Ambulance ride-alongs?

[Cranius]

This concept is a staple for pretty much every TV doctor show there is, but I'm curious as to whether it actually happens.

Do doctors (or students) ever go out on ambulance runs? And while we're at it, is there ever a doctor on an air ambulance?

Hope someone knows something about this

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[littlefield]

Most EM residencies have some ambulance ride-alongs included in the curriculum, with optional air experience. Very rarely are you allowed to do more than watch.

The Mayo Clinic EM residency has an impressive EMS experience: You are trained to serve as a flight physician, and work a few shifts with the air ambulance team as an active member every month you are in the ED. There are probably other residencies like this, but I only know of this one.

I know of few attending ER docs who ever ride along. Usually, they just provide online medical control.

 

[notstudying]

We do an ambulance shift as part of our required emergency medicine course. No air time (not much space in the copters!). It was interesting to see the process, but we can't do anything but watch, and I think one was plenty.

 

[chuck deli]

In Wisconsin our helicopters always have a RN and MD along, (no paramedics). However most of the MD's are attendings from community hospitals looking for trauma practice. Occassionally, if a resident gets on the waiting list early, they can get some shifts in the air...doesn't have to be EM either (anesthesia residents seem to enjoy the air time). As far as ride alongs on the ground, that's more complicated. An ambulance service can only do procedures/push drugs etc. that they are certified for. So, even if an MD were to ride along, he/she could only perform up to the service's certification. Therefore, an MD will ride along if they have a desire for the experience, or if they are considering a medical director position. At least that's how it works in WI.

 

[ERMudPhud]

Here in Denver the EM residents and medical students can arrange to do ride along in the ambulances if they want. A good chunk of the time in the ambulance seems to be spent parked at 7-11 watching the hookers walk by. Some of the rest is spent driving like hell to things that turn out not to be emergencies and a few calls turn out to be the real deal. The potential for any procedures isn't that high. As EM residents we also had the option to do flights in the helicopters and participate in care of those patients. Most of the time neither the helicopters nor the ambulances are staffed by MD's. Some residencies have much more prehospital experience. Pittsburgh and UMass are two that come to mind.

A friend of mine is medical direct for a medical transport service that flies commercial jets to foreign countries to bring back sick or injured Americans. Their flights are not generally staffed by MD's unless the patient or family request it.

 

[peptidoglycan]

At Tulane, the first year med students are required to do one ride-along with EMS. You don't get to do so much, but it is a valuable experience. Also, through the Emergency Medicine Interest Group, med students (I'm talking even first and second years) are given the opportunity to go along on helicopter flights. Sometimes they transport people to or from other states or even out of the country. Pretty cool stuff.

 

[trauma_junky]

Originally posted by chuck deli
In Wisconsin our helicopters always have a RN and MD along, (no paramedics). However most of the MD's are attendings from community hospitals looking for trauma practice. Occassionally, if a resident gets on the waiting list early, they can get some shifts in the air...doesn't have to be EM either (anesthesia residents seem to enjoy the air time). As far as ride alongs on the ground, that's more complicated. An ambulance service can only do procedures/push drugs etc. that they are certified for. So, even if an MD were to ride along, he/she could only perform up to the service's certification. Therefore, an MD will ride along if they have a desire for the experience, or if they are considering a medical director position. At least that's how it works in WI.

Not in Texas. If an MD says do it, or wants to do it, it's done!

 

[Tbonez]

Working as a paramedic, I once had a 3rd yr. ride along. I let him push morphine, and the ***** slammed it in, and caused transient hypotension. Don't they teach medication adminstration rates in pharm? Then he got all nervous when I told him what he had done wrong, and threw away the plunger for the morphine into the sharps container. When I asked him what the hell he was doing, he tried to reach into the sharps container full of bloody needles to get it back and damn near stuck himself. Finally, I just had to tell him to stop and take a breath. Then he got his nice new brown doctor shoes puked on. All day long he tripped on oxygen hoses, had his stehoscope on backwards, and had to ask me how to read the 12 lead. Perhaps an ambulance isn't the best place for a 3rd yr. who may or may not have had any patient contact experience prior to med. school. Let them do clinical time in a more controlled environemnt first. Then do EMS rides in residency. Every doctor no matter the residency should have to do an EMS ride or two in my opinion, the trick is figuring out when.

 

[Smurfette]

Originally posted by Tbonez
Working as a paramedic, I once had a 3rd yr. ride along. I let him push morphine, and the ***** slammed it in, and caused transient hypotension. Don't they teach medication adminstration rates in pharm? Then he got all nervous when I told him what he had done wrong, and threw away the plunger for the morphine into the sharps container. When I asked him what the hell he was doing, he tried to reach into the sharps container full of bloody needles to get it back and damn near stuck himself. Finally, I just had to tell him to stop and take a breath. Then he got his nice new brown doctor shoes puked on. All day long he tripped on oxygen hoses, had his stehoscope on backwards, and had to ask me how to read the 12 lead. Perhaps an ambulance isn't the best place for a 3rd yr. who may or may not have had any patient contact experience prior to med school. Then do EMS rides in residency. Every doctor no matter the residency should have to do an EMS ride or two in my opinion, the trick is figuring out when.

I know I was never taught dosing, let alone administration rates during pharm (we were told that would be learned "on the job" per se).... Most of the things you complain about are learned during 3rd and 4th year as the med student encounters them on the wards. EMS training is very specific to what you guys do; med school is a lot broader---to assume a third year med student would know how to stabilize a patient in the field, dose and push emergency drugs and so on is rather foolish, IMO.

 

[chuck deli]

I'm curious Tbonez, what became of that situation? Personally, I won't let the med. student do anything but sit and watch-- Everyone's gotta learn at some point. Perhaps you both learned something that day...

 

[Tbonez]

Originally posted by chuck deli
I'm curious Tbonez, what became of that situation? Personally, I won't let the med. student do anything but sit and watch-- Everyone's gotta learn at some point. Perhaps you both learned something that day...

Absolutely. I learned that my MSIII was a walking medical encyclopedia, but had the common sense of a pencil eraser. You should at least know however, that certain IV drugs have adverse effects at certain adminstration rates. If you don't learn that in pharmacology, then you should.

 

[Tbonez]

Originally posted by Smurfette
I know I was never taught dosing, let alone administration rates during pharm (we were told that would be learned "on the job" per se).... Most of the things you complain about are learned during 3rd and 4th year as the med student encounters them on the wards. EMS training is very specific to what you guys do; med school is a lot broader---to assume a third year med student would know how to stabilize a patient in the field, dose and push emergency drugs and so on is rather foolish, IMO.

I guess you're right. Just the other day, I stuck a pencil in my eye, because since I haven't been to my 3rd yr. yet, I don't know any better. Come on. If medical school is so broad, then why did he throw my tubex in the sharps container? Then why did he stick his hand into the bloody needle-filled sharps container? You seriously believe that you learn this in 3rd and 4th year? These dictate only comon sense, not killer scores on step 1.
I can't even grant you about the drug administration. To not know that morphine has adverse hemodynamic effects at rapid infusion rates means that you DIDN'T PAY ATTENTION in P-COL, or that you should sue your school for failing to provide you a proper education. I never gave him any leniency in caring for the patient. He was there to watch. I was well aware that a MS3, has little to know "putting it all together" experience and is in clinical settings to gain exposure. I gave him the order, and only allowed him to administer it. What I did learn is that perhaps we shouldn't give someone benefit of the doubt just because he/she managed to get through 2nd yr. But again, the other two things above (the sharps container incidents) require only common sense. Thus, maybe it is medical school which is very specific. No wonder most people equate "medical student" with the dorks on "ER" that stand around wide-eyed and ask stupid questions. Also, I didn't ever say that I assumed a 3rd yr. could stabilize a patient, dose drugs, etc., so don't call me foolish. That's just rude.

 

[notstudying]

Originally posted by Tbonez
I guess you're right. Just the other day, I stuck a pencil in my eye, because since I haven't been to my 3rd yr. yet, I don't know any better. Come on. If medical school is so broad, then why did he throw my tubex in the sharps container? Then why did he stick his hand into the bloody needle-filled sharps container? You seriously believe that you learn this in 3rd and 4th year? These dictate only comon sense, not killer scores on step 1.
I can't even grant you about the drug administration. To not know that morphine has adverse hemodynamic effects at rapid infusion rates means that you DIDN'T PAY ATTENTION in P-COL, or that you should sue your school for failing to provide you a proper education. I never gave him any leniency in caring for the patient. He was there to watch. I was well aware that a MS3, has little to know "putting it all together" experience and is in clinical settings to gain exposure. I gave him the order, and only allowed him to administer it. What I did learn is that perhaps we shouldn't give someone benefit of the doubt just because he/she managed to get through 2nd yr. But again, the other two things above (the sharps container incidents) require only common sense. Thus, maybe it is medical school which is very specific. No wonder most people equate "medical student" with the dorks on "ER" that stand around wide-eyed and ask stupid questions. Also, I didn't ever say that I assumed a 3rd yr. could stabilize a patient, dose drugs, etc., so don't call me foolish. That's just rude.

I'm an MS4, I have done all the requirements, and I'll be released into the cold, hard world quite soon. Unfortunately, med students, especially at private hospitals where most of the medication administration, etc is done by nursing staff, don't always learn the practical skills. I'll grant you that fishing around in the sharps container is royally stupid, and indicates to me that the student is not very good under pressure (he probably could tell you that was stupid, but at the time was overwhelmed by the fact that he had just screwed up with a patient).

However, I'm still confused as to why placing the tubex (whatever that is) into the sharps bucket was a bad thing-I was never taught what should go in there, and probably should have been. I was also not taught morphine administration rates in pharm-probably because we never actually administer it. It did come up eventually in the context of my ED rotation, in 4th year. To assume that a 3rd year knows anything is dangerous, as you found out. As the student's supervisor it was your responsibility to go over the pertinent aspects of the "procedure", which in this case would include that "pushing" a medication doesn't mean going fast. It really irks me when attendings tell you to do something, don't explain it well, and then blame us for doing it wrong. I really think that medical students should be observers only on ridealongs, precisely because the EMS staff will not know what the skill level is (if any); it places both the EMS staff and the student at risk for making medical errors.

1st and 2nd year have very little to do with practical knowledge, that's why there are clinical rotations and residency.

 

[streetdoc]

you don't throw away the tubex of morphine because it is required to account for every last drop of a conrolled substance. if you don't give (not push) the whole amount, you better have the syringe to show the physician...other wise, they may blame your good mood on you finishing off the morphine.

common sense can go a long way....unfortunately medical school is slowly draining me of all my common sense i gained as a medic.

streetdoc

 

[donnyfire]

Originally posted by chuck deli
In Wisconsin our helicopters always have a RN and MD along, (no paramedics). However most of the MD's are attendings from community hospitals looking for trauma practice. Occassionally, if a resident gets on the waiting list early, they can get some shifts in the air...doesn't have to be EM either (anesthesia residents seem to enjoy the air time). As far as ride alongs on the ground, that's more complicated. An ambulance service can only do procedures/push drugs etc. that they are certified for. So, even if an MD were to ride along, he/she could only perform up to the service's certification. Therefore, an MD will ride along if they have a desire for the experience, or if they are considering a medical director position. At least that's how it works in WI.

I'm not sure if the law has changed on this or not, but I know of one ambulance service in southwest WI which used to have docs ride along fairly often (they lived in town). The service was only EMT-B, but they had a locked cabinet with ALS drugs which the docs could access and use in the appropriate setting.

 

[chuck deli]

Thanks for the info Donnyfire. Perhaps I shouldn't be so quick to genealize to all of WI (Go pack!)

As for tbonez, I still don't understand your rant about ride-alongs. Have you never made a mistake? As that student's supervisor, YOU should have asked him if he was comfortable in pushing pain meds. I don't have to lecture anyone that if it's your rig, you're in charge. The first time I was at a major trauma site, I ran outta the rig without gloves on. Does that mean that I don't know to wear gloves? No, I was just "caught up in the moment". Perhaps he'd never seen a tubex before? You don't have to be venting on medical students, because personally I think you're at fault. Ride-alongs, if done with an experienced medic, can be a great experience for students. Nothing personal, just "my $.02"

 

[donnyfire]

I've been riding an ambulance in some form or other for eight years now.
Yes, it's true that one of the first things you are taught are "scene safety, BIS"
Meaning watch your a## and put on some gloves.
I've been a paramedic for six years, and consider myself experienced. I'm a preceptor for the local paramedic program.
However, that being said, there have been times when I've forgot to put gloves on. It's not often, and usually at about four in the morning, but it happens.
As does someone throwing away a tubex. Especially if they don't know that it's reusable.
The bottom line is that it seems that this particular 3rd year was green. Big deal. He was in an unfamiliar environment with unfamiliar people. Maybe he was even seeing some things he hadn't seen before.

I'm with Chuck Deli on this. I wouldn't let him do anything but watch, at least the first time he/she was out with me.

 

[12R34Y]

I don't think it is very practical for medical students to be learning push rates on drugs as well as all of the other bologna that goes along with the drug.

Realistic situation: Doctor/resident is working in an ED and asks the nurse to titrate morphine to pain relief on a chest pain. The doc doesn't sit in this one patient's room and give 2mg increments every few minutes monitoring the chest pain.....docs just don't give meds very often if ever. I wouldn't expect a third year to know that. Nor should anyone else.

Having said that........when the patient becomes hypotensive after the admin of morphine the doctor will know WHY and how to fix it....narcan.

later,

 

[Smurfette]

Originally posted by Tbonez
I guess you're right. Just the other day, I stuck a pencil in my eye, because since I haven't been to my 3rd yr. yet, I don't know any better. Come on. If medical school is so broad, then why did he throw my tubex in the sharps container? Then why did he stick his hand into the bloody needle-filled sharps container? You seriously believe that you learn this in 3rd and 4th year? These dictate only comon sense, not killer scores on step 1.
I can't even grant you about the drug administration. To not know that morphine has adverse hemodynamic effects at rapid infusion rates means that you DIDN'T PAY ATTENTION in P-COL, or that you should sue your school for failing to provide you a proper education. I never gave him any leniency in caring for the patient. He was there to watch. I was well aware that a MS3, has little to know "putting it all together" experience and is in clinical settings to gain exposure. I gave him the order, and only allowed him to administer it. What I did learn is that perhaps we shouldn't give someone benefit of the doubt just because he/she managed to get through 2nd yr. But again, the other two things above (the sharps container incidents) require only common sense. Thus, maybe it is medical school which is very specific. No wonder most people equate "medical student" with the dorks on "ER" that stand around wide-eyed and ask stupid questions. Also, I didn't ever say that I assumed a 3rd yr. could stabilize a patient, dose drugs, etc., so don't call me foolish. That's just rude.

Speaking of rude, I do believe that I learned the whole pencil-eye thing well before my years of higher education. I must be some sort of prodigy in that respect, I guess. OK, so you still seem to be bitter about that ridealong incident, I understand that. But don't attack those of us who are just trying to tell you what realistically a third-year med student in that position likely would or wouldn't know.

Notstudying, I think your reply was right on.

I can tell you 100% that we were never taught rapid infusion rate of morphine causes hemodynamic instability in Pharmacology (if that's what you mean by P-COL). Obviously, there's a dose effect, but infusion RATE (per se) was never addressed. What rate is considered too fast??---I have no idea. If someone hands me a syringe, I ask "how much of this should I push?". Was I taught to do so? No. But I hate it when people I work with assume I know more than I do, so I double-check that I am understanding them correctly. Your ridealong should have confirmed how much to push at that time. But then again, if you handed it to him and said, "Push it!", I could understand that he may assume to give it all then. In the same sense, you should have told him to push it slow.

And the hand into the sharps container? Dumb. Very very dumb. Obviously lacking in common sense, but I've seen people do it....med students (even med1's should know better than that), MDs, PAs.

 

[ERMudPhud]

So a nice innocent thread on whether medical students or residents can ever do ride alongs suddenly morphs into a paramedic vs med student flame war. I know I've thrown at least one tubex into the sharps container and it was long after I was a student. Most physicians with the exception of anesthesiologist are completely unfamilair with infusion rates for the drugs they order. Nurses have a very useful drug handbook though that gives routes and rates for everything. It's worth looking at if you are ordering something unfamiliar to them and you.