I would strap our bags next to me on the bench and work out of them, there was very little that I didn't have in the bags that I needed during transport.
the 100% directionless thread
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I would strap our bags next to me on the bench and work out of them, there was very little that I didn't have in the bags that I needed during transport.
But then I have to restock my bags after the call when I could have just used truck equipment. I'm already one of the faster medics in this system, I just don't care about the times I take for my actually sick patients when I run entire calls in <45 minutes quite regularly already. Even with me taking 20 minutes on scene to do CPAP + meds + full assessment and reassessment and getting plenty of high acuity calls quite regularly, I still average a time on task of <60 minutes month after month. I don't care to be faster and I'm just not gonna try. If coverage is a problem (which it often is) I'm not the cause of it nor the solution.
The number one determinant of outcome in the prehospital environment for the patient is time from call to arrival at definitive care.
Costs and efficiency drives the bottom line, something that matters in for profit, non-profit, and government systems. Even in a non profit the cost to the system is a huge deal, often even more than in non-profits as it really is the bottom line keeping the system open. That being said effiency matters to the patient. The bus will never be the ED, which is (most of the time) not a referral center, which is not an OR or ICU.
I push effiency and times just as hard in the ED as in EMS. It helps in bottom line, but it is also the best thing for the patient.
DesertMedic66
Forum Troll
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So do I but that doesn’t help with me being able to reach the patient. Sure I can grab a syringe and draw up meds but in order to give them, I’m gonna have to unbuckle.
In what patients? STEMI? Stroke? Trauma? Sure. I'll agree 100% there. I've managed a 12 minute dispatch to hospital time because I recognized the importance for that patient. What good does rushing to a hospital and cutting corners on care do for the overdose, hypoglycemic, epileptic, cardiac arrest, asthmatic, or Hyperkalemia patient with a a wide QRS?
Cost and efficiency matter and I don't agree with consistently being slow and making coworkers pick up the slack. However I also like safe and controlled work environments and a moving ambulance isn't what I would call one. When I can take factors out of the equation that I have to deal with while transporting, I absolutely will, numbers be damned.
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This is only true in a very small subset of patients.
NomadicMedic
I know a guy who knows a guy.
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I agree. In the entirety of EMS patient contacts, very few require time sensitive interventions.
SandpitMedic
Crowd pleaser
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It’s so strange how people who do the exact same job (or nearly the exact same) can have such different perspectives on the most basic principles of it. It is interesting.
PotatoMedic
Has no idea what I'm doing.
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Bleh... Filled out my e-QIP background check this morning. Took a nap and woke up in the middle of it remembering I forgot to include a part time job I had a few years ago. Now just waiting for an email back on how to fix that.
I think that everyone's opinion is shaped by their experience.
Back when I was in the fire service I would have been a lot more amicable to the stay and play opinion. I didn't know or understand how much more advanced management is in the ED or ICU.
That belly pain that ends up being a ovarian torsion, incarcerated hernia, intussusception (which I have seen in several adults), and so on are time sensitive but can present in a way that doesn't seem that way in the field.
Slightly altered homeless guy might have a head bleed, and I've had more than one that we had to send for emergent evacuations in the OR who were reported to just be drunk.
That teen who is high and agitated is actually overdosing on meth laced MDMA and is febrile and having intermittent seizures and needs a large amount of antiepileptics and airway management (I had one guy who got 25mg of versed, a gram of keppra, and 600mg of phenobarb in his hour in the ED with me before he went to the unit). I had one that was delayed because he was treated in a medical tent at a concert until he went into status epilepticus and coded, we never got him back.
Codes are ran differently. I've had ED codes where we are giving meds based on labs, placed chest tubes, evacuated fluid with pericardialcentesis, performed CPR through PCI, and so on and these patients lived because of interventions that could not have been performed in the field.
It's all a matter of you don't know what you don't know. Not once in our EMS or nursing peer review committee have I had a referral where the clinician willfully neglected care, people do what they think is right. In the vast majority of cases it is a lack of education.
You know, throughout the last month or so of your posts I’ve seen you:
1) Considering EMS pay laughable to the point of being insulting.
2) Considering EMS providers not knowing what they don’t know.
3) Considering EMS inefficient if they display even a modicum of initiative.
That, and the anecdotes/horror stories about bums with brain bleeds, women with ovarian torsion etc plus the constant referrals to the fire service you started with, leads me to believe that you’re speaking from a very specific perspective of a fireman who became an RN and suddenly has seen the light.
This isn’t an ad hominem. This is exactly what myself and many others have dealt with while pushing gurneys for the various FDs in SoCal. This whole “just load up and go”, “don’t play a doctor” and “who cares, the ED will figure it out” mindset which is so prevalent in the fire service doesn’t really stem from understanding their limitations but rather from a) indifference and b) scare tactics employed during the peer reviews.
All the big words that you just dropped, have associated symptoms that any competent clinician can recognize. A brain bleed doesn’t present with just AMS, an ovarian torsion is more than just “belly pain”, a meth’d out teen is clearly not “just high” et cetera. So, instead of pushing for immediate transports and creating the mentality of “who cares, just get them to the hospital”, how about treating street medics like adults and professionals who actually know a thing or two ?
P.S. I’ve seen enough f**kups in the ED, to know better.
1: I do think the pay that EMS gets is insulting, I don't know why you would consider this a bad thing. Why should a college educated profession get paid so little as to be a member of the working class?
2: This is a problem in all of the medical field. I don't pretend to be an ID expert, I don't consider myself to be an expert in flight physiology, or one in law enforcement. I call for advice and help from the labor deck, oncology, pharmacy, and several other specialties every day. This is the dunning kruger effect.
3: I have no problem with EMS having initiative, but like in any other healthcare area it needs to be evidence based. Simply doing something without evidence isn't advancing any field of medicine.
I was a fire medic. I never worked EMS only, and I don't have any need to hide that. Unlike most fire departments we trained hard every day, usually for two to three hours. Our officers had us reading about architecture, fire behavior, rescue tactics, or whatever else every day. We cut up cars, surveyed the district, checked cisterns, flushed hydrants, went to the burn tower, or did some kind of hands on training every day. I think I was a pretty average medic, I'd like to think that we were great firefighters. I'm proud of the work that I put into being a firefighter, and that also spilled into the work I put into being a medical provider.
With that I never ran back to back medicals for 12 straight hours. I didn't get hounded by corporate nonsense. I didn't deal with nonsense drunk calls, social problems, and the like. Our district was very lucky, when we got EMS calls they were sick. I can't pretend to be a 'street' medic or have that experience.
I enjoyed the medical component but realized that advancing in EMS beyond paramedic just really exist. I didn't want to fly so that cuts out HEMS. I wasn't going to leave my fire job so that cuts out any kind of community program. There was no way I would ever go work for a private EMS company. I considered medical school but I didn't want to spend the next decade in medical school and residency, I considered PA but that can narrow down job choices and localities, I considered pharmacy but I was concerned I would miss the hands on care. I went into nursing because I could complete the program in less than two years and have my BSN. I have immense flexibility in care environment, my schedule, and where I can work. I figured out where I want to be. I still get to do some EMS with our specialty program, I work in the ED, I work in the units, and I get to develop and shape our practices in our committees and councils. I don't think that being a nurse makes you "see the light," I think that having experience in a multitude of care environments helps you to understand how complex healthcare really is. There are many nurses who don't understand this. There are many healthcare providers beyond nurses who understand this. I don't think being a nurses is some kind of magical answer nor is it the right choice for many people.
There is a difference between making a good assessment and wasting time on scene. Make a good assessment, make a plan, and execute that plan. Any extra time is a waste. If part of that plan for example is having a sober ride take someone home then that is great, if it is fiddling around for no good reason then it is wrong.
If you think that every patient presents with textbook symptoms they you have a lot to learn. There is a reason why we don't just take a history and physical exam and send a patient to the OR for an emergent appy or torsion. You list your differentials and then include or exclude them. Being in the twenty first century this typically includes labs and imaging, these cannot be performed in the ambulance.
A lot of those drunk head bleeds to EMS looked drunk, they didn't know (nor did we for that matter untill they sobered and gave us a better story) that the patient had been in a fight the previous day. In fact I would have said the patient was also probably drunk, but without a head CT we can't exclude a bleed.
EMS wouldn't have known that a 19 year old's molly was laced with meth, we found that out on his utox.
We wouldn't have known that a complaint of intermittent LLQ pain over two days with dysuria was a torsion, the ultrasound showed that.
The fact that a more advanced and extensive workup in the ED doesn't mean that care delivered by EMS was bad or wrong, but rather that the patient needed a more extensive workup than can be provided in the prehospital environment.
If the patient is going to need or want transport to the ED, then why waste the time if it doesn't benefit the patient. There are plenty of non-emergent patients who are going to end up going whether they can be fixed by EMS or not (or even if they don't have a problem at all) because that is the American healthcare system.
The practice of medicine will always have errors and room for improvement. That being said we should push for that improvement. Errors certainly happen throughout the hospital (and clinics for that matter) very much including the ED, but we should learn from that and get better.
Most of the medics I work with are professionals. They don't waste time on scene, they don't wast time on the biophone, and they don't waste time in bedside report. You can deliver good care without needlessly wasting time.
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No one here is advocating staying on scene with someone who has belly pain or AMS just to sip coffee and shoot the crap. When they say "stay and play", that is shorthand for "do whatever meaningful management is indicated on scene". That's all.
None of those anecdotes you listed are going to have their outcomes negatively impacted by the time it takes a competent paramedic to do a good assessment and make a "sick / not sick" determination and then formulate a working diagnosis and treatment plan. I for one do understand "how much more advanced management is" in the hospital (and I think a lot of the EMS guys have a better idea than you give them credit for), and I also know that it isn't as if clueless paramedics are slowly lallygagging in with unrecognized critical patients and then the heroic ED staff takes one look and immediately brings to bear the force of all the expertise contained within the medical faculty and whisks the patient off to emergency surgery just in time. That's a (bad) TV show; not reality.
There's no ED that immediately rushes everyone with belly pain or who is apparently drunk right to CT. No one is going to be harmed because a paramedic spent a moment on-scene taking a BGS and looking for signs of intoxication and trying to ascertain the most likely cause of the AMS and determine the best place to take the patient. No one is going to die because the same paramedic spent a couple minutes getting a good history on the belly pain and making sure the patient was comfortable.
The research is pretty that cardiac arrests, especially, do better when they are resuscitated on scene prior to transport. It's also clear that there is almost never any correlation between transport time and outcomes.
CALEMT
The Other Guy/ Paramaybe?
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I think @Remi summed it up pretty well, so there’s no need for me to reiterate on what he said. I’m just going to go over some minor detail.
First, I can tell that you haven’t been an RN for too long. You’re still in the mindset of “us vs them” that was ingrained in you back when you were with the FD; that’s the kind of BS that wannabe paramilitary organizations indoctrinate their employees with.
Second, it’s a cool story about you deciding to pursue higher education, but the important component that you’re missing is that most of the people you’re interacting with here, are either still working or have worked in the past, for private EMS. Their choice of a career is their concern only, and taking a prima donna stance on it makes you look ignorant and arrogant. Same applies to the issue of pay rate in private EMS - it isn’t that the pay is low, it’s that you (as a dual role FF) were unjustifiably overpaid for, essentially, a menial job that does not require any higher education.
Third, you seem to completely miss my point about the “just load and go” mindset but @Remi already touched base on that.
And last, but not the least - the fact that you, admittedly, were an average medic, doesn’t mean that everyone else is.
SandpitMedic
Crowd pleaser
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For what job?
I don't know what you mean by "us vs them." Fire based EMS is a different approach than private/3rd service EMS. Fire based EMS is differenly ran between departments that transport and those that don't. Private EMS is ran different than 3rd service.
Or perhaps you mean paramedics versus nurses? Or docs, PAs, NPs, pharmacists, and therapies? We all have different education and to a large degree different ways of looking at a patient. This isn't an in group and an out group, these are just the facts.
Or do you mean when I say what I would do versus why I would expect a medic to do? I think that the average paramedic is going to look at things differently than I do. I was a paramedic, I am a registered nurse. I have worked in Adult and Pediatric EDs, adult ICUs, pediatric ICUs, congenital cardiac ICUs, and NICUs; I outreach and assist with transport for several of our specialty programs. I have worked in several tertiary/quaternary referral hospitals that patients literally come accross the globe to receive our care. I've worked in the woods as a medic, and in a level I trauma center as a nurse. I have five board certifications in emergency and critical care, and more classes to keep up than should be possible. I have graduate education in forensics and care of child abuse. I chair one and am a member of several quality and process improvement committees, I have monthly meetings with our executive cabinet and talk with them several times a week. I precept nursing students, paramedic students, flight nurses, and flight paramedics. I don't think it is unreasonable to think that I might have a different plan of care than most of the medics on here.
That story about higher education is because you accused me essentially of thinking I was better than paramedics because I went to nursing school, so don't act like that was out of the blue.
To that matter though I do think paramedics should have higher education. If you think I look down on paramedics then you really don't have touch of how most other health providers think of EMS. I think that until paramedics have a minimum of an associates and are on the way to a bachelors that isn't going to change.
Why should I be able to make more money roofing or doing yard work than working on a bus as a medic? In what world does that really make sense? I don't see expecting a living wage for working as a medical professional to be unreasonable, let alone pompus or arrogant.
As to delay of care. Delayed intervention is well known to have negative effects in the MI or stroke patient, the septic or bacteremic patient, patients requiring advanced cardiopulmonary intervention, dead gut, ruptured appendicitis, malrotation, incarcerated ischemic hernias, torsions, intra-abdominal abscess, spinal epidural abscess, meningitis, myocarditis, pericarditis, peumo/hemo/chylothorax, vascular flow obstructions to the great organs, and so on.
Infact, tell me how you would rule in/out pneumomediastinum in the field? How would you treat it? How do you evaluate and treat spinal epidural abscess? What are you doing in the additional time on scene to benefit these patients?
PotatoMedic
Has no idea what I'm doing.
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An NDMS DMAT. I'm not to worried but still frustrating on my part.