Can We Fix Paramedic Textbooks?

Short answer: No.

Apart from ranting about technology and video games, I love to rant about paramedic undergraduate education – mostly because I read a lot of hilarious bullshit about it. Talking about paramedic education seems to lean in two directions:

  1. Everything that isn’t FOAMEd is shit and all books are a total waste of time
  2. The textbooks are fine, they’re just not suitable entirely on their own

I was so close to the former, but now I’m firmly in the latter camp. One of the common refrains I hear is “You have textbooks? LOL WHY? I just read journal articles, so much better, and totally evidence based. Get on my level, peasant.”

Here’s something that people forget: almost all of these people learned the fundamentals from a textbook. Those who didn’t probably learned it from classes that were written with the aid of a textbook. Journal articles do not teach systematic approaches to assessment. They do not teach you practical skills. They are designed to present peer-reviewed research on particular topics for incorporation into practice. Once you know the basics, keeping up with journal articles (or more practically, following a website or service that does it for you) helps you to keep abreast of what’s changing. But learning the fundamentals from journal articles isn’t great, and usually results in failure.

A university in my state attempted to do this, under the guise of ‘evidence based practice’ – and they routinely failed miserably out on road, because they had absolutely no idea what the fuck they were doing. The journal articles they’d read never told them how to assess a patient, how to take a history, or how to do any other myriad of typical tasks. Did they know the current evidence on the effect on mortality of GTN? Yes. Did they know how much GTN to give to the ACS patient and why they were giving it? Nope!

What’s wrong with the textbook?

Pick any paramedic textbook, and I’ll find problems with it. Probably the most comprehensive and deep paramedic textbook is Paramedic Care by the incredible Dr Bledsoe – but in the 4th International Edition, published in 2014, it still advocated limited analgesia in prehospital abdominal pain to avoid masking conditions – something that has been soundly dismissed for ages. None of the textbooks are perfect.

The common argument is that “they’re too basic” and don’t go far enough. That’s true – there’s lots of things that are either missing or oversimplified. But it’s also a totally unfair point, because they’re trying to cover an obscene amount of content. Paramedic texts are for fundamentals – the basics of prehospital care. If you try to treat them as an ‘all in one’ book to tell you everything you need to know, you’re going to be disappointed. They’re the bare minimum standard of knowledge, not the top tier. They are brief by design, otherwise they’d be six times the length and practically impossible to read. When you’re trying to impart the basics, things will inevitably be left behind.

With that in mind, it’s hard to be overly critical of paramedic textbooks – they’re there to teach the basics of prehospital care, and to be fair they do that job very well (whichever one you pick or are forced to use). No other book actually manages to do that. Some will say “Oh just read Tintinalli” but medical textbooks often rely on diagnostic approaches that aren’t available to paramedics. We don’t really have access to medical imaging, arterial blood gases, routine bloods, and things like that. Tintinalli is great for learning about lots of different presentations, but when its diagnostic approach relies on tools you simply don’t have, it’s hard to apply it to the prehospital environment. There’s a reason so many doctors stand around looking confused when out of hospital at an emergency scene – without all of their extra hands, tools and tests, they’re basically stuck making educated guesses, just the same as we are. (That said, their educated guesses are often more educated than our own).

A Look at Medschool and Nursing…

The idea that there should be “one text to rule them all!” is absurd, and doesn’t bear out in many other professions. In medical school, the idea that you could learn everything out of one textbook is idiotic. Nobody would propose such a thing! And yet we routinely ignore this point and instead disparage paramedic textbooks (as I have done in the past!) because they don’t fit this ideal. In medical school, if you want to learn about physiology, you buy a book on physiology. If you want to learn about pathophysiology, you buy a book on pathophysiology. If you want to learn about clinical medicine, you buy a book on that… and so on. Books written for specific topics provide more information and depth than books that are trying to cross multiple subjects. That’s nothing new or shocking – that’s just basic logic.

My nursing degree had a multitude of textbooks. I had one for anatomy and physiology, I had one for pathophysiology, I had one for clinical skills, I had one for mental health, I had two for medical and surgical nursing, and I had one for cardiothoracic nursing. I had something like three for patient assessment and general care planning alone. Granted, not all of these got a lot of use (I think my A&P book saw the most use, my MH book saw by far the least), but they were all very useful for the particular topics that I had to know about. There’s no way that just a single book would have done the job for my nursing studies – especially because my lecturers were awful.

So why do we seem to think that a single textbook is all we need for paramedicine? Why does this myth persist? Why do we demand that one book does the work of four or more? It simply isn’t possible. Perhaps it has something to do with the way EMS is taught in the US – all the major paramedic texts are rooted in the US NREMT method. Perhaps it’s time for that to change.

Why we still need a paramedic text

One thing I’ve seen is that we should just skip paramedic textbooks altogether. The three reasons I see the most are:

  • Lectures are good enough!
  • Tintinalli/Rosen has the same stuff plus more!
  • Journal articles are more up to date than textbooks!

All three of these are wrong. I’ll tell you why/

Lectures are not good enough. In Australia, the average lecture lasts for about 1.5 hours – that’s actual content, not the lecture block itself. Anything longer and people stop paying attention. 1.5 hours is nowhere near enough to cover anything other than the barest basics of a particular topic. Some topics are split over multiple lectures to make up for it – but even then, 3 hours on cardiac conditions is pathetic. Tutorials help – but they’re inherently dealing with the practicalities of basic presentations. To really learn, you need to read – and it’s obvious to onroad officers who actually reads. The downside is that you need expensive textbooks, which on a student budget isn’t great. But it does make you stand out from the pack. Textbooks can fit more content in and often answer a lot of questions that students are afraid to ask. They flesh out the lecture much more than anyone else could hope to achieve.

Tintinalli and similar are great medical textbooks, but awful at prehospital care. The paramedic text is written for the chaotic, limited prehospital environment. Tintinalli is written for the emergency room. Compare the sections on shock from a major paramedic text and Tintinalli or Rosen’s. Looking at the medical text, you’ll see lots of references to lactate levels, urine output, CVP, ABGs, and so on – most of which you can’t do while the patient is lying on the side of the road. In a paramedic text? It’s much more focused on what’s safe and effective for prehospital care, with signs such as skin changes, the presence of a radial pulse, etc. Are they as accurate as other methods? No – but they’re as close as we get prehospitally. Medical textbooks simply don’t work prehospitally for a significant number of problems – we simply lack the diagnostic power to employ them. I still love Rosen’s and I’ve used it to expand my knowledge quite a bit – but I don’t rely on it to do my job, because I’d be trying to make decisions based on information that assumes I have double the diagnostic capacity.

Journal articles inform practice, not teach it. The people who say they just read journal articles and nothing else are either clinical paragons or full of shit. If you want to learn about new ways of doing things or why you’re doing something a particular way, then journal articles are great. They enable you to make better decisions and provide better care. None of them teach you the basics of how to be a paramedic. It’s like trying to build a car with a workshop manual when you can’t even change a tyre.

Paramedic textbooks do one thing well – they teach prehospital care. Yes, they’re out of date as soon as they leave the printer – every single textbook that was ever written was like that. It’s impossible for something to be contemporary and up to date unless it’s online and updated regularly. That’s why you have journal articles and FOAMed. But you need to learn the basics before you can do anything else. That’s why you have a textbook.

So what should we be looking at?

What should the new order for paramedic textbooks be? What should students look at getting? I’ve gone over this before, but in terms of broad categories, I think these books are the most important:

  • A paramedic textbook, to instruct you in the fundamentals of prehospital care
  • An anatomy and physiology book, to improve your knowledge (I’d recommend one aimed at undergrad med students like Tortora rather than an EMS or Nursing-focused book, but those are okay too)
  • An ECG book, because nothing else teaches ECGs like a dedicated textbook combined with YouTube!
  • An emergency medical textbook, to help flesh out your knowledge

There are plenty of others you could add in here, like a pathophysiology textbook, a clinical examination text, or a clinical medicine text. But these are all dependent on the person and how far you want to take your knowledge. Most of what you learn from the above books in conjunction with your degree and a bit of Googling will be more than adequate. If you want more though, I’d suggest:

  • A pharmacology book
  • A toxicology book
  • A clinical assessment book aimed at undergrad med students
  • A pathophysiology book (maybe one aimed at undergrad med students too)
  • A clinical medicine book (if you want to know more about non-emergency management)

Basically, I’d look at books that are aimed at med students. I don’t advise getting books aimed at nurses, because they’re typically suffering from the same problem as paramedic textbooks. They’re limited and attempt to simplify topics to make them easier to digest – and if you’re going that route, they’re not worth buying. None of these books are essential, especially in the modern age of Google – but if you want to expand your knowledge, they’re worth picking up. Once you’ve got the fundamentals of A&P under your belt, you can start to read books aimed at undergrad med students without much difficulty – and this will give you a much more complete understanding of what you’ve learned from paramedicine.

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