Thursday, September 9, 2010

Basic stuff in EMS

Those of us who have been in this business more than 10 days talk about making improvements. Those of us that have been in this business more than 5 years know we NEED improvements. Those of us that have been in this business more than 10 years know that if we don't force major improvements it will get much worse then it is now, which is pretty bad from the patients perspective. I think most of us agree that the reason we exist is for the patients.
 Rouge Medic has once again come up with a great post which speaks to the fundamentals of how we do business when it comes to the basics of assessing patients. This has long been one of my gripes. RM's post helped to make me realize one of the problems we might 'easily' solve in EMS 2.0 and how we might do it.
 As it stands now, we have a 'tiered' training system (my term). The Doctors receive their training, the Nurses receive their training, and we, EMS receive our training. None of these programs overlap, and none of these programs are parsed out against the others for relevance and compatibility, let alone cross training.
 Let's face it, we bring in patients and are oftentimes hit with a lot of criticism about our decision making process. This should not occur unless we exhibit incompetence. In addition most hospital side practitioners are not even vaguely familiar with what we are taught as working parameters.
 Case in point: I attended a CME about a year ago regarding adjustments to the State's Backboarding protocol. The CME covered all the points, which when boiled down meant that just about everybody gets a backboard. During the presentation which was delivered by a CIC (Certified Instructor Coordinator), the Medical Control Physician sat in the corner half listening and sucking on some chicken bones left from the buffet. At the conclusion of the presentation, the CIC asked the Physician if he had anything to add. The physician put down his chicken bone, cleared is throat, walked to the front of the room and said "Look, all this training is fine, but the fact is that we have too many people coming in on backboards. Ulcers begin forming in 15 minutes and if the backboard is not really needed, don't use it. Please think about your choices and only use the backboard when the patient really needs one. I would like to see an 80% reduction in backboard use." In three sentences the Physician had shot down the entire State protocol. He didn't care. He was looking at the patients, not the protocol. The Doctor was right. In our system, we backboard way too many people. As a consequence, the E/D staff pulls them off the backboards almost as soon as we bring them in. This leads to situations like the following: I brought in a PED patient that had suffered a direct blow to the head as a result of a sledding accident. She hit a small barn head first at the bottom of the hill. We boarded her based on MOI AND her symptoms and complaints, as well as our assessment. We considered a medevac, but chose ground transport instead. The E/D had her off the board before I finished my paperwork and I went to the attending and re-iterated the mechanism as well as our assessment. He ignored me. The girl was discharged in 4 hours and was taken to her family Doctor the next day along with the x-rays. The family Doctor found 3 separate skull fractures on the x-ray and had the girl admitted to a level 1 trauma center 60 miles away, within the hour.
 Until we are all training together on the same set of rules we shall remain in competition with each other. Basing a treatment of what actions occurred regardless of what ACTUALLY happened to the patient is just insane. Learning to treat the patient based on what actually happened is just the right thing to do. Call me a simpleton, but why is it so hard for us to get this one fundamental process right?

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