BEorP

:twisted: I'm just amused by the sputtering indignation of certain "stuffed shirts" who seem to think that nobody without a "P" on their license should be allowed to adminsiter this or that drug. I reminds me of a certain set of other stuffed shirts who think nobody who doesn't have "MD" after their name should be allowed to "play doctor". :roll:

I'm amused by uneducated EMTs who think that the only thing that matters is what skills/drugs they have and completely forget about education.

I'm from London, Ontario but go to school in Toronto. In September I will be entering third year of the Jont Paramedic Program (U of T/Centennial) so I'll be in my second and final year of actual Paramedic stuff.

Until the early 90's the NREMT immediately placed you on 6 months provisional registration until you completed that time as documented by your medical director. Then and only then, you were allowed to get your patches, certificate etc.. Other names could be provisional, Paramedic intern, etc.. not a new level, rather a designation that they have achieved the experience needed to have some autonomy.

Why not just add more preceptorship time?

To be able to proclaim, the title Paramedic one would have to have at least 1 year minimum or documented experience.

What would they be in their first year of work?

I will give you as much as you give me, you want to bash on my "education" at the basic level, I will come right back at you guys with your faults, otherwise that just wouldn't be fair now would it????

As I have said before but ignorance seems to cloud the issue so pardon the caps I want you to see it...................I BELIEVE IN EDUCATION!!!! But don't fault me for liking where I am as a basic, if you want more go for more, but don't bash on me for what I am and what I do!!

Do you think EMT-Bs should work on ambulances? (I mean real ones, not just transfer cars)

As far as getting rid of the Basic level, correct me if I'm wrong but isn't Canada doing that right now?

In Ontario, the lowest level of education to work on an ambulance is a two year college diploma. (Although I do not know of any volunteer services, they would need to meet the exact same requirement.)

And quint, I'm not a "paragod" especially since, as I have mentioned before, I am just a student. Don't fault me because I think that anyone who responds to a medical emergency should be educated.

Yes, basics are basics. Why do you then claim you're not under educated? You need a lot more education that EMT-B to be a health care professional rather than an ambulance driver.

Just wanted to mention that I went as an observed with SW Ambulance in Scottsdale when I was visiting last December and everyone there was very nice and welcoming... seemed like a relatively nice place to work.

We are far from under educated

Sorry... I stopped reading after that.

I believe this is the article here

The neglected art of the physical exam

By MARK ROCK, BA, NREMT-P

"Medic 12, respond Code 3 to an assault victim. PD on scene."

You and your partner arrive to find a young woman under the care of the city police department. An officer has dressed her left hand with a 4×4 dressing and a Kerlix wrap. He explains to you that the woman sustained a laceration to the palm of her left hand while fending off an attacker wielding a knife. The dressing has effectively controlled the bleeding, and the total amount of blood loss is estimated at less than 100 cc.

The patient, who speaks only Spanish, is fully oriented and answers questions quickly and appropriately through a police interpreter. She provides a history of the event consistent with what the officer has given: During an argument with a relative, she was attacked with a large kitchen knife and received the defensive wound.

The patient denies loss of consciousness, weakness, dizziness or shortness of breath. You check her capillary refill, which is less than two seconds. Motor and sensory functions are intact. Her blood pressure is 140/80, radial pulse is 100, strong and regular, respirations are 20 and non-labored with good tidal volume, and the skin is warm and moist with good color. The patient is negative for orthostatic changes. You ask if she was stabbed anywhere else, thrown to the ground or attacked in any other way. Through the interpreter, the answer is negative on all counts.

The patient wears a thick, pullover sweater, which you pull up to inspect the abdomen. Access to the chest is difficult due to the sweater's bulk, and, because you're concerned with the patient's modesty, you palpate the chest through the sweater rather than expose her chest. With the patient's stable presentation, you believe that placing your stethoscope into the collar of the sweater and listening for breath sounds on each side of the anterior chest is adequate.

Confident that no other injuries are present, you transport the patient BLS, code 2, to the nearest hospital, calling en route to let them know that you have a patient with a minor laceration to the palmar surface of the left hand with minimal blood loss secondary to the event and that all other findings are negative.

On arrival, hospital staff immediately remove all of the patient's clothing. With the sweater now off, a quick assessment reveals three separate quarter- to half-inch lacerations to the mid-thoracic region of the patient's back on either side of the spine. The emergency department (ED) physician conducts a thorough pulmonary assessment, inserts a swab to ascertain the depth of the punctures and orders an X-ray.

Discussion

The physical exam is both one of the most important and one of the most neglected elements of patient assessment. Long recognized as an integral part of the secondary survey for trauma patients, a physical exam allows us to identify and treat conditions that were not apparent during the initial assessment, which is concerned only with ascertaining and correcting immediate threats to the patient's airway, breathing or circulation.

Although the opening scenario involved a trauma patient, a complete physical exam is just as important when treating a medical patient in order to provide proper care and ensure that pertinent findings are not overlooked. We should approach a physical exam in the same way that we do vital signs: something that is performed on each and every patient we make contact with, regardless of complaint or apparent condition.

The missing link

Along with a baseline set of vital signs and a patient history, the comprehensive physical examination, particularly on trauma patients, completes what has historically been referred to as the secondary survey. Also known as the "head-to-toe survey" (or "detailed exam" in current curricula), the physical exam is now taught in some circles as an optional component of trauma assessment, and as something that is unnecessary altogether for most medical patients.1,2

This is a questionable position, given the potential for treatment errors and omissions that may arise from not performing this important step of the assessment. The physical exam is of benefit to the patient in several important ways:

1. The physical exam assists us in determining and correcting potential threats to life and well-being that were not apparent during the initial assessment. A patent airway and a carotid pulse may be present in a patient with a pneumothorax or severe abdominal bleeding — or, as in our opening scenario, potential penetrating wounds to the posterior thoracic cavity. These conditions may not manifest via initial changes to the ABCs but typically present with classic signs and/or physical findings that would be readily identified with a physical exam. Unrecognized and untreated, they can result in compromise of a patient's condition. (e.g., One patient who had become hypotensive as a result of pericardial tamponade was treated for dehydration instead.3 It was determined that failure to expose the patient and notice a penetrating wound to the chest was a crucial factor in the misdiagnosis. Further, the therapy based on this misdiagnosis — aggressive fluid resuscitation — hurt, rather than helped, the patient.)

2. The physical exam establishes a baseline of findings in the field. Over time, a patient's condition may improve, remain the same or deteriorate. An emergency physician will be helped immeasurably by a properly performed, thorough physical exam in the field that yields a baseline of findings. Together with an accurate time frame, any changes can give the physician a good idea as to the severity of an acute event.

3. The physical exam is an excellent way to uncover clues to a patient's overall health and general medical history. Even an alert, fully oriented patient might be a poor historian, may not recall or have on hand their prescription medications or even know if they've had a condition diagnosed. Peripheral edema, impaired sensation in the extremities, amputations, hemiparesis or flaccidity: All of these findings should raise our index of suspicion for certain conditions. So, too, should pacemakers, surgical scars, indwelling catheters and shunts or fistulas. The physical exam can alert us to possible etiologies of a patient's complaint.

4. The physical exam allows us to discover elements tangential to a patient's complaint or injury. Although not all problems revealed by a physical exam are life threatening, or even immediately relevant to a patient's complaint, good, thorough care requires that anything of potential medical significance be identified and taken into consideration. Examples might include impaired distal circulation, chronic abdominal distension, jaundice, wheezes or rhonchi/rales without shortness of breath. These findings may warrant field intervention, depending on the patient's clinical severity, level of distress or other indications that the sign or symptom requires immediate treatment.

The all-important first step: Expose the patient

The physical exam requires that we both visualize and palpate a patient. All too often, patients with trauma or significant medical complaints (including chest pain, shortness of breath, altered level of consciousness, or neurological signs/symptoms) are wheeled into the ED fully clothed. The techniques of the physical exam — inspection, palpation, auscultation and percussion — simply cannot be performed through clothing. We should remember that the patient care acronym, ABCDE, stands for airway, breathing, circulation, disability, expose the patient.4,5

It's truly disheartening to watch paramedics start IV lines on patients wearing shirts. Not only is the ED staff going to remove the clothing anyway (and untangle that IV line), delivering a patient in this manner indicates that the providers have not performed a proper physical exam.

Case wrap-up

In this case, the patient's injuries were covered by the sweater, which was penetrated by the knife blade but, due to its thickness and elasticity, showed no rips, tears or other damage. The language barrier prevented the providers from getting a reliable history of the event, despite the availability of a translator. Had the sweater been removed and a proper anterior/posterior physical exam performed, the injuries would have been identified.

Not being able to ascertain the depth of the wounds in the field, proper assessment and treatment for this patient would have included continuous pulmonary reassessment, pulse oximetry, an IV line, cardiac monitoring and, depending on local protocols, perhaps even spinal immobilization.

In the ED, the patient's wounds were cleansed and a topical antibiotic ointment applied. Dressings were placed over the injury sites, and the patient was given a tetanus shot. The patient was discharged from the ED three hours after being brought in and enjoyed a quick recovery with no complications.

The ED physician consulted with the providers who brought in the young woman who had been stabbed. He reported to them that the most serious of the three wounds to the back had penetrated the dermis into the fat layer, with no thoracic cavity compromise. Although the injuries in this case turned out to be relatively minor, he reminded them of the importance of performing a thorough physical exam.

Conclusion

Always perform a physical exam on every patient. The physical exam provides us with valuable information, which will guide our course of treatment and assist the ED team, thereby providing a much better service to our patients. Neglecting to do a proper exam can lead to inadequate or inappropriate care. A thorough and complete physical exam is vital to your patient's well-being and your reputation: Don't compromise either one.

do I bow now or after I catch my breath???? Paramedic attitudess will be the demise of our profession, so get as much praise as you can for your two years "ed"

1. I didn't ask you for praise. I am not a Paramedic, I am just a student. I said that I'm glad I know educated people will show up if I call 911.

2. If I were asking for praise then I would have told you that I am actually in a four year Primary Care Paramedic degree program. That's right, four years to do less than an EMT-J. Education... an interesting concept, eh?

Really? So, someone is unconscious/unresponsive due to an obvious narcotic OD, you need to call for orders first before narcan administration? I'm just curious, I figured it'd be standing as we do, as Canada is so progressive.

Oh I'm so silly. I must have forgotten that we judge EMS systems by drugs and skills.

It'd be a shame if we had to judge it by the fact that when I call 911 I know that I am getting two people who have AT LEAST two years of education and that no one with 120 hours of training will ever show up to help my family members. But we don't need this debate again :wink:

Narcan without even calling medical control... Don't ACPs even need to call for it?

Significantly longer than it takes to exsanguinate.

Longer than it takes to go from sinus tach to asystole.

Aren't you glad you don't live there?

And if you did live there, don't you think you would have been in your community leaders' faces about it by now?

I love Ontario.

If people want to have volunteer services, fine (although it sure seems like better care is offered by paid people who do it as a career rather than a hobby). But if you're going to have a volunteer service you should at least act like a service. That means answering calls! If it's just whoever wants to that answers the page and there's not even a schedule it sounds a lot more like a bunch of people with light bars on their cars who choose when they want to help.

ok, this is in response to all those who want to know what happens when the squad i'm on doesn't answer the page. what happens is they'll page us like 2 or 3 times, if we don't respond on the 2nd or 3rd page, then county will page Menomenie Fire for the run. as far as what happens after, i'm not sure, it's only ever happened once to my memory.

How long would it take them to get to the third page?

ok, now first off, we have 2 full time EMT's that are on duty from about 700 to about 1600 hours on the weekdays. during weekends, evenings, what have you... it's whoever answers the pager, and to my knowledge, we've not missed a call that often. though it may be different in each area. another thing is that alot of times, there's only 2 EMT's on the rig for most runs; one driving, one in back with the patient. and that seems to work out fine for us.

And what happens when you do?

If you were the Code Blue patient, would you rather be "worked on" with a simple BVM, or a combitube that was properly placed with skilled hands. Tough choice...

If I were VSA and you were working on me I'd want you using proper BLS adjuncts and maneuvers. Jaw thrust, head tilt-chin lift, OPA, NPA, proper bagging including a good face mask seal... ever heard of any of that? Maybe they didn't have time for that in your 200 hour class. Idealy if I were VSA I would want an ETT placed by skilled hands, but yours are not skilled and there's a lot more to EMS than "skilled hands."Do not take this as an insult, I am halfway through my PCP program and I do not claim to have skilled hands or know everything... but I also understand why BLS providers can't use advanced airway devicdes.

The other day i was driving priority to a MVA I was going pretty fast about 85 on a 65 road i had a state patrol car pull up behind me and ride my butt with his lights going so i figured if he wanted to go faster id go in the right lane and let him around but he pro ceded into the right lane so i got back in the left and pro ceded to the call. He then ran up to me and yelled at me to stop and began yelling at me for speeding. WTF It was a nasty wreck and we were the first unit on scene. After pt care i graped the Sargent and the officer and the officer told me he should write me a ticket for wreck less driving for going that fast and the Sargent flipped out on the officer.

What are the rules in your state about speed limits when responding at the highest priority?

Why not, because I've successfully applied learned skills in First Aid? What the hell? Everyone else I know took the classes and never applied it. I saw the blood, I saw the blue lips, and I acted perfectly according to my instructions; my actions have save two lives, excuse me for bragging a bit.

I want more instructions, I want more protocol. I want to do it again, because I did it well.

Well I don't want someone who has two DUIs caring for my family members. If you've saved two lives already then just keep doing what you're doing since it sounds like it's working.

Please please please let this be a joke

If some would explain to me why this is such a joke, I would appreciate it.

Because if you are serious then you the model person who should NOT be in EMS.

Well my Dad was a volunteer, and he was talking about hooking up IV's, shooting up stabbing victims with morphine, stitching up wide open wounds, etc. Maybe it's cuz I'm from a more rural area, maybe he was telling some tales. I don't think they'd give a fancy symbol to ambulance drivers.

You know who saves trauma pts? Trauma surgeons.

We drive them to the hospital and do what we can on the way.

I was in a college town, and blew less than .1 percent each time. Thats about 3 pints per arrest.

Ummm the legal limit in Ontario is 0.08 (I assume yours is somewhere near this) so why would I care if you were only "a little bit" drunk while driving? I had a close friend killed by a drunk driver. Not like once is excusable, but twice?!? (not to mention those are only the times you've been caught)

[As a side note, EMS is a lot more than massive trauma.]

You made at least two very poor choices in your life so find a different career and think about your actions first next time.

Thanks for all the feedback.

Another question regarding non-in-house ACP training... how hard is it to get into? (even with experience)

What is it that they look at with admissions that you can be working on in your few years as a PCP before applying?

Thanks for your input, Dust. I didn't mean to exclude the Americans completely and it's good to get your input, especially since it's different than EMT-B to EMT-P.

As a PCP? I don't see what would change. People have degrees, ACLS, BTLS, PALS, NRP, Man of the Year, Nobel Prize, whatever... I don't think it really would change things if you wanted to be a PCP...

I mean is it easier to get a job as an ACP than a PCP?

Do you think 1-3 years of experience is worth it even if it is with a county service like Huron or Bruce where the call volume is extremely low?

Also, you said that ACP(f) requires 2000 hours as a PCP so if you got to ACP before then you're out of luck? (probably a stupid question...)

What are everyone's thoughts on going straight to ACP with no experience at the PCP level?

I know some of our American friends have said that there is no point in working as an EMT-B and have pointed out that other health professionals do not need to start at a BLS level. I am wondering if they feel the same way about this with PCPs and also what Ontario medics think about this. (It seems that our situation is at least a little different since PCPs can get fairly well paying jobs and at least do a bit of SR.)

I know it is an expensive thing to do, but with our 500 hours field experience during PCP school enough to go onto ACP training?

Will it make the job hunt easier than trying to find employment as a PCP?

What about EMS politics, will it be frowned upon by other medics if you are an ACP who spent no time as a PCP?

If money were no object, would you (an Ontario Paramedic) have gone straight to ACP?