How important is all this education?

[DrParasite]

Something I was pondering...

So Mr. Brown is all about getting the bright orange jumpsuit so he can become a helicopter doctor. But I am thinking to myself, most helicopters I am familiar with don't have doctors, they have a nurse and a paramedic.

I know some CCT units have a doctor on board, but many are going to nurse/emt/emt, or nurse/paramedic/emt, or nurse/CC EMT, or something like that.

For interfacility transfer, we do EMT/EMT, but some do EMT/Medic, or Medic/medic.

it seems that there is no real standard, and if people really wanted a doctor on the helo, or a nurse on every transport or any other highly educated person on an interfacility, we would see people dying due to the uneducated and unskilled providers, which I challenge anyone to show me published documentation showing that be the case.

 

[MrBrown]

Man don't jumpsuit hate, recognise it lowers mortality rate!

Note: Lowering of mortality rate by HEMS, specifically registrar/consultant staffed HEMS, has yet to be proven and is therfore not implied or said to be fact, hypothesis or statement worthy of any form of merit. Widespread overuse of HEMS may be contributing factor, link not yet establshed. Not a guarentee, mileage may vary, each sold seperately, batteries not included, limited time and participating stores only.

Do I want an orange jumpsuit to wear to the pub and pick up chicks or something? No. I do not see a future for myself as an Ambulance Officer and can either spend 3 years going to RN school or 4 years and become a Physician. I wanted to be a pilot but that never happened and I really like planes and all this medical stuff so there you have it, a perfect match.

Truth be told I could never be anything but an Anaesthesist or Intensivest. I think medicine has been largely infiltrated by profit hungry pharmaceutical companies who seek to simply manage symptoms of what are largely preventable diseases (heart disease, diabetes, oeteoarthritis etc) rather than find an actual cure. Hence why I am not one to sit in a GPs office and dish out uppers, I want to actually make really sick people better and not stock the coffers of some giant pharma company with drugs that may not even work or have some seriously nasty side effects which are worse than the disease itself.

People who are traumatically injured or critically ill represent a challenge and what better way to apply all that awesome knowledge and skill I will have obtained (which in itself is fufillling enough as I love to learn) than to swann in out the sky in an awesome looking orange jumpsuit with "DOCTOR" written on it and make a real difference?

Oh, and to answer your question, does that helicopter NEED a doctor on it? I don't know.

Where is Gareth Davies when you need him"

 

[DrParasite]

just so there is no confusion, I am not anti-education, nor do I think dumbing down the EMT/Medic/RN/MD program is a good idea. However, I am in favor of having the appropriate education levels in order to do the job safely and effectively, and not artificially inflating the educational requirements in hopes of getting higher pay rates, or for some other non-job performance reason. The right education level to do the job right.

 

[DrParasite]

People who are traumatically injured or critically ill represent a challenge and what better way to apply all that awesome knowledge and skill I will have obtained (which in itself is fufillling enough as I love to learn) than to swann in out the sky in an awesome looking orange jumpsuit with "DOCTOR" written on it and make a real difference?

Oh, and to answer your question, does that helicopter NEED a doctor on it? I don't know.

that's kinda what I mean.

As a doctor, in theory you have better assessment skills than a nurse or paramedic. However, would your population of sick and injured people be treated just as well (for half the price) if a nurse or medic was doing the assessment and field treats, communicating that to a doctor on the phone, and when landing at the hospital, having the doctor examine him with all the xrays, labs, CT, specialists, and the rest of the support system that exists in a hospital? after all, you don't have the support system when you are in the middle of nowhere in your orange jump suit as you are leaving the helo (to the best of my knowledge anyway).

and how many interventions will you be able to perform either on the scene or in the helicopter that a medic won't be able to perform, because (again), until you land, you don't have the support system to manage the patient using surgery or a chest tube (pulling random examples out of my ***) in case something goes wrong.

Do I think you should not become a doctor? absolutely not. but should they put a doctor on the helo or on an ambulance, that is my question (as it relates to you anyway)

 

[MrBrown]

...should they put a doctor on the helo or on an ambulance, that is my question (as it relates to you anyway)

I kind of think the same way, but they say you don't know what you don't know so ... I don't know! Doctors on the helicopter are always anaesthestists, intensevists or emerg registrars or consultants who will see more severe trauma and illness in thier six or twelve months than your average Paramedic does in a year or two. After all its no good putting a bloody junior podiatory reg on the helicopter now is it?

They become very good at assessing, beginning to treat and triaging those patients back to the most appropriate facility. A doctor can also carry drugs a Paramedic can not in some instances (like in the UK) which may or may not be a contributing factor to thier existance.

Where is one of the our resident phyisicians when you need them? Probably out getting thier jumpsuit fitted.

 

[enjoynz]

FYI ...Uk have a doctor on board.

As attached

http://en.wikipedia.org/wiki/London_Air_Ambulance


Cheers Enjoynz

 

[medicdan]

Man don't jumpsuit hate, recognise it lowers mortality rate!

Note: Lowering of mortality rate by HEMS, specifically registrar/consultant staffed HEMS, has yet to be proven and is therfore not implied or said to be fact, hypothesis or statement worthy of any form of merit. Widespread overuse of HEMS may be contributing factor, link not yet establshed. Not a guarentee, mileage may vary, each sold seperately, batteries not included, limited time and participating stores only.

At least here in the US, there has been a whole lot of mortality associated with EMS, the past few years... and that needs to change.
http://www.jems.com/article/vehicle-ops/reducing-inappropriate-helicop

 

[Veneficus]

a doctor is like a mercedes

"You may not need one, but you want one."

Sorry, I love that commercial...

More to the point.

What a physician brings to the table is knowledge, experience, and the unrestrained ability to make a decision.

Emergency "protocols" or scope of practice in various nations of the world are based off of epidemiology. They are treatments that will help or at least do no harm (so we thought) the most common afflictions.

Whether or not we need a physician on an ambulance or helicopter depends entirely on the manner in which they function. If all they are doing is following a script (aka protocol) then no, they are not needed and it is a tremendous waste of money and time.

Most in the US seem to think a doctor is beholden to an institution with labs and xrays and all manner of technological might. It is simply not true.

A doctor determines what is going on with a patient by collecting data. Sometimes it is possible to collect lots of data, like in an academic hospital on a stable patient. Sometimes the data available is more limited, like on an unstable medical/trauma patient during the monsoon in Bangladesh.

Now all this data collection and the word we all love, "diagnosis," may give the impression that there is a lot of focus on learning what is wrong and not so much on fixing it. It is a common blue collar mistake to think what you see is all there is to it. Once you know what is wrong, for a physician, and even for more senior medical students, what to do about it is intuitive. If a patient is bleeding, then the bleeding must be stopped. If the patient is in heart failure, then after the acute symptoms are treated, something must be done to make the heart pump more efficently, as well as reduce modifiable factors which advance the disease. We have all manner of things available, medications, surgeries, and various technologies with which to work with.

In the absense of all of this stuff a physician is still not at a loss. The founding knowledge of science allows things to be "made up" or "scrounged" in order to help a patient. For example, I know that lidocaine does not work on intact skin, and I also know that many OTC burn oinments contain 0.5%. So I can reduce pain without a vial of stuff and a needle. I can calculate the nutritional values and compositions of various foods to reduce/increase the amounts of a specific amino acids or trace elements to bring a patient relief in various disease states.

Whether it is a basic talking about a medic, or a medic talking about a nurse, or a nurse speaking of a physician. The world is filled with people who think the value of these providers is in psychomotor skills or the depth of protocol they follow. What happens when a patient doesn't fit a protocol? How do you know if a patient doesn't?

Practice makes perfect. My textbook for history and physical exam is not only written at a higher educational level, but it has far more findings than most EMT books have pages. In orderto even make use of it you need detailed knowledge of several basic sciences. From just looking at patient I can gather far more information than most in EMS. Data collection at its finest. I listen to heart tones on every patient i see or have seen for the last 4 years. How often do EMS providers? Will the information gained benefit an EMS provider? Not always, but it always benefits me, even if it is normal.

Whether a doctor is econmical or beneficial is dependant on how the system utilizes her, not on the considerable abilities the physician brings. In one system a physician might be the greatest asset in the world. In systems like urban USA, it is a tremendous waste that is totally unnecessary.

What good is sending a physician to a hospital where they cannot practice because they don't have priviliges or force the physician to simply follow a protocol no matter what the patient or finding?

On the other hand, the value of one who can operate to the fullest of independance can keep people out of hospitals, reducing healthcare costs and providing better care. As well, when you have a really complex patient, simple training will not do. If it were somebody special to you, you might want the person who could handle it, rather than a person who couldn't that was cheaper.

 

[MrBrown]

I see you pretty much have the same hypothesis as me; its not so much about what "skills" the physician can do but the knowledge and experience they bring to a job.

Lets try a recent case as an example: A dude got run over by a horse and ended up with a severed trachea, fractured clavicle and several fractured ribs. My main concern was his airway, unstable chest which could lead to a haemo or pneumothorax as well as head and abdominopelvic injuries.

Plan of action? Knock him out and intubate what is left of his trachea, clamp the two halves around the endotracheal tube, package him and fly him to a high level trauma centre with orthopaedic and ENT facilities with much of the fastness.

What about this case would be different if you were approaching it as a physician and not a paramedic?

 

[Veneficus]

I see you pretty much have the same hypothesis as me; its not so much about what "skills" the physician can do but the knowledge and experience they bring to a job.

Lets try a recent case as an example: A dude got run over by a horse and ended up with a severed trachea, fractured clavicle and several fractured ribs. My main concern was his airway, unstable chest which could lead to a haemo or pneumothorax as well as head and abdominopelvic injuries.

Plan of action? Knock him out and intubate what is left of his trachea, clamp the two halves around the endotracheal tube, package him and fly him to a high level trauma centre with orthopaedic and ENT facilities with much of the fastness.

What about this case would be different if you were approaching it as a physician and not a paramedic?

Plan, knock him out, cut his neck open, put a tube in there, forget about the upper trachea that can be fixed at the hospital. Decompress the chest because there is probably already a pneumo, if the transport is short forget about the chest tube because the bleeding may tamponade itself, if the bleeding is severe, chest tube and auto transfuse. (waste not, want not) If nothing else life threatening is found on exam, package and take him to a critical care surgeon in house who can massive infuse with blood and do more damage control, after that call ortho to fix his pelvis. (You always have to let ortho work first or you will be doing all your work again) After which coordinate with cardio thoracic to fix his chest and trachea, and finish him off with plastics and rehab.

Total on sceen time for trach, chest tube with auto transfuse, packaging, and transferring care to Brown because I am not getting on a HEMS unit, 20 minutes tops.

 

[MrBrown]

Sounds like a plan

Here we have a presentation by Robyn Mitchell from Auckland City Hospital about whether infact there is a role for a doctor in prehospital care.

http://www.adhb.govt.nz/trauma/08inj_talks/Mitchell/Mitchell.htm

I think a physician on a ground ambulance is probably a waste of a resource but the helicopter is a different story alltogether where you can have wide spread of a scant and highly efficent resource.

Is there a role for a doctor prehospitally in medical emergencies such as cardiac or asthma; I am not sure. Without a doubt if I am traumatically injured on the street somewhere a dude in an orange 'Doctor' jumpsuit will be a welcome sight.

Or, you know, a black ninja outfit carrying a large sword .... and a Thomas pack

 

[Foxbat]

I've just been reading a discussion on the Internet about physicians in EMS.
A short background: Russian/former Soviet EMS system consists of "general" units (staffed by either MDs or PHPAs) and "specialty" units (pediatric, toxicologic, cardiologic, neurologic, etc.) staffed by MDs (who specialize in pediatrics, toxicology, etc. respecively) and PHPAs who assist the MDs. Specialty units back up "general" units on calls like AMI, CVA, pediatric emergencies, etc. The EMS philosophy there is to bring the doctor to the patient, start treatment on scene until the patient is stable enough to transport, or, if the condition is minor, to give definitive treatment on scene and release the pt. instead of clogging up the ERs.
Now, what's currently happening is that the gov't of one of the Russian big cities ordered removing all MDs from ambulances to save costs. EMS personnel is furious over it and they predict skyrocketing mortality and morbidity. Their arguments are, basically, that EMS physicians are much better than PHPAs when it comes to figuring out what the problem is, and that PHPA giving the wrong diagnosis and delivering pt. to a wrong hospital (not to mention giving the wrong treatment) will kill a patient (especially given large transport times in many Russian cities).
Granted, this is a completely different health system, but i think their arguments are worth listening to.

 

[Foxbat]

Oh, and I love it when people bring up the whole princess Diana story to "prove" that physicians in prehospital setting are bad. Because we all know how that paramedics or EMTs would have always saved a patient in such a setting, and we all were there and know what needed to be done

 

[Veneficus]

The ability to for a treat and release is where having a physician on an ambulance pays for itself.

Let's look at the US system.

Anyone who can't get a doctor's appointment in a timely manner for whatever reason calls 911.

Enough transport resources have to be allocated to handle all these calls in a reasonable amount of time. (as I saw on a video "no award for same day service")

Currently the amount of calls exceed the ability to handle them all timely and the volume just keeps increasing.

Once the pt gets to the ED, triaged to either the waiting room or to be seen sooner, a plethora of expensive tests that likely have no bearing on the pts condition must be run. Both the facilities and the staff must be available onsite 24/7 and considerable consumable resources are used.

The pt is discharged with treatment, in many cases symptomatic control as the ED is not equipped or staffed to handle the long term medical needs. The other route is patient is either admitted to the hospital to either an ICU or observation/floor

Since the ICU is for sick people those admitted clearly needed the emergency system.

Those admitted to a various obs unit, CDU, telemetry, etc, may need a hospital but cannot be left to their own devices.

Those admitted to general medicine need medicine but are likely going to wait several hours (recently a relative of mine waited nearly 36 hours) to be seen by a doctor.

for the people who need symptomatic treatment and followup and apparently the ones who probably need medicine but will not be seen for the better part of the day, an on scene physician with EMS has the ability to redirect them from the ED. either they can be left at home and followed up with, treated and released, or admitted directly to a service they need bypassing the ED and all of its expense.

This lowers the amount of transport units needed, probably to a point where you can put some cars on the road to get people places that are not $90K+ ambulances with another $100K worth of equipment.

You can reduce both staff (including radiology, lab techs, and other "nonvisible staff" in addition to nursing and physicians) and capacity.

Consumable resources are reduced, unneccesary tests are reduced. People get better care faster.

Of course in order to realize this fantasy land 3 major obstacles must be overcome.

1st Malpractice claims and awards have to be controlled.

2nd medicare/medicade and private insurance needs to adequetly reimburse physicians and agencies for this money saving service.

3rd physicians need to be reminded how to work without a CT scan and every lab test known to man of every patient. (the new handheld ultrasound should help a lot)

the rest of the issues and details are rather minor and easily fixable compared to those herculean tasks.

The Russian EMS system has too much redundancy for my taste. If a pt is having an MI that patient needs a hospital, having a GP and a cardiologist on scene is absolutely a waste. Also the pt might better benefit from rapid transport than a bunch of Docs standing around wishing they had a portable cath lab in somebody's house or trying to perform exploratory surgey on a kitchen table and wonder why the patients always die of infection after.

 

[Foxbat]

The Russian EMS system has too much redundancy for my taste. If a pt is having an MI that patient needs a hospital, having a GP and a cardiologist on scene is absolutely a waste. Also the pt might better benefit from rapid transport than a bunch of Docs standing around wishing they had a portable cath lab in somebody's house or trying to perform exploratory surgey on a kitchen table and wonder why the patients always die of infection after.

In a perfect world every patient would be quickly transported to a definitive care. In real world, our service often transports patients from our local ER to trauma center, stroke center, or cath lab, because someone in the field did not assess the pt. adequately, and I'm wondering whether more time is lost in this case than if there was an MD on the ambulance.
Another thing I heard from Russian physicians is that "scoop and go" philosophy ultimately results in higher M&M than "stabilize on scene, then transport", but I do not know enough to say if it's true or not.

The ability to for a treat and release is where having a physician on an ambulance pays for itself.

Unfortunately, it's a double-edged sword. When the public knows there's a physician on the ambulance who can give them a prescription etc., it encourages EMS abuse.

 

[Veneficus]

Another thing I heard from Russian physicians is that "scoop and go" philosophy ultimately results in higher M&M than "stabilize on scene, then transport", but I do not know enough to say if it's true or not.

I agree with the idea stabilize on scene may be more beneficial. When you look at the Us military forward surgical areas prior to transport to even a field hospital, the value is clearly evident.

Having said that and understanding the biochemical and molecular level activity is the same for trauma and acute medical emergencies, if you don't have the ability to fix or alter something on scene, then you are just wasting time. (like PCI or direct arterial TPa)

Unfortunately, it's a double-edged sword. When the public knows there's a physician on the ambulance who can give them a prescription etc., it encourages EMS abuse.

If the Doc is getting paid and it is cheaper than entering them into the emergency system, who cares?

 

[Trayos]

A few key benefits?

Trying to condense this topic down a bit

Reasons for physician assistance on emergency medicine units:
1. More comprehensive on-scene diagnosis, leading to better allocation of resources.

2.Ability to draw from a more extensive educational background to tailor together a more specific response package, as opposed to just using SOP.

3. Ability to deliver various ALS techniques without requiring confirmation over radio/other mediums (and thus saving time).

Am I missing any big ones?

 

[LondonMedic]

Trying to condense this topic down a bit

Reasons for physician assistance on emergency medicine units:
1. More comprehensive on-scene diagnosis, leading to better allocation of resources.

2.Ability to draw from a more extensive educational background to tailor together a more specific response package, as opposed to just using SOP.

3. Ability to deliver various ALS techniques without requiring confirmation over radio/other mediums (and thus saving time).

Am I missing any big ones?

A far wider range of procedures and drugs.

 

[JPINFV]

Oh, and I love it when people bring up the whole princess Diana story to "prove" that physicians in prehospital setting are bad. Because we all know how that paramedics or EMTs would have always saved a patient in such a setting, and we all were there and know what needed to be done

I'd argue that the problem there was the philosophy used (stabilize on scene to a fault) and not the providers. Whether even prompt non-emergent transport would have changed something, we will never know.

 

[jjesusfreak01]

Reasons for physician assistance on emergency medicine units:
1. More comprehensive on-scene diagnosis, leading to better allocation of resources.

Problem here is resources. Physicians diagnostic skills will be better than a paramedic, but the lack of diagnostic equipment (imaging equipment, blood tests) will significantly dampen their effectiveness. Once when I was working in an ER radiology office, I saw a physician wait for the results of an X-ray to decompress a tension pneumo. It makes you wonder about their reliance on these methods.

2.Ability to draw from a more extensive educational background to tailor together a more specific response package, as opposed to just using SOP.

True to some degree, but still a problem of resources. I can certainly think of situations in which physicians would be able to make a difference, but the things that come to mind involve emergency surgical interventions. Otherwise, they would be severely limited by the equipment held on an ambulance.

3. Ability to deliver various ALS techniques without requiring confirmation over radio/other mediums (and thus saving time).

In my county, you don't call for permission, ever. The MD is available anytime for consult, but you wouldn't call unless you needed permission to violate protocol or had an out of protocol patient. The MD interviews all of the medics and trusts that they are competent and professional enough to use their training and skill without his guidance.