Clinically speaking, thereís a whole lot of medicine out there that I donít know.
I mean, paramedics like me go though a few thousand hours of training in emergency medical care. We get a few years of classes covering the things we need to know about treating the most common of truly emergent medical conditions. Heart attacks? Check. Strokes? Check. Airway Management and Respiratory Support? Check and Check. We paramedics are experts in the acute medical emergency. If youíre dying, we are well equipped and trained to support you until a doctor and a team of medical people in a hospital can take over your care. If you have a medical emergency somewhere outside of a hospital emergency room, weíre the first people you want to see.
But, what if you have a particularly nasty case of Strep Throat?
WellÖ thatís called ďPrimary CareĒ and it covers a lot of non-emergent medical conditions. Strep throat hurts and it makes a person feel like crap. The times that Iíve chanced to become infected with a nasty strain of Strep ďAĒ itís made me feel like a warmed-over Code Brown Sandwich. It sucks being sick and thatís why people go to the doctor. Patients present to doctorsí offices for myriad reasons. Pink Eye, Influenza, the ďcreeping crudĒ, bronchitis, and gastrointestinal problems are common occurrences there. When I worked at an urgent care clinic we saw plenty of those. Up to two-hundred patients per day came in with just these kinds of complaints. There were lacerations, fractures, and other kinds of cases that came in too. Rarely did we need to call for an ambulance and while we did sometimes advise people to go to the ER on their own, that was rare as well. A good primary care doctor can catch most minor conditions and adequately treat them right there in the clinic, negating any need for an expensive emergency room.
However, the problem lies in actually getting access to a primary care physician to take care of you when youíre sick.
Yesterday, my mother-in-law (I call her ďMILĒ for short) called me up. One of the people she works with had an injury to his fingernail. He tore a good part of it clean off while working out in their warehouse. It hurt, of course, and it was bleeding. Their company is a small five person shop that theyíre building from the ground up. A Workersí comp claim would go right against their small and shared pocketbook and start-ups donít have the cash for that kind of stuff. She wanted to know the proper first-aid for this and was trying to avoid the doctor. He was too. As owner of the company he didnít want to have to pay for it and a fingernail injury just doesnít seem all that severe. Still, it hurt and they were worried about infection. The guy understandably wanted proper treatment.
I told him that fingernails either grow back, or they donít. Eventually it would be fine if he cleaned it with mild soap and water and put a non-adhering bandage over the nail bed to keep it clean and protected. I told him in a day or so to put some Vaseline-based antibiotic cream on it as well to keep it moist and stave off infection.
Donít worry, I wasnít practicing medicine without a license. I have my First-Aid Merit Badge from the Boy Scouts of America and that was covered somewhere in there, Iím sure. However, youíre right to think that fingernail injuries arenít covered anywhere in the National Standard EMT or Paramedic curriculum. We are taught to bandage it up and take it to an Emergency Room.
Yep, if he would have presented to my care on the ambulance, I would have had to transport the guy to the ER for a physician to do what I told him to do. If he refused the $500 (or so) transport fee and the (astronomical) ER fee, I would have had to have him sign an ďAgainst Medical AdviceĒ (AMA) refusal form and could not legally give him any medical advice other than to be transported to the ER.
Fingernail guy didnít have an option for treatment where he was other than to go to the ER. In the area where he was located, there arenít any Urgent Care facilities. There certainly arenít any cheap ones anywhere you go, but their cost is much lower than the local ER he was near. He didnít have an option, so he had his coworker call her son-in-law (SIL) for advice. I gave it, and saved everyone involved a few hundred if not a thousand dollars. Sure, the guy could have called his primary care physician and gotten an appointment a month laterÖ but I would think that as a self-employed small-business owner he probably doesnít have access to health insurance at a less-than-oppressive cost.
A while back, I wrote the piece ďDid I do Good?Ē regarding what I think EMS 2.0 should become. I think that Paramedics should be educated and empowered to step into the realm of primary care and be able to provide primary care in the field. Now to be sure, as Rogue Medic will point out, thereís evidence that states that Paramedics and EMTs are bad at triage and we are not currently equipped with the right education to provide these services at this time. However, I think that educating a group of excellent paramedics to the proper standards, giving them the proper tools, and empowering them with the proper legal authority could revolutionize healthcare.
Every community has a group of paramedics and/or EMTs and nearly every community (I would say every, but I have no stats in front of me) has less-than-optimal access to primary care across the spectrum of patient populations. To me, there is a clear solution that makes sense. Could Paramedics, once properly educated, equipped, and empowered, provide limited primary care services, appropriate triage, and transfer in the field? How about at fixed sites and clinics? We could follow protocols, utilize tele-medicine, and function much as we do now, but with a much lower-acuity class of patients.
Sure, there are Nurse Practitioners, Physiciansí Assistants, and other healthcare providers that can provide these services, but let them work with us as we work with them. There doesnít have to be an adversarial relationship. We all have different training and that one set can be used to compliment the other.†
EMS 2.0 is about thinking outside the box for EMS. Itís about finding new ways to face the challenges. Thinking the way we have in the past wonít fix the problems that it failed to fix before. My belief is that with Paramedics providing Primary Care, we would greatly increase access to care, more properly triage patients to the proper healthcare pathways, save gobs and gobs of money, and just might ďfixĒ this whole healthcare mess without all that legislation and legal wrangling.
Any suggestions on where we begin?