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There has to be a balance..*PRPG thinks out loud* within any region.

In any given time span, there are only so many patients to perform skills on. So, having too many medics, I would think would cause less skills to be performed by the providers in the region.

So, with less skills, comes less proficiency.

But, the reverse is, not enough medics causes irrepairable damage in the light of less available ALS at the times where you need it.

So, this seems to be a need for a balance between the two things. So, less isnt more, but more isn't more either.

Seems to me this article is a complete waste, and the number of providers in any region should be based on a calculation between your call load, and maintaining this balance.

Its 3:40 AM. Did this make sense?

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Dust & Rid, sorry if that seemed a little harsh. I still have a lot of friends in Tulsa who work for EMSA, I guess I am a little protective of my homies. :?

Rid, I started another paragraph last night that covered the fact that the protocols are way behind the times, but I almost fell asleep so I cut it short. That was why I mentioned Sacra was better than Mengis Khan (I can't remember how to spell his damn name, Meninges?). Anyway, that was one of the things I did not like at EMSA. It was quite a shock to go from Multnomah County EMS protocols to EMSA protocols. Sacra loosened them up a bit, now they are on standing protocol, no med control, but they are still limited in scope. The excuse I was always told was short transport time, so we did not need expanded scope/meds. So your right, no pumps, limited meds, no RSI, etc.

Another thing I found interesting is how protective they are of their protocol books. I still have my Multnomah Co. EMS protocols and my Denver Metro protocols, but I had to turn in my EMSA protocol book to get my final paycheck. Weird.

I have been critical of EMSA on these boards before, I am not a cheerleader for them. I just wanted the people who work or have worked there, to get credit for the high arrest save rate. I still agree the study is complete B.S.

Peace,

Marty

:thumbleft:

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Interesting things are occurring. Even with the so called "high saves" which if you look at the numbers there are really no significant changes. Tulsa F.D. ( under Dr. Sacra wing), and a few other F.D. are doing a trial study on allowing enhanced EMT/I's to administer certain medication(s) that are not usually allowed. It is no secret that Tulsa F.D. does not want to be in the EMS business or have Paramedics, however; part of their city agreement was that they would be able to perform ALS treatment (hence Intermediates) .. cheaper and fulfills their obligations.

What surprises me is more and more studies or so-called theories of skill attribution rate etc.... and NONE EVER ADRESSES PHYSCIAN LEVELS ! C'mon with all the patients physicians see, how many intubations, central lines, etc. are they really proficient at ? Especially if they have either been placed on fast track side for a while or playing internal medicine or some other specialty. When was the last time you think that surgeon intubated someone? But, where is those studies at? Although, I am glad we are being paid attention to and definitely we need to improve, it does appear and seem we might be interfering with either physicians skills or treatment plan or reduction in costs.

I am aware there are more and more pressure and studies to "secure" positions in hospitals. For example one state has just passed a bill allowing only a physician or CRNA can establish an EJ/ I.V. The same is true now here in mys state regarding consious sedation, it is now that no RN can give conscious sedation except for CRNA's and physicians in a hospital settings. (Can you imagine what speciality endorsed this ruling?) Now, physicians are complaining that they cannot administer meds, intubate, etc.. all at the same time, and reversal of the ruling is expected. Again, studies were performed to "justify" such actions.

As the "old saying" goes studies are just as good, until the next one is published.

We in EMS ned to pay close attention of not just what is published or performed, but how well the study is conducted and validity of it as well.

Be safe,

R/r 911

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What surprises me is more and more studies or so-called theories of skill attribution rate etc.... and NONE EVER ADRESSES PHYSCIAN LEVELS ! C'mon with all the patients physicians see, how many intubations, central lines, etc. are they really proficient at ? Especially if they have either been placed on fast track side for a while or playing internal medicine or some other specialty. When was the last time you think that surgeon intubated someone? But, where is those studies at? Although, I am glad we are being paid attention to and definitely we need to improve, it does appear and seem we might be interfering with either physicians skills or treatment plan or reduction in costs.

1. Not all physicians need to intubate, place central lines, or all those other EMERGENT procedures. Unlike paramedics (who's skill sets focus on emergencies), only a few specialties have any focus on medical emergencies at all (trauma surgeons, emergency physicians, anesthesiologists, to name a limited few. Emergency physicians being the main group that treat emergencies). Personally, I don't care how well my PMD can intubate or set a central line. I'm more concerned about how well he can juggle medicines in case I ever get put on a ton of different types. I don't care how well a psychristist can intubate or put in place a central line. I care about how well he can treat mental disorders. So on and so forth through the medical specialties that do not treat emergencies.

2. Not all hospitals are trauma centers. If we keep sending all the critical patients that need central lines, chest tubes, and all of those other trauma procedures, then of course the emergency physicians at other hospitals are not going to be as good at those procedures then those at a trauma center. Are you suggesting that we start transporting all trauma patients to the nearest paramedic receiving center or that we should close down all emergency rooms that are not trauma centers?

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What surprises me is more and more studies or so-called theories of skill attribution rate etc.... and NONE EVER ADRESSES PHYSCIAN LEVELS ! C'mon with all the patients physicians see, how many intubations, central lines, etc. are they really proficient at ? Especially if they have either been placed on fast track side for a while or playing internal medicine or some other specialty. When was the last time you think that surgeon intubated someone? But, where is those studies at? Although, I am glad we are being paid attention to and definitely we need to improve, it does appear and seem we might be interfering with either physicians skills or treatment plan or reduction in costs.

Au contrere:

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

and my personal favorite...

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

You will not find literature on the success rate of surgeons at intubation because they just don't do it. It's like trying to find literature on paramedics doing colonoscopy. Although, I did have a surgical resident ask if she could attempt to intubate a trauma pt once. Perfect esophageal intubation on the first (and last) attempt. So, based on my study with an n=1, they need to be remediated in their intubation skills (though I don't think my power will be very high if I took the time to calculate it). Each specialy has its own scope of practice and when there is a procedure that needs to be done, they consult the appropriate specialist. I would never let an ER doc take out my gall bladder, but I would have no problems with them dropping in a central line. I would never let a surgeon do an LP, but give me an ER doc or neurologist and I would have no problems.

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2. Not all hospitals are trauma centers. If we keep sending all the critical patients that need central lines, chest tubes, and all of those other trauma procedures, then of course the emergency physicians at other hospitals are not going to be as good at those procedures then those at a trauma center. Are you suggesting that we start transporting all trauma patients to the nearest paramedic receiving center or that we should close down all emergency rooms that are not trauma centers?

All of those procedures are used in more than just the trauma setting. There are plenty of medical pts that get central lines and chest tubes. Standard of care for septic shock is a central line. Even those docs that aren't in a trauma center does these day in and day out (although the chest tubes decrease in frequency dramatically outside of a trauma center).

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True, but those procedures aren't necessarily done by the emergency physician. The procedure is done less frequently and spread out over more doctors. Whereas the trauma center has a larger number being placed and a specific group preforming the procedure.

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I understand where you are coming from; however not all states have trauma centers and would be very surprised how many truly verified Trauma Centers there is : (http:// www.facs.org/trauma/verified.html ) and of those that claim to be one. As well in a lot of rural and smaller locations, it is not unusual to see physicians be on the code team. This maybe surgeons or O.B. etc.. so yes, they are bound to secure the airway, establish a central line placement etc..

Just because they are a specialty group does not exclude them of general knowledge and practice of a physician. Do the hospitals not require them to have BLS and ACLS?.. and as well, they are not required to maintain their resuscitation skills?.. I am sure if you were to pull up their credentials for privileges and procedure abilities you would find that it would be checked off .. I doubt that they excluded themselves when applying for accreditation and privileges at that hospital (s).

Again, would like to see ACEP or another credible group perform a study on comparisons). Similar to the recent study of Lasix administered prehospital to that in hospital. After the hBnp & CXR was performed the medics were criticized for misdiagnosis... wow, who wouldn't be >90% with those diagnostic tools?.. It would had been more informative to see a study of using the same diagnostic of assessment skills of the Paramedic, Physician, and then with the use of diagnostic tools.

Like I stated, I am all for progressing, but I believe there is a lot of bias allowed. Not being able to have an EMS advocate I believe is slanting the studies. As well, unfortunately many do not read into the studies in-depth to see if the study was truly valid and statistically correct, and take many studies at blind faith. Like I described they are usually all good until the next study performed.... such is medicine.

R/r 911

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Perhaps I'm a little off here, but, I don't see how less equals more in this instance.

Wouldn't this be more of an issue with QA/QI programs instead of HR? If the medics aren't receiving enough calls to keep certain skills current and fresh, then either pull them from the book or offer more frequent refreshers with CMEs. This is where I believe it's up to the service in co-operation with the base hospital/medical director to do some research and tailor the needs of the medical protocols to the community.

peace

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