Ridryder 911

If you come out from school not knowing differential between medical ailments or not knowing how to perform assessment techniques and having the knowledge of the current medical treatments, then you came from a piss poor school or are a poor student/ medic. You should not be performing patient care. What are we producing out there ? Yes, clinical experience is necessary and definitely is needed, to hone the skills not to teach what the illness is. Having cookbook protocols is not the answer. No matter how many protocols you may have in your book, one still needs to have and posses assessment skills to make the determination of the clinical impression (diagnoses). If one does not know the treatment regime of treating medical illnesses or emergencies, then we have more problems in education than I realized. What was taught in you education ? Again, this adds more support of formal education and the removal of training, as well as the proof of not allowing those lower than Paramedic level administer medications and perform ALS skills. Again, how much reading and studying do most medics actually perform? ...Do you assess all patients, so clinical experience can be obtained? There is no excuse of having poor knowledge, and not being able to perform and deliver at a competent level. It is a shame that it continues! Ignorance is NOT blessed nor should it be allowed or tolerated! Sorry, Doc ; I now see why physicians are getting more concerned about protocols...it is not that way everywhere. R/ r 911

If the patient has been documented having no resuscitation measures prior to arrival for an extended period of time or and the patient is confirmed in aystole (2 leads or more) or if the patient does not respond to ALS intervention, then yes! Field termination or cessation is not new! This has been presented for several years even by the AHA/ECC and much emphasis in the development of sounded protocols for such. If it was only 2/100 it would be different. How much resuscitation efforts is made after a patient arrives in ER, when that patient has been in sustained aystole? There is no change in treatment and usually outcome. As far as writing protocols, yes, actually I do write some of the protocols. We have committees with the medical control (physician) directly involved. He expects us to investigate, research, and validate such protocols. He definitely does not want "trained" followers, to just follow the steps. If this was the case protocols would never be challenged or changed for the needs of the medical community. This should be a team effort, with them as the captain or leader. He prefers not to have cookbook medics, and for us to use educated rationale judgement and decisions. He is quite aware, that protocols should be suggested guidelines only, and that each situation is unique. To be able to perform the needed care or to consult him when and if needed. Involvement of the medics of knowing why, how, and limitations are important. This should to be a team approach, not just "do as I say". Again, we go back to education .. if everyone was properly educated NOT trained, then they could develop a more proper understanding on why certain resuscitation efforts are futile, and when they are not. Clinical exposure ( more than a couple hundred hours, and true in-depth education of emergency care is essential. R/r 911

First welcome to the site ! Having an active medical control is essential for development of having a progressive EMS. However; just having one is not the key. As a medical director are you very active ? A physician(s) should be developing a rapport and trust. Performing testing, observations, ride alongs and education classes can be increasing trust between the physician and EMT's. Yes, they work under your license, and yes you are responsible. However; what many do not understand you have power to see what and whom and the calliber of medics that is being hired. If I was a physician, I would want those to have autonomy, and knowledge..not a bunch of trained "chimps" that follows protocols. You are the one that can make that difference. Protocols should be written as suggestions or guidelines, and never direct "what to do"; as well having a thick protocol does not mean they will improve or deliver better care. They should had been educated in the professional & medical standards that you expect in delivery of care. Again, you can control this without step by step protocols. Each subject or situation should not have to be written out, if they need one, then again there is an education problem. You as a medical director apparently feel that they are not able to make rationale decisions upon their license level, or is it that you are covering your ass because of the potential incompetence that could cause litigation? Even having a step by step protocol can actually increase litigation's, by medic not following each letter of the protocol for every situation one increases the chance. That is why more and more emphasis is placed on education, QI, and protocols for specific problems or illnesses. As well how much can one really cover on protocols? Do you really need a section for everything? I hope not ... again they should be generalized guidelines, with the bottom line " upon description of the Paramedic". If you do not feel that you are able to trust them with this type of descisions then there needs to be some house cleaning or education. I highly suggest you check out National Association of EMS Physician web site : http://www.naemsp.org/ There is several EMS medical control that have developed systems and education for EMS personnel. Respectfully, R/r 911

I feel that there has be to be some time to develop by themselves. To develop autonomy, and self confidence. as knowledge of their strengths and weaknesses or limitations. R/r 911

EMS is always looking for excuses on why they should not have to meet standards or receive an education. It is amazing, instead of making sure that we provide the best available care, with the highest educated personal, we are always making up more titles and whining. You have a hospital or clinic in your community, hell even a nursing homes ? If they have a nurse or physician.. guess what they attended college or a university. It is a shame that even nursing homes will have a either an equivalent or higher educated person, on duty. ( LPN 14 month vo-tech - Paramedic 14 month Vo-tech,: or RN -ADN Paramedic- AAS). Why do they provide at least this level? Because it is mandated.. shame, level of care cannot be mandated in EMS. Your community cannot afford professional EMS, okay place well trained first responder and rendezvous with an ALS crew. Some communities have found out that some urban areas will even contract out and place a ALS unit in town or maybe one closer to you. Again, instead of looking for reasons not to upgrade, we should be turning our attention on how we can improve and increase better care. Diluting the education is not the solution. Hell, even John Q. Public is even more aware of this than some EMT's. In this month's Men's Health there is an article on heart attack and how EMT's should be advanced and provide ALS care. It is a shame that the public recognizes this more than the profession. I live in a rural area, have primary worked in either urban or rural, and it has always irritated me that people assume that because you work rural, you are allowed to "dumb it down" ! People who live in these areas deserve and should be expected the same initial care, as those that live in a large metro area. Just because you are in small areas, does not excuse you from having the same education, or the skills, needed to provide care. In fact, one needs to be more educated and experienced because of the lack of resources. I have always attested Paramedics are needed for those that are a distance from a tertiary hospital, not those that are a just couple of blocks away. Again, look for solutions on how to increase revenue, to off-set costs, grant monies for rural health education. Look for a solution not an excuse. As far as education, and CEU's it has became very easy. With the invention of internet, week-end conferences, there is no excuse anymore not to imrove or maintain certification. Hell, even the majority of CPR and ACLS can now be obtained over the internet.. R/r 911

Until the early 90's the NREMT immediately placed you on 6 months provisional registration until you completed that time as documented by your medical director. Then and only then, you were allowed to get your patches, certificate etc.. Other names could be provisional, Paramedic intern, etc.. not a new level, rather a designation that they have achieved the experience needed to have some autonomy. I agree on some medical oversight, however we need to be control of ourselves not another regulating board. Nurses control themselves, other health care professionals regulate themselves. It is time we grow up and handle our own affair, the worst we could do is screw it up, like it is already. We have too many fingers in our decision already, that is why we never gain or proceed ahead. Too many organizations are worried that they are not going to be fairly represented.. then the medic is left out in the end. R/r 911

It is obvious some have very little experience of exposure of arrests. Is it truly compassion to perform resuscitation on a dead body? (yes that is what non viable patients are called) .. Whom are you really doing it for ? If you know, that they are going to immediately cease all resuscitation efforts upon arrival, really, what have you really done? ... I find this not only a tragedy against the family but highly unethical as well. Practicing (since you know NO +outcome is going to be achieved) should be regarded as such. Okay, fine, don't read research and literature, you have just made my point on the need of education versus training...Believe it or not, one can actually be educated, & have clinical experience as well .. they call it knowledge! (I know it is scary, but it can really be done, even in EMS). Want to know what EMS will respond to ? There are plenty of chest pains, MVC, diabetics, medical calls with illnesses that needs to be stabilized or treated before resuscitation measures have to be started. Do you not see the rise in call volume? I am licensed as a health care provider.. and non-viable patients, no longer meet criteria for me to perform or treat. It now is in the hands of the medical examiner, or funeral home. The family, is now my patient, and I will give empathetic, emotional support and perform as a professional as a health care provider. You may not care about the costs, the outcome, and again I ask who are you really doing this for.....? R/r 911

Okay. i think you are having some confusion. Actually, most rates even of 175 (sure it is SVT NOT V-Tach ? Can you really see those P waves at 175 ? ) it may have a pulse.. just because the electrical rate is 175 there still maybe perfusion of .. 60.. 40.. etc.. That is why it is so important to take pulses, not just the reading the monitor. If the patient is that critical where there is associated symptomology, then rapid cardioversion is indicated. This basically "re-boots" the heart and allows the the cycle to re-start, therefore there should be a pulse. When a "true PEA" is seen: again it is a SYNDROME; there is an underlying problem causing this SYNDROME The old saying Treat the patient, not the monitor , is never more true. ! It does not matter what is on the monitor, brady, tachy, or even a NSR. One has to treat the underlying cause.. hypovelemia, acid base, pnuemo, electrolyte, pericardial tamponade, etc.. one might even get a pulse after treating such cause. FYI.. most PEA syndromes are associated with brady or agonal rythms NOT tachyarrhythmias. Some physicians are performing more an more medications like fluid bolus, adenocard, lidocaine, cordorone, then possible cardizem on true SVT. Which has been proven very successful. Again, PEA is not the same as a tachy rhythm without a pulse. i.e SVT (which most Cardiologist would probably say it was really V-tach, if did not have a pulse.) I would definitely would not give epi.. the rate is high enough. R/r 911

Master of EMS Universe Start at the top. EMS would be removed from NHTSA, and have a Federal Division of its own. All State EMS Directors would had have EMS experience. Every State would have State Board of Paramedics, (similar to nursing) ran by Paramedics for Paramedics. Retirement and benefits set by state, similar to Fire Services. All State would eliminate, certification level for Paramedic level, and require license. EMS managers would have to have a minimum of a MBA, or equivalency of true management education. EMS Instructors would have to have a minimum of Graduate Level to teach. Chairperson(s) having at least a Doctorate level. All Paramedic level would be a minimum of undergrad (baccalaureate level). With option of RN/Paramedic, or Education, Management specialty for entry into graduate level. The wording "EMT" would be removed. To be able to proclaim, the title Paramedic one would have to have at least 1 year minimum or documented experience. All clinical hospital sites would have professor on site, like all other health careers. EMT position would be for non medical services such as rescue, LEO, 1'st responders, etc.. Reimbursement rates would be based upon level of care, and ability to increase with proper documentation of education of staff, and TQI. and active participation of involvement in health care systems. Benefit package and enough pay incentive that EMS personal would not have to supplement their income. Ones could actually retire form EMS More to come.. R/r 911

I agree larger tube size would be nice. But remember we need to think of potential cuff pressure and necrosis to chords as well, secondary to laryngeal edema. These type of patients I highly recommend them getting a trach after the 3'rd day of ventilator therapy. R/r 911

As well, all of Oklahoma EMS levels are licensed. From Basic on up... I am sure there are others, and it might be difficult to locate. Nice to know though... R/r 911

Does this mean school teachers will start getting compensated to?.. There are many that have undergrad even grad, and PhD's that make similar wages as medics. I agree, we should make more, and education definitely be part of the requirement, so should responsibility and increasing professionalism. Be safe, R/r 911

I went back to work 24 hr shifts in the field. It was much easier to get off for school, etc. than 12 hr shifts as a nurse. Since I only work 10 days a month, I can trade, or take off time. I suggest attempting to take classes twice a week ... albeit all day, one can accumulate many classes and credits that way. R/r 911

Thanks Asysin2leads for clarifying. Actually PEA is not a rhythm at all, rather a syndrome. It has nothing to do with rate, arrhythmia, or pattern. It as well has nothing to do with filling ventricular filling time, but as described it is between electrical firing (EMD) and then not being able to responding for muscle contraction(s). It was not until the late 80's the term PEA was introduced, to make one realize that PEA was a syndrome and the etiology was to be found & treated. It was common treatment to administer Calcium Chloride/ Gluconate, and actually worked quite well, unfortunately hypoxic seizures and cerebral swelling was a common adverse effect. Poor outcomes was revealed and why we no longer use it. Fast ventricular rhythms with poor filling time, should not be confused with PEA, since it is not lack of muscle contraction rather inadequate filling of the chambers to produce an adequate output. (Chances are there is really a pulse, although it may not be palpable) Be safe, R/r 911

Wow .. the weather must had been really bad.>! Now, I would like to see whcih ones have certification vesus license, and which ones requires college. R/r 911

Are you inquiring as a health administrator or governmental emergency management officer? As administration, I really suggest you have a working knowledge of how the system works, the need of knowing details, I personally believe would be a waste of time and money if you do not plan to administer care or be directly related with treatment.. Emergency and disaster planning for for health care administration really has nothing to do with the treatment regime. The American College of Emergency Physicians has an excellent guide for hospitals and communities to help prepare for disasters. There are related courses as well. I recommend high involvement of EMS & LEO, F.D, when developing any disaster planning for health care facilities. As well as public service utilities and media. These services can make you or brake you. If you are really considering municipal administration as a Emergency Management Officer (EMO), I highly suggest a degree program or course that is designed as such. I know one of our local universities has one. The EMO curriculum involves political disaster planning and Incident Command System and even the debated CISD. The studies of man-made and natural disaster and pre-planning as well. I wish you the best of luck. R/r 911

From what I have heard.. they get paid big bucks $$$ to sit and pass gas all day !

The problem is most hospital pumps are heavy, awkward, and very few hospitals I know of allow pumps to "just go with EMS". Personally, I do not know how EMS systems survive without one. The legal complications of placing most med.'s without one is just asking for litigation. Transporting patients on K+, Mg+, NTG, Nipride, Heparin, drips etc.. is a routine thing anymore. Pharmaceutical inserts now address that most of these med.'s MUST be monitored on IV pumps. Using a microdrip chamber sets, does not assure you that it is the proper amount, with road bumps etc.. yes, a few extra drops does mean a lot. Dial-a- flow, although are nice for fluids, should NEVER be used for medication(s) that need a accurate infusion rate. Again, like the discussion of pharmacology, I know very few Paramedics that are able to calculate drip ranges (drops per minute) as well as we used to. IV pumps are not that expensive, especially in lieu of a law suit. Be safe, R/r 911

We don't have specific "protocols" except to maintain an adequate airway, from there it is the medics discretion. I personally prefer to RSI, ASAP if there is signs of respiratory burns, that appear to compromise upper or lower airway. I worked as a burn nurse at a large burn center, and I can attest it definitely harder after edema, and it appears to happen quickly when it does. I know one should be cautious using Sux, etc. due to K+, but that is usually after 24 hr fluid shift, but I try to use an alternative paralytic. I had to trach. a patient once with severe edema to the face, throat. It was an event, I prefer not to have ever due again. Be safe, R/r 911

They have watered down the ACLS so bad.. I believe it could be presented to kindergarteners ..monkey see...monkey do. All credentials and respect have been basically removed from this course. It is a shame that they felt to e so politically correct.. yes, people failed the old course. and yes those should not had been taking care of people. Now, we allow anyone to attend, and it is near impossible to fail and in fact some courses have it where you can not fail.. I hope some legitimate course will develop.. R/r 911

I was fortunate enough to have a separate pharmacology course in my Paramedic course, in fact a hell of a lot more detail than my nursing. My professor, did not believe in the old "drug cards" method of teaching, rather he instilled the philosophy I have now adapted of learning the CNS and an in depth pharmacological effects, and in-depth pathophysiology. I agree that we have failed in educating Paramedics in even basic pharmacology. We need to address home prescribed medications, as well as in-hospital meds. So many patients are on diverse med.'s and many patients are transported with different medications. The "old days" of just knowing ACLS med.'s are long gone. My suggestion is to have one combined detailed pharmacology class of both nursing and EMS students. As well, nurses are not always educated enough in emergency med.'s this would be an asset on both sides. R/r 911

Actually yes, it does mean we DO NOT WORK THEM ! Don't where you have been, but actually since about the late 80's more and more EMS are terminating arrest. As well, very few services any more have traumatic arrest protocols.. if they are wise, they too would have termination protocols. Now, that you have worked them and gave the family "false hope" not, a piece of mind as you described, then demonstrated how foolish you were when the physician immediately terminates the code upon arrival to ER. They will appreciate that $3000 ER bill as well. You must be doing it for yourself, not the patient, again studies have shown dead is dead as well family members tend to deal better with immediate empathetic declaration of death. Not having false hopes presented, only to be let back down, your care should addressed to the family & their emotional needs, they are now the patient. I highly suggest you quit using anecdotal feelings and become involved in medicine. This means research, and studies. Cardiac arrest that is either without prior resuscitation and is in aystole (true) as well as traumatic arrest do not respond to resuscitation measures. Period. Even AHA, cites that termination and strict guidelines on when resuscitation should be continued, in the legal section of the ECC recommendations. R/r 911

Not sure which "college network" or if that is a trademark. I foreqarn to be sure that these courses are transferable .. just because it is college credit, does not mean it well.... Good luck, R/r 911

According to AHA, nothing.. some AED companies will perform an upgrade and some will for a costs.. and there are some..hmm you are out of luck. From my recent up-date instructor course, we were informed to use the old AED's if possible to perform 1-2 minute CPR on non-witnessed arrest. If not able to, they suggested to continue old initial standards, with new CPR ratio... Please check out AHA the publication for more detailed and accurate information: http://circ.ahajournals.org/cgi/content/fu.../24_suppl/IV-35 Be safe, R/r 911

I have used several different versions and all have their good points and bad alike. The best I have seen that has the your requirements is the IVAC or Alaris. I have used these for at least the last 20 years and have not had any major problems. I have used them in the helio (with great vibration) and in the field.. they are not cheap (as any other pump) but you can infuse 3 types of solutions as well as use syringe or the bag. They only accept their tubing like almost every other IV pump.. but only weigh about 2 pounds. They are rugged, but don't purposefully drop or abuse them.. like any other IV pump. We have one on each truck.. it is nice for transports.. Here is link to one EMS supplier... Good luck, R/r 911