.jpg)
Also posted over at Paramedicine 101. Go check out the rest of what is there.
So there I am sitting at home, still not finished with my response to the most recent comments from Anonymous - 3 parts, due to Blogger's character limit (4,095 characters if I remember correctly - not as limiting as Twitter's 140, but . . . ), when I receive a comment from Rachel of Rachel's Rants. Well, it made me smile like the Grinch on Christmas Day.
Why
This has been a debate among a bunch of crazy old men. I am assuming about Anonymous, but I do not think I am wrong about age or gender. Working in EMS pretty much guarantees the crazy part. As for Ambulance Driver, while he is creeping up on AARPville more slowly than I am, he did just put another candle on the cake.
The comment from Rachel is a bit different. She is a young woman and a relatively new paramedic. 3 years worth of new. Well, here is the comment to Teaching Airway - Part I. I do not need to add much to show you why it puts a spring in my step and whatever other optimistic metaphors might apply.
I have come across your blog from 9-Echo-1's site and I have to say as a 3 year medic, I'm all for more training on intubation or even just taking that skill out of the scope of practice altogether.
Of course, my Y chromosome translates that to A man's got to know his limitations. With the squint and everything. This may be the most important thing to understand in EMS, although it might be better to translate it to - A paramedic's got to know his limitations. Or her limitations.
During my 3 years I've only had 2 chances to intubate. I'm glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice.
And it is not just the opportunity to intubate, but the quality of education, the refresher training, and the quality of oversight.
I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill.
Exactly.
I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years.
Another excellent point.
The next two parts I switched to bold text. They deserve extra attention.
I've said this before sometimes the best intervention is a BASIC one.
Right there, you boiled AD's Airway Continuum down to one sentence.
I know hard concept for some to understand. Too often I see medics treat very aggressively and while sometimes that is indicated it should not be standard operating procedure.
I agree. Although I do not think that aggressive is the right word. I consider myself to be very aggressive in not using treatments that are not indicated. I often receive criticism from some other people in EMS, from some nurses, and from some doctors. Rarely from my medical directors. While I may be forgetting something, I don't think that I ever received much criticism from a medical director for under-treating a patient.
We need to figure out which patients are surviving to the hospital because of us, which are surviving to the hospital in spite of us, and how to tell the difference. This is where assessment combined with good research will make a big difference in what we do - and maybe a big difference in patient outcomes.
Anyway, go read Rachel's blog. She only posts about a once a month, but they are worth reading.
PS. Ambulance Driver has a new address for his blog A Day In The Life Of An Ambulance Driver, with a new banner that has more pictures of KatyBeth, Yay! Maybe there will be a blog from her, something like A Day In The Life Of An Ambulance Daughter.
.
6 Comments:
I was thinking about your posts on intubation yesterday, when I was watching a true crime show in Canada. Basically, a woman died, and the coroner declared it a choking death. The husband, who initially lied when being interviewed (due to a stress disorder) ended up serving something like 9 years, even though he insisted his wife had died choking on dry cereal.
The culprit? Improper Intubation by the paramedics and ER staff.
We need to figure out which patients are surviving to the hospital because of us, which are surviving to the hospital in spite of us, and how to tell the difference. This is where assessment combined with good research will make a big difference in what we do - and maybe a big difference in patient outcomes.
We need to figure out what direction we want para-medicine to head.
There are a lot of things we do as paramedics that have the potential for harm that are not done on a routine basis. Besides intubation, we give medications such as Cardizem and Dopamine, perform cardioversions, pace, do needle decompressions, and sometimes cricothyroidotomies, all within the scope of paramedics. Should we toss these out as well because they aren't practiced/performed on a regular basis and rarely needed. They all could be done later in a controlled setting.
Your asking for a redefinition of a paramedic.
Your turning us into a doctors office that calls an ambulance.
Do we want a paramedic that's a triage nurse. Great. We have figured out the problem and we'll take it to the appropriate hospital for treatment in a controlled setting. If that's the case then fine. I'm game. That's a lot less liability.
The role of a prehosptial paramedic is to come to the scene of an emergency after being contacted through an emergency medical system, assess for life threats, correct what can be corrected, or recognize what needs a higher level of care and attempt to stabilize enroute until that can happen.
Take the tubes off the truck, give me KingLT's, don't think I'm hanging on to them for reasons of a bang my chest, "ME MEDIC, ME TUBE" mentality. They are just tools.
Let's look at Racheal
During my 3 years I've only had 2 chances to intubate. I'm glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice.
Yes, you do need more practice and it's your fault for not banging on the door of your higher ups demanding more training and why do you need an MD to confirm your tube. Your training should allow you to know that way before.
I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill.
The person I want treating my family is the person trained appropriately, assesses and performs appropriate skills when necessary, recognizes change better or worse to take appropriate steps to correct, and deliver them to the appropriate next level of care. They may need you to do that skill, I hope you know how.
I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years.
You've never worked in a teaching hospital have you. Hold on to that dream.
Forgive me but are we or are we not emergency physician extenders. All the training, education, and pre-hopsital protocols are based on the fact that we are the eyes and ears of the physician in places he cannot be. We perform similar skills to achive the same goal of initial survival or the steps of patient discharge. If you withhold skills within your scope of practice because you want it to be performed by the ER physician then you contradict the very idea of what it means to be a paramedic. You are trained to do those skills however often in places that are not ideal environments. Is someones house or ambulance the best place for this, no, but it's where they need to be performed. It's up to you and the command physician to make sure your proficient with the ability to perform a proper assessment and are proficient in the skills needed to be an outstanding medic. That includes intubation, drug administration, and knowing when you need additional resources, just like when an attending has to call for an anesthesiologist for a difficult airway. Just because an physician can do a skill doesn't mean he's anymore proficient either. How many chest tubes a year do you think a non-trauma physician performs a year? Maybe none. Should he call a surgeon because he hasn't done it in a while or should he treat the hemothorax because it's in the best interest of the patient and within his scope of practice and previous training? Is he going to perform the skill as proficiently as a truama attending, no, but I bet he gets it placed, maybe he just needs to run the steps in his head a few moments before he makes the first cut.
Do you really think a skill has to be performed repeatedly for it to be successful?
Will it statistically be successful more often and performed quicker, absolutly!
An IV can be placed by most medic's without thought but we all still miss occasionally. Is that a reason to stop the skill? Do we need more practice? Or was it because that patient was a little more difficult then others?
In an arrest do we not give medications because we blew the IV or do we try an IO next or vice versa?
Recognize the need and perform, if you recognize and don't then that's the medic I don't want in my house.
RM-
I think this is a brilliant topic. Keep it going as it may be the only way things in EMS come to change. EMS 2.0 maybe? I agree with both you and Rachel 100%. Thanks, Mbb
Let’s respond to some of Anonymous’ comments”
"Yes, you do need more practice and it's your fault for not banging on the door of your higher ups demanding more training and why do you need an MD to confirm your tube. Your training should allow you to know that way before."
First let me say this before you go judging have your house in order and know your job. With that said, I do the initial confirmation of my tubes but in my system it is not considered a "successful" tube until verified by a MD at the ER. As for training, the places that are best suited for this according to my medical director and training officer do NOT want medics there so aside from going to the college on a regular basis and tubing a simulator, my hands are sort of tied.
“The person I want treating my family is the person trained appropriately, assesses and performs appropriate skills when necessary, recognizes change better or worse to take appropriate steps to correct, and deliver them to the appropriate next level of care. They may need you to do that skill, I hope you know how.”
If my patient needs me to do a skill then it gets done. I never withhold a treatment that I know how to do when that treatment is indicated. I however am not a cookbook medic. I was taught to think without needing a script for every patient. Sounds like maybe you should try it sometime.
“You've never worked in a teaching hospital have you. Hold on to that dream.”
I have. UNC Chapel Hill and Duke University and you worked where for your training?
“An IV can be placed by most medic's without thought but we all still miss occasionally. Is that a reason to stop the skill? Do we need more practice? Or was it because that patient was a little more difficult then others? In an arrest do we not give medications because we blew the IV or do we try an IO next or vice versa?”
Ok so now if you fail to successfully obtain a skill it’s the patient’s fault? I’ll remember that next time I am unable to get my IV. That is probably the single most moronic statement I’ve heard and why are you even bothering with an IV in an arrest situation? IO is quicker and the quicker you can get medications to the patient, along with continuous chest compression, the better outcome potential for the patient or did you miss that part at the last ACLS class?
Is it so hard for you to imagine that you may not be the best provider to do a skill for your patient or does your ego get in the way of treating your patients?
CrazyNewt,
I was thinking about your posts on intubation yesterday, when I was watching a true crime show in Canada. Basically, a woman died, and the coroner declared it a choking death. The husband, who initially lied when being interviewed (due to a stress disorder) ended up serving something like 9 years, even though he insisted his wife had died choking on dry cereal.
The culprit? Improper Intubation by the paramedics and ER staff.
Interesting.
Do you know the name of the show, if it is available on line, etc.?
Post a Comment