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RiverpirateEMT

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Ok , Im in the final stages of medic class ( 8 weeks to go ). The more I do clinicals the less I feel like I want to do the job. Ive been a EMT-B for 3 years and love my job. I basicly good at it ( not bragging ). As I run as a medic though I find myself questioning more and more why we do certain things. Im a big beleiver in the body knows what it needs. I find that some ALS provider do things just to do them and it concerns me because of my confliction to this.
My thought are not all patients "need" IV's. Not all patients "need" potentialy dangerous drugs. If a patient is not altered in anyway and says they feel fine why should we perform invasive practices on them for the sake of doing them? Most of the time the body knows what it wants.
Im really hoping my attitude about this stuff changes as I run as a medic. Right now i feel like im just going through the motions to please my preceptors and not really enjoying what i do.

Does it get better guys?
 
I can tell you what you aren't good at... Grammar.


On a more serious note, many ALS providers do in fact engage in a cornucopia of unnecessary treatments/procedures.

The issue is and always will be education. Your 9 months of paramedic class is nowhere near sufficient to be a competent and knowledgable provider. Competancy comes from two main places.

Clinical time in the field.
Furthering your education.

Now clinical experience will come with time but furthering your education is ALWAYS available to you. It doesn't mean you have to sit in a classroom per-say. This website alone for a newer medic like myself has been invaluable to furthering my learning. Read articles/journals/forums etc you will learn a lot.

When you work with a PARTNER you have a say regardless of being new. If you aren't comfortable with something you speak up and voice your opinion.

A person who thinks they know what they are doing is much more dangerous than a person who doesn't and is willing to admit it.
 
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Don't worry bro I have bad grammar too when I type. I`m use to quick Texting and old AOL chat. Then on top of that i`m at work so I have to type quick haha.


Anyways.. NY Is right... Not every needs a IV but I like to give everyone one unless it is a BLS call. The more you do.. the more you are better at it. Now.. i`ve never giving drugs to someone who didn't need it. That is jail time bro and if you are or see someone doing it be aware. I can see giving an IV if it's an ALS call but if the PT does not need a drug why give it to them? If you need practice giving a drug use a dummy..:wacko:
 
Yea , my grammar is horrible, so's my spelling ,typing and all that fun edumacaton stuff , lol.

Oh absolutely when it comes to experience as a medic i have zero. Wouldnt dispute that with anyone, same with knowledge. My thoughts are just that, thoughts. Im talking patients that really are ok and presenting ok.

Just seems to me im loosing the .........pleasure of the job? Hard to describe it. What use to be fun (enjoyable fun, not happy go lucky fun ) seems to be slipping away. It's most likely due to lacking confidence on my part, but it just seems like I despise clinicals and actually look forward to going to regular work.
 
RiverPirate,

You raise a REALLY good point.

First - Have you read The House of God?
Law #13 - the last one: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.


There is some serious truth in what you posted. I see a LOT of medics (including myself, sometimes) that start IV's because, well, I'm a freakin' Paramedic, and I get to start freakin' IV's on every patient. Because that makes me feel like I'm doing something to help the patient.

I'm not sure what medications you are talking about, but while I aggressively treat patients that are experiencing discomfort or other symptoms, I don't give "unneeded" meds often.

If they are having an asthma attack, they are getting albutorol, and will likely get a dose of IV Steroids, because the research shows that early steroid administration reduces hospital admissions in that population.

If they are nauseous, I will offer them Zofran (at least until we run out again). Having "been there", bad nausea can be painful in it's own way.

I am also aggressive at offering narcotic pain relief when warranted. Again, I offer, and if the patient declines, so be it.

I'm not sure if those are in line with the unwarranted medication administration you were talking about, or if you're thinking about codes. Yeah - there's very little science to prove that pharmacological intervention improves survival in a cardiac arrest. But it is the current standard of care - so what else can we do.



I'm not sure if you read any EMS blogs or not... please humor me, and go look at Rogue Medic's site. Tim over there has an acute dislike for "doing it because we can".

So... did this help? Or am I going in the wrong direction?
 
^^ good points. I hated clinical for 1 reason. I wasn't learning. Yes the first few were great. But when you have 10-12 students its hard to get a chance to do anything and improve your skills. I had to go out of my way for the nurses so they would come get me first to do IV's, Blood draws, ETC.. Some students in P4 were not even passed 5-6 IV starts.. Are school required 60 ivs in the 20 clinical we had to do.

I just don't go around poking everyone with a needle but I think there going to get a IV in the ER. I will try to do it in the truck. I usually give my self 2 go's at it. But yeah I do not with hold MEDS if the pt needs it. Crazy line of work we are in
 
NYMedic828 said:
I can tell you what you aren't good at... Grammar.

Now clinical experience will come with time but furthering your education is ALWAYS available to you. It doesn't mean you have to sit in a classroom per-say.
Click to expand...


Per se

Per se, a Latin phrase meaning "in itself".
Click to expand...

Ouch!!!
 
Alright. Enough grammar police.
 
Deciding how much ALS is enough comes with experience. In my first 6 months on the truck, everyone got a line.

Now, not so much. I'll start a line if the PT needs meds, fluid or I see a need to build myself a safety net. That is, I don't need the line now, but I very well might before we get to the hospital.

For example, I no longer routinely start lines on narcotic ODs. I use IN Narcan and by the time I'm ready to transport, they're "fixed".

Not every patient with rapid Afib needs Dilt. You'll learn when to use those calcium channel blockers. Not every allergic reaction needs 50mg of Benadryl. You'll learn how much is enough as you build your own comfort level and style of practice.

It's important to realize the "standards of care" can vary greatly from medic to medic. If you always do what's best for the patient, you'll never be wrong and you can always justify your treatment and interventions.
 
Jon said:
RiverPirate,

You raise a REALLY good point.

First - Have you read The House of God?
Law #13 - the last one: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.


There is some serious truth in what you posted. I see a LOT of medics (including myself, sometimes) that start IV's because, well, I'm a freakin' Paramedic, and I get to start freakin' IV's on every patient. Because that makes me feel like I'm doing something to help the patient.

I'm not sure what medications you are talking about, but while I aggressively treat patients that are experiencing discomfort or other symptoms, I don't give "unneeded" meds often.

If they are having an asthma attack, they are getting albutorol, and will likely get a dose of IV Steroids, because the research shows that early steroid administration reduces hospital admissions in that population.

If they are nauseous, I will offer them Zofran (at least until we run out again). Having "been there", bad nausea can be painful in it's own way.

I am also aggressive at offering narcotic pain relief when warranted. Again, I offer, and if the patient declines, so be it.

I'm not sure if those are in line with the unwarranted medication administration you were talking about, or if you're thinking about codes. Yeah - there's very little science to prove that pharmacological intervention improves survival in a cardiac arrest. But it is the current standard of care - so what else can we do.



I'm not sure if you read any EMS blogs or not... please humor me, and go look at Rogue Medic's site. Tim over there has an acute dislike for "doing it because we can".

So... did this help? Or am I going in the wrong direction?
Click to expand...

As far as Iv's, Im decent on them im about a 80-85% average on getting them the first time. Im talking about puting Iv's in people that really dont need them. People that for all intents and purposes could probably be BLS if it wasnt for protocol. A 5 second syncopal patient that says im fine this sometimes happens to me ( standing to quick ). Sure its a momentary drop in BP but by the time you get to them they are perfectly fine and really dont even want to go to the hospital. Stuff like that.

As far as med's, m not talking codes , im thinking more along the lines of throwing 500cc of saline in a person that doesnt really need because "thats what you do" or jumping straight to cardizem when a person is in a new onset a-fib and perfusing well with no complaints. ( sure its a command call but why call when you know its not needed or going to be given )

Weve been doing this for 10 months and these preceptors get upset if you hesitate for a second to think what your going to do next. Some get down right irritated if you dont do your assessment exactly the way they do it. Hell , weve only been doing clinical for 5-6 months and truthfully i feel like I dont know crap when im out there on most calls. Sure afterwards I can tell you exactly what to do on the same call but man in the thick of it......
Realy do feel sometimes that im not learning , just trying to get by "doing".

I do follow Rogue medics facebook blogs off and on. Some great reading most of the time.
Let me put this out there also. Im not a kid , im 40 years old and pretty laid back. It takes alot for me to get excited , but some of these medic precptors that are 10-15 years younger than me dont seem to stop and think about their patients as a person. Again most medic I know are not like this , just the few stand out to me.


ps , no making fun of my grammar above, lol
 
This is a symptom of "all-ALS" EMS systems. The overwhelming majority of patients do not need a paramedic. But, when you put a medic on every ambulance, in my experience, they tend to over-treat because they can (and I don't think it is a conscious decisions, necessarily). "Oh they're gonna get an IV anyway, might as do it to save the nurses the trouble." I'm waiting for medicare and medicaid to catch on to this and start denying payment for ALS when the patient was BLS to begin with.

I was looking over an annual report for a relatively large urban and suburban EMS system and it included a statistic of the number of patients receiving a medication - 14%. And there's a medic on every truck, why? It's silly.
 
RiverpirateEMT said:
My thought are not all patients "need" IV's. Not all patients "need" potentialy dangerous drugs. If a patient is not altered in anyway and says they feel fine why should we perform invasive practices on them for the sake of doing them?
Click to expand...

While I'll agree that just because we can do something doesn't mean we should, and some people can hold off until arrival at the hospital... the question then needs to be asked "Why are you calling 911 if you feel fine?" or "Why are you calling for my help if you refuse my help?"


If all I do for you from your home to the hospital is a staring contest (that I WILL win), then you called the wrong number.
 
What if a surgeon did procedures because they could?

An oncologist?

One of the things that seems to be intrinsic in medicine is that newer providers are better educated than experienced providers.

It actually provides a mutual benefit to academic institutions, one of the reasons academic institutions are superior to community hospitals is because of the interaction of students with more up to date academic knowledge interacting with experienced physicians who see the value in being constantly exposed to such students.

Unfortunately, EMS as a whole, puts more value on experience and chronological seniority than on knowledge.

As such, providers are measured purely on things like psychomotor skills to determine compentence.

There was a book published some years back which shows that surgeons spend 1/5th of their workday operating. That is 20%! What percentage of your EMS class, basic and medic is spent on skills?

In both the institutions I have taught EMS at it was 1/3. 33% just in primary education!

How many patients(in percent) do you perform this skill set on in a given workday? You point out providers that do this on every patient!

Who justify it by "what if..."

So what if...

The hospital is concerned with having to pay for a complications of IV therapy without reimbursment so they DC your IV and stick the patient again to ensure proper procedure is followed and can show complications came from your agency so they can be reimbursed?

What if...

You used the only good vein.

The hospital DCs your IV to triage the pt to waiting?

What if...

Cardioverting the afib pt. throws a clot and they have a stroke?

Because you could.

I submit most of the "skill monkey" medics don't see or concern themsleves with the ultimate patient outcomes.

They are saving lives!

Not only do I undertand the mentality, I did it, and was awarded for it.

Pt. intubated and every drug in the ACLS algoryhtm(which at the time was multiple antiarrhythmics) administered all in under 15 minutes, BLS secondary of secondary concern.

Some of those :censored::censored::censored::censored::censored::censored::censored:s lived in spite of it!

Standard of care and all...
 
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River,

I imagine once you finish internship and work on your own, you'll have more freedom to do your own critical thinking. Unfortunately, your preceptors aren't on the same page. It is very common to have a philosophy mismatch with them. If they just want to see that you know the written algorithms, then just give them that. Then be done with it.

Also, for some things consider there's a reason for doing things we might not know about. I've seen medics trying to be "critical thinkers", but screwed it up, because...let's face it, we have limited knowledge Just food for thought.
 
It's probably a good thing that you're realizing this now, River. You sound on the way to being a good paramedic.

We are not skills monkeys. We are medical professionals. We may not be treated as such, but we are medical professionals and need to be aware that "because we can" isn't the right answer.
 
Jon said:
First - Have you read The House of God?
Law #13 - the last one: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.
Click to expand...

Everyone should read The House of God. It's spot on about so many things –:censored:namely, Law #13, as above, as well as #3, AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE. (ever so useful for us newbies), and, for the extremely empathetic (empathy is good, freaking out is now), #4 THE PATIENT IS THE ONE WITH THE DISEASE.. Also, also: IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER., which has many meanings, from the lazy to the true –:censored:including...if you don't expose the site, you can't find the injury.
 
I'm troubled by "the body knows what it wants".
Unless you mean "Assess then treat", versus "Shoot the works just in case".
 
mycrofft said:
I'm troubled by "the body knows what it wants".
Unless you mean "Assess then treat", versus "Shoot the works just in case".
Click to expand...

Meaning if the person feels fine , they probably are fine or If a body is dehydrated the person is probably going to want something to drink ( fluids ). Say the person has a broken bone and you want to give them morphine but they say "it really doesnt hurt that bad" they probably dont "need" the morphine. This can apply to other drugs/treatments as well.
Ive refused morphine on 2 occasions. First was a broken clavicle. 1. because it didnt hurt that bad and 2. I know that it will make me constipated as hell. I literally argued with the doctor over this that i didnt want it. They kept insisting i needed it.
A body know what a body need if you just listen to it. Its all about symptoms. Some medics will just throw drugs at a problem because they can. Heres a couple more examples.

1. A-fib , perfusing well and breathing well - would you admin cardizem for it?
2. Short Syncopal episode, pt is CAO x 4 and states they feel fine w/ BP & Pulse fine - would you admin 500cc saline challenge because that is what protocol says?
 
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RiverpirateEMT said:
Meaning if the person feels fine , they probably are fine or If a body is dehydrated the person is probably going to want something to drink ( fluids ). Say the person has a broken bone and you want to give them morphine but they say "it really doesnt hurt that bad" they probably dont "need" the morphine. This can apply to other drugs/treatments as well.
Ive refused morphine on 2 occasions. First was a broken clavicle. 1. because it didnt hurt that bad and 2. I know that it will make me constipated as hell. I literally argued with the doctor over this that i didnt want it. They kept insisting i needed it.
A body know what a body need if you just listen to it. Its all about symptoms. Some medics will just throw drugs at a problem because they can. Heres a couple more examples.

1. A-fib , perfusing well and breathing well - would you admin cardizem for it?
2. Short Syncopal episode, pt is CAO x 4 and states they feel fine w/ BP & Pulse fine - would you admin 500cc saline challenge because that is what protocol says?
Click to expand...

I don't really ever believe the, "I feel fine" statement. They called an ambulance for some reason and the symptoms were descriptive enough to warrant a paramedic response. Obviously something is going on. I find old people to be incredibly stoic when faced with huge amounts of pain or discomfort. Even if the patient says they're fine, do a full assessment. You won't find things unless you look. For example, the guy who's having a STEMI and states that he feels fine, just a little tired.

and as for your scenarios, I would answer no to both. I don't treat atrial fibrillation unless it's symptomatic. And not every syncopal episode needs to have a 500ml fluid bolus. However, I would look for other issues and not just sit on my hands and have a staring contest on the way to the hospital.

People say they're fine for a lot of reasons. Maybe they're scared. Maybe they don't know that they're really hurt. I agree that you need to listen to the patient, but you also need to do that assessment and not just take everything the patient says at face value.
 
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