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Re: Paramedics Cannot Determine Which Patients Require Transport

By Guest guest, in Health, Medicine and Natural Healing 09

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Guest guest   

Guest guest
Posted

I truly see both sides of this argument, I am a proponent of Paramedic Initiated

Refusals, always have been and always will be, with the proper training.

 

Most of the arguments are the extremes.

 

For arguments sake, I do not advocate no riding chest pain, or abdominal pain

etc., neither can you convince me that every cut fingers and stubbed toes need

an ambulance. They need a chit to call a cab and get a ride to where they choose

to go and get their finger or toe cared for.

 

The argument that if the patient thinks it is an emergency, then it is......not

true. I can't remember all the times that the family member came screaming out

of the house about " all teh blood " , to find a small laceration with minor

bleeding controlled with a large band aid.

 

I have heard the argument that it takes as long to write a refusal as it does to

write a report, and thats true, but at the same time, with a refusal you are

back in service immediately, rather than after a trip to the hospital (trip time

dtermined by your own city/county).

 

Is there a place for them? Absolutely, is it in the near future? No. Do I see it

happening? Yes.

 

But I promise not to tell you 'I told you so'.....assuming I am still alive...:)

 

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 8:41 PM

 

Wow, really... Were none of you taught how to do a proper assessment? I knew

this was just how it would go... If you don't have confidence in your assessment

then maybe you should go back to school and learn what a proper assessment is

and how it's done. STEMI...that would show up under a proper assessment?! ?!

That's one thing I have noticed here on the Group... There are a lot of people

scared to move the field of EMS forward and make it what it really needs to be,

not just a taxi service. It's going to move forward with you or without you... I

suggest you get on board and learn the up and coming technology, ideas, etc. or

get left behind. I-stat machines are capable of doing certain level of lab work

with results that are just as accurate as a lab at a hospital, or the military

wouldn't be using them, they will eventually become a standard of care in the

field. Pull your heads out of the sand and look at the big picture. Change is

coming, either

embrace it or run from it... It's your choice.

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢® ; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

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Guest guest   

Guest guest
Posted

I truly see both sides of this argument, I am a proponent of Paramedic Initiated

Refusals, always have been and always will be, with the proper training.

 

Most of the arguments are the extremes.

 

For arguments sake, I do not advocate no riding chest pain, or abdominal pain

etc., neither can you convince me that every cut fingers and stubbed toes need

an ambulance. They need a chit to call a cab and get a ride to where they choose

to go and get their finger or toe cared for.

 

The argument that if the patient thinks it is an emergency, then it is......not

true. I can't remember all the times that the family member came screaming out

of the house about " all teh blood " , to find a small laceration with minor

bleeding controlled with a large band aid.

 

I have heard the argument that it takes as long to write a refusal as it does to

write a report, and thats true, but at the same time, with a refusal you are

back in service immediately, rather than after a trip to the hospital (trip time

dtermined by your own city/county).

 

Is there a place for them? Absolutely, is it in the near future? No. Do I see it

happening? Yes.

 

But I promise not to tell you 'I told you so'.....assuming I am still alive...:)

 

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 8:41 PM

 

Wow, really... Were none of you taught how to do a proper assessment? I knew

this was just how it would go... If you don't have confidence in your assessment

then maybe you should go back to school and learn what a proper assessment is

and how it's done. STEMI...that would show up under a proper assessment?! ?!

That's one thing I have noticed here on the Group... There are a lot of people

scared to move the field of EMS forward and make it what it really needs to be,

not just a taxi service. It's going to move forward with you or without you... I

suggest you get on board and learn the up and coming technology, ideas, etc. or

get left behind. I-stat machines are capable of doing certain level of lab work

with results that are just as accurate as a lab at a hospital, or the military

wouldn't be using them, they will eventually become a standard of care in the

field. Pull your heads out of the sand and look at the big picture. Change is

coming, either

embrace it or run from it... It's your choice.

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢® ; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

Share this post

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Share on other sites

Guest guest   

Guest guest
Posted

I truly see both sides of this argument, I am a proponent of Paramedic Initiated

Refusals, always have been and always will be, with the proper training.

 

Most of the arguments are the extremes.

 

For arguments sake, I do not advocate no riding chest pain, or abdominal pain

etc., neither can you convince me that every cut fingers and stubbed toes need

an ambulance. They need a chit to call a cab and get a ride to where they choose

to go and get their finger or toe cared for.

 

The argument that if the patient thinks it is an emergency, then it is......not

true. I can't remember all the times that the family member came screaming out

of the house about " all teh blood " , to find a small laceration with minor

bleeding controlled with a large band aid.

 

I have heard the argument that it takes as long to write a refusal as it does to

write a report, and thats true, but at the same time, with a refusal you are

back in service immediately, rather than after a trip to the hospital (trip time

dtermined by your own city/county).

 

Is there a place for them? Absolutely, is it in the near future? No. Do I see it

happening? Yes.

 

But I promise not to tell you 'I told you so'.....assuming I am still alive...:)

 

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 8:41 PM

 

Wow, really... Were none of you taught how to do a proper assessment? I knew

this was just how it would go... If you don't have confidence in your assessment

then maybe you should go back to school and learn what a proper assessment is

and how it's done. STEMI...that would show up under a proper assessment?! ?!

That's one thing I have noticed here on the Group... There are a lot of people

scared to move the field of EMS forward and make it what it really needs to be,

not just a taxi service. It's going to move forward with you or without you... I

suggest you get on board and learn the up and coming technology, ideas, etc. or

get left behind. I-stat machines are capable of doing certain level of lab work

with results that are just as accurate as a lab at a hospital, or the military

wouldn't be using them, they will eventually become a standard of care in the

field. Pull your heads out of the sand and look at the big picture. Change is

coming, either

embrace it or run from it... It's your choice.

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢® ; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

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Guest guest   

Guest guest
Posted

If the medical field didn't make some advancements of the hundreds of years we

would not be where we are today. By no means am I compairing myself to a doctor

or level of doctors knowledge, but you think doctors are 100% perfect? No, not

by a long shot, but they still have to do a proper assessment, run labs, etc. to

make a proper diagnoses. I'm not saying it would be perfect by any means, but

you take a chance every day you get on the truck. Non-STEMI M.I.'s, A.A.A.'s,

etc... It's going to happen, but if you have been trained, and yes even more

training would be needed, this would be a mute point. Like I said we can all

come up with the disease that very few have heard of, or the what if's that we

have all run into, but where do you draw the line and say let's move forward?

We can all draw out the worse case scenero and make it sound sooooo bad, but

what about the good cases that would exist too? I honestly believe the good

would out weight the bad by a long shot. Earlier was not a personal attack on

the individuals just a comment to open eyes and make you think about what we do

on a daily basis...

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

Share this post

Link to post
Share on other sites

Guest guest   

Guest guest
Posted

If the medical field didn't make some advancements of the hundreds of years we

would not be where we are today. By no means am I compairing myself to a doctor

or level of doctors knowledge, but you think doctors are 100% perfect? No, not

by a long shot, but they still have to do a proper assessment, run labs, etc. to

make a proper diagnoses. I'm not saying it would be perfect by any means, but

you take a chance every day you get on the truck. Non-STEMI M.I.'s, A.A.A.'s,

etc... It's going to happen, but if you have been trained, and yes even more

training would be needed, this would be a mute point. Like I said we can all

come up with the disease that very few have heard of, or the what if's that we

have all run into, but where do you draw the line and say let's move forward?

We can all draw out the worse case scenero and make it sound sooooo bad, but

what about the good cases that would exist too? I honestly believe the good

would out weight the bad by a long shot. Earlier was not a personal attack on

the individuals just a comment to open eyes and make you think about what we do

on a daily basis...

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

Share this post

Link to post
Share on other sites

Guest guest   

Guest guest
Posted

If the medical field didn't make some advancements of the hundreds of years we

would not be where we are today. By no means am I compairing myself to a doctor

or level of doctors knowledge, but you think doctors are 100% perfect? No, not

by a long shot, but they still have to do a proper assessment, run labs, etc. to

make a proper diagnoses. I'm not saying it would be perfect by any means, but

you take a chance every day you get on the truck. Non-STEMI M.I.'s, A.A.A.'s,

etc... It's going to happen, but if you have been trained, and yes even more

training would be needed, this would be a mute point. Like I said we can all

come up with the disease that very few have heard of, or the what if's that we

have all run into, but where do you draw the line and say let's move forward?

We can all draw out the worse case scenero and make it sound sooooo bad, but

what about the good cases that would exist too? I honestly believe the good

would out weight the bad by a long shot. Earlier was not a personal attack on

the individuals just a comment to open eyes and make you think about what we do

on a daily basis...

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

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Guest guest   

Guest guest
Posted

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

I have to disagree on a couple of points....

 

1) pt has a Hx of gallbladder issues

 

That certainly doesn't mean that's what his current diagnosis is....

 

2) vomited bile earlier(cause he's drunk too)

 

If he's drunk, then your ability to do a thorough assessment is already out the

window.

 

I realize your patient is just an example, but one that even as a proponent of

PIR's, I wouldn't 'no-ride' myself.

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 10:37 PM

 

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS interventions( I.V.,Phenergan,

etc.), just wants a ride to the ER and that's it... Okay! Now were back to the

" Taxi Ride " again. I have been dealing with such a pt for at least a year now.

Yes, I know things can memic other stuff, but do you think am I truly going to

" No Ride " an undiagnosed abd. pain? Uhhhh, No! Key word here is UNDIAGNOSED.

...and since we know his history and is non-compliant and wants just a " Ride " to

the ER... No, he can find another way! I'm tired of my tax dollars being waisted

on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

Share this post

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Share on other sites

Guest guest   

Guest guest
Posted

I have to disagree on a couple of points....

 

1) pt has a Hx of gallbladder issues

 

That certainly doesn't mean that's what his current diagnosis is....

 

2) vomited bile earlier(cause he's drunk too)

 

If he's drunk, then your ability to do a thorough assessment is already out the

window.

 

I realize your patient is just an example, but one that even as a proponent of

PIR's, I wouldn't 'no-ride' myself.

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 10:37 PM

 

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS interventions( I.V.,Phenergan,

etc.), just wants a ride to the ER and that's it... Okay! Now were back to the

" Taxi Ride " again. I have been dealing with such a pt for at least a year now.

Yes, I know things can memic other stuff, but do you think am I truly going to

" No Ride " an undiagnosed abd. pain? Uhhhh, No! Key word here is UNDIAGNOSED.

...and since we know his history and is non-compliant and wants just a " Ride " to

the ER... No, he can find another way! I'm tired of my tax dollars being waisted

on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

I have to disagree on a couple of points....

 

1) pt has a Hx of gallbladder issues

 

That certainly doesn't mean that's what his current diagnosis is....

 

2) vomited bile earlier(cause he's drunk too)

 

If he's drunk, then your ability to do a thorough assessment is already out the

window.

 

I realize your patient is just an example, but one that even as a proponent of

PIR's, I wouldn't 'no-ride' myself.

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 10:37 PM

 

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS interventions( I.V.,Phenergan,

etc.), just wants a ride to the ER and that's it... Okay! Now were back to the

" Taxi Ride " again. I have been dealing with such a pt for at least a year now.

Yes, I know things can memic other stuff, but do you think am I truly going to

" No Ride " an undiagnosed abd. pain? Uhhhh, No! Key word here is UNDIAGNOSED.

...and since we know his history and is non-compliant and wants just a " Ride " to

the ER... No, he can find another way! I'm tired of my tax dollars being waisted

on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

medic4319 wrote:

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reimbursements to doctors, hospitals and ambulances services are cut...

Something is going to have to give or a lot services will be shutting their

doors...

 

Yes...and unfortunately, the first thing that will happen is more and more

paramedics are going to lose their jobs and be replaced with EMT's who will

respond and transport rapidly to an ED while doing most of the stuff we

" reserve " for paramedics today.  Until we can prove that a paramedic makes a

difference over what an EMT can do... " changes " like being proposed currently

will lead to less care in the field and more of these patients being brought to

ED's for treatment.  So, we have a mechanism that pays for ambulances to

transport people...but we want to send paramedics to school for even longer

(which means we have to pay them even more) and then we use this extra education

to NOT transport people...and because we have all the proof in the world that

Paramedics make a difference in outcomes...someone is going to pony up the dough

for this?  Really? 

 

Take a good read through this healthcare reform language...you know what is in

the Senate bill for EMS???? NOTHING....that's right....NOTHING....the American

Ambulance Association is fighting like crazy to get a permanent 3% increase in

Medicare reimbursement included in the legislation...3%....that amounts

to about $11 for an ALS-1 Emergency transport...and if you declare your patient

dead and do not transport them (the only thing Medicare will pay you for if you

don't transport) then it is about around $8 bucks or so. 

 

So, in our little world RACKED with incredible government over-spending and tons

and tons of priorities in this healthcare debate that are currently much higher

on the food chain than us...how far do you think $11 a transport will go?  If

it was applied to ALL my agencies transports it would be around $45,000 a

year...which wouldn't even hire a single extra paramedic...but hey, we could

split it among all my current FT medics with all the extra education and 4 year

degrees and new MRI machines, x-rays and I-stats...and everyone would get an

extra $0.56 an hour.  Yeah...that is the just the motivation we need to get

kids out of high-school to enter the field...

 

I am not opposed to expanded scopes of practice...but someone, somewhere has to

show me

1. WHERE THE VALUE IS and

2. Who will foot the bill (which if you remember your economics will be answered

by #1)

 

Until then, paramedic treat and release is just like cap and trade and other

" green " initiatives....a solution looking for a problem.

 

Happy Labor Day everyone...by the way...if it is labor day...why do most folks

have the day off????  Hmmmmmmmm....

 

Dudley

Re: Paramedics Cannot Determine Which Patients Require

Transport

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting20their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and econ

omic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ;

D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity

indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0nec

essity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical nec

essity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Share on other sites

Guest guest   

Guest guest
Posted

medic4319 wrote:

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reimbursements to doctors, hospitals and ambulances services are cut...

Something is going to have to give or a lot services will be shutting their

doors...

 

Yes...and unfortunately, the first thing that will happen is more and more

paramedics are going to lose their jobs and be replaced with EMT's who will

respond and transport rapidly to an ED while doing most of the stuff we

" reserve " for paramedics today.  Until we can prove that a paramedic makes a

difference over what an EMT can do... " changes " like being proposed currently

will lead to less care in the field and more of these patients being brought to

ED's for treatment.  So, we have a mechanism that pays for ambulances to

transport people...but we want to send paramedics to school for even longer

(which means we have to pay them even more) and then we use this extra education

to NOT transport people...and because we have all the proof in the world that

Paramedics make a difference in outcomes...someone is going to pony up the dough

for this?  Really? 

 

Take a good read through this healthcare reform language...you know what is in

the Senate bill for EMS???? NOTHING....that's right....NOTHING....the American

Ambulance Association is fighting like crazy to get a permanent 3% increase in

Medicare reimbursement included in the legislation...3%....that amounts

to about $11 for an ALS-1 Emergency transport...and if you declare your patient

dead and do not transport them (the only thing Medicare will pay you for if you

don't transport) then it is about around $8 bucks or so. 

 

So, in our little world RACKED with incredible government over-spending and tons

and tons of priorities in this healthcare debate that are currently much higher

on the food chain than us...how far do you think $11 a transport will go?  If

it was applied to ALL my agencies transports it would be around $45,000 a

year...which wouldn't even hire a single extra paramedic...but hey, we could

split it among all my current FT medics with all the extra education and 4 year

degrees and new MRI machines, x-rays and I-stats...and everyone would get an

extra $0.56 an hour.  Yeah...that is the just the motivation we need to get

kids out of high-school to enter the field...

 

I am not opposed to expanded scopes of practice...but someone, somewhere has to

show me

1. WHERE THE VALUE IS and

2. Who will foot the bill (which if you remember your economics will be answered

by #1)

 

Until then, paramedic treat and release is just like cap and trade and other

" green " initiatives....a solution looking for a problem.

 

Happy Labor Day everyone...by the way...if it is labor day...why do most folks

have the day off????  Hmmmmmmmm....

 

Dudley

Re: Paramedics Cannot Determine Which Patients Require

Transport

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting20their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and econ

omic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ;

D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity

indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0nec

essity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical nec

essity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

Share this post

Link to post
Share on other sites

Guest guest   

Guest guest
Posted

medic4319 wrote:

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reimbursements to doctors, hospitals and ambulances services are cut...

Something is going to have to give or a lot services will be shutting their

doors...

 

Yes...and unfortunately, the first thing that will happen is more and more

paramedics are going to lose their jobs and be replaced with EMT's who will

respond and transport rapidly to an ED while doing most of the stuff we

" reserve " for paramedics today.  Until we can prove that a paramedic makes a

difference over what an EMT can do... " changes " like being proposed currently

will lead to less care in the field and more of these patients being brought to

ED's for treatment.  So, we have a mechanism that pays for ambulances to

transport people...but we want to send paramedics to school for even longer

(which means we have to pay them even more) and then we use this extra education

to NOT transport people...and because we have all the proof in the world that

Paramedics make a difference in outcomes...someone is going to pony up the dough

for this?  Really? 

 

Take a good read through this healthcare reform language...you know what is in

the Senate bill for EMS???? NOTHING....that's right....NOTHING....the American

Ambulance Association is fighting like crazy to get a permanent 3% increase in

Medicare reimbursement included in the legislation...3%....that amounts

to about $11 for an ALS-1 Emergency transport...and if you declare your patient

dead and do not transport them (the only thing Medicare will pay you for if you

don't transport) then it is about around $8 bucks or so. 

 

So, in our little world RACKED with incredible government over-spending and tons

and tons of priorities in this healthcare debate that are currently much higher

on the food chain than us...how far do you think $11 a transport will go?  If

it was applied to ALL my agencies transports it would be around $45,000 a

year...which wouldn't even hire a single extra paramedic...but hey, we could

split it among all my current FT medics with all the extra education and 4 year

degrees and new MRI machines, x-rays and I-stats...and everyone would get an

extra $0.56 an hour.  Yeah...that is the just the motivation we need to get

kids out of high-school to enter the field...

 

I am not opposed to expanded scopes of practice...but someone, somewhere has to

show me

1. WHERE THE VALUE IS and

2. Who will foot the bill (which if you remember your economics will be answered

by #1)

 

Until then, paramedic treat and release is just like cap and trade and other

" green " initiatives....a solution looking for a problem.

 

Happy Labor Day everyone...by the way...if it is labor day...why do most folks

have the day off????  Hmmmmmmmm....

 

Dudley

Re: Paramedics Cannot Determine Which Patients Require

Transport

Okay, I know I'm sure I'm going to piss off a lot of people, but get over it...

This is what discussion is for! Now back to my scenero from earlier... Under a

proper assessment you find the pt has a Hx of gallbladder issues, vomited bile

earlier(cause he's drunk too), refuses all ALS

interventions(I.V.,Phenergan,etc.), just wants a ride to the ER and that's it...

Okay! Now were back to the " Taxi Ride " again. I have been dealing with such a pt

for at least a year now. Yes, I know things can memic other stuff, but do you

think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No! Key

word here is UNDIAGNOSED...and since we know his history and is non-compliant

and wants just a " Ride " to the ER... No, he can find another way! I'm tired of

my tax dollars being waisted on crap like this.

Heck, for that matter the cut finger brought up earlier... well if they're on

blood thinners and dont tell you and you " No Ride " them and they die, then back

in the same boat! Proper assessment would find that they were on blood thinners

and this would be avoided!?!?

It's not going to happen tomorrow or next week, but it will happen and sooner

then you think. If the current administration gets their way and the

reembursments to doctors, hospitals and ambulances services are cut... Something

is going to have to give or a lot services will be shutting20their doors...

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and econ

omic benefits for emergency medical services (EMS) agencies

> > and

> > > > > receiving emergency departments. However, no consensus exists on the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> > to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ;

D*$¢®utilization

> > reviewD*$¢®; D*$¢®health servi

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity

indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0nec

essity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated. Results.

> > From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1). The

> > NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate NPV

> > of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> > inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> > and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical nec

essity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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Guest guest   

Guest guest
Posted

A proper assessment will keep the patient needing transport from being left at

home. Proper instruction will make for a proper assessment. Proper supervision

will assure good field personnel. I see nothing that would and could not be

fixed by the 3 things mentioned previously.

 Proper supervision will also keep the EMS field free of those that can not or

will not perform to the standards set. 

 I  believe that we as a profession can rise above and beyond what we even do

today. With caring indivduals and learn-ed professionals there is nothing that

TEXAS EMS cannot accomplish. I have seen it over the years. I continue to see it

every day. I hope to see it for years to come. 

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Re: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 6:47 PM

 

Fast forward three months...... ..A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

In a message dated 9/6/09 2:45:38 PM, THEDUDMAN (AT) aol (DOT) com writes:

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$〓triageD*$〓 ; D*$〓utilization reviewD*$〓; D*$〓health services

misuseD*$〓; D*$〓

> severity of

> > illness index,D*$〓 and D*$〓trauma severity indices.D*$〓 Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

Share this post

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Share on other sites

Guest guest   

Guest guest
Posted

A proper assessment will keep the patient needing transport from being left at

home. Proper instruction will make for a proper assessment. Proper supervision

will assure good field personnel. I see nothing that would and could not be

fixed by the 3 things mentioned previously.

 Proper supervision will also keep the EMS field free of those that can not or

will not perform to the standards set. 

 I  believe that we as a profession can rise above and beyond what we even do

today. With caring indivduals and learn-ed professionals there is nothing that

TEXAS EMS cannot accomplish. I have seen it over the years. I continue to see it

every day. I hope to see it for years to come. 

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Re: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 6:47 PM

 

Fast forward three months...... ..A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

In a message dated 9/6/09 2:45:38 PM, THEDUDMAN (AT) aol (DOT) com writes:

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$〓triageD*$〓 ; D*$〓utilization reviewD*$〓; D*$〓health services

misuseD*$〓; D*$〓

> severity of

> > illness index,D*$〓 and D*$〓trauma severity indices.D*$〓 Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

Share this post

Link to post
Share on other sites

Guest guest   

Guest guest
Posted

A proper assessment will keep the patient needing transport from being left at

home. Proper instruction will make for a proper assessment. Proper supervision

will assure good field personnel. I see nothing that would and could not be

fixed by the 3 things mentioned previously.

 Proper supervision will also keep the EMS field free of those that can not or

will not perform to the standards set. 

 I  believe that we as a profession can rise above and beyond what we even do

today. With caring indivduals and learn-ed professionals there is nothing that

TEXAS EMS cannot accomplish. I have seen it over the years. I continue to see it

every day. I hope to see it for years to come. 

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Re: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 6:47 PM

 

Fast forward three months...... ..A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

In a message dated 9/6/09 2:45:38 PM, THEDUDMAN (AT) aol (DOT) com writes:

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$〓triageD*$〓 ; D*$〓utilization reviewD*$〓; D*$〓health services

misuseD*$〓; D*$〓

> severity of

> > illness index,D*$〓 and D*$〓trauma severity indices.D*$〓 Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

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Guest guest   

Guest guest
Posted

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

medic4319 wrote:

>

>

>

> Wow, really... Were none of you taught how to do a proper assessment?

> I knew this was just how it would go... If you don't have confidence

> in your assessment then maybe you should go back to school and learn

> what a proper assessment is and how it's done. STEMI...that would show

> up under a proper assessment?!?! That's one thing I have noticed here

> on the Group... There are a lot of people scared to move the field of

> EMS forward and make it what it really needs to be, not just a taxi

> service. It's going to move forward with you or without you... I

> suggest you get on board and learn the up and coming technology,

> ideas, etc. or get left behind. I-stat machines are capable of doing

> certain level of lab work with results that are just as accurate as a

> lab at a hospital, or the military wouldn't be using them, they will

> eventually become a standard of care in the field. Pull your heads out

> of the sand and look at the big picture. Change is coming, either

> embrace it or run from it... It's your choice.

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS)

> agencies and

> > > > receiving emergency departments. However, no consensus exists on

> the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative

> Index to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health

> services misuseD*$¢®; D*$¢®

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated.

> Results. From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1).

> The NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate

> NPV of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95%

> confidence inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was

> 0.992 and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and

> third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

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Guest guest   

Guest guest
Posted

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

medic4319 wrote:

>

>

>

> Wow, really... Were none of you taught how to do a proper assessment?

> I knew this was just how it would go... If you don't have confidence

> in your assessment then maybe you should go back to school and learn

> what a proper assessment is and how it's done. STEMI...that would show

> up under a proper assessment?!?! That's one thing I have noticed here

> on the Group... There are a lot of people scared to move the field of

> EMS forward and make it what it really needs to be, not just a taxi

> service. It's going to move forward with you or without you... I

> suggest you get on board and learn the up and coming technology,

> ideas, etc. or get left behind. I-stat machines are capable of doing

> certain level of lab work with results that are just as accurate as a

> lab at a hospital, or the military wouldn't be using them, they will

> eventually become a standard of care in the field. Pull your heads out

> of the sand and look at the big picture. Change is coming, either

> embrace it or run from it... It's your choice.

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS)

> agencies and

> > > > receiving emergency departments. However, no consensus exists on

> the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative

> Index to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health

> services misuseD*$¢®; D*$¢®

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated.

> Results. From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1).

> The NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate

> NPV of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95%

> confidence inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was

> 0.992 and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and

> third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

Share this post

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Guest guest   

Guest guest
Posted

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

medic4319 wrote:

>

>

>

> Wow, really... Were none of you taught how to do a proper assessment?

> I knew this was just how it would go... If you don't have confidence

> in your assessment then maybe you should go back to school and learn

> what a proper assessment is and how it's done. STEMI...that would show

> up under a proper assessment?!?! That's one thing I have noticed here

> on the Group... There are a lot of people scared to move the field of

> EMS forward and make it what it really needs to be, not just a taxi

> service. It's going to move forward with you or without you... I

> suggest you get on board and learn the up and coming technology,

> ideas, etc. or get left behind. I-stat machines are capable of doing

> certain level of lab work with results that are just as accurate as a

> lab at a hospital, or the military wouldn't be using them, they will

> eventually become a standard of care in the field. Pull your heads out

> of the sand and look at the big picture. Change is coming, either

> embrace it or run from it... It's your choice.

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS)

> agencies and

> > > > receiving emergency departments. However, no consensus exists on

> the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative

> Index to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health

> services misuseD*$¢®; D*$¢®

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated.

> Results. From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1).

> The NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate

> NPV of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95%

> confidence inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was

> 0.992 and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and

> third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

Share this post

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Guest guest   

Guest guest
Posted

Good discussion on just this topic on this months EMRAP. Well worth

the subscription price!

http://www.theemrapproject.com/

Jim<

Re: Re: Paramedics Cannot Determine Which Patients

Require Transport

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

Share this post

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Share on other sites

Guest guest   

Guest guest
Posted

Good discussion on just this topic on this months EMRAP. Well worth

the subscription price!

http://www.theemrapproject.com/

Jim<

Re: Re: Paramedics Cannot Determine Which Patients

Require Transport

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

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Posted

Good discussion on just this topic on this months EMRAP. Well worth

the subscription price!

http://www.theemrapproject.com/

Jim<

Re: Re: Paramedics Cannot Determine Which Patients

Require Transport

Forgive me for taking only one part of your argument and fisking it, but

let's look at your 12 lead ECG and I-Stat examples.

#1. The Marquette interpretation algorithm used by just about every 12

lead EKG machine misses a fair number of MIs. It's pretty good as far as

specificity, but not so much for sensitivity. So how does one determine

if an MI is taking place, in the face of ambiguous or absent 12 lead

confirmation? You run lab tests.

#2. Except, of course, that the cardiac enzymes that elevate first are

not very cardiac-specific, and Troponin may take 6 hours or so,

post-event, to elevate. So what to do, what to do? Is my patient having

an MI, or not? Does she need to go to the hospital, or not?

This is a conundrum that PHYSICIANS, with ten times our education and

experience, struggle with. Often as not, that physician will order a 24

hour admission, complete with continuous telemetry monitoring, serial

cardiac enzymes and serial EKGs, because HE isn't sure. And he isn't

sure, because he has been schooled long enough to KNOW WHAT HE DOESN'T

KNOW. Conversely, paramedics receive just enough training - and it's a

stretch to call most of it education - to believe themselves capable of

saving lives and stamping out disease and pestilence, but not nearly

enough to make them cognizant of how truly ignorant they really are.

So what makes you think the decision-making process will be any less

fraught with peril when the decider is the bottom rung, barely-polished

turd at your ambulance service whose 20 years of " experience " in EMS

have only taught him some good war stories and the location of all the

fast food joints that give EMS discounts?

Bottom line is, PARAMEDICS DO NOT HAVE THE EDUCATION TO MAKE SUCH

DECISIONS IN THE FIELD, and the fact that you blithely throw out

examples like 12 lead EKGs and point-of-care diagnostic testing in

support of your argument is proof positive of that fact. All the whiz

bang gadgetry in the world is pointless if the person doing it doesn't

have the educational background to accurately interpret the results, in

the context of the patient's current condition.

You want to embrace some coming change, you might start by recognizing

that current paramedic education is woefully inadequate at preparing us

to make those decisions, and advocating for a lot more education before

you push for expanding a scope of practice many medics haven't even

mastered in its current form.

Now if y'all don't mind, I'm gonna go stick my head back in the sand.

The sand fleas don't say things that make my head explode.

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Posted

As a person in favor of denying transport I do feel that we should not deny

chest, abd, or head related calls. Even Doctors with all their equipment have

trouble making accurate diagnosis. The calls that would be allowed denial would

be the minor trauma such as stubbed toe, the sneezed once and want to make sure

its not swine flu, the I just need a ride to the hospital so I can get to my

doctors appointment, the I really just need someone to talk to to help cope (

this one only if you have resources that can come there while you wait ).

The denial process would also involve as much if not more effort than just load

and go so would discourage abuse by that one lazy Paramedic that everyone seems

to know since he is mentioned often. ;)

I would like to see a study on EMS denials based on a system as described above.

If allowed denial of the items even Doctors have trouble with then it is doomed

to show we can not do it. It would also need a better criteria for mistake than

admission to the hospital. For example the stubbed toe might end up needing

surgery, yet nothing about the call required EMS, so admission was not a failure

in this case.

Well just my worthless idealistic thoughts.

Renny Spencer

The Idealistic Paramedic

> > > > >

> > > > > Abstract

> > > > > Introduction. Reducing unnecessary ambulance transports may have

> > > > operational

> > > > > and economic benefits for emergency medical services (EMS)

> > agencies and

> > > > > receiving emergency departments. However, no consensus exists on

> > the

> > > > ability

> > > > > of paramedics to accurately and safely identify patients who do not

> > > > require

> > > > > ambulance transport. Objective. This systematic review and

> > meta-analysis

> > > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > > medical

> > > > > necessity of ambulance transport. Methods. PubMed, Cumulative

> > Index to

> > > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > > databases were searched using Cochrane Prehospital and Emergency

> > Care

> > > > Field

> > > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health

> > services misuseD*$¢®; D*$¢®

> > > > severity of

> > > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> > reviewers

> > > > independently

> > > > > evaluated each title to identify relevant studies; each abstract

> > then

> > > > > underwent independent review to identify studies requiring full

> > > > appraisal.

> > > > > Inclusion criteria were original research; emergency responses;

> > > > > determinations of medical=2

> > > > 0necessity by U.S. paramedics; and a reference

> > > > > standard comparison. The primary outcome measure of interest was the

> > > > > negative predictive value (NPV) of paramedic determinations. For

> > studies

> > > > > 20reporting sufficient data, agreement between paramedic and

> > reference

> > > > > standard determinations was measured using kappa; sensitivity,

> > > > specificity,

> > > > > and positive predictive value (PPV) were also calculated.

> > Results. From

> > > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> > studies

> > > > > selected for full review. Five studies met the inclusion criteria

> > > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > > physician opinion (n = 3), hospital admission (n = 1), and a

> > composite

> > > > of

> > > > > physician opinion and patient clinical circumstances (n = 1).

> > The NPV

> > > > ranged

> > > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > > meta-analysis using a random-effects model produced an aggregate

> > NPV of

> > > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95%

> > confidence inte

> > > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was

> > 0.992 and

> > > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > > determinations of medical necessity for ambulance transport vary

> > > > > considerably, and only two studies report complete data. The

> > aggregate

> > > > NPV

> > > > > of the paramedic determinations is 0.91, with a lower confidence

> > limit

> > > > of

> > > > > 0.71. These data do not support the practice of paramedics'

> > determining

> > > > > whether patients require ambulance transport. These

> > > > findings have

> > > > > implications for EMS systems, emergency departments, and

> > third-party

> > > > payers.

> > > > >

> > > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > > >

> > > > >

> > > > > [Non-text portions of this mess

> > > > > age have been removed]

> > > > >

> > > > >

> > > > >

> > > > > ------------ -------- -------- ----

> > > > >

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