Is Paramedics Hard?

“Paramedics is easy,” saith the Student with the confidence of the gods. “That’s why I do it.”

Replied the Qualified: “What the fuck? You’re shit at this job, fuck off.”

One of the questions I get from people outside healthcare (or sometimes in unrelated fields) is “Is paramedics hard to do?” or “Is it hard to be a paramedic?”

This is two different questions to me. Firstly, “Is it hard to be a paramedic?” asks more about the life of a paramedic, not the intellectual challenge alone. Usually when people ask this, they’re really asking about the coursework and training, and less about holding onto a monster shit for several hours while you shuttle the acopic to hospital. Most of the time they’re not interested in the long hours, assaults, sleep deprivation, and onslaught of mental health issues that come with being a paramedic. They want to know whether it’s an easy degree program to do, and whether it’s easy to be a paramedic after the degree.

Here’s my take on it.

The Degree Isn’t Hard

I’ve had lots of students come through who have said that the degree is easy to get good marks, and they’re planning on using it as a stepping stone to greater things (like medicine – though honestly, I’ve never seen that many make the jump). This is also said of nursing degrees. And to be fair – the degree program isn’t especially hard. It’s not a cakewalk, but if you pay attention it’s almost impossible to fail the theory aspect. Hell, in Australia you barely have to open a textbook – most of what I needed to know was spoonfed to me via lecture slides.

That’s just to pass though. To do well takes effort – the same as any other course. The student who actually reads their textbook and puts in extra effort will see higher marks in theory – and a fair portion of your Grade Point Average (GPA) is reflected in your essays and exam results. The more you read, the better your marks will probably be, especially because there aren’t any real traps or surprises on the exams. You’re just limited by time and motivation.

The initial few months are probably the most challenging for most people, especially if you haven’t got a strong anatomy and physiology background. It’s a lot to take in all at once, as well as having extra ‘soft’ subjects shoved onto you, like subjects about the broader healthcare system, and cultural awareness, and ‘communicating as professionals’. But once you’ve got the fundamentals, it gets easier.

That said, one aspect that wasn’t so easy for most were the practical assessments – the Observed Structured Clinical Examinations (OSCEs). These were scenario-based assessments that tested not only clinical reasoning but clinical skills too – all within a 20 minute block. But even here there’s no surprises – we all knew what the scenarios would be, we knew exactly what we had to do, we just had to do them – and if you fucked up, it was because you didn’t study, or you let your nerves get the better of you. Even someone who was a crap clinician could pass an OSCE well if they just practised the hell out of it.

So overall, yes – the degree isn’t hard, provided you’ve got the inclination to keep at it. It’s hard to get started, and it’s more difficult to do exceptionally well – but it’s not a hard degree to at least get decent marks in. It’s becoming slightly harder as the academia in paramedicine starts to ramp up (same as nursing) but it’s still not all that difficult.

But it’s actually just a small component of paramedicine…

Placements Sort the Wheat from the Chaff

Want to hear a story? (No? Too bad.) I once knew a guy who epitomised the idea of academia over practice. He was part of my volunteer first aid division. He scared the ever loving shit out of me. Originally an IT graduate who fancied himself a ‘medic’, he joined us to get some practical experience with prehospital care – we went a bit beyond ‘first aid’ and it was the chance for him to learn more about it. He then started the paramedic degree. He got good marks. He also had zero social skills and borderline failed every placement he ever attended. He still hasn’t been offered a job with any ambulance service in the nation.

This is where we learn the truth about a student. This is where we sort out those who are just parroting information and going through the motions, and those who are actually learning something. This is where we learn who actually opened a book and who just read the slides. Placements are the crucible – where you’re made or destroyed.

I’ve had plenty of students who got good marks and yet were utterly awful on placement – and placement is where it actually matters. Unfortunately, placements are pass/fail, not graded, and thus do not contribute to GPA. The universities apparently ignore feedback, because I’ve had students who deserved to fail and yet their university would not accept our assessments. Once they’re outside of the safe walls of textbook presentations and procedural knowledge, it starts to come apart, and they realise that the job isn’t quite that easy.

Few patients fit the textbook. The textbook tells you that all chest pain is either cardiogenic or a pulmonary embolism, unless it’s trauma. The student will go to an 80YOF in the middle of winter, with pleuritic chest pain, on a history of chest infection with physical findings clearly suggesting chest infection, and give them GTN – because they don’t know any better. All of the clinical decision making that they think they get taught at university suddenly vanishes – there’s an empty void where differential diagnoses should be, and the rudimentary, entirely procedural assessment they did on the patient suddenly amounted to nothing.

When the patient is wedged in a toilet and looks grey and diaphoretic, the student who was doing it “for the marks” falls apart. They don’t know what to do with them, beyond the fact that they look sick (“Or do they?” they seem to ask in their minds). The theory-practice gap seems like the Challenger Deep at this point. All of the slides and lectures, the tutorials, the practice with putting cannulas in the plastic arm… it all evapourates, replaced with a buzzing white noise.

Suddenly, the degree isn’t so easy. Suddenly, the difficulty becomes apparent. Your GPA means shit out here if you can’t actually do the job. You’ve got the knowledge, but can you apply it?

Of course most students will overcome this – they will accept the shock that the degree gives them the knowledge but not the capacity to be a clinician. Being a clinician takes more than that – it takes the ability to use that knowledge in clinical decision making (CDM). CDM is something that can’t be easily taught – you can learn all of the differentials, you can read about different models of thinking, but it’s up to you to actually do it and put the puzzle together. We have plenty of hard and fast rules and maxims to live by in paramedicine – but as the job gets more complex, those maxims start to fade away amongst the many shades of grey. As the student develops, the black and white disappears and they start to consider more and more things. This is how we bridge that theory-practice gap. They understand that doing well in the degree and having a high GPA doesn’t make them an outstanding clinician. What they do in the field is the true determinant.

Graduate and Qualified is as Hard as You Make It

Lots of learning still takes place when you’re a graduate paramedic, and later as a qualified paramedic. I don’t think I’ve ever stopped learning. But there’s a catch to it from here on out – it’s up to you to maintain it, and it’s up to you to decide how complicated the job is.

There are plenty of paramedics out there who keep the job simple – and to be fair, sometimes simple works best. They go to the patient with shortness of breath, treat symptomatically, and go to hospital (because they’re at their knowledge limit). They don’t find anything obviously emergent and don’t offer up a provisional diagnosis other than “short of breath”. Then there are those who will employ the full combined force of Rosen’s, Tintinalli, and a stack of BJM articles they read on their days off, decide the patient has nothing wrong with them, and leave them at home instead. Neither approach is necessarily wrong – depending on the situation – but one has clearly put in a lot more effort to continue their education and increase the complexity of their job. Under most ambulances services in Australia, neither is really frowned upon so long as it’s clinically justified, and taking the patient to hospital if there’s any doubt is still a safe option (and if there’s nothing wrong, they sit in the waiting room).

So really, it’s entirely up to you about how much further you want to take it. I like to sit in the middle of the road – I keep reading and learning, but I ultimately focus on what’s practical to the prehospital environment. Anything outside of that is in my ‘nice to know’ folder – great for telling the patient what to expect, but learning about CT scans and lab tests that I can’t do prehospitally won’t really change my practice.

That said, I do have two stories about people whose knowledge exceeded their clinical capacity:

  • A colleague went to a 40YOF complaining of generalised abdominal pain – about a 5/10, onset about 4 hours previously, not getting any relief, maybe some slight rigidity on palpation, vitals unremarkable… fairly standard abdo pain presentation. We spent thirty minutes while she ran through an obscenely long list of differential diagnoses, only for her to decide that there was no value in her going to hospital and to go get something from the chemist instead. I was newly qualified and didn’t speak up, even though I now know I should have. The patient later called back with worsening pain and was transported to hospital. I don’t know what she was diagnosed with in the end.
  • A crew went to an 80YOM with nausea and vomiting – nil other complaints except some mild abdominal cramping. They assessed him as being slightly tachycardic but otherwise well with no fever. He was left at home under the assumption that it was food poisoning. The family, falsely reassured by this, just kept him at home – assuming that his worsening symptoms would reach a peak and then subside. A few days later though he died in hospital – with a perforated bowel secondary to prolonged ischaemic colitis.

There are lots of little stories like this – crews understating the danger of a patient’s condition, discarding more serious provisional diagnoses because their knowledge base tells them that they’re uncommon or they don’t show the obvious external signs of being acutely unwell. At some point, our technology and capacity for diagnosis fails us prehospitally, and we have to play it safe. Knowledge is power, but I’ve seen it lead to a false sense of security – and it often takes a near miss (or an actual miss) to drive that point home.

GPA is Easy, Practice is Not

That’s what it ultimately comes down to – you can find it easy to get good grades, because it’s predominately about recalling facts and running through scenarios until you vomit, but I’m yet to see this translate into actual clinical competence without effort. It sets the groundwork, it gives you the foundation, but there are plenty of people with high GPAs who are awful paramedics. If you’re doing the degree with no intention of being a paramedic, get the fuck out now – because you’re guaranteed to be a shitty paramedic who is wasting everyone’s time when you come out on placement. Go do another degree that has no practical clinical aspect – like biomedical science – if you want to do that.

The real difficulty with paramedicine comes with clinical decision making, and once you’re out of university, it can be as easy or as a difficult as you make it. The more knowledge you add, the harder it becomes – the ‘rules’ you were taught start to have more and more exceptions. Even harder is recognising when you’ve reached your limit and should just transport and treat what you find – and that ‘limit’ becomes harder to find the more you learn. Being a competent clinician is where the real challenge is, and as academia ramps up and we put more pressure on ourselves to find reasons not to transport people (at least this is how it is in my service – not from management, but from our own colleagues!) it’s only going to get harder.

So yeah, it’s easy to get a good GPA – but it doesn’t make you a good paramedic.

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