# Prehospital command hierarchy, fitting it in with the regular medical community



## Hotshot007 (Sep 19, 2011)

Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?


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## Handsome Robb (Sep 19, 2011)

Paramedics can attend CCT transports. Ever heard of CCP-C or CCEMT-P?


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## CAOX3 (Sep 19, 2011)

Your comparing apples and oranges, on scene calls the EMT and medics are going to make the call unless the doctor wants to get involved. 

I dont take orders from any nurse on scene, I consider their advice but sorry its my call, if you want to get on the phone with my medical director and argue about it, thats up to you.

In the hospital I dont really have any standing as I am a pre-hospital provider.


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## Tigger (Sep 19, 2011)

Hotshot007 said:


> Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?



The more important question would be, "why does it matter?"

Also, where are LPNs supervising CCT transports? That has bad idea written all over it.


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## MedicJon88 (Sep 19, 2011)

Well- some Paramedics are employed as ER-Techs in parts of the country- They would definietly "out-rank" the LVN/LPNs in the ER. 

But most of the time it is Apples and Oranges... however MICN technically out rank a paramedic they are Med control most of the time around my parts... and CCT-RN can do more than CCT-Ps... considering drips and all.. but thats a RN union things not a difference in skill level.


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## MedicJon88 (Sep 19, 2011)

Tigger said:


> Also, where are LPNs supervising CCT transports? That has bad idea written all over it.



That does sound scary... very scary.


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## usafmedic45 (Sep 19, 2011)

Tigger said:


> The more important question would be, "why does it matter?"
> 
> Also, where are LPNs supervising CCT transports? That has bad idea written all over it.



My thoughts exactly.  Either you send an RN or an RT if they need more than a medic can offer.  LPNs are the basic EMTs of the hospital world:  The best of them have just enough knowledge to keep the patient alive until you get them someone with more education, the rest have just enough to be dangerous.


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## firecoins (Sep 19, 2011)

where in the world can an LPN supervise a CCT?


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## AlphaButch (Sep 19, 2011)

firecoins said:


> where in the world can an LPN supervise a CCT?



Not in Texas


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## jjesusfreak01 (Sep 19, 2011)

An LPN is closer in education to an Intermediate. Theyre nowhere near paramedic.


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## LondonMedic (Sep 19, 2011)

What about the truly important questions? Does a lawyer outrank a shopkeeper? Is a swimmer below a footballer? And is a nurse going to get me fired if they catch me having a smoke in the ambulance bay?


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## firecoins (Sep 19, 2011)

LPNs cant even accept care for our patients. They aren't recognized in NYC.


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## Shishkabob (Sep 19, 2011)

Paramedics are 'under' RNs?  Maybe in California, but nowhere else.  Infact, if your average nurse tried to tell me what to do, I wouldn't be able to control my laughter.  

The only person on Earth that can tell me what to do medically is my medical director.





You said 'prehospital' so I assume you mean on a call and not just 'in general'.  The EMS crew is always in charge of patient care in such a situation, with the only exception being a physician that desires to take responsibility AND go with the patient to the hospital.  CRNA, RT, RN, CNA, LVN on scene?  Cool if I need them, as long as it's understood that I'm running the show, and if they step on my toes, the law is on my side, and they will be escorted off scene by PD.   Straight up, the Paramedic is the utmost authority on pre-hospital medicine outisde of a physician fitting the above criteria. (Flight crews not-withstanding)


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## systemet (Sep 19, 2011)

Hotshot007 said:


> Hi all, my partner and I were having a discussion about where in the chain of medical command certain elements fall in. We established that EMT-Bs are lower than any hospital people except CNAs, paramedics are under RNs and the ER doc is basically god. What we were unsure about was the role of LVN/LPNs in relation. I said that they were above paramedics because they could supervise CCT transports, but my partner insisted they were below paramedics because paramedics can stick IVs in while basic LVNs cannot unless they get IV certified. Who is right?



A physician gives you orders.  As long as you're comfortable that the orders they've given are in the patient's best interest, you do what they suggest.  If you don't, either you (i) don't do it, or (ii) voice your concerns to another physician.

An RN, RT, NA, LPN, patient's family member, etc.  All these people are sources of information with expertise in different areas.  You use them as sources of information, evaluate their skill level and knowledge, compare it to your own, and make a decision.  

For an EMT, it might seem like you have to do whatever the medic says.  But you don't.  That a medic tells you to do something that's wrong isn't going to help you "get out of jail free", if you violate something within your own scope.  For example:  You respond to a 60 year old woman with nausea and epigastric pain.  Your partner spends 30 seconds on scene yelling at her, telling her she shouldn't have called 911 for an obvious gastroenteritis and should go to her family doctor.  You leave 20 seconds later, and as you're doing your paperwork she arrests.  You're going to be just as fired, and almost as liable.  Because you should have known better.

It's not the army.


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## Melclin (Sep 19, 2011)

Hierarchy? As long as we can all agree that I'm above Linuss, then all will be right in the world.  




LondonMedic said:


> What about the truly important questions? Does a lawyer outrank a shopkeeper? Is a swimmer below a footballer? And is a nurse going to get me fired if they catch me having a smoke in the ambulance bay?



Ohhh no no no. Look here, lets get one thing strait...


...soccer isn't a sport, mate.


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## Shishkabob (Sep 19, 2011)

Melclin said:


> Hierarchy? As long as we can all agree that I'm above Linuss, then all will be right in the world.



But if I don't agree to it, then we aren't all in agreement, are we?  ^_^



Authoritative Opposition Defiant Disorder.  Oh yes, I have legit medical reason why I hate being told what to do.


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## Melclin (Sep 19, 2011)

Linuss said:


> But if I don't agree to it, then we aren't all in agreement, are we?  ^_^



DAMMIT! Foiled again.

This won't be the last you hear from Professor Melclin! *flies away on rocket boots*.


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## Shishkabob (Sep 19, 2011)

Melclin said:


> *flies away on rocket boots*.



Guess you WOULD be "above" me then, wouldn't you?  :unsure:


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## ZootownMedic (Sep 19, 2011)

This is a interesting topic and as a current Medic student I will throw in my 2 cents for whatever they are worth. Paramedics are a strange breed in the world of medicine for several reasons and these reasons also factor into where we 'sit' in the heirarchy and also why certain other healthcare levels(ahem....RN's) dislike us. I recently just did a 12hr rotation in the ER and as a Paramedic student I was shadowing the Charge RN's. These are the top RN's in the ER and tell the other nurses what to do. I was very impressed with their knowledge of pathophysiology as well as their demeanor and expertise in the skills that I saw them do. That being said here we go with the main point......

CNA's can barely take a blood pressure so lets just leave it at that.

LPN's scope of practice varies greatly by state and additional training but for the most part they cannot do much more than a IV certified EMT can and a EMT-B here in the great state of Colorado can do quite a bit. Here a EMT-B can push any drug on the rig as long as the Paramedic TELLS them to do so. Kinda like how a LPN or RN needs a doc to tell them what to do. So I would put EMT-B's on the same level as LPN's but I think EMT-B's have alot more freedom.

Now the hard part...the classic RN vs Medic argument...haha....its funny because on one of my third rides last week for P school we did a transfer of a patient from this hospital up north to the central one with a RN. The protocols had just changed where Medics are allowed to transfer patients with chest tubes WITHOUT a RN on board...one of the RN's made a comment about this and how medics are 'growing up'. We just laughed at her overweight worthless self and let her think that she was a real healthcare provider(she just sits at a desk in a slow, deadpan ER). So we then got the REAL ER RN(who was quite good BTW) and took the patient. A friendly argument started in the back between my preceptor medic, the RN, and myself. Her argument was that she can push ANY drug and that we can push only the ones on our 'short' list of like 40-50. We retorted that we can give drugs on standing orders at our discretion and that she had to have verbal ordered permission. The argument also arose about abandonment. Since technically Paramedics often take critical patients from one ER to another without a RN on board she tried to argue that it wasn't the same and that we aren't the same level of provider. The bottom line is RN's are in there own little world in the hospital and report directly to a Physician. While Paramedics report to a physician as well it is much less DIRECTLY(some go weeks without talking to their MD) and have WAY more freedom to perform both good and bad medicine. 

In my opinion RN's are just pissed that Paramedics are getting more respect everyday and soon it won't even be a debate about who is the higher level of care and it will just be universally known that they are equal. As a side note as well I am talking in general about CRN's and ER RN's. RN's that are not really part of emergency medicine or a similar discipline aren't even close to Medics in their freedom, medical skills, or judgement making abilities. On the streets, Paramedics are the gods 96% of the time. Again, just a medic student who's in the thick of it's 2 cents.


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## JPINFV (Sep 19, 2011)

SmokeMedic said:


> While Paramedics report to a physician as well it is much less DIRECTLY(some go weeks without talking to their MD) and have WAY more freedom to perform both good and bad medicine.



Which is, of course, what makes the educational standards and general mentality of EMS so sad and dangerous.


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## ZootownMedic (Sep 20, 2011)

JPINFV said:


> Which is, of course, what makes the educational standards and general mentality of EMS so sad and dangerous.



Meh....I suppose. But I would say that the vast majority of Parmedics would be open to more continuing educaton, MD facetime/training, and the like. On the flip side of that coin though Paramedicine needs to get the respect it deserves as advanced medical providers and CLINICIANS. This is way past the days of the show 'Emergency' and there are TONS of excellent medics. The bad ones need to be weeded out but thats every profession ESPECIALLY bad doctors. People love to point the finger at EMS but there are just as many bad nurses and docs as Paramedics....we just dont SEE their screw ups as often as they get to see ours.


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## LondonMedic (Sep 20, 2011)

SmokeMedic said:


> Meh....I suppose. But I would say that the vast majority of Parmedics would be open to more continuing educaton, MD facetime/training, and the like. On the flip side of that coin though Paramedicine needs to get the respect it deserves as advanced medical providers and CLINICIANS. This is way past the days of the show 'Emergency' and there are TONS of excellent medics. The bad ones need to be weeded out but thats every profession ESPECIALLY bad doctors. People love to point the finger at EMS but there are just as many bad nurses and docs as Paramedics....we just dont SEE their screw ups as often as they get to see ours.


Is that because you're gods only 96% of the time...


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## ZootownMedic (Sep 20, 2011)

And to add to that last statement Paramedics are by far the LEAST compensated clinicians but still have incredible amounts of liability. Few people in EMS do it for the pay but its funny when people make comments about education and the like when Paramedicine is a 2 year degree in most parts just to scratch the surface. And EMS education standards vary across the board just as much as Nursing standards do..............


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## ZootownMedic (Sep 20, 2011)

You must have misunderstood......what I meant is that most of the time medics make in field decisions regarding patient care without a higher level of care intervening. We have standing orders which allow us to do things BUT we still have to know WHEN to implement those orders just as doctors do in the hospital setting. You don't just do a lumbar puncture because you feel like it, you do it when you need CSF to test for meningitis.....just like we don't intubate when we feel like it, we do it because its in the best interest of the PT. In the end though the decision usually stops with us.......


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## LondonMedic (Sep 20, 2011)

SmokeMedic said:


> You must have misunderstood......what I meant is that most of the time medics make in field decisions regarding patient care without a higher level of care intervening. We have standing orders which allow us to do things BUT we still have to know WHEN to implement those orders just as doctors do in the hospital setting. You don't just do a lumbar puncture because you feel like it, you do it when you need CSF to test for meningitis.....just like we don't intubate when we feel like it, we do it because its in the best interest of the PT. In the end though the decision usually stops with us.......


You must have misspoke because you appear to have a poor understanding and appreciation of your own future profession as well as everyone else's.


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## ZootownMedic (Sep 20, 2011)

LondonMedic said:


> You must have misspoke because you appear to have a poor understanding and appreciation of your own future profession as well as everyone else's.



Can you explain your insult? As I stated my opinion was my own and worth what you paid for it. If I offended you I apologize but you should get thicker skin. Not sure where in there I misspoke.........


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## JPINFV (Sep 20, 2011)

SmokeMedic said:


> And to add to that last statement Paramedics are by far the LEAST compensated clinicians but still have incredible amounts of liability.


They are also, by far, the least educated given what they are expected to do. Additionally, there are far too many paramedics who can't think past a protocol and advocate calling for any tough decision. One of the EMS (well, technically fire) legal blogs recently posted an open question regarding what if a patient wants to tape their own treatment. Someone actually answered that she would call medical control. 

There are too many in EMS who want the cream of being a profession (title, power, and status) without the responsibility of being considered a professional. As long as it's considered OK and part and parcel of EMS to call medical control as a form of liability control, EMS will never be a profession. 

Profession, it's a description, not an award. 




> Few people in EMS do it for the pay but its funny when people make comments about education and the like when Paramedicine is a 2 year degree in most parts just to scratch the surface. And EMS education standards vary across the board just as much as Nursing standards do..............


Yet how many EMS providers are actually involved in their profession besides manning an ambulance?


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## LondonMedic (Sep 20, 2011)

SmokeMedic said:


> Can you explain your insult?


If you're insulted by that, maybe you should have thought more carefully before expressing your overinflated sense of self-worth. You clearly lack the maturity and experience to recognise both the limitations of your knowledge and the limitations of your competence as well as the wider state of pre-hospital care in your country. :censored::censored::censored::censored: me, you think you know everything you need about the practice of hospital nursing in 12 hours.


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## ZootownMedic (Sep 20, 2011)

LondonMedic said:


> If you're insulted by that, maybe you should have thought more carefully before expressing your overinflated sense of self-worth. You clearly lack the maturity and experience to recognise both the limitations of your knowledge and the limitations of your competence as well as the wider state of pre-hospital care in your country. :censored::censored::censored::censored: me, you think you know everything you need about the practice of hospital nursing in 12 hours.



I never said I knew everything about the practice of hospital nursing and was just giving my opinion and I have spent far more than 12 hours in the hospital setting I was just using that rotation as an example. I will end this conversation now before it goes too far. I would have loved to hear your opinions on the matter and we could have had a discussion. [Removed inappropriate language.] I'd rather be inexperienced and know I have a lot to learn than be  pompous and arrogant like you.  Cheers, doc.


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## ZootownMedic (Sep 20, 2011)

JPINFV said:


> As long as it's considered OK and part and parcel of EMS to call medical control as a form of liability control, EMS will never be a profession.
> 
> Unless you want to pay for doctors to ride on ambulances you will have to have lower levels of care riding. Nursing isn't a profession? They have doctor supervision almost always in the hospital setting as liability control.....and EMS isn't a profession, Paramedicine is.
> 
> ...



I agree with you on this. Many do, many don't. It should be more.


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## LondonMedic (Sep 20, 2011)

SmokeMedic said:


> [Removed inappropriate language.]





> I'd rather be inexperienced and know I have a lot to learn than be pompous and arrogant like you.


Maybe prehospital gods should make sure that they're not the ones being 'pompous and arrogant' first... :rofl:


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## Katy (Sep 20, 2011)

This so-called "medical chain of command" is relatively diminished in the real world, and it sickens me that people are so caught up in their own certification and knowledge that we can't focus that certification and knowledge into helping our patient.


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## firetender (Sep 20, 2011)

London and Smoke, you can do better with each other.

Thanks


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## ZootownMedic (Sep 20, 2011)

firetender said:


> London and Smoke, you can do better with each other.
> 
> Thanks



Agreed


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## Tigger (Sep 20, 2011)

SmokeMedic said:


> LPN's scope of practice varies greatly by state and additional training but for the most part they cannot do much more than a IV certified EMT can and a EMT-B here in the great state of Colorado can do quite a bit. Here a EMT-B can push any drug on the rig as long as the Paramedic TELLS them to do so. Kinda like how a LPN or RN needs a doc to tell them what to do. So I would put EMT-B's on the same level as LPN's but I think EMT-B's have alot more freedom.



Citation please, the Rule 500 that I read from states that basics can push frontline cardiac meds during an arrest only, and nothing else.



> Now the hard part...the classic RN vs Medic argument...haha....its funny because on one of my third rides last week for P school we did a transfer of a patient from this hospital up north to the central one with a RN. The protocols had just changed where Medics are allowed to transfer patients with chest tubes WITHOUT a RN on board...one of the RN's made a comment about this and how medics are 'growing up'. We just laughed at her overweight worthless self and let her think that she was a real healthcare provider(she just sits at a desk in a slow, deadpan ER). So we then got the REAL ER RN(who was quite good BTW) and took the patient. A friendly argument started in the back between my preceptor medic, the RN, and myself. Her argument was that she can push ANY drug and that we can push only the ones on our 'short' list of like 40-50. We retorted that we can give drugs on standing orders at our discretion and that she had to have verbal ordered permission. The argument also arose about abandonment. Since technically Paramedics often take critical patients from one ER to another without a RN on board she tried to argue that it wasn't the same and that we aren't the same level of provider. The bottom line is RN's are in there own little world in the hospital and report directly to a Physician. While Paramedics report to a physician as well it is much less DIRECTLY(some go weeks without talking to their MD) and have WAY more freedom to perform both good and bad medicine.



Are there any reasons in favor of EMS not interacting with a physician more? I mean honestly it can only lead to the betterment of EMS given that we need the MD's help to advance. In order for MDs to really trust their EMS providers (and I know it does happen, just not where I am), we are going to have you know, actually talk to the doctor now and then. 

Also think twice about RNs only being able to implement procedures and interventions or asses a patient without an MDs orders. I've seen and been a part of codes worked at Penrose in C Springs where the ED physician was not present for any length of time. Everything went smoothly with only a few RNs, Techs, and RRT. A


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## Katy (Sep 20, 2011)

SmokeMedic said:


> So I would put EMT-B's on the same level as LPN's


This is where the problem is Are you seriously comparing a 120 hour training course for a 12 month rigorous education?


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## JPINFV (Sep 20, 2011)

SmokeMedic said:


> Unless you want to pay for doctors to ride on ambulances you will have  to have lower levels of care riding. Nursing isn't a profession? They  have doctor supervision almost always in the hospital setting as  liability control.....and EMS isn't a profession, Paramedicine is.




If the nurse has an issue with nursing care, in contrast to medical care, they aren't going to call the physician for orders. Additionally, they aren't going to call just because they're scared about liability. Personally, I think the "I'm not sure if the patient who's A/Ox4 and has capacity can sign AMA, so I'm going to call medical control just in case, and that way the liability is on them" type of call is nothing more than a -false- sense of security. 

I don't want to have physicians riding on every ambulance. I want the people who are providing care on an ambulance to be able to have the foundation to make decisions and justify those decisions without using medical control as a "I'm scared of the dark, and medical control is my blanky."

Furthermore, it's not even appropraite to compare a nurse calling for orders to a paramedic. The ward nurse more often than not is calling the patient's personal physician, who personally knows the patient, has examined the patient, and knows what the patient's current treatment plan is and why, where the medical control physician only knows what the paramedic thinks is important to tell him. 

Oh, and if EMTs aren't professionals, then they need not be on an ambulance without direct supervision. If paramedics are a profession, then they, as a whole, need to start acting like it, including demanding a proper education.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> This is where the problem is Are you seriously comparing a 120 hour training course for a 12 month rigorous education?



Not in medical knowledge....just in freedom of skills allowed


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## Katy (Sep 21, 2011)

SmokeMedic said:


> Not in medical knowledge....just in freedom of skills allowed


I'm not sure they surpass the LPN's in that area either.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> If the nurse has an issue with nursing care, in contrast to medical care, they aren't going to call the physician for orders. Additionally, they aren't going to call just because they're scared about liability. Personally, I think the "I'm not sure if the patient who's A/Ox4 and has capacity can sign AMA, so I'm going to call medical control just in case, and that way the liability is on them" type of call is nothing more than a -false- sense of security.
> 
> I don't want to have physicians riding on every ambulance. I want the people who are providing care on an ambulance to be able to have the foundation to make decisions and justify those decisions without using medical control as a "I'm scared of the dark, and medical control is my blanky."
> 
> ...



Well, I don't know where you work but I'm sorry you have such a low opinion of EMS. Half of the students in my class have bachelors and 75% have associates. Some of them have degrees in biology and other medical related sciences. EVERYONE in my class has taken college level A&P I & II, Psychology, and Microbiology. Plus almost everyone has been on the street as EMT's for a minimum of 1 year most have several years of experience. I'm not sure how you are equating all of this school and experience as undereducated.....Don't take one apple out a barrel and call the whole barrel bad


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## Katy (Sep 21, 2011)

SmokeMedic said:


> Well, I don't know where you work but I'm sorry you have such a low opinion of EMS. Half of the students in my class have bachelors and 75% have associates. Some of them have degrees in biology and other medical related sciences. EVERYONE in my class has taken college level A&P I & II, Psychology, and Microbiology. Plus almost everyone has been on the street as EMT's for a minimum of 1 year most have several years of experience. I'm not sure how you are equating all of this school and experience as undereducated.....Don't take one apple out a barrel and call the whole barrel bad


Maybe because the fact that such programs exist? And a good amount at that.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> I'm not sure they surpass the LPN's in that area either.



Maybe I don't know to be honest with you, all I can go on is my limited knowledge. I do know that EMT's where I work can start intravenous lines, perform assessments of OB, Geriatric, and Pediatric patients, as well as several other invasive procedures all on standing orders and without supervision. Again, not necessarily saying surpass, but probably equal. Now I don't argue that a LPN has significantly more understanding of A&P, patient care(esp longterm) and pathophys than the average EMT.


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## Katy (Sep 21, 2011)

SmokeMedic said:


> Maybe I don't know to be honest with you, all I can go on is my limited knowledge. I do know that EMT's where I work can start intravenous lines, perform assessments of OB, Geriatric, and Pediatric patients, as well as several other invasive procedures all on standing orders and without supervision. Again, not necessarily saying surpass, but probably equal. Now I don't argue that a LPN has significantly more understanding of A&P, patient care(esp longterm) and pathophys than the average EMT.


I'm pretty sure in the state of Colorado the EMT-B must be I.V. certified to do some of those things. If the LPN is certified, he/she can do all of the above and I bet more. And LPN's can assess patients, and are especially trained in focused and initial ones. Most of the time they are checked off or signed by the RN. Correct me if I am wrong though.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> Maybe because the fact that such programs exist? And a good amount at that.



I know that my school produces outstanding medics, has a 100% first time pass rate on NREMT, and have the respect of patients, ER docs, and peers when working the streets.


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## Katy (Sep 21, 2011)

SmokeMedic said:


> I know that my school produces outstanding medics, has a 100% first time pass rate on NREMT, and have the respect of patients, ER docs, and peers when working the streets.


Like you said earlier, you can't take an apple out of the barrel and judge the whole barrel based on that one. Your program is what we strive for, but sadly they aren't a standard practice.


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> Well, I don't know where you work but I'm sorry you have such a low opinion of EMS. Half of the students in my class have bachelors and 75% have associates. Some of them have degrees in biology and other medical related sciences. EVERYONE in my class has taken college level A&P I & II, Psychology, and Microbiology. Plus almost everyone has been on the street as EMT's for a minimum of 1 year most have several years of experience. I'm not sure how you are equating all of this school and experience as undereducated.....Don't take one apple out a barrel and call the whole barrel bad


That's great (even though I personally don't care about the year of experience bandaid fix to limited time). However, there are plenty of schools in California that turn out paramedics at the minimum 1000 hours without any serious pre-reqs (oh, wait, a 4-5 day A/P for Paramedics program). 

One bad apple spoils the bunch. The problem with EMS is that it isn't just one bad apple.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> If the nurse has an issue with nursing care, in contrast to medical care, they aren't going to call the physician for orders. Additionally, they aren't going to call just because they're scared about liability. Personally, I think the "I'm not sure if the patient who's A/Ox4 and has capacity can sign AMA, so I'm going to call medical control just in case, and that way the liability is on them" type of call is nothing more than a -false- sense of security.
> 
> I don't want to have physicians riding on every ambulance. I want the people who are providing care on an ambulance to be able to have the foundation to make decisions and justify those decisions without using medical control as a "I'm scared of the dark, and medical control is my blanky."
> 
> ...



Your being a little dramatic don't you think? I mean who calls a doc to see if a pt is AA0X4? Thats what a mental assessment is for. And you are saying that using Med Control is a crutch but that is the exception not the rule....most medics use Med Control for what its for....to obtain orders that exceed protocols and/or to get a higher and more educated opinion when the situation requires it. Rarely is it used to 'just get the load off my back' as you are implying....


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> I know that my school produces outstanding medics, has a 100% first time pass rate on NREMT, and have the respect of patients, ER docs, and peers when working the streets.



Google the phrases "statistical outlier" and "anecdotal evidence".


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> That's great (even though I personally don't care about the year of experience bandaid fix to limited time). However, there are plenty of schools in California that turn out paramedics at the minimum 1000 hours without any serious pre-reqs (oh, wait, a 4-5 day A/P for Paramedics program).
> 
> One bad apple spoils the bunch. The problem with EMS is that it isn't just one bad apple.



WOW...you have a really low opinion of EMS. Whats your experience? Im seriously curious...one state? Since California does EVERYTHING right :rofl:
And give me a break with the more than one bad apple.....your saying that there is a such a higher ratio of bad medics to good ones compared to say bad nurses or doctors to good ones? Show me some statistics or evidence other than your limited opinion?


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## ZootownMedic (Sep 21, 2011)

Katy said:


> Like you said earlier, you can't take an apple out of the barrel and judge the whole barrel based on that one. Your program is what we strive for, but sadly they aren't a standard practice.



Your point is valid, I just don't think it's quite as bad as people are making it out to be. You do still have to pass NREMT. Granted its just a test but it does say something.......


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## ZootownMedic (Sep 21, 2011)

usafmedic45 said:


> Google the phrases "statistical outlier" and "anecdotal evidence".



Don't need too....the fact that my school has a 100% pass rate is a fact not hearsay. Don't know why the negativity is so strong...........


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## Katy (Sep 21, 2011)

SmokeMedic said:


> Your point is valid, I just don't think it's quite as bad as people are making it out to be. You do still have to pass NREMT. Granted its just a test but it does say something.......


Also granted that the majority of Paramedics who had a halfway decent program and actually learned stuff thought it was relatively easy. Most people consider the NREMT a "joke" in regards to its difficulty.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> Also granted that the majority of Paramedics who had a halfway decent program and actually learned stuff thought it was relatively easy. Most people consider the NREMT a "joke" in regards to its difficulty.



Haha true.....All I can do is work hard everyday to be the best Medic I can be. I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about. I am a little surprised that current Paramedics haven't joined in this conversation.


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## Katy (Sep 21, 2011)

SmokeMedic said:


> Haha true.....All I can do is work hard everyday to be the best Medic I can be. I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about. I am a little surprised that current Paramedics haven't joined in this conversation.


I wouldn't consider them haters, you may sometimes see them as "harsh" because they are being critical of a career they care about. Tough love.


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## ZootownMedic (Sep 21, 2011)

Tigger said:


> Citation please, the Rule 500 that I read from states that basics can push frontline cardiac meds during an arrest only, and nothing else.
> 
> I will see if I can find it. And you may be right about frontline cardiac meds but as far as I know for most meds(maybe cardiac ones as well) if the Paramedic tells them to push it then they can. Again, you may be right.
> 
> ...



ER RN's are another breed. Truly professionals and I have been impressed with almost all that I have met. One of the ER RN's at Penrose is a mentor of mine and if I could be half the Emergency Medical clinician that he is I would be immensely proud.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> I wouldn't consider them haters, you may sometimes see them as "harsh" because they are being critical of a career they care about. Tough love.



Eh...I'm feeling a lot more hate than love or constructive criticism. And none of them are Paramedics so I don't really understand where their expertise is coming from other than observations in their limited area. It'd be like running into a couple burnt out RT's, Nurses or Doc's and saying that most Doc's, Nurses or RT's in the country don't know what they are doing. Pretty thin


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## silver (Sep 21, 2011)

SmokeMedic said:


> WOW...you have a really low opinion of EMS. Whats your experience? Im seriously curious...one state? Since California does EVERYTHING right :rofl:
> And give me a break with the more than one bad apple.....your saying that there is a such a higher ratio of bad medics to good ones compared to say bad nurses or doctors to good ones? Show me some statistics or evidence other than your limited opinion?


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## Katy (Sep 21, 2011)

SmokeMedic said:


> RN's that are not really part of emergency medicine or a similar discipline aren't even close to Medics in their freedom, medical skills, or judgement making abilities.


Honestly, this is hard for me to believe. What about a good ICU nurse? Or a nurse working in a Pediatric floor? These RN's must have good judgement making skills and medical skills.


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## ZootownMedic (Sep 21, 2011)

silver said:


>



Well played....and interesting if not weird<_<


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## ZootownMedic (Sep 21, 2011)

Katy said:


> Honestly, this is hard for me to believe. What about a good ICU nurse? Or a nurse working in a Pediatric floor? These RN's must have good judgement making skills and medical skills.



I don't know, maybe I have to eat some humble pie because of my foot in mouth. I'm sure they have OUTSTANDING judgement making and medical skills....they still get direct orders from a doc on their floor........


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> Your being a little dramatic don't you think? I mean who calls a doc to see if a pt is AA0X4? Thats what a mental assessment is for. And you are saying that using Med Control is a crutch but that is the exception not the rule...



For your reading from this very forum:
'The patient had 1 beer, is A/Ox4, and has capacity, but we need to call medical control just in case' http://emtlife.com/showthread.php?t=25667 

Contact medical control to prevent liability: http://emtlife.com/showpost.php?p=49156&postcount=2

Hey, this is completely out of my scope, but maybe medical control will say I can and I won't have any liability over it. http://emtlife.com/showpost.php?p=195714&postcount=46

"There is one advantage to always having to be under a doc.  the  liability insurance that each medic has is significantly less, as much  of the burden can be pushed off on the doc 		"  http://www.emtlife.com/showpost.php?p=201752&postcount=10

I could probably fine many more.

My personal favorite from outside of EMTLife is this gem from a Facebook discussion:

Terry: Oh, let's contact medical control to determine if a patient can film their own treatment because I can't make a decision on this non-medical decision! http://www.facebook.com/jemsfans/posts/234345126617406



> most medics use Med Control for what its for....to obtain orders that exceed protocols and/or to get a higher and more educated opinion when the situation requires it. Rarely is it used to 'just get the load off my back' as you are implying....



Again, stick around and it's going to come up sooner or later with someone honestly suggesting it.


It's not that I have a low opinion on what paramedics can be and should be. It's that I think EMS's biggest problem right now is that EMS tends to shoot itself in the foot more often than it actually advances towards the goal of being a paramedic. Until EMS decides that 1000 hours of post secondary training isn't enough and stops saying such stupid things like "EMS doesn't diagnosis" or "just call medical control," then it will continue shooting itself in the foot.


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## Katy (Sep 21, 2011)

SmokeMedic said:


> I don't know, maybe I have to eat some humble pie because of my foot in mouth. I'm sure they have OUTSTANDING judgement making and medical skills....they still get direct orders from a doc on their floor........


You don't think they have standing orders?


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> For your reading from this very forum:
> 'The patient had 1 beer, is A/Ox4, and has capacity, but we need to call medical control just in case' http://emtlife.com/showthread.php?t=25667
> 
> Contact medical control to prevent liability: http://emtlife.com/showpost.php?p=49156&postcount=2
> ...



So your comparing a few idiots on a internet forum and FACEBOOK to a profession where thousands of providers perform skills, save lives, and help people everyday? Don't know how to respond to that. And the reason EMS doesn't diagnosis is because how can you get a accurate diagnosis in the field? Do we have blood cultures or labs? Do we have incredibly accurate and reliable medical htx, medications, or family history? Dude, your killing me man. I see your point but you need to get out and find a good medic or two and ride on a ambulance with em. If you can't find one in Cali come to C Springs and I got about 75 you could roll with who would love to have you and change your mind.


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## ZootownMedic (Sep 21, 2011)

Katy said:


> You don't think they have standing orders?



No. If they did they wouldn't need a doctor they could just call him on the phone like we do. Hhaha...I was half kidding. I don't know what don't you educate me. What do they have standing orders for usually?


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> WOW...you have a really low opinion of EMS. Whats your experience? Im seriously curious...one state? Since California does EVERYTHING right :rofl:


...and your program is representative of every other program?

California is a terrible place, for the most part, when it comes to education. California, however, isn't alone. Look at Iowa, who calls their EMT-I/99 level "paramedics" and paramedics "paramedic specialists." Look at New York where a lot of providers go, "Hey, look, the EMT-CC level is just as good as a paramedic since they can do 95% of the interventions with 3/4ths the education." 

Look at all of the backlash over evidence based medicine when the evidence says, "Mayne we shouldn't be giving every patient oxygen via NRB mask or backboard every trauma patient." 

These are systemic cultural issues, not local regional issues. 



> And give me a break with the more than one bad apple.....your saying that there is a such a higher ratio of bad medics to good ones compared to say bad nurses or doctors to good ones? Show me some statistics or evidence other than your limited opinion?


First, I could easily turn this around and demand the opposite. Show evidence that your program isn't an outlier. 

Additionally, this has nothing to do with good or bad medics. This has to do with poor standards, and EMS believing, as a whole, that it's everyone else's job but theirs to kick up the education level to seriously begin justifying things like community paramedic programs, treat and release, and the like. The fact that one state is getting away with calling I/99s "paramedics," another state (New Jersey) still can't control a large number of their ambulances (volunteers via the First Aid Council), another state get away with a medic lite program, and California is a simple 1000 hour course says a lot. 

The fact that only 2 states apparently require even an associates degree speaks volumes. Sure, nursing still allows diploma programs, but the culture and pressure within nursing essentially dictates an ADN, if not a BSN for the good positions. Similarly, while medical school doesn't require a bachelors degree (90 units is the general standard), good luck getting admitted without one, and a growing number of medical students have masters degrees prior to starting (last number I saw was around 30%, and that was a few years ago).

If a majority of EMS providers felt that these are inappropriately low standards, why aren't they working to change it? How can paramedicine become a "profession" as long as paramedics don't take command of their work and their education system?


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## Katy (Sep 21, 2011)

SmokeMedic said:


> No. If they did they wouldn't need a doctor they could just call him on the phone like we do. Hhaha...I was half kidding. I don't know what don't you educate me. What do they have standing orders for usually?


Actually, I have found something better. Here is one where the Nurse is neither a ICU or ER nurse.
http://kbn.ky.gov/practice/medscollege.htm


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## JPINFV (Sep 21, 2011)

silver said:


>


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> ...and your program is representative of every other program?
> 
> California is a terrible place, for the most part, when it comes to education. California, however, isn't alone. Look at Iowa, who calls their EMT-I/99 level "paramedics" and paramedics "paramedic specialists." Look at New York where a lot of providers go, "Hey, look, the EMT-CC level is just as good as a paramedic since they can do 95% of the interventions with 3/4ths the education."
> 
> ...



I really don't want to argue with you anymore, and I agree with a lot of what you said. I think your still forgetting several important factors however. Modern EMS is barely 30 years old man......think about how far we have come from the days of the show 'Emergency'. You are comparing a baby profession(Paramedicine) to an adolescent profession(nursing) and a GREAT GREAT GREAT GRANDFATHER profession(medical doctor). We will get there man. Or did you forget that you used to put leetches on people?


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## ZootownMedic (Sep 21, 2011)

Katy said:


> Actually, I have found something better. Here is one where the Nurse is neither a ICU or ER nurse.
> http://kbn.ky.gov/practice/medscollege.htm



What about what MOST nurses are not the tiny majority of those in Emergency Medicine and Intesive Care?


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## ZootownMedic (Sep 21, 2011)

SmokeMedic said:


> What about what MOST nurses are not the tiny majority of those in Emergency Medicine and Intesive Care?



Sorry Katy...misread your post.


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> So your comparing a few idiots on a internet forum and FACEBOOK to a profession where thousands of providers perform skills, save lives, and help people everyday? Don't know how to respond to that. And the reason EMS doesn't diagnosis is because how can you get a accurate diagnosis in the field? Do we have blood cultures or labs? Do we have incredibly accurate and reliable medical htx, medications, or family history? Dude, your killing me man. I see your point but you need to get out and find a good medic or two and ride on a ambulance with em. If you can't find one in Cali come to C Springs and I got about 75 you could roll with who would love to have you and change your mind.



You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order? 


Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers. 

Heck, even your own language is betraying your side. There's a difference between the mindset between "skills" and "interventions." A "skill" is a mechanical action, like pushing a plunger on a syringe. An "intervention" is an attempt to change a patient in an appropriate manner to change the patient's current condition. Are you performing a "skill" because the cookbook says so, or are you providing an "intervention" because the patient's condition warrants it. It may be subtle, but it's a big difference in how medicine is approached between a technician and a professional.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order?
> 
> 
> Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers.
> ...



And we do come up with working diagnosis' and differentials all the time, everyday, on every call. That is completely different that 'diagnosing' as you said. EMS doesn't diagnosis. And yes if you want to say 'skills' are different than 'interventions'...fine. but again you are being picky. Intubation is a 'skill' but it is also a intervention used to ventilate, oxygenate, and protect the patients airway. Either way, I have class at 0900 and I need to get to sleep. Have a good night, I have enjoyed our conversation for the most part.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order?
> 
> 
> Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers.
> ...



Oh and BTW....almost NOTHING is black and white in Paramedicine. There is no room for technicians. Most don't graduate and almost none make it to the streets....at least where I am.


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> I really don't want to argue with you anymore, and I agree with a lot of what you said. I think your still forgetting several important factors however. Modern EMS is barely 30 years old man......think about how far we have come from the days of the show 'Emergency'. You are comparing a baby profession(Paramedicine) to an adolescent profession(nursing) and a GREAT GREAT GREAT GRANDFATHER profession(medical doctor). We will get there man. Or did you forget that you used to put leetches on people?




Modern evidence based medicine and modern educational standards for physicians really isn't that old. The Flexner report, for example, is just over 100  years old. Personally, I'd love to see what effect a Flexner style report on EMS education would have and what it would say. Also, EMS isn't that old compared to other fields that have gotten their butts in gear. Modern respiratory therapist certification can be traced back to 1960, and the EMS "White Paper" was published in 1966. Care to compare, in regards to attitudes of the providers, paramedics to registered respiratory therapists?


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> Modern evidence based medicine and modern educational standards for physicians really isn't that old. The Flexner report, for example, is just over 100  years old. Personally, I'd love to see what effect a Flexner style report on EMS education would have and what it would say. Also, EMS isn't that old compared to other fields that have gotten their butts in gear. Modern respiratory therapist certification can be traced back to 1960, and the EMS "White Paper" was published in 1966. Care to compare, in regards to attitudes of the providers, paramedics to registered respiratory therapists?



Nope. Not a fair comparison as their are FAR less RRT's then Medics. Good night


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> And we do come up with working diagnosis' and differentials all the time, everyday, on every call. That is completely different that 'diagnosing' as you said. EMS doesn't diagnosis.



What is coming up with a working diagnosis if not making a diagnosis? By that standard, emergency physicians don't "diagnose" the majority of their patients as the admitting team would end up doing that much further down the line. This also ignores the fundamental fluidity of a "diagnosis" as more information becomes known and the condition is treated. The admitting diagnosis and the discharge diagnosis can be very different things, but that doesn't make either of them any less of a "diagnosis."




> And yes if you want to say 'skills' are different than 'interventions'...fine. but again you are being picky. Intubation is a 'skill' but it is also a intervention used to ventilate, oxygenate, and protect the patients airway. Either way, I have class at 0900 and I need to get to sleep. Have a good night, I have enjoyed our conversation for the most part.



Exactly. However, when a paramedic forgets to say, maintain oxygenation while preparing for intubation (the dreaded "BLS before ALS cliche), they aren't failing at the skill of intubation, but the intervention of intubation and airway control. Picking the right intervention is more important than being able to perform any single skill. 


Also, it's subtle, and admittedly a bit nitpickey. However I put it up there with how the mindset of treating a patient with treatments X, Y, and Z because they are appropriate for the patient's condition and the mindset of treating a patient with treatments X, Y, and Z because the protocol says so. Protocols should be followed not because protocols are protocols, but because they represent the proper treatment the vast majority of the time. Hence it's not so much an issue of following protocols, but protocols matching the treatment plan that the EMS provider decided on. Similarly, if an EMS provider believes that an intervention isn't warranted because of an assessment point, then they should be free to deviate from protocol because their patient calls for it. 

It's a subtle mind shift, but it's the mind shift that justifies liberal protocols and increased education in contrast to technician cookbook work. 

Finally, if anything I hope you don't come around thinking I hate or look down on EMS. I think EMS has a long road to travel to get to where it rightfully should be. A road that requires some massive changes in EMS culture regarding how care is provided and what is appropraite (e.g. not every patient needs a hospital, the indication for supplemental oxygen is not "ambulance," "protocol" alone is not a justification for any treatment, etc), and changes that has to come before EMS can rightfully change it's status and reimbursment rates ("you call, we haul, that's all" is not sustainable). Additionally, while the destination is important, you can't plan a trip if you don't know where you currently are at.


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## usafmedic45 (Sep 21, 2011)

> I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about.I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about.



How about you get past the qualification exams first before assuming you'll be some form of a positive role model?



> Not a fair comparison as their are FAR less RRT's then Medics



Wanna bet? 105,000 (as of 2008) RTs and 210,000 EMS providers in the US, with most of those being basic EMTs.  However, I would argue that using respiratory therapy as a model is probably not the best idea given the tendency of the field to spend an inordinate amount of time chasing its own tail.  They have the educational goals but the problem is that the career path associated with those goals is rather stagnant.


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## systemet (Sep 21, 2011)

Opinions:-

* Paramedics have a large scope of practice because we are frequently the only healthcare provider present when someone is having a major medical or traumatic emergency.

* That we are able to perform a skill in the prehospital environment does not mean that we are equally qualified or able to perform that same skill in an in-hospital environment.  If you're working in a hospital as some sort of clinical paramedic, they're not going to be asking you to manage the difficult airway patient.  There are better trained people to do this, e.g. board certified EM and anesthesia physicians.

* Comparing our scope of practice out-of-hospital to the scope of practice of an in-hospital provider is pointless.  A paramedic may be the best person to intubate you if you are 20 minutes from the hospital and the other alternatives are a police officer, your neighbour, or Fluffy your pet cat.  In-hospital there are going to be other people better equipped to do this.  The scope of practice of in-hospital providers being narrower reflects the realities of their work environment.  Just as our relatively broad scope reflects the realities of the commonest environments that paramedics work in.

* Defining a profession by a skill set or scope of practice is a little silly.  I don't suddenly become more of a professional tomorrow if someone suddenly authorises me to insert arterial lines.  Especially if they do so without providing me with the necessary education to identify which patients are going to benefit from invasive arterial pressure monitoring, ABG analysis, not giving me appropriate training, or continuing education, or making sure that I can actually perform the skill in an acceptable manner, etc.

* A 2 year associate's degree is not a lot of education.  It just isn't.  We should not be happy with this as an "occupation".  If we want to start calling ourselves "professionals" and have it mean something more than the "professional" in "professional carpet cleaner", or "professional car detailer", then we need to increase our educational requirements.

* Trying to get into turf wars with nursing (Does anyone really want to fight the nurses?  I don't think the physicians even want that fight.), respiratory therapy or medicine, by comparing ourselves, and suggesting we're somehow better, is pointless at best, and counter-productive at worst.

----------------

Just re-read my post and realised I used a lot of unnecessary commas.  Anyone have links to a decent site for doing remedial grammar?


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## ZootownMedic (Sep 21, 2011)

usafmedic45 said:


> How about you get past the qualification exams first before assuming you'll be some form of a positive role model?
> 
> 
> 
> Wanna bet? 105,000 (as of 2008) RTs and 210,000 EMS providers in the US, with most of those being basic EMTs.  However, I would argue that using respiratory therapy as a model is probably not the best idea given the tendency of the field to spend an inordinate amount of time chasing its own tail.  They have the educational goals but the problem is that the career path associated with those goals is rather stagnant.



First off, I will pass my qualification exams so thanks. Secondly, he said RRT's not RT's. As a RT yourself I would hope you'd know the difference. And there are far more than 200k EMS providers in the US. FDNY has at least 20k by itself there stat boy. 200k Paramedics is more accurate.


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## usafmedic45 (Sep 21, 2011)

> Secondly, he said RRT's not RT's. As a RT yourself I would hope you'd know the difference.



Yeah, about $500 for a test and maybe a dollar or two an hour in extra pay.  99% of place have no differing skill levels between the two differing levels so it's not like the difference between an EMT and a paramedic.  The difference is more like that between a paramedic with an associates and an paramedic with a bachelors.  A few extra gen ed classes don't do much to increase one's clinical acumen. 



> First off, I will pass my qualification exams so thanks


Never said you wouldn't.  



> And there are far more than 200k EMS providers in the US. FDNY has at least 20k by itself there stat boy. 200k Paramedics is more accurate.



Uh....actually FDNY has 3,300 "uniformed EMTs" and 11,000 plus total personnel according to their website and Wikipedia. 

How about you call the US Bureau of Labor and Statistics and tell them they are wrong rather than trying to compensate for whatever it is that you're trying to make up for by attacking someone on a forum when they point out where you were wrong in dismissing a comparison because of your own bias?  They only count the folks who do it for a living which is actually the best way to look at it since it shows the folks who are spending the most time in it.  I've seen estimates of 140K paramedics and 600K EMTs although it's not clear how many of those folks are actively involved in the field given the disparity.  A lot of folks have the credentials and do nothing actively with them (such as many military members).


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## Shishkabob (Sep 21, 2011)

usafmedic45 said:


> A few extra gen ed classes don't do much to increase one's clinical acumen.



I told a nurse that several weeks ago.  She wasn't amused.




I was. ^_^


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## ZootownMedic (Sep 21, 2011)

Linuss said:


> I told a nurse that several weeks ago.  She wasn't amused.
> 
> 
> 
> ...



Where have you been Linuss! I have been holding off the whole world of Paramedic naysers. Could use a little backup from someone with far more expertise and experience than me...............not that its a war but the arguments have been pretty direct and there are some people on this forum with VERY low opinions of Paramedicine


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> VERY low opinions of Paramedicine



Opinion on the current state or opinion on where EMS should be?


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> Opinion on the current state or opinion on where EMS should be?



Hey brotha, as I told you before I agree with alot of what you said. There are alot of bad EMS providers out there, our educational standards in much of the country could do with vast improvement, and our young profession could use a transfusion of some new higher standards. With that being the case there are still far more good Paramedics out there than bad ones and to say that a few bad apples in our profession ruin it for all of us but that in other professions that isn't the case is hypocritical. You aren't in EMS anymore JP...I get it. Your on your way to be a Doc, thats great, seriously. But if I was bleedign on the street I'd want a Paramedic to roll up and not a nurse, or a doctor, or a RT. Pretty much sums up my whole point all along. In a pre-hospital setting, when emergency medicine is the need, Paramedics get it done because thats what they do. Alot of people hate because our education isn't as much as others but we still get a great amount of freedom and responsiblity. Its understandable....just say it like it is


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> Opinion on the current state or opinion on where EMS should be?



And if I could tell you the story of what my grandma went through several weeks ago in her last 3 weeks of life in the hospital it would make your heart sink. Horror stories from a AZ hospital where my 78 year old grandpa watched nurses and doctors and everyone in between treat the woman he loved for 60 years like complete crap as she wasted away. Does that mean I think all doctors and nurses are crappy? Of course not. But those ones were and that's all it means......


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## CAOX3 (Sep 21, 2011)

Linuss said:


> I told a nurse that several weeks ago.  She wasn't amused.
> 
> 
> 
> ...



But at least every RN on this planet has had a traditional anatomy class, that cant be said for the majority of EMS providers.


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## ZootownMedic (Sep 21, 2011)

CAOX3 said:


> But at least every RN on this planet has had a traditional anatomy class, that cant be said for the majority of EMS providers.



That is slowly changing.....Again, EMS is a young profession. They are working on nationally recognizing certifications and when that happens things will start getting where they need to be. Its hard when every state controls education standards because there is nothing across the board. Paramedics here in Colorado Springs are great, our Medical Directors and ER Docs have great confidence in us. Medics here can RSI & ET Intubate, Surgical and Needle Cric, push around 60 drugs etc all on standing orders. I know in some parts of the country you have to call for a Dope Drip. Thats the problem, some places have this and some have that. In due time it will get better. Sucks for the good ones in the meantime.......


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> And if I could tell you the story of what my grandma went through several weeks ago in her last 3 weeks of life in the hospital it would make your heart sink. Horror stories from a AZ hospital where my 78 year old grandpa watched nurses and doctors and everyone in between treat the woman he loved for 60 years like complete crap as she wasted away. Does that mean I think all doctors and nurses are crappy? Of course not. But those ones were and that's all it means......



Oh, I won't say that individuals in other health care providers don't provide bad care, and I don't have issue with the fact that EMS is no different (I'm one of many that thinks that the punishment for the recent incident in Tennessee was excessive). My issues is more of what I see as the systemic issues holding EMS back, not necessarily the action of any one individual.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> Oh, I won't say that individuals in other health care providers don't provide bad care, and I don't have issue with the fact that EMS is no different (I'm one of many that thinks that the punishment for the recent incident in Tennessee was excessive). My issues is more of what I see as the systemic issues holding EMS back, not necessarily the action of any one individual.



Again, I agree with you. There is a definite need for change and I think that nationally recognizing and standardizing minimun standards across the board can start getting us on the right track. In the meantime I just plan to learn as much as I can and be the best that I can be. I never plan to stop learning. I take the fact that people call us on their worst day very seriously and treat every patient as if they were a family member. Hopefully things will start to turn around in all aspects of healthcare.


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> You aren't in EMS anymore JP...I get it. Your on your way to be a Doc, thats great, seriously.


My current career plans includes EM, subspecialized in EMS. In the words of MacArthur, I will return. 




> But if I was bleedign on the street I'd want a Paramedic to roll up and not a nurse, or a doctor, or a RT. Pretty much sums up my whole point all along. In a pre-hospital setting, when emergency medicine is the need, Paramedics get it done because thats what they do. Alot of people hate because our education isn't as much as others but we still get a great amount of freedom and responsiblity. Its understandable....just say it like it is


Depends on the physician, but in general, I agree that the vast majority of physicians, including many emergency medical physicians aren't suited for prehospital care (lack of specific training, lack of specific experience). 

The problem with the freedom is that that freedom isn't everywhere, and the question for many of us, especially if we don't live near the high powered systems, is how much do you want to bet on getting hired at one of the high powered systems. Places like Wake County are unfortunately the exception, not the rule.


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## ZootownMedic (Sep 21, 2011)

On a side note they just changed(our will soon) the EMS provider levels. The new levels are Emergency Medical Responder(formerly First Responder), EMT(Formerly EMT-B), Advanced EMT(former EMT-I) and Paramedic(Formerly EMT-Paramedic. While the name changes don't neccessarily mean crap the certification levels have changed. The getting rid of the EMT in front of Paramedic shows that Paramedicine is much more about being clinicians rather than Technicians. Also, the new Advanced EMT level is supposedly much less advanced than the former EMT-I level. From what I understand usually Advanced EMT just means that they can start IV's and have more advanced cardiac skills. In the end, this is a small change but its moving in the right direction.


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## silver (Sep 21, 2011)

SmokeMedic said:


> On a side note they just changed(our will soon) the EMS provider levels. The new levels are Emergency Medical Responder(formerly First Responder), EMT(Formerly EMT-B), Advanced EMT(former EMT-I) and Paramedic(Formerly EMT-Paramedic. While the name changes don't neccessarily mean crap the certification levels have changed. The getting rid of the EMT in front of Paramedic shows that Paramedicine is much more about being clinicians rather than Technicians. Also, the new Advanced EMT level is supposedly much less advanced than the former EMT-I level. From what I understand usually Advanced EMT just means that they can start IV's and have more advanced cardiac skills. In the end, this is a small change but its moving in the right direction.



Have the minimum didactic and clinical hours increased?

Otherwise the name change doesn't mean much, other than to trick people into thinking its a significant change.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> My current career plans includes EM, subspecialized in EMS. In the words of MacArthur, I will return.
> 
> 
> 
> ...



On another note, kinda of sad and by no means indicative of ER physicians I have a story that happened several weeks ago. A guy I knew who was one of my best friends' friends was riding shotgun in a pick-up being driven by his drunk friend that did a 100mph french kiss with a streetlight pole. 

Dude I know hit the windshield breaking his neck instantly, and in turn jerking his torso so violently that he severed both his liver and spleen. My buddy from Paramedic school was first on scene(as the EMT on a ALS/BLS bus). He said as they were spinaling the guy a great ER doc that was driving by pulled up. The doc took patient care and they transported. Instead of letting the Paramedic who was familiar with pre-hospital care intubate the doc tried....and failed. Wanna know what she said? "WHY THE HELL DOESN'T THIS COT OR MY CHAIR(she was sitting in the airway/jump seat) GO DOWN?!"....to make matters worse the poor guy had a tension nuemo the size of a beach ball but when the Paramedic suggested a decompression she said it was unneccesary because the vitals were stable...(78/30 BP)...????
In the end this is just a point that you can be the GREATEST ER Doc in the world(I heard this ER Doc was a great ER Doc) but if your out of your element it doesn't mean much. They called the guy 20 minutes after arrival at the hospital. Probably would have died no matter what but you never know if he'd have gotten more timely and appropriate care.


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## ZootownMedic (Sep 21, 2011)

silver said:


> Have the minimum didactic and clinical hours increased?
> 
> Otherwise the name change doesn't mean much, other than to trick people into thinking its a significant change.



Not sure to be honest.....


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## usalsfyre (Sep 21, 2011)

I'd much rather have a BASIC doc or one of the HEMS docs from down under than the average US paramedic roll up If I was bleeding in the street...


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## JPINFV (Sep 21, 2011)

usalsfyre said:


> I'd much rather have a BASIC doc or one of the HEMS docs from down under than the average US paramedic roll up If I was bleeding in the street...



To be fair, there's a difference between the docs who regularly engage in prehospital emergency care, and those who don't.


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> I'd much rather have a BASIC doc or one of the HEMS docs from down under than the average US paramedic roll up If I was bleeding in the street...



Haha. Yeah since they know where everything on the ambulance is......but hey its your life


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## usalsfyre (Sep 21, 2011)

JPINFV said:


> To be fair, there's a difference between the docs who regularly engage in prehospital emergency care, and those who don't.



Exactly. To blanket make the statement that a paramedic is always better than a physician in the field is extremely shortsighted is the point I was making.


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> Haha. Yeah since they know where everything on the ambulance is......but hey its your life



"It is better to know some of the questions than all of the answers."- James Thurber


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> Haha. Yeah since they know where everything on the ambulance is......but hey its your life


Are you familiar with what these guys are and do?

I'll take my chances...


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


> To be fair, there's a difference between the docs who regularly engage in prehospital emergency care, and those who don't.



Haha exactly. When was the last time a regular doc started a 20 gauge IV, bagged, and intubated on a little baby whos mom is screaming in your face? But because they are a Doc they can do anything right? gimme a break.....


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> Haha exactly. When was the last time a regular doc started a 20 gauge IV, bagged, and intubated on a little baby whos mom is screaming in your face? But because they are a Doc they can do anything right? gimme a break.....



Just because someone's a medic makes them somehow suited to this?

Someone's been listening to their medic school instructors too much, your more arrogant and conceited than I am...and that's an achievement.


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## Handsome Robb (Sep 21, 2011)

SmokeMedic said:


> Haha. Yeah since they know where everything on the ambulance is......but hey its your life



Doesn't really matter if you don't know where stuff is in the truck if someone who does is riding in the back with you...

My question is why didn't the doc let the medic try and get the tube, and if they really couldn't get it why didn't this guy get a crike?

I sure hope the medic documented the living :censored: :censored: :censored: :censored: outta the call, it's his truck and his responsibility.


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## ZootownMedic (Sep 21, 2011)

usafmedic45 said:


> "It is better to know some of the questions than all of the answers."- James Thurber



Its probably also better to know where the equipment youll need is to perform a life saving intervention before the patient is dead.....just saying.....plus Doc's don't do pre-hospital interventions very often. Some interventions maybe but not some of the ones that count.


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## ZootownMedic (Sep 21, 2011)

NVRob said:


> Doesn't really matter if you don't know where stuff is in the truck if someone who does is riding in the back with you...
> 
> My question is why didn't the doc let the medic try and get the tube, and if they really couldn't get it why didn't this guy get a crike?
> 
> I sure hope the medic documented the living :censored: :censored: :censored: :censored: outta the call, it's his truck and his responsibility.



The Doc sunk a combitube on the guy after the failed ETI.....The doc assumed patient care and wanted to do it. The Paramedic on that bus is one of my training advisors...shes a great medic. I don't know about the documentation but Im sure she did........


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> Just because someone's a medic makes them somehow suited to this?
> 
> Someone's been listening to their medic school instructors too much, your more arrogant and conceited than I am...and that's an achievement.



haha what do you mean more suited to this? I know in some parts of our city its a weekly event! So yeah, practice makes perfect


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> Its probably also better to know where the equipment youll need is to perform a life saving intervention before the patient is dead.....just saying.....plus Doc's don't do pre-hospital interventions very often. Some interventions maybe but not some of the ones that count.



It was more of a general statement about some of the comments that have been made by a couple of the parties involved in this discussion than about the post that was inadvertently quoted.


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> Its probably also better to know where the equipment youll need is to perform a life saving intervention before the patient is dead.....just saying.....plus Doc's don't do pre-hospital interventions very often. Some interventions maybe but not some of the ones that count.



So your saying your average ED physician doesn't do airway control, place lines or administer medication very often?


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## ZootownMedic (Sep 21, 2011)

NVRob said:


> Doesn't really matter if you don't know where stuff is in the truck if someone who does is riding in the back with you...
> 
> My question is why didn't the doc let the medic try and get the tube, and if they really couldn't get it why didn't this guy get a crike?
> 
> I sure hope the medic documented the living :censored: :censored: :censored: :censored: outta the call, it's his truck and his responsibility.



And it's not the medics responsibility anymore if a licensed and practicing MD takes pt care and rides in with the pt.....as far as I know at least....


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## usafmedic45 (Sep 21, 2011)

usalsfyre said:


> Just because someone's a medic makes them somehow suited to this?
> 
> Someone's been listening to their medic school instructors too much, your more arrogant and conceited than I am...and that's an achievement.



This is what I was referring to but I am trying to be a little more civil than I normally am.


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> So your saying your average ED physician doesn't do airway control, place lines or administer medication very often?



you said a BASIC Doctor...not a ED physician. I'd take a ED physician over a average medic anyday....not a regular MD though that practices a different type of medicine


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## usalsfyre (Sep 21, 2011)

usafmedic45 said:


> This is what I was referring to but I am trying to be a little more civil than I normally am.


For whatever reason civility hasn't been on my agenda the past couple of days...


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## Handsome Robb (Sep 21, 2011)

Doesn't have to be pretty to work. 

The part of the story that makes me wonder is why this 'great' ER doc said vitals were stable at that BP with signs of a tension pnuemo...sounds fishy to me, no offense. I truly am sorry about what happened to your friend.



usalsfyre said:


> So your saying your average ED physician doesn't do airway control, place lines or administer medication very often?



I'll bite, at the level II here not too often for the airway and line placement.

RRTs and techs or nurses are so plentiful there's usually one around to take care of both tasks, respectively. Not saying they don't do it but more often than not it's someone else, in my _limited_ experience in the ER.


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> you said a BASIC Doctor...not a ED physician. I'd take a ED physician over a average medic anyday....not a regular MD though that practices a different type of medicine


You do know I was referring to the prehospital physicians in the UK when I said a BASIC doc right?


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> For whatever reason civility hasn't been on my agenda the past couple of days...



Its all good guys....this discussion has kinda gone in a argumentative direction. I'm not trying to sound arrogant I am just confident in the people I work with.


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## usafmedic45 (Sep 21, 2011)

usalsfyre said:


> For whatever reason civility hasn't been on my agenda the past couple of days...



Having the girlfriend around has tended to improve my mood significantly.  Take that as you will.


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## Handsome Robb (Sep 21, 2011)

SmokeMedic said:


> And it's not the medics responsibility anymore if a licensed and practicing MD takes pt care and rides in with the pt.....as far as I know at least....



It's still the medic's truck, and if not documented properly can turn around and bite you in the ***. Albeit the MD will go down too but the medic very well could be dragged down with them, from my understanding. Just like an EMT-B partner can get screwed by not speaking up when his Medic partner was being negligent.


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## ZootownMedic (Sep 21, 2011)

NVRob said:


> Doesn't have to be pretty to work.
> 
> The part of the story that makes me wonder is why this 'great' ER doc said vitals were stable at that BP with signs of a tension pnuemo...sounds fishy to me, no offense. I truly am sorry about what happened to your friend.
> 
> ...



THANK YOU. Since ER Doctors do IV's ALL The time. haha what a joke! And I don't know about the vitals. From what i gathered I think that the ER Doc was kinda scared to do surgical interventions in the field......again just out of her element.


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> You do know I was referring to the prehospital physicians in the UK when I said a BASIC doc right?



Yeah I did, I just had my mind reading class this week. Its a new thing for us lower, moron prehospital people


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> THANK YOU. Since ER Doctors do IV's ALL The time. haha what a joke! And I don't know about the vitals. From what i gathered I think that the ER Doc was kinda scared to do surgical interventions in the field......again just out of her element.


Ever seen a central line initiated? Not too far from an IV...


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> Its all good guys....this discussion has kinda gone in a argumentative direction. I'm not trying to sound arrogant I am just confident in the people I work with.



Well, you have to remember that just because you work with a good group, doesn't mean that it applies across the board so don't get so defensive when we are critical of the current state of things.  There is nothing wrong with being critical as long as it is meant to spur change for the better.  

I used to work with a really great group but I still won't trust anyone I haven't worked with further than I pick them up and throw them.  The best advice I can give is that if you want to instill confidence in yourself and your service is to demonstrate why your approach is better in a quiet manner.  Beating someone over the head with "WELL....EMS is GREAT! IT'S GREAT BECAUSE MY GROUP DOES THIS, THIS, THAT AND EVEN OCCASIONALLY PROVIDES A REACHAROUND TO THE CHARGE NURSE! IF YOU DON'T AGREE YOU HAVE AN ATTITUDE PROBLEM!" is pretty much the EMS equivalent of doing this to your career:

[YOUTUBE]http://www.youtube.com/watch?v=KDwODbl3muE[/YOUTUBE]


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> Yeah I did, I just had my mind reading class this week. Its a new thing for us lower, moron prehospital people



I'm one of those prehospital morons. I'm not in med school, heck I don't even have a college degree. 

The BASIC program is pretty well recognized by those with some familiarity of international EMS.

SmokeMedic, it's cool your excited about the profession. What's not so cool is that your truly clueless as to your limitations and knowledge gaps.


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> I'm one of those prehospital morons. I'm not in med school, heck I don't even have a college degree.
> 
> The BASIC program is pretty well recognized by those with some familiarity of international EMS.
> 
> SmokeMedic, it's cool your excited about the profession. What's not so cool is that your truly clueless as to your limitations and knowledge gaps.



Yeah well you guys have done a pretty good job of explaining them to me.


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## ZootownMedic (Sep 21, 2011)

usafmedic45 said:


> Well, you have to remember that just because you work with a good group, doesn't mean that it applies across the board so don't get so defensive when we are critical of the current state of things.  There is nothing wrong with being critical as long as it is meant to spur change for the better.
> 
> I used to work with a really great group but I still won't trust anyone I haven't worked with further than I pick them up and throw them.  The best advice I can give is that if you want to instill confidence in yourself and your service is to demonstrate why your approach is better in a quiet manner.  Beating someone over the head with "WELL....EMS is GREAT! IT'S GREAT BECAUSE MY GROUP DOES THIS, THIS, THAT AND EVEN OCCASIONALLY PROVIDES A REACHAROUND TO THE CHARGE NURSE! IF YOU DON'T AGREE YOU HAVE AN ATTITUDE PROBLEM!" is pretty much the EMS equivalent of doing this to your career:
> 
> [YOUTUBE]http://www.youtube.com/watch?v=KDwODbl3muE[/YOUTUBE]



HAHAHA That was great....


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> Yeah well you guys have done a pretty good job of explaining them to me.



One of the first things I was ever taught by my medical director was this: "The more someone says they know, the more scared of them you should be until proven otherwise."  Just something to keep in mind.


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## usafmedic45 (Sep 21, 2011)

SmokeMedic said:


> HAHAHA That was great....



You see my point though, right?


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## usalsfyre (Sep 21, 2011)

SmokeMedic said:


> Yeah well you guys have done a pretty good job of explaining them to me.


Crap, when did I become one of those crusty old arse holes peeing in the new guys cheerios?!? I'm too young for this!

That's why experienced folks are good to have around. I've bounced around EMS more than I would like (and I currently resemble a pinball) but it's made me a much more diverse, better schooled provider.


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## JPINFV (Sep 21, 2011)

SmokeMedic said:


> Yeah I did, I just had my mind reading class this week. Its a new thing for us lower, moron prehospital people




Stick around, you may learn something.


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## Handsome Robb (Sep 21, 2011)

usalsfyre said:


> Crap, when did I become one of those crusty old arse holes peeing in the new guys cheerios?!? I'm too young for this!



If you pee in my cheerios I'll come kick your old crusty :censored: :censored: :censored: !

But until the pee is discovered I will continue to listen attentively.


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> Crap, when did I become one of those crusty old arse holes peeing in the new guys cheerios?!? I'm too young for this!
> 
> That's why experienced folks are good to have around. I've bounced around EMS more than I would like (and I currently resemble a pinball) but it's made me a much more diverse, better schooled provider.



And to be completely honest with you, regardless of how I have come off on this forum I am actually one of the quietest people in class. I KNOW that I KNOW next to nothing. I do learn new things everyday though and do the best I can at everything I do. And I do have the benefit of being in a great medic school surrounded by great instructors and medics. Im spoiled I guess....but I will heed what many of you have said.


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## JPINFV (Sep 21, 2011)

NVRob said:


> If you pee in my cheerios I'll come kick your old crusty :censored: :censored: :censored: !
> 
> But until the pee is discovered I will continue to listen attentively.


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## ZootownMedic (Sep 21, 2011)

JPINFV said:


>



And yes, now that is a good one as well. "I think I see a squirrel down there next to the wack-a-mole...perhaps I can fashion and sharpen one of the screws from this playground apparatus into a arrowhead..."


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## usalsfyre (Sep 21, 2011)

NVRob said:


> If you pee in my cheerios I'll come kick your old crusty :censored: :censored: :censored: !
> 
> But until the pee is discovered I will continue to listen attentively.


I'm just trying to figure out how I started sounding like this before I've completed three decades on this rock. I SWORE at 20 I wouldn't be one of those guys. 

Plus now I have to admit maybe the old guys were right...d@mnit this is turning into a bad night .


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## ZootownMedic (Sep 21, 2011)

usalsfyre said:


> I'm just trying to figure out how I started sounding like this before I've completed three decades on this rock. I SWORE at 20 I wouldn't be one of those guys.
> 
> Plus now I have to admit maybe the old guys were right...d@mnit this is turning into a bad night .



Just don't be one of the guys that forgets what it was like when you were first starting out. Im 27, which is by no means old but Im not a young pup idiot either. I am pretty new to EMS and medicine in general but I served 3 combat tours overseas, have 2 daughters and a wife. Just remember that just because someone is inexperienced in something doesn't mean they don't have something to offer. Not saying your that person, but I've ran into more than a few in the fire, ems, healthcare arenas.......


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## systemet (Sep 22, 2011)

I respect your passion for EMS.  But I think you also need to look around at what some of the other healthcare occupations / professions do, in terms of practice and education / training.

* I find it hard to believe that a EM physician is going to miss a clinically significant tension pneumothorax, even in the back of an ambulance.

* I find it hard to believe that you work in a system where a critical neonate needing IV access and BVM ventilation is a daily event for any provider.  If so, your community needs better prenatal / antenatal care.

* I have a hard time believing that a paramedic is going to be better at airway management than an EM physician, though I accept that intubating in the field might be a bit of a surprise (and a very good experience) for any EM physician to have.

EMS is a fantastic field.  It may one day become a profession.  But we have some fundamental educational problems that need to be resolved first.  In my opinion.


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## CAOX3 (Sep 22, 2011)

SmokeMedic said:


> Haha exactly. When was the last time a regular doc started a 20 gauge IV, bagged, and intubated on a little baby whos mom is screaming in your face? But because they are a Doc they can do anything right? gimme a break.....



An ounce of humility is going to do wonders for both you and your patients.


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## LondonMedic (Sep 22, 2011)

The "I know where all the equipment in my ambulance is" argument is surely an argument against you ever progressing, let alone being employed by a different company as much as it's an argument against doctors doing pre-hospital care. I would tactfully suggest that it wouldn't take too long to show a physician around the back of an ambulance.

I would further suggest that SmokeMedic would take a lot longer to adapt to work in an emergency department, even if they succeeded in developing some of the necessary interpersonal skills.


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## abckidsmom (Sep 22, 2011)

usalsfyre said:


> I'm just trying to figure out how I started sounding like this before I've completed three decades on this rock. I SWORE at 20 I wouldn't be one of those guys.
> 
> Plus now I have to admit maybe the old guys were right...d@mnit this is turning into a bad night .



Wait till you're all 32 and stuff, like me.  These guys I'm working with all seem like they're 14.  

They're smart, most of them learn quickly, but DANG they're young!  They remind me so much of myself at the same point, and it's increasingly embarassing for ME!!!!  

My grandma has a cross-stitch that her mom made hanging on her wall:  "We grow too soon olde, and too late schmart."  

Glad I've got 40-50 years left, cause this is just starting to get fun!


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## JPINFV (Sep 22, 2011)

Does it even matter if the physician knows his way around the back of an ambulance? It's like complaining because a physician doesn't know his way around a Pyxis.


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## Shishkabob (Sep 22, 2011)

JPINFV said:


> Does it even matter if the physician knows his way around the back of an ambulance? It's like complaining because a physician doesn't know his way around a Pyxis.



If a doctor doesn't know how walk around something, I'd be slightly concerned as to their ability.


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## JPINFV (Sep 22, 2011)

Linuss said:


> If a doctor doesn't know how walk around something, I'd be slightly concerned as to their ability.


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## STXmedic (Sep 22, 2011)

JPINFV said:


>



You've got a picture for everything, don't you JP?


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## MedicJon88 (Sep 23, 2011)

I would much rather have an RN start a line on me than a MD.... god knows they are out of pratice.... and we have specialized RNs to start Central and PICC lines at my hospital- don't know if thats a common pratice though. 

Regarding RNs having to get MD orders for everything that is simply not true- thought i almost did die of laughter when i was told that RNs have to notified the MD if they increase O2 beyond 4lpm...but that is to update the doc not to get permission to do so...

-When a patient is admitted they have blanket orders/Holding orders till they are seeing by their Hospitalist/Internist MD- and each floor has their own protocals... ICU protocals covers pretty much everything without an MD present- I work in the ICU and have only seen ER MDs up here at night- and only when they missed something... ICU RNs does everything around here- Each type of Admission also has signed protocal by the MD... like Sepsis or CHF- not unlike our protocals in the field... so yes if something is out of the ordinary- they call the doc- same as us.


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## silver (Sep 23, 2011)

AchilliesOmega3 said:


> I would much rather have an RN start a line on me than a MD.... god knows they are out of pratice.... and we have specialized RNs to start Central and PICC lines at my hospital- don't know if thats a common pratice though.
> 
> Regarding RNs having to get MD orders for everything that is simply not true- thought i almost did die of laughter when i was told that RNs have to notified the MD if they increase O2 beyond 4lpm...but that is to update the doc not to get permission to do so...
> 
> -When a patient is admitted they have blanket orders/Holding orders till they are seeing by their Hospitalist/Internist MD- and each floor has their own protocals... ICU protocals covers pretty much everything without an MD present- I work in the ICU and have only seen ER MDs up here at night- and only when they missed something... ICU RNs does everything around here- Each type of Admission also has signed protocal by the MD... like Sepsis or CHF- not unlike our protocals in the field... so yes if something is out of the ordinary- they call the doc- same as us.



Making generalizations that an RN is better than an MD at starting a line isnt good. Anesthesiologists would be pissed off...In fact tell that to them when you go in for surgery.

Also blanket orders? what type of orders?
I know most units have emergency standing order meds (larger list for ICU/ED), but unless all hell is breaking loose giving blanket orders to all admitted patients seems like crap medicine (though a hospital that has EM MDs in the ICUs at night sounds a bit iffy too).


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## MedicJon88 (Sep 23, 2011)

silver said:


> Making generalizations that an RN is better than an MD at starting a line isnt good. Anesthesiologists would be pissed off...In fact tell that to them when you go in for surgery.
> 
> Also blanket orders? what type of orders?
> I know most units have emergency standing order meds (larger list for ICU/ED), but unless all hell is breaking loose giving blanket orders to all admitted patients seems like crap medicine (though a hospital that has EM MDs in the ICUs at night sounds a bit iffy too).



Blanket Orders like Cardiac maintence meds, Fluids, Diet, Activity level, Labs, Cultures, types of Antibiotics, antienemics, pain management meds- and I stand by what I say about starting lines- not including Anesthesiologists- how many lines do MDs start- VS numbers of lines RNs start in ONE shift. EM MDs write cover orders for Attendings that admit the patients- they are call HOLDING orders till the Attendings/hospitalists gets in to see the patients- sometimes they follow-up on the patients in the ICU. The RNs and RRTs pretty much manage the patients by themselves at night in the ICU- OB/GYN have MD and NPs throughout the night for obvious reasons. Med/Surg and AOU have less Blanket orders but their patients are also more stable and have less parameters to work with- so if anything is out of the ordinary- MD has to be informed inorder to change/modify Tx- which can be obtained over the phone. When something goes south- Rapid response or if really bad- Code blue is called- guess who responds? Charge Nurse from the ICU, Charge Nurse from Telemetry, Most Senior Respiratory Therapist, RN Supervisor (usually a NP)- and sometimes the ER MD... in the hospital-Nurses run the show.


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## MedicJon88 (Sep 23, 2011)

silver said:


> Making generalizations that an RN is better than an MD at starting a line isnt good. Anesthesiologists would be pissed off...In fact tell that to them when you go in for surgery.




Two words- Nurse Anesthesiologists.


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## usalsfyre (Sep 23, 2011)

AchilliesOmega3 said:


> in the hospital-Nurses run the show.


In small community ICUs with low acuity nurses MAY run the show. Your not going to find all that many tertiary centers that don't have hospitalist or residents available 24/7.

A whole host of folks can start peripheral IVs...big fricking deal....


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## usalsfyre (Sep 23, 2011)

AchilliesOmega3 said:


> Two words- Nurse Anesthesiologists.


A CRNA isn't exactly a bedside nurse...


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## MedicJon88 (Sep 24, 2011)

usalsfyre said:


> A CRNA isn't exactly a bedside nurse...



Anesthesiologists aren't hosptialists or ER docs either.


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## EMTPassion (Sep 24, 2011)

I have a quick question for someone on here who has EMT training in the US.  I read one of the posts on this thread saying that in parts of the US you can get your cert in a 120-150 hour course or something like three weeks? If so what is the EMT licenced to do there? just trying to compare to what my training was here in Canada.


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## JPINFV (Sep 24, 2011)

EMTPassion said:


> I have a quick question for someone on here who has EMT training in the US.  I read one of the posts on this thread saying that in parts of the US you can get your cert in a 120-150 hour course or something like three weeks? If so what is the EMT licenced to do there? just trying to compare to what my training was here in Canada.




In general, medical interventions include oxygen, OPAs, NPAs, PPV via BVM, AEDs, CPR, basic child birth, rigid catheter suctioning, oral glucose, and, in places that still carry it, activated charcoal. "Assisting" patients with their own nitro and epi-pens. Some places will include epi-pens, aspirin for suspected ACS (read "chest pain"), and inhaled beta agonist with varying levels of training. Trauma interventions are basic first aid, splinting, and spinal immobilization. Assessment is a basic head to toe along with a stethoscope (lung sounds, BPs) and blood pressure cuff. Some systems will include blood glucose testing, pulse oximetry, and/or 12 lead acquisition (not interpretation). Interfacility transports includes the ability to monitor basic IV fluids at TKO such as normal saline, D5W, lactate ringer, and TPN.


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## EMTPassion (Sep 24, 2011)

Thanks for the reply, sounds like there isn't a lot of differences. The only two things I've found are here we can give Our own Nitro and Epi (with permission from doc of course).


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## ZootownMedic (Sep 24, 2011)

EMTPassion said:


> Thanks for the reply, sounds like there isn't a lot of differences. The only two things I've found are here we can give Our own Nitro and Epi (with permission from doc of course).



Yeah it really just depends. Some places have more 'rigid' protocols for EMT's and some are lax. Here we don't carry Epi pens usually because almost all the rigs(except for way out in the sticks) are ALS so the Paramedic can push Epi if needed. Usually EMT's can also give Nitro up to 3 doses either via tablet or spray on standing orders.


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## Jay (Sep 25, 2011)

JPINFV said:


> For your reading from this very forum:
> 'The patient had 1 beer, is A/Ox4, and has capacity, but we need to call medical control just in case' http://emtlife.com/showthread.php?t=25667
> 
> Contact medical control to prevent liability: http://emtlife.com/showpost.php?p=49156&postcount=2
> ...



Looks like someone is trying to get their Moderator certification next 

(Just messin' with you)


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## JPINFV (Sep 25, 2011)

Jay said:


> Looks like someone is trying to get their Moderator certification next
> 
> (Just messin' with you)


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## Jay (Sep 25, 2011)

Cute


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## Shishkabob (Sep 25, 2011)

Hell, Michigan freezes over every winter... not that big of a deal to people who've actually been there.


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## Jay (Sep 25, 2011)

I was in Orlando back in the late 90's and we had almost *3 inches of snow* that scared the bejeezes out of the taxi drivers and put the airport into a serious delay. It only happens only every 7 years or so and it was my lucky year trying to take 2 weeks to go back and forth from Orlando Intl. to Newark Intl. I guess snow in Florida and the joy that it brings is sorta like hell freezing over


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## ZootownMedic (Sep 25, 2011)

Linuss said:


> Hell, Michigan freezes over every winter... not that big of a deal to people who've actually been there.



Yeah....Detroit is probably one of the closer places to Hell in the US


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## Shishkabob (Sep 25, 2011)

SmokeMedic said:


> Yeah....Detroit is probably one of the closer places to Hell in the US



I was actually speaking of the city called Hell, located in Michigan. ^_^


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## usafmedic45 (Sep 25, 2011)

SmokeMedic said:


> Yeah....Detroit is probably one of the closer places to Hell in the US



Actually I believe Ann Arbor and Lansing are both closer to Hell.


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## RocketMedic (Sep 25, 2011)

I dont see a hierarchy. We all have specialized fields, each important to our patients. Ranking people based on wallet cards only makes us all dumber.


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## ZootownMedic (Sep 25, 2011)

Linuss said:


> I was actually speaking of the city called Hell, located in Michigan. ^_^



It was just a joke. Detroit is having a really rough time on a lot of fronts though.......being a first responder there is like being in hell from what I've heard from several firefighters from there.


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