Now They’ve Done It

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First Michael Morse at Rescuing Providence gives his top ten reasons for not liking Community Paramedicine. Which of course spawned a number of well thought out comments. CCC of Captain’s Chair Confessions decided to respond in a post of his own Yes, Community Medics. Which is where I come in. I read CCC’s post first, then jumped over to Michael’s. Since as is often the case my comments started to take on the length of a blog post and I consider poor form to have comments that are longer than the original blog post (yes, I’m guilty of that sometimes), I decided to use their posts as easy blog fodder. If I get really ambitious I might even reply to some of the comments at Rescuing Providence over here.

Please go and read both posts and they both make some excellent points. That will give you context for what I have to say.

10. Insulin pumps are fairly easy to operate and monitor. It’s actually good to be familiar with them since they do go blooey once in a while and that creates emergency calls to 9-1-1 operators. Still, there are nurses who specialize in that sort of primary care thing and it’s not really what EMS does. Oh, even though I’ve never been a fire fighter, I’ve actually had high angle rescue training. We had a day long class in paramedic school and I’ve attended some other classes over the years. It’s actually fun rappelling down the side of a building or rock face. Once you get past the hysteria of thinking you’re going to plunge to your death, that is. Still, I wouldn’t do it unless there was no one else around to do it, because a few classes here and there don’t make me an expert.

9. I have to agree with Michael here, and here’s why. Drug addiction counseling is pretty specialized and even at that has about a 90% failure rate. The first step in beating an addiction is admitting you have an addiction and WANTING to try to rid yourself of it. I’m not sure what kind of conversations CCC has had with revived addicts, but mine generally consisted of trying to get basic information from them and sorting out the lies. It takes time to build the sort of relationship with an addicted person where they will start to trust you and listen to what you have to say. Occasionally I have had patients tell me that they want to kick the habit and when they do, I pass that along to the nurse at triage. Most hospitals have social workers who specialize in getting people into programs like this. I’ll mention a bit more about social workers further on.

8. I’m not sure of the point of either CCCs or Michael’s comments. I know a fair amount about non emergency cardiac drugs. I think that’s important for emergent treatment as is at least passing familiarity with a lot of what people take at home that isn’t directly related to what we do to them in an emergency. Knowing what drugs a patient takes can give you a good idea of what their history is, even if they can’t. Back to point 10, knowing that helps us do our jobs, but it’s not really what we do.

7. CCC misses the point. I know more or less where he works, but I don’t know if they use RNs on ambulances or if they use paramedics in hospitals. Over the years there has been tremendous resistance by organized nursing to using paramedics to do what they (and sometimes the law) consider nursing duties. It’s about job protection for the nurse, usually under the guise of protecting patients. From a practical standpoint, that makes perfect sense. It’s one of the reasons why nurse make so much more money than do paramedics. ONE of the reasons, and this is not a RN vs. paramedic thread. Nursing and paramedicine are not the same job and in fact any similarities are superficial at best. Many, no most, nursed do not know how to interpret a 12 Lead, don’t start IVs, certainly can’t intubate or even insert an LMA. Paramedics in general know less chemistry, very little about labs or metabolism, or many other nursing skills. Nurses who staff ambulance often have to at least challenge a paramedic exam (and pass) to work on an ambulance. In my state one must be an EMT or paramedic to work on an ambulance. A big children’s centric hospital has an ambulance or two that they use to go out and pick up sick kids from outlying facilities. That’s staffed with enough doctors, nurses, and other specialists to staff a clown car. One of those nurses is also a paramedic to meet the state requirements. The other paramedic…. drives the ambulance. I don’t know if they even let him or her even see the patient.

6. I too don’t see this as a cradle to grave government funded program. When my mother was alive, but chronically ill, she had visiting nurses a few times a week. They were to a woman pleasant and completely competent. They worked, not for the government or the Visiting Nurses Association, but for a large hospital group in the area where she lived. No doubt the hospital group billed Medicare, but they didn’t work for government. I agree with Michael and we can certainly have a debate on this blog about whether or not Medicare, Medicaid, or other government funded medical problems improve care OR save money, today is not the day for that.

5. I’d think that once a person has an allergic reaction they’d understand to stay the hell away from things that can kill them merely be them eating said things. No doubt their doctors and other practitioners say something like “You know Mrs. Smith, you might not want to send Billy out to whack that nasty bee’s nest with a stick. Call the exterminator and pay him instead.” Or maybe as delicious as they are, and drunk as you are, young man you might want to avoid the French Fries cooked in peanut oil at Five Guys. Still people who are deathly allergic to bee stings like to garden (some of them do) and bees like to be outside (but not at night), and the inevitable will happen. About the only thing I ever counseled people to do is talk to their doctor about getting a ‘script for an Epi Pen. And making sure that another family member knows where it is and how to use it. Other than, I just don’t know what we can accomplish with a home visit.

4. I like nurses too. Especially cute, flirty types of the opposite sex. In fact, if I hadn’t been happily engaged to Mrs. TOTWTYTR way back when I started my full time EMS career I have no doubt that I would have flirted back and probably dated as many of them as I could. Still, I’ve never thought that my role as a paramedic entailed making their work loads lighter. Certainly no nurse has ever done anything to make MY work load lighter. Which is why I never, ever, would start an IV “because they are just going to do that at the hospital”. My stock answer to that was that the patient might be getting a rectal exam at the hospital, but I had no intention of doing one in the field so the hospital staff didn’t have to do it. Not directly on point, but it usually stopped that particular conversation. Nor would I do a set of vital signs at triage so the nurse can sit in the chair at the desk and check her Facebook status or buy something from Land’s End. It took me a long time and a couple of nasty incidents to break nurses of expecting us to do their job, but it was worth it.

3. A lot of the things that we respond to are urgent, but not emergent. You’ll see that the two terms are not interchangeable. Nor is acute particularly interchangeable with either term. About 90% of what we do is non emergent, not particularly urgent, and not really acute. Which is why not every ambulance has to be, or should be, staffed with a paramedic. EMTs can actually handle 90% of what EMS does. Especially if they are “enhanced” with Epi Pens, Albuterol or Combivents, glucometers, Aspirin, and of course defibrillators. Which would allow paramedics to spend more time actually seeing patients with the few true emergencies we see. Which would make for better paramedics and patients that get better overall treatment. None of which encompasses checking in on Mrs. McGillicuddy, having tea, and counter out her pills for her.

2. Two words CCC. Turf. Protection. It’s something that we are horrible at which is why the fire service has encroached into a field that they have (with apologies to Michael) a history of providing in the worst possible way. NYC, Washington DC, Dallas TX, and any number of other fire based EMS systems are the ones that we generally see the horror stories coming out of. A friend of mine who is a retired lawyer and paramedic from Texas made a tidy living for a few years suing among others, Dallas Fire Department for malpractice of the worst sort. The problem is that we’ve made EMS, especially at the BLS level, a skill set. Not even a trade, let alone a profession. Paramedic school itself should be two years full time, including a college level A&P course, a lot of time in a sim lab, clinical time in units other than the OR and ED, and of course a couple of hundred hours on an ambulance. That’s before you get to sit for the test. Yeah, there are some programs that do that, but most don’t. Oh, and Michael, I know it’s not your decision, but Rhode Island should move out of the 1980s and get rid of that ridiculous cardiac technician level of care. Back to the original point. There are nurses who specialize in seeing patients and doing follow up. Either in the patients home or in a primary care setting. They don’t like the threat of paramedics horning in on their territory. Not only that, but as I mentioned earlier on, they have a fair amount of clout at the regulatory and legislative levels.

1. No CCC, the sad truth is that most people will still see us as “ambulance drivers”. When I first started in EMS, if people didn’t confuse us for cops, they confused us for fire fighters. When I retired from active EMS duty, if people didn’t see us as cops, they confused us with fire fighters. That’s 30+ years of confusion, despite our uniforms and vehicles not looking anything like those of the police or the fire department. Going into people’s houses and checking their blood pressures, sorting out their medications, and will only make them think that their hard earned tax dollars are going to support too many police officers or fire fighters. Not to beat a dead horse, but neither nurses nor doctors will thank us. It will just further reinforce their opinions, held even by many doctors who practice emergency medicine, that our value is limited to scut work.

I still have seen the huge gap in our health services that you see. The gap that is there is mostly from patients not caring enough to take responsibility for their own health care. They skip follow up appointments, they don’t fill scripts, when they do, they don’t take their medications, they go home and resume doing what got them into the hospital in the first place. It’s human nature and I don’t see it changing at all in the near term. Certainly not by our effort.

I worked odd hours and my experience is that if people weren’t calling us, they were generally sleeping. As a result, we had some down time during our shift. Not as much as people like to think, but enough to relax a bit. People who worked normal shifts, say 7:00AM – 7:00PM didn’t have that luxury. They’d run form call to call. If they transported dispatch was hounding them to clear for the next call. If they examined a patient and referred them to BLS for transport, dispatch was hounding them to clear for the next call. They didn’t have time to go and do “Community Paramedicine” between calls because there was not between calls. If you’re proposing to use dedicated medics for this, where are they going to come from? All I hear from services in my area is that they have a shortage of paramedics. I just don’t see the resources as being available.

By the way, who is going to pay these community paramedics? EMS is based on fee for transport. If paramedics work for a non EMS provider to do community paramedicine, where does the money come from? Home health care money is geared to paying nurses or non nursing “health aides”. Is ther even a mechanism to bill for a paramedic to provide these services?

Community paramedicine has been around conceptually since the 1980s and yet no one has made it feasible on a large scale basis. There’s probably a reason for that.

A note about social workers. To do the type of clinical social work that CCC proposes, one needs a Masters Degree in Social work. (MSW). That is a two year full time program that includes clinical work as well as a lot of theory. And yet those people have a hard time getting people to change their life styles. Where exactly will paramedics succeed when those people failed? We have crappy education in dealing with psychiatric and behavioral issues as is. How will we be effective counseling people for 10, 15, or 20 minutes in the back of an ambulance?

Let’s get to the point where all paramedics can read 12 Lead ECGs, maintain a patent airway, use medications appropriately, understand the mechanisms of cardiac disease, shock, stroke, and sepsis before we start finding new frontiers to conquer.

 

 

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

11 COMMENTS

  1. Community Paramedics IIRC would NOT be on a traditional ambulance, so it’s not a case of piling more work on an already-overworked day car. They would be more like the Quick Response Vehicles (QRVs) that local private ambulance companies have here: an SUV with all the ALS equipment except for a gurney (some have backboards, some don’t).

    With regards to who will pay for it, the answer is the same people who currently pay for a lot of healthcare. Don’t forget the nasty new CMS rules about not paying for re-admits within a certain window (30 days?). I can see large hospital groups or HMOs willing to pay for community paramedics to do follow-up on patients recently discharged from inpatient or ED. If it’s a case of paying a paramedic to make a visit or two and keep them out of the hospital; or eat the cost of a re-admit because the person was non-compliant until they had to call 911 again, the hospitals/HMOs would likely pay the lesser fee for a couple of home visits. Meanwhile home health nurses will still continue to work with people who need that kind of in-home care on a regular basis.

    As for getting the paramedics first able to read 12-leads, etc… maybe we can combine a couple of ideas. Have ambulances mostly BLS level, with paramedics on their QRVs to respond to true urgent or emergent calls. With the reduction in the number of paramedics, it would be possible to be a bit more selective in who gets to be a paramedic than “has a pulse and passed a multiple choice exam”.

    • QRV or ambulance, it doesn’t really matter. The staff has to come from somewhere. All I hear about is shortages of paramedics, so I don’t know that services are going to pull medics from transport units to do non emergency work. If hospitals are looking at home care and follow up for discharged patients (and they are), then they are going to look at professions with which they are already familiar and comfortable. Which means nurses for the most part, not EMS providers. I think moving paramedics off of ambulances is a good idea, but it’s not directly related to this topic. Of course the other thing services need to do is make sure that ambulances are available for the transport portion of the response. I’ve worked for systems where we responded in non transport capable vehicles and had to wait for an ambulance because the transport service, which was not the same as the ALS service, just didn’t have enough units available. It’s not really a comfortable situation when you know that the patient needs to be in the hospital and you have no way to get them there.

      • There is NO shortage of paramedics. Maldistribution? Yes – like physician assistants, who were supposed to serve rural areas, medics follow the money. If an area with a shortage will pay better, the shortage goes away.

        If a service doesn’t have enough units to serve a community, and won’t GET them, it should be replaced by someone who will do the job well!

        • Economics are economics. Who do you think the “someone who will do the job” is going to be? If it’s municipal bid then the low bidder is going to win. In most cases, that’s required by law. If it’s a municipal agency, it’s likely to be unionized and drive up the prevailing wages in the area. Ambulance reimbursement is what it is. Better collections will help up until the point where they become a public relations liability. You’ve been a chief, you should understand how the politics of this work better than do I.

  2. Great follow-up to both of the others… And the turf wars just continue!!! Remember when they first brought out the Flight Nurse concept??? O.M.G. you’d have thought the world was going to end!!! And the hospital nurses hated them as much or more than paramedics…

  3. Hello TOTWTYTR, and thank you for the excellent analysis of my admittedly poorly thought out post. I agree with most, if not all of your points, especially the RI EMT-C status, that is keeping us in the dark ages. Providence is likely among the worst EMS services anywhere. We are underfunded, under trained, under equipped and under staffed. My truck, Rescue 5 will top 6500 calls this year. It is ridiculous.

    • My intent wasn’t to attack RI or cardiac techs. I just wanted to point out that there is areas that all systems need to improve in when it comes to delivery of what our “core mission” is. Once we have everyone on the same page nationwide, then we can start looking into expanded scope and other avenues of career expansion. Which won’t fix the turf battles to which Old NFO refers. Turf protection and kingdom building aren’t exclusive to EMS, but we do seem to have a talent for it.

  4. All I hear from services in my area is that they have a shortage of paramedics.

    Yeah, but how many of them are fire departments who are convinced everybody’s going to die if every firefighter isn’t a paramedic? And by extension, how many of them are private services that can’t hang on to paramedics because of my first question?

    I’ve never been convinced that there is a paramedic shortage, anymore than I’ve been convinced about the nursing shortage we’ve been hearing about for 30 years. There very well could be a paramedic distribution>b> problem, but that is not a supply problem.

    • Nope, they are all private, for profit services. They lose many of their medics to the fire service, or PA school, or a police agency, or in one case I now of a medic became a lawyer. One thing that I’ve consistently said, but it applies more to private services than any form of municipal service is that there is a shortage of paramedics who will work for the low salaries, poor or non existent benefits, long hours, SSM, and other foolishness.

  5. As a critical care medic, as a medic that spent 20 years in a 911 response service, 10 of those years as an instructor, and as a medic that takes a great amount of pride in expanding his knowledge base, I will tell you the problem that I see with most paramedics: They have a hero complex and are inherently lazy. Most medics want to run the “cool” calls, but none of them want to run the “routine” calls.
    These same medics fight learning anything new, and they only want to do the bare minimum they can to get back to the station and watch TV. When confronted with new information, they usually say, “So? it isn’t going to change my treatment, because protocol won’t change, so I don’t need to know it.” These same medics brag about how many refusals they can get, some bragging that they can get a refusal from a code.
    On the other side, we have an industry that encourages this mindset by running off the best and brightest through poor working conditions, low pay, and an institutional dislike for anyone that wants to innovate, often seeing them as “rocking the boat.”
    As a profession, paramedics keep having their knowledge base increased, and are now expected to learn much more than they did ten years ago, but pay is actually less now than it was then.
    Like it or not, there are BIG changes coming. Learn to adapt, or go the way of the dinosaurs.

    • Change is likely coming, but that doesn’t mean it’s going to be change for the better.

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