Ridryder 911

Very good points. As well, NREMT is NOT a formal board either nor represent having formal education, rather a private testing firm; but people continue to place their titles as such. Ironically, I find Bledsoe's post confusing. It was not not very long ago we had discussed the possibility of having a Critical Care Paramedic level and in fact he had discussed with me (per e-mail) that the Registry had been contacted but the costs for it were astronomical. Thus, the decision to possibly link to the FP-C for credentialing. Again, Dr. Bledsoe is one of EMS best representatives in the business, and honestly a mentor for me and others. I can not speak enough and give enough praises of how his involvement has changed EMS. I do however; find the timing of this article strange when he has a new text "Success for the Critical Care Paramedic" coming out in a few weeks. I do wonder if this was a publisher timing. R/r 911

I believe there is a misunderstanding. How are you offsetting the costs by having a different level of charges? I bet, if you investigate you have ALS I or ALS II with multiple charges. As well, look into the billing.. speciality care is only charged when those calls are appropriate, not on every call. The citizens will pay for it one way or another, personally I much rather charge it to those that required the services and not to the broad spectrum of tax payers. R/r 911

You don't charge for your services? I too work in a rural third party type system and the reason I am promoting change is to be able to keep it. Why should we in EMS not be able to be reimbursed accordingly? Want to maintain those rigs, keep your staff, ever get a raise? Even potentially lower your overhead for the tax base? Sorry, this is the reason for billing SCT. Since you are from the St. Louis area, I suggest you look at your neighbors and why they are able to expand and flourish. Examples alike Central Jackson Fire District and others. Billing appropriately is not "placing" a burden on the residents, as much as raising taxes for off set the loss that was acquired. When in fact, insurance and Medicare could had supplemented financial losses. The reason to be able to bill for the services is the reason such a division was made, if you are able and are providing the services; why not receive appropriate payments? Your service deserves it. Sorry, healthcare is all about the money received. Don't believe me, stop the paychecks... stop paying for fuel and supplies. Look around on the number of EMS services closings or redistricting because of lack of funding. If one (EMS Service) is not savvy of the financial end of medicine, it will loose.. somehow. R/r 911

I find it ironic that nobody recognized that the ENA triage program is 18 sections long. That in reality, maybe as long/ with associated clinical experience as a EMT program.. just the triage portion alone. R/r 911

Give me a break!...Why is it you are so worried about becoming a profession? What is your fear that our profession actually be recognized within the medical community? Do you really have the best interest of our profession at heart or even the patients? Of course, I would not expect those in EMS to understand professional titles! Oh yeah, that's right .. got confused, forgot that one has to be in a profession, not a trade. Professional titles are just that, displaying to those in the profession that you took your job serious enough to go the extra mile.. not just the easy route. Although, I usually agree with Bryan this time I believe he missed his mark. Read his bio and as well as he makes note he too is board certified, etc. It was not that long ago, he wanted to establish a course and call it CCP... so I don't understand his reasoning. If we were took this even further, why should we address their title first in the name? Why say this is Dr. XYZ? Why not Mr or Ms. XYZ, physician. Again, professional courtesy. Alike I described, usually sour grapes... and those that fail to either pass the test or to understand what professional titles really mean. R/r 911

Then your service is asking to be poor. The difference in Specialty Care reimbursement and that of a normal Paramedic transport is sometimes double the reimbursement rate.. Now, that is cute to make an additional $12,000 yr for the cert... All because you are more than the traditional Paramedic because Medicare recognizes that level as such and along with that you should have more responsibility and be compensated for it. I know that I personally have brought an additional 6 figure number for my service & no my state does not have SCT or CCEMT/P observations nor does a state to get Medicare reimbursement. Again, most of those know very little of the business side. The reason I have abandoned my EMT/P title is because it is incorporated in my CCEMT/P as well if I could I would gladly remove the EMT portion, and yes I sign it on legal documents as well as my other titles. They are allowed since they are recognition of professional certification ... just as much as NREMT-P. In which itself is nothing more than a testing company recognition... If one don't like the title so be it.. usually it is sour grapes. Oh by the way, see if Bledsoe makes mention that he is Board Certified in Emergency Medicine or not... R/r 911

Remember, board certifications are titles above the level of license.. For example RN, CCRN .. a focused title that is recognized by all state boards as a RN that has successfully passed the ANA professional standards for critical care. Even Board Certified M.D.'s use such title for professional reasons. For example MD, FACS (surgeon) M.D. FACEP (emergency physician) .... something, I believe Bledsoe failed to emphasize in his article. If you want to see professional titles, work and look in an academic and teaching hospital. Thus the reason for even stating such is for those within the profession. To promote that you have participated and promote your focus and speciality by demonstrating you have studied, performed clinical experience as per experience or testing. R/r 911

One has the right to place CCEMT/P after passing the UMBC critical care transport & or Critical Care Paramedic course. It is a recognized continuing education and certification program. Yes, Bledsoe is correct in some of his statements but there is also some misleading areas as well. Technically, if a state does NOT have a recognized license or certification; Medicare and other payers only need documentation stating that they have exceeded the standard NHTSA Paramedic curriculum. Yes, there are areas that should be covered and yes they can be taught by other agencies however; UMBC has the copyright of the title "CCEMT/P". Even one that has passed the FP-C test can technically be called a "critical care" Paramedic due to their test has been recognized as being testing and certifying Paramedics in the area of "critical care". Both of these are usually recognized as the standards; unless the state has developed their own. Alike CEN, and even CCRN there is no "classes" or courses that teach such; rather it is a "board specialty" to recognize that you have mastered the minimal allowable knowledge in that specific area. Although I usually agree with Dr. Bledsoe, this time I feel that his viewpoint was more skewed. I have had personal contact and in fact an attempt was made for the NREMT to consider the additional level, but the costs would be extraordinary. Yes, I agree there should be a standardized course.. yet again, maybe there should be additional specific area of Critical Care Paramedic alike the CCRN. One can be a CCRN in adult or pediatric... Why should a Paramedic have to take an specialty adult examination, when they strictly work a neonate team? Although I hate multiple levels, such specialty after getting the "basics" of a Paramedic I can see. Much more than multiple levels of an EMT; which are used as an excuse or in lieu of a Paramedic. I am currently on our State CCP committee, attempting to formulate requirements for education and license. Due to the diversity of programs it is hard to determine, some are very similar and some are lacking. As well, one has to be careful of "locking" in programs because of payment structures that is linked to "specialty care transports". Doing so can definitely prohibit many services of transporting patients with multiple IV's and medications that are not in the "DOT" paramedic curriculum and may not receive payment because one must be a "SCT" to transport such... It has double edge sword effects and as well one has to be careful when opening Pandora's box.. R/r 911

Your right Doc there is a difference between MSE & triage. As well, most facilities do not allow an MSE to be performed until the patient is triaged. However; there is national standard programs of triage as recommended and endorsed by Emergency Nurses Association. Part of the triage(18 lesson) program is knowing what the initial diagnoses is then what standard of tests will be required to obtain a conclusive diagnosis. (http://www.ena.org/education/triage/default.asp ) For example, a possible sepsis patient that is hypothermic will need a complete work-up with C & S, multiple medications and time spent upon a diagnosis, where as a UTI will be more specific in nature with few lab and treatment modalities and would be triaged differently. Most triage criteria is not just based upon the initial assessment but as well as potential requirements and treatments that will be rendered to the patient. Sorry folks, medical triage is something that is NOT covered and taught in Paramedic curriculums. As well again, talk all you want but when the reviewers come in see where they will place the medics and whom they will ask if they triage and chart. Again a precedent has been determined and yes, we will see things change from now on unless your hospital likes writing checks out... It is much cheaper to hire someone qualified and prevent litigation than save a few bucks ...Sorry, I am all for Paramedics but they are not qualified to perform triage in an ER and now the court system has stated such. Stick a fork in it... it's a done deal. R/r 911

Again, if one does not know how it would be problem, I foresee a problem. Sorry, what maybe occurring and what is legitimate is a different story. Sorry, Paramedics are not adequately taught about medical conditions and treatment regime to make determination under the standard triage of emergent, urgent and life threatening. It is much more complex than .. who is sick and not.. Sorry, if your ER is doing such, they have not been caught .... yet! Just await, there will be someone who will notice and yes, someone will sue and yes you will loose. (Now it is a documented case, it will be used as a standard of care). It is also clearly defined in the EMTALA (Federal) regulations.. as well as in JCAHO and standard of care in most States. We all realize of Hospitals and EMS that do not do perform and do the right thing, but it does not excuse them... R/r 911

Actually this has been a standard for quite a while. Although, many attempt to circumvent around the standards. EMTALA has developed whom and what is required for a medical screening evaluation (MSE). Most states will allow RN's to perform, although there are a few that does not even allow that. JCAHO has been very firm on not recognizing anyone than an RN working in Critical Care areas. LPN/LVN's are usually titled as techs, as practical and vocational nurses are not recognized as "nurses" in those areas. They definitely are not allowed to perform triage or even "open" the chart as such as the first initial assessment, and then afterwards may document with the co-signature of a RN (as practicing under their supervision). Again, ED is whole different environment than the field and vice versa. Yes, I welcome new RN"s that were former Paramedics.. but; they do have to adjust to it. Assuming it will be alike the field is one of the first wrong things one can do. Yes, there is a lot of similarities, but that is where it stops. Alike Critical Care is not the same as the ED.. again, similar is some ways but definitely not the same. I forewarn those considering to pursue nursing and focus in the ED to be prepared for some changes. For example in triage, defining what can be assessed and treated in the first 30 minutes, what tests will be needed for diagnostics is one of the major proponents in triaging. Again, not knowing emergency medicine, one will not know what the initial diagnosis is, what tests will be ordered, what the average length of time for treatment and potential ability if one will be admitted or not. Again, not all Paramedics could perform... R/r 911

The best answer... As one of both nursing (two degrees) and EMS (one degree) I can attest I have seen many that thought that nursing was the cure all. What many are finding out, it alike EMS should be a calling. I love both, but they are totally separate professions and jobs. Sorry, the pay maybe a little better but one usually finds one works twice as hard as well. I am now seeing many veteran medics "regretting" for going into the nursing profession. The ideology and scope is definitely different mind-set.. (there is nothing wrong with it, just different) and it is NOT what they have expected. Let me inform those who keep referring to the pay.. if it sounds to good to be true... it probably is. If they are paying "big bucks" for nurses, there is a reason that they have to... be wise, investigate any profession thoroughly. R/r 911

Actually, it is very specific that ONLY an RN or a physician representative (NP or PA) is the only acceptable persons to be able to perform triage! If you see an LVN/LPN or even a Paramedic performing triage at a hospital setting in the ER, they might as well start writing out the checks. This is very specifically stated and described over & over in the EMTALA, COBRA regulations, in fact one example of whom that they use is for FAQ' s is a Paramedic allowed? The answer is an inequitable NO!. Sorry folks, not even a regular RN is responsible enough. Unfortunately, many see the "tree" as a pain in the arse and generally place the 'non-best" clinical providers in this area. I totally disagree, it is one of the hardest jobs if performed correctly. Emergency Nurses Association has studied and researched this thoroughly, and have developed training & education programs to increase and accurately triage patients. Paramedics might be able to perform such tasks in disaster setting, but this is a totally different setting and type of triage. Yes, everyone realizes chest pain but how about meningococcal rash or fifth disease? Yes, it matters. Yes, there are some seasoned and very well educated Paramedics that have expanded their role.. but; that is an exception and rarity not the common. Let's leave the ER to those that are trained and educated for that, we still have not conquered our specialty yet. R/r 911

Ironically, this is brought up. I have been contacted by three Paramedic schools for this fall to teach. One of the reasons is my "famous or is it infamous ?" assessment lectures and lab. Something I have found majority of those in EMS lacks is the skill to truly perform a thorough assessment. I teach a very thorough assessment technique over several days. Everything from hair growth patterns to use of opthamalscope and detailed Cranial Nerve tests. With this is an accompanying lab, to place and repeat it over & over. Now, I realize many of this is not always practical in a prehospital setting... or is it? Alike myself, I have found and developed an abbreviated or use portions when necessary according to history and situation. Does one always check for Chvostek's sign? No, but I have seen it first hand in patients in distress that were immediate post-dialysis. Again, having the knowledge and skill to perform a more thorough assessment as necessary. Can one not assess heart tones prior to that critical care transport? Seriously, how long does that take? ... Just alike any of our skills, we must be able to adapt it when and where appropriately.....this does NOT mean for us to excuse not knowing or even performing it if and when necessary. If one does not know normal from abnormal, then one cannot determine there is a problem. If one does not even assess or evaluate. then one is definitely not going to be able to find the abnormalities, determine the etiology and associated findings. Time those in EMS recognize the weaknesses and assessment skills is usually one of them. R/r 911

If the insurance is paying for "BS" calls then someone is "doctoring" the documentation. Sorry, insurance companies do not pay for such. They usually require the same requirements that Medicare require the need of an emergency. By law, one is supposed to inform the patient prior to treatment and transport (including Medicare) that services may not be covered, and the patient maybe billed for such services with a signature from them. It is such statements from medics that I question the integrity of the EMS. Personally, wish more Medicare and Insurance Fraud investigation would bust such EMS. This would help promote the need of being able to refuse service when not needed. As well, once the ER has accepted the patient the patient is in equal or greater hands and abandonment would have not occurred. R/r 911

Not trying to stray from the subject but it goes with any piece of equipment, skill, pay etc. I personally feel part of the problem that we rarely adress here on this forum is the lack of education and understanding of health care administration performed by EMS Directors and Administrators. I feel at least 90% of them have not a clue about the health care industry. Especially those in public service departments such as Fire, Third Party, etc.. Again, what would we expect our industry to be like if our leaders are not educated to perform do their job? I can assure you that most Fire Service Programs have no areas of Medicare, capitation, reimbursement issues. I doubt that most cover health care statistics. Again, what do we really expect the profession to be, when many of the "leaders" are in the wrong business. So many make the mistake assuming, John Doe was a great medic or supervisor, surely he will make a great EMS administrator.. and what will occur? .... Does one even really have to be in EMS to be a good EMS administrator? This is debatable, in which I see both sides. My point or emphasis is this. Until we have qualified leaders such as educators instead of instructors, health care administrators instead of Directors, our system will never change. What can we expect from a half-ass system.. half-ass results.. thus causing people never to take this profession seriously. Why should they? Why should Medicare, Aetna, Blue-Cross and the rest of the payers want to reimburse a fancy taxi-cab? Again, I don't wish ill to any EMS, but if & whenever Medicare cleans house with fraud & refusal to pay, demands more bang for the money; we will never see a change. But until then, we are going to see a slow hemorrhage of EMS. In regards to time delay for U/S; it is very fast device to use. Much more faster than hooking up a cardiac monitor or having that green EMT to attempt to start an IV. Would it not make sense to determine if the patient should go to a hospital with vascular capabilities? Or for one to have to wait... call u/s ..then make arrangements for transport and acceptance? Again, the same lame excuses I first heard of not wanting to by-pass ER's based upon severity, wanting to go the nearest one in lieu of the most appropriate. R/r 911

Okay, I am missing something? Is this an outline? It is full of inaccuracies, as well as not much detail for a thesis level presentation. First, attempt not to spout exact facts unless you are assure of them. For example not all ambulances were "hearses" I would present it as they were confining and many were used as hearses as well. Nor the television show "Emergency" had much to do with the initial design of EMS, since the show was created six years after EMS was created. Now, it was instrumental in promoting EMS and without it, one can say it would never had progress as rapidly. If this is a collegiate level paper, make sure your citations and references are from credible sources. There are plenty of credible literature search engines, as well as many generalized articles on the development of EMS, education and training requirements, etc.. Citations from such as Journal of Trauma, Emergency Medicine, JEMS , Heart & Lung, etc.. are more scientific and credible. Also, be sure to find out what format they want the paper in APA.. etc? Good luck! R/r 911

I agree, but again it comes down to an expectation level of what should be required. I believe there is a major line or division at this time between educators (not instructors) of EMS and those in management. On one side educators see an endless opportunity of expanded treatment and care of the patient. We tend to see "outside the box" as we realize the types and numbers" of patients will be drastically changing. Again, I believe our role will be totally re-defined.. not because we will want to but because we will have to. On the other hand, I am witnessing EMS administrators attempting to just "fill in" the empty slots, with whatever they can get. (Of course this a broad generalization) Wanting to maintain operating costs as low as possible, (this including wages) so an acceptable profit margin can be obtained to keep in business or at least "keep a float". As the old saying ..."it takes money to make money"..is never more true than in EMS. I am surprised that Medicare has not started a major overhaul in EMS. Personally, I would love to see formal investigations of the majority of operating EMS. There is NO accountability for delivery in care and operation in EMS from the payers viewpoint. I am surprised EMS receives as much compensation as it does. Personally, I would love to see that it would be highly recommended to be accredited by an organization such as JCAHO. At least some check & balances. Yes, EMS has such organization but it is not strong, nor does insurance companies require it alike JCAHO. Once we have an agreement between educators and EMS systems, then and only then we will changes. If administrators could see requiring legislative change for formal education, that this would allow them to argue for more reimbursement rates. With the increase responsibility and associated education, along of course comes increased in payment, which in turn increases the remainder of the system. Maintaining status quo as it is now, is only detrimental to the lifespan of EMS. Again, part of our problem is majority of EMS operators are not educated in business or health care administration. Alike most EMS positions in general, a created one as a "good ole boy". Do I foresee U/S uses.. you bet. The one I seen had very good quality to detect DVT, FAST programs and bluetooth capability for near real time. The device itself was under $5000. Alike digital watches, costs will continue to decrease with time. Is such for every service.. absolutely no. However; for one that is over one hour away from any true surgical intervention, it might be an adjunct device to aid in obtaining a better assessment not to replace a quality hands on assessment. We will see... if the education is taught properly and thoroughly, then it will a great device alike the other tools we have. If we promote and remain ignorant we will never see a change in our system and the outcomes of our patients. I ask this... Is what we are currently doing working? .. R/r 911

You know I heard the same crap when pulse oximetry was being introduced, AED and external pacing.. (awww.. we never will use them that much).. XII lead in the field . (awww. it will delay real care, EtCo2 ( great another device, it won't change my tx).. and so on... Actually, I think it will be a standard piece of equipment in the future. I met a sales rep last week (a former Paramedic) and was excited to introduce this product. So much the are placing a both at our local conference... only being about $5-$15K I can see the opportunity for multiple uses, especially if we can get Medicare reimbursement rates.. Again.. step into the light and out of the box.... change can be good. R/r 911

Hey, you are the one that continued to make the mistake... You get that type of attitude with QI, when you make that mistake in charting? .. R/r 911

Wish I could give more information on it. I just transported a female in active labor that the child was determined to have ventriculomegaly as well. The mother had been incarcerated and I had noted that she had several U/S along with an amniocentesis. I do realize that it required a C-section and they were preparing for NICU as well. You & your wife, will be in my thoughts and prayers.. R/r 911

As soon as the patient is responsive enough to ingest a proper dietary supplement. Why do we want to cause a rebound? Getting the patient out of the crisis mode and then properly correcting the problem with long term treatment. R/r 911

I do wonder what is sooo important one has to continue chattering all the time. Even more disgusting is those that want to share their conversation with everyone. Seriously, there was a reason for phone booths... R/r 911

We have just quit carrying Thiamine. I personally liked it but alas I am not the Medical Director. I do have to agree, I have not personally seen or even heard of any recent cases of Wernicke's encephalopathy. Yes, it is commonly used in a Rally pack/Banana Bag along with Folic acid, Mg", MVI, etc.. Now, back to the original post. Not too long ago, EMS or JEMS magazine (I can not remember which one) addressed that maybe we are "overkilling" the usage of Dextrose. From what I remember; the discussion that even a diluted D10w was strong enough to reverse the majority of hypoglycemia episodes. The need of such a strong concentrations hypertonic solution was not needed or warranted. I tend to agree. Over the past several decades I have yet found that such a strong solution was needed. The complications of rebound hyperglycemia, tissue extravasation, caustic irritation causing phlebitis. I use the same similar philosophy of my use of Narcan. I administer enough to get the patient out of the crisis mode then treat appropriately. Yes, there are some patients with such low metabolism and severe hypoglycemia it may take a full 25gms or even more to cause an increase in a +L.O.C. Of course dependent upon the situation, but I much rather have the patient ingest & intake a high protein, carbohydrate dietary meal. As discussed on previous posts such as pizza, even a PBJ. Again, previous assessment should had been made that the patient has adequate swallowing and mastication process. I do believe we will see that higher concentration levels will be changed in the future. Again, similar to previous non-sense regime such as "coma cocktails" etc.. R/r 911

Most of the names on the list joined after I did. Richard was one of the top posters and originals of EMT City, when I first joined. I was surprised when I found it, it was definitely not whom I first thought it was either. I hate to pop bubbles, but Dust joined not that long ago..... It is interesting to see the debate.... R/r 911