Question regarding Paramedics

[UrSexyLatinDr]

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Hello Guys,

What kind of palpations and physical assesments are paramedics taught to do? I am just wondering on their skill of knowledge since I know they do a lot for the patients.

Ed

 

[TerraMedicX]

Hello Guys,

What kind of palpations and physical assesments are paramedics taught to do? I am just wondering on their skill of knowledge since I know they do a lot for the patients.

Ed

Paramedics are generally taught the same physical exam that doctors and PAs use (at least I was, suppose I can't actually attest to any other program). That said, most of us never preform such an in-depth exam after school. Frankly, at this point, I have trouble remembering portions of it.

Nate.

 

[UrSexyLatinDr]

So is this like a general pt assessment, traumatic, assessment or what kind of assessments are there?

 

[viostorm]

So is this like a general pt assessment, traumatic, assessment or what kind of assessments are there?

Paramedics do a VERY basic physical exam.

HEENT: gross trauma, some may check for extraocular movements, depending on the patient PERL.
Resp -> auscultation only
CV -> pulses only
ABD -> only palpation
Ext -> paramedics will only notice if the limbs are there, if the patient can move them, and if they are grossly broken, edema
SKIN: minimal exam beyond wounds.
NEURO: orientation, light touch only, gross motor
PSYCH: will only assess if the patient has suicidal ideation.


Paramedics just don't see enough disease either practicing or in class to be good at physical exam. And they certainly don't see enough "abnormal" patients and no one is around if they do see one to explain the significance of the finding.

Paramedics don't listen to heart sounds, they don't percuss, they don't do reflexes, no fundoscopic exam, no otoscopic exam.

Paramedics are trained to pick up major immediate life threatening conditions, wheeze in severe asthma, crackles in CHF, absent lung sounds in pneumothorax, acute abdomen, gross spinal cord injury, basic neuro exam for acute stroke (cincinnati prehospital stroke scale), and edema in CHF.

I have to disagree with Terra, there is no way the paramedics are taught the same as "doctors."

 

[greytmedic]

You mean you don't do DTR's in the back of your ambulance? And try finding an ambulance with an ophthalmoscope and otoscope attached to the wall.😉

 

[TerraMedicX]

Paramedics do a VERY basic physical exam.

HEENT: gross trauma, some may check for extraocular movements, depending on the patient PERL.
Resp -> auscultation only
CV -> pulses only
ABD -> only palpation
Ext -> paramedics will only notice if the limbs are there, if the patient can move them, and if they are grossly broken, edema
SKIN: minimal exam beyond wounds.
NEURO: orientation, light touch only, gross motor
PSYCH: will only assess if the patient has suicidal ideation.


Paramedics just don't see enough disease either practicing or in class to be good at physical exam. And they certainly don't see enough "abnormal" patients and no one is around if they do see one to explain the significance of the finding.

Paramedics don't listen to heart sounds, they don't percuss, they don't do reflexes, no fundoscopic exam, no otoscopic exam.

Paramedics are trained to pick up major immediate life threatening conditions, wheeze in severe asthma, crackles in CHF, absent lung sounds in pneumothorax, acute abdomen, gross spinal cord injury, basic neuro exam for acute stroke (cincinnati prehospital stroke scale), and edema in CHF.

I have to disagree with Terra, there is no way the paramedics are taught the same as "doctors."

While I never PREFORM most of those advanced assessments, I WAS trained in them. And I do regularly auscultate heart tones, bowel sounds, preform neuro exams including gross assessment of cranial nerves II-XII as well as radial and ulnar nerves. Not regularly, but I DO percuss chest, abd and flanks. Yes, I don't always understand the full extent of these assessment findings, but I CAN recognize abnormal findings and relate those to ED staff.

As I said, I can't attest to the training provided by other programs, and I think that this illustrates that there is variation between programs.

Nate.

 

[deleted92121]

To be quite honest, Paramedics are required by the NREMT to recognize and be able to treat many common and many uncommon injuries/diseases/illnesses.

That being said, the most common that we recognize/treat/diagnose;

Respiratory: Abnormal LS caused by asthma, COPD, CHF, pneumothorax. To treat we use Rx like Albuterol and Lasix as well as intubation (conscious and unconscious) and chest decompressions.

Cardiac: Arrhythmias including heart blocks, V-Tach, V-Fib, and PEA for which we utilize Epi, Atropine, Sodium Bicarbonate, Vasopressin, Lidocaine, Amiodarone, and of course cardioversion/defibrillation. We also recognize and treat heart attacks with 12-lead ekg and certain drugs such as NTG, ASA, and MSO4. Hypotensive emergencies are treated with respect to what is causing it. Obviously with shock we treat with fluids and attempting to stop any external bleeding if any. We also may be forced to use drugs such as Dopamine. We are always careful when giving fluids however and must check LS before, during, and after administration.

Neuro: Altered level of consciousness calls are assessed for diabetic problems, strokes, and traumatic injuries. If diabetic, they receive dextrose or glucagon. If stroke, they get a stroke scale evaluation, high flow O2, an IV, EKG, and rapid transport. Trauma is usually supportive care with rapid transport. It should be noted that when dealing with ALOC patients, we try to gather enough past history on the patient to determine if they really are altered as sometimes it may just be a dementia patient.

Trauma: Recognize deformities, contusions, abrasions, pain, punctures, penetrations, paradoxical movement, burns, tenderness, lacerations, swelling. Then, treat life threatening injuries first followed by splinting/bandaging as needed.

I would say that is the basic of what we do. There is more but to be honest, not a whole hell of a lot. Truth is there is a ton of info in our paramedic textbooks that they think we should know but the problem is that you rarely see a hypernatremic seizure with tardive dyskinesia. However, I actually had someone with said diagnosis the other day and I remembered it from class. So really most of what we learn to recognize/treat comes from experience. In many cases, a 20 yr veteran EMT is much better in the field than a newly minted Paramedic.

just my thoughts,
dxu

 

[146233]

While I never PREFORM most of those advanced assessments, I WAS trained in them. And I do regularly auscultate heart tones, bowel sounds, preform neuro exams including gross assessment of cranial nerves II-XII as well as radial and ulnar nerves. Not regularly, but I DO percuss chest, abd and flanks. Yes, I don't always understand the full extent of these assessment findings, but I CAN recognize abnormal findings and relate those to ED staff.

I agree with Nate. I was also trained in a very thorough physical examination. While I don't do the whole thing every time (for the same reason as Nate), I do assess heart tones (tamponade), bowel sounds (obstruction, etc.), and so on. I haven't percussed anyone in quite a long time, but my next suspected tension ptx will surely get it. I don't specifically assess the radial and ulnar nerves, though. 🙂

 

[MacBook]

Hello Guys,

What kind of palpations and physical assesments are paramedics taught to do? I am just wondering on their skill of knowledge since I know they do a lot for the patients.

Ed

It all depends as to what the nature of the call. I don't do the same assessment for each and every call. Depending on whether or not it's a medical/trauma call or MOI, the patient condition and medical Hx etc..

There are way to many things I could list that would determine what kind of assessment I do.

Your level of training alone will affect the ind of things you are looking for. Without the background information (anatomy and physiology)you cannot make a differential dignosis which defeats the purpose of doign your assessment in the first place.

 

[fiznat]

Paramedics (even myself) tend to puff their chests out when they hear comments like those from viostorm. It is tough to read something like that and not take it as an attack, especially when it is directed towards a profession that tends to get misrepresented and misunderstood by the rest of the medical community. Honestly, though, what he says is mostly correct.

It is for a reason, though, that paramedics don't get too in depth with superfluous examination in the field: we simply have neither the time nor the resources to deal with that kind of stuff. I spend about a half hour with my patients from hello to turnover. I don't have time to do a detailed psych evaluation, and to be honest, to do so would be to get in the way of so many other things that matter much more. We deal with imminent life threats, and look for the things we can treat. Beyond that is academic, and even beyond that is showing off.

It doesn't mean that I am any less of a professional, and it doesn't mean that my contribution to the patient isn't extremely valuable or frequently life-saving. There is a lot of snootyness in this field, it seems like many people look for an opportunity to turn up their nose at someone they feel is below them. I'm not saying this is what viostorm is doing, but it happens...

 

[leviathan]

Good response, fiznat.

I try to be very rightfully humble about my training as a paramedic. We really do know next to nothing, but that doesn't mean we don't know enough to do our jobs, and do them well. There's always lots of room for improvement, though.

 

[MacBook]

I hadnt even read half of the things posted in this topic. The stupidity of some people is what makes the world go round and round...👍

 

[pseudoknot]

I really don't think it denigrates paramedics to say that there are others with more training. You're comparing a 6-9 month program to a 7+ year program. Of course doctors know more. As leviathan said, that doesn't mean paramedics aren't very good at their jobs.

 

[Tristan14578]

I really don't think it denigrates paramedics to say that there are others with more training. You're comparing a 6-9 month program to a 7+ year program. Of course doctors know more. As leviathan said, that doesn't mean paramedics aren't very good at their jobs.

only 6-9? thats short. mine was a 18. and tons of clinical hours.

 

[pseudoknot]

only 6-9? thats short. mine was a 18. and tons of clinical hours.

That seemed to be the typical length in California. I know that the programs vary in length, but I believe that is the minimum.

 

[leviathan]

That seemed to be the typical length in California. I know that the programs vary in length, but I believe that is the minimum.

It's about 3 years to become an ALS provider in Canada. I wish I could do a 7 month paramedic program! 🙂

 

[TerraMedicX]

It's about 3 years to become an ALS provider in Canada. I wish I could do a 7 month paramedic program! 🙂

Why? You still have to learn pretty much all the same material...you just have a LOT less time to do it!! Class five days a week from 8-5, two to three tests a week, plus clinicals and field rides! Hardest six months of my life!!

 

[pseudoknot]

It's about 3 years to become an ALS provider in Canada. I wish I could do a 7 month paramedic program! 🙂

Hey, I'll be an ALS provider in three more years! (MD 😀)

 

[deleted92121]

My medic class is almost one year and two nights a week for 4 hours. We have a certain amt of procedures we need to perform by the end of class. Example, 50 team leader calls, 30 IVs, 5 intubations. We are forced into ER/OR time b/c before we can tube in the field, we need one on the OR. It works out well.

Lucky for me, the medic class is done at my service (very large private service...70K calls per yr). So I run 40+ hrs on an ALS truck with a preceptor all week. I test in a little more than 2 months.

dxu

 

[deleted6669]

only 6-9? thats short. mine was a 18. and tons of clinical hours.

my certificate program in california yrs ago was 1 yr long with 4 mo class room, 4 mo hospital( 2 mo overlap with classroom), and 6 mo field training. we needed a min of 50 als field contacts with certain #s of different kinds. I spent over 600 hrs just in the field.
training and working as a medic was great prep for pa school!

 

[docB]

I think that this discussion is having a problem comparing apples to apples.

First off it seems like everyone has a different name for the level of cert we're talking about, EMT-P, paramedic, ALS provider, ect.

Second the overall calendar time spent is not as important as the hours. I've seen paramedic courses that run 9 months full time or 2 years part time.

The courses I run here in Vegas have 1400 hours split between didactic, clinical and field training. We are currently doing the didactic over ~10 months, 2 days a week. They then have 350 hours of clinical that takes about 3 months and 350 of field training that takes about 3 months. So it's ~16 months start to finish. We could do it faster if we did it all 5 days a week but it's the same training.

 

[leviathan]

Why? You still have to learn pretty much all the same material...you just have a LOT less time to do it!! Class five days a week from 8-5, two to three tests a week, plus clinicals and field rides! Hardest six months of my life!!

I spent 7 months in class 8-5, plus labs on weekends and evenings to become a BLS paramedic. ALS paramedics then spend an additional 1.5 years with the same amount of time involvement.

 

[viostorm]

I feel very qualified to answer the question, after completing my NREMT-P and my recent 2 year physical diagnosis course in medical school. I still work 12-24 hours per week on the ambulance.

The courses are absolutely not equal by any regard I stand by my statements. The purpose of the course is totally different.

You just can't get the experience or master clinical teaching as a paramedic, the best example is I heard more pediatric heart murmurs in my 1 week in the NICU then my entire 11 year career as a paramedic. But the list could go on, oh man the neuro exam, medicine, the pysch mental status exam, eardrums.

Not all is pneumothorax or the big killers. Will a paramedic say "hey that guy has black discoloration under the armpit ... maybe he has gastric cancer!"

I now recognize the hubris which many paramedics operate with, they don't even know what they don't know which makes them think they are masters in everything.

Paramedics are masters in a VERY narrow slice of medicine, they know prehospital care better then doctors! But however they do not know physical diagnosis better then physicians.

In most ambulances you can't even assess the right side of the patient.

Some of you I know are attending medical school soon. I hope you revisit this thread and maybe I'll have more people agree with me at that time.

 

[fiznat]

In most ambulances you can't even assess the right side of the patient.

Hah nicely put, I like that one.

 

[leviathan]

I feel very qualified to answer the question, after completing my NREMT-P and my recent 2 year physical diagnosis course in medical school. I still work 12-24 hours per week on the ambulance.

The courses are absolutely not equal by any regard I stand by my statements. The purpose of the course is totally different.

You just can't get the experience or master clinical teaching as a paramedic, the best example is I heard more pediatric heart murmurs in my 1 week in the NICU then my entire 11 year career as a paramedic. But the list could go on, oh man the neuro exam, medicine, the pysch mental status exam, eardrums.

Not all is pneumothorax or the big killers. Will a paramedic say "hey that guy has black discoloration under the armpit ... maybe he has gastric cancer!"

I now recognize the hubris which many paramedics operate with, they don't even know what they don't know which makes them think they are masters in everything.

Paramedics are masters in a VERY narrow slice of medicine, they know prehospital care better then doctors! But however they do not know physical diagnosis better then physicians.

In most ambulances you can't even assess the right side of the patient.

Some of you I know are attending medical school soon. I hope you revisit this thread and maybe I'll have more people agree with me at that time.

Diagnosing gastric cancer or knowing about pancreatic pseudocysts does not make a better paramedic. I think people need to realize that all viostorm and others are saying is that paramedics are blind to the other 99% of the medicine out there that isn't really important in pre-hospital care.

 

[Medic5150]

First and foremost let me introduce myself, and apologize for all future spelling and grammatical errors. My name is Ryan and I'm a FF/Paramedic is Los Angeles, and am attempting the medical school process. Ive been a Paramedic for 5 years and love it. I stumbled across this site, and absolutely enjoy it.

So back to the original post. As said earlier Paramedics are experts in a very very slim slice of medicine. Even the field of para-medicine is only around 50 years old ( In the civilian world) Even though we are taught how to do an extensive H&P we rarely use it in the field. Some reasons may be that a certain aspect of the Physical assessment may not be relevant, (such as an dermatological exam) we may not have the proper equipment (HEENT) or we may not be able to do to the environment. I remember learning how to auscultate heart sounds, but in the field, or even in the back of an ambulance heart sound seem to be muffled out by the sounds of diesel engines. Paramedic are taught to treat immediate life-threating problems, and we are also only with patients for a short period of time so a extensive H&P is impractical. Paramedics shouldn't kid themselves , while we do extensive H&P that are relevant to our aspect of EM they will never compare to an MD's. Not only because of the length of the training but also in the various disease processes that an MD may see in the ER everyday , as opposed to a Paramedic who rarely will see the same disease. I also seem to find that Paramedics may find an interesting physical finding but never follow up with the MD to see what the final Dx may have been. Finally you also have to remember that paramedics are the jack of all trades , not only do we do EM but a little teaching , therapist ,social work etc. Not to mention hazardous materials, technical rescue etc. So to tie this all together, we are all medical professional but with different little specialty which show during patient care. Sorry my reply got a little long in fact i think my reply is one long grammatical error.

~Ryan

 

[jbar]

Hah nicely put, I like that one.

That might by why it's so hard for me in med school to do my exams from the patient's right. I'm so used to doing everything from the left in the back of the ambulance.

 

[greytmedic]

Even though we are taught how to do an extensive H&P we rarely use it in the field. Some reasons may be that a certain aspect of the Physical assessment may not be relevant, (such as an dermatological exam) we may not have the proper equipment (HEENT) or we may not be able to do to the environment.

I wouldn't even say that paramedics are taught to do extensive H&Ps, but rather basic H&Ps. The "extensive" H&P that physicians perform include social history, family history, history of present illness, review of systems, and much more in depth physical exam. And its not that a dermatological exam is not relevant, but really could you tell the difference between a boil, furnuncle, carbuncle, or chancre? That's why it's not performed in the field, but there are rashes that are signs of emergent diseases. And HEENT exam, it is not because paramedics don't have otoscopes or opthalmoscopes, it is because they are not taught that aspect of the physical exam or what finding would even mean. Could you pick out papilledema on exam? That is a good physical sign that would be relevant to paramedics. And I wouldn't even say paramedics are the jack of all trades. Paramedics are the jacks of the pre-hospital environment and the additional responsibilities that brings.

 

[Medic5150]

Double Post

 

[Medic5150]

I wouldn't even say that paramedics are taught to do extensive H&Ps, but rather basic H&Ps. The "extensive" H&P that physicians perform include social history, family history, history of present illness, review of systems, and much more in depth physical exam. And its not that a dermatological exam is not relevant, but really could you tell the difference between a boil, furnuncle, carbuncle, or chancre? That's why it's not performed in the field, but there are rashes that are signs of emergent diseases. And HEENT exam, it is not because paramedics don't have otoscopes or opthalmoscopes, it is because they are not taught that aspect of the physical exam or what finding would even mean. Could you pick out papilledema on exam? That is a good physical sign that would be relevant to paramedics. And I wouldn't even say paramedics are the jack of all trades. Paramedics are the jacks of the pre-hospital environment and the additional responsibilities that brings.

Thats a lot of great points but I think I may not have been clear in all aspect of my last post.
1) Your right paramedics don't do extensive H&P with social / family history maybe moderate H&P but hey thats all just semantics. However I WAS taught how to do an detailed exam, but that may just be the PM school I attended. We actually used Bates & Brady's Paramedic Care 1-5
2) With the dermatological exam I was actually trying to find something I could relate and that just was the first thought In my head.
3) with the HEENT exam I was referring to the otoscope & opthalmoscope but I do look for things such as if the eyes are PEARRL ,nystagmus any battle's sign etc.
4) I have to disagree with your point of paramedics not being jack of all trade. Not only do paramedic do the medical aspect but also things as simple as scene safety, such as which side of the door do you stand on when knocking, cover vs concealment, Hazardous Material Ops or even how far do you stay away from an un-deployed airbag. So Paramedics do in fact have more on there plate than just Medicine, in fact we actually do a bit of social work , teaching, grief counselor, advocate, but that may just again be where I'm stationed

~Ryan

 

[Medic5150]

Since i mentioned Airbags in my last post I thought I would share this video

http://www.youtube.com/watch?v=b-qzxwjb8IU

 

[Eddie]

Paramedics take a lot of abuse for such low pay and long working hours.

 

[MedicFL]

Why are we fighting on this matter. Do we all do an H&P's yes. Are Paramedics good at what we do yes. But the more and more school I attend I realize how little medicine we actually know and practice. How can you even compare an H&P that you learned in a year or less to one that you learn in 4 years plus residency to. You can't I would expect that a physician is able to do a more in depth and detailed H&P. I can't agree more with some of the above posts, its one thing to find the symptom but it is another to know what,why, and how to fix it. I teach at a community college here and one thing that I can say is this. Most EMS educators in the US on average have only an AA, with I think the percent was about 15-20% have BS/BA. I forgot what survey I read that in.. Paramedics teaching paramedics no matter how long in the field only can do some much. Where I went paramedic school we had an EM Doc as the lead lecturer and he brought in other Docs such a cardiologist's, a toxic guy, an OB guy. I think this teaches to a whole new level that a medic is just not able to do.. I love the profession, been doing it since I was 17, but we work at a LOWER level of care. Many of us may go on to become doctors but at this time we are not all there yet...

 

[Eddie]

Why are we fighting on this matter. Do we all do an H&P's yes. Are Paramedics good at what we do yes. But the more and more school I attend I realize how little medicine we actually know and practice. How can you even compare an H&P that you learned in a year or less to one that you learn in 4 years plus residency to. You can't I would expect that a physician is able to do a more in depth and detailed H&P. I can't agree more with some of the above posts, its one thing to find the symptom but it is another to know what,why, and how to fix it. I teach at a community college here and one thing that I can say is this. Most EMS educators in the US on average have only an AA, with I think the percent was about 15-20% have BS/BA. I forgot what survey I read that in.. Paramedics teaching paramedics no matter how long in the field only can do some much. Where I went paramedic school we had an EM Doc as the lead lecturer and he brought in other Docs such a cardiologist's, a toxic guy, an OB guy. I think this teaches to a whole new level that a medic is just not able to do.. I love the profession, been doing it since I was 17, but we work at a LOWER level of care. Many of us may go on to become doctors but at this time we are not all there yet...

I co-sign your sentiment. 👍

 

[MacBook]

You have to remember that all we do is treat life threatening problems not diagnose AND treat with long term recovery in mind (tho its the real goal, make sure everyone does). We have these people for very short periods of times.

Treat and go

 

[Eddie]

You have to remember that all we do is treat life threatening problems not diagnose AND treat with long term recovery in mind (tho its the real goal, make sure everyone does). We have these people for very short periods of times.

Treat and go

The ol' "scoop and scoot". 😀