Bieber

Good morning! It is midnight when you and your paramedic partner are dispatched to a patient complaining of shortness of breath. The patient is coming from a local rehab facility, fourth floor. You find your patient, a 70 year old obese female lying supine on their bed with very labored respirations audible from outside the room. The patient is staring straight up at the ceiling and does not respond to your presence. From the door you can see that they are very pale with cyanosis around the lips. Staff mysteriously disappears after directing you to the room, thankfully someone has left the paperwork on the counter. Go!

Welcome! I'm from Kansas too. =) Hope you enjoy the forums.

Yes, please, break it down for me so that I can try to understand. Seriously? Don't be condescending, I'm not an idiot and I understand the breadth of what I am suggesting. At no point did I suggest that something to the extent of a PA would be rolling out tomorrow. Your opinion. Again, I never said I believed or wanted any of this to happen overnight. Baby steps. Uh, yes? Not to the extent of what it should be or could be, no. But other communities have already proven that the concept, even in a small, tamed format is possible. Since I hadn't "actually" been considering what I was saying, I went back and "actually" considered it and suddenly discovered it's silly. Takeovers never happen in health care or EMS. Thanks for showing me the light! =) It's a little bit more than that, but yeah, for the most part that's a good step for now. I never suggested that we go from where we are directly into a PA or NP equivalent level. Thanks for the debate, those of you who remained civil about it. I'm done with this thread for now.

It strikes me as odd that you see the two as mutually exclusive; that we cannot advance the profession in one way if the other battle is not yet one. Shall patients equally and ubiquitously, then, continue to suffer waiting for the whole to evolve? Should advances be withheld because of those services who refuse to advance? Don't get me wrong, I will continue to always fight for across-the-board increased in our educational levels, but I cannot accept withholding those paramedics and services that wish to advance because some would rather sit in stagnation. Paramedic practitioners and community paramedics can and have done some real good. Look at MedStar, look at Wake County. If we wait for the whole of EMS to catch up to those places that are not content to sit idly by while patients suffer both in their health and in their bank accounts, then we will be waiting a long time. It is only when innovation surges, and when the possibility of a better future comes into view, that we realize our potential and begin to strive for greatness. A paramedic practitioner or a community paramedic may not be on your list of issues that need to be resolved, but what about the gross misuse of ambulance and ER services for preventable conditions? Should we halt all efforts on that front because the fundamental education for EMS providers is in the shitter? Or should we let those who can, those who will, do what they can to improve conditions. It's not perfect, it never will be, and we should always work to better things, but if we refuse to fix the flat tire because the engine's not working as well as it should, all we're doing is making it harder on ourselves. Withholding progress doesn't do a thing to establish ourselves as health professionals, and even if a bandage won't fix the entire problem, it's a step in the right direction. These are things which will be vital to the future of EMS and EMS education if we're to become a cost-effective, evidence-based and beneficial service. You're right, I do want what's best for the patient. And yes, it does matter who's providing the care. After all, PA's only came about because physicians were too few and too costly to fill all the gaps. Were that to change tomorrow, you would want to find a way to stay in business, wouldn't you? As for the people I speak of, it's everyone who has a stake in bettering EMS, and everyone who has made efforts to try and improve EMS. The folks who have been pushing for community paramedicine, increasing our professionalism, degree requirements and opportunities, guidelines instead of protocols, evidence-based medicine--all of those things that are slowly but surely dragging us out of the dark ages and bringing us evermore closer toward being a true discipline and profession.

Paramedics aren't suited for the role of paramedic practitioner... Hmm... Well, misnomers aside, I will agree with you that we're not there yet, but I still think that we should be the ones to do it. For the sake of our profession, if nothing else. As for the long-term future of these programs, that remains to be seen; thus far, they've been well received (at least in their current manner). And it never will happen until we start making it happen. There are people willing to try and who are trying to unite EMS and to improve it and make it better, but what they need is for more EMT's and paramedics to join in their cause and to start supporting their growth. Things can get better, things WILL get better, but we have to make it happen. And that means pushing for EMS-based EMS, working to weaken the hold other professions have over us, and to evolve ourselves into providers worthy of all that. If you don't or can't believe in that that's fine, but I still do.

Well without knowing what "many" is or proof that that unspecified "many" really do have EMS backgrounds... That's fair. But it also means that we can't really say PA's have any advantage to working in an EMS setting than any other health care provider. I agree. Which is all the more reason why we need EMS-based EMS. Not fire-based, not nursing-based, not PA-based. EMT's and paramedics whose only job is to provide out-of-hospital medical care. We will never be a profession as long as our job is a patch attached to some other industry's uniform. I think that might be a bit of an overestimation (not much, but a bit). All the same, the solution you're suggesting is to eliminate EMS-based EMS and substitute it with PA-based EMS (to whatever degree), which does nothing to improve the EMT/paramedic side of the profession. True. Still, I'd rather see us elevate ourselves than call it quits, say we just can't do it, let's have someone better do it for us. We CAN be better, but it all starts and ends with not looking for reasons why we shouldn't elevate ourselves. True, but they'd be foolish to lose their edge as well. That's true, but the point is not to take-over primary care, it's to give our patients what they need. If the greatest need for our patients was better specialist neuro care, I'd advocate us pursuing that route too; or if they truly had a greater need for emergency care. I agree, though I think that fire will not buy into this as a whole. I also agree with that, but until we pilot these advanced educational programs and show that they are functional, useful and needed in EMS, we won't introduce them into the primary curriculum. Do you think that EMS systems are going to agree to an additional 6 months or more of education in community paramedicine or advanced practice until they see the dollar signs behind them? Much less the fire-based services.

It's actually 300 hours. But you're right, that's not enough. But it's a step in the right direction, and even a single step is something we desperately need.

Proof that most PA's come from an EMS background? Community paramedic program are on the rise, as are Bachelors level programs. Do you think that PA-based EMS confers some sort of advantage over EMS-based EMS in any way which is insurmountable given that we increase our educational standards? Is it better for us to continue to be carried along by other professions? We already have more higher level educational programs popping up. Additionally, I suspect that even an equivalently educated paramedic practitioner will still command fewer wages than a PA or an NP. While the lack of an appropriate pay incentive may keep paramedics from pursuing higher educational degrees, that may change once the CMS schedule of billing is improved. And until that happens NP's and PA's won't be interested in joining EMS anyway. Lol, sure thing. It's not about turning paramedics into primary care providers, it's about meeting our patients needs. Would you see EMS restricted to the few true emergencies we actually care for, and continue to confer little to no benefit to the vast majority of patients? Or would you rather see us provide the kind of care our patients are increasingly needing.

Where's the benefit to EMS in using PA's rather than appropriately educated, appropriately trained paramedic practitioners? Other than to fund our industry's resources into another profession? I would argue that if that were the case then PA's and NP's would have already slid into the position now being filled by community paramedics. I don't imagine there will be any greater interest in EMS by PA's, NP's or nurses until we're able to bill for service; other than to attempt to regulate our profession to protect theirs. I agree with that general degree progression, except for the PA part. Again, what about the community paramedic programs that are already up and going? What EMS system is utilizing PA's in the same manner? And why (yet again) allow others to do for us what we can do for ourselves, if we're willing to take on the challenge.

I am completely for paramedic practitioners. I do not think that they should be entering the hospital or clinic realm, as NP's and PA's and physicians already hold dominion over those areas; rather, I believe that we should focus on transitioning ourselves from emergency medical services to mobile health services. The notion itself is expansive, but it has a lot to do with our own perceptions of our profession, even down to little things such as referring to ourselves as out-of-hospital providers rather than pre-hospital providers (the latter implies that the next step is necessarily the hospital, something which we know to be untrue, even if it is the most commonly practiced model currently). Things such as community paramedics will pave the way toward this transition, I believe, and indeed may assume the roles of the first "paramedic practitioners", but as a current community paramedic student I will be the first to admit that the educational level needs to continue to grow and increase. Still, it's the first step. Some people have suggested that NP's or PA's fill the role of these out-of-hospital practitioners, which is something I simply cannot support. Since its inception, EMS has always been under the thumb of another, frequently unrelated group of professionals. Now, we certainly need to maintain some oversight, and that is perfectly fine, but on the same token we have to take charge of our own profession and become more self-regulating. EMS-based EMS. It's a great misfortune that through our own ignorance and lack of motivation that we have allowed our profession to be at the mercy of so many others; something which I do not see occurring among other providers or professions. We need to get away from that, and have the self-determination to truly become self-regulating; this means increasing our educational standards and improving our clinical practices from within, not waiting for other professions to elevate it for us. Someone also remarked that EMS shouldn't enter into the realm of primary care. Unfortunately, this is impossible. The majority of our calls are already non-emergent, but rather than provide us with the education and the tools to treat these conditions, we have simply relied on the expensive method of transporting all patients to the ER, where their needs can be somewhat met until the next exacerbation. In order to provide a greater benefit to our patients, we have to become stronger preventative and primary care providers; after all, it's from lack of these two care types that the community paramedic was born. This isn't to say that we should enter the hospital or clinic realm, but instead we should become a part of that continuum of care working in collaboration with the patient's physicians, NP's, PA's, hospitals and clinics and serve as the out-of-hospital barrier to preventable hospitalization. While I don't know if prescription powers are necessary or wise, I think that limited dispensing might be prudent in some circumstances. There are other skills and tools we need to add to our repertoire in order to become more potent primary care and urgent (non-emergent) providers in order to give the right treatment to the patient on scene instead of transporting them unnecessarily, but the primary focus should be on increasing our educational level. Associates degree minimum NATIONALLY, more Bachelors options, and even Masters and above. In doing all of this, we're going to have to avoid getting greedy. Ultimately, EMT's and paramedics exist because other health care professionals won't work for our wages. And while we certainly deserve better pay than what we receive now, I'm hesitant to feed into the mentality that increased wages aren't something that we must earn through elevating our standards. When that happens, though, and when the CMS changes the schedule of billing for ambulance services, I suspect we will face a greater challenge to hold onto our profession than we have before. Nurses will say "we have mandatory degrees, we're the right ones to do EMS!", NP's and PA's will say "why use community paramedics when we will do the job!" The answer which keeps EMT's and paramedics as the primary out-of-hospital health care providers will HAVE to be "we have equivalent education, and we'll do it for less" if we're to hold onto our jobs. Just as nurses vehemently oppose paramedics working as paramedics in the hospital, and NP's and PA's will oppose community paramedics, and as physicians have opposed mid-levels, we in EMS have to hold firm onto our profession if we want it to remain ours. Like I've said, since our inception we have pretty much constantly been under the beck and call of another group, whether it be fire or nurses or physicians, and if we're to survive and truly be our own PROFESSION, we've got to distance ourselves from the rest, be self-regulating, and demand the same level of professional autonomy as these other groups do. But at the end of the day, the cards are in our hands. Nurses have no vested interest in us increasing our educational standards, and may in fact have a vested interest in us remaining uneducated; NP's and PA's likewise have no vested interest in our community paramedics and paramedic practitioners becoming a greater threat to them. The ONLY ones who have a need for EMS to evolve are EMT's and paramedics, and until we realize that and start fighting for our own profession, we will never be just that: a profession. Going back to the clinical aspects of paramedic practitioners, yes I feel there is a need for better out-of-hospital health care. There are too many preventable transports, exacerbations of disease, and too many people without access to adequate primary care. We can provide that care, and we will provide it, if we get our hearts in the game.

How are Denver Health's protocols? What about the atmosphere of the service in general? Progressive, regressive, moderate, etc? I ask 'cause my brother's looking at them a little bit. How's the pay? Thanks.

I've never had any trouble with "right-handed" pants. I wear elbecos. On a related note, anytime I hear about "left-handed specific" stuff, I can't help but think of Ned Flanders from The Simpsons...

No, those are valid questions and I think a lot of it is service dependent. I don't believe we can be cancelled by providers not in our system once an emergency call for EMS goes out, unless it's a scheduled transfer. I won't disagree that it seems like things could have been handled better, but I also wasn't there and am not familiar with their system. I wonder if a supervisor responded, given the chaotic nature of the call--and if not, why?

Regarding the heated debate involving Mike... Though at my service we are no longer supposed to take orders from random physicians on scene if they contradict our protocols or appear unsafe, there is absolutely no reason ever to be rude or condescending toward any medical provider on scene and there's a way of expressing your own service's guidelines/policies/protocols in a respectful way no matter what they are. Remember, you represent yourself, your service, and our profession when you interact with other healthcare providers. We ought to be cognizant of that and behave in a way which brings respect and recognition to ourselves and our fellow EMT's and paramedics, and not in a way which will result in maintaining the same poor professional image we seem to tend to carry in general.

If the physician has a preexisting relationship with the patient (as seems to be the case in this scenario), then we follow their orders. We no longer accept orders from random on-scene physicians with no prior relationship to the patient, however; if they push the issue then we're supposed to connect them with our medical director and they can hash it out... but most likely I think she would just tell them thanks and have us follow our established protocols.

I'd go ahead and withhold resuscitative efforts.

Welcome to the forums! There sure are a lot of Kansans on here. =)

Spock, out of curiosity, is that 20 minute standard inflexible or do field providers have some discretion in it? If not, what do you guys do with cardiac arrests or, say, a hypoglycemic that is taking a while to work on?

Chief, here's a little something that I hope will set your mind at ease regarding palpation of abdominal aortic aneurysms. www.ncbi.nlm.nih.gov/pubmed/9892455 "Palpation of AAA appears to be safe and has not been reported to precipitate rupture."

Is this a personal bag or a work back? Also a glucometer really wouldn't be a bad tool to have, and I think they're pretty manageable cost-wise nowadays too.

Welcome to the forums! Good to see another Kansan here.

Is there something inherently wrong with that, though?

Uh... I really don't think we're not talking about the medic who is so stupid that they're doing blood draws and a 12-lead for a wrist fracture, that's not the scenario that was given in the OP nor the tone of the thread at all based on the responses so far. My understanding is that we're talking about medics who are providing either prolonging scene times to provide critical interventions when it may be conceivably be quicker to just transport or medics performing non-critical, non-life-saving but still clinically indicated interventions instead of simply "deferring" them to the hospital. There's no reason to delay or defer clinically indicated medical care if there are competent providers to administer it present. There is no reason to give non-clinically indicated medical care regardless of how competent the providers administering it are. If we're talking about medics giving care that isn't medically indicated, I will support you 100% in denouncing that practice; as I would denounce any provider giving care that isn't indicated. If we're talking about medics giving care that some people would rather they defer to the hospital, with no justification why except for vague excuses of "controlled environment" or "just because you can do it doesn't mean you should", then no, I don't support that at all.

Kate, I'm starting to get the feeling that you favor a minimalist approach to out-of-hospital health care. Maybe I'm wrong... In any case, the physical exam is crucial to making an appropriate field diagnosis and tailoring treatment plans accordingly. If the pain is too severe for the patient to tolerate the examination, it is appropriate to provide analgesia to help mediate that pain before continuing on. The notion that "if it won't change your treatment, you don't need to know it" seems so entirely out there that I can't for the life of me divine where it comes from, though you're certainly not the first person to suggest it. Also, as an aside, there's really no evidence to suggest that palpation of the abdomen in the presence of a AAA will exacerbate it... Nor have there ever been any incidents of iatrogenic spinal cord injuries in the setting of spinal trauma... Just my $0.02. -Bieber

Why delay treatment in order to expedite transport? Where's the benefit? To your point in general... No, I don't agree with "load and go", however I do agree with recognizing when there are no (more) field treatment to be done and at that point there's really no sense in staying on scene. More and more, though, I'm starting to start more lines on scene and push more drugs on scene before I even move to the ambulance. The way I see it is this: how long does it REALLY take to get things done? A good, thorough assessment with all relevant diagnostics? 10, 15, 20 minutes? An IV and drugs? Maybe 5-7 minutes? Patient movement, getting them packaged and ready to go? Another 5 minutes? Is delaying care and expediting transport so that the patient can be moved from point A to point B in order to receive that same care in another setting really better? Um, you're going to have to explain that one to me, 'cause I'm with Arctic on this one. It's not about doing something for the sake of doing it; it's a matter of giving clinically sound, medically indicated and patient appropriate treatment when it is needed or preferred in order to improve the patient's condition. Would you make a dyspneic patient wait to receive breathing treatments? Or a patient with a fracture suffer an unnecessarily long period of time to receive analgesia? Or obligate a patient with a compromised airway oxygen?