“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.

Comments

  1. Steve, this is an excellent post. I have often described myself as a great first responder/EMT that knows some things about drugs, electricity, and airways. Doing a good and thorough assessment, that includes a lot of listening to the patient, will always be important.

  2. My wife told me the second week into my EMT class (now 7 years ago) thst someday I would continue to Paramedic. I finally got my ‘upgrade’ this January. I knew that I wanted to be a good EMT before I went on the paramedic. I think that practicing good EMT skills is absolutly neccissary prior to furthering your EMS education. I have advised a few colleges, to wait until they are comfortable being an EMT before trying a medic class. One new EMT, ignored this advise and washed out of the paramedic class I was taking. He now realizes the importance and after a few years of working in EMS that he is ready to continue his education.

    BLS before ALS. Sounds easy but in practice it becomes overlooked. Thanks for a great post!

  3. Ross Judice says:

    Great post! Being a good learner now makes you a good teacher. I look forward to reading your future posts.

  4. you have been very helpful to me im gonna pass your site on to any/all of my fellow emt students we right now are tackling the complexity of the wording for patient assessments ….not the action itself… just the wording the book teaches..

  5. GREAT POST ! ! I’m going to start blogging as well, I hope I can write something that even come close to as good as yours

  6. Steve, I’ve read a number of your posts on this website and they are all excellent. I’m a retired critical care nurse/CNA clinical instructor/legal nurse consultant. Way back in the ‘ ’70’s it was my privilege to be a clinical proctor in the ICU for the very first class of FF/Ps in the state of Mississippi. You’re “spot on” about the basic/fundamental skills of assessment and the documentation of findings/actions. No matter what level or scope of practice one attains later in healthcare ( all the way up to MD), the number one thing is being able to truly observe your patient and environment, to listen very attentively to what they say and observe their body language, and to do careful physical/mental assessments before you do anything else. You cannot deliver good patient care unless you know what to look for and its significance to the situation. The most fundamental skills of assessment include attentive listening and attention to detail. I love your website!! Keep up the good work. While I don’t blog myself, I enjoy reading/replying to truly great ones such as yours.

  7. Steve,
    This is my first time reading one of your posts and i think it is great advice for all in ems no matter what “level” of care you are.

  8. Great post. Completely true. Even as a Basic I’ve seen other basics who are constantly trying shove airways into people who really you just need to be talk to.

  9. Mauri Manicotti says:

    Stevo ~ Excellent post here. Your aticles are very practicle. I could only hope that someday my department’s EMS department will get a guy like you in it. They don’t do a good job at teaching and most of us have to go out side to receive our CE hours. IS there a way you can certify your blog as CE’s?

  10. This is an amazing post. I just got my EMT license a few weeks ago, and am awaiting the phone call for a job. I am definatly waiting as long as I need to get better at my basic skill, to move on to medic. Thanks =]

  11. Thank you for this great post. I am a EMT-B in a private ambulance service which has several 911 contracts. Been in this career for 5 yrs. Im 53 yrs old and am not going to medic school. I enjoy my job as a EMT-B and feel that I have a job to do just as much as the medics I work with. There is still the “basic” stigma out there which some of the medics have here. They forget that they were basics once themselves. They feel that they are too good for the “basic” calls. A call is a call. A patient is a patient. Its just that.
    Thanks for making me feel that I have a purpose. 🙂

  12. I have been a EMT for almost a year now. i really havn’t been able to exercise my certification at this point. I can say that i do believe our title is as important as a EMT-P. we learn and practice alot of different things. things that could and would keep a person stable or alive. we may be EMT-B’s limited to basic life support. but in the long run our title deserves a hero in front of it just as any other rescue team. it takes a really caring person to do all that labor and go through all of the stress that comes with job and in return end up making pennies. But i care about people and i respect human life and the best reward for my work put in would be a family reunited or a spot in heaven from GOD.

  13. thank you so much i am thinking that i am just not getting the job done but it is not that i cant do it is just i dont think i can do it every one thinks that if your (just a basic ) you cant do anything that is wrong and you have showed it so well thank you this web site is so great i just found it and have been on it for two days lol and am going to tell everyone i know to look at i mean really look in it thank you again

  14. LEONARD C JOYNER says:

    Thanks, Now I know what to work on. Im almost done with medic school sometimes i seem lost but now im found.

  15. Thanks for the info. I have been an EMT-B in a town that has around 600 calls per year. There are about 15 to 18 full crew status EMTs with a fairly full schedule every week competeing for calls. My Basic skills fluxuate with the amount of calls per month. I’am 51 and have found that this is the field I really want to make a late career change to. Problem? I have applyed to all commercial ambulance companies in my area. Is there an unspoken age discrimination within the industry??? I have a resume that includes not only EMTB Cert but also Phlebotomy/EKG and Tactical BLS Cert. 16hr course completion. I have had no calls even for an intervue. Whats going on? Is the field becoming satuated with B Cert. Techs?

    Thanks sorry for the long winded reply

  16. Great article! I have been a first responder for a while now and I am in class for EMT-B. One of my classmates and actually the EMS chief in our firehouse feels that the EMT-B class we are taking is an overkill and as long as he can pass the state test he will be fine. He says “I will be good enough for a volunteer EMT and I don’t plan to make a career out of it”. Every time I hear him say this it just sickens me! If you or any one elses life depends on my actions, assement and treatments then I want to be sure that I have done everything I can. There is no reason I can not be as good or better than a paramedic at the skills I am responsible for.

    In our county an EMT-B is all you will get when you call 911. Even the leader of EMS for our entire county says “all you can do is give oxygen and burn the diesel fuel that is all we have to offer our patients oxygen and diesel fuel”. Every time I hear this from him it also sickens me. No matter what you did with/for a patient I gaurantee there is room to improve somewhere! His simple minded thinking has the rest of the EMT’s believing that is all they have to do is Oxygen and Diesel fuel. They often forget that the preparation of the next step, the hospital and staff depends on our proper assessment and timely communication with them. They forget that the 4×4 you are holding direct pressure on the head with is not the life threat of the patient.

    Keep writing I have learned alot from you! Thanks Nate

  17. I’m in basic class myself now. I’ve been a responder for some time now with my local volunteer FD and decided I loved it enough to change careers. Just so happens my instructor made it plain to us on the first day of patient assessment that there were guys in the medic class across the hall that would either not finish that class or would not be effective medics because they left BLS in this classroom.
    There’s also a hint of importance in assessment when that one topic is five times the length of almost every other topic with exception to airway.
    Great post…and great confidence booster to those of us still drying our ears. Thanks man

  18. Great post! I live in a rural town in a rural state. We are a volunteer service, which like Randy’s, sees something in the neighborhood of 650 calls a year. We are responsible for calls throughout the county as well as in town. Other than calling in an air crew, ALS is not an option; the “Basics” are it. There are two QRUs in the outlying areas; patients are passed from Basic to Basic, or from FRA to Basic. When we pass a patient on to a higher level, 90% of the time it’s going to be at the ER, and our assessments and interventions are closely examined. When your’e “it”, a strong foundation in the fundamentals is critical. These conditions are the norm in Montana rather than the exception. The state recognizes the necessity for Basics to provide a higher level of care and maintains an endorsement program. EMT-B’s can be licensed to provide advanced airways, monitor cardiac patients, initiate and maintain IV/IO, and have increased medications options including nebulizer treatment and analgesic therapy.

  19. I completely agree with you Steve. I’m a certified basic EMT as well as a senior in college, hoping to go for my Masters Degree in Physician Assistant studies, and I’ve always said, you can know anything and everything about the human body, but if you can’t relay it to your patients, it does no good… On some of my calls, I’ve noticed how the ambulance and EMT gear can be intimidating to patients, especially children, and having good people skills, and knowing your patient assessment, makes the patients realize you’re still a human, just like them under the uniforms.. I really respect your post and I love the fact that you’re not afraid to admit to your mistakes… Awesome man!

  20. I want “EMT skills are not basic. They are foundational.” on a t-shirt.
    Perfect.

    In so many things, people are in a rush to do “advanced” things and fail to appreciate the importance of a good foundation.

  21. Great column! Thank you!

  22. Steve,
    I must say that this is a great article. I have been in the EMS field for about 5 years now and am a Paramedic student at this time. I am also a FTO for my local and I always hear these “young guns” talk about “I am going to Paramedic school now” and I have always told them….you need to get confy with your BLS skills before you go ALS. It is so hard to convince people they need to get into the field and understand it before going to advance. It is amazing how the medical field changes on a day to day basis and nobody will ever know everything. As I have always said, the day you stop learning in this field is the day you need to find a new job.
    Steve, my hat is off to you and am happy to hear you have landed your job! Hopefully I will continue on and become a good Paramedic as well. Stay safe

  23. Your articles are for when it abosutelly, positively, needs to be understood overnight.

  24. Kevin CFD says:

    I’m sure some of you are great EMT’s, but your spelling and grammar are absolutely atrocious. I’m not typing just to hear myself talk, but I hope you aren’t writing your reports like this because I have seen how some of you write yours and it makes us all look bad when a doctor or nurse reads it…

  25. L. Bourke says:

    This is a lesson I learned long ago. When I started in this business my certifacation was “MULTI MEDIA FIRST AID”. I was taught some basic skills but had no idea how to use all of the equipment. The company was not professional at all and dated back to the old LOAD & GO days. I left there after a few months. When I re-entered the field it was as a EMERGENCY CARE ATTENDANT. A rating just below EMT, all the basic skills. I phrase the diferance as a ECA knows what to do, a EMT knows why to do it. I did eventualy get my EMT and went to EMT-I but had to drop out.
    I got to a point that I requested not to work with EMT-P’s. One day I had to work with one who 15 months ago woke up and decided to be a Paramedic. On 1 call we had a 102 female. We got the call as a City EMS refusal. We walked in and I started the paitant assesment and he talked to the family. All though her vitals were within norms, I started a nuelogical check. Her name, she has had her name for 102 years she got it riight., Her address, got it right, she had sived there proabaly for 80yrs.,. Whats the date; Feb 1982/ It’s May
    1994. OK she’s A&O X 2. I thought lets see how bad she is, Who’s the president/ Ronald Reagan?!?!?
    I informed my partner and suggested code 2 (we still ran code 2 in my area). He said no, code 1 will be fine.
    In route her condition started to detereate. As I was walking out of the ER I heard “CODE BLUE ER ROOM 2” her room.
    I knew more about that paitant walking in the door than he did with all his “FANCY” paramedic training.
    When it comes down to it I would rather have a good EMT than a bad Paramedic.
    I ended up working with troubled EMT’s and EMT-I. I couldn’t deal with the PARA-GODS. The EMT basic leval is a learning experiance and you should enjoy it.

  26. Steve, I stumbled across this site by accident. It didn’t even tell me the information I was searching for and I don’t care. What this post DID tell me will make me a better care giver and better instructor. You are obviously passionate about this and rightly so. I’m certainly going to bookmark your site and hunt around the rest of your posts. This one did post made me THINK and put perspective on foundational priorities. It is the foundation that is the strength of any structure. Sometimes we get so high up the building we forget what’s holding i up.

    Thank you for the ride to the basement 🙂

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