The Problem With Paramedic Texts

TL;DR? They’re all terrible.

Generally, I love having students on a car. It’s nice to be able to foster the next generation of paramedics. For those outside Australia, our paramedic students (we don’t have EMTs) go through a 3 year university degree, during which they do (unpaid) placements with the state ambulance service. It’s tough for them – they do the same things that we do, and they get relentlessly drilled too (at least some do – I hate that, but that’s a story for another day). I’ve had a parade of students recently, and one of them asked me about the “best paramedic textbook” to get – which one did I think was indispensable?

You know what I said? “Well fuck me, I have no idea, they’re all kind of shit.”

Recently I wrote about the best paramedic textbooks, and there are some that have good elements, but most of them are truly shit. Let’s take a look at a few of them:

  • Mosby’s Paramedic Textbook: Confused, has photos from the 80s, contradicts itself, its pathophysiology section is a mess, but it is comprehensive (it has a decent ECG introductory section I guess) if quite shallow.
  • Bledsoe et. al.’s Essentials of Paramedic Care: Accessible, fairly comprehensive, but outdated (Oxygen for everybody! Even you, ischaemic chest pain!) and a little bit confused in some areas. Not necessarily a bad book though. Surprisingly decentA&P section though.
  • Curtis et. al.’s Trauma and Emergency Care for Nurses and Paramedics: Poorly set out, confused, rambling, and apparently added paramedics as a chapter afterthought along with 3 lines of relevant info for each section. Written for nurses primarily, and thus isn’t good enough!
  • Nancy Caroline’s Emergency Care in the Streets: Basically a graphic novel of paramedic care which is great for a very basic understanding, and little else.

One of the best textbooks I’ve ever read wasn’t even aimed at paramedics. It was aimed at EMTs. It’s Prehospital Emergency Care by Mistovich et. al. (another of the Brady line of books) and contains one of the best explanations of perfusion I’ve ever encountered. It outlines some of the basic tenants of prehospital care, patient assessment, and conditions we regularly see. Does it cover everything? Hell no, it’s aimed at EMTs, all of it boils down to “Basic ABCs and take patient to hospital” but it’s astounding that basic concepts of how blood pressure works and the clinical significance of different vital signs are explained so well. Any of the other books above will give you a mess of explanations that are poorly integrated with actual patient presentations. It’s one thing to explain what a pulse pressure is, but another thing entirely to relate that to patient presentation and how you intervene.

So what’s wrong with paramedic textbooks? Why are they so bad? I think there’s a number of reasons why.

Firstly, they go out of date very quickly. Medicine moves fast, and no textbook will ever keep up. But some basic tenants rarely change, and that’s ultimately why we have textbooks. Textbooks should teach you the basics – the things we know work. That includes things like patient assessment, airway management, ventilation, and circulatory management. They should also teach you the basics of many common issues in prehospital care. Anything detailed is going to have to be in a different book – there simply isn’t room to cover everything, and we have our own protocols too – but a basic grip of what the disease is, how to recognise it, and the basics of management shouldn’t be beyond the scope of most textbooks. So many textbooks fail at this!

Why do they fail?

Let’s look at a fairly essential concept: shock, or to be more accurate, hypoperfusion. To really understand it, you need to understand how perfusion actually works, including the respiratory system. Simply knowing signs and symptoms isn’t enough – you need to understand how the body responds, and thus how normal perfusion is maintained. Let’s look at how the various books approach it:

  • Mistovich (EMT): Has two chapters – one on pathophysiology, and a more specific one on shock itself. The pathophysiology section contains a good rundown of perfusion (including respiratory input) and homeostasis. The shock section repeats some of that but then goes into a bit more depth. Briefly touches on fluids but most of that is outside the scope of EMTs.
  • Bledsoe: Has information across different chapters, but has much the same information as Mistovich without the integration. Goes into a bit of detail about the role of fluid and vasopressors. Fairly well presented if a bit disorganised.
  • Mosby’s: Vomits its information across several chapters, none of which offer a particularly good explanation of perfusion nor the pathophysiology behind it. Fairly confused explanations.
  • Curtis: Similar to Mosby’s except even less focused and somehow lighter on information despite having more words.

Such a critical concept explained so poorly. The two books that come the closest to succeeding are Mistovich and Bledsoe (the two Brady books), though either one alone isn’t useful. Why has something so important been so neglected by the others? Why do the other fail? The reason is simple: they’ve tried to cram too many concepts into books that can’t possibly cover that much detail.

The reason why the two books above succeed is that they focus on what’s relevant to prehospital care, and expect you to find out the rest elsewhere. Bledsoe’s book goes into more detail, although it splits its information across chapters where Mistovich’s book wisely keeps things together, but they cover the same essentials. If you want to know more about how the body works, you’re expected to read an anatomy and physiology textbook (which is fair enough – that’s why such books exist, and go into detail far greater than the others possibly can).

Another Example

Let’s look at something that’s the bread and butter for our work: acute coronary syndromes.

  • Mistovich (EMT): Tells you what it is and how it comes about but it’s written for EMTs so it stops being useful.
  • Bledsoe: Fairly good explanation of ACS and management (if a little outdated), makes reference to ST elevation but never explains it. Sort of mentions risk factors and pathogenesis but not much.
  • Mosby’s: More in depth with more ECG information provided, including risk factors, but set out poorly and lacks some at-hospital information that may be helpful in decision-making.
  • Curtis: Confused, too many words with nothing to say, and too focused on in-hospital management.

Something so basic is explained so poorly across all the textbooks. I guess the best of the lot is Mosby’s attempt, because it contains the most overall detail (even if it’s poorly set out). Bledsoe’s not far behind (and includes more at-hospital information) but lacks some ECG information that is kind of important with STEMI recognition. By this point we can see a pattern emerging – they all fail to maintain an appropriate level of depth (save for the EMT book). They either get too wordy and end up saying nothing at all, or they don’t go far enough. This is likely a symptom of trying to keep things concise (so that the book isn’t far too long) and yet having different focuses on what they want to get across. Curtis’ book, being aimed at nurses (and paramedics, apparently) routinely fails a paramedic check because it’s too heavily weighted towards nurses and in-hospital management. You can’t cover both professions – it isn’t possible. Mosby’s book meanwhile focuses very heavily on cardiac conditions (an entire section is dedicated to it) but completely screws up some other basic elements.

What’s the best solution?

I think for any aspiring paramedic student, you need to do the following to succeed as a paramedic:

  1. Get a good fundamentals of paramedicine textbook. Don’t expect it to teach you everything – in fact any “all in one” that says it can is probably lying. It should teach you the basics of patient assessment, ABC management (including a good understanding of perfusion and the body’s response to hypoperfusion), and some of the big-ticket paramedic items (like acute coronary syndromes, asthma/COPD, the various shock states, abdominal pain, and trauma in all its forms). If it can’t do that very well, it isn’t a good book.
  2. Get a good anatomy and physiology book. The combined A&P books are usually good for us – they have the right level of depth that a focused anatomy OR physiology book will simply shoot straight past. The ones that include pathophysiology generally don’t have enough information in them. Pathophysiology can be covered by your paramedic textbook to start with.
  3. Get a good ECG book. No “all in one” book will go into sufficient depth. Many people have different ideas on what a good ECG book is, but whatever you pick, make sure you understand how to read rhythms, axes, and ST segment changes.
  4. Learn how to use Medscape or a similar medical knowledge base. Whenever you learn about a condition, research it to find out the latest information. Medscape is totally free, and contains good information on most conditions, from pathophysiology and assessment to treatment and outcomes. It’s written for clinicians though, so unless you understand how the body works, it’ll sail over your head.

This represents the best combination of resources that I can come up with, and what generally works for me. To that end I’d recommend Bledsoe’s Essentials of Paramedic Care and even Mistovich’s Prehospital Emergency Care if you can afford it (or “find” it). Both of these books will give you the fundamentals of patient care and enable you to get a good grounding on how the basics of paramedicine works. Mistovich’s book is good for the absolute basics, which you can build from using Bledsoe’s book (read it for the extra assessment and management sections, the pathophysiology is largely the same believe it or not). For an A&P book, consider Principles of Anatomy and Physiology (Tortora et. al.) which has an excellent amount of depth that will greatly aid in understanding pathophysiology later on. For ECGs – I like Basic Dysrhythmias by Huszar, but there are others.

Things I recommend you get if you can:

  1. A book on pathophysiology. Tintinalli’s Emergency Medicine is the most popular and comprehensive, but it’s expensive and also goes into a great lot of detail focused on the emergency department rather than prehospital care. But if you’re getting it mostly for pathophysiology it’s still a good read.
  2. Books focused purely on medicine or trauma. The PHTLS book is an excellent trauma-focused book, and the Manual of Internal Medicine series is great for medical complaints. They’re quite in depth and take a bit of effort to read, but they’ll significantly expand your knowledge base.
  3. Emergency Journals. Impractical for some, but good if you can stomach them – they’ll update you on the cutting edge of medicine and help you to understand what you’re doing and why.

We have yet to come up with a really good, well written paramedic textbook. They’re all laughably bad in their own ways. Some are incomplete, others have absolutely no organisation or integration of information. The best solution is to find a textbook that covers the basics and makes sense to you, augment that with a good understanding of anatomy and physiology, and then look to the internet for more information. It’ll keep you up to date and enable you to really see what you understand of different conditions.

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2 thoughts on “The Problem With Paramedic Texts

  1. Yours was a fascinating and well written presentation. I’m now sixty-seven years old and many, many decades out of date. I was one of the first six paramedics ever in the state of North Carolina back in the early 70’s.

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