Equipment vs Education

[VentMedic]

I've been reading posts on a few different forums and it seems EMS is now focusing on equipment rather than education to pick up for the slack in education or common sense.

The EKG monitors for BLS, pulse oximetry, RAD 57 CO-OX (with MetHb option) monitor, ETCO2, various airways, automated BP monitors (complete with HR), CPAP, ventilators, etc have all been recent topics on different forums. However, what I am not seeing is more education other than a quick inservice on what the equipment's true purpose is. And of course, the entry level educational standard has not raised.

People say the ETCO2 is a "gold standard" for intubation. Pulse Ox is the only way to go when assessing oxygenation. Advanced airways are a must.

Advanced airways? Many people can not use the BVM adequately or bag correctly when they do have a tube. I asked a paramedic (yes, EMT-P) how he determined the correct tidal volume for a patient. His reply was by hand size and not chest rise or breath sounds. I did inquire futher and got "adults are all about the same". He truly did not know even a ball park figure for the volume of an adult bag. He's not the only one. Sometimes, I ask paramedics these questions for a reason and sometimes just for amusement even though I am disheartened by the answers.

I have also watched Paramedics stare at their ETCO2 monitor trying to "see a wave" when they should have physically assessed that their patient was extubated instead of "trouble shooting a monitor" as to why they weren't still getting a wave form.

Likewise, I have seen EMTs and Paramedics frantically trying to get a "sat" on people who haven't had good circulation below the shoulders in 10 years just to see if they needed oxygen. Whatever happened to assessing what the patient is saying as well as the physical signs for work of breathing or poor oxygenation?

There is even very little education or understanding about BP except "high or low". HR numbers are taken from automated equipment such as the pulse ox or automated BP without manual confirmation of rate or quality. And if you have a CR monitor, guess where the RR number is from.

None of those gadgets will make someone a better clinician if they lack the "basics" of a solid education. So the "education" is now as piece mill as the 48 different EMS certifications. Patchwork knowledge with little focus on the "basics" such as better assessment, A&P, mechanisms of injury or medication, better use and understanding of the equipment that is standard such as the manual BP cuff and stethoscope. It is truly amazing how many body systems one can assess with only a stethoscope and BP cuff.

We can also add on all the extra medications that different EMS levels are giving with a narrow view of what each one does. This is not just at the Basic level but also at the Paramedic level as they attempt to "extend their scope" in CCT by learning a couple more meds or a couple pieces of ICU equipment but without the benefit of critical care education. An 80 hour cert class is not enough if you have very little "basic" education or CC experience to begin with.

All of these tools can be very useful adjuncts in the field, but they do not provide all answers and can actually lead someone down the wrong clinical pathway without proper physical assessment. Yet, many in EMS are pushing for more gadgets "to provide better care" instead of eduation.

[JPINFV]

People are just taking the path of least resistance. It is easier to say, "We can use this piece of equipment for this type of patient, just tell me what to set the gages to" than "Teach me how this machine works, not just how to operate it."

Similarly, it is easier to ask "why take the longer, harder, more expensive route to x cert when I can do Y program and be treated the same as everyone else?" I find it disheartening that our governmental and industrial leaders are not stepping up to require higher standards.

[p3medic]

never mind :?

[Dustdevil]

never mind :?

Word.

Sorry, no offence to VentMedic, whom is among the most respected providers here, in my opinion, but I just can't even get into this discussion anymore. It's depressing and fruitless.

But yeah, your point is absolutely valid.

[Ridryder 911]

I guess the reason of the frustration is simple, many are no longer taught the old simplistic addage us old farts were taught ...

........." Treat your patient, NOT the monitors!......

[DwayneEMTP]

You know, I didn't completely understand this argument before I started my latest clinicals.

I’m precepting in the Springs now ( Colorado Springs) and have an amazing preceptor. The Springs has automated everything on their trucks, pretty much. But I don’t get to use any of it until I’ve decided what it’s going to tell me before hand.

I’ve taken my sig line to heart in my clinicals (Maybe seems silly to you Vent, but made a huge impression on me!). My greatest terror is to walk into a house and be presented with a scary patient, only find I have no mental tools to treat with. So my medic, and basic as well, are a perfect fit.

When I pull out the pulse ox I need to have decided what I believe it’s going to say before applying it. “What do you expect to see?”, “What lung sounds do you expect to hear?”, “Based on your assessment what do you expect to see on the monitor?” To the point now that I really don’t have any huge desire to use any tools beyond my stethoscope, BP cuff (I quickly lost faith in the auto BP while “playing” this game), my senses, and the tiny little brain in my head.

In the beginning I almost always wanted to see what a machine said, and then decide if that jibed with what I believed. I can see now where that was a terrible weakness, that it would have spread to everything I do, and make it weaker. I’m grateful my preceptor expected more from me than I knew to expect from myself.

When I was treating the chest pain with rales to near the nipple line bilat, have completed my chest pain pain/pulmonary edema interventions, and then was reassessing…was I happy to see 90% on the pulse ox? Hell yes! But his hands were pink and warm..no longer clamped on the armrests of his chair, breathing was starting to ease, pulse rate was down 25 BPM, the “oh hell, I am so dead!” was leaving his eyes…So I knew it was going to say something like that.

Have a great day all.

Dwayne

[Dustdevil]

When I pull out the pulse ox I need to have decided what I believe it’s going to say before applying it. “What do you expect to see?”, “What lung sounds do you expect to hear?”, “Based on your assessment what do you expect to see on the monitor?”

Wow! You know, that is such an excellent point! Certainly not a new one, but I do believe this is the first time I have ever seen it really addressed here like this. This is one that I am filing away in my notes to make sure I present to all future students as clearly as you have, because there really are very few concepts any more important in EMS than this one.

When you reach the point to where the vast majority of your patients' assessment results are jibing with your initial impression, it is very close to time for you to leave the temple, Grasshopper. We often speak of the "look of impending doom" when talking about cardiac patients, and that is one of those things you don't need any equipment to find. But there are actually a lot more visual signs like that one that can be seen in almost every patient. You just have to know what you are looking for and to actually be looking. That's why standing around and running through a SAMPLE and DCAPBTLS checklist without REALLY gathering that overall impression is so counterproductive. Just like taking vital signs alone is not enough, neither is asking a bunch of questions that you don't have the knowledge base necessary to interpret the answers to.

Of course, there will always be that five-percenter patient who throws you for a loop. The one who gives you no real reason for concern until you see those vital signs bottoming out, because he was compensating. The guy who complains only of a headache, yet has a pulse of 150 and a BP of 90. That's where we separate the firemonkeys from the medical professionals. The firemonkeys will immediately treat it as SVT either accomplish nothing, or drop his pressure to 40. But the medical proefssionals will recognise it as progressive sepsis because they took a temp and did a FULL examination and found the abscess in his groin that he was too embarrassed to mention. When that patient comes along, you are presented with an interesting challenge that will be a great learning experience. And you'll still see those after thirty years of practice too, which is why this field never gets old to the true professionals.

[MSDeltaFlt]

I've always said: "The best RN's have strong LPN skills, and the best medics have strong basic skills".

There is no such thing as a bigger and better mouse trap. If you can't do it with the basic equipment, then you can't do it.

It ain't the arrow, it @#$% indian.

With respects

[DwayneEMTP]

There is one piece of equipment that I believe I would be completely different without. My current and future patients would certainly suffer if it was ever broken...my computer.

I'm near finishing my degree in EMS...thanks to Dust.

I'm committed to being a diagnostician first, with or without tools...Vent.

I constantly review the physiology of the calls I run...in case I ever have to explain them to AZCEP...

Realize that things are rarely as they seem at first blush...Asysin2leads...

I am very much aware that there is a reason some medics are viewed poorly, and that I have the power to change that perception for myself....Any of the Docs...

If ever I decide all basics are idiots I'm to refer to Dawn's Law... ("The" Wendy I mean, of course)

And on and on. Of course all of these lessons over lap with many of those listed and those that are not...but I'm guessing you get the point...

I'm finding that medicine is very much a team sport. Not a team responsibility...at least from the medic perspective, but on each patient I pull from many sources. I've become convinced that a network of intelligent providers is necessary if most of us are going to excel in medicine. There are constantly a ton of new ideas, as well as a ton of ways to accomplish them...I find I like it that way...

Sorry Vent, I was just sort of trying to play on a paradox of your question. Equipment I can't do without and don't think I can educate myself passed. :wink:

Have a great day all.

Dwayne

[VentMedic]

Dwayne,

Don't take me for one that does not like technology. I LOVE my technology! That is truly the best part of being a Respiratory Therapist. However, I learned grass roots, look, listen and feel assessment skills way back when with Dust and Rid.

I could just sit in a dim ICU room all day and watch the lights on the machines. I love the graphics and every piece of pt info at my finger tips. I've got machines to double check machines. I can also be in a remote location and check on my machines. Eventually, I will be able sit by the coffee machine and control every breath the patient takes.

We do a lot of research so anything that will give us a number or a pretty print out is great. The patients have a probe in every orifice to send data to the computers. We have computer programs to tell us if we still have a viable patient. But, we still assess the patient the old fashioned way also. I've also been through enough hurricanes to know which of my equipment will get the priority plugs for several days.

So, I am not anti-technology. But, I look at technology like a really fine car in the hands of someone who appreciates the car for its excellence in engineering as opposed to someone who has the car to make him/herself look impressive.