Stay In Your Lane

Years ago, my parents called the same plumber anytime they had a plumbing issue.  Norman the plumber knew all about plumbing. Norman didn’t claim to know anything about carpentry, electrical work, or appliance repair. Norman didn’t claim that with a few more hours of continuing education, an extra certificate class, and his expertise as a plumber that he could do the job of a general contractor perfectly well.  Sounds ridiculous that a plumber, without anything outside of his experience as a plumber, would claim that he’s perfectly capable of being a general contractor, doesn’t it?

Yet, my friends, that’s exactly what we’re doing in EMS on a daily basis. At least in the United States, EMS exists because of the 1966 “white paper” entitled “Accidental Death and Disability: The Neglected Disease of Modern Society.” As a result of this paper, the United States began to develop an EMS system and trauma centers to care for the most severely injured patients. Around this time, emergency medicine began to emerge as a separate, distinct specialty of medicine.  Wikipedia (don’t laugh, it’s becoming a more respected source of information) defines emergency medicine as “responsible for initiating resuscitation and stabilization, starting investigations and interventions to diagnose and treat illnesses in the acute phase, coordinating care with specialists, and determining disposition regarding patients’ need for hospital admission, observation, or discharge.”  The National Highway Traffic Safety Administration defines EMS as “dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves.”

So, in short, EMS exists to take care of the acutely sick and injured and get them to the right hospital.  As I’ve defined it before, EMTs and paramedics should excel at the delivery of out of hospital urgent and acute care.  Further, we should excel at getting the right patients to the right hospital. In other words, we should know better than to take a patient that might need an ICU bed to a rural critical access hospital.  Likewise, the patient who demands to go across town to the hospital where their primary care physician “has privileges” might be just as well suited to go to the closest appropriate facility as it’s virtually unlikely that the patient will be admitted by their primary care doctor.

I expect a good paramedic to be able to provide advanced cardiac care, assess a patient, provide pain management, manage an airway, and get the patient to the right destination safely, among other things.  I don’t expect a paramedic, even with an additional “certificate course,” to be competent too far afield from emergency and acute medicine. While it’s true that EMS providers are seemingly a logical choice for any form of out of hospital care, the truth is that our current education model and skill set leave us ill prepared to deal with sub-acute complaints or routinely chronic conditions. It’s the definition of the old axiom “stay in your lane” – mind your business and keep moving forward.

Otherwise, when we keep telling EMS providers that the future is in mobile integrated healthcare, but don’t provide EMS providers the formal education necessary to be doing nursing and home health care, we end up fouling up and losing sight of what we do best — care for urgent and acute patients.  In a purely “hypothetical” case, you might end up missing an obviously septic patient because you ignored what the patient’s family had to say and kept suggesting “social work and home health care” because the patient also had chronic health issues.

When it all comes down to it, EMS has a basic mission.  Getting a patient into the healthcare system, ideally no worse than we first encounter our patient.

Which brings me to my final point.  By the time that EMS has been called, patients and their family members are already stressed and potentially frightened. If you’ve added to their stress, fear, or anxiety, you’ve failed the patient and haven’t been a good advocate for EMS.

Comments

  1. “Otherwise, when we keep telling EMS providers that the future is in mobile integrated healthcare, but don’t provide EMS providers the formal education necessary to be doing nursing and home health care, we end up fouling up and losing sight of what we do best — care for urgent and acute patients.”

    That’s why a really good CP/MIH program shouldn’t duplicate nursing and home health care, but truly provide something original, preferably something that builds on what paramedics already know and/or do.

    • Can you give some examples of some things that EMS brings to the table? I’m genuinely curious because I don’t really “get” EMS-based MIH, but I feel like I’m missing something.

  2. Cania Command says:

    I am amazed at how little MIH providers get in the way of education. My original MIH related class was about 14 weeks, but a lot of that was ‘filler’ time.

    I kind of think that maybe, just maybe, we should figure out what MIH should look like. And I get so tired of hearing “if you have seen one EMS system, you have seen one EMS system.

    Hospitals operate alike with little difference. As to fire departments, airports, police departments, doctor’s offices, department stores, etc.

    EMS should pretty much look the same anywhere. Maybe that is a part of the problem, is that EMS wants to be special where they are at and everyone resents/envies them.

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