Re: Dr. Bill Jermyn's Post on What's Wrong with EMS

[Guest guest]

Hidy Bill and Happy New Year!!!

Thanks so much for your reply. You raise some excellent counterpoints. So

let's examine them. (Read down).

GG

In a message dated 12/31/2001 15:33:07 Central Standard Time,

renojerm@... writes:

> Your criticism of how some people are using the concept of evidence based

> medicine are, of course, correct. As with anything, we humans tend to

> gravitate to: " If a little is good, a lot is better " and the evidence based

> proponents have the same problem. BUT, your comments about " common sense "

> medicine need to be examined. As we have begun examining our long held

> beliefs, we find that our common sense is often wrong. To use your

> examples, the MAST pants made common sense and were accepted because of

> such; fluids in penetrating chest trauma made perfect sense, but neither

> stood up to scrutiny.

Yes but the studies have not been done in other than limited settings, so the

" evidence " doesn't really extend to all uses of PASG. So turning back the

" evidence-based " argument, where is the evidence against use in patients

with low fluid volume from significant but now controlled external bleeding,

for example? This would be the patient whose arm was caught in an auger, who

bled, but now has been extricated and has lost half his blood. PHTLS and

BTLS both say use it in that setting, don't they?

> To do the " best practices " theory, you have to " know " (really know from

> studies) what is the best practice to do for the patient. Therefore, I

> cannot accept that there is anything in medicine that should not be looked

> at thoroughly.

And neither can I. We need to look at everything in the best way possible.

For example, from discussions on this list, everyone " knew " that paramedics

were

> excellent at intubating and had high success rates. Then, along comes a

> study that shows that in at least one service area, 25% of the intubations

> were unrecognized misplaced ET tubes. In this case, the medics " knew " they

> were doing a good job ( they were, after all, unrecognized misplacements)

> and the people receiving the patients " knew " the tubes were misplaced. They

> were able to demonstrate such by a study.

>

But that was ONE service area. Here, where good CA and CQI is done, we know

that our medics do as good a job as ER docs in tube placement. We know this

statistically. We also know that our medics are not shy about going to a

secondary device such as the CombiTube and that in those rare cases where

they have gone there the airway was successfully maintained.

Now, I have reviewed many cases where ET placement was incorrect and not

discovered until too late. What I am saying is that " best practices " demand

that tube placement be verified serially using multiple criteria. When that

happens, common sense does tell us that medics are placing the tubes

correctly.

>

> I could go on ad nauseum with examples of treatments that medicine has

> accepted without proper evidence. My opinion (and that is just what it is,

> an opinion) is that we have enough examples now to justify a reappraisal of

> most of what we do in medicine to be sure that it is the best way to treat

> our patients.

>

Hmmm. Are you saying that blistering and bleeding are bad? Leeches have

made a return. And also maggots. But there are probably studies on those.

>

> Designing those studies--especially with the med-mal lawyers lurking in the

> trees--is difficult, but well worth the effort.

By the way, I have fought with all my heart against the filing of

unwarranted lawsuits by plaintiffs' attorneys just as I have fought the

insurance companies when they have refused to pay those claims which were

clearly established. I have review many cases for the plaintiff and said,

" you don't have a case. " I have also told the defense, " you need to pay up. "

I cannot abide people with whorish instincts, and I fully support a system

of claim review which would eliminate most if not all of the so-called

frivolous suits. I'm on the defense of one that is SO frivolous that I think

the attorneys should be sanctioned for filing it.

If Tucson Fire is going to do a large scale study of defib vs CPR-defib, I

applaud

> them. This needs to be done. There are some good preliminary studies to

> support doing a large scale study. We will benefit from the results--be

> they positive or negative.

The results can only be positive, can't they? I mean, if the study shows

that driving up and immediately shocking the patient isn't as good as driving

up and doing 90 seconds of CPR, what's wrong with that? We DO want to do

what is right, in the patient's best interests, and what works. But we DON'T

want to be limited in what we do by those with a different agenda.

>

> Reimbursement:

>

> Well, I guess that I'd like to see you back up your statement that

> hospitals and ED physicians have not jumped on the band wagon for expanded

> scope of practice because of greed. I think this is a short sighted view,

> and very inflammatory.

>

Oops. Well, I knew I'd cause some local inflammation with that. Hopefully

it won't spread systemically. I speak from personal experience, and I have

not seen the majority of ER physicians and ED physicians vote for expanded

Paramedic practice. I have seen ER physicians automatically jerk the tube

and replace it when it was unquestionably in, so that they could bill for the

intubation. Yep, that's good for $200. I hate this, but I have seen it and

many other medics I know have seen it. Can we prove it? Of course not. But

it's happened and is still happening, believe me.

There exists a dichotomy of interest. First, there is the problem that many

EMS Medical Directors are mostly off-line MDs and are responsible for signing

papers and approving protocols. They are very conservative in what they want

to let their medics do. Many of them are not involved in pre-hospital care

in any way, have never been out in the field on a call and have no intentions

of ever going on one. They are not pro-active medical directors like

yourself or Ed Racht, Jeff Salome, Jui, or Persse, for example.

I know a couple of big service Medical Directors who haven't been on an

actual call in 10 years if ever.

Then there's the problem that the ER physician who receives the patient works

for a " rent-a-doc " service and not for the hospital. These people often

don't even know what the protocols are and so when asked for an order simply

refuse it. They may have little or no experience with Paramedic education or

training and could care less about it. But one thing they do know is that if

the numbers of patients seen in the ER go down, their jobs may be in

jeopardy.

>

> Most of us are victims of overcrowding. We are looking very hard at

> options. If the patient's problem is minor enough to be taken care of in

> the field, they are not a candidate for hospital admission. If they require

> admission, by definition, this cannot be cared for at home. Therefore,

> again, I guess I'd like some explanation about why you think hospitals are

> working against EMS systems just to garner more admissions.

>

Please see above. The great unanswered question is: Who will decide if the

patient's problem is minor enough to be taken care of in the field or if they

need to be transported to the hospital? This is the crux of the matter.

When ER physicians and EMS Medical Directors feel comfortable enough with

allowing Paramedics to make these decisions, then progress will be made. But

so far, given the controversies over the amount of education and training

Paramedics receive, the absence of a degree requirement, and vast differences

in the knowledge and performance levels of Paramedics overall, I couldn't

imagine myself as a physician granting them much leeway to make independent

decisions.

And although some hospitals are overwhelmed with patients in the ERs, others

are not. We have not developed a workable Trauma system which reliably

shunts patients to the appropriate facility. And we haven't even addressed

the medical patient in terms of where to take them. So there are some

hospitals putting up billboards and offering specials in order to get

patients and others going on divert. We do NOT have a system.

>

> I am the physician that was responsible for getting the legislative

> language inserted in our EMS statutes 4 years ago that allow expanded scope

> of practice in Missouri. Therefore, I come at this from your viewpoint, but

> I have not seen any good, large scale studies that show a cost saving or

> improved outcome to society. (Yes, I'm aware of Red River). Therefore, I'm

> not prepared to fully support that this is a solution we should adopt. It

> might be, but no one has conclusively demonstrated such.

>

You're correct, but perhaps the reason that no one has conclusively

demonstrated it is that so few have tried it. Red River didn't work like

they thought it would, but did they learn from their experiences and modify

the system accordingly? I don't know. Perhaps you do.

> I've had some discussions with list participants about the reimbursement

> issues for EMS. It seems to me that EMS is in a decent position to garner

> adequate reimbursement, because they have the option of charging the

> patient (or insurers) for care, and the option of dipping into the public

> coffers for tax support. When you look at how medicine is reimbursed, we

> are paid for " piece work " , ie, paid for each patient seen per hour

> (Lawyers, too, but I can't charge for phone calls!).

>

The problem is that EMS cannot " refuse " to serve the patient. So we have to

do it regardless of how we're reimbursed and just try to convince the bean

counters to pay us what we need. We charge for services but are routinely

denied total reimbursement. All reimbursement schemes employ a percentage

method. What's wrong with 100% of cost plus 10%, for example? Even

carpenters and plumbers get that much or more. But in EMS we get a

percentage that is far less than cost. What's wrong here? The ER physician

who intubates the patient charges for it. But the Paramedic who intubates

can't.

> Most EMS systems have a difficult time justifying high salaries when you

> examine from the " piece work " perspective, as much time is spent NOT doing

> patient care. If you are not doing direct patient care, you are not

> generating revenue--either for yourself or your system. Now, maybe we, as a

> society, want to pay EMS to sit around the station waiting to be called,

> doing public service work, IP, etc, but we need to make the decision to

> support with tax dollars to do so. If I only cared for 5 patients a shift,

> I would be making very little money.

>

Do you want to pay your police officers and firefighters on a " piecework "

basis? If the police are successful in reducing robberies by 50%, would you

advocate paying them 50% less salaries? Of course not. EMS is a public

service. That's where we're so off base. We want to view it as a business.

It's not. It's a vital service which should be funded adequately through

whatever scheme works best. Probably no one scheme works, but I view it as a

governmental function (HORRORS) and one that ought to be funded through tax

dollars at least to maintenance levels.

I would employ much greater utilization of EMS personnel if I were running

things. They would spend their off time teaching CPR and First Aid to

everybody in sight, including all school children and anybody else they could

corral. They would constantly be interacting with the community, making

visits to former patients, maintaining data bases on as many patients as

possible, making calls to check on them, doing medical education, and

getting to know as many people in the community as possible. There would be

NO sitting around the station reading the Enquirer. Shifts would be 8 hours

in most areas, and when not running calls the medics would be high profile in

the community, teaching healthy living, infection control, first aid and

general awareness of health issues.

The results of this would be that medics would occupy a much higher social

and professional status than they do, and the public would benefit greatly.

> As things have evolved, most EMS systems are funded by a combination of

> " piece work " revenue generation and tax dollars. If systems are not able

> to make enough from patient care reimbursement, perhaps they need to work

> harder for tax support. Fire sure has!

>

> OK, Gene, my Nomex is on. Take care, and have a Happy New Year, Bill

> Jermyn, DO, FACEP

>

> No need to don your Nomex. You're right on target with your comments.

Happy New Year.

Gene

E. Gandy, JD, LP

EMS Professions Program

Tyler Junior College

Tyler, TX