The Role of Education in ‘Toxic Heroism’

Reading Daniel Schwester’s recent article on “toxic heroism” and EMS,¹ I was struck by the accuracy of his depiction of paramedic practice and culture—I went through that same process he describes. I got into paramedicine for a job that was different and exciting. I dealt with the same existential crisis of realizing the practice environment is actually very different from what school had taught. And, fortunately, I made it past. I have been lucky to retain my positivity about what paramedicine is and could be. In this article I want to look at our schooling as one potential source of toxic heroism, the effects, and potential solutions.

Before we even apply to paramedic school, we are drawn in by awesome slogans that ask if we are ready to save lives and able to make quick decisions in stressful situations. These slogans are often followed by interviews of paramedics talking about the excitement and opportunities available, setting the first expectations for paramedicine as a career. School maintains these expectations, focusing largely on the most serious medical conditions we may be expected to treat. We are taught these conditions are serious and require prompt response and decisive actions.

Our schooling sets the stage for our careers 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 learned about in school—the most exotic, rare, or skill-intensive. The “bad” ones are uninteresting, common, and require little more than a drive to the hospital. Very quickly, though, even the standard for the “good” ones changes. A heart attack may have met the threshold initially but quickly loses its luster unless it has an interesting rhythm or requires more involved care.

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

Schools’ focus on the most critical calls also 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 becomes a waste of our time and resources, rather than a necessary part of the job. Why are we attending to an elderly patient who fell in the nursing home 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 assisted back to bed.

What’s an Emergency?

The other issue we run into is that the definition of emergency is very subjective. An individual’s perception of emergency depends on their prior experience, personal resilience, and situation. An emergency is also not necessarily time-sensitive. These patients will still receive appropriate medical care, but at a very different pace from what we are trained to expect in school. Also, in cases of chronic conditions, a patient may have multiple “emergencies” without a resolution in sight. As paramedics continue in their practice, this sense of emergency can become blunted. This might be the 100th heart attack they’ve responded to and one of the more minor presentations, but for the patient not only is it their first, but they are personally experiencing it.

At the same time significant attention is given to the skills we perform. I recall back in school the feeling of accomplishment as we focused on inserting airways, initiating IVs, and drawing up medications. This is an important part of our schooling, as we learn and develop the skills we will use on a regular basis. The downside is that we end up framing paramedicine (and our self-image) not by the role we play in the health care system but by the skills we perform along the way. Even if these skills are rarely performed, they can form an important part of our self-perception. We end up focusing more on our ability to get an IV or pass an endotracheal tube than our ability to communicate with the patient or our partners. In some of the worst cases, our ability to perform skills effectively becomes a reflection of our overall competence.

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 interfacility transport crews when both roles are important aspects of paramedic practice? Is there any surprise that, given the lack of “good” calls in practice, paramedics become frustrated? Disillusioned, they face 3 options: They can come to terms with the reality of paramedic practice, leave the profession, or remain jaded and further the negativity within EMS culture.

Transport Specialists

So how do we fix this? The first step is to start setting appropriate expectations of the job and the paramedic’s role in the health care system. First and foremost we are transport specialists, moving the patient from one location (a scene or hospital) to another (usually a hospital, sometimes home) while providing medical care along the way. It is necessary for paramedics to be trained in critical interventions, but this focus must not override other elements of patient care, which may be as simple as positioning the patient and moving them carefully from stretcher to stretcher. At the lowest ends it might involve merely checking in with the patient to ensure they are still comfortable.

To do this we must challenge the concept of an emergency as an urgent, life-threatening event. We must regularly reinforce the concept of empathy and remember that most patients do not have the same level of tolerance to difficult or novel situations paramedics do. We must also introduce the concept of chronic concerns and the reality that some patients will require repeat visits until they can receive the care they require. This is especially true of patients facing mental health or drug misuse concerns. Paramedics usually meet these individuals at their worst and in moments of crisis, not seeing the whole process and any improvements along the way. In managing these patients’ acute concerns, we can provide them the time they need to work on their chronic conditions. In prioritizing a willingness to help, we can look toward the positive accomplished in each call by improving someone’s day or helping them with their health care journey.

By receiving a fair understanding of the job from the outset, paramedics can be primed for its reality. We can also expand on the mentality by prioritizing a willingness to help and operate in irregular circumstances that occasionally may require some quick thinking. The earlier we can introduce these concepts, the quicker we can adjust expectations before they harden and become an element of the dominant culture.

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, for the most part, we would, since most paramedics sign up wanting to help, not be heroes. The issue is less that we’re attracting the wrong people but that we’re instilling them with the wrong expectations. With careful framing of job expectations from the outset, we could avoid many toxic pitfalls of the culture and work to create a more positive work environment.

Reference

1. Schwester D. Toxic Heroism and EMS: The Perfect Storm. The Overrun. Published March 27, 2022. Accessed August 16, 2022. www.overrunproductions.com/blog/2022/3/27/toxic-heroism-and-ems-the-perfect-storm

Radu Venter is a flight paramedic operating out of the Yukon Territory, Canada.