p3medic

Nope, they are not cuffed to prevent aspiration, just pointing out that there is such a thing to those who might not have known otherwise.

Actually you can get cuffed pedi tubes, in fact the local childrens burn center prefers we use them for children with inhalation injury.

I've seen LMA's in the ED as a back up to failed intubation, never seen one used as the initial airway of choice (in the ED). I 100% agree we should prove what we do. The problem is, when someone like Wang publishes a study based on ETI success in the entire state of Pennsylvania you are not looking at individual systems but the entire state. I agree that across the board intubation success rates should be similar, but we all know they are not. Every system should start their own airway registry and collect data on every tube to prove we improve outcomes, or perhaps we don't. Either way, a medic in system A is not the same as a medic in system B despite what we would like to think. The National Airway registry looks at ED intubations across the U.S., we have an airway registry for our department modeled after it. If it takes a physician x # of intubations to learn the skill, and x # to stay proficient it should stand to reason it would take a similar experience for a paramedic to do the same. I think live OR intubations would be the best, however some of the newer simulators do a fair job of creating difficult intubation senarios. QA/QI is an absolute must.

I'm not taking it personally, no worries there. I just get a bit worked up when these studies suggest we are causing harm, when they are flawed by design. Yes, the San Diego patients intubated prehospitally did worse, but the degree of "training" set them up to fail. Take 50 EM residents and put them through the same training, and let them intubate 2 patients a year and see how they do. EMS systems need to insure that their medics get the education and experience they need, and the medical directors (physicians) heading these systems (and collecting a paycheck to boot) need to make arrangents with the anesthesia staff to get their folks into the OR to manage airways if they are not getting enough tubes in the field. What is enough? Don't know, thats debatable, but I can assure you 2 isn't it.

What the San Diego study "proved" was how poorly trained the medics were, not weather prehospital intubation for TBI resulted in worse outcomes. They were set up to fail from the beggining. The training was inadequate, the real life intubation training was non existant and the average medic got 2 prehospital tubes!

Trauma, TBI in particular is a small subset of patients requiring prehospital intubation. San Diego and Los Angeles have medics coming out of their ears, way too many providers and very little skill use. 2 tubes a year doesn't cut it. Don't know much about Baltimore other than it is run by an east coast fire department, and the Wang study in Pennsylvania looked at the entire state, no just a city like Pittsburgh (3rd service) and I don't believe it addressed RSI. The data out of the Pacific Northwest goes contrary to the data from the California fire services, and our data, although not yet published would suggest and improved outcome in the TBI population, as well as other, non trauma patients as well. I agree that as it stands today, not every medic should be performing intubation, but the answer lies in education and experience, not on removing a potentially life saving skill, in my opinion.

The prehospital intubation data showing worse outcomes have come from systems that don't intubate much. San Diego medics average 2 tubes a year, no surprise the data showed worse outcomes in their study. Same patient population (TBI) in Seattle/King County with medics that intubate a lot of patients and guess what? Improved outcome. How can that be? Experience is the difference. Intubation when needed can and does improve outcomes, when it is performed appropriately by a skilled clinician.

I actually agree with you Rid, the problem is the physicians are not addressing the problem, so unless you can show that it benefits your patient population it is going to dissapear. The systems that believe it is important address training, QA/QI by maintaining records of all intubations, what meds were used, complications, number of attempts, underlying pathology, and outcome. Look at the fire service in California for example. In the large urban areas fire sends numerous medics to every call on fire engines and sometimes ambulances. The doctors have no control over this. They do have control to some extent as to what they will allow under their license. It would be damn near impossible to get all those medics off their trucks to mandatory rounds, OR time, etc...without resistance from the union and the chiefs. What can the doctor do? Don't allow a skill that can be more harm than good in the hands of a poorly trained medic. I am all for con-ed, with active involvement from the physicians, this shouldn't be optional but required! Those systems who can't or refuse to participate shouldn't be intubating, with or without drugs.

You are the exception. Look around the country, most medics don't get that number of tubes, hell, some get none! Look at the fire systems with a medic on every piece, LA and San Diego come to mind. They have so many medics that despite the call volume, the chances of intubating are low. In the infamous SD RSI in TBI trial, the average number of intubations per medic was a whopping 2 a year! How does anyone stay proficient at intubation with those numbers? OR time for tubes would be great, but in a system with 2,000 paramedics its damn near impossible. I think what you will start seeing is fewer systems intubating unless they can prove with hard data that they are proficient and patient outcomes are improved. If not, get used to the King, LMA, combitube or supraglottic airway of choice.

They are heavy, but worth every pound when you don't have to hump the 3-400lber down from the top floor.

I'm not sure I follow. What particular pathology would these patients be dying from that would be not of interest to the paramedics? Granted, the interventions at the BLS level are fewer, however in our experience patients triaged by ALS for BLS transport haven't had poor outcomes secondary to a ride in a BLS truck vs ALS. As for 2 EMT's working together without medics, it seems to work well for us, the EMT's are provided an additional 600hrs of training, not medic school by any stretch, but significantly more than most other BLS providers in the U.S. and they seem to do a good job. Are there gaps in their knowledge? Absolutuely, their are gaps in mine too.

I understand what you are saying, and in a sense I agree. The education for EMS providers at all levels in the U.S. is piss poor, no doubt about it. The problem as I see it is skill retention, intubation being the big one. IF we could provide continued clinical hospital rotations for intubation and other skills that would be much less frequently needed in a system that is all ALS, and we could prove that our ability to perform at a high level could be maintained then I would agree. The problem as I see it, from my little slice of the World is a high call volume with a small number (relatively) of critically ill/injured patients, spread over a small number of medics allows for frequent management of these most difficult patients, as opposed to the all ALS system which in my particular area would be treating and transporting a high number of non-acute patients, with much less experience with the most critical. Example, we run 5 ALS and 19 BLS on the average day shift. So, if in the average 8hr shift we have 20 very sick patients, that is 4 per ALS truck. If we were all ALS with the same 20 sick patients we would have less than 1 per medic truck per shift (2 medics per truck). I don't have all the answers, but as it is now, this particular tiered system seems to work well for us. Fire provides first responders on certain call types, they function at the FR level and don't have a transport role.

Yes, the 600hr EMT doesn't have the same education as I do, and I don't have the same education as ERDOC. I think the average EMT here is capable of doing a focused assessment and know when they don't know. Tying up two ambulances may not always sound efficient on paper, but the patient comes first. If myself and my paramedic partner can tend to a critically ill patient as a team, the patient, in my opinion is better served than the one treated by the single medic, with his parter driving. Is it cheaper to run single medic? Absolutely. Is it better for the patient? I don't think it is.

Don't be stupid, everyone knows that R's are silent. I think the system here works for us for a few reasons. One, our BLS recieve 600 plus hours in the Academy, above the 120-140 in the EMT program which in my opinion makes them much more capable of taking care of patients than the average EMT grad. Two, having fewer medics allows the medics to see a high number of very sick/injured patients, resulting in more experience in skills such as intubation which has come under scrutiny in many systems. The most identifiable reason for poor intubation/airway management skills is lack of experience. On that subject, we have our own airway registry wich allows us to track success rates and other data points. All RSI cases are reviewed by a panel of physicians for appropriateness. Three, having BLS ambulances available to transport lower acuity patients frees up ALS resources without having to resort to nonsense like ALS engine companies. As for the financial aspect, it is cheaper for the taxpayer to fund 19 BLS trucks and 5 ALS as opposed to 24 ALS trucks. Every patient doesn't require an ALS transport. Tying up an ALS truck to transport a minor illness does not make financial sense. In a large urban area, the vast majority of calls barely need an ambulance, never mind ALS. Anyone working in a city setting knows of the widespread abuse of the EMS system by people without access, or more accurately can't be bothered with transporting themselves to see their PCP.

Negative ghostrider.....The same reason they won't lyse cva w/cocaine use in last 48hrs...vasospasm.

And we have a winner!

In Boston a call triaged as needing an ALS response gets an ALS and a BLS ambulance. Calls are frequently triaged at a higher acuity, only to find out its not. In cases like this (not the OP's stab senario) ALS can and do refer the patient for BLS transport after ALS assessment, and document accordingly. All ALS charts have MD review, and it seems to work well. If the patient is ALS, the ALS transport, sometimes the BLS will drive the ALS allowing both medics to treat the patient.

How much time does the engine company spend at a cross street location? Not much I bet.

Probably....Gary, likes cigars.

I would like to go next year, a guy I work with went said he had a great time.

Any medic doing his/her clinicals in a Boston teaching hospital will have a clinical coordintator at the facility, with the knowledge of what is expected. I don't think anyone would just show up blind, at least I hope not. Anyhow, good luck.

I wouldn't let some pissy resident scare you away, your there as part of your education process too. The biggest place for competition with the resident is the OR for tubes, with increasing LMA for cases, fewer tubes = more competition. Be polite, but agressive, show up early, stay late, and don't just tube and screw, stick around for the case, that would be my advice anyway. The ED both adult and pedi is a different animal. You won't be competing for many skills. You won't be intubating down there, but you'll start more lines, drips, and meds than you could ever want. The trauma rooms have a code team assigned with predesignated roles, you will be primarily and observer there, maybe do some compressions or ventilation during a code. You will get to defibrillate, but if your a wallflower, you snooze, you lose.

Thanks for the correction, although Chinatown gets you pretty damn close!

As vent stated, your program will need to have a clinical coordinator at the facility you want to do your time at. There are several hospitals in Boston that accomodate various programs, so it will depend on which ones your program is affiliated with. The BMC, MGH, and Carney all have medic interns from various programs. If you are relying on the T for all your travel, the MGH would be the easiest, Red line Charles/MGH T stop. Carney is a few blocks south of the Ashmont T station on the Red line, it isn't a trauma center, but you will likely get more "hands on" as a team member there. BMC isn't too close to any subway stop, Broadway on the Red line, Mass Ave on the Orange line, however there are busses conecting to BMC from both. I'm not sure about BWH or BIDMC about medic intern opportunities, they might, but I'm not sure. They would be a quick walk from the Green line Longwood stop. Faulkner? Not sure, a long walk from Forest Hills on the Orange. St. Elizabeths is way out in Brighton, but a Green line stop at Cleveland circle or close to it would get you in the vicinity. Tuft/NEMC? don't know if they have any medic interns. They don't have an EM residency program there, so it might not be a bad gig if you can get in, Orange line Chinatown. Anyway, good luck. What program are you with? What is more important, ease of commute, "hands on", variety of medicine/trauma?

Thats too bad, you should be evaluated by the same person (in my opinion) for a set period of time, one shift doesn't cut it. It sounds like a tough place to work, you can tough it out, or perhaps look elsewhere. I have no idea where you are or what other opportunities you have but I wish you luck. My only advice is to try to take a little something from each of your FTO's, even if that something is how NOT to do something.