# is "ALS" a lie?



## Veneficus (Jan 11, 2011)

In the last 2 days I have had my hands in the chest cavities of 3 patients. 

If you have never been to a cardio surgery, I would really suggest making every effort to be a part of the experience. 

I had a few minutes to look around at the wonder that stood before me.

There was all of the anesthesia get up. Monitors of every shape and size, a gas mixer, a ventilator, even a machine that measured real time blood clotting. Then there was the cardio bypass machine and all of its wonderous functions. More stainless steel and electronic devices than I care to describe.  A team of 3 cardio surgeons, 2 anesthesiologists, 2 nurses, and a student.  

The event starts out as a procedure. No different from any EMS station or service I have ever been to. You come in, have some coffee, discuss what's going on, check the equipment, get assigned a patient, prepare yourself for what you are going to do, and then, start treatment based off of a guidline that tells you how everything should go and how you should go about doing it. 

Just like EMS, it doesn't always go like it should and in no time at all, you can find yourself completely off the map.

Now, when this happens, there is no research, no textbook, nobody to call. The various members of the team put their heads together to make something up. When you add it all up, this team has easily a hundred of years of education and experience. Without aid of a bar napkin, an idea is formed. 

What makes this team ALS, isn't a few gadgets or gizmos. A technological solution to make up for shortcomings. It is the ability for them use all of their mental faculties, anecdotes, and scientific wild A** guesses in order to attempt to achieve a positive outcome.

So it makes me wonder...

Why is there always somebody in EMS forums who when faced with a conundrum, always posts something like: "Our protocol says" or "we must follow the protocol" or "that's not in my protocols?" 

There is no lack of technology in EMS.

No lack of situations that go as far off the map as possible. 

But yet only a handful seem to have the capacity to step outside the comfort zone and engage their collective knowledge and experience to attempt to improve on what has been, as well as prepare for what might be.

Does the reliance on guidline, mathmatically measurable studies, or the ability to call for help, stop EMS from being advanced? From being all that it could be?

No matter the outcome (which I am happy to report so far has been 100% positive) there is no doubt as to why these surgical people are paid. No doubt why they are funded, and certainly beyond question if they are worth it. 

We talk a lot about education in EMS. Rather the lack of it. Ad nauseum. 

But the last few days, I have come to the conclusion it is not the education holding EMS back. It is the attitude of many of the providers. 

Not because it is antieducation, or antiadvancement. But because it is antiresponsibility. Everyone wants to be considered a hero, important, etc. But at the same time they want to be told what to do. They want all the quantities known. They do not want to be held accountable. They want it to be somebody elses problem.

It is like "hero in a can." No risk. All good, and the ability to punt on first down if need be and walk away clean. 

Perhaps we should stop our focus on education, and focus more on provider attitude?

Perhaps before weeding out the minimally educated, we should weed out the minimally motivated?

Often times the earlier EMS providers didn't have guidlines that were supposed to cover it all. They were given what was deemed adequte info to make a difference, then kicked out without benefit of FTO, or senior guidance to succeed or fail.

They didn't have benefit of technology, but they somehow saved lives. They didn't have the benefit of research, but somehow managed to cultivate their expert opinions to make a difference. Many didn't exactly "fit in" to society, but then EMS didn't need people who did. They needed free thinkers. People not afraid to take what little they had and make hard choices. They faced the same problems as today. Patients with social issues, medical issues, mental issues, even no issues. 

Those providers, like the surgical team weren't advanced because they had some invasive procedures. They were advanced because when the S*** hit the fan, they put their heads together and make something up. Usually more fearful they would fail the patient then get into "trouble" with the boss.

Doesn't EMS still need that?

If not, what is the value of EMS?


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## JPINFV (Jan 11, 2011)

I think it's a mistake to make an argument that education isn't a cause for this. If through out your training you were told you don't diagnose, just follow the protocol, and call medical control early and often if you have any concerns at all, or even for a quick "hello," is it any wonder that EMS is where it is? Providers aren't thinking, aren't making decisions, and shrugging off as much responsibility as they can (nothing says "not a professional" to me more than the entire concept of calling medical control because of "liability." That, to me, says technician, not professional) because that's what they're taught to do from day one. 

Why are we surprised when the majority of EMS providers are simply doing as they were taught during every piece of formal education they receive?


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## Shishkabob (Jan 11, 2011)

Because when you DON'T follow protocols to an extent, you're walking a fine line of "practicing medicine without a license"...

Would you be fine with medics using their "mental faculties, anecdotes, and scientific wild A** guesses in order to attempt to achieve a positive outcome."?

Personally, I would, we're not all the idiots some claim we to be, and as everyone claims, patients won't fit neatly in to all protocols and each needs to be treated individually... but alas, the law and current practice don't allow it.



Think about it.  I've been taught, by ED docs no less, that a good practice for opiod overdose, is get some IN Narcan in to bring back respirations, then do IM Narcan as a maintence so that when the initial dose wears off, they don't just drop out again, and it lasts longer.   I asked the head of QA at my agency, his reply was "Do we have that as an order?  Then don't do it"

Same with using IN Fent.  We have the MAD, we have Fent, we know IN Fent works and is safe... yet we don't have it in our guidelines, so if someone wanted to, they could throw a fit and get our license revoked.

Etc etc with other drugs outside of their normal EMS use, but still in an accepted capacity.




You're saying EMS isn't useful because we can't use our brains, but at the same time, we can't use our brains because the law doesn't allow us to be flexible in that manner.  I would LOVE if there was a national scope to where a Paramedic / RN doesn't HAVE to be directly working under a doctor to do certain things, but it's not like that.  I would LOVE if we had a bit of autonomy in emergencies to do what had to get done.  But alas, we don't.


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## thegreypilgrim (Jan 11, 2011)

I agree with JP. It really is, ultimately, the education problem from which all other problems emanate.

Of course, poor motivation is tied to other things as well. Essentially, it's from people viewing being a medic/EMT as merely a "tool" in their arsenal to get a nice job on a FD somewhere. It's not seen as an end in itself but simply a means to another end (where else does this actually happen?). This is why you get medics who act very much like technicians and don't harbor any interest in medicine whatsoever as it's not really what they want, but in order to do what they want they have to do EMS.

Solving the education problem will solve this problem though. If it takes 4 years to become a medic, none of the people who currently become medics just to get on with FD will be willing to go through all that. You'll attract a wholly different and much more motivated person.


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## JPINFV (Jan 11, 2011)

What if the "protocol" was something along the lines of, "Paramedics are authorized to use [list of interventions and drugs in the scope of practice without necessarilly mentioning route] in order to treat the sick and injured.

You can always follow up with a stardized playbook, so to speak, but that doesn't preclude a paramedic calling an audible.


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## abckidsmom (Jan 11, 2011)

Last night I sat in a class my medical director was teaching on allergies and anaphylaxis.  He said that things have changed now and he'd like to see ALL prehospital meds, especially epi in anaphylaxis, given IM now instead of SC.

I nearly lost my tongue to this same issue, Vene, when two providers raised their hands and said, "That's not in the protocol book, should we wait for the new revision (NEXT YEAR) or should we start right away?"

OMFG!!!!!!!!!!!!

I don't know why I keep on.  It's people like this, who think that the way they do it in one spot or another MATTERS, who think that physiology is not a worldwide CONSTANT, that just piss me off.

Hooboy.  Timely post, Vene.  I completely agree.

I call medical command from time to time, and typically have a collegial conversation when I'm stumped.  I learn a thing or two, I change my course (or not), and I arrive at the hospital.  Mostly I call medical command to cease resuscitation, though.


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## Shishkabob (Jan 11, 2011)

JPINFV said:


> What if the "protocol" was something along the lines of, "Paramedics are authorized to use [list of interventions and drugs in the scope of practice without necessarilly mentioning route] in order to treat the sick and injured.
> 
> You can always follow up with a stardized playbook, so to speak, but that doesn't preclude a paramedic calling an audible.



Honestly, I would love if it was "You're a Paramedic and/or RN, you've been trained and educated on all this, you have shown competency, now have at it in any way you deem necessary, on or off duty, to save a life"

Yes, even off duty.  



If something were to go wrong, look at it.  Otherwise, I call it a win.


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## Shishkabob (Jan 11, 2011)

Another example is the new ECC guidelines.  Atropine is gone, yet if I were to withold atropine in asystole, per what science shows, it'd still be going against what MY orders are, and it'd be MY *** hung out to dry, atleast until our guidelines are revised this coming month.  That's not right.


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## JPINFV (Jan 11, 2011)

My one concern with allowing off duty care would be the care and maintnance of medical supplies. Ok, sure, an off duty medic would be able to provide ACLS to a patient in cardiac arrest. Now where is the paramedic going to get the supplies to do so? Similarly, I would request a somewhat low bar for gross negligence as my once concern is that too many paramedics and EMTs would see off duty care as a carte blanche to do as they please.


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## Aidey (Jan 11, 2011)

I think Linuss hit the nail on the head. I will admit I have done some stuff that probably borders on that "practicing medicine" line. I have no delusions that EMS saves lives, so my goal is to help people and make them feel better if they can. That has meant treating withdrawal symptoms in an elderly female, double dosing Zofran in intractable vomiting, using fentanyl liberally, using benzos in dislocations to help with the muscle spasms etc. 

The problem is that our protocols are not really written with that in mind, they are written from a saving lives and stabilization stand point. I don't think things will change until the focus shifts to actually caring for patients and not this saving lives myth.


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## Shishkabob (Jan 11, 2011)

JPINFV said:


> My one concern with allowing off duty care would be the care and maintnance of medical supplies. Ok, sure, an off duty medic would be able to provide ACLS to a patient in cardiac arrest. Now where is the paramedic going to get the supplies to do so? Similarly, I would request a somewhat low bar for gross negligence as my once concern is that too many paramedics and EMTs would see off duty care as a carte blanche to do as they please.





Agreed, a few things would need to be changed with it as well.



But say I'm driving down a rural road and come upon an MVC MCI, and there's a single ambulance there with a lone Paramedic and EMT.  How is it right, in any fashion, to not let an off duty provider do what they can to help to save a life, advanced or not, so long as it's still within their scope?

Aside from the law, what makes a doctor any better at providing help off duty within their knowledge?  I'm not saying have a medic or nurse give consults etc etc, but if there's a patient having an allergic reaction, why not let them give Epi/Benadryl/Pepcid?

I worry of the Ricky Rescues with an ambulance in their trunk that they never check, of course, but what about those that actually DO care?




Why does my knowledge, experiences, and education just vanish the moment I clock out?


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## abckidsmom (Jan 11, 2011)

Linuss said:


> Agreed, a few things would need to be changed with it as well.
> 
> 
> 
> ...




Where do you work that this is the deal?  ALL and I mean ALL the systems I've ever worked in, the medical director has given us a little speech at our getting released meeting about how, if we need to do something off duty, out of the area, to go right ahead, within reason, and just to call him as soon as possible afterward.

My husband and I once guided some woefully ignorant medics through a trauma debacle in the middle of I64 in WV, assisting with the extrication, darting the patient's chest and intubating him.  While all of the home team providers were busy with the man in the car, a firefighter and I extricated the kids from the back seat.  

We called Dr Ornato when we got to the next town, and he patted us on the back and said he'd followup with that agency in a day or two.  He did.  It was fine.

I will say that the medics on that scene would not have let us help if they weren't more clueless than anything I've seen before or since, though.


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## JPINFV (Jan 11, 2011)

I think the biggest issue when it comes to protocols/scope of practice/practicing without a license is the inability of too many providers to properly articulate a thought process beyond "protocols told me to." 

Take spinal immobilization. Massachusetts statewide protocol has a list of assessment/treatment priorities at the start of each disease/mechanism. For the most part, they are repeated verbatim for each topic. For spinal immobilization, the line used is, "Ensure cervical spine immobilization and stabilization, when appropriate, and treat accordingly." 

For the actual spinal immobilization it reads, "When evaluating for possible spinal injury and the need for immobilization, consider the following factors as high risk:
AMS, history of spinal fracture, evidence of significant trauma above the clavicals, posterior neck pain, paresthesias, weakness, distracting injury, age under 8 or above 65, concerning mechanism (fall from over 3 feet, MVC over 30+MPH, motorcycle/bike/pedistrain vs auto, diving or axial load, and electric shock)."

To me, that protocol gives me just enough rope to hang myself. Nothing in that says that I absolutely have to immobilize anything, just to consider it. Therefore, if I can articulate that, even though the patient fell from over 3 feet (includes falls from standing height), but using NEXUS as a clinical decision tool, the patient is at low risk, I should be fine. I've articulated something past, "I don't want to" or "I did because of protocol." However, how many providers put thought into treatments past what the protocol book says?


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## JPINFV (Jan 11, 2011)

Linuss said:


> But say I'm driving down a rural road and come upon an MVC MCI, and there's a single ambulance there with a lone Paramedic and EMT.  How is it right, in any fashion, to not let an off duty provider do what they can to help to save a life, advanced or not, so long as it's still within their scope?


Agreed. However people working off duty need to know their place to an extent, and when on duty providers arrive, should be willing to step aside. In general physicians included. The biggest issue is insuring that people are who they say they are and have the experience necessary. Sure, here's my state EMT/paramedic/RN license, but I just got it in the mail and I haven't worked a day (I didn't include physicians because, in general, physicians aren't fully licensed until after their first year of residency, and the training license some states issue for PGY*1 wouldn't cover them for care outside of their residency program. 



> Aside from the law, what makes a doctor any better at providing help off duty within their knowledge?  I'm not saying have a medic or nurse give consults etc etc, but if there's a patient having an allergic reaction, why not let them give Epi/Benadryl/Pepcid?
> 
> I worry of the Ricky Rescues with an ambulance in their trunk that they never check, of course, but what about those that actually DO care?
> 
> ...



First, I'd argue that benadryl and pepcid are both OTC drugs and you could most likely get away with giving them anyways. Is a mother who gives their child an OTC drug or a friend that recommends a drug really practicing medicine without a license? 

As far as the difference, I'd like to think that having 2 years of classroom work followed by 3 years (years 3 and 4 of medical school plus PGY1) before being fully licensed, and 2 additional years of full time clinicals when board certified/eligible makes the average physician better than the other providers. There's also the issue of maturity, and that's largely due to age at initial licensure. How many EMTs or paramedics have a shirt saying something along the lines of "I fight what you fear" because they're also a fire fighter? I don't know about you, but I fear C. diff. or cancer or TB more than I fear a fire. Physicians, we fight what you really fear. There's a reason that that shirt isn't made. Vanity shirts like that aren't in and of themselves immature, but a reflection of immature wackeritis. 


*PGY=post graduate year. I.e. residency.


Edit: New signature playing off of the "we fight what you fear" motif.


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## rhan101277 (Jan 11, 2011)

Well when I come into a new scene, I try to consider as many differentials as I can as to why this problem has occurred.  We all have protocols but everyone has sound clinical judgment and we are allowed to use it where I am.  Every shortness of breath patient does not need an albuterol, lasix, nitro etc.  This is where education and experience come into play.  If you are not correct with your assessment then you may kill someone.  It is a big responsibility and should not be taken lightly.

We all have an arsenal in the toolbox, you just need to know which tools to use.

Sometimes a physician contacted for med control is the best thing.  If you have a doubt that what you are about to do may not be appropriate or you need a second opinion then errr on the side of caution.  It is not like we are out here cooking breakfast. This is someone else's son, daughter, father, mother etc.


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## abckidsmom (Jan 11, 2011)

rhan101277 said:


> *It is not like we are out here cooking breakfast.* This is someone else's son, daughter, father, mother etc.




Love this one, and will be incorporating it into my precepting.  LOL.


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## thegreypilgrim (Jan 11, 2011)

JPINFV said:


> To me, that protocol gives me just enough rope to hang myself. Nothing in that says that I absolutely have to immobilize anything, just to consider it. Therefore, if I can articulate that, even though the patient fell from over 3 feet (includes falls from standing height), but using NEXUS as a clinical decision tool, the patient is at low risk, I should be fine. I've articulated something past, "I don't want to" or "I did because of protocol." However, how many providers put thought into treatments past what the protocol book says?


I agree with what you're saying, but can you imagine trying to defend yourself like this as an IFT medic in Los Angeles or Orange? I just can't see that flying here.


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## JPINFV (Jan 11, 2011)

As an IFT medic in LACo? They have written into protocol selective spinal immobilization (EMTs have no choice). There is no such thing as an IFT medic in OC.


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## Shishkabob (Jan 11, 2011)

JPINFV said:


> As far as the difference, I'd like to think that having 2 years of classroom work followed by 3 years (years 3 and 4 of medical school plus PGY1) before being fully licensed, and 2 additional years of full time clinicals when board certified/eligible makes the average physician better than the other providers.




Just so you know, I meant that more as a "What makes people think we'll forget all we know when we get off the clock while a doc won't?"   I highly doubt any medic or nurse leaves their job and goes "Systolic?"

Plus, what if we do something like docs do before we get our "limitedly unlimited" license to practice medicine?  We spend a year or so on probation, playing by the book, and after that we can test again for more freedom? 




I can't think of a single reason why, as a rule, we should not be able to stay within our scope while off duty, or give us a bit of leeway in decision making, so long as it's sound decision making.


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## Shishkabob (Jan 11, 2011)

rhan101277 said:


> Well when I come into a new scene, I try to consider as many differentials as I can as to why this problem has occurred.  We all have protocols but everyone has sound clinical judgment and we are allowed to use it where I am.



Don't get me wrong, we DO have some leeway.  Heck, my current agency calls them "guidelines" instead of protocols, and Paramedics "clinicians" instead of technicians to open the door to critical thinking.

We even have a page in our guideline book that states, and I quote

"The very nature of critical and emergency care delivery outside the walls of a hospital demand some level of autonomy and flexibility.  Clinician experience and judgement should be utilized to assure the best patient care... Pre-hospital providers work with great autonomy, but autonomy demands maturity.  A key to maturity is recognition of the need for consultation or guidance from on line medical control"


So yes, we can deviate a bit, but we tend to be the exception.


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## thegreypilgrim (Jan 11, 2011)

JPINFV said:


> As an IFT medic in LACo? They have written into protocol selective spinal immobilization (EMTs have no choice). There is no such thing as an IFT medic in OC.



Yes I know but I'm talking more about the idea of defending your decision to step outside protocol or exploit its ambiguities in general.


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## MrBrown (Jan 11, 2011)

Once again this seems to be a uniquely American phenomonia.

Our Ambulance Officers do not have "protocol" or "medical control" and we seem to get on just fine.  There is a set of clinical guidelines which cover the major etiologies of what is likely to be seen in practice (eg cardiac arrest, seizures, asthma, hypoglycaemia) however much is left to the knowledge and experience of the crew, presentation of the individual patient and larger clinical context.  We also have unlimited drug doses inline with good clinical practice and prudent professional judgement.  

This is not to say we are rogue practitioners left unchecked to dangerous devices to practice cowboy medicine out in the wild frontiers of the street but rather are appropriately equipped to use our education and experience in the best interests of the patient.  In other words we do not box everybody into a standardised protocol pathway in order to treat them because thats all we know how to do and see everything black and white.

An example Brown can think of is a patient picked up from an urgent care centre who had shortness of breath and chest pain.  We couldnt figure out of he had asthma or some sort of cardiac event so went down the road of a little from column A and a little from column B.  

Maybe all American ambos are as colour blind as Brown is regular blind and see everything black and white?


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## DrParasite (Jan 12, 2011)

Question: how many paramedics want to have no oversight?   not "I want to do what I feel is best," but rather "I have no safety net, I can do what I want and if I'm wrong, it's going to all come down on me?"  

think of it this way:  what are the medical malpractice insurance costs for an ER physician?   now, compare that to a paramedic's malpractice insurance (if they even have it).... which do you think is greater?  and if a paramedic or an MD screws up, and is found civilly liable, which do you think will be a higher judgement?

Before someone jumps all over me for being anti-education, that is not the case.  I think education is a good thing, and I think some systems are waaaaaay too medical control dependant (like NJ's that has you call the doc on EVERY ALS patient).  But there are definitely some benefits to not being as independent as doctors, despite what some think


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## Veneficus (Jan 12, 2011)

Is pre education and employment personality compatability with the supervising medical director a viable solution?

Basically anyone who didn't meet the critical thinking bar would be prevented from entering a program?


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## MrBrown (Jan 12, 2011)

It seems the US will be forever comfortable with the Paratechnical operating modality and as such education and clinical praxis will reflect it.

Shame.


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## AnthonyM83 (Jan 12, 2011)

Veneficus said:


> Why is there always somebody in EMS forums who when faced with a conundrum, always posts something like: "Our protocol says" or "we must follow the protocol" or "that's not in my protocols?"



That one's easy. At least around here, prehosptial providers are rarely allowed to go outside the variability that protocols allow. Many times, it's not that a provider doesn't have a better idea, rather it's not an option at all, even if we pass it by online medical control. So, the best many providers can offer a conversation is sharing facts (rather than their own synthesis) of how things are done based on their experiences.

It should be mentioned that greater education allows people to push the boundaries of problem solving. It's important to be aware of one's own ignorances. I'm sure some talks with medical directors will yield plenty of examples in which the providers thought they had thought out a solution, but due to lack of deeper knowledge, arrived at an incorrect solution where the situation was made worse than if protocol had been followed.

So, really, I believe one needs both. One needs the desire to push the boundaries FIRST, but needs the further education BEFORE they actually do it.


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## Melclin (Jan 12, 2011)

Linuss said:


> Another example is the new ECC guidelines.  Atropine is gone, yet if I were to withold atropine in asystole, per what science shows, it'd still be going against what MY orders are, and it'd be MY *** hung out to dry, atleast until our guidelines are revised this coming month.  That's not right.



Exactly. I very much like the idea of IV benzos, titrated IV narcan, IN narcan, even nebulised opiates if pushed. Our service is pretty strict about routes. We have IN fent and IV morph...why not IV fent as well? Its simply an oddity of the introduction process and an attempt at reducing the amount of new information, but if we were to push some IV fent, or IN some benzos...clinical breach...unless you lie on the paperwork, which many do. We have more flexibility than many in our system but some strangely restrictive things as well. 

Something like O2 for example. If I wanna use a nasal cannula and titrate my O2 to an SpO2 of 94-98 like various forward thinking UK NICE guidelines like in strokes and MI, I would run into trouble. Firstly, its unlikely I'd have pulse oximetry. Secondly, the stroke experts and cardiologist from _here_ still want 8LPM by mask in the first 6 hours full stop. How can I question them? Not only are they physicians, but they are experts in those fields.  



Veneficus said:


> Is pre education and employment personality compatability with the supervising medical director a viable solution?
> 
> Basically anyone who didn't meet the critical thinking bar would be prevented from entering a program?



I had to have a university entrance score above the 85th percentile (nursing was somewhere in the low 70s  ), write a short essay explaining why you wanted to start a paramedic degree and have a resume, of sorts, showing various activities proving your interest in studying being a paramedic (volunteering, previous healthcare studies, etc).

You then have to put up with a a great deal of uni that has nothing to do with all the "sexy" stuff. 

This is nothing to do with the 1.5-2.5 year long employment/qualification process of panel interviews, tests, mentoring and training that will follow. 

However, it hasn't really succeeded in attracting people with a superior work ethic or commitment. You just get high achieving slackers rather than complete idiots. People who are perfectly capable of working out what Substance A, when given formulas of B and C is a series of chemical equations, but completely uninterested in a true commitment to improving themselves as providers. It also has to be said that to a certain extent, free thinking is drummed out of people because of a certain adherence to the old ways, but its not anywhere near solely responsible for our problems.

Don't get me wrong, our position is far more enviable than yours and it would be a great improvement for American EMS. I'm just saying, its not perfect, and in fact, comes with its own set of problems.


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## 18G (Jan 12, 2011)

The EMS system in play today was set into motion long before most of us were prob alive. I personally think protocols are very necessary for EMS.... some providers do fall heavy onto protocol reliance and refer to the protocols often, but why blame them? It is the trickle down effect. Physicians and people with many more years of school then Paramedics have set up this system to their liking. Why does the field provider always get the blame? Why not start blaming whoever was responsible for instilling this protocol driven care and mindset and education requirements? I don't agree with protocol excuses or over reliance but it is what it is. 

Until there is a vastly improved education base.... your not gonna see "free thinking" EMS care and not because current Medics are not capable but because the system does not allow for it. And even if tomorrow Paramedics were required to have 4yr degrees, how about the hundreds of thousands of Medics who don't? It's not something that can be transitioned that easily. The field is its own beast with its own unique dynamics. 

If you need to prepare for a procedure or prepare a med or infusion or whatever, you cant walk away from your patient and the chaos and go to the nice clean nurses station to do all of that. Simplicity is necessary in the field for efficiency and safety. 

Critical thinking is a must but we simply do not have the leeway to deviate from system standards and protocols. It's nice for everyone to convene on a message forum and tout this and that, but ultimately your future as a provider hangs on your abiding by established protocol and system standards.


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## JPINFV (Jan 12, 2011)

18G said:


> If you need to prepare for a procedure or prepare a med or infusion or whatever, you cant walk away from your patient and the chaos and go to the nice clean nurses station to do all of that. Simplicity is necessary in the field for efficiency and safety.



Why is the back of your ambulance constantly in a state of chaos?

While stabilizing critical patients (since, if it isn't a critical "has to be done this second" intervention, than you have time to breath regardless of where you are), is not the emergency department also a bit of controlled chaos.


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## 18G (Jan 12, 2011)

I didnt say that it was "constantly" a chaotic environment but is something that is known to happen from time to time. Regardless, the field requires a different approach then the ED. Nurses have as much time as they need with their patient's where EMS does not. And not to mention when EMS is called we are there from the very start of the illness or injury and get things moving when no assessment or interventions have been done. 

Nor does the ED usually have all the environmental factors to contend with that are present in the field.


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## JPINFV (Jan 12, 2011)

Are assessments not repeated in the ED? Shouldn't physicians and nurses be conducting a complete exam instead of saying, "well, I don't need to ask about this because someone else already did?" If you're at a doctors office or SNF, do you ask confirm what the transfer report covered when performing an assessment on your patient, or do you not question what you were told?

Do patients not present critical, but sans EMS in the ED?

Why does EMS have such significantly less time? Who's panties get in a bunch if you take a few extra minutes? Is a 'diesel bolus' always the best thing for a critical patient?

What environmental factors are present inside the ambulance? Do your doors not close? Is the HVAC system broken? Do you not have lights? 

On the other hand, it's not all rainbows in the ED anyways. How many patients do you care for at any one time? How much do the RNs in your area care for? The physicians? How often do you start drips or pumps? The RNs? How many different drugs do you have that require an infusion instead of a bolus? How many are available in the ED?

While I won't argue that there aren't differences between the ED and the field, I question how significant they are, and how many of them are the fault of EMS culture instead of tangible differences. The "Critical patient, starting transport is more important than stabilizing the patient" rush is an example of EMS culture instead of a tangible difference. Fast is slow, slow is smooth, smooth is fast. So, just because there may be time to go fiddle at the nurses station doesn't mean that it's all rainbows and puppies and the like.


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## 18G (Jan 12, 2011)

I think my minor point was taken outside of its intention. 

point is... ppl need to stop blaming the field provider for the flawed system. They didn't create it. The so-called higher educated people did which is a perfect example of education isn't everything. 

It's like lets create a brand new system for doing something and hire ppl to implement the system. These people do their job exactly the way they are supposed to within the system... but for some reason the system design isn't the best and the the results are crappy even though the people working are doing the job exactly the way they are supposed to. The workers can't improve because of the way the system was designed but yet the superiors want to blame the workers for their own messed up processes and mistakes. This is where we are in EMS. Someone else created this monster but yet lets make the people in the street look like the bad guy all the time.... BS.

Field care is field care... it's not meant to be nor was it ever intended to be definitive. EMS does what it can to provide comfort, reduce pain and suffering, and sometimes actually save someone from dying all within the very immediate onset of illness or injury. Sometimes I see people getting confused with the purpose of EMS. If you want to do more then become a PA or doctor or a nurse in a hospital. If I can reduce someones pain from a nasty fx or give someone relief from all night N&V and being dehydrated then I feel good about that. That is my job as a Paramedic. 

I think there is a threshold for what should be done in the field and what should be left to being done in a hospital.


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## Shishkabob (Jan 12, 2011)

> Who's panties get in a bunch if you take a few extra minutes?



Dispatch...  



While I don't want to turn this in to yet ANOTHER Medic vs Nurse:



JPINFV said:


> On the other hand, it's not all rainbows in the ED anyways. How many patients do you care for at any one time?  How much do the RNs in your area care for? The physicians?


  Me?  Often, one.  It's the nature of the beast, though.  How many patients does a triage nurse have to deal with at any one time?  One.

But how many "Critical" patients does a nurse handle at any one time as well?  Often one, sometimes 2 ... but with a lot of help if needed, as opposed to just me, with an EMT-B, maybe some first responders, an hour from a doctor.

When was the last time a nurse had to handle 9 patients with varying acuteness in sub-freezing temperatures in the middle of the road, dealing with extrication, triage, treatment and transport in the dark with limited resources?  Hey, I had to do that last week!




> How often do you start drips or pumps? The RNs?


  Fairly often, actually.   Mmm.. Tridil!  I love thee.



> The "Critical patient, starting transport is more important than stabilizing the patient" rush is an example of EMS culture instead of a tangible difference.



Luckily my medical director views EMS as an extension of the ED, and states as such "We bring the ED to the patient, not the other way around", so we actually GET to do some interventions and stabilizations in the field.


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## Ridryder911 (Jan 12, 2011)

18G said:


> I think my minor point was taken outside of its intention.
> 
> point is... ppl need to stop blaming the field provider for the flawed system. They didn't create it. The so-called higher educated people did which is a perfect example of education isn't everything.
> 
> ...



*Whoa!* Sorry, but there is *NO* such thing as "field medicine" or "hospital medicine".. etc. Medicine is medicine! It is exactly that ignorant mentality and poor insight of understanding what medicine is all about! I can inform you *it was not... " The so-called higher educated people did which is a perfect example of education isn't everything".... that caused the mess!* It was those in charge bending down and watering curriculum and curtailing to volunteer and poor EMS services not to adhere to traditional medical standards! Look around, what other medical profession does not require a degree entry level or to be accredited?... That's right.. no one else! 

Sorry, want to slap a bad-aid and run fast back to hospital, chose the wrong business.. that went out 40 years ago. Seriously, I work all sides of the counter and truthfully; there is little difference in the first few minutes of interventional therapy (if EMS is properly educated and have strong medical protocols). 

If we continue to restrict ourselves only to "emergencies" and those supposed "life threatening events", we will soon be finding ourselves hunting for a job or no need to be there; as we should be! Only about 10% of patients in the prehospital environment really require intravenous therapy and less require medications. We need to remove restricting ourselves in a box and only focusing upon tidbits of healthcare. Either be part of it or get out! There are so many avenues of medicine that EMS that needs to explore before ever trying to justify the "mythical" field medicine BS. 

Is there adaption within areas of medicine? You bet.. but; trying to differentiate care and treatment specifically is nonsense. I heard the entire rhetorical BS when they told us twelve lead, intubation, thrombolytics and chest decompression was "hospital care". Let's quit making excuses and get on with the profession, shall we?


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## Veneficus (Jan 12, 2011)

*Practicing medicine with a certification*

I saw a lot of posts so far detailing the legalities of practicing medicine without a license.

I thought we should look a little closer at this phrase.

Nurses have a license to practice nursing. 

PAs have a license to practice...

RTs have a license to practice...

OT/PT have a license to practice...

Chiropracters...

Podiatrists...

A physician holds an "unlimited license" to practice medicine. So logically I would conclude there is a "limited" license as well. Otherwise why would anyone need to qualify it?

If we consider what the practice of medicine is, it is the application of scientific priniciple for the purpose of diagnosing and or treating diseases. 

We already know that despite the best attempts of some so called "medics" to pretend not to diagnose, they do. I don't think anyone would argue that ALS providers "treat" patients. Otherwise you wouldn't need all that expensive gear.

So why does EMS have a certification and not a license if they are in fact practicing medicine?

Well, I don't really have the answer. But of course I have a theory. A certification simply states you have met the minimum training requirements. It does not govern practice. It also means that somebody with a license (which is governed) must be responsible. That means being certified instead of licensed absolves individual responsibility. 

But this is where it gets a little hazy. Since an EMS certification can be revoked, it is either being used practically as a license, or the minimum training to maintain it is constantly evolving past the initial educational course.

So why would providers want to be certified and not licensed? Well, it is an old point. 

If you a minimally trained, you have a skill. Similar to say fire suppression or water rescue. 

You as an individual can only be held accountable to your rules and standards and not intents. 

Any groups of people we know who would value those things?

Volunteers and fire departments. As a skill set, it precludes the need for advanced education to make decisions. As a limited liability, it means the volunteer has the least responsibility. After all, if you were the only one personally liable for your decisions, you really would have a lot to lose for your hobby.

But word analysis aside, EMS does in fact practice medicine. You can't help but do it. Otherwise you would never be able to choose the protocol for the signs and symptoms. You would never be able to offer treatment other than a ride.

Now I will be the first to point out that a skill set was the initial EMS education. But somewhere along the way, medicine even in the prehospital environment became too complex to be effectively performed as a skill. 

It is the attitude of providers that stops education moving forward. 

It begs the question; "Since EMS does practice medicine, what kind is it practicing?"

I have a modest suggestion.

http://www.youtube.com/watch?v=4sJxDUxrlqE


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## 18G (Jan 12, 2011)

Rid I have to respectfully disagree with most of your post. Those who make the changes to the curriculum aren't those working 3 jobs as a field provider! And yes there is most certainly a uniqueness to field care... how can u say it is the same as hospital delivery? 

The majority of what we do is not what is glorified on Rescue911, Third Watch, Trauma, etc... agreed. But these cases will ALWAYS be imminent so no, EMS providers will not need to be looking for a new job no matter how infrequent these cases are. Communities will demand EMS 24/7. 

I'm all for expanded EMS services in the community. I took this job to help in anyway I can. But do not try to say that the everyday EMS provider created the system we have today. If so, where was I over the past 20 years?


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## AnthonyM83 (Jan 12, 2011)

I don't know if that's really an issue as far as the current discussion. Certification and licensure is mainly semantics. Some states give licenses. Some give certifications. In California, EMTs get state certifications and paramedics get licenses. It doesn't seem to change much as far as LEGAL ABILITY to synthesize a solution rather staying within the protocols.

It's a chicken and egg problem, and which comes first depends on the provider, but also the agency. I'd like to come up with more advanced problem solving on-scene, but I know it can be dangerous because of the limits of my education. The thing is, people who are really too lazy or scared to can also use this excuse.

If everyone's educational minimum was increased, though, there wouldn't be that excuse as now everyone would have better base knowledge to work from. And then think of the converse, it would be inappropriate to start requiring more of the "making up ALS" on the go from people on scene without adequate education.


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## usalsfyre (Jan 12, 2011)

18G said:


> And yes there is most certainly a uniqueness to field care... how can u say it is the same as hospital delivery?



Medications don't act differently under a hospitals roof. There may be some differences in DELIVERY of care (which you seem to allude to) but not in the practice of medicine itself. 

Maybe 30 years ago we weren't in control, but the time has come to take back control of the profession.


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## Melclin (Jan 12, 2011)

On the topic of the differences between "the field" or "the street" (two unabashedly American terms, it must be said), I think it is fair to say there are considerable differences.

This is not at all to say that medicines work differently or that you don't need none o' that book learnin on the street. I understand that some idiots essentially do say that, which, along with nurses having a hissy fit in reply to any suggestion that they are not god's perfect gift to medicine, makes this topic fraught with danger. 

Part of being a new prehospital provider is about learning to manipulate your environment. One of the most noticeable differences I've found in working with our top tier providers (MICA/ALS) as opposed to our 2nd tier (Paramedics), is that they seem to have a supreme ability to turn a scene of considerable chaos into something comparable to the controlled environment of a resus cubicle.

To a rookie like me, its amazing how much clearer a pts condition is in a hospital cubicle. Lots of light. Plenty of time. Plenty of space. Plenty of help. A nice clear set of vitals and hx laid out in front of you on screens and charts. *But then I think I can actually have all of those things.*None of it is exclusive to the ED. But I have to _make_ it happen.

I think it should be a part of our skill set as prehospital providers to be able to mannipulate our environments to optimize a situation and negate the differences between the field and the hospital. In any case, our response to those differences certainly shouldn't be 1), to ignore them, or 2), to use them as a justification for substandard care.  



Veneficus said:


> I have a modest suggestion.
> 
> http://www.youtube.com/watch?v=4sJxDUxrlqE



Its not as bad as being rick rolled, but I'm still not happy with you.


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## 18G (Jan 12, 2011)

usalsfyre said:


> Medications don't act differently under a hospitals roof. There may be some differences in DELIVERY of care (which you seem to allude to) but not in the practice of medicine itself.
> 
> Maybe 30 years ago we weren't in control, but the time has come to take back control of the profession.



Yes, I am referring mainly to care delivery and with that comes certain limitations. Should all modalities suitable for the ED be ideal for the field? I don't think so. Some tout pre-hospital ultrasound as the next big thing. Is it cool to do?... of course. How will it really change the game? Will the patient be treated any differently? I only see it as a triage tool but since we already over triage as a safety net I don't see any real difference between having ultrasound or not having it in the field. If you suspect internal bleeds, tamponade, pneumo, or whatever, transport to the trauma center and treat based on PE findings which in those cases should be very obvious. Trauma centers and most other hospitals have bedside ultrasound that is on the patient within moments of arriving anyway. 

There is already the argument that ALS care delays definitive care and is worse for some patients. Adding to the scene time and trying to do 100 things in 15mins instead of 10 isn't registering with me yet. Like I said previously, when do we reach the threshold of what we should be doing pre-hospital?

And I agree very much that it's time to take the reigns of our profession and make Paramedic a minimum 2yr degree and have more 4yr EMS programs developed. I think we need more refinement on what we currently do and not look to adding tons more.


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## Veneficus (Jan 13, 2011)

18G said:


> I don't think so. Some tout pre-hospital ultrasound as the next big thing. Is it cool to do?... of course. How will it really change the game? Will the patient be treated any differently?



Having a picture of the inside of somebody doesn't help you with your treatment?



18G said:


> I only see it as a triage tool but since we already over triage as a safety net I don't see any real difference between having ultrasound or not having it in the field.?



That over triage costs an insane amount of money and has to stop. Not everyone needs to be transported to a level I trauma, major cardiac/neuro and other specialty center for every complaint. (even though I think they would be better off) Look at the amount of overuse of airmedical as an example of that. Those are very large bills.

I know EMS providers, and even admit I used to think this way, feel that the cost doesn't matter and it can be worried about later. 

That is simply not true.

While I still agree that the cost of treatment should not be a concern, the cost of diagnosis certainly needs to be. Outstanding medical expenses as I understand are the number 1 cause of bankruptcy in the US. Financial troubles the number 4 cause of divorce.

How are EMS providers serving their patients by bankrupting them and breaking up families because they need to so grossly overtriage? (apparently have no idea what they are doing. Or no more idea if a patient needs a hospital or what type than the average person anyway.)

Medicine is not some part of life removed from the rest of it. The purpose of any healthcare provider is to help people. Not to destroy patients lives to give the provider some mental comfort over their personal shortcomings. 

If an EMS provider not only doesn't help, but causes harm, why would anyone ever pay for them or even want to call them?  



18G said:


> There is already the argument that ALS care delays definitive care and is worse for some patients. Adding to the scene time and trying to do 100 things in 15mins instead of 10 isn't registering with me yet. Like I said previously, when do we reach the threshold of what we should be doing pre-hospital?



I think where prehospital has room to improve is not in doing treatments. It is in figuring out the best entry into the healthcare system for people.

I know that is not the original design, and I know most US providers lack the mental ability to do that for a variety of reasons, but that doesn't mean it shouldn't change. 

Why do people call 911?

Becuae they need help. 

Do they need medical help? Law enforcement help? Fire help? Rescue? Social?

It is all of these and more. Now I know some "first responders" like to think they are just for emergencies as defined by themselves, but let me point this out in the form of questions.

If you went to a doctor with the same concern would she refuse to make any effort to help you?

When a person asks a police officer for help with something like directions or keys locked in a car or because they thought they saw something suspicious does LE tell them to call back when they recognize a serious crime is being commited?

Does the fire department tell you to call back when you see fire when you tell them you smell smoke? 

Do they not show up for all manner of emergency and see if they are able to help?

Calling the fire department and telling them that you smell smoke doesn't result in a box alarm and engine companies tossing 10,000s of gallons of water on your house "just in case."

These two agencies have developed the skills and techniques to respond appropriately to community needs. 

EMS wants pay parody, ok, but how about value parody first?

There must be an answer other than an emergecy ride to the ED with IVs and oxygen. 

There will always be overtriage, but it cannot continue to be massive. EMS will have to develop the skills and techniques to respond appropriately to what they are called for. They don't need to add another gizmo or procedure that "saves lives in real emergencies" which are only very small fraction of calls. (less than 1 in 10)

We read all the time here about agencies wanting RSI, and all kinds of other procedures and treatments. Why do we not see threads about "What practicle steps can EMS take to address the needs of the callers not needing life saving interventions?"

It seems that EMS providers are more concerned with their own wants than the needs of the patients.

I guess ALS really is a lie. I feel as if I have done a great disservice to a great many people reflecting on what my EMS career entailed.


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## 18G (Jan 13, 2011)

Veneficus said:


> Having a picture of the inside of somebody doesn't help you with your treatment?



How does it? In the field were not gonna be operating. I will agree that perhaps the prehospital ultrasound may pick up something early when the patient has yet to display physically. It's kinda like an EMT with a glucometer... what does it really change treatment wise in the field. My views are always open for change but right now I just don't see it changing field care dramatically. 

And I do agree with the majority of what your saying. I don't necessarily agree with the over triage to the degree that it is implemented and hate the rash decision that providers make to call for air medical. Providers don't realize (or care) about not only the cost but the risk vs benefit to not only the patient but also to the HEMS crew. Especially given the number of HEMS crashes lately. It's not a decision to make lightly I agree.

I been doing EMS for almost 20 years and have a pretty open mind and view about the EMS system. Is the system really that broken like some portray? I agree that things can be done better and the time is here for a restructuring of the EMS system and a new expanded purpose. This is a HUGE task that I feel will take a few decades to accomplish. So, where is the starting point and how do you suggest we make the wheels turn faster?


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## Veneficus (Jan 13, 2011)

18G said:


> This is a HUGE task that I feel will take a few decades to accomplish. So, where is the starting point and how do you suggest we make the wheels turn faster?



Culling the herd.


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## firetender (Jan 14, 2011)

*Time to Chime In!*

I'm not sure what's going on here. You're talking like you're trained in medicine. You're not. You're trained to DELIVER medicine. There's a HUGE difference.

You are NOT the experimenter. Remember when the paramedic was the "eyes and hands" of the doctor? Who calls the shots? Well, hopefully, someone who's a bit better trained than YOU!

That's where Standing Orders came from. A group of doctors agreed that certain things could be administered under certain specific circumstances in a specific order without calling in for permission. The parameters had limitations according to the signs and symptoms leading to therapies that had been determined, through clinical study, to be the most consistent agent of the desired changes.

You don't have 1/1000th of the information necessary to call shots in the field that might be experimental. The ER Docs have that choice, but you know what? Even they only have 1/100th of the info THEY need. To a large extent they are largely delivery systems for interventions and therapies that have been proven elsewhere as well. They, however, unlike you, DO have license to experiment.

In the field, at today's level of training, if you're going to be effective, I think it would behoove you to be the best delivery system you can be. There's practicality to that, because the way medicine is set up today, there's more failure in trials than success. Why expose yourself to the liability of answering questions you're simply not trained to answer? 

There is ACLS, but it's not determined by you. You can influence HOW you deliver it, but it's really not your job to determine WHAT you deliver and WHEN.

Not until you get way better edumacated. Is that what you want? Is that what you're willing to sacrifice for as Vene, the OP is doing today?


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## 18G (Jan 14, 2011)

Is that a general "you" or specific "you" directed at someone specific?


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## DrParasite (Jan 14, 2011)

firetender said:


> I'm not sure what's going on here. You're talking like you're trained in medicine. You're not. You're trained to DELIVER medicine. There's a HUGE difference.
> 
> You are NOT the experimenter. Remember when the paramedic was the "eyes and hands" of the doctor? Who calls the shots? Well, hopefully, someone who's a bit better trained than YOU!
> 
> ...


Bingo!!!!  Someone else who gets it.

If you want to play doctor (push whatever drugs you think are the best, operate with no safety net, and and not have to deal with protocols), then go to medical school.  4 years for a bachelors, 3-5 for medical school, and throw in a residency for good measure.  Then you can have the freedom and expanded scope like some are asking for.

But a paramedics is AN EXTENSION of the ER, and you are operating under your medical director's license.  That means he or she who is more knowledgeable and experienced than you tells you what to do (whether it be online or offline medical control), and you do it.

I keep wondering why some people have trouble with this concept


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## MrBrown (Jan 14, 2011)

DrParasite said:


> I keep wondering why some people have trouble with this concept



Because in most other Western nations Paramedics have advanced far beyond being the medical directors' bumboy.

To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.

We leave people at home without asking the doctor, have unlimited drug dosages in line with good clinical praxis and prudent professional judgement without asking the doctor, have no "medical contro" so therefore do not have to ask the doctor for anything and are not bound to follow a "protocol" which blindly seperates patients into standardised treatment pathways thus removing nearly all critical thinking and professional judgement.

It seems that the US will always be comfortable with the "Paratechnician" modality of operating thus limiting the need for critical thinking and sadly also limiting the opportunity for professional advancement.


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## JPINFV (Jan 14, 2011)

...because you can't be a professional while acting like a technician. So pick one. Either be a technician with technician level respect, pay, education, responsibility, and freedom, or be a professional. What can't and won't happen is professional level pay and respect, with some sort of inbetween mush of clinical freedom (the "we don't want to call for everything, unless we can blame it on the physician" BS) and a technician level of responsibility and education. Pick one. I don't care which one, but you can't have it both ways.


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## clibb (Jan 14, 2011)

Veneficus,

I totally agree on some of your opinions. 
I think that a lot of ALS agencies are held back. I've read that AMR won't even let their IV CERTIFIED EMT- Basics start IVs. I mean, why not? If you've been trained correctly at it, why not let the person do it.
I'm fortunate enough to ride with a lot of smart people. A lot of these people are Paramedics, that is due to that they wanted to "advance" in EMS and that they have the experience.
But some EMTs that have a ton of years under the belt could without no doubt run an ALS right as a Paramedic without the certificate. They know all the medications, interventions, and how to run calls correctly as a Medic. The only thing the medic does is sit there and actually do the interventions and the medications, since they are cleared to do so. If there is anything the medic doesn't agree on, he/she will do differently. But, great minds think alike, as you pretty much stated. 
I think it has a lot to do with the Medical Director, though. If the doc has more trust in his EMS staff, he will let them practice more and better. We are lucky enough to have such a doctor.

That is actually why I wanted to start in EMS to begin with. To get the experience and to see how the streets are run. Then as an MD I will have more confidence in the staff on the streets and trust them with their decisions. 

Personally, I think of us in EMS as preventer's, not curers. We prevent until we get to the hospital where the staff there will cure.


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## MrBrown (Jan 14, 2011)

experience and education are not the same thing just because you can administer a medication or intervention does nor make you any more of a clinician and less of a technician


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## AnthonyM83 (Jan 14, 2011)

MrBrown said:


> To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.
> 
> We leave people at home without asking the doctor, have unlimited drug dosages in line with good clinical praxis and prudent professional judgement without asking the doctor


You can do those things and still be an extension of the doctor. That idea is used to explain the idea that we work within a limited framework of rules (which is absolutely required if we're working under a limited framework of education). Increase the education, THEN we can increase the framework.


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## Veneficus (Jan 14, 2011)

MrBrown said:


> To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.



But I want to be king! h34r:

Clibb,

It is very important that you do not see the skills a paramedic does and think that a basic can do just as good. 

While I would agree that you can teach anyone to run a code or follow a protocol even with no medical training, you cannot see the thought process that goes into the decsion making. 

That process whether coming from a medic or a doctor is the understahd of "why are we doing this, towards what aim."

As rid pointed out, so few prehospital patients actually need an IV, that the idea of even bothering to train basics to do it is a waste of time and money in all but the most remote of environments, where the options were that or nothing. 

I think it is a bit of being new and not knowing what is not known. The higher you advance in medicine, the more tenuous what the providers in the field are doing looks. 

(1st world nations with more advanced EMS programs excepted)


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## 18G (Jan 14, 2011)

"Education is the discovery of ones own ignorance" - one of my favorite quotes.


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## firetender (Jan 15, 2011)

18G said:


> Is that a general "you" or specific "you" directed at someone specific?



y'all. kinda general trend of the thread sorta thing.


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## firetender (Jan 15, 2011)

*Look at our exposure; look at what we do*

I'm thinking Mr. Brown here.

The role of a paramedic is short-term intervention in an illness or injury adequate to help the patient attain stability enough to get to a higher level of care.

Am I wrong?

Let's start there.


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## JPINFV (Jan 15, 2011)

firetender said:


> I'm thinking Mr. Brown here.
> 
> The role of a paramedic is short-term intervention in an illness or injury adequate to help the patient attain stability enough to get to a higher level of care.
> 
> ...



Are a lot of the interventions really "short term?"

Isn't an AED really a long term intervention?

What about hanging a bag of dopamine for someone who is hypotensive? 

What about CPAP? If you can give an intervention that drastically affects the rest of the patients treatment for the current disease, is it really short term? 

Are paramedics who give thiamine for ALOC/drunk patients really treating short term illnesses with it?


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## firetender (Jan 15, 2011)

JPINFV said:


> Are a lot of the interventions really "short term?"
> 
> Isn't an AED really a long term intervention?
> 
> ...



All of these interventions are short-term with the potential to be utilized long-term. Most are interventions that are begun in the field and very likely to be changed based upon further findings and/or testing. In some cases, they become just the first volley in a juggling act that may or may not help the patient; that's just the way it is.

*The goal is to get the patient to a higher level of care, expeditiously, alive and without further harm. Anything else is a bonus.* 

Does that seem like a reasonable statement of priorities?


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## DrParasite (Jan 15, 2011)

JPINFV said:


> Are a lot of the interventions really "short term?"


yes





JPINFV said:


> Isn't an AED really a long term intervention?


no.  it's a short term intervention.  it fixes the problem (vfib/vtach), hopefully enough to put the person back in a normal rhythm to stabilize the patient to get to the ER so the doctors can find out why he or she went into cardiac arrest.  once they determine the underlying cause, that becomes the long term intervention.





JPINFV said:


> What about hanging a bag of dopamine for someone who is hypotensive?


why are they hypotensive?  the dopamine fixes the hypertension, but stop the dopamine, and the pressure goes back up.  so it is a short term intervention, until the underlying cause can be determined, and dealt with using long term interventions.





JPINFV said:


> What about CPAP? If you can give an intervention that drastically affects the rest of the patients treatment for the current disease, is it really short term?


Are they on CPAP for the rest of their life?  don't get me wrong, I have seen CPAP do amazing things on CHF patients, and it can be a life saver.  but it is a short term lifesaver, until the patient is transported to the ER, and put on long term medication.  after all it's not like patients walk out of the ER still attached to cpap machines 24/7.


JPINFV said:


> Are paramedics who give thiamine for ALOC/drunk patients really treating short term illnesses with it?


Got me on this one.  I have never seen a paramedic treat someone who was just drunk, to the point of giving medications.  ALOC depends on the cause, but for an intox, it's usually a comfy ride to the hospital.


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## JPINFV (Jan 15, 2011)

firetender said:


> All of these interventions are short-term with the potential to be utilized long-term. Most are interventions that are begun in the field and very likely to be changed based upon further findings and/or testing. In some cases, they become just the first volley in a juggling act that may or may not help the patient; that's just the way it is.




Sure, they might be changed, adjusted, or what ever, but that doesn't mean that I'd consider them short term if it affects the entire course of treatment. Something like naloxone which might have to be readministered would be short term. Dextrose is short term. However, is dextrose more or less important than the sandwich following it, or do they go hand in hand in definitively treating an episode of hypoglycemia. To me, saying that a paramedic's treatment is only short term treatment sells short the importance of initial diagnosis and management. 

My mother had 2 strokes about 15 years ago and spent a significant amount of time in the hospital recovering and rehabilitating. The first month she spent in the ICU. Since that month was a minority of the time she was being treated, was the ICU short term care in the grand scheme of things? If it is, was it any less important than the rest of the time she spent in the hospital? 




> *The goal is to get the patient to a higher level of care, expeditiously, alive and without further harm. Anything else is a bonus.*
> 
> Does that seem like a reasonable statement of priorities?



Sure... if you want to be a glorified taxi driver. Is the goal of the emergency department making sure people get admitted without harm, or is it to try and improve and stabilize their condition to the best of their ability pending admission?


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## JPINFV (Jan 15, 2011)

The hell? My hands must be disconnected from my brain. I can't remember what my initial example was, but it wasn't supposed to be an AED.


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## JPINFV (Jan 15, 2011)

So... what's the definition of a short term intervention? Is it anything but long term medications or surgery? Would something like antibiotics be considered a short term medication because once the bug is gone, there's no need for bug juice?


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## firetender (Jan 15, 2011)

It can be NOTHING BUT SHORT TERM!

Why? Because our patient exposure is short term...the shortest of the patient's exposures in the scheme of his/her recovery. Our job is to BE short-term.

We are the jump-starters, if you will. We don't replace the battery.


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## Veneficus (Jan 15, 2011)

JPINFV said:


> So... what's the definition of a short term intervention? Is it anything but long term medications or surgery? Would something like antibiotics be considered a short term medication because once the bug is gone, there's no need for bug juice?



But even surgery can be short term.

Palliative surgery for cancer is quite common. Biological heart valve replacements are only meant to last 5 years. (though sometimes you can sqeeze a few more out) A bypass doesn't eradicate coronary artery disease, and for the best example, if you have your pancrease taken out, your trobles are only just starting.

Firetender, 

I respectfully do not agree that EMS is a short term solution. Rather I agree that it seems to be but shouldn't be.

EMS is perhaps the last large scale organization of providers who actually walks among the community it serves. It has the potential to be the help people need. Whether it be social, educational, or medical. That help in the front line trench is not something that can be effected by the most skillful surgeons, nor the smartest doctors who reside in the 9-5 offices or the ivory towers of medicine.

Rather than just not making things worse, I think it is past time that US providers step up to the level of their European and Australasian counterparts and truly serve those which fund them, rather than just serving themselves by doing as little as possible by only doing what makes them feel like heroes and playing it off as not having the education, the legal support, or the tools to be more. Laws can be changed, education is available, and I know of at least 1 lawyer who backs EMS providers.

I will give an example.

If a teenage prostitute comes to an STD clinic, and is treated with antibiotics for an STI, and the provider makes a strong case with social services to find her placement (no matter how rudimentary) as well as a meal and some job training, and therapy for alcoholism or addiction, what was the true intervention?

Was the long term therapy the antibiotics, or making the effort to help somebody out of a miserable existence?

They don't teach the non medical therapies in medical school.


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## Melclin (Jan 15, 2011)

clibb said:


> But some EMTs that have a ton of years under the belt could without no doubt run an ALS right as a Paramedic without the certificate.



I hear this all the time from first aid vollies. 

The important issue here though is that without the education that underpins these ideas, its not 15 years of experience, its 1 year repeated 15 times. 

I don't care if you've been a first aid volunteer with St Johns for 10 years, it does not trump my bachelors degree and a year of experience when it comes to assessing a patients needs. By that logic you could earn your MD with a hundred years on the job as a CNA. 

I went to a job with a first aid volly for a 57 female post syncope/SOB. O/A Pt looks SICK, extensive cardiac history, etc. The FA volly wanted to d/c her from the spot we found her after *drum role*... taking her pulse and finding it to be "normal". We had something of a disagreement about that and it ended up being taken out of my hands (long story). Afterwards, he tells me condescendingly that when I get a bit more experience I will learn that there are some pts that just don't need, as he called it, "excessive interventions" like taking her BP. MI wasn't even on his radar because there was no crushing central chest pain. The mind boggles. If you don't know the difference between syncope of reflex mediated/vasovagal origin, and a massive bloody anterior MI (or even what they are!!), then you don't get to make decisions about a pt who could have either (or a million other things), no matter how many times you've watched someone else do it. 



firetender said:


> *The goal is to get the patient to a higher level of care, expeditiously, alive and without further harm. Anything else is a bonus.*



I can't stand this idea. A taxi driver with a CPR card (*cough* EMT *cough*) could do this. 

One of my favorite examples in the struggle against this idea is falls in the elderly. 

*Option 1*: Turn up lights and sirens, collect dot point information that you don't understand put them on the bed, put them on the monitor & some absurd amount of oxygen, then successfully place an IV  on your third attempt (damn labile nanna veins). You take them to hospital and later complain about low pay and boring non-emergency jobs while sitting in the ambulance bay. You turn up every few weeks to the same person who keeps falling and you repeat the same meaningless collection of information, interventions and transports. A few months later you stop going to that person's house. You don't know it but they were moved to high care supported accommodation because of their falls and worsening health, away from their friends and the neighbourhood they've lived in all their life, and 18 depressing months later died of sepsis/community acquired pnemonia. 

*Option 2*: You turn up assess granny, find her to be in the best of health. You don't transport her because your system trusts that you are educated enough to be able to make these decisions. Then you look into why she fell. You know from your _education_ that oldies falling is responsible for a decent slab of injury, reduced quality of life and even death. After a little detective work, you discover that the lip of nanna's rug is catching on her slippers. So you move the rug. From your _education_, you know that low vision is high on the list of causes of falls in the elderly. You do a quick test of visual acuity and find its sub par. You use an amsler grid (READ: the pts living room blinds) to establish the possibility of age related macular degeneration and organise for her to see her GP as soon as practical. From keeping up on relevant research and health care initiatives instead of re reading your protocols for the millionth time, you remember that a local clinic is trialing a falls referral team so you give them a bell and they are happy to come and assess her the next day. You finish your cup of tea, bid nanna good bye and toddle off home.

I know which one sounds better to me. The list of examples like this is long. Gatro pts are another example. You could take them all to hospital (no doubt Code 3 with 15LPM O2), in the process infecting half the town, or you could risk stratify them and leave some at home after educating them and their family and writing a care plan including antiemetics, hydration/electrolytes and an appropriate medical follow up if necessary. In doing so you reduced the spread of disease, reduce ED work load and prevent an unpleasant and unnecessary few hours in ED for your pt. You may even increase their coping capacity so that when the pts husband has gastro a year later, they don't call an ambulance (probably a long shot ).

None of this stuff is really immediate (or in these cases even involve a trip to ED), but it is still very important and well within the realms of reasonable practice for a well educated (but sans MD) health care provider.


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## MrBrown (Jan 15, 2011)

Oz stop talking sense and come help Brown double-check the dosage of suxamethonium in this chap Brown is about to knock out and intubate on his living room floor.

What? He had the sniffles ....


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## clibb (Jan 15, 2011)

Melclin said:


> I hear this all the time from first aid vollies.



I don't work for a first aid volly. It's an ALS 911 hospital based company.


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## TransportJockey (Jan 15, 2011)

clibb said:


> I don't work for a first aid volly. It's an ALS 911 hospital based company.



EMT-B is about the same level as their first aid vollys


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## TransportJockey (Jan 15, 2011)

Melclin said:


> I hear this all the time from first aid vollies.
> 
> The important issue here though is that without the education that underpins these ideas, its not 15 years of experience, its 1 year repeated 15 times.
> 
> ...



I know which option sounds better to me too, and unfortunately as long as there are certain types of agencies running the majority of EMS in the US, it'll never happen


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## usalsfyre (Jan 15, 2011)

The problem is not really a particular type of agency, it's that there's no education and more importantly funding for option #2. As long as we only get paid to transport to the ED in the US, that's what will be pushed.


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## TransportJockey (Jan 15, 2011)

usalsfyre said:


> The problem is not really a particular type of agency, it's that there's no education and more importantly funding for option #2. As long as we only get paid to transport to the ED in the US, that's what will be pushed.



My experience was that any mention from the state of increased education and that agency pitched a royal fit. That's the main reason I said that.


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## usalsfyre (Jan 15, 2011)

jtpaintball70 said:


> My experience was that any mention from the state of increased education and that agency pitched a royal fit. That's the main reason I said that.



I see what your saying. Even with privates of you can convince competent management (competent EMS managment, there's an oxymoron) that increased education will bring increased reimbursment, you'd have a case. When "keeping brothers employed" is the goal then your sorta screwed.


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## Veneficus (Jan 15, 2011)

usalsfyre said:


> I see what your saying. Even with privates of you can convince competent management (competent EMS managment, there's an oxymoron) that increased education will bring increased reimbursment, you'd have a case. When "keeping brothers employed" is the goal then your sorta screwed.



With the amount of people looking for any job, much less a cush job like the fire service, slash the pay by 1/2 and if they want to strike or quit, let them.

We didn't have many problems when Regan came down on air traffic controlers.


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## TransportJockey (Jan 15, 2011)

Veneficus said:


> With the amount of people looking for any job, much less a cush job like the fire service, slash the pay by 1/2 and if they want to strike or quit, let them.
> 
> We didn't have many problems when Regan came down on air traffic controlers.



I was gonna make a smartass comment about that... but IIRC it was probably around the time I was being born, if not earlier


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## MrBrown (Jan 15, 2011)

It was 1982 if Captain Brown remembers correctly.

Poor PATCO.


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## Veneficus (Jan 15, 2011)

jtpaintball70 said:


> I was gonna make a smartass comment about that... but IIRC it was probably around the time I was being born, if not earlier



Damn kids 

They haven't figured out to beware the old guy because we somehow survived this long and nobody is that lucky.


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## firetender (Jan 15, 2011)

Melclin said:


> None of this stuff is really immediate (or in these cases even involve a trip to ED), but it is still very important and _*well within the realms of reasonable practice*_ for a well educated (but sans MD) health care provider.



Mr Brown and Melclin, just for the record, I AGREE with your descriptions of the way things should be and the way they may be over there, but we're in Kansas, NOT Oz! 

(I don't know if NZ qualifies as an Ozzie like place, but I'm an American, therefore ignorant of anything but my own back yard; besides, it's a fun metaphor!) 

...and we're talking TODAY and not some time in the future when

1) we are trained to have other than tunnel vision, and
2) we are allowed the TIME to be more involved with patient care

That just ain't so right now! So we have to work with what we have UNTIL we get our acts together enough to CHANGE the system we're in.

With the systems in place today, in the U.S., EMS is short-term intervention using either basic or advanced techniques and therapies designed to get the affected person to a higher level of care in part BECAUSE doing much more subjects the systems we are part of and ourselves to liability...and we've got to get to the next call.

We are not really health-care practitioners, we are the lowest end of the totem-pole and essentially just deliver the affected into a SYSTEM. We are the introductory agents; we are SPECIALISTS in a very limited job description that makes us think we do more than load and go, but really, we just do SOME stuff, then load and go.

Let's go back to the original post:



> Vene: Perhaps we should stop our focus on education, and focus more on provider attitude?
> 
> Perhaps before weeding out the minimally educated, we should weed out the minimally motivated?
> 
> Often times the earlier EMS providers didn't have guidelines that were  supposed to cover it all. They were given what was deemed adequate info  to make a difference, then kicked out without benefit of FTO, or senior  guidance to succeed or fail.



This is true, but at the same time we (and I was one of them) were working with a lot of ideas that were not clinically proven, as evidenced by the fact that most of what I used in the mid-1970's has been debunked. 

Now, the focus is on sticking to protocols that are believed to improve successful outcomes enough to GET THE AFFECTED PERSON THROUGH THE EMERGENCY AND TO THE FACILITY.



> They didn't have benefit of technology, but they somehow saved lives.  They didn't have the benefit of research, but somehow managed to  cultivate their expert opinions to make a difference. Many didn't  exactly "fit in" to society, but then EMS didn't need people who did.  They needed free thinkers. People not afraid to take what little they  had and make hard choices. They faced the same problems as today.  Patients with social issues, medical issues, mental issues, even no  issues.
> 
> Those providers, like the surgical team weren't advanced because they  had some invasive procedures. They were advanced because when the S***  hit the fan, they put their heads together and make something up.  Usually more fearful they would fail the patient then get into "trouble"  with the boss.
> 
> ...



Right now, Vene, you are working in a controlled environment. I don't think EMS will change to be anything but getting a person from the scene of their illness or injury; from chaos TO a controlled environment; to YOU. Whatever measures we employ, at best they are initial steps to provide enough stability to get the patient to the next phase of treatment.

The team cooperation you speak of simply is NOT available in the field. As with all professions, it is the renegades that define it, through much trial and error, and the ones coming up in the ranks who execute what was learned. Most often, the risk-takers get burned because in the trying, they lose lives. 

One of the things you're missing is that we/they "put their heads together and make something up." but many of those things (Bicarb, Epi, ZAP! Bicarb, EPI, ZAP!) were found to produce poor patient outcomes. Sure, out in the field I believed I really did save a lot of lives (pulseless and apneic converted to rhythm and breathing) but really what I was doing was manufacturing Cardiac Cripples.

...and that was only discovered AFTER they were part of the larger system designed to administer care within a broader spectrum.

The defining structure -- corporate, litigation-driven, institutionalized, for profit -- has carved out a small niche for the EMS provider to work in, and he or she works in it only TO THE EXTENT THAT IT SERVES THE LARGER STRUCTURE. 

You'll notice that I'm not talking too much about the actual needs of the human being involved, the patient. It's all about intervention within narrowly-defined parameters.

Maybe ALS is not the issue.


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## usalsfyre (Jan 15, 2011)

The system is absoloutely the issue here. Most of my scenes aren't any more chaotic than the ED, most of them are actually far less so. I would easily have enough time to assess and dispo a patient, especially if I didn't have to tote them to a facility 30-50min away for a minor complaint because they don't like/have nearly been killed by the meatheads at the local veterinary facility. The problem is, most paramedics aren't educated to tell the difference between what needs to be seen/can be discharged, many of them don't care to learn because it's not "saving lives" and most importantly, my company can't get paid if I don't transport. 

The game changer will be who figures out how to get reimbursed at a higher rate (but still much lower cost than an ED visit) for taking care of these minor medical issues.


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## Melclin (Jan 15, 2011)

firetender said:


> ...and we're talking TODAY and not some time in the future when
> 
> ....
> 
> ...



Fair enough. I think its important though to clearly define that though. If you argue against the idea of EMS in America being more, you've gotta be clear that you're simply talking about the definition as it stands currently and not what it should be. The thread after all is about what EMS _should_ be doing. Our system isn't quite universally up to the level I described in our options either (It depends on the paramedic's preferences). But I'm describing things how I think they should be. Still, I suppose its quite reasonable to argue that the OP has unreasonably high expectations for the _current_ system given its role, which I suppose is essentially what you were saying. 

I'm not sold on the idea of uncontrolled environments. I've worked at rock concerts where you pick a kid up from the mosh pit with a spinal injury or a MVA with car whizing around but those jobs and of course you're not going to get to be too thorough in those environments, but they are in the minority. Mostly we go to +65s with miscellaneous complaints that get mistaken through dispatch as CP, SOB or hemorrhage (which is why I never really got the exclusively American concept of "street EMS" or "street medicine" - it sounds so tough, like we bounce around with our hommies patching up gun shots with steely expressions). Many of our jobs involve sitting on a pleasant floral patterned sofa and chatting to sick old person #49856. I agree with usalsfyre, its mostly pretty controlled. 


Just on a side note, *does anybody do care plans* when they don't transport patients? I don't necessarily mean a formal multi-page document, but some form of clear plan of action for them. If so what form does it take? Do you/are there legal issues with recommending drugs?


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## clibb (Jan 15, 2011)

I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."


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## MrBrown (Jan 15, 2011)

clibb said:


> I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."



Cool story bro, not.

What do you think causes low pay?


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## Melclin (Jan 16, 2011)

*I knew there was something I forgot.*



18G said:


> Some tout pre-hospital ultrasound as the next big thing. Is it cool to do?... of course. How will it really change the game? Will the patient be treated any differently? I only see it as a triage tool but since we already over triage as a safety net I don't see any real difference between having ultrasound or not having it in the field. If you suspect internal bleeds, tamponade, pneumo, or whatever, transport to the trauma center and treat based on PE findings which in those cases should be very obvious. Trauma centers and most other hospitals have bedside ultrasound that is on the patient within moments of arriving anyway.



I'm not expert in US but I see it as being similar to prehospital 12 lead. Similar in the sense that it requires a considerable increase in education plus the funding for equipment. How much does a prehospital 12 lead change things? Sometimes. Its still a standard of care for top tier providers. STEMI alerts, risk strat of chest pain, posterior/inferior infarct recognition to avoid nitrates, generally good tool to investigate a number of different pathologies. 10-15 years ago, I wouldn't blame people for saying Chest pain = MONA + transport anything else is a bit beyond EMS and how much difference will 12 leads make anyway.  

Dr Smith's ECG blog is full of stories about bed side echo aiding diagnosis of MI.

You don't think abdo pain is something we could investigate with US? 

There aren't really any sure fire ways of identifying thoracic and abdominal aneurysms based on hx/physical. Ruptured ectopic pregnancy. The triage advantages are obvious as are the benefits in long transports. Taking someone to the appropriate hospital for their condition is a valuable thing. Its the difference between taking your 43 year old female with abdo pain to the local hospital ?renal colic or taking her to a major hospital with a clear picture of the ruptured ecto pregnancy. Real job.  

Assessing volume status in ?septic pts or dehydrated pts. 

We've had a bit of trouble with missing tension pneumos in the field. Not through poor clinical skills, just because of odd presentations/being hidden behind very otherwise sick pts. To the extent that there was some talk of prophylactic popping of chests in certain groups of trauma pts. Could we not be using US to identify pnemos. Which of course you mentioned, so I don't see how you are missing the benefits of identifying that.

There is also talk of certain abdo trauma/suspected haemorrhage being added to the list of situations when you should be judicious with fluids, a la penetrating truncal trauma. I imagine US would be useful in decision making in this regard. 

I've also read that there is no reason why US can't be done on the road or in the air, so it doesn't necessarily increase scene times.


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## Veneficus (Jan 16, 2011)

Dragging EMS out of the 20th centrury. 

US EMS currently operates in an industrial age mentality.

(A good job is one where you know yor skills and the bossman tells you what to do. As long as you do what your told, you are doing a good job regardless of outcome.)

But that was more than 100 years ago. 

At what point do you say "that doesn't benefit anyone anymore?" 

At what point does the value of your EMS service become so marginal that you are not worth what you are paid now?

EMS as it currently stands, will never have pay equal to police and fire. You know why?

It is not worth it.

It is jst an expensive taxi ride. The educational demands can be completed in roughly 6 weeks. 

Now the providers claim to be saving lives, and in some cases it is true. But how many? Enough to justify the expense?

If all it is is a ride, it is the paramedic that is the uneeded part of EMS. Not the basic. 

Imagine the cost savings of switching all ALS ambulances in the country to BLS.

Look at the countless posts where members state an experienced basic can do just as well as a paramedic. (Not saying that is true) but if that is the perspective of the providers, what is the perspective of the public?

One of the major points of the OP is that there is no doubt why cardiac surgeons and anesthesiologists are paid what they are.

There is all kinds of doubt as to whether EMS providers deserve anything more.

At 40 hours a week, in 3 weeks you could create an entire class of EMTs who can follow orders without thinking.

As was pointed out by Rid, and is apparent here, everytime somebody suggests adding something new, it is met by "That doesn't help or matter."

It is like modern US providers are hell bent on arguing the latest medicine doesn't matter to them.

It is like cutting your own throat and wondering why nobody gives you more for it.

I don't suggest a massive strike either. Since most of the payment comes from people who don't use the ambulance it would very effectively point out people can get along without you.


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## usalsfyre (Jan 16, 2011)

clibb said:


> I love this line that I heard from a medic once



Don't listen to this guy, he's an effin idiot 



clibb said:


> "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell



See my post elsewhere about seriously overestimating your value to the system. In many(most?) areas of the US, 7 minutes wouldn't even be noticed, as no calls would even be received. Large cities often have hours worth of call backlogs. Can you please explain to me how in 7 minutes is going to "go to hell"?



clibb said:


> and we'd get the pay we want."



Does he think reimbursement is going to magicly increase? What else has he got in his fantasy land? Did he at least share whatever he was on? :wacko:


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## MrBrown (Jan 16, 2011)

Brown is down a vial of ketamine, perhaps that explains a lot?


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## Veneficus (Jan 16, 2011)

Clibb,

I am not picking on you or anything, but the comments here are exactly the reason I argue that people *should not get "experience"* at the EMT level before moving on to a higher healthcare role. 

Be careful who you pick up as a mentor or look up to. It could have a very negative effect on your future. Especially in medicine, where many hold EMS persons in outright contempt for some of the absolutely stupid positions they advocate.


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## rescue99 (Jan 16, 2011)

clibb said:


> I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."




I don't know about 7 minutes but it may be the end result...at first.


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## Jon (Jan 16, 2011)

Wow. This is some really good food for thought.

Now that I've been practicing as a medic for a while, I'm finally starting to get the hang of this, I think.

I still follow my protocols. I also will occasionally check them on a call for the 2nd or 3rd line orders I never use. For example, we have orders for benzodiazepines after Zofran in serious nausea/vomiting. Only ever had to do it once (and my partner did it again last night).

I'm all about treating the patient to the limits of my protocols before I call a doc, and often my calling the doc is really a "protocol says I need to talk to you... but I'm not looking for any orders... Here's my ETA... Bye."

What I find is funny is that there are many medics in my area that call a doc before doing things clearly allowed by protocol - like narcs for extremity trauma. Why? Because they aren't comfortable w/o having direct orders.


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## medicRob (Jan 16, 2011)

I remember a specific lecture in nursing school, the course was called, "Intro to Professional Nursing" where we learned the history of our profession, the types of nurses (ADN, BSN, MSN, DNP, DSN), and the roles these nurses play in our profession as a whole. We spoke with regard to the hallmarks of a profession and the point at which a job becomes a profession. Position, Job, Occupation, Professional, and professionalism are all different things. 

To quote an excerpt from "Nursing Now" by Catalano:

"*Position:* A group of tasks assigned to one individual

*Job:* A group of positions that are similar in nature and skill that can 
be carried out by one or more individuals.

*Occupation:* A group of jobs that are similar in type of work and that are usually found through an industry or work environment. 

*PROFESSION* A type of occupation that meets certain criteria  (discussed later in this chapter) that raise it to a level above that of an occupation. "


Now on to those criteria.. 

1. High Intellectual level of functioning. 

2. High Level of individual responsibility and accountability

 Does this individual have enough knowledge to be held liable? 

3. Specialized Body of Knowledge 


A profession no longer relies on how things are "Traditionally done" but rather on what the latest science is  and what is working... 

4. Evidence-Based Practice 


The institutions responsible for the training and professional development of the paramedic need to introduce the individuals to the latest research and findings while the licensing (yes I said licensing) boards create new laws allowing for more autonomy in EMS, giving them the tools and the means to SAFELY and effectively render evidence-based care rather than following "cook books".



How many peer-reviewed academic journals are there in nursing where nurses are writing the articles and performing the research? 

How many peer-reviewed academic journals are there in paramedicine where the EMT-Ps are writing the articles and performing the research? 

We need to strive to go from an occupation to a profession, but to do this we will be required to make some drastic changes to the way we educate paramedics as well as redefine paramedicine as a whole.


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## Veneficus (Jan 16, 2011)

medicRob said:


> SAFELY and effectively render evidence-based care rather than following "cook books".



Here is unfortunately where I see the shortfall in nursing and do not think it will benefit EMS to emulate it.

Evidence based practice is not the end all be all of medicine. It is practice most likely to help a given condition. It is based on epidemiology and should be the likely starting point in most cases. It doesn't mean it will work for any given patient.

*Following these guidlines as the rule of best practice is cookbook medicine.* 

It is why I have seen nursing journals that criticize physicians for starting outside of these practices. Something that may very well be indicated or an acceptable treatment plan.

Treating people by epidemiology while useful and often neccesary doesn't mean you are doing what is best for any given patient. Nobody should mistake it as such. 

I asked one of the more respected and knowledgable cardiologists here why she is so set against paramedics and ALS not performed by physicians. Her answer left almost no room for an argument. 

The long and short of it is they overtreat. Everything is an emergency to them. 

Now whether you are following standing orders or the results of the latest study, you are still doing the same thing. Disguising it with different terminology doesn't fool any medical professional. 

Getting the best treatment for the individual is why people still seek out physicians. It is why when you go to a "midlevel" provider, you are basically resigning to hopefully falling into the epidemiology or settling for less. (In my experience nothing more than an overeducated protocol monkey doing no more or less than a paramedic)

When creating this "evidence based guidline." (aka protocol) where do you draw the line at acceptable losses? 10%, 20%, 40%, of total patient population with a given affliction?


How do you account for multiple disease processes? Certainly not treating each one like the other doesn't exist.

How do you account for things like inability to afford a given treatment? Just tell them they are out of luck?

What if they have reservations about a given treatment? Do you just not help them?

What about conditions where no known treatment exists?

Where no treatment is shown to be effective?

Just give up on them?

Of course not, you take them to a doctor who will make something up based on raw knowledge, not an evidence based guidline. Because one doesn't exist.  

I think many healthcare professions are attempting to condense their vast bodies of knowledge into over simplified "guidlines" and try to give them more credibility than they are worth by assigned terms like "evidence" instead of "protocol."

This evidence, has various levels of value and utility. It is a tool in the box. Not a substitute for knowledge. Not a substitute for the best care. Not a substitute for individual care. 

It is madness to try and industrialize medicine. It has been tried. It has failed in all respects. From Dx to treatments, to cost, to patient results. Especially in the US where the cost/result ratio is one of the most disproportionate in the modern world. So much so the whole system is on the brink of collapse.

If EMS is to be a profession, because the delivery method is not the same as a hospital, it will require more raw knowledge and more evidence based practices. But there is the rub, despite evidence against some practices they remain. The evidence for new practice disproportionate to old. 

I guess it has to be made simple for the masses.


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## clibb (Jan 16, 2011)

Veneficus said:


> Clibb,
> 
> I am not picking on you or anything, but the comments here are exactly the reason I argue that people *should not get "experience"* at the EMT level before moving on to a higher healthcare role.
> 
> Be careful who you pick up as a mentor or look up to. It could have a very negative effect on your future. Especially in medicine, where many hold EMS persons in outright contempt for some of the absolutely stupid positions they advocate.



That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.
Now, I do look up to some of the medics I have. The one who stated that is an EXCELLENT medic. I bet you anything that medic is better than a90% of the medics on this forum. Blunt statement? Maybe. But, if you compare EMS to an industrial branch of the workers system in the US, like Veneficus did. You will see unions that have gone on strikes. Now, there is no unions for EMTs or Medics, but nurses have one of the strongest unions in the US. So if people want to run EMS as a industrial business, then what would happen if all of EMS went on strike? Nothing good. I'm just saying, "What if". 

Now Veneficus, you know I wanna be a doc. So of course I wouldn't have a medic as a career mentor.


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## TransportJockey (Jan 16, 2011)

clibb said:


> That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.
> Now, I do look up to some of the medics I have. The one who stated that is an EXCELLENT medic. I bet you anything that medic is better than a90% of the medics on this forum. Blunt statement? Maybe. But, if you compare EMS to an industrial branch of the workers system in the US, like Veneficus did. You will see unions that have gone on strikes. Now, there is no unions for EMTs or Medics, but nurses have one of the strongest unions in the US. So if people want to run EMS as a industrial business, then what would happen if all of EMS went on strike? Nothing good. I'm just saying, "What if".
> 
> Now Veneficus, you know I wanna be a doc. So of course I wouldn't have a medic as a career mentor.



Really EMS doesn't have unions? I guess NEMSA  is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*. 
And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.


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## Veneficus (Jan 16, 2011)

clibb said:


> That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.



What makes you say that out of curiosity?


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## abckidsmom (Jan 16, 2011)

Veneficus said:


> What makes you say that out of curiosity?



Because if it's your life's ambition to stock rooms, get vitals, run labs and start IVs, you should definitely spend a significant period of time driving a truck, loading and unloading a stretcher, and eating McDonalds.  

All the great ED techs lay their foundations this way.


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## clibb (Jan 16, 2011)

jtpaintball70 said:


> Really EMS doesn't have unions? I guess NEMSA  is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*.
> And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.



Sorry, didn't know we had those. *Zipping mouth, locking, and throwing key away*


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## Veneficus (Jan 16, 2011)

abckidsmom said:


> Because if it's your life's ambition to stock rooms, get vitals, run labs and start IVs, you should definitely spend a significant period of time driving a truck, loading and unloading a stretcher, and eating McDonalds.
> 
> All the great ED techs lay their foundations this way.



I started that way 

ED tech was the best paramedic job I ever had. The hospital required a year of busy field experience to apply. Otherwise I would have been more than happy to go right from school to ED tech. As it turned out, there were several years in between.

But I mean from the medical standpoint.

Perhaps what has led to my successes in medicine has been my time having to actually make decisions on the road. They were not particularly involved decisions, but I don't have any peers in my class who can prioritize the vast amount of medical information so quickly when dealing with live (or dead) patients.

I am also really practiced at physical exam skills and history taking.

I have a couple of psychomotor skills I am rather adept at too. Like intubation and line placement. 

But all of that comes from being a medic, not a basic. I cannot really think of anything in my EMT-B education or experience that has had any impact on my medical successes.

Perhaps others have had a different experience and would share it with me?


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## Veneficus (Jan 16, 2011)

jtpaintball70 said:


> Really EMS doesn't have unions? I guess NEMSA  is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*.
> And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.



You forgot AFSCME and Teamsters.


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## firetender (Jan 16, 2011)

Veneficus said:


> But all of that comes from being a medic, not a basic. I cannot really think of anything in my EMT-B education or experience that has had any impact on my medical successes.
> 
> Perhaps others have had a different experience and would share it with me?



I'm a hound on this and it's probably a 50/50 split on opinions, but there are innumerable logistics that need to be handled on the scene of an emergency, often times the least critical of which have anything to do with advanced intervention.

It is an ART form where you are turning chaos into order. To minimize the importance of handling and then learning to MASTER all those niggling little details, primary of which is COMMUNICATION, is like saying the job is like re-stocking shoe store shelves.

It ain't, it's about creating a space to work, maintaining its integrity, and then moving a human being from one safe space to another.

Now screw the paramedic stuff and bring these skills -- this way of THINKING and ACTING--  into the outside world. What do you get? You get people who, with no more experience than in BLS, but trained by continual exposure and repetition -are capable of quick, responsive observation followed through by ACTION.

Lives get saved that way. They get damaged by inattention to those details deemed so irrelevant.

I don't think I need to belabor the point. Part of the problem is we don't take the time to acknowledge just how important each phase is and how its contribution is essential to being able to act effectively at the next level.

Vene, every foundational step of your in-hospital management of a crisis -- the same crisis' your MD-in-training colleagues fumble through -- is stuff you don't even have to think about anymore because it was ingrained in you while you were a hack.


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## abckidsmom (Jan 16, 2011)

Veneficus said:


> I started that way
> 
> ED tech was the best paramedic job I ever had. The hospital required a year of busy field experience to apply. Otherwise I would have been more than happy to go right from school to ED tech. As it turned out, there were several years in between.
> 
> ...



I was having an extreme bout of sarcasm.  Don't think there's a single thing in the world wrong with being an ED tech.  It is a good time, with lots to learn, but spending time on a BLS ambulance doesn't prepare you for it any more than an hour or two touring the ED could.

I've experienced what you're talking about, being the only one who can prioritize decisions and do a few skills, I think that just comes from already having jumped over the edge of talking to a patient, making decisions for a patient, and doing things to and for the patients.

I'm seen good BLS providers who can do the same, though, and quickly get over that hump in other educational settings.


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