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In four years working in emergency medical services (EMS), I’ve spent time in the back of countless ambulances, in the front seat of a few fire trucks, and in plenty of emergency rooms. I’ve had the opportunity to talk to many impressive emergency providers with fascinating stories and experiences. I doubt I’ll ever stop being awed by the variety of situations that providers can find themselves in, or the scope of knowledge and skills they acquire over lifetimes of work. I often still find myself impressed by the stories they share and bits of wisdom they impart.

The variety and unique challenges of EMS takes a while to fully grasp, even while working in the field. So it’s no wonder that from the beginning of my career, I had the impression that the general public didn’t fully understand the role EMS fills, as I was barely beginning to appreciate it myself! To appreciate various perspectives in the emergency medicine landscape, and to expand my own view of the field, I recently spoke with three other providers in different areas of EMS about the surprises and misconceptions they’ve encountered during their career.

Precisely defining the role of EMS is not an easy task, as the term “EMS” covers a wide range of services and agencies, with very different types of providers and levels of care. In fact, probably the biggest thing the public gets wrong is using “EMT” and “Paramedic” interchangeably. There are several levels of EMS providers, and although “EMT” technically describes a few of them, it’s really used only for one. Emergency Medical Responders (EMRs) provide the most basic level of response, performing advanced first aid measures. Other emergency responders, like police, are usually EMR-certified. Then, Emergency Medical Technician-Basics, “EMT-Bs,” or usually just “EMTs,” have several months of training and can give many medications and perform more advanced techniques. Their training requires an understanding of pathophysiology and life-saving procedures.

EMT-A (“advanced,” or also sometimes “intermediate”), is the level of certification I have. In addition to EMT interventions, I can start IVs and IOs (intraosseous infusions … think of them like IVs, but drilled into a bone!), give additional medications, and, in some cases, can perform more advanced techniques, such as intubation. EMT-Ps, Paramedics, or “medics” can also sedate patients, perform more advanced techniques, give a wider range of medications, and perform much more advanced cardiac monitoring.

From the level of Paramedic, training and areas of expertise increase even further, from critical care Paramedics, who can manage certain long-term treatments like antibiotics, to flight Paramedics, the apex of out-of-hospital care, who also understand the additional complications of managing a patient in a helicopter. For example, brain bleeds can’t be flown over a certain altitude, and atmospheric pressure can affect patients in various ways.

Exactly which medications and interventions each level of provider is trained in and allowed to do varies by state and agency. Every EMS agency operates differently in many ways. In some cities, the firefighters are also the medics. In others, the EMS and fire departments are completely separate. Some agencies will initially send a “basic” ambulance with two EMTs to less critical calls, with a medic to follow if needed, and others only have medics on their trucks.

There are many types of EMS agencies which may not fall under what people generally think of when they consider EMS. IFT (interfacility transport) and CCT (critical care transport) transfer patients from one facility to another. An IFT ambulance might bring a patient from a rehabilitation center back to a nursing home. A CCT truck might bring a patient from a small regional hospital to a large trauma center. Both can be staffed with a mix of Paramedics, EMTs, and other providers, although CCT ambulances always have at least one higher-level provider like a Critical Care Paramedic or even a doctor on board.

Of course, with all this variation it makes sense that people get confused on the specifics. Across all of the exact protocols and titles, there seems to be a general gap in understanding for much of the public, and even for other medical providers. To see if other providers felt the same way, I spoke to 3 other EMS workers. I chose to interview providers with different levels of experience and certifications, who have worked in different environments across the country.* I spoke with Anita Swiman, a Paramedic who has been working for over 20 years in a variety of settings. She is currently a Captain with her department and also works as a paramedic for a LifeFlight agency, but she has worked for private services, county departments, education programs, and other agencies as well. I also talked to Amelia Costello, an EMT-B with 3 years of experience, who has worked for a private ambulance, a rural fire department, and an event medicine service. Finally, I interviewed Vivian Zhang, a brand-new EMT-B who’s been working for an interfacility transport company for the past few months.

In undertaking these interviews with EMS workers in various fields, I wanted to know what they felt people got wrong about EMS — or what surprised them about the field initially. From my own experience and the experiences of these providers, two general categories of misconceptions about EMS emerged.

            First, and probably most commonly, people see ambulances as miniature hospitals, fully prepared to do anything an emergency room might. “I’ve had patients ask why we can’t do everything from prescribe an antibiotic to give them an x-ray to make sure their leg was actually broken,” says Swiman.

In reality, many interventions are performed on ambulances, but they are restricted by a variety of factors. If the procedure needs to be sterile or extremely precise — sutures, for example — it’s a good bet that it will be difficult to do in your home or the back of a moving ambulance. Storage of materials can’t take up too much space on the truck, and cost and utilization can be an issue, too. For example, whole-blood transfusions may be preferable to saline in long-term care settings, but in an ambulance the requirements for storage of blood and the fact that it expires quickly makes it unreasonable for most services to carry. MRI machines would obviously be difficult to fit in the back of an ambulance along with the patient, cot, and providers. EMS is advancing all the time, though, and new technologies like point-of-care ultrasound (portable devices which can even plug into a smartphone) are becoming available.

The limited amount of space, resources, and time that EMS providers have to work with is the defining factor in the scope of the EMS role. “People have this idea that when they call 911 they’re going to be cured on the ride to the hospital,” says Costello. “In general, though, what we’re doing is stabilizing and treating the symptoms, and figuring out what’s going on as best we can, so we can set up the hospital for success. The time that we spend with the patient in the truck is relatively short, usually. It’s less about fixing everything and more about making sure they reach a higher level of care as safely as possible.”

911 is, unfortunately, not a magic button to bring exactly what a patient needs. What it can bring is well-trained, dedicated providers with effective tools for stabilizing and treating a wide range of conditions. For the vast majority of emergencies, and many non-emergent conditions as well, EMS providers are able to give the life-saving care and treatment needed. “I was surprised at what [providers] can do,” Zhang told me. “I mean, you have medics who can intubate people or decompress their chest,” which she, and I, consider fairly astounding. Even though a lot of times Zhang might be “just” taking vitals, it takes time and training to understand what might be normal for this patient, and what could be going on if something isn’t normal, and how you could fix that, she said.

Not realizing the extent of the skill and experience of providers is the second mistake people make when they think about EMS. Swiman has a Master’s degree. Depending on their certification level, providers are required to have months or years of initial training, plus hundreds of hours of continuing education through their careers. After finishing this training, I remember being called an “ambulance driver” for the first time after a month or so of work. My partner told me I’d get called that a lot — and I did. To be fair, I am also an ambulance driver, and so are most all providers.** We’re just also much more than that. Most providers aren’t too offended by it, but the implications behind “titles” like this can minimize the importance of EMS. “People think we’re just a truck with a bed in it. Or worse, a ticket to be seen faster in the ER,” said Swiman.***

Zhang said this lack of respect can be even worse for EMS personnel who aren’t responding to 911 calls. Most of her work involves transporting patients from one level of care to another; for example, from a nursing home to a hospital, or from one hospital to another. “We just get very little respect, even from the other medical providers,” she says. She explains that she might not be dealing with a life-threatening call every hour of the day, but emergencies still happen often in this setting, and it can take a lot of skill and equipment to manage them. Zhang says people really only think of 911 calls when they think of EMS. “They really have no idea — and I had no idea before I started working here — what other things EMS does.”

An unfortunate consequence of both of these misconceptions is that EMS providers often feel they don’t get the understanding or respect they deserve. “I don’t know if people realize that it’s just really, really busy. I’m pretty much working call after call after call. For over 24 hours, usually,” says Zhang. All three of the EMS providers I interviewed agree that the work can be exhausting and that they can feel underappreciated. As Swiman says, “we don’t get vacations like the rest of the world; we work 24 hours a day.” She describes EMS as a “weird bridge” between healthcare and public safety. On one hand, providers perform heavy manual labor, moving patients and equipment. Costello says lifting, moving, and positioning patients is often one of the biggest parts of the job for her and other providers on a call. On the other hand, though, providers do plenty of mental work on 911 calls, calculating medication dosages and drip rates, considering differential diagnoses, and formulating treatment plans.

Most people also can’t understand how difficult EMS work can be on an emotional level. Swiman says that hearing “she knew what she was getting into” is a pet peeve of hers. “If people knew what they were getting into, they wouldn’t sign up for this job. I wish the public and others in the medical field would understand these things.” You don’t get a choice about which patients you see, she explains. You might have to intubate a friend, or be called to take care of an aggressive, angry patient. For many patients, the day they call 911 is the worst day of their life, so seeing people devastated or angry is expected and they are deserving of compassion, not judgment.

Cultivating this compassion and communicating with people during life-threatening situations is another tough part of the work, all three providers agree. It’s something Costello said she really had to learn on the job. “They don’t teach you in school how to have a conversation with someone who is very sick, while still communicating what you know to them, and also finding out from them what you need to know.” Talking to patients is one of the biggest parts of Zhang’s job, and what she spends the most time doing, since her transport times can be anywhere from a few minutes to over an hour. She says she likes making small talk to make them feel at home and to take the stress out of an emotional situation. She tries to remember that most of her patients are having a horrible day and not feeling like themselves. Being a friendly presence in difficult situations is just one of the many challenges providers take on daily.

Such a big piece of what I love about this job is the opportunity to give compassion to those who need it. I look forward to going to work and being thrown into challenging, widely varying situations — all of which involve people in need of kindness. Included among these people are the providers themselves, many of whom are volunteers, and all of whom devote their time to the safety and health of other people. Walking the line between healthcare and public safety is difficult, exciting, stressful, and wonderful. Each provider’s job and each day at work is challenging in unique ways, and I feel lucky to have volunteered and worked alongside so many incredible people.

*The views expressed by these individuals may not reflect those of their organizations. I’ve therefore chosen not to name any specific companies or departments in this piece.

**The driver may switch roles with the provider in the back, and the determination of which person drives and which provides care during transport may be determined based on certification and the severity of the call. Driving an ambulance isn’t easy work, either. As an aside, one thing about the transport in an ambulance which Costello mentioned is that ambulances don’t actually just run through red lights. This is a pretty big misconception as well. We’re actually taught to stop, check both ways, and go through the intersections very slowly. Also, ambulances usually don’t go much over the speed limit, if at all. Not only are they big, heavy vehicles which don’t get up to speed very fast — there are also often laws about how fast they can go, for the safety of patients, providers, and other drivers. The lights and sirens on emergency vehicles are meant to signal other drivers to move over — but in my experience, they often just cause people to panic and swerve.

**This is another misconception: in most jurisdictions, non-critical patients can be sent to triage or even the waiting room behind more emergent cases, even if they come in by ambulance. But when beds and waiting rooms are full, less critical patients can tie up EMS providers and resources for hours. Providers usually must wait with the patients until they are checked in and given a spot in the hospital system. And while they wait, other emergencies may be going unanswered.

About the Author

Amy Fulton is a junior at Duke University studying Neuroscience and Global Health. She is certified as an EMT-A and Firefighter-II and currently volunteers with Lebanon Volunteer Fire Department. She is the Training Officer for Duke University EMS. Originally from Ohio, she previously worked and volunteered with multiple EMS agencies in Ohio. When at home, she now works as a Clinical Technician at the Cleveland Clinic.

She is involved in research with Duke Global Neurosurgery & Neurology as well as the Duke Department of Neurosurgery. She is also involved with several health and wellness clubs on Duke’s campus, including her role as President of the Student Wellness Caucus and Co-President of Duke Women’s Wellness Club.

After two months volunteering with a global health initiative in Ghana, and three bouts of malaria, she now volunteers for the UN as an Ambassador for United to Beat Malaria. She is an officer for two martial art sport clubs at Duke, and her other interests include powerlifting, scuba diving, and car mechanics.

Amy would like to give a huge thank you to all three interviewees for taking the time to speak with her and agreeing to be quoted in this article. She found their insights fascinating, helpful, and inspiring, and hopes the readers agree.

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