My wife and I were just having a talk this morning about her newest intern that went directly from an EMT-Basic to an EMT-Paramedic.  We both thought that this advancement is quite a large learning curve and not advisable.  Here in California, there use to be a mandatory 6 months of experience as an EMT-Basic before a provider could advance to be a paramedic but that restriction was removed and now some of the local paramedic school instructors are telling their EMT-Basic students that they can go directly into the paramedic class.  I disagree and so does my wife but what do you think?  Is this something that we as instructors should be telling our EMT-Basic students?

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I agree with you two on this topic, in my experience I feel that without experience between levels it is impossible to be able to grasp the higher level education that is needed and the student does not get an appreciation of what is really needed. When doing my training in Australia we had up to twelve months on road experience between levels and exams before we applied for the higher grade training. My God it would be like teaching some one to operate a diesel generator then putting them straight onto a nuclear power station without training.
My stance has always been that any school worth it's tuition dollars should be able to take someone with zero experience and educate them to be a paramedic. After all, you don't have to be an LVN/LPN or CNA to go to nursing school nor a physician assistant to go to medical school. Similarly, there are plenty of PA schools that seem to manage to educate PAs without prior health care experience. What makes the basics of EMS so different that it takes 6 months to a year to get a handle on conducting an assessment and taking a blood pressure?
This is something we should absolutely NOT be telling our students! I remember when I started that National Registry made us have six months street experience just to be able to sign REMT-A after our name. There was a reason for that. There is a reason that we should not put a kid right through school from EMT-B to EMT-P. It is called experience leading to better clinical judgement.

In the bush of southwestern Alaska where I am teachng for another six months or so we are not even puting most of our students, who are mainly community health aides, all the way through EMT-B school all at once. We have them in for a week and train them as ETTs - Emergency Trauma Technicians. That is Alaska speak for FR. We then send them home to their villages to practice at their clinics, and later they come back for the ETT to EMT-1 (EMT-B) bridge class for two weeks. That said, our local part paid, part volunteer FD runs evening EMT courses & they will run people all the way through the EMT-1 course without any problems.

A couple of Alaska special requirements that we have. In order to enroll in an EMT-2 (I-85) class you have to document ten patient contacts and have them signed off by an EMT-2, 3, MICP, RN, PA-C, M.D., or D.O. Our EMT-2 course is only one long week of 50 hours.

In order to enroll in the EMT-3 (Not quite a much as an I-89) class you need to document ten IV sticks, no more than two of which can simply be blood draws. They need to be signed off by at least an EMT-3. The EMT-3 class is also a fifty hour class up here.

I just saw the post by Joe P. If there are any good PA schools taking students without prior health care experience of some sort I am not aware of them, nor are any of the many PAs that I work with in our training system. We just happened to have had this discussion last week.

We have PAs in our training system from CA, IL, NY, PA, WA, WI, and I think a few other places. We have PAs in our sub regional clinics, and at our hospital from a number of other states too.


Dave Springer said:
This is something we should absolutely NOT be telling our students! I remember when I started that National Registry made us have six months street experience just to be able to sign REMT-A after our name. There was a reason for that. There is a reason that we should not put a kid right through school from EMT-B to EMT-P. It is called experience leading to better clinical judgement.
However what sort of experience leading to clinical judgment can really be gained by a provider who has essentially zero education in the scientific foundation of medicine and where the stock answer to almost any medical scenario is "non-rebreather, request paramedics, emergency transport." I might be able to get on board with the concept of a paramedic being an advanced provider (in the sense of a critical care paramedic being an advanced paramedic) where experience is a good thing if foundational education was required for EMTs, but it's not. It should take longer to go from lay provider to EMT than EMT to paramedic, but since the EMT education is watered down to "do this, this, this, and this, and if it requires any sort of judgment, pick the most drastic option first (e.g. the only "indication" for nasal cannula being the patient won't tolerate a NRB mask)," it doesn't require any actual critical thinking. This is, of course, ignoring that the education is watered down to what's pertinent in a 10-30 minute time frame. Don't believe me? Ask an EMT about reactive oxygen species (because oxygen is, contrary to EMT education, not harmless).




I just saw the post by Joe P. If there are any good PA schools taking students without prior health care experience of some sort I am not aware of them, nor are any of the many PAs that I work with in our training system. We just happened to have had this discussion last week.

We have PAs in our training system from CA, IL, NY, PA, WA, WI, and I think a few other places. We have PAs in our sub regional clinics, and at our hospital from a number of other states too.

I will admit that I am unqualified to judge which PA schools are better than others, however even the ones that do are still accredited and still graduate students who can become PA-Cs and become licensed as a PA. Of course it still doesn't explain why I can't recall a single medical school requiring prior health care experience, and definitely none of them require a license in another field nor anything close to thousands of hours of experience. Shadowing (especially for DO schools, but definitely not even a majority of US medical schools)? Sure. Thousands of hours in a field that requires a license? Definitely not.
PAs and RNs both have significant clinical rotational periods that are required for their licensure. MDs and DOs both have a 2 year rotational requirement for licensure and a minimum 4 (3 for pathology but 5 for surgery and more if specializing i.e. trauma surgery) year residency for any hospital to allow privileges. All of these professions also have a standard basic sciences: anatomy, physiology, pathology, biochem and clinical reasoning components...
Meanwhile Paramedics do not have significant basic science prerequisites for paramedic licensure. Additionally, after 200 hours of clinical hospital time and 480-720 hours of field experience, a paramedic can qualify to take the licensing exam from the NREMT.
Not all paramedic programs/Nursing programs/Physician Assistant/Doctorate programs are created equal.
Most of the programs are worth their money precisely because they do provide the scientific background and then have extended clinical times to integrate the sciences into the art of medicine. Additionally most of these programs are competitive, wherein candidates that are not fully qualified are not accepted.
But I do not mean to belittle paramedicine, it is an honorable profession. My only concern was and is, should we as instructors be advising EMT-B students to go directly into EMT-Paramedic programs without any field experience?
Shouldn't EMT-B experience provide a buffer for the lack of substantial clinical time? What about providing the EMT-B student the opportunity to actually experience the job before they invest another year of time and money in a paramedic class? My fear is that economics are driving this decision to recommend these students to paramedic promotion prematurely.
Asked a different way, does working as an EMT-B provide no benefit prior to initiating paramedic study?
I have to agree with this. My wife and I have had this discussion on many occassions, and have reached one conclusion...that one must have at least a SOLID 6 months to a year at the EMT level before being considered for EMT-P. When I went to EMT-P school, the program wouldn't even consider a candidate unless him/her had ONE YEAR EMS experience...documented, with a letter of recommendation from their respective EMS service's ALS director. Then there was a 200 question written exam, 4 station practical exam, and if the candidate made it that far, had to pass an oral interview. I feel that this, or some similar process, should be the adapted by EMS programs across the board.

My time spent in EMS (20 years) at both EMT and EMT-P levels has revealed one consistency, that there have been no successful transitions from EMT to EMT-P with no time in between for any gainful experience. I've had the unfortunate experiences as an FTO with newly-licensed Medics who had no field time as an EMT, and these folks had no clue...none. Not even fundamental patient assessment skills. I then come to find out that their knowledge of pharmacology, pathophysiology, etc. is non-existent. These "medics" have all been train wrecks, and have subsequently had miserable field training experiences.

Like I always have said to past students..."You need a foundation before you build your house." Bottom line. EMS is a multi-tiered profession, one that cannot be compared to any other health discipline. It's like comparing apples to oranges. RNs, PAs, RTs, MDs...these clinicians all have extensive practical and clinical exposure prior to practing their respective profession. There is no "RN-1", "RN-2", or "RN-3". However, there ARE multiple levels of EMS clinician, and each one must be mastered before progressing to the next. The "EMT" must master his/her respective level of practice prior to advancing to "EMT-1/I", and to "EMT-2/P", etc.

I hope this helps. This is an excellent subject, one that we do need to confront and discuss, therefore I'm interested in reading others' opinions on this.

Cory T. Spankowski, NREMT-P


Dorian Matzen said:
PAs and RNs both have significant clinical rotational periods that are required for their licensure. MDs and DOs both have a 2 year rotational requirement for licensure and a minimum 4 (3 for pathology but 5 for surgery and more if specializing i.e. trauma surgery) year residency for any hospital to allow privileges. All of these professions also have a standard basic sciences: anatomy, physiology, pathology, biochem and clinical reasoning components...
Meanwhile Paramedics do not have significant basic science prerequisites for paramedic licensure. Additionally, after 200 hours of clinical hospital time and 480-720 hours of field experience, a paramedic can qualify to take the licensing exam from the NREMT.

...

My only concern was and is, should we as instructors be advising EMT-B students to go directly into EMT-Paramedic programs without any field experience?
Shouldn't EMT-B experience provide a buffer for the lack of substantial clinical time? What about providing the EMT-B student the opportunity to actually experience the job before they invest another year of time and money in a paramedic class? My fear is that economics are driving this decision to recommend these students to paramedic promotion prematurely.
Asked a different way, does working as an EMT-B provide no benefit prior to initiating paramedic study?
Here's my question about this. Considering that the environment paramedics is about as close to independent practice as possible (after all, how often do providers have their medical director on scene, especially in areas that do not mandate base hospital contact?), why do we seem content with knowing that the clinical experience and scientific foundation is severely limited? I'll also put forth that, while, EMT experience can help with the clinical aspect (more supervised clinical time during paramedic school would also help. Also EMT experience can lead to developing bad habits), EMT experience does absolutely nothing at curing the issue about scientific foundation.

In regards to asking if any pre-req is beneficial, I think we also need to ask why it's beneficial. Is this requirement present because we can't incorporate it properly into the curriculum (due to efficiency, supplies, etc. I'll completely agree that there's a difference between teaching A&P to 200-300 students versus 40-50) or because we don't want to incorporate it into the program (which is where I'd argue clinical experience falls into). Similarly, we should be asking "Should we advise this based on the current state of programs?" (which is where it currently is) as well as asking, "Would we advise this given the ideal curriculum?"
I agree. They need to see sick and injured patients. I think Australia and the UK have the right idea. Have a listen to episode 76 of the EMS Educast (should be posted by this weekend of Tuesday by the latest.
Joe P. said:

I'll also put forth that, while, EMT experience can help with the clinical aspect (more supervised clinical time during paramedic school would also help. Also EMT experience can lead to developing bad habits), EMT experience does absolutely nothing at curing the issue about scientific foundation.

While I do see where Joe P. is coming from with the aforementioned, I think that any bad habits/practice that would be developed in the field by the EMT would sooner or later rise to the surface in Paramedic school...as an educator I can see this every time. I look for these so the student can identify their "mistakes" and learn from them. However when one progresses from EMT to EMT-P with zero clinical experience, without being able to make these mistakes and learn from them, without the ability to hone skills needed to identify critical issues with patient illness/injury and subsequent treatment...there's no barometer for success and learning. This is the most fundamental step in education/learning. The example I use in class is when the child places his/her hand on the stove burner, that is a mistake that he/she won't make again. We desperately need to have exposure to patient care before making the commitment to advanced-level practice, it's a critical step in the EMS educational continuum.

Cory T. Spankowski, NREMT-P
This is a topic that has been debated for many years as well as many states recommending 6 months to one year experience. My first question is how do you measure experience as an EMT before entering a paramedic program? If the paramedic program does not do EMT written and scope of practice skills as an entrance requirement how would you know about their competency level. The next question is what does 6 months or a year mean as far as competency. Time is not a measurement of competency an often quality patient care is measurable through patient contact and EMS reports. It is recommended that EMTs have street experience but it is a variable. If an EMT is a lousy and there is no documentation time is irrelevant. People go throughout medical school taking care of patients as students but do not work as a healthcare provider outside of their education to become doctors. Competency assessment is done throughout the program and not relying on time. This is a problem in EMS education.
If you keep on gathering more and more pieces of abstract information without putting them together in an actual tangible physical way, you end up with a lot of confusion and no motor skills. In California, EMTs on BLS rigs don't get much excitement or 911 high-acuity patients, but they get some, and even if you didn't learn anything more than where to find things quickly on the rig, and how to maneuver gurneys in tight spaces, the active practice would be extremely valuable. Every medic at every level needs to know how to use his/her body as well as their mind, and do both very quickly and accurately. That requires hands-on practice and re-practice till it becomes natural and almost instinctive. I wouldn't hire anybody with just a Paramedic License and no experience whatsoever.

I think you should have to do some hours of hands on to gain experience  of patient management before proceeding to the next level of care.

 

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