I guess that's the Zen of the thing. The more advanced experts become, the more they come back to the primal fundamentals. They realized it was all right there in front of them at the beginning and the journey was not to somewhere else but to where they started....or something.That's the thing though - you do this every day. For us mere mortals who will probably BVM fewer people in a career than you do in a month, 1-person BVM technique is not so easy. I didn't realize how much I sucked at it until my OR time during paramedic school when I could look at the monitor and see what was going on.
you want my honest opinion? the generation of ALS and BLS providers before me (who are now in management positions) scare me because of what their education was lacking in both time and content, yet people didn't die from it, and the up and coming ALS and BLS providers worry me, because they are educated more than in the past, but they don't have the experience in dealing with sick people (especially at the ALS level, because there are so many paramedics and paramedics spend time with not sick patients). My generation has it's share of special people too, and I'm hoping we we move into the management positions, we can push for change.So as an EMT instructor what do you make of all of this?
I don't think it's complicated as you are making it out to be. Do I think they will understand all of it? and retain all of it? no. Do I think they can remember that 35 to 45 is where you want to be, if your cardiac arrest has an ETO2 of 5 when you pull up, the odds are he won't be coming back, and if the ETO2 is 60 on said cardiac arrest, than you should probably tell the firefighter to not bag as fast? sure.Do you think your students are, in general, ready for these added skills?
That problem isn't limited simply to EMS; every educational institution has to balance how much information can be delivered, knowing (without continual reinforcement ) the students will only retain about 30% of what was taught.How much more training and education is needed at the EMT-level vs. when do we abolish both EMT and AEMT to create one “basic” level of provider prior to paramedic?
I like the honest answer, and quite frankly this is very much a problem with most things scholastically. We learn just enough to get by, right?
Last I checked, we don't treat based on history. So if the person has a cough with a history of asthma, we don't get back to back albuterol treatments. if the person has rales 3/4 of the way up with no history of CHF, do we not apply cpap despite the lack of history?Exactly my point. It isn’t quite that simple in practice. A better approach is to go by history.
Treatment is based on assessment, a large component of which is history.Last I checked, we don't treat based on history. So if the person has a cough with a history of asthma, we don't get back to back albuterol treatments. if the person has rales 3/4 of the way up with no history of CHF, do we not apply cpap despite the lack of history?
sure, except in my scenario, there was no history of CHFSo if someone has a history of CHF and are displaying S/S consistent with CHF exacerbation, you would be wise to treat for a CHF exacerbation.
You are doing what I call "assuming facts no in evidence," and adding details to an otherwise strawman argument, to support your case.Albuterol would actually be a perfectly reasonable treatment for an asthmatic who is coughing, if coughing is known to precede an asthma exacerbation in that patient. Again, this would be based on history. That's actually a perfect example of where relying on capnography would lead you wrong.
I commend your honesty and humility. Can I ask, are you comfortable with the skills themselves, or are you comfortable enough to admit when they should or should not properly be utilized (e.g., Narcan)? Also, I agree with just about everything you’ve said.Right now, I am capable of performing pulse oximetry, glucometry, SGA’s, Epi, narcan, etc. I am comfortable there.
It is my personal belief (and this is only my opinion) that most EMT protocols should be If you see A, than do B. relatively rigid, so even the best mongo fireman can follow them and not kill the patient. Paramedics should have more leeway, because they are more educated, at least compared to EMTs. Also remember, many of our protocols boil down to lowest common denominator (which is why smaller agencies with very active medical directors can do a lot more, because the medical director knows what the lowest common denominator (which he can keep at a high level) is for his particular group)@DrParasite I’m hardly over complicating any of this. Can protocols follow “X,Y,Z” as you and @Remi have eluded to? Sure, but then again that is how many paramedic protocols are written, and look at what a mess it’s gotten our field into.
Guidelines are great for people who truly can read beyond them, but what about the other 80-90% who can’t, both EMT and medic?
Those ambulance drivers think they can take blood pressures and put on MAST pants? Bunk, I say, bunk!f we are to start pushing the boundaries with things like capnography then I believe that basic programs will need to be re-worked so that they cover more topics and require more clinical hours to hone in on these skills
What the heck are you talking about? Providing a counter-example equates to a straw man now?sure, except in my scenario, there was no history of CHFYou are doing what I call "assuming facts no in evidence," and adding details to an otherwise strawman argument, to support your case.
Again, you completely missed the point. The relevance of an example that someone provides is not contingent on the fact that your agency has so little faith in your judgement. If you can't figure out how my example of the asthmatic relates to the topic at hand, then I don't know what to tell you.I'm pretty sure QA and my medical director would ask me to explain why I gave albuterol to an asthma patient who wasn't wheezing, but only had a cough. But your MD might be different.
Training is where you should gain proficiency and being comfortable enough to do a skill. For intubation I knew what anatomical structures to look for, what equipment I preferred for the task (Mac vs Mil), ways to confirm tube placement, and s/s of DOPE. I built up confidence and proficiency in skills from the first time tubing the manakin to having it be muscle memory. Now, fast forward to my OR shift in clinical. We've now graduated to live people. Shaky? Yes. Nervous? Yes. But my confidence wasn't phased by the real deal due to how much I practiced on skills days and I felt comfortable with the skill on a live person.I’ve used them in training a handful of times so I’d be lying if I said I felt comfortable with this skill. However, if I am in a situation without ALS and know that I have to drop a tube then I believe I am capable of doing so. I’m sure my hands will be a little shaky though.
I agree, and I have no problem at all seeing the scope of practice for basics expand as long as it is done right and the curriculum in basic classes expands with it. I have to admit, if SGA’s are a standing order for basics in my area then it makes sense for us to have access to capnography as well. But then I’d like to ask, doesnt it make more sense for these skills to fall under the advanced or specialist emt’s scope of practice?. I’m clueless when it comes to the advanced emt’s scope of practice as this level of licensure isn’t recognized in my state.Those ambulance drivers think they can take blood pressures and put on MAST pants? Bunk, I say, bunk!
- Some Doc, c. 1969
Standards change over time, and the curriculum grows. And, don't forget, you've already got skills that are more invasive and/or potentially harmful than capnography.
I can agree with that statement. I guess it all depends on where you took the class. I certainly did not feel like I was given enough time to practice using this skill. However, being able to practice on real people in a clinical setting is invaluable. I would have loved to have been given the oppurtunity to do that although I’m sure SGA’s aren’t as common in OR’sTraining is where you should gain proficiency and being comfortable enough to do a skill. For intubation I knew what anatomical structures to look for, what equipment I preferred for the task (Mac vs Mil), ways to confirm tube placement, and s/s of DOPE. I built up confidence and proficiency in skills from the first time tubing the manakin to having it be muscle memory. Now, fast forward to my OR shift in clinical. We've now graduated to live people. Shaky? Yes. Nervous? Yes. But my confidence wasn't phased by the real deal due to how much I practiced on skills days and I felt comfortable with the skill on a live person.
It's a new toy, and one he probably had never used before. I don't blame him for being over eager. Yes, some education needs to be given, but in many other resp arrest calls, wouldn't you be ok with them dropping a king? At least this firefighter was being proactive about doing something involving patient care, or simply standing back and doing the circle of death until EMS arrived and told them what to do. Overeager firefighter (and offers to help) vs firefighter who doesn't want to touch the patient..... hmm which is better....Example- a righteously obvious heroin OD I had when we barely began switching to King airways was met by a FF asking me if I wanted to place a King in as soon as we stepped in the door.
you can't cure stupidity, some people will never grasp the concept of critical thinking skills, and unfortunately, medic mills are pumping out new medics because there is money to be made in paramedic education, and they don't want to fail people because it looks bad for the program.This is what I am talking about, and again, it isn’t something some paramedics never learn from, or grow out of themselves. So, if providers at my level still struggle with basic critical thinking skills, why do EMT’s, cops, and firefighters need expanded scope? A fair question, IMO.