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

[Veneficus]

Wait, no I forgot for a minute:

In the event of seizure, place 1 rectal diazepam suppository.

Been a few months since I have seen a peds patient, we actually prescribe these to parents.

If parents can do it, basics can do it.

 

[EMSLaw]

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

A quick, dirty, and of questionable reliability google search indicates that there are approximately 40 cases per 100,000 population of status epilepticus in a given year.

Which probably explains why despite answering numerous (n>30) seizure calls, I have yet to have one that hadn't broken prior to EMS arrival. Of course, it'll be nice to have medics if it ever does happen.

 

[Veneficus]

it'll be nice to have medics if it ever does happen.

That is the key phrase.

 

[DrParasite]

If parents can do it, basics can do it.

Now if only this was the standard.... if parents could do it, basics could do it.

think about it

BGL checks
Albuterol nebulizers.
Pulse Ox checks (yes, there are places where they are not considered to be BLS skills)
D50 for known diabetics (often kept in the fridge at home and used only for emergencies)
Epi Pens
Benedryl for allergic reactions

ahh, a man can dream...B)

 

[JPINFV]

I think there's a big different than a parent administering a medication to a child diagnosed with a specific disease with education on when to seek additional medical evaluation and an EMS provider doing an assessment, making a diagnosis, and then delivering said medication.

 

[usalsfyre]

The reason EMS does not control it's own destiny...

...is that the majority of medics are lazy, uneducated dumb@sses who would rather whine and complain about their situation rather than better it. The majority of those who aren't move onto better situations/other careers. Leaving the few of us who know better, want to improve and choose to stay stuck with major resistance from the first crowd. For EMS professed hate of the welfare crowd, they sure resemble it sometimes.

 

[DrParasite]

Our Intensive Care Paramedics can to thrombolysis, does that count?

Can you explain that to me? I am guessing you are giving them for CVAs right? But if it's a hemorrhagic stroke, thrombolysis would make the problem worse. And unless I am mistaken (which I may be), isn't the standard for a stroke to differentiate between a hemorrhagic stroke and a clot caused stroke done by running a CT or MRI scan?

Please share.

 

[JPINFV]

Thrombolysis can also be given for an MI.

 

[Akulahawk]

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.

While Quebec is basically BLS-only, they are slowly raising things to ALS. The Medical Directors there are convinced that nobody but Physicians are educated enough or can be educated enough to provide an advanced level of care. In their case, a lot of the pre-hospital EMTs want to provide better care... but they're restrained in doing so. Notice that this kind restraint is not applied anywhere else in Canada on such a large scale.

 

[abckidsmom]

...is that the majority of medics are lazy, uneducated dumb@sses who would rather whine and complain about their situation rather than better it. The majority of those who aren't move onto better situations/other careers. Leaving the few of us who know better, want to improve and choose to stay stuck with major resistance from the first crowd. For EMS professed hate of the welfare crowd, they sure resemble it sometimes.

Maybe not a majority, but a significant minority. The ones who aren't lazy and stupid often have more pressing needs than to revolutionize their industry.

I agree with your general sentiment, though.

 

[Veneficus]

Now if only this was the standard.... if parents could do it, basics could do it.

Where I am from:

BGL checks, standard

Albuterol nebulizers, not standard, but used in many agencies
Pulse Ox checks (yes, there are places where they are not considered to be BLS skills) standard as is attaching and printing an EKG (but not interpreting it)
D50 for known diabetics (often kept in the fridge at home and used only for emergencies): oral glucose.
Epi Pens: standard
Benedryl for allergic reactions: I really don't see why not, possibly some malox too.

ahh, a man can dream...B)

Well, support adding an educational increase and you might be able to reasonably lobby for such.

 

[Akulahawk]

Inline will be some arguments...

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.
Got an Epi auto-injector? You don't have to be a Medic or EMT to administer those. Vene makes a good point: SQ has a slower absorption time than IM. What they're looking to do is use that slower absorption rate to not stress the heart unnecessarily. Personally, I feel that if someone's bad enough off that they need the Epi to break their anaphylaxis symptoms, they're bad enough to get the Epi administered IM.
- A hypoglycemic patient could be permanently altered if they wait 30 minutes for D50.
The unconscious hypoglycemic patient, perhaps. However, they could still be given 1 mg glucagon IM. Hopefully that patient has sufficient glycogen reserves to utilize the glucagon...
- 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?
Most seizures break prior to EMS arrival. Those status epilepticus patients could be given rectal diazepam by BLS providers. Sure, absorption rate by suppository is slower than IV... but it works.
- 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?
Teach the EMT personnel to use mixed gas... like Heliox. If that doesn't work, then pull out Mr. Epi Autoinjector...
- What about field induced hypothermia for post-resuscitation?
While that works, it's nowhere near ubiquitous enough for it to be a issue even in an all ALS system.
- What about STEMI recognition and cath lab activation? BLS?
It's a novel idea in some systems to allow a Paramedic to hook a patient up to the machine and look for ***Acute MI*** result... instead of educating the Paramedic to interpret the results themselves and do a field activation of the Cath Lab...
I could add more and more examples.... a BLS only County is laughable and not in the Communities best interest.
BLS-only communities, if the community itself chooses that, it is what the community decides is best for it... for better or worse.

 

[Melclin]

How about RSI?
-traumatic brain injury.
-stroke.
-other misc hypoxic brain injury (hanging, drowning).
-Airway burns.
-Hyperthermia
-Post ROSC pt.
-status seizures.
-complex drug overdoses (selected polypharm, trycyclic).

Thrombolysis in MI with no cath lab nearby.

Chest decompression, both needle and otherwise.

Sedation for sync cardioversion, especially rurally?

CPAP.

Paralysis (separate to the idea of RSI), hypothermia and inotropic support for post arrest pts?

How about reducing the risk to ambulance providers and the community by treating some time critical problems on scene instead of fanging these BLS ambulances about all the time.

How about trauma triage? Can a BLS provider be trusted to bypass hospitals for trauma centres? If they can, will medical directors have to institute ridiculously overzealous triage protocols?

Will they be able to make use of the increasing prevalence of specialty centres. Stoke centres are increasingly prevalent. I've heard mention of cardiac arrest centres in the works too. Can BLS providers be bypassing EDs in favour of these hospitals (thats not rhetoric, I'm actually asking if EMTs are involved in bypass anywhere)?

Pain relief. I can't think of a more common complaint than pain in ambulance. There are lots of kinds of pain and lots of ways to treat it. Entonox is not enough (although a good option). Neither is "2mg IV Morphine for severe long pain fractures" or whatever that stupid protocol is. Maybe you guys are cool with transporting a banged up kid down a pot holed dirt road after a dirt bike accident or manuevering Nanna NOF out of the back room on the second floor of her block of flats, without proper pain relief, but I'm not.

Some of these things are just skills. But they are skills that require regular practice to stay proficient in. You can't get one tube a year and expect to be any good at it. Tiered EMS systems are important not only to provide the community with a certain level of care, but it leaves high acuity jobs for specialty providers. So even though there might not be a great deal of RSIs and chest tubes going around, you have them spread amongst a relatively small group of advanced providers. Also, I think you've got it arse up if you think the only choices for these tiers are EMT or Paramedic (at least, as you know them in the US anyway).

Well educated providers make incorporating new additions to scope much easier. Field cath lab activation for example. The price of POC lactate measurement is coming down and the push for early sepsis recognition and treatment is increasing, etc.

 

[MrBrown]

The problem is very simple. As far as EMS is concerned the United States is generally stuck in the stone age and between 5 to 30 years behind the rest of the Commonwealth nations when it comes to system design, education, scope of practice and clinical dexterity.

Now there are some things it does very well (induced hypothermia, CPAP, steriods for asthma/anaphylaxis, vehicle design and electronic PRFs) however when we look at some other things it really drags the whole system down.

In 1977 it took a recruit two years of education and experience to become a Qualified Ambulance Officer with the Metropolitan Ambulance Service (Melbourne) and they could do little more than oxygen and transport .... nearly forty years later, the US is yet to adopt such a requirement for even thier highest level practitioner.

 

[fortsmithman]

The problem is very simple. As far as EMS is concerned the United States is generally stuck in the stone age and between 5 to 30 years behind the rest of the Commonwealth nations when it comes to system design, education, scope of practice and clinical dexterity.

Now there are some things it does very well (induced hypothermia, CPAP, steriods for asthma/anaphylaxis, vehicle design and electronic PRFs) however when we look at some other things it really drags the whole system down.

In 1977 it took a recruit two years of education and experience to become a Qualified Ambulance Officer with the Metropolitan Ambulance Service (Melbourne) and they could do little more than oxygen and transport .... nearly forty years later, the US is yet to adopt such a requirement for even thier highest level practitioner.

Brown with me and other members from commonwealth countries you are preaching to the choir.

 

[Veneficus]

Brown with me and other members from commonwealth countries you are preaching to the choir.

Please include me in the choir.

I am not from a commonwealth country.

 

[DrParasite]

question: are there any quantifiable means (mortality rates, or anything scientific) that show how an educated medic is better than a lesser educated one?

meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.

 

[MrBrown]

Brown thinks you only have to look at the modalities of practice in jurisdictions with varying educational models to answer that question.

In Australia, New Zealand, the UK and parts of Canada Paramedics are given total clinical autonomy and freedom to use professional discretion in how to treat patients.

Each system has guidelines which are interpreted flexibly to suit individual requirements of the patient and situation without recourse to "medical control". So while guidelines provide the framework for approach to care and procedures for a broad macro-level classification of patients based upon symptoms or main problem they can be deviated from in line with professional practice.

For example in New Zealand we have unlimited dosages of IV analgesia (morphine, morphine+midaz and ketamine) as well as GTN and adrenaline. This means we can treat-to-effect and are unrestricted in the amounts of medications that our Paramedics can give.

This does not mean they are rogue cowboy practitioners who overdose people or practice without recourse to foundational knowledge or inline with tennants of good care as set down by the Guidelines (for example giving somebody so much morphine they respiratory arrest or contiue giving GTN when it is not effective in relieving pain) but rather that they are free to apply professional discretion and are trusted to do so.

Our Paramedics are also free to apply professional discretion and knowledge when it comes to other modalities of treatment for example non transport and alternate disposition.

With this freedom is also the responsibility that each Paramedic knows they are answerable to both thier Medical Advisor and Clinical Standards Manager and also they can be held criminally liable for gross negligence however it has never been a problem to date.

 

[Veneficus]

question: are there any quantifiable means (mortality rates, or anything scientific) that show how an educated medic is better than a lesser educated one?

meaning, if a 6 year medic program is better than a diploma mill medic, surely there would be some kind of statistic to show how they save more lives, or have fewer days in the hospital, or some other numerical quantifiable means to measure.

I doubt there would be statistics on it.

First off, mortality rate by itself is unreliable and full of confounders. There is a proverb I once heard:

Which doctor is better?

A doctor who is able cure cure 50% of his patients
A doctor who can cure all of her patients
A doctor whos patients never get sick

There are no numberical quantifiers showing how much a long spine board helps reduce spinal injury. But it is still done everyday.

You are not going to find a double blind placebo controlled study on the effectiveness of education in every area of medicine. It is outright stupid to even expect some of it.

Does having a doctor increase the number of diseases cured?

Does calling an EMT help more than calling your neighbor or friend?

Would you really go to a person who treats your loved one based soley on a protocol and if they didn't fall into it, too bad for them?

This constant assault on education is absolutely rediculous. Please never treat anyone I care about. Infact, you just earned a place next to ventmedic on the ignore list.

congratulations.

 

[MrBrown]

Which doctor is better?

A doctor whos patients never get sick