Using Ultrasound on the ambulance - Yes No Maybe?

[spenac]

I guess I lead you into assuming their acronym was "RUT".

Nope assumed nothing. Just used the acronym that had been established by your statement, though I had always used other terms. I am aware of the proper term for many other healthcare professions and I even have enough education to know a few body parts proper names and uses.

Though you obviously assumed much about how an educated pre-hospital healthcare professional would use this tool.

I guess as almost always to many think there is only one way to do anything. You refuse to look outside the box and consider the posibiltys. Do I realistically see this becoming standard of care? No. Should it be an option? Yes it should. As much as I am firm advocate of money no object when it comes to patient care sadly I know better. Do I know everything about every possible tool that we could get educated about and put to use in the pre-hospital field? No I don't, but I will continually investigate. I do not see this being improperly used as a tool any more than it is misused at hospitals, and yes I have witnessed RUT's ( :shock: theres that darn wrong term again ) and doctors etc mis read what they saw, so I am not so stupid as to think we might not miss something with the way it would be used in EMS. I do not think we would ever change course because of what we saw unless it was an upgrade.

So vent your education does not make you the only one qualified to decide what we need in the field. I have appreciated many of your educational posts and think wow how nice to share but at times you remind me of the type of people that want to hold ems back. Sorry not trying to fight or offend.

[VentMedic]

I have appreciated many of your educational posts and think wow how nice to share but at times you remind me of the type of people that want to hold ems back. Sorry not trying to fight or offend.

No, I just believe EMS needs to get its credibility through education and the correct legislative processes. I don't believe in a bunch or random certs without a solid educational foundation. If you think more "tools" and "patches" push the profession forward, that is your opinion. As other professions have proven over and over, get the education and the skills will follow. Reimbursement policy makers have also recognized this fact. I don't know how else I can explain the advantages of a solid education for any profession before trying to sell themselves and others on more "skills".

Will EMS be able to recoup their expenses for purchase AND maintenance of this equipment? How many will have to be purchased for each service? Training costs? What will have to be sacrificed for the purchase? Will only some get it and some not? Like the ETCO2 monitor, we have the haves and the have nots. Unfortunately even that "tool" gets used so infrequently by some that have it that competency in its use lacks.

I am familiar with US from my involvement with specialty transport and flight where this could be a more reachable reality. And yes, we explored many of the potential benefits especially on our long distance trips to the islands. Even there, we have to prioritize our equipment and budget into what will do the most immediate good for the patient for transport.

Respectfully

However, I do enjoy a good debate with you spenac. I believe we both have mentioned good points. Your situation due to distance to the hospital presents with a more challenging patient care environment.

[spenac]

However, I do enjoy a good debate with you spenac.

As do I. But I sadly agree fully that until we get educated it is hard to get EMS to advance. I would prefer it at the beginning but sadly EMS at this time is not that way so those that want to advance must do it one piece at a time. Maybe change will come soon.

[ERDoc]

We are medivcs and EMTs not OB doctors...are you kidding?

This shows a total ignorance of the issue. Do a little reseach and come back to have a worthwhile conversation. I agree with Ventmedic, we need to get EMS up to a national standard and not local standards. I also agree with the person that said that cost may be prohibitive. These machine can be pretty expensive (say $20k in some cases). I can also not see using them out of the ambulance. Keep them in the ambulance and use them once the pt is on board.

I can see them having a place in EMS. Let's just look at the FAST exam (Focus Abdominal Sonography in Trauma, for those that were wondering). You pull up to a scene where a pt had had an abd trauma (MVA, kicked by a horse, whatever). They have good vitals because they are compensating for their bleed. You put the US on and find free fluid in Morrison's Pouch. Instead of taking the pt to your community hospital you will redirect to the trauma center. A negative US should not loosen up your pucker factor. The FAST exam looks at four spots where fluid commonly collects. Sometime the blood does not collect in these areas, so you still need to have a high index of suspicion. You can also use the FAST exam to assess a hypotensive pt with abd pain for free fluid. You can look at the Aorta to look for aneurysms. You can look for pericardial effusions and treat tamponade. OB is also another area you can use the US. You can have a pregnant woman who has not had her first appt yet. She develops pelvic pain and you, the astute medic, put the US on her and realize there is no fetus in the uterus. Where could it be? Could be an ectopic. This may also change where you take the pt and how quickly they get seen at your final destination.

As to the comment about spending time with someone to perfect your technique, US is pretty easy to learn. As a physician I never spent any time with someone else other than my attendings. You learn them best by doing them and on the machine you are going to use. The quality of the machines that we use in the ER and that would be used in the field are much less than those used by the US techs. It would be like learning to drive a motorcycle by using a Suburban.

[VentMedic]

I can see them having a place in EMS. Let's just look at the FAST exam (Focus Abdominal Sonography in Trauma, for those that were wondering).

I was taking FAST to be Focused Assessment with Sonography for Trauma.

The FAST exam I was referring to covers alot of area with the 4 different regions: perihepatic, perisplenic, pelvis and pericardium.

As to the comment about spending time with someone to perfect your technique, US is pretty easy to learn. As a physician I never spent any time with someone else other than my attendings. You learn them best by doing them and on the machine you are going to use.

You have made my point for "build the educational foundation and the skills will follow".

You are a physician with many years of education and a variety of skills. You had probably already been required to look at various diagnostic images prior to doing US. And, you had the expertise of other physicians to mentor you. I know what our residents go through when they are first learning any procedure, including US, from their attendings. I understand if those days you would rather not remember.

Unfortunately, for some Paramedics that have met only the minimum requirement of 700 hours to get their patch and only have the A&P provided by the Paramedic text, the "whys" might not come as easily. Yes, they may go through the motions but understanding all the potential possibilities might not come as easily. I'm sure you've seen some of the scenarios played out on the forums and have seen the wide variations on working diagnosis. Not everyone will have the same mastery of anatomy and pathophysiology. Those that don't know what they don't know will be the weakest links but will profess to knowing the most with a little bit of "education".

Now for those that have put more effort into their education with at least picking up some college level A&P and pathophysiology may appreciate the true value and understand the limitations much better. The only other issue would be getting the experience on as many different body types as possible with various diseases or traumatic injuries. Like getting intubation time, that may be an issue in some regions.

[Ridryder 911]

You know I heard the same crap when pulse oximetry was being introduced, AED and external pacing.. (awww.. we never will use them that much).. XII lead in the field . (awww. it will delay real care, EtCo2 ( great another device, it won't change my tx).. and so on...

Actually, I think it will be a standard piece of equipment in the future. I met a sales rep last week (a former Paramedic) and was excited to introduce this product. So much the are placing a both at our local conference... only being about $5-$15K I can see the opportunity for multiple uses, especially if we can get Medicare reimbursement rates..

Again.. step into the light and out of the box.... change can be good.

R/r 911

[VentMedic]

You know I heard the same crap when pulse oximetry was being introduced, AED and external pacing.. (awww.. we never will use them that much).. XII lead in the field . (awww. it will delay real care, EtCo2 ( great another device, it won't change my tx).. and so on...

But Rid,

I still hear and see crap when it comes to the use of the pulse oximetry in the field and the hospital as well as reading it on the forums. And yes, when people waste time trying to "get a sat" on someone who hasn't had good circulation below the shoulders in 10 years...well whatever.

The AED was first introduced around 1983 (Stevie Nicks "Stand Back") and it has taken 2 decades for it to become accepted.

The 12 - lead came shortly there after and has been very successful in many parts of the country but is not even a thought in others. And then there are those that rely on the machine interpretation. Again, a skill without the education for some.

ETCO2 is not that widely available yet nor is RSI. The education for its proper use is even less. Many Paramedic programs still do not have it in their curriculum but hopefully that is changing.

And then, we have the IO. How many services have mastered it? EJs? All relatively simple concepts of access and yet not that widely used.

But, we have EMT-Bs doing ETI.

At least get a college level A&P class as the prerequisite for all Paramedic programs before adding more "certs" and technology which the richer FDs will acquire and do half-arsed because they can.

I am not one that is against change but with the different "certs" and "skills" EMS providers acquire the same argument against education will exist. Why go to college when you can do all this in just a few months for an exciting career? (Medic Mill commercial) Thus, EMS providers will still remain at a tech level in the eyes of legislators and other professionals.

Raise the bar on standards and not the budgets.

[firedoc5]

Money? (Expensive piece of equipment for IVs)

Durability?

Time on scene?

Transport time?

Training?

Competency?

More training?

Frequency of use? (Doctors may use them in the ED regularly to keep their skills.)

Retraining?

QA/QC?

Intervention capabilities?

Is the service able to do chest tubes and not just needle decompression?

What meds do you carry? Blood products?

What OB interventions? Yes, OB specialty teams may or may not use them. Usually they know their limitations in transport but also have more knowledge and skills in their "tool bag". They may also have more time at the sending hospital in a controlled environment to obtain a quality US scan.

Flight medicine is different but that also depends on total transport time and the abilities of the crew.

To expand just a little bit more:

Time to "set up" per patient?

Artifact and quality scan due to movement? Sit still at scene?

Room for equipment?

Power supply?

Hours of additional training? So many are "specialize", how long does it take to be proficient?

Time to be proficient at reading the results? I know many techs. that will not make even a comment on it no matter how obvious it is unless a doc looks at it first. And doesn't a definite diagnosis have to be made by a Radiologist?

If it can be done in the field, but not be read, what's the purpose other than already having it done to save a little time after they get to the ER?

Maybe I'm just being nit-picky, but I just don't see it happening. At least no time soon.

[spenac]

This shows a total ignorance of the issue. Do a little research and come back to have a worthwhile conversation. I agree with Ventmedic, we need to get EMS up to a national standard and not local standards. I also agree with the person that said that cost may be prohibitive. These machine can be pretty expensive (say $20k in some cases). I can also not see using them out of the ambulance. Keep them in the ambulance and use them once the pt is on board.

I can see them having a place in EMS. Let's just look at the FAST exam (Focus Abdominal Sonography in Trauma, for those that were wondering). You pull up to a scene where a pt had had an abd trauma (MVA, kicked by a horse, whatever). They have good vitals because they are compensating for their bleed. You put the US on and find free fluid in Morrison's Pouch. Instead of taking the pt to your community hospital you will redirect to the trauma center. A negative US should not loosen up your pucker factor. The FAST exam looks at four spots where fluid commonly collects. Sometime the blood does not collect in these areas, so you still need to have a high index of suspicion. You can also use the FAST exam to assess a hypotensive pt with abd pain for free fluid. You can look at the Aorta to look for aneurysms. You can look for pericardial effusions and treat tamponade. OB is also another area you can use the US. You can have a pregnant woman who has not had her first appt yet. She develops pelvic pain and you, the astute medic, put the US on her and realize there is no fetus in the uterus. Where could it be? Could be an ectopic. This may also change where you take the pt and how quickly they get seen at your final destination.

As to the comment about spending time with someone to perfect your technique, US is pretty easy to learn. As a physician I never spent any time with someone else other than my attendings. You learn them best by doing them and on the machine you are going to use. The quality of the machines that we use in the ER and that would be used in the field are much less than those used by the US techs. It would be like learning to drive a motorcycle by using a Suburban.

Doc thank you for the information on how US would be used in the field.

Doc I agree we need a national standard that is much higher than the standards in most areas. But I do think local areas medical directors should have ability to even require more based on need. As everyone knows that has been on this site long I come up with many ideas or mention things we do here that most think is totally unbelievable. Our Medical director (at what is now my part time job) requires us to be educated and expects us to perform many treatments that are just unheard of in the field in most areas. I hate that at my current full time job I have to dumb myself down to avoid going beyond what is allowed, yet according to many medics that travel in from big citys, those protocols are more advanced than any they have seen. So I dumb down yet they have to expand. And at my part time job we are currently working on a new set of protocols that requires even more education and allows many more procedures and meds. I guess that is why I get so frustrated when people do not want to expand EMS scope of practice. In a perfect world schools would be required to provide a much better education. Sadly though today we have no choice in EMS but to pursue education piece by piece. But I also see the do the minimum medics and understand why some think we should lose some treatments and skills. Myself I am a healthcare professional striving for the best not the minimum and I wish all the slackers would just leave my profession.

[Ridryder 911]

But Rid,

I still hear and see crap when it comes to the use of the pulse oximetry in the field and the hospital as well as reading it on the forums. And yes, when people waste time trying to "get a sat" on someone who hasn't had good circulation below the shoulders in 10 years...well whatever.

The AED was first introduced around 1983 (Stevie Nicks "Stand Back") and it has taken 2 decades for it to become accepted.

The 12 - lead came shortly there after and has been very successful in many parts of the country but is not even a thought in others. And then there are those that rely on the machine interpretation. Again, a skill without the education for some.

ETCO2 is not that widely available yet nor is RSI. The education for its proper use is even less. Many Paramedic programs still do not have it in their curriculum but hopefully that is changing.

And then, we have the IO. How many services have mastered it? EJs? All relatively simple concepts of access and yet not that widely used.

But, we have EMT-Bs doing ETI.

At least get a college level A&P class as the prerequisite for all Paramedic programs before adding more "certs" and technology which the richer FDs will acquire and do half-arsed because they can.

I am not one that is against change but with the different "certs" and "skills" EMS providers acquire the same argument against education will exist. Why go to college when you can do all this in just a few months for an exciting career? (Medic Mill commercial) Thus, EMS providers will still remain at a tech level in the eyes of legislators and other professionals.

Raise the bar on standards and not the budgets.

I agree, but again it comes down to an expectation level of what should be required. I believe there is a major line or division at this time between educators (not instructors) of EMS and those in management. On one side educators see an endless opportunity of expanded treatment and care of the patient. We tend to see "outside the box" as we realize the

types and numbers" of patients will be drastically changing. Again, I believe our role will be totally re-defined.. not because we will want to but because we will have to.

On the other hand, I am witnessing EMS administrators attempting to just "fill in" the empty slots, with whatever they can get. (Of course this a broad generalization) Wanting to maintain operating costs as low as possible, (this including wages) so an acceptable profit margin can be obtained to keep in business or at least "keep a float". As the old saying ..."it takes money to make money"..is never more true than in EMS.

I am surprised that Medicare has not started a major overhaul in EMS. Personally, I would love to see formal investigations of the majority of operating EMS. There is NO accountability for delivery in care and operation in EMS from the payers viewpoint. I am surprised EMS receives as much compensation as it does. Personally, I would love to see that it would be highly recommended to be accredited by an organization such as JCAHO. At least some check & balances. Yes, EMS has such organization but it is not strong, nor does insurance companies require it alike JCAHO.

Once we have an agreement between educators and EMS systems, then and only then we will changes. If administrators could see requiring legislative change for formal education, that this would allow them to argue for more reimbursement rates. With the increase responsibility and associated education, along of course comes increased in payment, which in turn increases the remainder of the system. Maintaining status quo as it is now, is only detrimental to the lifespan of EMS. Again, part of our problem is majority of EMS operators are not educated in business or health care administration. Alike most EMS positions in general, a created one as a "good ole boy".

Do I foresee U/S uses.. you bet. The one I seen had very good quality to detect DVT, FAST programs and bluetooth capability for near real time. The device itself was under $5000. Alike digital watches, costs will continue to decrease with time.

Is such for every service.. absolutely no. However; for one that is over one hour away from any true surgical intervention, it might be an adjunct device to aid in obtaining a better assessment not to replace a quality hands on assessment.

We will see... if the education is taught properly and thoroughly, then it will a great device alike the other tools we have. If we promote and remain ignorant we will never see a change in our system and the outcomes of our patients.

I ask this... Is what we are currently doing working? ..

R/r 911