# For anyone who has ever had a "Doctor" show up on scene



## Hockey (Aug 20, 2010)

Print out these cards and keep em in your pocket 

http://www.co.marin.ca.us/depts/hh/...s/May08FinalDrafts/GPC06A_MD_onscene_card.pdf


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## reaper (Aug 20, 2010)

A lot of services have those. But the policies would be system and state specific.

Just follow you system SOP for dealing with a Dr on scene.


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## Simusid (Aug 20, 2010)

I don't know all the details but apparently we had someone show up to a bad MVA and asked if he could help.   The medic allegedly whigged out with "who the &*)(^^&$%^ do you think you are???  get out of my scene!!"  and the response was  "I'm your medical director"


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## medicRob (Aug 20, 2010)

Simusid said:


> I don't know all the details but apparently we had someone show up to a bad MVA and asked if he could help.   The medic allegedly whigged out with "who the &*)(^^&$%^ do you think you are???  get out of my scene!!"  and the response was  "I'm your medical director"



I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was. At my service, we see our medical director in the ER almost every shift. He stops in to say hello at the station, we have lunch with him sometimes. Then again, my service is allowed to RSI, Needle Cric, etc. so it is quite obvious why he would want to be actively involved as much as possible. 

That being said, it was probably just a physician who arrived at the scene. In these situations, if they are not your medical director, you do not have to turn treatment over to them. If you do turn treatment over to them, they are required to ride with you to the hospital.


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## fast65 (Aug 20, 2010)

Hockey said:


> Print out these cards and keep em in your pocket
> 
> http://www.co.marin.ca.us/depts/hh/...s/May08FinalDrafts/GPC06A_MD_onscene_card.pdf




They forgot to put the first "t" in S*t*ate on the back of the card...just sayin


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## abckidsmom (Aug 20, 2010)

We used to have those stuck in the bottom of the clipboard, and called them "Doctor Go Away" cards.  

Never used one, and only a handful of times had a doctor on scene.  They were always completely appropriate and didn't overstep any bounds.  Plus, if they had a vested interest in the situation (their family) they were eager to ride along to the hospital, and our protocols and skills were sufficient to keep them quiet and helpful.


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## MSDeltaFlt (Aug 20, 2010)

medicRob said:


> I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was. At my service, we see our medical director in the ER almost every shift. He stops in to say hello at the station, we have lunch with him sometimes. Then again, my service is allowed to RSI, Needle Cric, etc. so it is quite obvious why he would want to be actively involved as much as possible.
> 
> *That being said, it was probably just a physician who arrived at the scene. In these situations, if they are not your medical director, you do not have to turn treatment over to them. If you do turn treatment over to them, they are required to ride with you to the hospital*.


 
That's not necessarily the case.  If they can provide documentation that they are a physician with a license in your area, then they trump you hands down.  If they do not wish to relinquish care, then they must ride in with you.  If they do wish to relinquish care, then they must document so or at least call your offline medical control and do it that way.

Which is why I absolutely hate it when a MD/DO shows up on scene.  The ones I've seen want to help, but don't want to go in with the crew.  That really tends to muck up the works.


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## abckidsmom (Aug 20, 2010)

MSDeltaFlt said:


> That's not necessarily the case.  If they can provide documentation that they are a physician with a license in your area, then they trump you hands down.  If they do not wish to relinquish care, then they must ride in with you.  If they do wish to relinquish care, then they must document so or at least call your offline medical control and do it that way.
> 
> Which is why I absolutely hate it when a MD/DO shows up on scene.  The ones I've seen want to help, but don't want to go in with the crew.  That really tends to muck up the works.



What kind of help do they want to do that mucks up things when they don't ride in?  I tend to treat them like a glorified bystander, who is able to either provide or elicit a really detailed history from the patient.  I've never had one who wanted to do any ALS skill, and the only time they tweaked the ALS plan it was more like, "did you consider XYZ?" and it's a reasonable suggestion, I either do it or not.  I guess I haven't encountered and crazy off the wall takeover guy.


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## medicRob (Aug 20, 2010)

MSDeltaFlt said:


> That's not necessarily the case.  If they can provide documentation that they are a physician with a license in your area, then they trump you hands down.  If they do not wish to relinquish care, then they must ride in with you.  If they do wish to relinquish care, then they must document so or at least call your offline medical control and do it that way.
> 
> Which is why I absolutely hate it when a MD/DO shows up on scene.  The ones I've seen want to help, but don't want to go in with the crew.  That really tends to muck up the works.



My service specifically states that unless they are authorized DIRECTLY to take control by MY medical director they cannot take over my patient without me asking them to do so. Otherwise, they have to act as another pair of hands. If my medical director gives them permission to take over, they must accompany the patient. It is given unto me the authority by authorization of my medical director to ask an on scene physician to stand down.

"Thy Medical Director is a jealous director, thou shalt put none other before him"


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## reaper (Aug 20, 2010)

Yes, every system I have ever worked, is the same way. I do not have to turn over care, even if they ask. The Pt is mine, till I decide to relinquish care to them.

Have had a few help on scene. Only had one that try to take over and was escorted off the scene. 

This is all a system by system SOP.


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## Shishkabob (Aug 20, 2010)

Same with me.  The only doctors license I use is my med control... if another doctor comes on scene I have the ability to refuse.  If I DO decide they can help (totally dependent on the situation, so it's unrealistic to say if I would or would not), and they want me to do something not in my protocols, they are to get on the phone with my med control and talk it out... if they can't agree then I stick with my med control, as again, his is the only license I use.    That is per my protocols about on scene physician intervention.


I have had to tell a doctor off before, not because he wanted to help, but because he thought he had the right/ability to tell me to hurry up on scene...


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## medicRob (Aug 20, 2010)

Linuss said:


> Same with me.  The only doctors license I use is my med control... if another doctor comes on scene I have the ability to refuse.  If I DO decide they can help (totally dependent on the situation, so it's unrealistic to say if I would or would not), and they want me to do something not in my protocols, they are to get on the phone with my med control and talk it out... if they can't agree then I stick with my med control, as again, his is the only license I use.    That is per my protocols about on scene physician intervention.
> 
> 
> I have had to tell a doctor off before, not because he wanted to help, but because he thought he had the right/ability to tell me to hurry up on scene...



I feel the same way. For instance, if I have a pt with radiating chest pain, ST elevation in 2 or more leads, and all the sudden the local professor of interventional cardiology comes up knocking on my ambulance doors, you best believe I am letting him take over. However, if an emergency dermatologist comes knocking, I will not. It is all situation dependent. Remember, our jobs are to facilitate the continuation of care to the best of our abilities by treating life threatening injuries and transporting our patient to definitive care.

Also, when I arrive to a hospital until I sign my run report over, that patient is still mine. If for one reason or another I don't feel like my patient will receive the best care at the facility, it is my right to load that patient back up and to divert to another facility. Mind you, I will have a lot of questions to answer to my medical director, supervisor, and service directors and I sure as hell better have a good reason for doing what I did.


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## AtlantaEMT (Aug 20, 2010)

medicRob said:


> ...if I have a pt with radiating chest pain, ST elevation in 2 or more leads, and all the sudden the local professor of interventional cardiology comes up knocking on my ambulance doors, you best believe I am letting him take over. However, if an emergency dermatologist comes knocking, I will not...



I knew an EMT for his EMT-I trauma assessment when asking "what resources do I have" the examiner said "you have all the recources you want" or something along those lines.  I told him he should have said that he had an orthopedic surgeon, cardiologist, intensivist, and some pararescue jumpers who overshot their drop zone and are providing scene safety.

In reality and also if we set our egos aside, is there anything a doctor could do in a medical emergency that a paramedic couldn't do with the supplies on an ALS truck?  And assuming the doctor is qualified for whatever emergency you are on.


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## Veneficus (Aug 20, 2010)

AtlantaEMT said:
			
		

> In reality and also if we set our egos aside, is there anything a doctor could do in a medical emergency that a paramedic couldn't do with the supplies on an ALS truck?  And assuming the doctor is qualified for whatever emergency you are on.



Having done both, any doctor is considerably more qualified than a paramedic. It is not so much a matter of qualification than comfort.

All of the skills you learn are taught to physicians in medical school. There is nothing a paramedic has or can do that hasn't been covered in considerably more breadth and depth. 

If a physician is actually willing, there is considerably more that can be done with what is on the average ALS vehicle.

The medications alone have more uses and effects than what is taught in medic school.

as some examples,

Use Mag sulfate no only to treat eclamsia, but also to sedate a patient, or stop labor. Administer epi prior to knowingly give somebody another medication they are allergic to if the benefit of them having it outweights the risks. Use a scalpel to cut any part of the body, not just an umbilical cord. Dilute IV infusions to come up with different concentrations. Stick an ET tube into a bleeding artery and inflate the cuff in order to stop bleeding. provide sedation/analgesia to terminal patients not going to be transported. Administer any available dose of medication on hand. Mix medications to potentiate effects. Lidocaine for local anesthesia. I could go on. 

But most important, a physician can do a considerably better assessment and dx, which can lead to instant recognition to deviation from protocols that are medically questionable, like high flow o2 and long boarding, or driven by epidemiology, like not using epi as the primary arrest medication, which could give the patient a better chance at survival as well as more complete recovery. 

I will admit some physicians are real jerks, some are uncomfortable performing outside of their daily routines or specialty, but it is not because one kind is lesser than another. 

Keep in mind that a physician is recognized by people as the highest medical provider all over the world. A US paramedic is lucky to function at such level outside the US or a lawless warzone.

It is foolish for paramedics to claim they can do anything a doctor can do in an emergency. It is simply ignorance.


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## Shishkabob (Aug 20, 2010)

Veneficus said:


> It is foolish for paramedics to claim they can do anything a doctor can do in an emergency. It is simply ignorance.



Medical cardiac arrest h34r:


Wel... 99% of it, atleast.


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## AtlantaEMT (Aug 20, 2010)

Veneficus said:


> Having done both, any doctor is considerably more qualified than a paramedic. It is not so much a matter of qualification than comfort.
> 
> ...
> 
> It is foolish for paramedics to claim they can do anything a doctor can do in an emergency. It is simply ignorance.



Cool deal.  I've always understood that a doctor is going to know much more than a paramedic (especially an EMT-I like me) but didn't know how it'd translate outside of a hospital setting with limited supplies.  One thing I did think about later is a doctor could do a tracheotomy.


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## medicRob (Aug 20, 2010)

AtlantaEMT said:


> Cool deal.  I've always understood that a doctor is going to know much more than a paramedic (especially an EMT-I like me) but didn't know how it'd translate outside of a hospital setting with limited supplies.  One thing I did think about later is a doctor could do a tracheotomy.



Critical Care Paramedic can do surgical cric and needle cric.


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## medic417 (Aug 20, 2010)

medicRob said:


> Critical Care Paramedic can do surgical cric and needle cric.



Our intermediates do that.  

If a doctor is able to assist I let them.  If they are in the way I kick them off scene.  I do not obstruct them doing their work at their office and I will not let them obstruct me at mine.  

Some doctors are great on scene yet others really are not comfortable with out of hospital care and are just in the way.  Comply with your local policy and keep in mind it is about what the patient needs not ours or the doctors egos.


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## jjesusfreak01 (Aug 20, 2010)

I know it isn't done a lot and isn't in everyone's protocols anymore, but I am wondering if anyone has ever been sued for doing a tracheotomy as a layperson? It seems to me that it is commonly thought (due to movies and TV) that anyone can do a tracheotomy with a pen knife and a straw. 

Its my opinion that in the realm of airways, there should be few skills, if any, that EMTs are not trained and certified to do. I can understand how I as an EMT lack the skills to give proper IV meds to a cardiac patient or read an EKG, but if I run into someone with a complete FBAO and I can't get it out using the heimlech maneuver or chest compressions, then that person dies right there, when it only takes a minute to do a tracheotomy (of course EMTs also aren't allowed to visualize and remove obstructions with a laryngoscope and forceps, which would be preferable to a surgical airway if possible). 

The same thing goes for an anaphylactic patient...trachea is starting to close up, and I am not allowed to intubate or use a surgical airway, and the patient may die if there is no epi-pen available.

What are you going to do when you are sitting there in front of the patient and everyone expects you to pull out your trusty pen knife and save the day...or worse, a bystander pulls out a knife and decides to do the tracheotomy. Am I going to stop them, probably not...

/end daily rant


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## medicRob (Aug 20, 2010)

jjesusfreak01 said:


> I know it isn't done a lot and isn't in everyone's protocols anymore, but I am wondering if anyone has ever been sued for doing a tracheotomy as a layperson? It seems to me that it is commonly thought (due to movies and TV) that anyone can do a tracheotomy with a pen knife and a straw.
> 
> Its my opinion that in the realm of airways, there should be few skills, if any, that EMTs are not trained and certified to do. I can understand how I as an EMT lack the skills to give proper IV meds to a cardiac patient or read an EKG, but if I run into someone with a complete FBAO and I can't get it out using the heimlech maneuver or chest compressions, then that person dies right there, when it only takes a minute to do a tracheotomy (of course EMTs also aren't allowed to visualize and remove obstructions with a laryngoscope and forceps, which would be preferable to a surgical airway if possible).
> 
> ...



I am authorized as a Paramedic to take such interventions in the state of TN, provided my medical director allows and I have a very good reason for backing up why I could not get an airway by any other means. However, I would NEVER attempt anything like this off shift without an ALS ambulance with all the bells and whistles + the drugs + medical director readily available by phone or radio to back me up in my decision to carry out such a measure.

Also, I don't carry an OB/KIT or a Pertrach kit etc, and I am not going to get my pocket knife dirty, hell no.


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## Shishkabob (Aug 20, 2010)

medicRob said:


> Critical Care Paramedic can do surgical cric and needle cric.



Heck, that's in my scope as a "normal" Paramedic... no need to be CC for that.

CCRN?  Sure, they do.  But it's common knowledge for a brand new Paramedic at how to do them.


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## medicRob (Aug 20, 2010)

Linuss said:


> Heck, that's in my scope as a "normal" Paramedic... no need to be CC for that.
> 
> CCRN?  Sure, they do.  But it's common knowledge for a brand new Paramedic at how to do them.



Yep, I was unaware however if this was true in AtlantaEMT's area so on the side of caution I said, "Critical Care Paramedic" just to be sure.


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## MSDeltaFlt (Aug 20, 2010)

medicRob said:


> *My service specifically states that unless they are authorized DIRECTLY to take control by MY medical director* they cannot take over my patient without me asking them to do so. Otherwise, they have to act as another pair of hands. If my medical director gives them permission to take over, they must accompany the patient. It is given unto me the authority by authorization of my medical director to ask an on scene physician to stand down.
> 
> "Thy Medical Director is a jealous director, thou shalt put none other before him"


 
Question. How would anyone be aware of that? Would communication be going on between said physician(s) while on scene with you caring for pt(s) or what?


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## medicRob (Aug 20, 2010)

MSDeltaFlt said:


> Question.  How would anyone be aware of that?  Would communication be between said physician(s) or what?



I'm not sure if I understood the question completely, but I assume you are asking how would I be aware that my medical director has given permission for the physician to take over. 

Our medical director keeps us updated with his cell # in case we cannot reach him via radio. I would pick up my phone call him, explain the situation and would say something like, "Dr. Smith, I have so and so patient here in critical condition, we are x minutes away from the medical center, and I have a bystander physician with me wishing to take over, he is an interventional cardiologist with X medical center and I felt it appropriate for him to speak with you before I allow him to take over any treatments" I would then hand the phone to the bystander physician so he could explain to Dr. Smith, why he wants to take over, why he feels physician accompanied transport is warranted, and can ask permission to take control. He would then hand me back the phone and Dr. Smith would either advise me to use him as an extra pair of hands, let him take over and have him ride with us to the medical center, or to not allow him to take over. 

This is one of the situations where Dr. Smith does not have any problem whatsoever with us contacting him on his personal cell.


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## Akulahawk (Aug 20, 2010)

Veneficus does make some good points, (for instance: mag sulfate's other uses, using a scalpel for cutting into the body, diluting meds with IV fluid...) a lot of that happens to be stuff I already knew about. I have no doubt that a Physician has a MUCH broader knowledge base than I do. I do hope, however that Vene was stating that an ETT could be placed transversely into a wound within which a large artery was severed, inflate the cuff, and tamponade the hemorrhaging and not into the lumen of a large artery, and then to inflate the cuff sealing the lumen, thusly providing a nice, smooth pathway for blood to spurt forth from the adapter of the ETT in such a way that the spurting may be more easily directed...  `

Then again, I'm probably a LOT more educated than your average knuckledragging Paramedic. Clearly though, I am not a Physician, and do not claim to be. 

Now to answer the point of this thread, yes, I have had physicians approach me on scene. I tell them they have 3 options. Assist me and be an additional set of eyes and hands under my direction (suggestions welcomed, but no medical control), take total control of the patient and ride to the hospital, or talk to my medical director to provide on-scene medical direction/care. I have had only ONE Physician ride in. The others usually said "thanks" and went on their way. Oh, and if I (or my crew) don't know you and you can't prove to me you're a Physician, I'm going to bounce you from my scene.

My conversation with the Base Physician (in our case) would go a LOT like medicRob's. I won't stop working on my patient while the bystander Physician consults with the Base Physician. I would expect a similar answer from my Base Doc... In my case, I've never had to contact Base for that purpose.


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## rescue99 (Aug 20, 2010)

Simusid said:


> I don't know all the details but apparently we had someone show up to a bad MVA and asked if he could help.   The medic allegedly whigged out with "who the &*)(^^&$%^ do you think you are???  get out of my scene!!"  and the response was  "I'm your medical director"



Guess he should have been a little more polite asking the question...big oops. 
If the Medic got into any trouble it would only be for the way the asked, not that asked who the guy was.


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## thatJeffguy (Aug 20, 2010)

http://www.dsf.health.state.pa.us/health/lib/health/ems/pa_bls_protocols_effective_11-01-08.pdf



> 904
> 
> ON-SCENE PHYSICIAN / RN
> STATEWIDE BLS PROTOCOL
> ...


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## MrBrown (Aug 20, 2010)

Our Ambulance Officers have a good working relationship with physician collegues and it's not often you find a Doctor on scene and much less often one volunteers to help out; not because they don't want to but because they respect AOs as being very good at extricating, doing a little stabilisation and transporting the patient to the hospital.

We do not have a specific guideline for Doctor-on-scene because we do not operate under such a horrendously restrictive and outdated legal framework like in the US.  A Doctor may request that an Officer administer a drug, fluid or treatment not contained in our Clinical Guidelines and the Officer may choose to follow such a request if they believe it is in good faith.

Should a Doctor approach me and ask "can I help?" it would be pig ignorant and foolish of me to say "no" even if its just another person to bounce ideas off.  It might take longer to become an Intensive Care Paramedic here than to get your MBChB (I ain't kidding) but you can't compare the education that's for sure!

At any rate, Brown has just sprinted all the way from the helicopter in his very hot orange jumpsuit with "DOCTOR" written on it and is sweaty and icky and lugging a bloody great Thomas Pack ... you wouldn't have made him do that for nothing would you?


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## firecoins (Aug 20, 2010)

Without proper ID, there is not an MD on scene.


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## Akulahawk (Aug 20, 2010)

Hey, if a Physician walked up and had his/her medical license displayed so that I KNEW the person is actually a Physician, and asked if I could use some help... You'd better believe I'd say "Thanks!!! Please do! Here's what I need...and are you willing to ride in with me?"


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## MrBrown (Aug 20, 2010)

Aw now now what are you saying, you wouldn't trust Brown if he showed up at a job, whipped a Thomas Pack out of his back pocket and said "yes hello I am Dr Brown, here, let me help, get me 200mg of ketamine to start...." :unsure:


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## Akulahawk (Aug 20, 2010)

LOL! Here Doctor... 200mg Ketamine should make you feel right at home....  Now where did I put that patient of mine...


ooh. Squirrel!


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## MrBrown (Aug 20, 2010)

Oh that is too funny, Brown deserved that


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## Veneficus (Aug 20, 2010)

.





Akulahawk said:


> I do hope, however that Vene was stating that an ETT could be placed transversely into a wound within which a large artery was severed, inflate the cuff, and tamponade the hemorrhaging and not into the lumen of a large artery, and then to inflate the cuff sealing the lumen, thusly providing a nice, smooth pathway for blood to spurt forth from the adapter of the ETT in such a way that the spurting may be more easily directed...



Actually I was thinking along the lines of cutting it down and placing it into the lumen of the large artery to keep the blood flowing. It is most often accomplished in a trauma bay with IV tubing, but it requires some stiches to work and that is usually not available on the average ambulance. Another good stand by is a clamped foley catheter, but you can clamp an ET tube all the same if you so desire. 

I have also met an Israeli physician who will open a chest in the field. 

Unless I am very much mistaken, paramedics are not authorized to do a tracheotomy, but rather a cricothyrotomy, which is a preferred emergency airway or the 2.

I have had physicians on scene a few times, there was never any issue, and they were always glad to help in any way they could. Even if all they did was carry some equipment back to the truck.   



Akulahawk said:


> Then again, I'm probably a LOT more educated than your average knuckledragging Paramedic. Clearly though, I am not a Physician, and do not claim to be.



It has nothing to do with being a "knuckledragging" paramedic actually. It has to do with a lot more schooling and an unlimited license to practice medicine. It permits more improvising without wasting time contacting online medical control as well as being able to perform a host of treatments not available to a paramedic. 

Years ago we had a couple of medics here lose their certifications for performing an episiotomy under online medical direction. The medical director was simply told it was an inappropriate order and to please not do it again. Had it been an onscene physician that performed it, I doubt it would have made the news. If it did it would have been a more "heroic" outcome.

One of the most frustrating things I found being a paramedic was knowing what to do but not being permitted to do it.


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## Akulahawk (Aug 21, 2010)

Veneficus said:


> .
> 
> Actually I was thinking along the lines of cutting it down and placing it into the lumen of the large artery to keep the blood flowing. It is most often accomplished in a trauma bay with IV tubing, but it requires some stiches to work and that is usually not available on the average ambulance. Another good stand by is a clamped foley catheter, but you can clamp an ET tube all the same if you so desire.
> 
> ...


Vene: I understand the frustration. I really do. While I do NOT have the same level of education that a Physician has, in the field I originally trained in, what I can do goes way beyond what any non-Physician EMS provider can do that I am aware of. 

And with your somewhat improved description of what you were thinking of with the ETT, that'll work, if the vessel lumen is big enough. That will contain the blood long enough to keep the patient alive long enough for a proper surgical repair. Given a relatively short duration that the device would be in place... problems with clotting shouldn't be a factor. Same with any other device you mentioned...

I am aware of a couple medics that did an emergency cesarean on a deceased female, with Base Physician Orders to do so, and the Paramedics lost their licenses and the BHP got a "you shouldn't have done that, don't do it again." IIRC, that was in Virginia a few years ago. That might be what you were thinking of. Made National News, that event did...

And while I agree that a Physician has an unlimited license to practice medicine, I don't necessarily think that it would be advisable for a GP to perform a lung transplant, or crash cesarean, Total Knee... or any number of other things right out of his or her Primary Care Residency. As you and I are both aware, the field of medicine is EXTREMELY broad even once you become a Physician, and the specialties and sub-specialties can require YEARS to master. 

My previous education was very specialized and took years to master. It's a shame that I can NOT use that education to it's full capacity... For what I do know, I'd be extremely useful in certain venues.


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## MrBrown (Aug 21, 2010)

I have seen some Doctors hiding in the corner having a panic attack while Paramedics work on the cardiac arrest in his waiting room or politely asking "now, you did give this asthmatic some salbutamol with his oxygen right?".

Not all physicians are confident in dealing with whacky situations like what Vene has described and I bet some would run away.  My GP (who is a bloody fantastic GP) wanted to be an emerg consultant but never did because the highly pressurised environment of an acute medical emergency is not one in which they felt most confident and of most value.

Brown on the other hand enjoys a good challenge and has no interest in being anything other than an intensevist or critical care anaesthetist.  Sitting in the Office going here is your prescription, ten bucks please, next ... ick!

Perhaps that is why I want to become a helicopter doctor? You don't see them doing house calls for the sniffles now do you


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## JPINFV (Aug 21, 2010)

MrBrown said:


> Perhaps that is why I want to become a helicopter doctor? You don't see them doing house calls for the sniffles now do you



They did on Trauma...


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## Veneficus (Aug 21, 2010)

Akulahawk said:


> I am aware of a couple medics that did an emergency cesarean on a deceased female, with Base Physician Orders to do so, and the Paramedics lost their licenses and the BHP got a "you shouldn't have done that, don't do it again." IIRC, that was in Virginia a few years ago. That might be what you were thinking of. Made National News, that event did....



They were seperate incidences, the one I spoke of touched off a change in our state which allowed a paramedic to perform any procedure the local medical director authorized to much more rigid statewide scope of practice. The latest state protocols are extremely conservative and now universal to all state services. It was definately a step backward in my opinion.



Akulahawk said:


> And while I agree that a Physician has an unlimited license to practice medicine, I don't necessarily think that it would be advisable for a GP to perform a lung transplant, or crash cesarean, Total Knee... or any number of other things right out of his or her Primary Care Residency. As you and I are both aware, the field of medicine is EXTREMELY broad even once you become a Physician, and the specialties and sub-specialties can require YEARS to master.



Something I am all too familiar with  However I was thinking more along the lines of emergent procedures like the crash c section. Usually when doing that, there is already significant fetal distress which is not responsive to treating the mother. (if she is even still alive)


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## MrBrown (Aug 21, 2010)

> They did on Trauma...


Yes true but Brown would like to keep his license to practice medicine and not be branded a rogue and unethical practitioner


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## Aidey (Aug 21, 2010)

We have some of those Thanks but no thanks cards we can hand out. I've never had an enough of an issue to use it. The biggest problem I run into when a family member is a MD (Or PA, ANP etc) is they are too helpful. Its like "please, sir, I need the patient to answer the question".


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## Akulahawk (Aug 21, 2010)

Veneficus said:


> They were separate incidences, the one I spoke of touched off a change in our state which allowed a paramedic to perform any procedure the local medical director authorized to much more rigid statewide scope of practice. The latest state protocols are extremely conservative and now universal to all state services. It was definitely a step backward in my opinion.
> 
> 
> 
> Something I am all too familiar with  However I was thinking more along the lines of emergent procedures like the crash c section. Usually when doing that, there is already significant fetal distress which is not responsive to treating the mother. (if she is even still alive)


Personally, I'd prefer a blend of the what your state had then and has now. There should be a single set of protocols that are common to ALL services. Why? So that any Paramedic can move around within the State and not have to learn the basics. Call it a Basic Scope of Practice, if you will. Then authorize each Local EMS Medical Director to authorize an expanded scope of practice and each Paramedic would "simply" have to be accredited for that procedure. Move out of that region and you leave your accreditations behind, but you still perform as a Basic Paramedic.

It is quite unfortunate that your state does NOT authorize a Paramedic to perform certain heroic measures AFTER making base contact. As I see it, if the mother is deceased and the fetus hasn't expired already, a crash c-section performed by someone authorized to do so, provides the best chance at life a fetus has instead of none. Those certain specific heroic measures should be documented though, in a heroic measures type of protocol. No base contact, no go for any of those.

I don't like the fact that mine doesn't authorize those either...


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## Shishkabob (Aug 21, 2010)

Texas does it right with it's form of delegated practice


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## emt seeking first job (Aug 21, 2010)

*anyone have a link for a new york state version of those cards ?*

thank you


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## MSDeltaFlt (Aug 21, 2010)

medicRob said:


> I'm not sure if I understood the question completely, but I assume you are asking how would I be aware that my medical director has given permission for the physician to take over.
> 
> Our medical director keeps us updated with his cell # in case we cannot reach him via radio. I would pick up my phone call him, explain the situation and would say something like, "Dr. Smith, I have so and so patient here in critical condition, we are x minutes away from the medical center, and I have a bystander physician with me wishing to take over, he is an interventional cardiologist with X medical center and I felt it appropriate for him to speak with you before I allow him to take over any treatments" I would then hand the phone to the bystander physician so he could explain to Dr. Smith, why he wants to take over, why he feels physician accompanied transport is warranted, and can ask permission to take control. He would then hand me back the phone and Dr. Smith would either advise me to use him as an extra pair of hands, let him take over and have him ride with us to the medical center, or to not allow him to take over.
> 
> This is one of the situations where Dr. Smith does not have any problem whatsoever with us contacting him on his personal cell.



Hence why I said you'd be trumped. Because if a physician showed up on scene you'd put that physician on the phone with your physician and let them hash it out. That is what I meant.


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## medicRob (Aug 21, 2010)

MSDeltaFlt said:


> Hence why I said you'd be trumped. Because if a physician showed up on scene you'd put that physician on the phone with your physician and let them hash it out. That is what I meant.



Of course I would, and I agree. He went to medical school, I did not. If given the circumstances my medical director sees fit for the physician on scene to take over, by all means I will allow him to take over. This takes the liability off me in case something goes wrong, and it assures me that my medical director will not end up chewing me a new one when I get to the ER.

Now, that being said.. It is my choice completely as to whether or not I would even pick up the phone and contact my medical director, I have the authority to tell the bystander physician to get off my scene if I wish, although it would be quite ignorant of me to turn away a cardiologist on an MI patient, etc and I probably would not.


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## MrBrown (Aug 21, 2010)

Our Officers can deliver an alternate dose of a drug or fluid or vary treatment from the Clinical Guidelines provided they can justify it.

This does not extend however to "winging it" and performing things that are not in any Offcers scope of practice such as performing a thoracotomy but rather gives us flexibility in deliving care rather than following a cookbook recipe.

A Doctor may request an Ambulance Officer perform a procedure that is not in thier scope of practice however they may only do so in good faith and may be declined.


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## Seaglass (Aug 22, 2010)

medicRob said:


> I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was. At my service, we see our medical director in the ER almost every shift. He stops in to say hello at the station, we have lunch with him sometimes. Then again, my service is allowed to RSI, Needle Cric, etc. so it is quite obvious why he would want to be actively involved as much as possible.



It's pretty weird, but not impossible. I was once in a system where I never even spoke to the official county medical director. I knew some medics who'd never met him either, though most of them had dealt with him somehow at one point or another. No way we'd have recognized him if he'd shown up on scene.


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## Bloom-IUEMT (Aug 24, 2010)

Veneficus said:


> Having done both, any doctor is considerably more qualified than a paramedic. It is not so much a matter of qualification than comfort.
> 
> All of the skills you learn are taught to physicians in medical school. There is nothing a paramedic has or can do that hasn't been covered in considerably more breadth and depth.
> 
> ...



You just became my personal hero with this post!  
 This may be off topic (too bad mods!) but did you find medic school or MS I/MS II harder? Just curious...


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## Too Old To Work (Aug 27, 2010)

medicRob said:


> I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was.



I don't find it hard to believe at all. Although I know and am on a first name basis with my medical director, in a lot of other services, the medical director is just a name on a form. In a system the size of NYC, it's quite possible not to recognize the medical director or even one of the assistants. 




Veneficus said:


> Having done both, any doctor is considerably more qualified than a paramedic. It is not so much a matter of qualification than comfort.



This is true. Doctors have more knowledge, but not much of a comfort level in emergencies unless they work in EM. 




> It is foolish for paramedics to claim they can do anything a doctor can do in an emergency. It is simply ignorance.



This is not true. I've had any number of doctors show up at emergencies over the years. With only one or two exceptions, they were out of their depth because they don't treat emergency patients on a regular basis. Someone who is a Primary Care Physician is not going to be better at intubating than a paramedic who does 15 or more tubes a year. Nor is a dermatologist going to know the ACLS protocols better than I do. When was the last time a psychiatrist started an IV or interpreted a 12 lead. 

Paramedics have a very narrow body of knowledge in relation to the rest of the world. However, what we know, we generally know very well. A late friend of mine, who was a great doctor and early proponent of EMS was well known for saying that in his ideal world, he'd want to paramedics and two ER nurses on his code team and no one else.


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## MrBrown (Aug 27, 2010)

Too Old To Work said:


> Someone who is a Primary Care Physician is not going to be better at intubating than a paramedic who does 15 or more tubes a year. Nor is a dermatologist going to know the ACLS protocols better than I do. When was the last time a psychiatrist started an IV or interpreted a 12 lead.
> 
> Paramedics have a very narrow body of knowledge in relation to the rest of the world. However, what we know, we generally know very well. A late friend of mine, who was a great doctor and early proponent of EMS was well known for saying that in his ideal world, he'd want to paramedics and two ER nurses on his code team and no one else.



You may be better at a few psychomotor skills than a physician simply because you have more exposure to them but that is really a false positive and like comparing apples to oranges.


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## Too Old To Work (Aug 27, 2010)

MrBrown said:


> You may be better at a few psychomotor skills than a physician simply because you have more exposure to them but that is really a false positive and like comparing apples to oranges.



Not at all. I'll be better at assessing a patient because I do a lot of it. Non emergency physicians don't spend a lot of time dealing with emergent situations, but paramedics do. I can't assess someone to determine if they have cancer, which a physician can do. OTOH, I can assess someone with dyspnea and figure out if it's CHF or COPD. Physicians who don't do that on a regular basis probably can't. 

The most important skill a paramedic possesses is assessment of patients in emergency conditions.


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## CAOX3 (Aug 27, 2010)

Too Old To Work said:


> Not at all. I'll be better at assessing a patient because I do a lot of it. Non emergency physicians don't spend a lot of time dealing with emergent situations, but paramedics do. I can't assess someone to determine if they have cancer, which a physician can do. OTOH, I can assess someone with dyspnea and figure out if it's CHF or COPD. Physicians who don't do that on a regular basis probably can't.
> 
> The most important skill a paramedic possesses is assessment of patients in emergency conditions.



This is funny...


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## rwik123 (Aug 27, 2010)

Too Old To Work said:


> Not at all. I'll be better at assessing a patient because I do a lot of it. Non emergency physicians don't spend a lot of time dealing with emergent situations, but paramedics do. I can't assess someone to determine if they have cancer, which a physician can do. OTOH, I can assess someone with dyspnea and figure out if it's CHF or COPD. Physicians who don't do that on a regular basis probably can't.
> 
> The most important skill a paramedic possesses is assessment of patients in emergency conditions.



i think you are underestimating something called medical school and residency. I'm pretty sure any doctor could identify CHF or COPD.. but you do have a point about the practical skiils.. id rather have a medic intubate me vs my primary care physician


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## Too Old To Work (Aug 27, 2010)

rwik123 said:


> i think you are underestimating something called medical school and residency. I'm pretty sure any doctor could identify CHF or COPD.. but you do have a point about the practical skiils.. id rather have a medic intubate me vs my primary care physician



No, not at all. I work in an area that has three medical schools. I see a lot of residents, in a lot of specialties. You'd be surprised how many of them can't differentiate CHF from Asthma. I also do a lot of ACLS teaching and have both residents and attendings in my classes. The ones that aren't EM physicians aren't that proficient at reading EKGs than the paramedics and RNs in the class. The ones that aren't anesthesiologists aren't any better at intubating than the medics in the class. A lot of doctors don't see acute patients in their daily practice and thus aren't very good at assessing them. Not all residency programs cover the same material. Pretty early on physicians have to start specializing because there is so much information in any given specialty or even sub specialty. 

In the same vein, I'm not very good at reading Xrays or CT Scans since I don't do it very often.


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## Veneficus (Aug 27, 2010)

Bloom-IUEMT said:


> You just became my personal hero with this post!
> This may be off topic (too bad mods!) but did you find medic school or MS I/MS II harder? Just curious...



Actually, the hardest part I found was relearning things I thought I already knew.

What is taught in US paramedic class is a highly oversimplified version of a very few disease processes.

MSI and MSII isn't really harder, mostly because there is already a foundation of basic science that most US paramedics don't have, but it is more volumous. I don't think it is fair to say the first 2 years are "harder" but I would compare paramedic class as a sprint, and medical school as a marathon.


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## Veneficus (Aug 27, 2010)

Too Old To Work said:


> No, not at all. I work in an area that has three medical schools. I see a lot of residents, in a lot of specialties. You'd be surprised how many of them can't differentiate CHF from Asthma. I also do a lot of ACLS teaching and have both residents and attendings in my classes. The ones that aren't EM physicians aren't that proficient at reading EKGs than the paramedics and RNs in the class. The ones that aren't anesthesiologists aren't any better at intubating than the medics in the class. A lot of doctors don't see acute patients in their daily practice and thus aren't very good at assessing them. Not all residency programs cover the same material. Pretty early on physicians have to start specializing because there is so much information in any given specialty or even sub specialty.
> 
> In the same vein, I'm not very good at reading Xrays or CT Scans since I don't do it very often.



I think this is only accurate for US medical schools. (which I am rapidly finding are not nearly as good as schools in other parts of the world despite their propaganda) Myself and most of my classmates that spend the summer in the US are finding we put the 4th year students to shame.


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## JPINFV (Aug 27, 2010)

rwik123 said:


> id rather have a medic intubate me vs my primary care physician



Of course the difference between a physician and a paramedic is a non-anesthesia or EM physician knows their boundaries and most likely look for another method whereas a paramedic would attempt even if a proper analysis would dictate more prudent measures. There's a reason that paramedics get hammered in intubation studies and primary care physicians don't, despite intubation being in the legal scope of practice of both.


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## MrBrown (Aug 27, 2010)

Veneficus said:


> I think this is only accurate for US medical schools. (which I am rapidly finding are not nearly as good as schools in other parts of the world despite their propaganda) Myself and most of my classmates that spend the summer in the US are finding we put the 4th year students to shame.



Brown, MBChB, FANZCA, FJFICM has more letters than Brown, MD, FABA

... so by default it's better!


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## mcdonl (Aug 28, 2010)

*This is what we have in Maine...*

It is right in our protocol books.



> NON-EMS SYSTEM
> MEDICAL INTERVENERS
> 
> Thank you for your offer of assistance.
> ...


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## Too Old To Work (Aug 28, 2010)

Veneficus said:


> I think this is only accurate for US medical schools. (which I am rapidly finding are not nearly as good as schools in other parts of the world despite their propaganda) Myself and most of my classmates that spend the summer in the US are finding we put the 4th year students to shame.



This is funny...


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## Too Old To Work (Aug 28, 2010)

JPINFV said:


> Of course the difference between a physician and a paramedic is a non-anesthesia or EM physician knows their boundaries and most likely look for another method whereas a paramedic would attempt even if a proper analysis would dictate more prudent measures. There's a reason that paramedics get hammered in intubation studies and primary care physicians don't, despite intubation being in the legal scope of practice of both.



While primary care physicians might be able to intubate, how often do you think that they run into situations where they have to intubate? My guess is not very often at all. I'll have to ask my PCP when he last intubated next time I see him. My guess is that the answer will be "During residency", which in his case was 15 or 20 years ago. 

If you look at the intubation studies, you'll see that it's not situations where the paramedics shouldn't have intubated, it's paramedics that have fewer opportunities to intubate for any number of reasons.


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## JPINFV (Aug 28, 2010)

I fully agree that very few medical specialties are normally in situations that require intubation. However I'll argue that even in situations that would necessitate intubation, physicians outside of those specialties are still not going to intubate because they know that they're out of practice. 

Now the question is, if paramedics in some systems are not getting the opportunities to intubate to maintain proficiency, should they be placing ET tubes to begin with instead of finding another way?


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## Too Old To Work (Aug 28, 2010)

JPINFV said:


> I fully agree that very few medical specialties are normally in situations that require intubation. However I'll argue that even in situations that would necessitate intubation, physicians outside of those specialties are still not going to intubate because they know that they're out of practice.



I agree with you. I don't agree that any doctor is more qualified than any paramedic at the scene of an emergency. (I don't think it was you that said that) In 30+ years of EMS in a city with three medical schools, and more than one trauma center, I've had doctors show up on scene any number of times. Well, at least they claimed to be doctors, but not one ever produced a license or other proof. Nor did any of them offer to accompany the patient to the hospital as our protocol requires. Not to mention sign off on the PCR. Not to mention the ones that were at social events and probably had alcohol on board. That's a different story. 

It doesn't seem to happen much anymore, but the day shift probably does see it more than I do. 



> Now the question is, if paramedics in some systems are not getting the opportunities to intubate to maintain proficiency, should they be placing ET tubes to begin with instead of finding another way?



Rust out is a severe problem in EMS systems that have too many medics and not enough skills. The intubation issues seem to be more severe in all ALS systems as opposed to tiered systems. The Gauche study from LA County a few years ago showed that some of the medics hadn't intubated in over three years. OTOH, in my system we have a much lower paramedic to patient ratio and a dozen or so tubes a year per medic are the norm. 

Exposure to a larger number of patients seems to make a difference in success rates for intubation. 

I think you raise a valid point and I think some systems with a low number of intubations per paramedice might start looking at alternatives to intubation. Other systems won't have to. The bigger problem is that EMS regulators, at least in many areas, take an "one sized fits all" approach to regulation and scope of practice. 

Personally, I'd reduce the number of paramedics in most systems. That's probably a topic for another thread.


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## firetender (Aug 28, 2010)

Too Old To Work said:


> Personally, I'd reduce the number of paramedics in most systems. That's probably a topic for another thread.



Please, do!


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## Too Old To Work (Aug 28, 2010)

firetender said:


> Please, do!



I see someone else has started a thread. I think I'll lurk for a while.


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## Veneficus (Aug 28, 2010)

Too Old To Work said:


> This is funny...



I find it kind of sad actually. They are nearer to finishing than we are, and not only do they not seem to know what is in their textbooks, they have almost no clinical skills to speak of at all.

In my observation they spend hours practcing how to tie suture knots with pieces of string, but cannot suture. 

A few weeks ago during a code I had a 4th year tell me he didn't know CPR. 

He didn't know when he was looking at a common anatomical variation on a patient. (right out of the textbook)

I met another who I taught how to staple wounds. Yet another who never started an IV. 

These are students in a really well known and "prestigious" school.

If this is "the best there is"  I sure do feel sorry for a patient who gets the mediocre. I am starting to think the reason that the US medical system discriminates against foreign doctors is because it is painfully obvious how badly the students here are trained when standing next to one. Perhaps they are expert at passing a standardized test, but the ones I saw can't do anything else.

I know I don't go to the most prestigious school ever, but I can say with certainty that nobody in my class would have made it out of the 1st year if they couldn't start an IV, perform cpr, draw blood, staple a wound, or perform a physical exam and interview a patient. 

In the second year we have a semester long class (one of our 7 per semester) that teaches you how to function with emergency patients both in and out of the hospital. All of the skills covered in a US paramedic class in addition to much of the bookwork is covered. You don't get to the next year if you fail a class.

Stealing a quote from one of my mentors:

"There are many people with medical degrees, but most will never be a "doctor."

Think about it, in July, these 4th year US students will be interns. A bit scary I think.


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## Too Old To Work (Aug 28, 2010)

Veneficus said:


> I find it kind of sad actually. They are nearer to finishing than we are, and not only do they not seem to know what is in their textbooks, they have almost no clinical skills to speak of at all.
> 
> In my observation they spend hours practcing how to tie suture knots with pieces of string, but cannot suture.



I'm don't know what country you were trained in, so I can't comment. However, I do know that we just had a "doctor" trained in another country fail our EMT training program. Apparently she was averse to actually touching patients. Anecdotal though it is, that's my experience. Not to mention the graduates of foreign medical schools I see in residency here. I'm not impressed. 

If our medical care is so bad, why is it that patients come here from all over the world to seek treatment? Hmmm...


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## Veneficus (Aug 28, 2010)

Too Old To Work said:


> I'm don't know what country you were trained in, so I can't comment. However, I do know that we just had a "doctor" trained in another country fail our EMT training program....



I am sure I would fail an EMT program. Probably for many reasons. Not least of which is I would have to forget everything I knew in order regurgitate treatment modalities that are clinically suspect or outright disproven. 



Too Old To Work said:


> Apparently she was averse to actually touching patients.



Is that a problem with the training or a problem with the provider? Sounds to me like both.



Too Old To Work said:


> Anecdotal though it is, that's my experience. Not to mention the graduates of foreign medical schools I see in residency here. I'm not impressed.



I would be very interested to know where you were at and where these students came from. I won't deny that there are school around the world, from South America to europe to Asia, where you can buy a degree without ever actually attending class or something in between great education and a bribe. But there are many countries particularly on my side of the pond who have been training physicians before the United States was founded and have quite respectable traditions and put out proficent providers on a regular basis. 

You of course know there is an informal list of facilities that many foreign graduates consult to find places that will accept them based soley on their USMLE score?

I wager I can teach anyone to take a standardized test in less than 8 months and do well.

There are also some facilities that will take foreign grads because a benefit of being a FMG is you don't have to go throgh match and can negotiate your salary requirements. There is no shortage of people who will spend a few years supported by family working like a slave for next to nothing in order to get a spot. There are also some rather infamous facilities (particularly in NYC. I am too kind to name them publically) that specifically look to take advantage of that.



Too Old To Work said:


> If our medical care is so bad, why is it that patients come here from all over the world to seek treatment? Hmmm...



I always love this question because it is so short sighted. But let me offer you:

Medical tourism is a booming business, it is not uncommon for people to leave the US in order to have treatments or procedures done that are unaffordable or even inaccessable. from Euthanasia, to various cancer treatments, plastic surgery, gender reassignment, and a host of others. Some hospitals overseas are even getting Joint commision accredidation so US insurance companies will pay to transport and have treatment performed at a much less cost than in the US.

Because in the US anyone with the money can have any treatment performed, if you have the means it is quite logical to go to someplace that has regular experience at performing treatments that are very expensive over going to a place that has capable people who have never done it before or do it so infrequently that the outcomes are often poor.

You also have to look at where they go and what they are coming from. It is much easier for somebody from Mexico to come to the US for care than to go to England. At the same time, outside of North and South America, the rest of the world is closer to somewhere else. (Like Sweden)

Often the aristocratic people are not going to the US to have treatment in any podunk hospital, they are going to specific facilities for highly specialized treatments and physician quality that can be found nowhere else. But those quality physicians are not always from the US. Because of the money available here to pay quality people, it attracts quality people. I encourage you to look up who performed highly comlex or experimental procedures and where they were trained. I think you will be surprised. 

I have spent time in a handful of countries, and I have seen people show up in the A&E departments of a British hospital, drop a stack of their medical records on the desk say "I have cancer help me." I even saw one guy at customs at the airport tell the agent he was in Britian soley to seek medical treatment and get let in.

I am from the US and I can tell you if some guy stopped in the airport told them you had nothing and were seeking medical treatment, you probably would get turned away. If you actually made it in, you certainly would not show up in the ED drop your record on the desk at the Mayo Clinic and expect the most advanced lifesaving medicine available that money could buy, nor the best physician in the country to put his paying customers on hold to take your case on charity. (not saying she wouldn't but I wouldn't bet on it)

Not just everyday people, but even some celebrities with almost limitless spending power go outside the US for medical care.

Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?

Medicine is not simply a procedure performed in a spa or factory, it is a totally encompassing event for people. The average American certainly doesn't have access to the private dieticians, physical therapists, home health physicians, etc. that the worlds wealthy purchase when they come here.

Also take a look at the outcome to cost ratio of US medicine. The US spends way more and gets way less.

recently I was at a facility where a patient was seen by a surgeon, an intensivist, a hospitalist, a nephrologist, and an infectious disease specialist. They were all making recommendations and some of the directives actually conflicted. The nurse dutifully carried them all out in the order they were given. When I asked who was coordinating all of this, everyone just looked at me like I was crazy. The answer: "that is how we do it here." My next question: "Do all of you guys bill for this?" The answer: Of course! Lets not forget the wound care NP, the dietician, and the pain control PA.

So a patient with cellulitis and new onset renal failure was seen and billed by 5 doctors whos total plan was: 2 a day dressing changes with xeroform, IV vanc. standard dialysis protocol, protocol diet for heart failure, renal failure, and diabetis. (basically chicken and rice every meal 2000 calories per day) IV dilauded 2 mg, 8 hours, discontinue fentynal patch, and percocet every 6 hours. Schedule for fistula.  

The best medicine their is didn't know fent. is excreted by the fecal route so you don't have to worry about building toxic levels like in dilauded and percocet. The PA was starting the pain protocol from the begining seemingly oblivious to the fact the intensivist wrote for dilauded. (which is not only compounding the opioid levels in the blood but is removed by dialysis so when the patient is dialyzed next AM they she might go 2-8 hours before any pain control is given)

You call that the best?


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## JPINFV (Aug 28, 2010)

The Doctor can come along anytime, provided that Ms. Pond rides up front.


/not entirely sure how obscure this will be for this board...


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## MrBrown (Aug 28, 2010)

I find medicine a funny subject.  The age old notion of doctor as healer has long been raped and pilfered by the medicopharmaceutical establishment and if Western nations have the best healthcare in the world how come we are amongst the sickest in the world?

I don't see hill people in China dying of heart attacks and stroke and the Type II diabetes on the insulin and ACE inhibitors for hypertension and being scheduled for cardiac bypass surgery which has no real evidence it even works by the way but sssssh don't tell the AMA, the Cardiologists or the drug companies.

New Zealand has overtaken the US as the nation with the largest percentage of overweight and dangeriously or mortubound obese people in the world.  Our public healthcare system is struggling to cope and waiting lists for elective procedures are getting longer, some specialties are not accepting referrals and I joked with my doctor that it's a case of "hurry up and die so we can give your place to somebody else", his answer? You're spot on mate, do you want my job?

Now this is only observational (the best kind of evidence there is according to Scientific Research 101 ... not) but I find the few American physicians that I know are (and treading carefully here) ... very cocky in thier perception of righteousness and somewhat cultured to believe that the letters MD after thier name mean Mircale Dealer.

Oh and I must ask, if the most important thing to most Paramedic (ALS) students I see on these forums is a standardised test that I have seen foreign trained non "American style" ALS Ambulance Officers and Paramedics pass and comment how ridiciously, indeed criminally, inadequate and easy it was .... why should we expect anything different from the USMLE?

Oh and I probably dont have to find out anyway, as a FMG with his MBChB Brown only has to take USMLE Step 3.


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## Too Old To Work (Aug 28, 2010)

Veneficus said:


> I am sure I would fail an EMT program. Probably for many reasons. Not least of which is I would have to forget everything I knew in order regurgitate treatment modalities that are clinically suspect or outright disproven.



Or maybe you're just not that smart. 



> Is that a problem with the training or a problem with the provider? Sounds to me like both.



If the other EMTs in her class can pass with the same training regimen, presumably she could have. 



> Because in the US anyone with the money can have any treatment performed, if you have the means it is quite logical to go to someplace that has regular experience at performing treatments that are very expensive over going to a place that has capable people who have never done it before or do it so infrequently that the outcomes are often poor.



Sounds like a terrible idea. Use your money or insurance to pick the provider with the most experience. Who could ever think that would work. 



> You also have to look at where they go and what they are coming from. It is much easier for somebody from Mexico to come to the US for care than to go to England. At the same time, outside of North and South America, the rest of the world is closer to somewhere else. (Like Sweden)



Really? Last time I looked, Saudi Arabia was not that close to America. Yet, a number of members of the Royal Saud family come to the US for treatment on regular basis. 



> Often the aristocratic people are not going to the US to have treatment in any podunk hospital, they are going to specific facilities for highly specialized treatments and physician quality that can be found nowhere else. But those quality physicians are not always from the US. Because of the money available here to pay quality people, it attracts quality people. I encourage you to look up who performed highly comlex or experimental procedures and where they were trained. I think you will be surprised.



I'd guess most of them were trained here, but I might be wrong. 



> I have spent time in a handful of countries, and I have seen people show up in the A&E departments of a British hospital, drop a stack of their medical records on the desk say "I have cancer help me." I even saw one guy at customs at the airport tell the agent he was in Britian soley to seek medical treatment and get let in.



All those stories I read about rationing in the UK, long waits for routine procedures, people being left to die in wards because there aren't enough nurses, must be made up to scare us silly Americans. 



> I am from the US and I can tell you if some guy stopped in the airport told them you had nothing and were seeking medical treatment, you probably would get turned away. If you actually made it in, you certainly would not show up in the ED drop your record on the desk at the Mayo Clinic and expect the most advanced lifesaving medicine available that money could buy, nor the best physician in the country to put his paying customers on hold to take your case on charity. (not saying she wouldn't but I wouldn't bet on it)



It would probably depend on a number of factors. You've made up an interesting scenario. I certainly know that if someone shows up at an Emergency Department and requests care they will not be turned away. There's a specific law about that. 



> Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?



I don't know that they are, but I do know that even Canadian politicians come to the US for care they can't get in their own country. I have a friend who's wife is Canadian. Her mother died from breast cancer because it took six months to get the needed diagnostic tests. By then it was too late. I know that Canadian routinely have to wait for month to get procedures that take days or weeks to get scheduled in the US. I know that California has more CT machines than Canada. Oh, and I know that Canada is now going to start letting it's subjects pay doctors to supplement the government run health services. Oh, and politicians in Canada are calling for it to adopt more US style health care. 




> Medicine is not simply a procedure performed in a spa or factory, it is a totally encompassing event for people. The average American certainly doesn't have access to the private dieticians, physical therapists, home health physicians, etc. that the worlds wealthy purchase when they come here.
> 
> Also take a look at the outcome to cost ratio of US medicine. The US spends way more and gets way less.
> 
> ...



It's better than just telling them to go home and die, which seems to be the norm in much of the world. Or letting them die in a heat wave because all of the nursing home staff is on vacation. As happened in France a few years back. 

I'm also surprised that you knew so much about a patient that you weren't involved in treating.


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## Veneficus (Aug 28, 2010)

MrBrown said:


> Oh and I probably dont have to find out anyway, as a FMG with his MBChB Brown only has to take USMLE Step 3.



Check that out closer to graduation.

Most states will not hire you unless you have a US residency. Nobody Anyone I know ever heard of can get malpractice insurance in the US. without a US residency. I even know a doctor who was a surgeon for 13 years in Europe who just took Step I and both parts of the step II to attempt to get a surgical residency to transfer here. 

The politics of US medicine are quite involved. But like I said, it really makes me wonder what really makes them think they are the best.


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## jjesusfreak01 (Aug 28, 2010)

Veneficus said:


> Check that out closer to graduation.
> 
> Most states will not hire you unless you have a US residency. Nobody Anyone I know ever heard of can get malpractice insurance in the US. without a US residency. I even know a doctor who was a surgeon for 13 years in Europe who just took Step I and both parts of the step II to attempt to get a surgical residency to transfer here.
> 
> The politics of US medicine are quite involved. But like I said, it really makes me wonder what really makes them think they are the best.



I would think it has a lot to do with the fact that US residencies rely on a very specific system of training, and residencies are also accredited by the ACGME, so imagine the situation that you get into when you try to get into EMS in another country (proving that you have the required training and then taking classes to fill the gaps) and then multiply that by 100.


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## Veneficus (Aug 28, 2010)

Too Old To Work said:


> Or maybe you're just not that smart.



That could very well be. Who knows?




Too Old To Work said:


> If the other EMTs in her class can pass with the same training regimen, presumably she could have.



Your logic is she had the opportunity to "unlearn" the medicine she learned in medical school in order to fulfil the mindless EMT-Basic requirements? Perhaps she forgot to consult med control before giving nitro or some other medication people take at home without the aid of an EMT?

Maybe she knew that "pink frothy sputum" was a histological finding and didn't think it was the answer she was supposed to pick because the scenario didn't state "on your morning sputum test you find..." (I am sure you know that sputum tests are best done in the morning.)




Too Old To Work said:


> Really? Last time I looked, Saudi Arabia was not that close to America. Yet, a number of members of the Royal Saud family come to the US for treatment on regular basis.



Is this a ventmedic alias?

I think you totally missed the point and are trying to argue something stupid.

My statement was that wealthy people will pick the most experienced place to buy their care and that other people who are less wealthy choose to go somewhere closer to home?

Because the Saudi royal family does it, it must be the best right? Maybe you might consider some of the other things they do too.
(pathetic)



Too Old To Work said:


> All those stories I read about rationing in the UK, long waits for routine procedures, people being left to die in wards becauseAmericans. there aren't enough nurses, must be made up to scare us silly



Don't know where you read your stories, but I have been there and not only did I not see anything remotely like that, but most of the people I asked about it laughed at the prospect. Have you been there?




Too Old To Work said:


> It would probably depend on a number of factors. You've made up an interesting scenario. I certainly know that if someone shows up at an Emergency Department and requests care they will not be turned away. There's a specific law about that.



As I understand the law, they cannot be turned away for stabilizing care, that does not include longterm health care, or surgery that returns them to previous function. I am sure there are more than a few hospitals that would provide it, but I am also sure there are atleast equal a number that won't do anything more than they absolutely have to.



Too Old To Work said:


> I don't know that they are, but I do know that even Canadian politicians come to the US for care they can't get in their own country.



Can't get for what reason? Because it costs a lot and there is no demonstrated benefit? 

Why don't you compare the cost of peritoneal dialysis to the cost of hemodialysis and then look at the outcomes?

Because they were ruled out for some reason?

In the US an alcoholic can pay for a liver transplant. Some former pro baseball player did a few years ago. In most countries I know of, being an alcoholic (aka drug abuser) disqualifies you from a transplant list. Truly medicine to be proud of I guess.

I doubt any of us are privy to the actual reasons such care was not available. Including the prospect that something might be made public that shouldn't be. 



Too Old To Work said:


> I have a friend who's wife is Canadian. Her mother died from breast cancer because it took six months to get the needed diagnostic tests. By then it was too late.



Too late for what? If there was already cancer would the diagnostic have made a difference based on the type of neoplasm? Please if you are going to argue this, I would love to hear the details, otherwise it is just hearsay.

If I may tell you somethign about neoplasms. Some develop rather aggresively, the treatment options are limited and the prognosis often poor. Some develop over years and if a diagnostic test (and I would be very interested to know exactly which one) that took 6 months to get determined life or death, I would seriously worry about their pathology departments. 



Too Old To Work said:


> I know that Canadian routinely have to wait for month to get procedures that take days or weeks to get scheduled in the US. I know that California has more CT machines than Canada..



Because Americans can't diagnose anything that doesn't appear on CT?
(just being the devil's advocate) actually a lot of the CTs performed in the US are really to appease the legal community more than medically neccesary. I have found the to be the consensus of every US physician I have met. A test that dissuades a lawyer isn't "good medicine."



Too Old To Work said:


> Oh, and I know that Canada is now going to start letting it's subjects pay doctors to supplement the government run health services. Oh, and politicians in Canada are calling for it to adopt more US style health care. ..



So what? Canada wants to have some form of private pay in addition to its government sponsored one? Does that make the medicine performed better? If the Us is any indication, increased payments does not equate to increased outcomes. I am sure many will agree, politicians are usually not really good at making decision about much, much less medical decisions.



Too Old To Work said:


> It's better than just telling them to go home and die, which seems to be the norm in much of the world..



First of all this is a pityful distortion and oversimplified. In many places I have been medical providers have accepted that there is not some mythical battle against death. The populations don't seem to think that the purpose of medicine is to live forever no matter what you have done to your body. There is a point where the quality of life you lead for a short while will be better than having you hooked up to every device in the hospital in an effort to turn you into frankenstein because you or your family seem to think people should only die on tv.

There is a point where a major surgery will not do anything significant for you. If you survive it at all. You might also find some of the best places in the US for various surgery rule out more people than they actually operate on. Keeps the success rate high. That is officially counted and published.



Too Old To Work said:


> Or letting them die in a heat wave because all of the nursing home staff is on vacation. As happened in France a few years back.



Because the US never let anyone die in an environmental disaster because the medical system was totally overstressed? 

A heatwave in Europe is an environmental disaster. No different that a flood in Idaho or a hurricane in the US SouthEast. I lived in Europe for several years and many buildings aren't even capable of mounting window AC units, central AC is not widespread either. 



Too Old To Work said:


> I'm also surprised that you knew so much about a patient that you weren't involved in treating.



Yea, people actually invite me to their institutions, give me an ID badge, show me around, and give me access to patient info.

I would actually be embaressed to not know a considerable amount about any patient I attended rounds on. But then again, I have professors who actually expect I can do things like review charts, formulate care plans, ask smart/hard questions, and be able to do more than just stand in the back of the room looking like I didn't know how I got there while tying suture knots with the drawstring of my scrubs hoping somebody would tell me what was going on.


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## MrBrown (Aug 28, 2010)

I can see it now .... Brown will present his resume listing such things as

- House Officer
- Senior House Officer
- Speciality Registrar (Anaesthesia)
- 12 month secondment in Year 4 to helicopter emergency medical service

... they will look at me and go "so what, you seated people and took thier order or something?"


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## medicRob (Aug 30, 2010)

*Back to the topic at hand*

Here is what the state of Tennessee protocols say about a physician on scene and how it is to be handled, taken from a screenshot of my "Paramedic Protocol Provider" app on my iPad.


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## Simusid (Sep 22, 2010)

medicRob said:


> I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was. At my service, we see our medical director in the ER almost every shift. He stops in to say hello at the station, we have lunch with him sometimes. Then again, my service is allowed to RSI, Needle Cric, etc. so it is quite obvious why he would want to be actively involved as much as possible.
> 
> That being said, it was probably just a physician who arrived at the scene. In these situations, if they are not your medical director, you do not have to turn treatment over to them. If you do turn treatment over to them, they are required to ride with you to the hospital.



Ok quick followup/clarification/correction.  It was a nurse at the receiving ER who yelled "who put in that central line?"  *medic points at guy in back*   "who is that medic?  who does he think he is??"  and it was Dr. X.   The correction is that he was not the Medical Director at this particular time, but he is now.   He told this story at rounds tonight.


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## medicRob (Sep 22, 2010)

Simusid said:


> Ok quick followup/clarification/correction.  It was a nurse at the receiving ER who yelled "who put in that central line?"  *medic points at guy in back*   "who is that medic?  who does he think he is??"  and it was Dr. X.   The correction is that he was not the Medical Director at this particular time, but he is now.   He told this story at rounds tonight.



As long as the doc rode in with you, it's on him, not you.


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## jjesusfreak01 (Sep 22, 2010)

> Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?



Thats easy. Most countries other than the US regulate the drug industry and cap the prices on prescription medications. What this means is that in a country with national healthcare the government can tell the drug companies, "we will pay you this much for your drug, or we won't buy it at all". In poorer countries without national healthcare, they have to make the drugs cheap so that anyone will buy them at all. In the US people have private insurance that covers prescriptions and we have no means to collectively bargain with the drug companies, so while the rest of the world gets cheap drugs, the US is subsidizing it all.

You can see then why the drug companies vehemently oppose letting people get their prescriptions from Canada. If everyone did that, it would completely kill their profit margins. What needs to happen is the US government needs to get it together and tell the companies that they have to start charging the same amount in similarly developed nations. The US gets drugs cheaper, and they cost a bit more for everyone else, but at the moment, its US citizens getting screwed by the actions of the Canadians, Europeans...everyone with national healthcare.


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