I don’t want to go to medical school.

Well, I’ll clarify that.

I want to go to medical school. I don’t want to have to go to medical school. So where do I go from here?

For more than a third of my life, which is the entirety of my adult life, I’ve worked in EMS. I was an EMT for three years or so before finishing medic school, and I’ve been working as a paramedic ever since. Honestly, I was hesitant to enter the field in the first place. Both of my parents were medics. My mother was killed in the line of duty when I was a child, and my father continued in his career as a medic, working his way up through the ranks until eventually becoming one of the preeminent clinical directors in his state. I’ve been surrounded by paramedics all my life. When I was younger, my father would bring his partners to my hockey games, and whenever there were family gatherings it always seemed like at least half of the people that were there were either EMTs or medics. It seemed like a natural thing to do when I had to decide what career to pursue.

That doesn’t mean that I didn’t enter the field without any sense of trepidation. For the longest time, I promised myself that I wouldn’t become one of those EMS people. You know the type. Each day is centered around responding to calls, all the topics of conversation they have is about that awesome MVA they had the other day. We all know and love these people. Yet it turned out that as my education and career grew, I became closer to the people I worked with and went to school with. I became enveloped in EMS culture and found myself surrounded by EMS people most of the time. When I had roommates, they would end up going to EMT school, I like to think in no small part due to my encouragement to join EMS society. But throughout all of this, I couldn’t help but notice one dark and looming theme that always hung over the heads of everyone I knew in EMS. Everyone was looking for the next thing.

When my father joined EMS in the 1980’s, there was a foreseeable career path. Many people entering EMS knew that there was room for growth and expansion. The industry was still new and exciting, and there were still myriad changes that would come to the industry to allow those involved to move up and provide for their families. As time passes, we see that this reality for past generations may not be a reality for future generations in EMS.

This seems contrary to the data. The bureau of labor statistics shows that the expected growth rate of jobs in EMS is 24% through 2024[1], so we know that the workforce is growing. But then why, anecdotally at least, did I see so many people using EMS as a stepping stone to move toward careers in nursing, or otherwise furthering their medical education and progressing to become physicians or PAs? The reason might be salary.

The same BLS statistics sheet shows that nationwide, the average annual salary of an EMT or a Paramedic is almost $32,000 per year. To be clear, the poverty line as dictated by the federal government for a family of four is $24,250 per year [2]. It can be assumed that many EMTs and paramedics are married, and thus have dual incomes to provide for their family. However, EMS is a well-known insestual society, and often we see EMTs and medics starting families with other EMTs and medics. Of course, this number is subjective to where you may live. For example, a medic that lives and works in the Tacoma, Washington area can make almost $80,000 a year[3]. But we all know that we do not enter this industry simply for the money.

Perhaps a bigger problem with retention in EMS is the job itself. EMS offers a career that is thankless, busy, and as mentioned above not terribly lucrative. Burn-out in EMS is common, and in some cases, may be more the rule than the exception. Because of paltry base salaries, often EMTs and medics must work overtime, or work at multiple jobs. This can lead to a lack of empathy when a patient throws up on you for the fourth time in three shifts. The more that happens, the more likely a provider will be to leave the profession. But we all enter EMS to pursue patient care, and to make the world a slightly better place then we found it, right? So why leave?

The simple answer is that the world we live has incentivized other careers over EMS. We are not without fault ourselves, as we often see EMTs act unprofessionally (See the FDNY EMTs who refused to treat a patient during their lunch break in 2009), or we are generally perceived by the public as ambulance drivers who have no training or experience. If the public wants to know that EMS is like, they turn on shows like Sirens and see the bumbling nature of our profession, or they turn on Night Watch (which is little more than EMS porn) and think that everything we see is an intense scene, but involves very little clinical patient care.

I looked at all these variables for myself and decided that this is the profession that I love, and I want to remain here as long as I can (hopefully for life) and provide the best patient care that I can. I pursued further EMS education, obtaining my FP-C, CCP-C, and CCEMT-P, becoming the only paramedic in my state to obtain all three certifications. This is something that I’m immensely proud of, but there was little I could do to change the practice of paramedicine in my state with the training I had received. I changed projects multiple times and worked in two different states, yet I felt no more fulfilled.

I began changing my education goals. As time passed by and I saw little change in the EMS system I knew that there had to be something more. There had to be some way to spread knowledge and information in a way that was somewhat untraditional, and would land with an audience of EMT or medic students. I can say honestly that going back to school was one of the best decisions that I ever made, but the longer I went to school, the more I noticed a difference in myself and in the students, I worked with. Many of my students had approached EMS for a far different reason than I had. On multiple occasions, I have had students offer that they entered EMS because the job seemed easy or that they liked the prospect of a 36-hour work week. This opened my eyes to something disturbing.

The simple reality is that EMS does not encourage furthering education the way that they should. There are dozens of websites and blogs, not entirely dissimilar to this one that offer new and cutting-edge information to the masses. The advent of podcasting, blogging, and the #FOAMed movement has provided more information in the past five years than has been available in the past five decades. However, I would ager that only approximately ten percent of EMS providers adhere to the principals that are taught through these mediums, and even less regularly encounter patients that suffer from the issues that they discuss. It is fascinating to hear about cutting edge treatment for hypertension in the emergency department and on the CCU, but it accounts for little more than trivia knowledge to people actively working in EMS. Make no mistake, I have nothing but the utmost respect for the Weingart’s and Rezaie’s of the world, and I certainly hope that if they ever read this they know that I am in no way intending to disrespect them or their practice. People cut from that cloth have changed the way that medicine in delivered, but it is simply not a sustainable way to change the way that EMS works, nor do I believe that it was, or is their intention.

In EMS, we adhere to this false standard of “we’ve always done it this way” which we all know is a recipe for disaster. The result of this false paradigm is that we end up with a culture of under-educated and ill-informed providers, which compromise patient care and lead to a high level of burnout for providers who could have otherwise been excellent in their fields. How does one approach changing that paradigm? One would have to begin teaching, so I did. I worked for years to obtain numerous teaching certifications and began teaching for multiple projects. The classes I led were dynamic (at least I think so) and employed the best practices of education. Flipped classroom became a calling card of my teaching style. I would send students new data and information to keep them up to date on the happenings of the EMS world, and why things are changing the way that they are. When spinal motion restriction came to my state, my site was one of the first to teach it. The same applies to BLS administration of Narcan, mechanical CPR, Epi-Pens, and the list goes on. I wanted to work to expand young minds and change the practice of EMS from the ground up. I was lucky enough to have a staff a faculty that was on board, in general. Those that did not subscribe to the new teaching styles eventually learned how to deliver lectures and classes differently and bought into the process. Our overall class scores went up. We had more students graduating and saw grade point averages rise. Each class we taught, we saw more and more students who were willing and excited to learn entering this field of EMS. I had high hopes that these students would make a part of the previously mentioned 24% rise in EMT employment and would work to change the industry for the better. Yet all too often these students would leave the academy and enter their positions with whichever organization they chose to join, and would invariably unlearn what they were taught.

I approached a former student of mine after a routine call not too long ago and asked why a task wasn’t performed. Namely, the EMT took a patient’s pulse with a pulse oximeter instead of laying hands on the patient. This is a far too common practice that I’m certain happens all the time, but the conversation that followed was representative of the culture we’ve developed. The answer was that the EMT was too lazy to take the pulse. This may seem like a paraphrase, or an accusation against the EMT, but it is not. The EMT had simply unlearned what they had been taught in EMT. Because the culture of the organization had bred that behavior into them. This is the dark under belly that EMS culture has both encouraged, and hid over the years. We work very hard to make sure that our employees and staff perform well at competencies, but how they perform in the field is up to them. The behavior concerned me, and though this was only the first time I encountered such behavior, it was certainly not the last time.

We are resistant to change, and we are our own worst enemies. We need not look any further than the seemingly constant battle of the use of lights and sirens in EMS response. This is a topic that this blog has covered before. The simple fact is that the use of RLS in EMS response does not change response times significantly and does not improve outcomes. Yet it is continually thrust upon us because “that’s the way we’ve always done it.” Each month, we see an EMT or a paramedic die in the line of duty[4], and there is little change to any EMS system overall.

This was not intended to be a condemnation of the EMS system, or of any one particular group or person. The question of this post is where do I go from here? I, like many others that have worked in EMS over the years am moving on to a new and different career path. I am not moving on or away because I want to. I love what I do, and I love medicine. Being a paramedic has been the honor and privilege of a lifetime, and I hope in my years in the field I have made a difference for more people than I have caused harm to. I leave EMS remorsefully, because I see behind me a system that is willfully broken, and encourages people to use the career as a stepping stone, and not a legitimate career choice. I hope it changes by the time I’m done with medical school. Perhaps my next step will be to become a medical director and try to implement top-down changes in the EMS system. In the meantime, I’ll be posting here at medschoolmedic.com, and will continue to spread as much information and knowledge as possible. Stay safe out there.

[1] https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm

[2] https://aspe.hhs.gov/2015-poverty-guidelines

[3] https://www.ems1.com/careers/articles/1187712-Is-an-EMS-career-right-for-you/

[4] https://www.ems1.com/LODD-Line-of-duty-deaths/