How Would More Education Make You A Better Medic?

[ccmedoc]

So really, you're talking about eliminating the EMT-B level altogether and making paramedic the new entry level, no matter what you call them.

I think this would be a great idea, as long as the education is there . As you said, the scope of practice in the majority of areas in the U.S. is adequate. The frightening part is that most medics don't have more than a basic knowledge of the "new" skills they are given, let alone the possible ramifications. This makes it difficult to foresee any possible problems, let alone remedy them when an untoward event happens. I think an Associates Degree is adequate for the entry level, but a Baccalaureate is not out of the question and should be preferred. With tech the way it is and the progression of medicine, how can we give more responsibility to EMS without the requisite foundation of education??? I believe that Microbiology, Advanced A&P, Chemistry, Bio-chem, Intro. Psych, Developmental Psych, Pharmacology, Composition/Grammar, and Algebra as minimum pre-requisites..This would give the educational foundation and tools to understand the physiological rationals for what we are asked to do. Some of the "paper-medics" that get a license or cert with the sole intention of firefighting and nothing else may find this a bit much, but if a medic is going to practice as a professional, these pre-requisites should not seem out of context..

I don't understand the argument against advancing the education requirements, as they only serve to further the profession, both economically and professionally. If you (generalized "you" and no one in particular) want to be seen as a professional, then you must first act like one. Advancing education is the best place to start. The days of becoming an EMT out of boredom or nothing else to do are over, one way or another. I am very concerned by all of the references to over education. Is there such a thing???

Spank away :roll: If I got repetitive I apologize, apparently some things need to be repeated a couple of times :wink:

[UMSTUDENT]

I'd like to add to this discussion by noting a phenomenon that I've been seeing ever since I recently became registered. I live and work in a fairly conservative state, from a protocol perspective that is. The state, probably in the best interest of its citizens, generally tends to develop its protocols based on the proficiency of the lowest educated, least skilled ALS provider. Basically, this state develops all of its protocols around the EMT-I and certificate level, protocol monkey paramedics.

What is totally sad about this is that in most cases it works…in safe, sorta mitigating way. Patients get to the hospital relatively intact with some level of palliative or supportive care. I recently got in an argument with a paramedic I highly respect. He works for a private flight service and generally knows his sh*t. We went to the workplace of a 26 y/o male patient who was experiencing a sudden onset of chest pain. The guy didn't describe it as substernal, but more of an encompassing "pain-like" sensation. He stated that he had recently been referred to a cardiologist who had diagnosed him with panic disorder.

I started a 12-Lead on scene to see what was going on. The 12-Lead came out and low and behold...nothing. The guy had an otherwise nondiagnostic, normal 12-lead ECG. I, as a fairly new ALS provider, handed it to this veteran and told him my findings. The guy's only cardiac mitigating history was that he recently quit smoking and had been unintentionally abusing his nicotine patches. The guy was in a normal sinus ECG w/o ectopy or other notable abnormalities. Perfect vitals, not diaphoretic, not in any obvious distress. My impression was that he was having a panic related event and needed to be treated accordingly. In our state, with the initiation of ALS, all patients complaining of chest pain get ASA and at least one nitro. So regardless of what you think is wrong, the protocol clearly states that you must perform this procedure.

The difference is that this paramedic looked up at this guy and said, "You know bud, I think I see something that concerns me, so I'm going to work you up. I don't exclude people based on history." To this I said, "Ugh, what do you see?" He said, "I see something in V1 that is concerning, plus he has poor R-wave progression and some elevation in V2 and V3." I said, "His QRS duration in V1 is normal, I doubt he's got RVH, and the elevation is 1-2 mm and nonspecific." "Oh, and I don't see a delta wave either." Now I also realize that there are a billion criteria for every interpretation of a 12-lead, but this guy didn't fit the bill. To me these were just normal variants, or as I like to say, fingerprints of a unique individual's ECG. No bundle, no benign WPW. Age, history, and simple probability don’t lend themselves to cardiomyopathy. Ischemia? There is chance he could have some. It does happen occasionally after all. Preventive ASA and nitro wouldn’t hurt the guy. A clear presentation to a consulting physician at bedside, with the ECG in hand would be an absolute.

We got in an argument later about the merits of using a patient's history in determining the level of care that would be provided. This paramedic believes that the results of an ECG are final in the interpretation of possible cardiac events 100% of the time. We didn't disagree on treatment, especially since the protocol clearly states what to do every time. I argued that he did more harm to this guy. IMHO, this guy was suffering from a psychological issue that was diagnosed by a physician and met all of the clinical manifestations of a panic related event. Telling him that something is wrong with him will only make him not believe his doctor and NOT seek help for his problem, which itself can be severely debilitating. I explained that the most appropriate thing to do was to treat him and let his doctors, with more definitive test, make that decision in a less stressful situation. Presenting the nitro and ASA as a preventive, “just-in-case” measure that is afforded to everyone presenting with similar ailments would have been a much more appropriate way to present the treatment. Besides, he opted for no oxygen!

Now the point of this story is that because of these protocols our treatments, regardless of the clinical interpretation we each had, would be the same. The difference between the two of us is the tact and presentation we would have made to the patient. Sure, would I be cautious and give the guy some aspirin? Sure. Would I have given him a shot of nitro? Maybe. Would I have told him that he has a potentially life threatening cardiac complication? Absolutely not. The evidence simply wasn’t there to get this guy worried about his heart exploding.

Now you may be asking, if you actually read this essay-long post, what is the different between the two of you? Well education for one. I had a fairly well-rounded education from a psychology stand point. I also have some experience writing on anxiety related conditions. Lastly, I had a very good, intense, well-rounded patient assessment class. My hunches are based on statistical information, common and uncommon presentations, good history taking skills, and a fairly thorough understanding of the human body. Not to say the other guy doesn’t, but I believe it’s more founded in experience and less in formal instruction.

The difference between an educated and uneducated paramedic may seem like nothing on the surface, especially in an environment (state) like I work in. If you were to look at this case from a QA standpoint, knowing nothing of the interactions between the paramedic and the patient, you would say he did his job. The difference is in the realization that being a professional, well-rounded paramedic isn’t just about performing skills. It’s about treating the whole patient, not just a perceived emergency. It’s about remembering that your interactions with that person will follow them long after they leave the ambulance. So to the person who says that skills must be commiserate with education, you’re flat wrong. Until more paramedics can thoroughly understand the basics of patient care and the basics of treating the complex, amazing machine that is a human being, then skills should probably remain see-do.

[vs-eh?]

In our state, with the initiation of ALS, all patients complaining of chest pain get ASA and at least one nitro. So regardless of what you think is wrong, the protocol clearly states that you must perform this procedure.

I truly don't know what to say.

So any (I assume adult and I hope at least it's non-traumatic) patient that says "chest pain" gets asa and nitro REGARDLESS of anything else? Assuming no contraindications?

WOW...

Do all patients who say they are "short of breath" get a salbutamol (albuterol) treatment or any other "breathing medication" that you carry? If not, why not? It's basically the same type of deal.

Screw this whole clinical evaluation thing and actually assessing the patient.

"Medic" - Hi sir, what's the problem.

Patient - My leg is bothering me.

"Medic" - Are you having chest pain?

Patient - Yes, but...

"Medic" - Ok, I'm going to start an IV and give you some...

Patient - Wait a second, I always have chest pain. Doctor's tell me I have something wrong with the cartilage in my chest. It's not my heart, I've been investigated many times. I take Tylenol...

"Medic" - Sir you are having chest pain, I have to do this. You could very well be having a massive heart attack.

LOL...

My time on this forum has shown me that there are educated EMT's and paramedics in the USA. Unfortunately, every time American EMS is brought up in my place of work, people think that the above "chest pain protocol" is how your system operates. Give the red drug to the red (heart) patient. I know this isn't necessarily true, but the fact that things like this still exist and the grossly inadequate education that is routinely available to those in EMS solidifies this stereotype.

[UMSTUDENT]

Absolutely that is the case. Certain obvious things dictate caution; for instance ECG changes indicating an inferior MI would indicate judicious use of nitroglycerin instead of blind implementation. The basics of med administration still apply. For instance, an allergy to a drug would obviously contraindicate its use. Otherwise, the protocol is clear. There is a gray area with this patient, since he was under 35. Another protocol would indicate he is a BLS patient. The interpretation gets fuzzy because most jurisdictions here indicate that once an ECG is performed, a solely diagnostic procedure, the patient is now ALS.

Stupid, but true. Sorry to tell you.

[PRPGfirerescuetech]

Ahhh... now you're making sense! Total agreement. It's just that, once you do that, they would no longer be EMT-Bs. So really, you're talking about eliminating the EMT-B level altogether and making paramedic the new entry level, no matter what you call them.

The ALS scope and education does need expanding, as they are both woefully undereducated to perform the job duties of an advanced provider.

Both ALS and BLS education and scope are far too low, and need to be brought higher to match our other peers in medicine. This is NOT just a BLS issue when it comes to poor education and scope of practice.

[Dustdevil]

The ALS scope and education does need expanding, as they are both woefully undereducated to perform the job duties of an advanced provider.

What do you think is missing from the current paramedic scope? Most states don't even define paramedic scope, other than to say it is whatever the MD orders. Considering that, I'd say our scope is pretty unlimited, except in places like Kalifornia and Maryland. And, as UMSTUDENT correctly implies, restrictions are currently a good thing in those places.

[croaker260]

Well dust, in addition to the tons of clinical knowledge I think we could/should improve on, I think we are also missing the things that people don't think about, such as how to read and do research...so you can make CORRECT and MEANINGFUL..not KNEE JERK reactions to research papers, assuming you wven read them (not meaning you DD, medics in general)...

I think we should have a bit on systems design, including QA and economics.

I believe we should have some introductory adult education classes, as I feel it is EVERY paramedics job to teach and learn.

Basically things that take an individual from being just a good clinician to having the tools to be a positive impact on the profession.

And BTW, I DO NOT think every provider, or every ambulance needs to be paramedic level. This thinking is what has landed these mother may I systems with a plethora of crappy medics and medic-mills. I do agree with degree requirement's, but I don't agree with over-saturating the market. Simply put, not every patient needs a medic, just like not every provider in a hospital is an RN....

T

Many, most even would do better with a well trained basic (agreeing that our current basic is not what I call "well trained" as a common generalization..some exceptions not withstanding).

I believe that 75% of 911 ambulances could be manned with EMT Basics or Intermediates...and take care of 90% of calls. 25 % (OR LESS) of ambulances should be highly trained/educated Medics (and I do not think that todays medic is typically "highly trained/educated", except in the KCM1 system and similar programs) running only on calls where they can be reasonably expected to use their skills, and BLS requested to others....thereby becoming HIGHLY TRAINED/EDUCATED and HIGHLY EXPERIENCED medics...something of a rarity these days.

ALS care is not the standard of care, unless we want to lower the definition of what quality ALS care really is....standard of care is APPROPRIATE care for the patients complaint. Often that is just a swell served by a well trained BLS/ILS provider.

[PRPGfirerescuetech]

What do you think is missing from the current paramedic scope? Most states don't even define paramedic scope, other than to say it is whatever the MD orders. Considering that, I'd say our scope is pretty unlimited, except in places like Kalifornia and Maryland. And, as UMSTUDENT correctly implies, restrictions are currently a good thing in those places.

Im working under the previously defined national scope of practice as the basis for my prior statement. That being stated...

The future of EMS is a larger pie of primary care, moreso as the ED's of this nation become overcrowded. We need to step up education and scope of practice, to meet the demands of our potential future.

[Dustdevil]

The future of EMS is a larger pie of primary care, moreso as the ED's of this nation become overcrowded. We need to step up education and scope of practice, to meet the demands of our potential future.

Still trying to understand just exactly what you are getting at.

Are you talking about movement towards the so-called "Paramedic Practitioner" concept, with field treat-and-release (diagnose-and prescribe) privileges? Clinical (non-street) privileges? Both? Or are you talking about an expanded scope within actual field EMS emergency care?

Though the Paramedic Practitioner concept is an intriguing one, and could be viable with the right educational preparation, there are things that worry me about it. Not so much that paramedics couldn't handle it. They could (again, with the right education). But my two primary concerns are this:

• 1. I disagree that our future success lies within taking a bigger slice of the medical pie. I think our future lies in specialisation. Doing one thing and doing it well is almost always a better choice than trying to be all things to all people.

2. You think EMS is abused now, when all we really offer is a ride to the hospital? Wait til people get used to us making house calls for minor ailments! The impact will be overwhelming. Not to mention that the AMA will strenuously oppose this every step of the way. We barely have the political clout to get wanker plates in this country. There is not the slightest chance that, within the next twenty years, we will possess the clout to achieve practitioner status.

• Aside from a clinically expanded scope, I just cannot think of much ambulance EMS type expansion we could ask for.