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"There is no money for training..."

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Well, let me first start off with some facts and to applogize, because I know there are some spelling errors that I missed.

1) The company I work for took over exclusive ambulance operations in two thirds of the county I live in almost two years ago

2) In 15 years, there was not one incident in a lack of pt care prior to the county awarding the contract to my ambulance service

3) In two years, there have been twelve documented cases of pt's either dieing or having some disability requiring extended stays in ICU's.

Well, there it is. Layed out right infront of you.

Before my company took over operations for two thirds of the county I live in, the crews took pride in the fact that they delivered above excelent patient care to the people they served. On average, I'm guessing they had a average of five years experiance, if not more, behind every medic. Training opportunities were there, there was a peer review. From what I've been told, the company actually gave a flying hoot about its employee's, supprisingly enough.

Now, two years later, the work force has increased almost four fold. The ratio of people who have experiance to those who are right out of school is getting ever so smaller. The turn over is so high, the average amount of time that EMT-B's are spending on a BLS unit before getting a ALS upgrade is going from more then a year, to six months.

Medic wise, there is a combo of people out there. Those who have been in the business for a while, that know what they are doing, that have the experiance to go along with the knowldge. Then there are those who are right out of school, that spent maybe a year on a BLS unit, with no ALS experiance, and all they are required to do is a five call (five ALS contacts), and ride duel medic for no more then ten shifts.

Now that a little bit of a background is out of the way, I can get to the heart of the matter, but there is more of that to come later, I don't want to spoil it to soon.

Last week, a email was sent out by my Union, it stated that the County EMS authority was setting out a new policy that prohibited paramedics from handing off BLS contacts, even a simple BLS transfer, to their EMT-B Partner. Why you ask? Eh, you must not of read #3 above. Since my company started running full time as the #1 provider to most of the county, there have been 12 cases, TWELVE, where the medic had screwed up, didn't do a assessment, missed something on his assessment, whatever the cause was, turned over the patient to his EMT-B partner, and took the pt in BLS. Those pts, later required extensive stays in the ICU, if not a trip to the morgue.

Example #1; Please, before you read this, keep this in mind. What I am writing here is heard at best, second hand. I have not first line knowldge of what happened. A hypoglycemic pt was taken in code 2 to the hospital. The medic reportidly tried only a couple of times for a IV, and took the pt to the hospital, where the pt coded. Now, when we are unable to get a IV, after the second try, per protocol, we're to give the pt one unit of glucagon. What I was told was that this medic didn't give to the glucagon because "it was out of reach". Now we work in the type II ford van styles. Even my partner, whos not the tallest person in the world, could reach the glucagon on the shelf from the jump seat (not saying thats where this medic was). Anyway, long story short, this pt ended up passing.

At this point, the county EMS was going to make it a county wide policy that all medics must tech the calls, that no EMT when working with a medic would have patient contact other then when the medic was doing the assessment on scene. But my company stepped up and said that they would make it a policy internally. Well, that went over about as well as giving a drowning man a glass of water. The union protested, and management gave in, going with the union that there would be change.

Now after this, there was only one training session for medics, and it was with regards to advanced airways. Ok. I can see the use on this. A skill that some people don't get a lot of practice on. Plus we were given a new piece of equipment, a ETTI (please don't ask me to spell it out). So, yea, new piece of equipment, we need the training.

So the latest incident, patient was attempting to shop lift from a store, well, security cought this person and beat the tar out of this person. Now I spoke with the medic today, and he stated that the pt presented with normal V/S, clear breath sounds, and no head/neck/back pain. Well, they took this patient in BLS. And that was the straw that broke the camels back with county EMS. Upon arrival at the hospital, the pt was c/o chest pain & SOB from the pnumo & the flailed chest, headache, light headed from the yellow/clear fluid coming from his ear as a result of the basilar skull fracture, and according to the EMT-B, the patient got the sub-q emphysemia from smoking.

Ok, yea, those are two out of the twelve cases, so you can see why we not only have the County EMS looking at us so closely, but now from what I have been told we also have State EMS watching us like hawks.

How is this happening? Why are these people still working? Why arn't they being punished? Are they being trained or remediated? They are all very good questions, that they were brought up in a recent metting with our union who has been meeting not only with EMS, but with our employeer. Some people have lost their jobs, others are on probation or investigation.

As for the training part, it goes back to the title of this little rant. In the contract my company has with the county, its required to provide training for its employee's, but there is nothing in the contract time frame wise as to the requirements, I looked. Well, our union has been flat out told by management that there is no money left in the budget for any training of any kind. No mandated training, no Field Training Officer observation ride alongs that are supposed to happen every three months, no PCR review by FTO's, nothing. And the county isn't helping matters either. They have what they are calling a run review coming up in a few days, and I've been told that they are going to focus on Hazmat. Hazmat? Hazmat? At last check, that was not our main problem.

So, instead of trying to work the problem to make it better, they are sitting back and letting it all go to hell. It might work out for them in the long run, it might not. They might lose the contract and all 400 people would be out of the job trying to get hired with whatever company comes in after us, they might not. Its all a waiting game, and I'm now done ranting.

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I feel your pain, bro. Despite your inability to find the "SpellCheck" button that is right in front of your face ( :D ), you are obviously astutely grasping obvious concepts that management can't seem to see. You're right... your medics have a problem. But you are also right that the problem is much bigger than just your medics. The real problem here is clueless and incompetent management.

One thing you don't really make clear though is what exactly happened to start this downward spiral? It seems that you are saying that this company was just fine until they took a partial contract with the county. Maybe I am misunderstanding the timeline? Are you saying that the COUNTY was just fine until your company got involved, or that your company was just fine until they got involved with the county? It's important to determine if there is some sort of cause and effect relationship.

Regardless, it does seem obvious that management is a major problem, and are making the problem worse. I mean, come on... if your paramedics are the problem, the answer is NOT to put them in charge of more patients! :roll: The answer to this problem -- besides better management -- is the same as the answer to every other question in EMS: Education. But a good first step would be to replace all of the EMTs with paramedics, in order to establish a field-level check-and-balance system that currently does not exist. Not only would it allow professional oversight on the scene, but it would prevent the further deterioration of the paramedics' attitudes that is sure to occur now that they will be forced to tend to every patient without a break.

Although it does seem pretty obvious, kudos to you for actually giving some serious thought to the matter instead of just accepting things as they are without any examination of the causes and possible solutions. If more people in your system did that, you would have the beginnings of some meaningful progress.

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It all started after the contract was put in place. A mass hiring was done, about eight months before I got hired here, and from what I was told, those people who had gone in and done the interviews, and who had suggested that this person or that not be hired for one reason or another, that person ended up being hired. They didn't care if they got experiance or not, they just wanted the bodies to fill the rigs.

And believe it or not, there is a person here who is the Clinical & Education Supervisor, but this person is to busy doing "invistigations" on this thing or that thing to do any kind of training, reviews, or whatever with medics. It should be called CES, it should be called CIS.

What really sucks about it is I grew up in this city, I've spent all but two years of my life in this city. But its a hazard to my career to work in this city. I don't want to leave, but then if I don't, then who knows.

Anyway, I'm done, thanks Dust for the fed back.

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Heah Coyotemedic,, seems like your EMS system is like MANY others in this country BROKE.

So, how do you fix it?

There are no easy answers, but I will proffer a few.

1. Field supervision. Having experienced medics responding on calls, and conducting what you call peer review is one.

2. medics ride for what did you say?? 5 or 10 ALS calls, before they are cut loose.????

That is simply not enough to be a MEDIC in charge.. What if the 5 or 10 "ALS" calls are simple traumas, where they put a line in and EKG and transport, or what if they only involve a hypoglycemic patient that gets D-50 and awakens.?... is this medic now capable or comfortable with running a mega code from hell, or dealing with a Pneumo-hemo, or massive MI ??? probably not.

I NYC, where they ride with 2 medics on the truck, and the medic course involves like 400-500 hours of clinical ER, OR and Medic unit time, they still do not let new medics work with each other until the document 960 Hours, (6 months) of working on a medic unit with a senior person. Now I'm not saying you have to get that draconian, but it seems like something needs to get tightened up.

Just out of curiosity, what does your agency medical director have to say about all this ????????????

Let us know how this works out.

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Hi CoyoteMedic:

One question: Is there a professional association in your State?

Here we have a, granted fledgeling, association with a mandate to investigate such situations and deal with the persons involved. I wish I had more help for you but you seem to have a good grasp of the problem you just need to find the right people to make it happen.

Good Luck.

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With a clearer picture now (although I would not claim to have an absolute understanding), I would suggest that your subject title is a little misleading. Training won't fix this problem. The problems are too complex. Again, supervision and management are at the very root of the problem, yet I doubt any of them are going to any additional "training" or education. They think they already know it all. But that seems like it may be the problem with a lot of these hastily hired medics too. No amount of training or experience will ever compensate for a lack of quality, foundational education. Sounds to me like you are getting guys who are ill prepared for practice, and sealing their fate by tossing them into a system that is ill prepared to nurture them into competency. What will a bunch of one-hour con-ed classes, merit badge classes, and M&Ms do for people who don't even have the basics to build upon? Even the best "training" programme will do little to fix that.

Now, I could have a mistaken idea of what is going on here. It could be that, in the haste to throw together a crew, you've ended up with a lot of people from different backgrounds who just need some focused direction in order to all get onto the same page and function smoothly. Could also be some well educated people who simply have not yet had the experience to put it all together yet into a competent practice. If that is the case, then yes, training is a must. But this would take a lot more careful planning and administration than was given to the hiring process you described! They're going to have to carefully select some training preceptors with proven medical and communicative abilities who they can assign to the task of bringing the n00bs up to speed. And those guys will have to be working under a proven and structured programme of education and evaluation, not just riding with them til they *think* they *seem* okay. Of course, this will cost the agency a good bit of money. Three men on a truck is expensive. And, like you said, they're probably not even going to consider that, so you're back where you started.

Again, I feel your pain. We've all seen this happen, I think. And it sucks when it is your hometown, where you hoped to make a future. But things run in cycles. Hopefully, the problems are being noticed by the powers that be, and not swept under the rug. If it gets bad enough, the MD says, "Forget it. I'm not putting my name on this anymore." Or, if enough bad press results, the city council steps in. I mean, I hate to see you take a personal hit on this deal when the company loses their piece of the pie, but it may come to that. But, if you're as professional as you come across, then I have faith that you'll land on your feet and looking good through it all.

And dude, I hate to rag on you, because really, your composition is actually quite good and a refreshing read here. And you're the one who brought it up in the first place. But come on... the SPELLCHECK button is RIGHT THERE IN FRONT OF YOUR FACE! :lol: You can't miss it, unless you're just lazy. Attention to detail and a give-a-shit attitude are the two things that make a difference between a paramedic and a professional paramedic. Show us which one you are.

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And dude, I hate to rag on you, because really, your composition is actually quite good and a refreshing read here. And you're the one who brought it up in the first place. But come on... the SPELLCHECK button is RIGHT THERE IN FRONT OF YOUR FACE! :lol: You can't miss it, unless you're just lazy. Attention to detail and a give-a-shit attitude are the two things that make a difference between a paramedic and a professional paramedic. Show us which one you are.

Thems fighting words dust!! I have to say my spelling sucks as well, and i know that spell check button is there but for some reason it locks up my system :shock:

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I also concur with the almighty DUSTDEVIL,, your title is misleading and "training" will probably not fix it,,, you need supervision, oversight, and strong senior people to do mentoring.....

I am also curious about your agency medical director, why is he allowing this to go on???????

All the providers practice under his license, all he has to do is say STOP; I will not underwrite this anymore, and that will FORCE the agency to fix to problem. or fire the medical director LOL.

Good luck, sounds like you will need it.

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Ooh Ooh, I have a question.

Coyote, who is in charge of hiring at your agency? Is it a typical Human Resources type setup?

This is the way it was at my agency for years. All they cared about was filling slots on a rig. The HR Manager wasn't even an EMS provider. They might have had a CPR card...but if so, it probably wasn't up to date.

Two years ago, the HR manager was kicked loose, and the Office of Recruitment & Retention was created. Since then, we've definitely seen a huge climb in the quality of providers, EMT & Paramedic alike.

What Dust said about the MD is too true. I saw it happen not long ago, the OMD didn't like where things were headed, and unfortunately because of a union, his recommended changes were not instituted, so he pulled out, and took his license to practice with him. I'd like to say that the agency in question woke the heck up, and did what was necessary...but they didn't. They looked around and found a half-a55ed doctor that would sit up & roll over...for a price.

I'm really sorry about the conditions in your county, and I pray that management does come around soon...for your sake, as well as that of your patients.

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Coyote, you have described a problem that enthralls many systems in the US. I too agree that the first step is management corrections, however if you're med-control doesn't care more about his license than to let those uneducated and inexperienced medics work the streets, then he is just as big an idiot. Remember, just because MD follows their name, doesn't always mean that stupidity isn't far behind. I am very sorry that you must be subjected to such irresponsiblity within your system. Unfortunately, I too once worked for a similar organization, and I felt like this :violent2: most of the time.

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