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

[DrParasite]

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

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

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

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

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

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

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

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

 

[JPINFV]

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

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

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

 

[MrBrown]

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

 

[Shishkabob]

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

We can.

 

[JPINFV]

We can.

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

 

[Shishkabob]

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

 

[JPINFV]

Touche.

 

[akflightmedic]

Touche.

Touche---Pronounced Too-Shay

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

 

[RUGBY66X]

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

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

 

[usalsfyre]

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

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

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

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

 

[EMSLaw]

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

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

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

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

 

[adamjh3]

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

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

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

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

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

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

 

[JPINFV]

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

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

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

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

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

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

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

 

[18G]

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

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

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

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

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

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

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

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

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

 

[CAOX3]

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

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

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

Education and training are completely different things.

Education is thought based, training is action based.

 

[firetender]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

[adamjh3]

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

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

 

[MrBrown]

Could be worse, you could be Brown

 

[Melclin]

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

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

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

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

 

[mgr22]

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

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