What do you think is the most important thing EMS does?

[Veneficus]

Over a period of years, on several threads, I have detailed what EMS does.

Most recently I mentioned that the universal function of EMS is to act as a portal for people to enter into the healthcare system. Whether you are in Australia, Germany, the US, Russia, or any other nation that has EMS, a healthcare provider associated with such service shows up, performs various levels of assessment, and either treats the pt, dispositions the pt to another healthcare or social service, and/or can usually transport to such.

Now we all have different education levels, and our focus on transport, treatment, or disposition may be different, and the way our systems are set up all vary considerably. even in the same nation on occasion.

Now it is therefore logical to me, that the ability to determine what is the issue with our patients is perhaps the single most important thing EMS does.

Figure, if you never check to see if somebody is breathing, how would you know when to ventilate them? If you do not understand pathology (even at the most basic level) how do you know when to call for more advanced help, initiate and invasive procedure, or begin immedate transport?

So why is it, that on many occasions EMS professionals never perform a reasonable examination? I read it somewhere: visualize, auscultate, palpate, percuss, and so on depending upon the need.

In another thread I neglected to ask if the patient had a medication patch on. It seemed so obvious to me, that when you examined the chest, listened to the heart, checked for abnormalities, and even put on an EKG, that if you saw a bg sticky square thing, it would register as being significant. Just as it would be if you saw a leech or a tic attached. I was then told that I never stated I was lifting up the pts. shirt. Now I am not posting this to complain, but some will think so. I am posting this because I want to hear some opinions.

Why are providers not performing a complete exam and history? I'll be the first to admit, I don't completely disrobe every patient I see. But I do make sure to selectively lift, move, etc, every piece of clothing untill I am satisfied there is nothing to find. Sometimes I simply ask the patient to check for me or tell me. But an unconscious patient is going to get the full workup. Nothing will be left to chance.

Whether it is a difficult airway prior to an RSI, or a refusal to transport decision, how could anything we do be more important than assessment?

Why do we spend so little time on it compared to other "skills?" Did simple memory aides like, DCAPBTLS, somehow excuse us from touching the patients?

In the US, we spend hours and hours practicing intubation. Exam techniques are barely touched upon. Some will say that you can kill a person if you mess up an intubation, but I think you have a lot better chance to kill a person with a poor or incomplete assessment and more often. Just ask the folks down in DC.

So how do we go about refocusing on assessment? How do we make it as important as applying a spineboard or reading a heart monitor? For either without assessment is useless if not harmful.

 

[MonkeySquasher]

You hit the nail on the head.

I caused an uproar at my volunteer company last month. I asked a group of our Basics and a CC* what the biggest difference was between a Paramedic and a Basic. All the Basics said "drugs!" or "tubes!" or "lines!", the CC said "education". I told them, no, assessment skills.

((*For those who don't know - In NYS, we have a level called Critical Care, which is between Intermediate and Paramedic. They have much of the same skill- and drug-sets as a Medic, but only do around 350 hours of class time and 200 hours of clinical time, as opposed to our almost 1300 combined hours. We affectionately call them "shake-and-bake Medics".))

Let's face it, other than you CCT/ICU/Flight Paramedics, how often do we REALLY use all those fancy drugs in the field? The core of any patient care is a proper thorough assessment. And outside of certain level-restrictions (ECG/12Lead, etc), Basics can, and SHOULD, be taught proper assessment and A+P more than anything. But I know this seems to be preaching to the choir on here.

I think the problem rests at complacency. People become complacent. Basics use "Oh, I don't know what to do", or "Well I can't do anything anyway", or "I don't know what's wrong". Medics tend to use the ol' "They're fine" or "I already know what this is" attitude sometimes.

Back to the above.. My volunteer company is a tad different. Take today for example.. We get a call to the local university for a 19y/o female, abdominal pain. We find her laying in fetal position on the bed. I usually stand back and let the crew do their thing and make sure no one dies (there's a story behind that one...), so I'm just listening. The crew (BLS) asked 3 questions... "You're having abdominal pain?", "Did you throw up?", and "Is anything else wrong with you?" From there it became "Okay, stand up and sit on the stretcher", and took her to the rig. On the rig, they attach the monitor's SPO2 sensor for HR/pulse ox, and the NIBP for pressure (no manual done). In the rig they asked History, Allergy, Meds, and if she was pregnant (not "is there a possibility"). All this as we transport.

On our end, it tends to come down more to inexperience than complacency, even though that's also rampant among ALS providers due to a hospital within our first due area.

 

[MrBrown]

You raise a very good point, and again I think it comes down to the limited foci and education of EMS providers that has worked its way into the "acceptable" pile.

I think assessment is the most important thing you can do and that it is from assessment you form a good working impression of what is wrong with your patient, or what you think is wrong.

The several cases which have come back to bite here have really focused around missed assessment findings or poor assessment e.g. the hypothermic PE, the large gentleman who had fallen several times (and did not usually fall), the hypoglycaemic patient who had a recent history of beeing poorly compliant and the young child who had early signs of meningitis what weren't picked up.

I think assessment is not focused on as well as it should be because its probably been thought up before and the majority of the time the answer I have heard is "it won't change anything" meaning it won't allow some alternate regimen of treatment.

Overly standardized and blanket protocols have really removed the need for a good, thorough assessment. For example give salbutamol in shortness of breath, GTN to chest pain, somebody is hypotensive so give them some fluid. It doesn't matter what is done in the field because the patient is only with the Ambo's for a half hour seems to be the mentality of some.

Our cardiac chest pain guideline is said to require "significant clinical judgement" in that it can be used on people we think are having a silent MI. However, I doubt some of our providers and the 24 week part time Technician wonders especially would have the ability to make "significant" judgement.

Judgement of when and when not to apply a particular treatment is far more important than the actual treatment itself; e.g. adrenaline and frusemide; look at how many trucks are having frusemide pulled (heck I hear its possible to diagnose lower back pain as cardiogenic edema in Los Angeles) and there was that those Firemedics in MA who had IV adrenaline removed or heavily restricted because of inappropriate use coming from poor assessment.

So how do we fix it and focus on assessment? Well first of all we need to figure out what sort of assessment we need out there in the field, to give an example this is what is written about our "primary" and "secondary" survey:

Primary Survey

• Airway: examine for and establish an adequate airway.
Consider the possibility of cervical spine injury, but the airway takes priority.

• Breathing: examine for and establish adequate breathing. Look at and feel chest movement.

• Circulation: examine for and establish adequate circulation. Feel
pulse rate and strength, look at and feel peripheral perfusion/ capillary refill.
Check for (and compress) external bleeding.

• Disability: check the level of consciousness using AVPU or motor
score of GCS. Consider immobilising the cervical spine if appropriate.

• Exposure, examination and environmental control: appropriately
expose and examine the patient. Keep them warm

Secondary Survey

The secondary survey follows the primary survey.
Do not conduct a detailed secondary survey if there are major abnormalities in the primary survey.

Central Nervous System
• Record a GCS. Individually examine and record each component.
• Check the patient can talk normally, move their face and move and feel all four limbs. Look for unilateral weakness.

Head and Face
• Look and feel for deformity, tenderness and bleeding.
• Look for pupil asymmetry and reaction to light.

Neck
• Look and feel for deformity and tenderness.
• Immobilise cervical spine if required and not already done.

Chest
• Look, feel and listen for symmetry of air entry, breath sounds, tenderness and crepitus.

Abdomen and Pelvis
• Look and feel for tenderness or distension.

Extremities
• Look and feel for wounds, fractures, colour, capillary refill, gross
sensation and movement.

Back
• Look and feel for tenderness and deformity.

FURTHER RECORDINGS
Following the secondary survey, recheck and document the patient’s
vital signs:
• Respiration rate including regularity and depth.
• Pulse rate including regularity and strength, peripheral perfusion and capillary refill time.
• Blood pressure.
• GCS.

The completeness and frequency of vital sign recordings requires clinical judgement and must take into account patient condition,
priorities, treatments and transport times. In general it is
inappropriate to stop the ambulance to perform vital sign
recordings and these should be performed enroute. Depending on
the patient’s problem it is appropriate to record and document
other parameters such as blood glucose, cardiac rhythm, 12 lead
ECG, SpO2 etc. These should be re-recorded at clinically appropriate
intervals and documented accordingly.

Take and document an appropriate history. This should include
mechanism of injury (if trauma), symptoms, prior events, medical
history, medications and allergies. All treatments and interventions
must be documented. Rhythm strips and 12 lead ECGs should be
attached to the hospital and audit copy of the PRF.

Does this mean that I have dont this on every patient I've been to or will ever go to? No, the key point here is what is clinically appropriate.

Here is the 1998 EMT-Paramedic techniques of exam cirricula

Here is the 1998 EMT-Paramedic patient assessment cirricula

Now both those look fairly good documents that cover the bases but do you honestly think people really give a crap about it or that you can learn it in the majority of time that most programs have to teach? No.

Can you learn it in 12 weeks at Houston Fire school or six months at the local community college? Is a couple hundred hours of "internship" adequate time to apply it? Are students able to understand it adequately when they've never taken decent science classes? Do all the whackers and batman and ricky rescues want to learn about all that boring stuff? No, no, no and no.

So how do we fix this you ask? Now I know I am preaching to the converted but again its very simple; better education and less emphasis on "skills" and "load and go" and red lights and sirens.

 

[firetender]

...and now, some reality...

If we're breaking things down to the bare essentials of what the most important thing we do, it boils down to this:

We are trained as professionals (a lot of us, anyhow!) to remove the injured, stricken, physiologically compromised, debilitated, discarded, bewildered, wounded, compromised, crippled, distraught, in short, those of the human race afflicted with any real or imagined, potentially disabling malady AWAY from the scene of their torment, but most importantly, AWAY from the view of able-bodied witnesses and into a system designed to intervene out of view of the public.

We are at the bottom of a trickle-down system that places us at the juncture between self-management and loss of control. Our job is to face the innumerable traumas, both big and small, of every day life (presumably on the medical end but we all know what a crock that is!) so that everybody else doesn't have to!

We are a reflection of a corporate-driven push to take the individual away from all of the "folk" resources that once formed the backbone of medical care and intervention so that they, whoever they are, can make some dough. This sort of self-protection is evident in the AMA and other professional organizations. In fact, if we are to make our lives better, we're going to have to protect our interests as strongly as they do theirs!

Essential to that end is removal, and that's our function.

Without pointing the finger (I said "pointing") too harshly, much of it revolves around we, as a people who are rapidly overpopulating the planet, becoming less connected with each others' real lives and more involved in the fantasy that we will live forever. Why? because most of us don't get to see a whole lot of otherwise, EMS takes care of that. It is the poor who watch each other die.

What's important is that MOST of the people out there continue to be productive citizens, and the rest, thanks to us, are taken into the back room where they can't be seen. If the people are really involved in the personal traumas of our community, there just won't be the time to be the vehicles of profit for the top of the food chain.

And on this site, we argue about who's cooler; Street Cleaner Level I, II or III.

Go figure.

 

[Veneficus]

Mr.Brown

As i read through your post I notice a lot of words that seem to not be followed by many providers in the field setting:

"• Breathing: examine for and establish adequate breathing. Look at and feel chest movement."

"• Exposure, examination and environmental control: appropriately
expose and examine the patient. Keep them warm"

Now this second statement can cause some confusion I'll admit. For example, what is "appropriately" referring to? Medically appropriate? Environmentally appropriate? How about Modesty?

the first two don't conccern me as much as the last. When most patients are seen by me or a doctor, they are more than ready to be disrobed, touched, questioned, and probed in every hole we can find. Occasionally making one or two new ones. This is all done so the proper dx and treatment, even those not relating to a chief complaint can be addressed.

Now it can be argued that is in the hospital and not the field, but here is the rub... If the purpose of EMS is to properly care for or direct patients to the proper resource, how the hell can you do that if you don't look for things other than what is apparent when somebody is wearing layers of cloths and maybe even a blanket or two?

How do you find that the difficulty breathing is because of the overly restrictive corset?

Even in my school we are taught all those bells and whistles on all those machines are "adjuncts" to the exam. We are not at the star trek level where the little machine tells you everything. (actually the more I learn the less the machine tells me)

You detailed "missed" exam findings. How is that in anyway suprising when people don't routinely perform a complete physical? If you don't retain your skill at intubation without regular performance, how could you possibly hope to retain something as encompassing as a physical exam?


Now we talk about education, and I respectfully disagree with MonkeySquasher, you cannot possibly hope to teach a basic a physical exam and history (assessment) that is adequete for anything more than airway breathing and circulation. Not because I don't value basics, but because the amount of knowledge required far in excedes determining whether or not something is "abnormal." The very nature of occult injuries or illness requires in order to determine if they exist, you must know what they are, where to look for them, and how. As an example, thyroid storm. It is not even mentioned in the basic text. It is a life threatening condition. Extra uterine pregnancy, not even mentioned in the paramedic text, a life threatening condition.

Now neither of these are treatable in the field, but let's face it. Neither is an MI. If it was you could just render care and leave people where you found them. But without even the knowledge those conditions exist, you could easily write a patients complaint off as BS. On people who are not obese, you can press on the abdomen and feel a kidney stone in a ureter.

Now in the time it takes to teach people all of the things they would need to know to do that, they would be called "doctor" at the end, so I am not suggesting we take it to that extreme, but I am suggesting we (more for the folks in the US, since they are far behind the world curve) need to step it up a bit in the education dept. But we here already know that.

But what I am really interested in during this thread is ideas for how we can get the current rank and file in the mode of performing better exams. an improper exam technique by a student is not nearly the issue it is of a current provider.

 

[DrParasite]

You hit the nail on the head.

I caused an uproar at my volunteer company last month. I asked a group of our Basics and a CC* what the biggest difference was between a Paramedic and a Basic. All the Basics said "drugs!" or "tubes!" or "lines!", the CC said "education". I told them, no, assessment skills.

Interesting.... According to a former medic student, the only difference between an ALS assessment and a BLS assessment was the use of a cardiac monitor.

BTW, yesterday I asked my Ops Supervisor (paramedic for 12 years) if a bleeding shunt should be an ALS dispatch. I said no, since you just control bleeding and rapid transport to the ER (which is exactly what the ER does). She said yes, as a person can bleed out. Also asked her about the toe pain call. After getting the quizzical look, I explained that on here, toe pain is an ALS dispatch, because it might be referred pain from an MI. She then told me if I ever called for an ALS unit for a patient with toe pain and no other symptoms she would fire me on the spot for being unable to differentiate between an ALS patient and a BLS patient.

 

[CAOX3]

Assessment!

 

[mycrofft]

Restraint.

Not of the pt's but of ourselves.

First we should do no harm, and part of that is assessment and then appropriate, considered and technically adept measures...if any.

 

[MrBrown]

Interesting.... According to a former medic student, the only difference between an ALS assessment and a BLS assessment was the use of a cardiac monitor.

I must disagree.

I
BTW, yesterday I asked my Ops Supervisor (paramedic for 12 years) if a bleeding shunt should be an ALS dispatch. I said no, since you just control bleeding and rapid transport to the ER (which is exactly what the ER does). She said yes, as a person can bleed out. Also asked her about the toe pain call. After getting the quizzical look, I explained that on here, toe pain is an ALS dispatch, because it might be referred pain from an MI. She then told me if I ever called for an ALS unit for a patient with toe pain and no other symptoms she would fire me on the spot for being unable to differentiate between an ALS patient and a BLS patient.

Severe bleeding should be an ALS job, control bleeding and start fluid therapy. Why must we be so obsessed with "ALS" vs "BLS" patients.

As for the toe pain ... nah I'm leaving them at home!

 

[Melclin]

As an example, thyroid storm. It is not even mentioned in the basic text. It is a life threatening condition. Extra uterine pregnancy, not even mentioned in the paramedic text, a life threatening condition.

Now neither of these are treatable in the field, but let's face it. Neither is an MI. If it was you could just render care and leave people where you found them. But without even the knowledge those conditions exist, you could easily write a patients complaint off as BS. On people who are not obese, you can press on the abdomen and feel a kidney stone in a ureter.


Now in the time it takes to teach people all of the things they would need to know to do that, they would be called "doctor" at the end...

A very great deal of our bachelors degree revolves around conditions we cannot treat and often can't really diagnose in the field with any degree of certainty, and people often moan and whinge about why we have to learn about things like extra uterine pregnancy, the difference between between a non-ketotic coma and DKA, the differential for an acute abdomen etc. We drive to hospital. Sometimes I believe they may have a point. I certainly got a bit sick of studying various genetic diseases knowing that I'd never know enough to make decisions about transport - the parents/carers know far more than we will.

I sit there and think, we should add this to the degree, we don't know enough about that...oh this too. Then I find I've put together a medical degree. It is difficult to know where the line is. I believe that you need to know enough theory to meaningfully interpret the information you collect. Other wise there's no point in collecting it.

As a St John's first aid volly we learn, for example, a respiratory status assessment: Assess - Position, Appearance, Speech, Rate, Rhythm, Effort, Breath sounds, Skin, Pulse and Conscious state. Problem is though, they can't interpret any of the information usefully. Think about how much information you could be gathering about a persons health status in all that. You can then say that you add the education necessary to identify the conditions that you have protocols for. Hear a wheeze? Its asthma. Hear a crackle? Its APO. Unfortunately disease are quite unaccommodating and have the audacity to present differently from time to time. So you learn a bit more. Then you have complicating issues? Oh you've got cystic fibrosis? Hmm, wonder what that means for my PASSRESPS. So you add more educations. You end up with hours of lectures on conditions you don't directly treat in ambulance but that you need to understand in order to practice competently. Then it all makes sense again. That CF kid with unusual SOB? He went to direct to the Alfred CF unit because the paramedic used to be a CF nurse specialist and knew he was in trouble. If it was EMT treating him, he would have ended up in nearest public ED, 90 miles from anywhere and the EMT wondering what CF was.

The toe pain that Dr Parasite mentions is I assume a reference to an earlier debate we had on education where a toe pain patient turned out to be a silent MI and the crew saw it for what it was so she went direct to the cath lab, arresting twice along the way. All of a sudden that three hour lecture on diabetic neuropathy you hated in 3rd year seems a bit more relevant and you realise that being an ambo is a little more than recording the 3 word answers to SAMPLE on your PCR. She didn't initially get an ALS response, it was the basic crew that identified it. Sending MICA to every toe pain on the off chance it might be a silent MI is absurd, however, the difference here is our definitions of basic. We all have a giggle over here about the fact that you blokes seem to think that an EMT is an adequate basic response, and a paramedic with his tubes and a monitor and his, at most 2 years of education, actually qualifies as advanced care. No, toe pain doesn't require a top tier response, but it does require an adequate evaluation by someone who actually understands the information they collect.

What about the "3:13am, Signal 2: Psych- non violent, non-suicidal"? You get there and a young girl is upset and complaining of shortness of breath. Is she having a panic attack? Or do the chemo therapy drugs she mentions and her mild fever make you think PE?

Triage (yeah I'm putting sub heading in my posts now..what of it?)
Most of all that education is all about triage. In an extended sense, (I realise its already been mentioned) that is at the heart of what we do. Firstly, of course there is your MCI triage. More commonly though, we decide which patients get flown to the Alfred trauma centre, which patients can go to Backwater creek urgent care clinic and which patients stay at home. These are difficult decisions to make, and you sure as hell can't do it with a advanced first aid certificate like the EMT. Then, the often unmentioned triage...triage nurses in the majority of cases barely touch the patient. And they triage based on what we tell them.EXAMPLE: Toe pain? Out in the waiting room with you. OR (?) Silent MI, and here's the ECG. Into resus you say? You've cleared a bed because I called it in 15 mins ago you say?

Whats that Paramedic, that bloke from the nursing home might be septic? Mmmm good idea, I'd better light a fire under Dr. Bobs arse and get him to write out those blood culture orders.

There are a million reasons why more education is better. Mostly though its about readjusting the odd standards you guys have in the states. There is this mindset like a bachelors degree is excessive education. Every other bloody HCP has one as an entry level requirement...get it together.

 

[Aidey]

So why is it, that on many occasions EMS professionals never perform a reasonable examination? I read it somewhere: visualize, auscultate, palpate, percuss, and so on depending upon the need.

.....

Why are providers not performing a complete exam and history? I'll be the first to admit, I don't completely disrobe every patient I see. But I do make sure to selectively lift, move, etc, every piece of clothing untill I am satisfied there is nothing to find. Sometimes I simply ask the patient to check for me or tell me. But an unconscious patient is going to get the full workup. Nothing will be left to chance.

None of these are meant to be excuses, but more explications as to why people find it easier to be lazy.

I work for a private service. People complain. A lot. If the patient isn't serious we are viewed as a taxi service and people want to know why we are messing around and don't just bring them to the doctor. On serious patients people complain because we "waste time" instead of taking them straight to the hospital. Patients complain they were exposed. Patients complain we cut their clothes off.* Patients complain when we ask them not to wear coats, sweat shirts etc (even though we provide blankets). Patients with 4 layers on complain that they will catch pneumonia if they have to take anything off (not kidding). You get the idea.

We do not carry any paper or cloth gowns, just as an FYI.

Our company is insane about seat belts, we are required to use several. If we undress the patient before putting them on the gurney it is hard to keep their upper chest/shoulders covered. If we undress them in the ambulance (without cutting stuff off) we have to undo everything, undress them, and then re-do it all up. It adds time and I think for a lot of people it is easier just to transport than mess with it.

It is especially a pain in the arse when you learn about a symptom 1/2 way through transport and want to do a 12 lead or re-check lung sounds and they are all trussed up like a turkey.

The easy solution is "just undress and redress them in the house before you transport, duh". The problem there lies in the fact we are an (ALS) transport agency in an area with mostly ALS first response FDs. We've had fire medics and fire officers COMPLAIN to our company when crews spend "too much time" on scene after the fire medic tells us to transport. Basically, if the fire medic doesn't do it, and we do it upsets their delicate egos because they think we don't trust them or whatever.

* True story, our company replaced the clothes of a patient who had his clothes cut off while unconscious because he raised such a stink about it. He was unconscious after consuming a large amount of alcohol and who knows what else.

 

[SanDiegoEmt7]

There are a million reasons why more education is better. Mostly though its about readjusting the odd standards you guys have in the states. There is this mindset like a bachelors degree is excessive education. Every other bloody HCP has one as an entry level requirement...get it together.

This post makes me want to move to Australia/New Zealand

 

[Veneficus]

"I certainly got a bit sick of studying various genetic diseases knowing that I'd never know enough to make decisions about transport - the parents/carers know far more than we will. "

You and me both my friend. Untill they tell me how to treat germ cell mutations in every cell in the patien's body, it is the same supportive care you could get from a nurse or a paramedic.

Along the same lines though: Most of the time we spend in genetics, pathology, and biochemistry in medical school, is so we know these conditions when we see them. It is no recognizing that the marfan syndrome guy who "isn't feeling well" today with N/V is predisposed to heart failure, so we send him to cardiology instead of discharging him with some antiemitics and maybe some theraflu.

You said it best, it is not about how you will treat, it is about understanding the findings you are looking at. (inspired,I am going to start using that.)


* True story, our company replaced the clothes of a patient who had his clothes cut off while unconscious because he raised such a stink about it. He was unconscious after consuming a large amount of alcohol and who knows what else.

Private companies are weird like that, I had a patient who was in a pickup truck that was run over by every axel of a "cane train." How this guy survived with only the minor injuries he had defies belief, there wasn't a piece of his truck undamaged. After we dropped him off at the hospital, I get a call from the supervisor: "Did you see the patient's glasses?" I related I didn't see a piece of intact glass or metal on the whole scene while we (the FD and us) were cutting him out. Long story short, we paid for his glasses.

Having worked as a medic on an FD, I can tell you that while the title is the same, the job is different. It doesn't surprise me that there is tension between the FD an your service. It does help to communicate your responsibility to them though, because when they compare what they are doing to what you are, the assumption is because it is not the same, you are wrong.

I realized this when I was working a 3rd service and a FD medic decided to ride with me because "the kid could crash." While my partner was in the squad bagging the kid in respiratory arrest (he was vent dependant for years and mom called 911 because despite being a very proficent care giver she couldn't make the machine stop beping) So I told my partner we would leave after I got the vent settings. The FD medic was stunned, how could I not rush off like a bat out of hell with a not breathing kid, "a real emergency". (who hadn't been breathing in years, which is why he was on a vent) I think he came to see what other substandard care I was providing. When we got to the hospital, the only question the doc asked at the door was "do you have the vent settings?" When I replied I did, he said "take him right up to ICU, they are expecting you." Said firemedic then humbly related he had no idea what being a paramedic was. His job was to show up and do skills until we did. Relations with the FD after that were much improved.

 

[Aidey]

Having worked as a medic on an FD, I can tell you that while the title is the same, the job is different. It doesn't surprise me that there is tension between the FD an your service. It does help to communicate your responsibility to them though, because when they compare what they are doing to what you are, the assumption is because it is not the same, you are wrong.

I realized this when I was working a 3rd service and a FD medic decided to ride with me because "the kid could crash." While my partner was in the squad bagging the kid in respiratory arrest (he was vent dependant for years and mom called 911 because despite being a very proficent care giver she couldn't make the machine stop beping) So I told my partner we would leave after I got the vent settings. The FD medic was stunned, how could I not rush off like a bat out of hell with a not breathing kid, "a real emergency". (who hadn't been breathing in years, which is why he was on a vent) I think he came to see what other substandard care I was providing. When we got to the hospital, the only question the doc asked at the door was "do you have the vent settings?" When I replied I did, he said "take him right up to ICU, they are expecting you." Said firemedic then humbly related he had no idea what being a paramedic was. His job was to show up and do skills until we did. Relations with the FD after that were much improved.

Unfortunately one of the provisions of our contract is that we (the company) can be fined if a fire medic or any fire fighter feels we have been disrespectful/argumentative etc. It is a very slow process to try and politely educate medics who have kids my age (plus I'm female which doesn't help). We're still working on not transporting pts in asystole.... (If the medics disagree, the one saying transport wins...guess which medic that usually is...)

*facepalm* acute vs chronic.....lol

My favorite "WTF are you doing" moment was when I had a PD dialysis pt who had a sudden onset of severe abdominal pain. She had drained her PD fluid before we got there to see if that would help (it didn't). I wouldn't transport until we got the bag loose from the set up and took it with us. The fire fighters were grumbly and all like "dude, your partner is freaking nuts" to my EMT, who was even like "WTF are you wasting time with that for?". We get to the hospital and I leave it with the RN. Several minutes later while waiting for the paperwork I hear the RN and doc talking. Doc said something like "We need x, y, z, a, b, c tests. Of course we don't have the fluid to do a culture on" and the RN replied "Well, actually the paramedic grabbed it, it's in the room". The doc said "Seriously? Best news I've had all day".


I wonder if the disconnect with stuff like that is because the FMs don't transport nearly as much, so they don't think about what the hospital will need. They think 'I can't use it, so I don't need it". Sure we can't do much with vent settings or dialysate in the field but the hospital can.

 

[Veneficus]

Unfortunately one of the provisions of our contract is that we (the company) can be fined if a fire medic or any fire fighter feels we have been disrespectful/argumentative etc. It is a very slow process to try and politely educate medics who have kids my age (plus I'm female which doesn't help). We're still working on not transporting pts in asystole.... (If the medics disagree, the one saying transport wins...guess which medic that usually is...)

I can't imagine how desperate for a contract your company must be, or who in their right mind would sign something that could so arbitrarily cost the company money.

I would say the solution to your concerns is to raise them with the medical director, who will probably raise them with the FD medical director, who informs the chief, and a top down approach is implemented, rather than a rank and file upwards. Clearly the field firemen are not capable of performing patient care.

I would probably be fired from or quit your agency in such circumstances, but not before I launched a state EMS investigation, a medicare one if they bill for it, and a public media drive and alert the local tea party (the enemy of my enemy is my friend) about how these guys do nothing and get a government cheque. You have much more patients for BS than I do.

(here about this time some cretin will post how good their FD is and how this type of behavior is not the norm in their little area, I hope I am spared from reading it)

But like I said, I know where they are coming from, in their little minds they believe it is acutely life or death or they shouldn't be involved.

A PD case is interesting though, don't often see much of that in the states, especially now with home hemodialysis.

But it all comes down to a good assessment. Knowing what and how to look for. Strangely enough, most emergencies are actually the end stage of chronic disease states. Trauma especially severe trauma has nationally been declining for decades.

 

[MonkeySquasher]

Er... Just to point something out, I'm confused now.

The core of any patient care is a proper thorough assessment. And outside of certain level-restrictions (ECG/12Lead, etc), Basics can, and SHOULD, be taught proper assessment and A+P more than anything.

Now we talk about education, and I respectfully disagree with MonkeySquasher, you cannot possibly hope to teach a basic a physical exam and history (assessment) that is adequete for anything more than airway breathing and circulation.

But then you said...

But it all comes down to a good assessment. Knowing what and how to look for.

I'm just curious on where we were disagreeing. haha

Was it that we can't teach a Basic those exam skills? Because I believe we can, and we should. It behooves us to. To the best of my knowledge, Canada does it... (This is a good time for that poster from Ontario to show up). I can't speak with certainty, but I've understood that even Canada's most basic pre-hospital EMS level involves college-level A+P and assessment techniques. They're trained to the knowledge level of a Paramedic, without being allowed to perform the skills. And that's how EMS -SHOULD- be, in my opinion.

 

[Veneficus]

Was it that we can't teach a Basic those exam skills?

I was pointing out that college A&P is not enough, you would also have to add some other clinical sciences, and when you do that you could easily make the course longer than the paramedic course. (which while it would be ideal, it is just not realistic to think that is possible in today's political climate in EMS.

Because I believe we can, and we should. It behooves us to.

There are lots of things like this. Not just limited to EMS.

To the best of my knowledge, Canada does it... (This is a good time for that poster from Ontario to show up). I can't speak with certainty, but I've understood that even Canada's most basic pre-hospital EMS level involves college-level A+P and assessment techniques. They're trained to the knowledge level of a Paramedic, without being allowed to perform the skills. And that's how EMS -SHOULD- be, in my opinion.

It is like this in many countries, and it should be. In one country i visited, both the paramedics and nurses sat in class together for basic science. After the first 2 years, nurses went to classes specific for nursing and medics went to classes specific for the field. I think that is absolutely ideal. In 21 years now of watching this argument, the US has actually gone backwards.

2 years ago I heard one paramedic instructor tell a class that all that stuff about cell biology in the front of the book was totally useless. I have seen dozens of intructors tell students there is too much information in the single volume text than is needed to be a medic. These instructors are still spouting that crap today, and I am willing to bet my experience is just the tip of the iceberg.

Back on point, what can we realistically do today to help providers embrace a proper assessment for all patients?

 

[Akulahawk]

[BIG snip]
2 years ago I heard one paramedic instructor tell a class that all that stuff about cell biology in the front of the book was totally useless. That instructor was right. It is. There needs to be MUCH more. I have seen dozens of intructors tell students there is too much information in the single volume text than is needed to be a medic. And I would be one to disagree. These instructors are still spouting that crap today, and I am willing to bet my experience is just the tip of the iceberg.

Back on point, what can we realistically do today to help providers embrace a proper assessment for all patients? First, define what would be considered a "proper assessment." Nurses, Physical Therapists, Occupational Therapists, Respiratory Therapists, Physicians, and Super Heroes all do their assessments differently, for different purposes, and those assessments are proper for that level of practitioner of patient care.

My comments above... in red. Once a "proper assessment" is defined, then figuring out the rest (what to teach) becomes much easier. Then show that with the increased education comes increased professional recognition, and scope of practice (because you KNOW what to do with what you've found) and greater command of salary. The other difficult thing to do is get EMS types to agree that's the way to go. That can be much like attempting to herd cats... all by yourself.

 

[mycrofft]

Asking the Lawyer's Question: "Isn't it possible?"

Anything which is not absolutely under any conceivable and some unconceivable sets of circumstances impossible is possible. Therefore, since something is going to be missed kon every exam, and it might be important, unlimited micro-management of history and exam is not only inevitable, but a darn good idea, no?<_<

Ask our program director. I was faulted when asking a pt about a simple headache for not getting a family history going back to grandparents. It was pointed out that knowledge of family hx of strokes or migraines could be useful. The guy had no accessory complaints, he just wanted a couple Advils since he did not have access to them (hello, locked facility).

The dynamic balance between directed and global exam has to be decided rationally.

 

[Melclin]

I was pointing out that college A&P is not enough, you would also have to add some other clinical sciences, and when you do that you could easily make the course longer than the paramedic course. (which while it would be ideal, it is just not realistic to think that is possible in today's political climate in EMS.


It is like this in many countries, and it should be. In one country i visited, both the paramedics and nurses sat in class together for basic science. After the first 2 years, nurses went to classes specific for nursing and medics went to classes specific for the field. I think that is absolutely ideal. In 21 years now of watching this argument, the US has actually gone backwards.

We have a similar arrangement at our university. We did A&P, legal, health sociology and communications subjects with the nurses, OTs, midwives, physios etc. Then we trot off to the paramedics building for field specific stuff in 2 and 3rd year. I understand they now have an inter-professional education subject in first year as well which sounds like a good idea. I would like to have done more with the nurses

The more we understand about other fields, the better we can work together, especially when it comes to things like falls referral.

Ask our program director. I was faulted when asking a pt about a simple headache for not getting a family history going back to grandparents. It was pointed out that knowledge of family hx of strokes or migraines could be useful. The guy had no accessory complaints, he just wanted a couple Advils since he did not have access to them (hello, locked facility).

The dynamic balance between directed and global exam has to be decided rationally.

True. We don't really have a culture here of doing absolutely every assessment we have on every patient. But then it could be argued that we have enough education to start choosing tests depending on whats going on. I laugh hard when someone comes into the St John's first aid tent at an event for a bandaid for a blistered heel and we have to take medical histories and repeat vitals.