Fire Medics

[spenac]

Former I took it as a rant against unnecessary procedures being done. It is frustrating when people think we should do something just because we can rather than what is best for the patient. I actually got QA/QI from an ex medical director because they thought I should have done a more advanced procedure than done. I of course politely asked have you followed up on my patient? If you have you know what I did took care of the problem and they were released from the hospital less than 24 hours later. Had I gone more advanced they would have had a longer stay.

So I guess my point is I understand where you are coming from.

[Doczilla]

This highlights an issue with prehospital intubation. The physical skill is easy to teach and to learn. WHEN to tube someone, how to look at the whole patient condition, then the whole scene, then the transport, then the ER visit, then the ICU admission, all in the blink of an eye, and translate this into a decision, instantaneously... THAT is the skill that takes so long to master.

'zilla

[treaux]

RSI is one of many things on a list of skills that have been removed from our scope here in California. The county I work in has also taken away the needle cric due to a single case of it being used inappropriately (on a traumatic code no less) and now we will never have the chance to use it again. RSI was taken away years ago due to that "San Diego Study" that basically showed we couldn't be trusted to make the right decision on when to RSI.

The general attitude of the fire medics where I work is one of apathy and laziness. Many don't want to run medical calls and when they do their attitude is a bored and uncaring one. This leads to their understanding of medical emergencies dwindling back to the pre-EMT level of not really knowing the underlying causes of the problems we treat. Day to day I get great one liners from fire like "We give albuterol to fix CHF" or "His blood sugar is 16, but we can't give dextrose because he has a CVA history and I heard it can be bad for his brain." This really dilutes the expectation of us being medical professionals and it's a reputation that is becoming very publicly known.

I'm not claiming this to be the state of all fire departments. Many do train often and want to provide good patient care. Several, however, prefer to show up on scene and not even take a blood pressure unless the patient very obviously appears to be dying immediately. They just wait for the ambulance to show up and then hand over their run sheet with a name and a birth date before leaving. This is why we lose respect and therefore the trust of our medical directors and health boards.

All we can do is try our best to lead by example and stay on top of our knowledge and skills so that we can maybe sway others into doing the same. It would be nice to have some slightly stricter standards for re-certification so that those who let their skills wane will be held accountable. Now it always seems those interns who "just don't get it" just get passed around until they find a preceptor they can bully into passing them, and the same goes for new hire field training and trainees.

I know it's a bit of a rant as well, but I look at myself and then I look at those medics I really look up to and find we're a small minority in a sea of medics who I wouldn't trust with my own life.

[P_Instructor]

Is it me, or have the level of training and professionalism in this business degraded over the past 15-20 years ????

Well, you posted this just as I am about to begin the airway section of my Paramedic class. Personally, training institutions do teach the 'skills' of airway control, but I agree with you there is a lapse of instructors that don't teach the necessity of assessing for the appropriate response for this control. Personal opinion is many new (young and slightly experienced) instructors like to teach what you can do without why you do it. It is a shame that this happens.

I agree within the other posts that you should only do what is best for the patient by fixing the problem first, any you need to assess what the real problem is. To many providers are using their protocols as 'Bibles' instead of what their real purpose is......'Guidelines'. How or why in the h*** does a provider perform these skills without really understanding what they are doing? I personally don't instruct this way, and my students need to know the big 'W's' in everything they do. Unfortunately, I guess I'm in the minorty of this type of instruction, and then don't have control of the student once they enter the work force.

This does give the impression to your initial question in regards to training and the pros.....

[HERBIE1]

This highlights an issue with prehospital intubation. The physical skill is easy to teach and to learn. WHEN to tube someone, how to look at the whole patient condition, then the whole scene, then the transport, then the ER visit, then the ICU admission, all in the blink of an eye, and translate this into a decision, instantaneously... THAT is the skill that takes so long to master.

'zilla

Agreed, doc. I would also add that "when" question should be applied in many situations. Just because you CAN do something does not mean it's what may be best for the patient, given a particular set of circumstances. Paradoxically, doing "everything you can" for the patient sometimes means doing less.

Judgment is not something that can be taught- it's the result of experience and training, and I happen to think it's one of the most important skills I have.

[Richard B the EMT]

I think sometimes new and experienced providers just want to do everything because they can and they forget what is in the patients best interestsd.

There's a Steve Berry panel ("I am NOT an Ambulance Driver" cartoon series), showing a patient with at least a dozen IVs started, caption reading "We didn't need any IVs, but this guy has such good veins..."

[fakingpatience]

The general attitude of the fire medics where I work is one of apathy and laziness. Many don't want to run medical calls and when they do their attitude is a bored and uncaring one. This leads to their understanding of medical emergencies dwindling back to the pre-EMT level of not really knowing the underlying causes of the problems we treat. Day to day I get great one liners from fire like "We give albuterol to fix CHF" or "His blood sugar is 16, but we can't give dextrose because he has a CVA history and I heard it can be bad for his brain." This really dilutes the expectation of us being medical professionals and it's a reputation that is becoming very publicly known.

I'm not claiming this to be the state of all fire departments. Many do train often and want to provide good patient care. Several, however, prefer to show up on scene and not even take a blood pressure unless the patient very obviously appears to be dying immediately. They just wait for the ambulance to show up and then hand over their run sheet with a name and a birth date before leaving. This is why we lose respect and therefore the trust of our medical directors and health boards.

Unfortunately, this is not only seen in fire medics where you work. Many of the medics and EMTs at the company I work are the same. They hate taking calls (What are you in the job for!) and don't seem to strive to learn anything more. I asked a protocol question about oxygen to a medic I was working with; we had a pt. who was presenting fine (called the ambulance for back pain), maybe 70 years old, who was stating 93% on room air on the pulse ox. I opted not to put oxygen on him because I was always taught "treat the pt., not the machine" but when I asked, the medic told me that he used to put a non-rebreather, high flow o2 on every pt when he was a basic, because that is what our protocols say to do, but now as a medic, he still would have put oxygen on the pt. What frustrated me the most about what he said was that he didn't even consider that, although the protocols say high flow o2 for every pt, it is often not needed, and can be harmful. Another medic I was working with encouraged a diabetic pt to sign a refusal, even though he had just woken up after we had given him D50 and his sugar was only 150 ish, and he was vomiting every time he tried to eat, AND didn't have a blood sugar monitor, but was still giving himself insulin. I was not surprised when another ambulance was called back to the residence a couple hours later for an "unresponsive pt with diabetes". Many of the people I work with never even get a manual BP, they simply rely on the monitor, which while good, I still thought that you should get at least 1 manual BP first.

Sorry for going off on the tangent; I just wanted to add that fire medics are not the only ones in our industry who are lazy, and resistant to learning anything more than they have to know.

[HERBIE1]

There's a Steve Berry panel ("I am NOT an Ambulance Driver" cartoon series), showing a patient with at least a dozen IVs started, caption reading "We didn't need any IVs, but this guy has such good veins..."

Richard-

I love that guy! I have his screen savers on my lap top, and use his power point templates for my lectures. I met him a few times, had a few beers with him, and he is an excellent and dynamic lecturer. I highly recommend seeing him if you ever get the chance. He also does a very moving tribute to a former partner who died of cancer, I believe.

[spenac]

Many of the people I work with never even get a manual BP, they simply rely on the monitor, which while good, I still thought that you should get at least 1 manual BP first.

Sorry for going off on the tangent; I just wanted to add that fire medics are not the only ones in our industry who are lazy, and resistant to learning anything more than they have to know.

Where did they learn that from? Oh yeah the RNs and Dr.s at the ER.

[HERBIE1]

Where did they learn that from? Oh yeah the RNs and Dr.s at the ER.

Well, I am much more likely to believe an automatic BP cuff reading from a patient lying on a stationary ER bed, than in a moving ambulance.

We do not use automatic cuffs, and I admit there are times it would be convenient, but I still prefer getting an audible BP. If presented with a choice, I trust myself before I trust a machine. It's simply a basic skill and we should all be proficient at it.