Jambi
Forum Deputy Chief
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This will deal with American EMS, but all opinions, thoughts, and suggestions are welcome.
My question is how do we go about changing our EMS systems for the better. By this, I'm speaking of better accountability, training, QA/QI, and consistency.
What sparked this delusion of grandeur was a post by SpecialK in the RSI thread in the ALS forum.
I know the barriers to excellence have been discussed numerous times here, and many have said that American EMS is hopeless because of many external factors with their genesis being paramedic education (vocational training really) that refuses to advance into the changing world and its needs, and other external factors that benefit from easy training (cost) and limited accountability (non-transport first response fire).
There are also other issues at play. It's hard to motivate someone to advance into the future when they're making $15/hr and having to work 70 hours a week just to pay bills.
I also understand there are some obvious stuff like, "get more involved, etc.," but this is also akin to what to study and being told, "the book."
And honestly, I don't know where to start, what strategies to use, or even how to advocate such things, but there is desire.
So shoot away and let's discuss strategy. I'd love to hear from some physicians on how this would affect them (QA/QI. etc., it all takes time after all)
My question is how do we go about changing our EMS systems for the better. By this, I'm speaking of better accountability, training, QA/QI, and consistency.
What sparked this delusion of grandeur was a post by SpecialK in the RSI thread in the ALS forum.
SpecialK said:RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.
They are selected based upon competence at a three part selection process involving
(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass,
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario involving a critical patient. These scenarios are not particular to RSI, but test ALS skills, knowledge and decision making,
(b) Mini simulation – Each person will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and
(c) OSCEs – Each person will undergo about six short skill and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each and are not scenario based. Examples of these OSCEs could include demonstrating a failed intubation drill, cricothyroidotomy, or answering some questions relating to capnography.
If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical. It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.
Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.
Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.
Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium. Post-intubation regimen is vecuronium, morphine and midazolam. There is talk of moving to rocuronium only in 2014.
There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory. Failed intubations are salvaged with an LMA.
To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.
RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure.
These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.
I know the barriers to excellence have been discussed numerous times here, and many have said that American EMS is hopeless because of many external factors with their genesis being paramedic education (vocational training really) that refuses to advance into the changing world and its needs, and other external factors that benefit from easy training (cost) and limited accountability (non-transport first response fire).
There are also other issues at play. It's hard to motivate someone to advance into the future when they're making $15/hr and having to work 70 hours a week just to pay bills.
I also understand there are some obvious stuff like, "get more involved, etc.," but this is also akin to what to study and being told, "the book."
And honestly, I don't know where to start, what strategies to use, or even how to advocate such things, but there is desire.
So shoot away and let's discuss strategy. I'd love to hear from some physicians on how this would affect them (QA/QI. etc., it all takes time after all)