- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
First name wouldn't have been "Donnie" - would it?
Perimortem C-Sections
- Thread starter alphaholic06
- Start date
First name wouldn't have been "Donnie" - would it?
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
Entirely different situations - one patient, one crew, versus full ED and waiting room with couple docs and nurses. A better comparison would be a crew coming into a MCI. The broken leg and the nausea are going to going to be tagged yellow and green and wait for the next bus, or the next, or the next. Sort of like how the ED prioritizes and the leg fx and nausea have to wait ... MCI's eventually end. In the ED, the waiting room just fills up again.
Oh, and EMTP for 12 before med school ...
i don't think he was saying there was anything wrong with that or that it could be done better somehow. its just a different environment and the 1-1 nature allows for faster delivery of pain and nausea management.
- Joined
- Nov 21, 2003
- Messages
- 3,443
- Reaction score
- 3,085
Shifting the 1st responder model towards a midlevel standard probably isn't affordable on a widespread basis. So few responses are emergencies that would benefit from advanced care on the scene that it wouldn't be practical pay midlevel type salaries to have someone sit around waiting. Most of the EMS systems I've worked with had a dual response system because they couldn't even afford to pay a medic's salary for every bus.
I would say that the trend in the industry would disagree with this assessment. Advanced practice/community health paramedicine is all the buzz now. Wisconsin just approved the first state-wide licensure level for this type of provider.
I don't think anyone is suggesting these providers be for "emergencies," but instead for dealing with lower-level complaints. Basically the non-emergent complaints that could be safely treated in the home. The theory is that by keeping people out of the hospital you could drive cost down. I know this idea has gotten some play at HHS. I'm pretty sure at least one of the community health paramedic programs got some of the Affordable Care Act's pilot/demonstration program money, so it's definitely not on the fringe.
D
deleted65604
If the problem could have been easily treated in the home, then they didn't need an ambulance and the patient was simply attempting to use the ambulance as a taxi. I don't see why encouraging people to contact EMS for non-emergent problems is going to drive healthcare costs down. I foresee it doing the opposite.
Picture an old fat guy sitting on a couch with a beer in his hand:
"Betty! Mah throat hurts, I need me some vicahdin."
"George, I ain't given you none of my stash, you know I need it more than you."
"Well take me to the ER, I'm too drunk to drive. One more DUI, and I go to prison."
"George, you know Honey Booboo is on in 10 minutes, I ain't goin' nowhere. Call the ambulance, they'll check you out for free!"
"What was I thinking Betty? Throw me the phone."
Last edited by a moderator:
D
deleted65604
So, enabling people even more to sit on their butts, not educate themselves on their own medical conditions and feeling noble as a society that we are a nanny state. Where is the money going to come from to fund these programs? Surely, the person who is incapable of figuring out diabetes... (Glucose too high, give insulin, eat less next time) isn't going to be a high functioning, resourceful person.
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
Perhaps I read a different passage? There was a *direct* comparison between ED and EMS care. He wrote about how much longer it takes to get things done in the ED versus the street. If I had one only one patient and access to my meds and nurse to push them right there then hell yeah they'd be getting instant care.
If it's a different environment as you say, then why try to make the comparsion? It's been said many times in the premed forums when someone talks out of turn, or out of their depth, but it bears repeating here: you don't know what you don't know. Quite a few of us have worked on both sides of the sliding ER doors.
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
Point to a couple of links so that we can read about this trend, please.
- Joined
- Nov 27, 2002
- Messages
- 7,890
- Reaction score
- 756
I'm crunched for time so this may sound a bit more terse than I mean it but but here goes...
There are 2 groups (with a lot of overlap) pushing these expanded roles for EMS. EMS providers who are gung ho and want to do more and EMS systems leaders who want bigger budgets. Neither of those make the idea good or bad. The idea will have to stand on its own.
The question is if doing this justifies the cost. Answering that gets into a lot of the usual arguments about socialized medicine. Should we devote more resources to making care even more available to people who take no personal responsibility? No. But since we're going to pay for it anyway due to EMTALA+the tort crisis we will pay anyway. So if EMS can keep these people out of the ED cheaper is it viable?
There are 2 groups (with a lot of overlap) pushing these expanded roles for EMS. EMS providers who are gung ho and want to do more and EMS systems leaders who want bigger budgets. Neither of those make the idea good or bad. The idea will have to stand on its own.
The question is if doing this justifies the cost. Answering that gets into a lot of the usual arguments about socialized medicine. Should we devote more resources to making care even more available to people who take no personal responsibility? No. But since we're going to pay for it anyway due to EMTALA+the tort crisis we will pay anyway. So if EMS can keep these people out of the ED cheaper is it viable?
I think that that's the key. I don't think anyone would say that EMS should, in an ideal world, be providing home health services a la community paramedicine. We don't, however, live in an ideal world. If the demand and societal expectation are already there (i.e. tort and EMTALA issues) and it can be more economical, why not provide both the education, oversight, and reimbursement to do so? Play the hand we're dealt, not the one we want.
I think one thing we can all agree on here is that EMS is an imperfect system and that it can only benefit from more active physician involvement. On both sides of the doors we need to be willing and open to change. We must keep looking to improve, adding skills/procedures when they are shown to benefit, and eliminating all those without value. To do this we need more providers on both sides interested in research as well as quality improvement. I tried to do this as a medic and I hope to continue as a physician.
- Joined
- Nov 27, 2003
- Messages
- 172
- Reaction score
- 6
Wow this thread exploded lol.
I just had a few points to throw in the mix.
- I think EMS is starting to divide into what needs to be transported immediately vs. what needs to be worked on the scene and stabilized immediately. The vast majority of cases, however, would do just fine without EMS at all (ie they aren't even 911-worthy, but people abuse the system)
- A doc on wheels with sig. advanced capabilities would have sig. advantages for situations/injuries that *can't* be transported rapidly (prolonged extractions, MCIs, etc), but these remain far and few in between. In the rest of the time, you'd be doing a great service to the community by maintaining continued QA/QI through *direct observation* of your EMTs & Paramedics. *Actual* medical direction lol. Win-win for all.
- Just like there's significant variation in EDs across the country (rural vs. academic Level I Trauma Center, etc), YMMV with EMS as well. An interesting example is a newly released study entitled "Pre-Hospital Cardiac Arrest in presence of Medical Director versus paramedics" (National Association of EMS Physicians 2012 Annual Meeting, Tucson, AZ, January 2012). I can't find the text online, but the conclusion was, patients had approximately a 33% higher ROSC AND discharge from hospital when the medical director was present at the scene. The reason? New director, new protocols, aggressive resusc protocols (Don't. Stop. Compressions. No matter what. Until. I. Say. So.) etc. In such cases, when you have a progressive Medical Director who can really push up-to-date practice and protocol and ENSURE good QA by being there, involved, on-scene, you can see just how a Fellowship-trained hands-on EMS Director can be a HUGE asset.
- Regarding dealing with the non-emergent 911 calls that come in non-stop, I can't remember if I mentioned this in an earlier post or not, but several cities have started using a novel solution to this, with great success: http://www.jems.com/article/vehicle-ops/omega-project-reclassifying-no. The short version: if you meet the criteria, you're pretty much told you don't need to go to the hospital, the Omega nurse sets up an outpatient clinic appointment for you the next day, and sends a taxi to pick you up and drop you off. My question was, "who pays for this?" Their answer: We do, but it's a HECK of a lot cheaper than paying for an ambulance ride...
I just had a few points to throw in the mix.
- I think EMS is starting to divide into what needs to be transported immediately vs. what needs to be worked on the scene and stabilized immediately. The vast majority of cases, however, would do just fine without EMS at all (ie they aren't even 911-worthy, but people abuse the system)
- A doc on wheels with sig. advanced capabilities would have sig. advantages for situations/injuries that *can't* be transported rapidly (prolonged extractions, MCIs, etc), but these remain far and few in between. In the rest of the time, you'd be doing a great service to the community by maintaining continued QA/QI through *direct observation* of your EMTs & Paramedics. *Actual* medical direction lol. Win-win for all.
- Just like there's significant variation in EDs across the country (rural vs. academic Level I Trauma Center, etc), YMMV with EMS as well. An interesting example is a newly released study entitled "Pre-Hospital Cardiac Arrest in presence of Medical Director versus paramedics" (National Association of EMS Physicians 2012 Annual Meeting, Tucson, AZ, January 2012). I can't find the text online, but the conclusion was, patients had approximately a 33% higher ROSC AND discharge from hospital when the medical director was present at the scene. The reason? New director, new protocols, aggressive resusc protocols (Don't. Stop. Compressions. No matter what. Until. I. Say. So.) etc. In such cases, when you have a progressive Medical Director who can really push up-to-date practice and protocol and ENSURE good QA by being there, involved, on-scene, you can see just how a Fellowship-trained hands-on EMS Director can be a HUGE asset.
- Regarding dealing with the non-emergent 911 calls that come in non-stop, I can't remember if I mentioned this in an earlier post or not, but several cities have started using a novel solution to this, with great success: http://www.jems.com/article/vehicle-ops/omega-project-reclassifying-no. The short version: if you meet the criteria, you're pretty much told you don't need to go to the hospital, the Omega nurse sets up an outpatient clinic appointment for you the next day, and sends a taxi to pick you up and drop you off. My question was, "who pays for this?" Their answer: We do, but it's a HECK of a lot cheaper than paying for an ambulance ride...
Last edited:
Forgive me for being new at this whole contributing thing, but now that residency is over I actually have some time to respond instead of just read.
It seems like there is quite a bit of negative energy towards EMS from some very established members of this community (who have probably been doing this longer than me and who I certainly respect). It's surprising to me, and I wonder if it reflects a partly hidden perspective of a majority of emergency physicians. I can't help but draw a parallel to the cardiologist or the trauma surgeon who looks down at the ED physicians. It seems quite similar.
Some have made the point here that EMS does't have a big impact, doesn't save many lives, is often running non emergenct calls, and that their interventions don't make much of a difference. I wonder what they are comparing to. Certainly it's not to what I am doing in the ED. So much of what I do is non emergent, might have been emergent", or "could have been emergent." In my experience, we don't change the outcomes of that many people. Even if you look at at who I send to the ICU, only a subset of those patients ever make it out. Every so often I make a diagnosis, that chest pain patient rules in, a correctly placed and well timed needle or tube saves a life - but those situations are be few and far between when you compare to them to the vast numbers of routine chest pain and abdominal pain evaluations that turn up not a damn thing. And that's not to mention the free pregnancy tests, chronic back pain evaluate for percocet patients, personality disorder evaluations, and "my baby had 3 stools today is she OK?" visits. I don't feel essential a lot of the time, and I don't work at a slow or low acuity medical center.
So I think the EPs are all correct that EMS doesn't save that many lives on their own, and that baby-sitting to life saving ratio is high, but the same seems true for the ED.
It seems that there is a syndrome in medicine. The next more specialized person up the chain always seems to look down on the referring provider. We do the same thing to PCPs as well, then we bitch at the cardiologists and trauma surgeons when they do it to us. Human nature, I guess.
It seems like there is quite a bit of negative energy towards EMS from some very established members of this community (who have probably been doing this longer than me and who I certainly respect). It's surprising to me, and I wonder if it reflects a partly hidden perspective of a majority of emergency physicians. I can't help but draw a parallel to the cardiologist or the trauma surgeon who looks down at the ED physicians. It seems quite similar.
Some have made the point here that EMS does't have a big impact, doesn't save many lives, is often running non emergenct calls, and that their interventions don't make much of a difference. I wonder what they are comparing to. Certainly it's not to what I am doing in the ED. So much of what I do is non emergent, might have been emergent", or "could have been emergent." In my experience, we don't change the outcomes of that many people. Even if you look at at who I send to the ICU, only a subset of those patients ever make it out. Every so often I make a diagnosis, that chest pain patient rules in, a correctly placed and well timed needle or tube saves a life - but those situations are be few and far between when you compare to them to the vast numbers of routine chest pain and abdominal pain evaluations that turn up not a damn thing. And that's not to mention the free pregnancy tests, chronic back pain evaluate for percocet patients, personality disorder evaluations, and "my baby had 3 stools today is she OK?" visits. I don't feel essential a lot of the time, and I don't work at a slow or low acuity medical center.
So I think the EPs are all correct that EMS doesn't save that many lives on their own, and that baby-sitting to life saving ratio is high, but the same seems true for the ED.
It seems that there is a syndrome in medicine. The next more specialized person up the chain always seems to look down on the referring provider. We do the same thing to PCPs as well, then we bitch at the cardiologists and trauma surgeons when they do it to us. Human nature, I guess.
- Joined
- Nov 27, 2003
- Messages
- 172
- Reaction score
- 6
Great post and point.
I just wanted to add that the remark I ALWAYS had when specialists were peeved at how or why we did certain things was instead of bitchin and moanin about what we did or how we did it, *come here and show us how you'd like it done.* Criticism is useless, unless it's constructive.
Likewise, if we're unsatisfied with our EMS system/providers, we should take an active role in making it better, *so it gets better.* Just saying it's subpar doesn't do any of us any good.
If anything, I think the better our EMS system is, and the earlier we make significant impact on the patient, the better the outcome in the long run. Just think of the CHFer that's saved an intubation by EMS placing them on CPAP during their 15 min transport. Not only does that improve mortality, but it decreases intubation rates and hospital stays, which is money and beneficial for all of us as a whole.
Now if you're of the mentality that EMS is useless period, and should just shut up 'n drive, that's a totally different discussion...
- Joined
- Nov 24, 2002
- Messages
- 24,434
- Reaction score
- 17,874
Yes, except for one thing: some of the very established members of this community that are saying the negative-ish things were EMS before. I don't think any of the trauma surgeons or cardiologists were full-time EM docs before they did their thing. It's like a CRNA that goes to med school and becomes an anesthesiologist: they know about what they are talking, because "they were there, man!".
Save the patients you send to the ICU or perform a procedure on (the minority of ED patients), don't you feel the same way about what the emergency phsyician does?
Interesting . . . so do you look back and think that most of what you did as a prehospital provider was pretty useless? And now that you are an experienced MD can you look back and see that you were just f-ing things up left and right when you were a paramedic? Pretty interesting perspective.
I haven't had the same negative experience with EMS, but I did train in a system where EMS was quite strong, so maybe that's why. Now that I am in the community, the paramedics are definitely weaker, but I haven't felt that they are complete failures either.
Where I trained, the physicians and the paramedics were employyed by the same organization. There was such a tight relationship, and the expectations of the prehospital providers was extremely high. It felt like we all had ownership of the paramedics, and there was always this back and forth on each patient in the department. I really miss that commraderie.
Now that I'm in the community most of my colleagues seem pretty disentrested - they don't expect much from the paramedics, and they don't give much either.
- Joined
- Nov 24, 2002
- Messages
- 24,434
- Reaction score
- 17,874
The post above that you quote of mine states one thing. Then, the interesting thing occurs here - that "treading lightly", and realizing that not doing anything was better than doing something just because I "could", you equate to "f-ing things up left and right". That is one hell of a reach (and quite, quite inaccurate, too). The glass half empty view of "most of what (I) did as a prehospital provider was pretty useless" sounds like you have a chip on the shoulder. Was what I did "useless"? No - I just didn't "do" as much as the guys who, for example, wanted to use every drug in the drug box, or put on MAST pants, or use the EOA, just because it was still there.
Think of that perspective - why was it that I, in 13 years on the ambulance in total, never once had to assault a patient with the clipboard? Was I just incredibly lucky, whereas others just happened to have patients attack them (and that they were in such a bad position to start)? I never shortchanged any patient - ever - in care that was needed, but I didn't delude myself that I was one heroic SOB, who was going to do "the right thing", even if those *******s in the ER didn't know what the hell they were doing.
Just like the doc in the ED, my view of EMT-P was that I was there for the "what if", but, just like in the ED, most of "what if" didn't occur. When it did, it was good that I was there, but, fortunately, most of the time, it - didn't.
Didn't mean to offend you . . . perhaps that was poorly worded. I was honestly interested in the persepctive of those who spent time on the street and now have been docs for a while, and surprised at the negative energy towards EMS in this thread, especially from those who have spent time on the streets. The perspective from many of the MDs in this thread is interesting to me because it is so different from what I have experienced thus far - which is comraderie between medics and docs, extremely high expectations that are usually met by the prehospital providers, good prehospital outcomes, etc. And then in this thread the perspective I get is that most docs are pretty unhappy with EMS. I'm just interested in that contrast. Maybe I was just in a special place.
I think what you say about doing less is very wise. I wish I could dare to do less a lot of the time in the ED. The more patients I see, the more I feel that I don't make a huge difference except for those rare instances when I do.
I think what you say about doing less is very wise. I wish I could dare to do less a lot of the time in the ED. The more patients I see, the more I feel that I don't make a huge difference except for those rare instances when I do.
- Joined
- Nov 21, 2003
- Messages
- 3,443
- Reaction score
- 3,085
EMS systems that are tightly integrated with academic training centers are going to have more involved medical direction and do a better job of training medics and maintaining skills. Out in the community, the relationships vary widely. At my last job, 3 EMS companies accounted for 90+% of our traffic and their medical director was also the ED director at one of our outlying hospitals.
At my current job, to reach 90% of our EMS traffic involves meeting with 13 ambulance companies. It's probably unfair to lump in private ambulance companies with FD buses, but it all tends to get dumped into the mental bin of "EMS interactions". I'm typically frustrated by the lack of history obtained by 1st responders (comatose nursing home patients with "change in mental status" for example). This has been worsened, IMHO, by electronic charting. This guarantees that we either get the run-sheet hours after the patient is dropped off, or it contains a bunch of checked boxes that convey no actual information about the patient. My views on EMS are mostly neutral, but there are interventions on many EMS protocols that are inappropriate for a given transport time.
Examples include: lasix for undifferentiated SOB, amiodarone for PVCs, pt w/ a BP in the 130s get 2 mg of atropine for a HR of 51 yesterday, plavix load for computer read of STEMI in field, etc. Also, everytime I watch a hemorrhaging dialysis graft with a 4 inch pile of 4x4s, an abdominal pad, and a single layer of Kerlix dripping a steady trail of blood from the strecher a part of me dies.
Certain things are amazing: prehospital CPAP is fantastic, fracture immobilization tends to be excellent, breathing treatments in asthmatics, glucose or glucagon for hypoglycemia, getting large bore IVs on trauma patients (not 100% but very nice when it happens), defibrillation for VT/VF. But working in a major metropolis with short transport times, I'm much more likely to think "why didn't they load and go" then "they did nothing for this patient". So while I never had the pleasure, I think I would have gotten along quite well with a young Apollyon dropping patients off at my ED.
I wanted to thank you for having the backbone to ask the hard questions.
To the individual who wanted references about Community Paramedicine, Google, "Community Health Paramedics" or "Advanced Practice Paramedic" or "Emergency Care Practitioner." If you have some decent research skills, you'll find some stuff. I'm not doing it for you. You went to medical school and are certainly capable of finding information, if you're interested. That's the key: IF you're interested in expanding your viewpoint beyond your own.
As a comment toward the former "EMS" docs. I've learned over the years that there is a BIG difference in what constitutes someone who claims to have been a paramedic. Either A) They were actually an EMT on their way to medical school admissions, B) They were a private transport paramedic trying to make money while funding their way through college, C) They worked in a horribly repressed, clinically inferior EMS system, OR D) They worked in a fire department, which 9 times out of 10, are also clinically repressed, inferior EMS systems.
Like 20% are legit. Almost every legit paramedic-to-physician that I've ever met has a healthy respect for how they started. To the few legit EMS physicians who act arrogant now, I've generally attributed it to a character flaw.
Let me clear: no legitimate paramedic thinks they're saving the day 24/7 (I certainly don't), but much of the resistance towards field-level primary care comes down to a simple fact: if patients start getting treated and released in the field, ED revenue goes down.
I think most paramedics have a healthy respect for physicians. I certainly do. No one is in any way insinuating that you're not useful, smart, accomplished, or super awesome. I only got involved in this thread because I saw some unflattering and false comments being spewed about a job I love. Remember that your MD doesn't mean you have a special license on facts.
- Joined
- Nov 27, 2003
- Messages
- 172
- Reaction score
- 6
When was the last time you interacted with a flight crew (which typically consists of a flight nurse and a paramedic)? Those are as skilled and "legitimate" paramedics (and nurses) as it gets. But having been on probably a dozen different program helicopters, I can tell you the overwhelming sense is "hey we KNOW what we're doing, and we're saving the patient from the doc."
Yes, and I LOVE my EMTs and Paramedics, and we have a great relationship. BUT, I can tell you that as a physician, I can clearly see what over a decade of education and training provides me in terms of an in-depth understanding of pathophysiology and its diagnosis & treatment, that most other non-MD medical workers lack. The result is typically the tendancy to treat based on pattern recognition, NOT on in-depth understanding. I think this especially holds true for most paramedics and nurses.
That's just my experience. Doesn't make me look down on anyone; just makes me realize that I need to make my OWN assessment each and every time, and double check things to ensure everything's on the right track. And on the flipside, for those paramedics and nurses that are interested and eager, I LOVE to teach and explain why we did this in this case, but we didn't do it in that one, based on the physiology. Why? Because the more info and understanding *everyone* has, the better it is for all of us - starting with the patient.
And that brings us back to the basic point. If you don't like what you're encountering, take steps to change/fix it.
D
deleted109597
Love it. Now you're reducing the credentials of the people here who were EMS because they obviously aren't as good as you.
Also, MD doesn't mean special license on facts, but due to the "sciency" nature of medicine, as opposed to the "vocational" nature of EMS and nursing, we do have special license on evidence.
Sorry, but you're never going to convince the people here that you know more than us, and we aren't as good as you. I love the copout of "I don't have to find you evidence to prove my points, you should find it yourself."
This may be part of the problem and I find it interesting to see how some of these systems work. Where I work: No Lasix. It was removed. Amiodarone isn't used period. Only lidocaine and pretty much only for stable V-Tach. PVCs would have to be multifocal, close to the R-Wave, or in sequential runs for it to be considered. Atropine is used exclusively for bradycardia now (no more arrest) and no one I work with (not even our biggest idiots) would consider pushing it for someone with a HR of 51. 90% of all bradycardias that I encounter are normal variants from beta blockers.
Do you know how bad nursing staff is in most nursing homes now days? I routinely run into foreign trained nurses who A) Barely speak English and B) Have absolutely no idea why the patient is comatose. I can't ask the comatose patient, so yeah, without a good history the patient is basically someone with an altered mental status. Check a blood sugar and make sure they're atraumatic and run to the hospital.
You can thank NEMSIS for this. Prehospital data trending is all about specific data points now. If you talk about getting the run sheet hours later it's no wonder. Average ALS report, done correctly, takes me about 30-45 minutes for a patient with a rather benign complaint. Why? We have to input EVERY vital sign, check what seems like a hundred little boxes, and write a good page of narrative information. Unlike yourself where a social history may be the abstract (living parents, smoker, occupation, etc) , we're expected to document the way the home looks, the interactions of family members, the patient's appearance, his/her position on arrival, etc, etc. I've seen a paramedic eviscerated by medical review for not describing, in detail, the type of protective clothing a motorcyclist had on. "Leathers" and "helmet" didn't cut it. We're expected to perform physical assessments that you probably haven't done in years. When was the last time anyone got on your butt about not percussing a chest? One errant blood pressure: better take a manual. Patient was nauseated two hours ago: Why didn't you give Zofran?
I've seen this one before too:
Why did you give albuterol to the CHF patient? He was wheezing? Well that could have been "cardiac wheezing." His blood pressure was 150/70! OMG! Clearly hypertensive! You say he had a history of COPD AND CHF? Well, why didn't you use your X-Ray vision and take a chest X-Ray and grab some labs? Don't use the fact that he had no pedal edema, no audible rales on auscultation, an endtidal waveform consistent with bronchoconstriction, and a normal sinus rhythm to your defense: hand slap!
Our tort and review environment is really that bad.
Interesting . . . aren't those protocol violations?
- Joined
- Nov 21, 2003
- Messages
- 3,443
- Reaction score
- 3,085
You stated that the trend (implying nationally) in EMS systems in delivering more resources in the pre-hospital setting. The EMS literature that makes it into the mainstream EM journals tends to support doing less in the prehospital setting (not intubating kids in the field for example). My experience in mid and large size cities has been that pre-hospital resources are being consolidated and the trend is towards the point of contact being EMTs, not medics. So it's not unreasonable to expect you to provide at least one article supporting your position. Expecting people unconvinced by your argument to do the research to support your side is frankly unreasonable.
So your estimate is that 90-something plus percent of paramedics are working in ineffective systems delivering ineffective care? Doesn't that suggest the trend in the country is towards putting fewer resources into the current pre-hospital system? Or are you suggesting that future MDs are significantly more likely to have worked in ineffective EMS systems than their non-MD obtaining colleagues?
Back up your statements with facts, a well-reasoned chain of logic, or appeal to a respected authority.
- Joined
- Nov 21, 2003
- Messages
- 3,443
- Reaction score
- 3,085
Sadly, only the atropine was off protocol.
With regards to Paratodoc, it's sad that we can collect so much information we don't need and can't get the information we do need. I reviewed a couple of thousand charts for a project in residency and the time period straddled the switch from paper records to electronic. Although the legibility was an issue with the paper records, I could actually abstract more data from them then I could from the electronic form.
- Joined
- Nov 21, 2003
- Messages
- 3,443
- Reaction score
- 3,085
Yeah, he has a stranglehold on the training for that particular FD and they have some really off the wall protocols. The plavix load bothers me the most though.
- Joined
- Nov 24, 2002
- Messages
- 24,434
- Reaction score
- 17,874
Do you try to be offensive, or is it just natural to you?
Or do you read the tripe you dump out? "Claims" to be - really? You think more than one person is going to claim to have been a paramedic when they were just EMT, for a bunch of people online? And, then, your percentage breakdown, which Firehouse, for example, would not support as your "clinically repressed, inferior EMS systems", is pulled directly out of your butt, and it sounds like you have a real complex towards those folks that did EMS but then moved upwards - they weren't "true believers" and didn't have the "thousand yard stare" (which is what you are saying - calling into play "street cred" - you know what, "you ain't fat - you ain't nothin'!").
Whatever metric you use, I rate as EMS. Again, I find your very provincial attitude, which you extrapolate to global, not based in any kind of substantial reality. Do I have to give you 4 paramedics, not including myself, that were career/"real"/street/ghetto medics, right off the top of my head, that are now board certified EM docs? On SDN, there is at least one other paramedic that is now an anesthesiologist, and I know of another guy that was a medic, and now is a surgeon. But, make no mistake - my EMT-P program was a year long, and one had to be at least an EMT to take it (I was actually EMT-I), so that is at least 3 semesters. It wasn't something simple that was just flipped off by the wayside as an afterthought.
I am not going to scan in my paramedic cards for your edification. However, if you are going to claim that people weren't "real" because their system was "inferior" and "repressed", or you are going to claim that they weren't paramedics, but were EMT-basics, then I reserve the right to call BS on every claim of saving rural America that you make. Oh, and, specifically, what does your wife do in the unit? Even if you said she was an intensivist, I promise you that your anonymity will be preserved. Your ephemeral and cloak-and-dagger way of wording it means she could be a doc, a nurse, an RT, enviro services, or a non-clinical manager.
And, before I forget, maybe you need to readjust your meter - having a "healthy respect" doesn't mean "unrestrained cheerleader". I, for one, look back on my EMS days with a circumspect eye; I take from then many lessons that have helped me, but I do not paint it all with a rosy hue. In the words of Billy Joel, "The good old days weren't always good". Finally, your assessment that the "few who act arrogant now" suffer from a character flaw is possibly the most offensive of all. It's either one of only a few things: get OVER yourself, you have NO IDEA about what you are talking, or you have an agenda.
I really actually agree with most of your suppositions. Yes, I do believe that most paramedics are working in ineffective systems and yes I also believe this supports the belief that some skills should be taken out of the prehospital repertoire. Would you also guess that I also believe that most paramedics are under educated? It is purely a lack of understanding, both of how EMS systems are deployed and also current trends, that causes many of the posters here to believe that one thing (removing skills and moving to a BLS-first model) is also intrinsically linked with not providing community health resources. Community health paramedicine is not sexy, nor does it have anything to do with bringing "more advanced" care to the majority of 9-1-1 responses. It's mundane, door-to-door prevention work. Deploying a community health paramedic would mostly be of use in suburban and rural areas, particularly hyper rural communities.
On intubation: Lots of conflicting literature. Verdict seems to be that unless paramedics receive regular exposure, intubation leads to poor outcomes. Cue debate about removing the skill instead of making sure your paramedics have exposure to plenty of intubations (i.e. anesthesia clinicals). Many progressive systems have removed it from the cardiac arrest pathway.
On ALS: No evidence that more paramedics on scene does anything at all. Not really a lot of evidence that ALS does anything in sudden cardiac arrest either. OPALS showed that plenty of ALS skills are actually associated with higher mortality (needle decompression for one).
Two Paramedic Ambulances: Argument it leads to skill degradation. Systems should be tiered, with only the most severe emergencies handled by ALS. High acuity leads to better paramedics.
Backboarding: Probably useless in all but a few cases. Some systems are removing it for most patients, particularly those involved in MVCs. Our system moved to the NEXUS criteria.
Response Times: Doesn't really matter with the exception of the First-Hour Quintet.
My larger point is that many paramedic-physicians worked in regressive systems that will inherently skew their opinion of the profession. If you, as a paramedic at the time, constantly saw dangerous things occur then wouldn't you want to escape as fast as possible? Once you were a physician wouldn't you also then look back at that profession with a bit of disdain? Smart people leave dysfunctional institutions. It should be no surprise that some of those smart people end up being doctors and, because of preexisting interest, some ended up specializing in emergency medicine.
Last edited:
I think this is an internet forum. I think people can claim whatever they want. Better yet, I believe this happens in real life all of the time, without the anonymity. Forgive me if, like you, I have a healthy amount of skepticism for people's claims. Furthermore, I have never worked in a "ghetto" EMS system. I am a rural paramedic. I take care of grandma and the little old lady down the street. I know the last names of the majority of my patients. I don't have a "thousand yard stare" because this isn't Vietnam, it's a job. I wouldn't ask for your "street cred," because it's ridiculous notion. I have worked in a fire-based EMS system and trust me, EMS isn't the priority. Not close. Putting the wet stuff on the red stuff is much more important.
Remember, you're the one getting upset and taking time out of your day because a lowly paramedic challenged your argument. You're the one who is upset over what is really an academic debate among adults. I know it just steams your boat that I'm even on here.
No, I'm not trying to be offensive, but your "one year EMT-P program" does not a professional paramedic make you. Arguably it is what is wrong with our profession. Congratulations on your road bump to being a physician.
D
deleted109597
If you aren't, then you're either very bad, or very dumb. Either way, this isn't an academic discussion. It is some academics challenging you, and you not offering anything in the sense of data, but plenty in the realm of anecdote.
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
We have that already - it's called the VNA.
- Joined
- Nov 24, 2002
- Messages
- 24,434
- Reaction score
- 17,874
Just go away, then. There IS an EMS/prehospital subforum here, and, I believe, more than one internet board that cater directly to prehospital personnel.
You have just laid the biggest cow pie I think I have seen this year - because I did a one year program, which, in the 1995-96 school year was worth 30 credits, I was not a "professional paramedic"? You know what you can do? You can stick that square up your ***. All you have been doing is talking about people who "talk the talk" but haven't "walked the walk" (in case you forgot, it was your 20% estimate). Then, you contradict yourself by saying "street cred" is a "ridiculous notion".
As my colleague says, if you are not trying to be offensive, you are either very bad, or very dumb. Am I upset? I don't think so, for, when I watch "Emergency" in 10 minutes, I shall have forgotten about you. You seem to look at things as black and white, in that you, first, are condescending with your "congratulations", and, then, diminishing with your reference to my EMS years as a "road bump". Huh?
If you had something substantial to say, I would listen. But you don't. You are inflammatory, and hide behind being a "lowly paramedic", while at the same time wanting to expand your scope. You use supposition and anecdote, and not even any anecdotes that are interesting - remember, if you are going to tell a story, make it good.
In your rural, not suburban, not urban existence, to how many physicians who were paramedics have you been exposed? Considering my own anecdotal list, which comes from a much larger cohort, I can only guess that you are talking without any reasonable basis at all.
"You will be appreciated for what you CAN contribute, not what you CAN'T." And you are not.
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
No, sonny. You see in medicine, and much of academics, the one who makes the claim provides the proof. A retort of 'google it' means one of two things: 1) you don't have the proof 2) you were talking out of your ass, and you don't have the proof
So either we are lying about our former medic tickets, or even if we weren't, we worked in subpar systems, so our experiences pales to yours and doesn't count. Amazing.
Hubris, pure hubris.
So in order to be 'legit' in your eyes, we have to agree with what you say. And even if we are legit and don't agree, then we're arrogant.
Again, pure hubris.
However, apparently having a medic ticket gives you a special license to spew 'facts' without providing any proof.
Can you give us a hint about the amazing, forward-thinking EMS system that you work in that is head and shoulders above the collective EMS systems that we've worked in? I'm curious.
Anyway, with about 15 minutes of Googling:
http://host.madison.com/wsj/news/lo...cle_8f5f2e46-f2db-5a80-bef3-6f257729285e.html
Minnesota was the state to pass the Community Paramedic license, not Wisconsin (my bad):
http://www.house.leg.state.mn.us/hinfo/sessiondaily.asp?storyid=2600
http://minnesota.publicradio.org/display/web/2012/09/10/regional/community-paramedics/
http://www.hennepintech.edu/news/pages/818
Maine too...
http://m.jems.com/article/news/new-community-paramedicine-law-maine-loo
Health and Human Services Evaluation Tool:
http://www.hrsa.gov/ruralhealth/pdf/paramedicevaltool.pdf
NYTimes...
http://www.nytimes.com/2011/09/19/us/community-paramedics-seek-to-prevent-emergencies-too.html
Nebraska Feasibility Paper
http://dhhs.ne.gov/publichealth/Documents/CommunityParamedicineReport.pdf
National Association of Emergency Medical Technicians
http://www.naemt.org/about_ems/CommunityParamedicine.aspx
The Emerging Role of the Emergency Care Practitioner, Emergency Medicine Journal (BMJ)
http://emj.bmj.com/content/21/5/614
http://emj.bmj.com/content/early/2012/02/13/emermed-2011-200484.short?rss=1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564336/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464396/
Effectiveness of Emergency Care Practitioners Working Within Existing Emergency Service Models of Care
http://www.sheffield.ac.uk/polopoly_fs/1.43742!/file/EffectivenessECPsPaper.pdf
Competence and Curriculum Framework for the Emergency Care Practitioner Consultation Document
http://ircp.info/Portals/22/Downloa... Care Practitioner Consultation Document .pdf
A couple of good reads. Remember, this is new stuff and different places are evaluating it because of the very arguments made on this forum. We'll see how it plays out in the coming years, but I believe there is some consensus among EMS leadership that it will be effective. The British model is encouraging. My point is that it does exist and there is clearly an argument for evaluating its effectiveness instead of just dismissing it as worthless.
http://host.madison.com/wsj/news/lo...cle_8f5f2e46-f2db-5a80-bef3-6f257729285e.html
Minnesota was the state to pass the Community Paramedic license, not Wisconsin (my bad):
http://www.house.leg.state.mn.us/hinfo/sessiondaily.asp?storyid=2600
http://minnesota.publicradio.org/display/web/2012/09/10/regional/community-paramedics/
http://www.hennepintech.edu/news/pages/818
Maine too...
http://m.jems.com/article/news/new-community-paramedicine-law-maine-loo
Health and Human Services Evaluation Tool:
http://www.hrsa.gov/ruralhealth/pdf/paramedicevaltool.pdf
NYTimes...
http://www.nytimes.com/2011/09/19/us/community-paramedics-seek-to-prevent-emergencies-too.html
Nebraska Feasibility Paper
http://dhhs.ne.gov/publichealth/Documents/CommunityParamedicineReport.pdf
National Association of Emergency Medical Technicians
http://www.naemt.org/about_ems/CommunityParamedicine.aspx
The Emerging Role of the Emergency Care Practitioner, Emergency Medicine Journal (BMJ)
http://emj.bmj.com/content/21/5/614
http://emj.bmj.com/content/early/2012/02/13/emermed-2011-200484.short?rss=1
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564336/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464396/
Effectiveness of Emergency Care Practitioners Working Within Existing Emergency Service Models of Care
http://www.sheffield.ac.uk/polopoly_fs/1.43742!/file/EffectivenessECPsPaper.pdf
Competence and Curriculum Framework for the Emergency Care Practitioner Consultation Document
http://ircp.info/Portals/22/Downloa... Care Practitioner Consultation Document .pdf
A couple of good reads. Remember, this is new stuff and different places are evaluating it because of the very arguments made on this forum. We'll see how it plays out in the coming years, but I believe there is some consensus among EMS leadership that it will be effective. The British model is encouraging. My point is that it does exist and there is clearly an argument for evaluating its effectiveness instead of just dismissing it as worthless.
- Joined
- Aug 2, 2002
- Messages
- 7,629
- Reaction score
- 381
Hmmm, a couple of states doing feasability studies and half the links being UK doesn't make it a trend or 'all the buzz' in the States. Nor does it signify leadership consensus, whatever that means. This is why providing links up front is critical to evaluate your claim, which appears inflated. There is a disconnect with what you state and what you claim supports what you state.
- Joined
- Nov 27, 2002
- Messages
- 7,890
- Reaction score
- 756
Let's all remember that the internet can distort the intent of a comment. I think everyone is having a legitimate discussion about some valid issues. Let's be collegial about it. And I'd point out that being steadfast in some of our opinions is a character trait that is shared by many of of older posters as well. Sometimes we just have to agree to disagree before it goes negative.
What we're really talking about here is the totality of EMS. Would it be better to raise the educational bar and devote those resources to it or should we degrade it to the days of ambulance driving? What gives us the best outcome/cost ratio? I don't know. I'd like to study it.
I also agree with ptarmigan:
EMS and EM are more similar than we might like to think.
What we're really talking about here is the totality of EMS. Would it be better to raise the educational bar and devote those resources to it or should we degrade it to the days of ambulance driving? What gives us the best outcome/cost ratio? I don't know. I'd like to study it.
I also agree with ptarmigan:
EMS and EM are more similar than we might like to think.
D
deleted65604
I totally agree with this. I feel happy when I feel like I helped as many as 25% of patients on a shift. The rest is just Kabuki theater for whiners, drug addicts, alcoholics, until I'm clinically confident to make them disappear with the magic wand of discharge paper-work.
"Nurse! I'm done here. Make them disappear!"
- Joined
- Apr 30, 2004
- Messages
- 4,265
- Reaction score
- 2,229
So glad you're so impressed with yourself and your service and have adapted so well to your protocol-driven system. I've seen so many medics like you over the years. You're a classic example of "you don't know what you don't know". You think as an EMT-P you have all the answers, and that somehow in your little rural service, you have somehow divined what it will take to bring EMS into the new dawning of pre-hospital care. Surely you've heard the term "paragod" before - it would seem to fit you to a T.
I'm curious - do you ever get really humbled with this attitude? Do you ever screw up? Do the physicians you come in contact with ever attempt to bring you back down to earth with the rest of us mortals? The attitude you have here is that you are the be-all and end-all of pre-hospital and even ER/ED care, and that if everyone else would just listen to you and your anecdotal blabbering about nurses who don't meet your idea of what an ER nurse should be and docs who despite their education just don't have the knowledge base YOU think they should have, that we'd all be better people.
Sorry - not even my area (except that before my current 30+ years in anesthesia I was a medic while you were still a glimmer in your daddy's eyes). Just had to add my two cents after reading all this drivel.
