# "Is Prehospital EMS (PHEMS) a Profession?"



## mycrofft (Jan 5, 2012)

Taken from a definition of a profession by sociologists:

1. Professional association
2. Cognitive base
3. Institutionalized training
4. Licensing
5. Work autonomy
6. Colleague control... (and) code of ethics
7. High standards of professional and intellectual excellence
8. Occupation with special power and prestige
9. An exclusive elite group
10. Quality of detachment
11. Autonomy
12. Group allegiance 
13. High degree of systematic knowledge
14. Strong community orientation and loyalty
15. Self-regulation
16. System of rewards defined and administered by the community of workers.
"The Rise of Professionalism: A Sociological Analysis" (Larson, et al). http://www.amazon.com/Rise-Professionalism-Sociological-Analysis/dp/0520039505

So how does PHEMS meet this checklist? IS it met in every state and county and EMSA?


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## JPINFV (Jan 5, 2012)

1. Met by NAEMT
2. Yes
3. Yes. 
4. Yes (even if it's called "certification" in some places).
5. Some places. 
6. Depends. Some places the oversight agencies are run by EMS providers, and some places they're run by nurses. 
7. No.
8. Yes. 
9. No, but I don't think this one is relevant. 
10. Huh?
11. Some places yes, but not in enough places. Even some places that seem to allow autonomy go on to provide cookbook protocols. 
12. Somewhat. 
13. I don't know if I would call it a "high degree" yet. 
14. Yes. 
15. See 6. 
16. No.


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## Veneficus (Jan 5, 2012)

No.

(perhaps the shortest reply I ever typed)


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## mycrofft (Jan 5, 2012)

9. Exclusive elite group: regarded as more than a skill set and you can't become one just by passing a test or by decree (elite) and has concerns, dirty laundry and points all the members of the group can be proud of as a grow; and denied to others. ("Secret handshake", that stuff).

10. Quality of detachment: for PHEMS: practice and standards based upon research about and/or by PHEMS, and if someone else lodges a complaint or compliment, the group will decide if it is relevant, not a knee-jerk reaction. (i.e., if I complain about the counter person at Burger King she is likely to be fired; if I complain about an EMT, it will not result in a knee-jerk firing, have to be considered and weighed).

I think about nursing. Despite claims to be a "profession", and in some ares it is treated as such, it does not truly meet all these standards. Like the "Pirates' Law", it is more of a guideline than a hard and fast rule.






 ...yaaar.


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## silver (Jan 5, 2012)

mycrofft said:


> 9. Exclusive elite group: regarded as more than a skill set and you can't become one just by passing a test or by decree (elite) and has concerns, dirty laundry and points all the members of the group can be proud of as a grow; and denied to others. ("Secret handshake", that stuff).
> 
> 10. Quality of detachment: for PHEMS: practice and standards based upon research about and/or by PHEMS, and if someone else lodges a complaint or compliment, the group will decide if it is relevant, not a knee-jerk reaction. (i.e., if I complain about the counter person at Burger King she is likely to be fired; if I complain about an EMT, it will not result in a knee-jerk firing, have to be considered and weighed).
> 
> ...



Just out of curiosity which ones?


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## mycrofft (Jan 5, 2012)

Nurses depend upon MD's for their protocols and have to have their work approved and signed off by physicians. For one. Or two.


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## silver (Jan 5, 2012)

mycrofft said:


> Nurses depend upon MD's for their protocols and have to have their work approved and signed off by physicians. For one. Or two.



You mean the medical treatment? However, all of their nursing care and theory has been developed by nurses.

edit: besides who is to say that Larson, et al is correct?


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## mycrofft (Jan 5, 2012)

All nurse care is subject to medical control by a MD. If I screw up a vital sign or bandage change a MD can ream me out, or yell at my nursing boss, who then calls me in to pas it on. Can you see a nurse reaming out a surgeon for sending  pt to his/her floor with a badly placed drain or a haemostat sticking out of their ear or whatnot?

Nursing protocols are required at least in Calif to be approved if not written by a MD. And "nursing care", as defined by nurses (and management), is less and less about bedside nursing.

Follow the money and follow the reamings.


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## usalsfyre (Jan 5, 2012)

Had a long post typed out in response and realized...some places meet this and some don't. Until all of us meet it we're probably not as "professional" as we like to potray.


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## usalsfyre (Jan 5, 2012)

silver said:


> You mean the medical treatment? However, all of their nursing care and theory has been developed by nurses.



Nursing theory and nursing diagnosis.

:rofl:


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## Rettsani (Jan 5, 2012)

1. DBRD and Verdi
2. Yes
3. Yes
4. Yes
5. not everywhere
6. It is a question of how you look at it. When in doubt, the emergency physician decides everything for us.
7. Yes. We must learn very much for everything and get certificates. But despite all what we learn, are prohibited  many measures,  by the medical associations.
8. No 
9. No, Rescue personnel has  no lobby here
10. Many places working with a quality management system
11. No. 
12. Group allegiance, there is here only in the fire brigade and volunteer civil protection/ EMS
13. Yes, I think. 
14. No. Since everybody constantly fears for his job must have here is often bullying on the agenda.
15. Yes
16. No


* Offtopic *
The forum looks weird on my PC ...:unsure:


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## silver (Jan 5, 2012)

usalsfyre said:


> Nursing theory and nursing diagnosis.
> 
> :rofl:



At least they have there own academia, whereas EMS has "instructors."


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## usalsfyre (Jan 5, 2012)

silver said:


> At least they have there own academia, whereas EMS has "instructors."



You don't see a legion of physician's assistant "academia", yet I don't see anyone arguing they're not a profession. 

Nursing academia is what's responsible for such malarky as pneumonia being called "impaired respiratory gas exchange" and Jean Watson claiming "caring" is more important than the medical care delivered. Excuse me if I look at that part of nursing as a list of stuff we need to NOT do under any circumstances.


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## DrankTheKoolaid (Jan 5, 2012)

usalsfyre said:


> Had a long post typed out in response and realized...some places meet this and some don't. Until all of us meet it we're probably not as "professional" as we like to portray.



This, pretty much says it all


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## mycrofft (Jan 5, 2012)

Let me inject as we all know that some individuals conduct themselves as the epitome of professionals no matter what they are doing, while others ensconced in a "profession" are slugs. Hats off to the former.


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## mycrofft (Jan 5, 2012)

Nursing theory and diagnoses...used more for teaching. If I were brought up for dismissal and cited one or the other versus hospital protocols, I'd be laughed all the way to my car with the cardboard box in my arms.

I bought my own copy of Marjory Gordon's Manual of Nursing Diagnosis (edition 1 if I recall) and used it to kerflubber my nursing clinical instructors who couldn't admit the real world trumped the school's philosophy.

NOW, that said, a bubble of nursing can form where an administrator who has a nursing background chooses to follow that philosophy in her span of control. However, that is pretty much a career killer if you want to advance. As I've commented a couple years ago, we need  more people with backgrounds as EMT's (paramedic and basic etc etc) to go on, get educated, get promoted, then turn around and pay not back.


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## atropine (Jan 5, 2012)

Being a fire medic is a profession, depending on where you work. As well as being a single role medic again depending on where you work.


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## EMSLaw (Jan 5, 2012)

It depends on the definition of a profession you use.  Mycrofft has suggested one.  But professions are characterized by a long period of formal learning, self-regulatory authority over the profession's members, and monopoly rights.  So, for example, to be a lawyer you must attend law school, the Board of Bar Examiners and/or highest court of the state must license you, and practicing law without a license is a crime.  Same for doctors - medical school, examination by the Board of Medical Examiners, and legal protection for their practice rights.  

As a lawyer, I was taught by lawyers, tested by lawyers who reviewed both my subject matter knowledge and my moral character to practice.  Lawyers determine my professional ethical responsibilities, and if I were to foul up, the discipline would be decided by lawyers.  The law protects my monopoly as the holder of a plenary license to practice law - you can represent yourself, but you can't just go out and take clients on the courthouse steps. (Though that's a bad example, since I can't either, except in Washington D.C., and even there, it has to be across the street.)  

EMS is not characterized by a length of training that would be equivalent to the three original learned professions (law, medicine, or the clergy).  EMS credentialing is not necessarily in the hands of EMS practitioners.  Only in the final point - legal protection and monopoly rights - is there some indicia of a profession.  And while it's illegal to act as a paramedic without a license, it's also illegal to barber, or be an electrician or carpenter, without appropriate legal authority.

I'd say right now, EMS is more of a skilled trade.  If it is to be more, it will require greater education, as well as EMS practitioners interested in becoming active in the political and regulatory aspects of their chosen career.


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## firetender (Jan 6, 2012)

Veneficus said:


> No.
> 
> (perhaps the shortest reply I ever typed)


 

Somebody grab me that AE...


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## mycrofft (Jan 9, 2012)

EMSLAW, I thought there was an older profession...


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## NomadicMedic (Jan 9, 2012)

atropine said:


> Being a fire medic is a profession, depending on where you work. As well as being a single role medic again depending on where you work.



Eh, I think I'd disagree with this. Most firefighters I know consider themselves more along the line of tradesmen. Like carpenters or masons, they are well skilled in a complex task, but singular in function. I'd consider them to be classed between a laborer and a professional.


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## 46Young (Jan 9, 2012)

Is prehospital EMS a profession? That depends largely on the employer. 

It's no wonder many who get into EMS thinking it's a profession come to the realization that it's not in most cases. It's not hard to see why when the employers require the bare minimum in education, offer low pay, poor working conditions, poor retirement, suspect job security, not much of a career ladder, "pulse and a patch" hiring standards, etc. 

For every King Co. Medic One there's numerous undesireable employers. When looking at EMS globally as a profession, that's really poor odds.

Is prehospital EMS a profession? The high rate of turnover suggests not. I believe 7-10 years in the field before leaving is average, although I suspect it may be even lower.


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## systemet (Jan 10, 2012)

No.

I have seen individuals act in a professional manner, but I've seen at least as many act unprofessionally, and sadly, perhaps more. 

I think EMS has the potential to become a profession, but it's got a long way to go.


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## St George (Feb 5, 2012)

Paramedics are considered healthcare professionals in the UK, however our equivilent EMT grades are not.


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## downunderwunda (Feb 5, 2012)

Yes. Yes. Yes.


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## RocketMedic (Feb 6, 2012)

St George said:


> Paramedics are considered healthcare professionals in the UK, however our equivilent EMT grades are not.





I've always wondered- what is the difference between an American paramedic and a UK paramedic? I met and spoke extensively with a friend of my instructor's who is a Scottish paramedic and he was very negative about the NHS and the UK way. He was really impressed with our pay here (apparently, after taxes, his wages are a pittance at best) and our scopes of practice. Apparently, although he is technically a "provider", his actual authorized scope is really, really limited.


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## St George (Feb 6, 2012)

Rocketmedic40 said:


> I've always wondered- what is the difference between an American paramedic and a UK paramedic? .



 Im still learning exactly what an American paramedic actually is (and isnt). In the UK all paramedics must be state registered in a similar manner to an MD or RN. As such they can struck off for misconduct, and using the title "paramedic" without holding state registration is a crinimal offence. I wouldnt say their scope is limited - certainely medical direction does not exist in any shape or form over here, thus making our paramedics completely autonomous practitioners. The pay is extremely poor though, and this is a sad consequence of there being an excess of supply vs demand.


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## Medic Tim (Feb 6, 2012)

mycrofft said:


> Taken from a definition of a profession by sociologists:
> 
> 1. Professional association
> 2. Cognitive base
> ...



according to this . Yes EMS in NB is a profession.


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## systemet (Feb 6, 2012)

St George said:


> I wouldnt say their scope is limited - certainely medical direction does not exist in any shape or form over here, thus making our paramedics completely autonomous practitioners.



You have guys in the UK running around giving tenecteplase, and there's no medical oversight at all?  They don't send the 12-lead to a physician, and consult for risk stratification before pushing thrombolytics?


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## St George (Feb 6, 2012)

systemet said:


> You have guys in the UK running around giving tenecteplase, and there's no medical oversight at all?  They don't send the 12-lead to a physician, and consult for risk stratification before pushing thrombolytics?



 No there is no legal requirement to do this at all. In some areas, they can transmit ECG recordings to a local CCU for advice. But this will be at the discretion of the paramedic. In fact paramedics can give any drug listed here, without the need to discuss with an MD:
https://www.collegeofparamedics.co....n_medicines_pre-registered_student_paramedics


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## systemet (Feb 6, 2012)

St George said:


> No there is no legal requirement to do this at all. In some areas, they can transmit ECG recordings to a local CCU for advice. But this will be at the discretion of the paramedic. In fact paramedics can give any drug listed here, without the need to discuss with an MD:
> https://www.collegeofparamedics.co....n_medicines_pre-registered_student_paramedics



Interesting.  This is one of the few things we always had to patch for.  

Although that list suggests you might not be able to give plavix or enoxaparin?


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## St George (Feb 6, 2012)

Enoxaparin = Heparin Sodium and that is on the list. Plavix (clopidogrel) is not widely used in the UK and its use in pre-hospital care not established. One thing though, we could never ever EVER use the word "Plavix"!!! Using brand names is a big no no in the UK.


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## JPINFV (Feb 6, 2012)

Enoxaparin is a low molecular weight heparin, but it isn't heparin proper. There's more than a slight difference between the two.


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## systemet (Feb 7, 2012)

JPINFV said:


> Enoxaparin is a low molecular weight heparin, but it isn't heparin proper. There's more than a slight difference between the two.



It's nice from an EMS perspective as it's usually a single dose, and not an infusion.

(I'm know JPINFV is aware of this, but just for anyone's who's wondering.  Sorry for the thread derail).


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## JPINFV (Feb 7, 2012)

You also don't have to monitor labs with LMW heparin.


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## R99 (Feb 7, 2012)

St George said:


> No there is no legal requirement to do this at all. In some areas, they can transmit ECG recordings to a local CCU for advice. But this will be at the discretion of the paramedic. In fact paramedics can give any drug listed here, without the need to discuss with an MD:
> https://www.collegeofparamedics.co....n_medicines_pre-registered_student_paramedics



That list is  quite limited, we have some UK  Paramedics here who say back in old country they could not pace, RSI, cardiovert, give IV adrenaline other than for cardiac arrest or sedate and are amazed at what we can do (shameless plug)

Our levels (for comparison)

Paramedic (UK Technician grade equivalent requires a Bachelors Degree)
LMA
Entonox
Paracetamol
Ondansetron
Adrenaline
Aspirin
GTN
Salbutamol
Ipatropium
Glucagon
IV glucose
Ceftriaxone
Midazolam
Morphine
Fentanyl
Normal saline
Loratadine
Amiodarone
Tourniquet
12 lead ECG interpretation
Cardioversion

Intensive Care Paramedic (UK Paramedic equivalent, requires a graduate degree ontop of bachelors)
Paramedic plus,
Intubation/RSI
Pacing
Ketamine
Adenosine
Atropine
IO access


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## St George (Feb 7, 2012)

Hi. The list I posted is in addition to Schedule 7 emergency drugs (which includes many on your list above) and non-injectable drugs (such as entonox/GTN/salbutamol) are not restricted under UK law. Very interesting though - pacing and cardioversion are certainely not permitted, this is probably due to ambulance trusts introducing AEDs in place of manual defibs!


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## RocketMedic (Feb 7, 2012)

An AED won't fix a problem that needs pacing or synchronized cardioversion...


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## Veneficus (Feb 7, 2012)

Rocketmedic40 said:


> An AED won't fix a problem that needs pacing or synchronized cardioversion...



An AED, not yet...

But I am sure somebody somewhere is working on an EMS model for basics or austere environments that will.

If the 12 lead can tell you the rhthym and that same monitor has a BF cuff and saturation monitor, it is not a large step in the software to pace and cardiovert. 

Or even a device that can be put on by a basic that once the appropriate devices are connected is automated from there.

There are already implantable pacer/defibrillators, certainly an external model is possible.


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## RocketMedic (Feb 7, 2012)

Veneficus said:


> An AED, not yet...
> 
> But I am sure somebody somewhere is working on an EMS model for basics or austere environments that will.
> 
> ...



I have no doubts that the technology will rapidly advance, I was commenting more on the UK ambulance trusts not _currently_ equipping them.


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## systemet (Feb 8, 2012)

Rocketmedic40 said:


> I have no doubts that the technology will rapidly advance, I was commenting more on the UK ambulance trusts not _currently_ equipping them.



I find this odd, as apparently they're thrombolysing people.  So they must have a 12-lead.  Presumably they've just hobbled the machine, so that you can't use manual modes for defibrillation / cardioversion.

It's not impossible that they're using LP12, or similar, monitors but they've been programmed to prevent pacing or cardioversion.


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## St George (Feb 8, 2012)

Far simplier answer guys. The have an AED and a seperate ECG machine to do 12 lead ECG.


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## RocketMedic (Feb 8, 2012)

That seems redundant. Not to mention the few patients who would benefit from cardioversion and pacing are SOL...

Why not trust y'all with ETT and electricity? Do y'all have CPAP?


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## St George (Feb 8, 2012)

ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf


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## jjesusfreak01 (Feb 8, 2012)

St George said:


> ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf



Are paramedics still allowed at least one decent BIAD, like a King? Doesn't make sense to phase out ETI when you don't have a decent backup.


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## crazycajun (Feb 8, 2012)

St George said:


> ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf



I think the biggest problem (according to some research) in the UK is unsuccessful intubations in the field. My understanding is about a 25% success rate. That is a very low number. I also understand that the esophageal intubation rate is somewhere around 47% which is extremely high. The US has also looked at taking ETT intubation out of the national scope however there is definitive proof that ETT is a needed option in some rural areas. RSI on the other hand is a technique that should be more closely monitored. It seems more and more medics are being allowed to RSI that cold not intubate in the first place.


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## systemet (Feb 9, 2012)

crazycajun said:


> I think the biggest problem (according to some research) in the UK is unsuccessful intubations in the field. My understanding is about a 25% success rate. That is a very low number. I also understand that the esophageal intubation rate is somewhere around 47% which is extremely high. The US has also looked at taking ETT intubation out of the national scope however there is definitive proof that ETT is a needed option in some rural areas. RSI on the other hand is a technique that should be more closely monitored. It seems more and more medics are being allowed to RSI that cold not intubate in the first place.



Those numbers don't sound right.  If you can find a source for them, I'd be interested in taking a look at them.

I doubt this is an issue that UK paramedics somehow have an inability to place tubes in the trachea.  It seems much more likely that the medical direction in the UK has never allowed their paramedics to use RSI or medication-facilitated intubation, and in light of the many negative, and a few neutral studies out there, aren't about to start.

The rural regions in the US and Canada may have something to do with the wider use of RSI there.  But I think a bigger reason is that both have incredibly disorganised and fragmented systems.  It's not uncommon to drive an hour or two down a highway, and pass through four or five different systems, with different delivery methods, e.g. fire versus private ALS, municipal ALS, private BLS, volunteer EMR, etc., and five different sets of protocols.  

While this sort of system probably isn't optimal, it leads to the use of different skills in different areas, which drives things forward.  There's also a similar driving effect from fixed wing and rotary wing air ambulance that's less prevalent in the UK.  I mean, if you're going to fly for an hour to land at a rural health center, staffed by an RN, to deal with some guy who got run over by a car an hour and a half ago, and then you've got to fly another hour to a trauma center, things like RSI become sort of, less risky and more desirable.

With the new UK medics getting a Bachelor's degree, and the UK Paramedic Practitioner program at the cutting edge of non-physician ALS development, it's hard to think that the reason they don't use RSI is some sort of widespread bungling incompetence.

Also, while cardiac arrest tubes tend to be pretty easy, if you look at a success rate in a system intubating with less than optimal agents, e.g. no drugs, or benzos alone, or benzos+opiates without paralytics, etc., the success rates are likely going to be lower versus using paralytics.  There's a decent paper out there showing a HEMS system using etomidate alone versus the same system using etomidate + succs, and their success rate varied greatly -- which may be partially due to properties of etomidate, but nonetheless interesting.

[I feel like I could also ramble on about how intubation success rate is a poor metric, e.g. if my first attempt takes 30 minutes, I can probably approach a 99% first pass rate, but everyone will be dead.]


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## Veneficus (Feb 9, 2012)

Has anyone considered the reason they don't have those tools is because the need to use them may be so low that it doesn't justify the expense?


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## systemet (Feb 9, 2012)

Veneficus said:


> Has anyone considered the reason they don't have those tools is because the need to use them may be so low that it doesn't justify the expense?



I've considered that.  It's a possibility, right?  It just seems that the variables involved are too poorly defined to be able to make a definitive statement in either direction.  

* Is prehospital intubation desirable?  There's not a lot out there comparing ETI to BVM.  We have the Gausche pediatric ETI via BVM study in LA / Orange Counties, showing equivalence.  But this almost feels like a win for ETI, because the intubation success rate was 57%, and still they didn't seem to be able to kill or vegetablise anyone at a significant rate.  None of the subgroups are really large enough to identify whether particular groups were at greater risk.  The San Diego trial's limited by methodology, but motivates against RSI in head injury.  The Aussies have data showing an improvement in 6 month neuro outcomes in the same patients.  But they're also successfully intubating 97% of their patients versus something like 88% in the San Diego trial.

* What does it cost to do well?  We still don't seem to be able to agree on what an acceptable level of initial and ongoing training is.  The Aussie's did well with 16 hours, 8 of which were in the OR with an anesthetist, but they started off with degree paramedics with postgraduate training, probably with substantial experience.  San Diego failed on 8 hours of classroom setting, using paramedics with substantially less education.  To see the benefits the Australians reported, do we need to increase initial training time for paramedics, restrict the skill to a small group, have periodic OR access, or a minimum number of tubes / paramedic / year?  And what are the ongoing training requirements at + 1year, + 5years, etc.

It doesn't help matters either that much of the poor outcome seen in earlier trials has now been attributed to hyperventilation, which is at least partially a technology issue that can be mitigated by widespread use of waveform capnography, or that there's been concerns voiced about frequent displacement / unrecognised esophageal placement in other studies.


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## Veneficus (Feb 9, 2012)

systemet said:


> I've considered that.  It's a possibility, right?  It just seems that the variables involved are too poorly defined to be able to make a definitive statement in either direction.
> 
> * Is prehospital intubation desirable?  There's not a lot out there comparing ETI to BVM.  We have the Gausche pediatric ETI via BVM study in LA / Orange Counties, showing equivalence.  But this almost feels like a win for ETI, because the intubation success rate was 57%, and still they didn't seem to be able to kill or vegetablise anyone at a significant rate.  None of the subgroups are really large enough to identify whether particular groups were at greater risk.  The San Diego trial's limited by methodology, but motivates against RSI in head injury.  The Aussies have data showing an improvement in 6 month neuro outcomes in the same patients.  But they're also successfully intubating 97% of their patients versus something like 88% in the San Diego trial.
> 
> ...



I was thinking more basic like:

If you don't have patients that meet the criteria for intubation very often, all the expense involved from intitial training to restocking expired supplies might not be worth it.

Example: If service A serving a population of 1 million people has 10 patients that even meet the indications for ETI, it probably is economically more beneficial to not have ETI.

Forget complications of ETI, successes, scene times etc. 

During the little time I spent in the British system, (almost 2 weeks) there were less extreme patients less often in a hospital bigger and serving a larger population than the hospital I spent 4 years at in the US. (also a major academic medical center)

While it is possible it was a slow time, the providers indicated that my black cloud was in play and they  were busier that time than usual. 

I saw 1 patient that required emergent surgery for traumatic injury, and that was ortho in nature. (An open extremity fracture without neurovascular compromise.)

During the same time, the only patient in A&E I saw that needed to be intubated was the same guy for agitation.

Stands to reason if one of the most esteemed medical centers in the whole country intubates 1 patient in A&E a week, how often would a paramedic need to?


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## systemet (Feb 9, 2012)

Veneficus said:


> If you don't have patients that meet the criteria for intubation very often, all the expense involved from intitial training to restocking expired supplies might not be worth it.



Perhaps, but I'd respectfully submit that most things done in EMS are pretty inexpensive.  The labour cost isn't that great to start with.  There's a small chance that it might be driven up if the paramedics demand extra pay on the basis of having more responsibility -- but this argument has never worked that well in practice for any of us :lol:  The drugs are cheap, as far as I know -- maybe there's some newer agents coming out that might cost more.  I would think any cost in the ambulance would pale in comparison to the cost of just having someone sit in a bed in the ER with the correct wrist band on and have a couple of blood draws and an ECG done, each by someone with a union number.



> Example: If service A serving a population of 1 million people has 10 patients that even meet the indications for ETI, it probably is economically more beneficial to not have ETI.
> 
> Forget complications of ETI, successes, scene times etc.



There's another set of problems connected to this too.  What's the goal of the EMS system?  We tend to assume that it's to reduce disability and "early" death, etc.  But that's more the role of the health care system.  In many places the EMS system is being funded by a municipal tax payer.  Does the city / county / urban service area, really want good clinical outcomes, or just the appearance of professional looking bodies when the citizenry calls 911?  



> During the little time I spent in the British system, (almost 2 weeks) there were less extreme patients less often in a hospital bigger and serving a larger population than the hospital I spent 4 years at in the US. (also a major academic medical center)
> 
> [...]
> I saw 1 patient that required emergent surgery for traumatic injury, and that was ortho in nature. (An open extremity fracture without neurovascular compromise.)
> ...



This is interesting.  Did you come to any conclusions as to why this was the case?  Were they simply not intubating patients who would have been intubated in the US, or another medical system, or was the acuity genuinely that much lower?  Your response suggests the latter.

Do you think it speaks to better access to primary care?  Or social factors?  Was the surrounding area perhaps more wealthy, with less social problems?

I'm genuinely interested.  Obviously the incidence of firearm trauma is much lower than in the US, as is the rate of obesity (although I hear they're working very hard to change both of those).  Just wondering what you put it down to.


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## Veneficus (Feb 9, 2012)

systemet said:


> Perhaps, but I'd respectfully submit that most things done in EMS are pretty inexpensive.  The labour cost isn't that great to start with.  There's a small chance that it might be driven up if the paramedics demand extra pay on the basis of having more responsibility -- but this argument has never worked that well in practice for any of us :lol:  The drugs are cheap, as far as I know -- maybe there's some newer agents coming out that might cost more.  I would think any cost in the ambulance would pale in comparison to the cost of just having someone sit in a bed in the ER with the correct wrist band on and have a couple of blood draws and an ECG done, each by someone with a union number.



Perhaps not the labor itself, but when you institute a standard of care, costs can add up quickly. In modern EMS (or other parts of medicine for that matter) When you instutute an ETI procedure, you need things like laryngoscops. While that device is basically nothing more than a battery pack with a piece of shaped metal (or plastic if you are unfortunate) and a lightbulb connected, the device manufacturers seem to think it is worth considerably more.

You are also going to need to have a method of cleaning/replacement. Extra parts, batteries, etc.

Then to live up to the quantitative standards of modern medicine you are going to have a capnograph. (and it's associated costs)

Multiply this by a couple of hundred units in a capital city, and that may cut into your public access AED fund quite a bit.

Let's be honest, if you were decidfing whether to have more public access AEDs or the ability for EMS to intubate, would you suspect that intubation after EMS response would save more lives or improve more outcomes?



systemet said:


> There's another set of problems connected to this too.  What's the goal of the EMS system?  We tend to assume that it's to reduce disability and "early" death, etc.  But that's more the role of the health care system.  In many places the EMS system is being funded by a municipal tax payer.  Does the city / county / urban service area, really want good clinical outcomes, or just the appearance of professional looking bodies when the citizenry calls 911?.



I think the goal of every EMS system is to do the most good for the most people. Similar to any healthcare system. 

It may sound bad, but you have to pick and choose who is going to get what help. In that situation, some people will always lose out. 

My point is, that in the population I cited, those who would benefit from ETI may be so low they might be considered "acceptable loses" in the overall system.



systemet said:


> This is interesting.  Did you come to any conclusions as to why this was the case?  Were they simply not intubating patients who would have been intubated in the US, or another medical system, or was the acuity genuinely that much lower?  Your response suggests the latter..



I think the volume of acutity compared to where I was in the US was exponentially lower. 



systemet said:


> Do you think it speaks to better access to primary care?  Or social factors?  Was the surrounding area perhaps more wealthy, with less social problems?
> 
> I'm genuinely interested.  Obviously the incidence of firearm trauma is much lower than in the US, as is the rate of obesity (although I hear they're working very hard to change both of those).  Just wondering what you put it down to.



I think it is a combination of several factors, most of which you included. Even the comparitive individual wealth is a factor. I spent many years working in inner-city US EMS/hospitals, the level of poverty I witnessed there was much more profound than many Western European nations I have visited.

Only in Central and Eastern Europe have I seen people with worse circumstances in terms of poverty compared to the US.

If I had to choose the most profound influences based on what I observed, I would say that individual health awareness coupled with easy access and effective primary care were the most significant.

(Despite being firmly entrenched in reacting to emergencies of critical illness and injury, I think it is obvious the best outcomes and focus of treating such is prevention.)

I have also noticed in my anecdotal observations, that European males seem to be more active in seeking out healthcare than American males. (with females about the same level)

I haven't been able to account for this phenomenon, as many European societies have a culture of males being "tough"/stoic. I continue to try to figure it out though. What is more vexing about it is at least in Central/Eastenr Europe, males seem to engage in more destructive behavior and more often than in America.

I welcome any insight you have on this matter.


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## RocketMedic (Feb 9, 2012)

Cost-effective or not, paramedics need to be able to intubate, among other things. If we worked on numbers, we would dry-run everyone obese, old, or with a terminal ailment or history.

What is actually taught to UK paramedics that differs from our (relatively standard) NR based on DOT curriculum?


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## Veneficus (Feb 9, 2012)

Rocketmedic40 said:


> Cost-effective or not, paramedics need to be able to intubate, among other things.



Why?

Did you know there are countries where the only people permitted to intubate are anesthesiologists?




Rocketmedic40 said:


> What is actually taught to UK paramedics that differs from our (relatively standard) NR based on DOT curriculum?



I would like to see the curriculum too, but I am willing to bet that at the very least, university level anatomy, physiology, pathophysiology, and pharmacology. 

Did you know the highest level US EMS textbooks are written at is 10th grade?


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## St George (Feb 9, 2012)

Veneficus said:


> Why?
> 
> Did you know there are countries where the only people permitted to intubate are anesthesiologists?



 The UK for one! 



Veneficus said:


> Why?
> 
> I would like to see the curriculum too, but I am willing to bet that at the very least, university level anatomy, physiology, pathophysiology, and pharmacology.



 Paramedics must have an accredited university degree (which takes 3 years) in order to attain state registration, which is a legal requirement.


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## RocketMedic (Feb 9, 2012)

Veneficus said:


> Why?
> 
> Did you know there are countries where the only people permitted to intubate are anesthesiologists?
> 
> ...



55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do?

Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school?

Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics? Where, aside from the "globally-recognized benchmark in knowing how to research things", do UK-style paramedics perform better and where are American paramedics stronger?

Why, exactly, is a simply-written textbook a poor substitute for a dense tome?


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## St George (Feb 10, 2012)

Rocketmedic40 said:


> Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school?



 The argument is they should use an alternative such as an iGel or LMA.



Rocketmedic40 said:


> Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics?



 In the UK paramedic training has to be paid for by the student, not the ambulance service. Theres an advantage when you are a bean counter! 



Rocketmedic40 said:


> do UK-style paramedics perform better and where are American paramedics stronger?



 I dont know, but that would be one hell of a reseach study!


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## Tigger (Feb 10, 2012)

St George said:


> In the UK paramedic training has to be paid for by the student, not the ambulance service. Theres an advantage when you are a bean counter!


This is more often than not the case with US paramedics as well.


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## Veneficus (Feb 10, 2012)

Rocketmedic40 said:


> 55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do??



This patient is going to die, probably from low output failure, and a tube in his throat you are blowing oxygen through is not going to change that.

If the highdose lasix isn't working and you have nothing stronger to reduce the peripheral resistance, then you have may also have a renal insult as well.

In any even, he is going to die, but you could try pacing as a palliative effort or in the absense of a pacer, perhaps some epi for b1 stimulation.



Rocketmedic40 said:


> Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school??



Some believe that psychomotor skills require constant usuage to maintain and anesthesia does intubates more than anyone else. Additionally, there is a valid argument that knowing how to do something is less important than knowing when.

Like in the example of your patient here.



Rocketmedic40 said:


> Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics?*Treat and release *Where, aside from the "globally-recognized benchmark in knowing how to research things",*Don't understand what you are saying here.* do UK-style paramedics perform better and where are American paramedics stronger?*I think this would depend on the benchmarks you are measuring.*





Rocketmedic40 said:


> Why, exactly, is a simply-written textbook a poor substitute for a dense tome?



If you have to ask, no words of mine will make a difference, but if I could make a suggestion?

Look at the shock management chapter in your paramedic text book, then compare it side by side with a Tome like Miller's Anesthesia or Fischer's Master of Surgery or Williams Obstetrics and see for yourself.


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## RocketMedic (Feb 10, 2012)

Igels and LMAs aren't as good as ET for a lot of things. Here they're intermediate or arrest airways.


Most American paramedics self-pay through school, and everyone pays with school or time served.

What do UK paramedics earn?


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## usalsfyre (Feb 10, 2012)

Rocketmedic40 said:


> Igels and LMAs aren't as good as ET for a lot of things. Here they're intermediate or arrest airways.


They are infinitely better than a misplaced or poorly placed endotracheal tube. 

Another mistake is defining it as an "intermediate airway". I am a paramedic because I have a unique body of knowledge about prehospital medicine, not because I can perform direct laryngoscopy. 

We have seriously considered removing DL from the skill set of our lowest level on the clinical ladder due to competency issues.


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## EpiEMS (Feb 10, 2012)

Rocketmedic40 said:


> What do UK paramedics earn?



Looks like paramedic salaries start at around $33k, up to $43k for more senior folks, and then capping out at $53k as a "senior paramedic," which seems a lot like a PA, almost. Also, seems like all levels can make up to 25% more if they work odd hours or overtime — so a medic with some seniority could make as much as $66k. Nurses are on the same salary schedule, but max out at a higher level ($105k), seemingly.

Compare that to $35k for physicians in their first year of residency. 


Found on:
http://www.nhscareers.nhs.uk/details/Default.aspx?Id=132 and http://www.nhscareers.nhs.uk/details/Default.aspx?Id=553 and 
(Why? Cause comparative heath systems is interesting )


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## RocketMedic (Feb 11, 2012)

That's roughly comparable(ish) to most large 911 services here.


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## RocketMedic (Feb 11, 2012)

usalsfyre said:


> They are infinitely better than a misplaced or poorly placed endotracheal tube.
> 
> Another mistake is defining it as an "intermediate airway". I am a paramedic because I have a unique body of knowledge about prehospital medicine, not because I can perform direct laryngoscopy.
> 
> We have seriously considered removing DL from the skill set of our lowest level on the clinical ladder due to competency issues.



Not disagreeing, but I don't think a UK-style absolute prohibition on paramedic DL and intubation is a good idea, nor should it be legally regulated to only anesthesiologists. Restricting it within companies and agencies to trained, competent providers via operational policy and protocols? Absolutely. Taking it away from competent, trained providers who use it appropriately now? That's dumb. The arguments against prehospital ETT are mostly solved by giving us new paramedics appropriate training.

ETI may not belong in some situations (cardiac arrests, if these new studies pan out), but it's still an important tool in our kits. Every technique has its uses. Should we toss 1:1000 epi amps in favor of Epi-pens simply because there's less in the way of possible mistakes, to carry the same logic forward?


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## St George (Feb 11, 2012)

EpiEMS said:


> Looks like paramedic salaries start at around $33k, up to $43k for more senior folks, and then capping out at $53k as a "senior paramedic,"



 Correct, depending on the current exchange rate of course!



EpiEMS said:


> Nurses are on the same salary schedule, but max out at a higher level ($105k), seemingly.



 True but for nurses to be earning close to this level they would have to include a large managerial component into their jobs OR be a clinical specialist. Remember PA's do not exist in UK medicine - this role is incooperated into the jobs of specialist nurses or other specialist healthcare professions.



EpiEMS said:


> L]]  Also, seems like all levels can make up to 25% more if they work odd hours or overtime



 Yes but the 25% is added to the yearly salary and taken evenly each month on top of regular pay. So for example a paramedic will earn the same in a month of weekends and nights as a month of nice and easy 9 to 5 monday to friday shifts.


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## systemet (Feb 11, 2012)

I'm not sure why the sudden interest in what UK medics make, but bear in mind the cost of living is quite different, if you're trying to compare the UK and the US.


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## mycrofft (Feb 25, 2012)

Corporals talk tactics, Majors talk strategy, Generals talk logistics


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## TatuICU (Feb 25, 2012)

mycrofft said:


> All nurse care is subject to medical control by a MD. If I screw up a vital sign or bandage change a MD can ream me out, or yell at my nursing boss, who then calls me in to pas it on. Can you see a nurse reaming out a surgeon for sending  pt to his/her floor with a badly placed drain or a haemostat sticking out of their ear or whatnot?
> 
> Nursing protocols are required at least in Calif to be approved if not written by a MD. And "nursing care", as defined by nurses (and management), is less and less about bedside nursing.
> .



Funny story, but my ICU director is probably the meanest B-i-t-$-h you'll ever meet and she actually did go to one of our Dr's lounges and chew a cardiologist's *** up one end and down the other for hanging up on a nurse who wanted to stop an amiodarone gtt because of a prolonged QT interval.  She chewed his *** right there in front of everyone and he just sat there and took it, then got wrote up, then had to go before an in house peer review board composed of other docs, admins, and nurses, then had to write a letter of apology to the nurse he hung up on.  There have also been times where she has called and chewed out docs for various other reasons including telling a CV surgeon that his art line which he specifically wrote (and quite rudely told) we were supposed to go by to titrate several pressors was quote " a piece of sh*t" and "if he thought her nurses were going to titrate vasoactive drips based on a poorly placed art line with a whip the size of Texas in it, then he needed to go back to whatever half-assed school let him escape with a degree."  Of course she has a PhD in something or another to go along with her MSN and various other credentials and she was brought in from out of state  by the company that bought our hospital to "turn things around." 

None of that is relevant to this discussion and I am only trying to add  a bit of levity here.  I thought it was fairly humorous at the time.


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## TatuICU (Feb 25, 2012)

Veneficus said:


> This patient is going to die, probably from low output failure, and a tube in his throat you are blowing oxygen through is not going to change that.
> 
> If the highdose lasix isn't working and you have nothing stronger to reduce the peripheral resistance, then you have may also have a renal insult as well.
> 
> In any even, he is going to die, but you could try pacing as a palliative effort or in the absense of a pacer, perhaps some epi for b1 stimulation.



Uh, epi in decompensated heart failure?  Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?

If you're looking to specifically increase CO/CI you would begin looking at  dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI.  Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances.  

And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.  

I also believe the term is CHF exacerbation, not exasperation, and lungs typically have 5 lobes, not four quadrants.


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## CH100 (Feb 25, 2012)

Not true, grasshopper!

Nurses do a lot more than administer drugs and treatments prescribed by MDs, and they are not supervised or evaluated by MDs - it's always other nurses.

And there is a whole additional body of "stuff" that nurses handle with no orders and no physician involvement.

Heck, in 14 states now, nurse practitioners don't even need a physician to diagnose and prescribe!



mycrofft said:


> Nurses depend upon MD's for their protocols and have to have their work approved and signed off by physicians. For one. Or two.


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## usalsfyre (Feb 25, 2012)

TatuICU said:


> Uh, epi in decompensated heart failure?  Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?


My guess is because your not going to find dobutamine or milrinone on a 911 ambulances?



TatuICU said:


> If you're looking to specifically increase CO/CI you would begin looking at  dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI.  Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances.


I have a feeling he's going to be aware of this. My question to you is this. What's your strategy when neither (or for that matter an IABP) is unavailable? The true test of a CCM provider(to me) is their ability to provide CCM level care in the proverbial mudhut.  



TatuICU said:


> And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.


Or we could get the afterload off and see if that increases LV clearing and the effectiveness of the CPAP, thereby avoiding a tube and all the complications that come with it.   



TatuICU said:


> I also believe the term is CHF exacerbation, not exasperation, and lungs typically have 5 lobes, not four quadrants.


I'll give a pass of exasperation as autocorrect fail has done the same thing to me.


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## Veneficus (Feb 25, 2012)

TatuICU said:


> Uh, epi in decompensated heart failure?  Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?.




I suggested it  because most US EMS agencies I am aware of do not carry digoxin to increase contractility. They do carry epi.

The studies on dig not improving mortality are based on long term usage. But there is disputably some short term benefit. 

The idea of using epi in desperation would be to mimic that effect with stronger contractile force. (No I don't think it would work very well, if at all, which is why I suggested it would be desperation) 

The primary treatment is to lower peripheral resistance. However, if your high dose diuretic, CPAP, and all the other treatments originally listed are not working, I still don't think the tube is going to be the solution.

More therapies could be tried in hospital depending on the patient's cardiac function, in order to further reduce peripheral resistance, but in a patient in such extremis as described, I stand by my statement, the tube will most likely not make anymore difference.    



TatuICU said:


> If you're looking to specifically increase CO/CI you would begin looking at  dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI.  Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances..



If you have them. I have only ever heard of critical care units with dobutamine available.  

I have not encountered a prehospital or interfacility service with milrinone.

I have seen many interesting treatments for CHF, including CVVHFT, but I have never heard of that being available on an ambulance.  



TatuICU said:


> And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.




_55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do?_

Think about this for a bit and get back to me. Do you really think intubation is going to be the magic bullet that makes everything all right after all else has failed?

But please consider, if this is a 55 y/o female, in such extremis, then she is definately in a world of hurt. Either she had a recent untreated MI, or she has some chronic pathology that is not going to be easily correctable with the finest of facilities, much less on a 911 ambulance. 




TatuICU said:


> and lungs typically have 5 lobes, not four quadrants.



Pointless to this discussion. 4 lung fields have been adequete for auscultation in many environments for many years. I think without a lateral xray, ct, or ultrasound, it would be very difficult to narrow physical findings down to the particular lobe of the right lung.


----------



## TatuICU (Feb 25, 2012)

usalsfyre said:


> My guess is because your not going to find dobutamine or milrinone on a 911 ambulances?



Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.




usalsfyre said:


> I have a feeling he's going to be aware of this. My question to you is this. What's your strategy when neither (or for that matter an IABP) is unavailable? The true test of a CCM provider(to me) is their ability to provide CCM level care in the proverbial mudhut.



My strategy is to first do no harm and epi would worsen this patient's condition. As you say, the true test is the ability to critically think and move on to a an inotrope that you DO have available, not to just give epi for the sake of giving it and increasing afterload thereby worsening a patient in decompensated heart failure.




usalsfyre said:


> Or we could get the afterload off and see if that increases LV clearing and the effectiveness of the CPAP, thereby avoiding a tube and all the complications that come with it.



huh? You want to lower SVR by giving a drug that's going to increase afterload? The situation has already assumed that Lasix has been ineffective.  I'd love to avoid a tube in this situation as well, and while CPAP can help to restore functional capacity, I think a patient in this situation is probably going to wind up intubated anyway.  Pts can fail on CPAP, happens every day during extubation efforts.  It would be cool if CPAP would work for this patient, but I just don't see it happening.  Why not get them intubated, get in control of their airway, and know that you are effectively ventilating at least if not necessarily effectively oxygenating yet? 



usalsfyre said:


> I'll give a pass of exasperation as autocorrect fail has done the same thing to me.


 
You're right, I stand corrected.


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## Handsome Robb (Feb 25, 2012)

TatuICU said:


> Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.



We don't carry it. Dopamine, which we do carry, could work in this situation, you'd just need to watch your dose. I'd pick somewhere in the 5-8ish range for inotropic effects while also trying to avoid the vasoconstrictive effects of a higher dose. 

Lasix sure, in the Hospital setting, but in the acute prehospital setting I'd be looking for my NTG first to drop the afterload along with the inotropic effects of the dopamine plus the increased airway pressures from the CPAP to try and ward off the ETT demon.

edited to fix my wonderful grammar


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## 46Young (Feb 25, 2012)

TatuICU said:


> Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.
> 
> 
> 
> ...



Here in the U.S. I've yet to see a 911 ambulance that carries dobutamine. I've worked in NY, VA, WV, and SC. For that matter, I don't know of any IFT ambulances that carry dobutamine, either. We just get it from the sending facility. I suppose ambulances in your country carry much more than ours.

As far as treating cardiogenic shock on the average 911 ambulance, the only things we have besides airway management are epi, dopamine, NS, pacing, and atropine.

I remember usalsfyre mentioning juggling ntg and dopa in lieu of dobutamine, which is not typically carried on our ambulances.

Really, at the point of cardiogenic shock, on a 911 bus, it's either a NS bolus for presumed rt sided failure, or pressors otherwise (or both). Pressors or pacing for the bradycardia bears mentioning. We have epi and dopa, and that's about it. What else do you suggest we do in that situation?

Edit: apparently NVRob likes dopa/NTG as well. Strong work.


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## TatuICU (Feb 25, 2012)

Veneficus said:


> I suggested it  because most US EMS agencies I am aware of do not carry digoxin to increase contractility. They do carry epi.
> 
> The studies on dig not improving mortality are based on long term usage. But there is disputably some short term benefit.



I wouldn't use Dig either.  I don't know of anyone in or out of a hospital that would use Dig for this instance first line especially since, according to this scenario, Lasix has been ineffective suggesting that perhaps there are some serious renal issues happening.



Veneficus said:


> The idea of using epi in desperation would be to mimic that effect with stronger contractile force. (No I don't think it would work very well, if at all, which is why I suggested it would be desperation)
> 
> The primary treatment is to lower peripheral resistance. However, if your high dose diuretic, CPAP, and all the other treatments originally listed are not working, I still don't think the tube is going to be the solution.



Epi is not a hail mary in this instance. Epi will worsen this patient's condition.  The increase in afterload even at a lower dose would increase SVR and offset whatever increase in contractile force it would provide, which would probably not be very much,  because as a patient with a heart this diseased probably has an LV that's as stiff as a board.  

Who said the tube would be a solution? I'm saying that a tube is most likely the most effective therapy in which to assure adequate ventilation.  And nothing is going to matter if you don't fix your pump problem (long shot here from the scenario described.)





Veneficus said:


> If you have them. I have only ever heard of critical care units with dobutamine available.
> 
> I have not encountered a prehospital or interfacility service with milrinone.




Most units I've seen or worked on do carry dobutamine and every unit carries dopamine which could also be used here for inotropic support.  Milrinone, you're right.






Veneficus said:


> Think about this for a bit and get back to me. Do you really think intubation is going to be the magic bullet that makes everything all right after all else has failed?
> 
> But please consider, if this is a 55 y/o female, in such extremis, then she is definately in a world of hurt. Either she had a recent untreated MI, or she has some chronic pathology that is not going to be easily correctable with the finest of facilities, much less on a 911 ambulance.



I detect an air on condescension here, any particular reason why?  Again, who said anything about intubation being a "magic bullet?" Please show where in my post that I suggested intubation was going to be the intervention to correct this patient's condition and I will certainly go back and edit it out.   Intubation is not going to be the magic bullet for this patient and in fact there is no pathology that I know of where intubation is a magic bullet that fixes anything.  Intubation is a therapy, and in this case I feel an appropriate one, to insure adequate ventilation for this patient.   You're also assuming that a patient in this extremis is able to protect their airway.  






Veneficus said:


> Pointless to this discussion. 4 lung fields have been adequete for auscultation in many environments for many years. I think without a lateral xray, ct, or ultrasound, it would be very difficult to narrow physical findings down to the particular lobe of the right lung.



That wasn't the point. In this instance you would probably not even need to lay a stethoscope to this patient to hear your problem.


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## DrankTheKoolaid (Feb 25, 2012)

Dont forget that Calcium can also be used for its inotropic effect, which you likely do carry.  Both in cases of hypocalcemia and in normal levels, 1g CA will act to increase inotropy.


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## TatuICU (Feb 25, 2012)

46Young said:


> Here in the U.S. I've yet to see a 911 ambulance that carries dobutamine. I've worked in NY, VA, WV, and SC. For that matter, I don't know of any IFT ambulances that carry dobutamine, either. We just get it from the sending facility. I suppose ambulances in your country carry much more than ours.
> 
> As far as treating cardiogenic shock on the average 911 ambulance, the only things we have besides airway management are epi, dopamine, NS, pacing, and atropine.
> 
> ...



That last bit in the first part you quoted should've said dopamine, my mistake. Epi is not a treatment because it will worsen this patient's condition.

The only the thing you can do is insure adequate ventilation, try to improve CO/CI with inotropic support, and start diuresis.  And drive real fast?

Also I don't know how one can determine LAsix to be ineffective after 20 minutes, particularly in an instance where renal insult is suspected?


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## Handsome Robb (Feb 25, 2012)

Corky said:


> Dont forget that Calcium can also be used for its inotropic effect, which you likely do carry.  Both in cases of hypocalcemia and in normal levels, 1g CA will act to increase inotropy.



You present an excellent point salesman.


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## usalsfyre (Feb 25, 2012)

Dopa is going to be only slightly less harmful than epi, although I would use it at moderate doses before epi.

My choice is to start dopa or epi and then load as much IV NTG on board as the MAP will allow. As you note, get the afterload off. While this is certainly an inelegant solution, it's using commonly available agents.

Finally, why are we so hell bent on diuresing this patient? While probably needed eventually, this isn't going to help us out short-term very much.


----------



## Handsome Robb (Feb 25, 2012)

usalsfyre said:


> Finally, why are we so hell bent on diuresing this patient? While probably needed eventually, this isn't going to help us out short-term very much.



Because he's an ICU nurse :rofl:

Sorry just had to point that out there dude. Your angle seems to be geared towards inhospital care rather than in the acute prehospital setting.


----------



## TatuICU (Feb 25, 2012)

NVRob said:


> Because he's an ICU nurse :rofl:
> 
> Sorry just had to point that out there dude. Your angle seems to be geared towards inhospital care rather than in the acute prehospital setting.



No my angle has to do with not killing your patient and actually doing something to help them. And in addition to being an ICU nurse I'm also a practicing paramedic.  is there something funny about working in an ICU that I am unaware of?

So your contention is that diuresis would not help the the patient in this crisis?


----------



## Veneficus (Feb 25, 2012)

TatuICU said:


> I wouldn't use Dig either.  I don't know of anyone in or out of a hospital that would use Dig for this instance first line especially since, according to this scenario, Lasix has been ineffective suggesting that perhaps there are some serious renal issues happening.



But this is not first line, we are discussing what to do when the therapies in the given scenario are not working.

I also mentioned the renal failure possibility in my original reply in response to the lasix not being effective.



TatuICU said:


> Epi is not a hail mary in this instance. Epi will worsen this patient's condition.  *The increase in afterload even at a lower dose would increase SVR and offset whatever increase in contractile force it would provide, which would probably not be very much*,  because as a patient with a heart this diseased probably has an LV that's as stiff as a board.



From: http://www.aic.cuhk.edu.hk/web8/inotropes.htm


"Epinephrine
Pharmacokinetics
Admin: IV/IM/infiltration
Elim: mostly degraded by conjugation with glycuronic and sulphuric acids and excreted in the urine. Smaller part is oxidised by amine oxidase and inactivated by o-methyl-transferase
Pharmacodynamics
*- stimulates alpha1 and both beta1 and beta2 receptors. Effects are mediated by stimulation of adenyl cyclase resulting in an increase in cAMP*
*- beta2 receptors more sensitive to epinephrine than alpha1*
CVS
*- positive inotrope and chronotrope (NB. mediated by all 3 receptors not just beta1)*
- increases incidence of dysrhythmias by increasing irritability of automatic conducting system
- constricts vessels of skin, mucosae, subcutaneous tissues, splanchnic area, kidneys (alpha effects)
*- vessels of muscle and liver are dilated at physiological doses (beta effect) but are constricted at higher doses.*
- cerebral and pulmonary arteries are constricted
- may precipitate angina in patients with IHD
- CVS effects reduced by acidosis
*- at low doses causes: increased cardiac output, slight reduction in SVR, increase in effective circulating volume and increased venous return. Net result: systolic BP rises but diastolic falls*
- higher doses: rise in SVR, decreased cardiac output and rise in both systolic and diastolic BP"




TatuICU said:


> Who said the tube would be a solution? I'm saying that a tube is most likely the most effective therapy in which to assure adequate ventilation.  And nothing is going to matter if you don't fix your pump problem (long shot here from the scenario described.)



The person who posted the scenario implied that when many prehospital treatments failed, that the tube would be a beneficial treatment.

My point was just as you said, attempting to address the pump is the solution to this problem.



TatuICU said:


> Most units I've seen or worked on do carry dobutamine and every unit carries dopamine which could also be used here for inotropic support.  Milrinone, you're right.



Could you please tell me who carries dobutamine?



TatuICU said:


> I detect an air on condescension here, any particular reason why?  Again, who said anything about intubation being a "magic bullet?" Please show where in my post that I suggested intubation was going to be the intervention to correct this patient's condition and I will certainly go back and edit it out.   Intubation is not going to be the magic bullet for this patient and in fact there is no pathology that I know of where intubation is a magic bullet that fixes anything.



Sorry, I thought you were trying to argue in favor of intubation being a helpful treatment in resolving the underlying pathology.



TatuICU said:


> Intubation is a therapy, and in this case I feel an appropriate one, to insure adequate ventilation for this patient.   You're also assuming that a patient in this extremis is able to protect their airway.



There are many ways to protect an airway. I would suggest a gradual escalation, especially in this patient which is listed as semiconscious. Even if you planned to move right to RSI, we would have to account for the difficulty of the intubation, which may preclude that option, and then we would be back to managing an airway without intubation.


----------



## TatuICU (Feb 25, 2012)

usalsfyre said:


> Dopa is going to be only slightly less harmful than epi,
> Finally, why are we so hell bent on diuresing this patient? While probably needed eventually, this isn't going to help us out short-term very much.



It is? A lower dose 5mcg/kg/min would not only increase inotropy but could also help stimulate dopaminergic receptors within the nephron of the kidney would could potentially promote diuresis.  

And why diuresis? Well because that's how you'd effectively decrease preload and afterload without hitting a shocky patient who most likely has a  MAP<65 with continuous NTG? Not sure why we wouldn't look to start diuresis?


----------



## Veneficus (Feb 25, 2012)

TatuICU said:


> It is? A lower dose 5mcg/kg/min would not only increase inotropy but could also help stimulate dopaminergic receptors within the nephron of the kidney would could potentially promote diuresis.



Just so you know, renal dose dopamine has been debunked for many years in several studies, including a Cochran Review.


----------



## Handsome Robb (Feb 25, 2012)

TatuICU said:


> It is? A lower dose 5mcg/kg/min would not only increase inotropy but could also help stimulate dopaminergic receptors within the nephron of the kidney would could potentially promote diuresis.
> 
> And why diuresis? Well because that's how you'd effectively decrease preload and afterload without hitting a shocky patient who most likely has a  MAP<65 with continuous NTG? Not sure why we wouldn't look to start diuresis?



Not much evidence supporting its use in the prehospital setting when compared to patient outcomes.


----------



## TatuICU (Feb 25, 2012)

Veneficus said:


> But this is not first line, we are discussing what to do when the therapies in the given scenario are not working.
> 
> I also mentioned the renal failure possibility in my original reply in response to the lasix not being effective.
> 
> ...



Bear with me, I can't do multiple quotes from my phone: 

With regard to the dig, it doesn't matter which line as there is no line for dig in this situation and I'm unsure off why dig was ever brought up. 

Ill pm a list of services here that carry doubt amine and will send you our protocol for it as well. 

The rest will have to wait a bit, headed to work


----------



## Veneficus (Feb 25, 2012)

TatuICU said:


> With regard to the dig, it doesn't matter which line as there is no line for dig in this situation and I'm unsure off why dig was ever brought up.



Says who?


----------



## TatuICU (Feb 25, 2012)

Veneficus said:


> Just so you know, renal dose dopamine has been debunked for many years in several studies, including a Cochran Review.



Just so you know 5 is not a "renal dose" it's a low inotropic dose that can promote diuresis. Renal doses were argued to be predicated upon increasing renal messenteric  blood flow, not necessarily by direct action on te nephron.


----------



## Handsome Robb (Feb 25, 2012)

TatuICU said:


> No my angle has to do with not killing your patient and actually doing something to help them. And in addition to being an ICU nurse I'm also a practicing paramedic.  is there something funny about working in an ICU that I am unaware of?
> 
> So your contention is that diuresis would not help the the patient in this crisis?



There's nothing funny about being an ICU nurse. Slow your roll. 

Your advocating using meds that are not readily available to most EMS crews, that's why I said it. 

Like I said, in the prehospital field I'm looking for NTG before Lasix because there is little evidence that supports the use of lasix in the field when compared to patient outcome.


----------



## TatuICU (Feb 25, 2012)

Veneficus said:


> Says who?



Are u serious??? You want to use dig in a patient with renal failure?  Why in the world would u choose dig in this instance?


----------



## Veneficus (Feb 25, 2012)

TatuICU said:


> Are u serious??? You want to use dig in a patient with renal failure?



that is not a part of the assumption

If you are going with the 30 minute transport with acute and critical CHF, with renal failure at 55, whatever underlying patholgy, and a potential unstable airway, you might be better off with just some versed and morphine in high dose. It will probably be kinder than treating the crazy elevated K+ in addition to the rest of this.


----------



## TatuICU (Feb 25, 2012)

Veneficus said:


> that is not a part of the assumption



So even though you assumed it it's not part of the assumption? And you guys are arguing that dobutrex is not practical because you don't carry it but dig is because you guys carry it? Digoxin but not dobutrex? Most services carry dobutamine, none that I know of carry dig


At work will return later


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## Handsome Robb (Feb 25, 2012)

TatuICU said:


> So even though you assumed it it's not part of the assumption? And you guys are arguing that dobutrex is not practical because you don't carry it but dig is because you guys carry it? Digoxin but not dobutrex? Most services carry dobutamine, none that I know of carry dig
> 
> 
> At work will return later



Who is this "you guys" you speak of?

I never said anything about dig. 

Our flight service carries dobutamine, our ground service does not. We don't carry dig either. 

I'm not the only person that has said they don't carry dobutamine. I've never heard of 911 units carrying dobutamine. IFT/CCT makes sense.

It seems like you're getting frustrated which is making you grumpy as well.


----------



## usalsfyre (Feb 25, 2012)

TatuICU said:


> It is? A lower dose 5mcg/kg/min would not only increase inotropy but could also help stimulate dopaminergic receptors within the nephron of the kidney would could potentially promote diuresis.


Which is why I'd choose dopa over epi. I think the diuresis is going to be more about increased renal perfusion though.   



TatuICU said:


> And why diuresis? Well because that's how you'd effectively decrease preload and afterload without hitting a shocky patient who most likely has a  MAP<65 with continuous NTG? Not sure why we wouldn't look to start diuresis?


So you want vasodilation from dobtamine (tied dose wise to your inotropy) but not from NTG (an independent factor you can adjust)? Which is it?

Diuresis is going to be important in say...20 minutes or so. In the next five while we're in the oxygenation death spiral its not going to help fast enough. You've got to get the afterload off and clear the LV *right now* to give the CPAP a chance to do its job. 

Ultimately she needs a baloon pump.


----------



## Veneficus (Feb 25, 2012)

TatuICU said:


> So even though you assumed it it's not part of the assumption? And you guys are arguing that dobutrex is not practical because you don't carry it but dig is because you guys carry it? Digoxin but not dobutrex? Most services carry dobutamine, none that I know of carry dig
> 
> 
> At work will return later



I think you are misunderstanding or interpreting the original discussion. 

I presented a potential course when you don't have the perfect solution. Based on what is commonly carried on a US ALS unit when after your primary treatments have failed. 

The original argument was that intubation would somehow help.

Since then, I have seen an argument against what I said, based most likely off of what you have seen or assume, as I have posted the very mechanism as to why epi might be a long shot. 

Giving dig to increase cardiac contractility in advanced CHF is in every medical text I have ever seen that talks about the subject.

There are several studies showing it does not improve mortality. But at least one that demonstrates a reduction in ICU admission. If it can be used chronically, it can be used acutely by the same mechanism. 

I have said it many times, in medicine, it is not "what" that makes a difference, it is "why."

http://jasn.asnjournals.org/content/15/8/2195.full

http://www.ncbi.nlm.nih.gov/pubmed/21180781

and as for inciting renal toxicity, in acute kidney injury, there are treatments in order to help mitigate that as nicely explained here.

http://www.ncbi.nlm.nih.gov/pubmed?term=N-GAL: Diagnosing AKI as soon as possible

and in the full publication of this:

Ren Fail. 2012;34(1):130-3. Epub 2011 Oct 20.

Using NGAL as an early diagnostic test of acute kidney injury.

We can make the scenario as complex as you like.

Just state what you want it to be.


----------



## RocketMedic (Feb 25, 2012)

From a new paramedic's point of view, I'd still think that a secure airway and good ventilation would be things to need. 

Another great reason for prehospital ETT- anaphalaxis or deep FBAO.


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## Veneficus (Feb 25, 2012)

Rocketmedic40 said:


> From a new paramedic's point of view, I'd still think that a secure airway and good ventilation would be things to need.
> 
> Another great reason for prehospital ETT- anaphalaxis or deep FBAO.



could I just inquire why you have this fascination with intubation?


----------



## Zeroo (Feb 25, 2012)

I don't really care what some checklist says. I consider it a profession


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## JPINFV (Feb 25, 2012)

Zeroo said:


> I don't really care what some checklist says. I consider it a profession



So it's a profession in name only?


----------



## Zeroo (Feb 25, 2012)

JPINFV said:


> So it's a profession in name only?



.... I wish I could understand what you was trying to get at. Seems rather vague of a statement. Maybe I am just a dunce though. Still gonna give it a go at replying. I would consider it a profession because its something I wanna do for the rest of my life. Granted that's obviously not what makes it a profession. However I really don't care.


----------



## JPINFV (Feb 25, 2012)

Zeroo said:


> .... I wish I could understand what you was trying to get at. Seems rather vague of a statement. Maybe I am just a dunce though. Still gonna give it a go at replying. I would consider it a profession because its something I wanna do for the rest of my life. Granted that's obviously not what makes it a profession. However I really don't care.



My point is that, despite it failing to meet many of the more important criteria defining a profession (unique body of knowledge, autonomy, self governance, etc), you're declaring it a profession because you don't care about those things. 

Just because you want to do something for the rest of your life doesn't make it a profession. Declaring something a profession, which given it's current state isn't, doesn't automatically confer respect or fix those aspects of the trade.


----------



## Zeroo (Feb 25, 2012)

JPINFV said:


> My point is that, despite it failing to meet many of the more important criteria defining a profession (unique body of knowledge, autonomy, self governance, etc), you're declaring it a profession because you don't care about those things.
> 
> Just because you want to do something for the rest of your life doesn't make it a profession. Declaring something a profession, which given it's current state isn't, doesn't automatically confer respect or fix those aspects of the trade.



Like I said in my post. I don't really care if it isn't officially considered a profession! So maybe it isn't. Not that big a deal.


----------



## TatuICU (Feb 25, 2012)

Veneficus said:


> I think you are misunderstanding or interpreting the original discussion.
> 
> I presented a potential course when you don't have the perfect solution. Based on what is commonly carried on a US ALS unit when after your primary treatments have failed.
> 
> ...




Why are you posting studies about efficacy of dig in chf? In any case you're the one who brought up digoxin for some reason and now you're posting studies to justify adding more treatments in the case of renal insult to give dig? Why is dig even a part of this discussion? What about posting studies to justify things everyone already knows is so fascinating? 

What do I want it to be? I couldn't care less. What do you even mean?


----------



## TatuICU (Feb 25, 2012)

usalsfyre said:


> Which is why I'd choose dopa over epi. I think the diuresis is going to be more about increased renal perfusion though.
> 
> 
> So you want vasodilation from dobtamine (tied dose wise to your inotropy) but not from NTG (an independent factor you can adjust)? Which is it?
> ...



Which is what? If I choose just ntg I'm not helping her cardiac status, I'm just killing her bp even more. The vasodilation fro
 Dobutrex is mild and is part of its profile to help increase cardiac output. Not sure what you're gettin at here, so yes I would prefer a drug that mildly vasodilates and increases inotropy than a drug that only vasodilates. Is that what you're asking?

Diuresis will be important in 20 minutes? Ok the scenario states a 30 minute transport time not counting scene time. We can get it started. Of course airway and breathing is first which I why I said intubation I feel is more appropriate given the gravity of the situation.  This doesn't sound like exac chf, it sounds like decompensated heart failure. Agree with the balloon pump


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## RocketMedic (Feb 26, 2012)

Veneficus said:


> could I just inquire why you have this fascination with intubation?



Its not a fascination with intubation, or any other tool. Its an example of advanced treatments we in EMS use- a low-use, high acuity skill with serios potential to harm but absolutely needed at times.
As a professional, I don't aim to use an intervention inappropriately,  but at the same time, I don't believe that infrequent use or risk justifies removal of skillsets. Would you stop teaching firefighters interior attack, police officers rifle use and movement under fire, or doctors surgical intervention? 

Intubation is one of the things that differentiates paramedics from technicians. Advocating removal of skillsets allowed by accepted standards of care on the basis of difficulty or infrequent use makes us technicians, not professionals. On the other hand, agency level controls on the applications of interventions make sense.


----------



## Veneficus (Feb 26, 2012)

TatuICU said:


> Why are you posting studies about efficacy of dig in chf? In any case you're the one who brought up digoxin for some reason and now you're posting studies to justify adding more treatments in the case of renal insult to give dig? Why is dig even a part of this discussion? What about posting studies to justify things everyone already knows is so fascinating?



Mostly to refute your absolute statements of what will and will not work and what is indicated and what is not.

One of the things I find more fascinating about medicine, and anesthesia in general, is there are multiple ways to achieve the same thing with not much matter in how to go about it.

As for the intubation, I don't think it helps enough in enough cases to keep it as part of a core skill in EMS.

You mentioned the epi would not work with absolute authority. Are there better things to use? Certainly. But in a fix, it epi can be used.

Do I think any EMS agency carries dig? No. But you seem to think that anyone with renal compromise was going to somehow die a nasty death by using it.

Which is not the case.

I added the other 2 studies because they talk about timely reversal of AKI for conditions where a patient maybe compromised renally, such as in CHF.

Many drugs have a narrow theraputic index like dig, but we still use them. It doesn't automatically exclude them.

Dealing with or as absolutes in medicine can make for some very long days. There is just more to it than: If-then/never.


----------



## TatuICU (Feb 26, 2012)

Veneficus said:


> Mostly to refute your absolute statements of what will and will not work and what is indicated and what is not.
> 
> One of the things I find more fascinating about medicine, and anesthesia in general, is there are multiple ways to achieve the same thing with not much matter in how to go about it.
> 
> ...




But you didn't refute anything.  You say yourself that neither is anywhere close to the best treatment. And who was speaking in absolutes?  You're really just talking in circles at this point.


----------



## TatuICU (Feb 26, 2012)

To answer the actual question at hand here, I feel that EMS is a non-profession that is worked mostly by very good professionals.  If that makes any sense.....


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## Veneficus (Feb 26, 2012)

TatuICU said:


> But you didn't refute anything.  You say yourself that neither is anywhere close to the best treatment. And who was speaking in absolutes?  You're really just talking in circles at this point.



I wasn't aware that talking about alternative therapies was a circle?

It was you who said my epi suggestion would not help.

It was you who seemed to think the use of dig in CHF was some kind of abomination?

Especially in renal failure.

I simply provided the argument and a small amount of evidence demonstrating they were both potential treatments. 

Hopefully somebody reading this found it more intellectually stimulating than you seem to.


----------



## TatuICU (Feb 26, 2012)

Veneficus said:


> I wasn't aware that talking about alternative therapies was a circle?
> 
> It was you who said my epi suggestion would not help.
> 
> ...



When did I say that use of dig, a drug used to treat chf, was an abomination in the treatment of CHF?  I said that using dig as a first line tx in the scenario would be stupid, and it would be.  Now youre just making things up.

And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie.  Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late.  Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.

What could be intellectually stimulating about this conversation?  I'm arguing for what i believe is a pathophysiologically sound tx with rationale and you're telling me I'm wrong by using if-then arguments for what are situationally not first line treatments.

If you want to continue this feel free to pm me or I can give you my phone number and we can discuss it verbally so theres much less potential for misunderstandings. I'm always up to learn something since i seem to be way off base in my understanding of cardiovascular phys and pharm, and to meet others in the business.


----------



## Veneficus (Feb 26, 2012)

TatuICU said:


> When did I say that use of dig, a drug used to treat chf, was an abomination in the treatment of CHF?  I said that using dig as a first line tx in the scenario would be stupid, and it would be.  Now youre just making things up..



Not making things up, that's how it looked when I read it. It still looks that way. Let's not dwell on it.



TatuICU said:


> And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie.  Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late.



Not true, you don't need a swan, there are physical findings. I'll detail it in a PM.




TatuICU said:


> Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.



I have no doubt, but it is probably more of a result of where you are rather than because it is not done.

I have read cases of cardiac bypass under region anesthesia. Never saw it, but it is happening.




TatuICU said:


> What could be intellectually stimulating about this conversation?  I'm arguing for what i believe is a pathophysiologically sound tx with rationale and you're telling me I'm wrong by using if-then arguments for what are situationally not first line treatments.



What you believe?


----------



## RocketMedic (Feb 26, 2012)

Veneficis, allow me to present an analogy. In the military, we have a grenade launcher known as a MK19. For the most part, its very effective and safe. If improperly assembled or employed, you risk it detonating in your face or wiping a squad off the map. Professionals understand and analyze the risks and make appropriate decisions based on use of certain toolsets. Just having it does not justify putting it in everyone, nor does it justify wholesale removal.

My dad once used an ETT to push a piece of taffee lodged near the carina of a pediatric patient clear of the airway and allow ventilation. He's been a 911 paramedic as long as I've been alive and can tube anything. His partners and coworkers have quite a bit of experience themselves. I think you may be judging EMS by its absolute lowest provider, and you can't do that accurately.

Does a paramedic like me belong as lead on a 911 truck? Young, inexperienced, with a decent core knowledge and a desire to learn? Personally, I think so. I know my limits, I'm not afraid to ask for help, and I know what I need to do at my level for most things.  I'm trying to go back to school and I'm trying to find a job that pays well enough to support myself. I'm a perfect hire for EMSA, AMR, or a lot of other places. To me, that says that I'm doing something right.

Long-term, don't delete us, empower us.

Personally, I think change starts at the instructors. I'm not proud of my medic mill, and if I'd been from a different background, I wouldn't feel safe with patients. However, that medic mill and others like it teach to a very low target standard. We must evaluate that standard and those instructors if we want positive change.


----------



## TatuICU (Feb 26, 2012)

Veneficus said:


> Not making things up, that's how it looked when I read it. It still looks that way. Let's not dwell on it.
> 
> 
> 
> ...



Responded to PM


----------



## CH100 (Feb 26, 2012)

Rocket, you sound like you have a pretty good head on your shoulders.

Much of what happens to a newly-graduated paramedic depends on where he or she lands.  An organization with a strong Field Training and Evaluation Program will teach that new medic the things that he needs to be successful, give him a chance to apply that knowledge and those skills, and evaluate his ability to meet the organization's clinical and operational standards.  In my experience (and my organization), that takes 6 months to 1 year with a paramedic Field Training Officer (FTO).

If a new graduate returns home to be "the only paramedic in town" or "..on the shift"  or "..on the truck," he or she is in for a tough time (or, the patients are in for a rough time).  Or, if he goes to work for a service where he is expected to function with an EMT partner as an emergency or critical care unit, same thing.  There is a gap, between "got my state license" and "being a journeyman paramedic" that has to be filled in somehow.  It is probably best filled in in an organized manner, and not just by accident.


----------



## usalsfyre (Feb 26, 2012)

TatuICU said:


> Which is what? If I choose just ntg I'm not helping her cardiac status, I'm just killing her bp even more. The vasodilation fro
> Dobutrex is mild and is part of its profile to help increase cardiac output. Not sure what you're gettin at here, so yes I would prefer a drug that mildly vasodilates and increases inotropy than a drug that only vasodilates. Is that what you're asking?


I never stated give her NTG alone, you give the NTG to treat the SVR in conjunction with an inotrope to increase CO. The NTG can be as mild or as severe as the dose will allow. Granted it doesn't have the greatest effect on the arterial side of the equation, but your far more likely to find IV NTG in asture environments than say, nitroprusside. 



TatuICU said:


> Diuresis will be important in 20 minutes? Ok the scenario states a 30 minute transport time not counting scene time. We can get it started. Of course airway and breathing is first which I why I said intubation I feel is more appropriate given the gravity of the situation.  This doesn't sound like exac chf, it sounds like decompensated heart failure. Agree with the balloon pump


Again, I'm not disputing diuresis, we've just got a crapload of other stuff to take care of before we get there. 



TatuICU said:


> And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie. Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late. Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.


It may seem like a dangerous game to play if you have a PA cath on the majority of patients. But I think you'd find there's a number of places where vasopressors, inotropes, ect are used on a fairly regular basis without that data, and patients aren't dying at any greater rate (trying to remember who did the data that said Swan's have no effect on outcome).


----------



## usalsfyre (Feb 26, 2012)

Rocketmedic40 said:


> Veneficis, allow me to present an analogy. In the military, we have a grenade launcher known as a MK19. For the most part, its very effective and safe. If improperly assembled or employed, you risk it detonating in your face or wiping a squad off the map. Professionals understand and analyze the risks and make appropriate decisions based on use of certain toolsets. Just having it does not justify putting it in everyone, nor does it justify wholesale removal.
> 
> My dad once used an ETT to push a piece of taffee lodged near the carina of a pediatric patient clear of the airway and allow ventilation. He's been a 911 paramedic as long as I've been alive and can tube anything. His partners and coworkers have quite a bit of experience themselves. I think you may be judging EMS by its absolute lowest provider, and you can't do that accurately.
> 
> ...



Rocketmedic, you have to choose procedures based on potential to harm and the lowest common denominator. If you want to see why, I suggest you seek to get involved in QA at a system. It's very often frightening. I was a staunch advocate for ETT. After being involved in QA and education, I can safely say the majority of paramedics I encounter have no business doing it.


----------



## TatuICU (Feb 26, 2012)

usalsfyre said:


> I never stated give her NTG alone, you give the NTG to treat the SVR in conjunction with an inotrope to increase CO. The NTG can be as mild or as severe as the dose will allow. Granted it doesn't have the greatest effect on the arterial side of the equation, but your far more likely to find IV NTG in asture environments than say, nitroprusside.



I agree, all I saw that you typed was NTG.  And Nitroprusside would be contraindicated in this patient anyway if you thought them to be in renal failure, unless we want to add cyanide poisoning to the equation. 




			
				Veneficus said:
			
		

> Again, I'm not disputing diuresis, we've just got a crapload of other stuff to take care of before we get there.



Agreed




			
				Veneficus said:
			
		

> It may seem like a dangerous game to play if you have a PA cath on the majority of patients. But I think you'd find there's a number of places where vasopressors, inotropes, ect are used on a fairly regular basis without that data, and patients aren't dying at any greater rate (trying to remember who did the data that said Swan's have no effect on outcome).



I'm not suggesting that every vasoactive or inotropic gtt requires a PA to effectively manage, not by a long shot.  We hang levo, dopa, dobu, epi, you name it without PA caths routinely in ICU and in fact Swans have been found to not be very beneficial in a lot of cases anyway.  The only time you'll routinely see a swan stay in is post cardiosurgery and they're usually out the next day even then.  We may balloon up, balloon down, and wedge real quick to get a PCWP in a sepsis patient if our intensivist wants it really bad but typically not.  I'm saying that we shouldn't hang epi in this instance and if you were to do it, the only safe way would be to have PA cath and stop the epi as soon as your SVR trended upwards.  It was less literal and more to get across my point of it not being a "meh, let's try this" drug in this scenario.  You have others weapons to use before you go to something that has the potential to worsen an already horrendous condition.  You don't throw a hail mary at the start of the 4th quarter. You throw it on 4th and 20 with :02 left on the clock.


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## TatuICU (Feb 26, 2012)

usalsfyre said:


> After being involved in QA and education, I can safely say the majority of paramedics I encounter have no business doing it.



Can you give some examples of cases? Are you speaking in terms of poor proficiency?


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## mycrofft (Feb 26, 2012)

Someone in another thread said something about "a trade, like plumbers". There is something to be said for that. It is a distinct branch of invaluable service, licensed, but without self-governance and its own science, drawing from civil engineering and long traditions (plus ads in the latest trade magazine). 
I'm glad t hear someone say "I don' care, I think of it as a profession" as long as that sort of person continues their education and is not adverse to organizing to get better benefits and treatment.


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## JPINFV (Feb 26, 2012)

mycrofft said:


> Someone in another thread said something about "a trade, like plumbers". There is something to be said for that. It is a distinct branch of invaluable service, licensed, but without self-governance and its own science, drawing from civil engineering and long traditions (plus ads in the latest trade magazine).
> I'm glad t hear someone say "I don' care, I think of it as a profession" as long as that sort of person continues their education and is not adverse to organizing to get better benefits and treatment.



Here's the problem with that.

Just because I say I'm a millionaire or the President of the United States of America does not mean I'm am millionaire or the President of the United States of America. Additionally, if EMS is a profession despite, you know, lacking the specifics that would actually make it a profession, why would he spend time working towards the things that actually make it a profession?


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## mycrofft (Feb 26, 2012)

Professional outlook/professionalism. I'd like someone who is technically adept and educated, but give me a click less of that with loads of professionalism versus an apathetic licensed professional.

I see your point, it is a good one for the future of PEMS.


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