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.