usalsfyre

What about a service like mine, where we provide EMS coverage for the vast majority of our service areas but have three transfer trucks?

For a HEMS service my choice would be.... StarStatMedCareLifeLiftFliteEvac That should cover every common flight service name.

If they're in badly decompensating (the folks with pressures north of 160/100, one word dyspnea, HRs of 130 or 140) it's pretty unlikely. SL NTG absorbs at a rate of around 60mcg/min, so three of them is 180mcg/min. Over at the EMCrit podcast Dr. Weingart says he starts people at this level of distress off at 400MCG/MIN :eek:, quickly backing down to 100mcg/min when he starts to see symptom relief.

You don't want to pop the seal if possible as you'll promptly derecruit any alveoli you've gained. I've been known on severe CHF'ers to dump the require 3 SL NTG under the tounge all at once and then move to a NTG infusion titrated quickly up to 50-100mcg/min.

This is actually the way it should be in my mind if there's not a strong commitment to RSI. RSI is often a semi-elective procedure, but when you have to cric, nothing else will manage that airway.

I am a currently medicated Paramedic with adult ADHD. I've been employed for 7 years as a medic. So it is possible. Finding things to keep yourself busy (I love my iPhone) helps tremendously, as do meds.

What I see is two anecdotal stories involving deaths due to massively bad judgment. In my region alone there's ususally multiple traffic fatalities a week due to, you guessed it, masively bad judgement. When someone can show me an argument about guns that doesn't involve anecdotal stories and the resultant fear, I MIGHT listen....

Agree with what was said before, if you arrest in the wilderness your dead. No reason to even try CPR. I'll go a step further and say if you arrest more than 4-6 minutes from a defibrilator your probably dead, no matter how long that process may take.

Crochity, none of the patients you mention are candidates for treat and release. No matter your personal feelings on the matter, there is an acceptable rate of death. No one is perfect. Some of the "minor" problems you transport because your scared of your own shadow will be released from the ED and go home and die. All you've done is shifted the blame so you can sleep at night. Unexpected death is not negligence, it's inevitable. I'm not sure what rainbow and unicorn reality you live in, but the truth is medicine is practiced by imperfect humans. Mistakes will be made and people will die from them. At some point cost absoloutely has to play a factor, otherwise no one will get any quality of care.

I have no doubt you are, but outside of going in busy EDs and discussing airway control on the patients that need it with the physicians I'm not sure how you'd do this. In a busy system, tight, nonpunitive, corrective QA would work, but tight QA on a couple of RSIs a year for the rural provider isn't enough feedback. Maybe someone else has gone through this and has a way that I son't know about?

I can teach you to pass a tube. Give me a week and I can make you extremely ready to pass a tube. What I can't do is given the current level of education and low clinical experince requirements is teach you the approprite time to knock someone down, vs do an awake intubation, vs use something like ketamine as a conscious sedation aide to intubation vs jumping straight to a rescue airway or cric. It's far more complicated than just listing out indications, and requires a very firm grasp on not only the immediate treatment modality but the expected clinical course once they get to the hospital (meaning looking sometimes a week or more down the road). So despite my earlier comments, y'all are right, it is possible to keep the psychomotor skill of intubation up. The clinical accumen of making the judgement to tube? Much, much tougher, and as much a skill that deteriorates just like the psychomotor part of it.

I've run far, far, far more than 100 calls. Not to mention I've made the decision to stay home vs go to the ED with my own kids. My kids have also gone to their primary care physician for fever, and never has a CBC been run. How oh how did the physician determine if my kid needed to be admitted without a million test? His 2 minute long assesment. Do we need ottoscopes in the truck? Probably, but figuring out otitis media isn't exactly rocket science. So why does the ED do it? Because someone established this overkill as a "standard of care". Ask any EM physician how much of a catch-22 running a CBC actually is, I have a feeling you'd be supprised at the answer. You know what's as bad as a lazy medic who actively seeks a refusal? A dumb medic who can't make clinical judgements based of his assesment and simply transports only starting an IV because he's too farking scared to actually DO anything (this guy sees lawyers on every scene). This guy is number two on my hit list when I take over the world, right after the guy that gets out with the clipboard in hand.

Very well said

Working on a bachelor's degree right now, not sure if I'm going to stay in EMS or go a different direction (very early stages). So, I'm trying to change what I can from inside the system right now.

Even systems and paramedics that do the actual skill of endotracheal intubation well often fail in the "when to place a tube" category. My system has excellent first time and overall success rates. The errors I've seen over and over again here are not failing to place the tube correctly, it's poorly managing them or placing the tube when it very well may be a detriment. Distilling indications down to a list oversimplifies things significantly. Maybe just facilitated intubation needs to go in the hands of a small pool of medics, but then that begs the question, "can these folks be managed more easily with a blind insertion device?" No idea, I'm hospital and not fire-based.

Our services areas sound similar, we have 3 trucks for 850 sq miles. We dump every truck in our station regularly as well. It comes down to how many times do medics perform ETT and it improves outcome vs complicates clinical course? The numbers aren't in US EMS's favor right now. If one patient who needs and ETT gets it and it improves his course vs four who die or have a more complicated course because of paramedic ETT we're not really helping much in the grand scheme. Really analyzing numbers like that is a cold, hard reality that many field medics don't seem to have the stomach for. The truth is some resources are simply not going to be available when they're needed. Their are easier ways of securing airways. Truthfully I'd rather see King airways with percutaneous cricothyrotomy as back up than ETT if the service is not willing to make the commitment to endotracheal intubation.

I think we're arguing for the same thing... I don't refuse transport now even when I know for a fact I'm dealing with a minor complaint. I'm not able to, I HAVE to offer transport no matter what. My argument is, currently Medicare pays roughly $400 for an ALS 1 TRANSPORT. Doesn't matter if it's an IV "just because" or a sick CHF patient getting ready to die, as long as it fits in the ALS 1 category. What if we switched and payed $200 for an ALS RESPONSE and assessment, plus appropriate billing for procedures (x amount for an EKG, x for an IV, ect) and then bill only for your transport mileage. This way you get reimbursed not for your truck, but rather the important part of the response, your knowledge. Plus, the more you do, the more your reimbursement is. Your assessment shows it can stay home? Congratgulations, you've just saved the system a $1k plus ED bill, which helps prove your worth. So how to keep services from doing inappropriate procedures and running up charges? On chart review if a procedure is not indicated it's not reimbursed. In addition, if service "A" has better outcomes than service "B", service "A" can negotiate for higher reimbursement. The part that most don't like about this plan? Paramedics now have to be VERY accountable for their decisions. The "I'm not a doctor" BS no longer flies under this model. Yes, it's a drastic change. Current providers at all levels are lined up against it, as it requires more education, shifts responsibility back on to them, may actually increase "EMS abuse", ect. However, I feel this is the direction we need to go for the good of healthcare and EMS. It's time to join the healthcare community and drop the "public safety" charade.

Your assuming insurance is going to continue to pay for in many cases is a fx awfully expensive taxi. If you'll notice I mentioned changes to the reimbursement model in another post. Our current model is unsustainable. We need to get it changed before it collapses.

Paramedics is general. I've never worked in New York, but from what I've seen in Texas and Virginia we as a whole aren't that good at it. Pretty well exactly what I envision. EMS clings to a "we all do it all" philosophy. If the patient could benefit from intubation and qualified crew isn't available, you do the best you can. Hospitals occasionally end up with two patients that need a particular service at the same time. It's expected to happen. The problem is their are serious issues with experience level needed and skill degradation. If I have one medic covering 4 stations worth of intubations, he's going to get comfortable with the procedure and do it enough to be good at it. If I have 4 or 8 medics doing those, it gets a lot less sure. Aus and NZ currently utilize LMAs for their regular road paramedics and call Intensive Care Paramedics (smaller pool)for patients who could benefit from intubation. I believe Melbourne was the first place to show improved outcomes from prehospital RSI beyond a shadow of a doubt.

So it's a completely made up by me figure, but I don't think it's all that inaccurate. I'm not talking about coming up with a discharge diagnosis, simply determining emergent, delayed (both transported) or able to be directed to other, less expensive treatment options. An example would be say chest pain. Emergent would be a STEMI, delayed would be a 50 YOM with risk factors but a non-diagnostic EKG and non-emergent is the 22 year old with sharp chest pain while coughing after three days of cold symptoms. If we want to start getting really technical, portable sonography and point-of-care labratory testing exist and would give you the tools most seem to think are needed to do this safely. The issue? No reimbursement....

I can't honestly say I consider direct laryngoscopy necessary or even a good idea to put in the hands of the majority of paramedics. Still something useful to have available? Absolutely! But restricted to a small pool of well educated/tightly monitored providers.

Do y'all honestly believe diagnostic services are that important? That the educated provider can't use physical exam and history to determine how emergent the condition is in 99% of cases? Or are you figuring because y'all are incapable of it no one is. The ED is FAR from definitive care in a lot of cases. In things like acute psychosis the ED environment will probably exacerbate the issue at hand. People like Beiber who understand there has to be some level of cost benefit analysis will rise to lead EMS in the future. The era of EMS being "at any cost hero/lifesavers" are over. Unless we are able to SHOW benefit to people uneducated in medicine (which we can't right now) EMS will be deskilled to taxi drivers. Want to stop this and have a say? Get involved in research, push for better education and work on changing our reimbursement scheme so it focuses on services performed and not the expensive as hell taxi service it is right now. Repeating idiotic crap about "saving lives" and trying to maintain the (not working) status quo is only hastening our demise.

Reducate? If your too stupid to realize you need to doccument any time you assess a patient I think the reeducation will most likely be lost on you. Decertification, and don't let the door hit you in the ass on the way out... I agree failure to doccument was probably these folks biggest failing.

Huh? This is hyperboyle and fear mongering it doesn't even border on inetligent debate. Using emotions to guide policy decisions is generally leads to poor policies, no matter what the party. I'm just as pissed of at the Republican tactics in the health care debate. Guns are not a magic self-defense talisman, they are part of a well thought out plan that may include martial arts, non-lethal devices and the biggest weapon of all, your brain. Last time I checked we didn't restrict where anyone can go. I see "gang bangers" in gun shops all the time. It's the price of a free society. As far as where you can take guns? In Texas you can take them a hell of a lot of places. Generally you will never know they are present. No, I don't think that a restricting things like gun types will deter crime. Criminals are generally planning on violating multiple laws anyway? Why are you so afraid of objects that kill far few people than automobiles (which you probably drive daily) do every year? Be afraid of intent, not the object. If someone is "too dangerous" to have a gun, why in the hell are they among free society anyway?

So I guess we need to highly regulate amendments 1 and 3-10 as well?!? The whole point is it's not supposed to be regulated. BTW, if you want to strictly enforce federal gun laws, Bloomberg and his ilk need to be in federal prison for participating in straw purchases during his little Virginia escapades.