Are They Dumbing Down Emergency Medicine?

[Scaramedic]

I have noticed a trend recently that concerns me greatly, the dumbing down of emergency medicine. I say emergency medicine because it is not just for EMS, it is for everyone M.D.'s, RN's, Para's, Basic's, etc.

On this site we have several discussions concerning this issue going on right now. Just reference the thread "New CPR standards." In this thread a study is cited that concludes that EMS and ED personnel should not intubate arrest patients. The study says that BLS procedures are the intervention of choice when it comes to ventilating certain arrest patients. Also several other threads reference the Basic course being simplified over the years.

The most glaring example of dumbing down I have seen is ACLS. I recently renewed my ACLS and was shocked to see the changes that have taken place. To give you a reference point, when I took my first ACLS course you had to know at a minimum the basic EKG rhythms, and strips were part of the test. The test itself was not hard but did require a bit of actual thought. We also had to base our joule settings on the patient's weight, yes a little math was involved, and we had to know such things as drip rates for various medications.

Fast forward to 2006, I am sitting in class with about 40 RN's, 2 M.D.'s, 2 Paramedics and 1 X-ray tech. In this room only about 5 people could read an EKG. But according to the new ACLS standards that's OK, because EKG interpretation is not part of the new standard. All you have to know is this, is the rhythm too fast, too slow and is it regular? There are some strips in the book for review but they are not part of the test anymore. And, if the test is too hard for you, you can use the handy dandy cards that are included with the book. The test is a little on the easy side too, here's an example...

A 42 yo male presents to your Emergency Department he is pale, diaphoretic and and is complaining of generalized weakness. His B/P is 88/45, PR 34, RR 28, the EKG shows a sinus bradycardia. After IV, monitor and oxygen your first pharmacological intervention should be..

A. Purina Dog Chow

B. Haloperidol

C. Atropine <---------This is the answer

D. Two ASA, discharge patient and have him call his Doctor in the morning.

OK, so that was an extreme example but I hope you get my point. No more EKG's, no more memorization of medications, drips and dosages, and simple tests. And to top it off, you can not fail the course, they will help you pass it with remediation.

I love the fact that on this website the push is towards higher education standards for EMS personnel. I think that the higher educated someone is the better care provider they become. The problem is, even though we are talking amongst ourselves about higher education it seems like the trend amongst many groups is going in the opposite direction.

So that is my question is this, are they dumbing down Emergency Medicine?

Peace,

Marty

:thumbleft:

[chbare]

I cannot speak for Physicians and other health care providers, however, I am startled by what I have encountered regarding nursing students. I see students nearing graduation that have very little knowledge regarding pharmacology and pathophysiology. I am talking about students giving Motrin that do not even know the basic mechanism of action of NSAIDS. I have asked people, do you know what prostaglandins are? "Prostawhat" is a common reply. I have talked with several students from many different programs and I am saddened when I hear that many students do not look up drugs or do drug cards on every medication they give, or are allowed to buy pre-printed drug cards. Students are doing very little to no preclinical work as well. I remember preclinical work involved several hours of researching you patients problems and writing down pathophysiology of the patients problems and explaining the implications of abnormal labs, in addition to starting the basics of a care plan the night before taking on patients. I have noticed very little instructor oversight of the students, especially when students are working specialty areas. I have a theory, I believe the shortage of health care providers creates an environment that encourages schools to make "shake and bake" health care providers. Pump out lots of new and under-trained grads into the field.

I have noticed problems with paramedic students as well. Poor instructor oversight of students, lack of motivation and good work ethic, and lack of basic knowledge regarding pathophysiology and pharmacology are problems of both nursing and paramedic students. I have seen many paramedic students simply copy all of their assessment information off of the patient chart over actually going in and assessing the patient. I remember not too long ago listening to an apical pulse and hearing a rather profound systolic murmur, I asked the paramedic student if he wanted to listen, and he told me no, "because I already know what they sound like." I no longer precept students because I will not let them give meds or provide care if they do not show motivation or fail to tell me the basics of how a medication works and at least have a fundamental understanding of the pathology behind a patients condition. Of course the expectation is different regarding a first semester student, but by graduation time you need to have a clue, and good work ethic/motivation is required regardless of where you are at in your education. On a positive side I have met many highly motivated students that "have their poop in a group." I just do not think schools are creating a challenging environment that promotes learning and good work ethic, and an environment that weeds out the dirt bags. This is just my opinion however.

Take care,

chbare.

[TechMedic05]

I believe they dumbing things down, across the board. I recently recertified ACLS as well, and was rather astonished at the way the instructor informed us. He flat out told us "This has all been either streamlined or dumbed down." in my class there were 3 Doctors, all internal medicine, 3 PA's of various backgrounds, 2 ICU nurses from our state's only level one hospital, and lil' ole me, Paramedic. I guess what was most amazing was how little everyone from the class knew about ACLS...Just the 'algorithms', never mind drug or CPR effects. One of the ICU nurses scenarios was a chest pain, RVI patient, who she told 'Well, all I'd do is wheel them to the ER"...?

I guess they may not be exposed to the prehospital or initial parts of ACLS, but why are they so opposed to try to learn it?

It's not that hard. Especially now.

[AKmedik8or]

The medical system is not being dumbed down as much as it is being run down. The effect is directed toward every worker in the medical field MD PA RN LPN EMT all the way down to the person slinging the prepackaged ready to warm fortified food in the hospital cafeteria.

The system we work in won't stand for a higher quality; there is no cost savings in a well rounded education. The quality is measured in high volume rapid treatment / testing using the lasted and greatest diagnostic tool. Promoted by some recently fired copier salesmen newly appointed to medical sales who pushes the sale off onto the hospital or sells to your EMS director who last ran a call when emergency was on prime time.

The days of having experience prior to advancing in the medical field are gone. The system is over burdened and broken. Patients are educated (brain washed) through TV ads as to the type of medications they need for their illness or lack of, heck, ASA cures all.

The first thing I attempt to show 3rd riders new EMT's and Paramedic students is using your head ears eyes nose sense of touch and humanity in patient care, otherwise known as a patient rapport & exam. The first diagnostic tool on the patient is your hands. I mean really WTF are schools being forced to teach? I realize the demand for medical care workers is high, in a system of high demand you would expect to produce a high quality highly experienced worker.

I too am bummed by the lack of knowledge that my colleagues. where is the desire to seek knowledge?

[Ridryder 911]

There was a response from an Emergency Physician I wish I could get his video that was posted. Unfortunately, it has been removed. He discussed the "dumbing down in emergency care".

This is a societal issue as well. Fail frying fires at McDonald's University then try being a Paramedic... chances are you will make it then return to McDonald's because the benefits are better.

Yes, ACLS has been "dumbed down".. a couple of reasons. One it is no longer politically correct to say to anyone " YOU ARE TO DUMB TO DO THIS JOB & YOU DO NOT NEED TREATING PATIENTS !" As the physician described in his lecture, we used to respect ACLS, because it meant you met the basic criteria , that you knew what to do !. Now, since it is NO longer a certification (hence a education credit, NOT a CERTIFICATION !) one cannot even fail the test.

Mega codes are no longer in place to challenge individuals of emergency cardiac care.. As he described in his lecture.. "these patients are sick.. the will die ! You are supposed to know. what to do. it is your job ! .. You don't know what to do ...then you fail!".. If you pass and are allowed to perform in the same manner, these patients will die and in a way you are grossly neglect.

Some of the other reasons emergence medicine has change. Is the reason I went back to the field full time EMS and quit being an ER/ RN. In ER, you rarely truly see an emergency patients.. It is not like it was even 10-15 years ago, where most patients that went to the ER was at least somewhat an emergency. It is estimated that 80% of ER patients now could had been seen in a physicians clinic. This means you are busy with a "toe ache" for 3 months, while you are taking care of the AMI and GSW, also as well with the patient that came in ER to have a pregnancy test performed.

Knowingly all the time if a patient complains....it is your arse.. and you better have all that paper work in order as well.

So what happens... those that really care and perform well in crisis situation(s) gets all the S*itty patients, along with minor and those that are pretty clueless of emergency medicine gets all the minor B.S. .... hmmm see the fairness ?

As one nurse told me.. " I could and would be better at emergency care, but why should I ? More work, more responsibility, more paper work, no more money.. no thanks !" After they said this they asked me. "Did you get to have a lunch break or go to the restroom?".. I did".. I can't argue with her there....

So now we are stuck with piss poor attitudes and the new "teaching" of everyone can do this.. and the "world is great attitude"...meanwhile more and more are entering with this new attititude.

R/r 911

[JakeEMTP]

We have to run a mega code in our oral boards to function as a Medic in our County. Our Medical Director insists on it, he also is the one who preforms this test.

I agree with the dumbing down problem. Although I am just a student myself, I do have a BSc in Biology. I can just look around the room at the confused looks from a select few who are just lost. Our instructor is very good and doesn't stand for any crap. Attrition will thin the heard. Too bad the pre-requisites we envision aren't in place or they wouldn't be in the class to begin with, but I digress.

[Wackie]

This is a super secret black ninja program the government has begun to help with population control.

Shhhh...don't tell anyone I told you.

[Khill]

I agree 1000%. 
It has infuriated me for years now how they are literally dumbing down EMS. Here in Hawaii they took our 18 month program for Paramedics and shortened it to 11 months. They made the cardiology and pharmacology sections “self study” and cut an entire rotation of internship out. It’s almost impossible to fail the program. One student had failed some rotations but then passed anyway by the instructor. 
After many years of frustration I finally understand why they are doing it. They want the fire department to take over EMS here across the state, and making the training easier and shorter will make it easier for the fire department to get their guys through training. Guidelines for care will Be shorter and easier to follow. They recently forced Pulsara on to the ambulances and made it mandatory to use. Only a fire based system has the extra people on scene to sit and type into a device and take pictures. They are also discontinuing our prehospital ability to transmit 12 lead EKGs which significantly reduces time to the cath lab. Even worse, we are now limited to 10mph over the posted speed limit when responding to and transporting patients. This will nearly double the time it takes to get someone to definitive care. All of this while taking away medications and skills needed by the medics for their patients. 
We have a broken system here in Hawaii that needs to be fixed but the department of health has zero interest in it and those running it are unqualified and refuse to take any input. We have zero voice on the national level and decisions are all made based on the bottom line while patients suffer and die. Meanwhile fire departments have seemingly bottomless bags of money and support from local, state, and federal government. 
Fire based EMS is NOT the gold standard and does NOT fix the issues, even if they all try to convince everyone that it is. 
EMS is not just a ride to the hospital. We are abused by the public, and many stakeholders and treated like taxis. We need to fix it and save our profession.