Academic Preamble

Prior to taking any nursing or general education course, nursing students at the institution I attend are required to take a course titled “Academic Strategies”.

I was not surprised to receive the syllabus on my first day of class that stated that the purpose of every nursing student's 16-hour, 5-day initial course was to facilitate personal and professional success as well as introduce nursing students to the purpose and process of nursing education.  This type of class is usually accomplished by holding a preparatory course, such as this one for longer programs and those offering degrees, or an in-depth orientation for programs that last less than a year and are presented as certificate programs.  The intention of the course was to explore a student's learning styles and present solutions for the potential time management problems and conflicts that are sure to arise in a two year time.  Discussion was also had regarding the mitigation of stressors while in school.  

Beyond this simple exploration however, I found the course to attempt to create a severe warning regarding the difficulty of what was to come in the program.  So much so, that it felt like it was trying to scare away the students who were unsure if this was the path they wanted to take.  On the other hand, there was a great deal of reiteration of the high degree support offered by not only the facilities available, but the faculty’s availability for tutoring.  All-in-all, I think the course intended to be as honest as possible about what we should expect, both in the coursework and support available.

As far as I know, most paramedic courses hold some type of preparatory course which are meant to explore the same topics discovered in the nursing course’s academic preamble course.  The paramedic preparatory course, however, is intended to present a far greater compilation of information than the nurse’s and, weighing in at 48 clock hours vs. the nursing 16 clock hours, I should hope so.  In addition to learning styles, stress level and time management, and a healthy dose of honesty regarding coursework, the paramedic preparatory course delves right into introductory paramedic theory.  For example, topics like medical math and pharmacology, ECG interpretation, and advanced patient assessment approaches are a key component to the curriculum.

This first class is where I began to figure out what is perhaps the major difference between nursing and paramedic school.  Paramedic school jumps right into skills-based lectures and wraps theory around the skills.  Nursing school is designed to present theory in elongated stages – that is to say, before I even touch medsurg nursing theory, I will have had eight months of anatomy and physiology with lab, four months of college algebra, speech, and microbiology, and four months of nursing fundamentals.  In addition to these courses, I had my english, psychology, and sociology courses transferred in, which would have been required prior to, or concurrent with, medsurg courses.

I spoke with the Director of Nursing Education at the school here regarding the nursing perspective of paramedics.  Bear in mind, the Director is an MSN and has worked in a number of different departments in local San Diego hospitals for greater than 10 years, so she has a solid background to draw from.  The Director stated that she agreed with my assessment that paramedics are not looked at as true professionals by nursing staff.  We are respected as hard workers and sometimes heroes, but not true professionals.  The reason?  We do not have the educational background and well-rounded academic experiences that RN's have.

I suppose the greatest revelation I came to during this first week is the potential resolution to the argument between nurses and paramedics and the level of respect given to prehospital providers – nurses receive far more theory than the paramedic while paramedics are focused on skills-based education.  If we, as paramedics, are to ever hope to be seen as equals to the nursing profession (or clinical practitioners as a whole), I believe we need to honestly examine our educational practices. 

Is the patient that we work with any less sick than that of the nurse?  No – and truthfully, they are often times far more ill, presenting with acute, remedy-necessary medical or traumatic illnesses.  Why, then, is our education less than that of the nurse?  Why are we not required to complete courses with the same social, psychological, and general education emphasis as the nursing student?  Why is the paramedic not required to complete courses that will subsequently confer upon them an Associate’s Degree in health care?

The paramedic and their patient alike would only benefit from a greater theory base and stronger understanding of anatomy and physiology, sociology, and psychology, and an improved command of the English language.  It is high time that we recognize that our practice needs to be equal to our education.

Admissions and Expectations

"This will be the hardest thing you have ever done."  

For the third time in my life I have been told that what I am about to undertake will far and away be more difficult than anything else I have ever attempted.  Prior to USAF Basic Training, the beginning of paramedic school, and now, I have had to build an accurate assessment of the task and compare it to what I have accomplished previously. 

To be fair to the intent of this blog, I am going to have to look at not only paramedic school as I knew it when I attended in 1998, but paramedic schools as they exist today and my involvement in assisting establishing the groundlings of a program in 2011 in Northern California as the Director of Academics for the School.  The assessment will be a comparison of what I undertook in paramedic school alongside the research I conducted to most efficiently start a paramedic program against my real-time experiences in a private postsecondary nursing school in Southern California.

This post’s intent is to look at the admissions process and requirements through acceptance and orientation for the program.  Now that I am admitted to, and have finished the orientation for nursing school, I am not convinced that this journey will be more difficult than other ones I have completed, but I do believe that it will be challenging.  After all, there are a whole new set of medical theories to be learned and a whole new way of thinking about medicine top adopt.  I attempt to gain something from any schooling I attend; I believe that if an individual sits through any type of class and learns nothing from it, the only excuse is that he must have been sleeping.

A few things to point out before we start:

1. This assessment is of generally like-institutions.  They are private postsecondary schools in the State of California, both governed by the CA Department of Consumer Affairs’ Bureau of Private Postsecondary Education, and both requiring accreditation for a continuance of their programs.
2. A major difference between these programs is that while the nursing school delivers an Associate’s degree at its completion, the paramedic school is a certificate program.  This is not uncommon for paramedic schools – RN schools are required to furnish a degree.
3. Graduates for either program are required to take a national examination in order to be licensed in the State to practice under the protocols or physician’s orders which direct them.  The paramedic examination is governed by the National Registry of Emergency Medical Technicians (NREMT) while the nursing examination is governed by The National Council of State Boards of Nursing (NCSBN). Both of these national examinations have a cognitive component; the paramedic graduate, however, must also complete a battery of psychomotor examinations.

Contact:

Getting in touch with any private postsecondary school is generally not incredibly difficult.  They are, in spite of everything, for-profit businesses and without your money, they don’t exist.  Even institutions that are not-for-profit have to earn your business somehow, be it by loans and grants, or your hard-earned green and believe me when I say that they work just as diligently to recruit and retain a student body as their for profit counterparts.

Admissions Requirements:

General – Both programs required the minimally accepted standards, such as a HS Diploma or GED, background check, and drug screening.  Both programs required immunizations and a Healthcare Provider CPR Certification from the American Heart Association.  An informational meeting with an Admissions Representative and, after acceptance, meeting with a Financial Aid Representative or Student Financial Assistance occurs to square away loans and grants if applicable, and any repayment plans. 

Application and Prerequisites – One of the major differences in this category is the length and requirements of the application process for the nursing and paramedic schools.  You will see by the chart below that some of the content is dispersed throughout the course, respective of the educational program.

	EMT-P	RN
Time in Field – Employer Verification Required	2080 Hours (EMS)	1040 Hours (Any)
Preparatory Course	Yes – 48 Hours	16 Hours “Academic Success”
Anatomy & Physiology Pre-Course	Yes – 72 Hours, then throughout course	2 Semesters of A&P required in school
Oral Board	Yes	No
Application Essay	Yes	No
References	3	No

If the student has not completed collegiate-level Anatomy and Physiology with lab, the nursing school will deliver it Anatomy and Physiology during its education model as stand-alone classes, formatted to meet the standard expectations of A&P in the community college.  Paramedic school requires a very brief brush with A&P prior to starting (or collegiate level A&P).  For those required to take this course, it was honestly intended to be used as a tool to determine whether or not an individual would be able to handle the pace of A&P covered during paramedic school where it is delivered in relation to a topic.  For example, when discussing cardiovascular emergencies, in addition to assessment patterns and treatment modalities, it is expected that the student would receive an immersion course in cardiovascular Anatomy and Physiology.  The reality is that paramedic education understandably concentrates on the assessment and treatment of emergent patients.  The problem with that is that the paramedic is potentially left without a firm understanding of anatomy and physiology in everything related to anything non-emergent.  It will be interesting to see how in-depth nursing school addresses A&P and whether it delivers a more solid base of understanding of the fundamental workings of the human body.

Testing – Almost every private postsecondary institution requires similar items to be considered for acceptance to their program because it is a field standard.  Often times, however, the entrance requirements are shockingly minimal.  For most programs, an assessment test is administered.  The Wonderlic Cognitive Ability Test is a common examination and is used to assess an individual’s problem-solving capacity over a range of occupations.  This examination a 50-question multiple choice test and is given over 12 minutes with instructions to the candidate to answer as many as possible in that time.  After a great deal of research, Wonderlic, Inc. claims a score of at least 10 points suggests a person is literate.  A warehouse worker should score 15, clerical worker should score 21, a journalist should place at 26, and a chemist comes in at 31.  http://en.wikipedia.org/wiki/Wonderlic_Test.

The Wonderlic was used by my former employer as well as the nursing school I am attending.  With programs such as Phlebotomy Technician, Emergency Medical Technician (Basic), and Medical Assistant, the bar is set around 16.  When applying for longer, more intense programs, the minimal score allowed increases, as it should.  There was an established a minimum of 21 for our paramedic school; my nursing school required 24.  I scored a 32.  After experiencing both the administration of, and taking the exam (a version I had never seen), I believe this exam is not an accurate portrayal of the probability of one’s success in educational programs.  Simple literacy does not equate to learning aptitude.  The true use at my school up north was as a tool to weed out individuals that would likely have difficulty with simple reasoning or the English language.

Additional examinations are required for both nursing and paramedic schools.  Paramedic school consideration required a field-specific examination at the EMT level to ensure the candidate had a firm handle on prehospital medicine at the basic life support level.  This examination was a 100 question 2-hour test of a randomized sampling of our reviewed and approved test bank for our EMT program.  The questions were evenly distributed across all required knowledge fields (medical, trauma, pediatric, etc.), and an 80% was required to continue in the evaluation process.  Noting that these questions come from an approved bank, it is important to also state that they are modeled after the NREMT test questions which, in my opinion, do not always ask questions with the intent to see if you have content knowledge.  Rather, some NREMT questions are written to specifically see if you are a critical thinker and will lead an answer series with “which is the most correct” or “which is the least correct”.  In my opinion, critical thinking is “critical” to being a successful practitioner, but it is not necessary to pose questions where there are arguably more than one correct action to take, or where no action is truly appropriate.

For nursing, however, a more well-rounded examination was administered.  My nursing school administered the Test of Essential Academic Skills (TEAS) which is a 170 question, untimed evaluation covering Math, English, Science, and Language.  http://en.wikipedia.org/wiki/TEAS_test.  We were required to score no less than 75% overall to continue in the admissions process.  I scored an 84% (which ranked me in the 96^th percentile nationally).  That said, a number of paramedic schools utilize the Health Occupations Basic Entrance Examination (HOBET) which will test the candidate’s knowledge of math and reading comprehension.  It does not, however, score any sciences or a language component, so while it is far more comprehensive than the Wonderlic, it does not come close to the TEAS examination.

Objectively, the nursing school admissions examination would is more useful in gauging a generalized academic knowledge base, and I believe, an individual’s overall readiness for school.  It gave me a clear understanding of the areas that I was weak in (physical sciences – I did well in life sciences) and I will be sure to keep that in the forefront as I progress in my education.  I believe the EMT examination for paramedic school entrance is useful as another tool to weed candidates out and ensure that those accepted to the program have a handle on the basics prior to moving to into advanced practice.  It does not, however, produce a global picture of the individual’s knowledge.

Interview/Oral Boards – While both the paramedic and nursing programs require some form of interview with the program head(s), I found that the intention of the interview for each program could not have been different from each other.

I attended the nursing program interview on 04-Jan-2012 with the School’s Director of Nursing along with approximately 10 other accepted or wait-listed individuals.  This interview was more of an informational session and a time to ask any questions we had of the Director.  Schedules were delivered and it was an overall pleasant experience.  The Director reviewed a few items in the nursing orientation handbook which we could have read ourselves, but I understand the necessity to cover it – not everyone would read it on their own.  This interview ended up being more of a meet and greet with a few possible classmates than an interview for admission.  We had already all been admitted prior to ever having our personalities being assessed.

Paramedic Oral Boards, on the other hand, are intended to act as an interview.  They are designed to see how an individual will react under the pressure of being questioned by 3-5 experienced providers and administrators.  The oral board is nerve-wracking, to say the least, and is designed to test an individual’s composure.  Points are awarded based on the board’s assessment of the candidate’s punctuality, answers to questions on attitude and teamwork, verbal communication skills, appropriateness of answers, and medical knowledge.  Once the candidate has answered pre-designated questions, they are required to complete a basic life support assessment of a simple patient and treat them appropriately; they earn points for both assessment and treatment.  The boards are intended to be neither supportive nor degrading – they are intended to objectively judge a candidate’s character and current medical knowledge.

Finances:

Unless a school is a “Title IV” school, they are not eligible for federal funding.  Accreditation does not automatically qualify a school for Title IV eligibility, and a school must have Title IV for the student to use funds received after completing a FAFSA, be them by grants or loans.  As the size of a paramedic school is generally quite smaller than that of a school offering an Associate’s Degree in Nursing, you would be hard-pressed to find a private institution that was able to offer federal loans and grants.

But… it’s a really good thing that the nursing school can offer such assistance because when all the finances are tallied and the bill is mailed home, after tuition, uniform, texts, cost of internship (paramedics have to pay additional), and all other incidentals, the damage is:

Paramedic – Approximately $14,000.00.

AS Nursing – Approximately $57,000.00.

So – Thank God for student loans for nursing students!  The backside is, upon graduation, a nurse has a far higher probability of paying off loans, as they can make easily 3-4 times what a paramedic can make, unless they are hired in the public sector or as a firefighter.  (Refer back to one of my initial posts stating that I was going to be making $11.00-$12.00 per hour in San Diego as a paramedic.  Nursing jobs are STARTING at $34.00-$38.00 here and can get up to $50.00-$60.00 in the SF Bay Area where medics don’t make much more than here.)

Orientation:

Orientation is a necessary component to both the nursing and paramedic programs.  Neither is significantly different, covering the School’s attendance policy, dress code for the program, parking situation, and other demographic incidentals.  Both programs tout the degree of support available for the student, something that I must say is rare to find in the public institutions.  Tutoring and additional assistance is commonplace with private postsecondary schools because it is vitally important to ensure a decent retention and graduation rate.

The research resources available to students seem to be more abundant with nursing school.  Their library has an actual librarian and their computer lab has indexed videos and resources available for the student.  While paramedic schools are required under accreditation to have some form of a library, most choose to opt for a virtual library like www.freelibrary.com, and they may or may not have a computer lab available.  I do hope, however, that we will see this change in the near future with the increase in focus on research for paramedic programs.

I think the thing that stood out most between the two programs during orientation was that for paramedic school, it is not uncommon to advise the student that for the next year and half, they can expect that they “will not have a life”; paramedic school is an absolute time commitment, sitting in the classroom up to 24 hours per week and an expectation of at least that much, if not double or triple in homework.  Beyond that, the paramedic student will often times find themselves working up to 72 hours per week (I did three 24-hour shifts during my schooling) because like paramedics, EMT’s make a dismal living.  The nice thing about working on an ambulance, however, is that any time you are not running a call, you can study.

During the nursing orientation, it was stated quite a few times that this program is incredibly fast and that a great deal of studying was to be expected, but when the student body representative spoke (beginning his second year now), he said to expect about an hour of homework for every hour spent in class.  I am scheduled for 10 hours per week for my first semester.  Further, the Director stated that she expected we take the program seriously and make a definitive commitment to it, but that “…for the next two years, I want you to have a life in addition to school.”  It was stressed that working part-time might be stretching one’s limitations, but it could be done.

Conclusion…

Prior to starting nursing school, I have found far more support in the process of getting started than is designed in the admissions process for paramedic school.  Paramedic schools have been designed to utilize many different tools to weed out individuals and scrutinize every component of the individual prior to being allowed to start.  In the field of Paramedicine, I find that attitude carried over onto our ambulances.  Our support system is a “sink or swim” environment and it is not uncommon to lose educational opportunities because we’re so busy defending ourselves.  I feel that because we are paramilitary, we intentionally look to best each other, and not in a way that is productive and supportive.  As a USAF Veteran, I can say that paramedic school resembles boot camp, minus the military campaign DI hats.

Nursing school has proven to be a gentler ride thus far than paramedic school or military basic training ever was.  Whether or not that will continue is yet to be seen.  I have my first day of class tomorrow at 0800.  My sister is a nurse and I’ve heard the stories about how nurses eat their own.  It may prove to be that the kindness I have seen so far from the School is secondary to the nature of the private postsecondary educational institution - $$$.

Off to bed for now.  My next post will be after the completion of the “Academic Success” class which I believe will be akin to the Paramedic Preparatory course and a preamble to the actual academics.

The Decision

Nursing school is a relatively recent decision for me.  I moved to San Diego in September of 2011 and intended on getting a job in the EMS field again as a paramedic.  After searching for a bit, I found that not only are there very few jobs available for paramedics here, but the pay is outrageous.  I shouldn't be as surprised as I am that jobs are scarce, after all, it is 2012; California, along with the nation, has a ridiculously high unemployment rate.  I was, however, shocked to find that paramedics in San Diego are paid in the neighborhood of $11.00-13.00 per hour; I was paid $11.50 in the San Francisco area in 2000!

The truth of it though, is I had an opportunity to get a job as a paramedic, but blew it.  I had passed American Medical Response’s cognitive paramedic exam with a 92%, but was unsuccessful on their practical exam (a megacode).  Don’t get me wrong, I didn’t kill the patient, but after 5 different rhythms from a pre-arrest pulsing ventricular tachycardia to a post-arrest third-degree block which I paced, I was unsuccessful because I pushed amiodarone after my second shock (the patient had been pulseless for a good four minutes).  San Diego County doesn’t give amiodarone unless the patient is pulsing post-conversion with a heart rate of greater than 60 BPM – and it’s only given as a drip.  As the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS) goes, I was on track, but according to the San Diego protocol was concerned, I was outside the bounds of what is allowable.  All that aside, I want to make clear that I am quite aware I should have been better prepared for the practical examination and I respect San Diego County’s EMS Agency for their decisions on their protocols.

What this setback afforded me was the opportunity to look at my options.  Nursing runs in my family, as does EMS.  My sister, grandmother, and step-mother are all nurses.  My father is an EMT and my aunt was an EMT/Firefighter with Berkeley Fire Department for many years.  As steeped as I am in EMS, working as a paramedic seems the viable option, but as I said, my current locale has only two ALS providers; Rural Metro is not hiring, and AMR, well, you know that story. 

Many have asked why I have not attempted to be a firefighter.  I believe it takes a certain type of person to run into a burning building, just as it takes a certain personality to be a paramedic.  It is an ill-conceived notion that the two are interchangeable.  There are those that fill both roles during their service to the community, but it is horribly unfortunate to find firefighters that become paramedics for the sake of getting a promotion or getting into the fire service, and it is equally detrimental for paramedics to become firefighters just for the pay raise and pension.  I mention this because by being in education as long as I have, I have seen it.  I am not one that has any intention of entering a burning building; it’s just not my thing.  However, I have the greatest respect for those who do, and I will stand by my brothers in a support role any day of the week.

As an administrator, I have been significantly removed from patient care as of late, and oddly enough, it has brought a great deal more stress than being a practitioner.  In 2010, I ranked 3^rd on the eligible list for Alameda County EMS Agency’s Prehospital Care Coordinator position.  ALCO EMS opened another position in 2011 and I was advised by a few members of the current administration that I had interviewed well before and should apply for the position again.  Had I of applied for this position, I believe it very well may have been offered to me, but it would have left me out of the patient care loop once again – and I had already begun my transition to San Diego.

I am a clinician at heart.  I get excited when anatomy and physiology are the topics.  I am intrigued at disease processes and new treatments found to ease the signs and symptoms of, or the cure for, an ailment.  Over the years, I have provided a great deal of medical interventions in the prehospital setting, and have always been interested in the outcomes of my treatment.  On some of the most extreme cases, I have been known to check in with the receiving facility regarding the status of a patient, but have found HIPAA to be a descent barrier to that information at times.  I want a full-circle picture of my treatment and am hoping nursing brings this. 

As a paramedic, I don’t think that a great number of prehospital providers think clinically; we weren’t trained to.  This is not to state that EMS providers do not have a firm understanding of body systems and how they are affected in acute illness, but I would bet that the large majority of prehospital practitioners would not think to include diagnoses like hydrocephaly, brain tumor, or a primary exertional thunderclap headache to a non-traumatic chief complaint of “the worst headache of my life” with no history of headaches.  Personally, I would immediately lean towards CVA, TIA, or Berry Aneurysm – these are what we see most often, and these are what we need to tend to.  It makes sense that we would focus on these diagnoses as they require the most aggressive treatment available in the prehospital setting and they are the most extreme cases of acute issues possible with this chief complaint. 

I have heard on more than a few occasions that prehospital care providers only think acutely and do not consider how their care will affect the patient once they arrive at definitive care and are in the hands of the clinician.  Prehospital practitioners administer the level of care that we do based on two factors, both of which are meant to err on the side of the patient undergoing a potentially having a life-threatening event.  Firstly, EMS providers must take in all the factors presented, including environmental conditions and the patient’s signs and symptoms.  From there, we must treat the patient based on a differential diagnoses that leans towards a worst-case scenario.  If we treated the patient based on assumption of a lesser severe condition, we might very well treat the patient inappropriately and not administer life-saving interventions.  Secondly, our diagnostic tools are limited in the field, so something that we can do nothing about, such as a primary exertional thunderclap headache, must be treated like a stroke by providing appropriate ventilatory support if required and choosing a destination that has a stroke team and computed tomography so the patient can continue to receive the highest level of care available.

So – why nursing school?  I hope that by progressing through nursing school, I will obtain a more well-rounded theory base regarding patient care.  With this understanding, I hope to be able to better illustrate to both sides that the care given by prehospital practitioners and clinicians alike is designed to provide the patient the highest degree of care and the greatest possible outcome upon discharge from the hospital.

In the next few years, I will review a great number of misconceptions that paramedics have of nurses and vice versa.  I hope this journey will contribute to both sides understanding each other a bit better and lead towards the maturation of the prehospital profession, both by encouraging a greater degree of respect from our clinical counterparts and challenging prehospital practitioners to earn that respect by increasing their knowledge base and practical application of crossover skills such as prehospital blood lactate monitoring as a rule-out tool for patients in septic shock.

Look for my next post which should be coming out at the beginning of next week – a comparison of the entrance requirements for paramedic and nursing school in the private postsecondary sectors.