txemsdoc
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Posts posted by txemsdoc
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these you achieve by good QA programmes, adequate training and Education, and involvement in service provision, not by making the guys and girls out on the road ask for permission to do things you have provided them with the education to do ...
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If medical direction are there to answer questions outside the protocol / guidelines, if medical control physicians are prepared to come out to scene where there is a clear need - that's great - that's what our medical directors i nthe NHS and Voluntary sector do
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making people ask for permission to do their jobs is nothing other than a power play ... needless to say in most c places outside the USA registered / licenced providers don't have to ask for permission to carry out interventions within their approved skill set...
It's not a power play. It's ensuring quality care when I've had enough example of poor care to be worried. When and if I'm proved otherwise, it might change. I'd have people being paralyzed for being confrontational, I'd have bilateral chest decompressions in COPD patients with no breath sounds, I'd have unrecognized esophageal intubations, I'd have torsades never getting magnesium, I'd have long periods of no chest compressions, I could go on and on. These are not all things EMT/PM have to ask for, but I pick up on by being there or on the phone as it is happening.
I said....
I think that the medical director's priority is not the happiness of the EMT's and paramedics. It is not to allow them to do what they want. They do not know best and are occasionally driven by what's best for them, not the patient. The medical director's main priority is the well-being of the citizens in the area his/her agency serves. And sometimes that priority trumps the desires of EMT's and paramedics.You said....
only where there is a power battle between the road staff and the medicla direcotors - especially where medical direction is provided by physicians with no appreciable field experience...
The battle for us is to ensure quality care. That's it. The battle is against laziness, passive aggressiveness and general disdain. The battle is against those who won't take responsibility for their actions. And lastly, we're not medical directors who write a protocol and delegate the running of the system and disappear. We are out on the streets more than some of our slower units. We do live fire training with the guys. We respond to all MCI's. We take call 24 hours a day all day. We get in the dirt and water. I don't think anyone would say we don't have experience.
chris
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Hi, thanks for responding...
First, are you really 79? If so, that's excellent to see that someone has maintained an interest in this area rather than withering away
But now to the nitty gritty!First welcome to the site !Having an active medical control is essential for development of having a progressive EMS. However; just having one is not the key. As a medical director are you very active ? A physician(s) should be developing a rapport and trust. Performing testing, observations, ride alongs and education classes can be increasing trust between the physician and EMT's. Yes, they work under your license, and yes you are responsible. However; what many do not understand you have power to see what and whom and the calliber of medics that is being hired. If I was a physician, I would want those to have autonomy, and knowledge..not a bunch of trained "chimps" that follows protocols. You are the one that can make that difference.
I would hazard a guess that my system has the most (if not close to) the largest medical director activity I've heard of. We're at 4 full time docs, 1 part timer (specifically does pedi EMS) and looking for one more. We all have our administrative areas and all have our own take-home response vehicle which we can respond to any EMS or fire call anytime wherever. Additionally, someone is on-call 24 hours a day and all cardiac arrests get called into us (through a centralized communications center which records the call) so we can provide direct oversight if we are not there in person. I can not begin to tell you how many times we ahem 'gently nudge' our EMT's and PM's in the correct direction. For instance, no ETCO2 in a witnessed arrest and you swear you saw the tube pass between the cords? Are you so sure? If we didn't demand what should rightfully be detected by them, we'd have an esophageal intubation. Similarly.. ah, so you want to push another 12 of adenosine for your irregularly irregular narrow complex tachycardia with no p-waves since the first 6 and 12 didn't work? Umm.. how bout no. Now, I know you are saying this is stuff that shouldn't have to happen, but I tell you it does happen. And, I don't think our EMT's and PM's are any more stupid than the average EMT or PM. They pass school. They pass National Registry. They are licensced with the state. And not all of them hate the job.
I agree with you about buildind rapport and trust. However, I (and the PM Supervisors in the system) should not be their brother or buddy. We should be their parent. We aren't there to back them up despite what they did wrong, that's what the union excells at. We are not in a position (as medical directors) to discipline. We can restrict duties (oh, I have to ride on a fire truck now, oh damn) but that's it. Otherwise we 'educate' and hope it doesn't happen again.
Protocols should be written as suggestions or guidelines, and never direct "what to do"; as well having a thick protocol does not mean they will improve or deliver better care. They should had been educated in the professional & medical standards that you expect in delivery of care. Again, you can control this without step by step protocols. Each subject or situation should not have to be written out, if they need one, then again there is an education problem. You as a medical director apparently feel that they are not able to make rationale decisions upon their license level, or is it that you are covering your ass because of the potential incompetence that could cause litigation? Even having a step by step protocol can actually increase litigation's, by medic not following each letter of the protocol for every situation one increases the chance. That is why more and more emphasis is placed on education, QI, and protocols for specific problems or illnesses.I guess in our environment, we have to dictate what to do to ensure it is done. When it is 30 minutes before my shift and I can cut corners, it happens. If it is in the protocols, then a formal disciplanary request can be investigated. If it is something under medical discretion then it's much less concrete. But, I'd agree with you that we can not possibly cover all circumstances. Also, if the protocols were more vague and relied on judgement more, we'd get more of the scenarios like this..."Doc, we're doing chest compressions but instead of 15:2 we're doing 20:2 because it looks like she's about to get a pulse back right at 14 and 15" WTF? That's one way to think outside the box...
As well how much can one really cover on protocols? Do you really need a section for everything? I hope not ... again they should be generalized guidelines, with the bottom line " upon description of the Paramedic". If you do not feel that you are able to trust them with this type of descisions then there needs to be some house cleaning or education.I highly suggest you check out National Association of EMS Physician web site : http://www.naemsp.org/ There is several EMS medical control that have developed systems and education for EMS personnel.
Respectfully,
R/r 911
Well, we cover a lot. General operational guidelines (like how to pick a hospital), describe how to do certain skills (stuff they should already know), a section on each medication we carry, and then adult, pedi, and trauma protocols which incorporate some 60ish emergencies. No, it's not everything and we have a protcol for just 'paramedic discretion when nothing else applies'. And for the last point, I agree but the former is not an option (we just make em EMT's and most wouldn't mind that) and I really don't believe, honestly don't, that it is a lack of education. They don't put what they do know to use, for whatever reason, good or bad.
Yea, I'm a member of NAEMSP and enjoy their conferences for the most part...when they don't 'go cheap' and serve only fish crackers at the receptions
Chris
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Hi,
I've read a lot of discussion about good vs bad systems, aggressive systems, etc... and some of it relates back to the level of medical control in the field and how much it intrudes into the daily activities of a paramedic or EMT. I realize that rules in this area differ state by state, but in Texas, the medical care is delegated to an EMT or PM and the medical director is ultimately responsible for the care given. It follows then, that a conscientious medical director would want to know what care is given, by whom, and how much he/she can trust them.
I'm left with the impression that a great many people here think that an ideal system has no direct medical director involvement during the actual care of the patient. But I am left wondering why, if this was your stance and you want to practice medicine independently, you didn't go to medical school on your own? People here talk about thick protocol books as if it is a bad thing as well. Because Rosen is thick, does that mean it is bad too? Protocols should be specific and address every medication you have at your disposal and when you are allowed to do certain procedures. Because, yes, in my neck of the woods, the medical director allows you to act for him/her.
I think that the medical director's priority is not the happiness of the EMT's and paramedics. It is not to allow them to do what they want. They do not know best and are occasionally driven by what's best for them, not the patient. The medical director's main priority is the well-being of the citizens in the area his/her agency serves. And sometimes that priority trumps the desires of EMT's and paramedics.
I realize this may be inflammatory here, but I'm truly interested in your thoughts and I realize that some things differ state by state and I base my comments on Texas.
Chris
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Are you advocating that patients who are in asystole (medical arrest) should not have an attempt at resuscitation by BLS or ALS?
And that bolded sentence is incorrect. A very few number of medical arrests without bystander CPR whose initial rhythm is asystole do respond to resuscitation and do have neurologically intact survival. If I was in my office, I could give you a percentage of my agencies experience. But say it is 2 out of 100.... is that worthwhile to you or not?
Chris
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This applies for everyone in the US.
Everyone forget about EMTALA?!!
If you have a patient that wants to go to a hospital on divert, THE HOSPITAL CANNOT REFUSE THE PATIENT!!! It's Federal Law. I've pissed off my fair share of staff because of it, but I don't care. I take my patients where they want to go.
Actually, you appear to be quite WRONG about this, unless the ambulance has already made it onto the property of the hospital... here's the relevant parts of the statute that I have found....
Cut and paste...
[a hospital is bound under EMTALA if the individual...]
(3) Is in a ground or air ambulance owned and operated by the hospital for purposes of examination and treatment for a medical condition at a hospital’s dedicated emergency department, even if the ambulance is not on hospital grounds. However, an individual in an ambulance owned and operated by the hospital is not considered to have "come to the hospital’s emergency department" if—
(i) The ambulance is operated under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the closest appropriate facility. In this case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property;
(ii) The ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance; or
(4) Is in a ground or air nonhospitalowned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital’s dedicated emergency department. However, an individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital’s emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. The hospital may direct the ambulance to another facility if it is in "diversionary status," that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital’s diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department.
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So, it appears to only involve hospital owned ambulances where EMTALA can be invoked, and even in that case, there may be exceptions...
Chris
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Wouldn't we all! And that is really the only key advantage to an FD administrated system. If anybody knows how to run a bureaucracy, it's the fire service. Just about every big FD looks wonderful on paper, with assistant chiefs paid to sit around and write policies and procedures, and publish statistics and mission statements, and all the other fluffy paperwork that impresses the academics. But you're right. If we could combine the best of both worlds, it would be great for the profession. However, I maintain that, aside from geography and taxes, there is nothing inherently superior about HFD that does not or could not be applied to any other service.
And, as Rid says, the numbers would have to be vetted to determine a true cause and effect relationship before I could climb on board with HFD being excellent on any level. And even then, I don't think it would be impressive to international visitors that HFD's ambulances happen to all be within 10 minutes of a trauma centre. That's hardly clinical sophistication.
Well, the numbers are there and available. I wish there was a 'clearinghouse' of stats and information if only to recognize your particular service is slacking (so you'd do something to change it) or excelling. People/Entities are too afraid to stand up for themselves and be subjected to scrutiny.
As for what makes HFD different... Well, there's quite a bit...good and bad. I would admit some prejudice and argue that the high level of PM supervison by supervisors and physicians lead to better patient care and outcomes. I'm talking education/QA/real time consultation (every arrest gets called in as it is occuring) and other forms...
Yea, about the trauma.. I was speaking more of cardiac resuscitation. Although HFD units in Kingwood, Clear Lake, and out west towards highway 6 would beg to differ on the transport time
Nevertheless, my whole point of interjecting into this conversation (other than just finding this forum) was that blanket statements like "Houston sucks" aren't 100% accurate, and that there is likely no place where an international visitor can get a thorough experience of all types of EMS.
I appreciate the lively discussion.
t
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So am I to understand that you are saying Houston F.D. has higher resuscitation rates than agencies such as Cypress Creek EMS, HCESD-1, Cy-Fair VFD, Northwest EMS, and Montgomery County Hospital District? If that is what you are saying, then show me the numbers as I have a real hard time believing that. Medically, Cypress Creek EMS has a greater than 80% ROSC on in field worked arrests with a discharge neurologically intact rate running in the low 40's% (As of earlier this year). Trauma wise, no EMS agencies have decent resuscitation percentages. EMS doesn't save the trauma patient, the trauma center does..........
Now if your referring to Houston hospitals having a higher resuscitation rate than the outlying hospitals, then yes you are correct. It may have something to do with the fact that the only level I trauma centers are downtown :wink: . My personal opinion, Houston does suck when it comes to trauma care. It's not Hermann's fault nor is it Ben Taub's fault. It's the fact that the 4th largest city in this nation needs more, but will probably never receive.....................
Sorry, got a little off topic (hope admin didn't see it!!!
)................Umm..in a short word, yes, until these agencies can provide real numbers. I don't give a crap about ROSC in field...it's worthless. I don't want massaged numbers which look at only vfib arrests, or witnessed vfib arrests. I want all-comers, all rhythms! THEN, we can talk. The numbers you quote are not for all arrests, I can guarantee it. Oh, and tell me what your patients are doing 6 months after their arrest. What is their level of function. This is what EMS agencies should be doing (and in fact, HFD does)...One caveat to this even is the quality of the hospital.. there are hospitals in town that you have less than a 5% chance of surviving with ROSC in the field, and others which are much much better (given that there is some self-selection done by the PM's)...
I'd agree with you on trauma btw. There's recently talk of Methodist getting into the Level 2 trauma business which is, from a street standpoint, the same as a Level 1. So maybe we'll get something somewhere else. A good rule of thumb is that if you are gonna get shot, do it 'in the loop'...
txemsdoc
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The most extensive protocols, drug list and skill set on earth isn't going to impress our international EMS friends if those in the field have a condensed 800 hour "education," can't talk intelligently about pharmacology or physiology, and don't even want to be on the ambulance in the first place.
OK, so here I agree.... so then, because someone doesn't want to be at the job, that system as a whole 'sucks'?
Maybe from the point of view of the individual EMT/PM I spose... But if I were in a trauma or cardiac arrest, I'd rather be in Houston proper than any of the surrounding entities...as long as they aren't in 'resource management' when unit availability is running low. The numbers simply show that Houston's resuscitation rates are in the top 2 or 3 of the US and exceed those of unincorporated harris county, neighboring counties, etc...(or those services don't track their numbers appropriately). What I wish is that you could merge the motivation of those in outlying systems (although believe it or not, there are some people in Houston Fire who don't want to run into a burning building) with the 'system' of Houston Fire and that would exceed Fire's already decent patient outcomes.txemsdoc
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Actually, I don't think we differ much at all in our definitions. ... A rideout with most large metropolitan fire based systems isn't likely to impress the international visitor who is accustomed to a greater clinical sophistication....
And most of all, I would hate to see an international visitor come here only to go back home with his lasting impression of American EMS being how a major urban FD breaks down paramedic education and practise into the lowest common denominator, and then staffs it with people who, for the most part, don't even want to be doing the job.
While I certainly agree that all of the factors you mention are extremely important for a service to be "good," the two most important elements of any system will always be the two you didn't mention: Education and people.
What do you mean be clinical sophistication? Is it an individual paramedic/emt thing, or is it based on the meds/procedures at the disposal of the pm/emt? If the latter, I would argue that the systems(I'd exclude air systems) with things like RSI are not 'sophisticated' and/or don't have a large amount of input from their medical directors because the evidence does not conclusively support pm's can do rsi and recognize all esophageal intubations.
Your comments about urban FD's and pm education seem somewhat personally slanted. I would think it unaccurate to say that a rural EMS providor is in any way better than an urban one (individual characteristics aside).. I would actually argue the opposite. Nevertheless, education in many cities is farmed out to a college or university setting which teaches off of standard curriculum. A better representation would be national registry pass rates, though colleges can 'adjust' who takes the test to get them higher percentages.
You are right about people in FD's and 'not wanting to be doing the job'. I think the connection was a matter of convienence for the powers that were to align ems and fire. A good firefighter doesnt' equal a good paramedic.
I agree with needing 'good' people to have a 'good' system. You don't need them to be terribly smart, just motivated. You can get through medical school with just determination. The education aspect I question, only because that is so entailed in the QA/QI process that should be happening.. more of an ongoing education.
Just my thoughts,
txemsdoc
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What exactly is a "mainport?" Airport, or seaport?
If you're looking for coastal, then Seattle, Washington is probably your best bet. There isn't hardly a decent coastal major metropolitan service in the country. All of California sucks. New York sucks. Houston sucks. Most of Florida sucks.
Even if you are not limited to coastal, Seattle is still probably very high on the list of your best bets.
If you don't mind me asking, what entails a 'good' system? I think our definitions would vary quite a bit, but I'm interested.
I think a good system has:
1) decent response times (though FR time is more important than ALS response times)
2) highly involved medical director(s) and other educational personnel
3) aggressive QA/QI program
4) Thorough patient followup program (esp. for cardiac arrests, but also for non-transports, patient satisfaction,etc..)
5) An attempt to minimize ALS personnel responding to non-ALS requiring patients (could be through dispatch, dual tiered system or other ideas)
6) Good cardiac arrest resuscitation #'s (and return of pulse in the field is NOT an indication of this)
What does not make a system "good"
1) Agressive care not based in evidence/science/fact (or anything more than anecdotal story) (just because something is standard care in an ER does not mean it should be done prehospital.)
So please tell me why those cities "suck."
txemsdoc
Medical Control and Protocols
in General EMS Discussion
Posted
Well, I don't feel 'fault' per se, as much as exasperation. I think a lot of it is specific to my system. There are firefighters on engines and ladders and then EMT's and PM's doing EMS. If we don't like their care, we can take them off EMS and then they go to fire. But, that's what they wanted to do when they joined and they would probably kiss me. They do lose a bit of money but not enough to be substantial. So, we're stuck trying to motivate people to do a job they would rather not do. For the last few years, we've had one-on-one counseling/education led by a physician when these things happened, and I don't think it has helped one bit. As I said before, I don't think it is an educational problem. I need to find the book, "how to motivate someone to do what they don't want to do". It puts me in such a odd position or mindframe. I don't understand how someone could not do all they could to help someone..I wouldn't have gotten into medicine if that was the case.
I should couch my remarks in the fact that we have almost 350 PM's and some 3500 EMT's so education is slow and arduous. Also, a sizable percentage do not meet the good-for-nothing descriptions I've given forth in my earlier comments.
Chris