# how to fix EMS



## Veneficus (Mar 12, 2011)

I figured it out reading the most recent active threads.

Eliminate medical control.

Think about it. 

All treatments would be defined by a scope of practice and performed at the discretion of the provider. 

Which would make that provider soley and officially responsible for care.

Those that are too inept to function without a protocol book would be weeded out sooner or later.

Providers would have to seek out more advanced education in order to figure out what they were doing.  No more "just following orders." 

Nobody to call and ask permission for things that are known to be needed. 

No more inept providers calling and disrupting the ED asking for permission to follow standing orders. 

The more I think about it, the more I like it.


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## Anjel (Mar 12, 2011)

Veneficus said:


> I figured it out reading the most recent active threads.
> 
> Providers would have to seek out more advanced education in order to figure out what they were doing.  No more "just following orders."



^^ This for sure. Basic training is a joke. And Paramedic is a crash course as well. I think a Bachelors degree should be the absolute minimum. You need one to run a company why not to care for another human being. 

And whether people wanna admit it. While that patient is in the back of your ambulance you are in control of their life. What happens to them and their well being. 

But we will trust a 18yr old dumb :censored: that went through 15 weeks of advanced first aid to get grandma where she needs to go and get her there alive.  Yes I am a basic and I will be the first to admit I don't know much. lol But I know my protocols, and I know what the 15 weeks taught me. And that's good enough for my state. I am learning a lot more...but not from class. More on my own research. 

ANDDD that's the end of my rant lol


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## 46Young (Mar 12, 2011)

Sounds good, but how will these depts feel about liability? They might go back to BLS in response. I don't believe that there's anything saying that the gov't is mandated to provide ALS txp.


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## Anjel (Mar 12, 2011)

46Young said:


> Sounds good, but how will these depts feel about liability? They might go back to BLS in response. I don't believe that there's anything saying that the gov't is mandated to provide ALS txp.



In my county all 911 calls have to be answered by an ALS crew with 2 medics. 

I think that is gov't mandated. county gov't anyway.


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## 46Young (Mar 12, 2011)

Anjel1030 said:


> In my county all 911 calls have to be answered by an ALS crew with 2 medics.
> 
> I think that is gov't mandated. county gov't anyway.



Is that something that was voted on, but can be repealed if they want? ALS is only 40 years old or so; I'm sure your county has existed for longer than that. Someone had to propose that mandate, and get it voted on. I'm sure they would reconsider the measure if $$$ were at stake.

Alternatively, are you referring to a contract that a private 911 EMS provider has with the county, or is your county 100% municipal EMS? 

My county says ALS calls must have two medics onscene, but that doesn't always happen, either.


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## FrostbiteMedic (Mar 12, 2011)

In reference to how to fix EMS, there is one big, recurrent theme: education. Yup, I said it again....
Call me weird, but I really don't know what it is like to be limited to a "normal" bls ambulance, as TN has EMT-IV (i/85) as the lowest level of EMT licensure (excluding first responder, and a _few_ fire departments that run in-house EMT-B, but neither licensure will get you employed in TN). You may have noticed that here recently I have been on sort of an education kick. Why is this? Because over the past few months I have realized just how woefully behind many of us (to include myself) are in our education. Part of the reason I came to this is due to physical issues (which I will not go into at this time) that made me wish I had decided to pursue more education sooner. It is the one thing that barring neurological injury/disorder that can never be taken away from you.


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## MrBrown (Mar 12, 2011)

You mean like how Australia, New Zealand, South Africa, the UK, all of Europe and parts of Canada have no "medical control" whatsoever?


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## JJR512 (Mar 12, 2011)

Nothing is getting fixed by what was proposed here because the proposal completely fails to address the cost of implementation. Oh sure, it's nice to sit back and say more education is the solution to any problem. In a dream world, I'd agree. But this is the real world. Who is going to pay for the "Bachelors degree should be the absolute minimum"? The people who want to be EMS providers, the companies that want to hire them, the communities that want to use them, or the government (grants)? There are a lot of problems in EMS. Simply saying "we need providers to be more educated" not only doesn't solve all of them, it also creates new problems or makes other existing ones worse.


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## reaper (Mar 12, 2011)

46Young said:


> Sounds good, but how will these depts feel about liability? They might go back to BLS in response. I don't believe that there's anything saying that the gov't is mandated to provide ALS txp.



Actually yes in FL. It is state mandate that all counties have ALS services. Now some of your poor counties may only have two ALS units for the whole county, but at least they have them. Some are mix of Medic units and EMT units. But every pt gets assessed by a medic, then may be handed off to an EMT for transport.


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## FrostbiteMedic (Mar 12, 2011)

JJR512 said:


> Nothing is getting fixed by what was proposed here because the proposal completely fails to address the cost of implementation. Oh sure, it's nice to sit back and say more education is the solution to any problem. In a dream world, I'd agree. But this is the real world. *Who is going to pay for the "Bachelors degree should be the absolute minimum"?* The people who want to be EMS providers, the companies that want to hire them, the communities that want to use them, or the government (grants)? There are a lot of problems in EMS. *Simply saying "we need providers to be more educated" not only doesn't solve all of them, it also creates new problems or makes other existing ones worse.*



As for the first bolded area, how did I imply that an Bachelor's was to be the minimum? I just said that we need to get more education. The government has already attempted to solve problems elsewhere by chunking money at them, hoping they'll go away, but it does not seem to be working. And continuing along that line, how does it create/worsen problems? Having more education only benefits, and never hurts.....


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## 46Young (Mar 12, 2011)

reaper said:


> Actually yes in FL. It is state mandate that all counties have ALS services. Now some of your poor counties may only have two ALS units for the whole county, but at least they have them. Some are mix of Medic units and EMT units. But every pt gets assessed by a medic, then may be handed off to an EMT for transport.



No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.


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## Veneficus (Mar 12, 2011)

JJR512 said:


> Nothing is getting fixed by what was proposed here because the proposal completely fails to address the cost of implementation. Oh sure, it's nice to sit back and say more education is the solution to any problem. In a dream world, I'd agree. But this is the real world. Who is going to pay for the "Bachelors degree should be the absolute minimum"? The people who want to be EMS providers, the companies that want to hire them, the communities that want to use them, or the government (grants)? There are a lot of problems in EMS. Simply saying "we need providers to be more educated" not only doesn't solve all of them, it also creates new problems or makes other existing ones worse.



Actually, it seemed a rather inexpensive idea when I thought of it.

I didn't even suggest mandating education. 

I did suggest that if they were held personally accountable for thier decisions, individuals might seek out further education on their own.

The rest of it is basically cutting costs.


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## rescue99 (Mar 12, 2011)

JJR512 said:


> Nothing is getting fixed by what was proposed here because the proposal completely fails to address the cost of implementation. Oh sure, it's nice to sit back and say more education is the solution to any problem. In a dream world, I'd agree. But this is the real world. Who is going to pay for the "Bachelors degree should be the absolute minimum"? The people who want to be EMS providers, the companies that want to hire them, the communities that want to use them, or the government (grants)? There are a lot of problems in EMS. Simply saying "we need providers to be more educated" not only doesn't solve all of them, it also creates new problems or makes other existing ones worse.



Wow....someone who actully gets it! It takes time to sort all of these details out. Clicking our heels and saying, "make it so", is the note on the napkin, not the marketable product.


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## Veneficus (Mar 12, 2011)

I wouldn't be opposed to hear how education actually makes things in EMS worse?


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## usalsfyre (Mar 12, 2011)

rescue99 said:


> Wow....someone who actully gets it! It takes time to sort all of these details out. Clicking our heels and saying, "make it so", is the note on the napkin, not the marketable product.



Except no one has even attempted to "sort out the details" in the 10 years I've been around. National Scope of Practice came out with the thought of establishing uniform levels, and it was derided because (gasp!) we might have to go back to school. It was watered down to the point of being basically the same thing we have now. We've had enough time. It's time to stop making excuses and DO SOMETHING.

The excuses are pushing me closer and closer to leaving the field entirely.


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## MrBrown (Mar 12, 2011)

46Young said:


> No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.



Right here, every day if you call up for something like a tooth ache, a sprained ankle or "my woogie hurts".


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## HappyParamedicRN (Mar 12, 2011)

In my state we are ahead of the game, as our only med conrol option is Heparin for STEMI... Everything else is standing order! 


Happy


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## ffemt8978 (Mar 12, 2011)

46Young said:


> No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.



There's an area that covers a couple hundred square miles not too far from here that has no fire or EMS coverage because they don't want to pay for it (via taxes, etc...).  There's about 15 homes in that area so there are some out there.

I'm not sure if an ambulance would respond if they were called to a home in that area (same for fire).


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## Aidey (Mar 12, 2011)

HappyParamedicRN said:


> In my state we are ahead of the game, as our only med conrol option is Heparin for STEMI... Everything else is standing order!
> 
> 
> Happy



That only makes you ahead of the game if your standing orders are good.


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## the_negro_puppy (Mar 12, 2011)

Although i'm just regurgitating what Brown has been saying- Aus, NZ England etc are all examples of this. We have no medical control and generally an education level of diploma or degree.

I guess the problem is that the US EMS is largely privatised with different companies having different drugs, guidelines, skills etc. Here as with the UK and NZ, Ambulance services are state or region run and funded.

This means that the services can afford to educate, train and employ people.

I am doing the Diploma method, where I work full-time for 2.5 years, complete papers and study in my own time, have assessments (CME's + exams) and skill training every 6 months and receive mentoring.

The other method is attend university, obtain a bachelors degree (3-4 years) and apply for employment.

Both the degree and diploma method both allow practice as paramedic witht he same skills.


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## firetender (Mar 12, 2011)

*EMS is a System Complex*

Eliminating Medical Control is bad medicine; it's tackling a symptom and saying the patient is healed.

The system needs to be re-structured from the ground up to reflect the services that are REALLY provided and designed with enough safety-nets so that its practitioners have what they need to actually make it a career..


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## Anjel (Mar 12, 2011)

frostbiteEMT said:


> As for the first bolded area, how did I imply that an Bachelor's was to be the minimum? I just said that we need to get more education. The government has already attempted to solve problems elsewhere by chunking money at them, hoping they'll go away, but it does not seem to be working. And continuing along that line, how does it create/worsen problems? Having more education only benefits, and never hurts.....



That was me that implied that. And that was me just dreaming of a perfect world. If you have a higher education, you get paid more money. That really isn't an option at the moment when they are shutting down police and fire departments (here at least). 

Or maybe the education that we do get needs to be a little more than memorization and follow the leader and a little more the patient is this this and this. Treat your PATIENT. 



46Young said:


> Is that something that was voted on, but can be repealed if they want? ALS is only 40 years old or so; I'm sure your county has existed for longer than that. Someone had to propose that mandate, and get it voted on. I'm sure they would reconsider the measure if $$$ were at stake.
> 
> Alternatively, are you referring to a contract that a private 911 EMS provider has with the county, or is your county 100% municipal EMS?



I am not sure about the voting part. And we have 2 contract 911 private companies I believe. Maybe 3. And some cities handle their own 911. Or the city responds and uses a private to transport. Or where I live. Auburn Hills contracts with a private company to use 2 of their rigss, and 1 medic. 

But in here it has to be 2 medics on a rig. A medic-basic rigg doesn't run. 15miles down the expressway in the other county Medic-basic is fine. 

I think EMS needs to be more uniformed in the way things work. County to County to state to state. 

I think Australia, UK etc have a pretty good system going on.


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## HotelCo (Mar 12, 2011)

46Young said:


> No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.



Detroit. 

Not due to progressive protocols, but mismanagement of money.


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## Sasha (Mar 12, 2011)

Duct tape.


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## 46Young (Mar 12, 2011)

the_negro_puppy said:


> Although i'm just regurgitating what Brown has been saying- Aus, NZ England etc are all examples of this. We have no medical control and generally an education level of diploma or degree.
> 
> I guess the problem is that the US EMS is largely privatised with different companies having different drugs, guidelines, skills etc. Here as with the UK and NZ, Ambulance services are state or region run and funded.
> 
> ...



What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.


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## 46Young (Mar 12, 2011)

ffemt8978 said:


> There's an area that covers a couple hundred square miles not too far from here that has no fire or EMS coverage because they don't want to pay for it (via taxes, etc...).  There's about 15 homes in that area so there are some out there.
> 
> I'm not sure if an ambulance would respond if they were called to a home in that area (same for fire).



I figured that some unincorporated areas would be w/o guaranteed coverage.


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## 46Young (Mar 12, 2011)

HotelCo said:


> Detroit.
> 
> Not due to progressive protocols, but mismanagement of money.



And then they try to throw the empoyees under the bus for having 20 min+ response times.


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## MrBrown (Mar 12, 2011)

46Young said:


> What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.



Not true, in Australia and NZ we get paid a student allowance to study in order to cover living costs.  Its not a great amount but its enough for a bunch of guys sharing an apartment or living at home with mum and dad to get by on especially considering programs like HECS HELP and Studylink pay the total amount of our books and tuition for us while we are studying and we do not pay it back until we earn enough to afford the repayments.

There is a program of significant cross-crediting for qualified Paramedics to enable them to earn the Bachelors Degree.

Remember our Bachelors Degrees are only three years long and we do not have "general education" or "liberal arts" and that tertiary education is significantly cheaper than in the US, we pay about half of what you do for a University degree.

The simple thing is that the Bachelors Degree is mandatory for employment in all but a few States in Australia and is almost mandatory in NZ.

Brown has said that replicating the requirement in the US is not the answer because the system is so radically different; however a massive increase in education is required and having Paramedic (ALS) as the entry to practice standard is also not the answer.


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## the_negro_puppy (Mar 12, 2011)

46Young said:


> What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.



The difference is that there are only limited intakes of the Diploma program, perhaps 100 positions a year for the whole state. Diploma students tend to be older, ex military/police/nurses and may already have uni degrees.

Once you complete the diploma you can convert it to a degree with 3 years part time study. As Brown said, most states here now require a degree- If i wanted to work in another state I would need a degree. Also in a few years it will be degree only, much like RN's here went from on the job training to degree.


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## rescue99 (Mar 12, 2011)

usalsfyre said:


> Except no one has even attempted to "sort out the details" in the 10 years I've been around. National Scope of Practice came out with the thought of establishing uniform levels, and it was derided because (gasp!) we might have to go back to school. It was watered down to the point of being basically the same thing we have now. We've had enough time. It's time to stop making excuses and DO SOMETHING.
> 
> The excuses are pushing me closer and closer to leaving the field entirely.



The education standards are slowly increasing however, there is so much influence by states to remain in control of their own EMS systems. Only D.C. can change it. Fact is, under a federal program, with regulations and various other details to work out (and fund), it's easier (and cheaper) to avoid change than to actually enact anything new. The DOT sets the minimum and each state either stays at that minimum or, they can add to the initial and recertification objectives. Unless all 50 states and D.C. agree to work cooperatively, EMS education will continue down the same slow path. States do not put EMS legislation very high on their list of priorities.


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## Melclin (Mar 12, 2011)

46Young said:


> No kidding. I'm also curious if any systems exist where an ambulance is not guaranteed if you call 911.



We have a system called 'refcom' that tries to organise more appropriate care pathways for people identified over the phone as not needing an ambulance. It seems to have been very successful, however, its not a large enough operation to cover all the jobs its should. There is often a disappointed tone to a paramedic's response when they see on their pager that the job was marked as 'refcom' but 'timed out' because refcom was busy with other stuff. It generally means you're going to a pretty ridiculous job.  



46Young said:


> What's the benefit of getting the degree first, earning no salary, and applying for a job, when you can be paid from day one, and get a similar education for almost the same time investment, and have the same career? Can you take classes afterward to complete the Bachelors, or are you stuck with just the diploma for life? If that's the case, I could see why one would get the degree first. Otherwise, it seems like you're giving up 2.5 years of compensation and tenure at your place of employment.



Firstly, I some cases you don't get a choice. The vocational method has been phased out in some states and as far as I know, most states a moving towards university only. 

Secondly, as Brown mentioned, university doesn't work the same way here. You don't really add credits until you've got a degree. Its more like that with the arts and science degrees, but with the professional degrees, it tends to just be all at once or nothing. The paramedic degree especially is all or nothing. They did at one stage have an upskilling program just after they created the bachelors so that people with diplomas could upgrade easily, but it was just a bridging program and no-longer exists. So a vocational diploma is worth almost nothing if you move to another industry, a bachelors degree, however, is still a bachelors degree. If I want to go do medicine, I can. If I want a masters in nursing, an MPH or I want change focus entirely and do an MBA, I can. If I want to apply for a job that simply requires a bachelors degree, I can. Healthcare administration? Research? Yep. 

Thirdly, the older vocational method has both ups and downs. Certainly, one learns to tick the basic boxes of how to be a paramedic far more quickly than a university student. You won't find to many vocational students fumbling with the O2 or dropping patients after 3 years, as uni students will. Uni students often struggle with many of the more practical aspects of being a paramedic; things that you can't learn from a book. However, you don't seem to have the same depth of education from a theoretical point of view, and the nature of your education can be very dependent on the group of clinical instructors you have been allotted over your time. Also, from what I've seen, the vocational stuff is very 'cook-book'. It doesn't seem to encourage quite the same deeper understanding of whats going on. So you get the problems that kind of thinking entails. Just a personal observation though.


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## HappyParamedicRN (Mar 12, 2011)

Aidey said:


> That only makes you ahead of the game if your standing orders are good.



Oh they are!  We are allowed to do more medication wise than most EMS systems in surrounding states.  We even have IV Nitro!   Heparin as already stated for STEMI.  

If your curious check out the NH bureau of EMS website...


Happy


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## MrBrown (Mar 12, 2011)

Melclin said:


> Thirdly, the older vocational method has both ups and downs. Certainly, one learns to tick the basic boxes of how to be a paramedic far more quickly than a university student. You won't find to many vocational students fumbling with the O2 or dropping patients after 3 years, as uni students will. Uni students often struggle with many of the more practical aspects of being a paramedic; things that you can't learn from a book. However, you don't seem to have the same depth of education from a theoretical point of view, and the nature of your education can be very dependent on the group of clinical instructors you have been allotted over your time. Also, from what I've seen, the vocational stuff is very 'cook-book'. It doesn't seem to encourage quite the same deeper understanding of whats going on. So you get the problems that kind of thinking entails. Just a personal observation though.



Brown went through the old vocational method of training but should declare that Brown also has a Bachelors Degree, although not in EMS so is reasonably familiar enough with both methods of instruction and you are correct in your observation.

While Brown would not call those vocationally trained more "cook book" than Uni ambos the Uni ambos have a much deeper appreciation for the larger context of ambulance practice and theoretical knowledge than their vocational counterparts.


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## JJR512 (Mar 12, 2011)

frostbiteEMT said:


> As for the first bolded area, how did I imply that an Bachelor's was to be the minimum? I just said that we need to get more education. The government has already attempted to solve problems elsewhere by chunking money at them, hoping they'll go away, but it does not seem to be working. And continuing along that line, how does it create/worsen problems? Having more education only benefits, and never hurts.....



There have been a lot of replies in this thread prior to my first. I didn't even reply directly after you. Why are you assuming that anything I said was in direct response to anything that you said? The bit about the bachelor's degree came from another reply, not by you:



Anjel1030 said:


> I think a Bachelors degree should be the absolute minimum.



As for how does it create or worsen problems...If people who desire to be EMS providers are required to get degrees, even if only at the Associate's level, and they are required to pay for it themselves, there will be fewer providers in the industry because not everyone can afford to pay for higher education, and not everyone will want to go through it even if they can afford it. So that's a problem. If they are required to get a higher degree but the cost of this is going to be paid for either directly by the employer or the community, or reimbursed later, then that's money the employer or community is going to have to get from somewhere, which will probably be the people who are treated. So that's the start of billing patients, or billing at higher rates if billing already happens.

Basically, any time you talk about changing something, you're talking about creating new and/or worsening existing problems, at least on a temporary basis if not longer. That's not to say that nothing is not also getting improved, though.


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## JJR512 (Mar 12, 2011)

Veneficus said:


> Actually, it seemed a rather inexpensive idea when I thought of it.
> 
> I didn't even suggest mandating education.
> 
> ...



Sure, eliminating medical control, in and of itself, is not only an inexpensive idea, it's probably a money-saving idea.

But nobody who is on duty provides EMS on their own. They do it while working for another entity, whether a private EMS company or a municipal fire department, whether being paid or volunteering. When the system changes to "when in doubt, contact medical control" to "when in doubt, use your best judgement", any smart employer is going to make sure their providers have the intelligence and education to actually have and use their own judgement. I would imagine that most, if not all, employers will mandate the "further education" you mention.

So whether the prospective provider decides on his own to seek out further or higher education, or if he or she is mandated to by local law or policy, one way or another further or higher education is going to be practically required, which means all the cost issues I mentioned come back into play. Are the cost issues prohibitive? I don't know. It may not be as bad as I'm imagining. It could be a lot worse.


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## ffemt8978 (Mar 12, 2011)

JJR512 said:


> When the system changes to "when in doubt, contact medical control" to "when in doubt, use your best judgement", any smart employer is going to make sure their providers have the intelligence and education to actually have and use their own judgement. I would imagine that most, if not all, employers will mandate the "further education" you mention.



Malpractice attorneys would probably love this type of scenario.  Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense.  The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.


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## 46Young (Mar 12, 2011)

ffemt8978 said:


> Malpractice attorneys would probably love this type of scenario.  Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense.  The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.



Annnnnnnnnd that's likely the end of this thread.


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## Anjel (Mar 12, 2011)

ffemt8978 said:


> Malpractice attorneys would probably love this type of scenario.  Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense.  The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgment" caused harm to a patient.



Wow... ^^ THIS TIMES A MILLION. 

I really didn't think about that. But that is the most valid point in this entire thread. EMS workers would be the first to be sued and the first to loose if we didn't have something to protect us.


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## JJR512 (Mar 13, 2011)

For an EMS provider to be found guilty of negligence, the EMS provider must have had a duty to provide care, must not have performed the duty to the standard of care, and damages must have occurred. It is the second part that is most especially relevant here. The standard of care is that which would have been done by a reasonably prudent person in the same line of work. Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?


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## ffemt8978 (Mar 13, 2011)

JJR512 said:


> For an EMS provider to be found guilty of negligence, the EMS provider must have had a duty to provide care, must not have performed the duty to the standard of care, and damages must have occurred. It is the second part that is most especially relevant here. The standard of care is that which would have been done by a reasonably prudent person in the same line of work. Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?



That covers negligence, but what about malpractice?  As to the second part of your question about doctors commenting on out of hospital treatment, they do it now.  An expert witness is somebody with education and credentials after their name, not a random lay person picked off the street (that's reserved for juries).

My personal feeling is that we need tort reform before we can really reform EMS in any meaningful manner.


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## JJR512 (Mar 13, 2011)

ffemt8978 said:


> That covers negligence, but what about malpractice?  As to the second part of your question about doctors commenting on out of hospital treatment, they do it now.  An expert witness is somebody with education and credentials after their name, not a random lay person picked off the street (that's reserved for juries).
> 
> My personal feeling is that we need tort reform before we can really reform EMS in any meaningful manner.



You may be right about tort reform, but as for expert witnesses, I wasn't proposing that a random lay person be used. I was proposing that only a prehospital EMS provider can truly say what a prehospital EMS provider would have done in a particular set of circumstances.

As for "what about malpractice", _malpractice_ is just a specific term for the type of negligence being discussed in these last few posts. That is, malpractice is a type of negligence in which a professional had a duty to act, failed to act according to the accepted professional standards, and damages were caused as a result.


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## ffemt8978 (Mar 13, 2011)

JJR512 said:


> You may be right about tort reform, but as for expert witnesses, I wasn't proposing that a random lay person be used. I was proposing that only a prehospital EMS provider can truly say what a prehospital EMS provider would have done in a particular set of circumstances.
> 
> As for "what about malpractice", _malpractice_ is just a specific term for the type of negligence being discussed in these last few posts. That is, malpractice is a type of negligence in which a professional had a duty to act, failed to act according to the accepted professional standards, and damages were caused as a result.



I understand, but was pointing out that the opposing attorney is going to stack the deck in the best way possible for their client.  If they think a doctor on the stand will be more credible to the jury, then that is what they are going to use.  It's going to be real hard for the defense attorney to convince a jury that the doctor is wrong and they should believe the defense's expert (an EMS provider) instead.  Right or wrong, that's the way the system works...the most credible witness is the one the jury believes.


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## JPINFV (Mar 13, 2011)

ffemt8978 said:


> Malpractice attorneys would probably love this type of scenario.  Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense.  The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.



Who said that there won't be expert witnesses on the defense's side if the defense's treatment plan is supportable? 

Just curious, how many people here have first hand knowledge of an EMT who was successfully sued while providing non-negligent care*? I'm willing to bet that the actual risk of being involved in a lawsuit for an EMT or paramedic is relatively low and I think has very little to do with a Befehl ist Befehl (orders are orders) defense.

*In other words, I don't want to hear about the idiot crew who were successfully sued for crashing an ambulance while transporting with lights and sirens.


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## JPINFV (Mar 13, 2011)

JJR512 said:


> Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?



Yes. A physician can say what medical care would be appropriate given the information at hand. Surprisingly enough, physicians don't just randomly order tests. Surprisingly enough, treatment may be begun before tests are arrived. Surprisingly, in plenty of cases, the standard of care is to treat either empirically (it doesn't matter what bug you're infected with, the antibiotic covers all in that class) or clinically (99% of the time a patient presents this way, this is the cause. The other 1% isn't life threatening. Here's your prescription, call us back in a week if it isn't working).


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## ffemt8978 (Mar 13, 2011)

JPINFV said:


> Who said that there won't be expert witnesses on the defense's side if the defense's treatment plan is supportable?
> 
> Just curious, how many people here have first hand knowledge of an EMT who was successfully sued while providing non-negligent care*? I'm willing to bet that the actual risk of being involved in a lawsuit for an EMT or paramedic is relatively low and I think has very little to do with a Befehl ist Befehl (orders are orders) defense.
> 
> *In other words, I don't want to hear about the idiot crew who were successfully sued for crashing an ambulance while transporting with lights and sirens.


http://www.washingtondcinjurylawyerblog.com/2011/03/familys_washington_dc_wrongful.html

http://www.washingtondcinjurylawyerblog.com/2010/10/washington_dc_wrongful_death_p_1.html

http://www.northcarolinainjurylawyerblog.com/2010/02/deceased_chapel_hill_high_scho_1.html

http://www.weitzlux.com/medicalmalpractice/OhioEMS_1934997.html


That's just from the first page of a quick Google search.  You can draw your own inference as to why they are all from law firms.  I'm sure the providers didn't feel like they were providing non-negligent care, but it is obvious somebody does.


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## JPINFV (Mar 13, 2011)

Paramedics refused care (the pulmonary embolism called GERD)
Paramedics refused care
Paramedics refused care (the paramedics who refused to transport a high school football player who was complaining about severe cramps and abdominal pain following practice).
Might be an actual malpractice case. 

Links go to EMTLife discussion threads on those specific cases... 

However, I didn't ask for a Google search, I asked about how many of your coworkers that have been sued. Additionally, all of those articles said that the lawsuit was filed, not that a judgment was rendered (albeit, I'm pretty sure that at least two of those are going to be rendered for the plaintiff). 


I can Google search and find physicians being hit with medical malpractice suites. There are bad apples in every profession, and Befehl ist Befehl isn't going to protect them anyways.

Also, med mal suits are expensive. Lawyers don't like to make bad investments. So the "OMG, I have to make a decision and I'm going to get sued for it" unless the decision is basically manifestly wrong anyways (because, you know, you're going to suggest that the chest pain patient has GERD, right?), there's a low risk of being hit with a suit.


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## JJR512 (Mar 13, 2011)

JPINFV said:


> Yes. A physician can say what medical care would be appropriate given the information at hand. Surprisingly enough, physicians don't just randomly order tests. Surprisingly enough, treatment may be begun before tests are arrived. Surprisingly, in plenty of cases, the standard of care is to treat either empirically (it doesn't matter what bug you're infected with, the antibiotic covers all in that class) or clinically (99% of the time a patient presents this way, this is the cause. The other 1% isn't life threatening. Here's your prescription, call us back in a week if it isn't working).



None of your "surprisingly enough" is any surprise to me. You don't need to speak to me like I'm a dumbass idiot.

Doctors can do all that because they have more training and education that enables them to do all that. What may be obvious to a doctor might not not be so obvious to a prehospital EMS provider, even one with an AAS. A doctor could think it should have been obvious what was wrong with the patient, and since the EMS provider didn't recognize it he's obviously incompetently negligent. And this is what he will say in court as an expert witness. This is why doctors should not be able to say what a prehospital EMS provider should have done. One cannot simply put a vast amount of knowledge and training out of one's mind and say what one with only a small fraction of that would have done. One can put it out of one's conscious mind, but it's still there in one's brain, and whether one realizes it or not it, it affects the way one thinks and reasons.

Perhaps this should be one of those tort reforms that ffemt8978 mentioned. Making sure that the standard of care is testified to on an expert basis only by someone of equal level and training as the accused.


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## JPINFV (Mar 13, 2011)

JJR512 said:


> None of your "surprisingly enough" is any surprise to me. You don't need to speak to me like I'm a dumbass idiot.



Saying that physicians don't know how to provide care minus the fancy tests and under stress (the underlying meaning of the line about "access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital") is like a physician calling paramedics "ambulance drivers" with the intent of honestly meaning that all they do is drive ambulances. So, yes, I'm a little bit sensitive to lines that discuss or imply that "physicians just don't understand EMS because they have access to an x-ray." 




> Doctors can do all that because they have more training and education that enables them to do all that. What may be obvious to a doctor might not not be so obvious to a prehospital EMS provider, even one with an AAS. A doctor could think it should have been obvious what was wrong with the patient, and since the EMS provider didn't recognize it he's obviously incompetently negligent.




While I agree that physicians can catch things easier because of our education/training, that doesn't mean that we expect everyone to pick up everything, especially the zebras. However, there's a huge difference between not picking up a final diagnosis and not picking up either what should be blatantly obvious, or patients who need to go to the hospital for a further workup. If paramedics are constantly electing to not transport patients who should get a further workup (let me point to Mr. Chest Pain case or Mr. HS athlete case above) or missing the blatantly obvious life threatening emergencies (otherwise known as their job), then I have to question if it's worth it to defend them under the status quo. Yes, I have faith that most physicians expect, at most, that paramedics and EMTs are supposed to be capable at their given the educational and diagnostic limitations and can differentiate what is reasonable. Not considering a pulmonary embolism as a potential cause of chest pain should not be an unreasonable expectation of a paramedic. 




> And this is what he will say in court as an expert witness. This is why doctors should not be able to say what a prehospital EMS provider should have done. One cannot simply put a vast amount of knowledge and training out of one's mind and say what one with only a small fraction of that would have done. One can put it out of one's conscious mind, but it's still there in one's brain, and whether one realizes it or not it, it affects the way one thinks and reasons.


Who should then? Would you rather have your care judged by someone who barely passed high school who seriously believes in protocols as cookbooks? 

Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law? Just about all of the malpractice cases I've heard about are either acts of gross stupidity or failures in technique. I can't recall any time that I've seen a suit for, say, misdiagnosing a pericarditis as an MI. Similarly, yes. I think a physician could validly say that a paramedic should be able to catch an esophageal intubation, regardless of the technology available. After all, it's infinitely more likely to be sued for not correcting an esophageal intubation than intubating (but catching and correcting) an esophageal intubation. 




> Perhaps this should be one of those tort reforms that ffemt8978 mentioned. Making sure that the standard of care is testified to on an expert basis only by someone of equal level and training as the accused.



The problem is that then we have the stupidity of "everyone with a trauma get's a backboard" or "everyone gets oxygen" because that's the classroom "standard of care."


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## MrBrown (Mar 13, 2011)

We have been leaving people at home for years, and yes some of them die.

It is however, not reasonably practical to transport every single person who calls for an ambulance now is it?


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## DrParasite (Mar 13, 2011)

best way to fix EMS?  scrap the entire system, and replace every ambulance with a doctor (to act as brains), a nurse (to do the clinical work), and an EMT (to drive and and act as muscle, but do very little actual patient care).

this way you get the best of both worlds, and you can scrap system that we have and replace it with one that is better for the patient.


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## MrBrown (Mar 13, 2011)

Brown does not think that physician based ambulances are the answer.

Significant Medicaid/Medicare reimbursement and taxation reform is in there somewhere however as is overhauled education and professional standards.

Why is there no incentive to move anywhere? Because your service has no money, your medical director does not trust you and nobody wants to pay taxes to support any of it and the system is so broken and fragmented nobody knows what anybody else is doing.


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## the_negro_puppy (Mar 13, 2011)

We do not have to worry about law suits as much as we are not a crazy litigious society (yet). We are immune from personal liability in the practice of our job, however our Ambulance service can be sued.


I might also add, while we do not have medical control, we are required and can consult for certain things. For example we cannot give fluids to paediatrics without a consult. However if we had in ICP with us, they would be able to give without consult.

We dont even have to notify hospitals that we are coming. The only time we call hospitals is if we have a critical patient/STEMI/Trauma or need to clarify if the hospital is suitable for a certain condition/illness/injury


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## MrBrown (Mar 13, 2011)

the_negro_puppy said:


> We do not have to worry about law suits as much as we are not a crazy litigious society (yet). We are immune from personal liability in the practice of our job, however our Ambulance service can be sued.



An Ambulance Officer here can be sued personally for negligence however they are protected by the Ambulance Services liability insurance.  The Ambulance Service can be sued but this has never happened.



the_negro_puppy said:


> I might also add, while we do not have medical control, we are required and can consult for certain things. For example we cannot give fluids to paediatrics without a consult. However if we had in ICP with us, they would be able to give without consult.



Who are you consulting with; a duty ICP (Manager of some sort) or Dr Rashford?


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## Outbac1 (Mar 13, 2011)

Knock wood! We don't worry too much about lawsuits here. We have insurance and a number of very well qualified Emergency Medicine Drs to back us up. We would have to drop the ball big time to get sued. Most of us have enough education to not do that. You can justify doing or not doing a lot of things if you really want to. 

 So my question is how much does it cost to operate a good system? A system where there are a lot of ALS medics, approaching 50%. Other medics are way beyond EMT-B but not up to "Paramedic". A universal fleet, equipment and standards of practice. 
 Here we have about 950,000 people and our province, (state), pays about $100,000,000. per year for that system. It includes all ground ambulances.(approx 140), a helicopter, a fixed wing, and a modern dispatch center and about 850 medics. Thats not much more than $100.00 per person per year. We pay for it with a provincial "Health Services Tax" of 8% on most goods at the point of sale. This tax generates way more money than what is needed for EHS. The rest goes for other health care. 
 Perhaps Brown and the Aussies can chime in with what it cost to operate their state wide systems.

 If your state has 10 million people, how much emergency health service could you buy for one billion $?


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## MrBrown (Mar 13, 2011)

Ambulance cost around $180 million last year.  That's to cover about 3.8 million people with ~500 vehicles, 1,000 paid Ambulance Officers, 2,500 volunteer Ambulance Officers, about 100 stations and attend, treat and/or transport over 370,000 patients.

Each year the Ambulance Service operates at a deficit and we expect it to be about $15 million this year


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## the_negro_puppy (Mar 13, 2011)

MrBrown said:


> An Ambulance Officer here can be sued personally for negligence however they are protected by the Ambulance Services liability insurance.  The Ambulance Service can be sued but this has never happened.
> 
> 
> Really? QAS gets sued all the time lol. Multiple suits every year. We have legal lectures at most of our training workshops.
> ...



Generally we are told to consult with a hospital emergency doctor- We have phone numbers for consultants at the major hopsitals. I have never needed to or been on a case that needed a consult, its pretty rare, coz the drugs needing a consult rarely get used for the circumstances needing consult.




Our service serves 4 million people over 1.77 million square kilometres.  From July to December last year we did 398, 240 cases. Unsure of budget will have to dig around


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## Melclin (Mar 13, 2011)

I'd like to point out that there is a difference between medical control in the sense of calling and asking for your 2mg of morphine every 15 mins, and medical direction in the sense that doctors are part of a _team_ of experts who come up with a bunch of best practice standards to follow. 

Scrapping online medical control and expecting American paramedics to do some thinking isn't a bad idea. But its absurd to suggest that physicians and indeed other HCPs wouldn't be involved in building accepted standards of practice.


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## mycrofft (Mar 13, 2011)

*In USA there is even absentee medical control.*

Sign the contract, and some MD in Florida or Delaware will review your paperwork, answer legal correspondence, and come up with canned protocols. 

Vene, I don't think "it" can be fixed, just our little corners of it one at a time. When it comes to fatcats lying about quality of care and pocketing millions, I get a little Bolshie.


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## JJR512 (Mar 14, 2011)

JPINFV said:


> Saying that physicians don't know how to provide care minus the fancy tests and under stress (the underlying meaning of the line about "access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital") is like a physician calling paramedics "ambulance drivers" with the intent of honestly meaning that all they do is drive ambulances. So, yes, I'm a little bit sensitive to lines that discuss or imply that "physicians just don't understand EMS because they have access to an x-ray."


 
I never said that "physicians don't know how to provide care minus the fancy tests and under stress". You should know me well enough by now to know better than to try to find the subtext or "underlying meaning" of what I write. There isn't any, and if you try to argue with me based on what you think you find there you're just arguing with yourself. I never said they don't know how to provide care minus anything, I said that it's hard (practically impossible) for them to put that out of their mind and think like someone who doesn't have the knowledge and experience of a doctor.

And there's no need for you to be a little bit sensitive to something that you (mistakenly) perceive as an insult to physicians, because you're not a physician so it's not like you're being insulted.



> While I agree that physicians can catch things easier because of our education/training, that doesn't mean that we expect everyone to pick up everything, especially the zebras. However, there's a huge difference between not picking up a final diagnosis and not picking up either what should be blatantly obvious, or patients who need to go to the hospital for a further workup. If paramedics are constantly electing to not transport patients who should get a further workup (let me point to Mr. Chest Pain case or Mr. HS athlete case above) or missing the blatantly obvious life threatening emergencies (otherwise known as their job), then I have to question if it's worth it to defend them under the status quo. Yes, I have faith that most physicians expect, at most, that paramedics and EMTs are supposed to be capable at their given the educational and diagnostic limitations and can differentiate what is reasonable. Not considering a pulmonary embolism as a potential cause of chest pain should not be an unreasonable expectation of a paramedic.


You're talking about specific situations or scenarios here as if that disproves anything I said. My statement was a very broad, simple, general statement that cannot be disproven by a few specific situations, which are known as _exceptions_.



> Who should then? Would you rather have your care judged by someone who barely passed high school who seriously believes in protocols as cookbooks?


First of all, we are not talking about _judging_, we are talking about providing expert testimony. The judge or jury does the judging, the expert witness provides the expert testimony.

Secondly, if I follow the protocols as a "cookbook" and the patient dies and I'm accused of negligence, then you're damned right I'd want another EMS provider who also follows the protocols as a "cookbook" to testify that what I did is exactly what he would have done, too. 



> Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law? Just about all of the malpractice cases I've heard about are either acts of gross stupidity or failures in technique. I can't recall any time that I've seen a suit for, say, misdiagnosing a pericarditis as an MI. Similarly, yes. I think a physician could validly say that a paramedic should be able to catch an esophageal intubation, regardless of the technology available. After all, it's infinitely more likely to be sued for not correcting an esophageal intubation than intubating (but catching and correcting) an esophageal intubation.


Sorry, I don't understand the question ("Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law?") There seems to be at least one word missing in there somewhere, I'm not sure if the "he or she" is referring to the physician or the paramedic, and I'm not sure what the "that" in "articulate that" is referring to. But in any event, again, you're providing a specific example that doesn't really disprove anything.

The fact of the matter is what we're talking about here, in this post and the chain of posts in this thread that lead to where we are now, is negligence. I've already provided the definition of negligence, and may I remind you that it says the care provided by the accused is to be compared with the standard of care that would be rendered by another reasonably prudent person in the same profession. Is a doctor in the profession of prehospital EMS? No. It's that simple.



> The problem is that then we have the stupidity of "everyone with a trauma get's a backboard" or "everyone gets oxygen" because that's the classroom "standard of care."



Maybe in your classroom but not in mine, and I just completed an EMT-B course for the second time (after letting my original certification lapse). We most definitely were taught that backboarding can do more harm than good if it isn't needed, and we were taught when to recognized when it is and isn't needed. We were taught that for the purposes of the exams, every patient gets oxygen because every patient scenario in the exams have been designed to require oxygen. We were also taught that in the real world, not every patient requires oxygen. We were taught to never withhold it if the patient actually asks for it, but otherwise, administer only if it seems needed, with "seems needed" being based on SpO2, appearance, assessment, complaint, work of breathing, etc.


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## JPINFV (Mar 14, 2011)

JJR512 said:


> First of all, we are not talking about _judging_, we are talking about providing expert testimony. The judge or jury does the judging, the expert witness provides the expert testimony.



That expert testimony requires the expert to make a decision, and subsequent argument, about whether the actions of the defendant are reasonable based on the standard of care and the science available (which are not necessarily the same thing as standard of care lags behind new science). There's a difference between "judging" in the sense of running a trial, "judging" in the sense of guilty/not guilty, and "judging" an action as reasonable/unreasonable based on the standards of the field. If the judge and jury were able to do that, there would be no need for an expert witness. I guarantee that one of the questions that the expert witnesses (plural since I'm willing to bet that both the defense and plaintiff will bring their own) will be asked, "In your opinion, was the care rendered acceptable?"  



> Secondly, if I follow the protocols as a "cookbook" and the patient dies and I'm accused of negligence, then you're damned right I'd want another EMS provider who also follows the protocols as a "cookbook" to testify that what I did is exactly what he would have done, too.



"Superior orders" is not a defense I would like to use in a court of law if the orders are manifestly wrong. That defense won't stand if the plaintiff can show that the EMS providers should have known better. All that would be shown was that there are two EMS providers who don't know how to do their job properly.

Also, if EMS providers are supposed to follow protocols to a T, why even provide 1000 hours of training? If the end all/be all is symptom relief based care based on a cookbook, than very little actual training is needed. There's definitely no need for foundation sciences (A/P, pharm, etc) in that case, since there's no reason to use it. Under this concept, I can train an EMT in a week, part time.



> Sorry, I don't understand the question ("Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law?") There seems to be at least one word missing in there somewhere, I'm not sure if the "he or she" is referring to the physician or the paramedic, and I'm not sure what the "that" in "articulate that" is referring to. But in any event, again, you're providing a specific example that doesn't really disprove anything.


If the physician can understand that the educational background underlying a paramedic's practice of prehospital emergency medicine is not the same as the physician's educational background in emergency medicine, why can't the physician apply that understanding when providing expert testimony. 



> The fact of the matter is what we're talking about here, in this post and the chain of posts in this thread that lead to where we are now, is negligence. I've already provided the definition of negligence, and may I remind you that it says the care provided by the accused is to be compared with the standard of care that would be rendered by another reasonably prudent person in the same profession. Is a doctor in the profession of prehospital EMS? No. It's that simple.



Who determines what the standard of care under that set of protocols is? 





> Maybe in your classroom but not in mine, and I just completed an EMT-B course for the second time (after letting my original certification lapse). We most definitely were taught that backboarding can do more harm than good if it isn't needed, and we were taught when to recognized when it is and isn't needed. We were taught that for the purposes of the exams, every patient gets oxygen because every patient scenario in the exams have been designed to require oxygen. We were also taught that in the real world, not every patient requires oxygen. *We were taught to never withhold it if the patient actually asks for it,* but otherwise, administer only if it seems needed, with "seems needed" being based on SpO2, appearance, assessment, complaint, work of breathing, etc.



First off, again, who determines the standard of care? If the standards that licensing/certification exams (since, in many areas, the NREMT exam is the de facto licensure exam for that state), does high concentration supplemental oxygen administration being a critical failure for NREMT practicals (which includes behavioral, which based on the sample scenario (PDF page 21) wouldn't have any oxygen indicated. Most of the rest aren't really indications for more than a NC in the absence of a pulse ox) mean anything? After all, those are the standards you're being tested on. What about AHA recommendations? Those play a part in determining the standard of care, and the sample cardiac scenario provided definitely doesn't indicate oxygen therapy under the 2010 guidelines. 

Why would you administer a medication only because the patient requested it? Isn't the EMS provider the professional providing care? What other drugs are going to be administered only on patient request absent any indication for use? "Gee, Mr. Paramedic. I'm in no pain, but I'd sure like a bolus of morphine." 

So you were taught that backboards weren't necessary for all patients. Was it NEXUS or Canadian C-Spine rule? What if your system doesn't support the use of it? So you were taught one standard and are now being held to a different standard based on protocol, which is right? What if the expert witness EMS provider works in another system that does the opposite (either does or does not allow for selective spinal immobilization)? Who's setting the standard of care in that case?

So your class taught the material correctly from a medical standpoint, but how many other classes in your area teach the mentality of everyone gets oxygen and a backboard? One problem with the standard of care being the sole judge is that there's a certain amount of 'majority rule' involved. The majority, however, is not always right.


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## JJR512 (Mar 14, 2011)

JPINFV said:


> "Superior orders" is not a defense I would like to use in a court of law if the orders are manifestly wrong. That defense won't stand if the plaintiff can show that the EMS providers should have known better. All that would be shown was that there are two EMS providers who don't know how to do their job properly.


The EMS provider cannot be expected to know more than what what was taught in class, whether in an EMT-B class or in an EMT-P course. The "superior orders" are essentially to apply what one has been taught. Therefore the plaintiff should not be able to show that the EMS provider should have known better, if the EMS provider was correctly applying what he or she was taught and following protocols, even if it's the protocol that says "if you're in a situation not covered by another protocol or you can't otherwise figure out what to do, contact medical control".



> Also, if EMS providers are supposed to follow protocols to a T, why even provide 1000 hours of training? If the end all/be all is symptom relief based care based on a cookbook, than very little actual training is needed. There's definitely no need for foundation sciences (A/P, pharm, etc) in that case, since there's no reason to use it. Under this concept, I can train an EMT in a week, part time.


To my recollection, nobody here is advocating following protocols to a T. Any part of my response that mentioned following protocols like a "cookbook" was in response to something you mentioned first, so you're just arguing with yourself again.



> If the physician can understand that the educational background underlying a paramedic's practice of prehospital emergency medicine is not the same as the physician's educational background in emergency medicine, why can't the physician apply that understanding when providing expert testimony.


I've already answered this once, maybe twice, so pay attention this time for I shan't say it again. It is my opinion and belief that a person of higher education, training, and experience cannot think in the way that a person of lesser education, training, and experience thinks. One _might_ be able to put one's education, training, and experience out of one's conscious mind but it's still there in the brain, influencing the way that person thinks and reasons. If the physician is predisposed to think something was obvious, then he will think it should have been obvious, and may not understand why it wasn't. Are there exceptions to this? Possibly.



> Why would you administer a medication only because the patient requested it? Isn't the EMS provider the professional providing care? What other drugs are going to be administered only on patient request absent any indication for use? "Gee, Mr. Paramedic. I'm in no pain, but I'd sure like a bolus of morphine."


I would administer oxygen if the patient asks for it because my protocols tell me to. Even if I was a paramedic, I would not administer morphine if I had no reason to do so, if the patient asked for it because there is nothing in my protocols that says I'm supposed to do that. Each medication that can be administered at both the BLS and ALS level has its own protocol (in Maryland) that says when it is and isn't appropriate to use it.

For the record, it appears I was incorrect to say that my protocols tell me to administer oxygen to anyone who asks for it. What it actually says is, "Never withhold oxygen from those who need it." However, I know I have heard the concept of "give oxygen to anyone who asks for it" somewhere in some type of training situation, whether it was in an EMT class or by a field trainer I can't say for sure. But I am intelligent enough to not assume that "give oxygen to anyone who asks for it" does not translate to "give morphine to anyone who asks for it".



> So you were taught that backboards weren't necessary for all patients. Was it NEXUS or Canadian C-Spine rule? What if your system doesn't support the use of it? So you were taught one standard and are now being held to a different standard based on protocol, which is right? What if the expert witness EMS provider works in another system that does the opposite (either does or does not allow for selective spinal immobilization)? Who's setting the standard of care in that case?


I don't know about "NEXUS or Canadian C-Spine rule". I do know that I was not taught one standard while being held to another, though. The standard I was taught was what our protocols currently say, which is that not everyone needs to get backboarded. So there is no "which is right" issue for me.

As for an expert witness EMS provider who works in another system...If I get sued for negligence, it's going to be for a patient I picked up in Maryland. All of Maryland has the same protocols. We don't have different protocols for each county, we don't have that each private company has it's own protocols. There is one set of protocols that applies to every Maryland EMS provider. If I get sued, it's going to be in Maryland, and it should be that the expert witnesses are providers of the same level from Maryland. Furthermore, if I'm the one getting sued, I'm going to expect that my defense attorneys pick expert witnesses who are very experienced and are familiar with the way things work in Maryland. And I'm also going to expect that if the plaintiffs attempt to use experts against me, that if they are not of the same level as me and from the same system, that my defense attorneys will attempt to have them disqualified as experts because they are not truly experts in the way things are supposed to work in Maryland at my level.


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## Phlipper (Mar 15, 2011)

> Basic training is a joke. And Paramedic is a crash course as well. I think a Bachelors degree should be the absolute minimum.



+1

We'll have to drag EMS kicking and screaming into the 21st century, though.  Anytime I've broached the subject at the two systems I work in the old guard gets bent out of shape.  

And that's why we will always be second level compared to RNs (soon to be a BS minimum, I'd bet).  Well that, and the fact that too many EMS systems present Billy Bob to the patient who walks in dressed like he just crawled out of a clothes hamper and says "Hey sweetie!  Whachu got goin' on tonight?".  The most awesome medic on the planet comes off as an idiot with many pts, families, and peers when he's getting his Bubba on.  :wacko:

More/better edumakation and a more professional attitude in the work we do will do wonders.


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