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“EMT Basic” Skills Are Not Basic.

I’m all for doing away with the title “EMT Basic”. When I first became an EMT they called the certification EMT-1A. Wouldn’t it be nice to just call paramedics EMT-1B’s or 2A’s or something more accurate like that? Then maybe we could quit calling EMT-1As “basics”.

So why this aversion the “basic” title you ask? Well, for one, it just doesn’t do justice to what an EMT is expected to know and do. I don’t see anything basic about the EMT basic skill set. Notice that my website doesn’t have a category dedicated to intubations or medication administration. However, I do dedicate an entire category to the discussion of patient assessment. That’s no accident. Patient assessment is a skill that a caregiver can and should continue to develop over a career. It’s an intricate, complicated skill ripe with subject matter. Those other “paramedic” level subjects just don’t have that depth.

Worse than lowering others expectations of us, the basic moniker can also cause us to lower our expectations of ourselves. And the results of that can be devastating. Maybe you think I’m being overly dramatic about this. Maybe I am … but let me tell you my story before you decide.

This isn’t something I talk about often. Failure is a touchy subject. Nobody likes to talk about failing. It’s kind of like the adult boggy-man. I want to tell you this story because, while it was painful, I learned more from this failure early in my career than anything else I have done in emergency medicine. These events shaped me as a paramedic, a teacher and a person. Besides, it’s just you and I talking here right.

When I left paramedic school I think most of my friends and family expected that I would sail through my field internship on my way to being a working paramedic. I had a good run as an EMT, was accepted to a tough paramedic school (UCSF) and scored near the top of my class. There was no hint that I was on my way to a major flop, and yet I was.

I went the full 20 shifts and then I got extended to five more … and then five more. And then my instructors had that awkward conversation with me. The one where they say, in as nice a way as possible, that maybe I just wasn’t cut out to be a paramedic. I was devastated. I was young and immature, just barely twenty-two years old, and I had never really failed at anything yet in my life. I had no idea what to do. I didn’t want to do anything but be a paramedic.
My school had no idea what to do with me either. Remember I had been one of the top students. What more could they give me? They gave me another internship. In another city, with a different company. But I didn’t get off to a great start there either. All of the same old problems kept popping up. And everyone seemed to have the same solution. More shifts, more time and more experience. Clearly, something wasn’t working and nobody could say what. Nobody until Jesse came along. Jesse was an experienced paramedic with a reputation for turning problem students around. Before I flopped for a second time someone got the bright idea to give Jesse a shot at me. That’s when everything turned around.

Jesse let me run calls for two shifts without saying much. He just watched. And then, after two painful shifts Jesse sat me down and laid it on me. He said, “Steve, I know exactly what’s wrong with your medicine. You’re a crummy EMT.” (He may not have used that specific word … crummy. I think his was more colorful.) Jesse really put it to me. He said, “Steve you can tell me every indication and contraindication for every drug in your paramedic box, but if I ask you to put your hands on your patient and figure out what’s wrong with them you can’t do it. You have no idea how to do a basic head to toe assessment. You can’t do your most basic EMT skills and that’s what’s holding you back.”

And then Jesse gave me the magic solution. He explained, “If you want to fix your medicine you need to put away your paramedic books. You need to go back and learn how to be a good EMT. You need to go dust off that old EMT text and relearn how to assess people.” And he was right. From the moment he said it I knew he was right. The bulk of my learning from that day forward had little to do with all of the “advanced” skills and knowledge I had convinced myself was so important to emergency medicine. After that I began learning about how to assess people. How to talk to people. How to do a real subjective interview and take good lung sounds. I learned how to do a detailed neurological exam and how to find clues in people’s eyes and nail beds.

And everything changed. After Jesse was done with me I went off and got that paramedic job that I had always wanted. Years later I found myself as a paramedic FI and, ironically, I garnered a reputation as the field instructor who was good with “problem students”. It wasn’t a coincidence. I knew the magic recipe. When a motivated paramedic student came along struggling to put it all together I would step back and watch them for a few shifts. The problem invariably had something to do with their basic skills. And then I’d tell them about the importance of good strong basic EMT skills.

I told you that I learned some of the most valuable lessons of my career from all this.

This is what I learned:

• Good EMTs make good paramedics, nurses, doctors etc. Bad EMTs make bad paramedics, nurses, doctors etc. I don’t care what level of medical knowledge you acquire. If you don’t learn basic patient assessment and the skill set that we assign to the basic EMT, you won’t excel at that level of care.

• There’s nothing basic about “basic” EMT skills. EMT skills are not basic. They are foundational. They are the foundation upon which you will build everything you ever learn about being an advanced caregiver. If you build yourself a rock solid, bombproof foundation, everything else will benefit. If your foundation is shaky, everything else will suffer. You will eventually reach a level of ability that you cannot surpass. I know.

I don’t know where Jesse is now. I’d like to thank him and tell him how his lesson has endured. I’d like to tell him about the troubled paramedic students I have had the opportunity to help along the way and the deep respect I have always maintained for the EMT skill set. I would tell him that I have repeated the lessons he taught me many times for many people. And when I decided to make a website dedicated to teaching people to become better prehospital caregivers, I never once considered calling it The Paramedic Spot.

I think Jesse would be proud.