by Charles E. Truthan, D.O.,
FACOFP
Copyright 1998 by FD Doc®
aka: Doc T DocTruthan@FD-Doc.com
Does it really require two thousand hours to train a Paramedic? I submit the answer is an emphatic "no"! In 1975, House Bill 832, the Paramedic Law, was submitted to the State of Ohio Legislature. The medical sections were written by Charles B. Schumacher, Fire Chief, Willoughby Hills, Ohio and by the Richmond Heights (Osteopathic) General Hospital. When it was passed into law, Ohio became the first State to provide a legal definition as to what an "EMT" and a "Paramedic" were, and what they could and could not do. It defined the training necessary to become one, the requirements to advertise your service as one, and the legal "teeth" to enforce it.
EMS training, at that time, consisted of: a 60 hour "Emergency Victim Care" course; a 6 hour "Vital Signs Observation" course; a 30 hour "In-Hospital Training" course; then a 200 hour "Paramedic Training" course. The EVC, Vital Signs and In-Hospital courses were combined and shortened to a single 90 hour EMT course. The paramedic training remained at 200 hours after EMT level. This basic amount of time is all that it took to train EMT’s and Paramedics to a very "street competent" level. It was intense, but it was also a reasonable length of time.
That first hour from the time of the injury to getting them to surgery. In the "major" cities where the greatest population is concentrated, there is a corresponding greater concentration of hospitals. Understanding that, it is obvious that the response time to a scene and the travel time from scene to hospital are relatively short. However, this is covering less than 20% of the geography in the United States. The remainder of the country is rural. The greatest percentage of Interstate Highway miles are located in the rural US.
In these rural communities, one finds Volunteer Fire Departments and Volunteer Emergency Medical Services. It is in these areas, remote from hospitals and even further removed from trauma centers, that the need for Paramedical services is greatest. It is also here that the ability for a volunteer to take a full year off of work (40 hours per week and 50 weeks to the work year equals 2,000 hours) to attend a Paramedic training course is the least likely to happen. My 1974-75, 200 hour long paramedic course was held on Tuesday and Thursday nights, three hours per night for 9 months (September to June). It was also encouraged, but not mandated, for the paramedic students to spend time in the ER and ICU. And guess what. We saved lives with this "little" amount of training! After all, that is what you are in this field to do, isn’t it?
Is there some reason why today we need ten times the number of hours to train a Paramedic than we did 23 years ago? Well, I should correct that last statement. When the Federal Government got involved in funding EMS 20 or so years ago, that is when the hours jumped ten fold. Why? The only reason I have been able to determine, after more than twenty years to cogitate on it, is that a bureaucracy exists only to perpetuate itself. By requiring these high times, they create a new industry. A new industry requires regulations and monitoring, which requires the bureaucracy.
What is the minimum, not the maximum, that they need to bring to the (medical/trauma) scene? I think it boils down to 4 main areas: 1. Advanced Airway management; 2. Intravenous access; 3. Cardiac monitoring; 4. Medications. Advanced airway management can be covered in 3 hours of didactic training and 6 to 10 hours of practical training (on a manikin and then real patients). Intravenous access should require no more than 6 hours (including the physiology of tonicity of body fluids, fluids and electrolytes etc.), and another 6 hours or so of practical training and experience. Cardiac monitoring with rhythm recognition, interpretation and treatment requires the majority of training time, around 100 hours. Medications, including cardiac medications, will require about 30 hours. That leaves 45 hours or so for training to expand basic anatomy, physiology and pathophysiology knowledge.
At this point in the story, you are probably saying to yourself "This guy is nuts! Everyone knows it takes a whole lot more than just 200 hours to be a paramedic!". I submit to you that it does not take more than this to train a street capable paramedic. Sure, more knowledge is better, but is it absolutely necessary? What is the difference in the street capabilities of a 200-hour trained Paramedic versus a 2000-hour trained Paramedic? Is one ten times more capable than the other? For that matter, does the "A" student perform better in the street than a "C" or even "D" student?
Is there a difference in the patient outcomes between a patient treated by a 200 hour Paramedic versus a patient treated by a 2,000-hour Paramedic? The Toledo, Ohio program started around 1977 with the 2000 hour trained Paramedics. With all of that extra time to train them, the Paramedics had to first send a rhythm strip by telemetry to the hospital, before they even started O2 let alone an IV access. Now, with "only" 1/10th of their training, my fellow (200 hour) Paramedics rarely sent any telemetry, by land line or radio. Fortunately, they quickly started to function at a greater level of autonomy, but "hold the O2 until you get the doc’s order"? Get real!
Well, I am waist deep in it now, so it makes no sense in any of us stopping at this point. One of the "several" things that I discovered during medical school was how little I really knew. I found, in fact, that the more I learned, the less I knew. A pathology professor of mine stated it very eloquently. He told us that "Half of the information you are going to learn during medical school is wrong. The problem, however, is that we do not know which half!". As a Paramedic, I used to be able to diagnose a heart attack within 30 seconds of the patient telling me their symptoms. But as a Physician, I found it took me much longer. I had to listen to all of their symptoms, family history, learn what risk factors for heart disease they had, prior episodes, any difference between the current symptoms and prior symptoms. Then, I need to get a 12 lead EKG (and a prior one for comparison if available) plus plenty of labs and maybe even a chest x-ray. Yes, diagnosis was simpler as a Paramedic, I simply had no idea of how many other diagnoses there were. And do you know what else I’ve discovered? For a Paramedic it does not make any difference!
As a paramedic, you are supposed to presume the worst possible condition for the patient’s symptoms, and treat (and transport) accordingly. So, if the patient’s chest pain, relieved by the sublingual nitroglycerin you gave them, turns out to be gastroesophageal reflux (GERD) instead of a myocardial infarction, it does not matter in how you as a paramedic treated it! There is nothing different you should do for your treatment of a patient who complains of substernal chest pain. Which now brings me to another observation which most of you are keenly aware of. The best performers in ACLS classes are paramedics, not physicians and definitely not cardiologists. Why? Because as a paramedic you are taught, and only need to perform at, the "knee jerk" treatment and response level. You (correctly) presume that all chest pain patients must be treated the same. Therefore, you learn algorithms, and you learn them very well!
As Paramedics, you only have to make a "working" diagnosis, treat for the worst possible condition, and keep the patient alive for 30 minutes to an hour. The physicians’ job is to sort it all out, make a definitive diagnosis, render treatment and eventually return them home, hours to days later. Each of these is the proper response for the level of care the patient requires. It is proper for the Paramedic to always presume that all patients complaining of chest pain are having a heart attack. For the Paramedic’s level of care is to bring all chest pain patients to the hospital, alive. "IV-O2-monitor" is a single word in treating chest pain patients. Position of comfort, aspirin, nitro and transport. Does itreally take 2,000 hours to learn that? Does the Paramedic really need to do anything more than that for the "stable" chest pain patient? I again submit to you that the answer is a resounding "no!".
Let us presume that the training costs for 10 paramedics to the 2,000 hour level (20,000 man/hours) is equal to training 100 paramedics to the 200 hour level (20,000 man/hours). Let us further presume that the wages paid to both groups during training would be the same. Would the citizens of the United States be better off having 10 times the number of Paramedics trained in 200 hours or 1/10th of that the number of Paramedics trained to a 2,000 hour level? Now, let us recall that volunteers do not get paid (in general) for training time. How many more volunteers could be funded to go through Paramedic Training? Let’s play with some numbers.
|
|
Number of students |
Wages paid ($20,000/yr) |
Cost to train ($10.00/hr/student) |
|
|
Paid, 2,000 hr. |
100 |
$2,000,000 |
$2,000,000 |
$4,000,000 |
|
Volunteer, 200 hr. |
100 |
$ 0 |
$ 200,000 |
$ 200,000 |
|
Paid, 200 hr. |
100 |
$ 200,000 |
$ 200,000 |
$ 400,000 |
|
Volunteer, 200 hr. |
2,000 |
$ 0 |
$4,000,000 |
$4,000,000 |
|
Paid, 200 hr. |
1,000 |
$2,000,000 |
$2,000,000 |
$4,000,000 |
Even when we use paid students, we can still afford to increase field paramedic strength by ten fold! One or two thousand paramedics on the streets for the same cost as one hundred. Hmmmmm, which would I chose? Which would you chose? There must be some way of making this work for the betterment of all the citizens of our great country.
Does it really require two thousand hours to train a Paramedic? Is that where we can get the best "bang for the buck"? I submit the answer is still an emphatic "no"!
Doc T.
Charles E. Truthan, DO, FACOFP
President & Medical Director, F.D. Doc®
www.FD-Doc.com
25 Years Fire
Service Experience
Member of Advisory Board, The American
Firefighter
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