I can’t help but wonder if the reason for the decline isn’t the quality of medic our educational institutions are putting on the street. They can test,and they can pass, and they can do memorized medicine, but they don’t know why they do what they do. Neither can they form a cohesive sentence or communicate with any effectiveness. Many look more like diesel mechanics than medics and argue with you when you tell them they can’t wear that hoop in their nose while on duty. Other healthcare professionals see this too, so what do we expect? Am I the only one not seeing this getting any better?

So wrote a long time friend of mine who was discussing the quality of pre hospital written reports. He has seen a depressingly steady decline in not only basic spelling and grammar, but in the appropriate use of medical terms.

I’ve also seen this and have heard a couple of medic trainees complain that our electronic documentation system doesn’t include a medical spell checker. I don’t think I won any friendship points when I pointed out to them that if they couldn’t spell a medical term, maybe they shouldn’t be using it in their reports. They didn’t like that and liked it even less when their preceptor told them that if they couldn’t spell it, it was likely that they didn’t know what it meant.

That may be a reflection of lower educational standards in general, but that’s not the subject of this post.

Since 1994 I’ve seen a decline in the education of EMTs due to the revised 1994 national curriculum. The idea was to improve EMT education and standardize it, but the effect has been less knowledgeable EMTs. At least that was the stated goal. In reality the committee also had to deal with a mandate that the course not be appreciably longer than the then current standard. It seems that some of the stake holders felt it would be hard to attract and retain new EMTs if the course were longer and more expensive. As a result a lot of the material in the “old” EMT course was deleted or made optional. The predictable result was that courses that wanted to compete with other programs left the optional material out. So, students learned that they aren’t supposed to differentiate the types of shock or even really know what shock is. Nor could they determine if someone had a fracture, let alone know that there are different types of fracture. Suddenly, EMTs were only deemed capable of administering Oxygen by non re breather because they had no way of knowing how much Oxygen a patient needed. Interestingly, EVERYTHING needed to need Oxygen. If I didn’t know better I’d think that someone on the committee had stock in a medical gas company.

Also dropped from the curriculum was a lot of the medical terminology that made it possible for us to communicate with other medical professionals in a common professional language. “He’s got a pretty obvious “silver fork” fracture to his left wrist” was replaced with, “He’s got a tender, reddened, deformed, area to his left wrist so I put it in a splint, put an ice pack on it, and gave him high flow Oxygen”.

Similarly, “Primary and Secondary” exams became replaced by “Initial and Detailed” exam. A lot of EMTs and medics are speaking a different language than are the other medical professionals that they deal with. I think this has caused nurses and doctors to think of us as lessor providers because we speak more like laymen than like medical providers.

All of this results in EMTs and paramedics that are less well educated than their predecessors. It also costs systems that truly want to have top quality care more in terms of training and education for new hires. A lot of systems can’t afford the increased costs, so they just do the best they can and hope.

The poorer education has also spawned a new industry specializing in Alphabet courses. Aside from ACLS and PALS, which have some good information, we have PHTLS, BTLS ITLS, AMLS, PEPP, NALS, ABLS, and other courses that try to make up for the lapses in knowledge caused by the poorer curriculum. Most of the information in these courses should be, and used to be, contained in EMT and paramedic programs. Not all of, but certainly a good part of it.

Paramedic programs are faced with the choice of becoming longer to teach the students the material that they aren’t getting from their basic courses or becoming diploma mills that churn out medics who can pass the National Registry or state paramedic exam, but don’t have the theoretical knowledge to understand why they perform the skills that they do. Paradoxically, at the same time that paramedics are learning less, they are being asked to do more. 12 Lead EKG interpretation and use of paralytics require more knowledge than many paramedics seem to be interested in learning. Yet, they and their systems want them to have new “toys” to use. Which, by the way, is a term I detest. They aren’t toys, they are medical devices which if used improperly can harm or kill. All of this while the science seems to indicate that all too many paramedics aren’t proficient with the skills they are entrusted to perform on patients.

A depressing number of studies have shown that too many paramedics don’t know how to accurately assess ET tube placement. As a result, patients are being transported to hospitals with advanced airways placed in patents esophagi, not their tracheae. It’s no crime to put a tube in the esophagus. The crime lies in being either too arrogant to or not capable of determining that, removing the tube and starting over.

A lot of this problem goes back to basic education. Education for paramedics, even the bare minimal paramedic course, is expensive in both time and money. The educational institution can’t just take the money, provide a “good enough” education, and then send these young heads full of mush out into the world. The students can’t be satisfied with just passing the written and practical tests. It is incumbent on them to go beyond what’s in the text books and ask questions. Lot’s of them as they try to learn how to be a proficient practitioner of the paramedic arts and skills. Sadly, a lot of students just don’t have the ambition to do that and the result is “bunny slope” paramedics that know what’s in the text books and little more.

The result is quantity prevailing over quality as systems of all types race to proclaim that they are “all paramedic”. Which in most cases means one paramedic per ambulance, not two. Lot’s of “ALS” ambulances, but not a lot of paramedics with the call volume of really sick people to become really good at what they do. Anyone, and I mean that almost literally, can start a line, put on a monitor, and give a NTG or two to someone with routine chest pain. It takes far more skill to recognize the not routine cardiac signs, do a 12 lead EKG, interpret it correctly, treat it appropriately, and convey all that to the hospital. Which is why an alarming number of EMS systems seem to be investing in smart technology while hiring dumb paramedics. A number of EMS systems are looking at acquiring expensive technology to acquire and transmit EKGs in real time to hospitals or medical control doctors so that they can interpret them and direct the care the paramedics give. This despite the fact that a number of studies have been published that demonstrate that well educated paramedics have a 95+% correlation with EM physicians when it comes to interpreting 12 Lead EKGs in the field.

For a variety of reasons it seems that many students and employers don’t want to invest the time or money to do it right. None of that helps those of us that want to professionalize this field. None of it makes life easier for us either.

I could go on and on, but you’ve either got the point, fallen asleep, or moved on to another blog by now.

I’m not even going to touch on the sloppy appearance issue, at least not in this too long already post.

To quote Taggart: “I am depressed”.