Teaching "treat what we see"

[medichopeful]

This thread is building off of the below comment on another thread:

Where we fail with paramedic students is all too often we only teach a "treat what we see" method, and some people can't think beyond that; that's a huge problem for another thread if anyone wants to start an actual discussion on it.

I took an odd route, and am going through paramedic school now (after having worked as an RN for a little while, which I still do). I'm lucky in that I've been able to see the progression of cases as time goes one.

Many of my fellow medic students have not been so lucky. In medic school, there was a lot of discussion of treating things as we see them. There wasn't much discussion about how treatments started in the field can affect the patient some time later.

I've only gone through one paramedic program, so I know that other programs are different. For my program, I had to spend 8 hours in ICU and 8 hours in CCU. I personally feel that this is not enough. I think that paramedic students should have to spend more time in ICU/CCU, and some time on a tele floor.

I think that this would expose them more to the treatment and disease course, rather then the treatment of the disease only in the "emergent" stage. With more experience to care further down the line, perhaps we can change the whole mentality of "treat what we see," without thinking about the sequelae that follows.

Thoughts?

 

[DesertMedic66]

For us the clinical shifts were used primarily just for skills. So while I personally would have liked some ICU time I can understand why we weren't sent there.

 

[VentMonkey]

Agreed, but it then goes back to the general gist of pushing for "further education" amongst the national, NATIONAL DOT standards, and restructuring the curriculum, which I have absolutely no problems with.

Adding something along the lines of a critical care block to a paramedic program would be phenomenal in my mind. What's the worst that could happen? It again, drives away the tools who see no "glory" in a critically ill patient who's already been intubated, and all of the "fun" taken away from them while the actual acuity lies directly in front of their eyes (I guarantee we all have these types at our services).

Many paramedic students who end up working the streets with no aspirations for being fire medics get bored, and want to pursue nursing, flight, critical care, or mid-level positions. How would a more in-depth curriculum to include ICU-type modules with some advanced respiratory modules, community paramedicine subjects, and general critical care topics be a bad thing?

I personally, think it's sad with all of the puppy mill style schools passing any, and everyone who put their money down to get some watered down education; it's a farce.

I'm seeing the results now, and the public suffers. This is no less a vocation than ever before, and until we up our entire curriculum to include semesters worth of the valuable education it's every provider for themselves when it comes to their level of education, and in turn compensation.

Funding or not, you get what you put in, and no one is deserving of anything they're not willing to earn themselves.

 

[StCEMT]

I had ICU time, but it came earlier in the program. Too early for me to fully appreciate and follow what there was to learn.

 

[shelvpower]

Im currently in my 3rd year of studies, busy doing my Bachelors degree in Emergency Medical Care and Rescue. We start with clinical practice shifts in year one. We need to work shifts at the following places.

Year 1:
Ambulance/ESV shifts (On an ILS/BLS bus)
Casualty/ ED shifts
Maternity ward
Control room/ Dispatch shifts (Only 2 shifts)

Year 2:
Rapid Response vehicle shifts
ED/casualty shifts
Maternity ward shifts
CCU shifts
Clinic shifts

Year 3:
Rapid response vehicle shifts
ICU shifts
Casualty/ ED shifts
Theatre shifts
Year 4:
Rapid response vehicle shifts
NICU shifts
Casualty/ED shifts
Theatre shifts

In 1st and 2nd year you have to work a certain amount of hours in each department (more if you haven't completed all your skills).

In 3rd and 4th year you only need to complete all the required skills and do not have to work a certain amount of hours in each department.

I can honestly say that I learn alot in the ICU, especially when it comes to ventilator settings and infusions etc.

The CCU shifts allowed me to see the progression of STEMIs on the ECGs over time and the effects of thrombolysis on the pt's ECG.

We get to perform a lot of our intubations in theatre and casualty as well. Working in casualty made me more proficient in a lot of skills like IVs. We can easily get 30 IV skills in one shift when we work in a government hospital here in South Africa




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[SpecialK]

I honestly don't think more time in ICU or CCU would be overly helpful.

Significantly more time in mental health, community, general medicine and geriatric or older persons would be immensely helpful. The level of clinical decision making around treat and refer is higher than its ever been. I know next to nothing about dementia, Alzheimers, Parkinsons, cerebral palsy, depression, schizophrenia, GORD, gout, renal failure, cancer, COPD, or well, most of the diseases the patients I encounter have. I know little about the drugs they are prescribed and most are on a significant number.

The degree is a good starting point for Paramedic level but honestly, in some regards is appallingly inadequate. For example, there is about 1,000 clinical hours in the degree (same as the nurses and most others) over the three years, but there are only two shifts in mental health and between two to four in community health. None in a general medical ward, none in a geriatric ward, and maybe one or two in a rest home.

As for treating what you see ... well it depends, if you can't make a firm diagnosis and you see something which needs treating, well treat it.

 

[Carlos Danger]

If you think about the short-term management and transport of folks with life-threatening situations - which is what EMS was invented to do and what EMS education is intended to teach - "treat what you see" is generally the right approach. I'm sure we can think of exceptions, but we mostly do just treat what we see. Bleeding? Use direct pressure and a tourniquet to stop it. It doesn't really matter what the platelet or hgb is or whether we can close the wound, because we are just going to stem the bleeding the best we can and take them to a hospital. Trouble breathing? Try to determine whether the cause is bronchoconstrictive or due to cardiac failure and then follow your protocol for that. The underlying principles of asthma or COPD management and the specific types of cardiac failure matter little to our treatment pathways. Chest pain? Try to determine the basic cause (anxiety, tachycardia, or an MI) and once you determine that, follow your protocol for that problem. This approach works fine the majority of the time, and it isn't even unlike the approach taken in the ED.

There's a lot more out there than emergencies though, and we all want to see EMS evolve to become more relevant and useful in the current (mess of a) healthcare system. That brings us back to the topic of changing and improving EMS education, which we discuss frequently on this forum. The way that education changes will be driven largely by how EMS itself changes. EMS can either stay primarily a public-safety function focused on treatment and transport of true emergencies - in which case I think with some improvements and additions, the current education is really not that bad - or it can evolve to be more of community health focused concept, which really requires a complete overhaul to how paramedics are educated.

I don't think adding a handful more hospital shifts (ICU or elsewhere) to the current education would be all that helpful. It's still just not nearly enough exposure to the bigger picture to make much difference.

 

[hometownmedic5]

One of the principal issues that has always plagued EMS is the variety in environments a one size fits all certification is expected to apply to. There are areas in this country that boast transport times consistently under five minutes. There are systems in this country with transport times measured in hours. These variations make it impossible to paint the entire industry with one brush.

If you have <10 minutes with your patient before you're indictably delaying definitive care, you're not doing much long term thinking. Diagnosing the greater problem, considering the long term results of your short term actions etc. is most likely not a part of your practice. You're most likely pidgeon holed into the mindset of doing the bare minimum required so you don't look like a boob(VOMIT) and playing the "we had a two minute transport" card.

If you're the 2 hour transport time, you most likely spend a lot more time working on actually solving problems with carefully considered decisions.

 

[EpiEMS]

From a systems perspective, I don't know if "treat what you see" is wrong, per se. Obviously we are all (here) not going to knock more education, but, again, at the macro level, I'm not sure what's sufficient for somebody in an urban area with a 10 minute time to the Level I is the same necessary for somebody in a rural area with a hour by ground to the nearest hospital that'll take an intubated patient on a vent.

What I mean to say is, systems need to be calibrated to the communities they serve - and so do the personnel qualifications, which flow up from educational standards.

 

[VentMonkey]

What I mean to say is, systems need to be calibrated to the communities they serve - and so do the personnel qualifications, which flow up from educational standards.

Why? Nursing programs aren't. What's so wrong with wanting to expand the knowledge base of the "highest" level of prehospital provider so much so that their assessment should reflect at minimum a 2-year education?

Then I hear "well supply and demand" as a rebuttal, ok, so there's less paramedics than there are now. I know at least where I work we're hurting for bodies even at the bare minimum standards level. How much worse can it get? In my mind, not much.

It would definitely take away the heroic complex many have with this industry as pomposity is rampant amongst the younger generations, not exclusively, but enough so that if they can muster at minimum two years of actual education and schoolwork. I simply fail to see how this is a bad thing.

Another thing that's often debated is the "let firefighters fight fires". Do you see many, if any fire departments wanting to send their people through 2-4 years worth of higher education for something that would (potentially) be viewed as more of a vocation than it is now? When was the last time they sent anyone of their personnel through nursing school?

Granted we'll never have the choices nurses do, nor should we, but by extending the curriculum to cover things as mentioned in my original post, plus coursework in emergency management you're giving people more diversity within a field that does offer some, albeit limited, options when the physicality has all but caught up to them.

By tailoring to specific systems you defeat the purpose of a nationally uniformed higher level of education. What happens when the paramedic from a neighboring county moves next door, or out of state only to find out the other system is a whole new ballgame? I can tell you, I've seen it, and it isn't pretty. The paramedic suffers, the patients suffer, their co-workers suffer.

I guess I just can't see how it's not a win-win-win. Higher educational standards for our industry with intent to segue into a profession, be able to assess at the level of a more advanced practioner to include a begin-to-end approach to the more acutely ill patients which in turn helps out the ED, and ICU RN's tremendously, and having enough know how for a prehospital setting to final be trusted in general, not case by case, with EM physicians given our pursuit of increased knowledge and educational curriculum.

 

[Handsome Robb]

I want to say I did somewhere in the realm of 10 twelve hour ICU shifts between PICU, CICU, MICU, TICU and NICN.

I thought it was fascinating but some of my classmates were less than thrilled.

I actually got used a decent amount in the ICU, skills wise.


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[EpiEMS]

@VentMedic, no disagreement - I think I should have qualified -- educational standards need to be raised certainly, but the levels should be aligned to the different sorts of communities out there if possible. For example, the baseline paramedic level of practice as it exists now is very well suited for a large number of emergent conditions during a short-duration transport but would be wholly unsuitable for managing a critical patient over a several hour transport. This would suggest to me that we need a nationally recognized level of paramedical practice like a critical care paramedic. I don't think you'd disagree? (I appreciate how my statement was much less nuanced than it should have been -- sorry for that)

 

[VentMonkey]

the baseline paramedic level of practice as it exists now is [B]very well suited[/B] for a large number of emergent conditions during a short-duration transport

No need to apologize, Ep. My feels on here are like my soul at work, left at the door. While a critical care paramedic at the national level certainly would be a step in the right direction, I'd say that many paramedics are hardly prepared to even provide this level of care.

Will I get flack, blasted or chastised on here? Perhaps, but oh well. I'm seeing it, firsthand, so while many on here many be certainly in pursuit of higher than average levels of education, and/ or planning to move on from being "just a medic", those that don't suffer the consequences of watching their peers fumble through many a call, even seemingly standard "emergent" calls.

I just don't see how we as a whole cannot correlate the relationship between the ED, and ICU when dealing with as you stated the "large number of emergent situations". I think we're honestly doing more harm than good as a whole, and those that seek to improve suffer in disarray of others who tapout at the end of "baseline" paramedic school. It defeats the entire purpose of what it is we were trained to do.

In other words: most are hardly even trained-technicians anymore, let alone clinicians.

 

[EpiEMS]

In other words: most are hardly even trained-technicians anymore, let alone clinicians.

Is it mainly a need for more pre-clinical training (A&P, biology, etc.)? Or clinical training? Perhaps both?

 

[VentMonkey]

Is it mainly a need for more pre-clinical training (A&P, biology, etc.)? Or clinical training? Perhaps both?

Again, solely my opinion which others may not share; that's fine. A degree program roll out similar to nursing, and all of its prerequisites, even at the associates level would be a great start...nationwide.

Once you're selected based upon completion of the standard allied-health prerequisites (imagine that, a paramedic program that doesn't just want your money, but has standards), you enter your didactic.

I don't know that ICU clinicals need to be more than 4 hours at a time, but certainly more than just hours to "kill" if you will. Round with the intensivists and their residents, ask questions, help them, and/ or sit in on procedures.

Add modules that review the management aspects so that the providers gain some knowledge, if not insight, of what it is that goes into this style of management (emergency management isn't without its own set of challenges) so that instead of pissing and moaning on an ambulance the student will have a better understanding of this angle, or perhaps want to effect change, not piss all over it blindly without knowing basic facts. It makes us all look foolish, IMO.

Include community paramedic subjects that help bridge the gap we have now between us, and the psych patients we can't assess without seeing a non-emergent call.

The word alone "emergent", that there is everything that seems to be backfiring in our faces. It's subjective, yours isn't mine, and mine isn't the next persons. So saying we do a good job with the emergencies now, which ones are we referring to? Where's the data?

I am sure you are well aware of, in fact more so than I, than EMS has no evidence-based factors for a legitimate existence, so what are we doing? How are we progressing?...50 years later.

But as long as none of this sounds as exciting as rushing to cardiac arrests to save yet another victim from the clutches of death, or running trauma after trauma we won't get anywhere, and that isn't the students fault; that's something that we've managed to create over 50 years steeped in tradition.

 

[SpecialK]

I don't think "having a degree" is the answer, it's what you put into the degree. We've had a degree for years but it teaches next to nothing lots of things. It is called a "three year degree" but in reality it's really about one and a half years of full-time education taught over three standard university years. Ideally, the degree would be extended to four years, the same as midwives, and include much more general medicine, psychiatry and community healthcare

Of course, you add things, and add things, and eventually you just need to send all of your paramedics to become doctors because then they will get taught enough? There has to be a balance somewhere.

 

[VentMonkey]

@SpecialK, with due respect this hardly pertains to your part of the world. You're in a different system with completely different sets of protocols, and educational standards.

This thread is more aligned with the lack of education in the United States when it comes to our paramedic curriculum.

And I don't think anyone said that we'd be training paramedics to the level of doctors; clearly you're missing the point here.

 

[EpiEMS]

@VentMonkey, I feel like (and I think you'd agree) that what we really need is some sort of radical revamp of our educational (and systems design) paradigm for EMS, but I don't see that coming any time soon.

I think your point about EMS as it exists now lacking much in the way of evidence is generally sound, but might be a bit broad: We've addressed most of the problems brought up in the White Paper with better engineering, namely, *but* trauma is still the biggest killer of kids and working-age adults. However, as you suggest, there is a real paucity of evidence saying that you need EMS as it exists today (certainly you don't "need" ALS) to mitigate that. As far as problems like sudden cardiac death, we've gotten better - but it's not necessarily because EMS changed, it's because of more emphasis on solid CPR and improved access to early defibrillation. So EMS needs a rethink. And with that needs to come a reworking of our educational programming.