Does EMS overtreat?

[Veneficus]

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]

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.

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]

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

That sucks.

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

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.

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"

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?

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).

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.

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).

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]

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]

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]

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]

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]

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.

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]

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]

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]

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]

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]

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.

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.

Thoughts?

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

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]

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]

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]

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.



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.



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



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.

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]

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?

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]

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]

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]

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.

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.