Making Requests for Protocol Changes

[Bieber]

Looking at it from your point of view I would be appalled too. My personal safety is of paramount importance, always. However, we work differently to you guys. The code is worked onscene according to protocol. Then, a decision is made to transport if the patient falls into the trial category (<75yrs and no other medical conditions that contraindicate) The service in question then uses an automated compression device and a transport ventilator (as opposed to a BVM). The drugs would have been drawn up before hand and would be given whilst in a belted, sitting position. The monitor is also so positioned that it can be used from a sitting position. Organ donation is not the primary aim, by the way. Of course we are far more focused upon making a save but we also realise that we can't save them all and so try and make the best of a bad situation.

Here's a pic of the inside of the vehicle for you to understand a little better what I mean:

Carl

Carl, I didn't realize you're from out of the country! That definitely makes a difference, and I can tell from that picture that your guys' safety is held in much higher regard than ours. Right now, we work the code on scene and transport (unless the initial rhythm was and has remained asystole) after getting the antiarrhythmics or the three doses of atropine in (for PEA). We also don't have automated compression devices, though I could see how transporting a code blue patient while using one of those wouldn't be an issue.

Nice truck, by the way! I really like your setup. Honestly, having never worked in a type II ambulance, I don't think it would be that much more of a pain than in a type III. I know people complain about not having easy access to the patient's right side, but even in our trucks where we do have access to that side, trying to squeeze in there to get an IV is still a pain in the butt, and I'm not a big guy.

Island, and everyone else, I agree with you guys. I think that you're right that I should narrow down my list of proposals to one or two, and field C-spine clearance is definitely at the top of my list. I've had two calls in the last two weeks where spinal immobilization, I felt, was more detrimental to my patients than beneficial, however my hands were tied on the matter.

[Carl Ashman]

Carl, I didn't realize you're from out of the country! That definitely makes a difference, and I can tell from that picture that your guys' safety is held in much higher regard than ours. Right now, we work the code on scene and transport (unless the initial rhythm was and has remained asystole) after getting the antiarrhythmics or the three doses of atropine in (for PEA). We also don't have automated compression devices, though I could see how transporting a code blue patient while using one of those wouldn't be an issue.

Nice truck, by the way! I really like your setup. Honestly, having never worked in a type II ambulance, I don't think it would be that much more of a pain than in a type III. I know people complain about not having easy access to the patient's right side, but even in our trucks where we do have access to that side, trying to squeeze in there to get an IV is still a pain in the butt, and I'm not a big guy.

And there's me wondering how I offended you....

I've never had an issue with type II, we just do everything on the right side. In fact, type II is relatively large here. Have a look how our other neighbour's do it:

Yes, you really are looking at a standard Mercedes with an ambulance built on top!! Now they really are a pain to work in (even if they are very comfortable and go like the wind)

[fiznat]

I think appropriate monitoring is (as you might guess) more appropriate than "thorough" monitoring. By that logic, we should put everyone on the monitor simply to be thorough. I don't think that SpO2 monitoring is, in general, too little when it comes to the administration of narcotics.

I do. SPO2 sucks, and it should never be the only means by which you monitor your patient. We aren't CNAs. You should put your monitor on the patient fully because (1) it is a non invasive procedure that costs you nothing to do, and there is no reason other than laziness to omit it. Also (2), "appropriate monitoring" for patients receiving pharmaceutical intervention in the field should include preparation and monitoring for adverse effects. Among a myriad of potential complications, narcotic medications can cause patients to hypoventilate or have allergic reactions: both of which require cardiac monitoring.

Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field?

Absolutely. First though, I would caution that you are going down a very dangerous road to suppose that you can predict what a hospital can and cannot do. There is a whole world out there that you (and I) are ignorant of, and to assume you know the limits and boundaries of that world is just silly.

Just for the sake of argument, though, here are a few off the top of my head: pericardiocentesis for tamponade, chest tubes for hemo/pneumothorax, specific antidotes and expert consultation for overdoses and poisonings, reversal of hyperkalemia, surgical intervention on hemmorage, managed warming methods for hypothermic arrests, ultrasound evaluation of supposed PEA, blood infusions, open chest procedures, etc etc the list goes on and on.

Don't forget that the "H's and T's" are supposed to represent reversible causes of cardiac arrest. Think about how few of those H's and T's we can actually fully intervene on. I'm not saying that we shouldn't leave *some* arrests at the scene. We should. I'm just saying that a "no transport" protocol on all "dead" people is going way too far. ACLS is not the end all/be all of cardiac arrest management.

Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest?

So don't use the lights and sirens. Drive carefully. Get help.

The thing is, we're not emergency providers. We're primary care providers who occasionally dabble in emergencies, and as such, as need to equip ourselves to more appropriately manage primary care conditions. Treating minor to moderate pain with the appropriate pain management is part of that.

I disagree completely. We are *NOT* primary care providers. The ambulance, and the emergency department, is not primary care. Just because a lot of people call us for typical "primary care problems" doesn't mean that is what we become. Furthermore, we are not trained as primary care providers, nor does the back of a moving ambulance serve as the proper environment to provide primary care. Patients don't need medication from the very first healthcare provider they set eyes on, ESPECIALLY if it isn't an emergency. Do you have any idea how much it costs to have a paramedic administer tylenol enroute to the hospital compared to just going to CVS to pick it up? If we are primary care why don't we do routine physicals, tetanus boosters, urinalysis, track hypertension and cholesterol, or any of the other hallmark duties of the primary care provider? That is not what the ambulance (or the Paramedic) is designed for.

Edited April 8, 2011 by fiznat

[Bieber]

I do. SPO2 sucks, and it should never be the only means by which you monitor your patient. We aren't CNAs. You should put your monitor on the patient fully because (1) it is a non invasive procedure that costs you nothing to do, and there is no reason other than laziness to omit it. Also (2), "appropriate monitoring" for patients receiving pharmaceutical intervention in the field should include preparation and monitoring for adverse effects. Among a myriad of potential complications, narcotic medications can cause patients to hypoventilate or have allergic reactions: both of which require cardiac monitoring.

So are you saying you apply the cardiac monitor to every patient you have? After all, the person with the broken toe could also be in atrial fibrillation. Worse yet, they could get a fat embolus that goes to their lungs and arrest on you too. That's the danger of over treating. I'm not saying that we shouldn't be APPROPRIATELY thorough, I'm saying we shouldn't treat every little thing like a life or death emergency that requires our full capabilities. What are the two most common side effects of narcotic analgesics? Hypotension and respiratory depression. An ECG may show an increase in ventricular ectopy as a RESULT of respiratory depression, but dysrhythmias are not generally going to be sequelae of administration of narcotic analgesics. Competent reassessment of the patient and their vital signs (SpO2 included) is more than appropriate for most patients to whom pain management is given.

Absolutely. First though, I would caution that you are going down a very dangerous road to suppose that you can predict what a hospital can and cannot do. There is a whole world out there that you (and I) are ignorant of, and to assume you know the limits and boundaries of that world is just silly.

Just for the sake of argument, though, here are a few off the top of my head: pericardiocentesis for tamponade, chest tubes for hemo/pneumothorax, specific antidotes and expert consultation for overdoses and poisonings, reversal of hyperkalemia, surgical intervention on hemmorage, managed warming methods for hypothermic arrests, ultrasound evaluation of supposed PEA, blood infusions, open chest procedures, etc etc the list goes on and on.

Pericardiocentesis requires the cessation of CPR, and the AHA states that interruptions to CPR should be kept to a minimum and they also discourage transporting patients in cardiac arrest. Furthermore, how are you going to screen potential tamponade patients in the prehospital environment? Unless it's a traumatic arrest (which we don't resuscitate unless there were vital signs upon arrival), you're going to have to have some VERY strong reasons to think that that's the cause of the arrest to not only justify the interruptions in CPR not only to transport that patient to the hospital, but also the halting of compressions to do the ultrasound and procedure itself.

Surgical intervention of hemorrhage? First of all, like I said, we don't transport traumatic arrests due to the low survival rates associated with them. Secondly, if it's a thoracic injury, you can't perform surgery without ceasing CPR; and I don't even think very many surgeons will begin operating on a patient in arrest unless they coded on the table.

Chest tubes are nice, but needle decompression can be done in the field. It's not a permanent solution, but unless I'm mistaken if the pneumothorax is bad enough to cause the arrest it will correct it enough that if you're going to get them back, you will. Otherwise, you're still just transporting a dead person.

We can reverse hyperkalemia (and by reverse, I really mean correct the imbalance) with calcium if there's a strong enough suspicion of it. Labs are generally going to take too long to be of great value in cardiac arrest, so specificity is out the window.

Managed warming of hypothermic arrest. Are you talking about warm intravenous fluid? 'Cause we can do that, you know.

Ultrasound evaluation of PE. So, you're going to stop CPR to do an ultrasound, find the PE, and then what? They can't surgically intervene while the patient's in arrest, and I don't think giving LMW heparin to patient's in cardiac arrest is necessarily wise--but I'm not an expert.

Blood infusions. Again, traumatic arrests are more likely traumatic deaths.

Open chest procedures?! Really? Let's stop CPR to crack the chest? The AHA is saying NO interruptions to CPR. Interrupting CPR is what's killing patients.

Don't forget that the "H's and T's" are supposed to represent reversible causes of cardiac arrest. Think about how few of those H's and T's we can actually fully intervene on. I'm not saying that we shouldn't leave *some* arrests at the scene. We should. I'm just saying that a "no transport" protocol on all "dead" people is going way too far. ACLS is not the end all/be all of cardiac arrest management.

I don't disagree that there should be some clinical decision making with regards to transporting arrests, but I'm saying that the therapeutic value of transporting MOST cardiac arrests, unless you have a mechanical compression device, is nil or in the negatives.

So don't use the lights and sirens. Drive carefully. Get help.

How about, barring that VERY rare patient for whom hospital intervention MIGHT make a difference, we just sit our happy butts there at the scene, get in good, quality, uninterrupted CPR, give these people the BEST chance for life they can, and when it's all said and done either call it or transport ONCE we have ROSC?

I disagree completely. We are *NOT* primary care providers. The ambulance, and the emergency department, is not primary care. Just because a lot of people call us for typical "primary care problems" doesn't mean that is what we become. Furthermore, we are not trained as primary care providers, nor does the back of a moving ambulance serve as the proper environment to provide primary care. Patients don't need medication from the very first healthcare provider they set eyes on, ESPECIALLY if it isn't an emergency. Do you have any idea how much it costs to have a paramedic administer tylenol enroute to the hospital compared to just going to CVS to pick it up? If we are primary care why don't we do routine physicals, tetanus boosters, urinalysis, track hypertension and cholesterol, or any of the other hallmark duties of the primary care provider? That is not what the ambulance (or the Paramedic) is designed for.

Oh you can disagree all you want, but whether or not we're trained for primary care, educated for primary care, or equipped for primary care, that is what we're doing the vast majority of the time. You're not going to undo the last forty years of telling people to call 911 for an emergency, for a question about their electric bill, or for help changing their lightbulb. We've got to adapt to the reality of our job and to the changing nature of the healthcare environment. The truth is we're not even all that good with emergencies. It may just be that we can't save people once they reach a certain stage, but you know what we CAN do? We CAN help those people who HAVEN'T yet reached the "oh shit" stage. Our most proven interventions are those which provide no life saving treatment at all. And in this era of evidence-based medicine, and pay for performance, we're going to lose the battle to justify our existence if we don't start showing the public that we're capable of more than just putting on a pretty show and claiming that it's actually making a difference--because the science is saying that it maybe and even probably isn't. It doesn't matter what the ambulance or the paramedic was designed for. We can't be like that, we can't be rigid--because medicine isn't rigid. It's fluid and dynamic and if we try to be anything but fluid and dynamic ourselves we're going to disappear as quickly as we came.

You're right that patient's don't need to be treated by the very first healthcare provider they set eyes on, but the truth is that even more of our patients than we think don't need to be treated by us at all. We've got to find a niche for ourselves in the healthcare industry because if you don't think there's people out there who don't think ambulances or paramedics are needed at all, you're in for a rude awakening. We can try to avoid the issue only for so long before we're going to have to face the fact that maybe the idea of EMS is a joke, and maybe the idea that we're needed at all is misguided. I think we are, but I could be wrong. Either way, I know that we've got to start showing that we're capable of doing more than just managing emergencies. We've got to start branching out and become "mobile health services" if we want to survive, or you and I could go the way of the dinosaurs. We need to be educating ourselves on more than just emergencies, we need to prove that we're good for more than just emergencies (and that we're good for emergencies to begin with), and we've got to take a more proactive approach to patient care. We're not just there to put bandaids on them and take them to the hospital. I'm not there just to treat your asthma and pass you off to the hospital. I'm there to tell you you need to quit smoking too, and here's why. I'm there to talk to you about your obesity, and why it might be related to your chest pain. I'm there to tell you that your cancer medications can cause a lot of side effects, and that's what you're experiencing today. It's okay, it's not an emergency and you don't need to go to the hospital, and I've got the education to tell you that directly.

We're not just dealing with emergencies, so we had better start shaping up and educating ourselves on more than just emergencies. We're taking care of people with primary care problems, and we've got to address them instead of just passing them on to the ER--because they're not primary care providers either, but at least they have the education to address primary care issues, even if it's not their forte. An EMT could transport a patient with primary care issues to the hospital and pass the problem along; it's going to take a paramedic, an evolved paramedic with more education than I currently have, to step up and manage those issues without necessitating transport to an inappropriate facility. There are lots of patients with primary care issues who only need immediate relief and counseling, not an arbitrary ride to the hospital. But until we get out of this mentality that we're only going to manage emergencies and ignore the fact that we're being called upon to adapt and overcome, and actually change the way we do business, we're going to continue to fall down the totem pull of healthcare professionals and remain disrespected, undereducated, incapable, questionably necessary, and increasingly economically scrutinized.

[Carl Ashman]

We're not just dealing with emergencies, so we had better start shaping up and educating ourselves on more than just emergencies. We're taking care of people with primary care problems, and we've got to address them instead of just passing them on to the ER--because they're not primary care providers either, but at least they have the education to address primary care issues, even if it's not their forte. An EMT could transport a patient with primary care issues to the hospital and pass the problem along; it's going to take a paramedic, an evolved paramedic with more education than I currently have, to step up and manage those issues without necessitating transport to an inappropriate facility. There are lots of patients with primary care issues who only need immediate relief and counseling, not an arbitrary ride to the hospital. But until we get out of this mentality that we're only going to manage emergencies and ignore the fact that we're being called upon to adapt and overcome, and actually change the way we do business, we're going to continue to fall down the totem pull of healthcare professionals and remain disrespected, undereducated, incapable, questionably necessary, and increasingly economically scrutinized.

An excellent, well made point there Bieber. Education is a substantial part of the answer but not the whole sum. Whilst I agree that, with better and broader (degree-based) education, providers should be given more options than taking a patient "hot" to the nearest ER, there are a number of issues. Safe clinical practice dictates that in the management of chronic illness you should be able to refer your patient to a primary care provider. Now I am not about to start a debate on the entire US healthcare system but it is fair to say that a large portion of the population don't even have a primary care physician, let alone an entire support network. Therefore, here's the dilemma: it's fine to refuse transport to the mild COPD patient, but who is going to manage his care after you've left?

Carl.

[Bieber]

An excellent, well made point there Bieber. Education is a substantial part of the answer but not the whole sum. Whilst I agree that, with better and broader (degree-based) education, providers should be given more options than taking a patient "hot" to the nearest ER, there are a number of issues. Safe clinical practice dictates that in the management of chronic illness you should be able to refer your patient to a primary care provider. Now I am not about to start a debate on the entire US healthcare system but it is fair to say that a large portion of the population don't even have a primary care physician, let alone an entire support network. Therefore, here's the dilemma: it's fine to refuse transport to the mild COPD patient, but who is going to manage his care after you've left?

Carl.

Exactly the point, Carl! We're not complete buffoons, but those are questions we haven't been taught to ask ourselves. How do you decide that this patient can be left alone after we treat the acute exacerbation? I can speculate that certain criteria would have to be met, but I've never been formally instructed in it. Is this patient in immediate danger? What long term treatments are in place or need to be in place in order to ensure their wellbeing? What follow up instructions do they need? How certain am I that a another episode isn't going to occur between now and the time the patient is reevaluated by another healthcare provider?

Not every patient is appropriate to treat and leave on scene. But we can't even begin to start questioning exactly WHICH patients would meet this speculative "treat and release" criteria until we educate ourselves on primary care conditions. The fact is, most of our patients lived with their diseases before we showed up and most will continue to live with them after they've been treated and released at the hospital. People LIVE with constantly low blood oxygen saturations, chronically high blood pressure, and regularly occurring angina all across the world. We're trained to treat for the worst, but physicians are trained to not only treat for the worst, but also to treat for the low risk conditions. Physicians have an educational level that allows them to be comfortable with releasing their patients to their homes when admission to the hospital is not clinically indicated. Can we rule out the need for every patient? No! Many of these patients need lab work and imaging to make that decision. But a lot of them don't. And THAT is the niche EMS can fill. If we can become more properly educated in the hospital side of things, if we can learn exactly what will happen to these patients at the hospital, and the decisions that will be made at the hospital for these patients, then we can become part of the decision making process for a select group of patients for whom hospital admission or immediately additional diagnostic testing is not indicated. For example, it doesn't take labs or even an X-ray to diagnose acute bronchitis. The diagnosis and treatment of it is made based on physical exam and symptoms.

Now I know prescription writing is still a new and tentative thing even in those places that are currently doing it, but it's not unreasonable to think that one day it will become widespread and common practice. And it's not my goal to get ahead of myself and start advocating THAT just yet (see, biting off more than you can chew), but it's time we start getting the ball rolling in the general direction of increasing and broadening our education, because if it turns out that paramedics and EMS IS a feasible model for treat and release of those select patients, and that it's even a feasible model for limited prescription writing capabilities such as those used by EPCs in the U.K., we're going to miss that bus altogether if we don't start getting our act together now. You're right that it's more than just education, it's really a multi-fold issue, at least here in the United States. We need to change the medicare schedule of billing for ambulance services to allow payment for service rendered as opposed to payment for transport rendered. However the only way to do that is to achieve professional recognition as a healthcare entity, not as a taxi service. To achieve that, and to achieve the goal of allowing any sort of treat and release practice, you have to increase educational standards because no physician is going to let some diploma mill parawannabe start treating and releasing patients. They're not even going to let two year degree paramedics do that. And if we're not treating and releasing, pay for service isn't going to be especially beneficial not only to our patients but also economically speaking.

Guys, I get it. I really do. I'm ambitious. I like a challenge and I like to improve whatever I step my feet in, and I'm not claiming to know what's best for EMS or to have the knowledge or experience to really even have a right to an opinion, but I know how noble a profession EMS is and I have very strong beliefs about what it can be and what I think it should be. We sell ourselves short and bring ourselves down more than any other healthcare provider ever has. We could be so much more, we could be so much smarter and greater and of so much more benefit to our patients. I don't mean to get ahead of myself with all this talk of treating and releasing and prescription writing, my real goal--the most important goal--is to just get us all moving towards taking that first step of increasing our educational standards. It is going to open so many doors for us and give us so much opportunity to grow and evolve. It seems like everyone always complains about how there's no opportunities for paramedics to climb the career ladder, but it's all because we've never put forth the effort to create those opportunities. We are a noble profession and we owe it to ourselves, our future paramedics, and our predecessors to not stay put but to continue to strive for excellence. I want your career in EMS to be whatever you want it to be, but I'm telling you this, you have got to be proactive about changing the playing field. You have got to be telling everyone you know why we need to increase our educational standards and you have got to be bugging your state and national bodies about it, because everyone in EMS is working AGAINST that. Everyone is too tired, cynical, or lazy to upset the status quo and I know that none of you on this forum wants that--if you didn't still have that drive to improve, you wouldn't spend your free time reading an EMS forum. So let's do this, let's commit ourselves every day to improving our profession, for our patients, for our services, and for ourselves.

Edited April 8, 2011 by Bieber

[Carl Ashman]

Everyone is too tired, cynical, or lazy to upset the status quo and I know that none of you on this forum wants that--if you didn't still have that drive to improve, you wouldn't spend your free time reading an EMS forum. So let's do this, let's commit ourselves every day to improving our profession, for our patients, for our services, and for ourselves.

Ouch, that is harsh. This can also be a good place to learn about how other people do things. It will give good ideas for the future. One good example, I visited the US in my capacity as EMS educator more than 10yrs ago. I saw CPAP in action and was impressed. I went home and hounded my Medical Director so long that he finally relented and we now have CPAP. Don´t underestimate the power of the net.

Other than that, you make good points. Prescribing is, however, a long way off, I fear.

Carl

[NYCEMS9115]

I am all for progressive change but I have been shot down and insulted because I think Paramedics need to be a Degree ONLY program. No more Certificate Programs. It needs to incorporate the CCEMTP into the curriculum. I want this. I've sent emails/letters to every EMS Alphabet Organization regarding this. Requesting for a meeting; so I could show them my proposal. Well not much progress. You guys are arguing what I've been proposing. I want the Paramedic to become more than an Ambulance Driver. I've also proposed that the EMT must receive more didactic hours and rotation hours. They must have a HS/GED; in NYS many courses don't ask and the state requires it but no proof needs to be submitted. I wanted to merge the EMT-I85 to the EMT-I99; I

wanted all the other various state EMT certifications to be eliminated that are not recognized by NREMT (EMT-B, EMT-I, and EMT-P). I am still fighting but its a weekly thing at most not daily as it once was.

Beiber, I am not discouraging you but be prepared to fight for your cause. Its going to be a long one. All the best....

[fiznat]

So are you saying you apply the cardiac monitor to every patient you have?

Every ALS patient, yes. If I performed an ALS intervention it becomes an ALS call. I think this is good practice, because I know from experience that we find at least as many clinical signs by mistake than we do on purpose. This is true for all levels of medicine. I understand you are just starting out as a paramedic, but it shouldn't take you long to realize that our most powerful tool is DILIGENCE. You have absolutely no good reason to omit ECG monitoring on these patients. The tools are right at your fingertips, you've got the time. Cast a wide net and I absolutely promise you will catch some fish.

Pericardiocentesis requires the cessation of CPR, and the AHA states that interruptions to CPR should be kept to a minimum and they also discourage transporting patients in cardiac arrest...

Sounds like you are out to re-write ATLS based on the information you obtained in CPR class. Doesn't that strike you as ridiculous? Pericardiocentesis is the definitive treatment for cardiac tamponade, performed only by physicians, and as you said, you have very little resources to make that diagnosis in the field. That all equals up to a patient who ought to be transported.

By the way, trauma is only ONE of the possible causes of tamponade...

Surgical intervention of hemorrhage? First of all, like I said, we don't transport traumatic arrests due to the low survival rates associated with them. Secondly, if it's a thoracic injury, you can't perform surgery without ceasing CPR; and I don't even think very many surgeons will begin operating on a patient in arrest unless they coded on the table.

Not only are you wrong (I've seen several of the scenarios you describe actually happen), but your point is based in the fallacy that you understand the perimeters by which these physicians make decisions. You don't. That's not an insult, it's just the truth.

unless I'm mistaken if the pneumothorax is bad enough to cause the arrest it will correct it enough that if you're going to get them back, you will. Otherwise, you're still just transporting a dead person.

And what is this assumption based on? Are you planning on eliminating chest tubes from ATLS also?

We can reverse hyperkalemia (and by reverse, I really mean correct the imbalance) with calcium if there's a strong enough suspicion of it. Labs are generally going to take too long to be of great value in cardiac arrest, so specificity is out the window.

Wrong again. An i-STAT is point of care testing that takes only minutes. Also, treatment of hyperkalemia does not stop at calcium. Are you really sure that you know exactly what resources the hospital has to offer these patients? Sure enough to decide concretely that nothing more can be done?

Managed warming of hypothermic arrest. Are you talking about warm intravenous fluid? 'Cause we can do that, you know.

LOL once again you fail to realize that there is a whole world out there of which you are not a part. Active internal rewarming STARTS with warm saline. It does not stop there, not even close. Not to mention that hypothermic arrests may benefit from extended resuscitation. How long do you plan to work these patients in the field before you decide the cause is hopeless? Maybe you should just transport.

Ultrasound evaluation of PE. So, you're going to stop CPR to do an ultrasound, find the PE, and then what? They can't surgically intervene while the patient's in arrest, and I don't think giving LMW heparin to patient's in cardiac arrest is necessarily wise--but I'm not an expert.

Damn right you aren't an expert. That's the whole point. Also, I said "PEA" and not "PE." Ahem.

Blood infusions. Again, traumatic arrests are more likely traumatic deaths.

Same rebuttals as above. Specific patients, specific populations, etc etc. This is getting tiring.

Edited April 8, 2011 by fiznat

[fiznat]

Open chest procedures?! Really? Let's stop CPR to crack the chest? The AHA is saying NO interruptions to CPR. Interrupting CPR is what's killing patients.

Uh, yes. Spent much time in a trauma room? Ever seen cardiac massage? This happens fairly frequently. Then again, you DO have the benefit of all that AHA CPR training. I'm sure you can make that judgement call in the field.

I don't disagree that there should be some clinical decision making with regards to transporting arrests, but I'm saying that the therapeutic value of transporting MOST cardiac arrests, unless you have a mechanical compression device, is nil or in the negatives.

"Nill or in the negatives?" What are these statistics based on? Also, how exactly does a "negative therapeutic value" play out in the cardiac arrest patient?

How about, barring that VERY rare patient for whom hospital intervention MIGHT make a difference, we just sit our happy butts there at the scene, get in good, quality, uninterrupted CPR, give these people the BEST chance for life they can, and when it's all said and done either call it or transport ONCE we have ROSC?

My whole point here is that other than specific circumstances (rigor, lividity, etc), paramedics are not capable of identifying the populations of patients for which physician intervention would have a positive outcome. Turning this into a black and white decision scheme is the wrong thing to do.

Oh you can disagree all you want, but whether or not we're trained for primary care, educated for primary care, or equipped for primary care, that is what we're doing the vast majority of the time..... .....It doesn't matter what the ambulance or the paramedic was designed for......We've got to find a niche for ourselves in the healthcare industry because if you don't think there's people out there who don't think ambulances or paramedics are needed at all, you're in for a rude awakening......maybe the idea of EMS is a joke.....We need to be educating ourselves on more than just emergencies.....We're not just there to put bandaids on them and take them to the hospital. I'm not there just to treat your asthma and pass you off to the hospital. I'm there to tell you you need to quit smoking too, and here's why.......

Blah blah. This is all very inspiring, but you are forgetting that the reason you brought this primary care issue up was to justify treating non-emergent conditions in the field. ...NOT as a segway into some "we need more education" circle jerk (which every thread here devolves to), but to justify NEW and MORE procedures. You say it yourself. If we are going to become something else, then let's do that. ...But that doesn't mean we should start "acting as if" right this moment and start handing out ibuprofen and tylenol. Once again, you are far too eager to make decisions outside of your scope. How about a little humility?