# Does EMS overtreat?



## Veneficus (Jan 21, 2011)

One of the Docs here is as antiEMS as I have ever seen. 

The main complaint is "overtreatment." But there are a plethora of others. 

Now I know in EMS (collective)we are always expecting the worst, and when it turns out not to be the case, then as far as we are concerned, life is good. 

But does the idea of always expecting, and therfore treating for the worst do a disservice to patients?

In the US, from initial education to protocols, the common worst cases are drilled into us. Perhaps to the point of being like blinders. No other medical or healthcare professional is inititially trained to think worst case first. 

But does our thinking stop there? Just like any medical specialist does EMS automatically file people into the column of things we need to treat?

Let's look at chest pain. Many things cause chest pain. So EMS comes out and starts an ACS protocol. Seems like the right thing to do to me, bt coming from that background, I am probably biased. 

Should the 12 lead be done first? Should there be an istat troponin done as standard of care? (because it is available in this day in age.) Let's face it, if you are spending money on capnography, you have money and probably more need for an istat.

While ACS treatment is being initiated, with diagnostics run simultaneously, what prevents a critical error like MONA to a aneurysm patient? Surely we are not relying solely on the discription of pain or radiation from a nonmedically initiated patient to give us the buzzwords?

Or are we?

Is giving a person having thier first attack of stable or unstable angina Nitro, morphine, and carting them off to the ED to repeat the myriad of tests done there in the best interest of the patient? Economically? 

It seems to me that a healthy balance needs to be struck. Just as we must reduce costs by getting away from transporting everybody to the ED, where most are not actually helped, maybe we need to stop treating worst case until proven otherwise?

I haven't made up my mind yet, so i figured I'd put it out there for discussion.


----------



## rescue99 (Jan 21, 2011)

Veneficus said:


> One of the Docs here is as antiEMS as I have ever seen.
> 
> The main complaint is "overtreatment." But there are a plethora of others.
> 
> ...



Well...as member of the uneducated providers club, which is what some people seem to think the U.S. is; perhaps we had better stick to over treating until we be schmarter  TGIF...have a good weekend


----------



## usalsfyre (Jan 21, 2011)

Veneficus said:


> One of the Docs here is as antiEMS as I have ever seen.



That sucks. 



Veneficus said:


> The main complaint is "overtreatment." But there are a plethora of others.



As opposed to overdiagnosing? You know, VOMIT, labs out the @ss and multiple consults 



Veneficus said:


> Now I know in EMS (collective)we are always expecting the worst, and when it turns out not to be the case, then as far as we are concerned, life is good.
> 
> But does the idea of always expecting, and therfore treating for the worst do a disservice to patients?
> 
> In the US, from initial education to protocols, the common worst cases are drilled into us. Perhaps to the point of being like blinders. No other medical or healthcare professional is inititially trained to think worst case first.



Probably, but when your only trained in "emergencies" everything begins to look like one. The old hammer adage. In addition, far too little time is devoted to finding non-life-threatening vs life-threatening in both initial education and most services CE programs as you note. Our foundation of care is built on "worst case scenario".

One of the problems with changing this is EMS providers seemingly pathological need to pass responsibility and blame. "Well it could have been life-threatening, so I treated it". The part I'm afraid of is that some would use this as an excuse to leave sick people home out of laziness. 



Veneficus said:


> But does our thinking stop there? Just like any medical specialist does EMS automatically file people into the column of things we need to treat?



Probably yes. Again, "hammer and nail" 



Veneficus said:


> Let's look at chest pain. Many things cause chest pain. So EMS comes out and starts an ACS protocol. Seems like the right thing to do to me, bt coming from that background, I am probably biased.
> 
> Should the 12 lead be done first? Should there be an istat troponin done as standard of care? (because it is available in this day in age.) Let's face it, if you are spending money on capnography, you have money and probably more need for an istat.
> 
> ...



A couple of points here. Most systems and GOOD medics I know are going to have 12 lead in hand first, if nothing else to prevent giving nitrates to RVI. Secondly, iStats are actually a good deal more expensive, both initially and in disposables, than capnography integrated into the monitor. Plus there's an issue with CLIA controls (how many of you run the controls on your glucometer like your supposed to, I can see you running to the rig now...). Not to mention you could hand a good number of medics a text in Klingon and iStat results they'd have about equal chance of interpreting them correctly. 

Finally, most ED's I have been around started emperic MONA at cardiac-sounding chest complaints after 12 lead EKG, and did not wait for labs and/or CT. Many of them started it in the waiting room (with the exception of the morphine of course). 



Veneficus said:


> Is giving a person having thier first attack of stable or unstable angina Nitro, morphine, and carting them off to the ED to repeat the myriad of tests done there in the best interest of the patient? Economically?



Of course not, but most EDs treat "worst case scenario until proven otherwise" as well. 



Veneficus said:


> It seems to me that a healthy balance needs to be struck. Just as we must reduce costs by getting away from transporting everybody to the ED, where most are not actually helped, maybe we need to stop treating worst case until proven otherwise?



Seems to be along the lines of disposition to areas other than the ED. If medics did a decent job at determining the needs of the patient, I'd agree completely. Right now medics are only good at "can I find something to do for this patient" to satisfy themselves and their managers (ALS1 or 2 vs BLS billing). 



Veneficus said:


> I haven't made up my mind yet, so i figured I'd put it out there for discussion.



Good topic, emergency medicine as a whole probably overtreats, but in the current social and judicial climate I'm not sure how to get around it.


----------



## medic403 (Jan 21, 2011)

When we hear chest pain, many of us immediately think MI. Why? Because that is the worse case scenerio, that is what is and has been pounded into our head. Think about your brand new EMT partner, goes to little old lady that rolls her ankle and your partner shouts out "do you have any chest pain or SOB?" but how do we rule this out besides a monitor? 
12 leads are fairly new, many are still learning how to read them, and many seasoned medics rule in the problem without a monitor, and even a seasoned basic can rule in a reason for CP generally. A vast majority of CP are secondary to a primary problem. this is done by ruling out other possibilities. Many of us do this in our heads. what are possibilities of CP?  

anxiety, AAA, pneumonia, muskoskeletal injury, pneumo/hemo, pleurisy, cardiac tampanade, gall stones, asthma attack, and so many more.
How can we rule all these out? Rule #1: Sensories: touching, looking, hearing, feeling. a monitor can not tell you many of the above complaints, but nitro will take care of many of the complaints above pain. #2: no meds without checking with rule #1. need to make sure we do a good assessment prior to jumping the gun to MI.

now let's break it down with a scenerio:

You are called for a 39 year clerk working at a local store as a clerk when he suddenly experiences chest, no med. history, no allergies, is obese, non smoker and non drinker, complains of a tearing pain in his chest. Skin is pale, wet, and cold. pt has no radial pulse on the left wrist but does on the right. appears strong and a rate of 70. LS are clear, RR is 22bpm. O2 sats are 98%. with palp you are unable to reproduce the pain, you see no obvious bruising on the chest and the pt denies any recent traumas. 

what is your thought process? what do you want to do for this pt? is this pt sick or not sick? What is your field dx with just this little bit of information? Do you really need a 12 lead, and the whole mona or fona cocktail? Is this an ACS call? 

Sometimes chest pain may not be really chest pain. Use all your senses and if all else fails use your intuition. There is nothing in NR books that state all chest pains need a 12 lead and nitro. But unable to rule out Cardiac CP with all other variables please do a 12 lead prior to giving any meds. It can make the difference of life and death. 
So add your thoughts to the above call and see what you come up with, and for all you seasoned EMS personell that already know the answer for treatment and DX help your partner or someone around you understand why the pt presents with some of the given symptoms. 
Take care and be safe all.


----------



## firetender (Jan 21, 2011)

Veneficus said:


> It seems to me that a healthy balance needs to be struck. Just as we must reduce costs by getting away from transporting everybody to the ED, where most are not actually helped, maybe we need to stop treating worst case until proven otherwise?
> 
> I haven't made up my mind yet, so i figured I'd put it out there for discussion.



*The questions that come up for me are based on the original concept of the paramedic program;*_* to intervene in life-threatening emergencies as close to the time and place as they originated and stabilize patients for transport to the next, more sophisticated level of care.
*_ 
What has changed? How more simple could it be? I honestly don't see EMS as a vehicle for other than stabilization for transport to a better equipped and staffed facility. We are trucks for Goddsakes and ultimately, we TRANSPORT. 

Whatever we deliver in the field is serious stuff and there's no reason to stretch the resources of the patient by "trying everything". Every drug we administer carries with it a backlash of side-effects and alters whatever drugs are used before or after. Is not an important part of our role to minimize the rebound effects of what we administer? 

Perhaps that's what more training should involve; getting medics to better understand what they are administering so in the field they can appropriately *limit *their treatments to what will do the most good for the limited time of the patient's exposure to the EMS system.

Now that is discernment that real professionals are trained to provide!

The only difference between BLS and ALS is that once it was "_*load and go*_" and now it's "_*stabilize as best possible and go*_". Is "stabilization" no longer the purpose of EMS? That's different than treating isn't it? I don't think we treat; we stabilize.

The operative word is *"GO!"*, that's the essence of what we do.

We are working within highly limited parameters. We NEVER have enough info or backup to make a definitive diagnosis (all that happens in more controlled environments), we are NOT engaged in long-term care. We are setting the patient up for the next level of intervention, Period. Everything more *IS *overtreatment.

I was trained to recognize as many life-threatening -- immediately life-threatening -- "entities" as possible and administer specific treatments to either eliminate or slow down the life-threatening process for long enough to get my patient to the hospital. One of my most important considerations was time; "How much time shall I spend HERE before I get my patient to THERE?"

Show me where that has changed, please. Maybe I'm naiive. Recognize, that I'm referring in broad strokes to current day EMS practices in the US. Our jobs here seem to revolve around getting to a scene, stabilizing emergencies for transport and then going to the hospital. We are neither trained for nor asked to spend more time with our charges and make sure they get to where they actually need to go. We either take them to an ER or leave them to their own designs. We're specialists whose job it is to be ready for the next emergency as quickly as possible.

Though I fancied myself as part of a bigger picture, i.e. as the first line of clinical care of the patient, in reality I was a stopgap measure, something transitional and not definitive.

Once again, tell me what has changed.


----------



## Bieber (Jan 21, 2011)

firetender said:


> *The questions that come up for me are based on the original concept of the paramedic program;*_* to intervene in life-threatening emergencies as close to the time and place as they originated and stabilize patients for transport to the next, more sophisticated level of care.
> *_
> What has changed? How more simple could it be? I honestly don't see EMS as a vehicle for other than stabilization for transport to a better equipped and staffed facility. We are trucks for Goddsakes and ultimately, we TRANSPORT.


The current trends in EMS are moving away from just "load 'em and go" and focusing more and more on providing what definitive treatment can be rendered on scene along with referral to more appropriate medical facilities and backing away from transporting every patient.  Whether or not you see EMS as a vehicle for anything other than stabilization and transport, that is NOT the vision shared by everyone in EMS and that is NOT the way EMS is trending towards.



> Whatever we deliver in the field is serious stuff and there's no reason to stretch the resources of the patient by "trying everything". Every drug we administer carries with it a backlash of side-effects and alters whatever drugs are used before or after. Is not an important part of our role to minimize the rebound effects of what we administer?


I don't think anyone here is advocating wildly pushing every drug in the box until the patient gets better at the expense of them getting worse.  We're talking about more decisive treatments provided by more educated practitioners and minimizing the number of transports as appropriate.



> Perhaps that's what more training should involve; getting medics to better understand what they are administering so in the field they can appropriately *limit *their treatments to what will do the most good for the limited time of the patient's exposure to the EMS system.


You're right that sometimes less is more.  Including less needless transports and visits to the ER.



> The only difference between BLS and ALS is that once it was "_*load and go*_" and now it's "_*stabilize as best possible and go*_". Is "stabilization" no longer the purpose of EMS? That's different than treating isn't it? I don't think we treat; we stabilize.


EMS as a whole seems to be moving more and more towards a Mobile Health Service, if you will.  In many countries outside of the United States and even in some places within the United States more and more services are moving towards this type of system, with great results.  And you've never treated nausea with an antiemetic or pain with an opioid?  If you want to say you "stabilize" their pain or their nausea, then you're just getting into semantics.  I don't know what you're doing, but I've been treating my patients that I was capable of treating and stabilizing those I wasn't capable of treating in the field.



> The operative word is *"GO!"*, that's the essence of what we do.
> 
> We are working within highly limited parameters. We NEVER have enough info or backup to make a definitive diagnosis (all that happens in more controlled environments), we are NOT engaged in long-term care. We are setting the patient up for the next level of intervention, Period. Everything more *IS *overtreatment.


The world is changing and so is medicine.  We have more tools and capabilities out in the field than ever before.  We are fast approaching an era where we DO have the ability in the field to make a definitive diagnosis on more conditions than ever before, thanks to the invention of devices such as the iStat and the portable ultrasound.  And whether we recognize it or not, we ARE engaged in long term care and what we do DOES have a profound effect on our patients' long term health.



> I was trained to recognize as many life-threatening -- immediately life-threatening -- "entities" as possible and administer specific treatments to either eliminate or slow down the life-threatening process for long enough to get my patient to the hospital. One of my most important considerations was time; "How much time shall I spend HERE before I get my patient to THERE?"


I understand that.  But you have to also recognize that the field of medicine is fluid and we're entering an age of technological advances and economic constraints that are encouraging those of us in EMS to transport less, refer more, increase our education and provide more definitive treatments.  It's the way of the world.



> Show me where that has changed, please. Maybe I'm naiive. Recognize, that I'm referring in broad strokes to current day EMS practices in the US. Our jobs here seem to revolve around getting to a scene, stabilizing emergencies for transport and then going to the hospital. We are neither trained for nor asked to spend more time with our charges and make sure they get to where they actually need to go. We either take them to an ER or leave them to their own designs. We're specialists whose job it is to be ready for the next emergency as quickly as possible.


You're right that we haven't been trained enough--yet.  Which is why we have to continuously push harder and harder for increased educational standards, a minimum of an associate's and more bachelor's options which will increase our ability to transition fully from EMS to MHS.



> Though I fancied myself as part of a bigger picture, i.e. as the first line of clinical care of the patient, in reality I was a stopgap measure, something transitional and not definitive.
> 
> Once again, tell me what has changed.


Don't sell yourself short.  You ARE the first line of clinical care to your patients, anything less undermines and shorthands all of your training and education and the advances in the EMS system as a whole.  We are clinicians on the cusp of achieving true professionalism and recognition within the healthcare industry, all we need is continue to push for higher education and become greater advocates for our patients.  They don't all need to go to the ER, they don't all need transport at all.  Services in other countries such as the U.K. and Australia have proven this, those of us in the United States need only follow their example and learn from them.

Enjoy.


----------



## mgr22 (Jan 21, 2011)

Good topic. I'd say I agree with most of firetender's comments. I don't have the training or the tools to do much more than diagnose and treat a few dozen conditions; and I'm probably stabilizing more than treating most of those. I can't think of a better next step than to offer my patients transport to a facility where people know more than I do. I don't control the cost of that care, and it's not my place to decide how much risk is worth how much money.

I wish things were different: I wish hospitals were less costly and more efficient. I wish I knew more. I wish I had better tools. I wish I had more alternatives. I'll continue to learn what I can, advocate for my patients, and try to think outside the box. But I'm still a medic, not a doctor.


----------



## usalsfyre (Jan 21, 2011)

mgr22 said:


> I don't control the cost of that care, and it's not my place to decide how much risk is worth how much money.



At some point (very soon probably)we're all going to have to start thinking about this. 



mgr22 said:


> I wish things were different: I wish hospitals were less costly and more efficient. I wish I knew more. I wish I had better tools. I wish I had more alternatives. I'll continue to learn what I can, *advocate for my patients*, and try to think outside the box. But I'm still a medic, not a doctor.
> (bolding mine)



Advocating for the patient means more than just "you could die if you don't go to the ED". Their financial and social well being are very much a part of the overall being.


----------



## mgr22 (Jan 21, 2011)

_At some point (very soon probably)we're all going to have to start thinking about this._ 

I think about medical expenses all the time. That doesn't make me any better qualified to decide what the patient should spend.

_Advocating for the patient means more than just "you could die if you don't go to the ED". Their financial and social well being are very much a part of the overall being._

Agreed.


----------



## 18G (Jan 22, 2011)

I'm to the point that I'm not even interested in entertaining these types of questions ne more. I became a Paramedic to do whatever I can from the time 911 is called until arrival at the hospital and to do it the very best I can. The EMS purpose is to alleviate feelings of sickness, pain, and stabilize patients so that the hospital has a viable patient to treat. Were not the definitive answer to a patients ailment! duh. Stop trying to apply a purpose to a machine that wasn't built to handle it. If you want a machine to do a more intense or totally different job then you need to build a new machine. Don't knock the old, faithful machine for doing the great job it was built to do!!!    

Everyone wants to knock EMS lately and personally I get sick of hearing it. It's not perfect but neither is every in-hospital encounter either! EMS works well and in my opinion serves it's intended purpose. If you want something better than start putting doctors on our ambulances if Paramedicine isn't good enough.

We treat based on whatever information we are able to ascertain given the most common tools available in the field. And no, my department could not swing the cost of an iStat right now. We have capnography because it came integrated in our LP12's so that is not a great example. 

I agree that Paramedic programs can be more in-depth but isn't that in the works? Give it time for the gears to get turning.

We have to treat empirically sometimes based on limited information. It's easy for a doctor to hate EMS because he thinks they over treat. If he doesn't like what he see's then tell him to do something about it or quit the *****ing.


----------



## Fish (Jan 22, 2011)

18G said:


> Everyone wants to knock EMS lately and personally I get sick of hearing it. It's not perfect but neither is every in-hospital encounter either! EMS works well and in my opinion serves it's intended purpose. If you want something better than start putting doctors on our ambulances if Paramedicine isn't good enough.
> .



I don't think that having a DR instead of a Medic(in most EMS systems) would be better, What is a DR without all of the diagnostic tools of a Hospital(Labs, xray, CT)? They would basically be limited to the same treatment as a Medic and only be able to do the same diagnostics as a Medic because the same tools and equipment that are available to us would be available to them. Dr.s are higher trained, and higher paid, because once we reach their Relm of the ER, they have the knowledge and ability to use all of the Hosp. resources and interpret them.(We dont) Among many other things, that they do.

Thoughts?

We have a purpose, we serve our purpose well. Our demand and need are growing and we are here to stay.


----------



## Veneficus (Jan 22, 2011)

firetender said:


> Once again, tell me what has changed.



The money.

You were not paid nearly what a modern EMS person gets and nowhere near what they want. 

Your service didn't bill nearly what modern EMS services do to stabilize and drive.

When you increase the money you are to be paid, you need to increase the service proportionally.


----------



## Veneficus (Jan 22, 2011)

Fish said:


> I don't think that having a DR instead of a Medic(in most EMS systems) would be better, What is a DR without all of the diagnostic tools of a Hospital(Labs, xray, CT)? They would basically be limited to the same treatment as a Medic and only be able to do the same diagnostics as a Medic because the same tools and equipment that are available to us would be available to them.



That is a completely inaccurate statement. 

What makes a doctor is not all of those fancy lab tests and xrays. Maybe that's all the US doctors are useful for?

But the knowledge of a doctor, the ability to do far more than a paramedic with the same tools and even add some makes this look like hubris. At the very least a gross misunderstanding of what a doctor actually is and does.



Fish said:


> Dr.s are higher trained, and higher paid, because once we reach their Relm of the ER, they have the knowledge and ability to use all of the Hosp. resources and interpret them.(We dont) Among many other things, that they do.



Like a proper physical exam.

Like a complete history.

Like the ability to correlate medical knowledge with these findings and create a care plan.

The ability to make sure the patient gets the proper help. Not just the glorified ED workup to decide nothing acute is going on.



Fish said:


> Thoughts?



You need to spend some time with doctors to find out what they actually do, not just make stuff up.



Fish said:


> We have a purpose, we serve our purpose well. Our demand and need are growing and we are here to stay.



No you don't, you are an overpriced taxi ride. The need for medical care and entrance into the medical system is growing, the need to drop people off at the ED and the outrageous costs associated with that is actually diminishing.


----------



## Aidey (Jan 22, 2011)

I'm going to go with yes and no. 

EMS and The Three Bears have a lot in common. We don't get it just right very often, usually we under treat or over treat, although the extent depends on the local protocols. 

As has been noted numerous times, there is a supply and demand mis-match. What people need are not what we supply most of the time, and I think that leads to a lot of the over and under treating that happens. 

We under treat critical patients. We under treat the very sick because we don't keep up with research and it takes years to change protocols. Sepsis/septic shock and the cooling of post arrest patients both come to mind. 

We both under treat AND over treat by transporting in a lot of cases. So many patients could be treated with OTC meds and referred to a non-ER doctor for the next day. But because all most of us can do is transport we under treat them by not providing any care, and over treat by taking them to an ER which they don't need. 

We over treat a large number of patients because of the few options available to us and a lack of updated protocols/education. Two words - back boards. Fentanyl for all pain because there are no other pain meds available, O2 on most patients, large amounts of fluids in trauma patients. You guys get the idea. 

As I said before, in some places it isn't as bad, they have non-opiate options for pain, more liberal treat and release protocols, a progressive MD who keeps up on new treatments and puts them into place. 

In my area I was ecstatic when we got saline locks instead of having to hang fluids on everyone. It gave me an option to treat people more appropriately, since labs and a route for IV meds is usually what is needed, not fluids. So much of EMS is still geared towards an "all or nothing" approach, and I think when we fix that we can fix other problems.


----------



## Shishkabob (Jan 22, 2011)

Does EMS specifically overtreat?  No.


Does medicine in general?  Hell yes.



The ones that "overtreat" are the ones that follow protocol to the letter.


----------



## Fish (Jan 22, 2011)

Veneficus said:


> That is a completely inaccurate statement.
> 
> What makes a doctor is not all of those fancy lab tests and xrays. Maybe that's all the US doctors are useful for?
> 
> ...



This made me giggle......

By no means was I down playing what an MD does, but give a Doc EPi and what more can he do with it than I? Same with every other med/piece of equipment we carry. Are you not from the US? Don't get so defensive and bent out of shape over another persons opinion, you put something up for discussion and here you have it.


----------



## firetender (Jan 22, 2011)

Veneficus said:


> The money.
> 
> You were not paid nearly what a modern EMS person gets and nowhere near what they want.



I dunno. You tell me. I left the field in 1985. I was making $5.64/hr. on a 56 hr. work week, meaning about $1,400 a month.

That was 25 years ago; more hours, maybe, but then, we were paid a good 20% LOWER than comparable Fire Services. What's the going rate today, and working in inflation, who was doing better?




Veneficus said:


> Your service didn't bill nearly what modern EMS services do to stabilize and drive.
> 
> When you increase the money you are to be paid, you need to increase the service proportionally.



The amount "billed" NEVER seems to trickle down to the providers of service, does it? 

Were we to increase the service, then we'd have rights to demand commensurate pay.

Wouldn't we?

...and that does NOT mean getting paid to overtreat.


----------



## Shishkabob (Jan 22, 2011)

firetender said:


> The amount "billed" NEVER seems to trickle down to the providers of service, does it?



Gotta love it.  Even if you work 1 ALS call an hour, the company gets $1,000, and you get less than $25 even with OT.


----------



## Journey (Jan 22, 2011)

Fish said:


> This made me giggle......
> 
> By no means was I down playing what an MD does, but give a Doc EPi and what more can he do with it than I? Same with every other med/piece of equipment we carry. Are you not from the US? Don't get so defensive and bent out of shape over another persons opinion, you put something up for discussion and here you have it.



This made me giggle......

What are your protocols for epinephrine?

What can you titrate to for a continuous infusion?

Can you run a continuous infusion for anaphylaxis?

How creative are your protocols for using several medications by continuous infusion and boluses to achieve a desired effect? 

How many different diagnoses can you identify which aren't specifically listed in your protocols for the use of an epinephrine infusion?

Ever use specific concentrations of epinephrine soaked patches over certain wounds like those seen in TENS? Do you know how to use it for pulmonary bleeding or to identify which pulmonary situations to use it and which you should not even think of instilling it? 

Epinephrine is a very versatile medication with many uses in the hands of someone very knowledgeable like a physcian.

Do you know what a physician can do with just a scapel which will exceed your protocosl? 

How much pain management can you do with what limitations and how willing is your med control to exceed those limitations?  How creative are you with pressors to achieve a certain level of pain management or comfort like what might be required for an intubated patient?

Many CCTs and specialty teams use doctors and RNs rather than Paramedics for many of these same reasons.

EMS systems in other countries use doctors, nurses and Paramedics with much higher education than what is required in the U.S. for a reason and that mostly has to do with the benefit of the patient rather than a _measuring contest _ .


----------



## Journey (Jan 22, 2011)

firetender said:


> The amount "billed" NEVER seems to trickle down to the providers of service, does it?





Linuss said:


> Gotta love it.  Even if you work 1 ALS call an hour, the company gets $1,000, and you get less than $25 even with OT.



You can bill whatever you want but that does not mean the insurances will pay that amount.  Please refer to sections 20 and 30 from CMS.

https://www.cms.gov/manuals/Downloads/bp102c10.pdf

This also works in your favor if you have insurance. If your insurance reimbursed for the full amount of each ambulance ride, doctor or hospital visit,  your employer would be asking you to pick up a much higher portion of the costs and you would probably never be able to afford the premiums.


----------



## Shishkabob (Jan 22, 2011)

Journey said:


> What are your protocols for epinephrine?
> 
> What can you titrate to for a continuous infusion?
> 
> ...




Shoot, I'm not even with MCHD like he is BUT:

1: Very varied

2: Standing orders alone,  2-10mcg/kg/min... however if more is needed (not likely considering the scenario) you can always call it in.

3: Yes

4:  Very.  Dopamine, Epi, Dobutamine, Levophed and Vasopressin for shock, just as an example.

5:  Any we need to, as our guidelines have a "catch all" that says treat patient condition per appropriate way.

6:Not much, actually, considering I, and Fish, don't have 'scopes' in the sense you would argue.

And finally, as per pain management:  1-2mcg/kg twice without thinking about it, and we can RSI with subsequent doses of narcotics, and contact med control if we want to do something else.




I fail to see the point of your post though:  It goes without saying that someone who CAN'T do anything they want, will be able to do less than someone who CAN do anything they want....


----------



## Journey (Jan 22, 2011)

Linuss said:


> Shoot, I'm not even with MCHD like he is BUT:
> 
> 1: Very varied
> 
> ...



Why don't you just post your protocols since you always seem to be bragging about them? Please share. You can copy and paste.  And don't include those which the nurses set up for you at the hospital for you to monitor but not touch during transport.


----------



## sredish (Jan 22, 2011)

You have to cover yourself.  Don't worry about the dr's that think you're over treating.  If he was smart he'd appreciate the efforts but if you expect the worse and hope for the best then you're covered.  If you expect the best and get a surprise, you're opening yourself up to negligence.


----------



## Shishkabob (Jan 22, 2011)

Journey said:


> Why don't you just post your protocols since you always seem to be bragging about them? Please share. You can copy and paste.



Actually, I can't as it's a PDF, and considering it's 281 pages, I'd rather not waste my time "Prnt scrn, paste, save, upload".



Take it at face value or not at all.  Your choice.  But you have no room to demand 'proof' when you refuse to do it yourself.


----------



## Journey (Jan 22, 2011)

Linuss said:


> Actually, I can't as it's a PDF, and considering it's 281 pages, I'd rather not waste my time "Prnt scrn, paste, save, upload".
> 
> 
> 
> Take it at face value or not at all.  Your choice.  But you have no room to demand 'proof' when you refuse to do it yourself.



There are  free PDF editors which allow you to copy and paste.

I'm not the one bragging.  I've also read several of your other posts which is also why I am inquiring.


----------



## Shishkabob (Jan 22, 2011)

Journey said:


> And don't include those which the nurses set up for you at the hospital for you to monitor but not touch during transport.



Hmm.. funny... I could have SWORN there's a section in my guidelines that state for medications not normally used in EMS, we are to call in to OUR medical control and get medication ranges to be used. and not rely on the sending facility.


Oh, and also how the Paramedic has ultimate control over patient care, even if an RN or RRT are on board.



But you'll just have to trust me on those.


----------



## Journey (Jan 22, 2011)

Linuss said:


> Oh, and also how the Paramedic has ultimate control over patient care, even if an RN or RRT are on board.



That would have to be only to a specific situation. In some places the Paramedic will drive or sit up front while the team works on the patient in the back. 

Usually RNs are placed on an ambulance because the equipment or medication is out of what a Paramedic can do.  An RN would need to be very, very cautious about accepting any orders from you for a medication or a piece of equipment that  you only know a few uses for. You may think you know it all but Linuss what will make you the most dangerous is that you may not yet know what you don't know.


----------



## 18G (Jan 22, 2011)

I agree that a dr will be more precise with making an actual diagnosis but as far as treatment I don't see much difference. Even if we don't have a precise diagnosis we are able to safely treat the S/S... end result is pretty much the same in the majority of day to day cases.

So a doctor makes a diagnosis that can only be managed in the hospital. So what is he gonna do out in the field? The same thing that we are and treat S/S and make pt. comfortable.


----------



## Bieber (Jan 22, 2011)

Journey, you seem to spend a lot of time trying to make paramedics out to be a bunch of idiots who can barely find their way out of a paper bag.  If you think we're so very incapable of anything but slapping on a bandage of driving as fast as possible to the hospital, wouldn't it make more sense to redirect all of that energy and time you spend trying to make us feel stupid towards trying to educate us?  You point out all of these things we're incapable of doing, well fine, why don't you teach me how to use epi soaked patches for pulmonary bleeding and how to use a scalpel with more precision and skill?

My state requires all paramedics to also obtain an associate's as part of the program requirements, but I still don't feel like I've learned anywhere near as much as I should.  So teach me, I'm willing and able to learn.  But what I'm NOT able to do is sit by and listen to someone tell me how stupid I am without so much as offering to educate me.  I'm all for increasing educational standards, but it's a moot point if the general consensus is to complain about how stupid paramedics are without offering solutions or education.

So how about instead of pointing out all these things we're ignorant of and pointing a finger at us saying "Nyah nyah!  You don't know how to do this, dummy!" why don't you make a thread educating us on all of those things you just mentioned?

Be part of the solution or be part of the problem.


----------



## firetender (Jan 22, 2011)

*The Question Has Been Answered!*

Just in case some of you missed this:



Aidey said:


> _*EMS and The Three Bears have a lot in common. We don't get it just right very often, usually we under treat or over treat, although the extent depends on the local protocols. *_


----------



## Journey (Jan 22, 2011)

Bieber said:


> Journey, you seem to spend a lot of time trying to make paramedics out to be a *bunch of idiots who can barely find their way out of a paper bag. * If you think we're so *very incapable *of anything but slapping on a bandage of driving as fast as possible to the hospital, wouldn't it make more sense to redirect all of that energy and time you spend trying to make us feel *stupid* towards trying to educate us?  You point out all of these things we're *incapable of doing*, well fine, why don't you teach me how to use epi soaked patches for pulmonary bleeding and how to use a scalpel with more precision and skill?
> 
> My state requires all paramedics to also obtain an associate's as part of the program requirements, but I still don't feel like I've learned anywhere near as much as I should.  So teach me, I'm willing and able to learn.  But what I'm NOT able to do is sit by and listen to someone tell me how *stupid* I am without so much as offering to educate me.  I'm all for increasing educational standards, but it's a moot point if the general consensus is to complain about how* stupid paramedics *are without offering solutions or education.






Bieber said:


> So how about instead of pointing out all these things we're* ignorant *of and pointing a finger at us saying "Nyah nyah!  You don't know how to do this,* dummy!" *why don't you make a thread educating us on all of those things you just mentioned?
> 
> Be part of the solution or be part of the problem.



All the negative words are yours. None of those words are in my posts. Maybe this bitterness is how you feel about EMS since your state requires an Associates degree.


The discussion was about physicians which you are not. I am not going to teach you something that is not within your scope of practice. I doubt if your state allows a field C-section.  I have no idea what you know or do not know about pulmonary disorders or what you have in your protocols for instilling medications in the ETT.  Nor should you always take medical advice off an anonymous internet forum to use as fact in your protocols without knowing the whole situation or having the education to compliment the skill.  I teach alot of things but to those who have the appropriate foundation education to advance their skills and knowledge to the next level.  You should also concentrate on perfecting the skills (ex. NG tubes) and medications you do have.

What state are you in that requires an Associates degree?


----------



## Bieber (Jan 22, 2011)

Journey said:


> All the negative words are yours. None of those words are in my posts. Maybe this bitterness is how you feel about EMS since your state requires an Associates degree.


The negative words are mine, but the implication was yours.  What do you mean about "this bitterness is how you feel about EMS since your state requires an Associate's degree"?




> The discussion was about physicians which you are not. I am not going to teach you something that is not within your scope of practice.


The discussion was about whether or not paramedics over treat, actually.  In your first post, you cited inequalities in paramedic ability versus physician ability under similar conditions with similar equipment due to differences in levels of education.  Which is true, paramedics DON'T have the same level of education as physicians.  But if a physician, or more correctly, if an authorized person with a higher level of education can be more useful with the same equipment as a paramedic, and provide better care to patients, then what we need is people willing and able to teach paramedics and be part of the advancement of our education--not to bash us.  We know our limitations.  We're all quite aware, I believe, or the deficiencies in EMS education in this country.  I'm asking for solutions, I'm asking you to be part of the solution by contributing to furthering our education, NOT to tell me to operate outside of my protocols.  I know my protocols and I will always operate within them.



> I doubt if your state allows a field C-section.  I have no idea what you know or do not know about pulmonary disorders or what you have in your protocols for instilling medications in the ETT.  Nor should you always take medical advice off an anonymous internet forum to use as fact in your protocols without knowing the whole situation or having the education to compliment the skill.


I agree, see above.



> I teach alot of things but to those who have the appropriate foundation education to advance their skills and knowledge to the next level.  You should also concentrate on perfecting the skills (ex. NG tubes) and medications you do have.


What do you mean when you say "but to those who have the appropriate foundation education"?


----------



## Fish (Jan 22, 2011)

This thread went from 0-11 all during the time of my post workout nap.

Journey,

Different Paramedic systems allow different things, Epi is infact infused here, cardiac drugs are infact bolus'd to effect before we hook them up to a drip.

You have got to remember, we have 3-20 min transports, most of that stuff you rattle'd off a Dr. would not get done that quickly. He would still be working on what an EMT and Paramedic does. Nobody here is hating on Docs that would be rediculous, I think every Paramedic by nature loves a Dr. seeing as we are the extension of one. I simply brought up something for discussion. Around here we have a high scope, and have an awesome working relationship with Hospitals and there ER MDs, our respect for each other is VERY high.


----------



## 18G (Jan 22, 2011)

Journey obviously has a personal agenda given his condescending remarks about EMS.


----------



## Veneficus (Jan 22, 2011)

Fish said:


> This made me giggle......
> 
> By no means was I down playing what an MD does, but give a Doc EPi and what more can he do with it than I? Same with every other med/piece of equipment we carry. Are you not from the US? Don't get so defensive and bent out of shape over another persons opinion, you put something up for discussion and here you have it.



What can I do with epi?

Well...

I can nebulize it. 

I can mix it with local anesthetic or anesthesia agents and inject it IM or SQ in order to potentiate the effects over a longer time.

I can saturate bandages with it and either dress a wound or insert the roll into the wound to help control bleeding.

I can inject it near the wound in order to aid in bleeding control long term.

I can spray it on the wound to do the same in the short term.

I can inject it SQ and IM for anaphylaxis or even just an allergic reaction or hypersensitivity reaction.

I can hang it as a drip for anaphylaxis, and inotropic effect, especially stacked with dopamine. 

I can give it to a patient in order to replace catecholamines lost to adrenal insufficency.

For chronotropic effect or CNS disorders as well.

That's all I can think of off the top of my head and it is late. What can you do with it?

Oh, I can give it for cardiac arrest too. not that I would choose to because I know it does more harm than good.


----------



## 18G (Jan 22, 2011)

> Oh, I can give it for cardiac arrest too. not that I would choose to because I know it does more harm than good.



Unless your a state recognized EMS physician you will not have any choice but to administer it because you have standing orders that tell you to administer it and its a standard of care. 

And if you are a EMS physician, why wold you not administer it? There is debate that it may do harm but there is also data that says it increases ROSC. You don't have the right to pick and choose what your gonna do and not do out of the protocols you are bound to follow. 

I would like to see you call medical command for orders to withhold epi during an arrest.


----------



## ah2388 (Jan 22, 2011)

hes a medical student..soon to be CCsurg/Anest resident...as i recall

it appears that the overwhelming attitude in this thread is that paramedics are "equal" to physicians.  The difference in education alone dictates that medics are less equipped to make decisions.  Factor into consideration that the type of individual that is attracted to becoming a MD vs. paramedic in the united states...and this argument becomes borderline ridiculous.

It isnt uncommon that medics in the prehospital environment administer the same or similar care as would a physician in the ED.  However, to think we are on par with them is absurd..


----------



## Veneficus (Jan 22, 2011)

18G said:


> why wold you not administer it? There is debate that it may do harm but there is also data that says it increases ROSC.



Because it constricts the arterioles in the brain, so unless you are planning to keep the heart going for organ donation, the ROSC isn't worth much.

I have yet to be turned down for any request for orders I make. (which is all day long, since I can't sign anything myself  )


----------



## Shishkabob (Jan 22, 2011)

ah2388 said:


> it appears that the overwhelming attitude in this thread is that paramedics are "equal" to physicians. However, to think we are on par with them is absurd..



I don't recall anyone saying that


----------



## Veneficus (Jan 22, 2011)

From post 11.

_*I don't think that having a DR instead of a Medic(in most EMS systems) would be better, What is a DR without all of the diagnostic tools of a Hospital(Labs, xray, CT)? They would basically be limited to the same treatment as a Medic and only be able to do the same diagnostics as a Medic because the same tools and equipment that are available to us would be available to them.* Dr.s are higher trained, and higher paid, because once we reach their Relm of the ER, *they have the knowledge and ability to use all of the Hosp. resources and interpret them.(*We dont) Among many other things, that they do._

As was said, the idea that a doctor can do no more than a medic is absurd. 

A doctor is not beholden to various data gathering tools to function.

And is in no way limited to the protocol based treatments of a medic, nor would always want to use them.

From diagnostics, to medications, to knives, the same tools in the hands of a doctor are exponentially more useful than in the hands of a medic.


----------



## Bieber (Jan 22, 2011)

Journey said:


> What state are you from that requires an Associates degree?


Kansas.



> See above post from Linuss. Texas only requires about 600 hours of training to be a Paramedic. Linuss is defending his state by saying there are others that require less which is a very sad statement for U.S. EMS.
> 
> In many places it seems EMS education requires no prerequisites and the sciences such as Anatomy and Physiology, Pharmacology and pathophysiology are watered down to just overviews.  If you do not have an adequate understanding of just these basic foundation classes it would be difficult to build an advanced understanding. Just doing a skill is not always good enough or at least it shouldn't be.


You are one hundred percent correct and I completely agree with you, which is why I am doing everything I can to increase my education (chipping away at my Bachelor's and thinking about PA school) and why I also advocate for increased educational standards across the board for EMS.  I am completely behind you that we need to have a stronger educational foundation in EMS, but not all states are created equal and not all schools provide only the bare minimum just like not all providers stop at the bare minimum.  I respect physicians and their knowledge, and only want the gap between the knowledge base of physician and a paramedic to get smaller.


----------



## Fish (Jan 22, 2011)

ah2388 said:


> it appears that the overwhelming attitude in this thread is that paramedics are "equal" to physicians...



This was never said, I 100% am aware of the distance between Medics and Doctors. I am very close with the Drs in our Healthcare system, i am talking going out to lunch with them, training with them and I ask them for advice and knowledge based questions all day long because I respect them and recognize the extreme amount of knowledge base that they have above my own, let alone 6+ more years of schooling. I simply brought up something for discussion earlier in this thread. Veneficus and Journey brought things to my attention I wasn't aware of, however I have no clue as to why they are even apart of this forum seeing as it is clear they do not respect the EMS perfession and Veneficus himself does not feel we have a purpose.


----------



## Fish (Jan 22, 2011)

Fish said:


> This was never said, I 100% am aware of the distance between Medics and Doctors. I am very close with the Drs in our Healthcare system, i am talking going out to lunch with them, training with them and I ask them for advice and knowledge based questions all day long because I respect them and recognize the extreme amount of knowledge base that they have above my own, let alone 6+ more years of schooling. I simply brought up something for discussion earlier in this thread. Veneficus and Journey brought things to my attention I wasn't aware of, however I have no clue as to why they are even apart of this forum seeing as it is clear they do not respect the EMS perfession and Veneficus himself does not feel we have a purpose.



*profession not perfession


----------



## Journey (Jan 22, 2011)

Fish said:


> Veneficus and Journey* brought things to my attention I wasn't aware of,* however I have no clue as to why they are even apart of this forum seeing as it is clear they do not respect the EMS perfession and Veneficus himself does not feel we have a purpose.



Just showing you there is so much more to the vast world of medicine. The lack of respect comes when some of the statements such as those about doctors were made to make some believe a physician has less skills and knowledge than a Paramedic.

There are Paramedics on the forums of other professions such as nursing and one could ask the same thing about their presence.


----------



## ffemt8978 (Jan 22, 2011)

Thread reopened.

If it gets closed again, the members causing it will receive a 90 day vacation from the forum.


----------



## JPINFV (Jan 22, 2011)

18G said:


> Unless your a state recognized EMS physician you will not have any choice but to administer it because you have standing orders that tell you to administer it and its a standard of care.
> 
> And if you are a EMS physician, why wold you not administer it? There is debate that it may do harm but there is also data that says it increases ROSC. You don't have the right to pick and choose what your gonna do and not do out of the protocols you are bound to follow.
> 
> I would like to see you call medical command for orders to withhold epi during an arrest.



The amount of variance allowed in protocols really varies from area to area. Not every place requires lock step adherence to the protocol cook book. However, considering that Epi is still the standard of care, I do agree that it would be hard for the average paramedic to justify not giving it. Atropine, now, at least has a fighting chance since it's been removed from the AHA guidelines. 

However, the ability to deviate from protocols on scene means little to how much power a paramedic has to influence protocols. An emergency medical physician will always know more about emergency medicine in general than a paramedic. However, there's nothing really stopping a paramedic from having some sort of interest in a specific area and becoming THE expert in that area. You see it all the time, especially online now that people have a platform. Tom Bouthillet runs a great blog about prehospital 12 leads. As another example, Miami-Dade Fire Rescue runs an anti-venom service for the local hospitals. Patient gets bit, goes to hospital, hospital calls MDFR, MDFR specialty trained paramedics pick the anti-venom from their stores, and goes and administers it to the patient including supervising hospital staff in reconstituting the anti-venom and administration. So, what's stopping you (generic "you") from being the Tom Bouthillet for resuscitation science or respiratory emergencies, or environmental emergencies? The medical director can't be some savant who's current on every little advancement in emergency services, but everyone can be the expert in their area of interest in prehospital emergency medicine, and inturn play their part in pushing protocols for that area of interest.


----------



## ffemt8978 (Jan 22, 2011)

Fish said:


> Veneficus and Journey brought things to my attention I wasn't aware of, however I have no clue as to why they are even apart of this forum seeing as it is clear they do not respect the EMS perfession and Veneficus himself does not feel we have a purpose.



Having a respect for the EMS profession is not a requirement to be a contributing member here...it's not even a requirement to be in EMS to be a member.  

We are an open forum about EMS related discussions, which means that we have members all the way up and down the chain.  We have doctors, nurses, PA's, paramedics, EMT's, patients, family members of patients, and people interested in EMS as members.  Each one joins for their own reasons, and has their own viewpoints about EMS and it's affect on their life.

The only people NOT welcome here are spammers and those who repeatedly demonstrate they can't abide by our rules.


----------



## Fish (Jan 23, 2011)

Journey said:


> some of the statements such as those about doctors were made to make some believe a physician has less skills and knowledge than a Paramedic.
> .



100% False, This was Never said.



Venecitus best of luck to you in Medical school, and thank you for helping to close the gap in the shortage of MDs, what is your specialty going to be, family practice, emergency medicene, cardiology?


----------



## Veneficus (Jan 23, 2011)

Fish said:


> This was never said, I 100% am aware of the distance between Medics and Doctors. I am very close with the Drs in our Healthcare system, i am talking going out to lunch with them, training with them and I ask them for advice and knowledge based questions all day long because I respect them and recognize the extreme amount of knowledge base that they have above my own, let alone 6+ more years of schooling. I simply brought up something for discussion earlier in this thread. Veneficus and Journey brought things to my attention I wasn't aware of, however I have no clue as to why they are even apart of this forum seeing as it is clear they do not respect the EMS perfession and Veneficus himself does not feel we have a purpose.



I am not antiEMS.

Actually I take a lot of crap for being proEMS from the doctors. But it doesn't mean that being proEMS is just coddling people and telling them what a great job they are always doing. When people do good work I like to celebrate it too. But showing up and doing the same things from the 1970s is not good work. 

I like to talk about real issues facing EMS, not what boots or pants are best. 

I like to offer my perspectives to EMS as I am a former provider and instructor of such. (technically my cards are still current, and I put forth the effort to keep them so) 

I like to share the insights that I have gotten, without charge, so that others in EMS can help it be better.

But I do get frustrated with the attitude and lack of desire for advancement at times. (more so as of late)

I sometimes take a hardline position that I don't really advocate to point out the flaw in other peoples positions or to demonstrate what there is to lose if EMS providers don't get their act together and advance into a profession.

When I started in EMS, one of the things that was taught, was that paramedics are not doctors. They like to recite that when it comes to taking responsibility but then turn right around and claim to be as good when talking about thier exploits or effectiveness. I find that rather agitating and think it should be saved as a pick up line, not put forth when talking about EMS with other practicioners.


----------



## 18G (Jan 23, 2011)

A Paramedic is no where near that of a physician and I don't recall anyone suggesting that they were. It was said that the same limited interventions would be performed in the field by either a Medic or a physician while working in the common, everyday EMS system in the US.


----------



## ah2388 (Jan 23, 2011)

18G said:


> A Paramedic is no where near that of a physician and I don't recall anyone suggesting that they were. It was said that the same limited interventions would be performed in the field by either a Medic or a physician while working in the common, everyday EMS system in the US.



no one is disputing the idea that a physician may perform similar treatments as  a medic in the prehospital environment, I think the take home point here is that physicians will generally make better decisions related to "when" to use these treatments as compared to a medic.


----------



## Veneficus (Jan 23, 2011)

18G said:


> A Paramedic is no where near that of a physician and I don't recall anyone suggesting that they were. It was said that the same limited interventions would be performed in the field by either a Medic or a physician while working in the common, everyday EMS system in the US.



I don't think that is true though. 

There are many interventions, especially medication uses, for things found on the common EMS ambulance that are readily performed by doctors that paramedics cannot perform. 

A doctor also has considerable diagnostic capability from physical exam findings, as well as advanced interpretation and correlation of various devices such as an EKG. 

The unlimited license to practice medicine also allows the use of equipment carried by EMS in ways not spelled out in EMS protocol.

As some examples, if EMS carries an OB kit with a scalpel and an ET tube, A physician can place a surgical airway even if EMS is not permitted. 

A physician can remove a foreign body, where EMS is largely restricted in that. 

A physician can perform a pericardial or pleural drainage with an IV catheter if so called upon. 

I covered the use of Epi already, but another good example is mag sulfate. that drug is seriously underutilized in EMS. I have even suggested and pushed it for sedation. (with permission from med control)

I think medics can be more than they are currently. But I also think the idea that a physician is limited to what a medic can do in the field with the same equipment is just inaccurate.


----------



## Melclin (Jan 23, 2011)

Its obviously a questions of economics.

It would be awesome if an interventional cardiologist turned up outside your house in a giant flying cath lab for every chest pain call. But there are a few issues with that. 

Obviously a doctor on an can do more than a paramedic but I think the question of "How much more?" and "To what effect?" are reasonable questions to ask when presented with the bill for replacing our 2500 paramedics with doctors. I realise that's not really being suggested, but I'm just extending the idea a little for the purposes of discussion. 

I think its reasonable to suggest that given the limitations placed on us by time, equipment and a highly risk adverse society, a doctor's extensive training is a little superfluous in _most_ areas of ambulance. 

That said, a paramedic's training, especially in America is woefully inadequate to meet the demands of the future (and quite probably, the present). 

To provide a different perspective, paramedics here are more educated than they _need_ be in some ways and less educated in many others. By virtue of how our university entry system works, the popularity of the degree and the courses before it going back probably almost 20 years, you get quite a few high achievers becoming paramedics. You then however, get an education system that is apologetic for teaching you anything other than guidelines or "need to know" facts, because our system is essentially designed to protect the lowest common denominator by restricting practice. As such, the high achievers skill atrophies or they never really bother developing them in the first place. You have a system full of people capable of much broader scope (if only the programs were put in place to allow it) held back by a few idiots. There are of course economic and administrative issues that complicate matters to no end, but there you go.


----------



## Veneficus (Jan 24, 2011)

Melclin said:


> Its obviously a questions of economics.
> 
> It would be awesome if an interventional cardiologist turned up outside your house in a giant flying cath lab for every chest pain call. But there are a few issues with that.
> 
> ...



So what is the fix?


----------

