America: What Part Of The Healthcare Cost Crisis Do You Own?

By:  The Musing Medic (@TheMusingMedic)

 

Over the past few years, health care expenditure has come to the forefront of American consciousness. Turn to any channel or examine any newspaper headline and you’ll see something pertaining to the rising cost of healthcare. Pundits, regardless of political persuasion, have something to say about the Affordable Care Act, also known pejoratively as “Obamacare”. There is certainly no dearth of opinion on these matters, and numerous entities are blamed for the current “crisis”.  Candidate culprits include big-business insurance companies, bottom-line focused hospitals, and greedy physicians, but…

 

The Players Didn’t Make Up The Game

While these groups do own some culpability, they are not the catalyst that spurred the issue. Rather they played the game in which they are participants. The adage goes “hate the game, not the player”. So who then is to blame for sparking this wildfire of excessive health care costs?

 

The general American populous.

 

That’s right, I said it.

 

Mr. & Mrs. John Q. Public are to blame for the exorbitant cost of modern health care.  At least partially.  And yes, that’s me and you.

 

But how?

 

The Stats Tell Us The Story…

Let’s take a look at some basic statistics:

 

37.5% of American adults are classified as obese

17% of American children are classified as obese

Source: CDC 2010

 

18.1% of American adults smoke cigarettes

Source: CDC 2012

 

80% of American adults do not exercise the recommended amount

Source: CDC 2012

 

Those are some basic statistics regarding three major components of a health profile. Naturally, all three are related to one another–especially in the cause-effect realm (eg lack of exercise can lead to obesity). There is a myriad of other healthcare issues, such as illicit drug use, poor diet, and so forth. Additionally, there are socioeconomic factors such as income, race, religion, and geography that can affect one’s health and even their access to health care. …however, that is another discussion for another time.  Perhaps I’ll cover those in my next entry.

 

Does it cost more to take care of an obese smoker?  Absolutely.

 

This post is all about holding the American public (all of us) accountable for our choices and actions that lead to higher costs.

 

How about we just take into account the three aforementioned modifiable lifestyle choices? All three can lead to significant health issues such as hypertension, diabetes, coronary disease, stroke, heart failure, renal failure, COPD, and more. Any of these conditions lead to adverse outcomes, disability, and (generally speaking) a significant financial cost.

 

Yes, we can say that medical errors cost us all a lot.  (And we should try to eliminate errors!) When a healthcare provider makes a mistake, we do all sorts of things like complain, bring suit, etc.  But listen:  when we’re morbidly obese there’s less wiggle room for errors.  Errors are, arguably, more likely when we require many more procedures than we would have otherwise needed owing to our obesity or other comorbidity.  There’d be no error, or at least we’d have less errors, if we weren’t so large that placing central lines or intubating us wasn’t that much harder.  Yes, healthcare providers (like me when I’m in the field) can get it done, but things would go right so much more easily if we, as Americans, helped out a little.

 

A lot of the trouble is the expectation, from all of us as citizens, that we will be taken care of without any problem despite whatever situation we may have gotten ourselves into.  No matter our size, smoking, or alcohol abuse, we expect healthcare where the procedure that is done to us (for us) simply must go right.

 

Help us (and yourself) out by avoiding lifestyle choices that paint healthcare providers into a corner when they show up to help.  It would make things easier on you and much safer.

 

Aren’t Insurance Companies Really To Blame?

It turns out that insurance companies use premiums to pay a large portion of their customers’ health care costs. The more medical conditions a person has, whether by genetics, lifestyle choices, a combination of both, or just dumb luck, the more likely it is that the patient is going to need medical care. And that medical care costs money. So, as the American population continues to go gray (i.e; baby boomers), the greater the need will be for medical care. Add in that there is an ever-rising number of persons under the age of forty-five with cardiac disease, respiratory conditions, and diabetes, and the issue compounds. Insurance companies have been forced to increase premiums to keep up with the needed expenditure. Additionally, hospitals and physicians have needed to raise their prices to keep pace and maintain staffing and proper equipment.

 

Is the story that simple?  Not really.  But the fact is that a sicker population means more expense.  Maybe insurers would have less of an excuse to raise prices if we all were just a bit healthier…

 

Imagine if those statistics mentioned previously were halved. What would happen? Would health care costs decrease?

 

I’m not sure I know that answer. More importantly it’s a moot point. You could hire an actuary to run those numbers along with economists, financial advisors, and health care administrators and still not have a clear cut answer. What is done is done.

 

…and I am not sure there will be anything but rising costs in the future. Like I mentioned though, this entry is not about finding an answer. It is about pointing a finger at the main offender, the ones who caused this “crisis”. That would be Americans like you and me.  (Hopefully, for your health, not you specifically!) Before citizens blame everyone around them, they should look in the mirror and ask themselves if they have contributed to the cost of health care in a negative or positive way. I doubt many would be pleased with the honest answer.

 

Agree?  Disagree?  Let me know beneath.

 

Till next time

 

The Musing Medic

Would You Like Fries With Your Healthcare?

By:  The Musing Medic (@TheMusingMedic)

 

One Night, While Working Triage…

Most of my professional time is spent in the emergency department, specifically floating on the floor or manning the triage office. Of those two places, my favorite is easily triage. There are a fair number of my colleagues that don’t care for triage for a few reasons. The most commonly cited reasons I have heard are too many patients and fear of missing something. While I can respect and understand both those reasons, I think triage houses prime examples of the patient vs customer debate.

 

I was covering triage for an entire shift the other day and was seeing patients at a high rate, hovering around eight patients per hour on average. Like most days, the majority of these patients were “fast-track worthy” and didn’t constitute a true medical emergency. In other words, they have an inconvenience-type problem rather than an emergency.

 

A Dental Pain Patient Complains We’re Not As Fast As Fast Food

So I am triaging one patient after another with a majority going from the triage office to the waiting room. The entire department was full that day and the non-urgent cases were forced to bide their time patiently. At one point, a patient who had presented with the complaint of dental pain became somewhat displeased with the length of time they had been waiting, which by my calculation was just less than an hour. This person started out relatively understanding and pleasant but then progressed to downright rude. But that isn’t unusual. We see this all the time. What really stuck with me was when they compared us to a popular fast food restaurant. They mentioned how they never had to wait as long for their dinner as they did to get a medical examination. How do you respond to this?

 

There is part of me that wishes I could have seen my facial expressions in response to this ridiculous comment. I think any health care worker would have the same response. My handing of the response was as good as could be expected. I conveyed my understanding but kindly refuted the notion that an ED is similar to a fast-food enterprise.

 

More importantly, this illustrates what John Q. Public thinks the ED does on a daily basis. We are not open 24/7 for every trivial complaint. (Some dental pain patients are very legitimate, yet this one was well known to use a dental pain complaint to attempt to obtain unnecessary narcotics.) We exist to treat diseases and injuries that are either acute or exacerbations of chronic conditions that could result in loss of life or limb.

 

The ED Isn’t A Fast Food Restaurant

The ED isn’t a fast food restaurant.  Do you know how I know?  Most fast restaurants aren’t open 24 hours and serving a burger is very different than working on someone who is near death.  I mean, come on.

 

When did patients think they became customers who are entitled to the same customer service that any fast-food restaurant or retailer extends to those who purchase their goods? Why has it gotten to this point? Who allowed it? And what do we do to curb this mindset? There is an issue of expectations that need adjusting.

 

Want the same level of speed and customer service you get with your burger at noon?  Vote for the government to reimburse us so that, at midnight, we have fresh staff who are just waiting to take your order.

 

Want outcomes that are perfect?  Require us to make only 7 meals instead of caring for hundreds of different conditions that vary by the patient’s age, sex, race, level of non-compliance, and a host of other factors.

 

…or with every dose of morphine we administer should we ask if they would like fries with that?

Opportunity Costs: PA Or A Physician?

 

By:  The Musing Medic (@TheMusingMedic)

 

 

Blast From The Past

 

During my sophomore year of undergraduate school, I was required to take an economics course. Now, I don’t remember much from that class, but I do remember one particular concept: opportunity cost. It’s a simple idea really. Assuming the best choice is made, the opportunity cost is the lost benefit–it’s the benefit(s) you would have had if you chose the other option.

 

For example, pretend you can only eat at one restaurant on one particular night. By choosing Restaurant A, you cannot have the food from Restaurant B. The cost of choosing A, then, includes missing out on the food from Restaurant B…which may or may not be better than the food at Restaurant A.

 

Choosing PA School Over Medical School?

 

Let’s apply this idea to choosing an occupation within the field of Medicine.

 

Let’s say a student has been accepted to both medical school and a physician assistant program. Choosing to attend medical school means at least 7-10 years of formal didactic and clinical education. It means incurring extensive amounts of debt from student loans. There is also delayed gratification in buying a house, new car, or having a family. By choosing this route, your “cost” includes what the PA program/profession offers such as shorter training, less debt, and lateral mobility within the profession.

 

Of course, choosing the PA route also has its own set of “costs”. Choosing PA means less autonomy, simpler cases, lower income, and initial limitations in medical knowledge. You may be a competent provider that works similarly to a physician but you will never be the expert. And, the truth is, one day you will be a twenty year veteran PA who will be supervised by a newly minted attending who is younger than your own children. Talk about a kick in the ego!

 

A Call To Action:  Tell Me What You Think!

 

Why do I bring this up?  It’s because I am currently in this position. If I had to choose right now, it would be medical school hands down. But if we examine the current climate of medicine as well as the future, the PA role may be a more economical and conservative one to embrace. As Medicine continues to grow as a multi-billion dollar business, there will be more impetus on hospitals and health care companies to lower costs. This puts the PA in prime position to move up the professional ladder and have continued employment opportunities across all specialties. That is not saying physicians will be without opportunity, as they will always have the top position in the medical hierarchy. (At least that’s how it looks right now.) But I can see their roles progressing to a more supervisory position over physician assistants who carry out a majority of the tasks. Perhaps, in a busy ED, you will see one or two physicians overseeing three to five physician assistants.

 

Now this is all speculation…but I’m not alone in thinking this way. In Doctored: The Disillusionment of an American Physician, Sandeep Juhar (an interventional cardiologist) comments extensively on the state of Medicine in America and its depressing trend of moving away from doing what is best for the patient and more towards customer satisfaction. He illuminates studies done over the past decade that indicate a number of physicians regret their career choice at the present moment and would steer their children and those interested away from the field. Such a depressing thought.

 

The opportunity costs riding on my decision really are very high no matter which direction I choose. I desire the autonomy and knowledge but at almost thirty years old, with ten years as a medic under my belt, the prospect of another decade of school is daunting. Throw in the overwhelming number of studies highlighting the unhappiness of American physicians in the 21st century and the conservation decision seems more and more clear. Still, potential regrets exist and the only thing I can do is attempt to minimize them.

 

…so, what do you think?  Are you a PA or physician?  Let me know what you decided and why!  Would you do the same nowadays?

Update Your Medical Knowledge Base!

By:  The Musing Medic (@TheMusingMedic)

 

Medicine is a fickle creature. It is equal parts art and science. The idea of perfection in the field is quixotic. Yet we continue to move forward with research and adapt our practices to the evidence…or at least we should.

Unfortunately, as we continue adding years under our belts, we move away from reading and updating our knowledge. I think this is true of any profession outside of academia. We become complacent to a degree. The only time we change our thinking is every four years or so when our certifications are in need of renewal. New information presented in the renewal course is blended into our practice. But outside of that and the occasional trade publication, we move along and do what we know. Is that ok?

Modern research has led to the revamping of many practices that were once considered dogma in clinical medicine. Two of my favorite ones that should have gone by the wayside (but have not) are the use of Trendelenberg positioning and the consistent use of supplemental oxygen in acute coronary syndromes. Evidence collected from completed and ongoing research has indicated both of these time-honored treatments, as benign or helpful as they may seem, are in fact detrimental to patients and influence morbidity and mortality rates.

Now I could have easily provided information regarding the aforementioned studies but since this is an article dedicated to keeping oneself updated, I think it would be hypocritical…and so I’m stopping here.

This, then, is your challenge:  go and find the information for yourself. Brush up on those research skills.  Tell me if you agree or disagree with my thoughts on Trendelenburg and supplemental oxygen in ACS as described above.

A Heated Argument About…Pens!

 

By:  The Musing Medic (@TheMusingMedic)

 

So I took a look back over my previous entries as well as those from other authors and it occurred to me that we could use a moment of levity. Allow me to address a topic that is both light and refreshing yet pertinent to all my colleagues.

 

A Heated Argument About The Right Tool For The Job

 

This is a hot topic in my workplace, particularly with physicians. The idea for this post came to me the other day when an attending and myself got into a heated discussion over what pen was the best type to use in our particular department. Now to many of you this is a moot point as EMR has become quite ubiquitous. But sadly, we continue to use paper charting (at least for the next few months). So choosing the correct writing utensil, in this case a pen, is actually pretty important.

 

I suppose a number of my colleagues will pick up whatever black or blue pen is stocked in the supply cabinet. Usually these are ballpoint pens with a cap rather than the click-type pen. These are not usually of the highest quality and are purchased in bulk. If one gets lost or covered with some bodily fluid, just chuck it in the garbage and grab another. But I have to say, the writing experience over the course of a twelve hour shift is terrible. These pens drag and blob, leaving unsightly marks all over the place. Additionally, the ink can wash out and be removed from official documents fairly easily so there is a security factor to consider. I can’t say I have much love for these all-too-common office staples.

 

On the other end of the spectrum are gel pens. Typically these pens are smooth and reliable. Very little residual ink stays on the tip of the pen and most are safe enough to use on official documents without risk of washing the ink out. I can see why those with the ability to prescribe prefer to use these. My only complaint is the ink runs out quickly and they are a bit more costly. Still, they are leaps and bounds above ballpoint pens.

 

There are a few other types of pens that exist but are less common. One is of course the classic rollerball pen. Think of a Pilot Precise V5 or V7. The ink is nice and dark with smooth writing. But these tend to feather or leak and are not safe for airplane travel as the pressure change causes the pen to leak ink all over the place. The other type is a fountain pen. I know a few people who use these but considering the cost and efficiency of using one in a busy ED, I think there are much better choices out there (however, I do use fountain pens away from work).

 

If I Had To Choose Just One Pen

If I had to choose one pen to write with it would be an advanced ink pen. These pens combine ballpoint and gel ink together. What you get is a smooth writing pen with dark ink and security. They cost a little more but the ink cartridge lasts a good while. These are fairly new on the market but a few of the most well known are the uni-Ball Jetstream, Pilot Acroball, and Papermate Inkjoy. But I don’t use any of these on a regular basis.

 

No, I use the Cello Topball 0.7mm in black ink. These pens are designed in Germany and manufactured in India. The pen is lightweight and has a needle tip. This allows for fine, precise writing. The ink is smooth and dark, composed of the advanced hybrid ink I previously mentioned. They are hard to find in the U.S. but can be ordered online.

 

I can’t believe I just wrote a whole article about pens but I think a little levity and banality is a welcome distraction from our normal topics.

 

Please share your favorite pen in the comments section.

 

Next week’s article will focus on Trendelenberg position and its utilization.

 

Till next time

 

The Musing Medic

 

Distance Education Is Legitimate

 

By:  The Musing Medic (@TheMusingMedic)

 

Hey, Much Of Education Is Inefficient

 

Let’s cut right to the chase and admit that education is inefficient. The amount of time spent on non-productive activities is staggering. In my experience, most of the wasted time is spent in the actual classroom setting. The reasons for this are varied, but addressing these issues is most likely an exercise in futility. What we can discuss, however, is the adoption of the ever-growing trend of distance based education and its appropriate utilization.

 

Distance Education Isn’t The Correspondence School You May Remember…

 

We all remember correspondence courses offered in fields such as medical transcription and private investigation. Late-night television was littered with ads for learning “horticulture at home”. Most of these courses were not for college credits and were generally not of the highest quality. Now fast-forward to the modern day, where we find that a number of reputable universities are offering college courses in an internet-based format. Some of these universities are regional, lower-ranked schools while some are Ivy-League, such as Harvard and Princeton. So how do these internet-based courses differ from the traditional brick-and-mortar classroom?

 

They Are No Different.

 

Okay , okay–so that may not be entirely true in the literal sense. Students enrolled in distance learning courses do not travel to a campus or sit in a classroom for a lecture. Nor do they have face-to-face interaction with professors or other students outside of the online video chats or virtual classrooms used by some programs. Outside of these few differences, there is almost nothing to distinguish between the two learning environments.

 

Consider how internet-based courses rely heavily on recorded lectures and textbooks. Professors generally will provide lecture notes in PDF files or powerpoint slides. Usually there is a class discussion board where students are required to discuss topics addressed in the course. Quizzes are taken online with some being open book and some are not. Also, assignments are e-mailed to the professors if required. As for exams, they are administered via proctor. This proctor can be at a local college or through an online proctor that utilizes a webcam to make sure no cheating occurs. The takeaway point here is that the material presented is exactly the same regardless of how the course is delivered, and modern courseware allows for both interaction and discussion.

 

As a student who has taken numerous internet-based courses, I think there plenty of advantages. Since some of these courses have no concrete class times, there is more flexibility.  That makes for a great option for those of us who are working adults or deal with the chaotic schedules seen in healthcare. There is no travel time which saves fuel and money. Professors that are boring or talk slowly–no problem! Just play the recorded lecture at 1.5x the normal speed. And no need to worry about in-class distractions such as texting or whispering. Just set up a home office and you’re good to go.

 

If there is a downside, it is that students need to be self-motivated and disciplined. Students need to setup a workspace that is conducive to learning. Eliminating distractions such as cell phones, televisions, etc., is key for success.  Additionally, a schedule must be created and adhered to strictly. Getting behind in a distance course is not going to lead to a good grade, or, more importantly, good learning.

 

Now Why Did I Bring This Topic Up On A Medical Blog?

 

…because medical education, at least the didactic portion, is no different. There is this old-wive’s tale that students can only learn when presented material in live lectures. This is absolutely not true and potentially detrimental to retention. Studies have shown that most students have an attention span of only twenty minutes before knowledge retention falls off precipitously. Unless professors in a traditional classroom are going to give breaks every twenty minutes, they are wasting a lot of their energy. And since this isn’t likely to happen, traditional lecture-based courses are somewhat ineffective. With all this being said, I realize that some medical schools have no attendance requirement. All lectures and lecture slides are provided on a centralized server for download and viewing. This allows for a better utilization of time and resources.

 

All of this comes down to one thought for me:  the delivery of educational material should come in multiple formats. Be open to the various methods of learning and good things will come.

 

 

P.S. I should mention that I have contacted a number of medical school admission offices to ask their opinions on distance education. A resounding number had favorable opinions and were no less likely to reject a student because of it. Which is a good thing to me as an applicant as more than one of my prerequisite courses was taken via distance education through an osteopathic medical school (!)

 

Questions, comments, thoughts on distance education and it’s place in healthcare?  Let me know!

Cover Your…The Idea Of Defensive Medicine

Cover Your . . . The Idea Of Defensive Medicine

 

By:  The Musing Medic (@TheMusingMedic)

 

Let me preface this article with a disclaimer:  I am not a physician nor do I claim to be one. The thoughts in this article are based on anecdotes and experience. My current education and training do not qualify me to do anymore than make observations. Hopefully this article will spur some discussion on the topic.

 

So What’s The Topic?  Defensive Medicine, a.k.a CYA Medicine.

After almost four years in a busy suburban ED, I have been witness to multiple instances of physicians practicing defensive medicine. Let me tell you, it doesn’t take a physician to witness what constitutes defensive medicine. But it may take a physician to know when defensive medicine is justified.

 

My Question Is:  “When Is Defensive Medicine Justified?”

 

I always thought the gold standard was to be evidence based medicine (EBM). After doing a little research, the actual percentage of EBM utilization hovers between 15-30%. That means more than 70% of clinical decision making is not evidence based. Why is this? Is it due to the litigious nature of modern Medicine? Is it the fear of missing a diagnosis resulting in a poor outcome?

 

These are questions that many of the ancillary staff ask ourselves, amongst ourselves. We discuss them in hushed tones, though some may be more willing to ask the physician “why’d you do that?” But, in my experience, many physicians view this as questioning their decision making or clinical prowess. That isn’t the idea behind the question though. Medicine is a complex amalgam of science, psychology, business, and customer satisfaction. Those of us without the medical school education and residency training are not privy to this information but we still want to know why. I think communicating these thoughts and ideas are beneficial to all involved.

 

Let Me Provide An Example From A Recent Case…

 

(If you don’t speak Medicine for some reason, ask a friend to translate.)

 

63 y/o F presents with left sided rib pain and left shoulder pain that worsens with movement x 24 hrs. States she fell while playing with grandchildren, landing on left side. PMHX of HTN, hyperlipidemia, and COPD.

 

Attending MD orders workup for r/o MI with admission to chest pain unit. Admission is out in prior to any testing.

 

Testing was within normal limits. ECG was NSR with no ST changes from previous ECG. Enzymes were all normal. CXR was that of a COPD patient. No rib or shoulder injury noted on films.

 

Never once did I get the impression this patient’s complaints were cardiac related. My thought was the patient suffered a MSK injury due to the fall. The onset of pain coincided with the fall. The pain worsened with movement and was localized to a very particular area. The patient had no other symptoms such as nausea, diaphoresis, etc.

 

When I asked the attending why the patient was being admitted to the hospital for r/o ACS, he stated “I have no way to tell if this pain is from the fall or not”.

 

Horses–Think Horses!

…Actually, you do. The puzzle pieces add up. Like I mentioned before, think horses when you hear hoofbeats not zebras. There were a hundred pieces that fit together. But he went another route and I am still asking myself why? What did he see or think that I didn’t?

 

But if I had to guess, he was practicing defensive medicine. Maybe that was the safe choice. I can’t answer that. But would’ve practicing EBM here resulted in a different disposition. I think it would.

 

This is a topic with no black or white answers. But discussion is possible. Feel free to leave some comments and provide your own thoughts, stories, or criticisms.

 

Till next time,

 

The Musing Medic

Moving Forward: Legitimizing EMS

Moving Forward: Legitimizing EMS

 

musingmedic

 

By:  The Musing Medic (@TheMusingMedic)

 

Anyone who has spent time around me in the professional setting knows I am critical of EMS with respect to the education involved. Every shift I am constantly reminded of the problems with the types of paramedics we are churning out. But, until now, the most I have ever done is verbalize my thoughts to those around me. Well…that’s not totally true. I have also worked with paramedic students and tried to impart to them the necessity of taking their job seriously and doing it the right way. What other steps can we take to improve the level of professionalism and education while we advance the field?

 

 Increasing educational requirements is a start.

Currently, most paramedic programs are certificate or diploma programs. If we want to gain professional traction, we need to move towards at least an associates degree requirement. This would legitimize the profession a little more. Requiring actual college coursework such as anatomy, physiology, and other sciences would lead to an increased understanding behind disease pathology. Additionally, it would help push forward for an increase in salary.

 

Next would be recruiting and attracting the right types of people.

Talent management is key in any organization. We should be actively seeking persons who are not interested in being a hero but who are interested in treating patients, from the sick to the not-so-sick. I know many a student who is working on their paramedic certification because the fire service they want to work for requires it. Look, I don’t want these types in my field. If you are not interested in the medicine and it is not your passion, walk away.

 

Eliminate volunteer services except in underserved areas.

How often do you find nurses or physicians volunteering their services? Sure they may volunteer for special events, health fairs, or mission trips. But volunteer EMS agencies provide 24/7 coverage for certain areas. This is bad for business. What does it say about our profession if we can get people to do it for free? Moving towards all paid services is one way to help provide credence to our field.

 

I realize that some of these thoughts/opinions will be poorly received, but, frankly, it needs said. We in the EMS community continue to be our own worst enemy. Change will only come from within and there are enough of us to make that change.

 

Comments?  Ideas?  Replies?  Let me know beneath.

 

Keep It Simple: Patient Assessment in EMS

 

By:  The Musing Medic (@TheMusingMedic)

 

These Two Ideas Keep Me Out Of Trouble

Whenever I take on a new paramedic student as a preceptor, I have two pieces of advice:

 

  1. There is no good treatment without a good assessment
  2. Occam’s Razor: With all things being equal, the simplest explanation is usually the right one

 

The question is how do you utilize these two tidbits of knowledge?

 

Keep It Simple.

 

In the pre-hospital setting, the paramedic is thrown into the unknown. We are expected to walk into an unfamiliar environment where we will assess, diagnose, and treat a complete stranger.  Our training prepares us to recognize and manage numerous pathologies of differing presentations. Everything from medical to trauma, pediatric to geriatric, walking wounded to circling the drain.  Just like our more well trained EM physician colleagues, we are expected to manage whatever comes through the door. Doing this requires the ability to perform a proper assessment of the patient and situation.  So how should a proper assessment in the pre-hospital environment go?

 

During my patient encounters, I focus on looking and listening.  Look at the patient for signs and symptoms of disease processes. Additionally, look at the patient in the context of their past medical history and current medications.  It is also wise to view the patient with regard to their environment, living situations, etc.  Most important though is to listen to the patient.  I don’t mean lung sounds or cardiac auscultation only.  Listen to their story closely, paying attention to the details.  The patient will tell you what is wrong with them. Then connect the dots between looking and listening.  Doing this, a very simple plan of attack, will always lead to a good assessment.

 

What about the common pitfall of misdiagnosis?  How can paramedics avoid misdiagnosing a common condition as a more obscure medical issue?

 

When You Hear Hoofbeats, Think Horses Not Zebras.

 

Zebras is common term in medical lingo.  They are rare, esoteric conditions or diagnoses that are infrequently encountered.  We learn about these conditions during didactics and may even encounter them at some point in the course of our career.  But if we see one hundred patients with similar signs and symptoms, the likelihood that one or more has the rare condition is between slim and none.  So keep it simple. Focus on the most likely cause.  Let the looking and listening skills mentioned previously guide you to the most likely medical issue.

 

If you keep these two thoughts in mind during your patient encounter, the best care will ultimately be provided.  It will also help avoid both overreacting and under reacting.  An even keel is the way to go.

 

Till next time

 

The Musing Medic

To Stay Or Go: Paramedicine As A Career

 

By:  The Musing Medic (@TheMusingMedic)

 

The Grass Is Always Greener

Most everyone is aware of the old adage “the grass isn’t always greener on the other side”.  And this rings true when considering a career in EMS versus moving up the medical hierarchy to another profession within the field.  I have made it no secret that my end game is becoming a physician but I certainly have considered other avenues.  But why should a paramedic consider a change of scenery?  I have identified the two reasons that make the most sense to me.

 

One Important Reason To Consider Is Finance

Probably the most obvious choice is financial considerations.  Paramedics and other pre-hospital workers earn a paltry wage that forces us to work two or three jobs with different services.  Around the Pittsburgh region, it is safe to say the average hourly wage is $15.00, give or take a dollar or two.  If a paramedic was to earn their RN certification, this would boost their hourly wage to around $22.00 to $25.00 as a brand new nurse.  Considering the average number of hours worked per year is a bit north of 2,000, that adds up to an additional $20,000 per year.  And that is just working one full-time job.  If they add on a part-time or per diem job, that number rapidly increases.  So less jobs held and increased wages is a solid reason to move from the paramedic to RN.

 

Obesity Epidemic Impacts Decision

Another consideration is the physical strain working as a paramedic puts on the body.  Climbing in and out of the truck, working in confined spaces, pushing, pulling, and lifting patients in awkward positions.  And let’s just put all the cards on the table here and mention that there is an obesity epidemic in the United States.  With a direct correlation between obesity and medical issues, it is no wonder that a significant number of scene runs involve a patient who is classified as overweight or obese.  Regardless of the technology available to pre-hospital crews, there is still a significant amount of lifting and the body can only take so much before it starts to break down.  Lower backs, knees, and shoulders seem to be the most common.  For a happy retirement it may be best to walk away from the pre-hospital environment before you are forced to limp away.

 

So What Are The Options Beyond Paramedic?

So what options are out there?  Well the quickest and most readily available path out of the pre-hospital world is nursing. Training is less than two years for a diploma or associates degree. There is a lot of versatility in the RN degree and the pay is certainly attractive.  But I think it could be difficult from moving from a very autonomous position as a paramedic to a position where autonomy is diminished and orders carried out.

 

PA Is An Option

Another option is Physician Assistant.  These mid-level providers are trained in the medical model and working in collaboration with an attending physician.  They diagnose, order tests, prescribe, and more. Physician Assistant programs are typically masters level so a bachelors degree is required first.  I think this is a solid forward move for seasoned paramedics.  The pay is fantastic at around $90k a year on average. Autonomy exists in spades typically but there is always a physician to bounce ideas off and consult with.  It seems like a logical extension of paramedic training.

 

Some Additional Options

What I left out were two other options; Nurse Practitioner and Physician.  I left these out because NP is an extension of nursing and being an RN is prerequisite for advanced practice nursing.  And I left out medical school because the duration of training and costs associated, both financial and non-financial.  After a certain age, the cost benefit declines sharply.

 

None of these options are the magic ticket to happiness but I think they are viable options for advancement and personal satisfaction.  So while the grass may not be any greener, maybe there is just more grass.

 

I’d be okay with that.

 

Till next time

 

The Musing Medic