No equipment: EMT vs Paramedic

[mycrofft]

Back to no-equipment assessment, EMT-B versus Paramedicc

PS:

HARDPOINT #2: there's always someone who is willing to teach you to do something you are not supposed to. Dr X may say "Hey, EMT-B, want to learn how to femoral sticks? They aren't that hard", and you may develop a technical expertise doing them, but it is not in your scope. (Watch out when the "teacher" says "I'll take responsibility for it". Yeah, right).

Now, there are legal getarounds in situations where you are overseen by a MD or such (e.g., in California licensed vocational nurses CAN perform things like starting an IV BUT they must follow a standardized procedure or protocol and their work must be under direct supervision of a MD or a similarly certified RN), but most employers won't do it because the paperwork proving you are proficient and updated is usually not worth the potential benefit.

Back to OP: if this is a Godzilla versus King King" thing, strictly assessment, no equipment, the AVERAGE paramedic OUGHT to do better than the AVERAGE EMT-B because of greater education and precepted experience.

 

[Michael]

On the original topic, percussion isn't generally taught in a basic course, so there is one. The abdominojugular test is another one.

If we include a stethoscope, you could add heart sounds, and carotid bruits, and if you include a bp cuff, the ABPI would be another.

Then you can add all of the neuro details. There is a tendency to think of Paramedics as rather useless without ALS equipment, but there is a massive difference in the knowledge base.

 

[medicsb]

While this is certainly true, I will point out that what really exponentiates a physicians physical exam and history is the knowledge of basic clinical sciences. You cannot apply the physical exam as a "skill" as taught in EMS and come anywhere near the level of exam a physician is capable of.

As well, the more the physician knows about basic clinical sciences, the more capable they are. (not all doctors are equal)

As Linuss said, there is nothing that stops you from learning it. But it is both cost and time intensive.

You neglected to mention the other HUGE (and maybe more important) component to learning the physical exam... repetition and thoroughness. You can know every thing about the clinical sciences (likely impossible) and not be able to find your own butthole with two hands and a flashlight if you don't look, listen, smell, and feel a patient over and over and over and over again (tasting would be going a bit far). The physical exam is my favorite part of medicine; I may not know every zebra out there (likely impossible), but if I can differentiate the subtle differences between normal and abnormal to build a clinical suspicion and a general direction in which to start looking for something, I'm happy. The best physicians at the physical exam who ever lived likely practiced prior to 1950. Most prominent would be Sir William Osler, who by our standard likely had a sub par knowledge of "clinical sciences" (e.g. germ theory was in its infancy - you didn't need to know the bug or its virulence factors or its make up of the cell wall to diagnose an infection.) The physicians practicing 100 years ago didn't need to know molecular biology, biochem, or germ theory to diagnose and treat, necessarily. (Though, I think medicine has come a long long way in the past 100 years and would rather see a modern doc than Osler circa 1910.)

Wait...time out. Medics are suspicious enough to put someone on the monitor and do a 12-lead? Then they dump it on a BLS crew? Where's the guy who was bragging about how KCM1 is "all that" and they don't dump patients on BLS crews? :huh:

Eh. I did it. E.g.: Get some 50 something woman complaining of weakness and yeah, I'd run a 12-lead to check for STEMI due to increased frequency of atypical presentations. And yeah, I'd turf patients like that to BLS if everything was benign.

An inverted T wave doesn't scream OMG ALS! to me... I wonder how many of these runs that "should absolutely be ALS and would be in any other system anywhere in the country but not here" are truly ALS runs and not just blown out of proportion...

I'm willing to bet most are blown out of proportion if for no other reason than there is nothing to do and the fact that they'd survive if the rode on someones back to the hospital... up hill... in a blizzard. Many potentially lethal conditions don't need a paramedic. Most acutely life threatening conditions kill over hours to days and not minutes. Appendicitis is something that can kill and I can tell you with certainty that most patients with an appy do NOT get rushed to the OR. It's usually within 6-12 hours and that even includes cases where it the appendix has perf'd. All depends on their exam (ok, and maybe their labs). Yet, in EMS, I commonly hear medics or EMTs cite a perf'd appy as a reason for a medic to "assess" or "ride in" a patient with abdominal pain.

 

[Veneficus]

You neglected to mention the other HUGE (and maybe more important) component to learning the physical exam... repetition and thoroughness. You can know every thing about the clinical sciences (likely impossible) and not be able to find your own butthole with two hands and a flashlight if you don't look, listen, smell, and feel a patient over and over and over and over again (tasting would be going a bit far). The physical exam is my favorite part of medicine; I may not know every zebra out there (likely impossible), but if I can differentiate the subtle differences between normal and abnormal to build a clinical suspicion and a general direction in which to start looking for something, I'm happy. The best physicians at the physical exam who ever lived likely practiced prior to 1950. Most prominent would be Sir William Osler, who by our standard likely had a sub par knowledge of "clinical sciences" (e.g. germ theory was in its infancy - you didn't need to know the bug or its virulence factors or its make up of the cell wall to diagnose an infection.) The physicians practicing 100 years ago didn't need to know molecular biology, biochem, or germ theory to diagnose and treat, necessarily. (Though, I think medicine has come a long long way in the past 100 years and would rather see a modern doc than Osler circa 1910.)

You are talking to the guy who went to Europe to learn physical exam because they are the masters of it.

I agree with what you are saying 110% and I did neglect to mention that. I also neglected to mention it really helps to learn it from a master. But unlike Osler, if you do know a lot about clinical science, not only can you dx an infection from physical exam, in some cases you can diagnose the very organism.

edit: you can also dx the difference between things like a type IV hypersensitivity reaction and type I.

In addition to looking real smart, Both examples will direct your treatment.

 

[Aidey]

I'm willing to bet most are blown out of proportion if for no other reason than there is nothing to do and the fact that they'd survive if the rode on someones back to the hospital... up hill... in a blizzard. Many potentially lethal conditions don't need a paramedic. Most acutely life threatening conditions kill over hours to days and not minutes. Appendicitis is something that can kill and I can tell you with certainty that most patients with an appy do NOT get rushed to the OR. It's usually within 6-12 hours and that even includes cases where it the appendix has perf'd. All depends on their exam (ok, and maybe their labs). Yet, in EMS, I commonly hear medics or EMTs cite a perf'd appy as a reason for a medic to "assess" or "ride in" a patient with abdominal pain.

Except that EMS isn't just about life or death interventions. There is a very valid argument to be made for pain control in a appendicitis case. Pain control is generally an ALS issue.

 

[Michael]

Except that EMS isn't just about life or death interventions. There is a very valid argument to be made for pain control in a appendicitis case. Pain control is generally an ALS issue.

They also would benefit from antiemetics, which would make it ALS.

 

[medicsb]

Except that EMS isn't just about life or death interventions. There is a very valid argument to be made for pain control in a appendicitis case. Pain control is generally an ALS issue.

I don't really think of pain control as an ALS treatment, but this is more in an ideal system (say, EU/Canada/AUS). It certainly shouldn't be, I would support AEMTs giving IN fentanyl or PO NSAIDs.

Anyhow, most appys, but not all, I've seen this year had good pain management with motrin (I did 2 weeks of inpatient pediatrics, 2 weeks of pediatric ED, and am currently rotating on surgery). I'm confident that fentanyl is not needed for pain management in a lotI of cases (probably the majority), but for whatever reason, EMS likes to go 'all or nothing'.

 

[medicsb]

You are talking to the guy who went to Europe to learn physical exam because they are the masters of it.

I agree with what you are saying 110% and I did neglect to mention that. I also neglected to mention it really helps to learn it from a master. But unlike Osler, if you do know a lot about clinical science, not only can you dx an infection from physical exam, in some cases you can diagnose the very organism.

edit: you can also dx the difference between things like a type IV hypersensitivity reaction and type I.

In addition to looking real smart, Both examples will direct your treatment.

Gotta admit, I'm jealous. Most docs I now have to learn from came up in the 90s - the age of CT scans. There have been a few (usually trained before the use of CTs), that were great diagnosticians whom I'd love to spend every day learning from, but unfortunately that is not possible. Anyhow, I'll still percuss bellies and chests when I can and love picking up murmers when the residents or interns did not. After having seen fluid waves, asterixis, shifting dullness, psoas sign, obturator sign, palmer erythema from cirrhosis, caput medusa, etc. etc., I love to look for things. Bummer is that when I think I've found something, it is hard to get confirmation. A lot of trial and error.

 

[ChorusD]

I transport patients all the time that in any other system would be ALS. If a 12 lead shows somewhat normal rhythm and the MD okays it they are going in my rig. In my example the patient had inverted T-waves but nothing else out of the ordinary. MD ok'd the BLS transport.

For what it's worth, inverted T waves are not necessarily something to be taken lightly. In fact, it can be an indication of something like Wellen's Syndrome which some would argue is a condition that would require rather urgent catheterization.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776372/

Having said that, I definitely wouldn't say you did your patient an injustice by not requesting ALS transport.

 

[RocketMedic]

Except that EMS isn't just about life or death interventions. There is a very valid argument to be made for pain control in a appendicitis case. Pain control is generally an ALS issue.

Did this last night, appy being transferred from a freestanding ER got 100mcg of fentanyl IVP to reduce her pain from 5/10 to 0/10 for the 30-minute transfer. ALS? Not at all, minus the pain management; needed to preserve life, probably not. But she felt better, and that was what differentiated EMSA from Yellow Cab.