Paramedic Incompetence Question

[Veneficus]

very fine points, but let me try to respond in 1 post

Don't forget, Vene, you are speaking from a place of having been exposed to the ins and outs and ramifications and sub- and advanced levels of diagnosis backed by a thorough study of disease entities.

Here, you're dealing with people who aspire to gain just a small piece of your knowledge while essentially working in a (non-self imposed) tunnel.

"throwing everything at somebody hoping something sticks" often becomes part of EVERYONE'S learning curve that helps them understand using the proper limits of a net.

Firetender,

You once again bring out a very good point and perspective.

In this post, I have read more than 11 pages of: "I can't."

Then there are a bunch of excuses as to why.

Most of which are total BS.

It begs the question:

Is there anything you actually can do?

I have read your work, twice. Though it was not pointed out specifically your whole book is about doing what you can with what you have.

Not making excuses for only doing what you did.

I admit that even today the tunnel you speak of in EMS is getting smaller and smaller. However, in this thread I see a self imposed tunnel that doesn't really exist. It probably boarders on agoraphobia.

Providers do not magically get smarter the day they get a specific degree in hand, they get smarter over the journey of obtaining that minimal measurable level.

The quest for more knowledge and more ability needs to be constant from the start. It is a personal quality, not reflected by cert level. I am certain we both know Basic EMTs we would put our faith and trust in. At the same time I have no doubt there are doctors we wouldn't.

If you cannot breach the glass ceiling, expand laterally.

Something else to think about. The maximum shotgun approach possible in the average EMS system is often going to amount to a basic initial assessment for a physician. It's not like the average paramedic is going to be able to shotgun lab tests outside of a BGL or order a CT, or any similar imaging test.

It is not just about lab tests or diagnostics. (which are over used anyway but that is a thread for a different forum)

The average system paramedic can do considerable harm with their "what ifs" particularly on the economic health of patients, which you know has actual health consequences in the long term in psychological and physiological stressors.

As was mentioned in this thread, one uncomfortable EMS provider has the ability to inflict thousands of dollars (if not tens of thousands) of harm because of their anxiety and inepness. Not only do they receive no sanction for this, the system is set up to perpetuate it.

The EMS provider does not see or have to deal with the fallout. They simply ignore it, or justify it as "Better safe than sorry." But when a family breaks up because of medical bills, becomes homeless, or winds up eating McDs 3 meals a day because it is the cheapest meal they can buy, they will not be safe and they will be sorry.

Take the helicopter out of the equation, research the difference in cost at your local hospital hospital for a trauma activation vs. an ED visit.

Tis not the season to tell kids there are no gifts because they had to pay to "be safe and get checked out because what if..." because the healthcare provider they put their trust in didn't make reasonable recommendations.

 

[systemet]

Any CME class that covers any disease process is also going to cover signs and symptoms of the disease. Besides, there's always the concept of life long learning. You don't need an instructor to pick up a book like Bates and integrate what you learn into your practice of prehospital medicine.

This is an excellent point. Something I realised after a few years of university was that a large percentage of the knowledge I'd learned was going to decay over time, or never be directly useful to me. However, what the experience did teach me, was how to teach myself. This is invaluable.

Edit: I also know of a case where a paramedic caught a dystonic reaction from what he learned from a scenario on an EMS forum. He did contact medical control to confirm the diagnosis and treatment, but without incorporating what he learned he would have never called medical control in the first place.

http://www.emtcity.com/index.php/topic/14938-emtcity-helped-me-make-the-diagnosis/

I think this is basic material that should be covered in a paramedic class (fortunately, it was in mine), especially if providers are going to be running around giving stemitil, haloperidol, droperidol, metoclopramide, etc.

I've seen a couple. One was an intentional haldol OD who had been discharged and developed dystonia at +48 hours. (My student worked this out by himself, and recognised the need for benadryl -- I was very proud). Another was in a family MD's office. He had called a neurologist at the receiving facility and told the patient he was having a CVA (I think he tunneled in on the oculogyrus), and wanted us to give 100mg meperidine IVP.

I think that there is nothing that I know as a paramedic that an EMT can't know, or be trained to understand. Even if they can't treat a dystonic reaction, does this mean that they shouldn't be able to recognise it? We're putting them on ambulances and sending them to people who call for help. An extra year or two of education might not hurt this. I realise that I'm preaching to the choir here.

 

[Veneficus]

This is an excellent point. Something I realised after a few years of university was that a large percentage of the knowledge I'd learned was going to decay over time, or never be directly useful to me. However, what the experience did teach me, was how to teach myself. This is invaluable.



I think this is basic material that should be covered in a paramedic class (fortunately, it was in mine), especially if providers are going to be running around giving stemitil, haloperidol, droperidol, metoclopramide, etc.

I've seen a couple. One was an intentional haldol OD who had been discharged and developed dystonia at +48 hours. (My student worked this out by himself, and recognised the need for benadryl -- I was very proud). Another was in a family MD's office. He had called a neurologist at the receiving facility and told the patient he was having a CVA (I think he tunneled in on the oculogyrus), and wanted us to give 100mg meperidine IVP.

I think that there is nothing that I know as a paramedic that an EMT can't know, or be trained to understand. Even if they can't treat a dystonic reaction, does this mean that they shouldn't be able to recognise it? We're putting them on ambulances and sending them to people who call for help. An extra year or two of education might not hurt this. I realise that I'm preaching to the choir here.

I think that is becomming obvious to more people that the minimum knowledge needed to function in today's medicine is considerably larger than what was needed when the idea of a provider who could do some basic interventions on the way to the hospital was formulated.

It is nice to see people actually catching onto the concept, even if they are still the minority.

 

[medichopeful]

But as an EMT, thinking is extra.

That's one of the scariest statements on this site I've ever seen h34r:

 

[Tigger]

That's one of the scariest statements on this site I've ever seen h34r:

Yes, yes it is.

 

[usafmedic45]

You must e from MD, where the revenue generated by outrageous airmedical use supercedes patient benefit by any justifyable measure.

Nah, they don't bill for the MSP flights. They just take it out in a tax on automobile registration. Not that it makes it any more medically justifiable....

luckily saner heads prevailed and the helicopter was canceled.

That's a first. They killed several people (including a friend of mine) because some girl had a dent in her car that was going to be expensive to have fixed.

That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.

LOL That's the most flawed logic I've seen in a while on EMTLife regarding HEMS.

How did you guess?

The smell of Kool-Aid and an inability to think non-linearly?

Just use some clinical judgement and don't blindly follow protocol...technically your pt (with GCS 9) is a category B trauma patient per my state's protocol, and you should request a medivac helicopter to transport your patient to the nearest Level 1 trauma center, with no need to consult beforehand with the trauma center and obtain permission. Don't be that guy.

Hmmm....always wondered what it would have been like to be an EMS provider in the mid-1980s. Then I was stationed in Maryland in 2001 and don't have to wonder any longer.

What's funny but the "it puts the patient in the helicopter or else it gets the hose again" caveat in the Maryland EMS protocols is the exact same one that existed in our protocols. The difference was the option of aeromedical evacuation was listed at the very bottom, surrounded by a bold red box containing the following statement in large font letters:
"Medical helicopters delay access to vital medical care and have no appreciable effect upon survival rates. Utilization of an aeromedical helicopter will result in suspension from clinical duties until such time as an investigation into the circumstances resulting in the request for a scene response has been completed. Punishment for excessive, egregious or medically unsupportable use of a helicopter may include further suspension, termination of employment or initiation of proceedings to revoke state certifications held by the offending individuals."

 

[rescue1]

LOL That's the most flawed logic I've seen in a while on EMTLife regarding HEMS.

Haha, hey, I try. But I think if you understood the messed up crap that is Kent County EMS you might be (slightly) more forgiving. I'm not saying what's happening is good...but for now, that's just what it is.
Until I get the hell out of here in May, anyway.

 

[systemet]

That being said, my local (small town) hospital won't accept most trauma, and I'm at least an hour from any trauma center. If I take someone by ground, ALS will be with us, meaning I'm taking away half of the county's ALS coverage (only 2 ALS cars in the county) for at least two hours, if not three. It's unfortunate that the situation exists, but sometimes for us, the helicopter is the best option simply because it prevents areas of the county from being left without coverage.

I missed this gem the first time, and then saw that usaf had responded to it. I've just got to add my .02 to this.

Please, please, be smarter than this.

You want to take a rotary wing air ambulance out of service with a subacute patient, who could be managed adequately by ground ALS, because you don't want to compromise the coverage for your county, in case there's no ALS when a hypothetical future call comes in?

Do you have any idea how much of a disservice that is to the flight crew, who put themselves at personal risk every day? Or every other person who lives and breathes anywhere within about 0.5-1.5 hours drive of the HEMS station? Now you have a real time-critical peds trauma 90 minutes by ground from the trauma center, but the helicopter is busy flying a patient who doesn't need their level of care, so that the coverage in your neighbourhood is safe? Not even remotely acceptable!

Your county's lack of tax base, political leadership, decent hospital, etc. doesn't get to trump everybody else's needs.

 

[usafmedic45]

lack of tax base

It's Kent County. There's nothing lacking about the tax base. It's just that the state EMS "authorities" have gotten hospitals so convinced that everyone who is even sporting abrasions needs to be seen at a trauma center, that few hospitals are willing to accept a "trauma patient" without said designation. It would be quite a comical situation if it weren't so damn risky because Shock Trauma- the crown jewel/polished turd of Maryland EMS- isn't even an accredited trauma center by the same body as everyone else. It's one of those "We're a trauma center because we say we are!" sort of defenses. This of course unless something has drastically changed since the Trooper 2 crash in terms of oversight but I seriously doubt it.

 

[usafmedic45]

But I think if you understood the messed up crap that is Kent County EMS you might be (slightly) more forgiving.

There isn't a county in that state that has their :censored::censored::censored::censored: together as far as EMS goes. It would take a full out coup (with the requisite "removal" of people who stand in the way) to get that state moved forward into the 1990s.


NOTE: I am in no way advocating harming the MIEMSS "leadership", just simply pointing out that until such time as the current "leadership" goes away things will never get any better.

 

[JPINFV]

NOTE: I am in no way advocating harming the MIEMSS "leadership", just simply pointing out that until such time as the current "leadership" goes away things will never get any better.

...but I'd love to see a bunch of EMS professionals go all Arab Spring on a bunch of EMS administrators nostalgic for Emergency!

 

[rescue1]

It's Kent County. There's nothing lacking about the tax base. It's just that the state EMS "authorities" have gotten hospitals so convinced that everyone who is even sporting abrasions needs to be seen at a trauma center, that few hospitals are willing to accept a "trauma patient" without said designation. It would be quite a comical situation if it weren't so damn risky because Shock Trauma- the crown jewel/polished turd of Maryland EMS- isn't even an accredited trauma center by the same body as everyone else. It's one of those "We're a trauma center because we say we are!" sort of defenses. This of course unless something has drastically changed since the Trooper 2 crash in terms of oversight but I seriously doubt it.

There was some minor changes after Trooper 2, I believe, but it happened right before I got into EMS, so I'm honestly not sure. There was a push to cut back on flying patients, and maybe the numbers did go down, but I can tell you, lots of people still fly.

As for systemmet's response, two points.
I would love to take people to Chester River Hospital all the time. It's close and I know I've been on flyouts where the patient has almost certainly walked out of Shock Trauma that night.
But, as a lowly BLS provider, it's one, not even my call. We get ALS on all calls, so it's the paramedic's decision as to when to fly. If I suggested taking the patient to Christina Hospital (closest trauma center) by ground, I'd bet you large sums of money that I'd be spending the call outside the ambulance. It's very ingrained in the culture here...and it makes sense why, from a selfish viewpoint. It's really easy to just wait around a few extra minutes for a helicopter and be done with it, as opposed to driving an hour yourself. This is helped by the fact that QA will probably jump on your *** for not following protocol with helicopter activation if you do take a trauma pt more then 30 minutes away by ground.

Is it good? No. It's stupid. But until something changes, like usafmedic45 said, it's something I have to live with. At least until I graduate college and get back to PA.

As for your comment about removing helicopter coverage for an area by tying it up with non-critical patients, almost everywhere in Maryland can get a helicopter in 20-25 minutes, even if the closest one is busy. Medivac coverage will never, ever be an issue in this state.

 

[systemet]

As for systemmet's response, two points.
I would love to take people to Chester River Hospital all the time. It's close and I know I've been on flyouts where the patient has almost certainly walked out of Shock Trauma that night.
But, as a lowly BLS provider, it's one, not even my call.

Sorry, I somehow got the impression that launching the chopper was your call. I apologise for giving you :censored::censored::censored::censored: for someone else's decision / responsibility. But please recognise that this practice of justifying overutilisation of the helicopter to preserve local coverage is terrible from a medical and ethical standpoint.

We get ALS on all calls, so it's the paramedic's decision as to when to fly. If I suggested taking the patient to Christina Hospital (closest trauma center) by ground, I'd bet you large sums of money that I'd be spending the call outside the ambulance. It's very ingrained in the culture here...and it makes sense why, from a selfish viewpoint. It's really easy to just wait around a few extra minutes for a helicopter and be done with it, as opposed to driving an hour yourself. This is helped by the fact that QA will probably jump on your *** for not following protocol with helicopter activation if you do take a trauma pt more then 30 minutes away by ground.

I have seen similar situations where helicopters have been launched for largely asymptomatic patients with severe MOI, and it's often seemed like the providers have had a vested in interest in not driving an hour to a trauma center. Of course, it's still a bad practice.

Is it good? No. It's stupid. But until something changes, like usafmedic45 said, it's something I have to live with. At least until I graduate college and get back to PA.

As for your comment about removing helicopter coverage for an area by tying it up with non-critical patients, almost everywhere in Maryland can get a helicopter in 20-25 minutes, even if the closest one is busy. Medivac coverage will never, ever be an issue in this state.

A lot of my experience comes from working in an area roughly the size of Texas with less than 4 million people, and two dedicated helicopters. So the helicopter seems like a much more precious resource to me, because we just had one that could fly my local area, and it was often being utilised (unfortunately sometimes for less acute patients, or patients who could have gone by fixed wing or ground ALS), when a major trauma needed it.

As an outsider it seems like maybe you need less helicopters and more trauma centers, or more ground ALS, or even BLS transport?

Once again, sorry for giving you a hard time for something that's not your fault. All the best.

 

[rescue1]

Hey, no hard feelings. I could probably do better myself, and I'm glad EMTlife has shown me the light of better prehospital care.

Basically, everything you're saying is right, it's just that since most of the providers have been trained in Maryland and worked in Maryland all their life, they see no issue with it. The whole system is designed around the "helicopter to Shock Trauma" method of delivery, and it will be a while before it changes.
Until then, I can look forward to taking my paramedic outside Philly, where the protocols are nice and the trauma centers are reasonably close.