# What do you think is the most important thing EMS does?



## Veneficus (May 1, 2010)

Over a period of years, on several threads, I have detailed what EMS does.

Most recently I mentioned that the universal function of EMS is to act as a portal for people to enter into the healthcare system. Whether you are in Australia, Germany, the US, Russia, or any other nation that has EMS, a healthcare provider associated with such service shows up, performs various levels of assessment, and either treats the pt, dispositions the pt to another healthcare or social service, and/or can usually transport to such.

Now we all have different education levels, and our focus on transport, treatment, or disposition may be different, and the way our systems are set up all vary considerably. even in the same nation on occasion.

Now it is therefore logical to me, that the ability to determine what is the issue with our patients is perhaps the single most important thing EMS does.

Figure, if you never check to see if somebody is breathing, how would you know when to ventilate them? If you do not understand pathology (even at the most basic level) how do you know when to call for more advanced help, initiate and invasive procedure, or begin immedate transport?

So why is it, that on many occasions EMS professionals never perform a reasonable examination? I read it somewhere: visualize, auscultate, palpate, percuss, and so on depending upon the need.

In another thread I neglected to ask if the patient had a medication patch on. It seemed so obvious to me, that when you examined the chest, listened to the heart, checked for abnormalities, and even put on an EKG, that if you saw a bg sticky square thing, it would register as being significant. Just as it would be if you saw a leech or a tic attached. I was then told that I never stated I was lifting up the pts. shirt. Now I am not posting this to complain, but some will think so. I am posting this because I want to hear some opinions.

Why are providers not performing a complete exam and history? I'll be the first to admit, I don't completely disrobe every patient I see. But I do make sure to selectively lift, move, etc, every piece of clothing untill I am satisfied there is nothing to find. Sometimes I simply ask the patient to check for me or tell me. But an unconscious patient is going to get the full workup. Nothing will be left to chance. 

Whether it is a difficult airway prior to an RSI, or a refusal to transport decision, how could anything we do be more important than assessment?

Why do we spend so little time on it compared to other "skills?" Did simple memory aides like, DCAPBTLS, somehow excuse us from touching the patients? 

In the US, we spend hours and hours practicing intubation. Exam techniques are barely touched upon. Some will say that you can kill a person if you mess up an intubation, but I think you have a lot better chance to kill a person with a poor or incomplete assessment and more often. Just ask the folks down in DC.

So how do we go about refocusing on assessment? How do we make it as important as applying a spineboard or reading a heart monitor? For either without assessment is useless if not harmful.


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## MonkeySquasher (May 1, 2010)

You hit the nail on the head.

I caused an uproar at my volunteer company last month.  I asked a group of our Basics and a CC* what the biggest difference was between a Paramedic and a Basic.  All the Basics said "drugs!" or "tubes!" or "lines!", the CC said "education".  I told them, no, assessment skills.

((*For those who don't know - In NYS, we have a level called Critical Care, which is between Intermediate and Paramedic.  They have much of the same skill- and drug-sets as a Medic, but only do around 350 hours of class time and 200 hours of clinical time, as opposed to our almost 1300 combined hours.  We affectionately call them "shake-and-bake Medics".))

Let's face it, other than you CCT/ICU/Flight Paramedics, how often do we REALLY use all those fancy drugs in the field?  The core of any patient care is a proper thorough assessment.  And outside of certain level-restrictions (ECG/12Lead, etc), Basics can, and SHOULD, be taught proper assessment and A+P more than anything.  But I know this seems to be preaching to the choir on here.  

I think the problem rests at complacency.  People become complacent.  Basics use "Oh, I don't know what to do", or "Well I can't do anything anyway", or "I don't know what's wrong".  Medics tend to use the ol' "They're fine" or "I already know what this is" attitude sometimes.

Back to the above..  My volunteer company is a tad different.  Take today for example..  We get a call to the local university for a 19y/o female, abdominal pain.  We find her laying in fetal position on the bed.  I usually stand back and let the crew do their thing and make sure no one dies (there's a story behind that one...), so I'm just listening.  The crew (BLS) asked 3 questions...  "You're having abdominal pain?", "Did you throw up?", and "Is anything else wrong with you?"  From there it became "Okay, stand up and sit on the stretcher", and took her to the rig.  On the rig, they attach the monitor's SPO2 sensor for HR/pulse ox, and the NIBP for pressure (no manual done).  In the rig they asked History, Allergy, Meds, and if she was pregnant (not "is there a possibility").  All this as we transport.

On our end, it tends to come down more to inexperience than complacency, even though that's also rampant among ALS providers due to a hospital within our first due area.


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## MrBrown (May 1, 2010)

You raise a very good point, and again I think it comes down to the limited foci and education of EMS providers that has worked its way into the "acceptable" pile.

I think assessment is the most important thing you can do and that it is from assessment you form a good working impression of what is wrong with your patient, or what you think is wrong. 

The several cases which have come back to bite here have really focused around missed assessment findings or poor assessment e.g. the hypothermic PE, the large gentleman who had fallen several times (and did not usually fall), the hypoglycaemic patient who had a recent history of beeing poorly compliant and the young child who had early signs of meningitis what weren't picked up.

I think assessment is not focused on as well as it should be because its probably been thought up before and the majority of the time the answer I have heard is "it won't change anything" meaning it won't allow some alternate regimen of treatment.

Overly standardized and blanket protocols have really removed the need for a good, thorough assessment.  For example give salbutamol in shortness of breath, GTN to chest pain, somebody is hypotensive so give them some fluid.  It doesn't matter what is done in the field because the patient is only with the Ambo's for a half hour seems to be the mentality of some.

Our cardiac chest pain guideline is said to require "significant clinical judgement" in that it can be used on people we think are having a silent MI.  However, I doubt some of our providers and the 24 week part time Technician wonders especially would have the ability to make "significant" judgement.

Judgement of when and when not to apply a particular treatment is far more important than the actual treatment itself; e.g. adrenaline and frusemide; look at how many trucks are having frusemide pulled (heck I hear its possible to diagnose lower back pain as cardiogenic edema in Los Angeles) and there was that those Firemedics in MA who had IV adrenaline removed or heavily restricted because of inappropriate use coming from poor assessment.

So how do we fix it and focus on assessment? Well first of all we need to figure out what sort of assessment we need out there in the field, to give an example this is what is written about our "primary" and "secondary" survey:



> *Primary Survey*
> 
> • *Airway*: examine for and establish an adequate airway.
> Consider the possibility of cervical spine injury, but the airway takes priority.
> ...



Does this mean that I have dont this on every patient I've been to or will ever go to? No, the key point here is what is *clinically appropriate*.

Here is the 1998 EMT-Paramedic techniques of exam cirricula

Here is the 1998 EMT-Paramedic patient assessment cirricula

Now both those look fairly good documents that cover the bases but do you honestly think people really give a crap about it or that you can learn it in the majority of time that most programs have to teach? No.

Can you learn it in 12 weeks at Houston Fire school or six months at the local community college? Is a couple hundred hours of "internship" adequate time to apply it? Are students able to understand it adequately when they've never taken decent science classes? Do all the whackers and batman and ricky rescues want to learn about all that boring stuff? No, no, no and no.

So how do we fix this you ask? Now I know I am preaching to the converted but again its very simple; better education and less emphasis on "skills" and "load and go" and red lights and sirens.


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## firetender (May 1, 2010)

*...and now, some reality...*

If we're breaking things down to the bare essentials of what the most important thing we do, it boils down to this:

We are trained as professionals (a lot of us, anyhow!) to remove the injured, stricken, physiologically compromised, debilitated, discarded, bewildered, wounded, compromised, crippled, distraught, in short, those of the human race afflicted with any real or imagined, potentially disabling malady AWAY from the scene of their torment, but most importantly, AWAY from the view of able-bodied witnesses and into a system designed to intervene out of view of the public.

_*We are at the bottom of a trickle-down system that places us at the juncture between self-management and loss of control. Our job is to face the innumerable traumas, both big and small, of every day life (presumably on the medical end but we all know what a crock that is!) so that everybody else doesn't have to!*_

We are a reflection of a corporate-driven push to take the individual away from all of the "folk" resources that once formed the backbone of medical care and intervention so that they, whoever they are, can make some dough. This sort of self-protection is evident in the AMA and other professional organizations. *In fact, if we are to make our lives better, we're going to have to protect our interests as strongly as they do theirs!*

Essential to that end is *removal*, and that's our function.

Without pointing the finger (I said "pointing") too harshly, much of it revolves around we, as a people who are rapidly overpopulating the planet, becoming less connected with each others' real lives and more involved in the fantasy that we will live forever. Why? because most of us don't get to see a whole lot of otherwise, EMS takes care of that. It is the poor who watch each other die.

What's important is that MOST of the people out there continue to be productive citizens, and the rest, thanks to us, are taken into the back room where they can't be seen. If the people are really involved in the personal traumas of our community, there just won't be the time to be the vehicles of profit for the top of the food chain.

And on this site, we argue about who's cooler; Street Cleaner Level I, II or III.

Go figure.


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## Veneficus (May 1, 2010)

*Mr.Brown*

As i read through your post I notice a lot of words that seem to not be followed by many providers in the field setting:

"• Breathing: examine for and establish adequate breathing. Look at *and feel *chest movement."

"• Exposure, examination and environmental control: appropriately 
*expose and examine the patient.* Keep them warm"

Now this second statement can cause some confusion I'll admit. For example, what is "appropriately" referring to? Medically appropriate? Environmentally appropriate? How about Modesty?

the first two don't conccern me as much as the last. When most patients are seen by me or a doctor, they are more than ready to be disrobed, touched, questioned, and probed in every hole we can find. Occasionally making one or two new ones. This is all done so the proper dx and treatment, even those not relating to a chief complaint can be addressed. 

Now it can be argued that is in the hospital and not the field, but here is the rub... If the purpose of EMS is to properly care for or direct patients to the proper resource, how the hell can you do that if you don't look for things other than what is apparent when somebody is wearing layers of cloths and maybe even a blanket or two? 

How do you find that the difficulty breathing is because of the overly restrictive corset? 

Even in my school we are taught all those bells and whistles on all those machines are "adjuncts" to the exam. We are not at the star trek level where the little machine tells you everything. (actually the more I learn the less the machine tells me) 

You detailed "missed" exam findings. How is that in anyway suprising when people don't routinely perform a complete physical? If you don't retain your skill at intubation without regular performance, how could you possibly hope to retain something as encompassing as a physical exam?


Now we talk about education, and I respectfully disagree with MonkeySquasher, you cannot possibly hope to teach a basic a physical exam and history (assessment) that is adequete for anything more than airway breathing and circulation. Not because I don't value basics, but because the amount of knowledge required far in excedes determining whether or not something is "abnormal." The very nature of occult injuries or illness requires in order to determine if they exist, you must know what they are, where to look for them, and how. As an example, thyroid storm. It is not even mentioned in the basic text. It is a life threatening condition. Extra uterine pregnancy, not even mentioned in the paramedic text, a life threatening condition. 

Now neither of these are treatable in the field, but let's face it. Neither is an MI. If it was you could just render care and leave people where you found them. But without even the knowledge those conditions exist, you could easily write a patients complaint off as BS. On people who are not obese, you can press on the abdomen and feel a kidney stone in a ureter. 

Now in the time it takes to teach people all of the things they would need to know to do that, they would be called "doctor" at the end, so I am not suggesting we take it to that extreme, but I am suggesting we (more for the folks in the US, since they are far behind the world curve) need to step it up a bit in the education dept. But we here already know that.

But what I am really interested in during this thread is ideas for how we can get the current rank and file in the mode of performing better exams. an improper exam technique by a student is not nearly the issue it is of a current provider.


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## DrParasite (May 1, 2010)

MonkeySquasher said:


> You hit the nail on the head.
> 
> I caused an uproar at my volunteer company last month.  I asked a group of our Basics and a CC* what the biggest difference was between a Paramedic and a Basic.  All the Basics said "drugs!" or "tubes!" or "lines!", the CC said "education".  I told them, no, assessment skills.


Interesting.... According to a former medic student, the only difference between an ALS assessment and a BLS assessment was the use of a cardiac monitor.  

BTW, yesterday I asked my Ops Supervisor (paramedic for 12 years) if a bleeding shunt should be an ALS dispatch.  I said no, since you just control bleeding and rapid transport to the ER (which is exactly what the ER does).  She said yes, as a person can bleed out.  Also asked her about the toe pain call.  After getting the quizzical look, I explained that on here, toe pain is an ALS dispatch, because it might be referred pain from an MI.  She then told me if I ever called for an ALS unit for a patient with toe pain and no other symptoms she would fire me on the spot for being unable to differentiate between an ALS patient and a BLS patient.


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## CAOX3 (May 1, 2010)

Assessment!


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## mycrofft (May 1, 2010)

*Restraint.*

Not of the pt's but of ourselves.

First we should do no harm, and part of that is assessment and then appropriate, considered and technically adept measures...if any.


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## MrBrown (May 2, 2010)

DrParasite said:


> Interesting.... According to a former medic student, the only difference between an ALS assessment and a BLS assessment was the use of a cardiac monitor.



I must disagree.



DrParasite said:


> I
> BTW, yesterday I asked my Ops Supervisor (paramedic for 12 years) if a bleeding shunt should be an ALS dispatch.  I said no, since you just control bleeding and rapid transport to the ER (which is exactly what the ER does).  She said yes, as a person can bleed out.  Also asked her about the toe pain call.  After getting the quizzical look, I explained that on here, toe pain is an ALS dispatch, because it might be referred pain from an MI.  She then told me if I ever called for an ALS unit for a patient with toe pain and no other symptoms she would fire me on the spot for being unable to differentiate between an ALS patient and a BLS patient.



Severe bleeding should be an ALS job, control bleeding and start fluid therapy.  Why must we be so obsessed with "ALS" vs "BLS" patients.

As for the toe pain ... nah I'm leaving them at home!


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## Melclin (May 2, 2010)

Veneficus said:


> As an example, thyroid storm. It is not even mentioned in the basic text. It is a life threatening condition. Extra uterine pregnancy, not even mentioned in the paramedic text, a life threatening condition.
> 
> Now neither of these are treatable in the field, but let's face it. Neither is an MI. If it was you could just render care and leave people where you found them. But without even the knowledge those conditions exist, you could easily write a patients complaint off as BS. On people who are not obese, you can press on the abdomen and feel a kidney stone in a ureter.
> 
> ...



A very great deal of our bachelors degree revolves around conditions we cannot treat and often can't really diagnose in the field with any degree of certainty, and people often moan and whinge about why we have to learn about things like extra uterine pregnancy, the difference between between a non-ketotic coma and DKA, the differential for an acute abdomen etc. We drive to hospital. Sometimes I believe they may have a point. I certainly got a bit sick of studying various genetic diseases knowing that I'd never know enough to make decisions about transport - the parents/carers know far more than we will. 

I sit there and think, we should add this to the degree, we don't know enough about that...oh this too. Then I find I've put together a medical degree. It is difficult to know where the line is.* I believe that you need to know enough theory to meaningfully interpret the information you collect.* Other wise there's no point in collecting it. 

As a St John's first aid volly we learn, for example, a respiratory status assessment: Assess - Position, Appearance, Speech, Rate, Rhythm, Effort, Breath sounds, Skin, Pulse and Conscious state. Problem is though, they can't interpret any of the information usefully. Think about how much information you could be gathering about a persons health status in all that. You can then say that you add the education necessary to identify the conditions that you have protocols for. Hear a wheeze? Its asthma. Hear a crackle? Its APO. Unfortunately disease are quite unaccommodating and have the audacity to present differently from time to time. So you learn a bit more. Then you have complicating issues? Oh you've got cystic fibrosis? Hmm, wonder what that means for my PASSRESPS. So you add more educations. You end up with hours of lectures on conditions you don't directly treat in ambulance but that you need to understand in order to practice competently. Then it all makes sense again. That CF kid with unusual SOB? He went to direct to the Alfred CF unit because the paramedic used to be a CF nurse specialist and knew he was in trouble. If it was EMT treating him, he would have ended up in nearest public ED, 90 miles from anywhere and the EMT wondering what CF was.

The toe pain that Dr Parasite mentions is I assume a reference to an earlier debate we had on education where a toe pain patient turned out to be a silent MI and the crew saw it for what it was so she went direct to the cath lab, arresting twice along the way. All of a sudden that three hour lecture on diabetic neuropathy you hated in 3rd year seems a bit more relevant and you realise that being an ambo is a little more than recording the 3 word answers to SAMPLE on your PCR. She didn't initially get an ALS response, it was the basic crew that identified it. Sending MICA to every toe pain on the off chance it might be a silent MI is absurd, however, the difference here is our definitions of basic. We all have a giggle over here about the fact that you blokes seem to think that an EMT is an adequate basic response, and a paramedic with his tubes and a monitor and his, at most 2 years of education, actually qualifies as advanced care. No, toe pain doesn't require a top tier response, but it does require an adequate evaluation by someone who actually understands the information they collect. 

What about the "3:13am, Signal 2: Psych- non violent, non-suicidal"? You get there and a young girl is upset and complaining of shortness of breath. Is she having a panic attack? Or do the chemo therapy drugs she mentions and her mild fever make you think PE?

*Triage* (yeah I'm putting sub heading in my posts now..what of it?)
Most of all that education is all about triage. In an extended sense, (I realise its already been mentioned) that is at the heart of what we do. Firstly, of course there is your MCI triage. More commonly though, we decide which patients get flown to the Alfred trauma centre, which patients can go to Backwater creek urgent care clinic and which patients stay at home. These are difficult decisions to make, and you sure as hell can't do it with a advanced first aid certificate like the EMT. Then, the often unmentioned triage...triage nurses in the majority of cases barely touch the patient. And they triage based on what we tell them.EXAMPLE: Toe pain? Out in the waiting room with you. OR (?) Silent MI, and here's the ECG. Into resus you say? You've cleared a bed because I called it in 15 mins ago you say? 

Whats that Paramedic, that bloke from the nursing home might be septic? Mmmm good idea, I'd better light a fire under Dr. Bobs arse and get him to write out those blood culture orders.  

There are a million reasons why more education is better. Mostly though its about readjusting the odd standards you guys have in the states. There is this mindset like a bachelors degree is excessive education. Every other bloody HCP has one as an entry level requirement...get it together.


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## Aidey (May 2, 2010)

Veneficus said:


> So why is it, that on many occasions EMS professionals never perform a reasonable examination? I read it somewhere: visualize, auscultate, palpate, percuss, and so on depending upon the need.
> 
> .....
> 
> Why are providers not performing a complete exam and history? I'll be the first to admit, I don't completely disrobe every patient I see. But I do make sure to selectively lift, move, etc, every piece of clothing untill I am satisfied there is nothing to find. Sometimes I simply ask the patient to check for me or tell me. But an unconscious patient is going to get the full workup. Nothing will be left to chance.



None of these are meant to be excuses, but more explications as to why people find it easier to be lazy. 

I work for a private service. People complain. A lot. If the patient isn't serious we are viewed as a taxi service and people want to know why we are messing around and don't just bring them to the doctor. On serious patients people complain because we "waste time" instead of taking them straight to the hospital. Patients complain they were exposed. Patients complain we cut their clothes off.* Patients complain when we ask them not to wear coats, sweat shirts etc (even though we provide blankets). Patients with 4 layers on complain that they will catch pneumonia if they have to take anything off (not kidding). You get the idea. 

We do not carry any paper or cloth gowns, just as an FYI. 

Our company is insane about seat belts, we are required to use several. If we undress the patient before putting them on the gurney it is hard to keep their upper chest/shoulders covered. If we undress them in the ambulance (without cutting stuff off) we have to undo everything, undress them, and then re-do it all up. It adds time and I think for a lot of people it is easier just to transport than mess with it. 

It is especially a pain in the arse when you learn about a symptom 1/2 way through transport and want to do a 12 lead or re-check lung sounds and they are all trussed up like a turkey. 

The easy solution is "just undress and redress them in the house before you transport, duh". The problem there lies in the fact we are an (ALS) transport agency in an area with mostly ALS first response FDs. We've had fire medics and fire officers COMPLAIN to our company when crews spend "too much time" on scene after the fire medic tells us to transport. Basically, if the fire medic doesn't do it, and we do it upsets their delicate egos because they think we don't trust them or whatever. 

* True story, our company replaced the clothes of a patient who had his clothes cut off while unconscious because he raised such a stink about it. He was unconscious after consuming a large amount of alcohol and who knows what else.


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## SanDiegoEmt7 (May 2, 2010)

Melclin said:


> There are a million reasons why more education is better. Mostly though its about readjusting the odd standards you guys have in the states. There is this mindset like a bachelors degree is excessive education. Every other bloody HCP has one as an entry level requirement...get it together.



This post makes me want to move to Australia/New Zealand


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## Veneficus (May 2, 2010)

_"I certainly got a bit sick of studying various genetic diseases knowing that I'd never know enough to make decisions about transport - the parents/carers know far more than we will. "_

You and me both my friend. Untill they tell me how to treat germ cell mutations in every cell in the patien's body, it is the same supportive care you could get from a nurse or a paramedic.

Along the same lines though: Most of the time we spend in genetics, pathology, and biochemistry in medical school, is so we know these conditions when we see them. It is no recognizing that the marfan syndrome guy who "isn't feeling well" today with N/V is predisposed to heart failure, so we send him to cardiology instead of discharging him with some antiemitics and maybe some theraflu. 

You said it best, it is not about how you will treat, it is about understanding the findings you are looking at. (inspired,I am going to start using that.)


_* True story, our company replaced the clothes of a patient who had his clothes cut off while unconscious because he raised such a stink about it. He was unconscious after consuming a large amount of alcohol and who knows what else._

Private companies are weird like that, I had a patient who was in a pickup truck that was run over by every axel of a "cane train." How this guy survived with only the minor injuries he had defies belief, there wasn't a piece of his truck undamaged. After we dropped him off at the hospital, I get a call from the supervisor: "Did you see the patient's glasses?" I related I didn't see a piece of intact glass or metal on the whole scene while we (the FD and us) were cutting him out. Long story short, we paid for his glasses.

Having worked as a medic on an FD, I can tell you that while the title is the same, the job is different. It doesn't surprise me that there is tension between the FD an your service. It does help to communicate your responsibility to them though, because when they compare what they are doing to what you are, the assumption is because it is not the same, you are wrong. 

I realized this when I was working a 3rd service and a FD medic decided to ride with me because "the kid could crash." While my partner was in the squad bagging the kid in respiratory arrest (he was vent dependant for years and mom called 911 because despite being a very proficent care giver she couldn't make the machine stop beping) So I told my partner we would leave after I got the vent settings. The FD medic was stunned, how could I not rush off like a bat out of hell with a not breathing kid, "a real emergency". (who hadn't been breathing in years, which is why he was on a vent) I think he came to see what other substandard care I was providing. When we got to the hospital, the only question the doc asked at the door was "do you have the vent settings?" When I replied I did, he said "take him right up to ICU, they are expecting you." Said firemedic then humbly related he had no idea what being a paramedic was. His job was to show up and do skills until we did. Relations with the FD after that were much improved.


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## Aidey (May 2, 2010)

Veneficus said:


> Having worked as a medic on an FD, I can tell you that while the title is the same, the job is different. It doesn't surprise me that there is tension between the FD an your service. It does help to communicate your responsibility to them though, because when they compare what they are doing to what you are, the assumption is because it is not the same, you are wrong.
> 
> I realized this when I was working a 3rd service and a FD medic decided to ride with me because "the kid could crash." While my partner was in the squad bagging the kid in respiratory arrest (he was vent dependant for years and mom called 911 because despite being a very proficent care giver she couldn't make the machine stop beping) So I told my partner we would leave after I got the vent settings. The FD medic was stunned, how could I not rush off like a bat out of hell with a not breathing kid, "a real emergency". (who hadn't been breathing in years, which is why he was on a vent) I think he came to see what other substandard care I was providing. When we got to the hospital, the only question the doc asked at the door was "do you have the vent settings?" When I replied I did, he said "take him right up to ICU, they are expecting you." Said firemedic then humbly related he had no idea what being a paramedic was. His job was to show up and do skills until we did. Relations with the FD after that were much improved.



Unfortunately one of the provisions of our contract is that we (the company) can be fined if a fire medic or any fire fighter feels we have been disrespectful/argumentative etc. It is a very slow process to try and politely educate medics who have kids my age (plus I'm female which doesn't help). We're still working on not transporting pts in asystole.... (If the medics disagree, the one saying transport wins...guess which medic that usually is...)

*facepalm* acute vs chronic.....lol

My favorite "WTF are you doing" moment was when I had a PD dialysis pt who had a sudden onset of severe abdominal pain. She had drained her PD fluid before we got there to see if that would help (it didn't). I wouldn't transport until we got the bag loose from the set up and took it with us. The fire fighters were grumbly and all like "dude, your partner is freaking nuts" to my EMT, who was even like "WTF are you wasting time with that for?". We get to the hospital and I leave it with the RN. Several minutes later while waiting for the paperwork I hear the RN and doc talking. Doc said something like "We need x, y, z, a, b, c tests. Of course we don't have the fluid to do a culture on" and the RN replied "Well, actually the paramedic grabbed it, it's in the room". The doc said "Seriously? Best news I've had all day". 


I wonder if the disconnect with stuff like that is because the FMs don't transport nearly as much, so they don't think about what the hospital will need. They think 'I can't use it, so I don't need it". Sure we can't do much with vent settings or dialysate in the field but the hospital can.


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## Veneficus (May 2, 2010)

Aidey said:


> Unfortunately one of the provisions of our contract is that we (the company) can be fined if a fire medic or any fire fighter feels we have been disrespectful/argumentative etc. It is a very slow process to try and politely educate medics who have kids my age (plus I'm female which doesn't help). We're still working on not transporting pts in asystole.... (If the medics disagree, the one saying transport wins...guess which medic that usually is...)



I can't imagine how desperate for a contract your company must be, or who in their right mind would sign something that could so arbitrarily cost the company money.

I would say the solution to your concerns is to raise them with the medical director, who will probably raise them with the FD medical director, who informs the chief, and a top down approach is implemented, rather than a rank and file upwards. Clearly the field firemen are not capable of performing patient care.

I would probably be fired from or quit your agency in such circumstances, but not before I launched a state EMS investigation, a medicare one if they bill for it, and a public media drive and alert the local tea party (the enemy of my enemy is my friend) about how these guys do nothing and get a government cheque. You have much more patients for BS than I do. 

(here about this time some cretin will post how good their FD is and how this type of behavior is not the norm in their little area, I hope I am spared from reading it)

But like I said, I know where they are coming from, in their little minds they believe it is acutely life or death or they shouldn't be involved.

A PD case is interesting though, don't often see much of that in the states, especially now with home hemodialysis. 

But it all comes down to a good assessment. Knowing what and how to look for. Strangely enough, most emergencies are actually the end stage of chronic disease states. Trauma especially severe trauma has nationally been declining for decades.


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## MonkeySquasher (May 2, 2010)

Er...  Just to point something out, I'm confused now.





MonkeySquasher said:


> The core of any patient care is a proper thorough assessment.  And outside of certain level-restrictions (ECG/12Lead, etc), Basics can, and SHOULD, be taught proper assessment and A+P more than anything.






Veneficus said:


> Now we talk about education, and I respectfully disagree with MonkeySquasher, you cannot possibly hope to teach a basic a physical exam and history (assessment) that is adequete for anything more than airway breathing and circulation.



But then you said...




Veneficus said:


> But it all comes down to a good assessment. Knowing what and how to look for.




I'm just curious on where we were disagreeing.  haha

Was it that we can't teach a Basic those exam skills?  Because I believe we can, and we should.  It behooves us to.  To the best of my knowledge, Canada does it...  (This is a good time for that poster from Ontario to show up).   I can't speak with certainty, but I've understood that even Canada's most basic pre-hospital EMS level involves college-level A+P and assessment techniques.  They're trained to the knowledge level of a Paramedic, without being allowed to perform the skills.  And that's how EMS -SHOULD- be, in my opinion.


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## Veneficus (May 2, 2010)

MonkeySquasher said:


> Was it that we can't teach a Basic those exam skills?



I was pointing out that college A&P is not enough, you would also have to add some other clinical sciences, and when you do that you could easily make the course longer than the paramedic course. (which while it would be ideal, it is just not realistic to think that is possible in today's political climate in EMS.




MonkeySquasher said:


> Because I believe we can, and we should.  It behooves us to.



There are lots of things like this. Not just limited to EMS.



MonkeySquasher said:


> To the best of my knowledge, Canada does it...  (This is a good time for that poster from Ontario to show up).   I can't speak with certainty, but I've understood that even Canada's most basic pre-hospital EMS level involves college-level A+P and assessment techniques.  They're trained to the knowledge level of a Paramedic, without being allowed to perform the skills.  And that's how EMS -SHOULD- be, in my opinion.




It is like this in many countries, and it should be. In one country i visited, both the paramedics and nurses sat in class together for basic science. After the first 2 years, nurses went to classes specific for nursing and medics went to classes specific for the field. I think that is absolutely ideal. In 21 years now of watching this argument, the US has actually gone backwards. 

2 years ago I heard one paramedic instructor tell a class that all that stuff about cell biology in the front of the book was totally useless. I have seen dozens of intructors tell students there is too much information in the single volume text than is needed to be a medic. These instructors are still spouting that crap today, and I am willing to bet my experience is just the tip of the iceberg.

Back on point, what can we realistically do today to help providers embrace a proper assessment for all patients?


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## Akulahawk (May 2, 2010)

Veneficus said:


> [BIG snip]
> 2 years ago I heard one paramedic instructor tell a class that all that stuff about cell biology in the front of the book was totally useless. That instructor was right. It is. There needs to be MUCH more. I have seen dozens of intructors tell students there is too much information in the single volume text than is needed to be a medic. And I would be one to disagree. These instructors are still spouting that crap today, and I am willing to bet my experience is just the tip of the iceberg.
> 
> Back on point, what can we realistically do today to help providers embrace a proper assessment for all patients? First, define what would be considered a "proper assessment."  Nurses, Physical Therapists, Occupational Therapists, Respiratory Therapists, Physicians, and Super Heroes all do their assessments differently, for different purposes, and those assessments are proper for that level of practitioner of patient care.


My comments above... in red. Once a "proper assessment" is defined, then figuring out the rest (what to teach) becomes much easier. Then show that with the increased education comes increased professional recognition, and scope of practice (because you KNOW what to do with what you've found) and greater command of salary. The other difficult thing to do is get EMS types to agree that's the way to go. That can be much like attempting to herd cats... all by yourself.


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## mycrofft (May 2, 2010)

*Asking the Lawyer's Question: "Isn't it possible?"*

Anything which is not absolutely under any conceivable and some unconceivable sets of circumstances impossible is possible. Therefore, since something is going to be missed kon every exam, and it might be important, unlimited micro-management of history and exam is not only inevitable, but a darn good idea, no?<_<

Ask our program director. I was faulted when asking a pt about a  simple headache for not getting a family history going back to grandparents. It was pointed out that knowledge of family hx of strokes or migraines could be useful. The guy had no accessory complaints, he just wanted a couple Advils since he did not have access to them (hello, locked facility).

The dynamic balance between directed and global exam has to be decided rationally.


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## Melclin (May 2, 2010)

Veneficus said:


> I was pointing out that college A&P is not enough, you would also have to add some other clinical sciences, and when you do that you could easily make the course longer than the paramedic course. (which while it would be ideal, it is just not realistic to think that is possible in today's political climate in EMS.
> 
> 
> It is like this in many countries, and it should be. In one country i visited, both the paramedics and nurses sat in class together for basic science. After the first 2 years, nurses went to classes specific for nursing and medics went to classes specific for the field. I think that is absolutely ideal. In 21 years now of watching this argument, the US has actually gone backwards.



We have a similar arrangement at our university. We did A&P, legal, health sociology and communications subjects with the nurses, OTs, midwives, physios etc. Then we trot off to the paramedics building for field specific stuff in 2 and 3rd year. I understand they now have an inter-professional education subject in first year as well which sounds like a good idea. I would like to have done more with the nurses 

The more we understand about other fields, the better we can work together, especially when it comes to things like falls referral. 



mycrofft said:


> Ask our program director. I was faulted when asking a pt about a  simple headache for not getting a family history going back to grandparents. It was pointed out that knowledge of family hx of strokes or migraines could be useful. The guy had no accessory complaints, he just wanted a couple Advils since he did not have access to them (hello, locked facility).
> 
> The dynamic balance between directed and global exam has to be decided rationally.



True. We don't really have a culture here of doing absolutely every assessment we have on every patient. But then it could be argued that we have enough education to start choosing tests depending on whats going on. I laugh hard when someone comes into the St John's first aid tent at an event for a bandaid for a blistered heel and we have to take medical histories and repeat vitals.


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## Akulahawk (May 2, 2010)

Melclin said:


> We have a similar arrangement at our university. We did A&P, legal, health sociology and communications subjects with the nurses, OTs, midwives, physios etc. Then we trot off to the paramedics building for field specific stuff in 2 and 3rd year. I understand they now have an inter-professional education subject in first year as well which sounds like a good idea. I would like to have done more with the nurses
> 
> The more we understand about other fields, the better we can work together, especially when it comes to things like falls referral.
> 
> ...


A _band-aid_ for a blistered heel? Just put some Skin Lube on a gauze pad and tape in place... If that doesn't work, 2nd Skin under some Moleskin or flexible adhesive tape works wonders. If only more runners knew that... 

It only takes a 4 year education to figure out that I don't need to do a full work-up on someone who presents with a blistered heel from running. Though I might want to see their shoes...


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## DrParasite (May 2, 2010)

Veneficus said:


> It is like this in many countries, and it should be. In one country i visited, both the paramedics and nurses sat in class together for basic science. After the first 2 years, nurses went to classes specific for nursing and medics went to classes specific for the field. I think that is absolutely ideal. In 21 years now of watching this argument, the US has actually gone backwards.
> 
> 2 years ago I heard one paramedic instructor tell a class that all that stuff about cell biology in the front of the book was totally useless. I have seen dozens of intructors tell students there is too much information in the single volume text than is needed to be a medic. These instructors are still spouting that crap today, and I am willing to bet my experience is just the tip of the iceberg.


question from a non-paramedic: is all that stuff really needed?  I was under the impression that a paramedic program was completely and totally focused on paramedicine.  ever lecture was directly related to paramedicine.  no well rounded person, no maybe helpful in the future, everything was all about prehospital EMS.  Take Cell biology.  is knowing about mitochondrial DNA, or what a vacuole is used for really all that helpful in the street?  Does it benefit the patient?  Yes, a smarter medic is a better medic, education is good, no arguments, but have studies been done to show that a well educated medic like in Australia or New Zealand have better patient out comes than us dumb USA EMS personnel?  remember, evidence based medicine is the key, not what individual feelings are.  show me that London EMS has a 4 years EMT program, and that patient outcomes increased 60% over when they had a 2 years program.  Explain to us dumb BLS providers how a 2 years EMT program will help the patients better than a 120 hour course.  Not just "well a smarter EMT is better" show actual facts to support your claim

oh and for our brothers from down under who can't seem to grasp ALS vs BLS: if you have a stomach ache, do you go to a cardiothoracic surgeon? If you break your arm, do you go to a GI specialist?  of course, not, you go to a general MD, who fixes you up, and refers you to a specialist when can't manage you properly.  A specialist only sees sick people or people who have issues with their specialty, so they are experts in that area.  For the majority of people in the US, their emergencies can be handled by a BLS provider.  Not that a medic couldn't treat them, but rather a medic wouldn't do anything different than a BLS provider would.  This means the medic only treats sick people, and BLS treats non-life threatening people, and when they need help, they call for help.  

I know it's hard to understand, but just like Koalas, dingos, and fosters beer, sometimes you need to try something new to understand how it works.


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## Veneficus (May 2, 2010)

I think it is a question of not knowing what you don't know. As was stated several times in this thread, you cannot know whether you even need an ED, BLS, etc. So I'll say it again, if you never heard of thyroid storm, you don't know the patient is really sick. Which a paramedic can help with since cardiac arrythmia is a symptom.

Talking about a stomach ache is not an emergency is just ignorant. Can you determine a surgical abdomen from say, crohn's? Not much to do about a surgical abd, other than recognize it. But crohns causes malabsorbtion and therefore dehydration which can be helped with paramedics. 

But deny if you must, economically the US system is failing and cannot continue. So if you are not educating and planning for the future, you might be at unemployment.

Cell biology. How is knowing about mitochondria going to make a difference prehospital? How about a patient that has MELAS, when they go into crisis what is ALS going to do for that? Bicarb is the treatment of choice for an acute attack. These patients are children. "this kid suffers and dies because I didn't feel the need to learn about the cell." outstanding.


It also important to remember that there is more to healthcare than the outcome of a hospitalization. There is the prevention of hospitalization and disposition to a more appropriate facility which can better care for a patient or provide the same care for less money. The measurement of that isn't outcome, it is in dollars.

When you break your arm you are going to an orthopedic surgeon, because a PCP doesn't have what they need to help that and nobody will possibly accept the liability of it. So when you do have a stomach ache depending on your age and the type of ache, you are better served by a GI doc. Peptic ulcer disease can be a precusor to a cancer. A PCP is certainly not going to scope anyone. Finding it early saves both lives and money. No ED, no ICU.

Not trying to be offensive, but if this is the way BLS providers think, perhaps it is time to stop reimbursing them, they clearly provide no more benefit than  taxi.

If you have a specific condition, why would  go to an ED doc? They can't help. But ambulances keep driving them there. Can't help a cardiac arrest patient most of the time either. The hospital also doesn't forgo the bill for the lab tests that come back 30 minutes after the patient is in the morgue, nor the emergent fee which is often $1000+ above the normal fee. Nor anyother diagnostic that makes absolutely no difference in the outcome.

I also think you don't understan the "handling" of emergencies. Showing up and giving somebody a ride doesn't handle very much. If it did, a lot of the frequent flyers would stop calling because thier emergency would have been handled the first time.

Do you really believe the stuff you posted here?


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## Akulahawk (May 2, 2010)

So... If I encounter a patient that's dehydrated, I'm going to attempt to rehydrate via oral intake method, a method which has an absorption rate of about 800 ml/hr when all is going good, when I can, if necessary, deliver that amount in about 15 min via IV? Umm. Yeah.

Yes, I've heard about Crohn's...

I've also heard about Thyroid Storm...

MELAS? Just looked that one up. Acute attack... of lactic acidosis. Bicarb, well, yeah. I can see how that would attempt to lower the pH. Unfortunately, I have yet to see a prehospital protocol that would allow me to treat for acidosis, let alone without having access to a lab that can give me blood pH.

If I had the ability to refer someone to the appropriate resource rather than send them to the ED, I most certainly would. Then again, I'm not the ordinary medic... I've probably had more education (and I'm not a nurse) than most medics have.


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## mycrofft (May 2, 2010)

*I'm outta this one.*

......................


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## Akulahawk (May 3, 2010)

*With mycrofft.....*



mycrofft said:


> ......................


Me too. This thread threatens to degenerate. Hope it doesn't, but comparing Med Student knowledge base to Paramedic (or anyone else) knowledge base is apples/oranges because of the different purposes of each.


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## 46Young (May 3, 2010)

DrParasite said:


> question from a non-paramedic: is all that stuff really needed?  I was under the impression that a paramedic program was completely and totally focused on paramedicine.  ever lecture was directly related to paramedicine.  no well rounded person, no maybe helpful in the future, everything was all about prehospital EMS.  Take Cell biology.  is knowing about mitochondrial DNA, or what a vacuole is used for really all that helpful in the street?  Does it benefit the patient?  Yes, a smarter medic is a better medic, education is good, no arguments, but have studies been done to show that a well educated medic like in Australia or New Zealand have better patient out comes than us dumb USA EMS personnel?  remember, evidence based medicine is the key, not what individual feelings are.  show me that London EMS has a 4 years EMT program, and that patient outcomes increased 60% over when they had a 2 years program.  Explain to us dumb BLS providers how a 2 years EMT program will help the patients better than a 120 hour course.  Not just "well a smarter EMT is better" show actual facts to support your claim
> 
> oh and for our brothers from down under who can't seem to grasp ALS vs BLS: if you have a stomach ache, do you go to a cardiothoracic surgeon? If you break your arm, do you go to a GI specialist?  of course, not, you go to a general MD, who fixes you up, and refers you to a specialist when can't manage you properly.  A specialist only sees sick people or people who have issues with their specialty, so they are experts in that area.  For the majority of people in the US, their emergencies can be handled by a BLS provider.  Not that a medic couldn't treat them, but rather a medic wouldn't do anything different than a BLS provider would.  This means the medic only treats sick people, and BLS treats non-life threatening people, and when they need help, they call for help.
> 
> I know it's hard to understand, but just like Koalas, dingos, and fosters beer, sometimes you need to try something new to understand how it works.



Early on I understood my limitations with just a BLS cert. I didn't realize how much so until I went to medic school. Anyone could get a phlebotomy cert, intubation cert, read Dubin's Rapid Interpretation of EKG's, and be okay with maybe 90% of their pts. Really, anyone could put every medical pt (and stable traumas as well) on an ECG/12 lead, SpO2, ETCO2 (nasal), do a temp and a BGL, and give O2, memorize the regional protocols, and appear confident and thorough to the ignorant. You could fake a whole career like that in some places. But what about the other 10%? Watching what the medics do with certain pts, and asking them why afterward doesn't make you as knowledgeable as a medic. Just knowing that a Cx pain that's not hypotensive should generally get MONA without the knowledge base isn't the same. Asthmas can get albuterol, mag, solu-medrol, atrovent, maybe CPAP and epi. But do you really know what these meds can do? What's the science behind giving five cycles of CPR before attempting a defib with a VF/PVT? And why do we do another five cycles afterward? 

Like Veneficus said, it's a question of not knowing what you don't know. Without an ALS assessment, you're going to miss some important stuff. Sure, statistically speaking, the medic won't need to do any "ALS interventions" for the majority of pts, but that level of education is vital to make that determination. That's key. Also, formal A&P is important, for the reasons Veneficus already covered. Also, as medicine advances, we'll need that base in order to absorb and implement future advances in prehospital medicine. The program that focuses solely on paramedic content may have been adequate in 1980, but medicine will continue to evolve. A simple inservice on a new procedure is inadequate without the knowledge to actually understand what the procedure is.


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## 46Young (May 3, 2010)

Akulahawk said:


> Me too. This thread threatens to degenerate. Hope it doesn't, but comparing Med Student knowledge base to Paramedic (or anyone else) knowledge base is apples/oranges because of the different purposes of each.



Good point. I've said before that I don't see the need for much if anything past the EMS AAS level of education for prehospital 911 EMS. I don't see how a 4-6 year degree is going to significantly change my assessment and tx. As medicine advances throughout the years this may change, but I don't see the need for additional education at the moment. 4+ years of education for 911 EMS is overkill IMO. 

As far as IFT, the "real" IFT is done through teams or RN's with specialties, such as the NICU nurse, PICU nurse, or from whatever floor the pt is going to. Pts going to various ICU's and such need a specialized crew for their condition and age. It would be impossible for the paramedic to gain proficiency in all those specialties like each txp nurse has in their area.

For this reason, I don't see the paramedic having the availability of any formal EMS clinical training past the two year degree. If one wants to do real IFT, they'll just become a nurse. Why do 4-6 years of school on an EMS track for an uncertain future regarding pay, benefits, scope, etc. that ought to accompany such education? It's a longshot at best to hope for that.


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## Melclin (May 3, 2010)

DrParasite said:


> Explain to us dumb BLS providers how a 2 years EMT program will help the patients better than a 120 hour course.  Not just "well a smarter EMT is better" show actual facts to support your claim



Your desire for evidence is not unreasonable, however, these things can be quite hard to quantify. Also, there is not way to actually _prove _that better education leads to better outcomes, there are just too many confounding variables to do a study like that. However, it is possible to make educated guesses about the affect of education. I've been interested in looking into the literature to find some evidence for better outcomes etc, a rationale for education. If I do that any time soon, I'll post it here. However some things do come to mind now.

RSI - of the ground based RSI trials done, I understand that the success of the trial has often been commensurate with the level of education of the providers. I believe our MICA paramedics out did any other service in terms of outcomes and ability. So much so that half way through the trial RSI was expanded from neuro injury only to a wide range of indications because it was clear that MICA were more than capable of handling it.

Soon we will be starting a therapeutic hypothermia trial in ICUs and the docs involved have enough confidence in paramedic abilities to extend it into the prehospital arena. Why? MICA know their s**t. 

In 1999 the Victorian government released a report on trauma outcomes which was in part responsible for the statewide increase in scope and education requirements for our basics, and it identified areas where people really were dying because paramedics could not perform certain procedures without more education. Our extra education allows for all providers to perform chest decompression - certainly life saving. It allows for cannulation and fluid resuscitation at the basic level. 

It also allows for 3 kinds of pain relief at the basic level. We know that pain has nasty physiological affects, but more than that, its humane. You can't put a number on that but it matters. 

Trauma bypass is a proven life saver. How could that be possible without well educated paramedics? You can't necessarily sit around and wait for ALS back up with a major trauma pt. But you also don't want to take them to East Arse nowhere ED. 





DrParasite said:


> oh and for our brothers from down under who can't seem to grasp ALS vs BLS: if you have a stomach ache, do you go to a cardiothoracic surgeon? If you break your arm, do you go to a GI specialist?  of course, not, you go to a general MD, who fixes you up, and refers you to a specialist when can't manage you properly.  A specialist only sees sick people or people who have issues with their specialty, so they are experts in that area.  For the majority of people in the US, their emergencies can be handled by a BLS provider.  Not that a medic couldn't treat them, but rather a medic wouldn't do anything different than a BLS provider would.  This means the medic only treats sick people, and BLS treats non-life threatening people, and when they need help, they call for help.



You don't seem to understand the concept of assessment. How do you know if the person is sick enough for a medic if you have no idea whats wrong with the patient or you don't understand the disease pathology, the medications etc. An EMT is a taxi driver with a CPR card. I would argue that spending money on them is less useful than spending a little extra on a service that is actually worthwhile. 

EDIT: LOL, I see Vene also appreciates the future of American EMS: the replacement of EMTs with the much cheaper and equally as useful CPR crosstrained taxi driver with cab companies contracted for EMS.


Veneficus said:


> I think it is a question of not knowing what you don't know.



Exactly. 

He who knows most, knows how little he really knows - Socrates (from my extensive classical education...certainly not from Brown's sig  )



Veneficus said:


> Cell biology. How is knowing about mitochondria going to make a difference prehospital? How about a patient that has MELAS, when they go into crisis what is ALS going to do for that? Bicarb is the treatment of choice for an acute attack. These patients are children. "this kid suffers and dies because I didn't feel the need to learn about the cell." outstanding.



While this is true, I think the cell bio stuff is more about the necessary underlying understanding. A long chain of knowledge that leads to being a better provider. Where is my understanding of shakespear directly relevant to paramedic practice? Its not, but learning those things in high school makes me better equipped to analyse the world and communicate with people and that is relevant. 

*Cell biology*? When you start learning about nerve conduction, how would you understand any of the terminology/anatomy? When you learn about APO, how are you supposed to understand the upset balance between hydrostatic and oncotic pressure without cell biology? Why does it matter? Because if you don't know the difference then you need to have protocols that say, if crackles give GTN, and you end up with post near drowning patients getting GTN from idiots who didn't think it was necessary to learn about the disease process they are actually treating. 



Veneficus said:


> It also important to remember that there is more to healthcare than the outcome of a hospitalization. There is the prevention of hospitalization and disposition to a more appropriate facility which can better care for a patient or provide the same care for less money. The measurement of that isn't outcome, it is in dollars.



These can be difficult to measure. Not because they can't be measured but because it is very difficult to attribute causality. Also, Dr Parasite, one of the reasons why little evidence exists is because paramedics and basics are not educated enough to do the research, and nobody else is interested enough to do it. That is quickly changing here. We built our own evidence base for IN fentanyl for example. Couldn't have done that without being educated, and now thousands of people all over the state have better, quicker pain relief and paramedics have more options.


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## Melclin (May 3, 2010)

46Young said:


> Without an ALS assessment, you're going to miss some important stuff. Sure, statistically speaking, the medic won't need to do any "ALS interventions" for the majority of pts, but that level of education is vital to make that determination.



Well said.



46Young said:


> Also, formal A&P is important, for the reasons Veneficus already covered. Also, as medicine advances, we'll need that base in order to absorb and implement future advances in prehospital medicine.



Another very good point. Its so much easier to introduce, say a new drug or a slight change in procedure when everyone already understand it, because 1, they are familiar with some of the literature and probably saw the change coming, and 2, they had a broad educational base in pharmacology. 

EG: We are encouraged to learn basic blood test rages at the basic level because its handy for IFT but also because in 20 years maybe we'll be using a range of different blood chemistry monitors in the PH environment. Won't it be so much easier to introduce lactate monitors for trauma and sepsis here where everyone at the basic level already understands the concept of anerobic metabolism, and related concepts such as the oxyhaemoglobin disassociation curve.



46Young said:


> Good point. I've said before that I don't see the need for much if anything past the EMS AAS level of education for prehospital 911 EMS. I don't see how a 4-6 year degree is going to significantly change my assessment and tx. As medicine advances throughout the years this may change, but I don't see the need for additional education at the moment. 4+ years of education for 911 EMS is overkill IMO.
> 
> As far as IFT, the "real" IFT is done through teams or RN's with specialties, such as the NICU nurse, PICU nurse, or from whatever floor the pt is going to. Pts going to various ICU's and such need a specialized crew for their condition and age. It would be impossible for the paramedic to gain proficiency in all those specialties like each txp nurse has in their area.
> 
> For this reason, I don't see the paramedic having the availability of any formal EMS clinical training past the two year degree. If one wants to do real IFT, they'll just become a nurse. Why do 4-6 years of school on an EMS track for an uncertain future regarding pay, benefits, scope, etc. that ought to accompany such education? It's a longshot at best to hope for that.



Very valid argument. Also it does depend on how you use those years. Our degree is three years, but you could cover the material in two. We also have a lot of primary care type education that will contribute to our ability to institute a great deal of alternative referral pathways in the future. It's not all tubes and cannulas. 

One thing I will say though is that having an extra bit of education can be beneficial for the person in many other ways. For example my bachelors degree means I can go on to do post graduate work in many other fields. 

If I wanna do a grad dip in health admin and move to managing hospitals, I can. 

If I wanna do medicine, well then I already have a pre-med bachelors degree, although I'd prefer to take a chem unit or two before then :blush:

If I want to change fields entirely and say, teach highschool, I need only do a grad dip in education (a bachelors degree in any field is required for teaching + a dip ed if the degree is not teaching related). Or maybe I've had enough and want to float myself on the job market..I'll get much better jobs because I have a bachelors degree. If I had an advanced diploma (our old qualification) it would be of almost zero use in any other field but paramedicine, despite the fact that there was relatively little difference in content. 

Making it a bachelors degree also attracts different people. I'm an academic kinda bloke and I never saw myself doing anything but going to a good university. I would have never even considered being a paramedic if it were a lower qualification because I simply would never have looked at literature from those kinds of institutions (to my detriment). Entry to the degree course is quite competitive and a little less than half of us already have degrees. The cut of lower ENTER score (like SATs I spose) was in the 83rd percentile I this year I think. This is for basics. How many EMT programs can say that? Not to say that anyone who doesn't have a degree is an idiot or anything like that, but you know what I mean.

*Vene*, to return to the actual question you pose, I think that a good way of getting better education requirements is to recruit public opinion. Government here have often made election promises about improving education levels for paramedics. In '99 (or 2000, I forget), the government ran on the notion of statewide ALS. The education of paramedics has always been a selling point for our service, and I would have thought that in America where services are actually selling them selves, education would be a selling point. There are always articles in the paper here about how little jimmy died because paramedics response times were too slow, or ALS couldn't get there in time. Why not encourage media like that regarding poor education?


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## Aidey (May 3, 2010)

Melclin said:


> The education of paramedics has always been a selling point for our service, and I would have thought that in America where services are actually selling them selves, education would be a selling point. There are always articles in the paper here about how little jimmy died because paramedics response times were too slow, or ALS couldn't get there in time. Why not encourage media like that regarding poor education?



There is a huge road block to this, and it is the fire unions. Seriously. Fire departments have regulated themselves out of a job. They have had to branch out their services in order to continue to justify their budgets. 

If the education requirements are increased it means more costs to send people to school, more time lost while they are in school, and it makes it harder for them to convince guys to go to paramedic school. In places were costs are already out of control it just isn't worth it to them. 

With reimbursement rates from medicare/medicaid/private insurance so low private companies don't want to have to pay higher wages either. With those two groups opposing more education there aren't any large groups left to counter them.

Even if the private companies wanted to lobby for more education they are fighting a major uphill battle. The FFs are America's Heroes while private companies are money-grubbing corrupt scum who only want more money. It would take a lot of money and effort to have any sort of successful campaign against the fire departments. Since many private companies are contracted to fire departments by campaigning against them they risk loosing their contracts (I know we would). It's a messy situation all the way around.


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## Melclin (May 3, 2010)

That is a pickle of a cowinkydink. :wacko:


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## Veneficus (May 3, 2010)

Akulahawk said:


> So... If I encounter a patient that's dehydrated, I'm going to attempt to rehydrate via oral intake method, a method which has an absorption rate of about 800 ml/hr when all is going good, when I can, if necessary, deliver that amount in about 15 min via IV? Umm. Yeah.



Having an IV was my point.





Akulahawk said:


> MELAS? Just looked that one up. Acute attack... of lactic acidosis. Bicarb, well, yeah. I can see how that would attempt to lower the pH. Unfortunately, I have yet to see a prehospital protocol that would allow me to treat for acidosis, let alone without having access to a lab that can give me blood pH.



These people may not live to get blood PH in the hospital. In 2 of the of three cases I saw, physician on scene (at his office) as well as at a home (call to online medical direction) Bicarb was adminitered without any lab work. It can be that profound.

My point is that you know about acidosis, and have the potential ability to treat it, because you do understand something about physiology above a basic level.




Akulahawk said:


> If I had the ability to refer someone to the appropriate resource rather than send them to the ED, I most certainly would. Then again, I'm not the ordinary medic... I've probably had more education (and I'm not a nurse) than most medics have.




I am not sure what you are arguing about? You seem to just be echoing my point.


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## DrParasite (May 3, 2010)

Veneficus said:


> If you have a specific condition, why would  go to an ED doc? They can't help. But ambulances keep driving them there. Can't help a cardiac arrest patient most of the time either. The hospital also doesn't forgo the bill for the lab tests that come back 30 minutes after the patient is in the morgue, nor the emergent fee which is often $1000+ above the normal fee. Nor anyother diagnostic that makes absolutely no difference in the outcome.


I have been wondering that every time people call for a chronic complaints.  but it's not like we can refuse to transport people


Veneficus said:


> I also think you don't understan the "handling" of emergencies. Showing up and giving somebody a ride doesn't handle very much. If it did, a lot of the frequent flyers would stop calling because thier emergency would have been handled the first time.


haha, are you serious?  do you actually work in EMS?  how about in a impoverished urban environment?  If you did, you would know the answers to these questions.


Veneficus said:


> Do you really believe the stuff you posted here?


the real question is, do you understand there is a difference between a paramedic and a doctor?

I am glad I am not the only one who had to look up what MELAS was.  I can admit it, I had no idea what it was.  And after Akulahawk said what it was, I can say that I am not aware of any prehospital protocols that allow for it, esp without any lab work to confirm your diagnosis.  Not saying that they don't exist, only that I am not aware of any.

But Vene, you have convinced me of one thing.  Every paramedic should have to go through medical school before they step of the ambulance.  That means a bachelors degree and 3 years of medical school, so they know of every disease, illness, and potential injury that may occur, and they can both diagnose said illness and injury without the luxury of all those fancy tests that doctors have available to them in the hospitals.  That is what you keep pushing for right, more education to better help the patients?


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## Aidey (May 3, 2010)

I admit it, I had to look up MELAS too, and here is all I have to say. 

We will probably never have protocols to treat it in the field. But at the very least when a family member says "they have MELAS. It's a mitochondrial disease" we should know WTF a mitochondria is and what it does. I bet if I polled my co-workers and the fire medics tomorrow 1/2 would have a hard time explaining what a mitochondria is and what it does. And THAT needs to be fixed.


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## SeeNoMore (May 3, 2010)

I see both sides of the discussion, education is essential and I'd rather err on having too much (not that I do now) but from a practical standpoint we should expect Paramedics to have enough education to do their job well. This might not mean knowing every single condition to a T, but certainly would include knowing enough to opt for or rule out interventions, make informed reports to other providers, and decide on where to transport.


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## Ridryder911 (May 3, 2010)

I believe sometimes we cannot see the forest for the trees in EMS. What is the most important thing we do? 

Short and simple we respond to a crisis that the average person cannot handle or know what to do at that time. 

Now, with that we can explore what extent and how much education is needed for those responding to emergencies. Futile discussions on what and the extent of education and training will always be debatable. Again, if it was your  emergency what extent would you feel be necessary? 

R/r 911


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## 46Young (May 3, 2010)

Aidey said:


> There is a huge road block to this, and it is the fire unions. Seriously. Fire departments have regulated themselves out of a job. They have had to branch out their services in order to continue to justify their budgets.
> 
> If the education requirements are increased it means more costs to send people to school, more time lost while they are in school, and it makes it harder for them to convince guys to go to paramedic school. In places were costs are already out of control it just isn't worth it to them.
> 
> ...



I'm not denying that fire unions have opposed raising educational standards, but that's far from the whole picture. To assign most of the blame toward the fire service is innacurate. There are many other players involved. 

I've worked for several privates, several hospitals, and a county run third service EMS agency before going fire. None of them asked or cared where I got my medic cert from, just if it was good or not. No one I've ever worked with knew of any place requiring degrees either. What mattered in some cases was relevant experience. You're talking about lobbying for more education, when in reality it's entirely up to the employer. That's right, you can blame the hospitals, the privates, and the muni third services as much as the FD's. 

On this forum I frequently hear about all this supposed overabundance of medics. If this is the case, would we not see more and more employers requiring degrees to get hired? It would make sense. However, what I see happening is that these employers still go with "a pulse and a patch" and instead keep salaries low since there's an ample supply to backfill the disgruntled.  If these employers were to start requiring degrees, then we would have no choice but to have one. I don't see any stepping up. Maybe a couple here or there, but that's it. Start pointing fingers there. In fact, there's an increasing trend in the fire service to require formal education for promotional purposes. What that has done is cause myself and quite a few others at my FD to return to college and put in work to upgrade our medic tech certs to the EMS AAS. Some recent FFM hires already have their EMS degree since it's well known that the educated ascend the career ladder much more rapidly, and that education is now a necessity to do so. I don't see any hosp based or third service depts requiring degrees for promotion. Again, maybe one or two, but certainly not a trend.

As far as regulating ourselves out of job, nothing could be farther from the truth. From deployment and staffing objectives to the ISO rating, there still needs to be a timely response to suppression incidents. Sprinklers don't put out fires, they just buy time, there will always be arson, mishaps with space heaters, outside fires, malfunctioning dryers, food on the stove, gas leaks, CO leaks, pin jobs, Hazmats, etc. This video clearly explains the validity and necessity of proper staffing and deployment to suppression incidents.

http://www.youtube.com/watch?v=a_K-K6o5cGc

I've posted this several times before, but I continue to do so since it both educates and validates our positions. It's also a great selling point for the FD to do EMS, right or wrong. The suppression staffing clearly needs to be there, so it only makes sense to use their downtime productively to provide EMS as well. I'm not looking to argue the right or wrong of that, I'm just saying that it's a convenient selling point since the suppression positions are easy to justify, regardless of call volume.


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## Aidey (May 3, 2010)

Ridryder911 said:


> I believe sometimes we cannot see the forest for the trees in EMS. What is the most important thing we do?
> 
> * Short and simple we respond to a crisis that the average person cannot handle or know what to do at that time. *
> 
> ...



Not trying to shift the topic, but do you really feel that accurately describes the basis for most 911 calls? 

The reason I ask is because it seems like more and more we are responding to non-crisis incidents that the person SHOULD know how to handle. We seem to be running into a lot of "911 solves everything, even if it isn't an emergency". Maybe it is because I grew up in a very rural area, but people seem to be less self-sufficient than they used to be.


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## Veneficus (May 3, 2010)

*Pearls before swine.*



DrParasite said:


> but it's not like we can refuse to transport people?



That is the problem! My point is that in every country except the US, somehow manage to keep their healthcare costs under relative control by providing education. Increased education does allow them to decide not to transport. It also allows them to direct the caller to somewhere more appropriate than an ED. It is about value and cost.The fact you cannot make a decision demonstrates your inability and the value education adds. I find it hard to be proud of my ignorance.

The status quo is not economically sustainable.(No matter what type of agency is providing service. That makes it a systemic problem with the way things are done)Agencies all over the US cannot keep pace with their volume. Endlessly throwing transport resources is not the answer. Increasing education for disposition is a solution, if you don't like that, what solution do you offer? Head in the sand?



DrParasite said:


> haha, are you serious?...If you did, you would know the answers to these questions.?



It wasn't a question it was a statement. I don't feel compelled to justify my resume to somebody with a first aid certificate who hasn't evolved from the industrial age mentality of a common laborer. I am not the only one who thinks EMS should not earn a middle class living because they have managed to master a task at the lowest common denominator. I think one of my friends says it best, "the poor creatures, they don't know any better." Demonstrating with pride how simple and mindless your job is doesn't win any points from higher ups.

I hope it occurs to you when discussing national and global EMS issues, regional socioeconomic issues are not the only piece of the puzzle. Some things are common to all systems. 

I realize it is not your fault, it is a cultural issue that is grander than your perspective, that of your agency, and probably region. Infact it predates your generation. But in 2010 the value of society isn't based on a labor like it was in the 1800s. It is based on education. Whether you accept it or not, those with education are more valuable to society than those with a skill, who are barely more valuable only than those without. As the knowledge of man increases, so does the minimum education to be worth anything. (Ever notice a highschool diploma no longer gets you jobs it used to? Why a Masters is required for jobs that once only needed a bachelors?) Again demonstrated by the hyperspecializaton of people in modern societies. It was once possible to master the collective knowledge of all mankind. As I recall Descartes was the last. Such a feat is now impossible. It is impossible to even master medical knowledge or engineering, much less everything.

I am not suggesting every person needs to be a Leonardo or a Musashi, but the value of trades are less. That is why you can get the same level of quality from a day laborer, in front of home depot, you can get from tradesmen. Transport payment is being slashed because what we we have been paying isn't worth it and is set by those "edumacated scule people" who use the same hollow BS lines about heroism and protecting the nation the military does to make emergency services feel better and proud (As Napolean said "A soldier will fight long and hard for a bit of colored ribbon") before they slash the budget yet again. The trend is going to continue to cut away the amount payed to EMS and current systems will price themselves out. Local payers are not going to be able to make up the cost and that will mean job losses. Jobs in your field, not mine. SO I dream, I want EMS providers to have value, at least enough to earn a good life without 3 jobs. If EMS providers don't want to amount to anything, I cannot force it. But I keep hoping that by pointing this out, it might benefit somebody reading. Even if you are a lost cause.

That is why I keep spending my time typing it. Of course when EMTs, later medics, if things don't change have to start living in those impoverished neighborhoods as the day maids and the nonmamagement career fast food workers, it was all preventable.

The fight against education is absolutely absurd. The only groups who do that are extrinsic religions and tyrants. (though it seems like the uneducated are taking up the banner too. Perhaps they just feel insignificant and want to drag everyone down to their level?)

Unrelated to this, it has been my observation that the people with the least amount of education always seem think they know the most. I haven't figured out why yet, but i am thinking the need for mental security. Anyone else have insight on this?



DrParasite said:


> the real question is, do you understand there is a difference between a paramedic and a doctor?



Yes, but I don't see how advocating for the advancement of EMS somehow blurs this. I do try to restrain my comments to that which is valuable to EMS. I have been forced to learn things beyond the minimum as a medic. I have 5 times more experience in EMS than I do in medicine. Does it seem illogical I would know more about EMS than medicine?

What about the idea that since I do understand both, my contributions might be more insightful than a person who only understands one?
(Hate to break it to you Copernicus, but you can master all there is to know about EMS including the administration of it in about 5 years combined education and experience. Mom would be proud.) 

It might also seem reasonable given the resistance to education from EMS that the people who most often dictate what EMS needs are physicians, who have more education than EMS providers. 



DrParasite said:


> I am glad I am not the only one who had to look up what MELAS was.  I can admit it, I had no idea what it was.  And after Akulahawk said what it was, I can say that I am not aware of any prehospital protocols that allow for it, esp without any lab work to confirm your diagnosis.



MELAS is not taught in medical school, it is my experience with it as a paramedic that I  have learned it. I'll say it again, you don't need a lab for the dx. It is Dx at birth and it is not curable. (you know, genetic mitochondrial defect from cell biology) When the patient is in crisis, the treatment precedes the diagnostics. Just like many acute coronary syndromes. Do you have protocols for every condition conceivable? This affliction demonstrates how raw education can help you make decisions and actually help a patient even if you haven't commited every disease process to memory. (which is impossible, even for pathologists) If you encounter it (I know most people, even physicians, may never see a case in their life) it is likely the family will tell you the treatment and complications, just like many chronic diseases cared for and when the medic hopefully calls med control to get orders for treatment not covered in the protocol, they can point the physician in the direction so that she can look it up faster and make an informed decision. (Imagine that, a paramedic with enough knowledge about an acute emergency to actually guide a physician, sounds almost like a professional team member and not an underling laborer. Something for both the medic and mom to be proud of) 




DrParasite said:


> But Vene, you have convinced me of one thing.  Every paramedic should have to go through medical school before they step of the ambulance.  That means a bachelors degree and 3 years of medical school, so they know of every disease, illness, and potential injury that may occur, and they can both diagnose said illness and injury without the luxury of all those fancy tests that doctors have available to them in the hospitals.?



That is a bit of an embellishment, I am sure some idiot said the same thing about Dx an MI with a 12 lead once. I don't think it is unreasonable to ask for paramedics to go through the same or similar basic science courses as a nurse to have a foundation on which to make educated conclusions. As part of that education I think that biology, general chemistry, anatomy, physiology, and pathology at a depth acceptable to an associate or bachelors' s not asking a lot. Especially if you are proud of the fact you have to make a decision without a doctor standing over your shoulder telling you what to do. (as with all of life, with privilige comes responsibility)

I think the education should be relavent to EMS practice and directly stated as to why. Did you know both the Mosby and Brady paramedic texts have pathology sections that are cut and pasted out of context from advanced pathology texts? Like "pink frothy sputum" which until terminal stage is actually a microscopic finding requiring staining. So go ahead and keep looking for it, you'll need some good eyes, and preaching it is definitive. I am also fond of "tracheal deviation," and the rumor it equates to death. Gross tracheal deviation is late, but diagnostic is 3mm or more. That's aweful small, and the texts don't define it or tell you how to look for it. (more cut and paste out of context)  



DrParasite said:


> That is what you keep pushing for right, more education to better help the patients?



More education for EMS providers doesn't benefit me any. (Does that make me altruistic?)


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## EMTinNEPA (May 3, 2010)

Assess, treat life threats, begin definitive care in the field, and transport.

A paramedic or EMT is only as good as his assessment.  The only difference between the physical exam of a paramedic and that of a really well-educated EMT is certain diagnostic tools (mainly glucometer and cardiac monitor).


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## Melclin (May 4, 2010)

Veneficus said:


> I haven't figured out why yet, but i am thinking the need for mental security. Anyone else have insight on this?



I have noticed this. I have often found that the more educated people are, the more they realise how hard it is to be "sure" or to "proove" something. Less educated people will often simply read something or hear something and take it to be gospel truth. My personal favourite is, "I've been doing this since you were in nappies/ I have a son your age" the inference being that I'm wrong. My reply usually being that *repetition of an error does not constitute experience*, and that *the plural of anecdote is not data*. Understanding concepts like the value of different levels of evidence and different kinds of studies is pretty damn important to anyone in any healthcare field. Critical thinking and understanding the nature of knowledge are perhaps good starting points for better prehospital types.



Veneficus said:


> Did you know both the Mosby and Brady paramedic texts have pathology sections that are cut and pasted out of context from advanced pathology texts?



Those American EMS textbooks are widely considered to be wastes of perfectly good paper here. Other than the fact that they are poorly written and confusingly laid out, any time you have a question to ask of them the answer is "ask medical control". In some cases I can't think of a more confusing and long winded way to describe often simple clinical issues. Occasionally they are patently wrong, as you say. There are entire topics like pain relief that are barely covered. We barely use them and nobody likes them. Tintinalli's Emergency Medicine is our go to text book on most subjects as well as our mediocre A&P (Martini) text and our much better Pathophys  text (McCance) (*which also happen to be the same A&P/Patho books all the allied health and nursing students use*), but the primary source material is always considered to be better.



Veneficus said:


> More education for EMS providers doesn't benefit me any.



It could and probably would. Most people will benefit from the services of EMS at some stage in their lives. Could be something as 'little' as breaking your wrist and not having any pain relief for 2 hours while the basic can do nothing and the medic s**ts himself over whether or not 1 or 2mg of morphine is to much. People who are against more education should consider, as Rid says, how they would feel when some idiot with a shiny new EMT cert screams in with his turn out gear and an AED ready to save the world.


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## MrBrown (May 4, 2010)

46Young said:


> Really, anyone could put every medical pt (and stable traumas as well) on an ECG/12 lead, SpO2, ETCO2 (nasal), do a temp and a BGL, and give O2, memorize the regional protocols, and appear confident and thorough to the ignorant. You could fake a whole career like that in some places.



Right there my friend is the entire problem, well said!!! B)

... and how did you get the closely guarded secret of the Houston Fire Department?


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## Melbourne MICA (May 4, 2010)

*Forests and trees*



Ridryder911 said:


> I believe sometimes we cannot see the forest for the trees in EMS. What is the most important thing we do?
> 
> Short and simple we respond to a crisis that the average person cannot handle or know what to do at that time.
> 
> ...



I'm with you Ridders. 

The most important thing we do is to be advocates for our patients.

Because even when it seems we have done virtually nothing for them that would be mentioned in some medical textbook, article, quoted by some famous author, taught in some education programme; 

- say put them on the stretcher and take them to ED - 

We have still advocated for them by delivering them from medical crisis to  medical intervention.

What was that line in the movie?

 "we did nothing wrong? - yeah we did  - we're supposed to fight for people who can't fight for themselves - we were supposed to fight for Willy".

MM


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## MrBrown (May 4, 2010)

All this talk of willy and forrests and trees which rhymes with birds and bees makes Brown wonder if we should all re-submit that working with children check


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## Aidey (May 4, 2010)

Melbourne MICA said:


> I'm with you Ridders.
> 
> The most important thing we do is to be advocates for our patients.
> 
> ...




Is it advocating for your patient they aren't in medical crisis and you still transport them to an ED when they would be better served by an alternative?


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## Melbourne MICA (May 4, 2010)

*Advocacy for patients*



Aidey said:


> Is it advocating for your patient they aren't in medical crisis and you still transport them to an ED when they would be better served by an alternative?



Yes it is. 

Despite the fact, (and we all know this happens) we are called to patients who don't need ambulance care (but may need something else) we nonetheless still advocate for the patient by providing access to a higher level facility/resource or area of access to health care that may be able to provide them with what they need (even if its not health care).

It may be the patients mistake (having called the ambulance in the first place) or may reflect problems within the health system eg lack of after hours GP services. But in serving the patient we have advocated on their behalf because hopefully somewhere down the line somebody questions why these patient were brought to the ED in the first instance. 

We have input through our own systems (services) to bring such problems to light via our bosses and departments, often have auditing and other processes within the organisation to identify inefficiences and can use other means (even kicking up a stink in the media or through a labor union eg) to encourage change - change that must always be in patients' interests.

So our advocacy, whether by choice, because of an mandatory obligation under legislation or  under a charter -  a statement of philosophical position enshrined in the services contract of business operation (as happens here in Melbourne - "The Ambulance Charter") still services patient need even when a transport seems wasteful/unnecessary.

We don't have to like being obliged to transport or having no alternative but our first moral (ethical) and professional obligation (in my opinion) is to the patient as their representative. It's our higher purpose if you like and one that on occasion requires humility and self sacrifice.

It really is the most important thing we do *for* people and the reason ambos rate so highly in public opinion.

MM


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## atropine (May 4, 2010)

Ridryder911 said:


> I believe sometimes we cannot see the forest for the trees in EMS. What is the most important thing we do?
> 
> Short and simple we respond to a crisis that the average person cannot handle or know what to do at that time.
> 
> ...



I totally agree with you that we are indeed responding to someone's crises, however in todays economy and buisness/capital like mentality patients are now customers. good custermer service should be cheap and effective at least to the custermer paying the bill, wheather it be insurance, subsity, taxes, or private party. once the averge Joe (custermer) know what their paying for and what they want to pay for ems will always be different or adaptive to the demographics it serves.


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## Melclin (May 5, 2010)

Melbourne MICA said:


> It may be the patients mistake (having called the ambulance in the first place) or may reflect problems within the health system eg lack of after hours GP services. But in serving the patient we have advocated on their behalf because hopefully somewhere down the line somebody questions why these patient were brought to the ED in the first instance.
> 
> ...
> 
> ...



I don't think its enough to take them to the ED and hope. I wanna see more referral options. There is no reason why we can't get the ball rolling on falls referral for example. Why should we simply hope that the nurse will notice? Did they see the house with power cords strewn everywhere and notice the large print text all over the house? They tried a program out rurally and it fell through unfortunately but I understand the powers that be (Walker et al) are keen on some new stuff in the pipes on the same issue. The RAD teams* are also a good idea, but I'm not sure how far they've expanded.

Being obliged to transport patients even if its not in there best interests reminds me of certain debates about doctors doing harm (euthanasia or abortion) despite the Hippocratic oath. I don't think its in the interests of the patient, us or the health system in general to transport them to the ED unless they need to go. 

I think the best piece of paramedic-ing I've seen on placement, despite lots of MICA jobs and chopper jobs, was a roadie who spend over an hour with a patient who had fallen but was perfectly okay, addressed the cause of the fall, wrote a letter to the GP and rang and had the appointment moved up, spoke with her council case worker and organised for a walking frame to be delivered from the council, and made a cup of tea. What good would a trip to ED have done? (Esp that particular ED :wacko

* http://www.peninsulahealth.org.au/s...e/response-assessment-and-discharge-rad-unit/


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## Aidey (May 5, 2010)

Melclin said:


> Being obliged to transport patients even if its not in there best interests reminds me of certain debates about doctors doing harm (euthanasia or abortion) despite the Hippocratic oath. I don't think its in the interests of the patient, us or the health system in general to transport them to the ED unless they need to go.



This is pretty much what I think. Transporting patients to the ED who are better served by other services sets off a chain reaction that affects the whole system negatively. 

The patient doesn't get the best care they could and other patients receive delays in care. Patients also don't learn about the alternatives. By transporting them we reinforce the idea that 911 and the ER fix everything.


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## eynonqrs (May 10, 2010)

EMTinNEPA said:


> Assess, treat life threats, begin definitive care in the field, and transport.
> 
> A paramedic or EMT is only as good as his assessment.  The only difference between the physical exam of a paramedic and that of a really well-educated EMT is certain diagnostic tools (mainly glucometer and cardiac monitor).




I agree. I have noticed a big difference in how the new EMT's are taught as vs the older EMT's.  It amazes me how the new EMT's in PA can't think for themselves. 

I don't know who made that remark about that BLS shouldn't get paid, it is offensive. 

Prime example. In Wyoming County PA there is only one ALS unit that provides coverage for the entire county and it is a fly car. The other ambulances are all BLS volunteers. The county is a huge area, where it can be 30+ min before ALS can get there. I bet ya the EMT's have to be on top of the game. This ALS unit is hospital based and they are looking to dump the service because they are losing money. That tells you that the hospital doesn't care, it's all about the bottom line.

EMS is over abused system. 

I can see this is leading to an ALS vs BLS argument again. I am not going to get into it. As I have my own point of view. 

That is all.


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## mycrofft (May 20, 2010)

*Waiter, Czech please.*

.........:deadhorse:


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