An EMT's take on not Needing more Medics.

Recently fellow bloggers have put forth a topic of discussion that I feel I would weigh in on. Medic 999 posed the question of  "Do we really need Paramedics on ambulances?", which caused a well thought out response,   "We don't need more Medics"  from 510 Medic.

Both Bloggers are Paramedics and offer, in my opinion, a surprising response. They both seem to say that more medics is not the solution to an overwhelming problem in EMS. There is no need to have a Paramedic on every single ambulance let alone two. In fact I am willing to argue that the common place of having Medics on every single rig has lead to a decline in patient care and a Medic's overall ability. 

Now don't get on your soap box and assume I'm saying that Medics abilities are poor, or we don't need medics. One the contrary my dear reader, I am merely making reference to my comment on 510 Medic's blog, which was:

"I agree totally, I feel it is leading to a downward spiral of our providers. EMT’s who may not get the experience from the BLS truck, may not be as experienced with the “basics”. EMT’s only riding on ALS trucks then feel the need to advance them selves in order to get more patient contact and more experience. Thus becoming Paramedics, and with declining con-ed budget’s, are still not being as experienced as their predecessors. These newly carded Paramedics who have a lack of the “basics” typically turn out to be poorer providers. "

By this I refer to the idea that EMT's are rushing them selves into a Medic class before having confidence in their own ability or exposure to really bad patients. EMT's see Medics doing more skills, being paid more, and being the "life saver". They do not get a sound fundamental skill set that they can rely on through their career in EMS by rushing their advancement. These providers are then welcomed into a world of diminishing providers by being thrown into the captains chair by being cleared. The expectation of a systematic transition to gain and hone the much needed street skills is pushed aside to the need for a warm body to fill a schedule hole. The response to the negligence of clearing a provider before they are ready? They can make up needed skills in the continuous education training that is expected of all providers and catch up on their need. Sounds great, and almost reasonable right? Except we enter the new age of declining education budgets and fewer instructors. Now the much needed continuous education isn't being offered or being set aside for a later date. Now the new medics have to rely on their experience and their fundamental skill set. When all else fails they can rely on the basics after all right?

So if you have followed along, you may have picked up on the criticism systematic failure that faces EMS. 

"I’m not saying we need to triple the BLS trucks on the road but rather put weight on the experience gained for our EMT’s in a BLS setting. As with any performance overhaul its typically a good idea to start at the bottom/beginning."

I think we need to understand and credit that there is an enormous amount of applicable skills that can be learned in the Basic ambulance arena. By putting weight on this experience, EMS will only benefit with strengthening our base structuring and ultimately our future Medics.

Be Safe
Ambulance Junkie

What Would I teach Lizzie?

-The Handover-EMS Blog Carnival Aug. Submission-

So your proficient in your skills, able to back board with the best of them. Fully capable of putting on a traction splint, vacuum splint and can sling and swath a shoulder. You've studied all the acronyms needed, DCAP-BTLS, PERRL, SAMPLE, and have a solid understanding of their use as it pertains to the patient.

You have a sound understanding that majority of calls will fall in the "grey realm". You'll have some black & white calls laid before you, but over all you'll have an unproportional amount of grey calls. Understanding that once on the streets the clinical decision making is in your hands. You do not solely rely on your initial education, rather the trends in EMS you have been continually researching and the Con Ed classes participated in.

When all else fails Lizzie, you know when to call for help. People become afraid to show weakness in this line of work, but don't be. The simple fact is the nature of the beast that is medicine is ever changing and progressing. It is impossible to be on the cutting edge of every single change in EMS, but hopefully some one else may have the knowledge where you haven't gotten to yet. We must never forget that we are serving for one single reason, and that is to do whats best by the patient. Sometimes that means to ask for help, but you know that already.

Solid fundamentals, capable clinical decision making skills, and the ability to admit to one's self that you need help. That pretty much covers the whole lot of attributes a newly carded EMT will need for the field, and you have them.

So what do I hope I've taught Lizzie? Keep your sense of humor girl! This Career/Stepping stone/Hobby/Calling surrounds us with people having the worst day of their life potentially. We are always in the thick of their crisis, and are the ones they have summoned to help. That is a lot of pressure on an individual, to be the sole saver of life, the Grand Puba of help. the Sultan of Assistance. In order to maintain our sanity we have to be able to keep our sense of humor. Humor is really just a matter of perspective after all. When in the appropriate times it lightens our moods and gives us that little extra to make it another call.

But I'm sure you already knew that Lizzie, you were always a great student.

Be Safe
Ambulance Junkie

A Black and White or a Grey Affair??

"Everyone thinks when they get out of the academy, everything is black and white.  Well you know what? It isn't.  We live in the gray." Southland. 

There is no amount of training or schooling that will prepare you for the gritty realization of life on the streets. There is the obvious right thing to do and the obvious wrong thing to do, but that only covers the extreme polar ends. What do you do the rest of the time? What would you do in the moment when none of your training and none of your schooling seems applicable? The moment you enter the Grey Zone?

Your presented with a Frequent Flyer drunk, we all know the one, you pull up on scene and know his Name, DOB, SSN, Medical Hx, his wife's name, and their pet cat named Fluffy. He's a block away from his apartment, and is shit faced. He left the bar the block back and has been fighting the ever ominous force known as gravity the entire time. A good Samaritan saw him fall while driving and called 911, though never felt the need to stop and help him.

So Black and White would say a male Intoxicated fallen is a transport to the ER, right? He has consumed alcohol and thus not allowed to refuse medical aide and transport because he has a mind altering drug on board. He is adamant in not going to the ER, and it will be a struggle the entire ride in to keep him relaxed and on your stretcher.

Grey would say that he was heading home, He's a block away, and he needs to sleep this off. Yes he is drunk but if he shows no signs of trauma after a full assessment and is capable of appropriately answering person, place, time and thing than he has the right to refuse Medical aide and transport. You can't take a man against his will and you know his non driving wife is home awaiting his eventual arrival.

So what do we do? In this exact situation it comes down to your way of thinking, which I have done both:

Black&White- You get your Malnourished Morgan Freeman look alike patient and sit him on the stretcher. He banters on about being taken against his will as you put his lap and leg belts on. He emanates enough booze out of his pores for you to inhale a contact buzz. You wrestle to keep him on the stretcher and avoid his misguided attempts at a punch. You use all EMS Mind tricks to distract him and take his attention off his disgruntlement.

Grey- I've signed off my local drunk and given him a courtesy ride home. Walking him to his door and helping him to his front door where he lets himself in. Seeing his worn and weathered wife looking with shame and embarrassment of the spectacle he must have caused from with in the house. We bid our patient ado, and reassure the wife that bringing him home was no problem and it'd save them some money from the ER bill. No doubt leaving the patient to crash on his couch and sleeping off his alcoholic induced life style.

No one prepares us for the split second decisions having to be made on the streets. No one prepares you for the second guessing you'll do the moment the call is over. EMS is Black and White except for when its grey. EMS is truly a conundrum.

No matter your decision, use you clinical assessments and sound medical judgment and stick by it; but always be able to learn from your mistakes.

Be Safe
Ambulance Junkie