# Appendectomy for Paramedics



## medic417 (May 15, 2012)

I have come to the conclusion that paramedics should have as standard practice the ability to perform appendectomy. This can be taught in just a matter of a few hours. It is a simple skill that does not require any real education behind it. What say you?


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## kindofafireguy (May 15, 2012)

...and so let slip the hounds of war.


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## Doczilla (May 15, 2012)

This is probably a joke. But uh... Yeah.


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## Sasha (May 15, 2012)

Oh sweetie. You forgot your meds again, didn't you?


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## medic417 (May 15, 2012)

Sasha said:


> Oh sweetie. You forgot your meds again, didn't you?



Nope. Why shouldn't we. Its just another skill a monkey can do.


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## Cup of Joe (May 15, 2012)

Maybe we should allow paramedics to do tummy tucks as well, I mean, while you're down there....


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## Sasha (May 15, 2012)

medic417 said:


> Nope. Why shouldn't we. Its just another skill a monkey can do.



Stop trying to stir the pot. :l


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## medic417 (May 15, 2012)

Sasha said:


> Stop trying to stir the pot. :l



Not stirring we need more skills. Plus think how much money we could make. Instead of ambulances we will be called mobile surgical suites.


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## kindofafireguy (May 15, 2012)

So MSCU ambulances instead of MICUs? 

To quote the great Guinness Draft company...

"Brilliant!"


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## DrParasite (May 15, 2012)

what about breast augmentations?


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## ffemt8978 (May 15, 2012)

If you want to do those procedures, there's an easy way to get permission to do them.

http://tinyurl.com/7dsf77t


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## Melmd (May 15, 2012)

I don't think that is possible, simple as it looks like in you tube but only surgeons can do it. Even doctors cannot do it if not trained in surgery.


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## STXmedic (May 15, 2012)

I smell what you're cookin'


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## FLdoc2011 (May 15, 2012)

Only if you also take on the liability, post op care and any complications that may arise......


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## kindofafireguy (May 15, 2012)

It would be just like narcan. You would do it and them dump them in the lap of a pissed off ER Doc and staff. 

Excellent idea!


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## FLdoc2011 (May 15, 2012)

kindofafireguy said:


> It would be just like narcan. You would do it and them dump them in the lap of a pissed off ER Doc and staff.
> 
> Excellent idea!



Why even bring 'em in?  Just leave in tub of ice to recover at home... Ultimate outpatient surgery.


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## CANDawg (May 15, 2012)

FLdoc2011 said:


> Why even bring 'em in?  Just leave in tub of ice to recover at home... Ultimate outpatient surgery.



It's the preferred method of organ thieves for a reason!


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## kindofafireguy (May 15, 2012)

Just stay away from Candy Mountain!


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## Akulahawk (May 15, 2012)

kindofafireguy said:


> So MSCU ambulances instead of MICUs?
> 
> To quote the great Guinness Draft company...
> 
> "Brilliant!"


MSCU... leads me to...


DrParasite said:


> what about breast augmentations?


Drive-by boob jobs...


ffemt8978 said:


> If you want to do those procedures, there's an easy way to get permission to do them.
> 
> http://tinyurl.com/7dsf77t


Nah. Why bother? Surgery is just a monkey skill...


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## RocketMedic (May 16, 2012)

Field brain surgery?


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## Akulahawk (May 16, 2012)

Rocketmedic40 said:


> Field brain surgery?


Let me see, I'll need a drill, circular saw...


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## firecoins (May 16, 2012)

medic417 said:


> I have come to the conclusion that paramedics should have as standard practice the ability to perform appendectomy. This can be taught in just a matter of a few hours. It is a simple skill that does not require any real education behind it. What say you?



That's a bls skill in NYC


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## firetender (May 16, 2012)

Yes, 417, I can picture your joy in getting to do appendectomies lasting until you realize that after every call, the back of your rig is going to have to be surgically sterile to OR standards and YOU will have to do it!

I trust your hallucination has passed.


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## kindofafireguy (May 16, 2012)

Nah, too messy. Everyone knows EMS doesn't like getting our hands dirty.


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## RocketMedic (May 16, 2012)

Quick! Preemptive heart transplant go!


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## Veneficus (May 16, 2012)

*sure, if you like.*

http://voices.yahoo.com/15-year-old-boy-performs-surgery-410268.html

But the patient may get a little upset without anesthesia, which might complicate things.

Not to mention the unit is going to be out of service and the "big one" might happen and you will not be available to drive somebody more needing, critical, or deserving to the hospital.


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## Doczilla (May 16, 2012)

OR that 30-40% of appendicitis can be treated with IV antibiotics alone, and you can't determine that line without CBC with diff, CRP, d-dimer/fibrinogen for DIC, imaging studies, or the trip to the hospital being over before you can even prep them--- but I digress. I think there's a troll in our midst...


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## STXmedic (May 16, 2012)

Doczilla said:


> OR that 30-40% of appendicitis can be treated with IV antibiotics alone, and you can't determine that line without CBC with diff, CRP, d-dimer/fibrinogen for DIC, imaging studies, or the trip to the hospital being over before you can even prep them--- but I digress. I think there's a troll in our midst...



I think he's throwing a rock at some recent threads, doc


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## FLdoc2011 (May 16, 2012)

I have to find it, but I vaguely recall reading a story about a Russian surgeon who was the doc stationed with an Antarctic several month expedition who developed appendicitis and he recalls performing an appy on himself.   

Pretty hardcore.   Makes me want to re-read it.


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## medicsb (May 16, 2012)

I did 10 of these when I was in Texas, working at the most rural and progressive EMS system EVER!


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## Doczilla (May 16, 2012)

I digress even further. Lol


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## mycrofft (May 17, 2012)

Lap bands, $10K a pop.


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## medic417 (May 17, 2012)

firetender said:


> Yes, 417, I can picture your joy in getting to do appendectomies lasting until you realize that after every call, the back of your rig is going to have to be surgically sterile to OR standards and YOU will have to do it!
> 
> I trust your hallucination has passed.



No sterile is overrated.  We would just mass dose them with antibiotics.  :rofl:

See how stupid it sounds to add skills that yes anyone can learn without the real education behind them. Sorry I am tired of lets add this or that yet not the science behind it.  Yes I know this is EMS the land of tradition trumps science but come on people get the education if you want the toys.


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## medic417 (May 17, 2012)

Doczilla said:


> I digress even further. Lol



Sorry doc I finally had all I could take I could take no more.  Do you guys offer a special padded room that comes with that comfy long sleeved jacket?


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## the_negro_puppy (May 17, 2012)




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## mycrofft (May 17, 2012)

medic417, if we ever meet, I owe you a beer or soft drink.


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## medic417 (May 18, 2012)

mycrofft said:


> medic417, if we ever meet, I owe you a beer or soft drink.



Can I make it a scotch on the rocks?


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## mycrofft (May 18, 2012)

If we're at the right venue. I don't drink, though.


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## jroyster06 (May 18, 2012)

NO MORE CPR....... Now we start with a chest crack and a cardiac massage! And instead of C-collars we will begin to apply our own prophalatic halo's on to pts, complete with screws and all. There will be an adapted made available in the near future for the EZ-io gun that will allow you to put these screws in place.


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## mycrofft (May 18, 2012)

Halos, along with nitrous oxide, in the field were being expounded around 1980.
We had someone here a couple years ago say his service would allow them to open the  chest in the field. Booed off.


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## Akulahawk (May 18, 2012)

mycrofft said:


> Halos, along with nitrous oxide, in the field were being expounded around 1980.
> We had someone here a couple years ago say his service would allow them to open the  chest in the field. Booed off.


I can see an escharotomy being authorized at some point in the future, but somehow I don't see "cracking the chest" being authorized specifically for the purpose of doing internal cardiac massage... however I can see teaching ICM for the purpose of restoring circulation if the heart is already exposed. I can also see that in such an instance, the possibility is strong that it would likely be a futile effort...


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## STXmedic (May 19, 2012)

Akulahawk said:


> I can see an escharotomy being authorized at some point in the future,


Lol! I actually just got out of our week-long CME class this week. Our medical director and our area trauma guru both told us that if we have a patient requiring one, they fully expect us to perform it... h34r:


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## medic417 (May 19, 2012)

Akulahawk said:


> I can see an escharotomy being authorized at some point in the future, but somehow I don't see "cracking the chest" being authorized specifically for the purpose of doing internal cardiac massage... however I can see teaching ICM for the purpose of restoring circulation if the heart is already exposed. I can also see that in such an instance, the possibility is strong that it would likely be a futile effort...


Escharotomy is already and has been for ages in the paramedic guidelines here.


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## Akulahawk (May 19, 2012)

PoeticInjustice said:


> Lol! I actually just got out of our week-long CME class this week. Our medical director and our area trauma guru both told us that if we have a patient requiring one, they fully expect us to perform it... h34r:





medic417 said:


> Escharotomy is already and has been for ages in the paramedic guidelines here.


I was referring to the procedure being part of a Paramedic's education and authorized for use in all locations/states. It may not be done very frequently, but like other things we do, when it's needed, it really is _needed_ right then. If you're authorized to do it and you're current, WOO HOO!! because if your patient needs it, you can provide what is needed.


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## EnviroMed (May 25, 2012)

the comments on this thread are hilarious.


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## medic417 (May 26, 2012)

EnviroMed said:


> the comments on this thread are hilarious.



:rofl::rofl::rofl::rofl::rofl::rofl::rofl:


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## TatuICU (May 26, 2012)

We can't even get everyone in EMS a friggin associates degree or a real A&P class. Surgical intervention sounds like a GREAT idea!


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## medic417 (May 26, 2012)

TatuICU said:


> We can't even get everyone in EMS a friggin associates degree or a real A&P class. Surgical intervention sounds like a GREAT idea!



Yup just as good as giving 120 hour rescue rickie hero want a be the right to do advanced procedures.


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## TatuICU (May 26, 2012)

medic417 said:


> Yup just as good as giving 120 hour rescue rickie hero want a be the right to do advanced procedures.



You leave Ricky Rescue out of this.  Oh btw, speaking of that, I think for my next paper I'm going to design some sort of mathematical model that describes the inverse relationship between how much crap a person carries on their belt and how much experience they have.  Thoughts?


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## ExpatMedic0 (May 26, 2012)

thought I was on 4chan for a minute, had to double check and make sure this was EMTLIFE.


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## mycrofft (May 26, 2012)

Would that be by weight of the belt, number of gadgets, a ratio of those versus carrier's body weight, or all three?


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## usalsfyre (May 26, 2012)

TatuICU said:


> You leave Ricky Rescue out of this.  Oh btw, speaking of that, I think for my next paper I'm going to design some sort of mathematical model that describes the inverse relationship between how much crap a person carries on their belt and how much experience they have.  Thoughts?



Probably setting dependent as well. While most ground medics shed their belt accessories rather quickly, several of the better flight providers I've known required vest to lug around all their extra stuff


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## hawkinstyler (May 29, 2012)

Appendectomy in the field? I would say only under *extreme* circumstances. When a patient is opened up in any type of invasive procedure they are exposed to the external environment which is loaded with bacteria and other organisms. Not saying we don't clean our trucks to the best of our ability, but what makes you think opening someone up in the back of an ambulance is a good idea? Highly unsanitary.. I would expect most patients having an appendectomy done in the back of a truck to come back some sort of a nasty infection. Bad idea in my opinion, there's a reason surgeons do these types of procedures in a controlled and as sanitary as possible of an environment.


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## STXmedic (May 29, 2012)

hawkinstyler said:


> Appendectomy in the field? I would say only under *extreme* circumstances. When a patient is opened up in any type of invasive procedure they are exposed to the external environment which is loaded with bacteria and other organisms. Not saying we don't clean our trucks to the best of our ability, but what makes you think opening someone up in the back of an ambulance is a good idea? Highly unsanitary.. I would expect most patients having an appendectomy done in the back of a truck to come back some sort of a nasty infection. Bad idea in my opinion, there's a reason surgeons do these types of procedures in a controlled and as sanitary as possible of an environment.



/facepalm

Read the rest of the thread.


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## hawkinstyler (May 30, 2012)

I have read the thread. Thanks for a most thoughtful reply =]


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## abckidsmom (May 30, 2012)

Melmd said:


> I don't think that is possible, simple as it looks like in you tube but only surgeons can do it. Even doctors cannot do it if not trained in surgery.



But we could install a flat screen TV where the clock is so we could play the video for prompting during the procedure.




FLdoc2011 said:


> Only if you also take on the liability, post op care and any complications that may arise......




No worries there.  We could just print something out and hand it to the patient.


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## STXmedic (May 30, 2012)

hawkinstyler said:


> I have read the thread. Thanks for a most thoughtful reply =]



Good =] So you were able to decipher that the thread was a joke and the OP was by no means suggesting that paramedics perform appendectomy =] But thank you for pointing out some excellent reasons of not performing surgery in the field; I honestly wouldn't have thought of any of that =]



=]


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## rmabrey (May 30, 2012)

medic417 said:


> Not stirring we need more skills. Plus think how much money we could make. Instead of ambulances we will be called mobile surgical suites.



Surgical suite driver sounds so much more professional than ambulance driver


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## hawkinstyler (May 30, 2012)

PoeticInjustice said:


> Good =] So you were able to decipher that the thread was a joke and the OP was by no means suggesting that paramedics perform appendectomy =] But thank you for pointing out some excellent reasons of not performing surgery in the field; I honestly wouldn't have thought of any of that =]
> 
> 
> 
> =]



Okay so I was simply expressing my opinion, something unheard of these days. But I digress, I'm no paramedic. So sorry to even bother, have a nice ego trip =]


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## Dwindlin (May 30, 2012)

Melmd said:


> I don't think that is possible, simple as it looks like in you tube but only surgeons can do it. Even doctors cannot do it if not trained in surgery.



I missed this earlier. Actually in the US if  you have an unrestricted license (MD + one year post grad training) you can do whatever you want. Now facility credentialing is a separate issue.


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## STXmedic (May 30, 2012)

hawkinstyler said:


> Okay so I was simply expressing my opinion, something unheard of these days. But I digress, I'm no paramedic. So sorry to even bother, have a nice ego trip =]



Thank you, I will indeed =]


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## TatuICU (May 30, 2012)

rmabrey said:


> Surgical suite driver sounds so much more professional than ambulance driver



Gives a whole new meaning to the phrase Ambulatory Surgery


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## medic550 (Jun 11, 2012)

maybe mobile sex change lab?


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## medic417 (Jun 11, 2012)

medic550 said:


> maybe mobile sex change lab?



Please lets stay on topic and serious.


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## mycrofft (Jun 12, 2012)

The thread is pseudoserious and overlong.


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## medic417 (Jun 13, 2012)

mycrofft said:


> The thread is pseudoserious and overlong.



Nope just the right length.


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## STXmedic (Jun 13, 2012)

Twss?


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## mycrofft (Jun 14, 2012)

..."And growing!".


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## medic550 (Jun 14, 2012)

Just for the record my comment was being sarcastic due to the topic of this thread.  I could never see ems providers doing surgery with the exception of a needle or surgical cric.  Dr's go to school for many years before they are even allowed to hold a knife over a patient.


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## medic417 (Jun 15, 2012)

medic550 said:


> Just for the record my comment was being sarcastic due to the topic of this thread.  I could never see ems providers doing surgery with the exception of a needle or surgical cric.  Dr's go to school for many years before they are even allowed to hold a knife over a patient.



Not in all schools.


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## AUSEMT (Dec 13, 2012)

See THIS is what i've been trying to convince folks to do for ages!!
I mean, its not like we in EMS don't have the training or education! and we sure as hell have the money!!

why just limit yourselves to appendectomies? people, this is the age of revolutions in EMS!

I'm thinking we engineer fluoroscopes into the back of our trucks so we can do PCPI in the field, 
take the cath lab to the patient!! 

12 lead, 15 lead, even 18 lead? 
NOPE contrast angiography!! now we're talking!

portable X-rays? the devices are there, they only Cost about 30K!! sping the xray around the patients head and you have a CT brain!, inject them with contrast and you have a CT brain with contrast!
lets start doing stroke CVA fibrinolysis in the field!
bring out the tPa!

actually, screw that, im thinking peri-mortem cesareans. it is a life saving intervention after all! and yes, there was the article about the two paramedics who got fired and sued for doing it under med control, but if were insured, what could go wrong?

im also thinking we let EMT-B's do surgical airways and suturing? i mean, think about it, they arent actually tricky skills? they're just a little bit invasive.

anyway, thats just my 2cents

lets broaden our horizons!


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## Obstructions (Dec 13, 2012)

> Once the diagnosis of appendicitis is made and the decision has been made to perform an appendectomy, the patient undergoes the standard preparation for an operation. *This usually takes only one to two hours and* includes signing the operative consents, patient identification procedures, evaluation by the anesthesiologist, and moving the patient to the operating area of the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids and antibiotics .
> 
> Read more: http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html#ixzz2EzzTkA3V




Why would there be a need for an emergent appendectomy? You'd run out of time in order to finish the procedure. It'd just be faster to go the hospital and have a physician, who has had 8+ years of training, complete the procedure. How would you keep your field sterile? What about all the liability and malpractice crap about anesthesia and surgeries? Can you really finish this surgical procedure with just you and a partner? Plus I'd be scared as hell if people like me who still don't really know what there doing were cutting into me and taking  a part of my body.


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## NYMedic828 (Dec 14, 2012)

Obstructions said:


> Why would there be a need for an emergent appendectomy? You'd run out of time in order to finish the procedure. It'd just be faster to go the hospital and have a physician, who has had 8+ years of training, complete the procedure. How would you keep your field sterile? What about all the liability and malpractice crap about anesthesia and surgeries? Can you really finish this surgical procedure with just you and a partner? Plus I'd be scared as hell if people like me who still don't really know what there doing were cutting into me and taking  a part of my body.



The entire thread is a joke... fyi.


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## VFlutter (Dec 14, 2012)

If medics get appendectomies then I should be able to intubate. Only fair


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## STXmedic (Dec 14, 2012)

Chase said:


> If medics get appendectomies then I should be able to intubate. Only fair



So once you get your CRNA/ACNP, does that mean we get fair game on abdominal surgeries?


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## VFlutter (Dec 14, 2012)

PoeticInjustice said:


> So once you get your CRNA/ACNP, does that mean we get fair game on abdominal surgeries?



Sure. We can put a Davinci on every ambulance


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## NYMedic828 (Dec 14, 2012)

Chase said:


> Sure. We can put a Davinci on every ambulance



That is officially one of the coolest things I have ever seen. (just youtubed it)


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## Norbi (Dec 14, 2012)

AUSEMT said:


> See THIS is what i've been trying to convince folks to do for ages!!
> I mean, its not like we in EMS don't have the training or education! and we sure as hell have the money!!
> 
> why just limit yourselves to appendectomies? people, this is the age of revolutions in EMS!
> ...



here in hungary, perimortem c-sections are in the medic scope after someone performed a successful(and widely publicised) one on a gravida in traumatic arrest


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## mycrofft (Dec 14, 2012)

*THIS reply is worth resurrecting the discussion:*



PoeticInjustice said:


> Lol! I actually just got out of our week-long CME class this week. Our medical director and our area trauma guru both told us that if we have a patient requiring one, they fully expect us to perform it... h34r:


 (red letters are my emphasis).

ANYTIME a doc tells you something like that, no matter how empowering it may sound, get it in writing through the formal protocol process. I've watched instances where MD's said "I'll cover you if you...", or "I am making a standing "(verbal)" order to do this...", or they send out an email or xeroxed written order on their own authority setting protocol, as it were. When you kill someone or it goes to court because they can't see, or have babies, or feed themselves anymore, where's that doc going to be?






No, that's not the Medical Director's Tribal Council hut.


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## Veneficus (Dec 14, 2012)

mycrofft said:


> (red letters are my emphasis).ANYTIME a doc tells you something like that, no matter how empowering it may sound, get it in writing through the formal protocol process. I've watched instances where MD's said "I'll cover you if you...", or "I am making a standing "(verbal)" order to do this...", or they send out an email or xeroxed written order on their own authority setting protocol, as it were. When you kill someone or it goes to court because they can't see, or have babies, or feed themselves anymore, where's that doc going to be?



I wouldn't even accept that.

History:

Back in the days of wooden ships and iron men, when i first started, our state scope was "anything the doctor told you to do." I thought that was really cool. I even got really angry when the state changed med directors and the new one started to significantly restrict what paramedics could do.

That was the first time I was told there is no EMT-Vene cert. That whil I could be trusted to do some crazy stuff, (actually the hallmark of my career) not everyone possesses the same ability. That is probably when I realized EMS just wasn't big enough.

Now:

A few years down the road, I have actually been trained in many things I was asked to do without training. I have learned what can go wrong. I have also learned the most important suffix in medicine. "Oid" meaning: looks like but isn't. (along with what it really is)

recently I had to argue with a nurse who questioned whether or not I knew what I was doing because it conflicted with her routine. As it turned out, she was under the impression that anaphylaxis caused by IV meds works like transfusion reactions and if you stop the infusion, you stop the progression of anaphylaxis. (Absolutely not the case) If it were, removing the insulting agent would stop all anaphylactic reactions, which we all know doesn't happen.

That illustrates very well why providers need all of that "book learnin."

As most nurses can attest, when something goes wrong, doctors are going to point to somebody else. Especially if there is no record. But one of the most terrifying questions I can think of to have to answer on a witness stand when you already know the answer is "no" is:

"Can you provide documentation that you were trained how to properly perform that procedure?"

If you are not formally taught how to do something with documentation, my advice is don't.

For those unknowing, if a paramedic instructor teaches you something outside of your scope of practice and you actually do it. They can be held legally responsible.

Just because a doctor tells you how to do something does not equal being taught.

The best piece of advice I have for any provider is: Always think about what happens next.

I sat in an ATLS class once where the instructor told us an anecdote about an emergency physician that performed a thoracotomy at rural hospital and then asked if the level 1 could fly a surgical team out to close the pt. (which logistically is not feasable, hospital privilidges, insurance coverage, even knowing where to find supplies)

His advice: If you can't close it, don't open it.

Comes into play with "what next?"


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## paramagician (Dec 16, 2012)

I like to call this the Paragod Complex.


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## Veneficus (Dec 16, 2012)

paramagician said:


> I like to call this the Paragod Complex.



Are you speaking of my post?


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## mycrofft (Dec 16, 2012)

Well, V, check out that avatar....

Seriously, the "paramedic=MD" thing  has another real drawback I thought of as I was making coffee. 

They say "When the tool on top of your tool chest is a hammer, everything needs a good bash".

When your education has been geared to detecting acutely and emergently life-threatening situations, will you, presumably without resort to sissy things like, oh, laboratories/specialists/radiology/medical records, be able to detect or address things like cancer, birth defects, tertiary syphilis, athlete's foot, gastroesophageal reflux, hemorrhoids, etc.?  These are the majority of real general medical practice, and over-treatment or non-treatment of these will leave a wide path of people needing someone else's care to fix your mess.

I am not saying a tech can't, with proper training and protocols and backup, DO a good job with most cases, especially if they know when to push the DEFAULT/MD button. But even years of paramedic experience will not help you if it is all codes, extrications, and long spine boards.


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## Clare (Dec 16, 2012)

I agree this is a great idea, it would have meant I did not need to spend all week in the hospital!


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## Veneficus (Dec 16, 2012)

mycrofft said:


> Well, V, check out that avatar....



That avatar was selected for me in the direcetionless thread, I much prefer the ninja, bit don't have the file on this computer.


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## Dwindlin (Dec 23, 2012)

NYMedic828 said:


> That is officially one of the coolest things I have ever seen. (just youtubed it)



They suck for the most part.  Add a lot of time (which equals adding a lot of money) on to cases and frankly outside of some Uro (Prostate) and GynOnc (low and ultra low anterior resections) they don't add much.


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## Veneficus (Dec 23, 2012)

Dwindlin said:


> They suck for the most part.  Add a lot of time (which equals adding a lot of money) on to cases and frankly outside of some Uro (Prostate) and GynOnc (low and ultra low anterior resections) they don't add much.



and they have a higher rate of impotence as a complication of prostate. 

I will go with the skilled hands of a surgeon if need be. 

Just another medical gadget that tries to replace experienced people with technology.

fail.


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