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I discovered that one of the essential historical documents of EMS is available to read online, for free: the famous “White Paper,” formally titled Accidental Death and Disability: The Neglected Disease of Modern Society. This is the document that led directly to the development of the first National Standard EMS Curricula, and EMS’ unfortunate association with NHTSA.
Sometimes, getting a result out of research requires statistics that are almost fanciful. What’s unusual is to catch the authors admitting that they changed their statistical strategy when it turned out their original statistics didn’t give the result they wanted.
A group studied NREMT data to test whether the adage about good EMTs making good paramedics holds true with respect to test pass rates. More specifically, they looked at whether time as an EMT or score on the EMT-B exam were associated with higher pass rates on the exam.
Not surprisingly, people who did well on the EMT-B exam were more likely to pass the EMT-P exam, and the numbers are striking: 81% of people who got at least 80% on the EMT-B exam passed, while only 69% of those scoring 76-80% did, and the numbers get worse as the scores get lower. Whether this is because this represents people who are better EMTs, better at studying, or just more familiar with multiple-guess exams in general is purely a matter of speculation (but probably involves all 3 reasons to some degree). The numbers are a little less clear for time as a Basic, however.
(I will ignore for the purposes of this post that the authors use length of EMT-B certification (calculated from date of NREMT-B passage to first attempt taking NREMT-P) instead of actual time spent working as an EMT.)
|
Years as
EMT-B |
Pass rate
(%) |
| <=1.6 | 62.1 |
| 1.6-2.5 | 65 |
| 2.5-4 | 63.8 |
| 4 | 63.8 |
| AFTER—— | ————– |
| <=1.6 | 62.14 |
| >1.6 | 64.22 |
On their first pass at the statistics, the authors grouped the EMT-B certification length into quartiles, much as they did with the exam scores. When they did this, they flat out admit that there was no statistically significant difference between the groups. They then placed everybody into 2 groups and magically found a statistically significant difference. The raw numbers, both before the switch and after, are at left to give you some idea of what we’re talking about.
The START triage system has been around for a few decades, but most of the research done on it has applied triage retrospectively–which is to say, to patients who have data in trauma patient registries. That makes it really refreshing to see a new study of how START is applied in the real world.
The study looked at the use of the START triage that happened after a train crash (which coincidentally happened about 1 hour before a scheduled countywide MCI drill–talk about timing).
First, the things START was good at in this study: making sure that red patients were transported first (on average, they arrived at hospitals an hour earlier than yellows and greens) and making sure that all sick patients made it into the red category. It was also good at sorting lesser-injured patients into the green category: of 58 patients traiged green, 55 were treated and released within 24 hours.
The one major problem with START actually seems to be that it’s too good at picking up heavily injured patients. It does such a good job, in fact, that of 22 patients triaged red, only 2 truly needed immediate lifesaving intervention, although another 14 were admitted for at least 24 hours. (Part of this might be due to human nature: 7 patients triaged as yellow or red were documented as walking on scene, which technically would have made them green.)
Overall, more than half of all patients were overtriaged by study definitions. This may not seem like a big deal until you realize that local EDs could be swamped with that initial wave of reds–and it could be really, really useful to find a way to make that “red” category more specific. The trick is how to do that without making the triage tool too complicated to use on a chaotic scene.
No, this has nothing to do with physicians in Nevada. Rather, it’s a column I find entertaining about “MD Envy,” a vague affliction of a few EMS providers who really, really would rather be doctors.
I was trying to add an admitted patient’s home meds to her orders this morning, and found a list of the meds on the initial trauma form, but without any doses. This began a search for the proper doses. Did I find them on the paper Home Medication Reconciliation form? The electronic HMR? The transferring hospital’s HMR?
None of the above: I ended up finding the doses on the EMS run sheet.
During my paramedic training, no one ever emphasized that I should collect not only the names of the patient’s meds but the doses. I started doing it a few years into practice, not realizing that someone else having the same thought would one day save my butt here in the hospital. Thank you, Carnegie EMS.
That’s something they don’t tell you when you enter any of the branches of medicine, nursing, EMS, or practically anywhere in medicine and allied health: half of your job is going to be what amounts to customer service. Sick people are notoriously cranky, and since you usually can’t make them less-sick in minutes, getting them to feel as if you’ve helped them–and, indeed, feeling as if you have–usually takes a little bit more than medicine. You can call it “customer service,” you can call it “caring,” you can call it whatever you want–but it’s there. Just simple little things that we might not think of, but that aren’t strictly required: I don’t have to spent 5 minutes of my time showing patients their X-rays on the computer, but it’s amazing how much something so seemingly trivial can mean to them.
Unlike most fables, I’ll put the moral of this story up front: don’t ask for a trauma team if you aren’t absolutely certain your patient needs one–by which I mean “fits the actual recommended ACS/CDC criteria.” (Note especially that “car rollover” isn’t considered a high-risk mechanism. Note also that you are perfectly allowed to take someone to a trauma center for borderline trauma without actually requesting a trauma team.)
It’s OK to ask for a trauma team–like you, I was trained to ask for one when in doubt. But now that I’m spending time on the trauma service, responding to trauma alerts and seeing admitted patients, I find that there is more and more reason to not ask for a trauma team whenever I think I can get away with it.
Put simply, having your patient resuscitated by the trauma team is not a benign process.
Maybe you’re not particularly concerned about the indignity of putting a not-clearly-injured person through public nudity and a rectal exam. Perhaps you don’t even care about health care costs (although since you’re helping pay for someone’s health care somewhere, you really should). However, there are 2 very real medical risks you should worry about if you want to do what’s right for your patient, if your trauma center is fairly typical (as I like to consider ours):
So what to do with all those patients that you think need to be at a trauma center, but aren’t sick enough to need the full trauma team right now? I guess it depends on your system–some places have a mechanism to have a doc (but not a full trauma team) show up upon EMS arrival for a quick glance at the patient. If the facility doesn’t have such a response mode, it might be worth calling medical command and saying the doc might want to take a quick look at the patient (just know that if you make a request like that on a recorded line, you’re kind of tying the doc’s hands–so don’t make such a request lightly). If none of these work, you and (more importantly) your patient might just be totally out of luck, and you both have my sympathy.
Since I am a Palm user, my list of helpful medical programs is entirely Palm based (and will remain so, once Verizon finally gets the Pre). For those of you with iPhones instead (how’s that non-replaceable battery thing working out for you on those long shifts?), one reader has compiled his own list of EMS-related apps.
I had no idea such a thing existed, but it does. I’m not sure how to celebrate such a thing, though–kill a bat? Get vaccinated?
Today, Pittsburgh hosts the first day of the G-20 Summit. And I’m not the only one who’s annoyed.
I’m looking at traffic cameras and the town is dead, as far as I can tell. None of the usual traffic backups are happening. Even more remarkable: there isn’t a single trauma alert on my pager since before 6PM yesterday.
