# Is a stupid medic a better provider than a smart medic?



## DrParasite (Nov 13, 2010)

So the title of the thread might be misleading.... maybe a better title would be "is an uneducated medic better than an educated medic?"

I read somewhere (I don't remember where) that a doctor has to run labs, get information about family history two generations back, and perform an assessment/12 lead/obtain full history/meds/vitals before a diagnosis of MI can be bother diagnosed and treated.  Basicly, takes a long time.

Now a paramedic, needs to get a full history, 12 lead, and complaint of cardiac related complaint, to treat a MI.  takes a little less time.  Can't do as much as a doctor, or be as educated as a doctor, but can still diagnose an MI in th field.

and EMT, needs to get a full history, and with a complaint of chest pain (along with associated potential cardiac symptoms) is treated as a possible MI until proven otherwise.  

Now, we all know a paramedic can treat an MI better than an EMT.  and I think we can also agree that a doctor is better qualified to diagnose an MI and treat than a paramedic (can we)?

But lets hypothesize for a moment,  if you lack the education, and still treat based on the patients symptoms, and treat appropriately, how important does the education become?

the other "extreme", a multi system trauma that occurs in the field.  an EMT might control bleeding, and monitor an airway, and transport to a trauma center.  a paramedic might control bleeding, intubate the patient, start two large bore IVs, and transport to a trauma center.  and a physician, along with a full trauma team of doctors, 2-4 nurses, 1 tech, and who knows who else, takes an extended time to do all the things a doctor does (can we agree that a trauma doctor has limited uses in the field?)

So, with the shortened education, is that an acceptable level to treat patients?  Meaning, if the patient doesn't suffer, and infact is treated more appropriately, isn't it a good thing?


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## JPINFV (Nov 13, 2010)

Let me know when the paramedics can do PCI in the field.

Let me know when the majority of paramedics can diagnose NSTEMI in the field.

Let me know when paramedics can do surgery in the field.


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## MrBrown (Nov 13, 2010)

Our Intensive Care Paramedics can to thrombolysis, does that count?


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## Shishkabob (Nov 13, 2010)

JPINFV said:


> Let me know when paramedics can do surgery in the field.



We can.


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## JPINFV (Nov 13, 2010)

Linuss said:


> We can.



Really, what type of surgeries can you do in trauma patients, or are you just talking about surgical airways? Are you opening up the abdomen or doing ortho in the back of the ambulance in parts of Texas?


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## Shishkabob (Nov 13, 2010)

You never said a specific kind of surgery.  ^_^


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## JPINFV (Nov 13, 2010)

Touche.


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## akflightmedic (Nov 13, 2010)

JPINFV said:


> Touche.



Touche---Pronounced Too-Shay

Douche---Pronounced Doo-Shay??  Why not?


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## RUGBY66X (Nov 13, 2010)

all points agreed but an MI isn't just an MI Your basic gives nitro a medic can go farther and uses other drugs and monitor to see that it works and docs have cath labs and such and can provide an even higher level of treatment. 

So yes while it does take longer for each level to perform their interventions it is done so that the care giver can provide care with a greater chance of recover through more sophisticated techniques because the day I go into cardiac arrest or anything i pray a couple of basics don't come strolling up my drive.


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## usalsfyre (Nov 13, 2010)

DrParasite, I'm not sure where your going with this but...

In regards to your first scenario my service/base hospital run a STEMI program in which we bypass the ED based on field activation. Meaning once I call the STEMI in the field the cath lab is notified and receives a copy of my 12 lead, I draw a venous sample that gets run as soon as we walk in the door, ect. In addition we initiate a heparin bolus and beta blockade (if needed). Our medics are also far better equiped to deal with problems in the ensuing transport if they arise. Considering basics in most states can't even initiate IV access this program wouldn't even be possible with basics.  

Trauma is a different animal but true surgical emergencies usually don't exactly grow roots in the trauma room. Generally the traumas you see languish around the ED are not time critical in nature. 

There's no point in blindly treating symptoms if you can do better. Since that's all a basic (and for that matter a lot of medics) can do, I'm 110% against basics being the primary provider on a transpot unit. This is primarily due to lack of education.


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## EMSLaw (Nov 14, 2010)

JPINFV said:
			
		

> Let me know when paramedics can do surgery in the field.



I'm hardly an expert in Paramedics' historical scope of practice, but I believe several "surgical" techniques have been removed over the years.  And, while every licensed MD can theoretically, under the scope of his license, start cutting on you, relatively few have the training and experience to pull it off.

That should not be taken to disagree with your basic point.  Comparing paramedics to physicians is like saying that a notary public is the same as an attorney because we both can administer oaths, and they're "better" because they'll do it no questions asked.  

As for whether an ignorant paramedic is the same as a more educated one...  Well, any monkey can follow a protocol book.  But patients have an odd habit of not fitting neatly into our preplanned notions.  The focus of EMS has to change from merely delivering a live patient to the ED to making those interventions that contribute to a continuum of care that eventually leads to the best patient outcome.  The more the medic knows about what he's doing and why, the better he's able to do that.


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## adamjh3 (Nov 14, 2010)

I think the question that should follow is: Do we really need the same amount of education as a doctor if our job is to make the patient comfortable until they reach definitive care, while improving the patient's condition if we can?

Yes, having a better understanding of chemistry, microbiology, anatomy, physiology and all the other classes many on here suggest should be taken will help us identify and treat the many, many different presentations in the field. BUT, the higher education standards will have to come with a re-definition of our profession. 

Instead of "tranport and care of the sick and injured" we would move to a "diagnosis and treatment of the sick and injured, with occasional transport," giving us more of a role AS definitive care. 

I haven't been in the field long; I don't know enough to say if this redefining of standards in this manner would be a good or bad thing. However, something is wrong, and something is going to change. Whether we go into it with open minds and open arms, or dragged into it kicking and screaming will be decided by many factors. 

From what I see on this board, many push for us having higher education and a higher level of care in the field. And from what I see in my co-workers and others in the field is content with where they are. 

Frankly, I'm not sure where our future lies.


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## JPINFV (Nov 14, 2010)

adamjh3 said:


> Instead of "tranport and care of the sick and injured" we would move to a "diagnosis and treatment of the sick and injured, with occasional transport," giving us more of a role AS definitive care.



Providing competent care requires a diagnosis. Unless you are following a chief complaint driven protocol word for word with zero discretion, you engage in the practice of making a diagnosis. Use what ever modifier like "working" or "field" that you want to come to peace with that concept, but you do diagnose. 

If EMS providers are supposed to be protocol drones, they we're over educated for that. It doesn't take 110 hours to learn how to take a set of vital signs and slap an oxygen mask on a medical patient or do the handful of basic trauma first aid interventions that EMTs do. Unfortunately, it takes over 110 hours to learn how to do that while also forming some sort of educated opinion on what is occurring and form a decent treatment plan. Similarly, it doesn't take 1000 hours to train a paramedic to be a protocol drone. 

Of course I've always hoped that EMS was something better than over paid, over educated protocol drones. 





> From what I see on this board, many push for us having higher education and a higher level of care in the field. And from what I see in my co-workers and others in the field is content with where they are.
> 
> Frankly, I'm not sure where our future lies.


Unfortunately, the vast majority of EMS providers that want a higher standard are those who seek parallel health care fields such as medicine or nursing that already have higher standards, reimbursement, and freedom.


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## 18G (Nov 14, 2010)

I had thoughts similar to the OP just yesterday... weird. 

To preface... I am all for as much education as one can obtain. Knowledge is power and it offers the ability to make a difference. 

To answer the OP... I see where u are coming from with the questions your asking. I think the field is just that... the field. It is not a definitive playground and I feel safe in saying it never will be. There is only so much that can and should be done in the field. The main goal of EMS is to get patients to definitive care (hospital) in better shape than we found them and ultimately get them to the hospital so that they are viable to the physicians awaiting them.

While I do not condone a skills based curriculum I do see where your thoughts come from. If a patient receives the necessary interventions to stabilize, provide comfort, analgesia, and efficient movement and transport, do we need providers with 4 years of education to do this? EMS is with a patient in most systems at most less than 20-30 minutes... our focus is on quick and immediate.  

I would like to see a study on patient outcomes that compares patients treated by Paramedics with a minimum of a bachelors degree and say 2 years of experience compared to a "Medic Mill" Paramedic with a similar experience base. 

Would there be any difference in the quality of care? 
Would patients rate their care any higher with the bachelors group?
Would the same interventions be performed by the two groups group? and would there be any delay in the interventions (ie delayed recognition)?
Would the increased education have clinical significance when working in the field?

For example, pre-hospital ultrasound. It sounds like a great thing but its kinda like an EMT having a glucometer who can't start a line and give D50 or give glucagon. So the Paramedic see's something on the ultrasound... what does it change? Could the maintenance of a high index of suspicion still result in the same decision making?

I believe EMS does need to increase its educational foundation and have an Associates degree as a minimum... the question is though... what is the threshold as to where you won't see any additional benefits in the field environment?

As the OP mentioned... a doctor in the field is only going to be able to do so much... now put the doc and patient in the hospital and its game on into overtime. I think that is the point.


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## CAOX3 (Nov 14, 2010)

RUGBY66X said:


> all points agreed but an MI isn't just an MI Your basic gives nitro a medic can go farther and uses other drugs and monitor to see that it works and docs have cath labs and such and can provide an even higher level of treatment.
> 
> So yes while it does take longer for each level to perform their interventions it is done so that the care giver can provide care with a greater chance of recover through more sophisticated techniques because the day I go into cardiac arrest or anything i pray a couple of basics don't come strolling up my drive.



Teach your family CPR, or it isnt going to matter who strolls up your driveway.

Education and training are completely different things.

Education is thought based, training is action based.


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## firetender (Nov 14, 2010)

*Q? Spell medicine. A> C-Y-A*



DrParasite said:


> a doctor has to run labs, get information about family history two generations back, and perform an assessment/12 lead/obtain full history/meds/vitals before a diagnosis of MI can be bother diagnosed and treated.  Basicly, takes a long time.



_*WHAT THE DOCTOR IS THINKING:*_ *"Was it back in April's JAMA they said be sure to include Calcium levels to be completely covered in a lawsuit?"*



DrParasite said:


> Now a paramedic, needs to get a full history, 12 lead, and complaint of cardiac related complaint, to treat a MI.  takes a little less time.  Can't do as much as a doctor, or be as educated as a doctor, but can still diagnose an MI in th field.



_*WHAT THE PARAMEDIC IS THINKING:*_ *"Good, got that done! How the hell am I gonna survive on less than 15 bucks an hour?"*



DrParasite said:


> and EMT, needs to get a full history, and with a complaint of chest pain (along with associated potential cardiac symptoms) is treated as a possible MI until proven otherwise.


_*
WHAT THE EMT IS THINKING:*_ *"No tools! What do I do now, just TALK?!"
* 


DrParasite said:


> Now, we all know a paramedic can treat an MI better than an EMT.  and I think we can also agree that a doctor is better qualified to diagnose an MI and treat than a paramedic (can we)?



not in the field. Most Docs are trained to NOT diagnose until the tests come in. Paramedics are told they CAN'T diagnose in the field but persist on doing so. Emergency situations require getting results, not contemplation AFTER getting "results".

Remember, however, Emergency medicine in the field is all about doing the best with the moments between here and there, therefore the scope of diagnostics is extremely narrow.



DrParasite said:


> But lets hypothesize for a moment,  if you lack the education, and still treat based on the patients symptoms, and treat appropriately, how important does the education become?



This is apples and oranges, what goes on in the field is immensely more different than what goes on in the hospital. _*Whatever a paramedic does is a precursor to management of a medical condition and no more*_. The education of a Doc is about long-term management with complete systems, NOT short-term intervention on specific parts or life-threatening entities.

I would like to see paramedics educate themselves on ALL aspects of the specific, targeted, life-threatening entities that they are most likely to encounter. *I really don't believe they should fill their heads with differential diagnosis of EVERYTHING any more than I believe that a Doctor should do ANY test or procedure on a human being to allay his/her own fears.*



DrParasite said:


> the other "extreme", ...isn't it a good thing?



I look forward to your next challenge. This one was kinda like Swiss cheese.


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## adamjh3 (Nov 14, 2010)

JPINFV said:


> Unfortunately, the vast majority of EMS providers that want a higher standard are those who seek parallel health care fields such as medicine or nursing that already have higher standards, reimbursement, and freedom.



And therin lies the root of the problem. The majority of providers that want more for the field get frustrated with the lack of change and thus the change never comes.


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## MrBrown (Nov 14, 2010)

Could be worse, you could be Brown


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## Melclin (Nov 14, 2010)

I think everyone is aware that paramedics don't need as much education as doctors. 

Undoubtedly there is a level of education that allows a person to adequately and appropriately go about the task of providing good pt care. 

But I think its pretty funny that some people think that a few months in the back room of a fire station constitutes that level. That a degree is "excessive" for paramedics. This is despite the fact that top tier (a "paramedic" in the US) prehospital care in just about every other developed nation is the domain of a highly experienced and well trained prehospital specialist (Advanced Care Paramedic, Intensive Care Paramedics, etc), a cross trained and experienced RN (as in Norwegian Ambulance Nurses), or a doctor.  

Do you wonder why medical directors have kittens about things like RSI, field cath lab activation, even adequate pain relief or removing blanket protocols like "everybody gets a NRBM @ 15L" or transporting all arrests to hospital? Its not because they question the idea/treatment/drug. They question the ability of the people applying them.


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## mgr22 (Nov 14, 2010)

Back to the OP, I think it's valid to consider different roles and scopes of practice for paramedics, but I see education as something that stands on its own merit. I can't predict when something I've learned will help me or my patient. That "knowledge is good" line from _Animal House_ is funny, but it's also true.

When I was in engineering school, I had to take liberal arts courses that had nothing to do with the technical part of the curriculum. I admit I didn't see the value of "Contemporary Civilization" or "Creative Writing" then, but they've definitely helped me understand and communicate with others. It would have been harder for me to appreciate the "art" of what we do as EMS providers without a broad-based education.


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## Veneficus (Nov 14, 2010)

*i was trying to come up with a tempered reply*

I problably failed.

For the 1,000,000th time. The way EMS is operating now is unsustainable economically. The effects may not have hit your area yet, but just give it some time. An ambulance is not a need, it is a want. 

*Transport to definitive care **DOES NOT MEAN AN EMERGENCY ROOM OR HOSPITAL*. Everyone in the whole world has figured that out. Even some places in the US.

I don't know why the OP keeps posting these "is it ok to be a common laborer" type threads. I hope it is to be the devil's advocate or illustrate this to coworkers.

It is not ok. At least not if you don't want to meet the same fate at GM or US Steel or any number of labor industries. People need cars and steel, but they do not need to pay an outrageous price for it so some uneducated laborer can have a middle class life by the US standard of living.

Education allows a person to make reasonable decisions. Not every chest pain is an MI. They don't always present with crushing substernal chest pain radiating to the arm and jaw. It is education that allows you to consider alternative presentations or figure out something you haven't memorized.

It is an educated medic that knows a 67 y/o female complaining of shortness of breath and a feeling of abd bloating could be an MI.

It is an educated medic who realizes that pneumonia is a common complication of CHF and doesn't administer furosimide because he hears "wet lung sounds"

It is a skilled medic who uses a coma coctail because he cannot tell the difference between an opioid OD, a hypoglycemic event, or any other condition that can cause an altered LOC. 

It is a skilled medic who tells patients they are having heartburn because there is no ST elvevation or crushing chest pain radiating.

It is a skilled medic who leaves a patient to die because he cannot tell the difference between a drunk and a severe trauma.

It is a skilled medic who sits on the pad at a hospital trying to start an IV or tube a patient in the back of the ambulance with the doors closed because he doesn't want to be embaressed by coming to the hospital without one.

The idea that a doctor needs all kinds of tests is flawed. There are a lot of tests that are run for lawyers, not for patients. Many times hospital staff all ready know the results of many tests before they are performed from physical findings.

Do you really think anyone needs to see a white cell count, or a bacterial culture to know if somebody is in septic shock?

Nevermind the future of EMS, lets work with now. One of the most important things a paramedic (or basic) can do is recognize a life threatening emergency. Even in the paramedic curriculum, not all of the common life threatening emergencies are listed. Which means if that is the only education they have they will sometimes not know an emergency when they are looking at it. 

It is much easier, cheaper, and has a better prognosis to treat patients before they decompensate. Just like it is all of those things to treat a peri arrest before it becomes an arrest. 

I was working as a medic in the field when you were a outstanding paramedic if you could run the whole ACLS algorythm on an arrest patient down to aministration of magnesium sulfate. (that is alternating high dose epi and levofed, plus one other drug for the young crowd and using the full dose of lidocaine, bretylium, procanamide, sodium bicarb and finally mag) in under 15 minutes. Including the shocks, iv start, and intubation. Most often with an EMT partner doing CPR the whole time.

We were skilled. In spite of that skill a very few of those patients actually lived. For a few days. Some for a few months. On a ventilator. Maybe one or two actually made it home with severe deficits.

When I was in paramedic school, my instructor had a 9 year old son who often was a victim for the class. He could perform any paramedic skill on any mannequin. He could even show students how to do it properly and anticipate their mistakes. He is skilled. Should we have let him loose on an ambulance? He could perform every skill any other paramedic could. More proficently than most.

A "skilled" paramedic who can only follow protocol and drive to the hospital is nothing more than an overpriced taxi and should be compensated accordingly. 

At minimum wage. I also dobt they are worth that. Perhaps all volunteer. You should also get a paramedic card if you can pass the NR skills exam as well. Even if you never set foot in paramedic class. The quality wouldn't be any worse.


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## 18G (Nov 14, 2010)

Veneficus said:


> so some uneducated laborer can have a middle class life by the US standard of living.



Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?



> An ambulance is not a need, it is a want.



Really? So communities do not need EMS and could be just as well driving themselves to the hospital? Anaphylaxis patients do not need EMS? Severe asthma exacerbations do not need EMS? These patient types and  similar just call because it's convenient?

We do need to see a rise in the minimum level of education...AGREED... and obtaining knowledge is a life long quest. The tone at which it is advocated is most often not appropriate and prob turns a few people off making the advocation less effective. It's not gonna happen overnight but each of us can commit to making ourselves more adept and eager to learn more and encourage our peers.  

My question is this.... why did all of the EDUCATED people who were responsible for designing and implementing EMS systems and curriculums allow EMS to get into the shape that it did? The EDUCATED people sucked all of the NON-EDUCATED people into their so-called flawed system design and now the EDUCATED people are acting like it's the NON-EDUCATED people's fault for the foundation and systems they created and kept in motion for decades. These EDUCATED people are the ones who sold everyone the lie that skills based EMS and minimum standards were all that was needed and ingrained it into our societies minds and now they want to chastise providers for their mistakes.

So where does the blame really fall? The EDUCATED or the NON-EDUCATED. 

NOTE: I do not use the term "non-educated" literally... it merely serves as a contrast.


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## reaper (Nov 14, 2010)

+10. Very well stated.


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## usalsfyre (Nov 14, 2010)

18G said:


> Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?
> 
> 
> 
> ...



Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements? 

(Most people here don't want to hear my theory on this).


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## Veneficus (Nov 14, 2010)

18G said:


> Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?



I think I am torn between elitist and realist. 

I think that unskilled and skilled laborers cannot expect the same quality of life as the people who do go to college. I think the price fixing by labor unions is one of the reasons that America is no longer competative in the world market and causes a net loss of jobs. Is the senior mechanic any more deserving than the junior? Because he may have been born earlier and therfore showed up for work longer? Or because he got hired earlier from nepotism?

The wages they demand compared to the job they perform is no less than legalized extortion. It is no wonder most union employees now are government workers. They have driven most other industries out of buisiness or country.

But I have some history with it. I am the first in my family to go to college. Mostly because my dad figured out it does lead to a better life and while he didn't force me, he certainly made every effort to encourage it. 

At one point I figured a job at a union shop was the best life going. But it only takes a few hours of heavy work a day to see that those "educated" people have it better. They earn more, get hurt less, actually don't work paycheque to paycheque hoping they don't miss a day of work and throw off paying all the bills. They get to take time off to go see their kids and school and stuff because they are so *valuable* that they have positions where their company would rather give them a day off and have them come back than wonder if they should get somebody else.

As my education progressed at some point I realized that I was getting paid for what seemed like really easy jobs compared to what I was doing before. 

Being around even higher educated people, I realized the disproportion of what they had compared to what my family had and how hard we worked for what little we had. I realized the wisdom my dad had in promoting education even though he had only completed 10th grade.

I also realized that the world was changing. As my family displaced American workers because they were willing to work for much less, new immigrants were threatening to displace my family. I realized there was no hope for a decent future as a laborer.

But the final straw was when I saw my friends who were IAFF members getting laid off. As the older guys voted to not take a pay cut that left the younger guys struggling to find a job or feed their families, I realized not only the extortion of it, but how the "all for one and one for all" of the fire service was only empty words or lies.

The collective knowledge of man has exponentiated in the last 20 years. The minimum knowledge a person needs to be of value to society (aka well paid) has increased. College is the only way to do that at the moment.  

There was a time when a highschool diploma could land you an outstanding job. Then it reqiured a 2 year degree, next a 4. In some disciplines now at least a 6. (psych and varios therapy) 

It is not whether or not somebody is deserving of a good life, it is how good of a life they can expect. If you again look at laborers globally, they are at the bottom of the food chain. They barely eek out a living in many places. US workers have been suffering the same, and it is only a matter of time before EMS is the same way. 

If you choose to deny that, it is yor choice, but I am altruistic just enough in my arrogance to not want a bunch of well meaning young people think that they are secure because they took a vocational EMT-B or a EMT-P and be a valuable healthcare worker with their few hours of training.

I started at the bottom, and while I learned a lot from it, that level of effort and sometimes suffering, is not mandatory. The earlier in life you realize it, the better your life will be.


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## Veneficus (Nov 14, 2010)

18G said:


> Really? So communities do not need EMS and could be just as well driving themselves to the hospital? Anaphylaxis patients do not need EMS? Severe asthma exacerbations do not need EMS? These patient types and  similar just call because it's convenient?



If communities actually needed EMS, there wouldn't be so many volunteer departments. What happens when volunteers don't show up? You find a way, get better, or die. 

If it was a neccesity, like roads, or police, etc. It would be required in all places. Some states do not mandate EMS. Across the US, EMS does not share pay parody and are not always officers of the state such as LE and Fire officials.

I think it should be a neccesary service, but the nation doesn't feel the same.



18G said:


> We do need to see a rise in the minimum level of education...AGREED... and obtaining knowledge is a life long quest. The tone at which it is advocated is most often not appropriate and prob turns a few people off making the advocation less effective. It's not gonna happen overnight but each of us can commit to making ourselves more adept and eager to learn more and encourage our peers.



I am tired of being nice. I am tired of pointing out the obvious, especially when people fight thier betterment with pathetic "not where i live" and "this is what I see today" arguements. I have been trying to advance EMS for a long time, and it is the laboer mentality holding it back. It is why "The best and brightest" move on to educated professions. Who with rare exception make considerably more in much better conditions.



18G said:


> My question is this.... why did all of the EDUCATED people who were responsible for designing and implementing EMS systems and curriculums allow EMS to get into the shape that it did?



When the system was designed, it was designed to add skills to a labor force. (Usually firefighters) Nobody at the time could have expected so much change so fast. Some of those "educated people" have died or even given up on advancing EMS. I admit I am reaching the point of giving up on it myself.

I absolutely think it was neglect by the physicians tasked with directing EMS or overseing its implementation that caused many problems. I have called them out on it more than once, both publically and privately. 




18G said:


> The EDUCATED people sucked all of the NON-EDUCATED people into their so-called flawed system design and now the EDUCATED people are acting like it's the NON-EDUCATED people's fault for the foundation and systems they created and kept in motion for decades. These EDUCATED people are the ones who sold everyone the lie that skills based EMS and minimum standards were all that was needed and ingrained it into our societies minds and now they want to chastise providers for their mistakes.



I agree, I was not one of those people. I am from the flawed system and I want it changed. Unfortnatly, most people don't like change and they fight hard against it.   



18G said:


> So where does the blame really fall? The EDUCATED or the NON-EDUCATED.



I think both share equal responsibility. The educated for the neglect and apathy. The non educated for the resistance and complacency. But who is to blame is not as significant as fixing it. Which will require both as well. But as physicians have long neglected EMS they will have to put forth significant effort to fix it. More than they are doing I am sorry to say.

There is a bit of an impass though, because the noneducated have made it easier to replace the physician than themselves, which very mch limits the physicians power to alter the system. (though they should have faught harder to maintain their authority to begin with.)


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## Veneficus (Nov 14, 2010)

*post trifecta*



usalsfyre said:


> Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements?
> 
> (Most people here don't want to hear my theory on this).



I want to hear your theory. But I am willing to bet if the standards EMS set for itself were higher than the minimums set by the others they will get to.


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## JPINFV (Nov 14, 2010)

usalsfyre said:


> Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements?
> 
> (Most people here don't want to hear my theory on this).



In part because only a handful of EMS providers join EMS associations like NAEMT that are supposed to advocate FOR EMS? On the other hand, I'm a member of the LA County Medical Association (free for students), California Medical Association (Free for students), American Osteopathic Association (free for students), and the American Association of Emergency Medicine (1 year free, afterwards reduced cost for students). These are all associations that not only reach out to students, but also allow students to attend the yearly House of Delegates meetings where policy proposals are submitted, and if the student section agrees, even submit policy proposals. 

How well have EMS agencies reached out to students to hook them in? How many people know what the mission of the NAEMT is past sponsoring courses like PHTLS?


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## firecoins (Nov 14, 2010)

Some people say there are no scientific studies showing ALS saves lives.  

Various trauma surgeons would get rid of als training because it adds another step before the patient gets to surgery.  

There is no doubt that most calls could be done by a driver with a wheelchair van and an o2 tank.


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## JPINFV (Nov 14, 2010)

firecoins said:


> Some people say there are no scientific studies showing ALS saves lives.



Is the only value added by paramedics and EMS lives saved?

Can that asthmatic patient survive another 5-10 minutes to run to the hospital? Most likely, so you aren't saving the asthmatic's life, but what about the reduction in suffering?

Can the pulmonary edema patient survive another 5-10 minutes without nitro, supplemental oxygen, and CPAP? Probably, but what about the reduction in suffering?

Does pain control save lives? Does it reduce suffering? 


EMS in general saves very few lives (especially patients in cardiac arrest), but it can do a lot to reduce suffering, and in some few cases, save lives.


----------



## firecoins (Nov 14, 2010)

JPINFV said:


> Is the only value added by paramedics and EMS lives saved?
> 
> Can that asthmatic patient survive another 5-10 minutes to run to the hospital? Most likely, so you aren't saving the asthmatic's life, but what about the reduction in suffering?
> 
> ...



Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs.   The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true.  There are MDs who do not see a need for prehospital ALS.

And yes, saving lives would be our primary justification.  Reducing suffering is a far second.


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## fortsmithman (Nov 14, 2010)

firecoins said:


> There are MDs who do not see a need for prehospital ALS.
> .



I think that's how EMS is run in the province of Quebec.  I read in another forum that the only level of prehospital care in Quebec is BLS only no ALS.  If there are any members from Quebec please correct me if I'm wrong.  I heard the reason for this comes from the College of Physicians and Surgeons in Quebec.


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## adamjh3 (Nov 14, 2010)

firecoins said:


> Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs.   The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true.  There are MDs who do not see a need for prehospital ALS.
> 
> *And yes, saving lives would be our primary justification.  Reducing suffering is a far second*.



How many on here (some with years - decades, even - in the field) can truly boast saved lives? Public perception - that we're heroes who roll up on a guy who died in a car accident and punch his chest a few times to bring him back to life - is one thing, the reality of it is another. 

As far as reduction of suffering: Why should that be a far second? That should be our primary concern (with the system in place now), making our patients as comfortable as possible for the trip to the ER. 

Vene, you have made some posts that have been extremely enlightening for me, both in this thread and elsewhere. You're frustration in the matter of not being able to fix the EMS system brings me back to what I poorly articulated in my first response in this thread. Is it worth fighting to change the system? It will break, hell, it is breaking. Would it be easier to fix it from the bottom up than to try to change the mindset of many hard-headed traditionalists?


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## JPINFV (Nov 14, 2010)

firecoins said:


> Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs.   The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true.  There are MDs who do not see a need for prehospital ALS.
> 
> And yes, saving lives would be our primary justification.  Reducing suffering is a far second.



The problem is that the majority of patients that EMS sees does not require saving in the time period that EMS is involved. Cardiac arrests need saving before EMS arrives (not witnessed or no bystander CPR essentially means the patient is dead by the time EMS arrives). Most of the other patients with life threatening diseases can wait several minutes, which makes it hard to judge statistically, or other wise, how many patients EMS "saved" in contrast to care provided in the emergency department. 

Yes, reducing suffering is achieved in the hospital as well, but why make patients suffer an extra 10-30 minutes that it takes for the patient to be transported, care handed over, and finally for the physician to make his or her way to the patient's bedside. A physician may be johnny on the spot to someone in bad shape, but not necessarily pain control. This is, of course, also ignoring the standing orders for RTs and RNs in the emergency department. 

Finally, yes, there are some physicians who seek to needlessly restrain EMS. However I'd argue that they aren't nearly as bad as the apathy and resistance found by EMS providers.


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## Veneficus (Nov 14, 2010)

adamjh3 said:


> Vene, you have made some posts that have been extremely enlightening for me, both in this thread and elsewhere. You're frustration in the matter of not being able to fix the EMS system brings me back to what I poorly articulated in my first response in this thread. Is it worth fighting to change the system? It will break, hell, it is breaking. Would it be easier to fix it from the bottom up than to try to change the mindset of many hard-headed traditionalists?



You are too kind.

The problem that I worry about letting EMS break is that if it does, the new version will be determined not by EMS professionals, and I think not even medical professionals, but by politicians and bankers.

If that happens, BLS only will be a real possibility. It has already been suggested by one Politician in Columbus, Ohio noting the short transport times and the lack of evidence ALS saves lives.

That makes it even more imperative in this current antigovernment spending political climate that real value be demonstrated. Policy makers are watching and there are loads of other programs that will demonstrate they should not be the one to take the cuts. Like farm subsidies and physicians.

I cannot possibly see EMS being made better by nonprovider parties.


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## medic417 (Nov 14, 2010)

http://www.emtlife.com/showthread.php?p=260501#post260501


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## ffemt8978 (Nov 14, 2010)

firecoins said:


> Some people say there are no scientific studies showing ALS saves lives.
> 
> Various trauma surgeons would get rid of als training because it adds another step before the patient gets to surgery.
> 
> There is no doubt that most calls could be done by a driver with a wheelchair van and an o2 tank.



That is why one county medical director in the next county over only allows BLS ambulances in his county.  He would rather the ambulance transport the patient to the hospital than to spend 15-30 minutes on scene doing ALS procedures.


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## 18G (Nov 14, 2010)

There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives. 

- An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway. 

- A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50. 

- What about a seizure patient who is status? We let them seize, become hypoxic and acidotic which leads them to arrest during the 30 minute BLS only transport? 

- What about the 12yo asthma patient who forgot his inhaler and is now in extremis? He endures BLS transport while struggling to breathe and eventually arrests?

- What about field induced hypothermia for post-resuscitation?

- What about STEMI recognition and cath lab activation? BLS?

I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.


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## Veneficus (Nov 14, 2010)

*more on perspective*

Not trying to pick on you, you bring forth a worthy debate.




18G said:


> There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.
> 
> - An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.
> 
> ...



Could I just also inquire what percentage of your agencies total calls fit the ones you have cited?


----------



## ffemt8978 (Nov 14, 2010)

18G said:


> There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.
> 
> - An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.


  Epi-pens are required on all ambulances in the state, by a law known as the Kristine Kastner Act.  Transport times in that county are usually less than 15 minutes.



18G said:


> - A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50.


  See previous comment about transport times.  Given that the nearest ALS unit to that county is 25 minutes away, assuming they are not on another call at the time, BLS transport is the best option available to them.  Also, they do have some ILS technicians which can give D50.



18G said:


> - What about a seizure patient who is status? We let them seize, become hypoxic and acidotic which leads them to arrest during the 30 minute BLS only transport?


  See previous comment about transport times and ALS response times.



18G said:


> - What about the 12yo asthma patient who forgot his inhaler and is now in extremis? He endures BLS transport while struggling to breathe and eventually arrests?


  Their ILS techs can administer albuterol.



18G said:


> - What about field induced hypothermia for post-resuscitation?


  You mean a procedure that is not nationally accepted yet, nor is it available in this state?



18G said:


> - What about STEMI recognition and cath lab activation? BLS?


  Their nearest hospital with a cath lab is an hour away.  Would you rather ground transport that hour with an ALS unit, or transport 15 minutes to a hospital for stabilization and transport by air?



18G said:


> I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.


The community in question doesn't think so, and it is really their choice.  This is a hospital based ambulance service, and that is what the community wants.  The issue has been brought before the voters before, who have rejected going to an ALS service because of the costs that they would incur.

Right, wrong, or indifferent, it is the communities choice and that is the one they have made.


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## Veneficus (Nov 14, 2010)

Wait, no I forgot for a minute:

In the event of seizure, place 1 rectal diazepam suppository.

Been a few months since I have seen a peds patient, we actually prescribe these to parents. 

If parents can do it, basics can do it.


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## EMSLaw (Nov 14, 2010)

Veneficus said:


> Could I just also inquire what percentage of your agencies total calls fit the ones you have cited?



A quick, dirty, and of questionable reliability google search indicates that there are approximately 40 cases per 100,000 population of status epilepticus in a given year.

Which probably explains why despite answering numerous (n>30) seizure calls, I have yet to have one that hadn't broken prior to EMS arrival.  Of course, it'll be nice to have medics if it ever does happen.


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## Veneficus (Nov 14, 2010)

EMSLaw said:


> it'll be nice to have medics if it ever does happen.



That is the key phrase.


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## DrParasite (Nov 14, 2010)

Veneficus said:


> If parents can do it, basics can do it.


Now if only this was the standard.... if parents could do it, basics could do it.

think about it

BGL checks
Albuterol nebulizers.
Pulse Ox checks (yes, there are places where they are not considered to be BLS skills)
D50 for known diabetics (often kept in the fridge at home and used only for emergencies)
Epi Pens
Benedryl for allergic reactions

ahh, a man can dream...B)


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## JPINFV (Nov 14, 2010)

I think there's a big different than a parent administering a medication to a child diagnosed with a specific disease with education on when to seek additional medical evaluation and an EMS provider doing an assessment, making a diagnosis, and then delivering said medication.


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## usalsfyre (Nov 14, 2010)

*The reason EMS does not control it's own destiny...*

...is that the majority of medics are lazy, uneducated dumb@sses who would rather whine and complain about their situation rather than better it. The majority of those who aren't move onto better situations/other careers. Leaving the few of us who know better, want to improve and choose to stay stuck with major resistance from the first crowd. For EMS professed hate of the welfare crowd, they sure resemble it sometimes.


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## DrParasite (Nov 14, 2010)

MrBrown said:


> Our Intensive Care Paramedics can to thrombolysis, does that count?


Can you explain that to me?  I am guessing you are giving them for CVAs right?    But if it's a hemorrhagic stroke, thrombolysis would make the problem worse.  And unless I am mistaken (which I may be), isn't the standard for a stroke to differentiate between a hemorrhagic stroke and a clot caused stroke done by running a CT or MRI scan?

Please share.


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## JPINFV (Nov 14, 2010)

Thrombolysis can also be given for an MI.


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## Akulahawk (Nov 14, 2010)

fortsmithman said:


> I think that's how EMS is run in the province of Quebec.  I read in another forum that the only level of prehospital care in Quebec is BLS only no ALS.  If there are any members from Quebec please correct me if I'm wrong.  I heard the reason for this comes from the College of Physicians and Surgeons in Quebec.


While Quebec is basically BLS-only, they are slowly raising things to ALS. The Medical Directors there are convinced that nobody but Physicians are educated enough or can be educated enough to provide an advanced level of care. In their case, a lot of the pre-hospital EMTs _want _to provide better care... but they're restrained in doing so. Notice that this kind restraint is not applied anywhere else in Canada on such a large scale.


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## abckidsmom (Nov 14, 2010)

usalsfyre said:


> ...is that the majority of medics are lazy, uneducated dumb@sses who would rather whine and complain about their situation rather than better it. The majority of those who aren't move onto better situations/other careers. Leaving the few of us who know better, want to improve and choose to stay stuck with major resistance from the first crowd. For EMS professed hate of the welfare crowd, they sure resemble it sometimes.



Maybe not a majority, but a significant minority.  The ones who aren't lazy and stupid often have more pressing needs than to revolutionize their industry.

I agree with your general sentiment, though.


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## Veneficus (Nov 14, 2010)

DrParasite said:


> Now if only this was the standard.... if parents could do it, basics could do it.



Where I am from:

BGL checks, *standard*

Albuterol nebulizers, *not standard, but used in many agencies*
Pulse Ox checks (yes, there are places where they are not considered to be BLS skills) *standard as is attaching and printing an EKG (but not interpreting it)*
D50 for known diabetics (often kept in the fridge at home and used only for emergencies): *oral glucose. *
Epi Pens: *standard*
Benedryl for allergic reactions: *I really don't see why not, possibly some malox too.*



DrParasite said:


> ahh, a man can dream...B)



Well, support adding an educational increase and you might be able to reasonably lobby for such.


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## Akulahawk (Nov 14, 2010)

Inline will be some arguments... 


18G said:


> There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.
> 
> - An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.
> *Got an Epi auto-injector? You don't have to be a Medic or EMT to administer those. Vene makes a good point: SQ has a slower absorption time than IM. What they're looking to do is use that slower absorption rate to not stress the heart unnecessarily. Personally, I feel that if someone's bad enough off that they need the Epi to break their anaphylaxis symptoms, they're bad enough to get the Epi administered IM. *
> ...


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## Melclin (Nov 15, 2010)

How about RSI?
-traumatic brain injury.
-stroke.
-other misc hypoxic brain injury (hanging, drowning).
-Airway burns.
-Hyperthermia
-Post ROSC pt. 
-status seizures.
-complex drug overdoses (selected polypharm, trycyclic).

Thrombolysis in MI with no cath lab nearby. 

Chest decompression, both needle and otherwise. 

Sedation for sync cardioversion, especially rurally?

CPAP.

Paralysis (separate to the idea of RSI), hypothermia and inotropic support for post arrest pts?

How about reducing the risk to ambulance providers and the community by treating some time critical problems on scene instead of fanging these BLS ambulances about all the time.

How about trauma triage? Can a BLS provider be trusted to bypass hospitals for trauma centres? If they can, will medical directors have to institute ridiculously overzealous triage protocols?

Will they be able to make use of the increasing prevalence of specialty centres. Stoke centres are increasingly prevalent. I've heard mention of cardiac arrest centres in the works too. Can BLS providers be bypassing EDs in favour of these hospitals (thats not rhetoric, I'm actually asking if EMTs are involved in bypass anywhere)?

Pain relief. I can't think of a more common complaint than pain in ambulance. There are lots of kinds of pain and lots of ways to treat it. Entonox is not enough (although a good option). Neither is "2mg IV Morphine for severe long pain fractures" or whatever that stupid protocol is. Maybe you guys are cool with transporting a banged up kid down a pot holed dirt road after a dirt bike accident or manuevering Nanna NOF out of the back room on the second floor of her block of flats, without proper pain relief, but I'm not. 

Some of these things are just skills. But they are skills that require regular practice to stay proficient in. You can't get one tube a year and expect to be any good at it. Tiered EMS systems are important not only to provide the community with a certain level of care, but it leaves high acuity jobs for specialty providers. So even though there might not be a great deal of RSIs and chest tubes going around, you have them spread amongst a relatively small group of advanced providers. Also, I think you've got it arse up if you think the only choices for these tiers are EMT or Paramedic (at least, as you know them in the US anyway).

Well educated providers make incorporating new additions to scope much easier. Field cath lab activation for example. The price of POC lactate measurement is coming down and the push for early sepsis recognition and treatment is increasing, etc.


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## MrBrown (Nov 15, 2010)

The problem is very simple.  As far as EMS is concerned the United States is generally stuck in the stone age and between 5 to 30 years behind the rest of the Commonwealth nations when it comes to system design, education, scope of practice and clinical dexterity.

Now there are some things it does very well (induced hypothermia, CPAP, steriods for asthma/anaphylaxis, vehicle design and electronic PRFs) however when we look at some other things it really drags the whole system down.

In 1977 it took a recruit two years of education and experience to become a Qualified Ambulance Officer with the Metropolitan Ambulance Service (Melbourne) and they could do little more than oxygen and transport .... nearly forty years later, the US is yet to adopt such a requirement for even thier highest level practitioner.


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## fortsmithman (Nov 15, 2010)

MrBrown said:


> The problem is very simple.  As far as EMS is concerned the United States is generally stuck in the stone age and between 5 to 30 years behind the rest of the Commonwealth nations when it comes to system design, education, scope of practice and clinical dexterity.
> 
> Now there are some things it does very well (induced hypothermia, CPAP, steriods for asthma/anaphylaxis, vehicle design and electronic PRFs) however when we look at some other things it really drags the whole system down.
> 
> In 1977 it took a recruit two years of education and experience to become a Qualified Ambulance Officer with the Metropolitan Ambulance Service (Melbourne) and they could do little more than oxygen and transport .... nearly forty years later, the US is yet to adopt such a requirement for even thier highest level practitioner.



Brown with me and other members from commonwealth countries you are preaching to the choir.


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## Veneficus (Nov 15, 2010)

fortsmithman said:


> Brown with me and other members from commonwealth countries you are preaching to the choir.



Please include me in the choir. 

I am not from a commonwealth country.


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## DrParasite (Nov 16, 2010)

question: are there any quantifiable means (mortality rates, or anything scientific) that show how an educated medic is better than a lesser educated one?

meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.


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## MrBrown (Nov 16, 2010)

Brown thinks you only have to look at the modalities of practice in jurisdictions with varying educational models to answer that question.

In Australia, New Zealand, the UK and parts of Canada Paramedics are given total clinical autonomy and freedom to use professional discretion in how to treat patients.

Each system has guidelines which are interpreted flexibly to suit individual requirements of the patient and situation without recourse to "medical control".  So while guidelines provide the framework for approach to care and procedures for a broad macro-level classification of patients based upon symptoms or main problem they can be deviated from in line with professional practice.

For example in New Zealand we have unlimited dosages of IV analgesia (morphine, morphine+midaz and ketamine) as well as GTN and adrenaline.  This means we can treat-to-effect and are unrestricted in the amounts of medications that our Paramedics can give.

This does not mean they are rogue cowboy practitioners who overdose people or practice without recourse to foundational knowledge or inline with tennants of good care as set down by the Guidelines (for example giving somebody so much morphine they respiratory arrest or contiue giving GTN when it is not effective in relieving pain) but rather that they are free to apply professional discretion and are trusted to do so.

Our Paramedics are also free to apply professional discretion and knowledge when it comes to other modalities of treatment for example non transport and alternate disposition.

With this freedom is also the responsibility that each Paramedic knows they are answerable to both thier Medical Advisor and Clinical Standards Manager and also they can be held criminally liable for gross negligence however it has never been a problem to date.


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## Veneficus (Nov 16, 2010)

DrParasite said:


> question: are there any quantifiable means (mortality rates, or anything scientific) that show how an educated medic is better than a lesser educated one?
> 
> meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.



I doubt there would be statistics on it.

First off, mortality rate by itself is unreliable and full of confounders. There is a proverb I once heard:

Which doctor is better?

A doctor who is able cure cure 50% of his patients
A doctor who can cure all of her patients
A doctor whos patients never get sick

There are no numberical quantifiers showing how much a long spine board helps reduce spinal injury. But it is still done everyday.

You are not going to find a double blind placebo controlled study on the effectiveness of education in every area of medicine. It is outright stupid to even expect some of it. 

Does having a doctor increase the number of diseases cured?

Does calling an EMT help more than calling your neighbor or friend?

Would you really go to a person who treats your loved one based soley on a protocol and if they didn't fall into it, too bad for them?

This constant assault on education is absolutely rediculous. Please never treat anyone I care about. Infact, you just earned a place next to ventmedic on the ignore list.

congratulations.


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## MrBrown (Nov 16, 2010)

Veneficus said:


> Which doctor is better?



A doctor whos patients never get sick


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## jrm818 (Nov 16, 2010)

DrParasite said:


> meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.



Surely you've just volunteered to conduct such a study.  I'd love to hear how you plan on doing it.  Do it well though, you have a lot of competition for space in the EMS section of the NEJM from all that other research coming our of other 110 hour EMT professionals.

Where do you think such a study would come from?  How many paramedics (never mind basics) have any involvement in research at all?  How many have even the most cursory education relating to how to interpret, never mind conduct, research?  Do you really think that EMS's relative disengagement from using an evidence-based rationale for treatments has no effect on patient care, whether or not a difference can be statistically demonstrated?

With the number of "per protocol" interventions that are now being demonstrated to be harmful, are you really seriously prepared to argue that EMT's/Paramedics don't need to be educated enough to keep up on the data and adapt to new knowledge?  

Even if its not practical to prove to "scientifically prove it," it's almost self evident that a paramedic who can read the literature in their own freaking field is less likely to perform harmful interventions and may actually be able to make judgments about when to perform beneficial interventions.


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## jrm818 (Nov 16, 2010)

MrBrown said:


> A doctor whos patients never get sick



If that's your goal, come to me instead.  I may cost a little more, but I guarantee I find less wrong with you than one of those silly educated doctors.....


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## DrParasite (Nov 16, 2010)

Veneficus said:


> I doubt there would be statistics on it.
> 
> First off, mortality rate by itself is unreliable and full of confounders.


I agree, mortality rate is unreliable and a bad gauge of if something was good.  but it was QUANTIFIABLE. If you know of a better method of measuring, I am more than willing to hear it. 





Veneficus said:


> There is a proverb I once heard:
> 
> Which doctor is better?
> 
> ...


nice proverb.  what's your response and why?


Veneficus said:


> There are no numberical quantifiers showing how much a long spine board helps reduce spinal injury. But it is still done everyday.


and yet, it is used every day.  you think maybe many years ago someone did a study to see if there were any neck injuries from mvas that had poorer outcomes when c-spine and LSBs were not used, for when spinal precautions were?  I don't know, but I find it hard to believe that someone had an idea, many years ago, and this idea has been adopted worldwide with no scientific evidence behind you.  heck, i bet if there was no science behind it, the trauma doctors, PHTLS and ATLS organizations would try to change it.


Veneficus said:


> You are not going to find a double blind placebo controlled study on the effectiveness of education in every area of medicine. It is outright stupid to even expect some of it.


are you kidding me?  there are double blind studies everywhere, companies are constantly looking to make improvements, and the only way they can convince the medical community, I'm sorry that should be the scientific community is with actual evidence.


Veneficus said:


> Does having a doctor increase the number of diseases cured?
> 
> Does calling an EMT help more than calling your neighbor or friend?


interesting questions, but really they don't apply to this topic.


Veneficus said:


> Would you really go to a person who treats your loved one based soley on a protocol and if they didn't fall into it, too bad for them?


Did I say that?  did I even imply that?  You were a medic, if you ever found a situation that wasn't covered in your protocols what did you do?  just say too bad for them?  even better, if a doctor has a patient where he doesn't know the answer, or what do to, does he or she just say "too bad for them?"


Veneficus said:


> This constant assault on education is absolutely rediculous. Please never treat anyone I care about. Infact, you just earned a place next to ventmedic on the ignore list.
> 
> congratulations.


You know no one forced you to comment.  I'm on your ignore list?  really?  cool.  So because you don't like what I have to say because I want you to act based on evidence and reality not on what you think is right (regardless of whether you are right or not), you don't want to hear it.  Do me a favor, don't ever treat any of my friends, family, coworkers, or people who live within 250 miles of me.  I want them to live and get better based on things that have been shown to work, not based on what you think will work but has no basis in reality.

Anecdotal evidence is great.  Emotional responses are great.  They support a position.  More education is needed for paramedics.  So lets make every medic go to school for 6 years, full time, before they are allowed onto the truck.  After all, more education is better.  or even better, you probably want every paramedic to go to medical school.  after all, if a little more education is good, than a lot more is even better.  But if your evidence is so great, it should be able to hold up to scrutiny.  and if you will only use evidence that can't hold up to scrutiny, then i'm pretty sure you will not be very successful in the medical field, if you are able to graduate at all.

There is a reason why the medical community does so many studies.  and the Scientific community requires quantifiable evidence before they give the results, and often state what would be quantifiable before they even state what the study is about.  Otherwise, it's just a waste of time and resources.

But I'm not a former medic / and medical student (or am I, no one really knows do they), I only know a bit about research from my time working for a couple small companies, Merck and Bristol Myers Squibb.  Maybe you have heard of them? Again, I'm not future doctor, but have a little bit of a background in research.


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## JPINFV (Nov 16, 2010)

DrParasite said:


> question: are there any quantifiable means (mortality rates, or anything scientific) that show how an educated medic is better than a lesser educated one?
> 
> meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.



Ok, let's design a study for that. Take a college educated medic and a medic mill medic, put them in a system with no protocols and only the bare necessity of policies necessary to facilitate transfer of care (i.e. policies on entry notifications, how to contact medical control (which will always based on paramedic judgment), DNRs, AMAs, etc), and have them, with consent of the medical director, individually pick their own formulary and interventions. No limits provided they can show proficiency in when, when not, how, and why of their procedures, and now we can monitor days in hospital, error rates, interventions, mortality, etc. 

However, as long as we're trying to compare a medic mill medic and an educated medic in a system designed for the medic mill medic, there shouldn't be much of a difference. The question then is, can we do better than a system designed for medic mill medics.


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## usalsfyre (Nov 16, 2010)

The laughable thing is that is EXACTLY how the LSB came into common use. With more education on  the background behind some common EMS interventions, you might be familiar with this. Oh yeah, I forgot education makes you a worse provider...


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## Foxbat (Nov 16, 2010)

JPINFV said:
			
		

> However, as long as we're trying to compare a medic mill medic and an educated medic in a system designed for the medic mill medic, there shouldn't be much of a difference. The question then is, can we do better than a system designed for medic mill medics.



So you think that in a current system (protocols, etc.) there is no point for a medic to obtain education beyond medic mill, since there wouldn't be much difference for patients?
Also, what you're proposing (comparing mill medics to educated medics in a system designed for educated medics only) doesn't seem more valid than comparing them in a system designed for mill medics only.
Perhaps we should, then, compare systems as a whole rather than providers. I.e., compare educated medics to mill medics, while confining mill medics to protocols while making no such restrictions for educated medics (and controlling for other variables).
Of course, this is all purely hypothetical. I would be very surprised if a study like that would be allowed in the US.

(On a side note, I suspect that protocols aren't in place just because of mill medics. Say, Russian EMS system is PHPA- and physician-based, yet, as far as I know, they have protocols. I'm not sure about other countries with physician-based EMS).


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## JPINFV (Nov 16, 2010)

Not all systems are designed the same.

If you want to make more progressive systems, you need to ensure that the providers are capable first. 

If the medic mill medics want to design their system as a mother-may-I, they can. Nothing is stopping someone from calling in and reviewing their plan on every patient or limiting themselves only to the prototypical prehospital drugs. 

There's a difference between protocols as an ideal treatment plan and protocols as cookbook. Are the physicians in Russia free to deviate from protocol as they deem fit?


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## Melclin (Nov 16, 2010)

jrm818 said:


> Do it well though, you have a lot of competition for space in the EMS section of the NEJM from all that other research coming our of other 110 hour EMT professionals.
> 
> Where do you think such a study would come from?  How many paramedics (never mind basics) have any involvement in research at all?



Truth. 

This is one of the things that restores my faith in our system if I get down about it. We have many paramedics involved in research. Paramedics were instrumental in the research that showed IN fentanyl worked well in the prehospital setting for example. The effectiveness of different techniques of vagal maneuvers is another example. Research interpretation and design is compulsory education for all our basic providers (ILS or there abouts), not just ALS. Many students have literature reviews and some have original research published in academic journals. I myself have a paper pending publication. Its always nice to look at American EMS if I ever have doubt about the value of education. 




DrParasite said:


> and yet, it is used every day.  you think maybe many years ago someone did a study to see if there were any neck injuries from mvas that had poorer outcomes when c-spine and LSBs were not used, for when spinal precautions were?  I don't know, but I find it hard to believe that someone had an idea, many years ago, and this idea has been adopted worldwide with no scientific evidence behind you.  heck, i bet if there was no science behind it, the trauma doctors, PHTLS and ATLS organizations would try to change it.



Hahaha there are a great many things used every day, especially in EMS that have no evidence to back them up. Spinal immobilisation is high on that list. Educate providers and encourage a culture of academia, research and evidence based practice then maybe you'll find a body of people to look into things like spinal immobilisation. 

There is undoubtedly an appropriate amount of entry level education for paramedics. But you clearly have no idea what is involved in something like RSI or cath lab activation if you think you can teach people about these things in six months with a barely qualified "instructor" at some fire academy. Like I said, I agree that there is a reasonable limit to the formal entry level education, but to think that medic mills are enough is patently absurd.

Its not proof (you'll probably never get any) but one has to wonder why countries that encourage education have success with extensive and complex care modalities, while why American medical directors wet themselves when you mention analgesia or RSI.   

Have you read the EMS agenda for the future?


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## adamjh3 (Nov 16, 2010)

What CAN we do to promote higher education standards? 

There seems to be a pretty well-built societal wall against improving standards of pre-hospital care here in the States. 

In the current climate, I gain only personal knowledge shooting for a degree which will take me several years as opposed to getting certified through a year long medic mill. There are no financial or societal gains for me to put in the extra work. Hell, some of the well-educated medics get LAUGHED at when others find out how long they spent in school.

What can we as individual providers do to change that? Sure, we can be the change we wish to see, but we need to do much more than that if we wish to see results. Honestly, though, I haven't the slightest clue where to start.


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## Aerin-Sol (Nov 16, 2010)

adamjh3 said:


> What CAN we do to promote higher education standards?
> 
> There seems to be a pretty well-built societal wall against improving standards of pre-hospital care here in the States.
> 
> ...



I would argue that is more of a cultural problem than a specific professional one. As a country, we are very anti-intellectual. Most people are only interested in education if it does lead to financial or societal gains. I don't think there's any way for an individual provider to change that. The type of person who would mock another person for choosing to get a solid education in their profession is simply not a person you can individually argue with.


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## jrm818 (Nov 16, 2010)

Melclin said:


> Truth.
> 
> This is one of the things that restores my faith in our system if I get down about it. We have many paramedics involved in research. Paramedics were instrumental in the research that showed IN fentanyl worked well in the prehospital setting for example. The effectiveness of different techniques of vagal maneuvers is another example. Research interpretation and design is compulsory education for all our basic providers (ILS or there abouts), not just ALS. Many students have literature reviews and some have original research published in academic journals. I myself have a paper pending publication. Its always nice to look at American EMS if I ever have doubt about the value of education.



Well thanks a lot...now I'm down instead  

I do get a bit jealous when I hear about your EMS system, especially the educational aspect.  At the same time its a bit encouraging to see you guys pull off a system like that....at the least it's empirical evidence that educated EMS can work.  Some day I'd really love to travel a bit and see in person how EMS systems function in the crazy queen-worshiping countries.

I think the research thing is huge.  I'd love to be in an environment where that sort of intellectual endeavor was encouraged, but alas, that seems to be very much the exception over here (at least according my brief experience in EMS).  The sad part is there is that I have no doubt that US EMS could attract and retain people interested in actually educating themselves and pushing the field forward, but I don't see that happening very much within the current structure.


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## MrBrown (Nov 17, 2010)

Education not only reduces clinical error, increases safety and patient outcomes but is also a useful tool at improving efficency and lowering cost.

Let us take Oz's fave scenario of the unconscious diabetic .... 

Sparky and Puddles show up with thier 110 hours of training are going to have but one option: take patient to hospital and need to call for a Paramedic to give glucagon or glucose and in some cases, they are needed to even check a blood sugar.

Meanwhile, in one of those funny speaking countries Smooth in his rapid response unit shows up, gives the patient some glucagon, decides the patient does not need to go to hospital, leaves them at home with an appropriate support person after seeing they wolf down a peanut butter sandwhich and goes off to the next job .... 

Hmm ..... which is more effective you ask?


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## EMSLaw (Nov 17, 2010)

Okay, the US EMS system is not all that and a bag of chips (or a packet of crisps, depending on where you're from)... But I don't think your example is very apt, Brown.  At the very least, at the Intermediate level, you can test BGL, start an IV, push an amp of D50, then feed gramps his PB&J, take his RMA and extort a promise to pay more attention to his diet and medication in the future.

If Gramps is conscious, and can swallow, it's so simple even an EMT-B can do it.  It's messier, though, that oral glucose gets all over everything. 

If, on the other hand, you take your dex stick and your handy-dandy meter reads "HI" or "999" or whatever it reads when they shoot off the top end of the scale, Gramps is going to the ED and thence to the ICU for a few days of quiet time. 

I'm a fan of the fancy book-learnin', don't get me wrong.   I'm just pointing out that you don't really treat a diabetic any differently than we do.


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## MrBrown (Nov 17, 2010)

Brown's example is plenty apt;

By saying to get an RMA from the patient you are essentially talking him into refusing care which is a bit crooked really, what we say is that "in our professional judgement as a Paramedic you do not need to go to the hospital"

By saying that an Intermediate EMT can infuse an amp of D50 is a bit cloudy too, you know as well as Brown that many if not the majority of ambulances in the US are staffed with Basic EMTs who may not even be able to check a blood sugar let alone give glucagon or glucose.  If the patient is unconscious what good is oral glucose going to do? They are going to have to call for an aditional resource (which might be an hour away) to deal with this patient.

In New Zealand, Australia, Canada, the UK, South Africa and all of Europe every entry level provider regardless of jurisdiction can give at least IM Glucagon and check a BGL.  In Canada, Australia and South Africa they can cannulate and administer 10% glucose too.

The modality of care is the same (ie reverse thier hypoglycaemia) however the syngergy of doing so and what happens to the patient afterwards are very different.

And that is just one example.


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## CAOX3 (Nov 17, 2010)

MrBrown said:


> Education not only reduces clinical error, increases safety and patient outcomes but is also a useful tool at improving efficency and lowering cost.
> 
> Let us take Oz's fave scenario of the unconscious diabetic ....
> 
> ...



We use both glucagon and glucose, given they have the stores available it works quite nicely.  Its not common for a BLS truck to get an unconscious diabetic but it does happen on occasion.

But I agree with your analogy most places a paramedic is going to be needed for even a simple diabetic.

My experience is most EMTs are reluctant to use medication of any type albuterol, glucagon, nitro or whatever I believe its a comfort issue, the education simply isnt there.


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## SanDiegoEmt7 (Nov 17, 2010)

EMSLaw said:


> ... take his RMA and extort a promise to pay more attention to his diet and medication in the future.



Being a lawyer, can you tell me the correct way to ascertain an RMA from a patient without increasing my own liability?  Anything but the patient adamantly refusing transport opens me up to a lawsuit when I don't go the full nine yards in trying to convince them to go to the hospital "Sir, your condition could be more serious than it seems, even leading up to death" (That is in my RMA guidelines).

I agree with JP.  In our current system there is no benefit to having a more educated paramedic.  The true benefit of a more educated paramedic would be witnessed in a system which gave more medical leeway to the medic.  BUT what comes first? More medical leeway or more education? :unsure:

As Brown has shown.  There are many countries which have figured it out better than us already, AND have put themselves in a position to keep figuring it out better.  We are stagnant.

There was another thread on this forum where I discussed education with a Medic from Los Angeles.  At the end of the discussion he made a comment about how wonderful it was that I had obtained a Bachelors in biology but was still earning less then him.  I think this persons ignorance reflects a good portion of providers feelings.


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## mgr22 (Nov 17, 2010)

SanDiegoEmt7 said:


> In our current system there is no benefit to having a more educated paramedic.



Really? That's very sad. I've never worked anywhere, in any industry, where more education had no advantages over less education.


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## MrBrown (Nov 17, 2010)

While there will be may be benefit to individua patients (less clinical error) it is true that in systemic, marco level terms there is probably little benefit to the US in increased education at the moment.

The system is designed for barely homeostasasasasing Parathinktheyare's who may or may not be Firefighters who may or may not have twelve weeks of skoolin down at the local patch factory plus a couple hundred hours of "skills" internship.


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## mgr22 (Nov 17, 2010)

MrBrown said:


> While there will be may be benefit to individua patients (less clinical error) it is true that in systemic, marco level terms there is probably little benefit to the US in increased education at the moment.



I think the benefits to patients go way beyond fewer clinical errors. IMHO education enhances communication. Better communication gives us more opportunities to relate to people. Connecting with patients often helps us do a better job assessing them, and gauging the results of treatment.


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