Big Box vs Small Box EMS Education

iews are my own, and do not represent my employers in any way.

I’ve been working on this post for a couple of weeks, and then along comes LUTL and Chris Kaiser who posts on pretty much the same topic, and does a better job of it, but I’m going to post it anyway. Here’s a link to Chris Kaiser’s article.

I was off for almost two months with a bum shoulder, and my inner EMS geek came out in full force.  I’d been following the Social Media and Critical Care Conference (SMACCUS) online for a couple of days, and it was both a positive and negative experience.  On the on one hand, it became completely apparent to me that we’re not providing the most cutting edge care that we can. On the other hand, it’s easier than ever for Paramedics around the world to provide that cutting edge evidence based medicine. Sea Can


Among my peers, there are two competing theories of EMS education, what my partner and I refer to as the “small box vs big box debate”.  The small box theory of EMS is the system that many of us come from.  In order to be a PCP I need to know how to perform the following procedures….I need to know the indications, contraindications, dosages and routes for the following medications…I need to know how to recognize, diagnose, test for, and treat the following conditions… And the reason we think that way is that’s the system that we come from, that’s the way EMS programs are designed, especially in light of Canada’s NOCPs. Crich

The big box theory states that I need to know all that, and lots more.  I’m a better paramedic who delivers more effectively treated patients to the hospital because I also know about things OUTSIDE my scope of practice.  I read up on ECMO, ROTEM, REBOA, blood products, rehab, and indications for procedures I can’t perform. Why? Because prehospital and retrieval medicine needs to be a team sport, and I can best support my ALS colleagues, the nursing team and Emergency Physician in the ED, the Trauma Surgeon in the MTC, the RTs and allied health care providers if I can anticipate their needs.  In the past two weeks I’ve approached my ALS colleagues with some neat things that I’ve seen thanks to @Ketaminh on Twitter, and in both cases they’ve been positively received.  An ETT setup that allows you to suction through the tube during VL or DL? Awesome!  A new use for the venerable Stiffneck? Hilarious, but great.

20150718_213034Let’s look at a “simple” skill, common across the full spectrum of practitioner levels: As the Paramedic Association of Canada describes it “Perform ventilation using a manual positive pressure device” which means everyone from First Responder and Occupational First Aid to EMR to CCP needs to know how to use a manual resuscitator (BVM) to assist or provide breaths to a patient. We all need to know it because we may all need to do it. We teach all sorts of people how to do it.  Poorly.  And we KNOW that using it poorly is potentially devastating to all sorts of patients!  Life-saving, yes.  Benign, no.

I’d been in EMS for almost a decade before an anesthesiologist showed me how to use a BVM properly, who took the time to explain what it was doing behind the scenes, on a physiologic basis.  It’s been over a decade since then, and despite the trickle-down effect of knowledge translation, it’s still a tool that’s used improperly by many Paramedics.  Paramedics with months in the classroom and hundreds of hours in practice still use it improperly, because the foundation their practice is built on is less than solid.

In his book Outliers Malcolm Gladwell says that expertise takes 10,000 hours. I was let loose on patients with 10 minutes of actual instruction and less than 10 hours of practicing bad habits, and it took me almost 10 years to realize it. Now I’m happy to say that AIME is one of the four-letter-acronym courses that I help deliver for BCEHS Learning, to every BC Ambulance Service Paramedic.  We talk about endotracheal intubation to people who don’t do it because it makes them better assistants. We show extraglottic airway placement to people who don’t place them because it makes them better assistants and helps them make that “call for help” decision.  In ITLS, our CME trauma course, we discuss and demo intraosseus infusion and needle decompression to people who don’t do it because it makes them better assistants.Facepump!

Our BLS crews are being dragged into the “big box” world, which is a relief for those who have been working in that larger medical world as their practice. We’ve moved from protocols to Treatment Guidelines, and our prehospital practitioners are free to pursue treatment goals versus applying treatment protocols.

CPAP in ClassThis puts a huge amount of responsibility onto the individual Paramedics, and none more so than the Primary Care Paramedics who staff the bulk of ambulances across British Columbia.  Over the past several years we’ve seen major leaps in PCP practice in BC.  We’ve added TXA, EGA, CPAP, PEEP, NPA, NODESAT and dimenhydrinate. We’ve added a pediatrics module to AIME, ITLS, and Cardiac Arrest Management to complete our ongoing “4-pillars” 20150726_192314training regime.  Our crews in the Lower Mainland are involved in the FRONTIER study.  The ROC TXA in TBI trial starts soon. An MCI update is in the works.  The scope of practice is advancing, and the knowledge base required to differentiate, to diagnose, to treat our patients is deeper than ever before.

There is a movement to bring “upstairs care downstairs,” to bring ICU level care to the Emergency Departments of the world.  As this movement gains momentum, Paramedics need to be prepared to bring that same level of care to the prehospital setting.  The key to doing this is to take a “big box” view of EMS education from the moment we set foot in the classroom, commit to career-long learning, and be prepared to up our game continuously.

2 thoughts on “Big Box vs Small Box EMS Education

  1. Neal

    As Paramedics our role in BC is bigger now than we have ever seen before, and it’s only going to get bigger. We have bypasses in place throughout the lower mainland with stroke, stemi, trauma, dyalysis, nd hip bypasses. We need to know and understand why these bypasses exist and what is available. These bypasses also change the dynamics of a prehospital call. No longer is it scoop and run to the nearest hospital. The transport decision is no longer the rapid or routine transport I was taught. It is which resource does the patient need, what method are you going to use to transport, and what information do you need to send to the destination. I cannot wait for the day I provide ultrasound and labs prior to arrival. It is coming and we need to be teaching big box thinking now.

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