So, I've been preparing lectures on A&P and pathophysiology for an EMT class, and it reignited something I've been chewing over for the past year or so.  I've come to view EMS education (the initial education, at least) as a pull between functional training and foundational education.  The opposing ends of the spectrum of medical training seem fairly clear-cut; if you're teaching a first aid class, you focus on functional training.  You see A, therefore you do B.  Physicians and other high-level practitioners, on the other hand, receive years of foundational training and then are allowed to use that foundation to practice medicine.  When I try to apply that to the various levels of EMS education, however, the waters muddy.  Where's the balance for an EMT, AEMT, or paramedic?  Obviously, a paramedic's education should lean more towards the foundational end of the spectrum than an EMT's.  But what should we be including, and in how much detail, especially at the EMT and AEMT levels?  That graphic in the National EMS Education Standards is nice, but doesn't give me the amount of hard info that I'd like.  I rarely 100% trust any of the commercial education products, and am prone to making my own lectures.  Many times I include more foundational material than the stock Powerpoints; other times I leave things out.  What are your thoughts on this topic?  I don't know if there's a "right" answer to this, just wanting to see what others are thinking and doing in this respect.

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Ahh, but after now experiencing the foundational model for some years in Australia, the functional transition has been lost.

Great to have the knowledge, the application is atrocious. Same as Nursing Medicine and most professions that expect some sort of hitting the ground running approach to internship in any profession is the way to go.

The foundational model must include functional learning and transitional training--a sort of "This is the reality of what you learn" model.

The foundational education MUST be there.  I can agree with Cannulator too. Too much foundation and not enough function leads to little more than a concrete slab with a few boards here and there on top of it.  How do we build the rest of the house??  

I think the foundation in anatomy and physiology is the most important part.  If you know how the body works you can anticipate things when it comes to treatment. 

Clinical time is important for creating the ability to act on the knowledge one has.  If you emphasize one over the other I would error on the side of more foundation than application.  Getting new employees up to speed when it comes to function is where the FTOs come in.  

I hate to compare ourselves to other members of the medical field but Cannulator did it already so here it goes...   EMS companies and agencies need to realize that they will have an orientation period with any new hire and a much longer one with a brand new paramedic.  I read an article the other day saying that new nurses were struggling to find jobs.  Even the hospitals know that brand new providers are not going to be at the same level a provider with experience will be.  

I dont think there is anything that can really change that.  Its part of the problem of using humans to perform tasks.  We require lots of time and repetition to be able to function at our peak.

There is a continual transition from first responder to paramedic where there is a higher emphasis on foundational education as we all know. I agree that the powerpoints we find associated with most EMS texts (particularly at the paramedic level) are pretty basic for the level of care that we are expected to provide. The biggest problem I see is that people coming into medic programs (from EMT-B) often haven't heard of acid base balance, don't know what normal pH, or CO2 levels are and cant get past the fact that a 3 lead EKG cable has 4 wires on most monitors. I progressed through basic, then intermediate, paramedic, and now into CCT by building a foundation that expanded as I progressed. Many programs for basics don't teach much if any foundational knowledge which leaves those instructors on the upper end of the spectrum 'holding the bag' so to speak when it comes to foundational knowledge. We need to incorporate more A&P in basic programs and we need to start introducing lab values to intermediates (soon to be advanced EMT's); otherwise we are doing ourselves, our students, and our patients a big disservice.

just say'n

Justin Poland; A.A.S., LP, NREMT-P, EMS-I

I would submit that there is no enough of either in today's USA EMS education programs.  We seem to have succumbed to the "quick and easy 80%" of what is needed to do the job, or maybe less.  Our didactic programs are weak and shallow, and our clinical education and field internships have been watered down to the point of their being meaningless (in terms of being able to produce a functional paramedic).

The beneficiaries of all this are our patients, who get to provide background for unsupervised "learning by experience" that constitutes the bulk of the education of today's American paramedic.

I love the discussion thus far....I found this in a comment on Roguemedic's blog and thought it fit perfectly:

You can’t take people with little or no science background and:
- put them in a program that is only 9 months long,
- and is based on textbooks written at a 10th-grade reading comprehension level,
- and is taught by instructors who have little or no advanced education themselves,
- and only requires a couple hundred hours of (very often completely useless) clinical experience,
- and evaluates the students solely using poorly-written exams,
- and expect to produce a clinician who is supposed to be able to function at the level of a physician within a very narrow scope of practice

This came up in the debate about spinal immobilization.  Why don't we have the same knowledge base about spinal injuries that PA's do?  Why can they clear someone off of a backboard, but we're still taught to assume that everyone with a bump on their head has a spinal injury? 

Graduates be able to do more than talk their way through an ACLS megacode. They should they understand why compression rate and depth are important, why hyperventilation is bad, and why hypothermia is good?  Then they should be able to incorporate that knowledge into applying something like a pit crew.

I agree with Skip.  To get to that level, we need more functional and foundational education.

Why don't we have the same knowledge base about spinal injuries that PA's do?  Why can they clear someone off of a backboard, but we're still taught to assume that everyone with a bump on their head has a spinal injury?

Our medics have been clearing spines for years.  If somebody else can't, it's because some medical director won't write a protocol that allows it.  What annoys me is when I see, despite the protocol, medics continuing to "board" people who don't need it.  Why?  "It's easier," "Just in case," and a variety of other reasons that have nothing to do with the patient's condition OR the patient's comfort.

It's simpler, you just need a degree level qualification with a assessable internship as the minimum professional pre-hospital qualification.

There is also more to being a pre-hospital professional than the sexy jobs too.

There is no need to believe you are near a doctor to justify the importance of your qualifications or skill set. Go and do med school if you want to be a doctor. Do what yo do and do it well.

It doesn't take brain surgery to clear a spine.

Fear based medicine is not what we are about.

This is a very interesting discussion, after doing a TSOP yesterday I brought up this very topic. I agree there has to be middle, as pre-hospital providers and educators I do believe we sometimes push too much on the foundation side but not enough on the functional side. How many times have we all heard “he/she is really smart Paramedic but can’t apply the knowledge”? Allot of the time the “really smart medics” end up teaching providers, but have yet to grasp the functional part of the job? The “really good functional medics” don’t have enough foundation.

I’m not sure what the happy medium is but things have changed over the last several years to the point that the foundation is harder but the functionality is much weaker. Don’t really know the answer but like to see/hear everyone’s opinion on the topic.

When EMS compares themselves to other health care providers it’s like comparing apples/oranges as far as I’m concerned. Totally different environments, expectations, responsibilities and finally totally different pay scales. We don’t do the same jobs no matter how hard some providers think we do. Just my two cents

 

SC

This is the chart developed by Walt Stoy, PhD., (U Pitt) when they were discussing this issue while developing the 2009 Educational Standards.

Paramedics are on the upper right.

EMTs are in the middle

EMRs are in the lower left.

< >>>

For EMTs:

Applies fundamental

knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill (or injured) patient.

Mike

 

As I student, I always appreciate instructors that go heavy on foundation materials. I have a very hard time memorizing things. However, if you give me a solid foundation to work off of, then I understand and don't have to memorize. As an instructor, I've seen students become overwhelmed by the foundation to the point they can't function. Everyone learns differently and it's hard to find the right balance. I think it changes with every group of students. I try to pick the middle ground, offer resources, links, and my time if they want a deeper foundation. I also try to show how to apply that foundation to the functional skills. I'll start by teaching the skill, then back up to the basic "if you see this, do that" and then I explain the deeper why for the foundation loving students. I hope that way to reach most of the students. Of course, I'm pretty new at this so my thoughts will probably change over time.

I think one of the biggest problems we have in clinical education is that we send paramedics (who focus on a very narrow acute medical model scope) and send them into hospital ER's to do clinical rotations where they are usually working underneath a nurse (nursing model scope) and expecting them to learn how to intervene in acute medical crises with independent judgement; it makes no sense.

I think it would be a lot better if Paramedics had to shadow an ER doc, or PA instead of cleaning beds, and running a hundred 12 lead EKG's a day and never getting to see how the MD assesses said 12 lead. When I went to medic school (Associates degree program) we were taught and expected to name the cartilaginous rings of the trachea and identify the arytenoid notches and the false cords in the OR with an anesthesiologist sitting beside you. Now they tube a dummy 8 times on a table in a lab and call them competent at intubating? Now wonder medics miss so many tubes.

I agree with Skip about the 'watering down' of EMS education; I think a great driver of this is the push to make every body a medic regardless of their comprehension ability. In cities especially there are way too many mediocre medics causing a dilution of skills.

As far as clearing C spines, I was doing this in 1998 as an EMT Basic under direction of Dr Peter Goth, MD so this is nothing new; EMS would be a lot better if we had a lot more of these medical directors

Just Say'n

Justin Poland. A.A.S., NREMT-P, LP, EMS-I

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