The role of EMTs in EMS

[kristo]

While some EMTs/paramedics (certainly seems to be a majority here) wants to advance their trade as an independant medical profession, this ambition seems to vary in quantity or quality.

The reason I'm bringing this up is the state of EMS in rural Iceland. In the capital city, where most of the people live (200,000 out of 300,000 total), we have a good system. However, in many rural areas, we do not. We don't have volunteer EMS, but in areas where the call volume is not very high (eg. one call a week or even less), EMTs do "normal" shifts where they get 30-45-90% salary (depending on the time of day/weekend/holiday) just for being able to come in immediately if there's a call. If there's a call, they get normal EMT salary for at least four hours. Those guys will usually have another job, where they have an arrangement with their employer, so they can leave if needed.

Now, the problem with this is, of course, education - not everybody has even an EMT-B certification. Problem no. 2 is the government not wanting to pay for more than one EMT on call at a time. Until about a week ago, this was a fact in two places. Press got to it, and the government all of a sudden assigned a bit more money, so now there's always two EMTs on call. :roll:

In those rural areas, it is customary for a doctor to respond with EMS. When there was only one EMT, the doctor would attend the patient in the back, without any assistance. Now, and in all other areas, the doctor would attend with the help of an EMT (without cert, EMT-B or even EMT-I).

Now, in those areas, EMTs seem to be content with this, and don't see any reason for more education, as the doctor is there to make all the decisions. The doctors tend to train them in advanced procedures like IVs, intubatons, CPAP, etc., which they will perform if the doctor asks them to. They do not see anything wrong with performing those procedures without the education, as the doctor is there to make the call.

Now, I'm not really sure what I feel about this (not that I have any influence in the matter )

On one hand, the education is there, with the doctor. On the other hand, there are people performing procedures they do not understand...

What do you guys think?

[Just Plain Ruff]

I'm sorry, but not this again?

[kristo]

I'm sorry, but not this again?

Okay, I'll rephrase the question. Do you think an EMS system where the medical director only wants to use the EMTs as extra hands and nothing more can work, as long as the extra hands (the EMTs) are fine with it, as well as the MD, who, in this case, is the actual care-giver? In this case, the medical director is on scene, so any technical problems related to communication and patient assessment through lay-persons are bypassed.

I'm not asking for another "EMTs should be able to diagnose and decide upon advanced treatment" debate here. And even if I was, we sure could use one. The City's been awfully quiet lately...

[chaser]

Kristo-

I don't think the city is quiet, more that this has been covered.

Here's a start:

http://www.emtcity.com/phpBB2/viewtopic.ph...=eucation+basic

Do a search and you will find tons of opinions and a general consensus regarding your question.

Good luck

[Just Plain Ruff]

Okay, I'll rephrase the question. Do you think an EMS system where the medical director only wants to use the EMTs as extra hands and nothing more can work, as long as the extra hands (the EMTs) are fine with it, as well as the MD, who, in this case, is the actual care-giver? In this case, the medical director is on scene, so any technical problems related to communication and patient assessment through lay-persons are bypassed.

I'm not asking for another "EMTs should be able to diagnose and decide upon advanced treatment" debate here. And even if I was, we sure could use one. The City's been awfully quiet lately...

Is the medical director on scene for every call? Sounds like he's a busy busy person.

I don't think that emt's should just be seen not heard. They also should not be just used as hands only. They should be able to assist the medic if needed. Two medic crews are great but they are just not the norm in many places so some places are stuck with the sub-optimum(according to some here) processes.

I think that if a medical director gives them education, and I'm not just talking this is how you do this, they have to have as much education on that particular procedure as a medic is.

for example - intubation - the education should be not only on intubations but the anatomy and physiology education to the level of medic education. So if medics have to have 32 hours of respiratory education, 12 hours or more airway and whatever other education that medics received. If that level of education is not met then I don't believe that any EMT has any business intubating or doing procedures that medics train for many many hours to do.

[Chief1C]

He must have been cloned.

[kristo]

Kristo-

I don't think the city is quiet, more that this has been covered.

Here's a start:

http://www.emtcity.com/phpBB2/viewtopic.ph...=eucation+basic

Do a search and you will find tons of opinions and a general consensus regarding your question.

Good luck

I don't think this is the same subject. I'm not asking if EMT-B's can function as medics, I'm not questioning the need for proper education for EMS providers and I'm certainly not questioning that most medics would want a fully fledged partner, not just a driver.

What I'm asking your opinion on is an EMS system with very low call volume, in which a doctor will be the primary care giver, accompanied by a driver and a tech assistant (EMTs). The EMTs are not being asked to be the physicians eyes or ears, merely provide an extra hand when the physican needs it. The physican will always be physically on scene, in the ambulance, working on the patient.

[Just Plain Ruff]

Ok, asked that way then yes I believe that your system can survive as you put it.

But you did mentioned advanced skills and that boiled over to education.

If the physician only wants the EMT's there as a pair of hands and the EMT's are OK with that lot in life then YEs they can.

[kristo]

Is the medical director on scene for every call? Sounds like he's a busy busy person.

I believe in these cases medical direction as in protocols, equipment, etc. comes from a committee of local doctors, or the senior physican at the local hospital or clinic. The doctor on the call will be the on-call doctor at any given time. Remember, we're talking 1-2 calls a week.

I don't think that emt's should just be seen not heard. They also should not be just used as hands only. They should be able to assist the medic if needed. Two medic crews are great but they are just not the norm in many places so some places are stuck with the sub-optimum(according to some here) processes.

I tend to agree. It would not seem that EMTs that are content with being extra hands in the ambulance and/or drivers for the doctor are very ambitious. I would also tend to agree that a medic/basic crew would perform care at a lower level than a medic/medic one.

However, and I'm really just playing devil's advocate here, technically, the medical command is responsible for EMS in its area, and if this is how they want to do it, i.e. do it themselves, with the help of (just) a pair or two of extra hands, that's the way it's going to be...

Please also bare in mind that EMS is not the career of those EMTs. You can't have full time EMTs for 1-2 calls per week (I would welcome any thoughts on this, though), so they may not see themselves as medical professionals at all(?).

I think that if a medical director gives them education, and I'm not just talking this is how you do this, they have to have as much education on that particular procedure as a medic is.

That's definately not what's happening. They are being taught certain skills, and as we all know, medical care is not about skills. They're just being taught enough to serve as extra hands for the physican, I believe.

for example - intubation - the education should be not only on intubations but the anatomy and physiology education to the level of medic education. So if medics have to have 32 hours of respiratory education, 12 hours or more airway and whatever other education that medics received. If that level of education is not met then I don't believe that any EMT has any business intubating or doing procedures that medics train for many many hours to do.

Agreed - or semi-agreed. Wouldn't you say that a lot of the education that medics receive is about deciding if, when, how? I think we can agree that in many cases, the actual act of putting in the laryngoscope and placing the tube is a mundane, manual task.

Remember, the doctor will always be there to assess whether the patient should be intubated or not, when it's done and how (or if he does it himself or has an EMT do it).

I'm not really sure as to how far the EMTs go in this. The state of EMS in the rural areas of the country have been in the media for the last few days and the minister of health just formed a committee to look into the matter. They're supposed to finish their work in October or November, I believe.

I'm still a bit torn on this. On one hand, why should we have first aiders pose as medical professionals? On the other hand, a doctor and two techs may be just fine. The call volume is certainly not going to wear the doctor out from always being the primary attendant. Is one doctor and two EMTs as good as two medics? Let's say we had medics there, would they be content with 1-2 calls per week? Would we want to pay them for siting idly waiting for those calls? Would their assessment skills deteriorate because of the low call volume? The on-call doctor is obviously also working in the hospital/clinic.

Getting medics to work in hospitals and go from there on EMS calls is another idea. In rural hospitals where there is sometimes just a nurse and a few orderlies (and a doctor at his home, available if called), there might not be a lot to do for two medics, though.

I'd like to make it clear that I am NOT advocating that EMTs should be making assessments or deciding treatments - I am merely speculating about a system that has been used for years, and is based on the usage of physicans on-scene, and the role of EMS as assistants for the doctor, rather than semi-autonomous providers.

Also, I do not believe that EMS, in itself, should be like this. EMS should be a career for well educated, motivated medical professionals. I wonder, however, if EMS in those areas could be done better - especially considering that a doctor is a very well educated medical professional and should, by all standards, be fully capable of handling this task.

[kristo]

Didn't see your reply until I had posted the next one, you answered some of my questions in your post.

Ok, asked that way then yes I believe that your system can survive as you put it.

Not mine, dude. 8) An old system, actually under review. But, yes, maybe it could survive.

But you did mentioned advanced skills and that boiled over to education.

Of course it does. But maybe the physican's education can suffice.

If the physician only wants the EMT's there as a pair of hands and the EMT's are OK with that lot in life then YEs they can.

This is an old system, I believe this is simply what they're used to. Again, this is often *not* their primary career.