Em & ems

[pianoman511]

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Hello everyone:

I am a MS3 (newly minted) and am interested in EM. I have been involved in EMS for about 8 years now and I am wondering if any attendings/residents still work on the streets (fly car/first response) in EMS or if malpractice or other concerns are big factors.

Thanks 😎

 

[Tiger26]

Hello everyone:

I am a MS3 (newly minted) and am interested in EM. I have been involved in EMS for about 8 years now and I am wondering if any attendings/residents still work on the streets (fly car/first response) in EMS or if malpractice or other concerns are big factors.

Thanks 😎

a very big blur about whether you'd act in the capacity of a physician or EMT, with a jury likely to hold you to the standard of a physician, despite having EMT resources

 

[Dwindlin]

Hello everyone:

I am a MS3 (newly minted) and am interested in EM. I have been involved in EMS for about 8 years now and I am wondering if any attendings/residents still work on the streets (fly car/first response) in EMS or if malpractice or other concerns are big factors.

Thanks 😎

I would imagine it is state dependent. Here in Ohio I know several docs who run for volly squads as EMT-B's, and they can act simply as an EMT-B.

 

[jbar]

There is the whole question of why you'd want to work at the EMT level. I too hope to stay involved with EMS, but I think it would get pretty boring as an EM physician without monitor, drugs, IVs etc. Also I can see one's desire to still be carrying 300 pound people down the stairs to lessen as you get closer to 40.

Doing BLS level care would be more tolerable if it's in the context of a more challenging situation (ski patrol, high angle rescue, search and rescue etc). But less so for the ambulance.

I think when you hear of docs working as EMTs, it's worth taking a good look at what kind of doctor they are. I could more understand a pediatrician, psychiatrist, neurologist etc. not feeling comfortable providing ALS care. But can't say I know too many EM docs running BLS. Most of those who are still involved who I know are either medical directors or acting at the paramedic level in a fly car.

 

[pianoman511]

There is the whole question of why you'd want to work at the EMT level. I too hope to stay involved with EMS, but I think it would get pretty boring as an EM physician without monitor, drugs, IVs etc. Also I can see one's desire to still be carrying 300 pound people down the stairs to lessen as you get closer to 40.

Doing BLS level care would be more tolerable if it's in the context of a more challenging situation (ski patrol, high angle rescue, search and rescue etc). But less so for the ambulance.

I think when you hear of docs working as EMTs, it's worth taking a good look at what kind of doctor they are. I could more understand a pediatrician, psychiatrist, neurologist etc. not feeling comfortable providing ALS care. But can't say I know too many EM docs running BLS. Most of those who are still involved who I know are either medical directors or acting at the paramedic level in a fly car.

That's more of what I was going for. In PA they have a "Prehospital Physician" which you are eligible for after your first year of residency and it seems after reading the new revisions to the EMS law that it's intended to be a way for newly minted second year residents to be involved in EMS as a "doc in the box". That kind of thing (i.e. physician fly car) is more of what I was thinking, although I know a physician in my area who is a member of a volunteer fire dept (with an ambulance) who volunteers as an EMT. Not sure how that works though...

 

[pseudoknot]

This is an interesting article I just ran across in relation to this thread:

http://www.ncbi.nlm.nih.gov/pubmed/20199229

Prehosp Emerg Care. 2010 Apr 6;14(2):164-6.
State requirements for physician emergency medical services providers.
Fullagar CJ, Prasad NH, Brown LH, Anaya N.

Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York 13210, USA. [email protected]
Abstract
OBJECTIVE: To describe requirements of physicians wishing to function as primary field emergency medical services (EMS) providers and variation of these requirements among states. METHODS: A simple mailed survey was developed and distributed to all 50 U.S. state EMS directors. The survey gathered information about each state's regulations concerning physicians performing as a primary EMS crew member. Data were entered into a Microsoft Excel spreadsheet and reported using simple descriptive statistics, including proportions and 95% confidence intervals (CIs). RESULTS: Forty-four (88%) of the states responded. In 32 states (73%), physicians can work as a primary member of either a basic life support (BLS) or an advanced life support (ALS) ambulance crew without any specific additional training. In 30 states (68%), physicians can work as a primary member of either a BLS or an ALS ambulance crew without any specific prehospital certification. All of the reporting states will allow a physician to become certified as an emergency medical technician (EMT) or paramedic and then work as a primary member of a BLS or ALS ambulance crew. Seventy-nine percent allow the provision of physician-level care on BLS ambulances, and 81% on ALS ambulances. There was no meaningful difference between the training requirements for becoming a certified BLS provider vs. a certified ALS provider. States were significantly less likely to require a skills examination of physicians wishing to become certified as a BLS provider (9%) compared with those wishing to become certified as an ALS provider (82%). CONCLUSION: Most states allow physicians to become certified prehospital care providers, although few states require physicians wishing to work as a primary EMS provider to do so, or even to undergo any specific EMS training. There is no national standardization of the preparatory requirements of physicians wishing to provide in-field EMS.

PMID: 20199229 [PubMed - in process]

 

[Siggy]

Call me a naive first year, but short of ambulance staffing requirements, why would a state EMS office be required to give their blessing for a physician to provide prehospital care? Wouldn't that be taken for simply by the physician's unrestricted license to practice medicine?

 

[pseudoknot]

Call me a naive first year, but short of ambulance staffing requirements, why would a state EMS office be required to give their blessing for a physician to provide prehospital care? Wouldn't that be taken for simply by the physician's unrestricted license to practice medicine?

As you said, it's the ambulance staffing requirements.

 

[Dwindlin]

Call me a naive first year, but short of ambulance staffing requirements, why would a state EMS office be required to give their blessing for a physician to provide prehospital care? Wouldn't that be taken for simply by the physician's unrestricted license to practice medicine?

Again, this is an example from Ohio, so take this for what its worth. A physician can in fact show up on a scene and act as a such. However they assume complete responsibility for the patient and MUST accompany that patient to the ED (ie. he can't do something even if I can manage it then leave the patient with me). If they actually hold a cert, then they are no different than any other EMS provider (ie. protected to a degree by EMS scope of practice).

 

[Siggy]

Again, this is an example from Ohio, so take this for what its worth. A physician can in fact show up on a scene and act as a such. However they assume complete responsibility for the patient and MUST accompany that patient to the ED (ie. he can't do something even if I can manage it then leave the patient with me). If they actually hold a cert, then they are no different than any other EMS provider (ie. protected to a degree by EMS scope of practice).

I'd argue that there's a very big difference between a physician operating as a part of the EMS system (say, providing advanced care in rural areas that lack paramedic service) and showing up unilaterally on scene and saying "my patient."

 

[jbar]

Considering that medical school doesn't teach backboarding, extracation, scene safety, haz-mat, c-collar application, PALS, ATLS, etc etc, I would hope that there would be some sort of requirement for training that a physician would go through before showing up on a rig. Or at least having to pass a test to show that they know what they are doing.

 

[docB]

Call me a naive first year, but short of ambulance staffing requirements, why would a state EMS office be required to give their blessing for a physician to provide prehospital care? Wouldn't that be taken for simply by the physician's unrestricted license to practice medicine?

I can tell you that certain certifying bodies, such as the one my EMS system is under, takes a keen interest in anyone who is on the rigs. If some doc started riding around on a rig without a well defined role there would be big trouble for the doc, the crew and the agency involved. His licensure would have nothing to do with it.

 

[Dwindlin]

I'd argue that there's a very big difference between a physician operating as a part of the EMS system (say, providing advanced care in rural areas that lack paramedic service) and showing up unilaterally on scene and saying "my patient."

My point was that technically your right, the physician doesn't need the states "blessing" in the form of an EMS cert to act as a physician pre-hospital. But if one wants to be affiliated with one regularly then it behooves you to have one for liability reasons.

 

[CajunMedic]

Where I work now, we have 3rd year EM residents ride with us for an elective. They go through a couple of days of orientation, then ride on the units for a month. When they are on the truck, they can pretty much do what they feel comfortable with. We've had some sit back and watch, i had one who used to beat me out of the truck with my med box and be in the house before you could turn around (he was a former Marine and industrial medic). They can also act as med control on scene.

IIRC, Houston TX Fd, and Wake County NC has docs that ride around in flycars with full sets of gear and can treat pts.

 

[polygonal]

I can tell you that certain certifying bodies, such as the one my EMS system is under, takes a keen interest in anyone who is on the rigs. If some doc started riding around on a rig without a well defined role there would be big trouble for the doc, the crew and the agency involved. His licensure would have nothing to do with it.

Can you please elaborate?

I still don't get much of this discussion. Most of these discussions in the past have been by students or EMTs that don't really understand state medical regulations. In general, a fully independently licensed physician
can legally see whatever pt they want, perform any procedure, in whatever setting they choose (now credentialling, payment, malpractice are a different story). In general, a physician cannot adopt a "delegated" role such as an EMT if they are licensed in that state.

 

[pseudoknot]

Can you please elaborate?

I still don't get much of this discussion. Most of these discussions in the past have been by students or EMTs that don't really understand state medical regulations. In general, a fully independently licensed physician
can legally see whatever pt they want, perform any procedure, in whatever setting they choose (now credentialling, payment, malpractice are a different story). In general, a physician cannot adopt a "delegated" role such as an EMT if they are licensed in that state.

Most (probably all) states/counties/jurisdictions have regulations that specify the personnel on an ambulance or other emergency response apparatus. For example, in Los Angeles County an ALS ambulance has to be staffed by two paramedics. If this is not the case, then it can't legally be used to respond to 911 calls.

 

[docB]

Can you please elaborate?

I still don't get much of this discussion. Most of these discussions in the past have been by students or EMTs that don't really understand state medical regulations. In general, a fully independently licensed physician
can legally see whatever pt they want, perform any procedure, in whatever setting they choose (now credentialling, payment, malpractice are a different story). In general, a physician cannot adopt a "delegated" role such as an EMT if they are licensed in that state.

Most (probably all) states/counties/jurisdictions have regulations that specify the personnel on an ambulance or other emergency response apparatus. For example, in Los Angeles County an ALS ambulance has to be staffed by two paramedics. If this is not the case, then it can't legally be used to respond to 911 calls.

Pseudo is correct. Beyond the staffing issue my certifying body would want to know why that doc is there, what their role is supposed to be and what their qualifications are. A doc who is not appropriately trained would definitely be a red flag and while (in my area) the Health Department could not restrict his license and say he can't treat patients they could absolutely say he can't ride on ambulances that they certify.

One big issue with all this which is a biiiiiiig deal in my town is scene command. We have fire and privates responding to every 911 call. There is a very specific pecking order on scene and feathers get ruffled when that is thrown into disarray. It has been an issue when I ride before but I know how to defuse it.

A good example of this is that a few years ago one ambulance company wanted it's critical care nurse rigs to respond to 911 calls. They wanted this because when the rigs didn't have a CCT call they were losing money. This was seen as unacceptable by fire because it meant that while they were suppose to command on scene they might have to defer to the CCT nurse in a disagreement because of the nurse's higher level of training. They were so upset by that prospect that they went to the Health Department and had the nurses formally restricted from taking 911 calls. We now use CCT Paramedics instead.

 

[Siggy]

This was seen as unacceptable by fire because it meant that while they were suppose to command on scene they might have to defer to the CCT nurse in a disagreement because of the nurse's higher level of training. They were so upset by that prospect that they went to the Health Department and had the nurses formally restricted from taking 911 calls. We now use CCT Paramedics instead.

The fire department complained? Why am I so not surprised about this?

 

[pseudoknot]

The fire department complained? Why am I so not surprised about this?

Actually, I am a little surprised. I think it's not an unusual situation that the person who has scene command (e.g., division chief) is not the person with the highest medical training and thus would be expected to defer to a lower ranking paramedic on strictly patient care issues. (In fact, this is almost always the case at any major incident.) I can imagine there may have been other things going on in the private/fire interaction that docB described.

 

[Siggy]

Pseudo, at least in the Los Angeles area, the fire department chest beating is a normal part of the system. It's gone so far that, untill a few years ago, a few of the fire department transport contracts (a lot of the fire departments contract the ambulance transport out to private companies who provide BLS ambulances with the fire medics only riding if need be) stipulated that the private company was supposed to stage off scene on all calls until after the fire department made contact. At least, out here, I have yet to seriously see anything patient centered from the fire department.

 

[pseudoknot]

Pseudo, at least in the Los Angeles area, the fire department chest beating is a normal part of the system. It's gone so far that, untill a few years ago, a few of the fire department transport contracts (a lot of the fire departments contract the ambulance transport out to private companies who provide BLS ambulances with the fire medics only riding if need be) stipulated that the private company was supposed to stage off scene on all calls until after the fire department made contact. At least, out here, I have yet to seriously see anything patient centered from the fire department.

Yes, I'm well aware. I worked for Gerber Ambulance for a year before med school, and we transported for the Santa Monica and Torrance Fire Departments. We did have the rule about not being first on scene and I remember several times having to literally hide the rig in an alley or side street so that people didn't see us waiting nearby.

I think the issue was more that they were concerned we were hopelessly incompetent, which was often true (obviously not in my case 😀). That's kind of what I was alluding to in my previous post.

 

[Siggy]

Yes, I'm well aware. I worked for Gerber Ambulance for a year before med school, and we transported for the Santa Monica and Torrance Fire Departments. We did have the rule about not being first on scene and I remember several times having to literally hide the rig in an alley or side street so that people didn't see us waiting nearby.

I think the issue was more that they were concerned we were hopelessly incompetent, which was often true (obviously not in my case 😀). That's kind of what I was alluding to in my previous post.

Ah, so you know the So. Cal. environment then. For better or worse, my experience with fire based EMS out here (the majority of which was in OC) and the first hand stories I've heard from others has made me lose almost all respect for EMS based fire suppression.

 

[pseudoknot]

Ah, so you know the So. Cal. environment then. For better or worse, my experience with fire based EMS out here (the majority of which was in OC) and the first hand stories I've heard from others has made me lose almost all respect for EMS based fire suppression.

You're not the first I've heard that from. I don't think my experiences support any blanket statements, although I would lean in the other direction and say that I think fire departments seem better able to recruit and retain quality personnel. Fire departments, at least on the west coast, pay very well, have great benefits, and run out of stations. The private companies I'm familiar with insist on paying next to nothing and using system status management to avoid paying for stations, so that turnover is extremely high. Richmond's EMS is run as a pseudo-third-service that follows that same model, and while they do have some excellent individual providers, I still don't think it's a winning formula. I am not personally familiar with any true third-service agencies so I can't comment on those.

I think that fire-based agencies that have a commitment to EMS can do a great job. Something else I noticed in LA was that agencies that transported themselves (Pasadena, LAFD) seemed to be a little more patient-oriented than the ones that contracted with private ambulance companies.

 

[pianoman511]

At least in respect to nurses, while they have a higher level of training it may not be applicable to the situation. Nurses may know how to assess patients, but most treatment protocols revolve around physician assessments and diagnoses that are already in place. In addition, many hospitals don't have nurses doing things like intubation, pacing, etc. In that case, I can understand why the medics would have a hard time with nurses "above them" on the chain of command.

In terms of a physician acting as an EMT on an ambulance - if they are dual certified (i.e. both a physician and have current EMT cert) and only act in the scope of practice of an EMT, are they still legally held to the standard of care of a physician ? I guess that would be my question in that scenario. Obviously, in a fly car situation, they are set up to act as on scene medical command, but on a rig it may be a different matter entirely.

 

[pseudoknot]

In terms of a physician acting as an EMT on an ambulance - if they are dual certified (i.e. both a physician and have current EMT cert) and only act in the scope of practice of an EMT, are they still legally held to the standard of care of a physician ?

I think this has already been addressed above, but there is not a definitive answer. It's going to depend on the state, and from previous threads it seemed like most places lack any specific regulations governing this scenario. Really, I would guess (and I'm not a lawyer) that it would depend on the jury or medical board that it came before. As docB says, it makes sense that you can't hold someone accountable for not doing something that an ambulance isn't equipped for, but I would imagine a physician is always going to be held responsible for his or her knowledge base.

Also, I noticed you mentioned the standard of care, which as I understand it, basically means what would be done by reasonable peers in your location. Well, in most areas there aren't physicians riding around doing patient care in ambulances very often. Maybe this means there is no "standard of care" in that situation. Or maybe it would be whatever your peers imagined they might have done in the same situation. I don't know.

 

[docB]

At least in respect to nurses, while they have a higher level of training it may not be applicable to the situation. Nurses may know how to assess patients, but most treatment protocols revolve around physician assessments and diagnoses that are already in place. In addition, many hospitals don't have nurses doing things like intubation, pacing, etc. In that case, I can understand why the medics would have a hard time with nurses "above them" on the chain of command.

However in this case we're talking about CCT-RNs who are specially trained
to deal with scenes, extrications, etc.

I think this has already been addressed above, but there is not a definitive answer. It's going to depend on the state, and from previous threads it seemed like most places lack any specific regulations governing this scenario. Really, I would guess (and I'm not a lawyer) that it would depend on the jury or medical board that it came before.

I was going to say exactly this until I read that pseudo beat me to it👍. I imagine there are very few if any states that have formal laws or regs that address the issue of physicians acting under lower level certs. There are probably a lot of regs about physicians on ambulances as medical directors, fellows, part of a specialized transport team (such as a neonatal team) but few on docs acting as EMT-Bs.

 

[willow18]

A good example of this is that a few years ago one ambulance company wanted it's critical care nurse rigs to respond to 911 calls. They wanted this because when the rigs didn't have a CCT call they were losing money. This was seen as unacceptable by fire because it meant that while they were suppose to command on scene they might have to defer to the CCT nurse in a disagreement because of the nurse's higher level of training. They were so upset by that prospect that they went to the Health Department and had the nurses formally restricted from taking 911 calls. We now use CCT Paramedics instead.

I'm not getting this. Fire was ok with deferring to a CCT medic but not to a CCT nurse? Or was it that Fire medics didn't wanna defer to nurses?

 

[Siggy]

You're not the first I've heard that from. I don't think my experiences support any blanket statements, although I would lean in the other direction and say that I think fire departments seem better able to recruit and retain quality personnel. Fire departments, at least on the west coast, pay very well, have great benefits, and run out of stations.

While I agree that they have that potential, there's also the reverse issue. Namely, how many fire medics are medics only because fire medic is a promotion level from being just a fire fighter, it's a requirement for applicants, or because it gives extra points in the application cycle? Unfortunately, my counter argument for quality of care was destroyed earlier this year when Riverside County (which is primarily AMR in contrast Orange and LA counties) went to the same asinine policy of relying on the machine interpretation for 12 leads as LA and OC. Additionally, the fire departments may be able to recruit some quality medics, but the county LEMSAs still don't trust the paramedics further than they can throw them (i.e. base hospital contact policies).

 

[docB]

I'm not getting this. Fire was ok with deferring to a CCT medic but not to a CCT nurse? Or was it that Fire medics didn't wanna defer to nurses?

They don't have to defer to the CCT medics because they're still medics. For some reason you don't have to defer to the most highly trained medic on a scene but you do have to defer to someone with a completely different credential like a nurse or a doc. It's more political than medical.

 

[Dwindlin]

What type of incident are you talking about DocB? Are you talking like a MVA? Or are you saying that fire had IC on everything?

 

[docB]

What type of incident are you talking about DocB? Are you talking like a MVA? Or are you saying that fire had IC on everything?

Fire has IC and Med Com on every call. They decide if they want to tech the call themselves or transfer care to the private. They decide if they want to transport in their rig or in the private rig. It's a wacky system. Clearly the FDs in our area have a lot of political power.

 

[Kling]

I'm an EMS director in my area, so i do "rides" all the time, HOWEVER, to provide care the state requires me to maintain a Paramedic certification and ALSO must be staffed on the ambulance as a paramedic. As such when on the ambulance i ALSO have to abide by prehospital protocols and act "within my scope" just like an RN working as a medic. So, i dont staff a bus, but i do a lot of rides with the medics I do med control for.

 

[FiremedicMike]

I'm not getting this. Fire was ok with deferring to a CCT medic but not to a CCT nurse? Or was it that Fire medics didn't wanna defer to nurses?

I do apologize for speaking out of turn here, I'm not a doc.. I think we're equating education with skill sets. I don't think anyone here at my department would argue that some specialties are certainly more capable of handling EMS calls (i.e. ER docs, CCM docs, trauma surgeons, etc) but imagine a dermatologist (as an example, no offense intended to derms) showing up on a shooting and trying to take over. Would that doctor really have a higher skill set, comfort level, and frame of reference for that gunshot victim than the medics who handle that regularly?

Another thing that has been left out of the loop so far is our medical control. In Ohio pretty much everything is off-line medical control with standing protocols. That said there is still an MD/DO medical director who has signed off on our protocol and essentially signs his name to every EMS run. It is under his direction that we can operate, and we are simply following his standing orders. He has also signed a piece of paper that says he approves every single person on our department (by name) to operate as a paramedic under his license. Imagine if that derm made an error in judgment and told us to do something different from our protocol. Sure he'd be ultimately liable, but so would the medics on scene as well as our medical director. As for the CCT nurse, I'd be comfortable saying the medic would get thrown under the bus when that lawsuit came out "So, you had standing orders from a doctor, but a nurse came along and did this and this and you deviated based on her orders?"

Yeah, just trying to play devils advocate from the other side of the street here, hopefully I didn't come across arrogant, not my intention.

 

[jbar]

I'm an EMS director in my area, so i do "rides" all the time, HOWEVER, to provide care the state requires me to maintain a Paramedic certification and ALSO must be staffed on the ambulance as a paramedic. As such when on the ambulance i ALSO have to abide by prehospital protocols and act "within my scope" just like an RN working as a medic. So, i dont staff a bus, but i do a lot of rides with the medics I do med control for.

Did you have the medic from before? Or did you have to get it after your MD? And did you have to take some sort of bridge class or was it just challenging the NREMT?

 

[Dwindlin]

I do apologize for speaking out of turn here, I'm not a doc.. I think we're equating education with skill sets. I don't think anyone here at my department would argue that some specialties are certainly more capable of handling EMS calls (i.e. ER docs, CCM docs, trauma surgeons, etc) but imagine a dermatologist (as an example, no offense intended to derms) showing up on a shooting and trying to take over. Would that doctor really have a higher skill set, comfort level, and frame of reference for that gunshot victim than the medics who handle that regularly?

Another thing that has been left out of the loop so far is our medical control. In Ohio pretty much everything is off-line medical control with standing protocols. That said there is still an MD/DO medical director who has signed off on our protocol and essentially signs his name to every EMS run. It is under his direction that we can operate, and we are simply following his standing orders. He has also signed a piece of paper that says he approves every single person on our department (by name) to operate as a paramedic under his license. Imagine if that derm made an error in judgment and told us to do something different from our protocol. Sure he'd be ultimately liable, but so would the medics on scene as well as our medical director. As for the CCT nurse, I'd be comfortable saying the medic would get thrown under the bus when that lawsuit came out "So, you had standing orders from a doctor, but a nurse came along and did this and this and you deviated based on her orders?"

Yeah, just trying to play devils advocate from the other side of the street here, hopefully I didn't come across arrogant, not my intention.

The bolded portion is actually not quite true here in Ohio. In Ohio if a MD/DO shows up on scene and wants to help they can. However if they do then by the O.R.C. they must assume FULL responsibility and MUST accompany the patient to the ED. So if an MD/DO shows up and tries to displace you they have to agree to accompany the patient to the ED, if they don't agree to that, they actually CANNOT participate in patient care (outside of what any bystander would be capable of).

Obviously this doesn't work with other providers, so me personally when I get anyone on scene telling me they are such and such healthcare provider I thank them for what they have done already and ask them nicely to give us some room so we can work. If I have a spare person I'll have them get a run down of what they saw/did.

 

[docB]

I do apologize for speaking out of turn here, I'm not a doc.. I think we're equating education with skill sets. I don't think anyone here at my department would argue that some specialties are certainly more capable of handling EMS calls (i.e. ER docs, CCM docs, trauma surgeons, etc) but imagine a dermatologist (as an example, no offense intended to derms) showing up on a shooting and trying to take over. Would that doctor really have a higher skill set, comfort level, and frame of reference for that gunshot victim than the medics who handle that regularly?

Another thing that has been left out of the loop so far is our medical control. In Ohio pretty much everything is off-line medical control with standing protocols. That said there is still an MD/DO medical director who has signed off on our protocol and essentially signs his name to every EMS run. It is under his direction that we can operate, and we are simply following his standing orders. He has also signed a piece of paper that says he approves every single person on our department (by name) to operate as a paramedic under his license. Imagine if that derm made an error in judgment and told us to do something different from our protocol. Sure he'd be ultimately liable, but so would the medics on scene as well as our medical director. As for the CCT nurse, I'd be comfortable saying the medic would get thrown under the bus when that lawsuit came out "So, you had standing orders from a doctor, but a nurse came along and did this and this and you deviated based on her orders?"
Yeah, just trying to play devils advocate from the other side of the street here, hopefully I didn't come across arrogant, not my intention.

Remember that we're not talking about some random nurse who wandered on to a scene. I'm talking about a CCT-RN staffed ambulance that has responded to a 911 call per contract with the city. The RN in this case has protocols signed by that agency's medical director just like the medic's. In this case the CCT-RN is bringing additional education and ( in practically all of the actual cases here) experience to the scene.

 

[FiremedicMike]

Remember that we're not talking about some random nurse who wandered on to a scene. I'm talking about a CCT-RN staffed ambulance that has responded to a 911 call per contract with the city. The RN in this case has protocols signed by that agency's medical director just like the medic's. In this case the CCT-RN is bringing additional education and ( in practically all of the actual cases here) experience to the scene.

Oh wow.. didn't actually see that part. In that case, at least at face value, sounds like a pissing match. Do these cct nurses work for the same agency and under the same medical director?

 

[tkim]

EMS based fire suppression.

Fire suppression-based EMS.

 

[docB]

Oh wow.. didn't actually see that part. In that case, at least at face value, sounds like a pissing match. Do these cct nurses work for the same agency and under the same medical director?

In this case the CCT-RNs were on private rigs. The medical directors were not the same. It was absolutely a big pissing match.

 

[Siggy]

Fire suppression-based EMS.

Which component of EMS based-fire suppression makes up the primary service offered as a component of runs? Fire suppression or medical calls?

 

[docB]

Which component of EMS based-fire suppression makes up the primary service offered as a component of runs? Fire suppression or medical calls?

You can tell by whether they run in an ambulance with SCBAs in the locker or on an engine with a med bag in the jump (I've worked on both).

 

[tkim]

Which component of EMS based-fire suppression makes up the primary service offered as a component of runs? Fire suppression or medical calls?

Perhaps you were being tongue-in-cheek and I wasn't picking it up, but I don't know of any EMS based-fire supression, but a lot of fire-supression based EMS, only it seems like the majority of runs are EMS and not the other way round.

 

[Siggy]

It's half a tongue in cheek, half pointing out that the primary mission of "fire department based EMS" is no longer fire suppression. If EMS isn't the primary mission of a service providing paramedic services and ambulance transport, then they need to get out of it for the sake of their patients. Maybe I'm biased by my experiences in Southern California, but I've seen nothing worthwild or good of forcing fire fighters to become paramedics simply to justify fire department budgets via run numbers.


Edit to clarify a few things.

It's crap like this or this [PDF file] from the Fire Service where their leaders are either arguing that there is no need for a proper education for paramedics or that fire service medics are too stupid to get an actual college education before playing with people's lives. Really, US Fire Admin, an associates degree is too much to ask of paramedics? Really, IAFC, asking for more than 110 hours (EMT-B minimum under the National Standard Curriculum) before someone can jump into an ambulance is too much to ask for? Really, expecting post secondary education is too much to ask? Really, ending the psuedo indentured servitude of requiring people to work was an EMT-B before paramedic to keep cheap labor and cover for piss poor educational programs is too much to ask for [as an aside, if experience is key, why didn't I have to become a PA before med school?]?


There are a few good EMS programs run by fire departments, but even some of those are more "administered by the fire department" than "fire department based" (e.g. Seattle Medic-1). However, the rest are just fighting for the lowest standards possible and it disgusts me.

 

[FiremedicMike]

Siggy I'm not exactly sure what your EMS background is, so I'll assume you have none as I answer.

I just wanted to make two quick points

1. As for the EMT-B before paramedic issue. Working at a busy department, we have various paramedic and emt-basic students riding with us pretty much every day, so I see students in that aspect as well as being an EMS instructor. I can tell you that with few exceptions, students who go from EMT-Basic school straight in to medic school with no experience struggle and generally perform poorly. While paramedic school does include many hours of structured field and hospital clinical time, it still remains a profession that is learned primarily from doing the job in the street. I actually went to a more academic based paramedic program and learned quite a few of the details that get left out of many paramedic programs. This brings me to my next point.

2. While I am definitely enjoying going back to college and the intellectual stimulation it has brought, it absolutely has no bearing on my job as a parmedic. Being a paramedic is essentially a common sense job. I apparently still have a bit of idealism in me because I still do a pretty thorough H&P on my patients, treat some things here and there, and report my findings to the ED staff. The thing is, deep down I know it's all irrelevant. It is extremely rare when anything I find makes a difference within the first 5 minutes of arrival to the ED. Truth be told what I really end up doing is IV, O2, Monitor 99% of the time. Occasionally throw a breathing treatment, some NTG/ASA, maybe some zofran, and that's about it. EMS does not honestly require higher education

 

[pianoman511]

Siggy I'm not exactly sure what your EMS background is, so I'll assume you have none as I answer.

I just wanted to make two quick points

1. As for the EMT-B before paramedic issue. Working at a busy department, we have various paramedic and emt-basic students riding with us pretty much every day, so I see students in that aspect as well as being an EMS instructor. I can tell you that with few exceptions, students who go from EMT-Basic school straight in to medic school with no experience struggle and generally perform poorly. While paramedic school does include many hours of structured field and hospital clinical time, it still remains a profession that is learned primarily from doing the job in the street. I actually went to a more academic based paramedic program and learned quite a few of the details that get left out of many paramedic programs. This brings me to my next point.

2. While I am definitely enjoying going back to college and the intellectual stimulation it has brought, it absolutely has no bearing on my job as a parmedic. Being a paramedic is essentially a common sense job. I apparently still have a bit of idealism in me because I still do a pretty thorough H&P on my patients, treat some things here and there, and report my findings to the ED staff. The thing is, deep down I know it's all irrelevant. It is extremely rare when anything I find makes a difference within the first 5 minutes of arrival to the ED. Truth be told what I really end up doing is IV, O2, Monitor 99% of the time. Occasionally throw a breathing treatment, some NTG/ASA, maybe some zofran, and that's about it. EMS does not honestly require higher education

1) I totally agree with that statement. I have seen many students go through the same progression and don't know the first thing about assessing a patient.

2) I think it's a matter of how someone approaches their job as a medic. Some medics do the bare minimum and take the patient only if they are on death's door. Others actually do understand the disease process and try to improve the patient's condition prior to arrival at the ED. Many times I have seen a patient with severe asthma receive a few nebulizers (albuterol, atrovent), solu-medrol, & occasionally Mag and arrive at the ED in no distress. In the past, EMS was straight load and go but we have evolved into first line treatment and transport. In the current climate of busy, overcrowded EDs that may be the best thing. It ensures patients receive prompt care and shortens the ER stay.