change one thing...

[Melclin]

I would like for evidence based decision making and reasonable practice to be defended publicly by the service.

Eg. Bogan x complains to the service that one of their miniature, fell over, scrapped its head. You left them at home using a combination of say the PECARN decision tool, common sense, physical exam, and minor head injury pt education and the kid then vomits once later after 3 litres of red cordial and they spend the evening in an ED waiting room only to be told the kid is fine and to go home. This of course turns into, "Your paramedic left my kid at home, he vomited blood and we had to rush him to ED".

I know of plenty of cases similar to this (although this one is completely hypothetical) where the paramedics involved were slapped on the wrist simply for PR reasons, not because anyone really thought they made a mistake. The pt's family could have complained that the paramedic failed to stop the sun from setting and they would still have been scolded.

Similarly, I left a pt at home once with one hour of minor generalised abdominal cramping, 1 day feeling generally unwell, 5 x diarrhoea since lunch time. Advised that he take OTC pain relief, keep his fluids up, see his GP in the next few days, or as required or if the pain/ his condition worsened to run him down to ED themselves. I saw them in the ED 2 days later, chap had appendicitis. They appreciated and followed the care plan I offered them and to good affect, but they just as easily might not have, then complained that I risked their sons life some how and I bet I would have been in the s**t for no good reason.

 

[systemet]

I would like for evidence based decision making and reasonable practice to be defended publicly by the service.

Not to derail, but I think what you describe is a very common problem. In the systems I've worked in, we haven't had as much freedom to make these decisions, but I've also noticed that there's a tendency to judge the provider by the outcome of their actions rather than by their intent and the information available to them at the time they made a decision.

And this is just backwards. You can't know what you don't know. If you're given a set of information, often an incomplete set, and you make a decision based on that, anyone who reviews that decision afterwards should make the effort to place themselves in your shoes. It's easy to say, "Well, harm to the patient ensued, and therefore the decision must have been wrong", but often harm occurs because a vital piece of information was missing, or because of something you couldn't have identified in the prehospital phase. The decision itself can be rock solid, based on the information at hand when you make it -- but, often, you're crucified if there's a bad outcome, even if there's no way you could have seen it coming or, or even if you were just unlucky.

 

[MS Medic]

It's not really derailing. The QA process is another one of those things that needs to be changed. From my experience and what I've read form other places, QA is usually performed by field personnel who have to do those duties ontop of their operational duties with little to no compensation for thier time. QA usually becomes a focus of billing or is taken over by the "I'm the greatest thing in medicine and everyone else is an idiot" crowd who then use it as a bully pulpit.

Now let me say that I am not speaking in absolutes so if this is not the case in your area, please don't get upset and then there is always the possibility that I am wrong.

I'm sorry for a lack of spell check. I can't access it on this computer.

 

[usalsfyre]

Look up Just Culture. I think it's long overdue for EMS.

 

[Tigger]

Look up Just Culture. I think it's long overdue for EMS.

I'm certainly glad I did this. The statistics associated with commercial aviation are quite telling, with the increase in acceptance of a just and pro-proactive saftey measures cultures the accident rate has decreased to very low levels despite a massive increase in flights. That industry is one that EMS can look up to, as both have and will continue to experience steep growth rates. Call volumes are increasing, can we ensure that our error rates do not increase with them?

 

[awesomemedic]

One, more education. 18 months in school and it still felt like a crash course. Two, I wish being nationally registered meant something since most states have their own requirements. Well, that has been my experience at least.

 

[Christopher]

EMTs have that mentality of SKILLS, SKILLS, SKILLS, and ironically lack in both skills and education. I would love to see EMTs be able to check blood glucose level, pulse oximetry, 3-leads, IV, and be able to administer a limited amount of drugs. Obviously I would also like to see a lot more training along with that. We really drop the ball when it comes to being emergency medical technicians.

Where do you work that EMT's can't check BGL, SpO2, or administer medication? Those are Basic Life Support skills...

In NC, Medical Responders--one step below EMT--can do all 3 (meds include Glucose/EpiPen). EMT's can acquire/transmit 12-Leads, give a multitude of medications (Albuterol/NTG/ASA/Tylenol/Epi/Benadryl/Glucose/Narcan), use BIADs (KingLT/Combitube/LMA), apply and interpret capnography; basically anything BLS.

EMT's don't need IV access. We really don't need anymore people who can start IVs. We don't even need IO for EMTs (even though I'm a firm believer it could be a BLS skill) as there is no benefit from moving BLS providers to performing ALS skills on cardiac arrests.

I think I'd like added:

- Reasonable dosages for medications (pain control and seizure control come to mind)
- Ketamine (although the NC medical board appears to be supportive)
- Rocuronium (coming in our 2012 protocols)
- CPAP for EMT's
- IM Glucagon for EMT's
- Mandatory waveform capnography for all advanced airways
- Ultrasound

 

[MedicBrew]

It's not really derailing. The QA process is another one of those things that needs to be changed. From my experience and what I've read form other places, QA is usually performed by field personnel who have to do those duties ontop of their operational duties with little to no compensation for thier time. QA usually becomes a focus of billing or is taken over by the "I'm the greatest thing in medicine and everyone else is an idiot" crowd who then use it as a bully pulpit.

Absolutely agree.

I actually took over the QA/QI position a few years ago and have worked hard to remove that stigma from the position. QA/QI should be a learning mechanism first and foremost!

As far as change, an increase in educational requirements for sure.

 

[MS Medic]

Where do you work that EMT's can't check BGL, SpO2, or administer medication? Those are Basic Life Support skills...

I know they can't here and from my understanding it is more common that they can't in a state than can.

 

[medicsb]

When I was on the street, I probably would have liked to have had more leeway to triage patients to BLS. Or guidelines instead of "standing orders".