UMSTUDENT

Wacker, yes, but was it necessary for everyone to really instigate that fight? Only people in EMS would even argue with someone that young over something that stupid. The whole "mine is bigger than yours." I also suggest that several of you take a college ethics class sometime so you can really understand what is, and is not, unethical. Drinking underage is not unethical just because it is illegal. Many nations and cultures allow their children to drink alcoholic beverages at a young age. Our culture allowed 18 year-olds to drink as early as 30 years ago. A responsible 18 year-old consuming a beer does no other person harm if they stay in their house. From a utilitarian perspective then the person is doing nothing unethical. The study of ethics is fluid and is determined by the culture one inhabits. I'm not sure our entire culture really thinks it is. There is a huge difference between the two unless you blindly, and without reason, think that breaking a law is unethical. They have a name for this: absolutism. Drinking becomes unethical the moment you allow it to endanger other people. This is unethical for everyone, 21 or not. Lieing, cheating, stealing, etc are all unethical in the same circumstances. When you harm other people or yourself (against the law of nature), you are acting in an unethical way. Even this depends on the theory of ethics for which you subscribe to. I DARE one of you to say that Martin Luther King Jr. was acting in an unethical manner because he broke a few laws. Yes, she said some stupid things, but what happened to letting things slide. Young kid doing stupid young kid stuff.

In an ideal world I think EMT should be increased to about 200 hours of acctual classroom time with another 100 hours or so of minimum clinical time with a certain number of skill proficiency's required. The problem with more education is that it isn't really needed when it comes to the scope of practice of what a first responder or EMT is doing. An intelligent person can absorb all the information in an EMT class in 120 hours. Monkeys could seriously learn most of the skills. I can say that EMT class required little or no effort on my part, nor does it for many people. The people who seem to have the most problems with EMT are a) The untraditional student whose been out of school for years and extremely intelligent people. The first group is just not use to learning and the second group often will find holes in the procedures or overthink what they're doing. Paramedic on the other hand should be a minimum of 1-2 years of acctual paramedic instruction. Atleast 1-2 years should be had obtaining basic college prerequisites Obviously, someone with a B.S. in Biology whose taken A&P probably doesn't need to do another year or prerequisites depending on the amount of time they've been out of school. Each paramedic program should require a type of internship similar to those done by physicians. Atleast 2000 hours of clinical rotations on the road and in several speciality centers. People, especially those people in the field already, tend to scrutinize the value of a higher education. Many of them fail to see the benefit of a sociology course, or language, etc. It's self-explanatory for most of the professional world, but apparently not us.

Maryland utilizes a statewide protocol through one central, state government sanction agency. Individual counties can choose to operate under a specific "pilot protocol," but it too requires approval from the state. MIEMSS (The Maryland Institute for Emergency Medical Services Systems) is the state agency responsible for EMS regulation and implementation. COMAR (Code of Maryland Regulations) Title 30 is where most of their jurisdiction is had. They are independently financed by the state. Unlike most states, they aren't under a department of health or a few cubicles in an office building. "The Maryland Medical Protocols for Emergency Medical Services Providers" is roughly 300 pages and dictates the protocols for both BLS and ALS providers. It can be found at http://www.miemss.org/Protocol2005.pdf Individual private services can choose to use further skills so long as they have a medical director willing to let them do so. At least that is my understanding. http://www.miemss.org

I think the volunteer issue will erode away in the next 7-10 years. I've heard and seen numerous facts and figures that show a tremendous growth in the EMS workforce to occur sometime around 2008. Seminars and all. The theory is that as the baby boomers get older, they will in turn place a significant demand on the EMS system throughout the U.S. Many people often push these lectures and figures aside because they believe there is nothing significantly different between the baby boomers and any other generation of people. They fail to realize that the baby boomers are an extremely unique group of people historically; themselves responsible for the majority of the social and cultural changes of the last 40 years. One of the first generations of Americans to really demand a comfortable existence. They won't put up with the current economical and political status of EMS in this country. I've already seen it in my community. Young and middle aged adults who move into the area often make comments about the lack of "professional, paid EMS in the area." They complain if the ambulance takes more than 4 minutes to get to their house. I had one lady as early as two years ago ask why we didn't "cruise around town and wait for calls to be dispatched so we would be ready." She was making a rudimentary reference to event driven dispatch and system status management. While it is arguable whether these forms of EMS are the best, it does bring a little hope to the situation.

Glucagon is regulated mainly by a humoral mechanism in the pancreas (low blood sugar), however, it can be stimulated by the sympathetic nervous system. Rising levels of amino acids (the base molecules of proteins) can also stimulate glucagon release. (Marieb, 2004) Glucagon is a 29 amino-acid polypeptide (10-50 amino acids). It is traditionally made in the pancreas by pancreatic islets or islets of Langerhans (specifically alpha cells). (Marieb 44, 49) The major target organ for Glucagon is the liver. It promotes the following actions: 1."Breakdown of glycogen to glucose (glycogenolysis) 2. "Synthesis of glucose from lactic acid and from nocarbohydrate molecules (gluconeogenesis)." 3. "Release of glucose to the blood by liver cells, which causes blood sugar levels to rise." (Marieb 630-631) It is important to remember that blood sugar levels fluctuate and are not always a tell-tale sign of how well the body is utilizing the said monosaccharide (simple sugar). You must remember that the amount of insulin in the blood, the number of receptors found on specific body cells, and the number and affinity (tightness and duration of bond) of the receptors are important. The amount of glucose in the body is a fluid process too since the the absorption of glucose from the small intestine is not a fixed process. The amount of cortisol in the blood is also important in this process. Hope that helps. Wanted to reference as much as possible so you don't think I'm crazy. Source: Marieb, E. (2004). Human anatomy and physiology. 6th ed. San Francisco, CA: Pearson Benjamin Cummings

Wow, that is probably the absolute truth! I have met more people with serious social deficiencies in EMS/fire than anywhere else in my life. So many people with ego problems or some other weird or creepy past. I've met a lot of people with some types of learning issues as well. It is so prevalent in EMS that modern instructor courses basically teach you to assume that the majority of your incoming classes will be unable to behave themselves and stay attentive. It's basically how to teach special-ed kids. I understand a lot of this is basic adult/non-traditional student education, but on the same note I find it kind of disturbing that you have to treat these people in a special manner because they're "public service workers." In regards to the volunteer/paid argument, I've made an argument similar to Dust's in the past. Many people will often argue that the volunteer community is the source of future career paramedics. Most of them will ask, "Where will a new paramedic get the experience necessary to operate successfully in the field?" I tried offering up that in a professional world, people would enter into college with the goal of being paramedics "just because." Doctors and nurses do it all the time. I also suggested that paramedics be made to go through small rotations and internships before they are released to the field, however, this was quickly shot down as being "unrealistic." I would say that 50% of the current EMS work force just doesn't want paramedics to be educated in the traditional manner.

Many universities allow students to have relationships with their professors/instructors. The only time it becomes a problem as far as most institutions are concerned is when it interferes with the fairness of grading the particular student or their classmates. I personally dislike the idea of a fellow student "sleeping" with a professor simply because the possibility of favoritism is possible; however, I also see where it would be detrimental to the goal of a collegiate atmosphere. Colleges,especially large universities, stress an academic and friendly relationship between the student and their professors. Many professors hold available office hours for this very reason. The free exchange of ideas is the entire goal of these institutions ,and while very few paramedic programs are found in 4 year colleges or universities (~14 or so), I think a certain amount of these policies should be maintained. The problem with most of the people who are in EMS is that they can't keep their mouth shut about something. The real ethical issue is had when the student has an affair with an instructor in order to gain an upper-hand.

People who believe experience is the ultimate judge of a person's skill. I know paramedics who couldn't tell me what insulin actually does in the body. I've seen "experienced" paramedics do some really stupid stuff. While the field can never truly be mastered, I think someone can come reasonably close with the scope of practice of our profession. There is always room from improvement, as there is with any profession, but I don't think it takes 20, 10 or even 5 years. Depending on your call volume and patient demographic I think an intelligent, well educated paramedic could compete equally with someone of 20-30 years. Especially if that person has done absolutely nothing to further their education or general knowledge. Depending on where the individual paramedic received their education and their current level of maturity and humility, I think someone could be considered VERY good after 4-5 years of high call volume EMS.

Actually, the Secret Service operates a pretty sophisticated EMS and medical system. Some of their medical control is run through Johns Hopkin's Division of Special Operations (DSO). The level of training these people go through makes them more that qualified to think quickly and do the job. The Secret Service gets the job done, a lot. It's amazing how much information you can commit to muscle memory. I've never personally seen them in action, but I imagine they are superb at doing the job. Also, remember that agents in the United States Secret Service are required to have at least one Bachelors Degree and that selection is extremely competitive for field work. They already have more education than the majority of paramedics in this country and are probably VERY capable of further education. I doubt paramedic would be hard for these guys to tame if they wanted to take it. These jobs require you to be an absolute boyscout now days. I'll admit, I'm not sure if their paramedics are neccesarily field operatives. They might just be that: paramedics.

Beat me to it. If AHA was the definitive source of knowledge on all things cardiac people wouldn't spend years in fellowship to become board certified cardiologist. There are at least a few studies that will detail how much of an interpretive science ECG "reading" really is. I believe one study* showed that a computer beat out a world famous cardiologist by almost 20% in diagnosing confirmed MIs. *Heden, B., Ohlin, H., Rittner, R., and Edenbrandt, L., "Acute myocardial infarction detected in the 12-lead ECG by artificial neural networks," Circulation 96 (1997) pp.1798-1802 As found from the book Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande.

Would make sense wouldn't it? It's kind of a no brainer that something like that couldn't be applied to national elections regarding Congress or the office of the presidency, but I'm not sure how King County may define voter eligibility for county elections. Could see it being interpreted as a Jim Crow law; however, AHA CPR is conveniently not fail-able. It'd almost be no different than requiring someone to take the time to fill out their voter registration card.

Minimum age for certification as an EMT in the state of Maryland is 16. Happens all the time. I've see a lot of them who are wonderful providers. They learn faster, are more adept to further education (they're still students themselves at that point), and are often more well rounded than their older peers. I've also seen a few not make it through the class... I think the younger the better in regards to certification as an EMT. Paramedics on the other hand should be at least 20. Shouldn't be able to start until they're able to handle narcotics, then they should have 2 years of higher education to back it up. I've seen a lot of young minds be turned away from EMS because they realize how stupid some of the adults are that inhabit the ranks of the profession.

Impressive system. King County Medic 1 is pretty well known and they get some press. I actually saw them mentioned, although not directly, in a video game once. I've also heard that in Seattle you have to be certified in CPR to vote. Is this correct?

Since we've beaten the education thing to death, let's assume that every paramedic in the country has at least an Associates degree. Now what would you like to see? Vote as before.

Over the summer, while sitting in an unfamiliar hospital, I was reading a Popular Science article that made mention of a new type of device being developed in the U.K. for use on ambulances. The device uses "the properties of light to detect infectious diseases such as pneumonia and Tb." The product is being developed by a company called "Smart Holograms" in Cambridge, England. Description: "A drop of blood is placed on a sensor embedded with a hologram, a polymer film imprinted with dots that refract light. If target bacteria are present, they bind to receptors; the reaction makes the film swell, changing reflection." "The Upshot:" "Emergency medical technicians will use a handheld scanner to diagnose bacterial diseases in the field." Source: Rosenwald, M. (2005, September). Will You Be Able to Predict--and Prevent--Your Demise? The future of diagnostics. Popular Science, 267(3), 57-63, 119. Are there any technologies that you would like to see in EMS? Perhaps more diagnostic materials, better stethoscopes, better stretchers, or safer ambulances? Kind of interested to see the response from everyone here.

Replace anger with common sense. Your comment is probably more warranted for the lawyers who find it necessary to sue every EMS provider out there. I love how our profession associates a little self-confidence in ones abilities as anger. Not everyone needs transported to the ER. I also agree with Dust on the documentation issue. Document every single detail about that refusal. Refusals shouldn't be easy so much as they should be used to lessen the burden of the entire medical system.

I can see points in both arguments. I definitely agree that they're plenty of people who have vested interest in keeping us stupid, fire departments especially. I've seen systems where college education is looked down upon by entire communities of EMS personnel. They fear it because it means change, and since change is the very thing we're seeking to accomplish, the solution may take decades. How do you get an entire state, a state where almost the entire EMS profession is found in fire departments, to change over to a system that promotes growth among only one facet of the department? The fire service has the IAFF and the nursing unions are just as big. I also believe that emergency physicians have a lot to loose too. Those are three powerful groups whom have members at every level of state and federal government. Fire brigades have been around since the 17th century in America. Fire halls were integral to town and city politics within the last hundred years in many communities (tell Ben Franklin thanks). I see the points of both authors. I think there are enough people in EMS who would like change, but they suffer from a few problems: 1. They don't tackle the problem efficiently. There is only one lobby group that I know of in the United States. Advocates for EMS. 2. Those who do care are spread throughout the country in small patches. They come from different types of systems with different types of problems. There is no way for those people to get together and organize. 3. Many people in our profession don't want to change. They're in the profession because it required the least amount of education needed to make above minimum wages. I don't think EMS will truly progress until we can market ourselves as something more. Something the above three organizations cannot do.

Completely agree. I had this argument with someone from my station the other day only to be shot down on several of these points. Too many of the people I deal with on a daily basis are unable to properly communicate via written language. I am constantly hounded at my station by own administrator because I refuse to abbreviate. Apparently my reports are also too "long." My rebuttal is simply that abbreviation, refusal to capitalize and a refusal use proper punctuation are signs of laziness that are easily seen by our counterparts in higher medicine. I also agree that higher education should fix this problem. Granted, most colleges and universities only require one to two courses in english composition; however, at the same time you will not survive a four year education at a respectable university with sub par grammar skills. I agree with Dust in that everyone must be made to meet the requirements otherwise the profession will never advance.

Then we agree for the most part. I don't feel that lacerations that require stitches for cosmetic reasons should necessarily be treated as an emergency. As a child, I had plenty of injuries that would have required stitches in order to "avoid scarring." In each instance my mother yelled at me for being stupid and asked me if I wanted to get stitches, advising me that some further pain and a lot more of my time would be had in a hospital. I chose to forgo the stitches every time and have a few blemishes on my knees because of such. I think a lot of my anger comes from the fact that, as a child, I was taught that it was only acceptable to call 911 in the most extreme circumstances. I was made aware at a young age that other people had more serious injuries and to sort of self-triage. Basically, unless mom was not around for some odd reason it went like this: 1. Consult mother 2. Get yelled at for doing something stupid. Jumping off tree house, playing ninjas with baseball bats, etc... 3. Wash it 4. Put a band-aid on it. 5. Go on with life. I was taught that it was kind of embarrassing to call 911 unless it was serious. In my time in EMS I've seen people call 911 for the most simple of injuries. Basic stuff that could have been taken care of with some soap and a band-aid. It's almost as if our culture doesn't have a consciousness for what is truly serious. The same thing applys in regards to accidents. A car can be flipped over an embankment and a women running around screaming outside and not one person will stop to help (Yes, I've seen this too).

I believe my example was a "lacerated finger." I don't consider that an acute injury needing immediate transport to a facility of higher care. Sorry, a band-aid will fix that. I consider it an "event of everyday life." Seeing a spider is also an event of everyday life. You're obviously not able to read into the context of what I'm trying to report, but that's OK. Again, I don't expect you, or any other paramedic for that matter, to be able to make these decisions of responsibility for themselves. Most of the paramedic workforce is arguably not equipped to make those decisions. Common sense isn't something a lot of jurisdictions allow their providers to be able to utilize in their protocols. Unfortunately our entire profession has been centered around sets of protocols so stringent that they have told us how to think and approach every single scenario. I see this all the time. Our profession is scared to utilize half the skills they've been allotted because of poor education and a lack of confidence. We use the self-defeatist attitude that since we're not doctors we must not be qualified to make basic, "mom" decisions. I also never advocated "encouraging" anyone to not go to the hospital. You make the service available, advise them of what you think, and inform them that you, a paramedic, are not a "doctor" and therefore not the definitive level of medical knowledge they may be seeking. You let them make the decision from there. Fortunately for those advocating transportation every time, our profession has done such a good job of making ourselves look like technicians that most people, in my experience, take up the offer.

Oh? I've seen it and yes I understand that it can happen with very, very little amounts of blood. Well known psychological event called hemophobia. The fainting reaction you speak of is commonly associated with a mini panic attack that people experience at the sight of blood. Blood pressure increases, heart-rate accelerates, hyperventilation (absent in the case of a parasympathetic response) occurs and the person eventually passes out. Depending on what theory of psychology you speak of, this reaction is most likely "learned." From a basic Freudian prospective, the patient probably associates the blood with danger which would make complete since seeing as most injuries, which are in fact dangerous, occur with some exposure to blood. Unfortunately for EMS providers, this reaction can occur to any number of the hundreds of documented phobias. Using your "theory," if a person has arachnophobia and has seen a spider they should probably be transported to the hospital. The only support I can see for the argument is that hemophobia is decently prevalent, and like most psychological traumatic experiences, can have a sudden onset. Again, people have friends...have them drive you. Also, AGAIN...this is the patient's choice. You also know nothing about me and sound extremely pompous making wild claims about my level of experience. I clearly do understand. The fear of refusals in this industry seems to be founded more in the fear of taking responsibility. I'm guessing that's why most of us don't become doctors. How dare we ask the paramedics of the world to learn the diagnostic criteria to make educated judgments about the current medical state displayed by a patient. We do not need to tell every patient they need to go to a hospital. Tell them the truth, tell them what you think! I'm not talking about paramedic initiated refusals but instead giving the patient all the facts in regards to what is truely going to happen.

Have someone else drive you. People have friends-call them. If it's bleeding so bad that you can't deal with it for a few hours with direct pressure then yes, you should go via ambulance. That is a serious problem. There is also no way that a paramedic can tell if someone has some psychological issue with blood. Certain amounts of blood loss will not kill you through physiological means. Besides, no paramedic should let someone refuse if they are profusely bleeding. They let them refuse once the bleeding is under control and THEN drive to the hospital. If the patient thinks they can handle it and signs a refusal, by all means they should be able to drive and save themselves a 600 dollar bill. Our culture is defective in my opinion the very minute we associate blame with a paramedic because someone can't handle the sight of blood. At that point in their life, 16 or so years old (when you can drive), they should be able to know if they can handle the sight of blood. As far as fainting at the immediate sight of blood and going unconscious-How in the hell are they going to activate the system if they're at home, by themselves on the floor unconscious? They won't! There had to be some conscious, free will and volition utilized in making the decision to call 911. Paramedics come, clean-up the wound, put a bandage on that covers the injury and let them make an informed decision on whether or not they want transported. Sorry, I find the previous notion absolutely ridiculous.

See I hold a difference of opinion when it comes to refusals, especially because I've seen my share of absolute bullshit calls. I also feel paramedics, properly educated paramedics mind you, are perfectly capable of determine when someone does not need to go to a hospital by "emergency" means. This is all within reason of course. For instance, why should someone with a laceration to their finger need to go the hospital unless it requires stitches? Hell, if we would raise the standards and educate our providers properly we could probably administer a tetanus and suture in the field. Now if a patient REALLY wants to go to the hospital, that's another thing all together. Chest pain in a patient over 35 (our protocol), with family history, abnormal risk (obesity, etc), trouble breathing, etc should definitely ALWAYS be transported ALS. So should someone with a hole through their abdomen. DUH!. I think there a lot of doctors out there who might advocate for a world without massive amounts of radiation. Everyone doesn't need to have a full body scan to diagnose a problem or we'd have everyone in medical school specializing in radiology. I believe, without data to back it up of course, that a properly educated paramedic could tell people they're going to be OK once and awhile. Mothers have been doing it to worried children for thousands of years with injuries a lot more severe than the cut finger I see once and awhile. When I was a kid, there were plenty of times I probably should have gone for stitches and didn't. A lot of those times, judging from my experience, would have been socially acceptable ambulance rides in our current culture. Getting in the car and having your wife drive you to the hospital that is 10 minutes away isn't going to kill you either if you're having gas pains. When I was a kid and I told my mother this, do you know what she said? "Fart!" Our culture has allowed people to become babied. If a paramedic doesn't take someone to the hospital for a laceration and they develop an infection because their too damn stupid to use antibacterial soap the paramedic is held responsible. We no longer expect people to take care of themselves. Personally if your having chest pain, trouble breathing, a traumatic injury, or sudden, severe onset of pain or weakness for no apparent reason you deserve ALS transport ALL the time. This isn't normal by any means and something, most likely something very, very bad, caused it. If you cut your finger, or aren't "feeling well" for the last three days you can get in the car or call a taxi and go to the hospital. Every patient should be allowed to go for ANY reason they want, but when they ask "What do you think?" We should be able to say, "Well man, I think you need to go sit on the toilet and make a bowel movement." This system is for immediate life saving care. We are not WebMD, nor the local social services.

I don't know, I guess this stuff happens because we really don't have a voice to come out and say "Hey, a lot of paramedics spend significant amounts of time in the hospital environment. Many of them do rotations in ORs practicing intubation and are familiar with how they work on an integral level." In the end, the paramedic got scared and ran out the door potentially killing everyone in the OR. She came across as an untrained worker. It would have been no difference if she was a janitor or someone working in the cafeteria (not that these aren't perfectly fine jobs). She was never presented as a healthcare professional capable of handling the situation she was in, but instead as a simple bystander caught in the heat of the moment. That bothers me and I think it should bother others. Yes, on the outside it makes good TV but the attitude towards the EMS profession was shown in whomever wrote that script. Most likely his degree wasn't in medicine either, which says lots about how the general public views us.