Prmedc

Recently, I switched from working in a small town of ~12,000 with <10 min transport times to a rural area with extended transport times. It's around 30 minutes to our nearest hospital, and at least an hour (depending on location in county) to the nearest hospitals with PCI, neuro, trauma, etc. capabilities. One thing I've noticed is that my scene times have increased for most patients without an absolutely time critical diagnosis. Previously, I would average 10-15 minutes (IV, O2, monitor - meds enroute) on a scene and now it's 15 - 25 minutes. I tended to think the opposite would be true since more could be done while enroute, and that is the case with patients with acute CVA, STEMI, etc. unless they have acute symptoms that need immediate stabilization. With other patients I tend to give more treatments while on scene with my partner and hopefully see results while transporting. I'm also doing a lot more procedures - which I expected. That might also be contributing to longer scene times. I'm interested in your thoughts - do you "stay and play" or treat while transporting?

Taking it in February for first recert - should be fun.

Interesting points! If the patient is alert and oriented, I tend to offer them several options, then the reasons that I believe one of the options is more likely than the others. I understand your point - however, the reason I attempt to form field diagnoses is because I believe I render better patient care with that as my goal. I don't necessarily tell the patient more than they need to know to feel reassured that they are receiving appropriate care. To me, "field diagnosis" means the underlying condition that I am treating. Obviously, I could screw up and treat a pneumonia patient for CHF or vice versa, but the fact is that we assess the patient to come up with a functional diagnosis so we can treat, even if it is simplified compared to what a physician would determine with the aid of labs and imaging, plus wider range of medical knowledge. I think this is mostly semantics, and textbooks cloud the issue by declaring "only physicians diagnose". Awesome technique, Dwayne. I'm definitely going to be using this. The driving force behind this post was working double medic for 90 days as part of new employment orientation, and watching other medics perform assessments.

How do you work on improving your assessments? As a relatively new medic, I find myself fighting the urge to jump to conclusions prior to completing a full assessment. Usually I find myself recalling several useful questions or assessment techniques post - call that would have helped to rule in or rule out my field diagnosis. I tend to be correct but would like to be performing thorough assessments on every patient. I also tend to form a field diagnosis way too early in the call, which just exposes me to confirmation bias pitfalls. I've been using a Lippincott Signs and Symptoms guide that has been immensely helpful due to the emphasis on "old school" assessment tools used prior to mass imaging availability (as an example, recently learned about the psoas sign test following transporting 14 y/o m with probable appendicitis). I'd be interested to hear how you all form differentials and bear them in mind throughout the assessment and your general thought processes, as well as how you improve your assessments over time. Feel free to share assessments tips as well, I'm sure there's plenty of cool assessment tips and tricks floating around out there.

Absolutely. Currently I'm focusing on expanding my anatomy knowledge and cardiac interpretation skills, as well as airway. I'm accumulating a small medical library and also working on my diagnostic abilities as well. I've found focused goals with concrete results (better 12/15 lead interpretation, shorter scene times, etc.) tend to motivate me more than simply reading through a book.

We had a call a couple of years ago to the local ED for "Male Patient, abdominal pain, requests transport to Big City ED" (about one hundred miles away). We arrived to find one of our local "cruisers" sitting outside the ED door in his electric wheelchair. Apparently the patient had been placed on antibiotics, didn't feel that was sufficient treatment (aka no pain meds), signed AMA and called us. The ED staff side of the story included the patient ripping out his IV and trailing the saline bag out the door. Patient refused to sign Hospital Bypass or ABN form, so we wheeled him back to his room (much to the dismay of the assembled nurses). We did obtain a refusal of care. Of course, in the rural setting we don't have the consistent waiting room waits, and it's rare to wait for a room if you come in by ambulance. Prmedc

As demonstrated by the crushing weight of student debt that doctors possess. I agree with you that having a college degree in addition to a paramedic's license can't hurt, and in most cases is helpful. However, is it really better (from a medical knowledge standpoint) to go from pass/fail minimum grades per test to requiring only a C average? Be that as it may, current paramedic degrees only tack freshman classes onto the DOT curriculum and clinicals. Ergo, a complete rewrite of the college EMS degrees (to a more science based curriculum) currently offered would be needed to do some good. It's ridiculous that the lab techs have four year degree programs and we don't - with the exception of "management" programs (again, an amalgamation of a two year degree with two years of business classes) . We might not be considered an "official medical profession" but let's face it - until the widespread use of the automobile EMS wasn't practical except in small areas with large numbers of patients (battlefields). The doctor went to the patient, usually with a nurse or two. As long as what we do consists of ultimately delivering the patient to a higher level of care, then we won't be viewed on the same level as the professions that spend weeks with the patient as opposed to minutes. Regardless of the fact that our care tends towards dealing with more acute conditions, or how many degrees we have. We get paid (mostly) for what we do, transport. If we don't transport, the patient doesn't get a bill. In any profession, you have the people who get paid for what they do, and people who get paid for what they know. We tend towards the former, as demonstrated by our reimbursements. Doctors are the latter. But hey, we're also somewhat separated from the problems of the "medical professions". We have property and sales tax bases to draw from that very few hospitals enjoy. Let's just not be in a hurry to dive deeper into the layers of bureaucracy that the medical professions are enveloped in.

Just to comment on the "two year degree" buzzphrase: I moved to a state that required a two year degree (generally through community colleges) to become a paramedic, specifically because I believed that the additional education would make me a more "well rounded" provider of medical care. I found a medic population full of drug users, fired law enforcement, and just plain incompetents. All of whom possessed a two year degree and multiple student loans. Needless to say, I got the hell out of there and went to a well recommended technical school. No two year degree, although I did receive college credits if I decide to pursue a degree. My point is that slapping some English, math, and freshman psychology classes together with a paramedic class doesn't "make it better". Give me a four year B.S with reasonable tuition and college level A&P, chemistry, biology, etc and then EMS as a profession will see some benefits to possessing college degrees. Unfortunately if you want that level of education you might as well get into nursing and work towards CRNA or something similar that has decent wages. Oh, and writing the EMS texts to 8th-10th grade levels doesn't help our case much. Prmedc

We are a public "third service" covering West Plains and the southern half of the county - St. Johns covers the northeast portion of the county. We have several employees that work for both services. As for the "new medic" bit, I guess the answer would be both, lol. I've only been licensed for eight months. Sent from my ADR6300 using Tapatalk

The problem with a place that has overtime "always available" is that the temptation to throw you in there the first week will be overwhelming. You're much less likely to get a comprehensive orientation if you're working the truck the same day you get hired (ironically, to cut down on OT costs). As a new EMT, you need that orientation (especially the driving component, since that's not generally covered in EMT classes). Most "good" companies will be fully staffed with little overtime. The companies with lots of OT have high turnover rates, and increased stress on the remaining staff. If you really want that extra time, you'd be better off finding a regular FT job and PRN somewhere else. Not only will that give you more control over your hours, you'll be able to compare two services and figure out best practices. Good luck with class! Prmedc

In 2010: -EZ-IO -CPAP -RSI -LP-15 Working on IV pumps and associated drips (nitro, heparin) for 2011.

Hey everybody - New paramedic working for rural service in Missouri. My interests lie in EMS and critical care, looking forwards to taking CCEMTP in July and FP-C eventually. I tend to be a lurker, but it looks like you all have some decent discussions going. Take care, Prmedc