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The Hardest Thing In EMS


EMS is hard. Really hard. EMT school isn’t that hard, unless you want it to be. Then it’s hard. The hard part comes after you finish the program and have to take the Cognitive and Psycho-Motor tests. Those tests are difficult, but not because they are challenging. They are difficult because the Cognitive part is based on questions which may or may¬† not have “right” answers. They have “best” answers, which might not be even close to correct and are sometimes worded so arcanely that you have to decipher the question before you can answer.

The Psycho-Motor tests are, or at least were, like scripted plays. Again, they often have no connection to real world EMS. They are a sort of Kabuki Dance which one must pass in order to prove that you aren’t a danger to the public.

Or something.

I’ve often referred to the EMT (or paramedic) exams as being the “Bunny Slope of EMS.” All that passing allows you to do is start the process of learning how to treat patients. This is the Affective Domain of learning. Which you can read about here. I think of the Affective Domain as the “putting it all together” domain. It’s where you take the book learning, the learning of the skills, and put them into practice. This is hard and many people just can’t do it. I worked with a number of providers, especially paramedics who were way smarter than am I. They could talk about medical theory in far more detail than I ever could. They even understood Axis Deviation and Hemi Blocks. I can learn those, and have. Several times. I just can’t retain that.

What those other folks could never do was put that all together when standing or sitting in front of a sick patient. I used to call it “Vapor Lock”, but other called it “Analysis Paralysis.” I was lucky, I guess, in that I could usually put what I was seeing, hearing, and all too often smelling (yech) together and figure out what was going on with a patient. And then devise and implement a treatment plan on the spot.

There were medics far better at it than I was, but I did my best to learn the intangible things from them and treat my patients well.

One of the highest complements we ever gave people was “He (or She) can recognize a sick person.”

That’s hard, but it’s still not the hardest thing in EMS.

This is.

Unlearning old untruths.

Far too many providers in this field refuse to keep current on the state of the science in EMS or medicine in general. In the last ten years a lot has changed in EMS.

The barbaric practice of strapping patients with possible spinal injuries to hard boards, driving them over often bumpy roads to hospitals, and then leaving them on those boards at the hospital, sometimes for hours, has finally been debunked. Not only did that “treatment” not help patients, it caused demonstrable harm. Patients with respiratory illnesses, especially the elderly, found it hard to breath and sometimes got ill. Patients that had minor aches from falls or low speed collisions, had significant pain, sometimes with attendant neurological deficits after being “treated”.

Finally, the science caught up with what just about every field provider knew. This was a poor practice that was meant only to protect cowardly medical directors and risk managers. It had nothing to do with medicine and was a horrible practice.

Most, if not all EMS systems, have abandoned the practice, yet there are providers who insist that we are going to fill the streets with quadriplegics in electric wheelchairs because we have stopped performing a vital treatment.


For most of the 1990s and well into the current century, stupid medical directors insisted that ALL patients that needed Oxygen be given high concentration doses via non rebreather masks. The pin headed logic was that EMTs and paramedics were incapable of assessing patient respiratory status. Thus, the only viable treatment was to flood their systems with Oxygen. Besides, the Chicken Soup School of EMS told us that it couldn’t hurt and might help. Then the science started to turn. Physicians started to study the effects of high levels of cellular Oxygen and found out that it not only didn’t help, it definitely caused harm.

All of those Stroke, Seizure, and Cardiac patients that we were giving boatloads of Oxygen to were suffering from the effects of the release of free radicals. Stroke patients in particular were prone to extension of the Stroke because of the effects of Oxygen.

Still, it took a number of years for EMS systems to change protocols and more time before individual providers were convinced that this was the right course of action.

Trendelenburg, Traction Splints (in most cases) and giving high doses of Dextrose to hypoglycemic patients have started to follow the same path. Those will take more years as the dinosaurs retire and younger, hopefully better educated, providers not only take to the field, but take to the classrooms and teach the new science.

It’s hard to let go of the old “truth” and embrace new ideas, techniques, and procedures. Hard, but important. All too many providers believe that once they have finished their class, passed the test, and received “their card” that all they have to do is go to a refresher (now renamed “National Continuing Competency Requirements) class and listen to some boring lectures that repeat the misinformation of the past. Go to some other boring classes, keep up your CPR and ACLS cards (you can sleep through those classes) and you are a “minimally competent” provider.

Just lovely.

I have a friend who used to work for one of the state OEMS regulatory agencies. We used to joke that one day we were going to start out own EMS company. We’d call it “MMS Ambulance Service”. Meets Minimum Standards Ambulance Service. Our motto was going to be “We’re minimally competent”. Not exactly confidence inspiring, but that seems to be the goal of both individual providers and many systems.

They seem to mistake mediocrity for excellence.

If you want to be more than just minimally competent, you have to work at it. First you have to be willing to take some classes beyond what is minimally required. Then, you have to be willing to case off old ideas as they become outdated and proven wrong. Finally, and this might be the toughest part, you have to stand up to mediocrity and laziness amongst your fellow providers.

See? I told you EMS was hard.

Good luck.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.