Advanced Protocols?

[Eydawn]

I would say there's value in being able to balance the book learning with experiential information. However, if one does not have the educational foundation to understand the medicine that we are working with, all the "truck time" in the world will not a competent paramedic make... actually, that's a very dangerous thing- someone with a knowledge deficit who thinks that their blind operation, though smooth, is the same as excellent patient care.

Wake up, buddy. It's not about breaking down someone who's smart or who's learned a lot and making them your mini-me. Learn from each other, and teach the person with less "street time" the skills that will enable them to succeed- don't belittle them for what they can't possibly be expected to know yet.

I've been on the receiving end of that kind treatment, and it farking SUCKS. Be the leader, not the follower- break stride and do the right damn thing instead of what was done to you.

Wendy

CO EMT-B

[DwayneEMTP]

Not likely he'll be back to this thread I'm thinking....

[Kiwiology]

I would say there's value in being able to balance the book learning with experiential information. However, if one does not have the educational foundation to understand the medicine that we are working with, all the "truck time" in the world will not a competent paramedic make... actually, that's a very dangerous thing- someone with a knowledge deficit who thinks that their blind operation, though smooth, is the same as excellent patient care.

Wendy this is exactly the problem that many people miss and some can't understand there needs to be a balance between theory and practical and that one is enhanced by the other. I am a true believer in education being the great liberator; it doesn't necessarily mean we are going to administer more treatment to a patient at the time we consult with them but physical examination and pathology knowledge are areas where huge gains can be made from a solid knowledgebase to allow alternate referrals, leaving at home etc

You are showing you are truly a person who understands how education enhances ones practice, well done!

Not likely he'll be back to this thread I'm thinking....

Not bloody likely indeed I mean he hasn't even offered us any hot Florida beach and roller blade chicks, bro, seriously

[systemet]

I've worked under various guidelines. Some systems I've been in have had no mechanism to patch, and lots of drugs and toys. Others have been more restrictive and required patching for interventions that I wouldn't need to call for in others. I've heard the argument before that the patchless systems had "better paramedics" because they didn't need to call, but often it seemed like they just had less active medical directors, and were less accountable for their mistakes. (I am not intending to suggest this is the way it is in NZ".

Arguably the dumbest protocol I've had required us to patch before administering adenosine. At the time there was no telemetry requirement / capability, but we were supposed to patch first because a review had shown too many a.fib patients getting adenosine. However the response didn't address this, e.g. "35 year old male, prior hx of SVT in a regular narrow compex tachycardia at 190 bpm, 4/10 ischemic pattern chest pain and a pressure of 90/60, I'd like to give 6/12/12 adenosine", etc. There was no mechanism to actually ensure that the tachycardia was narrow. The whole situation was farcical. The same protocols allowed me to cardiovert the second I judged the patient to be unstable --- and you could make an argument for that as well in this hypothetical situation. It felt insulting to have to call for a class I ACLS intervention.

But then you have other situations. 60 year old male, HTN, obesity, NIDDM, suspected anginal chest pain x 2 hours, nausea, anterior wall MI on 12-lead. Standard ASA, NTG, +/- gravol +/- morphine given etc. What next? Should we go to PCI? Is there a room available? How long until the next one? Or should we thrombolyse and go to the ER? Which local center has the best resources? If we're going to wait an hour for PCI, is his risk better with thrombolytics now? Do I need to transport him to somewhere with PCI on-site in case he needs rescue angio, or do I have ICU beds at another site where they can just do secondary transfer? What if we throw in some more risk factors, or change some of the variables. Is thrombolysis going to be superior to PCI if we throw in some more co-morbidities? Are beta-blockers appropriate here? This isn't a bad time to chat with an ER doc or cardiologist, and get their opinion.

Or renal patient, missed dialysis x 5 days, 3rd degree AV block w/ wide QRS response @38bpm, general malaise, nausea, vomiting, doesn't meet Sgarbossa criteria for STEMI. No clear ischemic pattern chest pain. Pressure's 98 / 50, fine rales, +1 pitting peripheral edema, and an S3 gallop. Should we pace? Is atropine a better idea? Is it better to sit on him until the ER, and let them get 'lytes. Or should we start pushing calcium and bicarbonate for a presumed hyperkalemia? This isn't a terrible time to chat with someone more educated.

19 year old female, idiopathic pulmonary hypertension, SpO2 of 86%, looks like death. What next? Who has standing orders for this situation?

60 year old male, tearing substernal chest pain, radiating to left arm, writhing in 10/10 pain, left arm pressure 230/140, right arm 180/100, 0.5 mV STE in V1, 0.2 mV aVR. Vomiting. What do we do about this? Are going to give IV nitroglycerin? SL? a patch? Metoprolol? What's our target MAP? ASA? Leave it alone?

80 year old cancer patient, 8/10 refractory pain, currently receiving 50 mg MS po bid, 2mg hydromorphone SC via 'clysis q4h, with another 1mg prn for breakthrough, and they're taking benzodiapines as well. It's 4 am, and there's a 1 hour transport, palliative care is unavailable. How much morphine should we give this patient?

I guess what I'm trying to say, and perhaps my examples aren't that great, is that sometimes having the ability to contact a physician can enhance the care delivered. I strongly disagree with mandatory patching for things like airway management. I hate arbitrary restrictions on pain control, like "call if you give more than 20mg MS". Or chemical restraint. But I don't see it as a great affront to my grand total of 3 years of training to have to occasional run an idea by an ER fellow, or reach out for a little help.

Edited February 17, 2012 by systemet

[BrandonDrew87]

PMD is short for paramedic.

Oh and Dwayne, I don't suppose you have had a green paramedic or student that has a god complex? Going out there and save everybody... I have, and sometimes they need a little brashness to help them become a better provider. So excuse the hell out of me for not being a lilly ass and not nurturing these "good kids".

[paramedicmike]

Aaaand the attitude comes out.

Look, there's a difference between nurturing and implying that you kick the snot out of these kids. There are different ways to nurture a newbie. Dwayne and I recently had a disagreement over how to counsel one of our new up and comers regarding some silly comments that were made. We both had the same goal. We each had a different approach.

What I read in your comments here, however, and it looks like it's the same as what Dwayne read, is that you have little patience for those educated differently or better than you were trained. Based on your comments it sounds like you look down on these kids and try to kick the education out of them with your street smarts.

Theory and application are two sides to the same coin. You can't have one without the other. Sure. Some may be a little slow on the uptake in a practical setting. But implying that you kick the snot out of them to put them in their place is really pretty unprofessional. If that is, in fact, what you do then it is blatantly unprofessional.

[DwayneEMTP]

System, I've never felt more like a poser than I did after reading your post. At each paragraph I thought, "Holy shit! I don't have any idea what to do with any of these people!" Thanks for your post...it was awesome.

Brandon, of course anyone with any time in EMS has had those kids. The problem I find with most people with that attitude is that it doesn't apply only to those kids, but a general 'breaking in' time of trying to show the pussy college kids how it's 'really' done on the streets.

We've had a gazillion firemen before you crowing about "I don't need to take a bunch of Home Ec and Basket Weaving courses to know how to treat patients on the street!" As our good friend Rob used to say, "there seems to be no one that has more understanding of the complete lack of value derived from a college education than those without one."

And your 'lilly ass' nonsense doesn't impress nor intimidate me brother. I've done medicine and nurtured newer medics on the streets, in Afghanistan, Mongolia, and now Papua New Guinea. How about you? What is your history, work and education, that allows you to know that your 'tough love' approach is what's needed to turn out good paramedics? Where did you get your medic education?

No one is discounting your theory that street smarts is important. Only your need to deride education while doing so. When I first started on the street I was significantly more educated than my basic partner, yet his street smarts were commonly useful and several times saved my ass.

You work in one of the most notoriously damaged systems in the U.S. with educational standards that are completely in the toilet when compared to the more progressive systems represented here. That's not a terrible thing, and a committed paramedic can over come that. But when you come here with your initial posts representing exactly the ignorant attitudes expected to come out of such places, you shouldn't realistically expect them to be welcomed with open arms, right?

And, in case you're missing it, the 'new' medic with the God complex that needs to be mentored without anyone being all 'lilly ass?" Today....You're him.

I hope you stay for a while. I look forward to your opinions.

Dwayne

[Vorenus]

They can teach you anything in a classroom but the most crucial lessons are often learned in streets. I help teach PMD class sometimes and those green guys can rattle off all of the cranial nerves... Big shit, when they get on the truck with me its a different story.

Lol.

All too often heard.

Street experience can help you in a variety of situations and comes in handy in nearly every call. Without a profound education, your street cred only helps you to best carry your patient and to best handle your equipment, as well as move at an emergency situation, though.

You won`t be able to diagnose or treat different sicknesses only with experience. That`s the point, where for example the cranial nerves come in handy...

[ERDoc]

Here we go again, another testament to the sorry state of EMS in the US. Newbies with a god complex, sounds like the pot calling the kettle black. There is a reason "street smarts" is also called "street sloppy." Your hero-worship street experience means nothing without the proper education to back it up. Street smarts is just another way of saying that you keep making the same mistake over and over without knowing you are making it.

Welcome to the city. If you are looking to have intelligent conversations about medicine and prehospital care you have come to the right place. If you are looking to have your ego stroked and be worshiped for how many people you have told to fuck off on a call, you will not be happy here.