Addressing toxic heroism in the EMS education system

Reading Daniel Schwester’s article on toxic heroism and EMS, I was struck by the accuracy of his depiction of paramedic practice and culture, no more so than because I went through that same process he describes. It is worth identifying where some of that toxicity arises and how best to manage it.

Perceptions start at the outset of our training

Before we even apply to paramedic school, we are drawn in by slogans asking if we are ready to save lives and able to make quick decisions in stressful situations. Paramedic interviews center on the excitement of the job, setting our first expectations of paramedicine as a career. School maintains these expectations, focusing on the most serious medical conditions that we may be expected to treat. We are taught that these serious conditions require prompt response and decisive actions – and scenarios are instantly ended if we miss one.

Our schooling sets the stage for our career in more ways than we think. The presumption in prehospital care is that patients are critical and require urgent care and treatment. However, by framing certain calls as emergencies or “true emergencies,” the rest are automatically considered not to be. The “good” ones most directly reflect the scenarios we learn about in school – the most exotic, rare or skill-intensive conditions. The “bad” ones are uninteresting, commonplace and require little more than a drive to the hospital. Very quickly, even the standard for the “good” ones changes. A heart attack may have met the threshold initially, but quickly loses its lustre unless it has some new, distinguishing factor.

Importantly, many, if not most, of our education scenarios involve scene responses. In prioritizing scene response, interfacility transport is automatically seen as less-than, despite being a crucial role of paramedic practice. A false hierarchy develops, with 911 response paramedics seen as superior, as their role more closely fits what was discussed in school and ALS often affords a higher chance of interesting patient experiences and “good” calls.

Indirectly taught expectations

This focus on the most critical of calls implies that the role of a paramedic is to respond only to emergencies. As practitioners trained to save lives and operate under difficult circumstances, responding to “bad” calls is perceived as a waste of time and resources, rather than a necessary part of the job. Why attend to a low acuity patient when we could be standing by for a heart attack or cardiac arrest? This can also instill a false sense of superiority, that paramedics are meant to respond only to emergencies.

This obstructs the reality – that what makes paramedics so effective is our ability to provide mobile patient care, whether it is involved, as in the case of an anaphylactic requiring transport, or minor, as in the case of the elderly patient who fell and just needs to be assisted back to bed.

The definition of emergency is very subjective. An individual’s perception of emergency depends on their prior experience, personal resilience and the specific situation. An emergency is not necessarily linked to severity or time. Patients may be dealing with an emergency, but that does not mean it is necessarily severe or time-sensitive. These patients still require appropriate medical care, but at a very different pace from what we are trained to expect in school. As paramedics continue in their practice, this sense of emergency is blunted, requiring an ever-increasing standard. For our patients, their perception of the situation is very different.

More than the sum of our skills

Finally, significant attention is given to the skills that we perform. Recall the feeling of accomplishment as we learned to insert airways, initiate IVs and draw up medications. This was an important part of our schooling, as we learned and developed the skills that we use on a regular basis. The downside is that we end up framing not by the role we play in the healthcare system, but by the skills we perform along the way. Even if these skills are rarely performed, they form an important part of our self-perception. We focus more on our ability to get an IV or pass an endotracheal tube rather than our ability to communicate with patients or coworkers. In some of the worst cases, our ability to perform skills effectively becomes a reflection of our overall competence.

Three options for disillusioned paramedics

With this mental framework, is it any surprise that paramedics begin seeking the “good” calls over the “bad?” Or that the “bad” calls significantly outnumber the “good?” Is there any surprise that emergency crews are perceived as superior to inter-facility transport crews when, in reality, both roles are important aspects of paramedic practice? Is there any surprise that, given the lack of “good” calls in practice, paramedics become frustrated and jaded?

Disillusioned, we face three options. We can:

1. Come to terms with the reality of paramedic practice
2. Leave the profession
3. Remain jaded and further the negativity within EMS culture

Challenging the concept of an ‘emergency’

So how do we fix this? The first step is to set appropriate expectations at the outset of our education. First and foremost, we are transport specialists, moving patients from one location (a scene or hospital) to another location (usually a hospital) while providing medical care along the way. In training, we must focus as much on communication and patient interaction as we currently do on critical interventions and skill development.

By providing a fair understanding of the job from the outset, we can prime paramedics for the reality of the job, helping patients while operating in irregular circumstances and occasionally performing critical interventions. The earlier we can introduce these concepts, the quicker we can adjust expectations before they become part of the dominant culture. As this mindset becomes more prevalent, we can start to challenge the more toxic parts of our culture.

We can challenge the concept of an emergency and reinforce the concept of empathy, remembering that most patients do not have the same tolerance to difficult or novel situations that paramedics do. We must embrace the reality that some patients will require repeat visits from an ambulance as part of their ongoing health care, especially in the case of mental health or drug misuse. In managing these patients’ acute concerns, we can provide them with the time that they need to resolve their chronic condition. In prioritizing a willingness to help, we can look towards the positive accomplished in each call by improving someone’s day or helping them with their healthcare journey.

Schwester concludes his article by asking whether we would attract the same people if we focused less on the heroic elements of paramedicine. I believe that we would, since most paramedics sign up wanting to help, not to be heroes. The issue is less that we are attracting the wrong people, but more that we are instilling the wrong expectations in these people. With careful framing of the job expectations from the outset, we could avoid many of the toxic pitfalls of the culture and work to create a more positive work culture. Paramedicine can be a rewarding career with fantastic moments and excellent individuals if we can keep focusing on and developing its positive elements.