Med control for Morphine?

[MrBrown]

Most of our hospital staff are pretty cool; some have no interest in helping ambos whatsoever and one or two very, very experienced ED/med nurses I've talked to shake thier head and think of the ambos as "cowboys".

The topic at hand it would seem is an interesting one; I do not believe anybody with the correct knowledge and training should have to call a physician to give pain relief. I couldn't immagine working in such a system! .. even if I was given an autonomous number, say, 10.

As a side note, the American Board of Anaesthesology states to be minimally competent thier members should be performing at least 200 intubations a year, eh, but we know like five during clinicals is cool right?

 

[austinmedic2004]

Looks like we have a noobie to EMS and the world of medicine here as noted from the above two posts who also doesn't do his homework before spouting off things he knows little about.



That makes you an expert? Is that like sleeping at the Holiday Inn ad? Tell your girlfriend to get out more and see what her profession is all about so she can educate you better. You must be stifling her career. Jealous of her maybe?

I expect you are not from Oregon but from a state like Washington that has 8 different "cert" levels all based on one skill. Also, if you are in Washington state you should know who is on the Flight teams there and who does the intubating. Majority of your flight teams are RN/RN or RN/RRT. Even if they hold a Paramedic cert, it is their RN or RRT license they work under since it supersedes a Paramedic certification. RNs can also challenge the Paramedic test in some states. Other states have the RNs and RRTs just take a few weeks of things that might pertain to EMS but rarely to they have to take the 10th grade pharmacology or A&P when they have had college level courses. Nor do they have to do ED rotations to learn IVs and most are already ACLS, NRP, PALS etc plus many other specialty certs that require actual experience and not just a weekend no fail course. In fact, most RNs that do prehospital will have worked more codes in the hospital in one year, including leading them, than some Paramedics will work their entire career.

How many "hours of training" does you state require to be a Paramedic? Also, at that college, was the Associates degree MANDATORY or OPTIONAL with a "cert" program offered? I just checked the Washington website and their Paramedic "hours of training" requirement is no longer than most other states in the U.S.

Guess what? Both the RT and the RN licenses require no less than an Associates degree. It is not an OPTION.

At least you are correct here. Most IFTs are out of the scope of care for a Paramedic and that includes the majority of nursing home calls since they involve complex medical conditions that many Paramedics have little to no understanding.

BTW, you "insert" a Foley and not give it. The Foley catheter is not a medication. It is a tube that is passed through the urethra and into the bladder to drain urine.

The difference between RNs, RRTs and Paramedics is that the RN and RRT gets a solid educational foundation to build on for whatever specialization they desire. Thus, when the job calls for learning how to run a code or rapid response team in the hospital or do CCT/Specialty/Flight or become a prehospital RN, it is not that big of a stretch. On the other hand, the Paramedic learns a few technical skills without a lot of whys behind it and very little A&P or pharmacology, thus, they should not be allowed to touch a critical care patient on any IFT until they have finished a minimum of a two year degree. In fact, allowing them expanded scope of practice of any type, especially CCT, is probably not advisable for some Paramedics.

The other difference between RRTs, RNs and Paramedics is that RT and nursing saw what their weakest links were and did something about it. Thus, for that reason you will rarely see an LVN and the "Respiraty tech" is no more which means your information is very outdated. Both professions raised their educational standards after evaluating their bargaining and value in the world of medicine. They also realized medicine is constantly evolving and a "tech" cert is no longer good enough. EMS still has yet to embrace that concept. But, it is good that you at least got your degree.


And here's a news flash for you, Paramedics can not be certified in ATLS. They may audit the class but not participate in most of the skills labs and the audit is allowed only if the program has space to allow it.


Define extensively. Some Paramedic programs only require 5 successful passes on a manikin. Was your nurse girlfriend in training for MICN or PHRN? If not it was probably just a demo. Once she decides she wants to do transport, she will be trained by the doctors and given the opportunity to do many live intubations. And, she'll have the advantage of having seen many intubations prior to that time and probably would have participated in RSI many times. Thus, all she will have to do is learn the "skill" since she will already know the hows and whys of intubation. Some new Paramedics are put out on the street without any live intubation experience and may not even have seen one done except on a manikin. Sad but true. Thus, EMS then wonders why the statistics for unsuccessful Paramedic intubations are getting noticed.

There is one other little thing about the U.S. Paramedic that is now particularly annoying. It has be dumbed down to where every FF can become a Paramedic in just a few short months whether they want to or not. Most will do it for the extra few dollars of pay and "attempt" their one intubation per year while on an ALS engine.



Have you actually read your protocols or are you just shooting from the hip here? "Taking" a drip and "managing" one are two very different things. Yes the RN can get the drip all set up for you to watch on your drive inbetween hospitals and hopefully you are not one that just shuts the IV pump off when it goes beep, beep.



A trauma center using LVNs? As CNAs I hope and not as actual nurses. I haven't seen an LVN in an acute hospital in well over 20 years? Where did you say you were from?



Wow! You really have a very closed view of the world of medicine and of nurses. Is this a personal issue with your nurse girlfriend?

Let me explain the world of NPs and PAs to you. A PA now requires a Masters degree in many states and soon that will be their entry standard. They first get an undergraduate degree which could be anything from Biology, Art history (as long as the sciences are present), RT, or a BSN. Following the 4 year degree they enter another 2 years of training.

The NP has a lot more advancement ability and practice opportunities than the PA which is actually rather limited in some ways. Also, the NP is raising their educational standard to doctorate in a couple of years. Trauma Nurse Specialist, Neuro NPs, Pedi NPs and Neo NPs are a great asset to their field. The PA also has their place but the NPs have already organized their field and scope. I do have faith the PA will catch up as both of their organizations are also working together for improved patient care quality.

It sounds like you will never match my 30 years in EMS because you have too many low opinions of other health care professionals. You also believe the Paramedic is perfect and needs no improvement even when "hours of training" is still the standard. It also appears you don't believe the EMS degree is necessary even though you got one. No education is a waste of time. Until those in EMS realize the shortcomings of their profession, it will not advance. Take notes from what the RN, RRT, OT, SLP, PT etc have accomplished.

BTW, since you are new, I will just give you some friendly advice. There is a spell check feature on this forum.

Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information.

Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.

We as medical professionals (all of the above are included) need to further our education to suppliment the areas where we are weak and to expand our knowledge base.

The bottom line is, the answer cannot be found just in the amount of education but how it is applied.

 

[MrBrown]

Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information.

Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.

We as medical professionals (all of the above are included) need to further our education to suppliment the areas where we are weak and to expand our knowledge base.

The bottom line is, the answer cannot be found just in the amount of education but how it is applied.

I sort of agree. Having formal education at university level in adult learning and teaching I can say that education (as you say) is not just what you know (congitive) but also practical (psychomotor) however the first is required for the latter to be effective.

Anybody can teach somebody to stick an IV into a vein and pop an ampoule of adrenaline but can that same person also explain to you the whats and whys and what-ifs about the same thing? Probably not.

Competence in Paramedicine is often thought of in terms of practical dexterity to take out the stretcher, start an IV line, give meds and generally do ten things at once upside down in a ditch at one o'clock in the morning with some book learning thrown in while "competence" for counterparts in nursing and other health disclipines is about 60% theory 40% praxis; our Paramedic degree here is around 2,400 hours theory/sim and 1,200hrs on the street.

I take a very lowly view of anybody who says "oh you know, ambos dont need to know all that theory stuff, we never use it" oh but you do! If you have a solid background in the theory of the physiology, pharm and patho of what you are treating you'll be 100x more confident and .... I don't want to say "better" but maybe thats the right word ... in dealing with it because you can anticapte whats going to happen or what might happen and plan with it accordingly.

This is called "cognitive" knowledge and relies upon that knowledge you have to build up a picture based upon selectively using that knowledge to process information and draw up what you know to formulate a plan to react to the situatuon whereas this can be constrasted against "behaviourist" type reactions which are simply "ah, this is situation A so I will do B".

For example you take two ambo's and give them an asthma patient. One knows resp physiology, the pathophysiology of asthma and the pharmacology of salbutamol and adrenaline because it's included in those college level courses he took. He's able to use that information to process a plan of action based upon how sick the patient is, what tools he has and his experience.

The second ambo in this scenario can tell you the basics of what I've mentioned and he knows what to do because he's reacting to the stimulus the patient is giving off, but, he might not be able to tell you all the ifs and buts and hows and whys.

I would argue long and hard the first guy is who I want treating me.

A bloody fantastic follow on to this is dynamic hyperinflation when bagging an asthma patient. I often smash my head on the desk in despiar because it's so hard to explain to people as they just can't grasp the underlying concepts of the physoology of how hyperventilating an asthma patient can be fatal because they just dont have the knowledge of A&P.

 

[VentMedic]

Looks like there are a lot of generalizations being made here with regards to the "quality" of education of different medical professionals. The education received is only as good as the person retaining and applying the information.

Whether you are the graduate of a paramedic certification program, a paramedic AAS program, a nursing AAS program, a BSN program, a Registered Respiratory Therapist program, occupational therapy program, speech language pathologist program, physical therapy program, etc; the education alone does not make you "better". Certainly there is opportunity to be better prepared dependent on the amount of education provided by the program; but the real preparedness comes from the application of the knowledge in a practical setting as well as continuing education related to the specialty or desired specialty.

We as medical professionals (all of the above are included) need to further our education to suppliment the areas where we are weak and to expand our knowledge base.

The bottom line is, the answer cannot be found just in the amount of education but how it is applied.

I expected that this would be an agrument 0f someone TX which has one of the lowest "hours of training" requirements in the U.S.

So should there be no minimum education required for any medical professional? Should doctors not go to college and maybe just be OJT? Should nurses for back to diploma programs? Is a 1 year LPN good enough for patients in ICUs? Should RRTs just go back to being a 1 year equipment tech? Should we just have the 2 year programs for NP and PA? Are these Physician Extenders just a waste of time and especially with all that education?

You have good and bad in every profession whether it requires 1 day of training or 12 years. However, that does not mean you bash the higher education and eliminate it just to fit someone who didn't want to go beyond a few hours of training.

Just because EMS has always accepted a few hundred hours of training as being good enough doesn't mean the rest of medicine has to lower its standards to make the lowest denominator look good. May you should spend less time criticizing other professionals about wasting their time on education and look at what education has done for those professionals. EMS needs to stop with this "we're so different crap" and become part of the medical community as a profession.

It is also those with very little education that always seem to come up with the "just as good with little education as those with lots of education" comments probably because they don't know what they don't know but that "I've seen really great Paramedics with only 624 (TX) hours that are better blah, blah, blah". If you don't have a lot of "educated" Paramedics around you who have taken the time to get at least a 2 year degree, what do you really have to compare it with? Imagine how good those 624 hour Paramedics might be if they had a decent educational foundation. Performing a couple of "skills" well does not make a good Paramedic if they can't explain why or why not those skills are used. It may also not be enough to instill great confidence in your medical director that you are ready for protocols that you might have to think rather than calling med control and/or following the recipe exactly.

You bash other professions for being educated and not knowing what they are doing but then maybe you don't know what they should be doing since you are not in their profession and have never worked alongside other health care professionals. Many judge nurses from a 1 minute conversation about the patient and few realize that is not his/her only patient that they are caring for. Again, EMS has alienated itself from the rest of the world just because some believe the "we're so different" and a couple of "skills" puts you way ahead of the rest.

I guess by your way of thinking, all the Canadian and Australian Paramedics are also probably wasting their time because they are required to spend some time getting educated. Hell, they could just come to the U.S. and be a Paramedic in 3 -4 months instead of 3 - 4 years. Don't need none of that book learnin' to be worshiped by others who have the same about of "hours of training".

Establishing a higher level of education gives a profession a chance to see which students are motivated to acheive that level of education and to provide a foundation for the professional to develop. It also gives the legislators a definition for that profession to be measured so that the proper reimbursement can established.

Education is never meant to be an end all to the learning. Unfortunately, EMS has been in the tech schools too long where the "learn a few skills and start earning in a few weeks" mentality has become a slogan for EMS education in way too many areas in this country.

So yes, keep on bashing higher education and stating examples where YOU don't believe it is necessary so that EMS can stick with the PDQ medic mills and continue on the same path it has for over 40 years.

As far as the quality of EMS education, you failed to mention accreditation of EMS programs. Other professions do require accreditation for ALL of their educational programs. However, EMS is just starting to look at that. Except for California and most of the programs affiliated with colleges, accreditation is not really something a lot of EMS programs have obtained. At this time none of the EMS medic mills in FL have obtained accreditation and unfortunately they make up 50% of the programs in FL. TX lists 15 accredit programs which are the colleges. Are there others that are not college based in TX which aren't accredited? Now you are probably going to go on a rant that "accreditation" doesn't make a good school also and it may not but at least they have met some standards.

In summary, tearing down other professions, including EMS in other countries, that have raised their education standards still doesn't eliminate the issues in EMS and the reasons some medical directors don't always extend a lot of protocols to their Paramedics.

I have come to the conclusion that EMS is destined to continue as it has and there will be great resistance to any change including the new levels and the accreditaion because of those like yourself who feel it is better to hope for a few bright stars with a few "hours of training" rather than have the potential for many brighter stars to enter EMS for reasons other than the cool medic mill commercials which promise a fast education without alot of book learnin' to waste their time.

 

[VentMedic]

For example you take two ambo's and give them an asthma patient. One knows resp physiology, the pathophysiology of asthma and the pharmacology of salbutamol and adrenaline because it's included in those college level courses he took. He's able to use that information to process a plan of action based upon how sick the patient is, what tools he has and his experience.

The second ambo in this scenario can tell you the basics of what I've mentioned and he knows what to do because he's reacting to the stimulus the patient is giving off, but, he might not be able to tell you all the ifs and buts and hows and whys.

I would argue long and hard the first guy is who I want treating me.

A bloody fantastic follow on to this is dynamic hyperinflation when bagging an asthma patient. I often smash my head on the desk in despiar because it's so hard to explain to people as they just can't grasp the underlying concepts of the physoology of how hyperventilating an asthma patient can be fatal because they just dont have the knowledge of A&P.

Another good example to that would be those arguing which tidal volume is best with the "5-6 ml/kg" or "7-8 ml/kg" while totally missing the point that when resistance is high, you won't be able to ventilate regardless of what your recipe states. Sometimes the situation doesn't doesn't call for a particular "tidal volume" and now pressure control must become the concern and hopefully adequate VT can be met or an adjustment to minute volume can be made.

It is also for these reasons we do not take "phone orders" from physicians who are not near the patient and work under our own protocols for ventilator settings either in the unit or on transport. If they can't see the patient, the chest rise and the graphics or know the ventilators, they should not be ordering generic recipes. They can make suggestions but that is all. Some ALS/CCTs fail to know their own equipment and just try to "match numbers" from a big expensive ICU ventilator to their little ATV which unfortunately is all some are trusted with by their medical directors.

 

[Seaglass]

A bloody fantastic follow on to this is dynamic hyperinflation when bagging an asthma patient. I often smash my head on the desk in despiar because it's so hard to explain to people as they just can't grasp the underlying concepts of the physoology of how hyperventilating an asthma patient can be fatal because they just dont have the knowledge of A&P.

The other night, I got yelled at by my training officer for not bagging an asthma patient quickly enough in a scenario. When I explained why, I got a blank stare and "You know our protocols say we need to bag at this rate when the patient is breathing at that rate." Desk, meet head.

 

[Melclin]

Here is our pain management protocol. They give us much lead way on such matters. All of the protocols say consider, not you must etc.

http://img5.imageshack.us/img5/3073/painalgorithm.jpg

P.S.

I like distraction procedures for pain off 6 or less. Though there is no protocol for what those procedures are.

"IV prochlorperazine"

Now this annoys me. I've been told again and again that you cannot give prochlorperazine IV because of the cataclysmic reaction it will have with the blood. Now I see this, I hop onto Ovid Medline, do a little research and see that IV prochlorperazine not only possible, but in fact, indicated for a number of conditions in the ED. Why must we be fed such bull:censored::censored::censored::censored:?

Rant over.

 

[MrBrown]

"IV prochlorperazine"

Now this annoys me. I've been told again and again that you cannot give prochlorperazine IV because of the cataclysmic reaction it will have with the blood. Now I see this, I hop onto Ovid Medline, do a little research and see that IV prochlorperazine not only possible, but in fact, indicated for a number of conditions in the ED. Why must we be fed such bull?

Rant over.

Well speaking from personal experience I got dosed on 25 of IV promethazine and even tho it was well diluted it burnt like a mother fu*ker man wow did that sting something horrid, got a big red rash all up my arm too but eh in a minute or two i was dancing on the ceiling with pink elephants and talking to sommersaulting purple dogs which did not exist, so, i didn't mind at all

 

[swindlman]

So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some. She said even a paramedic must call med control before administration of a narcotic. We can administer it without med control though so I decided not to argue.

Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash. I explained that one must be developed so we can decide which protocol to follow and left it at that.

I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to. Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<

From my understanding is that if you have time for the med control then use it, just as with all meds. But if you are using your MONA and they Pt is refractory to you dropping 3 rounds of NTG to control the pain then start with your morph if the guy is going down the drain. And advise the Dr. when you call in what you did, as long as you have just cause for your actions then you will be alright. A lot of it depends on your relationships with the doctors and if they know you and trust your judgment.

I have lucked out with how my program is set up, all my RN hosp preceptors were once medics and most still have their licenses. So they know how things work on the road and in the hospital. We get around a lot of the grudges between the RNs towards the Medics. Plus the docs trust them so they push the students in the middle of the codes so we get to participate in alot in the ER.

 

[redcrossemt]

From my understanding is that if you have time for the med control then use it, just as with all meds.

You have to use med control for all medications?? Wow, that'd be a long, long day; and a lot of extra RF exposure...

But if you are using your MONA and they Pt is refractory to you dropping 3 rounds of NTG to control the pain then start with your morph if the guy is going down the drain.

Not exactly sure what you mean by "going down the drain"... but if my patient's BP is dropping or their mental status is decreasing, I'd be very, very careful with giving morphine. Especially without orders, not that I need them.

And advise the Dr. when you call in what you did, as long as you have just cause for your actions then you will be alright. A lot of it depends on your relationships with the doctors and if they know you and trust your judgment.

Someday this could get you in big trouble. Sure, you can get away with a lot of things not in the protocol. But wait until a patient gets worse, or better dies, and then you call med control and say, "hey I gave the morphine I wasn't supposed to, and now the patient is dead, okay, we'll see you in a minute." No doctor will support "cowboy" paramedicine after-the-fact, especially with a poor outcome. They don't want to be sued or tied up with the lawsuit against you.

I have lucked out with how my program is set up, all my RN hosp preceptors were once medics and most still have their licenses. So they know how things work on the road and in the hospital. We get around a lot of the grudges between the RNs towards the Medics. Plus the docs trust them so they push the students in the middle of the codes so we get to participate in alot in the ER.

If the above is what they are teaching you, I would suggest you be very careful. I'd be interested to know which school you are going to, and what your clinical sites are... I am glad that you get to participate, though.