Thursday, September 10, 2009

The man is keepin' us down!!! it were...

Today I had a revelation of sorts. Our instructor climbed up on his soapbox about MAST trousers (a soapbox I share, given my hard science background and the overall lack of research that goes into most EMS decisions). Having come to the Promised Land of EMS (as the People's Republic of Maryland would have you believe) from a state that didn't believe in killing thousands of trees every year just to change 3 words in the protocols, I have viewed much of EMS here quite skeptically. From the insistence of people (who should damned-well know better) on flying patients based on their MOI to the hospital that is within visual distance of the accident scene,to new regulations every time the governing body gets bored, to in refusal of the state medical board to allow medics to use medications that are used every day in other parts of the country, I have become heartily tired of the stupidity that runs rampant in the EMS systems around here. Rogue Medic's recent posts have only provided food for thought.

I digress. At any rate, during the discussion of MAST trousers and why we are suddenly prevented from using them, he began railing against a certain segment of the medical community and why paramedics are the only licensed professionals in the entire country (that I'm aware of, please correct me if I'm wrong) that have a group of other professionals over-seeing, passing judgement and making rules for us. I think I've been slowly approaching this particular revelation, but today I got smacked in the head with it, and it makes sense.

To use the examples used in class today, sitting on the next computer over when we take our licensing test is a plummer, and next to the plummer is an electrician. Both of those professionals require a license, with the appropriate test, just as paramedics do. But neither one of those professionals has another person, say an electrical engineer, or a fluid mechanics physicist, sitting over top of them to give them codes and tell them what they can and cannot do, and what pipes or wiring they can and cannot use.

So why is it, that as a paramedic, I will have to defer to some guy sitting behind a desk somewhere, who hasn't touched a patient in decades, tell me that what I do for my patient is the correct thing to do? Why don't paramedics write protocols for paramedics? Why is it that doctors, who many times haven't the foggiest notion about what EMS is all about in the 'real world,' are the ones who say what we can do, what meds to give, and so on? (I admit that there are several exceptions to this, and I'm painting with a wide brush, but let's face the time many docs get to the point in which they are writing protocols, they are generally more politician and businessman than doctor). One person in the class answered that it was because paramedics usually only have a high school diploma, and because you are dealing with 'life and death' situations, which require the higher education of a doctor. He was challenged with the facts that electricians generally have high school diplomas and 2 or so years of education (same as most paramedics in this country), yet they are given control over their own domain. The argument of 'life and death' is a strong one, yet, if the electrician does a shoddy job, and the client's house burns down with the client inside it, is it also a life and death situation? Yes, there are shoddy medics, who do it only for the extra money or quicker promotion potential (in a FD run EMS system) and there are crappy programs out there that do nothing but teach to the test and just churn out as many medics as they can. Quantity, rather than quality, is often the idea.

I had an ER doc (granted, he wasn't a medical director, but in all honesty, what would stop him from becoming one if he wanted to?) once complain that paramedics only gave lidocaine for V-tach, when amiodirone was a much more effective drug. Here was someone who was giving paramedics drug orders via radio, who didn't understand that the state of Maryland does not allow amiodirone to be given under their protocols (not that I can blame them, given it's hideous expense).

So why is it that paramedics are forced to subjugate themselves under doctors? Because the AMA refuses to allow any profession that may challenge the all-knowing doctors. They don't allow nurses to diagnose..instead, nurses are relegated to 'nursing diagnoses' which say nothing important when they say 'the patient is having ineffective breathing' rather than stating the obvious 'the patient is having an asthma attack.' I've had doctors pitch a fit on me for 'diagnosing a patient,' which, given the lack of proper letters after my name, I am prohibited from doing. I have seen, over the past 10+ years, the progressive 'dumbing down' of EMT and yes, paramedics, due to the reluctance to do such revolutionary ideas as 'diagnose.' EMT's are now taught to pass the test, and not question the information they are given. No thinking...just treat.

And yet, what is the solution? Surely the 'dumb paramedic' issue could be solved with more programs that offer a bachelor degree in Emergency Medical Services. It leads (in my not-so-humble opinion) to better providers, as a provider who has been taught to think can better treat the patient. Even now, we are moving in that direction with the influx of Associate degree paramedic programs. I think that, much as nursing has, gradually we will move away from simple 'certification' programs, then away from the Associate degree programs and into the realm of bachelor degrees. Nursing, physical therapy, and several other medical related jobs have traveled the same route. But the problem is how to break free from the over-seeing doctors? They won't ever let EMS go willingly.

I know there are several arguments, but I have to go and will deal with them later...

No comments: