Home care paramedicine, why not like this?

[DFIB]

I understand the dangers of appropriate use or abuse of antibiotics. I used to live in a country where you could get antibiotics over the counter without an Rx.

That said I don't find the use of antibiotics to be all that complicated. What is more complicated is being able to prescribe without having the luxury of cultures and antibiotic susceptibility testing. Rural medics and Doctors have to have some crazy good clinical skills and a huge knowledge base. By observing rural Drs i have found that they are familiar with what is going around in their area and Rx accordingly. I also see them take "stabs in the dark". Most of the time their educated, well informed guess is correct.

All we really have to do is to be self motivated to study the material. If we can do it in college that is even better. I would start with a good microbiology class and move on from there.

You Rural guys play lIke you are not "the bomb". Your humility is appreciated although I tend to disagree.

Edited March 5, 2012 by DFIB

[mikemedic999]

You cannot get antibiotics today over the counter....

[DFIB]

You cannot get antibiotics today over the counter....

Nope. It is a thing of the past.

[DwayneEMTP]

You cannot get antibiotics today over the counter....

Maybe not where you are...but this is an international forum after all...

In Ulaanbaatar you can get full range of antibiotics, ED drugs, steroids, etc. I think, though I'm not sure about the steroids, that it's the same in Dubai. (Is it a coincidence that you can get Viagra and antibiotics at the same counter? It's a mystery....)

...By observing rural Drs i have found that they are familiar with what is going around in their area and Rx accordingly...

In my experience this is probably how 90+% of antibiotics are prescribed remotely by all levels of care. What a great point and a not invalid method of prescription I think as long as one is constantly on the lookout for zebras.

[Just Plain Ruff]

In the US it's going to boil down to this.

In court when the home care issue is challenged it's going to go something like this

"Mr Captain Kickass what are your educational qualifications?"

Me "I have a paramedic certificate from MCI Hospital in 1992, a bachelors degree in administration of justice in 1996, a masters degree in project management in 2003 and numerous CEU's over the last 20 years"

arrogant attorney "am I to understand that your employer felt comfortable to send you out in the home health arena to take care of these patients who had all sorts of medical issues such as post MI and chf complaints and make sure they were doing what they were supposed to be doing?"

Me "yes sir they do"

Arrogant attorney "what additional training did they send you to? did they send you to any nursing level courses?"

me "no, not really, I had a couple of home health nurses come in to give me some additional classes on what to look for and observe"

Arrogant attorney (rhetorically) "and do you think that was sufficient? I withdraw that question"

Current education that medics get no where near qualifies the majority of us out there to do home health nursing/medicine. Sorry if if ruffles(pun pun pun) anyones feathers here but it just doesn't. And in NO way does our current level of education qualify us to prescribe or give without medical control to a patient that we are NOT transporting to the hospital any medication regardless of it even being a tylenol or an aspirin.

If you want to go and do home health nursing get your nursing degree.

Why are we trying to the nurses job? Why do we continue to try to take over the physicians role. I'm not trying to hogtie us to just being transfer jockeys but our role is not be a home health nurse or physician assistant, we can many times BARELY do our EMS jobs right. Let's get our own ducks in a row before we try to line up the chickens and then the geese.

I am currently working on the ED computer project at the Childrens National Medical Center, My plan is to give them the best job that I can do for them and then I'll go on to maybe a hospital out in Seattle but I'm not goign to try to do both the Childrens hospital and the Seattle project at the same time but it seems like we in EMS want to do everything at the same time and in the end it's going to come aroudn and bite us in the ass.

[zmedic]

I think it depends on what your expectations are for the interventions. I don't think it takes that much training to show up and say "i know you aren't having an emergency today, but I want to go over:

1: What medications you are taking? Do you have a list of them?

2: What hospital are you followed at?

3: What is the name of your doctor?

4: When is your next appointment?

5: Are you in the process of getting home health help? No? How can we work on that?

6: Do you have a recording of your fingersticks?

Pretty simple. Now it's a very different skill set to have someone show up and say "I know you called 911 because you think you are having an emergency, but I'm going to decide that you aren't having an emergency and leave you here."

In the first case you are mainly providing social support to the patient and ensure that they know what they are supposed to be doing, that their medical information is gathered in a readable way. In the second case you are making diagnosis.

Now the question of if that second case is doable in the US is a different issue from the first case. The big problem in the first case is funding. If you target high system users it is cost effective. But maybe not expanding it beyond that.

I'd also point out that I don't think it's much cheaper to have a medic go around and do this than having an RN or social worker do it. Maybe it makes sense in places with low volumes where you could do some of this while in service.

[Just Plain Ruff]

I'd also point out that I don't think it's much cheaper to have a medic go around and do this than having an RN or social worker do it. Maybe it makes sense in places with low volumes where you could do some of this while in service

But it lessens the service or maybe the better term would be it cheapens the service when you are explaining a key important piece of information to the patient, you get a call and are interrupted and the train of thought is lost. The patient knows you said one thing, you know you said the other and in the end altogether the end message is that something completely different was said.

The patient in the end suffers and might or might not be injured in the translation.

That is an outcome that we do not want to have happen. Safeguards would have to exist and the entire visit that the medic was on when he got called away would have to be done completely over in order to make sure the patient got the information that they were suppoised to get they got.

Could the EMS agency bill for the return trip/visit? I don't know? Probably not. They probably should not be able to.

If we are going to start to send medics out to houses as home health medics then there needs to be additional education and maybe additional certs such as this

6 months of classes called EMT-P Home Health taught in an accredited nursing school focusing on home health topics.

A state exam based on the above

A new level of licensure level EMT-P/HH (home health)

No medic except those with the HH designation can make home health visits period.

[DwayneEMTP]

Yeah Ruffles, we've had the same argument for nearly every level of EMS.

Nurses can't do 'street medicine' because it's a specific skill set that they're not trained in. Yet there are some rockstar flight nurses, right? Paramedics don't have the education to do Flight for Life level of care, yet they do it, and many excel at it right?

Those arguments only hold true if the argument had been made that we make this a national scope of practice. But we didn't. I carefully mentioned that medics would have to be screened and trained specifically for this purpose.

What is it exactly that makes this a nurses job? Simply because it goes on in someone's home instead of the back of an ambulance? Then it wouldn't be a nurse's job either, right? As it doesn't happen in a hospital?

Is a medic, who's responsible for recognizing, when possible diagnosing, and then treating chronically, acutely, and critically ill patients suddenly going to forget those skills because he's not running to an ambulance immediately?

All of a sudden he's going to go into a house with a tripoding/diaphoretic patient, crushing chest pain, DOB and say, "Ahhh...I can see that you need some Albuterol." simply because he wasn't called emergent?

I am a much, much better clinician now than I was when I transported everything in right away. My assessments are much better, histories very thorough, attention to detail superior in every way, yet in no way have I found that that has made me weaker in spotting emergencies, nor more likely to try and be a superhero when I have other options.

To say that a properly educated medic shouldn't give so much as an aspirin, or advice on continuing a Drs prescribed medication unless it's in the back of an ambulance confuses me...there's nothing magic about that other than the fact that it ends up at the hospital. And we've all agreed that the vast majority of patients don't need to be there. So if a home medic can approach all patients with a high index of suspicion for needing to to be transported, and decide from there, what's the problem? Isn't that what we do each time that we consider a refusal?

And, as per the article, these patients have all been screened and treated at the ER multiple times, so other than looking for new onset acute issues, (which is kind of what we do, right?) it is only monitoring the continued physician prescribed care.

Other than trying to foster a humble attitude towards our education, I don't see the logic being applied here...

[Just Plain Ruff]

But Dwayne, we (medics) don't routinely manage chronic illnesses on a long term basis other than transport the patients. Sure we transport and manage them on a short term basis but to put medics in a house on a weekly basis to manage a chronic condition begs for better education.

Sure we can put our medics in houses on a emergent basis and manage this chronic illness that is out of control and our medics will do a good job.

I may not have been clear. Sure the medics can continue physicians orders/medications and prescriptions, because those are already prescribed but to prescribe new meds like cardiac meds or other medications we should not be doing such.

To further explain my befuddled thought process now that I've had some chance to enhance it there are rockstar medics who can work the ER and the floor in a hospital with the best of nurses.

There are also nurses that can work the streets on the truck with the best of every medic out there.

I advocate for better education, if medics are going to assume a role that has traditionally been routinely a nursing role (home health has been) then we need the education to back that assumption of that role up.

That's all I'm saying.

Does that make the water a little more clear on my thoughts?