fiznat

I really appreciate that we can go back and forth about this for so many pages, and avoid (for the most part haha) letting the thread degenerate into a shouting match. Everyone up to this point has been willing to pull back for a moment and reflect, and I think that speaks volumes about the quality of characters on here. I know I can be an ass sometimes haha but as I said before I do feel strongly about this stuff and I don't mind arguing about it at length. None of it is personal. Anyways, I called medical control yesterday and I was thinking about you guys. Here is the scenario. 22 year old male, driver in a car vs. car motor vehicle accident. This driver struck a parked car on the opposite side of the road, after witnesses saw him slumped over the steering wheel running a stop sign just previous to the site of the crash. There was some damage to the front of the patient's car, but really nothing too major (estimated speed 20 mph). No intrusion into the passenger compartment, no airbag deployment. On our arrival the patient was walking around outside the car, smoking a cigarette and completely without complaint. He is alert and oriented, GCS 15, but looks a little "off." He is profusely diaphoretic, tachycardic at 150, hypertensive at 160/100, incontinent to urine. Trauma assessment is completely negative. It took me 15 minutes to convince him to go to the hospital. I called in a routine notification radio patch to the hospital to let them know we were coming, but asked to speak to a doc quickly. The reason was, because this patient was involved in a MVC and has abnormal vital signs, the general practice is to do a "trauma activation." A trauma activation involves calling a bunch of medical residents, trauma surgeons, nurses, etc to the "trauma room" and do a rapid trauma assessment and treatment. It is very resource intensive and is in general very distressing to the patient. My discussion with the doc centered around whether this was a "pre crash" problem or a "post crash" (trauma) problem. I believed that the story we got from witnesses supports that this patient's condition caused the crash, and not the other way around, and that the patient might not need a "trauma" activation but rather a medical one. In addition, the trauma side of this scenario was very weak, with only minimal damage to the patient's vehicle and a reported low speed collision. I spoke with the doctor for maybe 45 seconds, and because we had that talk before we got there, the doc and I were able to both streamline care for this patient as well as maximize resources within the hospital.

Some of the old school medics around here talk about it, but I've never tried on anything other than a mannequin. I think my hand is too fat and my fingers are too short haha. I don't really understand the utility anyways....

This is exactly how we practice over here. I'm really not sure where you are getting this "US paramedics are under the thumb of their physicians" bias, but it really isn't the case (at least not where I work). Those examples you mentioned (above) to illustrate your autonomy may just as well have been written by me or one of my coworkers. That kind of clinical judgement is absolutely standard practice. I'm quite sure that your and my day-to-day practice is more similar than you seem to think. I was never talking about routine patients and routine clinical choices (versed dosage and withholding a spray of nitro is routine. So is deciding whether to hang a bag or start a lock... jeez). I'm talking about the need to maintain an open line of communication with a physician for the extreme cases where we meet the limit our of medical training. We paramedics need to face the fact that one year of abbreviated training with no real prerequisites is NOT a substitute or in any way equal to an actual medical education. I just do not understand what makes some paramedics think that they can handle a really sick patient as completely or skillfully as a physician, simply because they are "on the street." Such thinking is hubris. ...And just because you only have so much in your bag doesn't mean it is okay to put the blinders on and cut ties with the physician. Good medicine doesn't become something else simply because you decide to narrow your own field of vision. There is so much out there that we don't know, we should count ourselves lucky if we understand enough simply to ask the right questions. That isn't a result of systemic "inadequacies" or in any way an effort to "keep education standards low" (both which are insulting, by the way). This is respect for the importance of our job and the profound effect our actions can have on a person's life. Sometimes realizing his own weaknesses is the biggest strength a person can have.

Okay, I guess I understand this point. What I don't understand is what this has to do with whether or not we should be calling on-line medical control? They do if there is any question as to whether that medicine should be given or not. If you had to pick between the correct medicine a few minutes from now, or a harmful medicine right now, which would you pick? Not that this particular scenario is that extreme, but there are situations where things aren't so clear. Those are the ones I am talking about. Medical control WILL help you with your limitations. That is the whole point.

As a matter of fact, several of our ED docs here are ex-paramedics. That aside though, I disagree with your point that good medicine is something different in the field than it is in the hospital. Good medicine is good medicine, no matter where you are. I believe that our intention is to treat medical problems (pathology). Not symptoms. I took issue with you saying the following (from previous post): I think this is shortsighted, and the kind of thinking I really loathe in a coworker. It may or may not be the case with you personally, but when I read this comment I feel it smacks of a sense of contentment with ignorance. A robot can "treat symptoms." A clinician thinks about pathology and root causes (and THEN treats). How would you categorize yourself? It isn't what you said. You said that doctors only consult on critical patients and even then, only AFTER the patient had been stabilized. You say that right here: The distinction is important because I am pointing out that doctors consult THROUGHOUT the care of both critical and routine patients. It is an example, I think, of a professional humility and a responsibility that EMS shouldn't toss away lightly. Given time and available circumstances, I think we too should be consulting on a routine basis. It is a healthy feature of good medicine, not a kick to a Paramedic's ego. Yes we do! It's called on line medical control! I don't think I directly called you any names, but I guess I apologize. I feel strongly about a lot of this stuff and sometimes I get carried away.

I wasn't trying to call you (or anyone) out specifically, which is why I didn't quote you or use your name at all. Even if you have standing orders for pain control, there are likely others here who may have to call for it. My point was simply that our definition of "what is medical control" varies widely across our community here. That point stands. I don't think I said that it has to be a doctor, even though I do agree that a physician might make the most sense. Okay hot shot. The 3rd round of IM epinephrine in a status asthma is an on-line option for us here. Should we all have our "accreditation reviewed?" Things aren't the same everywhere Phil, and there certainly is a little room for thought in this scenario other than pushing the syringe down and hoping for the best. Do no harm. Epinephrine increases cardiac O2 demand. ...Or are you simply saying that nobody could definitively prove it was your epinephrine that did the damage, and therefore pushing this drug is okay? What a truly idiotic thing to say. Phil, there is more to our patients than we see at face value, and thinking in only two dimensions like this can have really negative effects. If you really believe that a patient does not exist who's presentation will exceed your abilities as a prehospital provider, you either have no experience in the field whatsoever or are a complete fool. Wrong. See above comment. Wrong again. Spend some time in the ED and follow a doctor around. You'll see. Nobody knows everything, and it is expected that individual providers will seek the advice and experience of those around them. That is part of what it means to be a professional. Doctors consult all the time. Before, during, and after both critical and routine care. I don't purport to represent all US paramedics of course, only myself. You are correct though that I am reluctant to conclude that we should "do away" with on-line medical control consultation. I'm not trying to say that paramedics should be calling doctors every day to ask for permission or help, only that they should have that option when things start to get out of scope. It may not have happened to you in a long time, but it does happen, and I feel it should be part of our professional humility to leave ourselves a lifeline if needed. Even though this was my example, I do agree with you. I feel that paramedics are quite capable of identifying STEMI on the 12 lead ECG on their own. In fact, good peer-reviewed research has shown that we can do this quite well. The problem in my area is that even though we may have gained some trust and respect from the ED physicians we deal with every day, we have almost none of that from the interventional cardiologists that we hardly ever see. To them, we are ambulance drivers, and I imagine they have a hard time answering that 3am call at the request of a technician. I only mentioned this because it is one of the main reasons I have called medical control in the recent past, and even though I feel it could be an unnecessary step, it has been successful for me and my patients.

lol So you're agreeing with me right? This is a good place to call on-line medical control. You suggest that crews might "just do it and write it up later," but come on. You gotta have a discussion with the doc. God forbid they turn out to actually be HYPO-k (which can present similarly)! Also, issues with cell coverage and disinterested ED staff should be nonexistent in a system that utilizes on-line medical control properly, which is what I assume is what we are discussing here... I don't know! That's really the point of calling medical control! There are a whole lot of treatment options out there that we don't know about, and even some that I wouldn't try without talking with a doc first. What about giving Calcium Chloride (or gluconate) to a Cardizem overdose? Would you really ever try that without talking to a doc first? I concede the point about VT (I guess), but the point still stands. ECG transmission for complex arrhythmia management is a valid use for on-line medical control. Agree 100%.

Maybe. If you are on your 3rd dose of epi and the patient is 55 years old (which makes epinephrine a dangerous proposition!), perhaps there is something else that ought to be considered. A lot of epinephrine in an elderly patient is something that isn't to be taken lightly. I agree that neither is respiratory distress, but we too abide by a "do no harm" principle. I personally feel like these kinds of "oh crap" situations deserve fresh eyes, and I don't consider it a personal insult to ask for help or a second opinion. Agreed. Although epinephrine infusions for this particular scenario haven't quite made it to the pages of our local guideline books (they actually do say "paramedic guidelines" on the front). An epinephrine infusion would definitely be the subject of my consultation with OLMC in this case. I understand that a paramedic could likely do this on standing order, but epi infusions are not yet commonplace here and it would definitely be prudent to have a talk about it with the doc before we start making things up based on what we may have read about or heard someplace. Hopefully if anyone can, its me! haha. How about: 1. Extended treatment options for field treatment of severe hyper-k without lab results. This is a dangerous condition that we can do something about in the field, but often do not for lack of definitive lab values (and reasonably so!). A conversation with a doc where the paramedic relays the pertinent clinical findings could lead to a field treatment that otherwise may not have been prudent, which could be life saving. This one is from my own experience. 2. Tox syndromes. Toxicology is a whole medical sub-specialty, and there is a lot more out there than the usual narcotic/beta blocker/TCA/organophosphate stuff we are more familiar with. A conversation with a physician in an unusual OD scenario can be extremely valuable. 3. Deep ACLS. Management of refractive brady or tachyarrhythmias (wide complex especially) can definitely benefit from a fresh set of eyes. I have absolutely no problem forwarding an ECG to medical control for a 2nd opinion if I am concerned about WPW in a patient that might otherwise get Cardizem, or a potential VT in a patient who is refractive to Amiodorone. These are tricky scenarios that even cardiologists sweat over. Why make this decision on your own if you don't have to? How about those? We talk to the ED attending that picks up the phone. Our local guidelines contain an agreement between hospitals that the receiving attending ED physician is the acting medical control doctor for that particular patient.

I think there are big differences here in what "on line medical control" means to each of us. I see some people commenting that they have to call a physician and ask about first round analgesia dosing, and I also see people referring to their protocol as "guidelines." These are two opposite ends of the spectrum, and both are represented here. Personally, I don't think we should ever be without on-line medical control for some things. Where I work, we call a physician on the radio when we truly need another opinion on a difficult topic (Should I give a third SQ epinephrine to this 55 year old woman with severe asthma? Do you agree with my assessment of this STEMI patient so that we can bypass the ED for the cath lab? I've got a difficult syndrome here in a critically ill patient and I'm not sure which path to take...). It is my feeling that these calls are open and honest consultations with colleagues, and a recognition that there is a whole lot out there that we Paramedics, or any individual for that matter, doesn't know. Even doctors call other doctors to discuss things if they get in a bind. Who's to say that we are too good for that?

I'm not sure, but I do know that Trauma is not the first to fail in that department. I can't think of a single show about medicine on TV right now (or recently) that is genuinely realistic. My guess is that in order to show realistic medicine, producers would probably have to compromise a portion of the drama, and nobody has been willing (or able) to do that yet. Maybe the compromise is different with cop shows, I donno. I bet it is really hard. This isn't unique to cop or medical shows-- I would imagine that EVERY show struggles to get their audience to connect with the characters on a level like that. If there were a simple formula then everyone would be doing it, but it seems to be pretty difficult because very few shows have attained that level of viewer involvement. Shit, you had to go back thirty years to find an example!

THANK YOU DWAYNE!! I agree 100%. I tried to say the same thing in the last thread and I guess I put it less delicately than you.

I work in a city where the are constant rumors that the municipal fire department will someday take over EMS. I don't feel that they would necessarily do a better job, and I try to make that point known every day though the way that I handle myself and my patients at work. There is a big difference in patient care between an EMT or MRT certified first responding firefigher, and the paramedic who arrives on an ambulance. I make sure that difference is obvious to my patients when I arrive on scene. To be honest I don't really care who or what department "runs" EMS. That argument, to me, is just about turf. What I care about are that individual providers have the equipment, opportunity, skill, and most importantly desire to do their jobs well. I'm not sure if a fire-based model precludes any of that, although I admit that individual experiences do vary.

Wow, -4 reputation with only a single post.. Harsh, guys! I believe I saw that T-Shirt for sale at the JEMS Conference, but nowhere else after that. Your best bet might be to just make one.

Do I really have to explain this to you? I'm not saying he "doesn't care" about our opinions. I just have a hard time believing that they are his primary motivation. My original point was that the direction of the show has, and will continue to be directed by ratings and profit margins. I stand by that point. The show's creator may be a fantastic guy, who knows, but it is ridiculous for anyone to believe that a multi million dollar project like this lives and dies based on the opinions of such a small group of uninvolved people. In order for the show to survive, we EMTs and Paramedics need to make up a small percentage of the viewership. Not the whole thing. He's got bigger fish to fry. Of COURSE he will be quoted saying that he cares deeply about how we feel about his show, he would be stupid not to. ...But at the absolute least I think any of you nitpickers would agree that his actions have spoken louder than his words. There is a difference between an implication and the main point of what is being said. Don't get distracted so easily next time your ego gets bruised. Are you chewing gum? I haven't seen you chew gum once, and frankly, even your gait is a bit unsteady. OK.

Ohmygosh! So the creator of the show went on record saying that he is concerned about the opinions of the professionals his show depicts?? This turns my whole world upside down! Ratings and profits probably had absolutely nothing to do with the decision to cancel or revamp this show. I mean hey, it's right there in black and white! Thanks for that little primer on "situational awareness," dude. Believe every single thing you read on the internet. Got it. Speaking of reading things on the internet, try re-reading my post. I didn't tell you all to shut up and deal with it. I merely suggested that we, as an EMS community, might be better served by focusing on theme and purpose rather than detail and minutiae. Listing menial detail errors in this show is missing the forest for the trees. Sorry if that got your panties all bunched up, but it is what it is.

So only people who agree are allowed to comment? Active conversation is healthy, guys. A forum where everyone just agrees with each other is no fun at all. Let's be real. The director (and whoever else) took notice of low ratings, not quibbles on this forum. I do admit however that is likely someone from that camp probably reads this stuff. My argument is simply that IF it is possible we could have some sort of impact on the trajectory of the show from here, maybe we should focus more on large scale stuff rather than the nitpicky details. Whether or not the portrayed dopamine calculation rate was correct, etc, is thinking small.

PLEEEEEASE stop nitpicking every freaking detail like this. The show will never portray every esoteric nuance to the perfection you guys seem to demand. It isn't a show for you, it is a show for everyone else. Deal with it. I'm happy enough that a public representation of us exists that doesn't portray EMTs/paramedics as subservient stretcher jockeys and simpleminded technicians. Say what you will about the supposed gold standard of "Emergency!," but those guys couldn't take a piss without calling up Rampart on the freaking radio and asking for permission. Not to mention - for it's day - I would say that show contained at least an equal amount of gratuitous TV-candy rescues and improbable situations. This "Trauma" show isn't nearly as good as it could be, but it hits some high points for me. Anything else worthwhile they come up with is just icing.

It has been elsewhere as well, but they've been doing it in Baltimore for the past 5 years or so. It has been in March for at least the past 4 years, usually about the same time. I think it is definitely worth the trip if you haven't been, especially since it is so close. I'm really surprised nobody else is going, and that this hasn't even been mentioned. Whats the deal? No interest? No money? No time?

Anyone going this year? It is this upcoming week, so I'm surprised I haven't seen a thread about this yet. I will be going with a few friends from work, and will be competing in the JEMS Games as well.

Anonymous submission PM'ed to me from one of our members: Earnings: $65,000 (give or take) counting little to no overtime. Job Title: Paramedic Experience: Newer medic/no previous bls experience Type: Private ambulance company State: Midwest/Western state Avg OT: 2 hrs/week (3on/4off, 4on/3off 12's) 401k 6% match, health insurance 25% employee pay/75% employer paid. 2wks/year combined sick/personal days ( 7 days PTO however you want to use it.) Rural/Low cost of living community. No retirement. Great work environment. Thank you to that user above, I appreciate that you were willing to still participate even though you had concerns about anonymity. Please, if anyone else wants to participate in this way feel free to PM me. I will keep your identity secure and post only the info you choose. Yeah and as others have already mentioned, this isn't a "who's got the bigger salary" competition. It is simply a resource (in progress) that others can look to so that they can give some perspective to their own earnings.

I'm not sure. Is it really even true that they don't burn out? Purely guessing, I would imagine that a lot of firefighters have certain things that we don't. A pension, municipal benefits, a long history and the traditions that come with it, automatic respect from the public, and a few other things... Just guessing though.

I disagree. This is a largely anonymous internet forum and I think it is important that we continuously compare ourselves with our peers to get perspective. If you don't want to participate then nobody is twisting your arm.

True, we can add that in as well. I didn't want to make it too complex out of fear that people wouldn't contribute. That was my intention with having people submit their state. Do you think it should be more specific then that? I guess it depends on the size of the state... That was my intention for "number of hours OT," which basically means how many hours over 40 are worked on each average week... Great ideas--- where's your info???

Yeah I think this is definitely true. It really only takes one good call to make 40 or 80+ hours of nonsense completely worth it for me. This stresses me out though, especially as I gain experience and the standard for what makes a "good call" keeps going up and up. The people I know who are happiest in EMS have a really impressive way of finding interest in even their mundane calls: be it a idiosyncrasy with scene management or a conversation with a patient, they are able to make themselves happy with the call volume as it is. Peter Canning (author/blog writer/paramedic, and one of the happiest long-time medics I know) is a master at this. I personally haven't been able to master that skill, and unfortunately I think that really puts me along with the majority of my coworkers.

I thought this might be an interesting thread. Since most of us are working on our taxes this time of year, I'd like to see what our average wages look like. If you feel like participating, please post how much you earned working EMS in 2009, your job title, years experience, type of EMS you work for, the state you work in, and the average number of overtime hours you work per week. To make things easier for people to read, please just cut and paste the format I'm using to post my info. If anyone thinks other information would be valuable for this "poll," please speak up! For me: Earnings: $65,682 Job Title: Paramedic Experience: 3 years as a medic, 5 years with company, 7 years in EMS Type: Private ambulance company State: CT Avg OT: 8 hrs/week