Bieber

"With the help of emergency medical services members". Nice. Real nice.

We have intubation per provider discretion, no requirements to tube if it's code blue, and I average about one tube a month more or less. No other opportunities for OR intubation practice, dubious whether or not we could get them to pass Fred the Head around, and we're saturated with a high number of paramedics (x2 per truck) plus we have two medic captains per shift who race to every critical call (and who love to intubate). No RSI. So yeah, it's amazing that our intubation success rates are as good as they are. Given that it's unnecessary in the vast majority of code blues, and we have increasingly more successful means of airway management for serious respiratory conditions, as well as the difficulty in trying to keep over a hundred paramedics competent in it, I wouldn't be surprised if intubation gets pulled for everyone but, say, the medic captains within the next five years.

Had this scenario come up recently. Motor vehicle versus motor vehicle, with three victims in the second vehicle: father, young child son, and infant son. Young child son was dead, but fire had started CPR which we continued for a few more minutes. I got father and infant son packaged and loaded it up in our truck (a second unit took the driver of the first vehicle), and we terminated resuscitation on the young child son on scene. Father had seen us working on young child son, and was extremely distraught en route to the hospital. He repeatedly asked us about young child son and we just told him that another crew was still working on him. We let the hospital know and they had a chaplain give him the bad news--which, from what I heard, left him screaming loud enough for the whole hospital to hear it. For the sake of infant son, and for the sake of allowing us and the hospital staff to do our jobs and take of father and infant son, we chose to withhold information that he had a right to know. Maybe it was right, maybe it wasn't, but I consider our first duty to be to tend to the health care needs of our patients, and like Dwayne said, while "always tell the truth" is a good rule, it really isn't always the best medicine--and in my opinion, the most important thing at the time was delivering good medicine.

ERDoc, I completely agree. Perhaps going off onto a different tangent than what this thread is meant for, but what would you consider an appropriate educational level in order for paramedics to safely refuse transport to those patients for whom transport is not necessary?

I had a talk with our medical director the other day after one of our medics suggested that we broaden our spinal immobilization protocol to include ALL neck and beck pain (as opposed to only pain over the spinal processes), and I was pleased to hear that our medical director is looking in the direction of using the boards for patient movement alone as opposed to using them as immobilization devices.

I think so, Dwayne, but unless the doc's doing it pro bono, I doubt the average individual (especially if they work for EMS) could afford to pay for the doctor's medical direction.

Saw it too. I actually wasn't as offended as I thought I'd be. It's atrocious, but more and more I'm becoming less concerned by the layperson's perception of us and more concerned by our own efforts (or lack thereof) to elevate our own profession. Still, it is by far the worst description of a paramedic that I think I've ever seen.

There've been some good replies here, so I'll just add one small thought: "In other news, an EMS instructor has been placed on administrative leave today pending an investigation into allegations that she allowed a student into an EMS program knowing that the student had an addiction to pain medications. Other department staff state that EMS students must perform clinical rotations as part of their education and that they routinely have access to narcotic medications. They also state that it is against their policy to allow students into the program who have a current ongoing issue with drug abuse. If found guilty of these allegations, the EMS instructor in question could be terminated and have her instructor license pulled by the state board of EMS." "In other news today, a local EMS program was criticized today by a student hopeful who was denied entry into the program. The EMS instructor for the program stated that the student in question has been fighting an ongoing battle with drug addiction and explained that she elected to defer the student's enrollment into the program until the student had been through a drug rehabilitation program and medically cleared. Other department staff state that it is the department's policy to refuse entrance to any student who currently abuses drugs, and note that students must complete clinical rotations as part of their education during time which they may have access to narcotic analgesics. More on this story later." Which headline can you live with? Furthermore, which path has the consequences you can live with? I can pretty much guarantee you that it will be easier to publicly defend yourself for erring on the side of patient safety than it would be to defend why you let someone you're familiar with--and who you know has a problem with drug addiction--into a situation where he could further abuse drugs and possibly harm patients. Take care.

Were you being paid to provide medical service? The law cares if you're being compensated to provide medical service, not what you have on your vehicle. The article below is pretty informative: http://theemtspot.com/2009/06/23/what-is-the-duty-to-act/

So, my partner and I are getting a paramedic student tomorrow and will be serving as his preceptors throughout his internship (~3-4 months). It's crazy to think that I will be teaching a paramedic student, and even crazier to think that I was a student myself not so long ago back in 2010. So, any advice? Tips? Recommendations? Lessons you've learned along the way?

We have had a very high level of gun violence here lately, so the issue is hot in my area. It's a complex issue and like Chris pointed out, there are countries with high gun ownership and low crime rates and countries with low gun ownership and low crime rates. I tend to agree with him that it seems to be a cultural issue. I'm not sure what the solution is, but I tend to cringe when I hear people promoting more guns. Anybody have any hard numbers on the actual incidence of crimes successfully prevented/stopped by legal gun owners? I agree with ERDoc on gun licensure, although I admit that I don't know how efficacious it would be. I also tend to agree with what the President said about how assault weapons belong in the hands of soldiers, not civilians.

You can use the adult spine board, or the KED. We have the Pediatric Immobilization Device, which is all right but only works within a certain height/weight range. I once put a fourteen month old in a short vacuum splint. I've used a KED without a board too. It's good for those patients who are nauseous/vomiting who you really don't want to lay flat.

Nope. Competent patients have the right to refuse treatment. Simple as that. Furthermore, what was the patient's end outcome? Did he suffer any adverse sequelae as a result of the blood accumulation? How quickly did it accumulate to the point of being appreciable? Minutes? Hours? Days? Would either your or the hospital have discovered the accumulation of blood if he had been transported? If so, what would they have done about it? Anything at all? Would they have discharged him before the condition occurred? If it took hours, would the hospital had even held onto him long enough for it to develop? What I'm getting at is... was there any benefit you could provide the patient in the back of the ambulance, other than to physically be present to assure he made it to further care? If not, what is the necessity of an ambulance? Was there any benefit to the patient being seen at the ER? If not, what is the necessity of an ER evaluation? It's a dead horse, but I'll keep beating it: the idea of transporting everyone to the ER--or even offering transport to everyone who calls 911 for an ambulance--is an archaic and flawed concept that's on its way out the door. We owe our patients better than a permanent offer of transportation. We owe them evidence-based, cost-effective care that provides tangible benefits.

Some other things to consider are: -Local and state ordinances/laws regarding the governing of an ambulance service, as well as its registration. Like Mobey said, you'll probably need a lawyer to help you go over the laws and make sure you're in compliance with all of the paperwork needed to register/certify this service. -Stocking. Do you know how to do it? Do you know how to legally acquire prescription drugs for EMS use? What about narcotics? More paperwork that you may need legal guidance to understand/complete. -Radios or other communication devices. What are the laws regarding EMS communication standards? Do you know how to obtain the right radios (if that's what's required and/or what you intend to use) and how to program them? If not, do you know who to turn to to obtain that service? $$ -Ambulance decals/paint. $$ -Advertising for non-emergency transfers. $$ -Competing for, winning, understanding, and complying with hospital contracts for non-emergency service. Better just keep the lawyer at your side 24/7. $$ -Complying with federal, state and local employee relations. Wages, insurance and other benefits, retirement, sick leave, vacation, hiring standards, rules and regulations on terminating employees. -Taxes. I don't know about you, but doing my own personal taxes is a real bitch--doing taxes for a private company seems like a monster to me. You'll either have to learn how to do it, or shell out the money to pay someone to do it for you. -Billing. This is another huge field where you're probably going to have to pay money to someone smart enough to understand how it works. When you can bill, when you can't bill, what to do when medicare says your information is incomplete or just refuses to pay. Maintaining compliance with their rules and regulations, etc. $$ Aside from the pure monetary cost of creating an EMS service, there are a lot of things to it that require specialized knowledge that will require either a lot of research on your part or a lot of very intelligent people who all share your dream and who are dedicated to making it a reality. I don't want to discourage you, but just keep in mind that even Dwayne's million dollar estimate could very well be the case and in fact even be an underestimate. If this is what you really want to do, then by all means pursue it, just be ready to have the answer to every possible question/problem/dilemma you might face (or have access to someone who can help you get the answer), and consider that even if you do everything right, it could still fail--in which case you need to have an answer for that problem too, because the debt you incur in this endeavor won't disappear so easily.

Like Asys said, you're wrong about the threat of hyperoxia. Oxygen is a drug, and like any drug, it should NEVER be given when it's not indicated. You wouldn't give a patient aspirin, nitro, or glucose "just because", would you? There is NO evidence that routine oxygen use in uncomplicated MI's provides any benefit (http://www.ncbi.nlm.nih.gov/pubmed/20556775, https://depts.washington.edu/respcare/public/hmc_files/journal_club/articles/20110912/routine_use_of_oxygen_in_mi-systematic_review.pdf), and as such, it should not be given just because every EMT book for the last forever has advocated for high flow oxygen for any and every condition. Also, on a side note, there is no evidence of benefit to spinal immobilization. Which may be why you've experienced paramedics who don't "take backboarding seriously".

Kyle, it's more than appropriate to take a couple of minutes on scene to provide good patient care. Probably the biggest source of errors that I've seen in EMS--and one which my organization has been really trying to correct--is when crews rush to get to the hospital instead of sitting on scene for a bit to provide good, quality care. We've got to get it out of our heads that our primary goal is to get people to the hospital and get it in there that our primary goal is to provide patient care. Especially when it comes to treating pain (which you said they didn't do, which is unfortunate but I wasn't there so I can't speak for their reasons). Out of curiosity, what happened when you got to the hospital? Like, did they immediately give you something for pain? How long did you have to wait for pain management? For tests? For a diagnosis? For other treatment?

No experience here, but there's a couple of folks here with experience working in the middle east and remote duty medicine in general. An interesting read on working EMS in Saudi Arabia is the book Paramedic to the Prince.

Do you guys have standing orders or what? I know that out of hospital emergency physicians are much more common there than here, but to what extent? What I've heard is that you guys need an order for everything unless it's a life or death emergency--is this true? Do you guys have protocols or are you able to act independently?

In Kansas we have... First Responder - Don't know much about it, to be honest. EMT - One semester. Advanced-EMT - An additional semester and a replacement for the previous EMT-Intermediate. The new AEMT will have more drug options, including some cardiac drugs if I'm not mistaken... Paramedic - Formerly Mobile Intensive Care Technician (MICT). It's a mandatory two year degree (Associate's) program in this state. I think the rest of the country is moving to this scheme as well, except that paramedic remains non-degree in most other states (but most states have an Associate's option). I think the NREMT (National Registry of Emergency Medical Technicians) is calling them NREMT, NRAEMT, and NRP now too. Every state is kind of different in what their individually require (to meet or exceed) the National Registry's standards, and many of them have different titles for their state-specific certifications as well. I also think that for most paramedics in order to recertify to meet the NREMT's new educational standards they have to take a transition course. Not something we have to do here so I honestly don't know much about it... Unfortunately, man, you'll get about fifty different answers anytime you ask about EMS certification levels and requirements in the U.S. The national stuff is, obviously, national, but the state-specific levels seem to get pretty complex. There's a (very) brief overview, though, I'm sure someone else can give you the nationally required hours--'cause I sure don't recall them!

The best use for a backboard is to prevent an unnecessary vacuum in one of the ambulance's outer compartments.

Oh, I'd beg to differ, but that's a whole other thread entirely. I'd first argue that the amount of time we spend with a patient as well as the amount of time they may be waiting on an IV will prove to be non-significant when it comes to the timeframe on changing IV's. Also, if the patient is stable, why NOT wait to get the IV? If the patient is going to get an IV eventually, does it matter that EMS gets it and not the ER? To be honest, lighting has never been an issue in getting an IV for me. The back of the truck has terrific lighting. Also, having additional hands to start an IV makes the hospital more resourceful, not controlled. Finally, if there is a lack of control due to the ambulance being in motion, that's a problem easily mitigated with the gear shift. In that case, we should be advocating for EMS to perform their interventions before transport, since that is the real problem--not that they're starting IV's. What would that do to complication rates? Would it put them on par with the hospital? We don't know. Is it preferable to delay IV access until it is truly needed and possibly impossible by the (i.e. if the patient deteriorates, etc)? Is emergency IO access better than early IV access? Will restricting IV access drop its use to the point that paramedics are no longer able to competently perform the skill reliably, such as ET intubation? And are the benefits of maintaining that skill an performing it early worth the risks of complications? What about nursing workload? Is there a benefit to paramedics starting IV's over nurses so that they have less to do? Is there any particular reason why an IV that will be needed is better off being started later on by a nurse rather than early on by a paramedic? Good discussion... Also, sorry for a the spelling errors. I'm posting this all from my phone at work.

The anticipated need for IV access isn't enough? If the patient will get an IV anyway, and we can reasonably be sure of this, we should defer establishing that IV access for... what purpose, exactly? Controlled in what way? What parts of the hospital are more controlled than the back of an ambulance? The lighting? The temperature? The mood? Well, if we're going to accept that IV's are not being magically bent by IV gremlins who simply don't exist in the hospital, there must be a reason why field IV's are presenting "messier" than in hospital IV's. What reason do you think is the source of those IV shortcomings? Is it training? Is it that folks aren't taking enough time when they start their IV's? Are they being encouraged to get IV's em route or being discouraged from taking their time getting them? Are they being discouraged from starting IV's in the field and are not getting enough experience doing them? Isn't it part of the job of EMS to adequately prepare patients for hospital care? We take 12-leads even though we cannot perform field angioplasty, for example.

Wendy, thanks for the reply. A couple of things: I agree with you that not every patient needs IV therapy, my question about withholding it or delaying it when it is known (or suspected with good reason) that the patient will need IV access at the hospital (even if we ourselves will not give fluid or medications) was where the reasoning in that lied. I agree that we shouldn't start a reason simply because we can, and that there should be a reason behind establishing IV access. I'm confused, however, by what you mean when you say we shouldn't start an IV when we think we should? I'm sure you didn't mean that in the way it came out. Im sure you didn't mean your list of EMS indications to be exhaustive, so I'll move on to the next and final point you made, and that is that the IV could "wait" if we don't plan on pushing any medications. Do you mean to imply that even when it is known that the patient will receive an IV at the hospital, we should not establish IV access unless we specifically plan to give fluids or medications during our portion of patient care? Can you explain the rationale behind that?

Not to derail the topic, but I'm not quite understanding how it is not justifiable to initiate IV access when it is anticipated that it will be used to draw blood or push meds in the hospital? Also, maybe what metropolitan areas are you referring to? I work in a fair sized urban city and I would find it appalling to withhold appropriate treatment because the transport time is short. Thanks.