Basic v.s. Paramedic

[ffscm72]

This is just a rant....it's late so bare with me....

Been reading a lot the post on here. Seems to be a lot of Medics bashing Basics and vice versa.

All I've been reading is "I'm smarter than you," or "Buck up and get your Medic", and "Bunch of ****y Medics".

guess things don't change much outside of lil' ole delaware.

8 years of observation has taught me this....the job is the same no matter what level of education or skills you have. Get the patient to higher level of care. Neither basic nor medic can give this care. Only the doctor at the appropriate facility can do that.

I guess what I'm saying is......EMT-Basic stop pretending to be medics just because thats what you really want to be and EMT-Paramedic stop pretending to be Doctors just because you have a few years of college.
Our job as EMS is to make the patients ride to the hospital as comfortable as possible and tell the doctor what we saw. Nothing more, nothing less. Neither Basic nor Medic is better than the other, just one has more drugs to ease the patients pain.

Ok i've got that out of my system. have at it fellow EMT's I know somebody has something to say....

[Ridryder911]

The same could be said similar in nursing. Nurses aide or RN. The EMT very similar to the nurses aide to deliver very basic, basic care and not understanding what medicine is about. Ironically though, most of them recognize their lack of education and do not pretend to know what is best for a patient alike most EMT's.

Isn't ignorance blessed? ....

R/r 911

[LasVegasEMS]

8 years of observation has taught me this....the job is the same no matter what level of education or skills you have. Get the patient to higher level of care. Neither basic nor medic can give this care. Only the doctor at the appropriate facility can do that.


Are you trying to say that only physicians can provide definitive care to a patient?

[veneficus]

ffscm72,
I just cannot agree with this. I have worked for years as both a basic and a medic, the job, responsibility, and required knowledge are very different.
It is not a good idea to equate what you see with what differences are. If you spend some time in an OR you would think any medic could do what an anesthesiologist does there. But there is considerable more knowledge in the decision making process which is invisible.
Also, paramedicine (if there is such a word) has evolved to more than just a ride to the hospital in an ambulance. I have experience working in a nontraditional role where treat and release was our goal with a ride to the hospital being the option of last resort.
It is always wrong to be arrogant, no matter what your title, and this argument has raged for longer than 8 years. It is not unique to the EMS profession. How many factory workers claim they could do what an engineer does based on what they see? How many soldiers claim they could do what a general does?
The difference in the EMS profession (which I still claim to be part of) is that we have measured our abilities by skills for so long; no thought is given to the knowledge behind them.
An AED can recognize and defibrillate v-tach and v-fib
An IV drug user can start a line better than a lot of medics.
Ask any member of your family what drugs work better for your aches or cold symptoms.
The local crack dealer can mix you up the perfect concoction for whatever ails you.
Should we start letting these people treat patients? Clearly they have the same skills we do. I’ll bet they can even drive to the hospital.
Whether you are a basic or medic, you are more than a ride to the hospital or doctor. If you haven’t had family, friends, and neighbors ask you for your opinion as a “knowledgeable” healthcare provider, you haven’t been doing this very long. When this person close to you asks you if their cut needs stitches do you call 911 and send them by squad to go see a doctor at the local ED?

If you irrigate the wound, put some OTC antiseptic on, and bandage it and punt them back out to the playground is that not definitive care?

[Ridryder911]

Again, it always comes down to those without the knowledge, experience, and expertise making asinine statements. Seriously, it would be like me informing a surgeon that his practice has too many surgeries or takes too long performing them.. a self proclaimed expert.

Many in EMS have never been past the doors of ER unless it was a clinical or delivering a patient. Yet, they take 150 hour first aid course and whamo they are an expert...

R/r 911

[emt161]

Neither Basic nor Medic is better than the other, just one has more drugs to ease the patients pain.

I was almost with you- until this statement, because it proves you have no idea what the frack you're talking about.

[LasVegasEMS]

I was almost with you- until this statement, because it proves you have no idea what the frack you're talking about.

But which parts were you with ;)

[ffscm72]

Are you trying to say that only physicians can provide definitive care to a patient?

legally.... yes.

[ffscm72]

Apparently I ruffled a few medic feathers.

And apparently some of you have forgotten your real job. So let me remind you......Your not a doctor. If you want to be a doctor "Buck up" and go get the rest of the college degree so you can diagnose the symptoms.

Your job is to treat the symptoms not the disease. Which I a lot of Medis AND Emt's do. If we could treat the disease we have a heck of a lot more drugs to drag around.

[ffscm72]

Again, it always comes down to those without the knowledge, experience, and expertise making asinine statements. Seriously, it would be like me informing a surgeon that his practice has too many surgeries or takes too long performing them.. a self proclaimed expert.

Many in EMS have never been past the doors of ER unless it was a clinical or delivering a patient. Yet, they take 150 hour first aid course and whamo they are an expert...

R/r 911

The same can be said for medics who take a 2 year course believing that makes up the 9+ years it takes to become a doctor.

[ffscm72]

[QUOTE=veneficus;2261052]ffscm72,

It is always wrong to be arrogant, no matter what your title, and this argument has raged for longer than 8 years. QUOTE]

I think this simple sentence is what i was trying to say.... and yes i'm very aware that this has going on for more than 8 years. Just a darn shame really.

[LasVegasEMS]

Apparently I ruffled a few medic feathers.

And apparently some of you have forgotten your real job. So let me remind you......Your not a doctor. If you want to be a doctor "Buck up" and go get the rest of the college degree so you can diagnose the symptoms.

Your job is to treat the symptoms not the disease. Which I a lot of Medis AND Emt's do. If we could treat the disease we have a heck of a lot more drugs to drag around.

So are you saying that ER doctors treat the disease? Last time I checked, ER docs handeled the life-threatening, emergent stuff, and I realize how broad this has become in the last decade, and then they refer you out to your PCP. ER docs don't really do anything to manage your disease process, that is left up to PCP and specialist. The ER Doc doesn't treat disease processes like COPD, IDDM, CHF, etc. etc., he or she merely takes care of the s/s and as I already stated, refers you to PCP.

As far as definitive treatment, I agree that we are not docs, never claim to be. However, if you are o/s of say, a diabetic, you check a BGL, admin sugar in one form or another, and then you leave the patient home, I would call that definitive treatment. Does that really require a doc? Same can be said for diagnosing, I'm a firm believer that paramedics diagnose; otherwise how are you forming a treatment plan???

I understand what you're getting at but you're painting with a little to broad of a brush.

[VentMedic]

So are you saying that ER doctors treat the disease? Last time I checked, ER docs handeled the life-threatening, emergent stuff, and I realize how broad this has become in the last decade, and then they refer you out to your PCP. ER docs don't really do anything to manage your disease process, that is left up to PCP and specialist. The ER Doc doesn't treat disease processes like COPD, IDDM, CHF, etc. etc., he or she merely takes care of the s/s and as I already stated, refers you to PCP.



Part of the problem with EMS and EDs is that people don't have PCPs and don't follow up with any clinic appointments they are given. ED doctors do fix broken bones and do treat that COPD or asthma attack often without admission. The person gets a few nebs, steriods and/or antibiotics in the ED and then some scripts and/or a hosptial issued inhaler. When that runs out, they are back. The same for all of those aches and pains. If it is serious the doctor will again try to refer. For the most part, unfortunately, the ED has become a clinic.

Only if the patient is admitted will they see an intensivist, specialist of some type, hospitalist or a private physician on call. Once they get the disease somewhat controlled, the patient is discharged with some scripts and the process starts over.

Some ED doctors have the misfortune of being on when the same people come in so they are almost like PCPs to the patient. In the ED we are not allowed to tell callers which doctor is on because if it is the caller's favorite, they will come in. If it is a doctor they didn't get the meds they wanted from, they stay away.


As far as definitive treatment, I agree that we are not docs, never claim to be. However, if you are o/s of say, a diabetic, you check a BGL, admin sugar in one form or another, and then you leave the patient home, I would call that definitive treatment. Does that really require a doc? Same can be said for diagnosing, I'm a firm believer that paramedics diagnose; otherwise how are you forming a treatment plan???


As far as field fixing of glucose problems, there is a downside to that. The patient may need their insulin or dietary intake adjusted. There may be other medications interfering with their regulation or another disease process that wants attention. This can also happen when patients go to busy clinics and just the obvious gets treated while something major needs attention. Then, the patients become emergencies which should never have happened.

Paramedics provide a small part of a "treatment plan" that usually takes care of the immediate symptoms but there is too little differential diagnostics to definitively treat the problem. CHF in itself is only the immediate problem that may clearly present or symptom that is stemming from a much more serious disease process than a Paramedic is capable of diagnosing. You may not know even what system is the point of orgin that is affecting the other systems. No x-rays, lab data, CT Scans etc to even give any more information than just what is in front of you. The Paramedic program doesn't even begin to cover disease processes or definitive treatment plans to any great length.

[ffscm72]

So are you saying that ER doctors treat the disease? Last time I checked, ER docs handeled the life-threatening, emergent stuff, and I realize how broad this has become in the last decade, and then they refer you out to your PCP. ER docs don't really do anything to manage your disease process, that is left up to PCP and specialist. The ER Doc doesn't treat disease processes like COPD, IDDM, CHF, etc. etc., he or she merely takes care of the s/s and as I already stated, refers you to PCP.

As far as definitive treatment, I agree that we are not docs, never claim to be. However, if you are o/s of say, a diabetic, you check a BGL, admin sugar in one form or another, and then you leave the patient home, I would call that definitive treatment. Does that really require a doc? Same can be said for diagnosing, I'm a firm believer that paramedics diagnose; otherwise how are you forming a treatment plan???

I understand what you're getting at but you're painting with a little to broad of a brush.


I'm trying my best to not to be so broad...lol But I'm referring to Doctors in general, PCP, ER, Surgeons, and other form of higher level of care.

As far the diabetic patient, you admin the Dex. 50/50 or whatever med you use in your state, you haven't solved the problem. You've merely treated the symptom of a larger picture. If the patient refuses service after you brought him/her from their coma is on them.

I don't know of any drug that EMT-B's, I's, and P's can admin, that can give definitive care. We are just EMT's whether or not some of us like that, that's all we are.

[imallset2]

ffscm,

overall i agree with your logic that generally EMS does not provider definitive care...however that is not always the case....

the best example i can come up with is allergic reaction. most ALS providers can do everything an ED would do....epinephrine, benadryl, fluids, steriods, airway management including surgical airway....there is not a whole lot else that the ED would do for these people.....the only further step would be an allergist if the cause was unknown but that would, like stated above be done later...not in the ED.

another example would be shortness of breath caused by asthma. field medics have albuterol, atrovent, sol-medrol, mag, fluid, and airway management. there isnt really much else is a straight up ashtmatic...

also consider Vfib/pulseless Vtach and certain causes of asystole/PEA. field medics can do almost everything an ED can do..and everything that is commonly done in code situations. the area of cardiac arrest that i believe field providers lack some of the ED tools is in the area of post resuscitation management. Prior to ROSC, the vast majority of the skills done are able to be done by ALS.

i agree that overall EMS is only a part of the treatment and care spectrum however there are something things that we really do have all the tools for and are very good at treating.

i am in no way advocating that EMS can provide for all medical needs, or that EMS can replace anyone else in the health system..im just offering my perspective of ALS care.

[Ridryder911]

In all actuality, there is very few medications that actually "cure" disease processes rather we rather treat or correct a condition. Yes, such agents as chemo and even antibiotics can be considered "curing" medications, other medications are rather again treating the symptoms or treating per prophylactic.

I agree there is not a lot of definitive care in EMS, neither does a large portion of medicine. Rather the majority of the medicine we do perform is preventive and acutely to correct a dire condition. Immobilizing, splinting, are examples of treating but not correcting but defibrillation or administration of medication(s) terminating life threatening arrhythmias could be considered correcting although truthfully unless we correct the cause we actually just treated the side effects of the disease process. One could even argue a lot of medicine rarely treats the etiology, rather just the side effects of the disease process.

Most diseases we see are terminal or chronic. Diabetes is a good example, we only attempt to control or regulate the disease and treat the side effects of it, but there is no cure as many others. Even in ER rarely is a diet history performed when a patent arrives in hypoglycemia, and as well very little time is placed upon changing medication levels, rather turfed off to the PCP that is familiar or in charge of the patient. Again, alike us even physicians treat and do not cure most of what is brought in rather treat the condition related from the disease process itself.

Now you are definitely wrong in your statements..." only physicians can bring definitive care".." There are other(s) now that can provide medicine, and diagnose without being a physician. Such as physician extenders being Nurse Practitioners & Clinical Nurse Specialist.. yes, without even being attached to a physician. I suggest you increase your education in knowledge before making such broad statements...

R/r 911

[Fairyqueen]

I am not a Doctor. As a medic, I know just enough to know that. I understand that I was taught in paramedic school the basic, rudimentery knowledge about disease, illness and trauma. (I have tried to learn more on my own). I even tell my patient who ask me what's wrong. "I'm sorry, I'm not a doctor, this is what I THINK is going on but only more tests, x-rays, etc and a DOCTOR can give you a better answer."

Having said that, I am not an EMT. I do know more then an EMT. I do more then an EMT. I have more responsiblity then an EMT.

I am a paramedic. I try not to be ****y. (though when I get a very hard IV on the first try, feel that little rush of air after I decompress a chest or feel a pulse on the 10 year old I just pulled lifeless from a pool, I feel like a GOD.)

The "fight" between EMT's and paramedics have been around since a the two positions were made seperate. Is it silly? Yes. Is it human nature for one group or person to try to assess dominance over another person? Yes. Is it ever going to end? No.

So basicly, stop whinning about it. If you don't like it you have three options. 1. Go to school and become a medic. 2. Get another job. 3. Suck it up.

[DrParasite]

That's pretty funny. a medic is definitive care? I don't think so.

think of it this way: Can a medic discharge a patient? ie, he doesn't need an ambulance, he is ok now? Even releasing a patient to BLS, the patient isn't dischanged, he is being given to a BLS unit to transport to definative health care.

Using the example of the diabetic who you woke up, once you wake him up, can you just leave saying he is ok? or does he have to refuse transport to an ED?

Only a doctor (or PA, NP, extension of a doctor, etc) can discharge a person, after making sure he is stable. Or to make things even clearer, a doctor can kick a person out of the hospital even if the person wants to stay. a medic would lose his job and cert if he did that.

BLS treats the signs and symtoms. ALS can do more to treat the signs and symptoms. MDs treat the causes of the signs and symptoms. That is why MD's are definitive care, and a medic isn't.

[ffscm72]

I am not a Doctor. As a medic, I know just enough to know that. I understand that I was taught in paramedic school the basic, rudimentery knowledge about disease, illness and trauma. (I have tried to learn more on my own). I even tell my patient who ask me what's wrong. "I'm sorry, I'm not a doctor, this is what I THINK is going on but only more tests, x-rays, etc and a DOCTOR can give you a better answer."

This all really had to say

Having said that, I am not an EMT. I do know more then an EMT. I do more then an EMT. I have more responsiblity then an EMT.

You so very wrong here. To think that you not an EMT is almost a joke. You are just a higher level EMT. You still have to do the basics!


So basicly, stop whinning about it. If you don't like it you have three options. 1. Go to school and become a medic. 2. Get another job. 3. Suck it up.

1.) As soon as I get the funds I'll be a medic and when I do I hope not to be ****y lil' medic. 2.) I don't have to change jobs just cause I don't like something about it 3.) I'll suck this up when you can admit you just an EMT w/ more drugs to play with. Just like I can admit I'm just glorified band-aid whacker..lol

[ffscm72]

That's pretty funny. a medic is definitive care? I don't think so.

think of it this way: Can a medic discharge a patient? ie, he doesn't need an ambulance, he is ok now? Even releasing a patient to BLS, the patient isn't dischanged, he is being given to a BLS unit to transport to definative health care.

Using the example of the diabetic who you woke up, once you wake him up, can you just leave saying he is ok? or does he have to refuse transport to an ED?

Only a doctor (or PA, NP, extension of a doctor, etc) can discharge a person, after making sure he is stable. Or to make things even clearer, a doctor can kick a person out of the hospital even if the person wants to stay. a medic would lose his job and cert if he did that.

BLS treats the signs and symtoms. ALS can do more to treat the signs and symptoms. MDs treat the causes of the signs and symptoms. That is why MD's are definitive care, and a medic isn't.

OMG!!! THANK YOU!!!! You sir are my hero! Thats exactly it! nothing more nothing less!!! If i could kiss you i would...lol

[LasVegasEMS]

Part of the problem with EMS and EDs is that people don't have PCPs and don't follow up with any clinic appointments they are given. ED doctors do fix broken bones and do treat that COPD or asthma attack often without admission. The person gets a few nebs, steriods and/or antibiotics in the ED and then some scripts and/or a hosptial issued inhaler. When that runs out, they are back. The same for all of those aches and pains. If it is serious the doctor will again try to refer. For the most part, unfortunately, the ED has become a clinic.
Agree 100%, that is why I stated that I know how broad the definition of emergent has become in your local ED. Unfortunetly, I dont ever see this changing in my life time.


Only if the patient is admitted will they see an intensivist, specialist of some type, hospitalist or a private physician on call. Once they get the disease somewhat controlled, the patient is discharged with some scripts and the process starts over.
I may have spun my definition of specialist different then yours. I was using it to refer to someone like an allergist, who a patient would see after leaving the ED for continued care of their first allergic Rx.


Some ED doctors have the misfortune of being on when the same people come in so they are almost like PCPs to the patient. In the ED we are not allowed to tell callers which doctor is on because if it is the caller's favorite, they will come in. If it is a doctor they didn't get the meds they wanted from, they stay away.
Unfortunetly, I agree 100% again.


As far as field fixing of glucose problems, there is a downside to that. The patient may need their insulin or dietary intake adjusted. There may be other medications interfering with their regulation or another disease process that wants attention. This can also happen when patients go to busy clinics and just the obvious gets treated while something major needs attention. Then, the patients become emergencies which should never have happened.
Agreed. However, if it occurs one time and isn't recurrent, I think most would calculate that up to an isolaed event; such as I took my insluin then something prevented me from eating. Anymore then once in a short time frame I agree needs to be evaluated.


Paramedics provide a small part of a "treatment plan" that usually takes care of the immediate symptoms but there is too little differential diagnostics to definitively treat the problem. CHF in itself is only the immediate problem that may clearly present or symptom that is stemming from a much more serious disease process than a Paramedic is capable of diagnosing. You may not know even what system is the point of orgin that is affecting the other systems. No x-rays, lab data, CT Scans etc to even give any more information than just what is in front of you. The Paramedic program doesn't even begin to cover disease processes or definitive treatment plans to any great length.
As far as the paramedic program, agreed. Also, agree that EMS is a small portion of the "treatment plan."

I don't really disagree with your post at all. I still think a broad brush was used to paint a general picture and that was where my "beef" was LOL

[LasVegasEMS]

I'm trying my best to not to be so broad...lol But I'm referring to Doctors in general, PCP, ER, Surgeons, and other form of higher level of care.

As far the diabetic patient, you admin the Dex. 50/50 or whatever med you use in your state, you haven't solved the problem. You've merely treated the symptom of a larger picture. If the patient refuses service after you brought him/her from their coma is on them.

I don't know of any drug that EMT-B's, I's, and P's can admin, that can give definitive care. We are just EMT's whether or not some of us like that, that's all we are.

First, as already mentioned above, there aren't a ton of medications our there that cure a disease or that give "definitive" treatment, merely drugs that control s/s.

Second, thinking like "we're just EMT's" is the reason that this profession has such a difficult time furthering itself in the realm of healthcare. We are ALL so much more then "just EMT's." Its only a matter of showing everyone else that. There is no reason EMT's and Paramedics should have to work second jobs or tons of OT to survive, they should be able to do that on their base salary. Standards need to rise, thinking like that needs to go away, and we, as a profession, need to be more organized.

[LasVegasEMS]

I am not a Doctor. As a medic, I know just enough to know that. I understand that I was taught in paramedic school the basic, rudimentery knowledge about disease, illness and trauma. (I have tried to learn more on my own). I even tell my patient who ask me what's wrong. "I'm sorry, I'm not a doctor, this is what I THINK is going on but only more tests, x-rays, etc and a DOCTOR can give you a better answer."

Having said that, I am not an EMT. I do know more then an EMT. I do more then an EMT. I have more responsiblity then an EMT.

I am a paramedic. I try not to be ****y. (though when I get a very hard IV on the first try, feel that little rush of air after I decompress a chest or feel a pulse on the 10 year old I just pulled lifeless from a pool, I feel like a GOD.)

The "fight" between EMT's and paramedics have been around since a the two positions were made seperate. Is it silly? Yes. Is it human nature for one group or person to try to assess dominance over another person? Yes. Is it ever going to end? No.

So basicly, stop whinning about it. If you don't like it you have three options. 1. Go to school and become a medic. 2. Get another job. 3. Suck it up.

or 4. We continue to get more organized and raise the standard of care.

[LasVegasEMS]

That's pretty funny. a medic is definitive care? I don't think so.
I don't believe ANYONE said paramedics were difinitive care, however, I think in CERTAIN situations they can be, Yes.


think of it this way: Can a medic discharge a patient? ie, he doesn't need an ambulance, he is ok now? Even releasing a patient to BLS, the patient isn't dischanged, he is being given to a BLS unit to transport to definative health care.
Apparently someone has never heard of paramedic initiated refusals. You call for an ambulance, the paramedic evaluates you, if you dont need an ambulance, they tell you no and provide you with a list of ways to get to the ED on your own. Quite an effective tool if EMS uses it right. Sounds like discharging to me???

I only use the terminology discharging to apply it to your statement, just putting that out there.


Using the example of the diabetic who you woke up, once you wake him up, can you just leave saying he is ok? or does he have to refuse transport to an ED?
See above.


Only a doctor (or PA, NP, extension of a doctor, etc) can discharge a person, after making sure he is stable. Or to make things even clearer, a doctor can kick a person out of the hospital even if the person wants to stay. a medic would lose his job and cert if he did that.
Again, a very broad brush. I understand what you're saying but I think it's to blanket of a statement.

See the paramedic initiated refusal section above and consider this, if a paramedic/emt is transporting someone who, without a medical cause, becomes aggressive or deragatory towards the provider, that person has every right to stop the truck and tell them to get out. I understand this isn't the standard but i've done it and would do it again. That doesn't exactly fit your broad brush, see what I mean?


BLS treats the signs and symtoms. ALS can do more to treat the signs and symptoms. MDs treat the causes of the signs and symptoms. That is why MD's are definitive care, and a medic isn't.
Again, as most of these discussions boil down to, I think our definition of difinitive care if just different, but not by much.

In reference to your MD statement, I stand behind my statement that most ER physicians treat a lot of s/s and less pathology. Again, you get a bee sting, you have a reaction---->Paramedics administer the course of meds for such a c/c and then transport to the ER. The ER does what, other then make sure there is no relapse and draw some blood??? How does the ER MD treat the cause of the bee sting, kill all the bees.....

[DrParasite]

Apparently someone has never heard of paramedic initiated refusals. You call for an ambulance, the paramedic evaluates you, if you dont need an ambulance, they tell you no and provide you with a list of ways to get to the ED on your own. Quite an effective tool if EMS uses it right. Sounds like discharging to me???I heard that paramedic initiated refusals were initiated as pilot programs, and most of them were ended following their pilot time frame. Can you cite any that actively do these types of refusals as standard practice?

Also, I think we can all agree that this is not the standard across the US, for paramedics or EMTs
See the paramedic initiated refusal section above and consider this, if a paramedic/emt is transporting someone who, without a medical cause, becomes aggressive or deragatory towards the provider, that person has every right to stop the truck and tell them to get out. I understand this isn't the standard but i've done it and would do it again. That doesn't exactly fit your broad brush, see what I mean?We call that a refusal by action. It basically means the patient doesn't want to be there (hence the aggressive or derogatory comments), and you accept they not wanting your care as opening the doors and allowing them to leave. Very different than a person who wants to go to the hospital for the sniffles and you tell them to get out and take a taxi to their PMD.
In reference to your MD statement, I stand behind my statement that most ER physicians treat a lot of s/s and less pathology. Again, you get a bee sting, you have a reaction---->Paramedics administer the course of meds for such a c/c and then transport to the ER. The ER does what, other then make sure there is no relapse and draw some blood??? How does the ER MD treat the cause of the bee sting, kill all the bees.....Also remember if it's serious enough, you will be admitted and seen by a specialist. if the ER doc can stabilize you, he refers you to your PCP for further treatment. The ER doc also has a lot more tools to assess you and treatments to respond to your illness or injury.

and yes, paramedics are EMTs. Another term for a paramedic is EMT-P. Don't forget that you have EMT in front of that P.

[LasVegasEMS]

I heard that paramedic initiated refusals were initiated as pilot programs, and most of them were ended following their pilot time frame. Can you cite any that actively do these types of refusals as standard practice?
LA County does them, don't quote me on that, let me call my partner in a few but i'm pretty sure thats where he was working at. Give me a bit to get a list together.


Also, I think we can all agree that this is not the standard across the US, for paramedics or EMTs
Agreed. However, I think we will begin to see more and more of them since the patient population tends to continue to grow without a sufficient increase in prehospital resources. There is no reason an ambulance, ALS or BLS, should be transporting a 30 yr. old female with blisters on her feet. The you call we haul phenomenon will disappear by the time my career is over.


We call that a refusal by action. It basically means the patient doesn't want to be there (hence the aggressive or derogatory comments), and you accept they not wanting your care as opening the doors and allowing them to leave. Very different than a person who wants to go to the hospital for the sniffles and you tell them to get out and take a taxi to their PMD.
I call this a play on words hehe, but I know what you mean. I will also say I've had people that still wanted to go but couldn't control their language and tone with me, those people still got left on the side of the road; probably still falls under your definition but I view it differently.


Also remember if it's serious enough, you will be admitted and seen by a specialist. if the ER doc can stabilize you, he refers you to your PCP for further treatment.
But if the ER physician stabilizes you, I.E. treats the disease/underlying problem, why does someone have to go see their PCP?


The ER doc also has a lot more tools to assess you and treatments to respond to your illness or injury.
No argument here, you're absolutly correct. Though, remember that many things over the last 30 years have moved from only a physician in a hospital can do them to the back of our trucks. Things continue to make their way out of the hospital and into our hands, it's the responsibility of all pre-hospital providers to stay current with their various uses.


and yes, paramedics are EMTs. Another term for a paramedic is EMT-P. Don't forget that you have EMT in front of that P.
I have no problem with the term EMT, other then we're not technicians anymore. I think the mainstream has become that EMT-Basics are just referred to as EMT's and EMT-Paramedics are just referred to as Paramedics. This creats a play on words and is nothing but mixing semantics when you refer to each one, respectivly.

[veneficus]

QUOTE=LasVegasEMS;2261075] Same can be said for diagnosing, I'm a firm believer that paramedics diagnose; otherwise how are you forming a treatment plan???[/QUOTE]

Paramedics do diagnose, it is foolish to think otherwise. Sure everyone and their brother comes up with words that basically skirt the word diagnosis for many reasons, but being involved in the med school event, I can see no difference in what I do now vs what I did as a medic. I just have more information at my disposal to make a decision with. (a few more toys too)


Definitive treatment does not require a doc either. I think that is an excuse to try and avoid responsibility for an individual’s judgments and treatments.

[VentMedic]

but being involved in the med school event, I can see no difference in what I do now vs what I did as a medic. I just have more information at my disposal to make a decision with. (a few more toys too)


Definitive treatment does not require a doc either. I think that is an excuse to try and avoid responsibility for an individual’s judgments and treatments.

You must be just starting med school?

Get back to us when you are in your 2nd year of residency on the comments you just made.

As Rid already mentioned, physician extenders such as NPs can also provide definitive treatment.

Without some of those "toys", things can be missed and one may make the wrong diagnosis, or clinical assessment judgement, which may lead one to believe they have provided all the "definitive" treatment needed.
http://www.ems1.com/ems-products/patient-handling/articles/405680-Paramedic-probe-over-UK-boys-death

[LasVegasEMS]

Without some of those "toys", things can be missed and one may make the wrong diagnosis, or clinical assessment judgement, which may lead one to believe they have provided all the "definitive" treatment needed.
http://www.ems1.com/ems-products/patient-handling/articles/405680-Paramedic-probe-over-UK-boys-death

Agreed. Nothing can be a substitute for sound clinical judgement, which includes knowing when to force someone to go. The biggest problem with things like this, is that people use laziness as their reason for non-transport instead of sound clinical judgement.

[veneficus]

You must be just starting med school?

Get back to us when you are in your 2nd year of residency on the comments you just made.

As Rid already mentioned, physician extenders such as NPs can also provide definitive treatment.

Without some of those "toys", things can be missed and one may make the wrong diagnosis, or clinical assessment judgement, which may lead one to believe they have provided all the "definitive" treatment needed.
http://www.ems1.com/ems-products/patient-handling/articles/405680-Paramedic-probe-over-UK-boys-death

No, I didn’t just start.
I just find that the steps involved in making a diagnosis are the same. It is just done with considerably more information such as knowledge of biochemical reactions, anatomical and physiological info past the entry level, and a healthy degree of patho. Physical diagnosis is just not that difficult. Yes the toys help a lot, as it would be very difficult to clinically figure out liver enzymes without a lab. But epidemiology also comes into play. Yes you have to do some work to figure out and treat (very rarely cure) less common and rare ones. Sometimes mistakes are made, and it takes a while. But my point is the process is the same. People self diagnose all the time. I’ll bet you have, sometimes correctly, sometimes not. With education and experience your accuracy increases.
Believe it or not, physicians are not the all knowing gods, who are the only ones who can make an informed decision.
I suspect when I am a second year resident, I will have more experience and education. I know EMS providers are taught from EMT school the doctor is the omniscient being in the world, but it is time to start getting over this.

[Ridryder911]

Agreed. Nothing can be a substitute for sound clinical judgement, which includes knowing when to force someone to go. The biggest problem with things like this, is that people use laziness as their reason for non-transport instead of sound clinical judgement.

Excellent points! Actually we have a "no transport policy" and have had one for several decades. On non-sense calls such as the "stubbed toe" or "minor, superficial abrasions" we can contact medical control and they will deny permission to transport. Again, thorough documentation and as well a very detailed assessment should proceed.

It is not hardly used because of the potential liability, but I have on a "spider bite" that was several days old. Now with saying, I personally made sure the patient was followed up by visiting health agency, and transportation was made to see PCP. Something, I just personally & professionally felt to do.

R/r 911

[dr-exmedic]

Agreed. Nothing can be a substitute for sound clinical judgement, which includes knowing when to force someone to go. The biggest problem with things like this, is that people use laziness as their reason for non-transport instead of sound clinical judgement.
And the second biggest problem is a lack of sound clinical judgment, which is more common in some areas than others.

[LasVegasEMS]

And the second biggest problem is a lack of sound clinical judgment, which is more common in some areas than others.

tooshea, or however you spell it LOL

[mitllesmertz1]

Medics are EMT's, with a few extra treatment options, and a (hopefully) broader understanding of what's going wrong.
Never, ever forget that medics are EMT's.

Watch a good ED Doc perform an exam on a pt. It should look just like what a good PAC does, and what a good RN does, and what a good medic does, and what a good EMT does.
They ask a BUNCH of questions.
Check a few things out by look/listen/touch.
Then they run some tests.
The only part that differentiates what is done in the field vs what is done in the ED are the tests performed after the exam.
The vast majority (90%) of your exam is done with your hands in your pockets, just asking, and listening, and observing.

Granted, I don't usually use an otoscope, or a percussion hammer (remember those threads, anyone?)
But, most ED Doc exams aren't using them either :)

"Definitive" treatment means the person who ultimately fixes the problem.
Nobody is "fixing" diabetes, or asthma, or CHF. (unless they are transplanting a new heart).
Everybody treats the s&s for diabetics,asthmatics, and CHF'ers.
even specialists and highly paid cool-guys.
If a medic gives D50W to a diabetic, ascertains the cause for the low BS (forgot to eat,oops), and leaves the pt, they were the definitive care.
If you give a neb and steroids to a mildly wheezing pt who left their inhaler at home, you were definitive care.

And we will never reach a time when pts are routinely left at home unless the liability laws are changed.
Docs aren't gonna hang their asses out on the line just because we think the pt is ok.

And I think it's Touche' :)

[ffscm72]

Medics are EMT's, with a few extra treatment options, and a (hopefully) broader understanding of what's going wrong.
Never, ever forget that medics are EMT's.

Watch a good ED Doc perform an exam on a pt. It should look just like what a good PAC does, and what a good RN does, and what a good medic does, and what a good EMT does.
They ask a BUNCH of questions.
Check a few things out by look/listen/touch.
Then they run some tests.
The only part that differentiates what is done in the field vs what is done in the ED are the tests performed after the exam.
The vast majority (90%) of your exam is done with your hands in your pockets, just asking, and listening, and observing.

Granted, I don't usually use an otoscope, or a percussion hammer (remember those threads, anyone?)
But, most ED Doc exams aren't using them either :)

"Definitive" treatment means the person who ultimately fixes the problem.
Nobody is "fixing" diabetes, or asthma, or CHF. (unless they are transplanting a new heart).
Everybody treats the s&s for diabetics,asthmatics, and CHF'ers.
even specialists and highly paid cool-guys.
If a medic gives D50W to a diabetic, ascertains the cause for the low BS (forgot to eat,oops), and leaves the pt, they were the definitive care.
If you give a neb and steroids to a mildly wheezing pt who left their inhaler at home, you were definitive care.

And we will never reach a time when pts are routinely left at home unless the liability laws are changed.
Docs aren't gonna hang their asses out on the line just because we think the pt is ok.

And I think it's Touche' :)

I believe we have a winner!

[LasVegasEMS]

Medics are EMT's, with a few extra treatment options, and a (hopefully) broader understanding of what's going wrong.
Never, ever forget that medics are EMT's.

Watch a good ED Doc perform an exam on a pt. It should look just like what a good PAC does, and what a good RN does, and what a good medic does, and what a good EMT does.
They ask a BUNCH of questions.
Check a few things out by look/listen/touch.
Then they run some tests.
The only part that differentiates what is done in the field vs what is done in the ED are the tests performed after the exam.
The vast majority (90%) of your exam is done with your hands in your pockets, just asking, and listening, and observing.

Granted, I don't usually use an otoscope, or a percussion hammer (remember those threads, anyone?)
But, most ED Doc exams aren't using them either :)

"Definitive" treatment means the person who ultimately fixes the problem.
Nobody is "fixing" diabetes, or asthma, or CHF. (unless they are transplanting a new heart).
Everybody treats the s&s for diabetics,asthmatics, and CHF'ers.
even specialists and highly paid cool-guys.
If a medic gives D50W to a diabetic, ascertains the cause for the low BS (forgot to eat,oops), and leaves the pt, they were the definitive care.
If you give a neb and steroids to a mildly wheezing pt who left their inhaler at home, you were definitive care.

And we will never reach a time when pts are routinely left at home unless the liability laws are changed.
Docs aren't gonna hang their asses out on the line just because we think the pt is ok.

And I think it's Touche' :)

Hey, I like the way I spelled it, it adds character LOL. I agree with everything you said, it better articulates what I was trying to get at; let's just see who may or may not have a problem with it.

[veneficus]

(didn't quote for brevity)

Well said Mit.

[ffscm72]

I believe mit has it wrapped up.

[VentMedic]

Yes, aren't we lucky that everything can fit so nicely into those few little general "diagnosis" in the paramedic text. Everything is straight forward without any multisystem issues.

Yes, some asthma can be fixed if it has another orgin such an GERD or sinus infection.

Yes, some CHF can be fixed with a new valve or finding another source.

Throw some antibiotics at a cough for "definitive" treatment.

The quick and easy forms of "definitive" treatments are what has led to resistant strains of infections, advance renal failure and progressive diabetes issues.

[veneficus]

Yes, aren't we lucky that everything can fit so nicely into those few little general "diagnosis" in the paramedic text. Everything is straight forward without any multisystem issues.

Yes, some asthma can be fixed if it has another orgin such an GERD or sinus infection.

Yes, some CHF can be fixed with a new valve or finding another source.

Throw some antibiotics at a cough for "definitive" treatment.

The quick and easy forms of "definitive" treatments are what has led to resistant strains of infections, advance renal failure and progressive diabetes issues.

Paramedic and multisystem issues included, how many of the patients with conditions you mentioned ever get “definitive” treatment?
Really, with the latest stats I heard, 47 million Americans uninsured, countless others underinsured, emergency departments and charity hospitals closing every year, and to top it off the ED has become the primary point of care for so many, do you really think that anyone except the very wealthy or those fortunate enough to have a job in healthcare will ever get definitive care? I spent 3 years in an ED and even did a peds ED rotation where the MD/DO basically told the patient: “we can only address your chief complaint today.” I am sure you are aware of patient “shopping” around till they find a doc that will give them what they want. Like antibiotics for their influenza infections. I better not start on the failings of western medicine.
The private payer system is beyond workable. So long as we have it, I foresee more and more “definitive” care being nothing more than addressing symptoms. In your honest opinion what do you see the difference being between a medic giving a CHF patient furosimide, or the ED giving it and discharging the patient because they cannot take up a bed? Sure in the ED all kinds of tests are run, you even get an x-ray so you can see it. But it doesn’t change anything other than the amount the patient is billed.
Your examples are right on the money, but reactive airway secondary to GERD is getting some albuterol, maybe some atrovent, maybe some prilosec and bounced with a Gastro consult in a month. By then the Pt. will no longer be in crisis, and won’t show up anyway. What changes if we have a medic give an albuterol even if they do not know all the complicating factors? Even when we know the complicating factors in the ED care often doesn’t change though more about the individual disease progression is discovered.
Even in primary care who bothers to differentiate between osteomalacia and osteoporosis? Different diseases, different treatments, one x-ray and one bone density test. How definitive is that?
Just my opinion, but I will take a good medic, a good nurse, or a good PA over a mediocre doc any day. I guess I have this idea that that it is the individual that provides superior or more definitive care, not the title.

[VentMedic]

The private payer system is beyond workable. So long as we have it, I foresee more and more “definitive” care being nothing more than addressing symptoms. In your honest opinion what do you see the difference being between a medic giving a CHF patient furosimide, or the ED giving it and discharging the patient because they cannot take up a bed? Sure in the ED all kinds of tests are run, you even get an x-ray so you can see it. But it doesn’t change anything other than the amount the patient is billed..

Just give a little furosemide and discharge? What caused the CHF? Renal? Cardiac? CXR? How about BNP? If I am in CHF I could care less how much I am billed. Nor, do I want to keep coming back to the ED because what is causing the CHF is not regulated or resolved. Just giving someone a script for furosemide may not be the treatment of choice.


Your examples are right on the money, but reactive airway secondary to GERD is getting some albuterol, maybe some atrovent, maybe some prilosec and bounced with a Gastro consult in a month. By then the Pt. will no longer be in crisis, and won’t show up anyway. What changes if we have a medic give an albuterol even if they do not know all the complicating factors? Even when we know the complicating factors in the ED care often doesn’t change though more about the individual disease progression is discovered.


Just give albuterol? Atrovent?

Do you actually know how the relationship is established between GERD and reactive airway disease? You seem to be pulling "treatments" only from paramedic protocols. I thought you were studying to be a doctor.

Obviously you have never seen anyone with breathing difficulties. For a person to do away with their rescue inhaler dependency is priceless.

To change the disease progression is the "definitive care". Why should someone have to come back the next day for more furosemide because that is the "definitive care"? Why should someone keep coming back repeated to the ED for breathing problems when their rescue inhaler is becoming less effective and the cause of their breathing problems has been masked by all the "definitive care"?

For the problems and ED doctor can not treat definitively rather than just alleviating the symptoms a referrable should be and will more than likely be made.

Even physicians have this discussion continuously as to who is better qualified to provide definitive care for a disease process. GPs may think they can treat everything and end up doing "definitive care" to every little symptom until the person is on 30 different medications without a true idea about what they are being treated for. Specialists may extend their education for another 2 - 7 years on top of the usual 10 - 12 years with college, med school and residency to provide a more indepth knowledge of some specialties.

ED physicians do treat the immediate symptoms and hope the patient follows up with referals. ED physicians do treat acute onset and non chronic illnesses definitively such as broken bones, lacerations, common viruses (flu and colds), food poisoning, uncomplicated dehydration etc. They are not stupid and know their limitations and write for the referals or call for consults.


Just my opinion, but I will take a good medic, a good nurse, or a good PA over a mediocre doc any day. I guess I have this idea that that it is the individual that provides superior or more definitive care, not the title.


Medic? RN? PA?
3 very different healthcare professionals with very different educational requirements and very different areas of focus.

Which of these individual professionals would over step their scope to jeopardize their license?

Can all of them order the necessary tests, write scripts, refer to a specialist and admit to a hospital? The PA, yes, can do some of these things but even the PA is now very specialized in their focus. Some may just want to work with Cardio-Thoracic surgeons and not do clinic work.

Yes, I would take any of these professionals as my patient advocate, but I would really like my own, or for those people I care about, health problems "defined" before more serious medical treatment is required and they do become chronic issues. Permanent organ damage can occur quickly in many disease processes if "definitive treatment" is not provided.

[veneficus]

Just give a little furosemide and discharge? What caused the CHF? Renal? Cardiac? CXR? How about BNP? If I am in CHF I could care less how much I am billed. Nor, do I want to keep coming back to the ED because what is causing the CHF is not regulated or resolved. Just giving someone a script for furosemide may not be the treatment of choice. .

What if they are already taking furosimide and are still in crisis? I am not saying it is the treatment of choice or even the complete treatment, but it will most likely be the first step in treatment, even in the ED.


Just give albuterol? Atrovent?

Do you actually know how the relationship is established between GERD and reactive airway disease? You seem to be pulling "treatments" only from paramedic protocols. I thought you were studying to be a doctor. .


Yes I am quite aware of the relationship between upper GI and respiratory issues, I was not suggesting it was the definitive treatment, I was stating that it is the common symptomatic treatment in the ED prior to GI becoming involved. The ED treatment protocols also look remarkably like the paramedic protocols. Sometimes in the ED protocols are deviated from, but not as often as one might think.

Obviously you have never seen anyone with breathing difficulties. For a person to do away with their rescue inhaler dependency is priceless. .

The patients I am most involved with are only concerned where the next rescue inhaler comes from; receiving the care to not be dependant on it is a dream beyond dreams.

To change the disease progression is the "definitive care". Why should someone have to come back the next day for more furosemide because that is the "definitive care"? Why should someone keep coming back repeated to the ED for breathing problems when their rescue inhaler is becoming less effective and the cause of their breathing problems has been masked by all the "definitive care"? .

That is my point; they should not have to come back because treatment masked the cause. But under the current system they will. I can only work with the system I have, not with ideals that only a small percentage of people even have access too.

For the problems and ED doctor can not treat definitively rather than just alleviating the symptoms a referrable should be and will more than likely be made. .

Undoubtedly a referral should be made, which is why it is done. But The patient populations I have and continue to work with, if 5% even go to the referral that is amazing.

Even physicians have this discussion continuously as to who is better qualified to provide definitive care for a disease process. GPs may think they can treat everything and end up doing "definitive care" to every little symptom until the person is on 30 different medications without a true idea about what they are being treated for. Specialists may extend their education for another 2 - 7 years on top of the usual 10 - 12 years with college, med school and residency to provide a more indepth knowledge of some specialties.

ED physicians do treat the immediate symptoms and hope the patient follows up with referals. ED physicians do treat acute onset and non chronic illnesses definitively such as broken bones, lacerations, common viruses (flu and colds), food poisoning, uncomplicated dehydration etc. They are not stupid and know their limitations and write for the referals or call for consults. .

I am not speaking poorly of EMs. They unfortunately have become the long term care for a lot of people. They don’t like it; they as well as I know it is not optimal. But under the current system and healthcare trends it is reality.


Medic? RN? PA?
3 very different healthcare professionals with very different educational requirements and very different areas of focus.

Which of these individual professionals would over step their scope to jeopardize their license?

Not sure where you are going with this.

Can all of them order the necessary tests, write scripts, refer to a specialist and admit to a hospital? The PA, yes, can do some of these things but even the PA is now very specialized in their focus. Some may just want to work with Cardio-Thoracic surgeons and not do clinic work.

My point of my entire statement was that because proper follow up care with referrals was not common, that all of the proper tests become superfluous. I am looking for 1 good reason to strain the economics of the entire current system for tests that will only in a small percentage of patients ever get followed up on.

Yes, I would take any of these professionals as my patient advocate, but I would really like my own, or for those people I care about, health problems "defined" before more serious medical treatment is required and they do become chronic issues. Permanent organ damage can occur quickly in many disease processes if "definitive treatment" is not provided.

Yes, permanent damage does occur everyday, and in my experience often because there will never be “definitive” treatment for a particular patient.

We probably agree on more than we disagree on, but in my post I was speaking of problems at the system level, not at the individual level, which you seemed to focus in on for your reply.

[VentMedic]

I am only going to comment about this:

The patients I am most involved with are only concerned where the next rescue inhaler comes from; receiving the care to not be dependant on it is a dream beyond dreams.

Your patients may not have been provided the correct education or treatment for their breathing problems. That's what happens when people believe they know it all about something they actually know very little about.

You obviously know very little about respiratory medications or many others except fuorsemide. People can become less dependent and actually off rescue inhalers.

Reality check for the system in the U.S.: Paramedics have between 500 to 2500 hours of education and training. In other words, some states only require 500 hours for a paramedic cert and a couple require a 2 year degree. There are 48 different levels of "certs" in the U.S. mostly based of "hours" of skills training. A concept like the Paramedic Practitioner is good but a long way off for even a Bachelors degree. Even at that, it is much less education than the physician extenders.

Most of us have come to understand this in the U.S. and even though we may not like it or agree with it, the "system" is only as strong as its weakest links.

[dr-exmedic]

The only part that differentiates what is done in the field vs what is done in the ED are the tests performed after the exam.
And, I would argue, what's going on in the head of the provider, since (as you pointed out) different levels of providers have different levels of understanding as to what's going on.

[dr-exmedic]

You know, it's really funny for me to watch how much of the debate on this thread centers over the exact meaning of "definitive"... :)

[veneficus]

I am only going to comment about this:


Your patients may not have been provided the correct education or treatment for their breathing problems. That's what happens when people believe they know it all about something they actually know very little about.

You obviously know very little about respiratory medications or many others except fuorsemide. People can become less dependent and actually off rescue inhalers..



I am not understanding, how you draw the conclusion between indigent care, and what I know or don’t know about respiratory meds.
I simply stated that in lower socioeconomic areas proper education and care is not provided. This should not be news to anyone. This population receives much of its care in the ED. (in other words: the minimum) For this I gave some basic examples. I did not set out to type out everything I ever learned or every possible condition or treatments of any given body system.

I am sure I do not share your passion for long term respiratory illnesses or treatments and as such you probably know considerably more than I do about it.(at least I hope you do if you are passionate about it) But I would not say my knowledge of it was lacking or limited to a few drugs or basic conditions.

I did stipulate that if we are doing the minimum for indigent patients what is the difference who is doing it?


Reality check for the system in the U.S.: Paramedics have between 500 to 2500 hours of education and training. In other words, some states only require 500 hours for a paramedic cert and a couple require a 2 year degree. There are 48 different levels of "certs" in the U.S. mostly based of "hours" of skills training. A concept like the Paramedic Practitioner is good but a long way off for even a Bachelors degree. Even at that, it is much less education than the physician extenders.

Most of us have come to understand this in the U.S. and even though we may not like it or agree with it, the "system" is only as strong as its weakest links.

I am not arguing about the educational requirements for medics, that is another thread and I have exhausted my arguments on it.

Don’t know if you realize it or not, but the current health care system we understand in the US is not going to be able to economically sustain itself much longer.
Moreover, I try not to get into medical arguments on the EMS forum. I am a member of a few other forums that deal in conditions that interest me for that. But I can say for certain that no ED I have ever been in has attempted to provide care to respiratory patients outside of crisis management. They don’t manage patients that have cancer, autoimmune diseases, or many genetic diseases outside of crisis either. It is simply not what they do. IF you want to come over here to lecture health and lifestyle changes in the local hood and set up and drive them to their follow ups, be my guest. You may not find them as receptive to the idea as I am though. Certainly nobody is going to pay for it. So they will probably settle to call 911 when they don’t feel well, and 99% of the time they will get standard protocol treatment from EMS and/or from the ED.

[VentMedic]

I IF you want to come over here to lecture health and lifestyle changes in the local hood and set up and drive them to their follow ups, be my guest. You may not find them as receptive to the idea as I am though. Certainly nobody is going to pay for it. So they will probably settle to call 911 when they don’t feel well, and 99% of the time they will get standard protocol treatment from EMS and/or from the ED.

Get your stories straight. One post you are a med student in Europe and now you are in an ED in the U.S. in the hood?

Indigents still get treatment. We do not discriminate nor to we take it as fact that they do not want care or that they just want to abuse the system to make the healthcare system miserable.

[veneficus]

Get your stories straight. One post you are a med student in Europe and now you are in an ED in the U.S. in the hood?

Indigents still get treatment. We do not discriminate nor to we take it as fact that they do not want care or that they just want to abuse the system to make the healthcare system miserable.


You caught me, I hold dual residence. To straighten the story, I do both, I work on my summer vacations at home in the US(as a paramedic), life only revolves around school in Europe for 9 months a year :) Does it make you angry that I have a large veiw of the world? On my school vacations I also do my best to fill up my passport visiting healthcare organizations around the world, so I actually can comment on how things work in the hood in the US and hospitals all over the globe. Diversity is part of my charm. :cool:

[DrParasite]

But I can say for certain that no ED I have ever been in has attempted to provide care to respiratory patients outside of crisis management. They don’t manage patients that have cancer, autoimmune diseases, or many genetic diseases outside of crisis either. It is simply not what they do. you mean they handle the emergency? who would have thought it, the EMERGENCY room only handles the EMERGENCY. once the EMERGENCY is handled, the patient can be admitted to the cancer floor, or the autoimmune floor, or whatever specialty floor should their condition be critical enough to warrant it. or once they are stabilized, they can be referred to their PCP for follow up.

I know, radical thinking, isn't it?

[veneficus]

you mean they handle the emergency? who would have thought it, the EMERGENCY room only handles the EMERGENCY. once the EMERGENCY is handled, the patient can be admitted to the cancer floor, or the autoimmune floor, or whatever specialty floor should their condition be critical enough to warrant it. or once they are stabilized, they can be referred to their PCP for follow up.

I know, radical thinking, isn't it?

and people think my views are extreme. :)

[twelthfan]

:cool: botom line! everyone on scene needs to know their level of training and provide the best patient care possible!

[ffscm72]

:cool: botom line! everyone on scene needs to know their level of training and provide the best patient care possible!

well said!!!

[dragoon311]

I am not a Doctor. As a medic, I know just enough to know that. I understand that I was taught in paramedic school the basic, rudimentery knowledge about disease, illness and trauma. (I have tried to learn more on my own). I even tell my patient who ask me what's wrong. "I'm sorry, I'm not a doctor, this is what I THINK is going on but only more tests, x-rays, etc and a DOCTOR can give you a better answer."

Having said that, I am not an EMT. I do know more then an EMT. I do more then an EMT. I have more responsiblity then an EMT.

I am a paramedic. I try not to be ****y. (though when I get a very hard IV on the first try, feel that little rush of air after I decompress a chest or feel a pulse on the 10 year old I just pulled lifeless from a pool, I feel like a GOD.)

The "fight" between EMT's and paramedics have been around since a the two positions were made seperate. Is it silly? Yes. Is it human nature for one group or person to try to assess dominance over another person? Yes. Is it ever going to end? No.

So basicly, stop whinning about it. If you don't like it you have three options. 1. Go to school and become a medic. 2. Get another job. 3. Suck it up.

last time I check medics were still emt's (emt-p)

[dragoon311]

I don't believe ANYONE said paramedics were difinitive care, however, I think in CERTAIN situations they can be, Yes.


Apparently someone has never heard of paramedic initiated refusals. You call for an ambulance, the paramedic evaluates you, if you dont need an ambulance, they tell you no and provide you with a list of ways to get to the ED on your own. Quite an effective tool if EMS uses it right. Sounds like discharging to me???

I only use the terminology discharging to apply it to your statement, just putting that out there.


See above.


Again, a very broad brush. I understand what you're saying but I think it's to blanket of a statement.

See the paramedic initiated refusal section above and consider this, if a paramedic/emt is transporting someone who, without a medical cause, becomes aggressive or deragatory towards the provider, that person has every right to stop the truck and tell them to get out. I understand this isn't the standard but i've done it and would do it again. That doesn't exactly fit your broad brush, see what I mean?


Again, as most of these discussions boil down to, I think our definition of difinitive care if just different, but not by much.

In reference to your MD statement, I stand behind my statement that most ER physicians treat a lot of s/s and less pathology. Again, you get a bee sting, you have a reaction---->Paramedics administer the course of meds for such a c/c and then transport to the ER. The ER does what, other then make sure there is no relapse and draw some blood??? How does the ER MD treat the cause of the bee sting, kill all the bees.....

As a former vegas emt i can proudly say that stopping your rig and and telling a patient to get out is abandonment and can get you sued and your cert pulled once care is started you have to complete it or transfer to high level provider, if patient is aggressive you need to employ measures to restrain them so that you can reach the appropriate facility or call for police intervention

[veneficus]

As a former vegas emt i can proudly say that stopping your rig and and telling a patient to get out is abandonment and can get you sued and your cert pulled once care is started you have to complete it or transfer to high level provider, if patient is aggressive you need to employ measures to restrain them so that you can reach the appropriate facility or call for police intervention

Just to clarify,
The paramedic initiated refusal, is/was a protocol that was tried out at least at EBR EMS (I don’t know of anyplace else that has done it) The System when I was there(some years ago) ran double medics, after an exam the lead medic could decide you did not require EMS transport, and you were left to your own devices. There was considerable QC, and it was not against the law in LA for a medic to decide you did not need emergency care. If treatment was started, since the pt obviously received care, the patient had to be transported at that point. It was meant to reduce 911 abuses, not as a treat and release protocol.
I don’t know if it is still on the books there, but from my anecdotal experience, it did work for what it was designed for, though often it was easier to transport than to run the refusal protocol and many medics defaulted to just giving people a ride to save time.

[dragoon311]

(if a paramedic/emt is transporting someone who, without a medical cause, becomes aggressive or deragatory towards the provider, that person has every right to stop the truck and tell them to get out. I understand this isn't the standard but i've done it and would do it again.)
this was the statement that I was referring to

[LasVegasEMS]

As a former vegas emt i can proudly say that stopping your rig and and telling a patient to get out is abandonment and can get you sued and your cert pulled once care is started you have to complete it or transfer to high level provider, if patient is aggressive you need to employ measures to restrain them so that you can reach the appropriate facility or call for police intervention

Negative. You have to look at the context and situation in which I meant it. As stated, this is not a standard and is definitly not something that goes without a phone call to a supervisor and other imperative people.

Second, before you proudly say anything, go back and read/examine the laws. Instead of just regurgitating what you learned in your emt class.

[LasVegasEMS]

last time I check medics were still emt's (emt-p)

And hopefully, as EMS progresses, we can move further and further away from this.

[dragoon311]

Negative. You have to look at the context and situation in which I meant it. As stated, this is not a standard and is definitly not something that goes without a phone call to a supervisor and other imperative people.

Second, before you proudly say anything, go back and read/examine the laws. Instead of just regurgitating what you learned in your emt class.

This is not regurgitation it is what is posted with the national registry and furthermore you are why people in Vegas don't like emt's and I don't view a paramedic any different than a basic or intermediate because we are all there to provide service to the patient and we are all emergency medical technicians

[LasVegasEMS]

This is not regurgitation it is what is posted with the national registry and furthermore you are why people in Vegas don't like emt's and I don't view a paramedic any different than a basic or intermediate because we are all there to provide service to the patient and we are all emergency medical technicians

First, the National Registry does not make/enforce/establish laws for anyone. They have position papers and that is it.

Second, you don't know anything about me or who I am. How could you possibly make a statement like that. Also, I never experienced the dislike for EMT/Paramedics that you have stated. Perhaps they just didn't like you.

And finally, hopefully with the expansion of paramedic curriculums, including pre-reqs and general ed, will move us away from technician and more into a clinician role. You're absolutly right that we're all there to help the patient, but so are doctors, nurses, RT, social workers, etc, are you putting yourself on par with them??? I can tell you that in my current system, no one is a technician and everyone, give or take LOL, is a clinician. Sorry you feel so bad about your position.

[MrPookie]

Most of this subject boils down to egos. Of course EMT-Paramedics know more than EMT-Basics, they've been to more schooling and probably been through more experiences. But, for any paramedic to act insulted to even be in the same category (EMT) as a basic is ridiculous. First of all, there is not that much education that separates the two of you (and I think this opinion would be shared by many). There are some EMT-B's who have the potential to (and will) become better paramedics than some of the current ones. The way I view it, EMS is obviously a team and needs to treat each other as teammates. All of that being said, I would prefer an EMT-P to provide care to somebody in my family who was injured, but I sure do wish I could deflate some of the big heads in here.

[DrParasite]

All of that being said, I would prefer an EMT-P to provide care to somebody in my family who was injured, but I sure do wish I could deflate some of the big heads in here.does that include a member of your family who had neck pain folowing a minor mva? or sprained his ankle walking down the stairs?

and how you would you feel if while the medic was treating your family's sprained ankle, there was no medic available to help your neighbor who suddenly began having severe chest pains, nausea and vomiting, as well as trouble breathing? so he might die, so you can feel better because a medic is treating your family member?

[MrPookie]

It does include a member of my family if they had neck pain, or a sprained ankle. I'm simply saying that if there were an EMT-B and an EMT-P both standing around my house, doing nothing, just hanging out (I know, fictional scenario), I would prefer the EMT-P do the treatment because of my assumption that they probably have more experience, more reps in what they area doing, and some more knowledge. Not that the EMT-B couldn't do it. I think you misunderstood what I was saying, and that's probably because I wasn't very clear. I would not want to pull away resources where they were needed. Of course I would rather have the neighbor treated who had more serious symptoms...sorry for the confusion.

[AZCEP43]

Yet another unrealistic scenario. You know very well that if someone else needs a resource, and your family needs the same one you don't care about anyone but your family.

Sure a basic could probably manage these seemingly simple situations, but how do you know that they are in fact this simple without the base of information that a paramedic has? A basic cannot make a treatment decision based on the level of information they are exposed to.

[MrPookie]

Maybe in your case, but not mine. If somebody in my family sprained their ankle, and my neighbor was vomiting blood and having chest pains, I would definitely direct the more experienced provider to my neighbor. But, if my neighbor was vomiting blood and somebody in my family was less hurt, but still seriously injured, of course I would want my family taken care of first. That is natural for anybody. This is beside the point I was trying to make in my original post anyway.

[emt161]

does that include a member of your family who had neck pain folowing a minor mva? or sprained his ankle walking down the stairs?

I want the one with more than 2 weeks of first aid training.

[Ridryder911]

Again we continue to fight. Mainly because most are ill informed or lack an understanding of EMS Education. When one really evaluates the EMT training* (training & education are not the same) in regards to the current & even proposed curriculum, one will find out several factors.

The EMT is very limited in their general knowledge base. Does this mean one that has been an EMT for 10 years is still limited; no. However; based upon what is demanded in their job, what is expected and certified/licensed as is a minimum. Just a little above the common layman advanced first aid course. That is why it is called B-A-S-I-C.

Most EMT texts are written just a little over the elementary grade school level and the skills of the Basic EMT have been determined to be very simplistic. When evaluated for proficiency level as in education it has been determined that with repetitious training and practice, almost everyone could master them with ease.

Does this remove the importance of the EMT. No. Does this mean their current level of education & training meets the current demands of emergency services. No, as well. Rather, they now meet the standards of a first responder to initially begin care and prepare the patient for transport, as well some may have gained knowledge & experience to assist Paramedics.

Again, the expected role does not meet the demand nor does current education and training methods meet these as well. This is not a personal issue, rather an professional issue regarding our staff and levels in EMS.

I don't care if you have a PhD in basket weaving. If you are a Basic you will still be limited upon what you can do at that level. Be it the local certification, the scope of practice, or your knowledge level of patient care. Even if you did have higher knowledge of care, you still would be restricted at that level. Case point, don't like the level.. change.

It's absurd that we are even having such a debate. Unfortunately, we have not changed EMT training in the past 40 years, except to make matters worse. For some reason we still exploit and hype the Basic EMT level more than it is. Possibly, if we actually told the truth many would never enter programs or they would go to other medical professions. No matter what is being told; the EMT is just the entry point, nothing more.

Those who succeed do have a role but it is not as many assume or even is suggested in their Basic EMT. Something that needs to be changed. This is why we still have a constant confusion and turmoil between the levels. One could make a similar comparison of nurses aides to an RN. At least their profession has made it definitely clear what their individual roles and the hierarchy are within their profession.

We either have two solutions. Either change the hype and expectations of those in the Basic EMT programs or to increase the education level to meet what is expected. Although, I do believe we would see much difference outcomes. It would be possible that those that enter the profession would have a better understanding of their role in EMS, and or be very competent EMT's. We may see very few entering & exiting the EMT programs. Which in itself is not always a bad thing. Those exiting would have a much higher likelihood of having more in-depth knowledge and or may pursue to move upwards within the EMS system.

R/r 911

[DrParasite]

Does this mean their current level of education & training meets the current demands of emergency services. No, as well. Rather, they now meet the standards of a first responder to initially begin care and prepare the patient for transport, as well some may have gained knowledge & experience to assist Paramedics. You know, if every 911 medical call was actually for a life threatening emergency, I would agree with you 100%. if every 911 call would be treated and release by a paramedic, I would agree with you. Heck, if every 911 call could have interventions started by paramedic (other that an hep lock) that would beneficial, then I would agree with you.

unfortunately, studies show that between 60 and 80% of EMS calls don't need any ALS interventions. That tells me (and most of the world) that the EMT system just fine, regardless of what some misinformed people thinking

[veneficus]

You know, if every 911 medical call was actually for a life threatening emergency, I would agree with you 100%. if every 911 call would be treated and release by a paramedic, I would agree with you. Heck, if every 911 call could have interventions started by paramedic (other that an hep lock) that would beneficial, then I would agree with you.

unfortunately, studies show that between 60 and 80% of EMS calls don't need any ALS interventions. That tells me (and most of the world) that the EMT system just fine, regardless of what some misinformed people thinking

I agree, but to take it a step further, if you don’t need a paramedic, you most likely don’t need a doctor either. But then who makes that decision?
What do you do if an EMT decides you don’t need a medic? Drive them to an ER, where they figure out they don’t need a doc either?
I think the problem cannot be solved simply by education levels of the provider. The whole idea of EMS being a ride to the ED, instead of a more public health model needs to change. I realize that may take some out of their comfort zone, and whatever you choice of divine being or not forbid anyone would be accountable for the decisions they made(it would be your license and your responsibility), if you advance education you must also advance the responsibilities of the professionals. Otherwise, who needs some person with an A.S., B.S., M.S., or PhD to drive the limo to the hospital?
Forgive my sarcasm, but it would not be a tragedy if we stopped billing $300-600 for what amounts to a limo ride.(you can share a taxi ride) I think it is interesting many current systems in the US basically amount to a pilot and a flight attendant every time some lay person thinks they need “emergency” medical care. (Even if they legitimately cannot get to primary care for whatever the reason.)
I know the fire service people will now call me names and harp about how they are serving the public, but the considerable resources it takes to provide EMS and using it as a ride doesn’t serve the people paying for it or the people who actually need it when they are waiting for the next free unit or one farther away. Maybe we could spend the municipality’s entire budget by staffing a dual medic ALS ambulance on every corner. (or $600,000 big red non-transporting fire truck)

[DrParasite]

I agree, but to take it a step further, if you don’t need a paramedic, you most likely don’t need a doctor either. But then who makes that decision? i disagree. in many medical cases if you don't need a paramedic, you don't need an EMERGENCY doctor. many medical cases could be handled quiet effectively with a patient's PCP/PMD.

injuries, well, they happen, people do stupid stuff and sometimes it's better to go to the ED than a PM. but most injuries, short of major traumatic injuries, don't need ALS interventions, they need x rays, prescribed pain pills, maybe a muscle relaxant or so, even some bandages or a cast and other interventions that an ED doc has readily at his or her disposal that a medic doesn't.
What do you do if an EMT decides you don’t need a medic? Drive them to an ER, where they figure out they don’t need a doc either? umm yes? the doc looks them over, tells him there is nothing they can or need to do for you, and send you home, telling you to follow up with your pmd.

I think the problem cannot be solved simply by education levels of the provider. The whole idea of EMS being a ride to the ED, instead of a more public health model needs to change. I realize that may take some out of their comfort zone, and whatever you choice of divine being or not forbid anyone would be accountable for the decisions they made(it would be your license and your responsibility), if you advance education you must also advance the responsibilities of the professionals. This is going to sound harsh: if you want to be able to do what you are proposing, go to medical school and become a doctor. then you can make your own choices based on what you think is right, and not have to answer to anyone.
Otherwise, who needs some person with an A.S., B.S., M.S., or PhD to drive the limo to the hospital?
Forgive my sarcasm, but it would not be a tragedy if we stopped billing $300-600 for what amounts to a limo ride.(you can share a taxi ride) I think it is interesting many current systems in the US basically amount to a pilot and a flight attendant every time some lay person thinks they need “emergency” medical care. (Even if they legitimately cannot get to primary care for whatever the reason.)maybe that's because most of EMS, from it's inception, is a fancy ride to the hospital?
I know the fire service people will now call me names and harp about how they are serving the public, but the considerable resources it takes to provide EMS and using it as a ride doesn’t serve the people paying for it or the people who actually need it when they are waiting for the next free unit or one farther away. Maybe we could spend the municipality’s entire budget by staffing a dual medic ALS ambulance on every corner. (or $600,000 big red non-transporting fire truck)I have no idea what you are talking about.....

You know, it's realy funny when people say medics think they are like the greatest thing since sliced bread. they can handle any emergency. they are better equipped to deal with any medical call, much better than their BLS counter parts.

the truth is medics are taught how to intubate, taught how to start IVs. they are taught how to give drugs as well as the pros and cons of giving those drugs. And when you get a serious cardiac or respiratory emergency, I want one of those medics treating me, because they are damn good at treating cardiac and respiratory emergencies. I'm sorry, that's not actually true. They are are damn good at treating cardiac and respiratory emergencies until they can turn the patient over to a doctor. They are extensions of the ER docs in critical situations, they don't replace them.

But let me ask you this: on your next shift, ask your ALS coworkers to explain to you how the lymphatic system functions. or the endocrine system, not referencing diabetes. or ask him what causes ulcers, and what is the single best cure for an ulcer is, especially in the starting stages; and then ask him why it is so effective. or ask him what the non-life threatening causes of a headache are. or a guy has been had blood in his urine for a week, what are the potential causes for this, and what can be done prehospitality to fix the problem? or even better, what makes up a human cell, and what causes antibiotics to work on some bacteria and not work on others?

I'm betting most medics would not know the answer to these questions, not because they are bad medics, but because IT'S NOT THEIR JOB TO KNOW. You want to know more? go above a medic. become an NP/PA/MD/DO then you can know more and apply that knowledge.

totally unrelated, but i had to get blood drawn a few weeks ago. nice lady, stuck me, took some pints, we got to talking. She told me she did everything an RN did but got paid half of what she made. She was a CMA. I have no doubt she could perform the skills of an RN, but I don't think she knows why she did those things that way.

same with a medic and a doc. they might have similar skill sets, but the knowledge a doc has far surpasses what a medic knows.

[veneficus]

i disagree. in many medical cases if you don't need a paramedic, you don't need an EMERGENCY doctor. many medical cases could be handled quiet effectively with a patient's PCP/PMD..

I should have been clearer, “emergency” doctor is what I was referring to. The problem is that most patients I have seen do not have or cannot timely see a PCP, which has forced this duty to the EMs. In a perfect world, all docs are capable of being PCP first and specialists second. But it is just not the case.

injuries, well, they happen, people do stupid stuff and sometimes it's better to go to the ED than a PM. but most injuries, short of major traumatic injuries, don't need ALS interventions, they need x rays, prescribed pain pills, maybe a muscle relaxant or so, even some bandages or a cast and other interventions that an ED doc has readily at his or her disposal that a medic doesn't...

Unfortunately, this is not the case. I have spent a considerable amount of time in the ED, both as a paramedic and medical student and a majority of cases (I estimate 90%) have nothing to do with emergencies or untimely injuries. It has become the 24 hour STD clinic, pregnancy testing center, “I have a headache” make me feel better, I need narcotic pain meds for my toothache, no cash upfront primary care clinic.

A personal story: I once tried to make a PCP appointment with my family doc for my wife, with the best insurance money can buy and being an employee of the hospital. I was told the very next appointment was a month and ½ away.(Are you going to wait 6 weeks to treat a UTI?) So I called work and asked them to keep a bed for a few minutes. I can only imagine what it is like for the average uninsured or underinsured person on the street to get an appointment outside of the ED.
It is pointless to try and argue specific interventions with such limit space as this forum.

umm yes? the doc looks them over, tells him there is nothing they can or need to do for you, and send you home, telling you to follow up with your pmd.
This is going to sound harsh: if you want to be able to do what you are proposing, go to medical school and become a doctor. then you can make your own choices based on what you think is right, and not have to answer to anyone.
maybe that's because most of EMS, from it's inception, is a fancy ride to the hospital?.

In order to save ever dwindling resources and provide better patient care, we need to move beyond this idea you need a doc. Why not an NP/PA or similar? It is also not about me, I did go on and it was at this point that I saw how much more a medic could be.
Medics stopped being just a fancy ride to the hospital when they started working in environments other than ambulances. Such as employee health clinics, ships of various purposes, etc. Certainly medics need more education to do this proficiently, but it is a reality that you could work your whole career as a medic and the only time you spend outside a facility is during your class ride time.
If I asked you to fork over taxes to drive somebody in a limo to their doctor every time they called a number, you might not think it is a good idea. I do not think what EMS has become is a good idea. I think it could be better, even though I will be an ancillary part of it.

You know, it's realy funny when people say medics think they are like the greatest thing since sliced bread. they can handle any emergency. they are better equipped to deal with any medical call, much better than their BLS counter parts.

I don’t think they are the greatest thing since sliced bread, only that it could be better than what it is now. Is it wrong to always want to be better than yesterday?

the truth is medics are taught how to intubate, taught how to start IVs. they are taught how to give drugs as well as the pros and cons of giving those drugs. And when you get a serious cardiac or respiratory emergency, I want one of those medics treating me, because they are damn good at treating cardiac and respiratory emergencies. I'm sorry, that's not actually true. They are are damn good at treating cardiac and respiratory emergencies until they can turn the patient over to a doctor. They are extensions of the ER docs in critical situations, they don't replace them.

I am not saying the medic should replace the EM physician, only that since medics are finding more diverse roles, that they could become a better part of the health system overall, with just a few changes.

But let me ask you this: on your next shift, ask your ALS coworkers to explain to you how the lymphatic system functions. or the endocrine system, not referencing diabetes. or ask him what causes ulcers, and what is the single best cure for an ulcer is, especially in the starting stages; and then ask him why it is so effective. or ask him what the non-life threatening causes of a headache are. or a guy has been had blood in his urine for a week, what are the potential causes for this, and what can be done prehospitality to fix the problem? or even better, what makes up a human cell, and what causes antibiotics to work on some bacteria and not work on others?.

You are quite right; most medics I have ever met could not answer such questions. A few of my ALS coworkers could do so quite handily. Not because they had higher education, but because they have spent more time in healthcare facilities than out of them. Obviously education for what we expect from ALS providers today needs to increase, you will not find me arguing against that. I certainly don't think today's paramedic education is
adequate.

I'm betting most medics would not know the answer to these questions, not because they are bad medics, but because IT'S NOT THEIR JOB TO KNOW. You want to know more? go above a medic. become an NP/PA/MD/DO then you can know more and apply that knowledge.?.

I think it is now their job to know. I am working on the part above medic, and from here I think we could make medics into more. My opinions on EMS are often not what is best for me, but what I see as best for the public as a whole. (Granted most of those opinions would be good for the EMS professionals also) I like Win/Win

same with a medic and a doc. they might have similar skill sets, but the knowledge a doc has far surpasses what a medic knows.

I am quite familiar with the difference in knowledge between a medic and an MD. Many of my replies sound quite repetitive in this in this thread. I have concluded I am arguing for what could be, you are pointing out what is from an EMS ambulance perspective. I think we both have valid points and do not think you were being harsh. I do wish that rather than simply pointing out the inadequacies of medics you might help me to figure out practical ways to make it better.

[veneficus]

http://www.emsresponder.com/interactive/2008/06/25/open-airways-stories-from-the-back-of-the-ambulance-8/

thought everyone here should listen to this :)