What is it a paramedic does?

[firetender]

how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients? I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time.

I would love you to take your thoughts here, tweak them a little to begin a new exploration and START A NEW THREAD, so we can give this the attention it deserves. It's a little out of context here, yet, very valuable.

 

[firetender]

Terrific Stuff!!!

Responses here have been quite wise. They show lots of people understanding what they are part of. In reading them all over, however, I have a couple more things I'd like to reflect on.

Most systems of EMS, as they stand, are overburdened by people mis-using the services. Notice, I did not say "abuse". Once again, it's not their fault; in part because our Western medical approach has convinced us:

* folk remedies don't work, therefore
* connection with a relative or friend, etc. to advise/treat you is of no value
* medical intervention begins with a drug you can buy at a store, that you've heard about through an advertisement
* if the drug doesn't work, THEN you must seek a professional
* professionals usually maintain Banker's hours,
* they have a facility that you have to go to
* want insurance or money up front
* make you wait for attention

We have been dis-empowered as a community and trained, because economics dictate it, to go outside ourselves for medical assistance. Once we felt dis-empowered, we began to sue. That resulted in establishing a culture of "defensive medicine" which complicated treatments and limited universal access even more.

It also made each patient a puzzle to be successfully solved, rather than a human being to be responded to. Studies are showing how separation and lack of human connection appears to be at the root of most emergency room visits. People go to great extremes to get compassion. The culture of the paramedic and of emergency medicine denies this reality. This must be dealt with in order for EMS personnel to become effective.

Once medicine and medical care became an industry, people began to see they could either work around it or take advantage of its weaknesses. One of its major weaknesses is that it will send a professional to your door if you holler loud enough. The people count on the responder to be compassionate.

The most readily available "faces" of the professional medical system are Ambulance personnel. They were originally conceived as primary response units for emergency situations but evolved into primary response units for what ails you.

The larger SYSTEM (US) continues to nudge more and more people into the Ambulance loop. That offers their first contact with medical professionals. But it does so WITHOUT providing back up to medics so they can be freed to provide real emergency services for people in real emergencies.

In reading these posts, and hearing how some of our compatriots in the British Empire are seeing things evolve there, I have to say I'm not all that convinced such systems as theirs will work in the US.

In terms of emergencies, I don't think we can wiggle out of sending the most qualified and specifically trained non-Physicians available -- just on liability factors alone. The "eyes and hands" of the doctor are indispensable on the scene. How long they tie themselves up on the scene, however, is something that must be controlled.

NO, I don't think an emergency paramedic should have to do the hand-holding or transporting of the non-emergent elderly, but someone should. It doesn't make sense. To get paramedics involved in that would require three times as many ambulances available, each with highly trained medics as described in the NSW system or others as identified on this thread. Tying up many more EMS personnel also lowers their exposure to emergencies, therefore reducing experience levels across the board.

The Emergency Paramedic should, however, be cross-trained well enough to quickly discern the next level of care, whether it be non-emergency transport, referral to another agency, 5150 hold, or whatever and then be able to get the next provider of care to the patient quickly while remaining available for the next call.

Based on these posts, now I'd offer a slightly different model with Two Levels:

Level One requires the equivalent of an Associate's Degree in Emergency Response. Training in handling physical emergencies would be to the EMT level, and beyond that would be extensive training in use of medical, psychiatric, social and community resources. The job would occasionally require transportation. The operative description would be post-stabilization referral and transport, with an emphasis on "movement" of the patient to the next appropriate level of patient care.

(As an aside, I believe EMTs can learn how to respond to patients human-to-human without losing their effectiveness. If you re-define their role to INCLUDE providing the vital human link in the healing process, THEY will find they can be more effective AND fulfilled in their jobs.)

LEVEL TWO builds on that knowledge to the Bachelor's Degree level, with Emergency training to the Paramedic level and an expansion of the Associate's program to promote the ability to Triage patients appropriately. The Level II Emergency Responder would primarily make the judgment call to call in Level I in the event that the call is not really an Emergency. If a true emergency, Level II should both treat AND transport.

Perhaps we should expand the profession from the ground up, rather than the top down. The EMTs of today should be trained to be able to effectively deal with the bulk of what our calls really are: non-emergency. Entry level would be upgraded to Associate's level which still makes the profession accessible.

Paramedics should be better trained, but used appropriately so they can render and be available to offer immediate advanced emergency medical care and transportation. Other than that, their job would be to mobilize a second tier of support services.

Our dispatchers could be easily trained (decision-tree style) to discern whether to send Level I or Level II as first responders. Any doubt, send Level II.

I wonder: If we were to go to the NSW system as described here in the US, wouldn't that encourage more inappropriate use of the EMS systems? Then, people would know that paramedics are there for hand holding.

When the first responder is a Level II unit (and yes, I agree, it would work best as a vital protection agency separate from Fire services) it sends the message USE IN EMERGENCY ONLY!

One way or another, the system of tomorrow is going to have to provide support for paramedics if it wants them to effectively handle real life-threatening emergencies. That support does not exist today. Rather than expect outside agencies to step up to the plate, we should better train our personnel to handle what really is.

 

[Veneficus]

a respectful opinion in 2 parts

“Most systems of EMS, as they stand, are overburdened by people mis-using the services. Notice, I did not say "abuse". Once again, it's not their fault;”

I don’t think it is just because of medicine, for a long time in human existence, culture as defined in anthropology, the protection of home range resources and reproductive rights, has shifted from that of the group to that of the individual. With the loss of social support, psychological and emotional support has been lost. Community knowledge and collaboration is almost nonexistent in the US, and quickly fading in Europe. I can’t speak about the other hemisphere but I imagine it is similar. What used to be supported by communities is now supported by counseling and medications. This coupled with society’s stigma and legal ramifications, people struggling to cope have resulted in “medical care” being the only nonjudgmental help available. Moreover, there are few effective support mechanisms available unless you can pay. A bit counter intuitive as people struggling emotionally and psychologically often have already lost control of their finances or had none to begin with which led to the condition. As we discussed, the emergency system has become the safety net.

Likewise, western values of “rescue” assistance while heartwarming is extremely wasteful and ineffective.

For example, how many people gave a crap or even knew where Haiti was prior to an earthquake? How many people made every effort to supply money or aid with the fervor created by TV? This same scenario plays out every day all over the world. “Out of sight, out of mind.” How many complain about giving aid to foreign peoples offer to pray and contribute during disasters that could have been avoided had there been even a fraction of the contribution earlier.

Especially in the US, we have lost our sense of community. “team work” “united we stand” “hang together or hang separately” are ideals lost to history. I find it ironic that a government of the people is supposed to support and provide for its people without contributions from them or as minimal contribution as one can get away with. These same people who value “helping people” then turn around and call what little there is “abuse.” More than anything they don’t want to pay another cent towards a sustainable or equitable solution. We cannot blame “medicine” for these ills.

 

[Veneficus]

"in part because our Western medical approach has convinced us:"
(I would say culture, not medicine)

"* folk remedies don't work, therefore"

There is a whole medical specialty devoted to healthy living and practical remedies. But it is out of reach of the common mans’ ability to afford it. A cheeseburger is a money/time saving value than healthy food. Especially for people who need to spend more time earning income instead of preparing meals for continued survival.

"* connection with a relative or friend, etc. to advise/treat you is of no value"

It was not medicine that destroyed these values, it was greed. (More for me without any concern for others)

"* medical intervention begins with a drug you can buy at a store, that you've heard about through an advertisement"

A tragedy for certain, but attributable to corporations with an interest, there are both legal and ethical checks to police this behavior among providers.

* if the drug doesn't work, THEN you must seek a professional"

If you can afford it. If not, you are out of luck. Then all of society will complain you are a leech when you shift from a viable producer to strictly a consumer.

"* professionals usually maintain Banker's hours,"

This I would agree is the fault of the providers. There was a time when medicine was a dedicated lifestyle. In the effort to have the prestige and money, but not the sacrifice, we have tried to have our cake and eat it too. It has cheapened provider, once a pinnacle of humanity and society, no different now than a loan shark or pimp.

"* they have a facility that you have to go to"

Unfortunately this is a product of our knowledge and technology. We simply cannot provide the level of medicine now considered acceptable in a mobile way.

"* want insurance or money up front"

I would say this is because in America nobody feels they should pay for medicine. A perception it is a right you don’t have to pay for, from insurance companies to those considering themselves “upstanding citizens,” the purpose and value of medicine has been lost. Plus there is the problem of the cost to the provider. My debt to school alone will exceed many peoples lifetime income. The bank doesn't care about my altruism.

"* make you wait for attention"

I respectfully take issue with this statement.
I have not met one medical provider in any country I have ever been in who made a patient wait for any reason other than lack of resources. I think this stems from a phenomenon I call “McMedicine” The idea that no matter what a patient does to themselves over however long, they will simply show up at a medical provider and order the cure off the menu to be delivered at the speed of digital media. Medicine, Western or otherwise, was never meant to work like this. I doubt it ever will.

Many great minds have offered solutions to the resource problems. Nobody wants to fund them. From medical and nursing schools, to hospital beds, to physical therapy spots, in the US there is a gross lack of resources.

In the US nobody wants to prevent, pay for, or wait for medicine. Modern man is extremely specialized in their knowledge. Why is there not a high school class dealing with when and what a person can do prior to calling on a professional? We can teach CPR and AEDs but cannot teach people that when you acquire an influenza infection going to the hospital hoping to get a prescription will for a bactericidal drug isn’t going to help. That you really do get pregnant when you have sex and it is not a medical emergency. The test down at the drug store is just as good as the one in the ED. (and you do have to pay for it.)

 

[ivanh3]

I have to disagree with the notion of requiring a degree for medics. I wholeheartedly appreciate that there are degree options out there for medics, but to require it could decrease some patient's access to ALS response in some areas (rural, etc). I like that idea that paramedic courses are awarded college credit and could be applied towards a BS degree. With that model the public is served and EMTs are afforded the opportunity for personal and professional growth.

In terms of what we do as a profession, for me that has always been simple. We do it all: some of it medical, some of it psychosocial, and even a wee bit of law enforcement sometimes. That is the upside of it. The downside is that our ceiling for growth is lower than other professions. Which I why I think there should at least be degree opportunities (not mandates). Having those degrees can offer other options for medics (law school, med school, research, academia, etc).

I think the method of patient care has to be region/population/volume specific. There have been many good ideas proposed in this thread. It would be exciting to see some of the put into play.