The further I am from active practice of EMS and the more I do on the Quality Improvement side of the industry, the more disheartened I become.

Now, I realize that I was spoiled working for Sorta Big City ENS. Even back in the early days of EMS, at least in this part of the country, I was fortunate in that SBC EMS had close ties to a couple of really good hospitals. Paramedics and the EMTS who were so inclined could have serious discussions with doctors and nurses (yes we can learn from nurses) about medical topics that weren’t even touched upon in EMT or paramedic school.

As a result, while I can’t claim to be smarter than the average paramedic, I had exposure to and learned from some really sharp people.

I was spoiled and thought that this sort of thing was the norm in EMS. Boy was I wrong.

Part of what I do is read patient care reports and audit them for accuracy and appropriateness of care. I haven’t kept a spread sheet on what I’ve found, but here are my impressions from reading literally thousands of reports a year for a few years now.

Paramedics depend too heavily on their technology and assessment skills are weak. In particular, they are over reliant on pulse oximetery even though when I talk to them about that, they deny that they use it as a clinical crutch.

A lot of paramedics can’t read an EKG rhythm strip, let alone assess a 12 Lead EKG for signs of ischemia, injury, or infarct. They rely on the computer generated interpretation instead of understanding what they are looking at. When I see a paramedic write on a report “Normal sinus rhythm, with occasional PACs, PJCs, and varying P-R interval.” I know that they didn’t understand what they saw, because what they saw was Atrial Fibrillation.

When they are presented with a patient who gets short of breath after walking up a flight of stairs and give him an Albuterol treatment instead of treating him for his unstable Angina, I know that they have never heard the term “Anginal Equivalent” and are stuck in the paradigm that if there is no chest pain, there can’t be a cardiac issue.

Or, when they look at a 12 Lead EKG and don’t see any evidence of ST segment abnormality, they concluded that the patient’s chest pain can’t be cardiac in origin because there have to be ST changes for it to be a Myocardial Infarction. Only they are wrong.

These aren’t, at least for the most part, stupid or lazy people. They are however, people who were victims of bad education and probably bad continuing education. The problem there being that there are just too many paramedic programs and thus too many paramedics in the country. Or maybe the distribution of paramedics is wrong, since some services insist that every ambulance has to have at least one paramedic on it.

Which is patently false since most ambulances don’t do emergency calls and most patients need little more than a slow and safe ride to the hospital with a person that can do a brief examination to determine whether they need more care or not.

Of course I’ll get comments from people who will tell me how wrong I am. If that’s true, explain why even in an “all ALS” system, less than 20% of the patients need ALS. I see a lot of “Well, we’re ALS so we better start an IV on this patient even though they don’t need it.” medicine.

But, that’s a post for another day. Back to assessment.

Paramedics should be able to determine if a patient is having an episode of Congestive Heart Failure (CHF) or an exacerbation of their Chronic Obstructive Pulmonary Disease (COPD). That is a common differential diagnosis that paramedics, or even a good EMT should be able to make. Yet, I frequently see cases where a patient who desperately needed nitroglycerin and CPAP, but instead got Albuterol or a Combivent because the paramedic thought he heard wheezes and wheezes can only mean Asthma or COPD. They don’t understand that fine rales (please don’t call them “crackles”) have the same effect as bronchospasm, but require a completely different treatment.

They look at a number in isolation or they misidentify what they hear and go down the wrong treatment path.

Let me detour slightly from my rant here to say that it’s not just paramedics that make this mistake. I’ve seen doctors who should know better do the exact same thing.

This drives me crazy because when I read the PCRs, I can see what’s wrong with the patient. The paramedic writes all the correct things, but somehow fails to understand what it is they are seeing in front of them.

I’m fortunate in that the other part of my job involves going out and discussing some cases with paramedics. My employer is quite firm in that what we do is education, not punishing or berating the paramedic. Which is the traditional approach to Quality Assurance in EMS. It’s a sort of “The beatings will continue until your performance improves” mentality.

I find in discussing cases with individual paramedics that many of them didn’t learn or more likely were not taught, how to properly assess a patient. What they were taught was how to pass a skills exam testing their ability to examine a patient. That’s a huge difference and one that can have an impact on the patient.

So, a lot of what I do in the teaching (not remediation) aspect of my job is go over basic things with paramedics. Things that someone, somewhere along the line should have, but didn’t teach them.

One day I spent 45 minutes discussing a case with a paramedic and discussing in detail why it was not good care to sit up a hypotensive patient to do “postural vital signs”. Another stupid thing we teach in both basic and paramedic level classes.

As I said in a post a little bit back, this is the kind of thing I wanted to do when I made the decision to retire. Again, I’m not bragging or conceited about how smart I am or what a terrific paramedic I am. I think that I do have some knowledge and experience that can be of value to the younger generation and the thought of not passing it along was discouraging. I’m not out there running calls any more, but I hope. that by passing my knowledge along I can still indirectly help patients.

I just think it would be better for all of us if paramedics were better educated from the beginning.