saving lives?

[SanDiegoEmt7]

No.

At one point, the OP is talking about telling patients the hospital to get out of the hospital and go live what little lives they have left. I'm all for that, but that's not EMS. Once they get admitted—once an EMS provider gets the patient to the hospital—we have no business telling them it's now time to leave where we just brought them.

EMTs and Paramedics aren't doctors. It's not up to us to decide if the patient is best-served by being left at home or getting taken to the hospital. Our job is to get them to the hospital where someone else can figure that out.

He's not saying that he's not going to treat patients and tell them to leave. He's was noticing to himself that he wishes they would tell people these things, because its hard to watch medicine do absolutely nothing for people except consume the last bit of time they have left. This can be food for thought in EMS just as it is to hospital providers

If the patient doesn't want to go, they should refuse to go. If they're not capable of competently refusing, then...well...that's a problem, sure. That's a specific problem that does affect and involve EMS, and that's one I'm all for trying to figure out how to fix, sure.

Again, your taking everything at face value. This thread was brought forth because it was the internal thoughts of a Medical Student who had a week of dead and dying patients. I bet there are many paramedics who felt the same way, as shown by the responses above. Do you really think I'm taking about AMAing patients and telling them to go skydiving?

Again, it's not for an EMS provider to say what's the point of that. Well, we're perfectly able to say what we personally think about it. What I mean is it's not our decision to make. We're not doctors. We can't decide on the spot that there's no point trying to save this patient, I mean we certainly can't act on any such decision (and believe me, I agree with you, I'd be thinking the exact same thing myself if I was in that position).

He's not tell you to make a decision. Do you think he's telling you to not treat you patients? He's offering up an antithesis to the common perception of modern medicine (which is very reminiscent of the book House of God)

Now who if failing to comprehend what someone wrote?

Using the fact that most people are not compelled to attend patients' funerals as evidence of our limited involvement and thought regarding patients is a moot point in my book.

I have no idea what an ED doc says to an ICU doc when care is transferred. I'm sure some, maybe many, do a follow-up check on their former patients later on. I know I've seen that happen in some of the hospital reality shows on the Discovery Health channel.

It's an analogy my friend. I'm not asking you to produce a fictitious dialogue, or to recall what happened on Trauma: Life in the ER. All I am saying is that, we are part of the continuum of care. Having discussions on the topics brought up by Veneficus doesn't me we don't do our job. It just means, do your job but don't be ignorant about the prognosis of patients and modern medicine's ability to change that. As a patient's often point of entry, EMS is part of healthcare in my book and as such the views of the "in the hospital" (as you put it) are important to me, regardless if I'm obligate to strictly follow my protocols.

And I'll admit I'm often curious to know what happens to patients after they leave my care. Sure I wonder. But am I ever going to go find out what hospital room a patient has been admitted to so that I can go tell them they should get out of the hospital and enjoy what's left of their life? No. That's not for me to do, and it's not for me to decide. I don't know what's really going on with the patient, and even if I read the patient's entire chart I still wouldn't really know because I don't have years of medical school, internship, residency, etc. to interpret that chart and make that kind of decision.

Again, you looking at everything in a two dimensional way. Am I talking about convincing patients to leave hospitals? NO. Is that what Veneficus is explicitly saying? NO. ITS FOOD FOR THOUGHT

So if you want to do something about protocols and cookie-cutter EMS, be my guest. Let me know if there's anything I can do to help. But again, once we transfer care, leave the doctoring to the doctors is how I feel.

It has nothing to do with being cookie cutter. EMS is required to be strictly protocol based because of the minimal training that we have received (thats entirely another thread).


JJ, look, I'm not here to debate you protocols. I'm not here to tell you to convince you patients to abandon hope with modern medicine. I simply couldn't believe that you missed the point of Vene's post. I'm not going to go back and forth on this, you'll get the last word in your next post. Just try to have an open mind to what he saying. A great many problems with prehospital care, arise from the fact that paramedics and EMTs can't see past their protocol book and see the big (and perhaps depressing) picture.

 

[Aidey]

Ok so i'm on my phone, sorry for any typos. I also have a nice long reply to the OP on my computer at home, but I had to jump in now.

If what Vene is talking about isnt EMS, than apparently I don't work in EMS anymore. In whatever field I work in (lets call it EM for emergency medicine for :censored::censored::censored::censored:s and giggles) Vene's post is absolutely relevant.

He is advocating caring for people, you are advocating being a taxi driver. In my jobin EM I run into end of life issues all the time. What the pts baseline is vs what their prognosis is vs how sick they are now vs what kind of care they need to continue at an acceptable level vs what kind of care they want vs the pt or family wanting a natrual death.

If someone has a problem but doesn't want transport it is my job to see if I can solve that problem or not and respect the patients wishes. It is not my job to just chuck them in the amb and let the doctor sort it out. Frankly as a medical provider in EM I'm insulted by your posts, and the insinuation I don't know enough to care for my patients without transporting them.

We are the first line of defense to keep these people from being unnecessarily hospitalized. If we can help solve the problem right there we can save the patient and their family the trauma of that patient having to be transported. If a patient and/or their family don't want transport I will do everything within my power to assist them. Be it something simple like showing them how to use the pts nebulizer, to calling anyone I think can help.

My job is NOT to transport people, my job is to provide medical care and take care of people. My job may or may not include transporting someone as part of that care. If you don't think that is appropriate, you can get out of my profession.

 

[SanDiegoEmt7]

Thank you for putting into words more clearly then I was able to. That is exactly what I'm getting at. It's late and I'm not all there.

 

[Aidey]

No problem. I've had this discussion before unfortunately, so my speech is well rehearsed. This transport and turf attitude infuriates me.

 

[JJR512]

He's not saying that he's not going to treat patients and tell them to leave. He's was noticing to himself that he wishes they would tell people these things, because its hard to watch medicine do absolutely nothing for people except consume the last bit of time they have left. This can be food for thought in EMS just as it is to hospital providers

I understand that he wishes "they" would tell people these things. Keep in mind, though, that my entire response was in direct response solely to what I quoted from the OP, which was his question, "How does this relate to EMS?"

If the OP had left that one single line out, my reply (if I bothered to post one at all) would have simply consisted of, "You've said some things that I agree with, and given me some other things to think about." That's it.

I'm not saying that the OP is wrong, that I disagree with him, or anything like that at all. As I think I did actually manage to do at least once in my original reply, and as I indicated in the previous paragraph, I do actually agree with much of what he's saying. It's just that he asked how it relates to EMS, so that's what I answered. You were supposed to be able to tell that I was answering that question by the way I quoted it, and only that, at the start of my first reply.

Again, your taking everything at face value. This thread was brought forth because it was the internal thoughts of a Medical Student who had a week of dead and dying patients.

First of all, taking what's written at face value is what I excel at. I am utterly useless at looking at one set of words and figuring out how the writer meant some completely different set of words. It's a skill that is beyond me. I'm sorry if that upsets you, I'm sorry if that compels anyone to call me stupid or lacking in common sense. Whatever.

(By the same token, I expect and demand that everything I write be taken at face value. I rarely make implications, and when I try, I usually fail. Do not ever "read between the lines" of what I write, because all that's there is blank space.)

As for the OP being a medical student, I didn't know that. I guess that explains why much of the original post seemed to be written from the point of view of someone who has been spending a lot of time inside a hospital!

Using the fact that most people are not compelled to attend patients' funerals as evidence of our limited involvement and thought regarding patients is a moot point in my book.

Just as you continue to tell me how I'm missing the point, once again I have to say the same thing right back at you. In fact, I thought I had made it pretty clear that I wasn't "using the fact that most people are not compelled to attend patients' funerals" as evidence for anything. Once again, let me spell it out: I mentioned that thread only to provide a source citation for a quotation. The quotation itself was quite easy to adapt to my point in reply to the OP's question of what does what he was talking about have to do with EMS.

Having discussions on the topics brought up by Veneficus doesn't me we don't do our job. It just means, do your job but don't be ignorant about the prognosis of patients and modern medicine's ability to change that. As a patient's often point of entry, EMS is part of healthcare in my book and as such the views of the "in the hospital" (as you put it) are important to me, regardless if I'm obligate to strictly follow my protocols.

Again, what I was discussing was solely related to the one thing he said that I quoted. I did not say that anything he said was wrong; I think I agreed with at least one thing he said, although at this point I'm no longer sure if that was in my first reply or second, and I'm not going to bother to scroll up and find out. I do know that I expressed some kind of agreement with something he said somewhere. And I'll say again that I am in general agreement with much of what was said, and there's plenty of stuff to think about. All I was addressing was the one thing I quoted, though.

It has nothing to do with being cookie cutter. EMS is required to be strictly protocol based because of the minimal training that we have received (thats entirely another thread).

It has already been the subject of many threads.

But it did seem to me that strictly following some set of guidelines that tell you what to do is one of the key issues at the heart of what the OP was talking about. Like he wondered, why was CPR started on the one guy? Because that's what they do, the doc said. When the situation is X, do Y. It seemed to me that's something Veneficus was complaining about.

It's even like what you yourself was saying about the patient who had been in a coma for 40 years. Why transport that pt. to the hospital for arrest? Because that's what you do. Arrest = transport. Call the doc in the box, describe it to them, do they even need to think about it? Arrest = transport. Bring 'em on in. That's what the protocols say to do, right? That's one aspect that you and Veneficus are complaining about, right? The rigid structure of modern medicine? And let's be more accurate with that, too, by adding the word Western in there somewhere.

And please note that I am, in general, agreeing with you.

JJ, look, I'm not here to debate you protocols. I'm not here to tell you to convince you patients to abandon hope with modern medicine. I simply couldn't believe that you missed the point of Vene's post.

Again, it's not me that missed the point, it's you. The point of my reply was to directly answer only that which I quoted. See earlier in this post if you need further explanation.

Just try to have an open mind to what he saying. A great many problems with prehospital care, arise from the fact that paramedics and EMTs can't see past their protocol book and see the big (and perhaps depressing) picture.

My mind is open. I've already stated general agreement with much of what was said; how much more open do you need me to be?

 

[SanDiegoEmt7]

Veneficus, I got side-tracked

Your post brings up valid points that I think any healthcare provider feels at some point or another,or maybe the during the entirety , of their career. I've read somewhere, where is escaping me at the moment, that people who have worked in EMS prior to attending medical school typically have issues of burning out sooner than others during the clinical and residency years since they have already lost that naive ambition to cure the world.

 

[JJR512]

He is advocating caring for people, you are advocating being a taxi driver.

I'm not sure who this is addressed to. I'm assuming it's not me because you're usually not absolutely wrong, which is what you'd be if you are addressing me.

I never said we should just drive people to the hospital.

What I was discussing can be boiled down to a concept expressed simply as, "After we have transferred care and left the facility, then our involvement with the care of the patient, whatever it has been up to that point in time, is concluded."

The way I interpret the "taxi driver" concept is, "Find the patient, toss them in the back and drive them to the hospital without providing any care at all whatsoever. The end."

The first concept is what I said. The second concept is what you for some reason seem to think I said. Do me a favor: Next time you want to tell me what you think I said, put the phone down first. I'm pretty sure you're really not so stupid as to think that these two concepts are the same thing. These two different concepts don't even involve the same frames of time.

If someone has a problem but doesn't want transport it is my job to see if I can solve that problem or not and respect the patients wishes. It is not my job to just chuck them in the amb and let the doctor sort it out. Frankly as a medical provider in EM I'm insulted by your posts, and the insinuation I don't know enough to care for my patients without transporting them.

And I'm insulted by yours. Maybe you really are that stupid after all. Again, I never said EMS is a "you call, we haul" job. Absolutely we provide care. But that care ends at some point in time. Please understand that my post was directed at someone who was discussing things happening inside a hospital, and his question of what does that have to do with EMS. So most of my post was couched from the point of view of a patient who is going to the hospital. Now, of course not all patients go to the hospital. Regardless of if we transport or not, we do provide care for them, if they need some kind of care provided that we are capable of providing. Absolutely and of course! I'm not saying otherwise. Never have and never will. All I'm saying is that for a patient that we do transport, once care is transferred, that's pretty much the end of our involvement, at least in terms of making decisions about their care.

My job is NOT to transport people, my job is to provide medical care and take care of people. My job may or may not include transporting someone as part of that care. If you don't think that is appropriate, you can get out of my profession.

Why don't you pull your halo out of your *** long enough to consider what it was I was actually replying to (hint: it was in a quote box at the top of my original reply), and the context in which the reply was given (hint: I mentioned that earlier in this reply), then see if I've ever actually written (by "written", I mean actually directly expressed with words that you can see on the screen, as opposed to words that you mistakenly think you can interpret or find "between the lines" and even then only by ignoring the context) anything that justifies your final statement. (One final hint: I agree with your description of our jobs as EMS providers.)

 

[JJR512]

Veneficus, I got side-tracked

Yep, that can happen when you don't pay attention to what it is exactly that a reply is actually in reply to.

So getting back on track...

Your post brings up valid points that I think any healthcare provider feels at some point or another,or maybe the during the entirety , of their career. I've read somewhere, where is escaping me at the moment, that people who have worked in EMS prior to attending medical school typically have issues of burning out sooner than others during the clinical and residency years since they have already lost that naive ambition to cure the world.

Regarding the first part, I know (and in fact have already said in this very thread) that I've certainly felt that way at times. I have often wondered what is the point.

I've done a lot of inter-facility transports, and consequently transported a lot of people that seem to be no longer really in this world. I mean, mentally, they seem gone. Nobody's home, know what I mean? But then I wonder: How do I know for sure? How does anyone know for sure, even doctors? Sure, they can measure certain things, do an EEG, but really, I don't think consciousness is very well understood.

This actually once got me wondering whether it would be better to retain normal mental faculties but lose all control over one's body, or for all body functions to remain essentially normal but for the mind to go. Personally, I think it would be horrible to be an intelligent mind trapped in a useless body. And I mean useless, utterly being incapable of expressing yourself or letting anyone know that yes, you really are "still home".

 

[Aidey]

EMTs and Paramedics aren't doctors. It's not up to us to decide if the patient is best-served by being left at home or getting taken to the hospital. Our job is to get them to the hospital where someone else can figure that out.

You do remember what you wrote don't you? Or did you mean something else by this, that we were supposed to pick up by reading between the lines?

I might not be a doctor, but that is exactly what my job is. My job is not to get them to the hospital where someone else can figure out whether or not they needed to be there in the first place.

 

[jrm818]

I don't think there's any question that this applies to EMS. It's an issue of our focus. Should our primary goal be preserving life?(as it generally is now, from what I've seen). Or should it be alleviating suffering, and trying to improve quality of life (or mitigate loss of quality of life).

"High performing" EMS systems are those that have the highest cardiac arrest save rate.

Stroke is important to recognize because it is a huge cause of death (not because of the huge toll on quality of life for survivors).

Pain control...eh...who really cares. Nice, but they can wait, suffering for 20 minutes isn't that bad, they aren't going to die.

Avoiding the hospital altogether? Not our job (Even though I think we all know that granny smith who fell down is speaking some amount of truth when she says "I'm not going to the hospital...that's where people go to die.")



I also wonder how much the push to really focus on using evidence based medicine has to do with the obsession with preserving life. I don't know nearly enough about the history of medicine to be able to evaluate if this is really a "new" push, it does occur to me though that the sort-of default primary endpoint in a lot of research (especially in EMS) is mortality.

The choice of death as a research end point may be a reflection of a social obsession with avoiding death, may be due to the relative difficulty of evaluating quality of life improvements (its much easier (practically and mathematically) to evaluate the binary dead/not dead than it is to evaluate relative levels of depression, debilitation, pain, etc.) or may not even be as prevalent as I think. But, if the research that informs our practice is so focused on death, is it surprising that the practitioners are similarly focused?

 

[JJR512]

You do remember what you wrote don't you? Or did you mean something else by this, that we were supposed to pick up by reading between the lines?

You do remember what that was a reply to, don't you? That's all you need to remember, no searching between the lines necessary.

I might not be a doctor, but that is exactly what my job is. My job is not to get them to the hospital where someone else can figure out whether or not they needed to be there in the first place.

In specific regard to someone who is in cardiac arrest, someone who has needed CPR, they need to get transported. Regardless of whatever you can do for them in the field, they also need to get transported. At least that's true where I come from, maybe your EMS system and protocols allow you to leave someone who was arresting in the field after you recover them, I don't know.

Context. Look it up. I'll be happy to quote what the OED has to say about it, if you'd like. Or you can get smart and get this thread back on track just like SanDiegoEmt7 and I did.

 

[firetender]

Clear the patient...ZAP!!! (360 Joules)

How does this relate to EMS?

It relates to all healthcare everywhere. Whether you are deciding to terminate efforts, not start efforts, or run the dialysis derby on patients being hacked away a limb at a time.

How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?

This was the starting point; have we lost our way? What is really the WAY?

I appreciate some who define where their roles start and where they end, but what I think Vene is seeking is "Are you conscious of more than your next call? Are you aware of the overall system of which you are a part? And maybe we ought to look more closely at the human beings involved and their Quality of Life."

ALL of us are involved!

Hopefully, after this defibrillation the heart of this important conversation will beat again! It has not hit "Dead Horse" status yet, though some people seem to be working on hobbling it.

Wait...there's something coming up on the screen...

 

[SanDiegoEmt7]

You do remember what that was a reply to, don't you? That's all you need to remember, no searching between the lines necessary.



In specific regard to someone who is in cardiac arrest, someone who has needed CPR, they need to get transported. Regardless of whatever you can do for them in the field, they also need to get transported. At least that's true where I come from, maybe your EMS system and protocols allow you to leave someone who was arresting in the field after you recover them, I don't know.

Context. Look it up. I'll be happy to quote what the OED has to say about it, if you'd like. Or you can get smart and get this thread back on track just like SanDiegoEmt7 and I did.

I apologize in advance firetender, particularly since your post reflects my own thoughts.

Just a point I'll make, then I'm leaving this thread forever. NOT EVERY PATIENT WHO IS IN CARDIAC ARREST GETS TRANSPORTED. Many patients are called on scene after being worked for a certain amount of cycles, since most EDs can't do much more in the regards of ACLS than paramedics. Sometimes a transport is done out of consideration for the family on scene, its very traumatic for them to watch the decision made in their living room.

Perhaps your stance on the ORIGINAL ISSUE (read Firetender's post, don't attack me on ACLS) is due to you being an EMTB where you don't have the opportunity to make a great deal of decisions regarding patient care, because I think that's when the majority of people start to wonder why they make they decisions, albeit most likely the proper decisions set forth by protocol, that they do.

SDEMT out

and please don't tell me I'm smart for avoiding a debate with you, thanks

 

[JJR512]

I apologize in advance firetender, particularly since your post reflects my own thoughts.

Just a point I'll make, then I'm leaving this thread forever. NOT EVERY PATIENT WHO IS IN CARDIAC ARREST GETS TRANSPORTED.

and please don't tell me I'm smart for avoiding a debate with you, thanks

This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of leaving a resuscitated patient wherever they were found arresting seemed shocking.

Regarding your last comment, I don't recall telling you any such thing. However, the tone of your comment doesn't seem to be like you're trying to avoid a debate, so after that, I wouldn't make such a comment anyway; no need to ask me not to now.

 

[Veneficus]

This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of leaving a resuscitated patient wherever they were found arresting seemed shocking.

Regarding your last comment, I don't recall telling you any such thing. However, the tone of your comment doesn't seem to be like you're trying to avoid a debate, so after that, I wouldn't make such a comment anyway; no need to ask me not to now.

If I could just point out to add to the discussion I am enjoying passively watching.

As far back as 2002 in my EMS employment, paramedics were deciding when to inititiate resuscitation or to discontinue it without online medical direction.

In 2003 I was employed by an agency where a paramedic could refuse to transport a patient who fit the criteria of not needing emergent transport to an ED.

It is always important to consider the full spectrum of what is happening in EMS. That includes everything from the cutting edge to the bleeding edge, as well as what is happening in other nations.

The role of EMS is not restricted nor defined by any single locale.

 

[JJR512]

The role of EMS is not restricted nor defined by any single locale.

Indeed it is not. Hence my original qualifier of, "At least that's true where I come from, maybe your EMS system and protocols allow you to blah blah blah."

And I agree with paying attention to what other localities are doing, as long as a provider is careful to not let that get in the way of them dong what they're supposed to be doing according to their own local protocols and scope of practice. Now if something that somewhere else is doing seems more intelligent and makes more sense than what you do locally, by all means, point that out to your local EMS management. Try to get your protocols and scope changed. Obviously, one would need a bit more conclusive proof that the other place's ways are superior besides that it's just what some dude on some internet forum said.

I am not yet at a point in my education and experience where I can intelligently evaluate studies and reports and analyze how other methods/practices/policies/whatever are better than my own. But I do keep an eye on EMS news when I get a chance, and I read a lot of things that sound very interesting in terms of research and advancing EMS.

 

[Veneficus]

This was the starting point; have we lost our way? What is really the WAY? ...

I thought the way was to help people. At the very least "do no harm."

The treatments for neoplastic blood disorders are the most perfectly designed witches brew of poison known to man. Designed by the doctors who spend their lives trying to improve and save peoples' lives to purposely destroy the cells a person needs to live.

It will cause harm. What I wonder is: when you know you are harming, physically, mentally, emotionally and economically, and in your collective experience and knowledge, the treatment is not shown to work or you know the patient is beyond that treatment, why do we go through the motions?

Is it better to live well for 2 years or suffer for 3 or 4? Where is the dividing line? What when the "treatment" you hope will work cuts it down to suffering for 8 months?

I guess my real issue is the industrialization. Once a person is placed in the machine, the wheels turn, often without consideration or response until the cycle is completed. A system where the only outcome is normal or death. There is no middle ground.

EMS is not immune nor removed from this practice. Even before I went back to school I could tell you a kid who went into cardiac arrest was not coming out unless a very narrow set of circumstances were met.

Costing a family tens of thousands of dollars they didn't have, delaying thier grieving process, spending resources other members of their family desperately needed, and absusing the corpses of their loved ones, didn't help them nor me.

Why do people advocate that?

I don't really think it is a question of burnout. I see it as questions that need to be reconciled.

I also think the whole idea of protocol driven medicine is a wrong turn. Helping most of your patients the most often is not medicine. Helping all of your patients to the best of your knowledge and ability is medicine. Protocols just don't even come close. Even in EMS we know the common ones often cause harm.

What justifies the quest of making things easier on ourselves when it doesn't serve those who came to us for help?

It is not a matter of not knowing something future generations will that we don't. Nothing can change that. The real matter is why continue to do what we know won't help?

 

[Aidey]

This is news to me. It's also news to some of the paramedics I just asked. Well, strictly speaking, you're right. If the patient is resuscitated and refuses transport, they don't get transported. If they die in a SNF or hospice, etc., they don't get transported. As I said, maybe it's different where you are. Around here, the concept of leaving a resuscitated patient wherever they were found arresting seemed shocking.

Who the heck said anything about a resuscitated patient? I said that my job involves figuring out whether or not a patient needs to go to the hospital. A patient who has been resuscitated generally falls into that category. In some cases they may not be transported, it really depends. In my agency if someone is GCS 15 they can refuse anything, no matter what is going on.

Here is a more realistic case, patient on Hospice, end stage cancer with mets everywhere, given days to live by Hospice, wants to die at home. When the patients mental status starts to decline the family panics and calls 911. Transport and let the doc sort it out, or try and sort it out at home?

 

[Aidey]

I agree that it is very sad that people end up spending a lot of their decent time left in a hospital. I think we got here several ways.

Somewhere along the way "Do no harm" became "Do not let die without doing everything medically possible". Doctors aren't allowed to talk about death, becuase death is the ultimate harm, and doctors are supposed to avoid that. With advances of science and the internet a lot of non-medical people feel that their loved one will become the next one who beats the odds. If they don't think everything that can be done was done they will continue to think that if that one thing had been done, the outcome would have been different.

It has been interesting reading information about the doctors working to make palliative care a specialty, like EM, or OB/GYN. They have a lot of evidence that people are treating themselves to death, making their last days miserable. People who are on their 5th or 6th round of chemo, and are receiving it up until the day they die. People diagnosed with things like stage 4 pancreatic cancer who want to do everything possible, when the remission rate is abysmal.

The doctors themselves admit that they receive little to no education in traditional medical school about end of life issues, and how to have those discussions with patients. I remember one said that they found it easier to just give the family what they wanted, even though the outcome was going to be death and nothing was going to change that.

Protocols offer protection. When in doubt it offers a safety net to fall back on. It is a written example of what should be done, so providers can say "well, I followed the protocol". Even if it doesn't stand up in a legal setting, it makes people feel better because they can blame someone other than themselves, "I followed the protocol, I don't know why it didn't work".

I think at its core this is a psychological problem,from EMS on up. The script is transport, treat, do everything possible. When we deviate from that it makes people uncomfortable because it makes us confront our own mortality.

 

[Smash]

It is very difficult to move past the technical imperative - that is we can do something therefore we must do something. This seems to be particularly true in EMS due to the nature of the training over education model that is prevalent.

EMS most certainly should be involved in end-of-life care and decision making, far beyond the usual routine of "Bed bound, nappy wearing, persistent vegetative state, cancer ridden 80 year old has arrested, therefore commence CPR". To me, that doesn't seem like doing no harm...

There are small glimmers of hope on the horizon for us making some rational decisions and having a positive impact on patients and families in end-of-life scenarios. Personally I do not start resus on every cardiac arrest patient I am called to. I certainly do not transport every cardiac arrest patient I am called to. I am legally allowed to verify death in certain circumstances, thereby removing the extra strain on the family of having to get more paperwork done by other agencies or getting coroners involved and all the unpleasantness that involves.

We are also becoming more involved in better care for palliative patients who wish to remain at home. We are forging stronger relationships with the doctors who oversee palliative care, and this is (slowly) resulting in more appropriate care. For example we can administer morphine to patients with breakthrough pain and leave them at home to be followed up by the palliative care services.

These are small steps, but important ones to make, and hopefully they will lead to great bounds in our care for these subsets of patients. End-of-life care is most definitely something we need to be involved more heavily in, as we are often on the "front lines" of caring for these patients and their families.

I undertand what you are saying Vene about the industrialisationof medicine. The phrase I have heard and like to descrive this phenomenon is McMedicalisation. Outcome becomes secondary to the process, and while we become more and more proficient at following a process, we become less and less proficient at actually managing a patient. This is certainly the case in EMS where we continue to accept atrociously low levels of education in our providors, so we attempt to manage risk by making every patient fit into a predetermined protocol and writing more and more protocol to try to cover ourselves for every eventuality. That way lies madness, yet we persist!

What can we do about it? I don't know. We are making our own small steps where I work, but it is hard to see how we can transform our entire industry to better cope with these sorts of issues. Maybe we need to stop wondering whether a King is better than a Combi-tube, and start focusing on some real education instead, education that has a bit more of the humanities thrown in rather than just the sciences.