EMS education

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frosted2

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Hello folks,

MS1 and medic here. I am giving a presentation at my former service and the topic was left up to me. What are some things that you wish EMS providers did better/need further education and what would you like to see as far as areas of improvement? We are a fire-based EMS service, the vast majority of trucks we run are dual ALS.

Thanks!

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Hello folks,

MS1 and medic here. I am giving a presentation at my former service and the topic was left up to me. What are some things that you wish EMS providers did better/need further education and what would you like to see as far as areas of improvement? We are a fire-based EMS service, the vast majority of trucks we run are dual ALS.

Thanks!
Vitals signs. I need your last set of vitals more than anything else.
 
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Vitals signs. I need your last set of vitals more than anything else.
Cosign that. Report "vital signs stable", and not give numbers, that's worthless. Worthless. Either the crew is lazy, uneducated, or just poor employees.

Emphasize "good BLS beats bad ALS eight days a week". Especially junior and self assured, egotistical medics need to realize that you're appreciated for what you can bring, not what you can't. If they bring in the pt worse than they got them, make sure it's due to pt condition evolution, not medic error. The best mistake is the one you don't make.
 
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Cosign that. Report "vital signs stable", and not give numbers, that's worthless. Worthless. Either the crew is lazy, uneducated, or just poor employees.

Emphasize "good BLS beats bad ALS eight days a week". Especially junior and self assured, egotistical medics need to realize that you're appreciated for what you can bring, not what you can't. If they bring in the pt worse than they got them, make sure it's due to pt condition evolution, not medic error. The best mistake is the one you don't make.
Thanks Apollyon. I practiced by the "just because I can, doesn't mean I should" motto and it served me well.
 
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Glucose! I mean, you’d think this is EMS 101 but I can’t tell you how my times it doesn’t get done.
 
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For the love of god, for altered patients, we need to know last known well/alive, their baseline level of functional status (do they walk and talk, are they normal, are they demented, do they use a walker or a wheelchair?) If family isn't coming along we need at least one person's name and working phone number.
 
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I don't think many medics can accept that intubation, especially in cardiac arrest, is really not a lifesaving measure and in many cases causes more harm. It detracts from high quality chest compressions, defibrillation, and things that we know improves survival. The majority of them haven't really been trained well at 2 handed BVM technique (the number of them that walk in with one handed BVM where the mask is basically not even making contact with the patients face is mind boggling). They also should be taught that LMAs are more than sufficient for the majority of cardiac arrest patients provided they are registering end tidal CO2 and the airway isn't floridly contaminated (I would stress to them that in the prehospital setting end tidal CO2 is absolutely a vital sign and just as important as the others, especially when it comes to airway). It goes back to the point made earlier that good BLS care is really the most important thing.

Also stop wasting time on scene with sick TRAUMA patients. These folks don't need an IV. They don't need an EKG, or blood sugar. They rarely in my experience need an airway. If you are going to make an intervention on a trauma patient in the field, it needs to be a quick and life saving intervention i.e. needle decompression, surgical airway, something of the like. Otherwise, get them to a surgeon.

For medically sick patients, they actually should be spending more time on scene. The number of cases I have QA'd where the patient was moved while being extremely unstable and ended up arresting during transport would make the general public really queasy. It's better to take a hypotensive patient or a hypoxic patient, and correct things on scene to the best of your ability with fluids, pressors (if in protocol), NIPPV, prior to moving the patient. When they move these patients and they are unstable, most of the time it's never even recognized when transporting them down the stairs or the elevator that they ended up arresting. Could have been avoided the vast majority of the time if they had stabilized and not freaked out.

They need to understand components of the history that are absolutely CRITICAL. ED physicians don't care about the allergies, or the fact that the patient is on atorvastatin. They care about the last known normal for the stroke patient, or whether they took their Eliquis this morning. When you pick up a patient from a nursing home, try to get as much information as you can, bring their meds etc, it makes an enormous difference to the ED team. For god sake, if the patient is DNR, bring the paper work from the SNF.

I also have given lots of lectures to medics about creation of a differential diagnosis, cognitive overload, resilience, breaking bad news, coping with stress/PTSD etc. They have been pretty well received. EMS providers in my opinion have some of the highest amounts of workplace stress compared to any profession in the workforce. Despite the snafus, and the critcisms I've highlighted above, they play an absolutely paramount role in the healthcare system today. You should communicate that to them.

I've done medical direction for some not so good fire based services, as well as for some really cutting edge ones. The vast majority of medics I've worked with are outstanding and willing to learn. As a medical student and future physician, you can also make a big difference and have an influence on them in a positive way.

Good luck.
 
Glucose! I mean, you’d think this is EMS 101 but I can’t tell you how my times it doesn’t get done.
True story: about 25 years ago, had a rollover accident pt on the on ramp from a spur to the Interstate (I-290 to I-90 ramp). Guy is out of it. Coincidentally, the closest hospital is also the trauma center. Board and collar him, code 2 to ECMC.

He's a trauma activation, team is there, and they start their eval. They're on the secondary survey when a nurse gets the blood glucose.

Dude is altered because he's hypoglycemic.

I forgot to check, but, so did the residents. So, with deference to my EMS fellowship trained colleague above (I started this post before he posted his), the BG is something that is a quick intervention, and can be done on the fly. But, absolutely agree that "stay and play" is a "no go".
 
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For the love of god, for altered patients, we need to know last known well/alive, their baseline level of functional status (do they walk and talk, are they normal, are they demented, do they use a walker or a wheelchair?) If family isn't coming along we need at least one person's name and working phone number.
+ 584

Actually our EMS guys are pretty good at last known normal.
 
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I don't think many medics can accept that intubation, especially in cardiac arrest, is really not a lifesaving measure and in many cases causes more harm. It detracts from high quality chest compressions, defibrillation, and things that we know improves survival. The majority of them haven't really been trained well at 2 handed BVM technique (the number of them that walk in with one handed BVM where the mask is basically not even making contact with the patients face is mind boggling). They also should be taught that LMAs are more than sufficient for the majority of cardiac arrest patients provided they are registering end tidal CO2 and the airway isn't floridly contaminated (I would stress to them that in the prehospital setting end tidal CO2 is absolutely a vital sign and just as important as the others, especially when it comes to airway). It goes back to the point made earlier that good BLS care is really the most important thing.

Also stop wasting time on scene with sick TRAUMA patients. These folks don't need an IV. They don't need an EKG, or blood sugar. They rarely in my experience need an airway. If you are going to make an intervention on a trauma patient in the field, it needs to be a quick and life saving intervention i.e. needle decompression, surgical airway, something of the like. Otherwise, get them to a surgeon.

For medically sick patients, they actually should be spending more time on scene. The number of cases I have QA'd where the patient was moved while being extremely unstable and ended up arresting during transport would make the general public really queasy. It's better to take a hypotensive patient or a hypoxic patient, and correct things on scene to the best of your ability with fluids, pressors (if in protocol), NIPPV, prior to moving the patient. When they move these patients and they are unstable, most of the time it's never even recognized when transporting them down the stairs or the elevator that they ended up arresting. Could have been avoided the vast majority of the time if they had stabilized and not freaked out.

They need to understand components of the history that are absolutely CRITICAL. ED physicians don't care about the allergies, or the fact that the patient is on atorvastatin. They care about the last known normal for the stroke patient, or whether they took their Eliquis this morning. When you pick up a patient from a nursing home, try to get as much information as you can, bring their meds etc, it makes an enormous difference to the ED team. For god sake, if the patient is DNR, bring the paper work from the SNF.

I also have given lots of lectures to medics about creation of a differential diagnosis, cognitive overload, resilience, breaking bad news, coping with stress/PTSD etc. They have been pretty well received. EMS providers in my opinion have some of the highest amounts of workplace stress compared to any profession in the workforce. Despite the snafus, and the critcisms I've highlighted above, they play an absolutely paramount role in the healthcare system today. You should communicate that to them.

I've done medical direction for some not so good fire based services, as well as for some really cutting edge ones. The vast majority of medics I've worked with are outstanding and willing to learn. As a medical student and future physician, you can also make a big difference and have an influence on them in a positive way.

Good luck.
Thanks for taking the time to write such a thorough reply. I was fortunate to come from a great service (started out at one of the not-so-great ones though) where we do have good protocols, we are allowed to do quite a bit, and our medical director has placed a lot of trust in us. It was a great experience. He was also a medic before becoming an ER doc :)

Also, where I came from, EtCO2 was required on all intubations! If you didn't do that, you're getting a meeting with the chief and the medical director... I can't believe that isn't standard practice everywhere, especially as simple as it is to do...

From my experience, I agree that many medics stay when they need to go and go when they need to take a deep breath and work right where they are... for example a cardiac arrest-- you can't tell me that you are doing them any favors by snatching and going! Stay right where you found them and give it your best effort. It was a very difficult thing to convey to both non-ALS crew members as well as the firefighters who are doing their best to help and want to "grab and go to the hospital, they are more capable." I agree on that, but not until they have a pulse in a vast majority of cases. Even after you get a pulse back, my motto was to take a breath, get that baseline set of vitals, EKG, hang vasopressors, make sure they weren't about to code again, and then gently move their already fragile body to the unit for an easy transport.

I'll be sure to pass on the information about last known normal, proper documentation from SNFs, and anticoagulant status. All good points that I know can be overlooked if in a hurry.

EDIT: One of my most frustrating experiences that still pisses me off to this day was a multi vehicle MVA in a rural area. I think there were 12(?) patients. Severely injured patients in every car you looked in on initial triage. Roads blocked both ways. What does command do? Calls for a helicopter. Then another one. Then a third one. They ask "what do you need?" I said "an ambulance and a driver so I can transport this unconscious and unresponsive child." "We've got the 4th helicopter on the way and your ambulance is blocked in so you'll have to make do." Waited 45 f'ing minutes for a helicopter to come from another state to fly this kid. I'm sure you know the outcome. You can't stay and play on something like that. You can't "just make do." Move people and get me an ambulance. Would it have changed the outcome? I don't know. But I do sometimes wonder if it would have if we could have gotten them out of there quicker.
 
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