Paramedics and EMTs are Special, a salute to the Spork!

Ah, the humble Spork. At once it is an example of utility and futility. It is well suited to nothing but bridging the gap between the usefulness of its parent utensils and the burden of having to provide a separate spoon and fork. Sporks are great for when you need to have an eating utensil that is suited to a variety of food consumption scenarios but do not have the space nor the gumption to provide separate utensils. Sporks can perform lots of tasks but they do nothing very well. While I love the concept and the fact that the name is *really* fun to say (Spork? Spork… Spork!!), eating anything with a spork is a challenge. I mean, have you ever tried to eat soup with a spork? You’ll end up wearing a percentage of it. Heaven forbid that you have to use it to hold something you have to cut with a knife like a piece of meat. It’s nearly impossible. I suppose that eating salad with a spork would be fairly manageable but not if you have a lot of non-lettucy stuff in the salad like cherry tomatoes, mushrooms, and/or pepperoni. Honestly, who wants a salad that is comprised only of rabbit food? 

Die hard Sporksters, that's who

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.

Or women with sporks, you know. That too.

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.

"Stick a Spork in me, I'm done" should be part of your daily speech patterns

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.

"Sporks and Phasers" would be a good name for a Rock Band

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.

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  • http://transportjockey.wordpress.com/ Transport Jockey

    Incredible post my friend. You put the reasons why we exist pretty much in perspective.

  • Totwtytr

    When you consider how little knowledge we actually have, it's amazing that we are given the great amount of responsibility for treating patients that we routinely see.

    In addition to the famous white paper, increasing technology started to tie doctors to facilities, so the house call started to die. They were common when I was done, but are rare now. EMS was not created to fill that gap by design, but by default ended up filling that role.

    The truth is, EMS is all things to all people. How often have you been called to a totally non EMS situation because the police, family, “concerned citizens”, the FD, or someone else had no idea of what to do? We have become the responder of last resort for everyone. The police love EMS (at least in my area) because we make problems go away. Sometimes literally by taking a person to the hospital even though that's not where they need to go. Sometimes figuratively because we figure out who to contact and then contact them.

    We may be Jacks of all trades, but I'd say we are master of most of them.

  • Paulgeorgesilva

    I guess that I can see where you are coming from with the whole “spork” thing. But here's the rub: what happens when the education and scope of practice starts to approximate more and more that of the PA and RN? What happens when EMS stops working the “E” part and just becomes “medical service”. Are sporks still needed or does the line between “spork” and “place setting” become so blurred as to be indistinguishable? Like every other field, the push is on for more and more education and a change in the role of the medic from its current role and when that happens is the “sporK still the right answer?

  • Filoo

    You just nailed it “”EMS providers are generalized in nature and that generalization is specialized into the random nature of the work in which we perform.”
    I haven't read a better description that captures the reality of EMS like that!!!

  • JP

    Absolutely wonderful! you said what has been on my mind for a long time!! good Job!!

  • http://twitter.com/podmedic Jamie Davis

    An amusing article and an appropriate metaphor. I think some of my nursing colleagues might take offense at being referred to as merely the assistants in the patient care process with docs but I won't open tha can of worms here.

    All in all a good way to describe what we do and why we ended up doing it. Kudos sir!

  • Kmcallister911

    Nurses are not, and have never been, assistants to doctors. Nursing is a distinct and autonomous profession, with it's own knowledge base and body of research. Nurses function autonomously.

    Now, as soon as I calm down, I'll come back and finish the post ; )

    BTW – EMS breaks away the superficial and excels at the necessary, and while I love the spork analogy, I think of EMTs and Paramedics as human swiss-army knives – everything you need when you need it.

  • Jamie Davis, the Podmedic

    We talked about this article on the Insights in Nursing podcast recorded today. I'll link back to the article in my shownotes when it is released on Friday. We talked about the common misconceptions people have about the nursing profession and it struck me as mighty similar to the same discussions about EMS. Things that make you go, Hmmmmm . . .

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  • http://www.investmentinterest.net/ investment earnings

    Thanks for best news!

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    Ianto Jones
    The Natural Alignment Movement – Freedom of Choice from the Orthopedic Conspiracy
    Oh, dear G-d. This was hilarious, but I'm fighting not to find it dangerous as well -- someone's gonna share it on FB, and one of _their_ friends is going to send it to Bright Star MorningGlory Rainbow, who will send it to her YahooGroup, and someone there will reply that he *thinks* he broke…
    2014-11-18 09:54:00
    Thad Torix
    Patient Friendly Jokes
    Have you heard my construction joke? I'm still working on it.... (Credit to my youngest daughter for that one. My partners are absolutely sick of hearing that joke...) On another note, what a fantastic blog. If you are ever in SW Missouri, stop by and say hello. Thad Torix - EMS Instructor & Clinical Coordinator…
    2014-11-03 18:27:00
    mr618
    Welcome to the Club
    Well said, Chris. We can't save everybody, but the ones we don't save tend to stick around a lot longer than the ones we do save.
    2014-10-18 14:40:00
    Steel City Medic
    Welcome to the Club
    Particularly appropriate for me this week. Thanks.
    2014-09-23 21:46:00
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00
    Us and them
    Us and them
    We Need Some New Stories
    We Need Some New Stories
    Safety: Hillsborough at 25
    Safety: Hillsborough at 25
    Respect in Ferguson and everywhere else
    Respect in Ferguson and everywhere else
    Missing
    Missing

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