A meme that predates the Internet and goes back at least to the days of “Bulletin Board Services” (BBS) is that paramedics “Do everything that an ER doctor does, but we do it in a ditch on the side of the road.”

To which I say, bullshit.

I don’t know any good paramedic that believes that, not a one. In fact, I don’t know if I know any crappy paramedics that believe that either.

The truth is that paramedics have limited knowledge. Even the best two year Associates Degree programs barely scratch the surface of medical education. An experienced paramedic who spends a lot of time going to classes, reading, and talking with doctors might know more about a few specific illnesses than an intern or junior resident.

That’s not the same as doing (or knowing) everything that an ER doctor does. Not even close

Here is a graphic representation.

Paramedics know this much,

about this much,

about medicine.

Overly confident, but not well educated, paramedics that pose the real threat to paramedics. It’s easy to get in over your head if you “don’t know what you don’t know” as the saying goes.

I was never a “throw everything in the drug box as the patient” type of paramedic. It was drilled into me during my training that it’s easier to do harm than good with many of the medications we carry on ambulances.

Back when we Sort Big City EMS was training up for the use of Rapid Sequence Intubation, one of the doctors who did our lectures reminded us that we used two of the three drugs then utilized for execution by lethal injection.

Think about that for a minute. We had drugs that could render a patient unconscious and chemically paralyze them as part of the process of intubation. If we couldn’t succeed in intubating the patient, then we ran a risk of serious harm.

That was well over 25 years ago and I’ve never forgotten the class or the doctor.

As Clint Eastwood once said,

Of course in cases like this, if we made a mistake, we weren’t the ones that were as risk of dying.

Back to the arrogance of the “Ditch Doctor.”

I never once treated a patient in a ditch, but that’s mostly because I worked in an urban setting and ditches generally didn’t end up with cars in them. Except that one time when a driver managed to drop his car into a ditch being dug for installation of a main sewer line. He wasn’t injured, but his car certainly was.

I did intubate a patient on the first floor of a house that was on fire, but the fire was actually on the second and third floors. The fire department had rescued the patient who had inhaled a large volume of smoke and more solid debris from the fire. A touch intubation, but certainly nothing that an Emergency Physician shouldn’t have been able to do.

At no time did I think to myself that this was some great accomplishment, although the ED physician at the hospital was impressed enough to write a letter commending my partner and me.

The point of all of this is that paramedics should be careful about their bragging. We’re not any sort of doctor, let alone a “Ditch Doctor.” Our job is to keep the patient alive, what I call temporizing, until we can get them to the real doctor.

Very rarely do we “save a life.” That happens, but not often. By my count, and I worked in a very busy system, I responded to one call a month or so where my care made a big difference in the patient’s life. Most of those were either respiratory or trauma related. As to trauma, keeping the patient’s figurative head above water was the goal. Keep them viable enough so that the surgeons could do their magic.

Respiratory patients were people that we could help, but most of the time they didn’t need treatment as much as they needed to be in the hospital. As a BLS co worker used to say, “Transport is part of the treatment.” Sometimes it, along with our observations and reports, was the most important part of the treatment.

As time moved on, that equation changed somewhat towards the treatment end as we got CPAP, better medications, 12 lead EKGs, a better idea of what was important for Strokes and Sepsis. Still, very rarely did we “cure” a patient and eliminated the need for transport.

The good news is that there really is a Ditch Doctor that does things that no ED Physician can do,

A friend who knows that I have a blog sends me news articles from time to time. Today, he sent me a link to this story. Apparently, there is a thread on it somewhere on Facebook, but my footprint there is pretty minimal so I have no idea where it is. Besides, EMS threads on Facebook are either boring or devolve into a contest to see who can make the most snide and stupid comments.

As a general rule, I try not to make judgements on popular media accounts of EMS calls. Or much of anything else for that matter. This case is a little different because there is video, extensive video as a matter of fact, of what went on during the call.

Interestingly, and maybe damning to the police, their body camera video has been deleted and “technical difficulties” have caused the dash cam video to be lost. That is not going to help the police case, but that’s outside my area of expertise.

Cops took man to DUI test, not hospital, after crash, lawyer says. He died days later

For dumb ideas, that is.

NY considers changing sound of first responder sirens

NEW YORK — If two New York City lawmakers get their way, the long, droning siren from police cars, fire trucks and ambulances that has been part of the city’s soundtrack for generations — WAAAAAhhhhhhh — would be replaced by a high-low wail similar to what’s heard on the streets of London and Paris — WEE-oww-WEE-oww-WEE-oww.

Their reasons for the switch: The European-style siren is less shrill and annoying and contributes less to noise pollution.

People frequently complain about siren noise.That is until they need the people who are riding in those noisy machines are coming to help them. Then it’s the sweetest sound in the world.

I also remember when the use of the “European High Low” sound was discouraged because it was too European and disturbed some people who had left there in the wake of World War II. Most of those people are gone and to be frank, I never met a person who complained about that. Still, it is ironic in a way.

I also remember a woman who complained about the “Yelp” siren that was very popular at one time. Her contention was that the sound bounced off of buildings in Sort of Big City differently than the long wail that the two New York City “law makers” are complaining about.

“Europeanizing” New York sirens would not change the decibel level — still topping out at roughly 118 — but would lower the frequency and thus make the sirens less shrill but still ear-catching enough to grab attention.

“The alternating high-low siren required by this legislation is not as piercing,” adds co-sponsor Carlina Rivera, a Manhattan Democrat.

Since the purpose of the siren is to warn other motorists than an emergency vehicle is approaching, I have to wonder if this is a plus. Modern cars are very well sound proofed and sirens often can’t be heard inside. I’m probably a bit more alert for this sort of thing than most motorists, but it’s still easy not to hear a siren until the vehicle is very close.

That’s what the “Rumbler” siren does. It’s so low pitched that it shakes the ground in front of the emergency vehicle. Think of some of the knuckleheads you see (and hear) driving by with their car stereos blasting at 800 db and “bass” at maximum. Same concept only the speakers are mounted outside the vehicle.

One of the ambulances I was assigned to way back, well about 10 years back, had an early version of the Rumbler. It was not only effective at moving traffic in front of us, but I discovered that it drove an annoying partner of mine crazy when I used it. 🙂

At community board meetings, Mount Sinai’s Emergency Medical Services Director Joseph Davis played various siren options to find out which one locals preferred.

“People hated them all,” Davis said, “but the ‘high-low’ was least intrusive. It didn’t have that piercing sound.”

I repeat, the piercing sound is a feature, not a bug. Besides, half the pedestrians I see have ear buds stuck in their ears and can’t hear anything anyway.

Half the drivers I see these days seem to have their heads firmly planted somewhere else and don’t hear or see anything outside of their vehicles.

I don’t know if New York City will pass this “law”, but it won’t surprise me if it does happen.

It also won’t surprise me if it doesn’t change the number of complaints about siren noise by the self absorbed citizens of the city.

The Center for Medicare and Medicaid Services (CMS), which is the federal agency that sets the rules for EMS reimbursement, among other things, has announced a new program for payment. The big news is that for agencies that choose to participate, there will be reimbursement for some non transports and some transports to facilities other than Emergency Departments.

Emergency Triage, Treat, and Transport (ET3) Model

The Center for Medicare and Medicaid Innovation’s (Innovation Center) Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare beneficiaries following a 911 call. Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.

The goal apparently is to relieve over crowding in Emergency Departments by providing alternative care sites for patients who can’t wait for a primary care provider appointment, but still need care.

Transports to free standing urgent care centers will be reimbursed, as will treat and stay home in some cases. The service is centered around ambulance services providing 9-1-1 responses. The language is a little convoluted, but municipal, hospital operated, and apparently private services providing 9-1-1 response, are eligible. Participation is voluntary and will cover an initial five year period.

The key participants in the ET3 Model will be Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers. In addition, to advance regional alignment, local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic areas where ambulance suppliers and providers have been selected to participate in the model will have an opportunity to apply for cooperative agreement funding.

There is the bureaucratese version of what I said.

As I said, this could be a huge change in how EMERGENCY ambulance service is provided in the United States.

A couple of areas where I can see change are in treatment of diabetics who have an episode of hypoglycemia. It’s not unusual now for services to treat and then accept a patient refusal for diabetic patients who suffer a hypoglycemic event. The problem with that is that there is no reimbursement mechanism. As a result, the ambulance service has to absorb the cost of response and treatment. Which in it’s turn means that we all pay a bit more for ambulance transport to make up for the services lost.

I can tell you folks, that isn’t cheap. A few years ago the chief of a small (three ambulances) fire based system told me it cost $1,500.00 each time one of his units rolled out the door. That’s whether they transported or not.

Think of that next time someone complains about how expensive an ambulance is.

Under this model, the EMS system can bill for the response and treatment, even without a transport.

Another thing that this will likely allow EMS systems to do is respond to cardiac arrest calls, treat, and terminate resuscitation in the field.

Everyone who has worked in EMS for more than a short period of time has responded to a cardiac arrest and transported a patient that they knew was not going to be resuscitated. It ties up resources in the field and the ED as well endangering the public. Some systems already do field terminations, but don’t get reimbursed for it, so again there is a cost that is absorbed by the rest of the public.

This could tie in with and provide payment for the Community Paramedicine projects that are going on around the country. As of now, they are being funded either by hospitals, grants, or in a few limited cases medical insurance companies. Up until now, CMS has had no mechanism to pay for this type of care.

Also, this could be a career extender for creaky old paramedics that can still do most of the job, but for whom lifting and moving patients is no longer possible.

It will be interesting to see how this works out over the next several years, but it could bring about a sea change in how and where EMS is delivered in the United States.