Future Priorities for Parameidcs - Assessment or Interventions?

Firstly, I would like to say thank you to Paramedicine 101 for the invite to start posting some of my thoughts on this blog. I am flattered to be asked, and I look forward to having some discussions with some new readers about my thoughts and musings.

This post is a combination of two that I have had over at my blog this week, and I post it here as I would like to have your opinions too....

I 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.


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 agree that treatment and assessment are intertwined and to be an efficient and effective EMS provider, you need to be proficient at both, but I also think there is another way to think about it.

Are we now getting close to the limit of what we can do with interventions for our patients?

I for one cannot see much more that would be of benefit or that would be practicable to try and perform in an out of hospital setting with our current level of technology (who knows ones we get into Star Trek land though!).

I have been on a number of courses around assessing and treating a patient suffering from traunatic injuries (ATLS, PHTLS), but there are very few advanced general assessment courses, primarily aimed at the medical patient for me to go on.

If we take it as I said that we cannot physically do much more for our patients, then should we now be looking at where we can go to further help our patients by concentrating more on our assessment and diagnostic abilities?

Or maybe I am just barking up the wrong tree??


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Adam Thompson, EMT-P said...

Welcome to the blog 999. I was impressed with the work you and Happy have done. I had to send you the invites. Great first post.

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Mystery Medic said...

Wow 3 spam posts to one of the best posts I've read in a long time. I'll comment more later but in my system this hits the nail on the head. In my local I have many hospitals to choose from and based on my initial exam I choose the destination due to an ALS assessment. Stroke, MI, Trauma, Burns, and Co Poisoning I route my patients to the appropriate hospital that can provide the quickest "APPROPRIATE" care. There are surrounding EMT based crews that will cancel the medic enroute when they arrive on scene to the patient and just transport to "The Closest Hospital" but just because they are in a hospital doesn't mean they are in the right hospital. Example: A local BLS crew gets dispatched for chestpain. They are 2 minutes away and the ALS intercept 8 minutes away. BLS has a patient w/ chestpain outside, loads, cancels ALS, and transports to closest hospital. The closest hospital doesn't have a cath lab but that doesn't matter to the BLS crew because they took the patient to the closest hospital and bill. The patient, after 10+ minutes gets an EKG to find they are having a MI when the ER tech gets in there to do it and the doc assesses the patient 10+ minutes later and then transfers the patient to another hospital for a cath. This patient just spent over 40 minutes with his heart dying. Play the same scene, ALS arrive 6 minutes later, a quick 12 lead, anterior MI, 10 minutes transport time to a futher hospital with a command notification to activate the cath lab, 2 18G IV's in place, nitro, morphine, and ASA are all on board. Better for the patient to have a longer life. Paramedics are there not only to treat but to provide the best treatment options!

Mystery Medic said...
This comment has been removed by the author.