medic5740

You have received lots of good advice here, but I thought that I might add one more little piece. In my opinion, the assessment skills are the key to everything else. You need to know what each part of the assessment is, why you are doing that part of the assessment, what you find in the assessment and what it means for the patient, and only then know what you can do to resolve the issues that your patient is having. It is the understanding of what you find in the assessment and what it means that will get your patient the treatment he or she needs, not only prehospital, but also in the hospital. This basically means maintaining your curiosity from the beginning of your journey in EMS until you finally leave EMS. Once you think you know what's wrong with your patient, treat it, and don't be afraid to follow up to find out if you were correct, and learn from your mistakes. This is the heart of a caring EMT or paramedic. Good luck! :?: :?: :?:

This is a terrific idea! The healthcare professions should be jumping up and down with excitement because this will excite high school students about health careers. Having done something similar in this very rural area which required every tenth grade student to take a medical first responder program without certification, the number of graduates from our high school going into health related careers grew exponentially. Some went into nursing, some went into pharmacology and radiology, some into PA school, and some even continued in EMS, but this exposure gave them a good idea of some of the options in healthcare. I would be more interested in hearing about those who went on into other healthcare fields and not just those who continued in EMS.

I did not walk into the Emergency Medical Coordinating Committee meeting at the state level and demand that Basic EMTs and Intermediates be allowed to do these treatments. These treatments are defined in the protocols directly from the state and have been adopted by more than 23 counties in this state. I'm not sure where you can come off and opine that the decision made by the emergency physicians on the committee , the instructors, and the paramedics in twenty-three counties are completely wrong about this issue, but I really don't care if you do think they are all wrong, and that you are all right. Your personal attacks do not change the facts that Basic EMTs in this state are granted permission and required by their protocols to provide these treatments. In Michigan, this is the Standard of Care. The albuterol neb treatments, the nitroglycerin, the aspirin, the epi-pen, and the D50 protocols are all post radio contact, unless a serious communications outage occurs. I can't change the protocols. My point is that IF these protocols are going to exist in 23 counties in the State of Michigan, then we need to make certain that the prehospital providers are educated, trained, and have clinical experience to follow the protocols. Your opinion, and that is all that it is, an opinion, is that they shouldn't be allowed to provide the treatments at all. That opinion accomplishes nothing. They are allowed to do the treatments as written into the state protocols after medical control physician consent. I will not continue to argue with you about whether these protocols should exist or not. They exist whether either of us agree with them or not. I happen to know from experience that they work and they work well in the rural area of my county, and I assume they also work in the other twenty-three counties too. I'm betting that there are lots of other treatments that we provide that you wouldn't agree with either, as long as they fall under your definition of what only a paramedic should be able to do. My guess is that you were also against AEDs when they first came out, but now we have PAD with lives saved by people whose knowledge is zero and only are willing to follow instructions given by a machine. Here is where we differ. You would lobby against the machine existing. I would lobby that since the machine exists, we better train the operators of the machine. I would argue that we better train them well and often.

Thank you, Dust Devil, for turning this into a personal vendetta of negativity. You do not know me, my experience level, my background, or my motives. I am a licensed paramedic and paramedic instructor. I am a volunteer paramedic in my community. I am also an ACLS instructor, PEPP instructor, PALS instructor, ITLS instructor, and, of course, a BLS instructor, but this discussion isn't about me. I am not, and never have been, a country bumpkin, and neither are my EMTs. Every treatment that I have discussed, which the exception of the SQ injections, are already part of the state protocols and available to all county medical control physicians to adopt. All of these treatments were determined by a state organization named the Emergency Medical Coordinating Committee, which is composed of emergency physicians, paramedics, and instructors. Every one of my EMT-Specialists is trained and educated in acid base balance and fluid resuscitation or they would not be starting IVs. They also have the clinical experience to provide this level of care. My whole point here has been that the education should be IMPROVED for these kinds of programs, but, more importantly, we do not need a National Scope of Practice or a national curriculum that would deny our state or our county medical control physicians the opportunity to make these changes. Some of us would call these changes improvements.

I'm having trouble with the "all or nothing" concept. In your system of logic, it appears that a person must either complete the entire paramedic curriculum and training based upon a national standard, or they are not able to do any (I repeat, ANY) of the paramedic skills. That logic does not work in my rural area. Just because this is the model in use for many years does not mean that it is the only model that makes sense. It may make sense in your area, but not in mine. I'd like to have a scope that spells out minimum levels, and be able to provide services, after serious discussion and education, that are needed in specific areas. If my community has several brittle diabetics and anaphylactic emergencies, if my medical control physician allows the training and the treatment, and if my EMTs are educated and trained in assessment of diabetic emergencies and anaphylaxis, IV administration, SQ injections, and D50 administration, I want them to be able to provide that definitive treatment in my community without a National Scope of Practice that denies this ability. This is just one example. Albuterol neb treatments, Nitro and aspirin administration in cardiac events, and epi SQ administration are others. We have several anaphylactic events each year. Why are we spending hundreds of dollars for epi-pens when our EMTs can easily be trained to properly administer the proper dose for a much lower cost? Each of our ambulances carry two adult epi-pens and two child epi-pens. This is more than $200 in costs. One vial of Epi, a syringe, alcohol prep pads, etc. for an Epi-kit would cost less than $15. The gain is more than the $185. The gain is measured in better educated EMTs and a community that receives the needed treatment. I don't care whether you call them EMT-Specialists. EMT-Intermediates, EMT-IV, EMT-SQ, EMT-Advanced, EMT-II, low level medic, or any other label. I just want my friends and neighbors to get the needed life-saving treatments. With a minimum transport time of over two hours to the nearest hospital, some of these treatments are necessary not just desired. There are even times when our patients cannot be transported due to weather, such as fog (like this morning), blowing snow or freezing rain. We don't need a National Scope of Practice that denies our patients needed treatments. As long as my EMTs are trained, educated, and have received clinical, I need them to be able to provide these treatments. I might be the person having the heart attack one day. This small, very rural, community cannot afford paid paramedics. It just isn't going to happen here.

If the EMTs have had the education, the training, and the clinical, I really don't see why they can't start IVs. In Michigan, an EMT-Specialist can intubate and start IVs with about 90 more hours of education, training, and clinical. Doing the easy math of two topics in 90 hours, that makes an EMT-IV in about 45 additional hours of education, training, and clinical. Remember that clinical is not based upon hours, but upon successful IVs. So, the question is not whether they can do them if educated, it is whether they are allowed to do them. Please tell me why, if they are educated, trained, and have clinical experience, why EMTs should not be doing IVs?

I want to be the first rural volunteer to post a reply here. I was upset that the new scope of practice for all levels including paramedic would deny those in my area from providing patient care that we have provided for several years now. That was why I lobbied against the Scope of Practice. I don't believe 110 hours is enough training and/or education to get anyone ready to provide Basic Life Support in any community. My Medical First Responder class is 90 hours. My basic EMT program is over 200 hours with clinical measured in successfully completed tasks and objectives and not in hours. I have been a volunteer EMS provider for twenty years. I support all those who are fortunate enough to have a paying EMS career. My career in EMS and as an EMS instructor has been in a rural area that is lucky enough to have the money to replace the supplies and equipment on the rig. We worked for 14 years to get enough savings by fundraising to offer a paramedic class, so we could provide the advanced level assessments and treatments that our patients deserve. After twenty years of work to get our level of treatments at this high of level, I certainly don't want someone diluting the treatments that we are able to provide with a watered down Scope of Practice. I have not read the new article you suggest, yet, but I can assure you that I will not support elimination of treatment modalities from any level of EMS care unless there is scientific evidence that these do not benefit the patient. Political motivations, such as the fire chief's comments are just not worthwhile reasons to make changes. Give me a patient care reason to change--something that will help my patient, and then I'll investigate the suggestion, and make the choice on my own. I was studying EKGs when I was a basic EMT, drugs and 12-leads when I was an intermediate. Now that I can provide IV pump medications, induce hypothermia, and actually give my patients some comfort from pain, and a chance to survive, why would I want to go back to a watered down curriculum with lowered expectations. Our basic EMTs can give nitro, aspirin, and albuterol neb treatments. Our Intermediates can push D50 for insulin shock. We got these treatments by earning the respect of our medical directors and ER physicians. Why should we give them up? Why doesn't the Scope of Practice embrace these levels of care? Right down the road, there are basic EMTs starting IV's. Is there a reason that they shouldn't be doing that if they are educated and trained to do the proper treatments? I'm sorry if I am coming on strong, but this is one person who believes that education is power. I supported the level of care named Advanced Paramedic with the higher level of education that would accompany a higher level of provider. That one lasted a very short time in the discussion phase in Scope of Practice discussions. Let's move EMS up the ladder of professionalism by increasing education and knowledge instead of moving backwards. Let's set the bar higher so our profession can strive to improve the level of patient care for every person in every community.

Thanks! I needed a good laugh! Your post was the highlight of the afternoon.

In a large number of cases, it is the perception of the "wronged" person rather than the intent of the "person doing the wrong." I believe that we get into EMS because of the kind of person we all are. We are either very sensitive people to others problems, or we don't stay in EMS. When our perception abilities get slightly screwed on crookedly, we may see things that are really not there. Now, I am not saying that there are not people out there who purposely want to stir things up, but I find that things unsaid cause more problems than things that are said. Try a "thank you" to the crew that was on just before you when they leave the rig in excellent condition. Try a "good job" when someone splints a fractured femur properly. Try a "Certificate of Excellence" when someone does consistently good work. If someone does something slightly different than the way you would do something, I find that asking how or where did you learn that method without a negative tone of voice can be a learning experience for both EMS providers. I know I retired from volunteer EMS after 20 years because the local government did not take the time to pass a "Thank you" resolution for those twenty years of service. My perception was that I was not appreciated. Things like this don't cost any money at all, but provide great returns on the little effort that is invested. The more you provide positive investments, the more positives you will reap.

I certainly will not say the rural EMS providers are better than urban EMS providers, but I will say that a rural provider has to learn how to develop a relationship with a patient due to the longer transport times. The urban providers must become much more efficient at providing the treatments due to the (sometimes) very short transport times, like 15-20 minutes. In the rural areas 15-20 minutes is a short transport time for most of rural Michigan anyway. If the hospital in less than 10 minutes away, how can an urban provider develop any kind of patient relationship. How do you convince a patient that you are providing patient care, not just treatment(s), in such a short period of time? I am not being negative. I am actually asking a valid question. Our transport times are about two to three hours most often. The major treatments are completed in less than 20 minutes usually. So talking to the patient, holding his/her hand, and monitoring the patient are pretty much required to fill in the rest of the time.

I am sure that some of you out there will disagree with me, but I certainly feel that helping my friends and neighbors is the reason that I volunteered for EMS. The local governments here support the volunteer fire department with a budget twice as large are the EMS budget even though EMS runs from 15 to 20 times as many calls as fire even in this rural environment. So busy does not necessarily mean paid services. Distance is an issue for rural EMS especially when drug boxes are designed for urban services. I have posted a story with pictures about a 12 hour EMS run that occurred here. You can read it on my website: http://ruralemsisdifferent.com There are several stories there, but the "Unusual Transportation is Sometimes Necessary" story does tell you about a fairly unusual ambulance run. Time is an issue, but burnout is another issue. I have been the only year-round paramedic in my community for four years. When I leave for an ambulance run, my family never knows where I will end up for the night, how I will get home, or whether to call in for my paid job as a teacher in the local school or not. I'm a school teacher, but as of this summer, I have retired from both teaching and EMS. Burnout is my excuse, but at least I recognize that I have it. Some don't recognize it until it's too late. In rural EMS, it is WHEN will my patient get to the hospital FIRST, and WHEN will I get HOME last. I'd like to hear from others about ending up stranded 60 miles away from home after transporting a patient, the only way possible, in a USCG helicopter. There I was standing at the airport with $20,000 worth of cardiac monitor and IV pumps with no way to get home at 3 a.m. That's when burnout really sits in. Good luck to all of you who volunteer. Keep up the good work of helping your friends and neighbors. One of these days, I might be in your community and need your help. WAY TO GO VOLUNTEERS! You all deserve a pat on the back and big THANK YOU!

I wrote some fictional EMS stories about situations that have occurred in our community. I changed patient age, locations, etc., disguising the patient information including dates, time of the year, etc. Here is my question: Did I violate HIPAA by providing general information about the types of medical and trauma emergencies that occurred in my community? In other words, does historical fiction violate HIPAA? The townships' lawyers state that I violated patient privacy and HIPAA by revealing information in the stories, even if the patient could not be identified by the general population. Did I violate HIPAA? Did I violate patient privacy?

I am from a very rural area, and when the weather is foggy, or there is a blizzard, and you can't transport a patient off this island, then you can't get any more rural than 32 miles of water from the closest hospital. When there is no boat, no plane, and no way to get the patient off, then you have some time to remember why you are doing this EMS service. We do it for free because our community cannot afford to pay us. None of the fire service is paid, so none of the EMS service is paid. So, here is the bottom line, if we didn't volunteer to provide EMS here, there would be no EMS here. We do EMS as volunteers because we care about our friends and neighbors. When someone gets ill or injured, someone needs to be available to help. As soon as the local governmental units come up with a paid position, you can bet that I will gladly apply. The thought that all EMS is the same no matter where you are is not at all true. Rural EMS IS Different! Check out the website: http://ruralemsisdifferent.com OR email me at medic5740@yahoo.com and I'll gladly send you a few stories about how different it can be.

I think every call in the rural area opens your eyes to the humanity of all the patients. If you live and work EMS (or volunteer as I do) in the rural areas, every patient is a neighbor and/or a friend. This is the most difficult aspect of rural EMS. You care about every patient and your patient care has to reflect that or you will hear about it from the entire community. That puts a lot of pressure on the providers in the rural area. I have a few stories about some of the challenging calls here in rural America, and particularly when you are 32 miles of Water away from mainland Michigan and any hospital. Fog and blizzards are the enemy. Unavailable air transport is the biggest challenge. Read more at http://ruralemsisdifferent.com If you have any really different calls that required you to work outside the written protocol book, I'd really like to hear from you. Email me at medic5740@yahoo.com

We are very fortunate on the one hand and very remote on the other. We have a rural health center staffed with a Family Nurse Practitioner. Our local EMS works hand in hand with the staff at the rural health center. It's a good thing, too! We have not had one single response and transport that lasted less that forty-five minutes even if the patient fell and broke her hip at the local airport right next to the airplane. Weather and air transport non-availability are the enemies when you work EMS on an island 32 miles from mainland Michigan. I can sympathize with the Alaskan post because some of our patients have been monitored for days before transport could happen due to fog or blizzard conditions. One of the most interesting cases can be read at http://ruralemsisdifferent.com. It's a cardiac patient with serious problems that took us more than twelve hours to get to the mainland. "Unusual Transportation is Sometimes Necessary" is its title. I'm glad to have found this Rural EMS area. I'll gladly share some stories with you if you will email me at medic5740@yahoo.com.Rural EMS IS Different