crotchitymedic1986

Cant argue with that -- my point is that the culture of the company should push those who are pushable in that direction. If the culture is "my job is to sleep, watch tv, and gossip in betwen ambulance calls" then some who may have been teachable might take the path of least resistance, and join the herd of mediocrity. Maybe i am being polyanish, in hoping that i could capture another 1 or 2% from the darkside, but i always hold out hope.

I would also challenge the "leaders" in our company, which is not always the people with brass on their collars. Look around in the morning, the employee that has everyone gathered around him/her is a leader --- they may be a negative leader who is undermining the company, but they are a leader. TOo often, the bar is set too low, with the only expectation being "lets get through today's call volume". If the brassed and nonbrassed LEADERS set a higher expectation, most employees will rise to it. If you set a low expectation, they will settle to that as well.

Also, you have to realize that many instructors are used to talking TOO people and not WITH people, so sometimes it is they that have the communication issues with their subordinates. Anthony was also right in that all you know is your "book learning" right now. I am not trying to minimize that, but you need to get "experience" before you start questioning anyone on the scene. A better way to handle the situation for now, is at some point after the call is over, go to the instructor and supervisor and say, hey I want to ask you about that call -- i think i was under the impression that we were supposed to do "cde" but you choose to do "fgh", so please help me clarify what i should do in future calls.

And remember, when presented with the option of being right OR being NICE, choose to be NICE.

First of all wendy, you should be commended for even stepping up and admitting, "I might have a problem". Some simple suggestions:

1. Smile. You can tell someone to go to hell as long as you are smiling. Conversely, you can say have a nice day with a smirk and piss someone off. So smile.

2. Ask yourself, do i listen to hear, or do i listen to formulate my response. Many people do not really listen to what is being said, but merely scan through hearing the catch words, to formulate their answer.

Sounds silly, but try listening, and then repeating silently in your brain what the person said before you talk.

3. Dont add in your two cents every time you get the chance -- sometimes, especially when you are the new person, it is better to be silent for awhile. Many people have to add their two cents in during every conversation -- sometimes it is better to just listen and not talk.

4. Pick your battles -- you could wind up 100% right in every arguement you get into with your superiors, but wind up unemployed. I am not saying to compromise your values or morals, but ask yourself should i die on this hill, or live to fight another day ?

Amen to that, but i would shift the blame a little. In any business, 5-10% of employees are exceptional, 20% are just waiting to get fired, and the rest are somewhere in the middle. If you extend school to a 4 year program, you might be able to teach "everything" a medic might encounter in his/her career, but I am not sure you can guarantee it. I think a good bit of the blame falls on ems companies themselves and lawyers. The doctor kevorkians and drug abusers in our field just get passed from employer to employer instead of getting removed from the system all together. A better in-house orientation/training program would help those who are teachable, but many systems only have the most bare-boned and pencil whipped programs to educate their employees (I said many, not all).

I am learning that quickly through this forum, thought i had it pretty good -- guess you dont know how poor you are till you meet some rich people. You guys obviously work for some pretty cutting edge services.

I live in Canada, but i do not work in EMS any longer, my field experience was all US. We purchased the heaters you are discussing, but the problem was that they didnt last long, and as you stated the heated to over 90 degrees which was outside the range recommended by the fluid manufacturer (too hot is as bad as too cold). The heat/cool units with programmable thermostats were $300-1000 each, which was too costly for our budget. We then went to a heating "tray" (a heating pad on one of the ALS shelves, which also allowed us to heat linens) as part of all new vehicle purchases ($600) as it was easy to hide that in the overall purchase price.

I think you have to figure out what you can do to be DIFFERENT. If the only difference between you and the other employers is the color of your uniform, then why would someone jump ship for you ? How can you be different:

Different schedule, higher pay rate (or same pay rate for less hours), better equipment, liberal or cutting edge protocols, you can be more employee driven (employees have a voice), be active in the community, do clinical studies that get published, have a real career ladder - EMT 1,2,3 -- Pmdc 1,2, FTO, LT, Capt, Colonel. Note that many of these suggestions do not cost $$$, some are just an expenditure of time and planning. Make your service "KNOWN" for something positive. If you do that, word of mouth will bring them in, because sadly, too many companies are different in color of uniform and ambulance only.

I think orientation should be flexible in time parameters -- some people may need weeks, more veteran employees may just need a day. At a minimum, they should prove that they can operate every piece of equipment on the truck, go through some driving training, soem territory training, and ride third until a senior medic gives them the OK, but even when on their own, I think there should be a thorough review of every call. I do not subscribe to the sink or swim philosophy, because when they sink, patients tend to die. This is where a good field training officer program can work wonders.

I have a buddy that decided to be a CDL truck driver --- i was struck by the similarities and differences between his orientation and ours in EMS --- he had to go to school for 4 weeks and pass his CDL exam, that was administered by the state, and has a significant failure rate. The school was upfront in saying we only teach you to pass the CDL test, it is up to your employer to teach you to drive their truck (lots of differences in regular 18 wheeler, flatbed, and tanker -- not to mention hazardous materials). After passing the test, and getting hired, every employer required an 8-10 week orientation period where he was paid less than minimum wage. At the place he got employed, he spent 4 weeks in classroom and practice driving in their "yard", then drove the next 4-5 weeks in every condition imaginable -- mountains, city, urban, rural. He was not given his own truck until he passed every driving and written test. Out of the 19 that started his orientation class, only 2 received a job offer. And they start a new orientation every week, because they are so short. But unlike some EMS employers, they feel the "cost" of hiring someone who cant pass the rigors of this orientation period is too much of a risk (the average cost of an accident involving another vehicle is over $300k).

no otoscope -- should have said eardrums

I do not practice in canada -- my part-time job i took in sales 10 years ago ended up paying more than my fulltime medic job --- i got transferred to the canada office -- havent been on a bus in 6-7 months.

ERDoc, i respectfully disagree about having a white count in atleast one specific area -- pediatrics. Medics and EMTs are sometimes to quick to diagnose fever as something minimal (ear infection / teething) with no data to back up that theory (we cant even look in their ears to see if they are red). I have a friend who worked in the local pediatric hospital ER, and he claimed that they easily did LPs on about 10-15 kids per week. Although the majority were negative, the test was indicated by the high white count, usually found at the doctors office or other ER, after an EMS crew told the parents to give tylenol q4 and follow up with their pediatrician. He claimed that the vast majority that tested positive for menengitis did not have a petechia rash or stiff neck (he claims that is usually a late sign, you also have to figure in the fact that small children are scared and reluctant to admit symptoms if they are old enough to understand). It might also be useful with some nursing home patients to determine a diagnosis. Will it change field care, probably not, but it might mean someone gets transported that wouldnt have before --- damn, did i just make the point for keeping 12-lead ? hate it when that happens.

It doesnt do it any faster, but it does it in the field --- so again, much like an initial H&H after trauma, the receiving facility would have an initial level to compare to. Those that are already elevated, but have asymptomatic pain, might be discovered and not left at home or told to follow up with private MD. It does most of the basic lab levels (chem panel, CBC, Enzymes, etc..), the last time i used one, which was 8-10 years ago, it didnt do drug levels or a CMP (if that is the right letters for the CHF test).

Unless the ambulance is left running, or you use some type of space heater, the drugs will be 30-40 degrees. Thats why i said, use a meat thermometer on a few random days and you will shocked. When i looked at this, we were specificially looking at IV fluids, and even though our trucks were housed in heated bays, the IV temps were still in the 60-70 degree range. Now you take your person struck by auto thats been laying on cold pavement for 10-15 minutes, in 30 degree weather, then pump 60 degree fluid in the patient.

I would argue that if you need a pulse ox to treat respiratory distress, you should go back to school. But I was trained before there was such a thing, so i am biased. And you have a good eye -- i am a yankee american in canada.

Most drugs are supposed to be kept at a temperature range of 65-80 degrees, which is problematic for EMS in hot or cold climates. It is also another reason that many trauma patients arrive at trauma centers in a hypothermic state --- you cut all their clothes off, cover them with a thin sheet --- then pump in 1000 cc of 50-70 degree normal saline into a 98.6 degree body. The problem is that the drug breaks down in temperature extremes, so it may not work as well when you need it too. The problem is that most of the heater/coolers that we have tried to use either break down alot, or werent designed for medications (usually food/drink designed). If you take your average meat thermometer to your drug box in summer and winter (even those who house vehicles indoor), you will be shocked at the readings you get.

OK, after reading another post, i have to change my answer. having an ISTAT machine (for those that do not know, it is a handheld lab machine that is accurate but expensive) on my truck so that i can get troponin levels, H&H, or a white count. That would definitely change the quality of care provided in the field.

That is the day i am dreaming of -- ISTATs that are cheap enough to be put on ambulances -- think about troponin levels, knowing an intial H&H right after a traumatic event, being able to get a white count to determine if an illness is viral or bacterial. That will be a happy day in EMS.

I feel your pain -- and although changing training standards seems reasonable, i doubt it will have the outcome you desire (not all nurses are certified emergency nurses). Here is what we did instead: we met with the ER that we go to the most and talked with them about trying to purchase the same monitor (either us transition to theirs, or they transition to ours), but that didnt work, as the monitor they preferred didnt work well in the field. JCAHO had recommended that hospitals who had different styles of monitors make sure that they moved to a single type of monitor for the whole hospital (employees would only need to be trained on one monitor -- not a different monitor for every floor, crash cart and unit). Our hospital had already spent alot of money on that improvement, and werent interested in switching to another brand after that expenditure. So what they did do, is go in with us to (half/half) to purchase another spare monitor for us. That way when we arrived at any hospital, the monitor could remain on the patient as long as necessary. A supervisor would bring us another monitor, and wait the 30-40 minutes it usually took to safely transition the patient to the hospital's monitor. After the purchase, we attended a monthly ER staff meeting, and had a training session (which all ER nurses took and signed off on the training) with the staff. The bad news is that with turnover, you have to go back ever so often to review with the new staff. But ER managers generally are receptive to it, because it is training that looks good to JCAHO.

I always think more education is a good thing, but let me play devil's advocate for a moment. In my area, the hours (class room) needed to gain paramedic certification was significantly increased a few years ago. The result was, emts who might have went for medic decided to go for nursing instead (more money, better benefits). The medic shortage got worse in the rural areas, so EMT B was allowed to occur (previously we only allowed EMT I). So the end result of longer educational requirements was "less" educated personnel in the field. If this were implemented nation-wide, why do you believe the result would be different ?

I agree with taking another look at "who gets flown". I can remember when there was only one helicopter in my city, now there are 8-10. A good many of the trauma patients are not salvageable and are only being flown because no local hospital will accept them. Much like it doesnt make sense to start CPR on a 98 year old with contractures, I think we need to ask is it worth the lives of helicopter crews to transport brain injury patients that have no hope of recovery, burn pts with greater than 75% BSA, or patients that dont have a scratch on their body (or minimal injury) but have "mechanism". This is assumming that a trauma/burn center can be reached by ground within the golden hour. But remember, on the vast majority of helicopter calls --- you have a 10minute ems response time, the chopper is called and has 10-20 minute response time, then they have to assess and package the patient so they spend 10-15 minutes on scene, and then they have the flight time to the hospital, which pretty much eats up your golden hour anyway.

i know reaper, but its still a box on the back of a pickup chassis --- I am talking about something new from the ground up. Like UPS has their own truck. My idea of an ambulance may not look anything like what we have on the road now, maybe it would be the same, just safer --- maybe it would be on a special toyota/lexus chassis to give us better reliability.

I am new, so forgive me if this is a stupid question, that isnt worthy of the room, but i see quite a bit of experience and ems genious in the membership of this forum. So if I were the magic genie in the bottle that you rubbed, and i granted YOU ONE WISH, and only one wish that you could only use to change ONE THING in the EMS Industry, what would you change ? Think hard, you only get one wish ?

Personally, I would like to see an ambulance that was built from scratch, from the ground up, designed by and for medics in the field, with all aspects of ergonomics and safety considered. Instead of whatever is the cheapest way to throw a box on the back of a pick-up chassis.

I am new here, so forgive me if i ask a dumb question; but wasnt the original posters question about getting a refusal on an intoxicated patient ? If a person made out a new will and testament while intoxicated, i am pretty sure it would be thrown out of court (I recall the phrase I ____________ being of sound mind and body). So if the signature of that document was not legal, couldnt the same arguement be made for a medical refusal of care ? I dont know of an EMS system in my area that hasnt at one time or another had their horror call, where the drunk was left behind, and something bad happened. I agree that i hate policies, procedures and protocols that are written for the "one" bad call that occurred 10 years ago, by the rookie or idiot, are a bad thing --- but lets face it, medics are human, and do make mistakes. As one respondent put it, you should ask what is best for this patient ? If you always do that, you will be able to defend yourself in court.

Reaper, your system is obviously more advanced than mine --- how does the location of the MI change your "field" treatment ?