How important is all this education?

[Cory]

The only helicopter unit in Cincinnati is UC Air Care provided by UC hospital, they have two choppers, and are staffed by one emergency physician and one trauma nurse, or just two physicians. No medics or EMT's. And they run a very large amount of calls every day, because UC hospital is pretty much the main trauma center to three large and highly populated counties. I wouldn't doubt if it is one of the busiest air-EMS agencies around, and the standards are very high.

So not everyone will staf medics in a helicopter.

EDIT: There is also usually a resident on board.

 

[Veneficus]

I'd argue that the problem there was the philosophy used (stabilize on scene to a fault) and not the providers. Whether even prompt non-emergent transport would have changed something, we will never know.

Multisystem blunt force traumatic arrest.

I would be willing to bet if she was ejected onto the table at a gathering of trauma surgeons who were already scrubbed in it wouldn't have mattered.

 

[Veneficus]

The only helicopter unit in Cincinnati is UC Air Care provided by UC hospital, they have two choppers, and are staffed by one emergency physician and one trauma nurse, or just two physicians. No medics or EMT's. And they run a very large amount of calls every day, because UC hospital is pretty much the main trauma center to three large and highly populated counties. I wouldn't doubt if it is one of the busiest air-EMS agencies around, and the standards are very high.

So not everyone will staf medics in a helicopter.

EDIT: There is also usually a resident on board.

Metro life flight also staffs 1 nurse/1 physician of some discipline. (usually emergency or surgery)

 

[Veneficus]

3 replies in one read, i think it is a record.

I must respectfully disagree.

Problem here is resources. Physicians diagnostic skills will be better than a paramedic, but the lack of diagnostic equipment (imaging equipment, blood tests) will significantly dampen their effectiveness.

This is actually a bit more complex. Many of the data collection tests are done for defensive medicine, in order to cross the T's and dot the Is to avoid a lawsuit. It is actually uite often that the physicians have rather accurate findings even before all of that stuff is done to confirm suspicions. I have never met a surgeon who required white cell counts to diagnose and remove an appendix. Prophylactic antibiotics are started well before cultures are done. (sometimes by days)

Once when I was working in an ER radiology office, I saw a physician wait for the results of an X-ray to decompress a tension pneumo. It makes you wonder about their reliance on these methods.

There is a large problem with US physician's and medical imaging technology, I would never deny that. There is even an acronym for it.

VOMIT

Victim Of Medical Imaging Technology.

Usually referring to a patient when a physician cannot treat a him without an xray or ct because of seriously lacking physical exam skills or treating the radiograph regardless of pt presentation.

However, a pneumo is not always immediately life threatening contrary to what they teach in EMT/medic class. The xray allows a physician to determine the extent, if it is progressing, and if it can be managed without decompression or a chest tube. I have seen places that do not treat a pneumo until it is >15% on xray.

True to some degree, but still a problem of resources. I can certainly think of situations in which physicians would be able to make a difference, but the things that come to mind involve emergency surgical interventions. Otherwise, they would be severely limited by the equipment held on an ambulance.

I find it to be quite the opposite. The physician can make more of a difference by redirecting non emergencies. Field surgeries, while simple on the front end, simply cutting and clamping and such, are heavy on the OR and ICU ends. It is not a save until the patient is able to leave the hospital with some level of quality function. Patients that die hours or a few days later in the ICU are not "saves."

As well, the equipment on an ambulance can be changed to better suit a physician. A portable ultrasound (like the new one that is the size of a palm) is of far more use to a properly trained physician than it is to a medic. As is the simple stethoscope or an otoscope. as LondonMedic pointed out, an increase in the doses and variety of medications is also possible.

In my county, you don't call for permission, ever. The MD is available anytime for consult, but you wouldn't call unless you needed permission to violate protocol or had an out of protocol patient. The MD interviews all of the medics and trusts that they are competent and professional enough to use their training and skill without his guidance.

A physician with an unlimited license to practice medicine never has such an issue.

They trust that the medics are professional and competent enough to use the skills and training they have, which in many places is based on epidemiology reports that show what will be beneficial to the most number of people with the least amount of risk. You said yourself you need to call to violate or step outside when a patient doesn't fit these predetermined treatments. It seems evident that the medics are not trusted to use their judgement past preset limits.

 

[Foxbat]

A physician with an unlimited license to practice medicine never has such an issue.

Another peculiarity of some ex-USSR EMS systems - they do have field protocols, they are just called "standards" As far as I understand, they apply even to physicians. I've heard EMS physicians there complaining about these standards being obsolete and not always applying to real-life situations. I wonder if other European physician-based EMS systems have anything similar.

 

[zmedic]

I'd like to see some data from those who claim that having physicians in the field reduce costs. I would think that a physician in the ED can see a lot more patients in an hour than one on the street because they can go from room to room and see people who have been all set up by the RNs and techs (in a gown, med list obtained, vital signs etc) The truth is that those people who really don't need to be in the ED, need no blood tests or imaging, are such a quick discharge that I don't think that justifies having the doc in the field.

Now systems where there isn't much ED care, where prehospital patients are seen by the doctor and are admitted directly to a unit thereby bypassing the ED may be a little more helpful. But I'm still not convinced. Researchers are having trouble showing that having a medic on a call over an EMT basic improves morbidity and mortality, let alone having a doc in the field. I'm sure that a well trained physician has a better differential diagnosis, does a better exam. But it would need to be shown that having that take place in the field rather than the ED improves outcomes.

There is also the financial issue, given what medics in the US make and current reimbusements, there is no way that you could pay a physician enough to have widespread prehospital physicians. (Having a full time medical director who jumps a few calls and goes the MCIs is different, they are being paid to be medical director not for their call running) Considering the average ER doc makes somewhere around $125 and hour and the average medic probably makes $20-30, no way in hell massive numbers of medics are going to be replaced by docs.

 

[Veneficus]

I'd like to see some data from those who claim that having physicians in the field reduce costs. I would think that a physician in the ED can see a lot more patients in an hour than one on the street because they can go from room to room and see people who have been all set up by the RNs and techs (in a gown, med list obtained, vital signs etc) The truth is that those people who really don't need to be in the ED, need no blood tests or imaging, are such a quick discharge that I don't think that justifies having the doc in the field.

Now systems where there isn't much ED care, where prehospital patients are seen by the doctor and are admitted directly to a unit thereby bypassing the ED may be a little more helpful. But I'm still not convinced. Researchers are having trouble showing that having a medic on a call over an EMT basic improves morbidity and mortality, let alone having a doc in the field. I'm sure that a well trained physician has a better differential diagnosis, does a better exam. But it would need to be shown that having that take place in the field rather than the ED improves outcomes.

There is also the financial issue, given what medics in the US make and current reimbusements, there is no way that you could pay a physician enough to have widespread prehospital physicians. (Having a full time medical director who jumps a few calls and goes the MCIs is different, they are being paid to be medical director not for their call running) Considering the average ER doc makes somewhere around $125 and hour and the average medic probably makes $20-30, no way in hell massive numbers of medics are going to be replaced by docs.

I don't think anyone was stating that in the Us medics would be replaced by docs.

I don't have any hard numbers, however, there is a movement towards more home care physicians in the US and increased reimbursment for them.

I think having a physician on a response vehicle waiting around for a call is not what I envision. I see something more along the lines of a public health physician with both preventative and home care duties who also responds.

Are you suggesting a direct admit by a physician is not considerably cheaper than a run through the ED first?