croaker260

Clearly ,a tiered approach is optimal. Well , I think a system with BLS or ILS first responders, and ILS ambulances , with a few , highly trained and highly utilized medics staffing a few ALS ambulances running only priority ALS calls. The BLS/ILS units handle 80% of volume (with a goal of 90% accuracy to be responding on BLS/ILS call), and the ALS units responding with a goal of 90% accuracy for ALS calls. BLS/ILS ambulaces transport anything not handled by ALS. As the system is refined, somethings only the BLS/ILS first responder would role on and evaluate, with transport called PRN. For cardiac arrest, the closest defibrillator would be called...be that ALS, BLI/ILS, or a police car equipped with a defib, or the fire marshal with an AED doing his rounds. All request of 911 assistance gets as a minimum BLS/ILS first response unit. The transport unit is either an ALS or an BLS/ILS unit based on call type. Therefore the ALS units only are first in on priority calls, Since you dont have a lot of ALS units, there are still plenty of calls to keep what ALS units you have busy. This results in a highly experienced ALS core, and as a side note a very refined BLS/ILS core as well. Why is this important? Well, remember that it has been constantly shown that all the high risk skills (i.e. intubation) success rate is directly dependant on EXPERIENCE with the procedure as well as whatever training/education you throw at the system. You cant have one with out the other. A tiered, targeted (not just tiered, but tiered and targeted) system provides the experience requirement. BLS /ILS handles everything else. Remember in an urban/suburban system, your mostly not more than 15 minutes fromt he hospital , probably less. The system will provide JOINT training at all levels, and JOINT QA. BLS providers and first responders will be reviewed as stringently as the ALS providers, to see that they did more than simply wait for the ambulance. They are after all , health care providers too. They will be reviewed to see that they call ALS when needed, and dont call when it is not. The ALS providers will be QA-ed to be sure they dont practice lazy medicine, and be sure they don't turf any ALS patients to BLS, or take BLS patients that dont need to go. (They can wait for a BLS/ILS transport if it is reasonably quick). The pre employment standards will ensure that only people who want to do medicine make it to the ALS level, not those who simply want a job. Providers at all level of the system will be paid a living wage and with good benefits and retirement. The service will have an intensive FTO program for those who are hired. Those who dont cut it will be retrained, those who still dont cut it will be cut loose. The doctors will be on a first name basis with the medics, the medics will work only 36 hours a week (Average) scheduled with 4 hours clinical time (rounds, OR time, lectures, labs , PR, PAD/CPR classes, or teaching) every two weeks. Since there is a huge educational burden on this system at all levels, there is always someone needing teaching . In the unlikely event there is to many medics to do all the tasks, they will be tasked with following up on patients and assisting in research. Full time education department with all CE and training provided. No minimum 48 hours per two years and some class-in-a-can refresher course. There will be so much documented education in so many venues, the only hassle about recertification will be writing it all down. In addition, exceptional employees and specialty teams will go to national conferences to bring back the latest. The education department will also be the hub agency for all research in the area for EMS.

Well dust, in addition to the tons of clinical knowledge I think we could/should improve on, I think we are also missing the things that people don't think about, such as how to read and do research...so you can make CORRECT and MEANINGFUL..not KNEE JERK reactions to research papers, assuming you wven read them (not meaning you DD, medics in general)... I think we should have a bit on systems design, including QA and economics. I believe we should have some introductory adult education classes, as I feel it is EVERY paramedics job to teach and learn. Basically things that take an individual from being just a good clinician to having the tools to be a positive impact on the profession. And BTW, I DO NOT think every provider, or every ambulance needs to be paramedic level. This thinking is what has landed these mother may I systems with a plethora of crappy medics and medic-mills. I do agree with degree requirement's, but I don't agree with over-saturating the market. Simply put, not every patient needs a medic, just like not every provider in a hospital is an RN.... T Many, most even would do better with a well trained basic (agreeing that our current basic is not what I call "well trained" as a common generalization..some exceptions not withstanding). I believe that 75% of 911 ambulances could be manned with EMT Basics or Intermediates...and take care of 90% of calls. 25 % (OR LESS) of ambulances should be highly trained/educated Medics (and I do not think that todays medic is typically "highly trained/educated", except in the KCM1 system and similar programs) running only on calls where they can be reasonably expected to use their skills, and BLS requested to others....thereby becoming HIGHLY TRAINED/EDUCATED and HIGHLY EXPERIENCED medics...something of a rarity these days. ALS care is not the standard of care, unless we want to lower the definition of what quality ALS care really is....standard of care is APPROPRIATE care for the patients complaint. Often that is just a swell served by a well trained BLS/ILS provider.

Excellent point Kev, Dont forget that Haldo can lower the SZ threshold , and increase heat production (when EPS occurs- Mopvement disorders). It seems to me from previous discussions with other providers that there is a bias against using benzos , presumably because they are "controlled" and haldol is not. We need to get away from the idea that haldol is safer than benzos, when in this setting it clearly is not.

Actually on re reading your post, we are saying pretty much the same thing....My bad.

I would ammend that to say there is very little we can do (as in the prognosis is very poor) for patients who code (even witnessed arrest)...that said, there is plenty we can do before cardiac arrest that may avert it...hence the need for PROPER chemical restraint and proper restraint period, as well as mitigation strategies targeting the co-morbid factors.

Because the physiologic stress (heat, cardiac, metabolic and toxicologic) in these situations can be fatal in some of these patients. and the police cruiser on the way to the jail or the ER is the LAST place we want these patients to code...and the only ones who feel stronger about that is the cops themselves. Interesting enough I said SOME and not MOST or ALL..there is enough research that we can approach this from a point of view of assessing "co-morbid" factors, just like we do when we use the ones we use for determining if a patient needs to go to a trauma center. Not 100% positive or negative for inclusion or exclusion, but a good place to start.

We have training on Excited Delerium/Agitated Delerium, I can provide you the PPT if you like. ANyway, our protocols are here: http://www.adaweb.net/departments/paramedics/swo2006.asp Our specific protocol is here: SECTION: M-14 PROTOCOL TITLE: Behavioral Emergencies and Combative Patients REVISED: 15 April 2006 GENERAL COMMENTS: Behavioral emergencies and combative patients are some of the most pitfall filled patients EMS personnel will encounter. Many of these patients will have multiple underlying pathologies, including illicit drug use, which will pose many challenges to overcome. Patient care should be focused with preventing/mitigating hyperthermia, agitated delirium, positional asphyxia, hypoxia, and physical self-harm. BLS SPECIFIC CARE: See adult General Medical Care Protocol M-1 - Assess for medical causes for altered LOC/violent behavior. - Involve law enforcement as early as possible. - Restraints may be used for patient and/or rescuer safety. Do not restrain prone if possible. 4 point restraints are recommended Observe and prevent positional asphyxia. Monitor airway and respirations closely. If restrained, do not release restraints until at the hospital unless required for essential patient care - Do not leave patient unattended. - Allow for adequate heat dissipation. ILS SPECIFIC CARE: See adult General Medical Care Protocol M-1 - IV access (to a max of three attempts) only if needed due to severity of underlying injury or illness, otherwise defer until arrival of ALS providers. - Assess BG to rule out hypoglycemic episode. ALS SPECIFIC CARE: See adult General Medical Care Protocol M-1 Sedation - Diazepam (Valium) IV: 2-5 mg every 5-10 min PRN. IM: 5-10 mg repeated once in 20 minutes PRN. Max of 20 mg. - Midazolam (Versed) - Haloperidol (Haldol) IV/IM: 2.0-5.0 mg IVP PRN to a max of 10 mg. Strongly consider co-administration of Benadryl. Caution with Hyperthermia, seizure risks, and Hyperdynamic drug use. Adjunctive medications: These medications are given for their potentiation of other drugs effects or for the prevention/treatment of certain side effects (nausea, EPS, etc) of drugs used in sedation. - Phenergan (Promethazine) IV: 6.25-12.5 mg IVP diluted. IM: 12.5-50 mg - Benadryl (Diphenhydramine) PHYSICIAN PEARLS: ALS Providers may decrease the dosage, or prolong the administration intervals of any medication with sedative properties when doing so would decrease adverse effects and still likely obtain the clinical goal. Cautions with using medications to restrain a patient: Respiratory depression. Loss of gag reflex. Occasional paradoxical reaction results in increased agitation. Increase effect of other CNS depressants. Limit mental status assessment and neurologic examination during sedation. Among the most difficult tasks is determining the etiologies of combative patients and treating accordingly. • Psychiatric (functional) • Non-psychiatric (organic) – Medical (CVA, Hypoglycemia, Increased ICP, Meningitis etc ) – Toxicologic • Approximately two thirds have non-psychiatric (organic) etiology.

Part of our trainign and education on this for our medics is reviewing the research, part of wich shows great blood gasses after 4 hours on the combitube. We also discuss the airway edema that occurs durign routine combitube placement, emphasizing that it will be a difficult tube at best. Therefore, since there is no good reason to replace it once its in (assuming it is working), leave it and move on to other important tasks. We had to do the same thing for our local docs as well. Than and had to convinve them that the "pull the onion from the ground" method of removal wasnt the best either. BTW, simply cutting the cuff lines DOES NOT completely deflate the combitube....only removing the air with a syringe does. And DUST, I am so lost as to your point that I dont even know where to begin. Could you start with explaining how me thinking that EMT B's need more hours in their instruction before any more skills/scope are even considered , whether you call it education or training, means I dont support education? I am beginning to think you are just trying to start an argument...for argument sake.

Dust, I am confused how you got that I am focused on skills when I mentioned the requirements of training (and my thoughts on that) several times related to airway management.. Dude, I think we are probably on the same sheet of music, just at different parts of the symphony.... AZCEP, As for the combitube, well I wont disagree that their are not the best rescue airway out there, and "rescue airway" is the common term these days, is it not?..anyway, hence I mentioned "airway de jour"...I myself am NOT a fan of the LMA....the King LTD shows a lot of promise but I haven't actually laid on hands with it yet...but having used the combitube (and the PTLA, and the old EGTA)as a BLS/ILS and a medic....as well as wrestling with the issues of training and standardizing response in a system with several agencies wanting to use this, I am a fan of the combitube because of the ease of training, the trouble shooting procedure is simple, and durability. Is it perfect, no, but its a good fit for the BLS/ILS level I believe, who in most systems will use this far less..like 1-3% of call volume...than other skills. and while I may be stoned for this, from the beginning I did not think that ET was a good fit for the BLS/ILS level..we have a hard enough time getting medics to do that skill right in the field. And yes I recognize that there are other rescue techniques out there, including retrograde and the various versions of a needle/surgical airway. There is also the bougie (which is AWESOME! Love it!). DO I think it is a replacement for the ETT at the ALS level? No, But I would rather a medic go through his ABC difficult airway approach (A-Alternate -provider/blade, B- Blind airway/BVM/Bougie, C- Cric) systematically, and get sometype of airway control or decision in under 7-10 minutes (or much less preferably) than sit on scene or in the rig for 30 minutes dicking around with the airway while the patient stayed hypoxic....which I have seen happen (including by a flight crew).

Am I the only one confused... As a side note, The library of congress has been very helpful in me finding that study..that in and of itself has been a learning experience and I have new respect for those who are career librarians....finding the actual copy of this is harder that you would think... -Steve

And that is the only role for combitubes at the BLS level. I dont think anyone ever suggested that BLS levels use it for anything else. considering that in many rural areas of the country with out the skill set, skill practice, training resources or call volume to support a medic. I wish more services , including major metro services, would either go to a tiered response system to promote truely ADVANCED life support, or get offf the pot so to speak...and focus their paltry efforts to BLS. Idaho is full of areas like this, frontier areas where the ONLY ALS is by air, and often grounded in winter due to weather. Whether 5 minutes and 5 hours from hospital (usualy a PA staffed clinic), having these skills in an ALS poor environment, to get them to ALS or to get them to the local clinic or hospital, is essential . I would rather have a well trained EMT-B/I with a combitube that a poorly trained medic with an ETT. To suggest otherwise that it is better to have a medic when you know that medic isnt going to get the training support or calls needed to stay proficient, is the real cop out and excuse..that "ALS is the standard of care". It is not. It (ALS ) should only be there for systems that can prove the need, and more importantly IMHO the ability to support paramedic level care. The simple fact is that if you move out to the wilderness, and you chose to not support your community on providing GOOD paramedic service, then you not only deserve BLS/ILS care, but are in all seriousness, are probably better served by it. Having worked in TN with combitubes and PTLAs at the BLS level, as well as a Paramedic there, I do think they are a valuable tool for BLS. Medics should have the combitube (or airway de jour) as a rescue airway, with extensive (read: lots more than most services require) airway training and RSI. if a service choses not to support a true advanced level of care...then those agencies should function at a BLS or mother may I ILS level, tubing only dead floppy patients. I dont careif you are DC metro or BFE Idaho. besides in most cases BLS or ILS is all thats needed.

Bryan, You are misreading my point. I am not arguing that the whole concept of trauma care has radically changed since then. The article itself does not debate or even address that. My point is the principle, that the basic premise of the article (not of your thoughts) , that there is NO scientific evidence (not poor, not LOE 7, not inconclusive, not anything other than NO EVIDENCE), is not accurate, and therefore the article (since this was its sole basis and point) IS INVALID (assuming my theory on the missing study is correct). But, if (and only IF) I am right, then there IS scientific basis, just not good , relevant, or significant scientific basis, but some. A subtle difference, but an important one and the sum of my whole argument. That Cowley didn't pull it out of his @ss and bamboozled all of us for his own gain, which is the unspoken implication. Does this change or effect any of the other thoughts you have put forth, no. Is this meant to insult or any other way disparage you, no. Does this mean that the concept of the golden hour holds water, no. What it does mean (IF I am right) is that the articles research method was flawed, that they (the researchers) either deliberately or accidentally, failed to follow up on a single but crucial piece of evidence, and therefore came to an erroneous conclusion. Why is this important? The principle of the matter. (and yes, I have pissed off many many of my coworkers simply because of the principle, what can I say, its a serious character flaw that has caused me no end of trouble.) OK, RA Cowley may have had it right or wrong..or both depending on how trauma care has changed since then. But that isnt the point. The point is that this article has been extrapolated to mean that the basic concept of the golden hour is wrong when the article does not address the validity of the concept at all, it only addresses if there is any verifiable research behind it (the golden hour concept).... Now if Cowley is wrong, he is wrong...if times have changed, then times have changed...what ever.....but lets get our facts straight. Rewriting history with out sound evidence is something I would expect out of many agencies and individuals, but not clinically oriented people and not out of you. In short, whether you agree with the "golden hour" concept literally, generally, or not at all... it does not pertain....The point is that the article many people cite as proof the golden hour isnt a real concept may be flawed and basically inaccurate in its core assumption. All I'm saying is lets get the story right. After all Bryan, 15 years or more after you die, I would hope that when others (maybe me?)are writing text books and such, talking about people who advanced our profession, they get your story right too, and not imply that something you did was purely made up when in fact it wasn't. Think of it as karma..the good deed you do today will comeback to you tomorrow. After all, presenting the FACTS is a focus of one of your (very fine I might add, I attended it some years ago) lecture series, medical myths? So the lingering question is, if I am right (and I intend to hunt down this study to see), and say you were to give a medical myth lecture series on the golden hour argument.... would you say there is no evidence, or poor and irrelevant evidence behind the golden hour? By the way, if I am wrong, then I will of course admit it, and will owe you the microbrew/hard liqueur of your choice. They do drink bourbon in Texas don't they? Comments welcome.

After reading (again) the article in question, ONE STATEMENT STICKS OUT.... So I whipped out my trusty copy of this out of print book. The discussion is on page 10 and 11, some discussion on page 12. Speaks to removing the blood from the dogs and dripping it back in, and gauging "data" and recovery time. Really sounds like the title description of that study. It fills me with a need to really really find the article I cited above as POSSIBLY being the missing study. Curiously enough, it predates most other studies mentioned in the article by 9 years or more, and it did not come up for me on a search for the term "golden hour" (which was the primary search criteria for the article in question), only by looking at ALL the studies attributed to Dr. Cowley on medline did I find it. Simply put, according to the article, the term golden hour was earliest referenced in the early 70s and late late 60's. so (with out reading the study yet) it seems unlikely that Cowley had even conceived the term, or barely even the concept in 1960. of course this is pure speculation. Not saying I am a master researcher...but given the comments in "SHOCKTRAUMA" (which was referenced in the article), the time frame (early 60's, late 50's, when his focus was still mainly cadiothoracic surgery) it seems to fit. Especially since it seems that the articles authors seems to let the trail of the "canine study" die quickly and quietly. While they discuss their medline search for the terms golden hour" and describe it in detail who referenced who, there is no mention of the canine study OTHER than it was not referenced in the book SHOCKTRAUMA. I have queried the National Library Of congress to see if they archive these journals, or can point me on the tract of finding it. I am also thinking following up on the archive of his personal papers as well, looking for this specific study and not for the term "the golden hour". The American College of Surgeons does not have an archive link (I am not even sure they inherited this archive). Bryan (got the name right that time) are you interested in putting me on the right track to find this OLD out of print article? Not asking you to fork over $$, just ideas. PM/email (colemedic@hotmail.com) me if you want. I have done a some amount of medical research reading and scavenger hunting, but nothing this old.... If it is found, wouldn't it conclude that the term "golden hour" was indeed based on some research, no matter how obscure, and not smoke and mirrors as the authors claim. Not that I am passing judgment on the QUALITY or the RELEVANCE of that research, only that I suspect that is does INDEED exist, contrary to the findings of the 2001 article. And like the researchers of the article state, I agree more research is needed. Now all I got to do is actually find the damm thing. Comments more than welcome

got it on the re-edit. You guys are too quick though.

Brian (you dont seem the type to be hung up on "doctor", being a former medic. I can call you Dr. Brian if you prefer ) 1- I certainly agree with the reference to the "bronze week". See it here as well. 2- I am not refuting your other comments, including that a response time of 8 minutes or less had no effect on major trauma. 3- I am sure you will correct me if I am wrong, and I am open to correction, but my understanding is that there is evidence for the golden hour, just not in humans. From reading SHOCKTRAUMA as well as other various sources, RA Cowley did his research in DOGS. Granted even he (as mentioned elsewhere) admits the chosen time of 1 hour was part marketing, it is not totally mercenary and unfounded as many want to claim. Given the state of medical research , and trauma research, and the atmosphere surrounding it at the time, I think it was a good ground work effort. Wouldnt be the ifrst time animal studies were the key to bigger and better things. So perhaps a better statement is that there is not great evidence to support it, instead of no evidence. Just hate to see a guy who, like you, has given so much to EMS, be bad mouthed post mortum when it may be not entirely accurate. Again, I am sure you will correct me if I am wrong. Besides, I liked his style. Personality goes a long way. Just ask Jules and Vincent. BTW, I have looked and looked, I THINK this is the original study, but I could be wrong, I am having trouble accessing it due to its age. Perhaps you can assist, as you probably have better resources to do so. If you wanted to send me on the right track, I would also track it down at my expense, but I've hit a dead end. Hemorrhagic shock in dogs treated with extracorporeal circulation. A study of survival time and blood chemistry levels. COWLEY RA, DEMETRIADES A, MANSBERGER AR, ATTAR S, ESMOND WG, BESSMAN S. Surg Forum. 1960;11:110-2.Links PMID: 13696112 [PubMed - OLDMEDLINE] Anyway, looking forward to your reply. -Steve

I know I know... Several things lead up to this.. 1- Potential introduction of other agencies working under our SWO's. 2- two cases of "oh crap" that happened the month before this protocol was written. Cant go into details, but both cases were weird, and would have probably not had a 12 lead done by 90% of the medics here, and we havent had any (to my knowledge) miraculous catches since..but there it is. Its about the only thing I didnt like, but considering everything else, its an acceptable loss. Remember also, we have deviation procedures and allowances...not thast I would use them on something so routine.

Here is our guidelines for 12 leads where the complaint is other than a suspected MI (in other words all other medical patients)

Well, I cant agree more regarding the use fo the term "clearing C-Spine". technically, C-spine can only be cleared with Xrays or increasingly CT, something more and more doctors are becoming comfortable releasing patients from the ER with out (for many reasons, economic and medical both). Now at this point you are saying WAIT, what do you mean they arnt getting Xrays? What do they use to determine who gets them and who doesnt? the same basic criteria that a good SSI (selective spinal immobilization) protocol uses to determine if someone is boarded to begin with. Its a subtle point, but an important one that clearly reflects the thought process needed for this: We do not "Clear" anyone in the field. We chose who would benefit from immobilization just like ANY OTHER treatment. We selectively apply the board to patients who need it, just like we give NTG to people who need it, not everyone who has chest pain (trauma, etc). Nor do we splint everyone who has pain in their leg…I could go on and on and on…but you get the point. Just to be sure you get the point of the "theory" behind SSI, so you procede in your protocol development correctly, let me repeat: You should not look at it as if we are deciding NOT to do a normal thing…and act of omission. We are in fact determining if someone would benefit from a treatment…the board, like oxygen, NTG, and morphine…is a treatment. And it is a treatment with VERY REAL complications, just as it has some limited benefits. So we look at the patient…we ASSESS them, and the MOI, and it is a DETAILED AND FULL ASSESSSMENT, based on a GOOD CLINICAL KNOWLEDGE BASE, and TRAINING. Then we decide if a treatment would be beneficial and if the potential benefit for THAT PATIENT would outweigh the RISKS/COMPLICATIONS. Then we SELECTIVELY APPLY THAT TREATMENT. It’s “SELECTIVE SPINAL IMMOBILIZATION” of the whole spine, not CLEARING the C-SPINE. My point is that we should look at boarding like every other treatment, and do it based on clinical assessments.We are taught to always "rule in" before we "rule out" immobilization as an option. I view this..spinal immobilization, as a treatment and intervention like any other...good for some, harmful for others. And make no mistake, It can be harmful in select patients. (pain, pressure sores, neuropathic injury, respiratory issues from being prone). Kinda like chest pain, you "rule in" the potential for cardiac, then when you find out it is chest wall pain, pleuratic, and so on...you dont give NTG do you? Heck no..you make an assessment and make a CLINICALLY based decision. It is important also to note the start of the use of this procedure/concept was based on a 15 year review of spinal cord injury research. That research found that "our patients are not suffering from “occult spinal injuries,” they are suffering from lack of assessment and lack of a prehospital standard of care for evaluating and deciding risk for spine injury. In fact, No assessment criteria are absolute, but one study of 34,069 patients concluded that the accuracy of its assessment criteria would result in less than one missed injury for every 4,000 patients. Now if I recall, that was for Fractures of spine, an even smaller number would have been missed for cord patients. I would personally go so far to say that since we see an increase of immobilization of patients in some sub catagories, that not having such a protocol may increase your risk for missing a true injury. Even if you , after doing the research, would still subscribe to the "board 'em all, let the X-ray sort them out" school, I would still recommend you use the protocols and articles out there to improve both your assessment focus and your documentation of immobilized patients. What about MOI? As one study stated, "MOI has not been shown to be an independent predictor of injury or the lack thereof." It is , however a good gauge for when assessment of need for immobilization shoul occur, a subtle but important difference. So just to be clear: MOI is important, but of limited value to NO value when that is ALL you use, to rule in , or to rule out. Your protocol MUST have assessemnt (subjective and objective) factors in it. And let me say this again too: IF YOU CANT GET A GOOD ASSESSMENT, THEN YOU SHOULD BOARD. Remember that there are complications of use of a spine board, it is not as benign as we are taught in EMT/medic school. The use of a systematic assessment based decision making process can safely determine who needs to be boarded and who doesn't. Remember that in every protocol the medic can always chose to board the patient based on gut feeling. In fact, most services report they board MORE patients under the protocol than when they "winged it". The keys to successful implementation is : 1- Educational preparation. A training program that discusses the WHY's behind boarding, not boarding, the decision process, and the anatomy involved. If your service is not willing to do the training , the rest will fail. 2- Medical oversight, review, and retraining. 3- adhearance to the protocol. In our service we had a missed (stable) Fx with out cord involvement. On review it was not the protocols fault, the EMT did not follow the protocol, and just winged it. If you follow the protocol, you will pick up the information you need to make the correct decision. Some more thoughts... - Most missed injuries result from inability to get a good assessment due to altered LOC, or distracting injury. That’s why if you cant get a good assessment you board them. - In our protocol, major trauma or high mech of injury gets boarded. In addition over 70, under 8 (SCIWRA is the reason), and osteoporosis are also inclusionary criteria. So the "a guy who falls on his head off a fast moving vehicle that looks fine"...would probably get boarded regardless. This is for those "gray area patients" who probably don’t have injury, but lets have a systematic approach to the assessment and decision making process. An approach that is based on medical evidence. Why? Because boards hurt patients too. - There is some debate on if this should be an EMT-basic level skill, based on initial education and cont ed on the A & P behind this. In my observations, some EMT-s properly trained in my system seem to be some of the most rigid in adherence to the protocol...but again this is after orientation and then they are all trained by Medic FTO's, and only work with a medic. Those new reserves in my system (straight out of school) seem to have problems with this. - While it is tempting to focus on the cervical spine, it is important to assess and clear the entire spinal column. Any good protocol and good clinician addresses this. It is in my experience, more common to see a Fx (however stable) in the lumbar region, but that is a commonality of MOI issue. Some reading for you: An excellent article by an ER doc on the subject. The article is from 2004, and I believe that sense the article was posted the protocol has been approved in most of his area of practice. The article is so good it is mandatory reading for our yearly SSI test. http://www.sehsc.org/news/cspine.htm Here is our SSI protocol: http://www.adaweb.net/departments/paramedics/swo/1y.pdf Here are our SWO's in general: http://www.adaweb.net/departments/paramedics/swo2006.asp More Reading: ~ Sahni R, Mengazzi JJ, Mosesso VN Jr. Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care 1(1):16–18, Jan–Mar 1997. ~ Cone DC, Wydro GC, Mininger CM. Current practice in clinical cervical spinal clearance: Implication for EMS. Prehosp Emerg Care 3(1):42–46, Jan–Mar 1999. AANS and CONS published a position paper at http://www.spineuniverse.com/pdf/traumaguide/1.pdf and it has lots of citations. ~ Domeier RM: "Position Paper, National Association of EMS Physicians: Indications for prehospital spinal immobilization," Prehospital Emergency Care. 3(3):251-253, 1999 ~ Domeier RM, Evans RW, Swor RA, et al: "Prehospital clinical findings associated with spinal injury," Prehospital Emergency Care. 111-15, 1997 ~ Goldber W, et al: "Distribution and patterns of blunt traumatic cervical spine injury." Annals of Emergency Medicine. 38:17-21, 2001 ~ Hendey GW, et al: "Spinal Cord Injury without Radiographic Abnormality: Results of the National Emergency X-Radiography Utilization Study in Blunt Cervical Trauma." Journal of Trauma. 53(1):1-4, 2002 ~ Hoffman JR, Wolfson AB, Todd K, Mower WR: "Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)." Annals of Emergency Medicine. 32(4):461-9, 1998 ~ Holmes JF, et al: "Epidemiology of thoracolumbar spine injury in blunt trauma." Academic Emergency Medicine. 8(9):866-72, 2001 ~ Panacek EA, et al: "Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury." Annals of Emergency Medicine. 38(1):22-5, 2001 ~ Stroh G, Braude D: "Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization." Annals of Emergency Medicine. 37(6)6098-615, 2001 ~ Ullrich A, et al: "Distracting painful injuries associated with cervical spinal injuries in blunt trauma." Academic Emergency Medicine. 8(1):25-9, 2001 ~ Viccellio P, et al: "A prospective multicenter study of cervical spine injury in children." Pediatrics. 108(2):E20, 2001

We dont carry keys. We purchased these really small hand gun safes for the primary lock, they have a key code, and thats mainly it. No keys, narcs are right by the jump bags so we can get to them easily.

Well, here are my thoughts. First , regarding "their plan": It makes sense to me (except the SOB part..but I wont judge until I hear what the other agencies can do..as in are they EMT-I that can give breathing treatments? questions like that). Now I am assuming that the responding units can request ALS ANYTIME (that is the way our system works) for things like pain control, etc. Now regarding your plan...Your plan has three issues. First, "more ALS" does not equate "better ALS", and from a system point of view....not a responder point of view...this is a consideration. I wont rehash the concept of paramedic over saturation here, but you can research it if you want. Just look at the King County Medic One approach. Second, Stuff like a broken arm with pain is an ALS response, but not necessarily an automatic ALS response. Nor is it something a BLS/ILS unit cant handle if ALS isn't available. Third, Your plan to stick an ALS unit in every small burb sounds good on paper but is probably not practical. I am making some assumptions on our service , but most ALS services are 30% tax based and 70% fee for service based, even "Municiple" third services and many fire based agencies. Considering this, with out supplementing the tax base with an additional local contribution (wich some places do), then there is no way you can add additional units. What you are talking about is a (assuming one RRV or Ambulance for every small community) 500-600%increase in expenditures WITHOUT the revenue to make that up. I know from looking at the cost vs benefit ratio for several of our own small communities that is the case. Now many are the first to say " how can you say that, a life is priceless"...but the ambulances have to have fuel, paramedics have to get a wage to care for their families, drugs and equipment have to be bought, training has to occur. And when it comes down to it, no budget is bottomless. And if you were an administrator, and you had funds for 6 ambulances, would you place them where volume demanded, or for rural response times? Sorry if this isnt what you wanted to hear, but it is honest. I know that from dealing with our rural communites, they often assume motives and maliciousness where there is none, because they dont want to look at the big picture or our side of the story..because we are "the big city folks"...simply not true 99% of the time.

I could repeat or elaborate on what others have said, but instead I will just post an extract of our pain control protocol: Regarding Abdominal Pain: Narcotic analgesia was historically considered contraindicated in the prehospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon's evaluation of abdominal pain. It is now becoming widely recognized that severe pain actually confounds physical assessment of the abdomen and that narcotic analgesia rarely diminishes all of the pain related to the abdominal pathology. It would seem to be both prudent and humane to "take the edge off of the pain" in this situation with the goal of reducing, not necessarily eliminating the discomfort. Additionally, in the practice of modern medicine the exact diagnosis of the etiology of abdominal pain is rarely made on physical examination. Advancement in technology and availability has made laboratory, x-ray, ultrasound, CT scan, & occasionally MRI essential in the diagnosis of abdominal pain. Therefore medication of abdominal pain is both humane and appropriate medical care. 'Nuff Said

To be specific, Demerols metabolite, nor-meperidine lowers SZ threshold. In addition, for those patients unfortunate enough to still be on MAOI's, it will have a lethal reaction. Also, when demerol works, it works well. When it doesn't, it doesn't at all. Not predictable ion my book like Morphine...but thats my experience.

Etomidate for cardioversion is the only part of our protocol that is a call in (or diviation proceedure) so it is not done that much, most prefer Versed...That said, in the event that the patient is grossly hypotensive, it is a good option

Here is our protocol: (Available at: http://www.adaweb.net/departments/paramedics/swo/m12.pdf) (Complete Set availble at: http://www.adaweb.net/departments/paramedics/swo2006.asp) SECTION: M-12 PROTOCOL TITLE: Adult Pain Control and Sedation REVISED:15 April 2006 GENERAL COMMENTS: Ada County EMS is committed to the relief of suffering in its patient population. Accurate and standardized evaluation of the pain is an essential component of pain management. Assessment should be on the 0 → 10 scale whenever possible, using OPQRST as an assessment tool, to provide a quantitative level of discomfort and allow accurate documentation. Providers at all levels should take a multifaceted approach to pain control and sedation. BLS SPECIFIC CARE: See adult General Medical Care Protocol M-1 - Treat underlying injury or illness as appropriate. - Consider that proper splinting may either exacerbate or relieve pain, use good clinical judgment in deciding course of action. - Assist patient in maintaining position of comfort. - Use distraction (through conversation, etc) and breathing techniques to help patient alleviate pain. - Ice packs or similar cold therapy for swelling. ILS SPECIFIC CARE: See adult General Medical Care Protocol M-1 ALS SPECIFIC CARE: See adult General Medical Care Protocol M-1 Analgesia- Morphine Sulfate IV/IM: 2-5 mg, repeated every 5-10 min PRN to a max of 20 mg. - Fentanyl Citrate (Sublimaze) IV/IM: 25-50 mcg IVP Repeat every 5-10 min PRN to a max of 200 mcg Sedation for painful procedures and injuries - Midazolam (Versed) IV/IM: 0.5-2.5 mg repeated every 5-10 min PRN to a max of 5 mg. - Diazepam (Valium) IV/IM: 2-5 mg repeated every 5-10 min PRN to a max of 10 mg. - Etomidate (Amidate) IV: 0.15 mg/kg slow IVP For use in very brief, painful procedures where the pain response is expected to be significantly reduced post procedure. (e.g. Cardioversion). Must be prepared to intubate if needed. Spasms - Midazolam (Versed) IV/IM: 0.5-2.5 mg repeated every 5-10 min PRN to a max of 5 mg. - Diazepam (Valium) IV/IM: 2-5 mg repeated every 5-10 min PRN to a max of 10 mg. Adjunctive medications: These medications are given for their potentiation of other drugs effects, or for the prevention/treatment of certain side effects (nausea, etc), of drugs used in pain control or sedation. - Phenergan (Promethazine) IV: 6.25-12.5 mg slow IVP, diluted. IM: 12.5-25 mg May dilute as needed for patient comfort when giving IV. - Benadryl (Diphenhydramine) IV/IM: 25-50 mg PHYSICIAN PEARLS: ALS Providers may decrease the dosage, or prolong the administration intervals of any medication with sedative properties when doing so would decrease adverse effects and still likely obtain the clinical goal. Regarding Abdominal Pain: Narcotic analgesia was historically considered contraindicated in the prehospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon's evaluation of abdominal pain. It is now becoming widely recognized that severe pain actually confounds physical assessment of the abdomen and that narcotic analgesia rarely diminishes all of the pain related to the abdominal pathology. It would seem to be both prudent and humane to "take the edge off of the pain" in this situation with the goal of reducing, not necessarily eliminating the discomfort. Additionally, in the practice of modern medicine the exact diagnosis of the etiology of abdominal pain is rarely made on physical examination. Advancement in technology and availability has made laboratory, x-ray, ultrasound, CT scan, & occasionally MRI essential in the diagnosis of abdominal pain. Therefore medication of abdominal pain is both humane and appropriate medical care. [fade:fbdd84d3f4]Like our protocols and approach to medicine? Hiring in June! www.adaparamedics.org[/fade:fbdd84d3f4]