Bieber

Congratulations! My Facebook isn't working right now, but I'll check out the ultrasound images as soon as it is.

Well, we've finally got some promotions going around here where I work, and that means there's some full time paramedic spots that have opened up. I've got my interview today in just a couple of hours, so I'm keeping my fingers crossed that I'll be one of the lucky few to be offered a full time position. The pros: steady work, steady pay, mad amounts of experience. The cons: all new full timers automatically go to nights. But that's all right, I'll just be thankful to get the job. Keeping my fingers crossed, wish me luck!

Welcome to the forums, Joey! I'm a newly graduated paramedic from Kansas. What's EMS like in Tennessee? Do you teach paramedic level education, EMT, or continuing education courses?

Hi, and welcome to the site! There's no stupid questions here (trust me, I've taken that challenge already), and you'll find that even if a question seems silly to you, the folks here are more than happy to help you in any way they can. The job is honestly as stressful as you want it to be. Like any job, it has its pros and its cons and not every day is awesome, but as far as how stressful it is, that's all on you. There's stressful situations that arise, but they're only going to become an issue if you don't learn to cope properly--at least, that's what I believe. At the same time, you have a lot of responsibility on your shoulders as an EMS provider, and you have to treat that with a hearty amount of respect. What happens when you make a mistake? Well, if you're worth half the money you spent on your education, you'll fess up to it and face the consequences like an adult. As to whether or not you automatically lose your job over a mistake, that's all unfortunately situational. In all malpractice suits, there are four parts: a duty to act (which is established by you being an emergency provider), breech of that duty (i.e., you failed to act as another provider of your level of education would in that situation), proximate cause (you were the actual cause of the injuries), and actual injury (as in, there was actual harm that resulted as a direct cause of your actions or inaction). I'm not a lawyer, and that's paraphrased from my paramedic book, but you should get the idea. Every situation is different, and you have to understand that we're working in less than ideal and emergent conditions. Nobody expects you to be perfect, only for you to act as a competent provider would in your situation, and to follow the creed of primum non nocere (first, do no harm). Depends on where you work. For me, an average day is about six calls. A bad day would be more than twelve calls, with no time in between to work on charts or take a quick break. A really good day, for me, is steady. I don't know a whole lot about California, but I've heard it's less than ideal educational standards, heavily fire based, and very conservative protocols. Around here we work twelve hour shifts, two days on, two days off, three days on, two days off, two days on, three days off. As much as you want, if you're in a twelve hour system. With twenty four hour shifts, it would depend on how busy the system is. You're welcome! Now I have a question for you, why do you think you might want to become an EMT? If you become an EMT, are you planning on taking it all the way to paramedic? What are your academic goals?

This right here. Now I'm not an expert at PR or marketing or anything like that, but I know that as a citizen of my community, that is the single biggest thing I would look for outside of good patient care, a great attitude, and a professional appearance. Unfortunately, it seems that we in EMS often fail to connect with our community except when they call us in their times of crisis.

I couldn't have said it better myself. It's not my intent to try and get everyone bugging their medical director about adding dermabond to their trucks first thing tomorrow, but to get people thinking about the fact that we need to start rethinking our practices if we want to survive. Like you said, the two major hurdles that we absolutely have to address before we can even consider something like this are our educational standards and are billing schedule. I agree one hundred percent with you. Like I said, this isn't going to be something for every ambulance but more for mobile advanced clinicians, who can afford to be out of service for the time it would take to close the wound and give the patient instruction on wound care. USMC Chris, I agree with you wholeheartedly as well.

All levels of paramedic need the education to properly assess and treat wounds of all kinds, however from a logistical standpoint not every ambulance should be put out of service in order to do so; the actual treatment could be performed by advanced paramedics in "fly cars" or SUVs. Did you reject paramedics adopting 12 lead EKG capabilities because it was adopting other people's jobs? Or adding medications to our repertoire? Clearing C-spine? Advancement is for the benefit of our patients as much as it is for ours. And adding additional education and minor wound care will hardly make us jacks of all trades. Two years of school is a joke, a Bachelor's degree ought to be the minimum. I agree with you one hundred percent that education should be about solidifying our foundation, at the same time, the socioeconomics of healthcare dictate that we have to justify our existence more than we currently are. Why is anyone going to pay for paramedics with increased education if it doesn't change the quality of care? You're right, it's not about skills. And like I've already said, wound care like what I've suggested isn't feasible until we change the medicare schedule of billing for ambulance services to reflect payment for service, versus payment for transport. Like I said, it's not my intention for EMS to replace primary care services, but to take a greater part in the full continuum of care for our patients. And hey, if I do find a wound care class around here, I will take it! Not because it will change what I can do, but because it will give me more knowledge, and allow me to have a better idea of what my patients can expect at the ER (and even tell them what to expect). Thanks. We don't have to agree on everything to agree that increasing our educational standards is a must for EMS. I know I'm ambitious, and I don't claim to know what's best for EMS, but the whole reason why forums like this exist is so we can share ideas and learn from each other.

Easy Street.

I'm not saying people aren't irresponsible, but we can't be their nannies either. People have a personal responsibility for their care, and there is an established line between what we as medical providers are obligated to provide and what the patient is expected to do for themselves. It's not an assumption and I have on multiple occasions observed and taken part of the wound care process in our local ERs. The most recent (and personal) experience was when my fiancee got bit on the lip by a german shepherd at work. Now, this type of injury would most certainly be out of the question for EMS (due to the more advanced cosmetics of facial injury repair), but I can tell you that the follow up instructions did not include daily checkups. For major injuries, I can certainly imagine it would and those are not the kinds of injuries that EMS would or should be treating in the field. In the instance you're referring to, yeah, if I was operating outside of my scope, I'd be checking that wound for signs of infection every day too. But I'm not talking about paramedics acting outside of our scope, I'm talking about adding minor wound care to the additional education I advocate EMS to adopt every day.

And? Patients or their caretakers are perfectly capable of monitoring for signs of infection on their own with proper instruction. The hospital doesn't have patients regularly return for daily wound care checkups for minor injuries--why would we? Why would the risk of improper irrigation be any greater in the back of the ambulance versus the hospital? That's not a problem of location, that's a problem of technique. Also, I have to question, if you think it's such a bad idea to be done in the field on the basis of it's done in the field--as opposed to a problem with the providers--why would you ever consider doing it yourself? Are your neighbors less important than any of your other patients? Those same terms would apply to any prehospital provider doing wound care: if signs of infection appear, you need to seek higher care. The future belongs to those who dream, and those who are willing to work for those dreams. I've said it before and I'll keep saying it, there is a growing movement of folks out there who are demanding that we show that we're worth the pretty penny that funds us, and to be honest, as we currently are, we just might not be. There's a growing body of evidence that most patients don't benefit from ALS, or at least that they don't benefit from as early ALS care as EMS provides (rural EMS being the exception). If we don't find additional services to provide for our patients, we could return to the early days of really being "just ambulance drivers". There's even some service in Ohio (Cincinnati, maybe?) that's talking about switching to an all BLS service. What's going to happen if they do that, and it ends up that there's really no statistical difference in end care results? Paramedics go bye-bye. And if all we can provide is emergency care that ends up being maybe not necessarily unnecessary, but statistically neutral when it comes to end patient results, then people all over this country are going to seriously begin to question why in the hell they're paying 15 bucks an hour for a paramedic when a 10 buck an hour EMT will do just as good. Like I've said, I think paramedics are vital. But I'm not perfect and I'm not always right. I do know, however, that most of my patients don't end up requiring anything more than my observation. And policy makers aren't as concerned with the fact that we all know patients deserve a proper assessment from a highly educated provider, they just care about the numbers. Is ALS making a statistical difference? Is that statistical difference correlating to an efficient cost-benefit ratio? People are no longer willing or able to pay for medical treatments that haven't proven their worth, and that includes much of emergency medicine. It could simply be that we haven't yet reached a point in our development where we can save the most serious of conditions, or that they're simply incurable. And outside of those most critical patients, most of our patients need palliative measures and monitoring alone--which the economists say can be just as easily done by an advanced EMT, and for only half the cost. Justifying our existence is going to become an ever more difficult thing if we don't become more than only capable of treating emergency conditions. I'm not calling for us to replace primary care. I'm calling for us to do our part of weeding out those patients for whom hospital transport is unnecessary. And with proper education, and with proper funding (i.e. changing the medicare schedule to allow payment for service, not pay for transport), we can do a lot more than we currently are. Not every patient needs an ER and not every patient has a primary care doctor or one that can see them immediately, but every patient can contact EMS day or night, wherever they are, and with proper education, we can properly assess many conditions and alleviate the patient's suffering or symptoms with adequate referral to a more appropriate destination than just the ER. It's not for every patient or every primary care condition, nor should it try to be, but it ought to be more than it currently is.

Continuing to play the Devil's Advocate, why would the patient need daily follow up care to check for infection?

Who said anything about eliminating facets of our assessment? I'm calling for us to be wiser in our interventions, not to just simplify things down to "this must always be done, regardless of the situation!" for the sake of the lowest common denominator. I'm sorry if you don't think we need to expect more from our providers, and not just dumb things down to their level or maintain the overly ridiculous simplification of "BLS" and "ALS". I respect very much how little we know, which is why I don't think much of what I've suggested is possible unless we seriously rethink and readjust our educational standards, and why I have ALWAYS called for greatly increased educational standards for paramedics. Furthermore, I agree that some code blues ought to be transported to the hospital, as I've said multiple times now. Why are you ignoring what I am saying? Instead of simply telling me "I don't know what treatments the hospital might possibly give", why don't you present some actual references that show exactly what those treatments are? You're right that we can't predict what every physician might do, but most follow a similar standard of care; something which every one of us can research through the miracle of literature. I think you're trying to bend my words and oversimplify my argument to try and justify yours; instead of that, why don't you address my issues directly, actually SHOW me where I'm wrong (because yes, I readily admit that I just might be) and give me more than just "well, you don't know what they might do! They could have some wonder cure that you've never heard about because it's a top secret that only physicians are privy to!" I never said we shouldn't transport ALL codes, eliminate ECG monitoring for ALL patients, try to replace ALL primary care, or ALWAYS skip going to the hospital.

Ruff, in our current incarnation, as EMS is today, I agree with you one hundred percent. I am in no way advocating this practice start being adopted by EMS services or paramedics first thing tomorrow, what I mean to do is get the creative juices flowing and get rid of this defeatist attitude we've held for so long and try to shake people out of this "I can't" philosophy. Yes, we can, but it's going to take people who have a thirst for education and knowledge and improvement to look at things like dermabond and say, "Well, damn, we ought to be doing that someday!" and to get those same people to say, "I'm determined to bring our educational standards up to that level where we ARE educated enough and capable enough to make that desire to be able to benefit our patients in such a way a reality. It's a liquid skin adhesive for wound closure, yes. http://www.dermabond...duct/index.html

I think this would be a great addition to our arsenal, and represents one of those areas where EMS could truly provide definitive care (or at least a greater component thereof) if two conditions were met: the first, and always foremost, is education. Like I've been ranting about in another thread, we need to expand our understanding not only of emergency medicine, but all fields of medicine in general. I hear a lot of people in this thread questioning whether or not paramedics could safely determine what wounds are candidates for dermabonding, and the answer is YES! We CAN do that, with the proper education and training. Wound sealing and referral to the patient's primary care physician for antibiotics (I think five days of Keflex is the commonly prescribed antibiotic for prophylaxis of open wounds? Someone correct me if I'm mistaken.) or even (potentially, and understand that I realize how long the road is before we reach this point) actual prescription writing privileges for those patients who don't have a primary care physician. The second component is money. Just like medicare won't pay for the IV supplies and the amp of sugar we use when we wake up diabetics and send them on their way, they're not going to pay for wound care treat and release practices either. Until we can bill for service, no EMS service is going to waste the money on supplies and training to make this a reality. This is one of those niches where EMS could really step up and prove its worth. There are plenty of minor wounds that don't require an ER visit, and by paramedics becoming educated and capable to handle simple wounds on a treat and release basis, we can not only help to bring down the cost of unnecessary ER visits, but also tack on another treatment to the currently small list of things we do that have actually been shown to be cost effective and beneficial to our patients. We've got to stop thinking about pure emergencies and start thinking about minor injuries and illnesses, because, like I've said, we're really not as good as we think we are or as effective as we think we are. The healthcare environment is becoming more and more about "prove to me you're worth your cost", and this is something we really ought to consider capitalizing on if we don't want to go the way of the dinosaurs.

Well, there's your problem right there, you're still thinking in the archaic mindset of BLS and ALS. Instead of trying to divide patients into two groups and decide that they automatically need all "ALS" interventions, why not treat patients according to what their medical condition necessitates? Everything else is just dumbing down medicine so that undereducated providers can scrape by. Diligence doesn't mean throwing every tool we have at every patient who meets the "catch all" BLS and ALS divisions. You haven't answered my question. Unless you're advocating transporting all code blues so that they can rule in/out tamponade, you still haven't told me how we're supposed to determine whether the patient is a candidate for pericardiocentesis. Furthermore, prehospital ultrasound exists and could become more prevalent in the coming years--which makes pericardiocentesis possible for EMS personnel. Like I said, transporting a traumatic arrest that had no vital signs upon arrival is kind of like beating a dead horse. Secondly, while surgical intervention may be possible, again, to crack the chest, you've got to stop CPR. For some patients it may be appropriate, but that number I suspect is very small. http://www.resusme.em.extrememember.com/wp-content/uploads/2011/01/patients-in-prehospital-traumatic-cardiac-arrest-Chest-decompression-during-the-resuscitation-of-1.pdf Why would I call for eliminating chest tubes? They're a vital continuation to needle chest decompression, in fact there's no reason why we couldn't be performing them in the field; studies have shown that there's no significant difference in the efficacy or success of the procedure between physicians and paramedics. So, after running the code on scene with good quality CPR and IV medications, you're going to have an extended period of poor CPR during transport, more extended periods of poor CPR during the transfer of care, more delays (every one of those mere "minutes" counts in cardiac arrest, you know) during the transfer of care, delays waiting on the i-STAT and then--THEN--finally, if we find out that the patient is hyperkalemic, assuming that the patient hasn't already been treated for hyperkalemia by the paramedics, they can give him or her some... what, exactly? Insulin? Takes a while to start working. Glucose? That can be given in the field. Diuretics? Gonna take a while too. Kionex? Hours to DAYS, even. Not to mention there's some debate over whether or not it's even helpful, not to mention it comes with a risk of colon necrosis (somewhat moot in the case of cardiac arrest, but if it's not useful then you're just tacking on complications). Sure that maybe good CPR with limited interruptions along with calcium, sodium bicarb, and maybe even some glucose isn't going to give that patient the best possible chance at survival? I'm well aware of other rewarming techniques, and I agree that hypothermic patients may represent one of those subsets of patients that may benefit from transport to the hospital. Technically, additional rewarming techniques aren't unfeasible for us to do, but I think those techniques will be a long time coming. Excuse me, I misunderstood what you meant. Let me correct what I said: you know we can do ultrasound in the field, right? And bringing ultrasound to the patient as opposed to the patient to ultrasound is most certainly going to increase what little chance of survival those patients have.

Exactly the point, Carl! We're not complete buffoons, but those are questions we haven't been taught to ask ourselves. How do you decide that this patient can be left alone after we treat the acute exacerbation? I can speculate that certain criteria would have to be met, but I've never been formally instructed in it. Is this patient in immediate danger? What long term treatments are in place or need to be in place in order to ensure their wellbeing? What follow up instructions do they need? How certain am I that a another episode isn't going to occur between now and the time the patient is reevaluated by another healthcare provider? Not every patient is appropriate to treat and leave on scene. But we can't even begin to start questioning exactly WHICH patients would meet this speculative "treat and release" criteria until we educate ourselves on primary care conditions. The fact is, most of our patients lived with their diseases before we showed up and most will continue to live with them after they've been treated and released at the hospital. People LIVE with constantly low blood oxygen saturations, chronically high blood pressure, and regularly occurring angina all across the world. We're trained to treat for the worst, but physicians are trained to not only treat for the worst, but also to treat for the low risk conditions. Physicians have an educational level that allows them to be comfortable with releasing their patients to their homes when admission to the hospital is not clinically indicated. Can we rule out the need for every patient? No! Many of these patients need lab work and imaging to make that decision. But a lot of them don't. And THAT is the niche EMS can fill. If we can become more properly educated in the hospital side of things, if we can learn exactly what will happen to these patients at the hospital, and the decisions that will be made at the hospital for these patients, then we can become part of the decision making process for a select group of patients for whom hospital admission or immediately additional diagnostic testing is not indicated. For example, it doesn't take labs or even an X-ray to diagnose acute bronchitis. The diagnosis and treatment of it is made based on physical exam and symptoms. Now I know prescription writing is still a new and tentative thing even in those places that are currently doing it, but it's not unreasonable to think that one day it will become widespread and common practice. And it's not my goal to get ahead of myself and start advocating THAT just yet (see, biting off more than you can chew), but it's time we start getting the ball rolling in the general direction of increasing and broadening our education, because if it turns out that paramedics and EMS IS a feasible model for treat and release of those select patients, and that it's even a feasible model for limited prescription writing capabilities such as those used by EPCs in the U.K., we're going to miss that bus altogether if we don't start getting our act together now. You're right that it's more than just education, it's really a multi-fold issue, at least here in the United States. We need to change the medicare schedule of billing for ambulance services to allow payment for service rendered as opposed to payment for transport rendered. However the only way to do that is to achieve professional recognition as a healthcare entity, not as a taxi service. To achieve that, and to achieve the goal of allowing any sort of treat and release practice, you have to increase educational standards because no physician is going to let some diploma mill parawannabe start treating and releasing patients. They're not even going to let two year degree paramedics do that. And if we're not treating and releasing, pay for service isn't going to be especially beneficial not only to our patients but also economically speaking. Guys, I get it. I really do. I'm ambitious. I like a challenge and I like to improve whatever I step my feet in, and I'm not claiming to know what's best for EMS or to have the knowledge or experience to really even have a right to an opinion, but I know how noble a profession EMS is and I have very strong beliefs about what it can be and what I think it should be. We sell ourselves short and bring ourselves down more than any other healthcare provider ever has. We could be so much more, we could be so much smarter and greater and of so much more benefit to our patients. I don't mean to get ahead of myself with all this talk of treating and releasing and prescription writing, my real goal--the most important goal--is to just get us all moving towards taking that first step of increasing our educational standards. It is going to open so many doors for us and give us so much opportunity to grow and evolve. It seems like everyone always complains about how there's no opportunities for paramedics to climb the career ladder, but it's all because we've never put forth the effort to create those opportunities. We are a noble profession and we owe it to ourselves, our future paramedics, and our predecessors to not stay put but to continue to strive for excellence. I want your career in EMS to be whatever you want it to be, but I'm telling you this, you have got to be proactive about changing the playing field. You have got to be telling everyone you know why we need to increase our educational standards and you have got to be bugging your state and national bodies about it, because everyone in EMS is working AGAINST that. Everyone is too tired, cynical, or lazy to upset the status quo and I know that none of you on this forum wants that--if you didn't still have that drive to improve, you wouldn't spend your free time reading an EMS forum. So let's do this, let's commit ourselves every day to improving our profession, for our patients, for our services, and for ourselves.

So are you saying you apply the cardiac monitor to every patient you have? After all, the person with the broken toe could also be in atrial fibrillation. Worse yet, they could get a fat embolus that goes to their lungs and arrest on you too. That's the danger of over treating. I'm not saying that we shouldn't be APPROPRIATELY thorough, I'm saying we shouldn't treat every little thing like a life or death emergency that requires our full capabilities. What are the two most common side effects of narcotic analgesics? Hypotension and respiratory depression. An ECG may show an increase in ventricular ectopy as a RESULT of respiratory depression, but dysrhythmias are not generally going to be sequelae of administration of narcotic analgesics. Competent reassessment of the patient and their vital signs (SpO2 included) is more than appropriate for most patients to whom pain management is given. Pericardiocentesis requires the cessation of CPR, and the AHA states that interruptions to CPR should be kept to a minimum and they also discourage transporting patients in cardiac arrest. Furthermore, how are you going to screen potential tamponade patients in the prehospital environment? Unless it's a traumatic arrest (which we don't resuscitate unless there were vital signs upon arrival), you're going to have to have some VERY strong reasons to think that that's the cause of the arrest to not only justify the interruptions in CPR not only to transport that patient to the hospital, but also the halting of compressions to do the ultrasound and procedure itself. Surgical intervention of hemorrhage? First of all, like I said, we don't transport traumatic arrests due to the low survival rates associated with them. Secondly, if it's a thoracic injury, you can't perform surgery without ceasing CPR; and I don't even think very many surgeons will begin operating on a patient in arrest unless they coded on the table. Chest tubes are nice, but needle decompression can be done in the field. It's not a permanent solution, but unless I'm mistaken if the pneumothorax is bad enough to cause the arrest it will correct it enough that if you're going to get them back, you will. Otherwise, you're still just transporting a dead person. We can reverse hyperkalemia (and by reverse, I really mean correct the imbalance) with calcium if there's a strong enough suspicion of it. Labs are generally going to take too long to be of great value in cardiac arrest, so specificity is out the window. Managed warming of hypothermic arrest. Are you talking about warm intravenous fluid? 'Cause we can do that, you know. Ultrasound evaluation of PE. So, you're going to stop CPR to do an ultrasound, find the PE, and then what? They can't surgically intervene while the patient's in arrest, and I don't think giving LMW heparin to patient's in cardiac arrest is necessarily wise--but I'm not an expert. Blood infusions. Again, traumatic arrests are more likely traumatic deaths. Open chest procedures?! Really? Let's stop CPR to crack the chest? The AHA is saying NO interruptions to CPR. Interrupting CPR is what's killing patients. I don't disagree that there should be some clinical decision making with regards to transporting arrests, but I'm saying that the therapeutic value of transporting MOST cardiac arrests, unless you have a mechanical compression device, is nil or in the negatives. How about, barring that VERY rare patient for whom hospital intervention MIGHT make a difference, we just sit our happy butts there at the scene, get in good, quality, uninterrupted CPR, give these people the BEST chance for life they can, and when it's all said and done either call it or transport ONCE we have ROSC? Oh you can disagree all you want, but whether or not we're trained for primary care, educated for primary care, or equipped for primary care, that is what we're doing the vast majority of the time. You're not going to undo the last forty years of telling people to call 911 for an emergency, for a question about their electric bill, or for help changing their lightbulb. We've got to adapt to the reality of our job and to the changing nature of the healthcare environment. The truth is we're not even all that good with emergencies. It may just be that we can't save people once they reach a certain stage, but you know what we CAN do? We CAN help those people who HAVEN'T yet reached the "oh shit" stage. Our most proven interventions are those which provide no life saving treatment at all. And in this era of evidence-based medicine, and pay for performance, we're going to lose the battle to justify our existence if we don't start showing the public that we're capable of more than just putting on a pretty show and claiming that it's actually making a difference--because the science is saying that it maybe and even probably isn't. It doesn't matter what the ambulance or the paramedic was designed for. We can't be like that, we can't be rigid--because medicine isn't rigid. It's fluid and dynamic and if we try to be anything but fluid and dynamic ourselves we're going to disappear as quickly as we came. You're right that patient's don't need to be treated by the very first healthcare provider they set eyes on, but the truth is that even more of our patients than we think don't need to be treated by us at all. We've got to find a niche for ourselves in the healthcare industry because if you don't think there's people out there who don't think ambulances or paramedics are needed at all, you're in for a rude awakening. We can try to avoid the issue only for so long before we're going to have to face the fact that maybe the idea of EMS is a joke, and maybe the idea that we're needed at all is misguided. I think we are, but I could be wrong. Either way, I know that we've got to start showing that we're capable of doing more than just managing emergencies. We've got to start branching out and become "mobile health services" if we want to survive, or you and I could go the way of the dinosaurs. We need to be educating ourselves on more than just emergencies, we need to prove that we're good for more than just emergencies (and that we're good for emergencies to begin with), and we've got to take a more proactive approach to patient care. We're not just there to put bandaids on them and take them to the hospital. I'm not there just to treat your asthma and pass you off to the hospital. I'm there to tell you you need to quit smoking too, and here's why. I'm there to talk to you about your obesity, and why it might be related to your chest pain. I'm there to tell you that your cancer medications can cause a lot of side effects, and that's what you're experiencing today. It's okay, it's not an emergency and you don't need to go to the hospital, and I've got the education to tell you that directly. We're not just dealing with emergencies, so we had better start shaping up and educating ourselves on more than just emergencies. We're taking care of people with primary care problems, and we've got to address them instead of just passing them on to the ER--because they're not primary care providers either, but at least they have the education to address primary care issues, even if it's not their forte. An EMT could transport a patient with primary care issues to the hospital and pass the problem along; it's going to take a paramedic, an evolved paramedic with more education than I currently have, to step up and manage those issues without necessitating transport to an inappropriate facility. There are lots of patients with primary care issues who only need immediate relief and counseling, not an arbitrary ride to the hospital. But until we get out of this mentality that we're only going to manage emergencies and ignore the fact that we're being called upon to adapt and overcome, and actually change the way we do business, we're going to continue to fall down the totem pull of healthcare professionals and remain disrespected, undereducated, incapable, questionably necessary, and increasingly economically scrutinized.

Exactly! Like I've said, my state requires two year degrees, but that's still nothing compared to what my education should have been, and yet that's the general movement within U.S. EMS. Like I said, it's backwards motion.

Carl, I didn't realize you're from out of the country! That definitely makes a difference, and I can tell from that picture that your guys' safety is held in much higher regard than ours. Right now, we work the code on scene and transport (unless the initial rhythm was and has remained asystole) after getting the antiarrhythmics or the three doses of atropine in (for PEA). We also don't have automated compression devices, though I could see how transporting a code blue patient while using one of those wouldn't be an issue. Nice truck, by the way! I really like your setup. Honestly, having never worked in a type II ambulance, I don't think it would be that much more of a pain than in a type III. I know people complain about not having easy access to the patient's right side, but even in our trucks where we do have access to that side, trying to squeeze in there to get an IV is still a pain in the butt, and I'm not a big guy. Island, and everyone else, I agree with you guys. I think that you're right that I should narrow down my list of proposals to one or two, and field C-spine clearance is definitely at the top of my list. I've had two calls in the last two weeks where spinal immobilization, I felt, was more detrimental to my patients than beneficial, however my hands were tied on the matter.

Okay, just to clarify, I'm well aware that septic patients don't get antipyretics as the standard care. I guess I should have said I would like to have a protocol for febrile (non-septic) patients AND a protocol for specifically septic patients. Carl, you've offered one possible in-hospital treatment, PCI with continuous mechanical compressions. The studies I've read show that while it is possible, it's still an emerging science and I haven't seen any that directly address PCI following out-of-hospital cardiac arrests on their own. The fact is still the same that if you can't do adequate CPR while en route to the hospital, what's the point in getting them to a PCI center so they can have their heart revascularized and wake up with massive neurological deficits? I think that trying to get a return of spontaneous circulation on scene followed by PCI after transport to the hospital would hold more positive outcomes than transporting those patients before they've attained ROSC. The second thing you've suggested is organ donation, and to be honest I'm a little appalled by that. Not because I'm against organ donation, because I'm not, but look at it this way. You want us to transport patients who are still in arrest, something which is known to greatly decrease their chances of survival, as well as put every provider in the back of the ambulance in harm's way (we, like most services in this country, don't have seating which allows providers to remain seat belted in while doing CPR), not for the purpose of saving the patient, but to save his or her organs. I'm all for organ donation, but our role is to try and save our patients, and to keep ourselves safe in the process.

Yeah, I know. I meant more of having a generalized protocol for patients presenting with a fever and/or SIRS/sepsis. It's better than morphine, that's for sure. I think it can still cause a bit of hypotension, though nothing major.

What's wrong with imitating hospital care?

I did read an article regarding it recently, as a matter of fact. Most likely the same one as you. I think appropriate monitoring is (as you might guess) more appropriate than "thorough" monitoring. By that logic, we should put everyone on the monitor simply to be thorough. I don't think that SpO2 monitoring is, in general, too little when it comes to the administration of narcotics. Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field? Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest? The thing is, we're not emergency providers. We're primary care providers who occasionally dabble in emergencies, and as such, as need to equip ourselves to more appropriately manage primary care conditions. Treating minor to moderate pain with the appropriate pain management is part of that. Sorry. It would be intermediate level triage. And yes, it is a ridiculous, but currently if we do an EKG or start an IV, they're a yellow; and if they're a yellow, they get an EKG and an IV. I don't think SpO2 monitoring is inappropriate, however I don't think that an EKG is necessarily necessary. The truth is there is nothing more vital than CPR during cardiac arrest, and trying to perform just about any other treatment besides CPR during cardiac arrest risks interrupting it, which defeats the purpose all together. The science is clear, CPR is what saves lives, everything else is just the butter on the toast. Ketamine would be ideal, however I don't know if ANYONE around here is using it, not even in the hospitals. I don't really think fentanyl or morphine would be appropriate for a patient who is hemodynamically unstable. Yeah, that's true. I'm surprised that antipyretics don't help to reduce the incidence of febrile seizures, though. I really need to look up the standard model of care for sepsis and SIRS with regards to this protocol. Thank you!

Wow. With all due respect, it is rare that I hear something so audacious and offensive to my sensibilities that my jaw drops the way it did when I read this. What else can intermediates do in your area? Can they push narcotics as well? ET intubation? NG tube placement? Manual defibrillation? EKG and 12-lead interpretation? Why are they even hiring paramedics? If they can get away with just letting an EMT-Intermediate with two semesters of coursework take the place of a paramedic, where's the incentive to hire the higher educated provider? This is exactly the kind of backwards thinking that is dragging EMS down. Instead of providing higher education opportunities for paramedics, we're catering to EMTs and just tacking on skill after skill until what you have is a cheap paramedic substitute with not even half of the education but all the power to do harm. It's no wonder people don't take us seriously, we're not even taking ourselves seriously when we allow this kind of shit to pass. Can you imagine what our colleagues in the hospital must be thinking? That we're seriously allowing people with only two semesters of education to give all the same drugs everyone else in the healthcare industry must spend YEARS of education to earn the right to push? It's madness. And no, this isn't personal. I'm not attacking you, sir, but the system you're working in. Unless you're an advocate for this kind of crap, in which case, with all due respect, you're out of your freakin' mind. Paramedics as they currently are probably shouldn't be doing a lot of the things we are, yet we're letting EMTs grow ever closer to paramedic level care?

To be honest, guys, I don't think EMTs should be pushing medications. I know there's a lot of socioeconomic factors at work here, and that a lot of places only have EMTs, but it comes down to quality. Making us into skill monkeys doesn't help the profession, and I think that if we want to elevate the profession, these new changes for EMTs and AEMTs are going to hurt more than help. Like I've said before, we require a degree in my state to become a paramedic, and I still don't feel like I have the kind of knowledge to do the things I'm allowed to do. So how can I agree in good faith to letting providers less educated than I do these things?