Things we can do nothing about?

[usalsfyre]

"Since you called and we're here, why don't we take you to checked out? If it turns out to be nothing, the peace of mind will be worth it. Whaddya say?"

The problem is the "peace of mind" really isn't worth a trip to the first/second/third highest cost center (depending on the source) in medicine for something that's going to sit in the waiting room. It's a part of the reason health care premiums continue to rise and there's difficulty funding Medicare. It's really better for everyone, including the patient, from a cost and continuity of care standpoint to refer these folks to their PCP for treatment in the outpatient setting. The "we're not doctors" excuse is a copout, and simply shows we're a)not educated enough and b)unwilling to take responsibility for our actions like professionals.

All that said, we have no mechanism to refer patients elsewhere, so they get transported anyway :angry:.

 

[mycrofft]

Tongue in cheek answer to the title of this post.

Vital sign monitor, continuous EKG, NP airway, oxygen, long spineboard and KED, start an IV of SNS TKO, or interosseus if you can't get a vein because the pt is struggling, blanket (to maintain body heat), and an ET tube if they get mouthy.
These are all "just in case".

 

[mycrofft]

Tongue in cheek answer to the title of this post.

Vital sign monitor, continuous EKG, NP airway, oxygen, long spineboard and KED, start an IV of SNS TKO, or interosseus if you can't get a vein because the pt is struggling, blanket (to maintain body heat), and an ET tube if they get mouthy.
These are all "just in case".

PS: If appropriate :rofl: alaso apply pads and turn on AED, and break open a field OB delivery pack.

 

[WuLabsWuTecH]

I've seen too many instances in which EMTs are a bit too wishy-washy. If a patient asks me if I think they should go, I'm a step ahead of them saying something like:

"Here's what I'd like to do for you... we're going to put you on some oxygen, take a look at an EKG of your heart and give you some medicine that can help the pain. So we'll get you to our ambulance and get you going to the hospital. Sound good?"

So far, the answer has always been "yes."

If it's not an emergency, I'll say something like:

"Since you called and we're here, why don't we take you to checked out? If it turns out to be nothing, the peace of mind will be worth it. Whaddya say?"

I usually get a "yes" for these folks, too.

No skin off my nose to take someone to the hospital. Last I checked, it's what they pay me to do.

Im sorry - I'm paid to provide emergent care outside of the hospital to hopefully prevent someone dying...not to play taxi to the lazy.

It IS skin off my back to take someone who doesn't need to go because theyre taking potentially life saving resources out of service for upwards of 3 hours...and yes, I have cleared from a call where an ambulance wasn't needed to being literally 30 seconds away from doing a critical life saving intervention. If we had transported, the next ambulance was 20 minutes away....he would have died without a doubt in my mind.





The sooner we drop the "you call, we haul" mentality...and the supporters of it, the beyer as we can move on to real medicine. Not everyone that calls needs to go by ambulance.

Ok, so while I agree with the treat the emergency in front of you and not the emergency you might have later mentality of resource management, what if the emergency in front of you isn't an emergency? A trip to the hospital takes us out of services for 190 square miles for 2 hours. If it's not necessary, and we can suggest a better option, why not offer an alternative to our transport. The transport everyone mentality just doesn't cut it when you don't have that many resources to begin with!

And I agree, they pay you to care for sick people, not to take people to the hospital per se.

When I worked the fast life in the big city, we were much more like what you described. Out in the sticks, though, we're a "kinder, gentler" service, for lack of a better term. Nobody on our service is fooling themselves by thinking everything we do is "real medicine," nor is it our goal to drop our current methods because we rely on donations and billing to survive.

Now I know I'm raising some hackles with that last statement. We are not driven by finances. We don't needlessly transport patients or "up-code" our billing. We transport and treat appropriately and we take it as a matter of pride that we play the finances straight. We don't go to calls looking to drum up business.

But if we have the choice of encouraging the patients to allow us to take them, why wouldn't we? All other things being equal, we're happy to take someone to the hospital. Our townsfolk LOVE us, send us donations and thank-you cards with regularity. This year we also sought a significant increase in our town's budget line because we have to start funding a new ambulance. Without so much as a murmur, the vote passed unanimously. And a big part of that is because our community knows we care about them. Since we only do 250 to 300 calls a year, we're not too worried about overlapping calls. It's only happened a couple of times in the past two years.

If your resource management allows you to do so, then that point does not apply to you. But except for a handful of urban areas that have those resources, most areas do not have the resources to transport everyone who needs a taxi ride!!!

 

[Elk Oil]

Ok, so while I agree with the treat the emergency in front of you and not the emergency you might have later mentality of resource management, what if the emergency in front of you isn't an emergency?

But except for a handful of urban areas that have those resources, most areas do not have the resources to transport everyone who needs a taxi ride!!!

This really speaks to a larger and more frustrating part of EMS -- what to do with the patient who wants nothing more than a taxi ride. Let's face it... MOST of our calls aren't true emergencies. Yet we transport anyway.

You say that most areas don't have the resources to transport everyone who needs a taxi ride, yet don't we transport people who just want a taxi ride?

The reality of putting the judgement in the hands of EMTs has proven to result in disaster. People have died because cynical, embittered EMTs haven't transported. The system isn't going to give that level of subjectivity to EMTs... nor should they. If each of us doesn't feel a tinge of hesitation by applying a "what if" scenario to a patient we think doesn't need an ambulance, we haven't learned form others' dreadful mistakes.

 

[WuLabsWuTecH]

This really speaks to a larger and more frustrating part of EMS -- what to do with the patient who wants nothing more than a taxi ride. Let's face it... MOST of our calls aren't true emergencies. Yet we transport anyway.

You say that most areas don't have the resources to transport everyone who needs a taxi ride, yet don't we transport people who just want a taxi ride?

Sometimes we do, but we shouldn't. If we are really thinking that it is not emergent, we can recommend that they go via POV. If they insist on going, we'll take them, but often we can say, yeah, that cut will need to be stitched and you should go to the ER, but it's not necessary that we take you though we'll be happy to if you want us to.

This has also led to our neighboring run district no longer soft billing--they send collections on you if you don't pay in hopes that they will reduce the number of taxi-calls. I think this is awful and the results of the policy are already showing. We have people from their run district driver either to our station for help, or drive across the county line, pull over to the side of the road, and call 911 then. Our dispatchers have gotten more than a few callers who have asked: "Which squad will I be getting?" and "Can I get <Insert our name here> instead?" when they are told they can't get us because we only go mutual aid into their county and their squad is available.

The reality of putting the judgement in the hands of EMTs has proven to result in disaster. People have died because cynical, embittered EMTs haven't transported. The system isn't going to give that level of subjectivity to EMTs... nor should they. If each of us doesn't feel a tinge of hesitation by applying a "what if" scenario to a patient we think doesn't need an ambulance, we haven't learned form others' dreadful mistakes.

Clearly we shouldn't trust EMTs.... <_<

They pay me FOR my judgment. You should ABSOLUTELY put judgment into the hands of EMTs. If you can't trust your EMTs to make good judgments, or at least your In Charges to make good judgment, then you need to find new guys to work for you.

And EMTs, many like yourself, wonder why people don't take them seriously! It's because you don't yourself seriously enough to think you and your judgment can be trusted!

 

[JPINFV]

You should ABSOLUTELY put judgment into the hands of EMTs. If you can't trust your EMTs to make good judgments, or at least your In Charges to make good judgment, then you need to find new guys to work for you.

When dealing with people whose entire medical education is less than 200 hours, how much judgement are they capable of making?

 

[Elk Oil]

Sometimes we do, but we shouldn't. If we are really thinking that it is not emergent, we can recommend that they go via POV. If they insist on going, we'll take them, but often we can say, yeah, that cut will need to be stitched and you should go to the ER, but it's not necessary that we take you though we'll be happy to if you want us to.

This has also led to our neighboring run district no longer soft billing--they send collections on you if you don't pay in hopes that they will reduce the number of taxi-calls. I think this is awful and the results of the policy are already showing. We have people from their run district driver either to our station for help, or drive across the county line, pull over to the side of the road, and call 911 then. Our dispatchers have gotten more than a few callers who have asked: "Which squad will I be getting?" and "Can I get <Insert our name here> instead?" when they are told they can't get us because we only go mutual aid into their county and their squad is available.



Clearly we shouldn't trust EMTs.... <_<

They pay me FOR my judgment. You should ABSOLUTELY put judgment into the hands of EMTs. If you can't trust your EMTs to make good judgments, or at least your In Charges to make good judgment, then you need to find new guys to work for you.

And EMTs, many like yourself, wonder why people don't take them seriously! It's because you don't yourself seriously enough to think you and your judgment can be trusted!

It's not that I don't agree with the essence of what you're saying, it's just that none of us can deny that not all EMTs posses the aptitude or are trustworthy enough to make a proper judgement call. And yes, CLEARLY there ARE EMTs we shouldn't trust. Do you believe we should blindly trust ALL EMTs simply because they passed their 120 hour course?

Unless we can guarantee ALL EMTs meet some competency level for making those judgements at the moment they are on scene, we should err on the side of caution -- which is what the system does.

Many EMTs HAVE shown they can't be trusted. Has your head been buried in the sand, or are you just looking at the world through rose-colored glasses?

 

[MrBrown]

If there is no other realistic option available to them then they are usually transported

If their concern is petty or realistically able to be better handed by their GP or the A&M clinic or w/e then no we can refuse transport

 

[Shishkabob]

what to do with the patient who wants nothing more than a taxi ride.

Easy: Tell them to call a taxi, as we are not taxis, and they called the wrong number, then we leave.

 

[Elk Oil]

Easy: Tell them to call a taxi, as we are not taxis, and they called the wrong number, then we leave.

Personally, I wold welcome that. But to my earlier point, patients have died because EMTs made wrong calls; they misjudged and underestimated, or they tried to diagnose and failed.

Look, we can banter back and forth all we like about what should be, but we're faced with what is. Would I like all EMTs be trustworthy? Of course! Would I like all EMTs to posses the medical expertise to make sound judgement? You bet! Will we ever get to this point? Nope!

And my outlook has no bearing on what will or will not be accomplished. We must operate within the limits of our protocols that are imposed on us. Any subjectivity or judgement is granted us in those protocols.

And I'll promise this: There isn't an employer in the world that won't drop any of us like a hot potato if they get sued because we were negligent and jeopardized a patient.

 

[Shishkabob]

Personally, I wold welcome that. But to my earlier point, patients have died because EMTs made wrong calls; they misjudged and underestimated, or they tried to diagnose and failed.

Patients have died from doctors making the wrong call too. It's the nature of the beast when dealing with human health.



If we're able to RSI. If we're able to make STEMI notifications solely off our assessment. If we're able to do ALL the advanced things that Paramedics do... why can we not tell someone with a laceration to the finger that "No, you do NOT need an ambulance, you need your family member standing right here to take you to an urgent care clinic in the car that they drove to the end of the driveway to meet us in"

It makes no sense.

 

[WuLabsWuTecH]

When dealing with people whose entire medical education is less than 200 hours, how much judgement are they capable of making?

When they have been in the field and have thousands more hours of real education and their Medical Directors get to know them, then yeah, I think they are capable of making that call. I don't care about the 2016 hours of education the guys next to me in my medical school class has, I would trust some of the guys I work with over any of them for me or my family in a heartbeat.

It's not that I don't agree with the essence of what you're saying, it's just that none of us can deny that not all EMTs posses the aptitude or are trustworthy enough to make a proper judgement call. And yes, CLEARLY there ARE EMTs we shouldn't trust. Do you believe we should blindly trust ALL EMTs simply because they passed their 120 hour course?

Unless we can guarantee ALL EMTs meet some competency level for making those judgements at the moment they are on scene, we should err on the side of caution -- which is what the system does.

Many EMTs HAVE shown they can't be trusted. Has your head been buried in the sand, or are you just looking at the world through rose-colored glasses?

I think you're still living in a black and white world where evrything has to be black or white. Why do we need to guarantee that "ALL EMTs meet some competency level for making those judgements at the moment they are on scene"? Protocols are written such that the MD knows who he trusts to make judgments. There are some volunteers on our department that I would trust with little more than driving us to the hospital. But not all of us are qualified to run as in-charge. Only the in-charge can make certain decisions and even then different people can have slightly different scopes. We are getting RSI soon and the MD has straight up told us: this is a skill that some of you will be allowed to have once I have seen your competency and I can trust you. Some of you might never get to use this skill just on the fact that I don't know you well enough.

My head is neither in the sand nor do my glasses need to be cleaned, I just understand that you don't have to treat all EMTs equally.

 

[WuLabsWuTecH]

Personally, I wold welcome that. But to my earlier point, patients have died because EMTs made wrong calls; they misjudged and underestimated, or they tried to diagnose and failed.

Look, we can banter back and forth all we like about what should be, but we're faced with what is. Would I like all EMTs be trustworthy? Of course! Would I like all EMTs to posses the medical expertise to make sound judgement? You bet! Will we ever get to this point? Nope!

Patients have also died because doctors made the wrong calls. And they have tens of thousands of hours of training if not hundreds of thousands. Maybe we should not let them make decisions either?

We will never get to the point of all EMTs being able to have the same set of ideal judgment skills, but why not let those who have it use it rather than blindly following a policy where you agree can strain some of our resources!?

 

[Elk Oil]

Patients have died from doctors making the wrong call too. It's the nature of the beast when dealing with human health. (1)



If we're able to RSI. If we're able to make STEMI notifications solely off our assessment. If we're able to do ALL the advanced things that Paramedics do (2)... why can we not tell someone with a laceration to the finger that "No, you do NOT need an ambulance, you need your family member standing right here to take you to an urgent care clinic in the car that they drove to the end of the driveway to meet us in"

It makes no sense.

1. Doctors can make decisions that result in death and it's okay. Doing so is part of their job -- NOT ours. It's only not okay if they're reckless or negligent. This is because unlike any EMT, doctors engage in health care RESEARCH, trying new methods and techniques. Doctors try to find treatments and cures. EMTs do not. They take risks and try new things that EMTs shouldn't do. Take the recent litigation in NYC in which two medics were sued for delivering a baby by C-Section. Their defense was that they did it under medical direction. How THAT work out for them?

2. WE aren't. YOU are. Knowingly overstating the obvious, medics have much more training than other certification levels. It's too difficult when your a state EMS bureau to make the delineations between certification levels with regards to expressing the kind of subjectivity you're talking about.

Patients have also died because doctors made the wrong calls. And they have tens of thousands of hours of training if not hundreds of thousands. Maybe we should not let them make decisions either?

We will never get to the point of all EMTs being able to have the same set of ideal judgment skills, but why not let those who have it use it rather than blindly following a policy where you agree can strain some of our resources!?

Because there is no feasible way to separate those who have the ability to express the kind of judgement you're talking about and those who don't unless you limit it to certain certification levels. But even that's not feasible.

Honestly, I can't believe I have to explain this stuff. You guys insist on being frustrated by what should be, yet is not. Embrace what is and make the most of it. If you want to move things closer to what you believe they should be, get involved with your state's protocol committee or medical control board. Otherwise, you're just whistling in the wind.

 

[JPINFV]

1. Doctors can make decisions that result in death and it's okay. Doing so is part of their job -- NOT ours.

Then every drug that can be misused in a way to cause death should be removed from the ambulance. Any use of independent judgement should also be removed from EMS protocols and EMS providers need to stop whining about being considered a profession because they obviously aren't under this situation (lack of independent judgement).

It's only not okay if they're reckless or negligent. This is because unlike any EMT, doctors engage in health care RESEARCH, trying new methods and techniques. Doctors try to find treatments and cures. EMTs do not. They take risks and try new things that EMTs shouldn't do.

...and it's a wonder why there is as much prehospital literature as there currently is.

Take the recent litigation in NYC in which two medics were sued for delivering a baby by C-Section. Their defense was that they did it under medical direction. How THAT work out for them?

Research!=unilaterally increasing one's scope of practice?

 

[abckidsmom]

Then every drug that can be misused in a way to cause death should be removed from the ambulance. Any use of independent judgement should also be removed from EMS protocols and EMS providers need to stop whining about being considered a profession because they obviously aren't under this situation (lack of independent judgement).



...and it's a wonder why there is as much prehospital literature as there currently is.

This lack of motivation to acheive independent judgement is a severe stressor on EMS.

That and I think that most providers just don't have the call volume to get really comfortable with their independent judgment before they're 10 years in and laziness is what establishes their habits.

 

[JPINFV]

This lack of motivation to acheive independent judgement is a severe stressor on EMS.

The problem is that the entire reason to increase education is to make providers capable of independent judgement, and without the ability to use independent judgement (which is not the same as acting without a medical director. Just because someone administers an intervention on their own counsel doesn't mean that they aren't following a protocol. It does, however, provide a certain amount of leeway to provide treatments tailored to the individual patient), then EMS can never be a profession.

Heck, without independent judgement, the only thing that needs to be taught is to follow the cookbook line by line and how to do each procedure.

 

[abckidsmom]

The problem is that the entire reason to increase education is to make providers capable of independent judgement, and without the ability to use independent judgement (which is not the same as acting without a medical director. Just because someone administers an intervention on their own counsel doesn't mean that they aren't following a protocol. It does, however, provide a certain amount of leeway to provide treatments tailored to the individual patient), then EMS can never be a profession.

Heck, without independent judgement, the only thing that needs to be taught is to follow the cookbook line by line and how to do each procedure.

My nephew is just getting started as an EMT-B, and I'm having the hardest time overcoming the stuff he's been taught in class, to teach him how to actually *interact* with people, consider the next step after hearing what they have to say instead of "Uh, chest pain, uh, 15 L NRB, uh..."

I haven't precepted a complteley green EMT in a loooong time. I knew the class was useless, but I'm just shocked at how useless it is.

 

[Elk Oil]

I got a crazy idea...

How 'bout everyone who has been griping about what I've been saying offer up a feasible solution that you can actually implement and see to fruition? You can't because people who aren't you control the structure of the emergency medical system, our levels of certification and scopes of our practice. Simply saying what should be does NOTHING to help the cause. You can become an EMT understanding the scope of what we do, or you can buck it and get frustrated because all of a sudden you know so much more than when you originally got certified.

Read the posts from prospective EMTs on the forum. Remember what it was like to be new, nervous, wide-eyed and curious? Now, you've become disillusioned and frustrated because you think your years of experience have somehow turned to wisdom befitting doctors and that for some reason your scope of practice should be expanded because you've been at this for a while.

Big whoop. We're all still and just EMTs. If it's not good enough for you the way it is, either get involved so you can actually change it or do something else.