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

[Veneficus]

i was trying to come up with a tempered reply

I problably failed.

For the 1,000,000th time. The way EMS is operating now is unsustainable economically. The effects may not have hit your area yet, but just give it some time. An ambulance is not a need, it is a want.

Transport to definitive care DOES NOT MEAN AN EMERGENCY ROOM OR HOSPITAL. Everyone in the whole world has figured that out. Even some places in the US.

I don't know why the OP keeps posting these "is it ok to be a common laborer" type threads. I hope it is to be the devil's advocate or illustrate this to coworkers.

It is not ok. At least not if you don't want to meet the same fate at GM or US Steel or any number of labor industries. People need cars and steel, but they do not need to pay an outrageous price for it so some uneducated laborer can have a middle class life by the US standard of living.

Education allows a person to make reasonable decisions. Not every chest pain is an MI. They don't always present with crushing substernal chest pain radiating to the arm and jaw. It is education that allows you to consider alternative presentations or figure out something you haven't memorized.

It is an educated medic that knows a 67 y/o female complaining of shortness of breath and a feeling of abd bloating could be an MI.

It is an educated medic who realizes that pneumonia is a common complication of CHF and doesn't administer furosimide because he hears "wet lung sounds"

It is a skilled medic who uses a coma coctail because he cannot tell the difference between an opioid OD, a hypoglycemic event, or any other condition that can cause an altered LOC.

It is a skilled medic who tells patients they are having heartburn because there is no ST elvevation or crushing chest pain radiating.

It is a skilled medic who leaves a patient to die because he cannot tell the difference between a drunk and a severe trauma.

It is a skilled medic who sits on the pad at a hospital trying to start an IV or tube a patient in the back of the ambulance with the doors closed because he doesn't want to be embaressed by coming to the hospital without one.

The idea that a doctor needs all kinds of tests is flawed. There are a lot of tests that are run for lawyers, not for patients. Many times hospital staff all ready know the results of many tests before they are performed from physical findings.

Do you really think anyone needs to see a white cell count, or a bacterial culture to know if somebody is in septic shock?

Nevermind the future of EMS, lets work with now. One of the most important things a paramedic (or basic) can do is recognize a life threatening emergency. Even in the paramedic curriculum, not all of the common life threatening emergencies are listed. Which means if that is the only education they have they will sometimes not know an emergency when they are looking at it.

It is much easier, cheaper, and has a better prognosis to treat patients before they decompensate. Just like it is all of those things to treat a peri arrest before it becomes an arrest.

I was working as a medic in the field when you were a outstanding paramedic if you could run the whole ACLS algorythm on an arrest patient down to aministration of magnesium sulfate. (that is alternating high dose epi and levofed, plus one other drug for the young crowd and using the full dose of lidocaine, bretylium, procanamide, sodium bicarb and finally mag) in under 15 minutes. Including the shocks, iv start, and intubation. Most often with an EMT partner doing CPR the whole time.

We were skilled. In spite of that skill a very few of those patients actually lived. For a few days. Some for a few months. On a ventilator. Maybe one or two actually made it home with severe deficits.

When I was in paramedic school, my instructor had a 9 year old son who often was a victim for the class. He could perform any paramedic skill on any mannequin. He could even show students how to do it properly and anticipate their mistakes. He is skilled. Should we have let him loose on an ambulance? He could perform every skill any other paramedic could. More proficently than most.

A "skilled" paramedic who can only follow protocol and drive to the hospital is nothing more than an overpriced taxi and should be compensated accordingly.

At minimum wage. I also dobt they are worth that. Perhaps all volunteer. You should also get a paramedic card if you can pass the NR skills exam as well. Even if you never set foot in paramedic class. The quality wouldn't be any worse.

 

[18G]

so some uneducated laborer can have a middle class life by the US standard of living.

Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?

An ambulance is not a need, it is a want.

Really? So communities do not need EMS and could be just as well driving themselves to the hospital? Anaphylaxis patients do not need EMS? Severe asthma exacerbations do not need EMS? These patient types and similar just call because it's convenient?

We do need to see a rise in the minimum level of education...AGREED... and obtaining knowledge is a life long quest. The tone at which it is advocated is most often not appropriate and prob turns a few people off making the advocation less effective. It's not gonna happen overnight but each of us can commit to making ourselves more adept and eager to learn more and encourage our peers.

My question is this.... why did all of the EDUCATED people who were responsible for designing and implementing EMS systems and curriculums allow EMS to get into the shape that it did? The EDUCATED people sucked all of the NON-EDUCATED people into their so-called flawed system design and now the EDUCATED people are acting like it's the NON-EDUCATED people's fault for the foundation and systems they created and kept in motion for decades. These EDUCATED people are the ones who sold everyone the lie that skills based EMS and minimum standards were all that was needed and ingrained it into our societies minds and now they want to chastise providers for their mistakes.

So where does the blame really fall? The EDUCATED or the NON-EDUCATED.

NOTE: I do not use the term "non-educated" literally... it merely serves as a contrast.

 

[reaper]

+10. Very well stated.

 

[usalsfyre]

Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?



Really? So communities do not need EMS and could be just as well driving themselves to the hospital? Anaphylaxis patients do not need EMS? Severe asthma exacerbations do not need EMS? These patient types and similar just call because it's convenient?

We do need to see a rise in the minimum level of education...AGREED... and obtaining knowledge is a life long quest. The tone at which it is advocated is most often not appropriate and prob turns a few people off making the advocation less effective. It's not gonna happen overnight but each of us can commit to making ourselves more adept and eager to learn more and encourage our peers.

My question is this.... why did all of the EDUCATED people who were responsible for designing and implementing EMS systems and curriculums allow EMS to get into the shape that it did? The EDUCATED people sucked all of the NON-EDUCATED people into their so-called flawed system design and now the EDUCATED people are acting like it's the NON-EDUCATED people's fault for the foundation and systems they created and kept in motion for decades. These EDUCATED people are the ones who sold everyone the lie that skills based EMS and minimum standards were all that was needed and ingrained it into our societies minds and now they want to chastise providers for their mistakes.

So where does the blame really fall? The EDUCATED or the NON-EDUCATED.

NOTE: I do not use the term "non-educated" literally... it merely serves as a contrast.

Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements?

(Most people here don't want to hear my theory on this).

 

[Veneficus]

Kinda arrogant and condescending don't ya think? So only the people who go to college deserve to have a good life?

I think I am torn between elitist and realist.

I think that unskilled and skilled laborers cannot expect the same quality of life as the people who do go to college. I think the price fixing by labor unions is one of the reasons that America is no longer competative in the world market and causes a net loss of jobs. Is the senior mechanic any more deserving than the junior? Because he may have been born earlier and therfore showed up for work longer? Or because he got hired earlier from nepotism?

The wages they demand compared to the job they perform is no less than legalized extortion. It is no wonder most union employees now are government workers. They have driven most other industries out of buisiness or country.

But I have some history with it. I am the first in my family to go to college. Mostly because my dad figured out it does lead to a better life and while he didn't force me, he certainly made every effort to encourage it.

At one point I figured a job at a union shop was the best life going. But it only takes a few hours of heavy work a day to see that those "educated" people have it better. They earn more, get hurt less, actually don't work paycheque to paycheque hoping they don't miss a day of work and throw off paying all the bills. They get to take time off to go see their kids and school and stuff because they are so valuable that they have positions where their company would rather give them a day off and have them come back than wonder if they should get somebody else.

As my education progressed at some point I realized that I was getting paid for what seemed like really easy jobs compared to what I was doing before.

Being around even higher educated people, I realized the disproportion of what they had compared to what my family had and how hard we worked for what little we had. I realized the wisdom my dad had in promoting education even though he had only completed 10th grade.

I also realized that the world was changing. As my family displaced American workers because they were willing to work for much less, new immigrants were threatening to displace my family. I realized there was no hope for a decent future as a laborer.

But the final straw was when I saw my friends who were IAFF members getting laid off. As the older guys voted to not take a pay cut that left the younger guys struggling to find a job or feed their families, I realized not only the extortion of it, but how the "all for one and one for all" of the fire service was only empty words or lies.

The collective knowledge of man has exponentiated in the last 20 years. The minimum knowledge a person needs to be of value to society (aka well paid) has increased. College is the only way to do that at the moment.

There was a time when a highschool diploma could land you an outstanding job. Then it reqiured a 2 year degree, next a 4. In some disciplines now at least a 6. (psych and varios therapy)

It is not whether or not somebody is deserving of a good life, it is how good of a life they can expect. If you again look at laborers globally, they are at the bottom of the food chain. They barely eek out a living in many places. US workers have been suffering the same, and it is only a matter of time before EMS is the same way.

If you choose to deny that, it is yor choice, but I am altruistic just enough in my arrogance to not want a bunch of well meaning young people think that they are secure because they took a vocational EMT-B or a EMT-P and be a valuable healthcare worker with their few hours of training.

I started at the bottom, and while I learned a lot from it, that level of effort and sometimes suffering, is not mandatory. The earlier in life you realize it, the better your life will be.

 

[Veneficus]

Really? So communities do not need EMS and could be just as well driving themselves to the hospital? Anaphylaxis patients do not need EMS? Severe asthma exacerbations do not need EMS? These patient types and similar just call because it's convenient?

If communities actually needed EMS, there wouldn't be so many volunteer departments. What happens when volunteers don't show up? You find a way, get better, or die.

If it was a neccesity, like roads, or police, etc. It would be required in all places. Some states do not mandate EMS. Across the US, EMS does not share pay parody and are not always officers of the state such as LE and Fire officials.

I think it should be a neccesary service, but the nation doesn't feel the same.

We do need to see a rise in the minimum level of education...AGREED... and obtaining knowledge is a life long quest. The tone at which it is advocated is most often not appropriate and prob turns a few people off making the advocation less effective. It's not gonna happen overnight but each of us can commit to making ourselves more adept and eager to learn more and encourage our peers.

I am tired of being nice. I am tired of pointing out the obvious, especially when people fight thier betterment with pathetic "not where i live" and "this is what I see today" arguements. I have been trying to advance EMS for a long time, and it is the laboer mentality holding it back. It is why "The best and brightest" move on to educated professions. Who with rare exception make considerably more in much better conditions.

My question is this.... why did all of the EDUCATED people who were responsible for designing and implementing EMS systems and curriculums allow EMS to get into the shape that it did?

When the system was designed, it was designed to add skills to a labor force. (Usually firefighters) Nobody at the time could have expected so much change so fast. Some of those "educated people" have died or even given up on advancing EMS. I admit I am reaching the point of giving up on it myself.

I absolutely think it was neglect by the physicians tasked with directing EMS or overseing its implementation that caused many problems. I have called them out on it more than once, both publically and privately.

The EDUCATED people sucked all of the NON-EDUCATED people into their so-called flawed system design and now the EDUCATED people are acting like it's the NON-EDUCATED people's fault for the foundation and systems they created and kept in motion for decades. These EDUCATED people are the ones who sold everyone the lie that skills based EMS and minimum standards were all that was needed and ingrained it into our societies minds and now they want to chastise providers for their mistakes.

I agree, I was not one of those people. I am from the flawed system and I want it changed. Unfortnatly, most people don't like change and they fight hard against it.

So where does the blame really fall? The EDUCATED or the NON-EDUCATED.

I think both share equal responsibility. The educated for the neglect and apathy. The non educated for the resistance and complacency. But who is to blame is not as significant as fixing it. Which will require both as well. But as physicians have long neglected EMS they will have to put forth significant effort to fix it. More than they are doing I am sorry to say.

There is a bit of an impass though, because the noneducated have made it easier to replace the physician than themselves, which very mch limits the physicians power to alter the system. (though they should have faught harder to maintain their authority to begin with.)

 

[Veneficus]

post trifecta

Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements?

(Most people here don't want to hear my theory on this).

I want to hear your theory. But I am willing to bet if the standards EMS set for itself were higher than the minimums set by the others they will get to.

 

[JPINFV]

Better question, why do we allow others to set the minimum standards for our profession while continuing to wallow around? Physicians set the standards for physicians, nurses for nurses, RRTs for RRTs. Who sets it for paramedics? The government, physicians and RNs. Why can't paramedics set our own educational requirements?

(Most people here don't want to hear my theory on this).

In part because only a handful of EMS providers join EMS associations like NAEMT that are supposed to advocate FOR EMS? On the other hand, I'm a member of the LA County Medical Association (free for students), California Medical Association (Free for students), American Osteopathic Association (free for students), and the American Association of Emergency Medicine (1 year free, afterwards reduced cost for students). These are all associations that not only reach out to students, but also allow students to attend the yearly House of Delegates meetings where policy proposals are submitted, and if the student section agrees, even submit policy proposals.

How well have EMS agencies reached out to students to hook them in? How many people know what the mission of the NAEMT is past sponsoring courses like PHTLS?

 

[firecoins]

Some people say there are no scientific studies showing ALS saves lives.

Various trauma surgeons would get rid of als training because it adds another step before the patient gets to surgery.

There is no doubt that most calls could be done by a driver with a wheelchair van and an o2 tank.

 

[JPINFV]

Some people say there are no scientific studies showing ALS saves lives.

Is the only value added by paramedics and EMS lives saved?

Can that asthmatic patient survive another 5-10 minutes to run to the hospital? Most likely, so you aren't saving the asthmatic's life, but what about the reduction in suffering?

Can the pulmonary edema patient survive another 5-10 minutes without nitro, supplemental oxygen, and CPAP? Probably, but what about the reduction in suffering?

Does pain control save lives? Does it reduce suffering?


EMS in general saves very few lives (especially patients in cardiac arrest), but it can do a lot to reduce suffering, and in some few cases, save lives.

 

[firecoins]

Is the only value added by paramedics and EMS lives saved?

Can that asthmatic patient survive another 5-10 minutes to run to the hospital? Most likely, so you aren't saving the asthmatic's life, but what about the reduction in suffering?

Can the pulmonary edema patient survive another 5-10 minutes without nitro, supplemental oxygen, and CPAP? Probably, but what about the reduction in suffering?

Does pain control save lives? Does it reduce suffering?


EMS in general saves very few lives (especially patients in cardiac arrest), but it can do a lot to reduce suffering, and in some few cases, save lives.

Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs. The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true. There are MDs who do not see a need for prehospital ALS.

And yes, saving lives would be our primary justification. Reducing suffering is a far second.

 

[fortsmithman]

There are MDs who do not see a need for prehospital ALS.
.

I think that's how EMS is run in the province of Quebec. I read in another forum that the only level of prehospital care in Quebec is BLS only no ALS. If there are any members from Quebec please correct me if I'm wrong. I heard the reason for this comes from the College of Physicians and Surgeons in Quebec.

 

[adamjh3]

Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs. The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true. There are MDs who do not see a need for prehospital ALS.

And yes, saving lives would be our primary justification. Reducing suffering is a far second.

How many on here (some with years - decades, even - in the field) can truly boast saved lives? Public perception - that we're heroes who roll up on a guy who died in a car accident and punch his chest a few times to bring him back to life - is one thing, the reality of it is another.

As far as reduction of suffering: Why should that be a far second? That should be our primary concern (with the system in place now), making our patients as comfortable as possible for the trip to the ER.

Vene, you have made some posts that have been extremely enlightening for me, both in this thread and elsewhere. You're frustration in the matter of not being able to fix the EMS system brings me back to what I poorly articulated in my first response in this thread. Is it worth fighting to change the system? It will break, hell, it is breaking. Would it be easier to fix it from the bottom up than to try to change the mindset of many hard-headed traditionalists?

 

[JPINFV]

Reducing suffering can be done at the hospital by an MDs if medics didn't waste more time on scene doing enhanced assessments and pt care as argued by some MDs. The idea the retraints in education for solely coming from EMS, volunteers, FD etc is not true. There are MDs who do not see a need for prehospital ALS.

And yes, saving lives would be our primary justification. Reducing suffering is a far second.

The problem is that the majority of patients that EMS sees does not require saving in the time period that EMS is involved. Cardiac arrests need saving before EMS arrives (not witnessed or no bystander CPR essentially means the patient is dead by the time EMS arrives). Most of the other patients with life threatening diseases can wait several minutes, which makes it hard to judge statistically, or other wise, how many patients EMS "saved" in contrast to care provided in the emergency department.

Yes, reducing suffering is achieved in the hospital as well, but why make patients suffer an extra 10-30 minutes that it takes for the patient to be transported, care handed over, and finally for the physician to make his or her way to the patient's bedside. A physician may be johnny on the spot to someone in bad shape, but not necessarily pain control. This is, of course, also ignoring the standing orders for RTs and RNs in the emergency department.

Finally, yes, there are some physicians who seek to needlessly restrain EMS. However I'd argue that they aren't nearly as bad as the apathy and resistance found by EMS providers.

 

[Veneficus]

Vene, you have made some posts that have been extremely enlightening for me, both in this thread and elsewhere. You're frustration in the matter of not being able to fix the EMS system brings me back to what I poorly articulated in my first response in this thread. Is it worth fighting to change the system? It will break, hell, it is breaking. Would it be easier to fix it from the bottom up than to try to change the mindset of many hard-headed traditionalists?

You are too kind.

The problem that I worry about letting EMS break is that if it does, the new version will be determined not by EMS professionals, and I think not even medical professionals, but by politicians and bankers.

If that happens, BLS only will be a real possibility. It has already been suggested by one Politician in Columbus, Ohio noting the short transport times and the lack of evidence ALS saves lives.

That makes it even more imperative in this current antigovernment spending political climate that real value be demonstrated. Policy makers are watching and there are loads of other programs that will demonstrate they should not be the one to take the cuts. Like farm subsidies and physicians.

I cannot possibly see EMS being made better by nonprovider parties.

 

[medic417]

http://www.emtlife.com/showthread.php?p=260501#post260501

 

[ffemt8978]

Some people say there are no scientific studies showing ALS saves lives.

Various trauma surgeons would get rid of als training because it adds another step before the patient gets to surgery.

There is no doubt that most calls could be done by a driver with a wheelchair van and an o2 tank.

That is why one county medical director in the next county over only allows BLS ambulances in his county. He would rather the ambulance transport the patient to the hospital than to spend 15-30 minutes on scene doing ALS procedures.

 

[18G]

There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.

- An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.

- A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50.

- What about a seizure patient who is status? We let them seize, become hypoxic and acidotic which leads them to arrest during the 30 minute BLS only transport?

- What about the 12yo asthma patient who forgot his inhaler and is now in extremis? He endures BLS transport while struggling to breathe and eventually arrests?

- What about field induced hypothermia for post-resuscitation?

- What about STEMI recognition and cath lab activation? BLS?

I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.

 

[Veneficus]

more on perspective

Not trying to pick on you, you bring forth a worthy debate.

There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.

- An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.

But it doesn't take an ALS provider to fix that, there are areas where an epi autoinjector is a BLS skill. If that wasn't interesting enough, IM epi has a faster absorbtion rate than SQ, and most paramedic protocols for epi are SQ admin.

That means that a BLS intervention is the same with a more rapid effect.

Some areas even have issued epi pens to Police units because they have faster response times than local EMS agencies.

Nebulized albuterol is also a basic medication in a fair number of places.

- A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50.

Why couldn't you give oral glucose or a IM glucagon injection? If you can ok IM epi autoinjector surely you could write a protocol that says if glucometer reading <60 administer 1mg glucagon IM>

- What about a seizure patient who is status? We let them seize, become hypoxic and acidotic which leads them to arrest during the 30 minute BLS only transport?

Fair enough, but how often do you see this?

- What about the 12yo asthma patient who forgot his inhaler and is now in extremis? He endures BLS transport while struggling to breathe and eventually arrests?

Nebulized albuterol/atrovent, BLS intervention many places. It is cheaper to write a new BLS scope and training than it is to staff ALS 24/7 if they really get bad, you could always stab them with the IM epi too.

- What about field induced hypothermia for post-resuscitation?

Not common throughout all areas. Largest problem isn't EMS but the hospital side providing of this care.

- What about STEMI recognition and cath lab activation? BLS?

BLS hook up 12 lead, If machine says "Acute STEMI!!!" transmit and transport to cath lab. Isn't technology wonderful? See, always bank on knowledge, never on skill.

I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.

Do you have equal or greater credentials than the physician medical director to make such a medical judgement or are you just telling us how you feel?

Could I just also inquire what percentage of your agencies total calls fit the ones you have cited?

 

[ffemt8978]

There are times EMS saves lives and is why we have invested much in being prepared for those cases. Yes, the whole "EMS saves lives" is mostly hype but EMS can and does save lives.

- An anaphylactic patient cannot wait 30 minutes to make it to a hospital to get meds and an airway.

Epi-pens are required on all ambulances in the state, by a law known as the Kristine Kastner Act. Transport times in that county are usually less than 15 minutes.

- A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50.

See previous comment about transport times. Given that the nearest ALS unit to that county is 25 minutes away, assuming they are not on another call at the time, BLS transport is the best option available to them. Also, they do have some ILS technicians which can give D50.

- What about a seizure patient who is status? We let them seize, become hypoxic and acidotic which leads them to arrest during the 30 minute BLS only transport?

See previous comment about transport times and ALS response times.

- What about the 12yo asthma patient who forgot his inhaler and is now in extremis? He endures BLS transport while struggling to breathe and eventually arrests?

Their ILS techs can administer albuterol.

- What about field induced hypothermia for post-resuscitation?

You mean a procedure that is not nationally accepted yet, nor is it available in this state?

- What about STEMI recognition and cath lab activation? BLS?

Their nearest hospital with a cath lab is an hour away. Would you rather ground transport that hour with an ALS unit, or transport 15 minutes to a hospital for stabilization and transport by air?

I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.

The community in question doesn't think so, and it is really their choice. This is a hospital based ambulance service, and that is what the community wants. The issue has been brought before the voters before, who have rejected going to an ALS service because of the costs that they would incur.

Right, wrong, or indifferent, it is the communities choice and that is the one they have made.