fiznat

I dont know about this one. I see where you're coming from, but that logic is a slippery slope. Why BLS anything then, if the requirement to do so is the complete exhaustion of every possible serious illness. The "oh but it COULD be..." mindset is one that ignores basic assessment and clinical judgment. Get the vital signs, check the sugar, do a H+PE and pass it on to the EMT. Thats what I do. As far as getting refusals from drunk kids though, I agree that it is usually inadvisable. It isn't black and white though, as I have in the past obtained refusals from "moderately" intoxicated patients who answered questions correctly and seemed mentally capable. 21 or not, as long as they're over 18 and AXO. I dont understand what the legal drinking age has to do with an adult's ( >18 ) decisions about their health care anyways. To answer the above poster, yes in the US you need to be 21 to drink. You are an "adult," however, at 18.

I've noticed that our attitudes about this work vary pretty widely. There are those considered to be "sparkey," those who are "burnt out," and many in between. All of these people seem to have different feelings in regards to what they want at work. I wanted to see what the consensus (if there is one) within this community. I'll admit it, I need a critical call - a patient that makes me think and actually do something - fairly often in order to enjoy my work. If I go too long doing basic routine ALS with nothing interesting I get depressed and pessimistic about the job. I absolutely cannot stand doing transfers and I will do everything I can to avoid them. Some people have different attitudes. I hear paramedics request long-distance transfers or easy BLS calls all the time. "Its a nice break," they say. I say to hell with that. Where do you stand? EDIT: I just realized I think I posted this in the wrong section. I guess it should probably be in general? Mods please move this if it is necessary...

I don't know if I'm qualified to answer the original topic as I really don't have much to do with HEMS in my system. The trauma centers around here have helicopters that they send out to the rural areas, but it shouldn't be surprising that we've never used them here in the city. Still, I see the helicopter crews come in sometimes with their patients and often they are NOT critical at all. I see patients of minor motor vehicle accidents getting flown in, basic chest pains, basic extremity fractures... etc. I admit I am not a part of that system and am looking in from the outside, but it seems to me that the number of patients flown could be dramatically reduced if there were more stringent qualifications in determining which patients get flown and which do not.

I don't use the term in my run reports, but I admit I am guilty of it in my hospital patches/notifications. I mean to say "within normal limits," as others have said, and I believe it is understood this way on the other end of the line. It may be technically incorrect, but there is something to be said for the colloquialism of it as well. I'm not patching to the hospital to give them a precise overhaul of everything I've found with the patient (they'd stop listening halfway through), but rather to give them a quick summary and to let them know how long till I get there. I tell them what they need to know, and they understand. You're right though, I probably should say "within normal limits," but comeon- that's a mouthful isnt it? :wink: Oh, and I always take more than one set of vital signs.

Just to clarify something, the studies I posted don't really comment on the ability of a paramedic to GET the tube, but rather how patients fare after they have been successfully intubated.

I don't get this. What is obvious? Who needs to be intubated and who doesn't? I don't think its that obvious. ...And what makes our patients anything other than statistics? Everything else we do (or don't do) is driven by research! ACLS? Determined through research. Oxygen? Supported in the literature. C-spine? Derived from journals. Medicine is the practice of procedures laid out through the tough work of academic research, and (ideally) nothing more. Some ideas that are passed down from generation to generation without evidence of value are slowly getting weeded out as the profession becomes more precise. Nobody likes to change, but sometimes we really do find out that what "we've always done before" may not actually be the best thing for our patients. How do we find that out? Statistics.

It isn't ETI-or-nothing. Come on. BVM me. Give me a combi-tube, or an LMA, or a king. High flow O2 as well. That kind of black and white thinking gets us in trouble. Where is the research (the evidence) that an intubated patient is better off than a bagged or rescue-airway'ed one? I just posted seven studies that suggest that patient might actually be WORSE with a tube in his throat.

What evidence do you have to back up this statement? Careful, you're talking about thousands of paramedics here. I posted seven studies, some of which are quite large. Are ALL of those paramedics slobs? What are the chances each of these studies managed to find only the dysfunctional paramedics?

True enough. ...Although I did post seven studies. Are ALL of those medics undertrained? I do agree with you though. I get about 8-10 tubes a year and I know full well I am not nearly as proficient at ETI as I could be. I have unlimited access to mannequins but that really isn't the same, and access the OR is tough when you have to compete with medical students/residents. Even then, intubation of a prepped patient on propofol in the OR is not the same as one with a vomit-filled airway in a dimly lit bathroom on the fifth floor with no elevator...

These studies don't say anything about the REASON the results are what they are, nor do they attempt to suggest what actions we should take to correct these problems. They can't say either of those things because the data they collected could not possibly support such conclusions. I'm not saying any of these things, either. I'm not saying paramedics shouldn't intubate. I'm not saying we don't have enough education. I'm saying hey, reliable data suggests the way we do things now doesn't seem to be working very well. Perhaps this offers a bit of insight as to the original topic, which questioned why prehospital RSI may be frowned upon by most doctors. ...And don't take things so personally! These studies aren't saying we're not "good" at intubation, they're saying that prehospitally intubated patients generally have a poorer prognosis. Maybe that is physiological, who knows. We don't have to get our hackles up like this because someone might take away one of our "skillz." Let's look at what matters MOST: are we helping our patients. In the face of all this research, and even amongst whatever "yeah, buts" you can come up with, can you really say intubation makes a difference for your patients? How can you support such a conclusion?

:shock: Wait just a minute there. Peer reviewed, scientific research is now "ignorant," "speculation," and "nonsense?" You think EMS is somehow special, not to be constrained by mere statistics? You've got to be kidding me. You wax philosophical here all the time about a lack of education among our ranks, but dude. Scientific literature is the engine that drives medicine. It is the best tool we've got to try and make sense of all that happens with our patients. If you think you can do without it, you are painfully, horrifically wrong. We're not THAT special. ...And don't tell me that ALL of these professional researchers are suffering from some inability to properly interpret the statistics. Statements like those you highlighted are typical within scientific literature, and are reflective of a humbled, scientific approach. They don't claim to have all the answers because they conducted a few studies, rather they intend to contribute to the existing pool of research so that the realities of these situations may be more fully described through aggregate data. I posted seven research articles which all largely say the same thing. Are you going to contribute all of that to some cantankerous old researcher who doesn't understand, or has it out for EMS workers? Really? It pains me to see you so casually brush off this kind of evidence. It may very well be true that these studies don't fully describe the nuances and texture of you and your particular brand of medicine. ...But believe me, this is as clear as it will ever get, and our medical control doctors are listening. Maybe you should, too. Oh, Actually these studies CONTROL for this kind of thing. If you take a few minutes to click those links, even in the abstracts you will see that the patient populations are of similar ages, demographics, and injury severity. It is a basic tenant of research that the two groups you are comparing must be, well, COMPARABLE. Those egg-head researchers are a little smarter than you think, Dust.

There is actually quite a bit more than that. Eckstein et all: Effect of prehospital advanced life support on outcomes of major trauma patients. Los Angeles. http://cat.inist.fr/?aModele=afficheN&cpsidt=1343863 Murray et all: Prehospital intubation in patients with severe head injury. Los Angeles. http://www.ncbi.nlm.nih.gov/pubmed/11130490 Wang et all: Out-of-hospital endotracheal intubation and Outcome after traumatic brain Injury. Pittsburgh. http://cat.inist.fr/%3FaModele%3DafficheN&...le=presentation Bochicchio et all: Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain Injury. Baltimore. http://cat.inist.fr/?aModele=afficheN&cpsidt=14580258 Davis et all: The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. San Diego. http://cat.inist.fr/?aModele=afficheN&cpsidt=16915454 Davis et all: The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. San Diego. http://cat.inist.fr/?aModele=afficheN&cpsidt=14686493 Stiell et all: The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. Ontario. http://www.cmaj.ca/cgi/content/full/178/9/1141 Admittedly all of these studies are limited in that they only look at trauma patients, but then again this is probably the population that would most often require RSI. The sheer volume of all of these studies in agreement is staggering. Trust me, these are the articles our docs are looking at when they shake their heads "no."

I would be interested to know what various services do to promote skill retention. We don't do much here. Every year we are required to go to "skills review" sessions in order to maintain our medical control, which basically covers airway (intubation, surg, rescue airways), ACLS megacode, peds, IO/IV, and a BLS station (usually KED/backboard/Traction). It is all on dummies and takes about 3 hours total. (We also have CME hour requirements but these arent necessarily skill-specific) How many of you guys actually get the opportunity to go to cadaver labs, or to the OR to practice your airways? We've asked our medcon about it, but we are a large group of medics competing with Med students/interns/residents for these tubes and it almost never happens.

I don't think paramedics are allowed to do what they do based on a prediction of how many times they might need to perform that procedure. I have a surgical airway kit in my truck, and I've never used it. I may use it once in 10 years or less, who knows. I still need to have that kit in my gear because the value of performing that procedure outweighs the potential negatives of not having it available. I'm not so sure that the same can be said for RSI, and perhaps (gasp!) even intubation. THAT is the reason why docs are hesitant about these procedures, and for no other reason.

Couple things: 1. One thing that hasn't been mentioned much here is that the actual clinical value of prehospital intubation is in and of itself questionable. Adding RSI to increase the amount of intubated patients might seem like a valuable endeavor if intubation in fact did our patients some good. There are studies out there that say the opposite, though. It isn't a small percentage of patients in which prehospital intubation does HARM rather than good. I understand (believe me, I'm a paramedic too and I REALLY understand) that intubation is seen as a key ALS skill, but how much of this is based in pride instead of actual patient care? More is not always more. 2. In regards to increasing skill and identifying errors. This may be more specific to my service but here all paramedics work with EMT-B partners. I've been "cut loose" on my own as a medic for just about 2 years now and I have worked alongside another paramedic once. I've met up with other medics on scene before, yeah, but in general I never assess and develop a clinical plan in concert with another ALS provider. It just doesn't happen. I feel like that is a problem. I don't advocate double-medic ambulances because I think that decreases self-reliance of individual medics, but I think we need opportunities to see how other providers do things- to watch and learn, maybe pick up a few things and identify our own errors.

You never mentioned if this patient actually regained a pulse and blood pressure. A few bumps on the ECG at a rate of 6 sounds like an agonal rhythm or PEA. ...Neither of which are "saves" by any measure. ACLS says to treat them just like asystole, which they essentially are. I'm not trying to take away from your story, just wanting more info. We've all heard of stories like this in the news before. I guess it happens. I am surprised that the news got such a thorough look at the medical records, though. It sounds like someone who doesn't know medicine wrote this article anyways, so I wouldn't be surprised if something was lost in the translation.

ALS, no question about it.

haha hey I didn't say anything about being content! I'm jumping ship just like everyone else, taking classes and moving up in the whorl'. I'm just saying, as far as an EMS job I'm not sure that anyplace else can offer much more than what we've got right here. If they can, I'd like to see it. That's why I clicked on this thread.

I like it Dust, but for the sake of argument let me play a little: You suggest that we manufacture a demand for highly educated prehospital providers more or less by force. What gets lost in the translation is whether this truly is the best thing for our patients. Research suggests that the value of ALS in critically injured patients (particularly in trauma) may not be as high as expected. This value is further diminished with proximity to a hospital, which means that our most paramedic-dense areas (cities) are the same areas that need it least. Unfortunately, urban areas seem to be the only places capable of shouldering the financial and educational load that comes with ALS saturation. Your conclusion that "more is more" seems to be well founded observationally, but I'm not sure if the science would agree. Regardless of how much we'd like to rally and force a change for the betterment of ourselves, it might be prudent to give pause and reflect on the following truths: 1. Medicine is becoming increasingly expensive each and every day, which limits patients access to care. 2. Raising the educational bar of each intermediate step to "doctor" both increases cost and muddles continuity of care. 3. The value of a highly trained, ultra-advanced prehospital provider has yet to be verified. Nevermind our current level of ALS. You are suggesting that we establish a system that costs more for a questionable benefit. I understand other professions have "made it happen" through organization and whatever else, but is this really the responsible thing to do? Who's interests are we really looking after?

I have to say, I work for that 3-lettered company that gets such bad press 'round these forums, but most of the features you guys say make or break your dream jobs: we've got em. Progressive protocols, off-line med con, high 911 volume, a responsive EMS coordinator/control, etc. Sure, there is the frustration that comes with working for a national private ambulance service, but in general I think we've got it pretty good here. I make $22 an hour as a newish medic (18 months cleared now) which is very competitive, and I work alongside some truly excellent people. As far as an EMS job goes, it really aint' so bad here. Hartford, CT.

I don't usually mix saline into the drugs I give, with the exception of Ativan and sometimes D50. Both of those are pretty thick and sometimes go a little easier with the addition of a little saline. I also dilute Promethazine as it is required by our protocol (12.5 mg in 10cc). Magnesium goes in a 100 bag NS for asthma and that's about it except for the standard drip drugs. As far as diluting solutions for the sake of a slower push-time or whatever, I usually don't have the time or desire to do that.. I'd rather just push the syringe slowly than have to play erector set and draw/re-draw/mix stuff in the back of the ambulance.

Only time I've ever seen IV glucagon was for beta blocker overdose, and that wasn't prehospital by any means.

Refractive bradycardia I believe.

That >6 hour rule in your protocol is garbage, but I don't think you personally did anything wrong. AOX4 patients with no complaints of pain/tenderness and a lack of significant, glaring mechanism or distracting injury will get cleared nine times out of ten here also. We tend to err on the side of caution with that stuff, but in general if the fall is old and there aren't any complaints I don't think anyone can blame you for not subjecting the patient to a full c-spine. Cover your bases, document well, follow your protocol, and you'll be fine. 8)

I would be careful with morphine if I thought there was a potential for multisystem trauma based on the mechanism of injury. If there is strong evidence that suggests the injury is isolated to the extremities, I'd probably go ahead with the drug. Otherwise, it's a CYA call to the medcon for me. Morphine in trauma can get you in trouble if you're not careful... As far as the boot, hell I'd cut it all off. I'm not going to take all day carefully snipping around the boot so that only certain parts remain there while others are removed, screw that. ...Barring some aspect of this decision that isn't obvious without actually seeing it, I'd just cut it off, stabilize, treat and transport. The less time we spend on scene with trauma, the happier I am.