Things we can do nothing about?

JPINFV

Gadfly
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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.

If you can talk, you're in a place to help influence those in position to make changes. Furthermore, there's nothing stopping anybody from working with the state agencies that do make those decisions. There are plenty of career ladders in EMS, just not plenty that keeps people perpetually in the ambulance.

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.

First, some of us are becoming doctors. Second, there's nothing wrong with expanding the scope, provided that initial education is also expanded. Just because the system is set up how it currently is doesn't mean that setup is forever set in stone.

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.
No, we all are not all just EMTs.
 

abckidsmom

Dances with Patients
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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.

I work in our system to better educate providers on the streets, and in the CME. I work with our medical director to help with QA. I can show numbers on how what I do makes a difference.

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.

I'm not just an EMT. I practice emergency medicine within my scope of practice with the same brain I use for critical care, cardiology, and family practice nursing. While I'm only using my paramedic certification and not my nursing license, I am bringing a lot more to the table than a patch-factory medic, or a new basic EMT.

I think that if you set the bar too low, and expect people to *always* function with the same knowledge base as they got in class, you're asking too little. I expect providers to act like newbie EMTs only for the first 6 months to a year. After that, I want to see them thinking more, considering the implications of their decisions, and making plans that include abstract thought. It's a tough bill, but doable.
 

usalsfyre

You have my stapler
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As long as we have statewide protocols and uninvolved medical directors, what is will continue to be.

Push for real QA, an involved medical director, guidelines that are able to be written for specific groups of providers and stronger education. Accepting the status quo is failing our patients.
 

abckidsmom

Dances with Patients
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As long as we have statewide protocols and uninvolved medical directors, what is will continue to be.

Push for real QA, an involved medical director, guidelines that are able to be written for specific groups of providers and stronger education. Accepting the status quo is failing our patients.


Statewide protocols are a new concept to me. We don't have them here. We do have regional protocols, but agencies have individual medical directors who give providers a little leeway with that.
 

Elk Oil

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I work in our system to better educate providers on the streets, and in the CME. I work with our medical director to help with QA. I can show numbers on how what I do makes a difference. (1)



I'm not just an EMT. I practice emergency medicine within my scope of practice with the same brain I use for critical care, cardiology, and family practice nursing. While I'm only using my paramedic certification and not my nursing license, I am bringing a lot more to the table than a patch-factory medic, or a new basic EMT. (2)

I think that if you set the bar too low, and expect people to *always* function with the same knowledge base as they got in class, you're asking too little. I expect providers to act like newbie EMTs only for the first 6 months to a year. After that, I want to see them thinking more, considering the implications of their decisions, and making plans that include abstract thought. It's a tough bill, but doable. (3)

1. Good on you. We need more people like you.

2. Yes, but if your system is anything like mine, when you're working as an EMT, you're restricted to that scope of practice. If you pull out a nurse or doctor level of expertise, you're no longer acting as an EMT.

3. Agreed, but thinking more doesn't give anyone license to work outside of their scope of practice, which is what some are contending when they say we should be deciding whether or not people take our ambulances to the hospital.

I can't be the only one who is content to work within my scope of practice, am I? I'm learning new things, getting new certifications, taking classes and course all the time. Yet I don't feel the same frustrations others here do. Maybe I'm just more serene about it all.

If I want to be able to do more, I get certified to do so. If I felt compelled to change our scope of practice, I'd work to get involved with our MCB, protocol committee and the like.
 

Shishkabob

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2. Yes, but if your system is anything like mine, when you're working as an EMT, you're restricted to that scope of practice. If you pull out a nurse or doctor level of expertise, you're no longer acting as an EMT.

Wait, what? I'm not allowed to use things I learn outside of Paramedic school because I'm only working as a Paramedic? I've used knowledge on calls that many a nurse, the supposed "higher" provider, don't even know and questioned what I did until a doctor told them I was right, things I've learned from doctors directly or my own research.


Go ahead and give a benzo and narcotic to a patient and see how much a nurse freaks out about a "Paramedic performing conscious sedation!?!?!"

You can use whatever knowledge you want, so long as what you DO doesn't surpass your scope. My knowledge might tell me the patient is experiencing a certain disease process, and treat up to my scope... however having said that, there's also leeway. If I think something must be done to help a patient, all I have to do is explain my reasoning to a doc and chances are I can do what I have to do, even though it's out of my "scope" (which doesn't exist in Texas, BTW)





Any state that has statewide protocols are archaic. Any legislator and any physician that endorses statewide protocols as a ceiling need to be kicked out of their positions. Statewide protocols, at the very most, should be a floor, NOT a ceiling. It needs to establish a minimum consistency of care throughout the state, not a maximum "Tough luck if you need more"


Texas got it right before any other state: No such thing as state protocols, and the legislature has no say whatsoever in what an EMT or Paramedic can or cannot do. It is up to the individual agency, and as such, med control, to decide what is and is not a good match for their employees, their agency education, and their QA.

That's why here in Texas, you have agencies that have RSI, beta blockers and heparin for MIs, tPA for strokes, chest tubes, pericardiocentesis, needle and surgical crichs, ultrasound for things such as FAST exams, Paramedic initiated code strokes and code STEMIs that allow straight bypass through the ER, saving precious time.


(Then you have agencies like Dallas fire, who can't intubate or give narcotic analgesics....because they don't give a damn about education)



PS Elk... Paramedics are not EMTs.
 
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WuLabsWuTecH

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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?

The percentage of doctors that engage in research puts them in the minority. The number of cases they do trials on in even smaller. The MAJORITY of their mistakes that result in negative patient outcomes are not from research. I've been in medical research for the past 3 years, and I would argue that those patients are safer the the rest of the population at large with the amount of checks and rechecks in place!

I think a lot of us are missing the crux of your argument here which I just realized after reading this last post. Your argument is not that most EMT's can't use good judgment, but rather all EMT's shouldn't be asked to use judgment. You are claiming that our job should not be to use judgment right? If so, most of the arguments outlined here are moot because a lot of stopple are arguing that some EMT's can use good judgment.

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.

It's extremely feasible! Let the medical directors decide as they do now! I'm telling you that we have certain in charge people who can "turf" someone with whom they think there is nothing wrong! Their refusals are QC'ed by the medical director and their refusal rate is posted on a chart.

Similarly, at another department, certain in charge people can clear C-spine in the field. These are generally the guys who have decades of experience. And they also have the judgment to know when not to use this privileged. The clearing of c-spine has been on our protocol a year and I'm having trouble remembering the last time I saw it used...



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.

Agreed, having good judgment means also knowing when you lack the wherewithal to use your judgment and to defer to others' judgment (aka med control or protocol)
 

WuLabsWuTecH

Forum Deputy Chief
1,244
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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.

Read the last post I just posted, we have things like that implemented. It's just a matter of whether you want to try to advance the field or sit on your butt and say it's ok the way it is right now. Sorry for double posting but you posted while I was still working on my last post!
 

Elk Oil

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Wait, what? I'm not allowed to use things I learn outside of Paramedic school because I'm only working as a Paramedic?

You can use whatever knowledge you want, so long as what you DO doesn't surpass your scope.

We agree. I think that's what I've been saying. Forgive me if I didn't convey it.

PS Elk... Paramedics are not EMTs.

That'll be our little secret. But I could have sworn that before your "P" is an "EMT." Last I checked the National Registry (the body that has certified you) says you're an Emergency Medical Technician - Paramedic, but I promise I won't let them know. In fact, you say it yourself by listing it as your training under your avatar, so don't look.
 

JPINFV

Gadfly
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2. Yes, but if your system is anything like mine, when you're working as an EMT, you're restricted to that scope of practice. If you pull out a nurse or doctor level of expertise, you're no longer acting as an EMT.
You're limited in assessment tools and interventions available, however there's a lot that you can do with your basic senses to improve your assessment as well as your interpretation of your assessment.

3. Agreed, but thinking more doesn't give anyone license to work outside of their scope of practice, which is what some are contending when they say we should be deciding whether or not people take our ambulances to the hospital.
Scopes of practice can be changed and adjusted. They aren't static.
 

WuLabsWuTecH

Forum Deputy Chief
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First, some of us are becoming doctors. Second, there's nothing wrong with expanding the scope, provided that initial education is also expanded. Just because the system is set up how it currently is doesn't mean that setup is forever set in stone.

Correct! When I work in other states or meet people from other states and tell them I'm a basic but in Ohio I can intubate, people look at me as if I had a second head! But that is within our scope here! And we have the initial training for it!

Since I started 3 years ago, we now can do 12 lead EKG transmissions, CPAP, and albuterol to name the changes we encounter most commonly.

No, we all are not all just EMTs.

+1

I'm not just an EMT. I practice emergency medicine within my scope of practice with the same brain I use for critical care, cardiology, and family practice nursing. While I'm only using my paramedic certification and not my nursing license, I am bringing a lot more to the table than a patch-factory medic, or a new basic EMT.


Wait, what? I'm not allowed to use things I learn outside of Paramedic school because I'm only working as a Paramedic? I've used knowledge on calls that many a nurse, the supposed "higher" provider, don't even know and questioned what I did until a doctor told them I was right, things I've learned from doctors directly or my own research.

You can use whatever knowledge you want, so long as what you DO doesn't surpass your scope. My knowledge might tell me the patient is experiencing a certain disease process, and treat up to my scope... however having said that, there's also leeway. If I think something must be done to help a patient, all I have to do is explain my reasoning to a doc and chances are I can do what I have to do, even though it's out of my "scope" (which doesn't exist in Texas, BTW)

Any state that has statewide protocols are archaic. Any legislator and any physician that endorses statewide protocols as a ceiling need to be kicked out of their positions. Statewide protocols, at the very most, should be a floor, NOT a ceiling. It needs to establish a minimum consistency of care throughout the state, not a maximum "Tough luck if you need more"

Texas got it right before any other state: No such thing as state protocols, and the legislature has no say whatsoever in what an EMT or Paramedic can or cannot do. It is up to the individual agency, and as such, med control, to decide what is and is not a good match for their employees, their agency education, and their QA.

That's why here in Texas, you have agencies that have RSI, beta blockers and heparin for MIs, tPA for strokes, chest tubes, pericardiocentesis, needle and surgical crichs, ultrasound for things such as FAST exams, Paramedic initiated code strokes and code STEMIs that allow straight bypass through the ER, saving precious time.

(Then you have agencies like Dallas fire, who can't intubate or give narcotic analgesics....because they don't give a damn about education)

PS Elk... Paramedics are not EMTs.

Thank you guys for not checking your brain at the bay door. And I like Texas's legislation. Your medical director knows his people the best and knows what they can learn and are willing to learn.

Also Linuss--in Texas, paramedics are not EMTs, but in most places, they still are. Not everyone has that fancy paramedic degree you guys got down there! And while I'm giving you a shout-out, hopefully you guys get some rain this weekend!


As long as we have statewide protocols and uninvolved medical directors, what is will continue to be.

Push for real QA, an involved medical director, guidelines that are able to be written for specific groups of providers and stronger education. Accepting the status quo is failing our patients.

+1, that's why we got a new medical director. When you have drugs listed on your license that are no longer produced, it may be time to get someone a bit more involved...

3. Agreed, but thinking more doesn't give anyone license to work outside of their scope of practice, which is what some are contending when they say we should be deciding whether or not people take our ambulances to the hospital.

I'm slightly confused now. You said you guys have a statewide protocol, and telling someone they may not need to go is outside of that scope? So you have to try to convince each and every patient to go in the state? That's baffling!
 

Elk Oil

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I think a lot of us are missing the crux of your argument here which I just realized after reading this last post. Your argument is not that most EMT's can't use good judgment, but rather all EMT's shouldn't be asked to use judgment. You are claiming that our job should not be to use judgment right? If so, most of the arguments outlined here are moot because a lot of stopple are arguing that some EMT's can use good judgment.

I think we're pretty close on this. My contention is that there have been some nasty historical precedents by people who have shown they can't be trusted to express sound judgement. That only serves -- in some systems -- to prevent others from being allowed to expand their capabilities within their levels of certification.
 

Elk Oil

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You're limited in assessment tools and interventions available, however there's a lot that you can do with your basic senses to improve your assessment as well as your interpretation of your assessment.


Scopes of practice can be changed and adjusted. They aren't static.

I agree on all counts.
 

WuLabsWuTecH

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That'll be our little secret. But I could have sworn that before your "P" is an "EMT." Last I checked the National Registry (the body that has certified you) says you're an Emergency Medical Technician - Paramedic, but I promise I won't let them know. In fact, you say it yourself by listing it as your training under your avatar, so don't look.

He's referring to specifically another level in Texas above EMT-P called "Paramedic." My friend was trying to get me to accept a job out at her summer camp a couple of years ago since they needed a full time EMT and I was looking up the licensure requirements which is the only way I know this. I ended up not taking the job since Texas is hot and I had just laded a similarly paying job back here!)
 

WuLabsWuTecH

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I think we're pretty close on this. My contention is that there have been some nasty historical precedents by people who have shown they can't be trusted to express sound judgement. That only serves -- in some systems -- to prevent others from being allowed to expand their capabilities within their levels of certification.

The problem we run into here is that one bad apple ruins them all... I think you have to prove to your MD that you can use sound judgment on certain topics for him to let you expand out to fill in what he think you are capable of. By no means would I advocate for letting every EMT be allowed to advise someone that they might not need the ambulance. Even though I can do so, as a basic, I know my skills are limited and haven't ever advise someone they don't need to go without a medic present also concurring.
 

Shishkabob

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That'll be our little secret. But I could have sworn that before your "P" is an "EMT." Last I checked the National Registry (the body that has certified you) says you're an Emergency Medical Technician - Paramedic, but I promise I won't let them know. In fact, you say it yourself by listing it as your training under your avatar, so don't look.

Go back and check the NREMTs newsletters. The "EMT-Paramedic" is to be known as "Paramedic". Currently the post-nominals are still "NREMT-P", but when 're-certified' it will then be "NRP" for Nationally Registered Paramedic.

This is due to the NHTSA taking EMT off of Paramedic.


It's been decided that Paramedics are no longer to be considered technicians.




And while I'm giving you a shout-out, hopefully you guys get some rain this weekend!

It rained while I was riding my motorcycle home from work the other day. I was not expecting it to rain due to only a 10% chance.... gah.
 
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Elk Oil

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The problem we run into here is that one bad apple ruins them all...

Yes! Precisely. I wish all systems had the same latitudes to allow certain EMTs the ability to do things others with the same level of certification, but the ones around me aren't so progressive.
 

usalsfyre

You have my stapler
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I thought NR had stopped putting "EMT" in front of "P". Let's be honest though. Calling a paramedic an EMT is like calling a chef running a five star kitchen a cook. They may have a little overlapping knowledge, and they both have important jobs, but the knowledge base is clearly not equal.
 

usalsfyre

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Yes! Precisely. I wish all systems had the same latitudes to allow certain EMTs the ability to do things others with the same level of certification, but the ones around me aren't so progressive.

Because your OMDs or management are uninvolved or too afraid to think outside the box. Not that unusual unfortunately.
 

usalsfyre

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My contention is that there have been some nasty historical precedents by people who have shown they can't be trusted to express sound judgement.
I see your point, but disagree mightily. If they're too unreliable to make a relatively simple judgement of something that clearly doesn't require transport, then why do we trust them with complex decisions like when to take an airway, administer meds that are potentially lethal, when to call for HEMS, ect, ect...

If they suck that bad, reeducate. If they still suck, fire and/or decertify them.
 
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