"EMS is a hoax"

[jbar]

It sounds a little silly to conduct studies attempting to demonstrate that having epi in the scope of practice improves outcomes in the event of an anaphylactic reaction, but maybe that's the kind of thing we need to be working on.

Epi is a great example. Possible research questions could include:

1: What percentage of patients have their own epi pens?

2: What % of patient die of anaphylaxis treated by BLS in systems without ALS.

3. Are outcomes in a BLS system where EMTs can carry and give epipens equivalent to ALS systems?

etc.

MAST pants seemed like a great idea too till the research got done.

One thing I worry about is that in the U.S. it doesn't take much training to get your EMT. So research done in big cities with active systems that says "good BLS is equal to ALS" may not really transfer to areas with low training, low call volume. The question is that if you lower to standard to just mainly BLS how many bad BLS people are you going to get who don't know how to bag well or control bleeding. Also I think systems with medics make the BLS better by doing training of EMTs, providing mentoring and feedback. I still think there are a lot of calls that can be handled by EMTs, but I think a few medics sprinkled around a system is a good idea. Though five medics on a firetruck is crazy talk.

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[howelljolly]

anyway

About the mortality difference driving the latest guidelines. I disagree that mortality is what makes a difference to the patient. Morbidity or even physiologic endpoints can be more appropriate in some situations. Mortality is actually an unlikely outcome in anything we do in EMS. Even most trauma patients survive their illness.

The way I see it, we as medics dont yank people off the brink of death on a daily basis. We do, however, make more educated transport decisions, keep patients status quo and buy time before the ER docs can have at them, and at times make death easier on families. Sometimes we will ease a patients suffering 15 minutes earlier than the ER doc would have, and sometimes we'll decompress that tension ptx.

OK, thats enough. My point is, intuitively, the mortality difference between a patient who needs treatment X and gets it in the ER vs. the one who needs treatment X and gets in on the MICU, should be negligible. The severity of the disease tends to drag itself into surrogate endpoint status in most of these studies. What we should look at is the advantages of prehospital ALS in terms of infrastructure, morbidity, Sx-onset-to-drug times, and things like this.

I keep coming back to it, but having worked in a region where ALS does all of the out of hospital non-emergency pronouncements... I can't imagine it any other way.

 

[howelljolly]

Someone correct me if I'm wrong, but isn't pericardiocentesis the definitive treatment for tamponade? Isn't that within the capabilities of any functioning emergency department? Isn't that a good example of something where you don't want to delay treatment driving an extra 15 minutes to a trauma center, or screwing around for 10 minutes on scene trying to start an IV that won't benefit the patient?

There you go, thinking like a medic... You skipped: "What about the patient who has a recent history of cardiothoracic surgery, and the BLS crew who doenst know how to do an appropriate H&P, and doesnt understand the complications of CT surgery". Think postcardiotomy syndrome. Pericardial window with an ICU admission is a better choice in this case.

Also, in this particular case, the EMS brought the patient to the closest hospital, knowing fully well that the small community hospital does not have a cardiothoracic service at all. As soon as the patient rolled in the door, the ED staff was on the phone with critical care transport to get the patient to an appropriate facility. The transport decision was so inappropriate it was mind-boggling.

 

[pseudoknot]

There you go, thinking like a medic... You skipped: "What about the patient who has a recent history of cardiothoracic surgery, and the BLS crew who doenst know how to do an appropriate H&P, and doesnt understand the complications of CT surgery". Think postcardiotomy syndrome. Pericardial window with an ICU admission is a better choice in this case.

Also, in this particular case, the EMS brought the patient to the closest hospital, knowing fully well that the small community hospital does not have a cardiothoracic service at all. As soon as the patient rolled in the door, the ED staff was on the phone with critical care transport to get the patient to an appropriate facility. The transport decision was so inappropriate it was mind-boggling.

I'm not a medic. I did invite correction if I was wrong, and I was sincere. However, it appears from my cursory reading that pericardiocentesis is indeed considered appropriate treatment for tamponade even if due to effusion from postcardiotomy syndrome (which appears to be fairly rare). Obviously you feel strongly about this but I don't see how this transport decision, if incorrect, was "mind-boggling" if the patient was suffering from tamponade.

EDIT: I asked two paramedics about this, one of whom is a med student and the other a cardiac ICU nurse. Neither had heard of postcardiotomy syndrome. I don't think this is an ALS vs BLS issue.

I do agree with your earlier post that morbidity is a more useful measure for most purposes than mortality.

 

[howelljolly]

Sorry, I was just busting your chops. Ive seen you around the SDN enough to know that you know what you are talking about.

I feel strongly about that particular case because I was involved with it. The hospital at which the patient had the cardiac surgery was five minutes down the road. The extra five minutes would have been a better option than an ED pericardiocintesis, and ED critical care for 45 minutes while the critical care medics were on their way... and then the 5 minute transport...

Guess you gotta be there

 

[MedicFL]

I agree I used to teach in paramedic school, and a lot of medics get caught up in all the "cool" procedures you can do. I always tried to get the point out that anyone can be taught how to do a procedure, that takes almost no skill the skill comes in when knowing when to do and not to do a procedure.

 

[docB]

I agree I used to teach in paramedic school, and a lot of medics get caught up in all the "cool" procedures you can do. I always tried to get the point out that anyone can be taught how to do a procedure, that takes almost no skill the skill comes in when knowing when to do and not to do a procedure.

You are exactly right. The real skill is in knowing enough about what you're doing to know when and when not to be highly aggressive in a given situation. I think that's where folks like Tired are missing the boat. I think that ALS does help (although I can't prove it with prospective, randomized, blinded, multi-center, blah, blah, blah, studies yet) but I think we may see protocols that evolve that dictate witholding ALS under certain situations, primarily based on transport times. That is going to take a more highly trained and disciplined paramedic.

 

[pseudoknot]

I feel strongly about that particular case because I was involved with it. The hospital at which the patient had the cardiac surgery was five minutes down the road. The extra five minutes would have been a better option than an ED pericardiocintesis, and ED critical care for 45 minutes while the critical care medics were on their way... and then the 5 minute transport...

Well, as you say sometimes you gotta be there. Hope it turned out OK regardless!

 

[fiznat]

Maybe my experience is unique in this, but I don't feel like "paramedics" can be taken accurately as a single group. I feel that anyone who has worked any time in EMS knows full well that the difference between a "good medic" and a "bad medic" is staggeringly large. There are some excellent clinicians riding in those ambulances, and they sit right next to piles of horse manure that I wouldn't let assess (nevermind treat) my worst enemy. Guess what, they both wear the same patch on their shoulders. I don't find it surprising that the rest of the medical community (and indeed, scientific research) has a hard time telling the difference between the two on a large scale.

EMS suffers from a severe lack of control and oversight. Start chopping out those who are incapable of performing this job intelligently, and I think you'll start seeing our numbers rise pretty quickly.


Inappropriate ALS that I have witnessed this week:

1. An unrecognized esophageal intubation. It was obvious, and we have ETCO2 capability.
2. Epinephrine 1:1000 through an IV for hives to a 70 year old.
3. Prehospital IO line for the sole purpose of delivering dextrose to a hypoglycemic.
4. Lidocane to a patient in asystolic cardiac arrest.

Tell me that crap isn't playing into the research results somewhere.

 

[howelljolly]

I agree that often, those gung ho medics who couldnt wait to shove a tube in something during medic school are among the most dangerous. You train a goat to do these procedures, the real medicine is in everything else.

But the same is true for med school. (Or maybe thats just my experience in the Carribean, but I doubt it) Some people go into the anatomy lab, and you cant pry the scalpel out of their hand... and then they wind up doing the worst on the Boards...

go figure.

 

[chimichanga]

I feel strongly about that particular case because I was involved with it. The hospital at which the patient had the cardiac surgery was five minutes down the road. The extra five minutes would have been a better option than an ED pericardiocintesis, and ED critical care for 45 minutes while the critical care medics were on their way... and then the 5 minute transport...

Guess you gotta be there

I used to work on a CCT rig (RN)...mostly interfacility, but some 911 (if we were last/only ALS avail)...

Called to assisted living. CVA symptoms 100 minutes prior to our arrival on scene. acute hemiparesis, aphasia, etc.

I decided to bypass closest facility (small level II, cardiac hospital...weekend) for an extra five minute transport to a level one stroke facility (BNI)...

shift commander (long time medic) read me the riot act for bypassing closest.

I explained to him my rationale, and that I was well within the three hour window (we went lights/sirens, and arrived 55 minutes before three hour window), and other hospital not really as equipped for acute CVA

He made some comment like I don't "think like a medic"



pt was in CT w/in 10 minutes of our arrival

 

[firecoins]

I used to work on a CCT rig (RN)...mostly interfacility, but some 911 (if we were last/only ALS avail)...

Called to assisted living. CVA symptoms 100 minutes prior to our arrival on scene. acute hemiparesis, aphasia, etc.

I decided to bypass closest facility (small level II, cardiac hospital...weekend) for an extra five minute transport to a level one stroke facility (BNI)...

shift commander (long time medic) read me the riot act for bypassing closest.

I explained to him my rationale, and that I was well within the three hour window (we went lights/sirens, and arrived 55 minutes before three hour window), and other hospital not really as equipped for acute CVA

He made some comment like I don't "think like a medic"




pt was in CT w/in 10 minutes of our arrival

This is a good example of legit pre-hospital ALS treatment. However, I think you think like a good medic. You don't think like a bad medic.

 

[leviathan]

A better example: we've developed a national obsession with CPR and defibrillation, trying to more effectively treat...death? So, how much money do we put into having AEDs on every street corner and every police car, etc.? What if we put that money into vaccines, or preventive care for DM and HTN? Might we not save more lives? Would people care since those things aren't dramatic and sexy like cardiac arrest?

Old thread but I think
1) It IS sexy, which is why it's got more focus than things like DM/HTN
2) It is a LOT easier to see the direct results of CPR/AED to people in arrest. I think an arrest would fall under the extreme of 'acute' medicine, especially when compared to chronic problems like DM/HTN. In the span of one year, our service saw an immediate 20% increase in survival to discharge without neurological impairment after adopting the new 2005 AHA guidelines. Not bad...now try convincing people to spend as much time on chronic disease managment, when the results take decades to surface.

Nevertheless, in the end, you are absolutely right that our money is better spent on CDM than on dead people.

 

[COMedic2Doc]

Okay, so from what I'm seeing this is a dead issue so not even goin to waste the time posting my reply to Tired in regards to my EMS system vs. his. I would absolutely agree that there are good medics and there are bad medics, and sadly the good seem to suffer because of how they think (more clinician vs. like some of the bad medics I've met).

 

[BostonEMT]

But it's not the dispatching of an ALS unit when a BLS unit is appropriate that runs up costs. It's the dispatching of an ambulance for something that needs no interventions whatsoever, and the inability to tell that person that they are not going to be taken to the hospital.

Ding! Ding! Ding! We have a winner.

You propose to make EMS providers stupider so that residents like yourself get angrier when they present a patient to you? You forget the EMS providers are human, and will rise to their level of incompetence no matter what you do. By cutting out all of the thinking, you are going to end up with people that do not want to do any thinking. Everyone else will leave the career and go so something else. Thats how it is already, motivated intelligent EMTs become medics, motivated medics become RNs, MDs RTs.... brain drain effect.

Thank you. Though I do understand the frustration of a the poster you were responding to, you are right. This is actually what's happened in Rhode Island with EMT-C's ("cardiacs"), intermediates who are trained to give some pretty serious meds by the color of the box. "Hmmm, pale, cool, diaphoretic? Yellow box, full amp!"

Sounds like the future of EMS, huh?

 

[emttim]

I think this is an extremely important point.

I think that the editorial made some a lot of good points and wasn't really singling out EMS.

Certainly we are getting a bit carried away in many areas of medicine, including EMS. Does it help to have a paramedic for a small subset of EMS calls? I think so. Do we need five of them onscene for every single call, most of which need only a taxi? Absolutely not. I was on a shift in LA where 5/6 firefighters were paramedics. That's insane.

Why do we have this cult of CPR in this country? Why do we respond code 3 to most calls, putting the public at risk for no benefit most of the time?

Also, I think Leviathan needs to be a little more careful with his quoting, lest he put Tired's words into someone else's mouth again

I think thats a good point... but what can be done about that?

This thread is a little old but these are good points. We don't need all the FF/medics that we have. In fact, we probably don't need any if there is a private ambulance company that contracts for 911 in that area. FF/medics, at least in California, are paid anywhere from $70,000 to $90,000 or higher depending on seniority. You could probably shave a decent amount off that figure if they didn't have paramedic training; if we reduced their pay and didn't require them to be medics anymore and did that across the country then the amount of unnecessary ALS providers would diminish. So far from what I'm seeing in P-school, you don't need a bunch of medics on scene, you just need a bunch of hands to help out /one/ medic.

The other thing we can do is start making it a misdemeanor and/or felony (depending upon how many offenses and severity) for people to abuse the 911 system. I think that would cut down on unnecessary calls very significantly.

Although honestly if you want to reduce the cost of health care, there's other things that cost a lot more money than EMS ever will. Get rid of cost sharing and lawyers (so you can get rid of defensive medicine) and then maybe the prices will start to be more reasonable. Oh yeah, and for EMS, just in case its necessary put in a protocol nationwide that allows the paramedic to call medical direction if he/she feels transport is unnecessary to verify with the doc and refuse transport. You could also look at trying to get rid of EMTALA so people stop using the ER as a friggin' primary care clinic. </rant>

Sorry, I'm just surprised people are complaining about the cost of EMS when there's far more ridiculous things in medicine that are contributing a lot more to the cost dilemma...hell it's not like most of us even get paid that much. Unless you're a firefighter, you're making more as a resident physician or a waiter than we are.

 

[COMedic2Doc]

This thread is a little old but these are good points. We don't need all the FF/medics that we have. In fact, we probably don't need any if there is a private ambulance company that contracts for 911 in that area. FF/medics, at least in California, are paid anywhere from $70,000 to $90,000 or higher depending on seniority. You could probably shave a decent amount off that figure if they didn't have paramedic training; if we reduced their pay and didn't require them to be medics anymore and did that across the country then the amount of unnecessary ALS providers would diminish. So far from what I'm seeing in P-school, you don't need a bunch of medics on scene, you just need a bunch of hands to help out /one/ medic.

I would absolutely agree that making every Firefighter have to become a Paramedic is a waste of time and money for the department. In fact, many FF/Medics that I know completely agree with this statement. Should we ban all FF/Medics? Probably not. There is no private ambulance service that will ever be able to compete with the Fire Department's response to calls, I'm sorry it's just impossible when you consider how conveniently close Fire Stations are in relation to homes based on the requirements of the city. So, we should cut down on the number of FF/Medics but not ban them completely, as it would compromise patient care. There are great FF/Medics and there are bad Private Medics as we have already discussed. Also for our good Medics is it truly an issue to pay them a decent salary to encourage them to stay as Paramedics? I know all too well what FF/Medics make (approx $58k/year to start with our most competitive departments here in the Denver Metro), and sadly it is the truth of Private EMS (which is for profit, and any Private Ambulance company is there to make money any way possible =paying Private Medics as we are because it = good business as they can easily replace you if you don't like it, and consider the difference in cost of ALS vs BLS costs, Code 2 vs. Code 3 transports, etc, etc), so if we want to cut down on costs, perhaps looking at more city and county based services versus Private EMS taking care of all 9-1-1, would be a good idea (most private companies don't really want to be in 9-1-1 anymore because of the reimbursement rates). Also, not to mention Private services definitely charge more to the patient as Fire Departments use mill levies, etc to raise funds which in my humble opinion offsets the cost of care to the patient.

The other thing we can do is start making it a misdemeanor and/or felony (depending upon how many offenses and severity) for people to abuse the 911 system. I think that would cut down on unnecessary calls very significantly.

Hmmm, not so sure that our juidicial system really wants to deal with this. We are already experiencing issues with overcrowding of prisons. For the typical system abuser, they really wouldn't care anyway just would make it easier to make sure their healthcare was covered by society instead of them.

Oh yeah, and for EMS, just in case its necessary put in a protocol nationwide that allows the paramedic to call medical direction if he/she feels transport is unnecessary to verify with the doc and refuse transport. You could also look at trying to get rid of EMTALA so people stop using the ER as a friggin' primary care clinic.

On Paramedic initiated refusals, this is both a blessing and a curse. It can be a blessing in that you can refuse to take the patient to the ER and be able to get back in service sooner, not to mention wasting resources for a pointless call. However, just because it is a good idea and makes us warm and fuzzy inside doesn't mean it would be efficient or in the patient's best interest, we simply don't know whether it would be good for the patient or not. It can be a curse, because it can cause a hornet's nest because the patient feels that they didn't receive appropriate care and therefore seek an attorney, malpractice, etc. (which by the way, malpractice may or may not be covered depending on your agency, and when doing a Paramedic Initiated Refusal you are the one "painting the picture" to the doc if you choose to call the doc, depending on your protocols, so the doc has a chance to conveniently testify with a biophone recording exactly what you told them and if it's not the full truth then you're dead in the water for facing charges of malpractice by yourself)

There is way too much that we're already doing without evidence to back things up, and even when we do know the research behind something doesn't mean that we're necessarily listening to it and changing our protocols, etc. I believe that we should indeed do some research into this issue to help alleviate the ER's unnecessary volume. The main issue with Paramedic initiated refusals is making sure that every Paramedic is competent to make this decision in the field, and also the liability issue of being sued for malfeasance or negligence. This is the same issue with determining C-Spine Clearance (something that is based off of scientific research is the fact that we immobilize way too many people, often to a patient's detriment), with C-Spine Clearance we face the issue of the patient then deciding that they have C-Spine tenderness because a lawyer talks them into it. (anyway, this is probably another discussion in and of itself) However, in the Denver Metro area we have recently started seeing our Physician Advisors allow for C-Spine Clearance in the field based on specific criteria, which with proper and full documentation protects the Paramedic from lawsuits later on.

Do you really want to ged rid of EMTALA? Are you sure? Ok, getting rid of EMTALA =an ER being able to refuse your patient and make you transport to another hospital that could quite possibly be miles and miles away. Case in point, before EMTALA a Paramedic Instructor of mine was forced to take a patient from Denver to Pueblo (roughly two hours away) with Cardiac complaints. There wasn't EMTALA so there was no backup for him to be able to say "no". So, are you really sure EMTALA needs to be done away with?

Sorry, I'm just surprised people are complaining about the cost of EMS when there's far more ridiculous things in medicine that are contributing a lot more to the cost dilemma...hell it's not like most of us even get paid that much. Unless you're a firefighter, you're making more as a resident physician or a waiter than we are.

When comparing our pay as Medics to that of Residents, do be careful to consider all of the facts. Many Residents work twice as much as we do for the same or equal pay if you research the pay within Residency programs (i.e. an Intern makes typically around $38k a year to my understanding). We as Paramedics depending on your agency make between $32k-$50k a year approximately, depending on your agency once again for working roughly 44 hrs a week or 10-12 24 hr shifts a month at which point you can go home and if you work more you get paid more OT (not so in the case of Residents from my understanding). Residents in many programs are working at least 80 hours a week, and that is if your program is compliant, not to mention they have at least 4 times our responsibility even in the most critical of calls for a Paramedic, and they also have eons more training than we do or ever will have. Okay, so there's my comments. Please understand that I do appreciate your point of view, this is my point of view and based somewhat on my experiences and also on facts as well.

 

[emttim]

I would absolutely agree that making every Firefighter have to become a Paramedic is a waste of time and money for the department. In fact, many FF/Medics that I know completely agree with this statement. Should we ban all FF/Medics? Probably not. There is no private ambulance service that will ever be able to compete with the Fire Department's response to calls, I'm sorry it's just impossible when you consider how conveniently close Fire Stations are in relation to homes based on the requirements of the city. So, we should cut down on the number of FF/Medics but not ban them completely, as it would compromise patient care. There are great FF/Medics and there are bad Private Medics as we have already discussed. Also for our good Medics is it truly an issue to pay them a decent salary to encourage them to stay as Paramedics? I know all too well what FF/Medics make (approx $58k/year to start with our most competitive departments here in the Denver Metro), and sadly it is the truth of Private EMS (which is for profit, and any Private Ambulance company is there to make money any way possible =paying Private Medics as we are because it = good business as they can easily replace you if you don't like it, and consider the difference in cost of ALS vs BLS costs, Code 2 vs. Code 3 transports, etc, etc), so if we want to cut down on costs, perhaps looking at more city and county based services versus Private EMS taking care of all 9-1-1, would be a good idea (most private companies don't really want to be in 9-1-1 anymore because of the reimbursement rates). Also, not to mention Private services definitely charge more to the patient as Fire Departments use mill levies, etc to raise funds which in my humble opinion offsets the cost of care to the patient.

You are correct, one medic on scene is crucial for any call since any legitimate call has the potential to require ALS so if the FD is first on scene then yes they need to have one FF/medic. However, as you stated and I agree, the amount of FF/medics they have now is simply ridiculous. I don't necessarily fault FFs for this though; a lot of FDs are so incredibly competitive to get hired on with that a lot of FFs seem forced to get their medic just to have a chance at getting a job. This problem would be fixed by changing the ways our FDs operate in both hiring and as well as the attitudes since a lot of fire chiefs probably feel like all their FFs should be medics as well, and while if they're good providers that's not a problem, when you have six FF/medics on every call its inevitable that skills and knowledge is going to deteriorate. Having far less FF/medics would both be economically sound and also sound for patient care since that one FF/medic will constantly be using his/her skills & knowledge and will be a more competent health care provider.

Hmmm, not so sure that our juidicial system really wants to deal with this. We are already experiencing issues with overcrowding of prisons. For the typical system abuser, they really wouldn't care anyway just would make it easier to make sure their healthcare was covered by society instead of them.

I know our judicial system doesn't want to handle this, and perhaps some people would just intentionally abuse the system then to get free room & board by going to prison, but this problem has to be addressed because it is simply ridiculous that someone can call 911 for a stubbed toe, get FD and possibly private ambulance to respond too, and then they're forced to transport that person "just in case" so they clog up the 911 system, they take an available ambulance out of service, they increase congestion in the ER and since they're not going to pay the bill, that cost gets passed on to you and me.

On Paramedic initiated refusals, this is both a blessing and a curse. It can be a blessing in that you can refuse to take the patient to the ER and be able to get back in service sooner, not to mention wasting resources for a pointless call. However, just because it is a good idea and makes us warm and fuzzy inside doesn't mean it would be efficient or in the patient's best interest, we simply don't know whether it would be good for the patient or not. It can be a curse, because it can cause a hornet's nest because the patient feels that they didn't receive appropriate care and therefore seek an attorney, malpractice, etc. (which by the way, malpractice may or may not be covered depending on your agency, and when doing a Paramedic Initiated Refusal you are the one "painting the picture" to the doc if you choose to call the doc, depending on your protocols, so the doc has a chance to conveniently testify with a biophone recording exactly what you told them and if it's not the full truth then you're dead in the water for facing charges of malpractice by yourself)

This is a risk regardless of whether you transport or not. Reducing risk of malpractice lawsuits will only happen if we increase the education requirement for paramedics, we change legislation so that a malpractice lawsuit can only be filed after determination by a competent (IE if its a suit against a medic, a panel of medics, suit against a doctor, panel of doctors) source that it is legit. Frivolous lawsuits waste everyone's time, and unfortunately, even if the person is innocent the insurance company would rather settle out of court than fight it because it's cheaper. This broken "justice" system of ours has to stop before that ever stops being a risk. I realize what you're saying that this has a host of possible complications, however, again I think increased education of paramedics and repairing our broken legal system would do a lot to correct that. Again unfortunately, I don't think the latter will ever happen even if the former does.

There is way too much that we're already doing without evidence to back things up, and even when we do know the research behind something doesn't mean that we're necessarily listening to it and changing our protocols, etc. I believe that we should indeed do some research into this issue to help alleviate the ER's unnecessary volume. The main issue with Paramedic initiated refusals is making sure that every Paramedic is competent to make this decision in the field, and also the liability issue of being sued for malfeasance or negligence. This is the same issue with determining C-Spine Clearance (something that is based off of scientific research is the fact that we immobilize way too many people, often to a patient's detriment), with C-Spine Clearance we face the issue of the patient then deciding that they have C-Spine tenderness because a lawyer talks them into it. (anyway, this is probably another discussion in and of itself) However, in the Denver Metro area we have recently started seeing our Physician Advisors allow for C-Spine Clearance in the field based on specific criteria, which with proper and full documentation protects the Paramedic from lawsuits later on.

Right, we don't have a lot of evidence-based research and that does indeed need to change for people to start giving EMS professionals more leniency as far as what to do in the field. However, I cringe at the thought of giving EMS professionals too much more freedom with stuff like C-spine clearance unless the minimum level of training is increased a lot. If it was up to me, I'd do away with EMT-B, EMT-I and EMT-P and there'd just be EMT and paramedic...EMTs would have the level of training of an EMT-I and paramedics would remain the same. I think having an EMT-I on every scene, if nothing else than to support the medic, would be a huge benefit since he/she could do procedures that will cost the medic time. I think one of the complaints by someone else in this thread was that medics take too long on scene. Well, maybe, but that's because they're the only ones allowed to do anything. What if the EMT could start a line while the medic was drawing up the medication? That would be just one instance of an excellent time saver and it would increase the knowledge of the EMTs in the field.

Do you really want to ged rid of EMTALA? Are you sure? Ok, getting rid of EMTALA =an ER being able to refuse your patient and make you transport to another hospital that could quite possibly be miles and miles away. Case in point, before EMTALA a Paramedic Instructor of mine was forced to take a patient from Denver to Pueblo (roughly two hours away) with Cardiac complaints. There wasn't EMTALA so there was no backup for him to be able to say "no". So, are you really sure EMTALA needs to be done away with?

Well, that particular instance is ridiculous; any legitimate chief complaint should be looked at by an ER. The ERs in this country are just simply too abused. If we're not going to try getting rid of EMTALA, we need to either modify it to help prevent abuse, increase education programs in the communities of when to call 911 and when to go to a clinic (for instance of innocent abuse) and/or have 24 hour clinics open in every hospital that has an ER so that if someone comes in with a complaint that can be handled by internal medicine, then they can be referred over there. Another benefit of that, in addition to decreasing congestion in the ER, is that the bill wouldn't be as much (hopefully unless the hospital is greedy) so it would give the patients more incentive to pay which would help with the problem of cost sharing.

When comparing our pay as Medics to that of Residents, do be careful to consider all of the facts. Many Residents work twice as much as we do for the same or equal pay if you research the pay within Residency programs (i.e. an Intern makes typically around $38k a year to my understanding). We as Paramedics depending on your agency make between $32k-$50k a year approximately, depending on your agency once again for working roughly 44 hrs a week or 10-12 24 hr shifts a month at which point you can go home and if you work more you get paid more OT (not so in the case of Residents from my understanding). Residents in many programs are working at least 80 hours a week, and that is if your program is compliant, not to mention they have at least 4 times our responsibility even in the most critical of calls for a Paramedic, and they also have eons more training than we do or ever will have. Okay, so there's my comments. Please understand that I do appreciate your point of view, this is my point of view and based somewhat on my experiences and also on facts as well.

True, a more accurate comparison would have been a waiter or someone else along those lines. I made this comment before my coffee in the morning which was my problem.

I appreciate your point of view a lot and enjoyed responding to your reply. Hell, it's only through intelligent discussion of the problems in health care that we're ever going to approach a possible solution to any of the problems.

 

[COMedic2Doc]

You are correct, one medic on scene is crucial for any call since any legitimate call has the potential to require ALS so if the FD is first on scene then yes they need to have one FF/medic. However, as you stated and I agree, the amount of FF/medics they have now is simply ridiculous. I don't necessarily fault FFs for this though; a lot of FDs are so incredibly competitive to get hired on with that a lot of FFs seem forced to get their medic just to have a chance at getting a job. This problem would be fixed by changing the ways our FDs operate in both hiring and as well as the attitudes since a lot of fire chiefs probably feel like all their FFs should be medics as well, and while if they're good providers that's not a problem, when you have six FF/medics on every call its inevitable that skills and knowledge is going to deteriorate. Having far less FF/medics would both be economically sound and also sound for patient care since that one FF/medic will constantly be using his/her skills & knowledge and will be a more competent health care provider.

Sadly, you are absolutely correct with the statement regarding Fire Chiefs. There are way too many departments that require every Firefighter to become a Paramedic, which results in some huge issues in regards to keeping competency, etc. A story that amazed me is that one of the local Fire Chiefs was warned not to make every Firefighter be required to become a Paramedic, yet he ignored the advice from another Fire Chief and still made the requirement of every Firefighter becoming a Paramedic (this is in a city that still uses a private service to do the transports in the 9-1-1 system). Many Firefighters have absolutely no desire to become Paramedics, yet due to mandates like this they're forced to become Paramedics. Personally, if we are going to require this, then why not do their own transports as well with maybe a private service to back up the system?

I know our judicial system doesn't want to handle this, and perhaps some people would just intentionally abuse the system then to get free room & board by going to prison, but this problem has to be addressed because it is simply ridiculous that someone can call 911 for a stubbed toe, get FD and possibly private ambulance to respond too, and then they're forced to transport that person "just in case" so they clog up the 911 system, they take an available ambulance out of service, they increase congestion in the ER and since they're not going to pay the bill, that cost gets passed on to you and me.

I completely agree here, and as a Medic I have been known to advise the ER that the patient I was bringing in or my partner was attending on was actually a Triage request, thus forcing the patient to wait for hours in the waiting room over their non-emergent/urgent issue. I believe more public education may indeed help this issue, yet there will always be the system abusers that believe everyone else has to pay for their healthcare expenses.

Right, we don't have a lot of evidence-based research and that does indeed need to change for people to start giving EMS professionals more leniency as far as what to do in the field. However, I cringe at the thought of giving EMS professionals too much more freedom with stuff like C-spine clearance unless the minimum level of training is increased a lot. If it was up to me, I'd do away with EMT-B, EMT-I and EMT-P and there'd just be EMT and paramedic...EMTs would have the level of training of an EMT-I and paramedics would remain the same. I think having an EMT-I on every scene, if nothing else than to support the medic, would be a huge benefit since he/she could do procedures that will cost the medic time. I think one of the complaints by someone else in this thread was that medics take too long on scene. Well, maybe, but that's because they're the only ones allowed to do anything. What if the EMT could start a line while the medic was drawing up the medication? That would be just one instance of an excellent time saver and it would increase the knowledge of the EMTs in the field.

With the local systems that are allowing their Medics to do C-Spine Clearance in the field using pre-set criteria, we have actually noted a huge success with no one being refused immobilization that needed it. Perhaps it is that we truly do over-immobilize in this country which has been shown by some of the studies that have been completed on this. I could definitely see the benefit of having EMT-Is used more efficiently, however I'm not sure that this would help the cost issue as you would have to pay the EMTs more to function as Is.

Well, that particular instance is ridiculous; any legitimate chief complaint should be looked at by an ER. The ERs in this country are just simply too abused. If we're not going to try getting rid of EMTALA, we need to either modify it to help prevent abuse, increase education programs in the communities of when to call 911 and when to go to a clinic (for instance of innocent abuse) and/or have 24 hour clinics open in every hospital that has an ER so that if someone comes in with a complaint that can be handled by internal medicine, then they can be referred over there. Another benefit of that, in addition to decreasing congestion in the ER, is that the bill wouldn't be as much (hopefully unless the hospital is greedy) so it would give the patients more incentive to pay which would help with the problem of cost sharing.

I defintely agree that EMTALA probably needs to be revisited and modified to better suit the needs of everyone involved. Paramedic initiated refusals may indeed end up being a good way to stop unnecessary transports, I just think we need to better research this topic better and make it more scientific based that Paramedics can actually make this decision quite well (which personally I believe we can, we just need a system that will back us). More clinics that are free clinics and operate on a 24 hr basis may be an answer. I'm not sure how I feel about Socialism in the healthcare system, but that's a completely different discussion altogether.

I appreciate your point of view a lot and enjoyed responding to your reply. Hell, it's only through intelligent discussion of the problems in health care that we're ever going to approach a possible solution to any of the problems.

Perhaps in the future, when the current generation of Medics becoming Physicians and keeping our hands in the field, we will truly be able to affect change within the systems we work in. I know that would be my hope is that through Physicians that have previous experience as Medics or EMTs (that worked in the field) becoming Physicians we'll see better changes to the EMS System that will benefit more people. Just a random thought there, but perhaps it will truly make a difference one day.

 

[docB]

On a mildly-related note:

Today I called for an ambulance to pick up a patient from my clinic and transport him to the Emergency Room. I explained to the dispatcher that I was his physician, that he was perfectly stable and had an isolated musculoskeletal injury, and that I only needed an ambulance because his injury prevented him from sitting comfortably in a car.

They arrived with an ACLS rig, three EMTs, a fire-truck, and four firefighters.

Despite me telling them that he had no injury to his neck and I had clinically cleared his C-spine, he was strapped to the board, put in full spiral immobilization.

Of course, they did this after rolling him on his side to "check his back", but didn't bother to log-roll him.

By "called for an ambulance to pick up a patient" I assume you mean you called 911. Emergency responses are really an all or nothing thing in a lot of places. That has to do with contract issues between the agencies and jurisdictions and liability in that no one can really be sure who is calling and how legitimate their info is. I know that the 911 for a transport ambulance thing happens all the time but in this case it sounds like a gurney van type of resource would have been more appropriate. However gurney vans like MediCar et. al. require insurance preapproval and are not there in 10 minutes so they are not often used by clinic docs.

 

[howelljolly]

And on a similar note I was rotating on the psych service, when an assisted living facility was being given explicit instructions by the psychiatrist to call 911 and demand that the patient be taken to Hospital X, in case of acute decompensation. Nobody seemed to understand that a 911 ambulance will not drive for 45 mins, past 10 hospitals to bring the patient to Hospital X. They will more likely give the patient a B-52 in the backside, and take them elsewhere.

 

[EMmedic]

The other thing we can do is start making it a misdemeanor and/or felony (depending upon how many offenses and severity) for people to abuse the 911 system. I think that would cut down on unnecessary calls very significantly.

How could you enforce this? Everyone's definition of an emergency is very different - the callers may have minimal to no medical knowledge. If something scares them, then it is an emergency in their minds. When you place a legal punishment on calling 911 for the wrong medical complaint, then you strongly run the risk of people NOT calling for legitimate reasons. The elderly woman with chest pain who is embarrassed about calling 911 because she thinks she is making a fuss out nothing...now she certainly won't call because she will think she might get in trouble if its just indigestion. Or the man experiencing numbness in his arm might wait hours before calling and seeking medical attention for fear that he will be told that he is abusing the system. I know that things seem obvious to healthcare providers but you have to remember that a lot of people don't actually know basic things about their own bodies. I'm not saying there aren't patients that abuse the system (I've certainly taken several), but this idea would do more harm than good.

You could also look at trying to get rid of EMTALA so people stop using the ER as a friggin' primary care clinic. </rant>

any legitimate chief complaint should be looked at by an ER.

.

This is actually what EMTALA means. It means that everyone is entitled to be examined by a physician to determine whether their condition is an emergency or not. They have to be seen before it can be decided that their condition is legitimate or not legitimate. That's why you can't turn a patient away at the door.

 

[docB]

This is actually what EMTALA means. It means that everyone is entitled to be examined by a physician to determine whether their condition is an emergency or not. They have to be seen before it can be decided that their condition is legitimate or not legitimate. That's why you can't turn a patient away at the door.

You are correct. But while EMTALA has done what was intended by its creators* it has caused the pendulum to swing so far toward the end of seeing and treating every primary care type of issue in the ED that the system is worse for it. Just ask the 3 seperate people I saw this week for rashes of greater than 3 weeks duration each who came in via EMS secondary to no other ride.

* It did fulfill the wishes of it's creators. It provided an unfunded entitlement to free emergency care and delayed the mandate for congress to do anything meaningful about healthcare for decades. Also note that by "anything meaningful" I'm not advocating socialized healthcare here. For my money (and it is my money) it would be just as meaningful for them to issue a proclamation that says "You're Americans dammit! Suck it up!" as to lunch the largest state run program in history.

 

[jkelly2]

Well, that particular instance is ridiculous; any legitimate chief complaint should be looked at by an ER.

It should be, but EMTALA stops hospitals from cream-skimming, or turning away "emergency" patients unable to pay for care and accepting only paying patients.

 

[pseudoknot]

I've been meaning to respond to this thread but haven't had the time. Briefly though:

1. I understand the concerns of some posters about EMS/ED abuse, but I really think that it's not the biggest problem out there. The literature will tell you that legitimate patients are overwhelming the capacity of our system.

2. I agree with EMmedic above that it's dangerous to scare people away from calling 911. I also think repealing EMTALA is a horrifying idea that would take us further in the wrong direction. Fortunately that has no chance of happening in the foreseeable future.

3. I don't see how you can be nervous about selective application of C-spine precautions, which is pretty well supported by research (and, I might add, I'm aware of no evidence that spinal precautions are beneficial even for the rare unstable spinal fracture), and yet be in favor of paramedics refusing transport. Consider that determining who is sick and who isn't is something that even EM residents still struggle with. Look at what recently happened in DC. This is a bad idea unless you start staffing ambulances with board certified emergency physicians.

4. In general, I just don't think the EMS system is so broken that we need to make these kinds of radical changes.

 

[howelljolly]

I was fortunate enough to work in a tiered system.

Fire rigs were only dispatched if the patient was on fire.

Everything was covered by BLS ambulances which were volunteer, municipal, hospital based, or private.

A BLS ambulance was sent to all jobs, and if the dispatcher decided it was warranted, a Medic fly car was sent simultaneously. The medics were sent out of the regional Trauma-1 center. If they werent needed (either by their own, or by the EMTs decision) they could leave, and immediately be signaled as available for another job. If they were needed, they would treat, and escort the ambulance to the ER.

The system worked with low overhead, and almost no misuse. Medics stayed up on their skills, because every case they were on warranted ALS. BLS stayed up on their skills because they learned to be self sufficient, while knowing when to ask for help.

 

[emttim]

I was fortunate enough to work in a tiered system.

Fire rigs were only dispatched if the patient was on fire.

Everything was covered by BLS ambulances which were volunteer, municipal, hospital based, or private.

A BLS ambulance was sent to all jobs, and if the dispatcher decided it was warranted, a Medic fly car was sent simultaneously. The medics were sent out of the regional Trauma-1 center. If they werent needed (either by their own, or by the EMTs decision) they could leave, and immediately be signaled as available for another job. If they were needed, they would treat, and escort the ambulance to the ER.

The system worked with low overhead, and almost no misuse. Medics stayed up on their skills, because every case they were on warranted ALS. BLS stayed up on their skills because they learned to be self sufficient, while knowing when to ask for help.

I don't have time to respond to everyone since I'm studying but I did want to drop a quick note and say that I appreciate everyone's input. Perhaps EMTALA would be better off being revised than revoked. Granted, abuse of 911 may not be as widespread as some of us EMS providers seem to think, but I still think there needs to be something done to prevent 911 from being used as a taxi cab service. Perhaps there could be some sort of form that we can fill out, like there is with elder abuse, child abuse, etc. where the person is legitimately abusing the system, and they know they are (IE drug seekers, people using us as a taxi to go somewhere close to the hospital, etc.), we can file a 911 abuse form and its investigated by an appropriate governing body. Like with elder or child abuse, it doesn't need to be evidenced and isn't an accusation, it's just basically a "hey, go check this out" to the police.

Anyway, as far as the tiered system goes, sounds like that's the ticket to ensure appropriate responses, help minimize wasting of resources, and probably significantly reducing costs too since if you don't have an ALS ambulance responding to every call, you don't need to pay to have nearly as many medics. Hell, you could pay that one medic on the ALS ambulance here and there more and still come out well on top, it would attract brighter minds to the field, and would help the push for more education since it could be justified that in order to pay that one provider more then he/she needs to have a higher level of education than medics currently do. Anyway, thoughtful discussion. As far as Tired's recount of him calling for a gurney, I've come to the conclusion that he just hates EMS and isn't telling the full story as far as that goes. The only way you would get that sort of response to a clinic is by calling 911 and of course you're asking for trouble when you know what calling 911 entails and you do it anyway for a non-emergency transport. 911 is for emergencies only; it's not for calling cabs. There are plenty of transport ambulance companies that you can call directly and obviously they'll show up with one BLS rig, and unlike with gurney vans, you don't need to pre-pay for it since BLS transports are covered by insurance (typically). Plus, unless the company sucks, they get there within 15-20 minutes since the transport business is all about customer service. Unlike an emergency, they only get the call if they're better than their competitor, so that's what they aim to be.

 

[chimichanga]

On a mildly-related note:

Today I called for an ambulance to pick up a patient from my clinic and transport him to the Emergency Room...
They arrived with an ACLS rig, three EMTs, a fire-truck, and four firefighters.

Despite me telling them that he had no injury to his neck and I had clinically cleared his C-spine, he was strapped to the board, put in full spiral immobilization...

Did you call 911?

If so, the error was yours. (though your heart was in the right place).

The situation you described could have been handled by a simple wheelchair (or stretcher) van...Not an ambo...

 

[leviathan]

Did you call 911?

If so, the error was yours. (though your heart was in the right place).

The situation you described could have been handled by a simple wheelchair (or stretcher) van...Not an ambo...

Not many places have stretcher vans that I'm aware of.

 

[docB]

Not many places have stretcher vans that I'm aware of.

AMR has this program which is pretty widespread. Many other communities have similar independent companies.

 

[leviathan]

AMR has this program which is pretty widespread. Many other communities have similar independent companies.

I think I'm now suffering from Foot-In-Mouth disease. In my area we have about 99.9% of our interfacility transfers done by the ambulance service. There are a few small-time private transfer services around, but I guess that's a lot more prevalent in the states.

 

[chimichanga]

They're pretty common...Our small town (less than 30,000) serving two hospitals, has at least three running 24/7...

I was pointing out that some of the "waste" in EMS is the ignorance of the public, and the misuse of 911 by those in health care (i.e. the "nurse" at the nursing home calling 911 at 0300 for a cough and fever); In most areas, this can be handled by:

private ambo
wheelchair van
stretcher van
taxi

A whole crew of firefighters usually means the requestor called 911

 

[emttim]

They're pretty common...Our small town (less than 30,000) serving two hospitals, has at least three running 24/7...

I was pointing out that some of the "waste" in EMS is the ignorance of the public, and the misuse of 911 by those in health care (i.e. the "nurse" at the nursing home calling 911 at 0300 for a cough and fever); In most areas, this can be handled by:

private ambo
wheelchair van
stretcher van
taxi

A whole crew of firefighters usually means the requestor called 911

It must be different where you're at...a nurse calling 911 for a cough and fever in a SNF? They get investigated if they call 911 too often in a certain time frame...at least here you'll have these geniuses call a transport company (not even 911) for a patient with chest pain or SOB who's had it for 8 hours or more. Hell we've responded to a patient who was stroking out over 12 hours ago and they didn't call 911. I'd be thankful they were calling 911 at all there..

 

[chimichanga]

...They get investigated if they call 911 too often in a certain time frame...at least here you'll have these geniuses call a transport company (not even 911) for a patient with chest pain or SOB who's had it for 8 hours or more. Hell we've responded to a patient who was stroking out over 12 hours ago and they didn't call 911. I'd be thankful they were calling 911 at all there..

Wow...Interesting contrast from the reality here...

 

[MedicFL]

Wow...Interesting contrast from the reality here...

What do you mean are you trying to say this doesn't happen? If happens all the time here in Orlando as well. THey can call private emergency without call 911 and its not a ding or call 911.

 

[musashi]

I think this is really accurate summary, thank you.

Accurate only until your loved one or child is in need of life saving tx. Then I'll bet the farm you're calling a 3 digit number we all know. Btw, I'm a medic and just 2 days ago I fought at death's door on behalf of a 12 y/o involved in a terrible MVC. The ER attending told me and my crew if it wasn't for our intervention the kid would've bled out prior to getting to the hospital.

I wonder if her parents agree with your philosophy?

 

[leviathan]

The ER attending told me and my crew if it wasn't for our intervention the kid would've bled out prior to getting to the hospital.

What intervention was this?

 

[MedicFL]

Agree with the above^^^^^^?? Bandaging and giving fluids just buy time...

 

[leviathan]

Agree with the above^^^^^^?? Bandaging and giving fluids just buy time...

It's just anecdotal. There's no saying someone wouldn't survive had you not been there to bandage a bleed. All the literature on IV fluids show it makes no difference or worsens survival if you don't yet have control of the bleed. Anyone can put pressure on a hemorrhage too.

 

[MedicFL]

It's just anecdotal. There's no saying someone wouldn't survive had you not been there to bandage a bleed. All the literature on IV fluids show it makes no difference or worsens survival if you don't yet have control of the bleed. Anyone can put pressure on a hemorrhage too.

Thats my point there is nothing you are going to do in the field that is going to "save" a bad trauma they need an OR.

 

[EMmedic]

Thats my point there is nothing you are going to do in the field that is going to "save" a bad trauma they need an OR.

I mostly agree. My two exceptions would be a tourniquet and chest decompression. If someone truly needs a tourniquet and you apply it, then I think it could be argued that you made a real difference. Same for chest decompression. Obviously these are very rare, but these would be my exceptions to that statement.

 

[howelljolly]

I think that if the patient was dragged out of the vehicle by her ankles, and told to "walk it off" she would have surely died.

 

[MedicFL]

I mostly agree. My two exceptions would be a tourniquet and chest decompression. If someone truly needs a tourniquet and you apply it, then I think it could be argued that you made a real difference. Same for chest decompression. Obviously these are very rare, but these would be my exceptions to that statement.

After I posted that I knew someone would call me out on that I would like also to add airway issues....

 

[leviathan]

I'm just playing devil's advocate here.

 

[chimichanga]

What do you mean are you trying to say this doesn't happen? If happens all the time here in Orlando as well. THey can call private emergency without call 911 and its not a ding or call 911.

Not at all...

I'm saying that based on this forum, things vary in different places...

In the Phoenix area, SNFs are mostly calling 911 for all their "needed" transports...They certainly could call a private company, they choose not to, and there are no repercussions for 911 misuse...I'm happy to hear that in your neck of the woods, people are correctly choosing who to call...

 

[flightmedic1507]

About how many med. students here and doctors do not understand the medical system outside of a hospital. I am also amazed that EMS services still use BLS ambulances. But I see it every day.

EMS is needed. In Texas Paramedics are protocoled very well and truely make a diff. They give all prehospital cardiac meds, PAI, Pericardiocentisis, Pressors, Of course airway managment, Pain medication.c-spine clearance......

In rural area where im at we are 45 min. from a community hospital and over an hour from a level one. I fly on a helicopter now, but still work the ambulance from time to time to remember where the real work is done.

These Med students should have to ride on a ambulance, pull up to a scene with a family of 5 ejected onto a roadway, some screaming, some with agonal respirations,some dead.Then as you and your 1 partner (who may be a basic) are to handle this. Help is on the way but its 20-25 min till they arrive. Its dark maybe raining. This is emergency medicine

Yes all medics are not created equall. Some are destined to be Transfer medics ,some are good enouh to handle emergencies. But dont give that medic crap when he walks into that ER. You have no idea what hes been through that night, and the grass in the IV tape your complaining about only makes you look like a rookie.

And on the other side of the coin, that medic didnt want to get his tired ass up and bring you that stomach ache , just as much as you didnt want them in your ER.

forgive any grammatical errors im only a medic

 

[deleted6669]

About how many med. students here and doctors do not understand the medical system outside of a hospital. I am also amazed that EMS services still use BLS ambulances. But I see it every day.

EMS is needed. In Texas Paramedics are protocoled very well and truely make a diff. They give all prehospital cardiac meds, PAI, Pericardiocentisis, Pressors, Of course airway managment, Pain medication.c-spine clearance......

In rural area where im at we are 45 min. from a community hospital and over an hour from a level one. I fly on a helicopter now, but still work the ambulance from time to time to remember where the real work is done.

These Med students should have to ride on a ambulance, pull up to a scene with a family of 5 ejected onto a roadway, some screaming, some with agonal respirations,some dead.Then as you and your 1 partner (who may be a basic) are to handle this. Help is on the way but its 20-25 min till they arrive. Its dark maybe raining. This is emergency medicine

Yes all medics are not created equall. Some are destined to be Transfer medics ,some are good enouh to handle emergencies. But dont give that medic crap when he walks into that ER. You have no idea what hes been through that night, and the grass in the IV tape your complaining about only makes you look like a rookie.

And on the other side of the coin, that medic didnt want to get his tired ass up and bring you that stomach ache , just as much as you didnt want them in your ER.

forgive any grammatical errors im only a medic

great post.
I had days like that too with multiple sick pts and no adv. help.
my 1st call on my 1st day as a new medic involved a head on mva. none of the drivers or passengers had seat belts and 1 vehicle had 5 folks in the back of the open pickup who got ejected. 2 I called on scene with injuries incompatible with life, 6 by ground and 2 by medevac. quite an intro.

 

[pseudoknot]

The EMS community needs to move past old war stories and start paying attention to science. "Amazed that EMS services still use BLS ambulances?" On the contrary, most calls can be handled fine at the BLS level and it's not clear that having a medic on every street corner does anything for patients.

Anyway, I think that this has been a pretty good discussion and most of the participants have EMS experience. I'm sorry that flightmedic doesn't think we understand EMS, but hey, I'll be on duty tomorrow night. Maybe it will all become clear to me then. In the meantime, if you want to criticize please bring some data.

 

[EMmedic]

About how many med. students here and doctors do not understand the medical system outside of a hospital. I am also amazed that EMS services still use BLS ambulances. But I see it every day.

EMS is needed. In Texas Paramedics are protocoled very well and truely make a diff. They give all prehospital cardiac meds, PAI, Pericardiocentisis, Pressors, Of course airway managment, Pain medication.c-spine clearance......

In rural area where im at we are 45 min. from a community hospital and over an hour from a level one. I fly on a helicopter now, but still work the ambulance from time to time to remember where the real work is done.

These Med students should have to ride on a ambulance, pull up to a scene with a family of 5 ejected onto a roadway, some screaming, some with agonal respirations,some dead.Then as you and your 1 partner (who may be a basic) are to handle this. Help is on the way but its 20-25 min till they arrive. Its dark maybe raining. This is emergency medicine

Yes all medics are not created equall. Some are destined to be Transfer medics ,some are good enouh to handle emergencies. But dont give that medic crap when he walks into that ER. You have no idea what hes been through that night, and the grass in the IV tape your complaining about only makes you look like a rookie.

And on the other side of the coin, that medic didnt want to get his tired ass up and bring you that stomach ache , just as much as you didnt want them in your ER.

forgive any grammatical errors im only a medic

Most of the medical students and doctors posting in this forum are current or former EMS providers. Personally, I have been in EMS for almost 10 years. Just because I am a medical student doesn't mean I don't know what happens on the road.

Look, I love EMS. I think its great. I think its ridiculously important and I respect medics and EMTs. I think its meaningful and I want to contribute to it when I'm eventually an EM doc. However, it really irks me when people sensationalize it to try to convince others of its worth. Let's be honest here, how many times have you had a call like the one you listed above? Most of EMS is routine, mild/moderately acute patients with a few sickies here and there. People who have never been in the back of an ambulance have this idea that its wild and crazy and blood and guts and out of control. Sometimes. But mostly...not really. I hate it when EMS providers play into this and try to convince others that its like this.

 

[deleted6669]

you're right, there is a lot of routine bs but at a busy station it's not uncommon to get 1 "real" call per shift like the medical or trauma arrest, the tricyclic overdose, the big mi, the multivehicle mva with several critical pts, etc
In backwater nowhere this is probably a lot less common but in LA, ny city, detroit, etc good calls are not that rare.