and it is directly threatening their life, chances are that an EMT or Paramedic can intervene in a meaningful way. Our specialty is to stabilize and stop the progression of the acute disease process or chain-of-events in an injury that will eventually lead to death. We plug holes and we do it with a knowledge base taught to us by physicians. Our generalization is across the entire spectrum of possible patients, from field delivery of neonates, to jumping in to help stabilize patients in outpatient surgery centers, to taking care of the elderly in nursing homes. Whether a patient is crushed in an industrial machine, is trapped in a rural car accident, is having a heart attack on a baseball diamond, or whatever happens to a person wherever it happens to them, the Paramedic or EMT is the person most specialized in coming to their aid. We gain knowledge and hone experience not just in the treatment of our patients’ medical conditions, but also in the environmental circumstances in which we find them. We may be generalized sporks when it comes to treating any possible injury or acute illness across any patient population, but we’re highly specialized utensils when it comes to treating emergency conditions anywhere at any time.
No other healthcare provider fits into our role… and that seems to make us a full-fledged utensil in my opinion. We are unclassifiable into any other role yet indispensable for our own.
And we need to get out there and let everybody know just how special that role is. Nobody has developed the breadth of knowledge in our specialty that we have. We have made the spork our own.
And that, folks is my answer to why no other healthcare professional can quite full our role. While as a paramedic I am competent in the basic skills needed to say, work in a endoscopy unit, I would not function there to the level of a person experienced and knowledgeable as an endoscopy nurse. Neither would they be able to manage a traumatic airway upside down in a crushed automobile at night as well as I would. It’s my specialty to do the latter, not the former, even though the basic skills may be the same.
For more on this, g’head and read “Any Random Person” an older post of mine. Then get out there and shine up your sporks.