usmc_chris

Let's see if I can get it right this time. I had my whole reply typed and my browser went back two pages instead of deleting something I was trying to edit before posting! Pupils are equal, round, and reactive to light and accommodation. Pt's last PO intake was a ham sandwich, a small bag of potato chips, and a can of diet soda, pretty much his normal shift. Pt works 2nd shift (3pm-11pm) and was just heading to work. Pt denies eating or drinking anything out of normal for him for the past day or so, denies any insect bites/stings or other possible allergens. You note no swelling, hives, or itching. Dwayne, the pt is lifted from the car on the stretcher and placed immediately into the ambulance. There are no law enforcement present that he would feel the need to lie to (of course, I know they lie to us too), and he adamantly denies any recent illicit drug or alcohol use. A new set of vitals is obtained. Manual BP is 128/86, HR is 77 in a NSR. RR 20, easy and unlabored. SpO2 is 98% on room air. He continues to tell you the same story of events: he just left home, was driving along, turned to look in the rearview mirror and felt that very mild "pop," no more severe than an insect bite. Shortly thereafter symptoms began, which are still the same. Upon assessing the neck you feel no point tenderness along the spine, normal range of motion, no evidence of a bite or sting, he does c/o 2/10 pain to the left posterior of the neck, but you can see nothing wrong upon visual inspection. Pt states he is compliant with his meds, does not have them with him. He does state he hasn't been to his primary doctor in over a year. Pupils are normal. Your partner placed a 16ga IV in his left AC with a liter bag of 0.9% NS running at KVO. As for the rhythm strip, I stated II thought) that those things that you can diagnose from a rhythm strip weren't there. But when you do the 12-Lead, you see no T wave inversions, no ST-segment elevation/depression in any lead. QRSd is 80mS, PRI is 150mS, QTc is 420mS, and R-axis is 10 degrees. Poor R wave progression noted in V1-V4 but nothing acute seen anywhere. Because this doesn't line up with what you're seeing, as he really looks like he's not doing so well, you go ahead and do a right-sided 12-lead as well, but you see nothing in V3R or V4R. Pulse quality is normal strength with a regular rhythm corresponding with the cardiac monitor. As far as you can tell the patient is being open and honest with you in all regards. He has no history of anxiety or panic attacks and denies any recent stressors that might trigger one, however, it doesn't rule it out. He rates his nausea as a 4/10, doesn't feel like he is going to vomit. You have IV access, would you like to push the ondansetron? You have an approximate 5 minute transport time. Airway is patent. RR 20, breath sounds are clear/equal in all fields. Symmetrical chest movement, normal depth, easy and unlabored. Pulse is of normal quality with a regular rate. No abnormalities. Pt denies any recent trauma, GI bleeding, etc. No evidence of a hole in your patient's skin is seen anywhere. No bruising seen, abdomen is soft, non-tender, and non-distended. Pt is now on high-flow O2 via NRB. 3rd set of vitals - BP 123/84, HR 80, RR 20, SpO2 100% on high-flow. GCS continues to be a 15, although he is slightly lethargic. Skin turgor normal, pupils as above. Grips are equal, pronator drift test negative, no facial drooping, speech is regular and not slurred. 37.0 is normal temp in Celsius, so corresponding Fahrenheit temp is around 97.6. EKG's as above, BGL is 130 mg/dl. Vehicle is in good condition, late model foreign sedan. No apparent damage, pt denies a collision, stated that when this began he pulled over into the parking lot you are currently in. No further medical information can be found. You begin transport and place a second, 18ga IV, saline lock, in his right forearm. Any thoughts? Anything else you'd like to know or do?

Upon looking at the pt, he is seated in the driver's seat, and you and your partner give each other the "look." It's both in the back of your minds that he looks like an imminent arrest. He is profoundly pale and diaphoretic, alert and oriented but slightly lethargic. Pt is c/o extremely severe dizziness and mild nausea. Cincinnati stroke scale is negative. Because of the public place and the proximity of the ambulance, you immediately pull the pt out of the car and move him into the back to begin working on him. He tells you that he just left home, is headed to work, only made it about a 1/2 mile when this began. He tells you that he had turned to look in the mirror and kind of felt a "pop" in his neck, however denies any recent trauma. Spine is non-tender to palpation, mild 2/10 pain to the left posterior area of his neck, a dull sensation. No recent illness. BP 138/97, RR 20, HR 83, rhythm strip shows regular sinus rhythm, no AV heart block or bundle branch block. SpO2 is 98% on RA. GCS is 15. Temp is 36.8 C. Respirations are easy and unlabored, although pt is very worried, relates he feels like "crap." Breath sounds are clear/equal bilaterally in all fields. Medical history is hyperlipidemia and depression. Pt is taking Atorvastatin and Zoloft, denies any other medications or medical history. NKDA. Pt continues to tell you that he doesn't feel so good, no alleviation of the dizziness or nausea after lying down.

Well, I accidentally double posted this earlier, and apparently both threads somehow got deleted, so I'll try it again. You are working on a double Paramedic ambulance with a non-driving EMT-B trainee. It is a sunny day, about 84 degrees F. You are dispatched to a 58 y/o male pt complaining of severe dizziness and sweating, pulled over in the parking lot of a local business. The call is EMD-coded as a 31D4, unconscious/fainting. You have an approximate 4 minute response time. While enroute, you are updated by dispatch that your patient is now complaining of "heavy" breathing. You arrive on scene, and the heavy rescue truck from the local fire department staffed with a single paid FF/EMT-B is on scene. The EMT is leaning over the patient in the driver's seat, and upon witnessing your arrival waves frantically for you to come over to your patient. Tell me what you want to do and what you want to know!

Scene size up: What does the house look like? Does the yard appear clear of debris, etc? Is the scene safe? Patient assessment from a distance. You stated obvious trouble breathing. How is it obvious? Do we hear wheezing or obvious pulmonary edema from across the room? Anything coming out of her mouth (sputum, etc) ? Skin condition? PPE - gloves, face masks if indicated due to severe CHF. The stairs thing - I'm assuming you mean she's standing in the doorway of her residence with a couple stairs out the front door. Let's get her seated on the stretcher as quickly as possible, I don't like to let respiratory patients stand / walk for a long time. Upon approaching pt - is she alert and oriented? Any complaints other than shortness of breath? Breath sounds? Medical history, especially anything that would cause a respiratory problem (CHF, COPD, etc)? When did this start? If it's been a while, what made it worse right now that made her call 911? Have my partner obtain vitals, including RA SpO2, BP, pulse, 3-lead ECG for now, respiratory rate, and probably EtCO2.

I don't know what I want to do without more information. Questions to ask the CNA/RN: -What is the patient's baseline? -What was the last time the patient was seen at her baseline? -Advanced directives? Any directions about when/if to treat/transport the patient in the transfer packet? (I ask because we have a kind of "super" DNR form called a MOLST around here, which allows the patient/HCP to specify that the patient is not to be transported unless permission is specifically given by the patient and/or family and MD if the patient isn't competent, by checking all the "comfort care" options. Not quite hospice care, but it allows people the option when terminally ill to stay where they are rather than being forced to the hospital). -Medical history, especially any h/o diabetes or previous CVA. If previous CVA, what are the residual deficits, if any? Patient assessment: -Is the patient alert and oriented? If not, are they at their baseline if they have dementia? -Full Stroke Scale, including facial droop, speech, and grips/pronator drift test. -Vitals, including BG? That should get us started.

According the the Virginia Reciprocity packet I have on my desk, you need two things to obtain Virginia certification. (1) current, valid National Registry certification and (2) a current Virginia address or employer. I've obtained my NR and am waiting to submit the packet until I have a job offer, or an address. As soon as either my wife or I have a job offer we're gonna be moving.

An interesting spin on the conversation, where I'm from, the "medical" person on an ambulance (more specifically referring to the volly services that run EMT/Ambulance Driver crews) is always termed a "medic," while when they're looking for an ALS unit (flycar or full ALS/BLS ambulance), they always ask for a "tech." I don't know why, it still confuses me, and kind aggravates the *&%^ out of me in some ways that the Emergency Medical TECHNICIAN is called a "medic" while the PARAMEDIC is referred to as a "tech." That being said, it's how EVERYBODY terms it here, especially when talking over the radio.

Red Bull drink lifts stroke risk: Australian study According to this article, there is some correlation to increased risk of stroke and cardiovascular disease, especially in the younger population. I can't seem to find an abstract of the original study, but perhaps my searching skills aren't as good agns others on here. I do know that the U.S. military published a pamphlet and poster warning service members of this when the study first came out, advising us to reduce consumption. Coupling these effects with the stress of our job, I can't help but think that energy drinks compound the problem. Admittedly, I'm addicted to coffee, but that's where I draw the line. No energy drinks for me! Edit: rereading the article, according the Red Bull employees anyways, the caffeine content is roughly equivalent to a regular cup of coffee anyways, so maybe just all caffeine is bad!

Most Android phones have Wi-Fi capabilities as well. I know mine does, I'm not sure what exactly works over the wi-fi vs standard cell service though. Just to give you more options. That being said, I'm probably getting an iPhone when my 2-year contract is up.

Just one comment... probably not a true tonic-clonic "grand mal" seizure, but rather a Stokes-Adams Attack. I've seen the V-Fib "Dance of Death" before (as, I am sure, have many on here) and it sure does look like a seizure... until you glance at the monitor and pucker up! That aside, how does this guy not have an AICD/pacemaker??? Also, at one of my employers, we have a dispatcher that has been a "save" at work at least twice that I know of, and apparently once at home as well. I don't know if the same medics worked on him both times at work... it would have been management staff, but those change so often around here...

Do you have CDL's and/or a livery driver's license? How about state authorized livery vehicles? The laws may vary from state to state, but for the kinds of transports you're talking about, similar requirements to a taxi service apply. In the case of "medically necessary" transports, such as the bed-confined or oxygen dependent population, you would have to become a fully licensed/certified ambulance service the EMT-B level or higher. You need to check with your local emergency response squads. Before a Certificate to operate (if required for BLSFR in your state) is issued, the state will often ask for their approval. And I don't believe this question meant 'practice' certificates, as in your CFR/EMR certification card. What is meant, is a certificate of need/public convenience/whatever your area calls it, which essentially means that the State agrees that this service is needed/will be useful, and authorizes you to run the service. Without said certificate, you simply cannot operate. The State office of EMS would have more information on this process. No, you don't already have the insurance on your vehicles, I would guess. Standard automobile insurance WILL NOT cover your response to emergency incidents. It REALLY won't cover you if you do the non-emergency transport thingy you were talking about as well. If they find out you're doing this, they'll drop you like a hot potato. You need to purchase coverage through one of only a few specialized insurance plans that covers authorized emergency vehicles. It WILL cost more than your standard coverage. As for malpractice insurance, there's a few different options. I personally have a policy through HPSO, but I don't know if they issue agency policies, which is what you would need. It's around $200 a year for Paramedic-level coverage, I have no idea what personal EMR/EMT-B level coverage would cost (I never got my own coverage until I had the stuff I could REALLY hurt people with, just relied on my employer). Do you know anything about billing insurance carriers? It's not that easy. You have to have a certificate to operate and all the other necessary stuff. You would need to legally incorporate. Once that is done, you'd have to apply to CMS for a Medicare billing number (since most of the folks you're talking about transporting would be on Medicare). Once that's issued, you can apply to the State for a Medicaid billing number. You can't bill either program without their respective billing numbers. I hate to break it to you, but there will most likely be a cost to this. Municipalities/counties, depending on your state, are often required to take 911 calls, but they often have no legal obligation to provide dispatching services, at least for free. Even if the dispatching service is free, radios/pagers will set you back THOUSANDS of dollars. I can guarantee those won't be free. You probably need to rethink the above. Just getting this off the ground could be in excess of $100,000. I would suspect that your personal vehicles would not be approved for use (there are some states that would allow it, but your insurance carrier may not). Even if your personal vehicle were approved for use, do you want the PERSONAL liability attached to using it? There's a certain level of protection if you have a "company owned" vehicle for use instead. Portable radios are easily $500 each. Tone-activated pagers are around $400 each last I knew. I have no clue how much a mobile radio for your response vehicle would cost. As for supplies, sure, disposable supplies are pretty cheap. But I guarantee that your state has a "minimum equipment list" for BLSFR services. This would almost certainly include non-disposable, durable supplies that will quickly add up. Among them include an AED, probably a short board or KED, and some sort of portable suction unit. Those three things alone will set you back almost $4,000 easily. But that's not you said. You did in fact allude to getting paid for non-emergency transports. The problem is, the non-emergency medical transport industry and the BLSFR 'industry' are two completely separate things. You would need to be separately licensed for each. You would probably need different vehicles for each. I realize you think everybody's jumping on your back, but we're just trying to give you a dose of reality. If there's truly a need for either of these things, you can make it happen, but it can't be just your buddy and yourself. It really truly would take total community involvement. The reason that some people are jumping at you is that you described it from the outset as a "business." The word business has a connotation that a profit is involved. Most of us understand that is not necessarily the case, but in the context you used it, it certainly sounded as if you wanted to make a profit. A better term would have been a "service" or "non-profit" etc., if you really don't intend to make money. I wish you luck in your endeavors, but I would strongly suggest thinking this over more before you jump in with both feet.

Somebody wasn't thinking right! It happens to everybody at some point, though, especially if they were overwhelmed. As to "diversion" systems. As usalsfyre said, in most areas, there is no such thing as true "diversion." Hospitals aren't allowed to turn away patients (unless they have some sort of really good reason, like the building is on fire... overcrowding isn't a good enough reason). The systems in place are courtesy requests that EMS attempt to take patients elsewhere. Of course, patients have the right to insist on going to whatever hospital they choose. And there are also protocol requirements, like trauma centers, stroke centers, hospitals with cath labs, etc. In my region, about a year ago, they removed the system of hospital status we had. We have five hospitals in our county, with varying capabilities. This was done as a trial to "see what happened." They actually found that it improved drop times! As such, the system hasn't been re-introduced. What was happening is that hospitals were using the concept of diversion as a crutch, so that EMS patients would usually go somewhere else, so they didn't have to clear out the ED as quickly. Since they no longer have this crutch, the hospitals have streamlined processes to ensure that patients are adequately triaged and placed as soon as possible. I used to wait up to four hours for a bed at the local trauma center, my average drop times are less than an hour on the rare occasions I go there now, even for lower level medical problems.

I agree that they do more than we think they do... I found that out during Paramedic clinical rotations! But what caught my eye that I wanted to reply was the above portions of your post, just looking for clarification. Do you mean to say that as you were rolling through the doors the triage RN was trying to tell you to go somewhere else? Sorry lady (or gentleman as the case may be) but once the patient hits the doors (actually some distance outside of the doors, just not sure the specifics) the patient belongs to you (the hospital as the generalized "you"), per EMTALA. Just curious about the way you worded this.

I'm in upstate New York. NY isn't a Registry state, but I'm getting mine because my wife and I plan on relocating, most likely to Virginia, so we're closer to her mother, and we like the area, etc. Now, I completely agree that more education should be required! That being said, even with EMS education as it stands today, the test could have been a lot more thorough! As I said in my OP, I seriously think a trained monkey could have passed it. Another poster stated that they can test on the DOT curriculum, current ACLS and current PHTLS standards. Most of that wasn't in there! If it was, there were an average of less than 3 questions per subject, and even those seemed similar to one another. Now, it probably doesn't need to be 1000 questions, but I seriously question the validity of a test that can even come to predict competency over a broad range of subjects with a grand total of 80 questions, and no more than about two per subject. I suppose I wouldn't object to the difficulty level of the test if I knew that all areas of the country were closely supervised by medical directors, with strict standards and QA processes. It is, after all, easier and more thorough to manage competency at the local level, IMO. Unfortunately, there's too many systems that are "a patch and a pulse." You have the patch, and a pulse, you go on the road, with all your toys, and little to no oversight in how you use them, until you screw up big time. Or perhaps until you screw up big time multiple times. And by then it's too late for your patients that you screwed up on. (I understand, everybody screws up. But most of us recognize when we do, and report it, and correct the deficiency. The above comments are directed to those services/areas where the level is set so low providers may not realize they even did mess up.) If more people fail, so what? (IMHO) That makes the schools actually teach the curriculum! Of course, the curriculum standards need to be increased too, but I'm honestly of the opinion that schools could be seriously shortchanging their students, even given the current standards, and still have a high pass rate. The curriculum standards will NEVER change until what's already being "taught" is ADEQUATELY taught!

You're right, it isn't difficult. But it's also a high standard, even for the military. It's the longest run of any branch. We do pullups rather than pushups. And the CFT - completely not relevant to EMS. Maybe you could modify it to make it relevant, but it would be very extensive modification. Think about employees in most indepentent EMS services. How many can run 3 miles in 27:59 or less? How many can do 3 pullups (how many can even do 1???). How many can do 55 crunches in 2 minutes? My guess would be 1 in 10... or less. I COMPLETELY agree that some physical fitness standards should be maintained, some sort of fitness test. But let's make it RELEVANT to what we do. I'm gonna take some flack for mentioning these guys, but how about standards similar to fire departments (entry standards, not 20-years-on-the-job-getting-fat-eating-donuts standards). I would suggest that is much more relevant to EMS than a test designed for the Marine Corps. Again, it would need some modification. A 1 or 2 mile run, sure. Pushups and situps, sure. Some sort of lifting test, absolutely. Maybe a timed relay carrying a certain amount of equipment. Maybe someday, in the far distant future, we could hold EMS'ers to Marine Corps standards. But to be honest, I don't ever see it happening. In any case, given the current fitness levels I see around me, we need to start with baby steps.

I fully agree with your last statement, Ridryder. However, I guess what I was getting at was what you state, that I quoted above. Are they even testing these standards/curricula? I truly believe that the bar is set a little low. I don't recall a single question about ACLS. There were only two cardiology questions! I understand the idea of CBT testing, but I'm not really sure if I buy the idea that with CBT, the computer can be 95% sure that you are going to pass based on your answers to 80 questions, when the full test is 150 questions or so. And while I understand that on any such certifying test, only a representative sample of questions is going to be asked, it seems that the test could have been much more in depth. What's even scarier, is the abysmal first-pass rate of even this, at least from my perspective, seemingly low standard. Of course, as has been mentioned hundreds of times in these forums, the answer is to get everybody on the same page (or at least reading the same book would be a good start), and vastly increase educational standards. And then hold students to those standards in the test that formally certifies them.

So, I took the NREMT-P written test yesterday, and found out this morning that I passed (pass/fail results posted on the website). Now, let me preface what I am about to say with the following disclaimer: I completely understand for individuals going through Paramedic school (or EMT school, for that matter) that the final written test can be nerve-wracking. 15 months ago, when I took the New York State written, I was confident I could pass, but was still scared about it, because it was the "moment of truth" so to say. My thoughts on the matter. I went in, with almost no pressure at all. My wife and I would like to move, which is why I am obtaining my Registry certification. However, as I'm already a State certified Paramedic, and NYS doesn't require the NR, I really had no big "pressure" to pass. That probably helped. I did find the test somewhat harder than the NYS written, but not much. It was shorter, however. The CBT cut me off after 80 questions. I finished in about 25 minutes. Now, I COMPLETELY agree with Dwayne, Dust, Lone Star, et. al. on the topic of increased educational standards in EMS. That being said, is the NR (or state written that I took just over a year ago), really the minimum standard that needs to be passed? I, for one, don't really think it truly assesses what Paramedics need to know - it doesn't even begin to assess that, IMHO. Now, I would hope that most Paramedic schools would teach far above and beyond what is required to pass the NR, but the sad fact is, they don't. Many of the Patch mills out there teach to pass the test, and that's it. I am reasonably certain that my basic partner could pass the written test without ever having set foot in a Paramedic classroom (admittedly, he's one of the best BLS technicians I've met, but I digress). I remember after taking the state written exam, my nervousness about passing was over. To be honest, I almost felt insulted by the content on the exam. I truly think it's scary to think that there are medics out there that are ONLY taught the MINIMUM to pass this test. That, coupled with a lack of an adequate QA program in many agencies... it's scary to think about how many patients we could be seriously harming through a lack of knowledge, through just being a "skills monkey." I seriously hope that certifying bodies such as the NR and various state Offices of EMS wake up and "smell the coffee" and raise the bar. They don't even have to make the classes harder! Based on what is supposed to be taught in the curriculum, the tests could be much more in depth. We talk about raising educational standards, but it makes me wonder whether the "standards," such as they are; are even being fully explored in class, or whether many programs are simply "teaching the test" and teaching the bare minimum that will allow their students to pass the NR. And by some reported first-attempt pass rates, it makes me wonder whether the they are even teaching that much! Excuse my ramblings, but after being through both the state and NR written tests, I really am kind of scared at exactly what the competence level of some of the people that could be showing up at my door step if I ever had my own medical emergency. Your thoughts and inputs are appreciated.

A 3 mile run? Really? I agree with some sort of physical agility/endurance test, but if you put almost any of my coworkers through a PFT and a CFT, you'd need a dozen extra response units standing by to transport them all for chest pain, syncope, SCA, etc! That aside, I do get what you're saying. Maybe, say, a half mile or mile run. And pushups instead of pullups (like the Army does). Crunches can stay. As for the CFT... maybe we can do a Lifepak lift instead of an ammo can lift. And a gurney push instead of the boots & utes run. OK, I'm being a little facetious now. A start would be employers allowing their employees to get out of the ambulance for at least some of their shifts. No wonder we're fat, when we eat McDonald's all day long, and sit on our ever-fattening as*es in the front seat for 12 hours a day, 4 days a week. I know, this scenario doesn't apply to everybody in EMS, but it is typical of most system-status management services.

Yes, cost would certainly be a factor. Maybe they'll come down in price someday. Here's hoping.

I just thought I'd add... the technology to perform field lab tests DOES exist. Coupled with increased educational standards, more field testing could certainly equal more patients directed to appropriate care. In fact, with appropriate labs, and on-line consultation, provided the hospital isn't too busy, I could foresee a day when not only do we refer (or even transport) patients to non-hospital health care facilities, but where we could admit the patient directly to inpatient floors completely bypassing the ED. Once again, this is predicated on INCREASED educational standards. The Pediatric ICU team that my service works with has an iSTAT to perform field labs without relying on the outlying hospital lab (which takes so long so much of the time), it works great. So far they only do ABG's, but I'm fairly certain other cartridges exist for the machine to perform other labs. I see no reason (other than cost) why this technology shouldn't be in the hands of Paramedics, as well. Do we need to do routine labs on EVERY patient. NO, but neither does the hospital. With increased educational standards, however, and therefore providers knowing WHEN to assess lab values and WHAT they mean, we can provide much better care for our patients. Does this mean longer on-scene and patient contact times? Yes, so we will probably need more units in order to deal with the load. That being said, you wouldn't need as many hospital beds, especially in the ED, so from a Health Care SYSTEM perspective, it is MUCH better patient care. And I completely agree, payment SHOULD be for services provided, not being a meatwagon. It's ridiculous that we only get paid, most of the time, if we transport to the hospital. What about field terms? It's ridiculous that we transport DEAD people, but if we don't, we can't get paid, despite all the medications we dumped into the person before, with on-line consultation, declaring them to be deceased.

I agree, this is excessive. But so is the entire TSA! I understand the need to feel safe, but here's my theory... Prior to 9/11, most skyjackings were for the purpose of taking hostages and getting money. That's why nobody fought back. It wasn't worth getting hurt over. So the skyjacker had a box cutter? OK, they're going to land somewhere, demand a million dollars, and drive away then the cops will get them. Post 9/11, there is NO WAY I can conceivably see a skyjacking to be successful. Citizens understand the risk, and, I think, would be willing to fight back should something like 9/11 ever be attempted again. Could a dozen terrorists take over a plane now? NO, I don't think they could. The would immediately be piled upon by the other 100+ people on the plane. So, while REASONABLE security measures, such as metal detectors, bag scanners, explosive detectors, etc, are completely appropriate, the level of patting down and "full body scanning" is, IMHO, a complete waste of money, better spent elsewhere. I understand the premise that you could use a 6-year old to carry something they shouldn't be, the measures I suggest will catch 99.9% of it. Absolutely no need for these searches.

I'm not sure about wound closures with something like Dermabond, but I fully agree with the concept of "treat and release," coupled with adequate education, a modified Medicare payment schedule, and an intact referral system. That is, if we chose to release a patient following treatment, we could refer them to their primary care physician or a specialist for follow-up evaluation. Ideally, we could schedule the appointment prior to departing the scene. That being said, like the above poster said, the emergency department provides detailed discharge instructions to every patient that leaved the ED. If we were to implement such a policy as EMS, we need to be able to provide a similar document in the field. This would, of course, mean that we would most likely have to install printers in the ambulance. Alternatively, several "categories" of instructions that could be pre-printed for distribution. This wouldn't be as good as having access to the database that hospitals use to provide discharge instructions (typically, what I have seen, is the instructions are pre-selected from a database where they can pull up instructions based on the patient's chief complaint, with the physician having the option to add additional instructions should he/she choose to do so). In the area I used to work in, we had a pre-printed sheet with follow-up instructions to hand out to all people who refused treatment/transport after signing the RMA. While not very detailed, I think this concept is great, and needs to be expanded if and when EMS expands more into primary care. Whether we like it or not, we ARE the defacto primary care providers for a large segment of society. I think efforts like this are not "expanding" our "skill set" etc., but rather acknowledging what society actually uses EMS for and adjusting ourselves to better fulfill that role. Of course, I am in full agreement that the minimum standard to allow anything like this should be a 4-year baccalaureate degree.

Haha, I'm smart, sorry. I'm in Rochester NY. The closest scheduled exam on the NREMT website is I think NYC. That's over a 6 hour drive for me unfortunately. If I have to do it, I have to do it, it'll just suck is all

Hello all, looking for a little help. My wife and I are planning on moving south. We are looking at the greater Richmond area in Virginia. There are several services I have looked into and am interested in applying to. I have a little problem though. Virginia requires NREMT for reciprocity. My Paramedic school, while it is considered an NREMT test site, hasn't conducted a NREMT practical in a while. The school is under a lot of pressure not to assist us in getting our National Registry, I think, from the local commercial agencies who are already having trouble staffing, so they don't want us too "mobile." Does anybody have any suggestions? I'm about 13 months out from my NYS test date, I know NREMT allows you up to 2 years after completing your original class to test. I don't mind driving to take the practical if I have to, but I certainly don't want to drive 12 hours and then have to retest. Thanks for your help Chris

That's weird that they limit the number of services you can be a member of / be employed by. Let me tell you, if I didn't have four jobs I couldn't support myself. Now for my take on your real question. No, you should not take the AEMT program. Go straight to Paramedic. That being said, I don't think you should spend 19 years as an EMT before becoming a Paramedic. There are, as you stated, various reasons for and against going straight to Paramedic school. My suggestion is, find out how long the Paramedic program is for you. Research a few different programs in your area, if there is more than one within driving distance. Most importantly, find out whether they are certificate programs, AAS degree programs, what the prerequisites other than EMT certification are, etc. My advice is that next semester you should start taking prerequisites for Paramedic school, then when you've finished those, go straight into the core Paramedic content. That will give you a year or two on the road as an EMT, and put you head and shoulders above the rest when you start the Paramedic class. Of course, if the local Paramedic program blows the average program out of the water, it won't be necessary... but I digress. I would suggest the following classes. College composition - at least 1 semester, 2 semesters if possible [For most Paramedic students, being taught how to write isn't a bad idea. I am a QA auditor for my local Paramedic program, reviewing the students' mock "PCR's". Most everybody on here would be appalled at what SOME people turn in as a chart. If they write like that when they are working on the road, I'm surprised we as a profession don't get sued even more often than we already do. That being said, your posts seem to be well thought out and generally free of significant grammar or spelling errors. Keep it up and reflect that in your PCR writing] College-level algebra, and any math classes you need to get you up to speed for algebra if you didn't do well in Math in High School College Biology 1-2 semesters (whatever is considered a prerequisite for A&P 2 SEMESTERS OF COLLEGE LEVEL ANATOMY AND PHYSIOLOGY [i really wish I had this myself, it would make me such a better provider - I plan to take it eventually] College Chemistry Micro/Cellular Biology [some schools offer a 1-2 semester class called "Biochemistry for Health Science Majors" or something like that - often used for nurses. It will teach you what you really need to know to have a good foundational knowledge so you can later understand pharmacology. If a class like this is offered, it could take the place of the Biology, Chemistry, and Microbio classes. Of course, you still would need to take any prerequisites for A&P - if there's any ONE thing on my list to take, it's A&P] I know it seems like a lot of coursework, but it WILL make you a better provider. If it were up to me, all of these classes, or a reasonable equivalent, would be required to even start the Paramedic coursework. Preferably all incorporated in a 4-year Baccalaureate degree. But at least for now, I'm dreaming. If anybody has any addition/substitutions/corrections to my list of suggested coursework prior to starting Paramedic class, feel free to chime in. I don't pretend to be a definitive source.