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  • #31
    Originally posted by edpmedic View Post
    "If A then do B and check for outcome," huh? Your what's commonly referred to as a cookbook medic. Not every pt fits into a neat little textbook presentation. For example, consider that many CHF pts developed that CHF secondary to their COPD (emphysema) over the years. Pulmonary HTN is a common contributing factor. They have dyspnea, and they're fairly tight, too tight to hear rales. Do you think they're having a COPD exacerbation? Are they developing APE? Is it both? What do you do first? How do you manage both conditions, and how do you go about that? That requires using at least two protocols. Take a good look at Wake Co, NC's EMS clinical guidelines. Their medics use guidelines, as in best judgment, rather than the simplistic "see A, do B."

    Do you understand the mechanism with which succinylcholine (one of the RSI meds) can cause hyperkalemia, and how that can lead to malignant hyperthermia? I'll bet the in house "pharmacology for EMS" that waters down a college pharm course into a week, and only covers the thirty meds or so didn't teach you that.

    Do you understand how to use the ETCO2 capnoline (nasal ETCO2 for non-intubated pts) for applications other than verifying tube placement? I'm guessing that the two week watered down "A&P" for EMS that the medic mill gives in lieu of requiring college A&P didn't give you the education to fully understand capnography and capnometry. Can you tell me how to diagnose a STEMI with a pt that has a LBBB or paced rhythm?

    To take NVCC's EMS AAS program as an example, you get human biology (A&P), general pharmacology, pathophysiology, advanced patho, a class dedicated to just 12 leads. EMS management is what you study when you progress past the AAS and go for an EMS Bachelors, BTW.

    When over 90% of pts in EMS are non-acute, or non-time sensitive, I wouldn't expect the numbers to differ much from the degree medics to non degree medics. We're talking about maybe 5-10% of the pt population that would fare worse if they weren't given more than an O2 NRB and txp. Part of that 10% would be cardiac arrests, who typically stay dead regardless. That opens a whole other can of worms regarding the importance of ALS response and pt outcomes. Consider that a dept's current protocols reflect the medic's lack of education. That's why your friend in Australia, who is likely an Advanced Care Paramedic, which is above the Primary Care Paramedic, can treat and release. In NYC, you can't even give an albuterol in-line neb for an APE pt. Even if you could, that would be jumping protocols, and you would have to spend a few minutes on the phone with the doc-in-the-box giving a complete head to toe while your pt deteriorates.
    To me it's not the degree per se, It's the time that is needed to learn the finer points you just touched.

    That was a good post. We are HEAVY into cardiology now, then we go to 12 lead, Then to ACLS. YAAAAAAY
    Get the first line into operation.

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    • #32
      I personally learned more functional A&P in my non degree paramedic classes than I learned in general A&P. We also didn't learn a single thing about capnography in my college A&P.

      It comes down to the time to learn the information and the instructors taking the time to teach a good amount of A&P. (My instructor was an A&P instructor during the months when there was no medic program).

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      • #33
        When you're talking about paying paramedics (or EMS folks in general), don't forget that Medicare/Medicaid and the insurance companies pay squat for EMS. If they started paying the true cost of the transport, maybe companies could afford to raise the pay of the medics. A significant number of our transport are Medicare/Medicaid, so we're stuck with what they pay...

        I'm with a small, independent not-for-profit ambulance. We staff one P 24/7 and rely chiefly on volunteers for drivers and basics. We still need a subsidy from the towns we serve to break even...
        Opinions my own. Standard disclaimers apply.

        Everyone goes home. Safety begins with you.

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        • #34
          Originally posted by tree68 View Post
          When you're talking about paying paramedics (or EMS folks in general), don't forget that Medicare/Medicaid and the insurance companies pay squat for EMS. If they started paying the true cost of the transport, maybe companies could afford to raise the pay of the medics. A significant number of our transport are Medicare/Medicaid, so we're stuck with what they pay...

          I'm with a small, independent not-for-profit ambulance. We staff one P 24/7 and rely chiefly on volunteers for drivers and basics. We still need a subsidy from the towns we serve to break even...
          The nursing profession started out with diplomas. As a profession, they decided to move to degrees. They emphasized the benefit to their pts above everything else. They were able to justify increased compensation and insurance reimbursement for that reason, and the gains in benefits, salary, working conditions and such followed. CRT's are becoming obsolete in favor of RRT's (respiratory therapists). You need to have a BSN to work in certain health systems; an RN is no longer adequate. EMS is really the only medical profession that doesn't require a degree.

          As far as the cost of txp, when you think about it, 80 plus percent of out txp's could be done by a taxi or ambulette.
          "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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          • #35
            Originally posted by edpmedic View Post
            The nursing profession started out with diplomas. As a profession, they decided to move to degrees. They emphasized the benefit to their pts above everything else. They were able to justify increased compensation and insurance reimbursement for that reason, and the gains in benefits, salary, working conditions and such followed.
            And, oddly enough, the best nurses I know are diploma nurses. I don't know where you are but there's no difference in salaries and benefits between diploma and BSN nurses here. An RN is an RN.

            IMHO, there is no inherent benefit in requiring an Associates level degree to be a medic. If you want to improve the quailty and consistency of medics, you need to improve the quality and consistency of medic programs. You don't need to tie them to an academic degree to do that.

            EMT-Ps fill a specific niche in the health care system. If you're looking for something more, I'd suggest moving on to another profession higher up the food chain rather than trying to make a silk purse out of a sow's ear.
            "Nemo Plus Voluptatis Quam Nos Habant"
            sigpic
            The Code is more what you'd call "guidelines" than actual rules.

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            • #36
              Originally posted by edpmedic View Post
              The nursing profession started out with diplomas. As a profession, they decided to move to degrees. They emphasized the benefit to their pts above everything else. They were able to justify increased compensation and insurance reimbursement for that reason, and the gains in benefits, salary, working conditions and such followed. CRT's are becoming obsolete in favor of RRT's (respiratory therapists). You need to have a BSN to work in certain health systems; an RN is no longer adequate. EMS is really the only medical profession that doesn't require a degree.
              This is true, but we're also the only part of the medical profession where many patients think they shouldn't have to pay for the services provided to them.

              As far as the cost of txp, when you think about it, 80 plus percent of out txp's could be done by a taxi or ambulette.
              This is true, but the decision for this not to happen is made by people with college degrees, not EMS itself.

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              • #37
                Originally posted by DeputyMarshal View Post
                And, oddly enough, the best nurses I know are diploma nurses. I don't know where you are but there's no difference in salaries and benefits between diploma and BSN nurses here. An RN is an RN.


                IMHO, there is no inherent benefit in requiring an Associates level degree to be a medic. If you want to improve the quailty and consistency of medics, you need to improve the quality and consistency of medic programs. You don't need to tie them to an academic degree to do that.

                EMT-Ps fill a specific niche in the health care system. If you're looking for something more, I'd suggest moving on to another profession higher up the food chain rather than trying to make a silk purse out of a sow's ear.
                I don't know where you live, but since I was in HS back in the early 90's, and probably before that, you needed at least an RN degree to work as a nurse. Diplomas were no longer sufficient. That was NYC. Now, here in VA, you need a BSN to get into a hospital system in NOVA, unless you have a hook somewhere. In addition, there's no career advancwment opportunity for anything less than a BSN. It's also difficult to get work as a CRT; preference is given to the RRT. A PT degree went from four to six years some time ago.

                Employers and insurance companies have no reason to pay more than what's currently offered since anyone can become a six month wonder, sometimes even qucker. I don't see the quality of medic programs improving on a grand scale. These are typically for profit entities. They make their money by running as many classes in possible, in the least amount of time possible, and getting their students to pass the NR or state exam. To make the program more difficult, or to require college A&P and pharm at a minimum as a pre-requisite, would drive their business to quicker, easier schools. with EMS given as a degree, you're assured at least a minimum standard of quality with the program. The instructors would also need to be formally educated to be allowed to teach. The students will have passed basic English composition, be proficient in math as it applies to drug calculations (read any EMS forum and look at all the students that struggle with med math, which is simple algebra, ratios and fractions), and understand basic chemistry and how it applies to the human body, so that they can actually understand what our meds and therapies are doing to the pt on the callular level. Otherwise, you get "CPAP pushes lung water," (this is how some instructors explain CPAP), that atrovent opens the lungs in a different way than albuterol, or the inability to grasp that not all pts need high flow O2, you get the inability to grasp science behind permissive hypotension, when and why to use albuterol, bicarb, and how much fluid and when for a crush syndrome, or what to infer from a reading from an ETCO2 capnoline (nasal). You lack the inability to understand and implement best practices and evidence based research.

                Evidence based research is why we have permissive hypotension protocols, post arrest induced hypothermia, why lasix isn't routinely used for APE, why we don't pace asystole, why we can double up on ntg and repeat more than the arbitrary three times for APE, and how we can use CPAP for more than just CHF pts. Certain systems, such as mine, allow us to call OLMC for "extraordinary care," which is asking for orders within our scope that differ from protocol, but are in line with current evidence based research and best practices. I knew long ago that an APE needed more than three ntg five minutes apart, that you could give the same pt concurrent albuterol through an in-line neb in certain cases, how hyperventilation reduces CPP in the head trauma pt, hoe hyperventilation in a cardiac arrest impedes coronary perfusion. It's about keeping up with the most recent science, and being able to explain why you're requesting it to the doc, when simply following the "see A, do B" protocol isn't the best treatment course for the pt. I know of someone who got permission from OLMC to give high dose dopamine (30 mcg/kg/min IIRC) with ntg spray prn to mitigate a significant rise in BP for the cardiogenic shock. He basically rendered the same effect as dobutamine, which is given for it's inotropic effects. Who would have ever thought of that with the condensed pharm for EMS, with it's 30 or so 911 meds? Matter of fact, there's a whole interfacility side to EMS. The medic will need exposure to hospital meds as well. Most non-college paramedic programs only teach you the bare minimum of A&P and pharm that you need to simply pass the test. Three weeks of A&P and pharm combined just ain't cutting it. If someone was treating one of your family member, would you want someone who was groomed to pass a test, given just the bare essentials to do so, or someone with the educational background to follow the latest studies and research, and be able to apply that to them? Do you want to live where the EMS system is restricted to blanket protocols, with providers who don't fully understand why they're doing what they're doing, but just following the steps so they don't get jammed up by QA/QI?

                Unless they start employing FF/PA's, or FF/RRT's in the near future, I don't plan on moving up the food chain. I like medicine, but I like fire more.
                "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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                • #38
                  Originally posted by FireMedic049 View Post
                  This is true, but we're also the only part of the medical profession where many patients think they shouldn't have to pay for the services provided to them.

                  This is true, but the decision for this not to happen is made by people with college degrees, not EMS itself.
                  Not true. How many people use the ER as their PCP, and have no intention of paying? They're either using a medicaid entitlement, or are uninsured and know the hospital has no way to find them after being treated.

                  In other countries, the people who would otherwise engage in 911 abuse are able to be triaged out onscene, and sent to the appropriate destination by other means. This may be urgent care, outpatient psych services, etc. Others need to be educated how to manage their disease, such as diabetics and CHF'ers, so they don't need to call 911 as often. This is what's possible in other countries where you need a four year degree to be a medic. Wake Co. EMS in NC does this with their Advance Care Paramedics.
                  "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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                  • #39
                    Originally posted by mspangler View Post
                    I personally learned more functional A&P in my non degree paramedic classes than I learned in general A&P. We also didn't learn a single thing about capnography in my college A&P.

                    It comes down to the time to learn the information and the instructors taking the time to teach a good amount of A&P. (My instructor was an A&P instructor during the months when there was no medic program).
                    A&P doesn't teach you capnography/capnometry; rather, it teaches you what to make of the numerical values and waveforms, and how to guide your pt care with that real time information. In-house A&P is hit or miss, and will never cover what a college level one does. You can also take more advanced A&P w/lab, O-chem or microbiology if you choose, and get way more than the functional A&P that you're talking about.
                    "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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                    • #40
                      Originally posted by edpmedic View Post
                      I don't know where you live, but since I was in HS back in the early 90's, and probably before that, you needed at least an RN degree to work as a nurse. Diplomas were no longer sufficient. That was NYC. Now, here in VA, you need a BSN to get into a hospital system in NOVA, unless you have a hook somewhere.
                      Interesting. My ex-wife has her nursing degree, but does not have her BSN, nor does she intend on getting it, and has been given job offer one after another since she graduated 5 years ago - ICU, SICU, ER, etc. This down here in the Richmond area, and isn't unusual at all for this region.
                      Career Fire Captain
                      Volunteer Chief Officer


                      Never taking for granted that I'm privileged enough to have the greatest job in the world!

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                      • #41
                        Originally posted by BoxAlarm187 View Post
                        Interesting. My ex-wife has her nursing degree, but does not have her BSN, nor does she intend on getting it, and has been given job offer one after another since she graduated 5 years ago - ICU, SICU, ER, etc. This down here in the Richmond area, and isn't unusual at all for this region.
                        That was five years ago that she graduated. Like you say, it isn't unusual for the region. I might get lucky and get an RN job in the NOVA health system if I was working as an ER Tech or somehting first. Otherwise, it's exceedingly difficult to get hired as a basic RN in NOVA. Five + years ago, RN's were is short supply. You could write your own ticket. It was well known that the nursing profession was wide open. The nursing courses filled up with teeny boppers, and now there are plenty of RN's in the area. It's competitive to get into an RN program nowadays. You need to have a high GPA, and you're still put on a waiting list. The nursing profession has tried to make the BSN the minimum standard, but that hasn't worked out yet. What has been happening instead is the inreasing trend to grant specialty assignments and offer promotional opportunities to BSN's and higher. Exceptions are made, of course, for the experienced RN, or if you have a good hook.

                        I was looking at Valley Health in Winchester. They want a BSN, or 3-5 years experience as an RN, and that's for a non-ladder position. Unless they're desperate, you're not getting on as a new grad. I expect more of the same nationally as the years go on. I hardly ever see LPN's/LVN's anymore, except for NH's.
                        "The democracy will cease to exist when you take away from those willing to work and give to those who are not." Thomas Jefferson

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                        • #42
                          Originally posted by BoxAlarm187 View Post
                          Interesting. My ex-wife has her nursing degree, but does not have her BSN, nor does she intend on getting it, and has been given job offer one after another since she graduated 5 years ago - ICU, SICU, ER, etc. This down here in the Richmond area, and isn't unusual at all for this region.
                          RNs have rich opportunities.

                          INOVA has been "rightsizing" health care, replacing many RN assignments with lesser credentialed caregivers. The RN becomes the nursing care supervisor and patient care manager.

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                          • #43
                            Mike, I know what you mean. One reason that my ex didn't persue her BSN was because she has no desire to be a nurse manager...but as time goes on, she continues to be pressed into management/decision making roles, despite her desire to only give one-on-one patient care.

                            It's amazing the difference in both in-hospital and pre-hospital care once you get north of Spotsy.
                            Career Fire Captain
                            Volunteer Chief Officer


                            Never taking for granted that I'm privileged enough to have the greatest job in the world!

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                            • #44
                              Originally posted by BoxAlarm187 View Post
                              It's amazing the difference in both in-hospital and pre-hospital care once you get north of Spotsy.
                              Agreed!

                              I also see it with ED physician coverage (at least in DC), more PAs and NPs and fewer MDs.

                              Mike

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                              • #45
                                Originally posted by edpmedic View Post
                                Not true. How many people use the ER as their PCP, and have no intention of paying? They're either using a medicaid entitlement, or are uninsured and know the hospital has no way to find them after being treated.
                                I think you missed my point. I'm not talking about knowing you will be billed and having no intention of paying or utilizing some sort of public assistance health insurance.

                                I was referring to the belief that they shouldn't be billed in the first place for utilizing EMS.

                                In other countries, the people who would otherwise engage in 911 abuse are able to be triaged out onscene, and sent to the appropriate destination by other means. This may be urgent care, outpatient psych services, etc. Others need to be educated how to manage their disease, such as diabetics and CHF'ers, so they don't need to call 911 as often. This is what's possible in other countries where you need a four year degree to be a medic. Wake Co. EMS in NC does this with their Advance Care Paramedics.
                                It's possible now for people to be referred to alternate treatment facilities. The ability to do this doesn't necessarily curb 911 abuse.

                                If a patient needs to be taught how to manage their disease, then that education should be provided by their PCP or clinic, NOT by EMS during a 911 response. Just like you can't teach a paramedic the "background" knowledge of most diseases in order to make the type of independent treatment decisions you are advocating for in less than an hour, you won't be able to teach somebody to manage their disease in the time frame that EMS is typically with a patient (less than an hour). Part of properly managing any medical condition is the inclusion of a physician. That's where education regarding chronic medical conditions should be done.

                                Do you also advocate EMS providing on scene psychiatric counseling?

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