Advice for New Paramedic Students

Starting a paramedic degree next year?

So you’ve been offered a place at university to learn to become a paramedic. Firstly, congratulations! Secondly, welcome to a nightmare of sleepless nights, long placements, and a baptism by fire of learning. Paramedicine as a field is going through a transition period from predominately vocational, protocol-based learning, into a profession of its own with evidenced-based guidelines. You’re coming in at an exiting and difficult time. Here’s some advice for you:

Your textbooks are equal parts helpful and useless

There are a few common textbooks that universities seem to like to prescribe. Some of them are great, some are awful, all are inadequate to some degree. You’re going to need your textbook, not just for what it tells you, but for what it doesn’t tell you or what it gets wrong. Most paramedic textbooks are entirely inadequate for the level of education expected of you today. They go out of date before they’re even printed. And yet they’re still the best way to learn the fundamentals of paramedicine – because knowing the latest sepsis fluid resuscitation research is useless if you can’t even manage an airway.

You’ll probably be told to get Mosby’s Paramedic Textbook, or Emergency and Trauma Care for Nurses and Paramedics. Which ones are worth actually getting? What other books do I recommend from the paramedic-focused textbook library?

  • Mosby’s Paramedic Textbook is merely adequate, and nothing more. It’s not an awful book, but it’s a jumbled mess of halfway explanations that never quite offer a complete understanding. It’s okay, but I wouldn’t pay full price for it.
  • Emergency and Trauma Care for Nurses and Paramedics is absolutely awful and should be avoided. It’s even more of a mess than Mosby’s attempt, it adds paramedics as a mere afterthought, and most of its explanations are a confusing mess that make absolutely no sense. It’ll teach you very little.
  • Nancy Caroline’s Emergency Care in the Streets is almost never recommended anymore, but it’s not actually a bad book. It’s very simple and easy to understand and read. It’s also awfully expensive, and there are better options.
  • Paramedic Care and Essentials of Paramedic Care are some of my favourites. The Paramedic Care series of books can be had as a set of eBooks from Amazon Kindle (you can skip the operations and absolute basics book) for around what you’d pay for Mosby’s, and it’s better written. The Essentials of Paramedic Care book is even cheaper (around $60 AUD for the eBook) but it’s also quite out of date… but with that said, you only ever want these books for the absolute fundamentals, so it may not matter.

Don’t fall into the trap of many students assuming that they only ever need to purchase their paramedic textbook and nothing else. It won’t – you’ll end up with an incomplete understanding of conditions that will ultimately sink you, either during placements or when you end up with a job. They never have the information you really need. All you want them for is to teach you how to assess patients, how to manage most airway, breathing and circulatory problems, and how to do a few out of hospital procedures and skills. That’s about it. Their general treatment protocols are merely adequate and typically way out of date, even in modern textbooks. Don’t rely on them for that.

Some other books you’re probably going to want to get your hands on:

  • Textbook of Adult Emergency Medicine is an Australian medicine textbook often recommended in place of the above by some Australian universities. It’s comprehensive and easy to read, provided you have the requisite pathophysiology background. Definitely worth having, this teaches you more than the paramedic textbooks on how to treat a host of conditions.
  • Tintinalli’s Emergency Medicine: A Comprehensive Study Guide isn’t cheap, and it isn’t Australia-focused like the above, but it’s way more comprehensive and covers paediatrics too. It’s not quite as easy to follow, but it’s one of the most authoritative sources on the fundamentals of emergency medicine. If you can get a cheap copy, I’d pick it up in a heartbeat, particularly if it’s in eBook form. Probably more useful than Textbook of Adult Emergency Medicine in some ways. Note that if it doesn’t say Comprehensive Study Guide in the title, it’s inadequate – there’s another quick reference guide with a similar title that lacks the same detail.
  • A good ECG book is pretty much mandatory these days. Almost every service is moving towards paramedics reading 12 lead ECGs for more than just STEMI identification, so you’re going to need to brush up on your ECGs. Read as much as you can, and interpret as many examples as you can.
  • A good pathophysiology and pharmacology book is also very, very helpful. While neither are absolutely essential, if you can get your hands on them for cheap, they’re worth having around. Both will give you a far better understanding of the conditions you’re studying than any paramedic textbook, and you’ll understand how your treatments work to a much greater degree.

Textbooks are expensive, and you probably won’t be able to afford to buy them all. The second hand market is often your best bet – if it’s an edition or so out of date, it probably won’t matter too much in the long run, because your course will cover what’s new and changed. You may also seek out eBooks or other sources (ahem) to acquire textbooks. Sometimes universities offer digitised access to some textbooks.

For my part, I made use of Essentials of Paramedic Care along with Tintinalli and Adult Textbook of Emergency Medicine. My ambulance service had an excellent internal 12 lead book which I used to learn 12 lead ECGs. Although my paramedic textbook is quite out of date, I only used it to learn the basics of prehospital assessment and management, then set the book aside. Tintinalli taught me most of the rest of the fundamentals, and I learned best practice from reading article updates. It’s up to you what you do, but don’t feel like your textbook will teach you everything. It won’t. And seriously think about getting a good pathophysiology textbook – they usually explain things extremely well.

Your scenarios are useful for procedural knowledge, and little else

There are plenty of students who did extremely well in scenarios, who subsequently did absolutely awful in the field. The reason is simple – scenarios (and OSCEs in particular) are all about procedural knowledge. That’s why you walk in and say “Okay, is there any danger?” rather than just treating the patient like you would in the field. It’s about doing things in order, about ticking boxes, and doing it within the 20 minute time limit. Doctors go through the same nonsense. It’s not about doing something in accordance with best practice, it’s about doing something according to the checklist.

If you don’t treat an OSCE like an actual job, but rather like a checklist, you’ll do very well. This leads people to thinking that because they can do the checklist, they’ll be excellent paramedics. This falls apart when the patient stops fitting the checklist, and suddenly these people flounder.

My point is that OSCEs are a useful tool for some jobs, like cardiac arrests or major trauma where procedures are essential, but don’t feel like they’re the be-all and end-all of paramedics. They’re actually a kind of skill you need to master, because you’ll be doing more of them later on in your career. Some universities are moving away from these silly checklists into a more dynamic scenario environment that reflects real life, and thank the maker for that.

It’s a constant bombardment of information, and it’s often confusing

Right from the get-go, you’re going to be filled with lots of information, and it won’t ever let up. Your first year will be an onslaught of anatomy, physiology, pathophysiology, and the fundamentals of paramedic assessment, skills, and a few basic conditions and drugs. You will go on placement and feel like you know nothing – because you pretty much don’t know anything. You’ll learn lots, and enter your second year, when it ramps up even further – and you’ll feel like you know nothing again. You’ll do more placements and feel like you’re on top of it… then starts the third year when they introduce paediatrics and obstetrics, and it feels even worse.

When it’s finally done, and you graduate, and you get into a graduate program… all of that stuff evapourates and you feel like you know nothing again. Then you qualify, and the same feeling hits you.

There’s always more to learn. You will forget things. Concepts you knew last year will fade away and are replaced by new concepts. You won’t get a break from learning, there’s little real time to consolidate. You’re rushed – you just don’t have time to take it slow. Your instructors will also give you contradicting information – they contradict the state clinical practice guidelines, they contradict other instructors, and they contradict themselves. This is the nature of paramedicine. Be prepared to get confused and to be asking a load of questions for clarification.

Your peers will make you feel like an idiot, but that’s okay because they’re idiots too

When you do a scenario on a new concept, you’ll probably screw up. All of the people in the room will sit there watching you. Some of them will be shaking their heads going “Well, that’s not what would have done!” or snickering to themselves. When you relate a story from clinical placement, someone will go “Well, went to [some horrible job] and we did [some exciting procedure.” This will continue on during the whole year, and will make you feel inadequate. You’ll feel like everyone else is better or smarter than you.

They’re frequently not. The person criticising your scenario probably wouldn’t have managed it any better, because they weren’t trying to manage the job and remember things on the fly. It’s easy to remember things as an observer without the pressure of being assessed. The person relating their story probably didn’t do anything except what they were told to do by their mentor, which might have been as exciting as shoving in an LMA they were given, or as minor as carrying the monitor.

Ignore them. It’s just bravado. Wait till you see them on placement, then make up your mind on whether they’re as good as they say they are. You’ll probably find them wanting.

Learn from your mentors, and be respectful

Some of your mentors will be awesome people who tell you lots of information, help you out and let you do lots of things. Others will teach you very little and just drive you around to jobs, letting you do only a few things. Some of them will appear like they’re teaching you things, but instead are just belittling you to make themselves appear intelligent. Whatever the case, your mentors will respond to your attitude, and you can learn from even the worst mentors.

If you appear disinterested, don’t want to perform skills or assess patients, or don’t want to engage with the learning opportunities presented to you, then I’m not going to waste time trying to mentor you. The shift is hard and long enough as it is. If you show an active interest in what’s going on, and try to get involved, I’m going to want to teach you things. I don’t mind if you don’t know something – so long as you admit it, and do something about it. I’ll ask you questions that I think are relevant to check your understanding, so that when we go to a job I know you have some idea of what to do. It’s not my job to spoon feed you information, or force you to study or participate – it’s your placement after all. I’m there to support your learning, not force you to learn.

If you do get a mentor who isn’t interested in teaching you, or who appears to do things that you think are wrong, then tell someone about it. You can try (respectfully) asking the officer first, but if you’re not getting anywhere, approach the OIC or the university if that fails. Sometimes officers do things because that’s what they were taught and haven’t been shown anything different, and what they’re doing may not be inherently unsafe or wrong. Assume good faith in the first instance in all cases.

But if you get a mentor who is just tossing questions at you to belittle you, and make themselves seem like clinical paragons by extension, you’re probably going to have to talk to an OIC. These people appear to be good mentors because they take the time to “educate” you, even if that’s not really their actual intent. These mentors are particularly difficult to deal with – you may just have to put up with it or try to refocus them on things that are relevant. Or you can just ask them lots of questions – these people love to talk incessantly about themselves.

Also don’t disparage the “protocol monkey” too much. Protocols are written to be safe first and foremost. None of them inherently harm the patient or deliver a significantly lesser standard of care. Journal article findings take time to be reviewed and incorporated into practice, and in the meantime the protocol is still valid. You should aspire to be more than someone who just does things because the protocol says so and for no other reason (because there are patients that don’t fit the protocols every single shift). But don’t somehow think that they’re useless paramedics or shouldn’t be in the job. They’re still doing a safe, effective job – which is what people expect from the ambulance service.

Above all else: study hard, practice everything

Putting in the minimum effort will end up with you failing miserably. It’s not enough to just read the textbook and the clinical practice manual. The expectations are higher. You need to read more than the basic paramedic textbook – I’ve read pretty much every paramedic textbook there is, and they’re all significantly lacking in the detail expected of modern, Australian paramedics with a university education. You’re going to need to read medical texts and journal articles to get a complete understanding. You’re going to need to practice all the skills you can, too. Practice on real people when the opportunity presents.

Don’t forget about free online materials too, like FOAMed (Life in the Fast Lane, RAGE, FOAMed on Reddit, Google FOAMed, an RSS Feed blog for FOAMed, or crowdsourced guidelines). These resources will teach you the most up to date means and methods of medicine – things you can incorporate into your own practice. Some seem like overkill, and sometimes they are – but lots of it is useful and interesting, and it’s presented in a way that means you won’t have to read stuffy journal articles written to appeal to academics. Also don’t forget about Medscape for quick access to information on a host of medications and medical conditions. These resources will keep you up to date once your fundamental knowledge is in place.

Finally, there may not be a job at the end of the tunnel… but keep trying

Your chances of getting a graduate position isn’t great. Your chances of getting a permanent position is worse. Your chances of getting a permanent position in a location that suits you is even lower. There’s an oversupply of graduates in every sector in Australia, and paramedicine is no exception. In fact it’s even worse, because there are very few places you can work with a paramedic degree. There isn’t a lot of room in the private sector for new graduates – such private opportunities that exist generally want experienced paramedics, usually of the critical care variety. But don’t stop trying – many people do end up getting in if they’re willing to keep trying.

 

Welcome to the paramedic degree. It’s going to be 3 years of hell. Some of you won’t make it – you’ll quit in the first semester, or in the first placement. The rest of you will fight it out for the few jobs available. If I sound a little defeatist, that’s because that’s the grim reality of the job market. But if you work hard, don’t just coast by on the minimum information and go beyond mere protocol-monkey knowledge, you should be okay. Just keep on studying and practicing!

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