Posted by: medicblog999 | March 16, 2010

The Future of Paramedics – Assessment or Treatment?

stethoscopeI have just finished reading a fascinating short article over on EMS1.com by Brian Bledsoe, entitled ‘Speed and Time in prehospital trauma care’.

I figured that I should read it as I am due on the EMS garage podcast in 20 mins and we will be discussing it!

However, it has left me with more questions that I expected.

I am already aware of the recent move to disprove the concept of the Golden Hour, and when I have been talking to colleagues at work about it, I have basically said that all it proves is that if your injuries are going to kill you, then it doesn’t matter if you are on scene for 10 minutes or 30 minutes (or so the current thinking is telling us), and likewise if you are going to survive, then you will unless you are kept out of the hospital for a significantly prolonged period of time.

I know that this goes against all of our training and is pretty much against the core values of how we look after our trauma patients.

But….

It has also got me thinking about other things.

Mrs999 and I have just had a conversation about it, and I came to a conclusion that I want to put out there and I would love to hear your thoughts on it.

There has and always will be the need for an ALS component to pre-hospital care. However, in the future (very near future in the UK already) will an ALS provider be defined by his or her ‘intervention capability’ or will a true ALS provider be defined by their assessment and diagnosis ability.

More and more in the UK, we have more varied options open to us for our patients. If I have a patient who is having a CVA, they go to a certain hospital or unit. An M.I will go to a different unit. Potentially significant head injuries go to one hospital whilst ‘less’ serious head injuries can go to a normal A&E unit. The list goes on and on, but shows that it is becoming more and more the paramedic’s responsibility to actually provide a provisional diagnosis to base their transport decision on.

If you get it wrong, then you can place your patient at risk by taking them to a hospital that may not be equipped to look after their needs at that time.

It also moves into the realms of minor injury and illness. Our experienced paramedics can ‘treat and refer’ or’ respond not convey’, which is completely reliant on a sound and thorough clinical assessment and a professional and eloquent patient care record.

Just take a look at  how often you pull out the magic box of ALS tricks and be honest and see how often they actually make a real and significant difference.

Now, don’t get me wrong, I am not saying that we should lose these skills and interventions. I have seen the benefit of them, and they are the times where we really, really feel good about what we can do and the differences that we make. All I am saying is, as we move forward with EMS 2.0, what really is the most important tool in our repertoire?

Is it our ‘awesome’ intubation, cannulation and drug therapies?

Or, is it our ability to make a clinical diagnosis, based on highly developed assessment skills and move our patient to the correct place for them to receive definitive care?

I would love to hear your thoughts.

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Responses

  1. This is where I'd like to see EMS go. Allow Paramedics and EMTs to be able to make more decisions for their patients. Instead of always going to the hospital at the drop of a hat. At the present time, this shouldn't be done. We need to re work what we learn and the amount of time we put into our training. As well, we need to start weeding out those who are a detriment to the profession as a whole.

  2. I very good question. As I have said on other discussions about the delivery of prehospital care, “there is no one answer or model for EMS delivery.” By it's very nature EMS is a dynamic and unpredictable sand box to play in. And although one style or model may work beautifully in one area or service, that doesn't mean it will in another. As you know, the UK does things very differently (and arguably in some ways better) then we do in the US. But that does not mean your way will work here. You indeed have many more transport options then we do, and that has helped model your way of care. Our model seems to be based more on field resources. The last three years of my career was spent in a system where 99% of the calls were responded to with an ambulance, a paramedic squad, and a fire engine. No less then two or three paramedics and six support staff on almost every job, even abdominal pains. This also in a area with less then a 10 min transport time to a trauma center. I can see why a medical director would limit the scope in this case. On the other hand, just in the next county over they have a single paramedic respond and have transport times of 45min plus. there scope has been extended. Bottom line is in the debate of skills vs knowledge, they are both integral, they need each other. skills without knowledge is dangerous, and knowledge without skills is a wasted resource and lessons the ability to better care for the patient. As our profession grows, so must we as professionals. It's great to be able to take a patient to the best most appropriate facility, but it's even better to start therapies early and provide care before you get there. But above all, regardless of you scope or resources. Do No Harm.

  3. So true. Any monkey can cannulate, drug therapy is mostly about following protocols, and intubation… Well, lets not go into that!Knowing *when* to make those interventions is what's important, both for the patient, and for the health service. When to treat and leave at home, when to refer to appropriate pathways, when to send to a DGH or when to transport to a specialist centre. All of these have positive outcomes for both the patient (appropriate treatment and minimised risks), the public (less transport = fewer crashes, and more available ambulances) and the NHS as a whole (less inappropriate expenditure).It's not any monkey that can make those calls.

  4. I started to write a comment, but it grew so long that I decided that blog etiquette required a post over at my place.

  5. My daughter (currently training as a paramedic) has sounded off several times about the concept of the ambulance service ending up being “cheap GPs”. Leaving aside the question of the remuneration – personally, in an emergency I'd prefer to have a paramedic with the appropriate training in emergency medicine/pre-hospital care to make an informed decision about whether I need to go to a hospital and, if so and there is the choice, which would be most suitable. GPs have a sound and proper place in the NHS, whatever the current government believes about our desire to see a doctor, any doctor, continuity is not important. They should be there to provide continuing, out-of-hospital medical care for the patients who have been diagnosed with longterm illness and to assist with the medical problems which are not emergent but beyond the abilities of Joe Public to cope with without medical knowledge. The knowledge basis and practical skills to do this are not necessarily those needed in an emergency and which require constant practice. There's a whole range of things the GP needs to know about which a paramedic doesn't – so I believe there is a valid future for a “pre-hospital care practitioner” role, but it must be defined correctly and the appropriate training roled out in a proper fashion. And the responsibility aspect must also be dealt with.

  6. Jeramedic said it well, all of this knowledge vs skills nonsence is just that nonsence. I have worked with knowledge junkies who can accuratly tell you what is wrong with the PT before the Doc gets out the the room in the ED but can't treat a PT worth anything. I have also worked with the skills junkies who will never miss an intubation but can't read an ECG strip. The fact of the matter is that unless you work on both you are cheating your patients out of the care they deserve. You have to be able to do an assessment and gain a good working diagnosis but you also have to be able to effectivly act on that diagnosis. We have to dissolve this imaginary line we have drawn between the two and work on being better medics in all aspects.

  7. I completely agree with this post. In some parts of California we are headed down this route as well. In Los Angeles there are several different levels of “pediatric” hospitals. Specialized hospitals are better equipped and trained to treat their “type” of patient. It also keeps costs down for the hospitals. We, as medics, have to make sure we perform a thorough assessment and get our patient to the right facility. I can't wait until we can send someone to an Urgent Care facility instead of a full blown ER.

  8. You can't treat unless you have correctly assessed the problem. People get hung up on the visible stuff and don't always treat the underlying cause. You can't just do the fun stuff you have to have good observation and questioning skills as well

  9. Maybe it is just the EMT-Basic in me and my options for treatment are few and far between, but EMS and any medical profession for that matter should be more about assessment then treatment. Without a thorough assessment you cant create a working diagnoses and without a working diagnoses you cant treat. When I was in school I couldnt figure out why we were spending weeks on end learning signs, symptoms, pertinent negatives, special questions, and practicing medical and trauma assessments every afternoon. All I wanted to do was to learn c-spine, splinting and the like. Now that Im in the field I know why we spent more time on assessment and less on skills, its because a monkey could take a BP, but it takes a well trained provider to act on those numbers. 1mgC

  10. “because a monkey could take a BP, but it takes a well trained provider to act on those numbers.” We have got to get away from this mind set because frankly a lot of this stuff that “a monkey can do” a Paramedic can't. Yes the assessment is the most important thing we do but all of you(speaking collectively not at 1mgc) who focus only on knowledge and don't worry about skills because “a monkey can do it” are worthless in the real world. The two are one and the same and inseperable if you want to be a good EMS provider. If you want to stand around and diagnose a PT get into med school and become an MD then you can have other people do the hands on skills for you. In the real world of EMS we have to both diagnose and treat. If you can't do both then you are worthless as an EMS provider. There is no line between the two both are vital skills and the combination of them is what sets us apart. Sure you can train a monkey to intubate, its an extremely simple task. So why is it that we in the field keep screwing it up? After all a monkey could do it.

  11. You can't treat unless you have correctly assessed the problem. People get hung up on the visible stuff and don't always treat the underlying cause. You can't just do the fun stuff you have to have good observation and questioning skills as well

  12. Maybe it is just the EMT-Basic in me and my options for treatment are few and far between, but EMS and any medical profession for that matter should be more about assessment then treatment. Without a thorough assessment you cant create a working diagnoses and without a working diagnoses you cant treat. When I was in school I couldnt figure out why we were spending weeks on end learning signs, symptoms, pertinent negatives, special questions, and practicing medical and trauma assessments every afternoon. All I wanted to do was to learn c-spine, splinting and the like. Now that Im in the field I know why we spent more time on assessment and less on skills, its because a monkey could take a BP, but it takes a well trained provider to act on those numbers. 1mgC

  13. “because a monkey could take a BP, but it takes a well trained provider to act on those numbers.” We have got to get away from this mind set because frankly a lot of this stuff that “a monkey can do” a Paramedic can't. Yes the assessment is the most important thing we do but all of you(speaking collectively not at 1mgc) who focus only on knowledge and don't worry about skills because “a monkey can do it” are worthless in the real world. The two are one and the same and inseperable if you want to be a good EMS provider. If you want to stand around and diagnose a PT get into med school and become an MD then you can have other people do the hands on skills for you. In the real world of EMS we have to both diagnose and treat. If you can't do both then you are worthless as an EMS provider. There is no line between the two both are vital skills and the combination of them is what sets us apart. Sure you can train a monkey to intubate, its an extremely simple task. So why is it that we in the field keep screwing it up? After all a monkey could do it.

  14. […] about if intervention or assessment is the most important skill set for a paramedic to work with. (here and here) Both are essential, but in the every decreasing percentage volume of genuine medical […]


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