I never cried in Paramedic school...

08/20/2012

It was not a level of difficulty, or an overwhelming sense of frustration from coursework that found me in a state of vulnerability, evidenced by the choked-up voice and tears falling from my eyes.  It was a hospice presentation, and a connection to the patient as a person who was afraid that they never again would spend Christmas with their family, that this hug was the last one, and that they were not going to out-live their parents.  Moreover, it was the realization that the hospice patient feared more for the loved ones they were leaving behind than for their inevitable end.

I did not receive a hospice lecture in paramedic school.  I did not learn how to hold someone's hand as they cried.  I did not have the opportunity to experience true empathy.  My head was buried in the pathophysiology of disease and the protocols designed to resolve life-threatening issues of the emergent patient.  This is the way it had to be - I had six months in class to learn the science and assessment skills to be able to ensure that mortality and morbidity was decreased to as low a level as I could possibly make them.  After this class time, my actions would cause real life consequences for those patients I was tasked with treating as I entered my clinical experiences and internship.

The point to this post is to state that I have grown as a practitioner, and more importantly, a partner in the health care of other people.  Science can be learned and is an important component to successful treatment for people with any given condition or disorder.  Comfort, empathy, and compassion is the emotion and art revealed by nurses as they recognize this science and put it to use in a manner that eases the patient's mind.

I do not mean to demean prehospital practitioners by this post, but from my experience, we do not express the same level of compassion as the nurse.  We talk about it and we try to put it into practice - I recognize this, but the reality is, our response to a great number of people who are injured or ill is "suck it up" because we have a limited time with our patients and we can do only so much to ease their suffering.

A little time.  A bit of patience.  A moment to sit and listen.  None of these things are outlined in our prehospital protocols and we aren't taught these things in paramedic school.  Feelings rarely come into the conversation.  Perhaps they should.

Blur...

05/22/12

..explains the last four months...

Monday, 07-May-2012, was the last day of classes for my first semester of nursing school.  After completing my algebra, and anatomy and physiology lecture and lab finals, I leaned back and an wave of relief and wonder came over me.  Relief because I had a small break in front of me to recollect myself, and wonder... well wonder as to how fast the last four months had passed.  It is amazing that, when seriously focused, time seems to stand still.  But when that focus is lifted, and you're free to see the sky and visit the crashing waves of the ocean again, it seems like only a week ago when you clocked out from real life.  It is not the first time that I've experienced this time-lapse wonder, but it is an interesting phenomenon none-the-less.

I realized that, had this of been paramedic school, I would have just passed the 2/3 mark for the didactic section of school.  Two  more months and I would be starting my emergency room and hospital clinical rotations.  One month after that, I would be stepping onto an ambulance as  a Paramedic intern and really starting to apply the skills and knowledge I had been given in class.  This would last for four or so months, after which time, assuming I was successful, I would be graduating and eligible for the national boards (NREMT) and subsequent state licensure.  The entire process usually takes 11-12 months, if there are only minimal breaks in between didactic and clinical-field time.

In the time one can graduate from paramedic school, RN students are, at best, only half way complete with their education.  In a school like I am enrolled in now, the two year process includes any prerequisite courses that are required, so the paramedic curriculum model and the RN curriculum model that I am comparing are truly apples-to-apples, in what they include and require for graduation and and that they enable the graduate to sit for their respective national board testing requirements.  So what's the difference?  This past semester, I did not touch any of my nursing core material and this upcoming semester, I am starting nursing fundamentals.  I will have completed 8 months of school, including some preparatory clinical days, prior to ever touching my nursing core courses.

Paramedic schools are required to deliver a minimum of 728 didactic hours, which are dedicated to core EMS material.  So far, I have put in 120 hours of classroom time, none of which are nursing core.  Next semester, I will be completing 200 didactic hours and 24 clinical hours.  Of these, 40 didactic hours will be directed at my nursing core, as will the 24 clinical hours.  The breakdown of my actual class/study time for this last semester looks like this:

	College Algebra	A&P Lecture	A&P Lab
Class Time	39.31 Hours	38.63 Hours	39.95 Hours
Study	77.42 Hours	126.18 Hours

* I was enrolled in two courses and attended class two days/week for 5 hours/day.  I completed the semester with all A's and maintain my 4.0 - I think as one of 10 of my cohort.

During this past semester, the requirements completed that were not required in paramedic school were the following:

Anatomy and Physiology I:

• Review and comment on two journal articles.
• Osteoporosis – Useful for both paramedics and nurses to know.
• Dream state and consciousness – Less useful for paramedics than nurses, but does look to increase the base knowledge of the student.
• Write a paper on a disease.  This would have been useful in paramedic school, as it brought light to a number of different disease processes that I was unaware of beforehand.

Algebra:

• Everything except drug calculations.  A more comprehensive review of math would be useful for paramedics.  I know that this is a debatable subject, but I believe the greater handle you have on logarithms, statistics, and percentages, the greater the paramedic will be when required to calculate dosages. 
• Beyond just drug calculations, I believe that if the paramedic had a strong mathematical foundation, they would better understand not only their art, but how and why the company they work for chooses to run their business as they do.  This is instrumental if we, as paramedics, ever want to move past our incessant complaining about how little we’re paid, and into a position where we can either make better decisions about our employment or assist in changing the way things are done.

One of my earlier posts quoted a school official stating that this would be the hardest thing I have ever done.  So far, I can honestly state that paramedic school was more difficult.  Paramedic school is an immersion into insanity where, even though you have a background as an EMT, the material is so advanced and so in-depth, that many get lost.  I think that the unfortunate reality is that a great deal of the information learned, because it's done in such a condensed fashion, is lost to mental attrition.  That said, and to be fair to the conversation, I have not started my nursing core courses.  As I understand it, this is where the true challenges begin!

I suppose the question that needs to be asked (and remains to be seen) is, how will these past four months (and the non-nursing core courses for next semester) better prepare me to work as a nurse?  And, would the same preparatory courses assist in making a more well-rounded paramedic?

Note: As the new term starts tomorrow, comprehensive blog posts over the next four months may be less often, as my workload will increase incredibly.  I will, however, attempt to give monthly updates at a minimum, and will post if/when ground-breaking events occur.

Thanks for reading!!

A Candid Response To A Cause For Concern...

I want to take a break for a moment regarding posting about nursing school and address the responses to an article that I read this past week. These responses bring me a great deal of concern as they speak to the heart of the point of this blog - increasing the respect, practice, and salary of the paramedic. 

However, to stay true to the blog, I will quickly report that I've realized that while the content in my A&P course and Algebra course are far deeper than that experienced in paramedic school, I am not finding it horribly difficult. It is requiring the expected amount of studying, etc, but there is nothing so great that I have been unable to overcome it. Algebra has been a greater struggle than A&P, as would be expected with my weakness in math, and we'll see how I fair after Monday's second exam of the semester. My second A&P exams were last week, on which I received a 95%, losing 4% for careless mistakes, and 1% for an actual wrong answer. 

Now back to the point of today's blog... It is important to refer to the article I am speaking... EMS1 Article: "A collegedegree requirement for paramedics: Is it just B.S.?" 

My post today will address this sampling of responses to the article: 

"Yes...we should go into debt to make 14 bucks an hour...." 

"This is a horrible idea" 

"No, Common Sense first and foremost. I've see to many medics that should never have passed EMT-B" 

"Why should we have to go to college and do that much more only to make what we do now? I call bs." 

"Doesn't being a certified paramedic or emt mean you have a degree of sorts.i think it is a waste of time and money. There are a lot of people that can go to school and get degrees, but it doesn't mean they are going to be any good in the field" 

"I think you would make a better medic with 4 years of field experience vs 4 years book reading. But that's just me" 

"university degrees don't weed out the troublemakers, university degrees also don't give you the life experience needed for this job, unless alcohol poisoning is becoming a prerequisite" 

"No it isn't what do I need a degree for! Are they going to pay us anymore if we get a degree!" 

"If you want to have a degree in healthcare, go become a nurse. If you want to be on an ambulance, plenty of ambulance companies hire nurses. The issue doesn't seem like standard of care, as much as degree $$. I don't disparage education, but I can't get behind this. To much at stake for to many people." 

So... my response to all this is...

Currently, I am enrolled in an RN ADN program after having been a Paramedic for 16 years and receiving an Associate's in Paramedic Education and Management. Bear in mind, I only received the AAS.PEM last year. That said, the nursing degree requires two semesters of Anatomy and Physiology + Lab, Microbiology, English, Speech, Psychology, Algebra, and Sociology for completion, along with our nursing core. It is irrefutable that I have learned more in the A&P courses here than I have ever seen taught in paramedic school. 

Take the word degree out of the picture and ask yourself, honestly, would you be better at what you do if you knew more? Would you hold a greater degree of respect in the allied health and clinical health settings if your peers knew you were required to have the same level of knowledge that they had, with a different specialty? If wages are your point of contention, note that there is a clear increase across all fields when higher degrees are required in the job description. Lastly, and most importantly, wouldn't a higher degree of knowledge put us in a position to better understand disease processes and subsequently learn to treat them more effectively? 

I agree whole-heartedly that paramedics are not paid to what the potential of the profession has to offer. That said, the profession has not earned an equivalent place at the table alongside nurses and other allied health professionals that have a comprehensive understanding of A&P, pathophysiology, microbiology, anthropology, and a firm grasp on basic and abnormal psychology. If prehospital providers have any hope of moving forward we ABSOLUTELY must understand that an increase in our educational base as a profession is necessary. There are a number of individuals in EMS with EMS-specific degrees that do not see an increase in wages. The reason that exists is because the minimum qualifications do not require a degree, and management (of which I used to be a member) can, and do, base their employees' salaries off of what they can pay minimally to meet, what they believe, will get the job done. If there is no reason by proof of either education or increase in skill level and protocol to increase wages, they will not increase. 

I am not an advocate of higher education for the sake of education or without a requirement that the individual entering the EMS field has a solid handle on the practical components required to do the job. To suggest such a thing is ludicrous. Further, I do not believe that just any curriculum would be appropriate for EMS - We have the ability to compile our own curriculum and ensure that it meets the needs of not only the practitioner, but the employer, and most importantly, the patient. Take a look at the originating article and scroll down to two gentleman by the names of Marc Colbeck and Ben Hoffman. They present systems in Australia, New Zealand, UK, and Canada where there is a requirement for higher education and their paramedics are reaping the benefits in both remuneration and autonomy of practice.

To address the inquiries regarding whether or not patient care offered by those who have a higher education would be better than a certified/licensed person... There is a reason paramedics are unable to work in the ICU. We do not have the education. Period. It is a far cry from understanding acute signs and symptoms and stabilizing a patient for 25 minutes to thoroughly understanding what the causative factors of an illness are. 

If, as I have read, we are no more than EM(Technician) Paramedics... Emphasis on Technician... Then I say we have no excuse for how we are treated, and our profession had better become used to being viewed as a trade. We will not hold the respect that our counterparts have. Ever. We will always be paid poorly and seen as individuals who, while we garner respect in the shadows of the fire department, will never hold our own. 

Please note, however, that my view is not based in how well (or poorly) we are paid, which is the point of contention that I have read time and again. Rather, my view is with a grounded understanding that with education comes an increase in performance; with education comes a greater capacity to be involved in industry decision-making at a broad level; with education comes respect from not only our counterparts but those who set our protocols; with education comes the capacity to better treat our patients because we will understand the body better than the watered-down excuse of A&P that is delivered in paramedic school now. 

I hope that one day, the educated paramedic will not have had his time in school be nothing more than a skills course injected with A&P, psychology, or anthropology when it was necessary to discuss a specific acute condition, but rather the paramedic will be a practitioner that is capable of understanding the patient on a level now understood by nurses and above... not because of the degree they hold, but because of the courses they were required to take to earn that degree. That said, anyone who states they attended college and earned a degree and are unable to use what was offered, in my opinion, was asleep. Even in the most "irrelevant" courses, I have taken away something that I can offer the patient. 

I am saddened by the overwhelming push against increasing the educational requirements for paramedics. I get that there is a fiscal component to earning a degree, but at every step in my education, the more I know, the more I've commanded in salary. I, along with a number of my fellow practitioners, administrators, and educators, are those that, while some see it as putting the horse before the cart, are the ones that see what EMS can be. We will not sit idly by and allow the complacent to continue to complain about wages, respect, decrease in protocol, and overall dissatisfaction with their job situations while, in the same breath, denounce any mention of something that might move us forward and assist in alleviating these concerns.

Please understand that I say all of this with the utmost respect for the work done every day on the streets. I was one of the paramedics working 96-120 hours per week when I started. I get it. It's hard. It doesn't seem fair. But I was taught that if I wanted more, I had to EARN it. I do not DESERVE anything that I have not earned. As I look at nursing salaries, I see them rise with every degree earned. Why are EMS professionals so amazingly disillusioned that they don't have to follow the same path to earn the same respect and salary? 

Education cannot be just an individual standard. It must be an industry standard. 

Bonds And Weaknesses

I must say that these past few weeks have been tough.  The degree of difficulty of nursing school is easily on par with paramedic school.  It is impossible to say, however, how the core content of each program will compare because I am only in general education courses - College Algebra and Anatomy and Physiology I.

I was pleasantly surprised to find that each of the professors for my current courses, and as I understand, all of the didactic professors at the institution boast a minimum of a Master’s degree, and most with doctorate in their specialty.  The point is that I am relieved to know that the education being delivered at this institution, while far more expensive than its public counterparts, is not substandard.  Further, each of my current professors teaches at one of the local colleges (SDSU, USD, UCSD, or one of the junior colleges).

So about the academics…

I will be the first to admit that one of my more difficult subjects is math, and I know that I am not alone in that.  That said, I’m not an F student.  But I was today.  My algebraic cohorts and I received our grades for our first 2-hour, twelve question examination which included percentage calculations, mixture calculations, two equation/two variable and three equation/three variables, quadratic equations (thank you for the assistance, Mr. Weber, EMT-P), and linear equations.  Where I went wrong: For one problem, I used the entirely incorrect formula.  I received full credit for the two equation/two variable problems as well as the quadratic equations.  The issue was when I reached the three equations/three variables problem – I got stuck.  After an hour and 10 minutes had slipped by, I realized I had spent entirely too much time on one problem.  To make a long story short, I failed the exam.  However, after respectfully discussing my exam with the Professor, I was able to verbally review the steps I took to attempt to complete the problems that I was unsuccessful in.  I walked out of the meeting with a C+.  I can handle that.

For the Anatomy and Physiology examination scores, I received a solid B (85%) on the written exam, and am still waiting on the lab component where epithelial and connective tissue microscopy slide identification was crucial.  On the didactic exam, my errors were secondary to over-thinking questions.  For example, when asked which system regulates pH and blood plasma, I chose the urinary system, but the answer was the cardiovascular system secondary to its baro- and chemoreceptor capacities.  I am comfortable with the 85%, as it is added to the lab exam, which I feel most confident about.

It was noticeable after I received my Algebra grade that I was pretty upset.  The day the exam was given, there was a decent degree of drama, as no one felt the exam was valid.  We all felt that the questions (specifically three question/three unknown) presented numbers so far-fetched that it was difficult to come to a solid solution.  This was also where most of us spent our time.  It ended up that I hadn’t completed four of the 12 questions and got caught up where I got caught up.

I have made a few friends in the month I’ve been in class who offered support, but what was really encouraging was the fact that before I ever spoke to the professor, a great number of students that I hadn’t had the opportunity to meet on more than a superficial level showed concern simply because I looked upset.  It was an interesting dynamic.

In paramedic school, camaraderie is built into our system by our experiences.  We work as a family, constantly, and that seeps into the classroom.  It was nice to see that the professed caring nature of nursing seeped into my day.

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.

History

As an eighteen year-old senior in high school, I had no idea what I wanted from life.  I graduated from Concord High without wavering from that indecisiveness.  The summer came without hesitation and ended almost without incident.  However, near my 19th birthday in August of 1993, I decided that I would do something with my life and enlisted in the United States Air Force.  I was shipped to Military Basic Training at Lackland Air Force Base in San Antonio Texas on October 5th and had a hell of a time there.  You see, just a month before, I was acting in a play in Danville, California and had all the freedom in the world.  Despite my few encounters with my Army drill sergeant father over random summers in my youth, I was unable to comprehend that the military was not created to allow for individual differences, especially California differences of justice and equality; I graduated successfully, though, and in an honor flight at that.

I was stationed at Dover Air Force Base in Dover, Delaware on December 21, 1993 where I spent my time in the military as a Hazardous Materials Journeyman.  Interestingly enough, the date I arrived was the date that “Don’t Ask, Don’t Tell” was put into effect.  On October 31, 1994 I boarded a plane for California, honorable discharge in hand.  I told.  However, in my year and twenty-six days enlisted, I learned a great deal of discipline and structural ideologies about the chain of command – a great asset to my future EMS career.

After two years of attempting junior college and withdrawing from most every class because of boredom, my mother decided that I was going to go to school to be an Emergency Medical Technician-Basic.  In June of 1996, I started my 8 week EMT course, finishing around August.  Luckily, I was already connected to a few folk in EMS and was able to obtain a position as an EMT with Redwood Empire Life Support in Santa Rosa, California directly out of school.  While at RELS, I worked concurrently for Contra Costa County’s TeenAge Program teaching health and prevention at area high schools and juvenile hall.  Over the following four years, I worked at two other ambulance companies, Antioch Ambulance and Westmed Ambulance, as an EMT on basic life support, advanced life support, and critical care units in almost every county surrounding the San Francisco area.  I ended my time at Westmed in 2000 as a Field Training Officer and Station Chief for their Concord location.

I began paramedic school in 1998 and graduated in 2000.  Pooling resources from past jobs, I found myself at Redwood Empire Life Support again for two years working on EMT/Paramedic ambulances as the ALS partner.  I had to have been insane throughout these two years, as I worked anywhere from 96-120 hours per week.  I didn’t have much of a life, but it was not unlike the couple of years prior during paramedic school, in class three days a week and working three 24-hour shifts in my off days.  During my clinical externship, I had a three hour drive in each direction to my eight hour hospital rotations at Rideout Hospital in Marysville, California.  While my field internship was relatively close, I was working opposite Kelly shifts for my paid position at Westmed and my internship at American Medical Response – Contra Costa County; this schedule put me on an ambulance generally 5-6 days a week.  My paid paramedic posts weren’t at the busiest stations, so I got a decent amount of rest, and my company was amenable to downing my unit due to fatigue if need be.  Looking back, I realize that I had become accustomed to long hours and very little time at home, something I could do without nowadays.

The days away from work as a paramedic were generally filled working for either REACH dispatch as a rotor- and fixed-wing air rescue dispatcher or Kaiser Permanente Hospital as an Emergency Room Technician.  The exposure to in-hospital medicine made me seriously look at a future in clinical medicine and I decided to move away prehospital patient care for the moment and accept a full time position with Kaiser.  After an approved transfer, my plane touched down in Honolulu, Hawaii where I completed a six month stint in the emergency room at Kaiser Moanalua.

A return to the mainland in 2002 led me to Portland, Oregon, and I began my career in education as the Program Director for a medical assistant program.  While in Portland, I frequently taught paramedic pharmacology and anatomy and physiology, specializing in cardiology, pulmonology, and endocrinology across the border in Washington for Northwest Regional Training Center, Clark County, Fire District 5.  After three years in Oregon and Washington, I moved back to the San Francisco Bay Area.

In December of 2005, I accepted a position as the General Manager for a start-up ambulance company in Alameda County and spent six months setting up all of their standard operating procedures, completing all regulatory documentation to legally operate a medical transport company, and hiring the first round of employees.  After the company had a foundation, I returned to academics and remained there as the Director of Academics and Operations until September of 2011. 

On the side, I have been involved in volunteer medicine since I became an EMT in 1996.  I have worked at a number of different events from street fairs to car races, and love every minute of it.  This past year, my experience came in handy as the Logistics Medical Manager for San Francisco Pride; we handled nearly 220 calls in a two-day period, including a shooting incident with five patients.  Beyond emergency medicine, I continue to be involved in community medicine as a HIV counselor and public health volunteer.

That about brings things up-to-date with my experience in medicine, even though I’m sure I have left something out.  But, this is not an autobiography – I do hope that this quick insight gives you an idea of my experience and what I believe qualifies me to write a blog of this nature.

Thank you!  I look forward to any questions or responses to this blog!

EMT School

EMT School - C-spine

RELS ALS Ambulance in the Geysers, CA

Kaiser Moanalua Send-Off

As the GM of Royal Ambulance, San Leandro

Director of Academics at Fast Response, Berkeley, CA

Logistics Medical Manager - 2011
San Francisco Pride

Inception

As my first entry in this blog, I would like to thank you for tuning in!  I hope that, as a reader, you find it both enjoyable and informative. 

This is the first blog that I have ever created, but I have been writing seriously since I was in the 8th grade.  The majority of my published work has been creative writing and poetry, but I have a number of unpublished business proposals, academic papers, and business plans that have been used in the course of my career in medicine and education.  In addition to standard writing, I have written curriculum for a number of different health care programs.  That said, the style of writing I will use for this blog will be somewhere in between creative writing and a research paper; I hope this will give you a fact-based blog that won’t be used as a sleeping aid.

The first few entries will give you an understanding of my first days and experience in medicine, an up-to-date accounting of what I have accomplished so far in my journey of nursing school, and an analysis of what I believe my strengths and struggles will be during nursing school.  During the latter point, I will begin to compare and contrast my position now with where I was during paramedic school twelve years ago. 

Again, thanks for reading!  Feel free to comment on any and all posts!