Prehospital command hierarchy, fitting it in with the regular medical community

[JPINFV]

Your being a little dramatic don't you think? I mean who calls a doc to see if a pt is AA0X4? Thats what a mental assessment is for. And you are saying that using Med Control is a crutch but that is the exception not the rule...

For your reading from this very forum:
'The patient had 1 beer, is A/Ox4, and has capacity, but we need to call medical control just in case' http://emtlife.com/showthread.php?t=25667

Contact medical control to prevent liability: http://emtlife.com/showpost.php?p=49156&postcount=2

Hey, this is completely out of my scope, but maybe medical control will say I can and I won't have any liability over it. http://emtlife.com/showpost.php?p=195714&postcount=46

"There is one advantage to always having to be under a doc. the liability insurance that each medic has is significantly less, as much of the burden can be pushed off on the doc " http://www.emtlife.com/showpost.php?p=201752&postcount=10

I could probably fine many more.

My personal favorite from outside of EMTLife is this gem from a Facebook discussion:

Terry: Oh, let's contact medical control to determine if a patient can film their own treatment because I can't make a decision on this non-medical decision! http://www.facebook.com/jemsfans/posts/234345126617406

most medics use Med Control for what its for....to obtain orders that exceed protocols and/or to get a higher and more educated opinion when the situation requires it. Rarely is it used to 'just get the load off my back' as you are implying....

Again, stick around and it's going to come up sooner or later with someone honestly suggesting it.


It's not that I have a low opinion on what paramedics can be and should be. It's that I think EMS's biggest problem right now is that EMS tends to shoot itself in the foot more often than it actually advances towards the goal of being a paramedic. Until EMS decides that 1000 hours of post secondary training isn't enough and stops saying such stupid things like "EMS doesn't diagnosis" or "just call medical control," then it will continue shooting itself in the foot.

 

[Katy]

I don't know, maybe I have to eat some humble pie because of my foot in mouth. I'm sure they have OUTSTANDING judgement making and medical skills....they still get direct orders from a doc on their floor........

You don't think they have standing orders?

 

[ZootownMedic]

For your reading from this very forum:
'The patient had 1 beer, is A/Ox4, and has capacity, but we need to call medical control just in case' http://emtlife.com/showthread.php?t=25667

Contact medical control to prevent liability: http://emtlife.com/showpost.php?p=49156&postcount=2

Hey, this is completely out of my scope, but maybe medical control will say I can and I won't have any liability over it. http://emtlife.com/showpost.php?p=195714&postcount=46

"There is one advantage to always having to be under a doc. the liability insurance that each medic has is significantly less, as much of the burden can be pushed off on the doc " http://www.emtlife.com/showpost.php?p=201752&postcount=10

I could probably fine many more.

My personal favorite from outside of EMTLife is this gem from a Facebook discussion:

Terry: Oh, let's contact medical control to determine if a patient can film their own treatment because I can't make a decision on this non-medical decision! http://www.facebook.com/jemsfans/posts/234345126617406



Again, stick around and it's going to come up sooner or later with someone honestly suggesting it.


It's not that I have a low opinion on what paramedics can be and should be. It's that I think EMS's biggest problem right now is that EMS tends to shoot itself in the foot more often than it actually advances towards the goal of being a paramedic. Until EMS decides that 1000 hours of post secondary training isn't enough and stops saying such stupid things like "EMS doesn't diagnosis" or "just call medical control," then it will continue shooting itself in the foot.

So your comparing a few idiots on a internet forum and FACEBOOK to a profession where thousands of providers perform skills, save lives, and help people everyday? Don't know how to respond to that. And the reason EMS doesn't diagnosis is because how can you get a accurate diagnosis in the field? Do we have blood cultures or labs? Do we have incredibly accurate and reliable medical htx, medications, or family history? Dude, your killing me man. I see your point but you need to get out and find a good medic or two and ride on a ambulance with em. If you can't find one in Cali come to C Springs and I got about 75 you could roll with who would love to have you and change your mind.

 

[ZootownMedic]

You don't think they have standing orders?

No. If they did they wouldn't need a doctor they could just call him on the phone like we do. Hhaha...I was half kidding. I don't know what don't you educate me. What do they have standing orders for usually?

 

[JPINFV]

WOW...you have a really low opinion of EMS. Whats your experience? Im seriously curious...one state? Since California does EVERYTHING right :rofl:

...and your program is representative of every other program?

California is a terrible place, for the most part, when it comes to education. California, however, isn't alone. Look at Iowa, who calls their EMT-I/99 level "paramedics" and paramedics "paramedic specialists." Look at New York where a lot of providers go, "Hey, look, the EMT-CC level is just as good as a paramedic since they can do 95% of the interventions with 3/4ths the education."

Look at all of the backlash over evidence based medicine when the evidence says, "Mayne we shouldn't be giving every patient oxygen via NRB mask or backboard every trauma patient."

These are systemic cultural issues, not local regional issues.

And give me a break with the more than one bad apple.....your saying that there is a such a higher ratio of bad medics to good ones compared to say bad nurses or doctors to good ones? Show me some statistics or evidence other than your limited opinion?

First, I could easily turn this around and demand the opposite. Show evidence that your program isn't an outlier.

Additionally, this has nothing to do with good or bad medics. This has to do with poor standards, and EMS believing, as a whole, that it's everyone else's job but theirs to kick up the education level to seriously begin justifying things like community paramedic programs, treat and release, and the like. The fact that one state is getting away with calling I/99s "paramedics," another state (New Jersey) still can't control a large number of their ambulances (volunteers via the First Aid Council), another state get away with a medic lite program, and California is a simple 1000 hour course says a lot.

The fact that only 2 states apparently require even an associates degree speaks volumes. Sure, nursing still allows diploma programs, but the culture and pressure within nursing essentially dictates an ADN, if not a BSN for the good positions. Similarly, while medical school doesn't require a bachelors degree (90 units is the general standard), good luck getting admitted without one, and a growing number of medical students have masters degrees prior to starting (last number I saw was around 30%, and that was a few years ago).

If a majority of EMS providers felt that these are inappropriately low standards, why aren't they working to change it? How can paramedicine become a "profession" as long as paramedics don't take command of their work and their education system?

 

[Katy]

No. If they did they wouldn't need a doctor they could just call him on the phone like we do. Hhaha...I was half kidding. I don't know what don't you educate me. What do they have standing orders for usually?

Actually, I have found something better. Here is one where the Nurse is neither a ICU or ER nurse.
http://kbn.ky.gov/practice/medscollege.htm

 

[JPINFV]

 

[ZootownMedic]

...and your program is representative of every other program?

California is a terrible place, for the most part, when it comes to education. California, however, isn't alone. Look at Iowa, who calls their EMT-I/99 level "paramedics" and paramedics "paramedic specialists." Look at New York where a lot of providers go, "Hey, look, the EMT-CC level is just as good as a paramedic since they can do 95% of the interventions with 3/4ths the education."

Look at all of the backlash over evidence based medicine when the evidence says, "Mayne we shouldn't be giving every patient oxygen via NRB mask or backboard every trauma patient."

These are systemic cultural issues, not local regional issues.


First, I could easily turn this around and demand the opposite. Show evidence that your program isn't an outlier.

Additionally, this has nothing to do with good or bad medics. This has to do with poor standards, and EMS believing, as a whole, that it's everyone else's job but theirs to kick up the education level to seriously begin justifying things like community paramedic programs, treat and release, and the like. The fact that one state is getting away with calling I/99s "paramedics," another state (New Jersey) still can't control a large number of their ambulances (volunteers via the First Aid Council), another state get away with a medic lite program, and California is a simple 1000 hour course says a lot.

The fact that only 2 states apparently require even an associates degree speaks volumes. Sure, nursing still allows diploma programs, but the culture and pressure within nursing essentially dictates an ADN, if not a BSN for the good positions. Similarly, while medical school doesn't require a bachelors degree (90 units is the general standard), good luck getting admitted without one, and a growing number of medical students have masters degrees prior to starting (last number I saw was around 30%, and that was a few years ago).

If a majority of EMS providers felt that these are inappropriately low standards, why aren't they working to change it? How can paramedicine become a "profession" as long as paramedics don't take command of their work and their education system?

I really don't want to argue with you anymore, and I agree with a lot of what you said. I think your still forgetting several important factors however. Modern EMS is barely 30 years old man......think about how far we have come from the days of the show 'Emergency'. You are comparing a baby profession(Paramedicine) to an adolescent profession(nursing) and a GREAT GREAT GREAT GRANDFATHER profession(medical doctor). We will get there man. Or did you forget that you used to put leetches on people?

 

[ZootownMedic]

Actually, I have found something better. Here is one where the Nurse is neither a ICU or ER nurse.
http://kbn.ky.gov/practice/medscollege.htm

What about what MOST nurses are not the tiny majority of those in Emergency Medicine and Intesive Care?

 

[ZootownMedic]

What about what MOST nurses are not the tiny majority of those in Emergency Medicine and Intesive Care?

Sorry Katy...misread your post.

 

[JPINFV]

So your comparing a few idiots on a internet forum and FACEBOOK to a profession where thousands of providers perform skills, save lives, and help people everyday? Don't know how to respond to that. And the reason EMS doesn't diagnosis is because how can you get a accurate diagnosis in the field? Do we have blood cultures or labs? Do we have incredibly accurate and reliable medical htx, medications, or family history? Dude, your killing me man. I see your point but you need to get out and find a good medic or two and ride on a ambulance with em. If you can't find one in Cali come to C Springs and I got about 75 you could roll with who would love to have you and change your mind.

You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order?


Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers.

Heck, even your own language is betraying your side. There's a difference between the mindset between "skills" and "interventions." A "skill" is a mechanical action, like pushing a plunger on a syringe. An "intervention" is an attempt to change a patient in an appropriate manner to change the patient's current condition. Are you performing a "skill" because the cookbook says so, or are you providing an "intervention" because the patient's condition warrants it. It may be subtle, but it's a big difference in how medicine is approached between a technician and a professional.

 

[ZootownMedic]

You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order?


Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers.

Heck, even your own language is betraying your side. There's a difference between the mindset between "skills" and "interventions." A "skill" is a mechanical action, like pushing a plunger on a syringe. An "intervention" is an attempt to change a patient in an appropriate manner to change the patient's current condition. Are you performing a "skill" because the cookbook says so, or are you providing an "intervention" because the patient's condition warrants it. It may be subtle, but it's a big difference in how medicine is approached between a technician and a professional.

And we do come up with working diagnosis' and differentials all the time, everyday, on every call. That is completely different that 'diagnosing' as you said. EMS doesn't diagnosis. And yes if you want to say 'skills' are different than 'interventions'...fine. but again you are being picky. Intubation is a 'skill' but it is also a intervention used to ventilate, oxygenate, and protect the patients airway. Either way, I have class at 0900 and I need to get to sleep. Have a good night, I have enjoyed our conversation for the most part.

 

[ZootownMedic]

You do realize that list of differentials and a working diagnosis can be developed before lab results comes in. In fact, it's critical to determining which labs you need to actually order?


Also, I had the chance to meet some amazing people at EMS World Expo this year. People who are currently leading the field as paramedics, administration (and I'm talking operational staff, not accountants), and medical directors. One of the administrators openly lamented that EMS culture IS driving away some of the best minds to other fields. One of the physicians openly lamented that EMS is still hurting from the EMT 1994 curriculum. There's a reason why you have projects like the EMS 2.0 program online. EMS is broken. The people at the top realize it's broken. The problem is that there's too much apathy in the field by the average provider to fix the problems, and until you have everyone actually acting with a professional mindset (not "professional/unprofessional conduct" but things like ""Protocol" is not a standalone justification for a treatment" type thinking), EMS will remain broken, which is unfortunately fine for a lot of providers.

Heck, even your own language is betraying your side. There's a difference between the mindset between "skills" and "interventions." A "skill" is a mechanical action, like pushing a plunger on a syringe. An "intervention" is an attempt to change a patient in an appropriate manner to change the patient's current condition. Are you performing a "skill" because the cookbook says so, or are you providing an "intervention" because the patient's condition warrants it. It may be subtle, but it's a big difference in how medicine is approached between a technician and a professional.

Oh and BTW....almost NOTHING is black and white in Paramedicine. There is no room for technicians. Most don't graduate and almost none make it to the streets....at least where I am.

 

[JPINFV]

I really don't want to argue with you anymore, and I agree with a lot of what you said. I think your still forgetting several important factors however. Modern EMS is barely 30 years old man......think about how far we have come from the days of the show 'Emergency'. You are comparing a baby profession(Paramedicine) to an adolescent profession(nursing) and a GREAT GREAT GREAT GRANDFATHER profession(medical doctor). We will get there man. Or did you forget that you used to put leetches on people?

Modern evidence based medicine and modern educational standards for physicians really isn't that old. The Flexner report, for example, is just over 100 years old. Personally, I'd love to see what effect a Flexner style report on EMS education would have and what it would say. Also, EMS isn't that old compared to other fields that have gotten their butts in gear. Modern respiratory therapist certification can be traced back to 1960, and the EMS "White Paper" was published in 1966. Care to compare, in regards to attitudes of the providers, paramedics to registered respiratory therapists?

 

[ZootownMedic]

Modern evidence based medicine and modern educational standards for physicians really isn't that old. The Flexner report, for example, is just over 100 years old. Personally, I'd love to see what effect a Flexner style report on EMS education would have and what it would say. Also, EMS isn't that old compared to other fields that have gotten their butts in gear. Modern respiratory therapist certification can be traced back to 1960, and the EMS "White Paper" was published in 1966. Care to compare, in regards to attitudes of the providers, paramedics to registered respiratory therapists?

Nope. Not a fair comparison as their are FAR less RRT's then Medics. Good night

 

[JPINFV]

And we do come up with working diagnosis' and differentials all the time, everyday, on every call. That is completely different that 'diagnosing' as you said. EMS doesn't diagnosis.

What is coming up with a working diagnosis if not making a diagnosis? By that standard, emergency physicians don't "diagnose" the majority of their patients as the admitting team would end up doing that much further down the line. This also ignores the fundamental fluidity of a "diagnosis" as more information becomes known and the condition is treated. The admitting diagnosis and the discharge diagnosis can be very different things, but that doesn't make either of them any less of a "diagnosis."

And yes if you want to say 'skills' are different than 'interventions'...fine. but again you are being picky. Intubation is a 'skill' but it is also a intervention used to ventilate, oxygenate, and protect the patients airway. Either way, I have class at 0900 and I need to get to sleep. Have a good night, I have enjoyed our conversation for the most part.

Exactly. However, when a paramedic forgets to say, maintain oxygenation while preparing for intubation (the dreaded "BLS before ALS cliche), they aren't failing at the skill of intubation, but the intervention of intubation and airway control. Picking the right intervention is more important than being able to perform any single skill.


Also, it's subtle, and admittedly a bit nitpickey. However I put it up there with how the mindset of treating a patient with treatments X, Y, and Z because they are appropriate for the patient's condition and the mindset of treating a patient with treatments X, Y, and Z because the protocol says so. Protocols should be followed not because protocols are protocols, but because they represent the proper treatment the vast majority of the time. Hence it's not so much an issue of following protocols, but protocols matching the treatment plan that the EMS provider decided on. Similarly, if an EMS provider believes that an intervention isn't warranted because of an assessment point, then they should be free to deviate from protocol because their patient calls for it.

It's a subtle mind shift, but it's the mind shift that justifies liberal protocols and increased education in contrast to technician cookbook work.

Finally, if anything I hope you don't come around thinking I hate or look down on EMS. I think EMS has a long road to travel to get to where it rightfully should be. A road that requires some massive changes in EMS culture regarding how care is provided and what is appropraite (e.g. not every patient needs a hospital, the indication for supplemental oxygen is not "ambulance," "protocol" alone is not a justification for any treatment, etc), and changes that has to come before EMS can rightfully change it's status and reimbursment rates ("you call, we haul, that's all" is not sustainable). Additionally, while the destination is important, you can't plan a trip if you don't know where you currently are at.

 

[usafmedic45]

I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about.I hope if I run into any of these EMS 'haters'(on this EMS board btw) I can prove them wrong and show them what a good Medic is all about.

How about you get past the qualification exams first before assuming you'll be some form of a positive role model?

Not a fair comparison as their are FAR less RRT's then Medics

Wanna bet? 105,000 (as of 2008) RTs and 210,000 EMS providers in the US, with most of those being basic EMTs. However, I would argue that using respiratory therapy as a model is probably not the best idea given the tendency of the field to spend an inordinate amount of time chasing its own tail. They have the educational goals but the problem is that the career path associated with those goals is rather stagnant.

 

[systemet]

Opinions:-

* Paramedics have a large scope of practice because we are frequently the only healthcare provider present when someone is having a major medical or traumatic emergency.

* That we are able to perform a skill in the prehospital environment does not mean that we are equally qualified or able to perform that same skill in an in-hospital environment. If you're working in a hospital as some sort of clinical paramedic, they're not going to be asking you to manage the difficult airway patient. There are better trained people to do this, e.g. board certified EM and anesthesia physicians.

* Comparing our scope of practice out-of-hospital to the scope of practice of an in-hospital provider is pointless. A paramedic may be the best person to intubate you if you are 20 minutes from the hospital and the other alternatives are a police officer, your neighbour, or Fluffy your pet cat. In-hospital there are going to be other people better equipped to do this. The scope of practice of in-hospital providers being narrower reflects the realities of their work environment. Just as our relatively broad scope reflects the realities of the commonest environments that paramedics work in.

* Defining a profession by a skill set or scope of practice is a little silly. I don't suddenly become more of a professional tomorrow if someone suddenly authorises me to insert arterial lines. Especially if they do so without providing me with the necessary education to identify which patients are going to benefit from invasive arterial pressure monitoring, ABG analysis, not giving me appropriate training, or continuing education, or making sure that I can actually perform the skill in an acceptable manner, etc.

* A 2 year associate's degree is not a lot of education. It just isn't. We should not be happy with this as an "occupation". If we want to start calling ourselves "professionals" and have it mean something more than the "professional" in "professional carpet cleaner", or "professional car detailer", then we need to increase our educational requirements.

* Trying to get into turf wars with nursing (Does anyone really want to fight the nurses? I don't think the physicians even want that fight.), respiratory therapy or medicine, by comparing ourselves, and suggesting we're somehow better, is pointless at best, and counter-productive at worst.

----------------

Just re-read my post and realised I used a lot of unnecessary commas. Anyone have links to a decent site for doing remedial grammar?

 

[ZootownMedic]

How about you get past the qualification exams first before assuming you'll be some form of a positive role model?



Wanna bet? 105,000 (as of 2008) RTs and 210,000 EMS providers in the US, with most of those being basic EMTs. However, I would argue that using respiratory therapy as a model is probably not the best idea given the tendency of the field to spend an inordinate amount of time chasing its own tail. They have the educational goals but the problem is that the career path associated with those goals is rather stagnant.

First off, I will pass my qualification exams so thanks. Secondly, he said RRT's not RT's. As a RT yourself I would hope you'd know the difference. And there are far more than 200k EMS providers in the US. FDNY has at least 20k by itself there stat boy. 200k Paramedics is more accurate.

 

[usafmedic45]

Secondly, he said RRT's not RT's. As a RT yourself I would hope you'd know the difference.

Yeah, about $500 for a test and maybe a dollar or two an hour in extra pay. 99% of place have no differing skill levels between the two differing levels so it's not like the difference between an EMT and a paramedic. The difference is more like that between a paramedic with an associates and an paramedic with a bachelors. A few extra gen ed classes don't do much to increase one's clinical acumen.

First off, I will pass my qualification exams so thanks

Never said you wouldn't.

And there are far more than 200k EMS providers in the US. FDNY has at least 20k by itself there stat boy. 200k Paramedics is more accurate.

Uh....actually FDNY has 3,300 "uniformed EMTs" and 11,000 plus total personnel according to their website and Wikipedia.

How about you call the US Bureau of Labor and Statistics and tell them they are wrong rather than trying to compensate for whatever it is that you're trying to make up for by attacking someone on a forum when they point out where you were wrong in dismissing a comparison because of your own bias? They only count the folks who do it for a living which is actually the best way to look at it since it shows the folks who are spending the most time in it. I've seen estimates of 140K paramedics and 600K EMTs although it's not clear how many of those folks are actively involved in the field given the disparity. A lot of folks have the credentials and do nothing actively with them (such as many military members).