Things you've missed

[cosgrojo]

Most MD's don't spend thirty minutes with a patient in the ER. Is it fair to say that MD's have a higher education than ACP's? Knowledge is not the barometer for assessment time, so I reject the theory that Basics or PCP's don't stay on scene that long because they don't have the necessary knowledge to make it acceptable.

That being said, I have no problem sticking around scene if your patient is stable and you want to further your understanding of what happened. There is a lot of valuable information that tends to pop up after the primary survey. Also family, friends and bystanders tend to start to remember more after the initial shock of seeing all the pretty lights. I have no problem with 30 minutes on scene as long as you are not doddering around doing nothing. Although I prefer the sanctity of the truck so that nosy people stay away from my patient. Remember, every call has it's own circumstances, and every call needs to be treated differently based on those circumstances.

[hammerpcp]

I only mentioned RPN cuz it was the only thing I had to cmpare to. My percussion asseessment skills were just as in depth in my PCP training as it was in my RPN. How is this an objectionable statement? I didn't think that it was implying a superiority complex.... and when did I ever claim that an RPN is the same as an RN? I'm confused.... please explain.

We practiced chest percussion. We went over what the different sounds could mean when involved with different pathologies. When we learned a disease, we learned what would be found on percussion of the chest. What more is there to learn about percussion that a higher level would have that a PCP doesn't?

I agree with you totally, never seen it done... don't see it as practical at all in most cases.

I'm not taking issue with being on scene a long time. It was with the idea that an ACP needs almost double (according to Lithium's numbers) the amount of time in the house that a PCP does. I was asking him what he assesses that takes twice the time a PCP would to assess. That's all.

On chest percussion: let me simplify. Do you know enough about it to use it as a diagnostic tool? No. That's my point.

On RPN vs. RN. I wanted to clarify for our not so informed readers that although "nurse" is in the title of RPN, the term "nurse" when used in general language is not referring to the skill set of an RPN but rather an RN. Clarity.

I think you're last question has been answered.

[akroeze]

On chest percussion: let me simplify. Do you know enough about it to use it as a diagnostic tool? No. That's my point.

Yes, I do. The person has absent A/E in an area, they have a chest trauma, they sound dull when I percuss. I'm thinking Hemo. The percussion has assisted me in diagnosing the problem.

On RPN vs. RN. I wanted to clarify for our not so informed readers that although "nurse" is in the title of RPN, the term "nurse" when used in general language is not referring to the skill set of an RPN but rather an RN. Clarity.

I'm going to stop myself from getting into an RN vs. RPN debate cuz this isn't a nursing board, it's an EMS one. What I will say is that I went through 2 and a half years of school just like many of the RNs that are out there did. Many of my instructors (RNs) said many times that we were learning things in way more detail than they had to in their two years. Anyway, not the spot for this.

I think you're last question has been answered.

I disagree, but it's ok to disagree. Maybe I truly don't understand because I've had little exposure to ACPs, that's possible. What I haven't seen demonstrated here is what that time is spent doing. What do you do that takes double the time of a PCP? I really do want to understand.

[Lithium]

Alright, maybe I'm not done ...

akroeze, you admitted you have little exposure to ACPs. I'll simplify it for you, generally, PCPs have acces to five medications. ACPs around 18. See the difference? If you have more things to consider, it's gonna take you a lot longer.

Case in point ... when dealing with cardiac patients. Is this a rate, rhythm or volume problem? Do I need to slow them down or speed them up? If so, how do I want to do that, pharmacologically or electrically? Rhythm, again, pharm or electricity? Volume, too much or too little? Do I diurese them or top them off? Secondly, if it's inducing ischemia ... do I want to manage that before or after, perhaps if I correct the underlying problem it will disipate? How do I want to manage the ischemia? Nitro, or try jumping straight to morphine? If I'm gonna be using electricity, then perhaps a bit of sedation, but I don't wanna snow them. These things take time to consider and formulate a plan, and I'll be damned if I'm gonna be deactivated or decertified because you or anyone else thinks I'm spending too much time on scene. It's my license and my career.

peace

[Dustdevil]

Most MD's don't spend thirty minutes with a patient in the ER. Is it fair to say that MD's have a higher education than ACP's? Knowledge is not the barometer for assessment time, so I reject the theory that Basics or PCP's don't stay on scene that long because they don't have the necessary knowledge to make it acceptable.

The analogy is not wholly valid. There is much more to consider. First, the nurse does the first five to ten minutes of assessment for the doctor, shaving time off of his exam. Second, the doctor's knowledge and experience allows him to arrive at a diagnosis faster that a paramedic. Consequently, he will often forego much of the standard exam once she has an impression. And, of course, the medic is providing treatment at the same time she is performing her examination, further contributing to the disparity between her exam time and that of a physician.

Conversely, medics can't unilaterally decide to forego any part of their exam very often. You start leaving exam details out of your PCR or writing "deferred" in place of half of the exam and see how long it takes for your QA to call you on the carpet.

[Neesie]

I am so tired of hearing arguments like these. Just everybody do THEIR own job and don't worry about what other people are doing. We have all been trained to do certain skills and as we all know each level of education is different and each teaches different skills. Yes, as a PCP, I probably don't spend as much time on scene as and ACP would. I have my assessments and treatments that I do, they have theirs. My partner and I have the same level of training. I was taught 3 yrs ago and he was taught 18 yrs ago. There is a difference there. I spend more time on scene than he does. Partly I suppose because I am still thinking some things through that he wouldn't have to but I also do more of an assessment on scene than he does. My transport times range between 35 minutes and 5 minutes. Mostly between 5 and 10minutes. If it is an emergency, I make the decision to load and go and do as much as possible in the ambulance. If I feel (after doing an assessment)that I have time to stay and play a little, I do. I do as much as possible in the comfort of the pt's home. That is my descision to make. I also do not take as long on scene as an ACP would because I am limited to what I can do for that pt. It is in their best interest for me to get them to the hospital where a doctor is because that is what they really need. An ACP can do more, give more drugs, and they need that time to do those things. As soon as we start getting the "extras" for drugs (which we can do in Alberta) I will probably start spending more time on scene as well. Provided it is in the pt's best interests.

Basically what I am trying to say is don't worry about what other people are doing....worry about yourself. It is YOUR ass on the line if things go south and YOU were the one that spent too much time on scene. Use the education you have been given and do your job to the best of your ability.

[Dustdevil]

Neesie, I'm afraid I have to take issue with your primary point. We SHOULD be concerned with what others are doing. There is no better way with which to evaluate our own practice. In fact, it is the very reason I came to this board. I don't want to be blindsided by progress a year after the rest of the profession already knew about it. I want to see progress and trends coming from a long way off. I want to know what everybody else is doing. It is way too easy in EMS to become isolated in your own little world, doing only what you've always done and what everybody else is doing in your system, and have not the slightest clue when the rest of the world has found a better way. We see this here on EMT City constantly. People chime in with how they do it at the Hooterville VFD, completely unaware that their practices were obsolete three years ago, yet fully believing that they are practising the state of the art.

Being concerned with what others are doing is exactly what EMT City is all about. And I highly recommend it as a way to improve yourself.

[Neesie]

I didn't mean it that way dust. I totally agree with you that you can learn from seeing what others are doing. What I meant by not worrying about what others are doing was to make sure that you are doing your job to the best of your ability. I make sure that I do EVERYTHING that I possibly can for every pt that I come in contact with. I am not worried about picking apart what others do unless it is going to cause a negative effect for the patient. If it will harm them in any way, then yes, I speak up and make it a concern of mine. I have no problem telling my partner that we should get on the road. That he can do certain things in the back of the ambulance if we have had a prolonged on scene time. It is all too easy to lose track of time while on scene. I just feel that sometimes people worry too much about watching others to catch them in a fault than watching themselves and making sure they don't make the same mistakes. I am all for watching and learning from others. I spend a lot of time in the ER, OR and on the wards to better myself and my skills. I know I am not perfect and that is part of the reason that I do that and that I don't pick apart othes ways of doing things. Like it has already been pointed out, medics have the advantage of being able to do more things for a patient than I do. It makes sence that they would spend more time on scene if pt condition allows for it or if what they are going to do will make a huge difference in pt outcome especially if it will make that differnce immediately.

[MedicMal]

How many posts actually answered the original question?

[hammerpcp]

Akroeze you are contradicting yourself, and thus I am having a hard time taking your word for anything. You said initially that you have never seen or used chest percussion in the field, and then you say that you do have enough experience in using the skill that it can help you as a diagnostic tool. WTF? A monkey (if monkeys could talk) could describe what sounds they expect to hear/not hear when a certain condition is present. Does that mean that they can recognize those particular sounds when they hear them? No. Does it mean they can apply a certain sound to attain a working diagnosis? No. I call bull chit.

As far as nursing goes, you are not trained to the same level as an RN. To call yourself a Nurse to the public or people from a different system is misleading. Maybe this is inadvertent dishonesty but I doubt it. Just because nurses "used to" only have two years of college training is irrelevant. Ambulance attendants used to have only first aid, and before that they had only a driver’s license. CPR used to be a designated medical act. I could go on and on but I won't. I hope my point is clear.

If you feel that you can use chest percussion effectively as a diagnostic tool in the field, be my guest. But don't misrepresent your training or skills. It is very unattractive.

I think Lithium did a great job of describing his point. Maybe when you get out in the field your question will get answered to your satisfaction. As of now the best thing may be just to take peoples word for it that a half hour scene time is not uncommon and is not necessarily detrimental, in fact it can be quite beneficial to the pt. We did give ACP's all these extra toys so that they can use them in the field. Ultimately, it is in the pt's best interest to get treatment as fast as possible. And if they are receiving this treatment while still at home then what is the problem?

On the other hand I do not support delaying transport of a pt to which an ACP can make no difference. I have seen this happen on many occasions as well. The ACP gets so caught up in performing a particular skill that they do not initiate transport to the hospital where the pt can actually have some beneficial interventions performed.

Oh, and MedicMal, yes we have strayed from the original topic but I find this one so much more interesting don't you?