Paramedicine as a (K)NUTS profession: Rethinking knowledge, stress and professional becoming

Paramedicine occupies a distinctive position within contemporary healthcare, characterised by complexity, unpredictability and moral intensity. Unlike clinical professions operating in controlled environments, paramedics deliver care within dynamic, uncertain and often resource-limited contexts. While these operational challenges of paramedicine are well acknowledged, the philosophical and conceptual dimensions of paramedic practice remain comparatively underexplored. This paper proposes a reconceptualisation of paramedicine as a ‘KNUTS’ profession – extending Lupien's NUTS stress model (Novelty, Unpredictability, Threat, Sense of lack of control) by adding ‘knowledge’ as a fifth, epistemic dimension. This framework is used as a heuristic to explore the epistemological, ontological and existential nature of paramedic work. Using a conceptual analytic approach, the paper synthesises contemporary paramedicine literature with philosophical, sociological and educational theory. Key concepts from Heidegger, Schön, Polanyi, Dall’Alba and Lave and Wenger, are selectively engaged to explore how knowledge, uncertainty, judgement and identity interact in the everydayness of paramedic work. Knowledge emerges as the epistemic core of paramedic practice, legitimising autonomy and shaping professional identity. Novelty and unpredictability define the profession's lived reality, requiring practitioners to engage in rapid, situated judgement and ethical decision-making under uncertainty. Threat and control reflect the profession's existential tensions, as paramedics navigate vulnerability, accountability and limited autonomy within complex systems. Together, these interdependent dimensions reveal paramedicine as a practice of continual becoming shaped by embodied expertise, ethical reflection and adaptive expertise. Understanding paramedicine as a KNUTS profession provides a theoretically grounded lens to conceptualise its unique demands. Clarifying the heuristic use of a biologically derived stress model within a socio-cultural domain strengthens the framework's analytical contribution and highlights implications for education, leadership, policy and workforce wellbeing. This perspective carries implications for professional education, policy and leadership – emphasising the cultivation of reflective, ethically grounded practitioners capable of thriving amid complexity.