Replacing EMS with nursing revisited

[Veneficus]

The thing is, the BIGGEST complaint that this thread raises is a Paramedic's apparent inability to understand anything medical outside of emergency medicine. (Which is a stupid fallacy in and of itself)

I thought the point of the thread was to explore the possibility of replacing tech level EMS with licensed educated providers for the purpose of bringing EMS up to par with other modern nations. What do I know?

Truthfully, this isn't a problem of EMS and any supposed lack of education, but of the civilian population who utilize 911 for non-emergencies and primary healthcare. If EMS / 911 were utilized only for true emergencies, I'd venture to guess this thread would not exist aside from people WANTING us to get in to community Paramedicine.)

If in the perfect world from an EMS point of view the public only called for true emergencies, how many paramedics do you think would need to be employed? Since the common wisdom that 5% or less of all patients who activate EMS or go to the ED have an "actual emergency" then wouldn't that mean that only 5% or less of the nations paramedics would be needed? Where does that leave you?

I get to advocate for patients. I have no financial interest in bringing EMS up to date. I will never be an EMS medical director, I will probably never operate on an ambulance again. (past my 7 required days for school left)

It is not that I want to bring community paramedicine, it is that it has been demonstrated that is the future of EMS. Not just in Europe or Australasia, but in progressive EMS systems in the US as well. All of my harping on education and the lack of it is my attempt to pull EMS out of the 1970s. With the exception of the new gadgets employed, that is the dated treatment and perceived role of EMS by a large number of providers.

Honestly, if EMS had the ability to do what it needed to increase or even keep its value in society, a thread like this would be pointless. But I didn't make this gem up. There are physicians discussing this as the alternate to the resistance of EMS providers who don't like it. It is primarily being discussed as a potential form of healthcare waste that can be eliminated.

It affects every EMS provider in the US, whether you want to face it or not.

If reimbursement is substantially decreased, how will that change the game for FDs who use the revenue to prop up their budgets?

How will it affect the 3rd service EMS agencies where billing is the major part of the budget. I know at least 1 3rd service agency where only 20% of the total budget comes from taxes, the rest from soft billing. If they lost a substantial part of their revenue, they would be lucky to field 1/2 of thier current units. (which isn't enough for the area and volume now)

How will it affect private EMS providers whose sole source of income is billing?

And don't bring up that "The patient defines the emergency, not us" crap. No. A stubbed toe is not an emergency.

At anytime a patient can walk into an ED or call 911. Tell me, what makes EMS so special they only have to see emergencies that they deem appropriate?

What makes a paramedic so great they can tell people when to call for EMS when a physician in the ED takes care within the best of her ability and confines of resources any patient who comes in for any reason?

Do you think figuring out what to do about the chronic drug seeker is the best use of the talents of emergency physicians?

Do you think that some girl who comes in for a pregnancy test to the ED is the best use of that resource? Did you know that many EDs actually hand out plan B pills?

Do you know how many PID patients I have seen in the ED at 3 am as both a paramedic and medical student? It has to be in the hundreds.

Yet nobody tells them to stop coming because it is not an emergency.

That patient with the stubbed toe who calls 911 is probably keeping your system economically alive. They will be billed as emergency ALS response. The amount of resources used on them is utterly minimal. That maximizes payment/overhead.

If you think the patient doesn't define the emergency, I think you will have a lot of trouble convincing that to the rest of the healthcare fields.

US EMS has failed to advance itself in more than 30 years. If it can't get its head out of its *** and finally take the next steps, it will get left behind. Not because I think so. It is a demonstrated pattern in all antiquated industries.

Perhaps you are a lost cause for advancing EMS? But perhaps somebody reading this will be reached.

 

[Veneficus]

However, I have told a mom that calling 911 because her daughter started bleeding (Bleeding as in less blood than losing a tooth) in the mouth after brushing her teeth real hard before going to the dentist is probably not the best use of emergency personnel.

Just out of curiosity, how do you know it wasn't an early sign of Scurvy?

 

[Shishkabob]

Just out of curiosity, how do you know it wasn't an early sign of Scurvy?

Is scurvy caused by a sharp edge of a tooth-brush with a cut to the roof of the mouth?

 

[Veneficus]

Is scurvy caused by a sharp edge of a tooth-brush with a cut to the roof of the mouth?

No, but it is caused by life threatening vitamin C deficency which manifests in weak collagen fibres which are more easily cut by a toothbrush sharp end or otherwise.

 

[Aidey]

...

Yet nobody tells them to stop coming because it is not an emergency.
...

No, they turf them over to the fast track/urgent care part of the ED, so that the ER MDs time is used for people who have more acute problems.

 

[Veneficus]

No, they turf them over to the fast track/urgent care part of the ED, so that the ER MDs time is used for people who have more acute problems.

When there are fast track and urgent care in house. Which is not as common as it should be, usually due to older construction and the limit of space.

 

[usalsfyre]

Just out of curiosity, how do you know it wasn't an early sign of Scurvy?

Honestly, outside of determining diet/social history/"hey do you have any weird spots on your skin", do you really think the ED is going to evaluate for scurvy?

 

[Shishkabob]

No, but it is caused by life threatening vitamin C deficency which manifests in weak collagen fibres which are more easily cut by a toothbrush sharp end or otherwise.

And how, on the off chance that it was scurvy, is it a true emergency that a Paramedic should have dealt with, let alone taking to the ED, when the patient was going to the dentist, with much more education on the matter than the average ED MD, in mere minutes?

And how would a nurse on an ambulance been any better in said situation than a Paramedic? Do nurses have the ability to test for scurvy in the field any more than a Paramedic?

 

[Aidey]

The correlation is still relevant. They determine that the person does not need the services of the full ED, and they send them to an appropriate level of care. When we determine that someone does not need the full services of an ED we are still generally required to transport them.

Take the example of the pregnancy test and Plan B. Because I am not allowed to refuse transport or dissuade people from transport via ambulance I can't advise this person that they would better served by one of the 6+ or so urgent care centers in the area, and that pharmacies without a moral hang up will give Plan B to women 18 and older without a prescription.

Edit: Just to add, in this situation I would theoretically have maps showing the locations of the urgent care centers, pharmacies (specifically 24 hour ones), along with the appropriate contact information. I would be able to write out the instructions on a triplicate form that the patient would sign, providing both of us with a copy showing exactly what the instructions were, and that the pt willingly accepted them in lieu of transport.

 

[Veneficus]

Honestly, outside of determining diet/social history/"hey do you have any weird spots on your skin", do you really think the ED is going to evaluate for scurvy?

honestly I am pretty sure that Linuss's assessment was quite accurate, but I just wanted to make a point that there exists possibilities outside the obvious if you don't know what you are looking for.

No, I do not think the ED is going to evaluate for malnutrition, which is something more frequently done by Peds or family practice.

But there in lies one of the main tenants of the argument, the kid is better served by a dentist than by an emergency department. Unless of course an EMS provider was going to instruct them on how to brush their teeth and deal with oral wounds rather then giving them the riot act on what constitutes a worthy emergency.

 

[usalsfyre]

But this isn't really an EMS failure, it's a US healthcare in general failing.

 

[Veneficus]

But this isn't really an EMS failure, it's a US healthcare in general failing.

Yes, and EMS is part of the healthcare system. As such, I thin it has a duty to help meet thehealthcare needs of the public, not define its own role.

Moreover, since the US healthcare system is failing, wouldn't it feel better to be a valuable part of the solution rather than the weak link?

 

[usalsfyre]

Yes, and EMS is part of the healthcare system. As such, I thin it has a duty to help meet thehealthcare needs of the public, not define its own role.

Moreover, since the US healthcare system is failing, wouldn't it feel better to be a valuable part of the solution rather than the weak link?

^^^^^

When you put it that way, it's a darn good point. Unfortunately, we're currently a slave to the reimbursement model, and community health doesn't make money for the FD, county, private company managers, base hospital, ect....

 

[SerumK]

There's the patients inability to deal with the situation, and then there's a true emergent/urgent complaint.

Who said anything about attitude? But there is definitely a difference between an honest to God emergency, an urgent complaint that still needs treatment and transport or referral and those who just don't need medical services. Which is not something the patient defines.

More education is needed, but arguing that the patient is the only one able to define an emergency is dumb.

Why is it when anyone mentions that the majority of patients we treat and transport are not true medical emergencies (many times however they do fit in the urgent category) they get accused of being an uncaring bigoted ogre who lets their patients die?

I said the patient defines the emergency (thus they call 911) and we define the urgency (evaluate the situation and deal appropriately ALL things considered).

 

[Shishkabob]

Since I got...umm... flak, from a certain person in a way I cannot discuss, for my previous post, I shall reword it and make it "compelling":

"This thread is............... *dramatic pause*................... silly


We all agree that education lacks, yet disagree on whether that should be fixed or scrap Paramedicine altogether and just give it to nurses. Obviously, other of your "better" EMS countries separate EMS from Nursing, so why must we combine them?

Why was nursing given so long to change, yet EMS is expected to practically overnight?

Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?




Silly, silly, silly."

 

[Chimpie]

<snip>

Why was nursing given so long to change, yet EMS is expected to practically overnight?

Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?"

There are over 270 posts in this thread so I may have missed it, but who said EMS is expected to change overnight?

I completely agree that EMS has progressed, but just because it's progressed doesn't mean that we can stop now.

The Japanese use the word Kaizen which means "continuous improvement". Yes, we've made improvements. Now we have to look at where we are and we're going and create a plan.

 

[SerumK]

I have no idea why my image illustrating my point of pt emergency vs provider urgency was removed... it seemed to illustrate my point as well as be worth of its own thread for those people who have stopped bothering with this thread. If you want to see the image, click here:

http://www.emtlife.com/showthread.php?t=21204

Do it! It is hilarious!

 

[Chimpie]

Hey Veneficus, let me ask this cause after monitoring this thread since the beginning, I'm starting to lose focus (personally).

Is the reason to introduce the RN scope of practice in emergency medical response to provide better care prior to transport or to reduce the number of transports to help reduce ED traffic?

I am surprised someone from Florida would as this.

My apologies for not being clearer. I wanted to know what Veneficus's view was for creating this thread.

Florida has for decades be a leading in Community and Public health programs which include RNs. They also play a significant role in disaster preparedness and management since there is no way EMS could ever cover all the bases for the many health care and shelter needs in the community which includes medical patients and the homeless. If these RNs did not go out into the community at senior citizen centers and homeless shelters, which includes under the bridges, to identify and get these people the necessary care, there is no way even the best EMS systems in the area could handle all the calls.

Community and Public Health RNs, Social Workers and Case Managers (also could be RNs) have played a role in preventitive community medicine for investigating situations and providing them with the needed services which may involve calling the physicians associated with their agency for advise. There is absolutely nothing wrong with calling "med control". A few hours of training or even 2 or 4 years do not make anyone a doctor. This thing where Paramedics in the U.S. feel like it is bad to call a doctor just shows how little some might know about the many illnesses there are and may not realize their limitations. These Community and Public Health RNs are involved in so many projects around the country which also includes child and elder abuse as well as identifying and caring for medical problems of the homeless under the bridge. Many times they are called to investigate a person whose neighbor has seen EMS at the home many times but each time a "refusal form" is signed and EMS has cleared because the patient was okay since they know their name and place or didn't have any obvious trauma or illness. Unfortunately just knowing your name and where you are does not mean you can't be in need of some medical care or a different living situation. But, for many in EMS, "not my job to be a social worker, I just do the emergencies" is often the response. Is this just the lack of training or is it just "not my job" that prevents them from expanding their sight into preventitive care?

In San Francisco there is a Paramedic, Niels Tangherlini, who started an outreach program for frequent 911 users including the poor, homeless, mentally ill, elderly, disabled, and alcoholics and drug abusers. Prior to starting this program he got a degree from UC Berkeley in Social Welfare and formed an alliance with the Department of Public Health. He also enlisted the assistance of RNs and RRT as well as many others involved in the health care systems to cover the medical needs he did not have expertise in. I would say Mr. Tangherlini had the foresight to know the limits of his Paramedic training and the limitations of the EMS system to see the bigger picture to provide the needed services.

Very good points all the way around.

 

[Veneficus]

We all agree that education lacks, yet disagree on whether that should be fixed or scrap Paramedicine altogether and just give it to nurses.

I would hope that bringing such discussion to light would serve to help EMS step up rather than languishing in its complacency.

Obviously, other of your "better" EMS countries separate EMS from Nursing, so why must we combine them?

Because their providers did step up. US providers are not. If a trade cannot maintain relevance it gets eliminated. Natural order of economics.

Why was nursing given so long to change, yet EMS is expected to practically overnight?

Nursing wasn't given so long, it changed of its own accord. It saw what the future demanded and worked towards it. In fairness, they didn't have other nations who already figured it out to emulate. So EMS really isn't being asked to be the groundbreaking model that nobody ever saw before, it simply needs to copy what others have figured out.

Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?

The progress? I taught EMS for 7 years, I resigned this september because it is actually going backwards. That means there is no progress there is regress.

I understand very well what is being introduced. Even more well how it will be improperly implemented.

Perhaps in skills and toys you think there is progress, but I would be sort of concerned when technology makes my job so easy anyone could do it.

I have reviewed EMS texts and I can tell you that the quality is going down, not up. That the trend is being demanded by the publishers not the authors. So why would a publisher demand that? Because it wants to sell books. So it plays to its audiance, like any successful business. Those in EMS who want to see it advanced are a small minority. The voices of those holding it back are much louder. I think that they do it for mental security, not out of malice. But like I have said, sticking your (not you particularly) head in the sand telling yourself you are doing all right when every similar industry in modern nations in the world has surpassed you by condiderable margins is not really a good thing.

Is it too late? I don't think so, I think that with the recent political look at eliminating ALS in the urban environment with short transport times. The economic issues facing healthcare which no party wants to be cut from, but EMS is isolating itself and not doing what is required to assure it is not the loser in the endgame. That the time may be at hand.

As I keep pointing out, the very worst thing it is doing is defining what it wants itself to be, with more ferver than ever, rather than being what is needed.

The door is starting to close on EMS so while it is not too late, considering the speed at which it moves, it had better get it together because the voices against it are only going to grow.

Silly, silly, silly."

If I were banking on making a career in EMS, I wouldn't think silly, so much as I would think "scary."

If you feel the discussion is not worth the time, why be part of it?

 

[JPINFV]

Why are we dismissing the progress that IS being made in EMS education as inconsequential and too-little-too-late?

The problem is that change has to occur, be it over night or the long run. The problem is that if EMS changing, it's changing in the wrong direction.

As far as how fast the change can occur, again, look at other professions. It was only about 100 years ago that medicine (physicians, not nurses) began to install national standards. Medicine is a lot older than EMS, but they were somehow able to pull off closing bad schools and requiring increased educational standards relatively quickly, even overnight compared to how EMS handles change. Why is it that one of the original professions can change on a dime, but a trade trying to become a profession seems to have it's wheels spinning in the mud?