The Hubris of EMS; (or "Broke is Broke"...how I went full-circle about dx/tx)

[mycrofft]

When I was studying to become an EMT-A (then, "EMT-Ambulance") and USAF crash rescueman, I saved my money and bought Gray's Anatomy and the Merck Manual. My coworkers thought I was crazy and pretentious, but the overarching information came in handy and helped me develop a professional outlook and performance.

In keeping with the sentiment of the day, which was that we were not going to be doing the old "swoop and scoop" formerly peformed by the funeral home attendants and police ambulance drivers, we would stay on scene evaluating the pt before we saddled up and headed in to the hospital, where, as it turned out, they would essentially throw out everything we did because you cannot base treatment upon another person's evaluation if they are "further down the food chain", and keep your license.

Later, when as an NCO and then an offcier I was responsible for field medical support for masses of people, I came to realize that as much as I could do on the scene, I badly missed having a hospital real close because the more serious cases just needed it.

The ethic of stabilizing before transport, formulated by NHTSA in its creation of the EMT, was all well and good, but the extension of treatment and diagnosis time in the field delayed acces to definitve care; furthermore, when people started ignoring obvious clinical signs and symptoms in favor of watching dials and later LCD's, the hubris of the entire enterprise became increasingly clear...we were trying to show the hospital how smart we were, and trying to roll back death (but not necessarily disability) through sheer technical mastery of the esoterica, but ignoring the basic lifesaving immediate needs of the patientm, physically and psychologically.
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To re-quote my EMT instructor, Lance, when asked how to differentiate a fractured tibia from a fractured fibula in the field, he crossed his arms and said "A broke leg is a broke leg. Tibia, fibula, you're going to splint it anyway, so get on with it and make sure you complete your assessment instead of getting hung up on stuff you aren't going to to anything about".

There is a lot of quibbling about fine points which are acceptable in an internet forum or at Starbuck's with rival crews, but we are commiting the equivalent of arguing over whether it is fine water hammer vibration or Coriolis Effect causing the toilet to leak, when what is needed is three turns with a pair of pliers then wash your hands as the long line starts using the 'loo again. "Get on with it".

Look, listen, feel, palpate, smell. Observe the patient while approaching and assessing scene safety. Validate with your partner or coworker. Ask the patient questions. Don't let armchair EMT's or doctors or, heaven help us, beancounters and attorneys, start insisting you start counting molecules instead of "gettin' 'er done". EMT's are there to assess, stabilize what is needed to transport, then transport. Paramedics go further in treatment, but nothing which can't be done in the ambulance and will directly support transfer of care to the next stage. Field EMS is not defintive care, and that is not a bad thing if remembered and done right.

So sez me.

 

[Guardian]

...but we are commiting the equivalent of arguing over whether it is fine water hammer vibration or Coriolis Effect causing the toilet to leak, when what is needed is three turns with a pair of pliers then wash your hands as the long line starts using the 'loo again. "Get on with it".

I'm not sure I've seen this, maybe you could reference actual examples.

Paramedics go further in treatment, but nothing which can't be done in the ambulance and will directly support transfer of care to the next stage. Field EMS is not defintive care, and that is not a bad thing if remembered and done right.

So sez me.

Be careful with words like "nothing" and "not." Absolutes get you in trouble. We perform many treatments that are viewed as definitive. While most of what we do is not definitive in the strictest sense, because more can be done at a hospital, it certainly goes beyond simple "stabilization." In your sense, emergency departments aren't definitive either. They are simply transfer stations to more "definitive" care in the OR, ICU, etc. Maybe you better define "definitive" care for me, is it death? Is your goal in writing this to halt progress? Sorry, I will continue to try and increase standards of care and treatment, within reason. Is your point that knowing anything beyond what is absolutely necessary is delaying or hurting patient care? I've seen the exact opposite. More education usually allows faster care because providers can pinpoint and treat the underlying conditions faster and provide treatment that is more pertinent. Maybe you could restate you point in other terms, because I’m having a hard time understanding it. I would agree that to optimize an ems system, you have to balance level of care with resources and available personnel and type of personnel. Thus, MCIs get very poor standard of care. On the other hand, a single person calling 911 should get much better care. So the issue becomes how much education and money should be invested into each patient. Obviously that varies between localities, but we should hesitate putting a cap on it. One day my mother is going to call 911, and I want her to receive the highest level of care that is reasonable. I against following your model, because I disagree with its premise. Dumbing down people doesn’t usually speed up or improve care.


Does anyone else find the typewriter font annoying?

 

[teehehe]

This sounds like a blog entry.

 

[firetender]

I definitely went full-circle in my experience. At first, it was pulling teeth to get orders. I learned to ask for just what was absolutely necessary, nothing more -- all the while, champing at the bit to do more. Then, as a "Golden Boy" with redhot MDs backing me, I got to do everything and anything, up to and including cardiac sticks, and LOOKED for the opportunity, ANY opportunity to do more.

But then, as I matured in the field, I gradually went back to doing only that which was absolutely necessary to get the patient to the next level of care. Along the way, of course, it was going through the arc of pushing the edge of the envelope that allowed me to be much more discerning in my choices, which, toward the end of my career, became minimalist.

 

[Ridryder911]

When I was studying to become an EMT-A (then, "EMT-Ambulance") and USAF crash rescueman, I saved my money and bought Gray's Anatomy and the Merck Manual. My coworkers thought I was crazy and pretentious, but the overarching information came in handy and helped me develop a professional outlook and performance.

In keeping with the sentiment of the day, which was that we were not going to be doing the old "swoop and scoop" formerly peformed by the funeral home attendants and police ambulance drivers, we would stay on scene evaluating the pt before we saddled up and headed in to the hospital, where, as it turned out, they would essentially throw out everything we did because you cannot base treatment upon another person's evaluation if they are "further down the food chain", and keep your license.

Later, when as an NCO and then an offcier I was responsible for field medical support for masses of people, I came to realize that as much as I could do on the scene, I badly missed having a hospital real close because the more serious cases just needed it.

The ethic of stabilizing before transport, formulated by NHTSA in its creation of the EMT, was all well and good, but the extension of treatment and diagnosis time in the field delayed acces to definitve care; furthermore, when people started ignoring obvious clinical signs and symptoms in favor of watching dials and later LCD's, the hubris of the entire enterprise became increasingly clear...we were trying to show the hospital how smart we were, and trying to roll back death (but not necessarily disability) through sheer technical mastery of the esoterica, but ignoring the basic lifesaving immediate needs of the patientm, physically and psychologically.
----------
To re-quote my EMT instructor, Lance, when asked how to differentiate a fractured tibia from a fractured fibula in the field, he crossed his arms and said "A broke leg is a broke leg. Tibia, fibula, you're going to splint it anyway, so get on with it and make sure you complete your assessment instead of getting hung up on stuff you aren't going to to anything about".

There is a lot of quibbling about fine points which are acceptable in an internet forum or at Starbuck's with rival crews, but we are commiting the equivalent of arguing over whether it is fine water hammer vibration or Coriolis Effect causing the toilet to leak, when what is needed is three turns with a pair of pliers then wash your hands as the long line starts using the 'loo again. "Get on with it".

Look, listen, feel, palpate, smell. Observe the patient while approaching and assessing scene safety. Validate with your partner or coworker. Ask the patient questions. Don't let armchair EMT's or doctors or, heaven help us, beancounters and attorneys, start insisting you start counting molecules instead of "gettin' 'er done". EMT's are there to assess, stabilize what is needed to transport, then transport. Paramedics go further in treatment, but nothing which can't be done in the ambulance and will directly support transfer of care to the next stage. Field EMS is not defintive care, and that is not a bad thing if remembered and done right.

So sez me.

Welcome to 2008! Thank goodness most do not have the opinion as such or we would be back in the days of the funeral home. (hey, we are all going to die someday, mentality) .If one would had expanded their education and mind, one soon learns it is not the building (or lack of) that treats and heals the body.

Sorry, been doing this for a few decades now, on both sides of the fence and I can assure you that one can perform the start of definitive treatment. Apparently, you know very little about medicine (especially emergency and critical care) treatments in the field that have prevented needless hospitalization such as CPAP or pain control so management can continue. So would preventing an admission to ICU or not having to place the patient on a ventilator because of the treatment performed in the field be definitive care?

What portion of medicine alone, performs definitive care?

Really can ER's perform definitive care? Exactly what perception do you call definitive care? Resolvent of the problem? Even ICU's.. do we really perform the definitive care to allow the body to heal.... or is in it the rehab center? Again, all perception of what "definitive" care is.

Before "labeling" modalities of treatment, one should understand medicine, that there is not one step alone that it is a step by step process, to make up the treatment for definitive care. One does not get "healed" in a particular unit or even in a hospital. After time being a clinician, one realizes that disease and injury responses are usually given in increments, that each provider is part of the puzzle in treating the patient.. each has a very responsible portion and in the end the patient themselves owns the highest percentage.

R/r 911

 

[AlaskaEMT]

Before "labeling" modalities of treatment, one should understand medicine, that there is not one step alone that it is a step by step process, to make up the treatment for definitive care. One does not get "healed" in a particular unit or even in a hospital. After time being a clinician, one realizes that disease and injury responses are usually given in increments, that each provider is part of the puzzle in treating the patient.. each has a very responsible portion and in the end the patient themselves owns the highest percentage.

R/r 911

Well said.

 

[mikeylikesit]

I did the same as you as far as taking more education in that was beyond my current scope at the time and still do. Well happy to say most of it has paid off in ways that i was not looking for directly. I have an unfounded thirst for knowledge and i will do this forever. People ask why i don't just go to medical school, to them i say..."why don't you go to law school?"(police buddies)

 

[triemal04]

I suppose since you work in a jail that a some of your patients get transferred to a regualar hospital for one reason or another. I guess that means that you also are not definative care, and really, should not actually be doing anything for them either, just waiting until an ambulance arrives to take them to the real healthcare professionals.

Always sucks when your job get's called into question doesn't it?