# Pulling the plug on EMS



## Veneficus (Apr 5, 2011)

So today I was thinking about a reply to narcan in another post. 

It occured to me that there really is no use for narcan in EMS.

Perhaps one of the primary things that EMS can claim to fame is the support of ventilation and circulation. If you can do that without a medication, why wouldn't that be the first choice? The only choice?

Now when I took pharmacology class, the first slide on the first day, was of the founder of pharmacology who declared "all drugs are poisons." (interestingly enough he died from complications of alcoholism)

Why do EMS providers seem to think that medication is always the best answer?

I am sure there is a training component as students are forced to memorize, under pain of being kicked out of a program, treatment regiments, which include medications and if these prescriptions are not followed it is wrong?

Some blame must go to protocols which never seem to get updated in a timely manner. 

But it is not the instructor or medical director pointing a gun at providers telling them to always go to the max. 

Now I know it is popular to pull out the anecdotes and the "what if's," but really, how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)

I sort of singled out medications in this post, but it is not limited to that. 

Should EMS providers be prohibited from calling air medical services? Should they be banned from receiving bribes, I mean gifts and promotional materials, and "education" on the benefits and when to call airmed?

Now the point of this post isn't to pick on EMS or accuse it of negligence or substandard practice, but really. You have providers performing treatments that are often not needed, then turning around and not providing treatments in most cases that are!

That doesn't even get into treatments whos benefits are highly questionable. 

Perhaps we should start taking a more minimalist approach to theraputics for pathologies, and a more aggresive approach to reducing pain and suffering?

Perhaps we need to get drastic and either remove ALS or put such restricitons on it that only hospitals would be able to provide the infrastructure to support ALS providers.    

Look at the cost to maintain a quality intubation program compared to the benefits of intubation. In most areas it seems totally disproportionate. Especially in places where the hospital is so close, by the time you drop the tube you could have dropped the pt off at the hospital and been back at the station watching House and chomping on pizza.

Is it even realistic to ask EMS providers to take hubris, greed, and tradition out of the equation when deciding what treatments should be performed in the field?

When is EMS going to do more than pay lip service to the idea of what is best for the patient?

Or at least "do no harm?"


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## 46Young (Apr 6, 2011)

In most places, if you don't follow the whole protocol, (NYC as an example) you get flagged by  the QA/QI nazis.

Medical directors, in general, aren't going to omit therapies and other interventions unless sufficient studies come out, and then many other agencies also have to be doing (or not doing as the case may be) the same thing. The don't want to be sued for restricting their dept from doing what's standard practice elsewhere.


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## Amycus (Apr 6, 2011)

Note: I did not read the entire post, just the first few lines, but wanted to comment on something.

There's a medic I work with that I respect very much, who once went on a rant about how many medics just want to start lines/push meds, etc. His mantra is that the less he has to do, the better. Not from a laziness standpoint- but that if he doesn't HAVE to give a medication, or doesn't feel it's clinically beneficial to the patient, he won't do it. Don't overtreat, do exactly what is necessary for the patient.


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## dixie_flatline (Apr 6, 2011)

Veneficus said:


> So today I was thinking about a reply to narcan in another post.
> 
> It occured to me that there really is no use for narcan in EMS.
> 
> ...


Veneficus - I'm still new here, and you've obviously been around awhile and have more of a medical background than most.  However, this isn't the first thread I've seen in the past few months where you just kind of throw out all these ruminations, mostly lambasting the US EMS system and the idea of protocols.  From what I've gathered, you have formed some type of conclusion that EMS needs to go away, or die and be reborn maybe?  

Here, you ask several questions (some perhaps rhetorically), but don't seem to reach a salient point that I can see.  I thought at the beginning you were going to make an argument against the number of drugs that ALS providers can and do push, but that seemed to taper off at the middle and somehow you started talking about aeromedical services, then about intubation? By the end, you just seem to be saying "EMS providers are doing more than they should, and its not in the best interests of their patients".  Am I understanding that right?  

I think most of the people on these boards (the ones who are active more than looking to get a job or a license) are here to learn and discuss. We realize that EMS (perhaps especially in the US) isn't perfect, and are always interested in viable improvements.  Do you have a suggestion of some kind here, even if it requires a sea change (that will never happen) which would radically alter the nature of prehospital care?

There are so many moving parts though, I think you'd need to address a lot.  As you said, many of the agencies we work for here are urban.  I know that to drive an ambulance for my FD, you need to know the route to no less than 7 hospitals, and I think it's really more like 10, none of which are further than probably 30 minutes.  That's certainly not the case coast to coast however, and should that factor in somehow to 'protocols'?  It would seem that you are arguing against intubations for my type of short-haul environment, but the paramedics in Montana and Wyoming (and even the Eastern Shore in MD) with the long rides to Anywhere probably get even fewer chances to stay sharp with all those skills (someone correct me if that's a bad assumption).  

You talk about removing ALS entirely.  What do the numbers say with regards to something like pt survivability/morbidity in the case of witnessed arrest or the like when you compare ALS to BLS?  My hunch is that ALS isn't much more likely, statistically, to get a save than a competent Basic - but I bet that there are certain subsets of patients where an ALS provider makes a difference.  The next step would be to examine and address those subsets - what are they, how often, etc.  What is the threshold for adding a treatment/medication/protocol?  Obviously we can't treat everything, so what gets left out?

I'm only a basic, but I'm still wondering what made you decide that naloxone is unnecessary for prehospital pts?


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## 18G (Apr 6, 2011)

Vene is an extremist. An extremist who claims to be for EMS yet constantly contradicts himself with rambling posts such as this one. Mostly what he spews is rhetoric and accuses others of not presenting evidence to back their positions when he rarely does so himself. 

I mean come on... you couldn't pick a better battle than Narcan???? Your really going to argue against Narcan use pre-hospital??? What is wrong with you? Am I the only one your losing credibility with?

So your telling me that when we have a heroin OD were supposed to 100% of the time put in an NPA and just bag the patient the whole way to the hospital? When instead we can quickly improve the patient's own stimulus to breathe, allow them to ventilate themselves, reverse the problem, and mitigate the need to perform the continual intervention of assisted intervention and the inherent risks of doing so??? 

Hmmm.... lets see... bag a patient 30mins to the hospital, cause gastric insufflation, patient vomits, aspirates, and now has aspiration pneumonia? And not to mention emesis everywhere, the need to suction aggressively.... all for what? Or wait... place an NG tube to prevent all that??? why? How is this clearly better for the patient? And what if the patient is bradycardic and rate does not respond with the assisted ventilation??? Now what.. still no Narcan??? Or are you proposing we intubate these patient??? That is mostly stupid.... again, why?

When instead... you can place an NPA, bag the patient, start an IV and titrate your Narcan to adequate resp status!!! all within a few minutes! bam.... we take a respiratory arrest or damn close to it and give them the ability to breathe on their own all in under 10mins! And we accomplish this all with a very SAFE and EFFECTIVE medication. 

By your own philosophy, the hospital shouldn't give Narcan either. Why should the hospital poison the patient, right? Why not just have the RRT bag the patient until the opiates wear off? Isn't that exactly what your saying?

The point of EMS is to bring a lot of the ED care to the field. The treatment priorities of a narcotic OD are the same no matter if initiated in the field or in the Hospital. So, what's the problem?



> how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)



So you don't believe in preparation? Being prepared to treat all emergency's despite frequency isn't appropriate all of a sudden? So, tomorrow a building collapses and someone is crushed... lets just say its you for arguments sake? Your in favor of the Paramedic unit not having calcium Cl and sodium bicarb? You wanna take the chance when your extricated all because your the only patient in the past 5yrs this has happened to?

Or lets say you have a Child with severe asthma... nothing is working... albuterol, atrovent, epi, CPAP... all fail to reverse.... your son or daughter is moving closer and closer to resp failure and arrest. hmmm... mag sulfate has been showed to work in asthma cases refractory to traditional treatments... but since your son or daughter is the only case like this in the past 3yrs we no longer carry mag sulfate and your Child has now Coded. 

Think that's exaggerated??? I think not. It's real life on this planet although I'm not sure which one your living on. 

What's next on your list to remove from the EMS arsenal? D50? Band-aids, 4x4's? Alcohol Swabs?


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## JPINFV (Apr 6, 2011)

18G said:


> I mean come on... you couldn't pick a better battle than Narcan???? Your really going to argue against Narcan use pre-hospital??? What is wrong with you? Am I the only one your losing credibility with?


I think naloxone is an interest and somewhat appropriate choice. It's a drug that can be easily titrated, yet apparently all too many people push the maximum dose for no more reason than they can, if not other reasons. I've heard stories, both in real life and online, of people using naloxone as punishment for either the patient ('ruining the high'), the hospital (IV push the maximum dose right at the hospital so that the patient is puking and fighting with the ER staff), or both. Additionally, it is probably one of the most often used paramedic level medications. Finally, there seems to be an astonishing lack of understanding of it's actual role, which is probably best demonstrated by the fact that there's a JEMS Connect thread where a PALS instructor suggested using it IO.


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## Sandog (Apr 6, 2011)

Veneficus said:


> So today I was thinking about a reply to narcan in another post.
> 
> It occured to me that there really is no use for narcan in EMS.
> 
> Now when I took pharmacology class, the first slide on the first day, was of the founder of pharmacology who declared "all drugs are poisons."



Your quote of Paracelsus omits a key portion of the quote which paints quite a different picture.

*"All things are poison, and nothing is without poison; only the dose permits something not to be poisonous."*


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## DesertMedic66 (Apr 6, 2011)

When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed, or he just wants hospital based EMS. Down here most hospitals don't have the money for their own EMS. And people out here who are coding or unconscious don't walk into the hospital. Lol.


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## 18G (Apr 6, 2011)

firefite said:


> When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed



All of the above.


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## the_negro_puppy (Apr 6, 2011)




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## DesertMedic66 (Apr 6, 2011)

18G said:


> All of the above.



Alright. I just wanted to make sure I wasnt reading it wrong. 

He just wants us to do the bare minimum to patients if that. If someone is having an allergic reaction to something, which one is better for the patient, walking into the ER bagging the patient because we didn't want to "poison" him with epi because we just wanted to do the bare minimum in treatment or walking into the ER with a patient who we gave the "poison" to, that is breathing perfectly and is talking to staff members? From my EMT school we were taught that communication is a type of basic treatment. If I'm only going to do the basic treatment then I will have a patient in full arrest in the back of my rig and I will be asking him how his day is going and how he is feeling. Talking to a basically dead patient isn't going to help the patient at all. He isn't going to sit up from the gurney and say "wow, thanks for talking to me you saved my life by doing the absolute basic thing you could do."


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## HotelCo (Apr 6, 2011)

the_negro_puppy said:


>



THRILLER!

[YOUTUBE]http://www.youtube.com/watch?v=sOnqjkJTMaA[/YOUTUBE]


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## DrParasite (Apr 6, 2011)

firefite said:


> When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed, or he just wants hospital based EMS. Down here most hospitals don't have the money for their own EMS. And people out here who are coding or unconscious don't walk into the hospital. Lol.


yeah, you aren't the only one who picked up on that.

As a side note, my medical director was 100% in  favor of EMTs administering nasal narcan for suspected opiate overdoses.


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## Veneficus (Apr 6, 2011)

dixie_flatline said:


> I think most of the people on these boards (the ones who are active more than looking to get a job or a license) are here to learn and discuss. We realize that EMS (perhaps especially in the US) isn't perfect, and are always interested in viable improvements.  Do you have a suggestion of some kind here, even if it requires a sea change (that will never happen) which would radically alter the nature of prehospital care?



That is the question I think. 

EMS doesn't seem to want to change anything. So I am trying to find the way in which EMS can be forced to change in a reasonable amount of time.

One of the things that I have been learning as of late is that providers must always question whether or not they are doing the right thing for the patient or a procedure to satisfy themselves or a guidline. It is not limited to EMS, but this board is not really the right place to start talking about the best forms of anesthesia during CABG. 



dixie_flatline said:


> There are so many moving parts though, I think you'd need to address a lot.  As you said, many of the agencies we work for here are urban.  I know that to drive an ambulance for my FD, you need to know the route to no less than 7 hospitals, and I think it's really more like 10, none of which are further than probably 30 minutes.  That's certainly not the case coast to coast however, and should that factor in somehow to 'protocols'?  It would seem that you are arguing against intubations for my type of short-haul environment, but the paramedics in Montana and Wyoming (and even the Eastern Shore in MD) with the long rides to Anywhere probably get even fewer chances to stay sharp with all those skills (someone correct me if that's a bad assumption).



I think this needs to be put in a larger context. The point isn't whether there is a problem with the skill, the question is, is the skill even necessary or should there be tighter controls on it than every paramedic at every service is permitted.

In most services that use RSI, it automatically trigers an audit. Why doesn't every intubation automatically trigger an audit? I have worked for services where giving 2 mg of morphine triggers an audit, but cardioverting an SVT patient didn't.

I realize in many places this comes down to the medical control, but I don't see any reason why EMS supervisors cannot conduct a preliminary audit and then send it to the medical director if there is not clear resolution. 



dixie_flatline said:


> You talk about removing ALS entirely.  What do the numbers say with regards to something like pt survivability/morbidity in the case of witnessed arrest or the like when you compare ALS to BLS?  My hunch is that ALS isn't much more likely, statistically, to get a save than a competent Basic - but I bet that there are certain subsets of patients where an ALS provider makes a difference.  The next step would be to examine and address those subsets - what are they, how often, etc.  What is the threshold for adding a treatment/medication/protocol?  Obviously we can't treat everything, so what gets left out?



Actually the studies show that the primary benefit of ALS with a handful of exceptions are that they reduce hospital stay. Does the cost of EMS make up for the difference? Nobody knows.

One of the defenses of the status quo of EMS is to demand proof that ALS doesn't work. These providers are simply self serving fools. First, you cannot prove a negative, secondly they offer none of their own proof. They think spouting anecdotes and congratulating themselves somehow counts. Nobody in medicine is fooled by this. There just aren't many who care enough about EMS to "waste time" taking a critical look at it.

If providers of any level spend more time congratulating themselves on a job well done, rather than asking hard questions, improvement is impossible.



dixie_flatline said:


> I'm only a basic, but I'm still wondering what made you decide that naloxone is unnecessary for prehospital pts?



I was thinking that the point of narc reversal is to stabilize respiratory and vascular systems. Anesthesia never seems to use narcan, titrated or otherwise, and they give narc doses far in excess of EMS on a daily basis. One of the most common heard mantra of ALS providers is they are not afraid of narcs because they can reverse them, which of course, seems like flawed clinical judgement.

I am seeing from this forum that despite talk of wanting to be healthcare professionals, it is really just piss and wind. Few actually want to do the work involved, but at the same time want all the benefits. 

Physicians are constantly questioning their modalities, treatments, and decisions.

The only reason I can think it is labeled as extreme or anti here, is the lack of true professionalism. Providers just want to feel good about themselves. But believing without question is a dangerous mindset. When it is followed even more by positive reinforcement of ones actions as the best or true way, it is the sure path to extremism.

If you look closely, the people who always demand proof offer none of their own. Just feelings and anecdotes. Simple proof positive thinking. 

But I am rather hoping that out of these questions, people start thinking and true leaders arise or are inspired to prove themselves in a way that is convincing to somebody outside of EMS.


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## Aidey (Apr 6, 2011)

Can we just require that everyone has to read House of God before they are issued their cert?


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## Veneficus (Apr 6, 2011)

Aidey said:


> Can we just require that everyone has to read House of God before they are issued their cert?



Never read it, don't have time.


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## Sandog (Apr 6, 2011)

Vene, to be honest I did not quite get the point of your first post. Are you trying to say that current EMS procedures are too aggressive, and in many cases that providers need to think beyond a protocol? Is your point being that often times that less may be more? Just trying to get what you mean...


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## Veneficus (Apr 6, 2011)

Sandog said:


> Vene, to be honest I did not quite get the point of your first post. Are you trying to say that current EMS procedures are too aggressive, and in many cases that providers need to think beyond a protocol? Is your point being that often times that less may be more? Just trying to get what you mean...



My point is 2 fold, 

One that less is more.

The other is that EMS must start to look critically at the treatments it is performing.

I have a career full of anecdotes where the more rare EMS treatments I performed have actually probably made a difference.

But Anecdote is not evidence. Nor are the arugements of "what if" and "sometimes."

Like every other medical and healthcare provider, we must constantly scrutinize what we are doing.

Later this evening I expect to look up the exact physiological and pathophys of both opioid OD and the reversal of it to really see whether or not there is a flaw in the original theory of its use for EMS.

Withdrawing treatments that are grossly uneconomical, rarely used, or questionable in effectiveness should not be viewed as punishment or anti.

It shold be viewed as a professional behavior of people who are trusted by their patients to do the very best when trying to help.

I am always amuzed by the attempts at scaring me into accepting practices because somebody might die, or Bin Laden is coming to get me, or some such.

Truthfully, we could probably save some lives by hauling Westerners over the age of 50 into cath labs and placing stents preventatively. But that doesn't make it economical or good practice.

I tried to include some examples other than narcan to illustrate the point that other treatments/operations have alternatives which may be better.

Clearly because of the diversity of regional pathology a treatment that would be totally useless in one area or region might be the most helpful in another. (one of the reasons I think national scope might actually be a bad idea)

Questions we should be asking ourselves are.

1. Is the treatment put forth the best option?

2. Is it over/under used?

3. Is it for the benefit of the patient, the system, or the provider?

4. How to we reconcile the discrepency when the treatmnet is better for the later 2 than the former?

Consider this, ACLS arrest medications like epi and atropine have shown no benefit in decades of research trying to prove they have benefit. But they are on every ALS unit and ED in the country. Why? At what cost? Why are we spending money and time on those treatments if we can't get them to make a difference?

But at the same time, maybe we should be looking at other treatments like heparin on EMS units.

Treatments that were sound 20 years ago may not match the evolving pathology of the day. There should always be a constant critical eye on any treatment.

The feeling of helping somebody is not good enough. Actually helping them is. In many cases less is more.


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## boingo (Apr 6, 2011)

JPINFV said:


> I think naloxone is an interest and somewhat appropriate choice. It's a drug that can be easily titrated, yet apparently all too many people push the maximum dose for no more reason than they can, if not other reasons. I've heard stories, both in real life and online, of people using naloxone as punishment for either the patient ('ruining the high'), the hospital (IV push the maximum dose right at the hospital so that the patient is puking and fighting with the ER staff), or both. Additionally, it is probably one of the most often used paramedic level medications. Finally, there seems to be an astonishing lack of understanding of it's actual role, which is probably best demonstrated by the fact that there's a JEMS Connect thread where a PALS instructor suggested using it IO.



Toronto, Boston and others give Narcan to their junkies for self-tx, buddy tx, and guess what?  They don't go to the hospital tying up EMS and ED resources.


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## boingo (Apr 6, 2011)

Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet.  You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong.  Would reversing opiate OD in the ED be bad too?  Should they get a tube and a MICU bed?  Seriously, get your MD or DO under you belt and get back to us in a few years.


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## JPINFV (Apr 6, 2011)

boingo said:


> Toronto, Boston and others give Narcan to their junkies for self-tx, buddy tx, and guess what?  They don't go to the hospital tying up EMS and ED resources.





I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...


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## 46Young (Apr 6, 2011)

dixie_flatline said:


> Veneficus - I'm still new here, and you've obviously been around awhile and have more of a medical background than most.  However, this isn't the first thread I've seen in the past few months where you just kind of throw out all these ruminations, mostly lambasting the US EMS system and the idea of protocols.  From what I've gathered, you have formed some type of conclusion that EMS needs to go away, or die and be reborn maybe?
> 
> Here, you ask several questions (some perhaps rhetorically), but don't seem to reach a salient point that I can see.  I thought at the beginning you were going to make an argument against the number of drugs that ALS providers can and do push, but that seemed to taper off at the middle and somehow you started talking about aeromedical services, then about intubation? By the end, you just seem to be saying "EMS providers are doing more than they should, and its not in the best interests of their patients".  Am I understanding that right?
> 
> ...



If you want to see hostility and disdain towards EMS providers, you should search ventmedic's old posts.


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## JPINFV (Apr 6, 2011)

JPINFV said:


> I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...


Correction... I meant IO, however I doubt they're administering it IV as well...


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## rwik123 (Apr 6, 2011)

JPINFV said:


> Correction... I meant IO, however I doubt they're administering it IV as well...



IM I believe


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## 18G (Apr 6, 2011)

Baltimore, MD had a program at one time where they handed out Narcan to addicts also. This was a long time ago so not sure if they still do it or not.


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## Veneficus (Apr 6, 2011)

*Forgive me*



boingo said:


> Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet.  You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong.  Would reversing opiate OD in the ED be bad too?  Should they get a tube and a MICU bed?  Seriously, get your MD or DO under you belt and get back to us in a few years.



But this is by far the absolute most ridiculous reply I have ever seen in any forum.

My musing are often retrospective. Applying the knowledge I received today to my past and current experiences in EMS. 

As an EMS instructor, I am acutely aware of the rationale behind many of the field treatments. I have also seen so many emergency treatments thrown into question over the years in scientific study that any paramedic aspiring to be a professional should be aware of and capable of making informed conclusions and critisisms there of.

Is my past service on EMS protocol committees, and the research and discussions there not applicable because I am in the process of advancing my education? 

Does the fact that I spend a considerable amount of time learning and being tested on past treatments, current treatments, and future recommendations somehow make me less capable of forming an opinon on them?

How much time do you or any paramedic spend on it?

One of my semesters is worth more credit hours than any US paramedic school in total. I am a student, but more than capable of forming an intellectual opinion on the same treatments that a practicing vocational technician is. (the same certification I also hold I might add) 

It is yesterday's experts that recommended pouring crystalloid into patients until they bled cool aid. Been there, done that.

Relatively there are few physicians interested in EMS to put forth any effort to conduct studies on most of what is done. If Joe paramedic can decide what is being done is right, what makes vene paramedic less capable to question it?

Is my research above the level of any of my peers in pathophysiology somehow not worthy of consideration until after it is published or I put some letters after my name?

Tell me, what letters or publications do you claim to refute my conclusions?

How much research have you or US paramedics done to comment with any authority or knowledge on what EMS treatments are beneficial?

Let me address your questions.



boingo said:


> Would reversing opiate OD in the ED be bad too?.



It depends on a couple of factors. 

1. Are providers titrating it appropriately?
2. Are they using it punitively?
3. Are they doing it for patient benefit or their convienience?
4. If less aggresive treatment achieves the same thing, what makes acute reversal the treatment of choice?
5. What is the sequele if you induce irretractable pain or acute opioid withdrawel doing it? Is it worth that?



boingo said:


> Should they get a tube and a MICU bed??.



This looks like a strawman argument to me, i put forth the idea that less invasive treatment may be more beneficial and you ask me if the patient should recieve more aggresive treatment? Come on.



boingo said:


> Seriously, get your MD or DO under you belt and get back to us in a few years.



I'll play. 

I will have MD after my name before you can matriculate to med school unless you start this september and a second graduate degree before you finish your second semester. Get some medical education past vocational/community college If:then statements under your belt and get back to me in a few years.

Feel better about yourself now?


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## 18G (Apr 6, 2011)

Seriously... come down off your trip... your not above us. 

We want what's best for our patient's and question and research the same as you. What you suggest is pure BS and like your trying to be the trend setter with your rhetoric in hopes of one day being able to say, "I told you so". 

I am still shaking my head that someone who is almost a Physician would promote not giving Narcan.


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## 18G (Apr 6, 2011)

> Hmmm.... lets see... bag a patient 30mins to the hospital, cause gastric insufflation, patient vomits, aspirates, and now has aspiration pneumonia? And not to mention emesis everywhere, the need to suction aggressively.... all for what? Or wait... place an NG tube to prevent all that??? why? How is this clearly better for the patient? And what if the patient is bradycardic and rate does not respond with the assisted ventilation??? Now what.. still no Narcan??? Or are you proposing we intubate these patient??? That is mostly stupid.... again, why?
> 
> When instead... you can place an NPA, bag the patient, start an IV and titrate your Narcan to adequate resp status!!! all within a few minutes! bam.... we take a respiratory arrest or damn close to it and give them the ability to breathe on their own all in under 10mins! And we accomplish this all with a very SAFE and EFFECTIVE medication.



Scenario A or B. Which one is better for the patient, Vene? Just pick an answer.... A or B.


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## boingo (Apr 6, 2011)

JPINFV said:


> I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...



What does the route of administration have to do with the discussion?


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## boingo (Apr 6, 2011)

My degree is bigger than yours?   Seriously?  You my friend should seriously get over yourself, I deal with internationally respected and well published doctors on a regular basis, doctors who publish and do research that you haven't a clue about and have none of the opinions you hold about EMS.  Why is it you are in school in Europe, better education or lack of opportunity in the U.S.?


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## JPINFV (Apr 6, 2011)

Some posters found it interesting that Vene had picked naloxone as part of the discussion and I referred to this thread about naloxone via IO.


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## boingo (Apr 6, 2011)

Haven't seen your thread, I am responding to Venes current statements regarding the use of Narcan, period, not the route of administration.  I'll take a look at the other one.


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## JPINFV (Apr 6, 2011)

To be clear... I wasn't the original poster for that thread, I just referenced it for why I think naloxone was targeted specifically.


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## Sasha (Apr 6, 2011)

boingo said:


> Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet.  You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong.  Would reversing opiate OD in the ED be bad too?  Should they get a tube and a MICU bed?  Seriously, get your MD or DO under you belt and get back to us in a few years.



Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?

Vene is simply offering some food for thought. 

People are taking this as black and white, because he thinks narcan is overused, that it means all drugs should be done away with.

It really isn't too much to ask for providers to be educated enough to know when less is more and when less is not enough.


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## medicRob (Apr 6, 2011)




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## 18G (Apr 6, 2011)

Sasha said:


> Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?
> 
> Vene is simply offering some food for thought.
> 
> ...



I always appreciate a Woman's opinion  but that is not what Vene is doing. 

Maybe we should also allow patient's to bleed and allow the body's own hemostatic mechanisms to stop the bleeding. After all our goal is to always do the bare minimum to care for our patients.


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## Veneficus (Apr 6, 2011)

Sasha said:


> Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?
> 
> Vene is simply offering some food for thought.
> 
> ...



I think this sums it up well, but I do like to offer some alternative solutions as well. The trouble is when suggesting viable alternatives or worst case scenarios the defenders of the true faith seem to think it is heresy to not buy into the status quo or worship them as the divine heroes whose every intervention pulls people from the jaws of death.

I'll be back in a few, as promised, now that my real work for the day is done, I am going to go and find out the mechanisms behind the sequele of opioid overdose. So we can further the discussion on whether the pathology and circumstances matches the treatments.


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## 18G (Apr 6, 2011)

Veneficus said:


> The trouble is when suggesting viable alternatives or worst case scenarios the defenders of the true faith seem to think it is heresy to not buy into the status quo or worship them as the divine heroes whose every intervention pulls people from the jaws of death..



You couldn't be more wrong.


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## 82nd medic (Apr 6, 2011)

Veneficus said:


> So today I was thinking about a reply to narcan in another post.
> 
> It occured to me that there really is no use for narcan in EMS.
> 
> ...



There's a difference between taking morphine and putting yourself on high flow o2 because you have a cold and taking a medication that is life saving.
Take narcan: name a treatment that doesn't involve medication that can treat an Opiod overdose?
Same for atropine: name a treatment for a nerve agent that doesn't involve medication.
Are you seriously saying that human lives are not worth money when it comes to intubation?

We discussed European EMS in my class back in 2004: they're load and go, that's it. They don't even do spinal immobilization for car wrecks. Compared to that I think American EMS is pretty good


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## usalsfyre (Apr 6, 2011)

82nd medic said:


> Take narcan: name a treatment that doesn't involve medication that can treat an Opiod overdose?


Fluids, suction, an NPA and BVM?



82nd medic said:


> Same for atropine: name a treatment for a nerve agent that doesn't involve medication.


True, but autoinjectors make layperson administration a real posibility



82nd medic said:


> Are you seriously saying that human lives are not worth money when it comes to intubation?


I think what he's saying is EMS does a very poor job at intubation, and the cost/benefit of maintaining a proper program doesn't add up, especially considering the decreasing need for intubation. 



82nd medic said:


> We discussed European EMS in my class back in 2004: they're load and go, that's it.


Much of EMS in Europe is physician-based, the majority that isn't is nurse-based. Meaning it's far from load and go, and is more like to offer definitive treatment and outcome in the field.  



82nd medic said:


> They don't even do spinal immobilization for car wrecks.


How do patients live without this never proven to helpful, proven to be harmful, usually improperly applied, and painful treatment! Yet there doesn't seem to be a overabundance of paraplegics in continental Europe.... 



82nd medic said:


> Compared to that I think American EMS is pretty good


I think you need to do a little more research on US EMS vs EMS abroad.


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## usalsfyre (Apr 6, 2011)

I think Vene's taking an extreme stance to make us examine whether we're doing the correct thing or not. Which we should be doing constantly if we truly want to "save lives".


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## 18G (Apr 6, 2011)

NPA, BVM, and suction is supportive care in an opioid OD until the effects can be reversed. Narcan treats the OD and fixes the problem.

This is so elementary.


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## JPINFV (Apr 6, 2011)

18G said:


> NPA, BVM, and suction is supportive care in an opioid OD until the effects can be reversed. Narcan treats the OD and fixes the problem.
> 
> This is so elementary.



If you want to take that stance, naloxone is only supportive care until the patient's body can metabolize the opioids.


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## 82nd medic (Apr 6, 2011)

usalsfyre said:


> Fluids, suction, an NPA and BVM?
> 
> 
> True, but autoinjectors make layperson administration a real posibility
> ...



Resp distress isn't the only side effects of Opiod poisoning. What are those treatments going to do for bradychardia or hypotension? Fluids are a medication btw.

Out of the military how many lay persons carry atropine or know the S/S of nerve agents?

Intubation causes less damage than king lts/combi tubes. Yes those are quicker and easier but if you have time: why not be safe?

I'm just going off of what my UK born instructor said. 

Spinal immobilization is hazardous? Last I checked a broken bone that's stabilized poses less of a risk of further damage than one that's not. I've yet to see anything showing that it poses more of a risk than a prevention. Being strapped down to a spine board isn't any more painful than bouncing around in the back of an ambulance would be.
I have no clue about paraplegics, but in 2006 1:36.6 car crashes in Europe resulted in fatalities. The ratio of injured to killed was 48.5:1. In 2005, only 1:150 car crashes in the US resulted in fatalities. The ratio of injured to killed was 68:1. Statistically speaking, were doing something right.

I'm all for progression, I was stoked when civie EMS finally moved major bleeding to the front of the list and stopped that whole "tourniquets are a last result" bs. But arguing for progression and arguing for making EMS just delivery-boys and saying that medications that are proven to have saved lives is another


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## 18G (Apr 6, 2011)

No,the issue isn't clearing the opioid from the body. Ultimately that is what is desired but the problem that results in need for treatment is the respiratory depression, airway compromise, and bradycardia.

Narcan is the definitive treatment because it restores breathing, improves airway, and secondarily increases heart rate. 

Narcan is not supportive.


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## usalsfyre (Apr 6, 2011)

Naloxene duration of action is FAR shorter than most opioids. I would hesitate to place it in the definitive treatment category.


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## 82nd medic (Apr 6, 2011)

You're not limited to one dose. If it wears off push in another. A large percentage of medicine is just treating the symptoms until the body can heal itself, that's what Opiod antagonists do: they manage the possibly fatal side effects until the body removes the source.


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## JPINFV (Apr 6, 2011)

82nd medic said:


> Spinal immobilization is hazardous? Last I checked a broken bone that's stabilized poses less of a risk of further damage than one that's not. I've yet to see anything showing that it poses more of a risk than a prevention. Being strapped down to a spine board isn't any more painful than bouncing around in the back of an ambulance would be.



So, anything close to a majority of patients you c-spine have a spinal injury?

It makes sense to strap a normally curved structure to a flat board?

There's evidence that spinal immobilization decreases secondary spinal injury?

Malaysian/University of New Mexico retrospective chart review: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02615.x/abstract
Outcome, no benefit.

"The effect of spinal immobilization on healthy volunteers*Type of participants:* Twenty-one healthy volunteers with no history of back disease.
*Interventions:*  Subjects were placed in standard backboard immobilization for a  30-minute period. Number and severity of immediate and delayed symptoms  were determined.
*Measurements and main results:*  One hundred percent of subjects developed pain within the immediate  observation per iod. Occipital headache and sacral, lumbar, and  mandibular pain were the most frequent symptoms. Fifty-five percent of  subjects graded their symptoms as moderate to severe. Twenty-nine  percent of subjects developed additional symptoms over the next 48  hours.
*Conclusion:* Standard spinal immobilization may be a cause of pain in an otherwise healthy subject."
http://www.sciencedirect.com/scienc...35221faae7006f0e68a60164a846d51c&searchtype=a


"We conclude from our data that these devices produce a significantly  restrictive effect on pulmonary function in the healthy, nonsmoking man."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G9CB76-D&_user=945451&_coverDate=09%2F30%2F1988&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467727&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=53df0436f30430badda5e47cb9251fdd&searchtype=a


"Spinal immobilization significantly reduced respiratory capacity as  measured by FVC in healthy patients 6 to 15 years old. There is no  significant benefit of one strapping technique over the other."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G82KTB-J&_user=945451&_coverDate=09%2F30%2F1991&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467753&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=88ea3a5b2f9bdbd0e50e6afd483bc97e&searchtype=a


So, now show me a study where spinal immobilization improves outcomes.


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## usalsfyre (Apr 6, 2011)

82nd medic said:


> You're not limited to one dose. If it wears off push in another. A large percentage of medicine is just treating the symptoms until the body can heal itself, that's what Opiod antagonists do: they manage the possibly fatal side effects until the body removes the source.



Which an NPA, suction, BVM(more often just a little stimulation) and fluid can do more cheaply with a better side effect profile right?


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## 18G (Apr 6, 2011)

usalsfyre said:


> Which an NPA, suction, BVM(more often just a little stimulation) and fluid can do more cheaply with a better side effect profile right?



Are you discussing this and giving your thoughts objectively or are you trying to stay on the good side of certain people?

Narcan is not an expensive drug. And why not acknowledge what happens when you BVM a patient for 30mins? Is it warranted to create a potential for further airway compromise and aspiration needlessly when we can quickly give a medication which will allow the patient to breathe on their own and manage their own airway?

I can manage an opiate OD much more safely and efficiently with Narcan then I can with having to monitor the provider doing the ventilating, suctioning the patient, dealing with puke, giving fluids, placing an NG tube, etc etc etc. 

Doesn't anyone else see how much more involved this is? 

Hospitalization from infection because the patient aspirated because we caused the patient to vomit through prolonged BVM ventilation doesn't seem like a real good side effect profile to me.  

Narcan virtually has no side effects in and of itself which is the beauty of it. It's extremely safe , fast acting, and highly effective. 

And what sense does it make to BVM a patient the entire transport time, suction, place an NG tube, etc when as soon as you roll in the door at the ED, the patient is going to get Narcan any way. 

Field Narcan or ED Narcan? What is the difference? The patient needs it which is why they get it right away in the ED!


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## truetiger (Apr 6, 2011)

I don't think "it's cheaper" is going to cut it when the patient aspirates.


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## Veneficus (Apr 6, 2011)

*Opioid OD research tonight.*

Ok, firstly I do not plan to write a paper on this, so I will try to sum it up as best I can in a page.

I acknowledge that Harrison's internal medicine lists an antagonist as definitive treatment for opioid overdose. However, medicine is rarely simple, and this is no exception.

Of the 5 resources I checked (4 books and the chief of anesthesia who is one of my academic advisors) All except Harrison's clearly demonstrated that

1. Naloxone was studied and listed as safe treatment for accidental overdose in healthy individuals. (non opioid dependant)

2. The definitive treatment with naloxone is an infusion, that is needed to outlast the specific opioid. (between 6 and 72 hours) The effects of naloxone between 1-4 hours. 

3. Caution must be execised in the use of naloxone in opioid dependant overdoses with sub Q (you may recall IV is much more rapid.) doses as little as 0.5mg can precipitate severe withdrawel in as little as 2 hours which will require intensive therapy. The recommended dose is 0.4mg/500ml and run "slowly." (whatever the hell that means, but the advice I got was over 1.2 to an hour)

4. There are multiple types, (3) to be exact, of opioid toxicity. Of which 1 has a mechanism that is unresponsive to naloxone treatment. 

The primary pathology of opioid overdose is disruption of the breathing pattern from action on medularly chemoreceptors. Specifically opioid inhibits the breathing response to increased pCO2. The hypotension and bradycardia are subsequent to this respiratory depression and reverse themselves by correcting it.

Additionally, with the depression of pCO2 control, the body reverts to pO2 for respiratory drive. High dose oxygen is considered relatively contraindicated as it may knock out all intrinsic respiratory effort.

The Opioid toxicity which is unresponsive to Naloxone is from direct stimulation of mast cells resulting in shock from an anaphylactoid reaction. Treatment as per distributive shock.

Among the listed effects of acute opioid withdrawel are: rebound CNS activity, arrhythmia, and pulmonary edema. 

There is some dispute as to whether this pulmonary edema is caused from the reversal, the offending opioid, or aspirated stomach contents. (It is my observation when there are multiple disputed mechanisms, it is usually a combination) In any event, positive pressure ventilation is listed as the treatment of choice. (from the earlier discussion, probably without supplemental oxygen would be best)

So how does this all play out?

Basically, most of the sequele is mitigated by ventilatory support, which is listed as the primary emergency treatment everywhere. The bradycardia as well as hypotension in early intervention are resolved by ventilation. 

Late presentation of opioid OD includes findings of shock and dialated pupils from progressive shock, which must be treated like any other distributive hypotension. Especially in the case of anaphylactoid reaction.

In order to prevent aspiration and its subsequent sequele, the reversal agent may (nobody knows) have to be given prior to relaxation of the esophageal sphincters as the aspiration may be sub clinical and not gross vomitus. additionally vomiting may a side effect of acute reversal in chronic users and intubation for aspiration airway protection indicated. 

Because of the risk relapse given the naloxone life, a period of observation will have to be undertaken commensurant with the specific agent. So at least an ED or ward bed will be taken for 6+ hours.

Chronic substance abusers who OD will have to be admitted, I am told most beneficially to the ICU for a slower approach and management of these patients.

I was told I covered quite well my lessons of acutely reversing deleterious effects of analgesia so I will not rehash it here.

Additionally I am told, in the event of an actual or suspected oral opioid OD, lavage will be a treatment. NG/OG for decompression of those who do wind up in ICU is common practice.

So the questions then becomes:

Does EMS intervene fast enough to prevent aspiration in opioid OD?

Does the field administration of naloxone in the chronic abuser do more harm than good? (consider it may take ~2 hours for the onset of withdrawl symptoms, well beyond the average time EMS is with a patient)

Are EMS providers capable or proficent to use an infusion of naloxone?  

It would seem that if EMS providers are identifying opioid OD by pinpoint, rather than dialated pupils and not treating for hypotension of progressive shock, they may still be (again nobody knows) arriving early enough to manage the respiratory compromise and let the hypotension and bradycardia reverse themselves.

However, given the information about the effect of supplemental oxygen on knocking out what I will call the hypoxic drive of opioid OD, it raises the spectre that the initial method of managing the respiratory depression maybe iatrogenic, which leads to the perceived need for a reversal agent.

Now what? Back where we started.


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## Sasha (Apr 6, 2011)

18G said:


> I always appreciate a Woman's opinion  but that is not what Vene is doing.
> 
> Maybe we should also allow patient's to bleed and allow the body's own hemostatic mechanisms to stop the bleeding. After all our goal is to always do the bare minimum to care for our patients.



There you go taking things to the extreme. Stop looking at things as either black or white and use your brain to figure out when less is more and when you need to intervene. Come on, youre smarter than that.


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## lightsandsirens5 (Apr 6, 2011)

What I don't understand is why you would not want to restore a pts respiratory drive when you can do so with a cheap and effective drug that has been proven safe for many years. In fact, the only contra for Narcan is allergy to said drug, correct? As far as I have found, there are no cases of Narcan allergy. 

I don't see how that is a bad thing. You give the Narcan until the pts respiratory drive is restored, no more. No violent pt, no puke to clean up, and yet at the same time I don't have to bag some body, I don't have to maintain their airway for them, they do it! And life is good, yes yes? I know there are providers who use it to punish people. That is wrong, I agree. But a proven safe, effective and simple drug in the hands of field EMS personnel is about as non traumatic, non invasive as it gets. Ok, maybe bagging is less invasive, but have any of you attempted to bag someone for 90 minutes, by yourself, in the back of an ambulance while stuck in a snowstorm? It would wear you down! Yet with Narcan, my pt was breathing by himself, and all I had to to was monitor him.

I often agree with Vene, but I simply cannot see the logic behind this argument. I really can't even see the true argument. Why in the case of a simple, cut and dried narcotic OD would you not use a simple, time tired and proven procedure to correct (temporarily I admit) the problem until the body can correct the problem itself?


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## Veneficus (Apr 6, 2011)

82nd medic said:


> Out of the military how many lay persons carry atropine or know the S/S of nerve agents?



It is part of the required curriculum of all EMS education. Everyone knows about it. It is taught as mandatory curriculum in medical school as well. Sorry, no super military knowledge here. I have actually treated an organophosphate poisoning. There is not enough atropine on the truck. If there is any hope, you need to get to someplace that has a lot more before you run out. 

From the operations standpoint, the max dose of the atropine/2pam autoinjecotrs is 3, and you can bet your last dollar that I get my 3 before the patient gets any. 




82nd medic said:


> I'm just going off of what my UK born instructor said.



Gross misinformation. European EMS is considerably more advanced than US EMS. On par or with the physician units greater than AU/NZ 



82nd medic said:


> I have no clue about paraplegics, but in 2006 1:36.6 car crashes in Europe resulted in fatalities. The ratio of injured to killed was 48.5:1. In 2005, only 1:150 car crashes in the US resulted in fatalities. The ratio of injured to killed was 68:1. Statistically speaking, were doing something right.



Not getting into as many accidents perhaps. It is certainly not because anyone has that large of saves of potentially fatal blunt force trauma.



82nd medic said:


> I'm all for progression, I was stoked when civie EMS finally moved major bleeding to the front of the list and stopped that whole "tourniquets are a last result" bs. But arguing for progression and arguing for making EMS just delivery-boys and saying that medications that are proven to have saved lives is another



Show me the proof. An actual scientific study, not an anecdote. Because most of the cardiac arrest meds don't. The ones that do under a very limited scope of circumstances.


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## boingo (Apr 6, 2011)

Bagging a patient for an extended period of time isn't without risk also.  When the patient vomits and aspirates his stomach contents and ends up in ARDS on a vent because someone had the bright idea to forgo a well studied low risk reversal agent who's doing harm now?  Seriously, Narcan is the wrong tree to be barking up, it is well studied, safe, and used by lay-persons (junkies, EMT's and vocational school paramedics ) on a daily basis without sequelae.  Can you bag a patient until the opiate wears off?  Sure, if you have nothing better to do, however I'm willing to bet there is a better way.  

What about the cost?  Where is the uproar amongst the fically conservative clinicians about the cost of this?  Toronto tx's and releases these people without wasting resources in the ED.  On one hand, we talk about the ability to treat and refer as a means of saving money, on the other is the suggestion that us retard ambulance drivers sx, bag and place airway adjuncts and take them to the wicked smart special people in the hospital.  

Your pissing up the wrong tree, withholding Narcan in apneic opiate OD's is a  FAIL, pick another tx to demonize.


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## usalsfyre (Apr 6, 2011)

Seizures, acute withdrawal, pulmonary edema, and agitation are all side effects of narcan. Some of which are fairly common. 

I rarely find opiate OD's actually need ventilation, usually a little bit of gentle stimulation while monitoring ETCO2 and SpO2 is enough. As long as you ensure adequate oxygenation and ventilation the workloads really quite low. 

As for my own feelings vs staying on someone's good side? I've given narcan one time on the last two years, and that was an interns call. My own feelings happen to closely mirror Veneficus's on this, we spend too much time and effort on "life saving" treatments that may not be life at all and not nearly enough on the palliative stuff that makes a real difference.


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## boingo (Apr 6, 2011)

Veneficus said:


> Ok, firstly I do not plan to write a paper on this, so I will try to sum it up as best I can in a page.
> 
> I acknowledge that Harrison's internal medicine lists an antagonist as definitive treatment for opioid overdose. However, medicine is rarely simple, and this is no exception.
> 
> ...



No need for an infusion, nebulization works too.  I don't want to use my anectdotal experience, however seeing that I see opiate OD's almost daily, I will.  The chronic opiate abuser here doesn't get admitted unless there is some other pathology, these folks get Narcan, perhaps nebulized Narcan, observation and discharge.  The ones tx by there junkie pals don't get transported, however our agency tracks all suspected opiate OD's as well as self reported tx w/Narcan by other IVDAs' and have had no adverse outcomes.  These finding have yet to be published, hopefully soon.  My agency tracks trends of illness, including opiate abuse and is actively involved with the IVDA community, needle exchange and Narcan distribution among known users, so my experience isn't total BS.


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## boingo (Apr 6, 2011)

usalsfyre said:


> Seizures, acute withdrawal, pulmonary edema, and agitation are all side effects of narcan. Some of which are fairly common.
> 
> I rarely find opiate OD's actually need ventilation, usually a little bit of gentle stimulation while monitoring ETCO2 and SpO2 is enough. As long as you ensure adequate oxygenation and ventilation the workloads really quite low.
> 
> As for my own feelings vs staying on someone's good side? I've given narcan one time on the last two years, and that was an interns call. My own feelings happen to closely mirror Veneficus's on this, we spend too much time and effort on "life saving" treatments that may not be life at all and not nearly enough on the palliative stuff that makes a real difference.



Your experience is much different than mine.  My usual presentation is the cyanotic, pinpoint pupil IVDA who's near apneic with GCS 3.  You can administer all the "knuckle Narcan" you like to no avail.  There is no doubt you can oxygenate these people without administering a reversal agent, as a matter of fact, I love taking a new EMT-B and letting them manage the airway as we prepare to reverse the opiate, it is great real life experience using a BVM ( a skill that is usually poorly taught). 

I gave Narcan twice today.   h34r:


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## usalsfyre (Apr 6, 2011)

Bonigo, 

Could be your dealing with more IV heroin abuse where what we typically see is crushed and snorted "hillbilly heroin".


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## Veneficus (Apr 6, 2011)

boingo said:


> Your pissing up the wrong tree, withholding Narcan in apneic opiate OD's is a  FAIL, pick another tx to demonize.



I don't view looking critically at pathology/treatment which is seen like a nusance in the hospital more than an emergency as demonizing anything.

US EMS with perhaps with the exception of a handful of places doesn't treat and refer. If I am not mistaken there is also a study out of VCU that shows US EMS providers are not capable currently to determine who should be admitted.

Heparin is well studied, self administered by patients, relatively safe, why isn't that at many US EMS agencies?

Tell me, what makes any treatment modality anywhere, especially given the history of EMS treatments and effectiveness a free pass from scrutiny?

Incidentally how long in the toronto protocol are the patients being observed? Hours? 4? 6? 12?

I also don't veiw determining how to reduce an EMS system that won't advance to as cost efficent as possible as demonizing either.


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## boingo (Apr 6, 2011)

Maybe, although Oxy's are a huge problem here, when they can't find the clean burning pharmacy grade stuff they end up on H.


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## boingo (Apr 6, 2011)

Veneficus said:


> I don't view looking critically at pathology/treatment which is seen like a nusance in the hospital more than an emergency as demonizing anything.
> 
> US EMS with perhaps with the exception of a handful of places doesn't treat and refer. If I am not mistaken there is also a study out of VCU that shows US EMS providers are not capable currently to determine who should be admitted.
> 
> ...



Try to focus on the topic you raised, Narcan, your disdain for U.S. EMS is obvious, and I am on board with the need to revamp the educational requirements.


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## the_negro_puppy (Apr 6, 2011)

[YOUTUBE]http://www.youtube.com/watch?v=8xU_vcb3kso&feature=related[/YOUTUBE]


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## 18G (Apr 6, 2011)

I think this is appropriate... in the video there should be one that say's... "revolution is not Venificus"... 

But yeah, DONE about sums it up!

[YOUTUBE]http://www.youtube.com/watch?v=w3j5m1HukQE[/YOUTUBE]


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## medicRob (Apr 6, 2011)

18G said:


> I think this is appropriate... in the video there should be one that say's... "revolution is not Venificus"...
> 
> But yeah, DONE about sums it up!
> 
> [YOUTUBE]http://www.youtube.com/watch?v=w3j5m1HukQE[/YOUTUBE]



What is with all the aggression toward Veneficus? Is he not allowed to have an opinion?


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## 18G (Apr 6, 2011)

It's not aggression. It's strictly professional and certainly I don't lose sleep over it. He crosses the line and speaks his philosophy with authority as if it is above current standards of care. And it's not right. 

And I'm not one to hold back. I will address anyone who opens themselves up for debate directly. 

Like I said, its all good and just having fun with the debate that's all


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## Veneficus (Apr 6, 2011)

boingo said:


> Try to focus on the topic you raised, Narcan, your disdain for U.S. EMS is obvious, and I am on board with the need to revamp the educational requirements.



Certainly, 

Permit me to quote part of my original post?

_Now I know it is popular to pull out the anecdotes and the "what if's," but really, how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)

I sort of singled out medications in this post, but it is not limited to that.

Now the point of this post isn't to pick on EMS or accuse it of negligence or substandard practice, but really. You have providers performing treatments that are often not needed, then turning around and not providing treatments in most cases that are!

Look at the cost to maintain a quality intubation program compared to the benefits of intubation._

At which point in my first reply the only mention of narcan:

_I was thinking that the point of narc reversal is to stabilize respiratory and vascular systems. Anesthesia never seems to use narcan, titrated or otherwise, and they give narc doses far in excess of EMS on a daily basis. One of the most common heard mantra of ALS providers is they are not afraid of narcs because they can reverse them, which of course, seems like flawed clinical judgement._

You suggest that the idea you can give narcan should be the reason not to withold analgesia?


all the way down in post 18:

_Later this evening I expect to look up the exact physiological and pathophys of both opioid OD and the reversal of it to really see whether or not there is a flaw in the original theory of its use for EMS._

next time i mentioned narcan, right after you decided your argument was to put me in my place as a student :


_It depends on a couple of factors. 

1. Are providers titrating it appropriately?
2. Are they using it punitively?
3. Are they doing it for patient benefit or their convienience?
4. If less aggresive treatment achieves the same thing, what makes acute reversal the treatment of choice?
5. What is the sequele if you induce irretractable pain or acute opioid withdrawel doing it? Is it worth that?_

Next was a question about my choice of education. Probably because that was the only response you could dream up after your initial attempt an an insult didn't work.  

Honestly my first choice of school was the oldest in the Western world, my wife asked me if I would consider something closer to her home and i thought given her sacrifice it was the least I could do. But looking back I do not regret my decision to come to this school and I am rather proud of it. Especially when I see what is coming out of the US schools.

Tell me, Other than trying to coatail greater minds as demonstration of your greatness What exactly is your contribution?

somewhere in there, USA responded to a treatment question:

"Fluids, suction, an NPA and BVM?"

My next reply to narcan was the search I did on it.

So how far off topic am I?


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## 18G (Apr 6, 2011)

Veneficus said:


> But looking back I do not regret my decision to come to this school and I am rather proud of it. Especially when I see what is coming out of the US schools.



Sounds like you don't have much like for anything in the US. Maybe you should stay where you are?


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## Veneficus (Apr 6, 2011)

18G said:


> Sounds like you don't have much like for anything in the US. Maybe you should stay where you are?



I seriously entertain that idea, especially with the limitations on academic medicine in the US. 

Really my main complaint about the US though is the blind propaganda that they are the best at everything even when the facts dictate otherwise.

Regretably it is quite pervasive.

What can I say? I give a lot, I demand a lot. 

There is also probably a fair amount of counter culture shock as well.


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## 18G (Apr 6, 2011)

Umm.. people come to the US to receive medical care not available anywhere else. We are far from second-class world citizens. 

Now your kinda starting to piss me off.


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## Veneficus (Apr 6, 2011)

18G said:


> Umm.. people come to the US to receive medical care not available anywhere else. We are far from second-class world citizens.



Only the people who can afford it and a handful of charity cases. Most people in the US cannot dream of receiving the best care it has to offer. Most can't even go to a dentist.



18G said:


> Now your kinda starting to piss me off.



I am sure you will not be the last to say that.


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## Scott33 (Apr 6, 2011)

82nd medic said:


> We discussed European EMS in my class back in 2004: they're load and go, that's it. They don't even do spinal immobilization for car wrecks.




Citation?

Vac mats are the norm in certain parts of western Europe when immobilization is indicated. The spinal board is typically used for what it was designed to do - extricate the patient.

As for loading and going, you may want to Goolge _Emergency Care Practitioner_.


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## medicRob (Apr 6, 2011)

18G said:


> Umm.. people come to the US to receive medical care not available anywhere else. We are far from second-class world citizens.
> 
> Now your kinda starting to piss me off.



Name a procedure performed in the US that is not performed anywhere else in the world.


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## rwik123 (Apr 6, 2011)

medicRob said:


> Name a procedure performed in the US that is not performed anywhere else in the world.



With the exception of England, complete and partial facial transplants. Only one I can think of right now


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## medicRob (Apr 6, 2011)

rwik123 said:


> With the exception of England, complete and partial facial transplants. Only one I can think of right now



First Face transplant was carried out in France 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1315983/

"Less than a week after French doctors carried out the world's first partial face transplant on 27 November, the patient—a 38 year old woman—ate, drank, and spoke normally. Professor Jean-Michel Dubernard, who led the transplant team, said that it would be at least six months before they knew how much feeling or motor control the patient would have eventually."


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## Veneficus (Apr 6, 2011)

rwik123 said:


> With the exception of England, complete and partial facial transplants. Only one I can think of right now



The first was done in France if I am not mistaken. 

As well, There is a shift to the use of mechanical Aortic valves for replacement in the US, not because of efficacy, but because of legal liability and the potential to not be reimbursed for "preventable" complications by medicare now.


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## rwik123 (Apr 6, 2011)

medicRob said:


> London was one of the places of comparison I was going to use in any named procedure.



yeah the UK is almost if not 100% equal in the care provided and medical procedures performed. 

Does the US have some of the best teaching hospitals and care specific facilities? I would argue yes.

And yes the first one was performed in france


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## medicRob (Apr 6, 2011)

rwik123 said:


> yeah the UK is almost if not 100% equal in the care provided and medical procedures performed.
> 
> Does the US have some of the best teaching hospitals and care specific facilities? I would argue yes.
> 
> And yes the first one was performed in france



Please re-read my post (I apologize, but I did research and found that France did the first facial transplant, so I changed it completely)


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## Veneficus (Apr 6, 2011)

rwik123 said:


> Does the US have some of the best teaching hospitals and care specific facilities? I would argue yes.



It depends on what you call the best, compare what European students do in school, particularly in rotations to their US counterparts.

I probably shouldn't start in about teaching to the tests instead of medicine prior to residency so I won't.

Care specific is great. If you can afford it. It also depends on how you measure.

PS.

The first face transplant in the US was performed by A Polish born and trained Physician.


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## medicRob (Apr 6, 2011)

rwik123 said:


> yeah the UK is almost if not 100% equal in the care provided and medical procedures performed.



I agree 100%.  



rwik123 said:


> Does the US have some of the best teaching hospitals and care specific facilities? I would argue yes.



I agree. However, I do not agree with the thought that the US is somehow suprerior to all other nations in the practice of medicine in general. There are areas where we excel, there are areas where others take 1st place. 

What I am against is blind statements such as:

"Umm.. people come to the US to receive medical care not available anywhere else. "


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## boingo (Apr 6, 2011)

Veneficus said:


> Certainly,
> 
> *Permit me to quote part of my original post?
> 
> ...



The topic was Narcan, so your are still a ways off.


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## rwik123 (Apr 6, 2011)

Veneficus said:


> It depends on what you call the best, compare what European students do in school, particularly in rotations to their US counterparts.
> 
> I probably shouldn't start in about teaching to the tests instead of medicine prior to residency so I won't.
> 
> ...



Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals? In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.


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## Veneficus (Apr 6, 2011)

rwik123 said:


> Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals?



Life is never simple.

The US imports 24% of it's physicians by need. So just because the doctor is foreign doesn't mean they are great.

The US does pay the most, often doctors laugh that it is the only place you get paid more for results that don't matter.

Some foreign doctors who are exceptionally gifted do go to the US. Some stay, some don't. We have several doctors here who worked in the US and came back, in very prestigious facilities and research, Berkly, Philly, human genome project, artifical heart, off pump bypass, etc. 



rwik123 said:


> In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.



I think they just stand out more. As I said, the last stat I saw was 24%.


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## medicRob (Apr 6, 2011)

rwik123 said:


> Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals? In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.



It is true that a significant number of the physicians in the US are from India, Japan, or other countries.. However, I am sure this is true of other areas. I believe the US and London to be pretty much equal in medical capability. I do not think one is better than the other. There are too many factors to consider. 

I am sure there are just as many physicians who migrate to London from the same countries of origin as those who migrate to the US. However, I can't really speak on that as I have never been to London, and haven't researched the topic.


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## JPINFV (Apr 6, 2011)

18G said:


> Umm.. people come to the US to receive medical care not available anywhere else. We are far from second-class world citizens.


That doesn't mean every part of the system is the best though...


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## Veneficus (Apr 6, 2011)

boingo said:


> The topic was Narcan, so your are still a ways off.



_I used bicarb on Sunday during my treatment of a polydrug OD with a suspected TCA, Mag is used fairly often, the inner city is full of severe asthma patients, and Atropine is used on occasion for peds induction and symptomatic bradycardia._

*So what you are saying is aside from mag, you rarely use these drugs?*

_Care to cite your source for over treatment in those who don't need it and under treatment in those that do?_

*Come on, do you really want to get into an argument about the overuse of spineboards and the underuse of pain medication in the US as a whole?

I doubt there are statistics on it anyway, but I'd like to think we have way too much respect for each other for that. Besides, do you really want to argue the opposition on that statement?*

_Don't know what it costs, I get plenty of opportunity. Intubation isn't for everyone, if you can't get the experience you shouldn't be doing it, this goes for the doc working the rural ER too, if they intubate twice a year, they should be reaching for a supraglottic airway too, gasp!_

*So my question of the global application is met with "in my service?"*

_The patient given opiates in theater are completely different than the recreational opiate abuser seen in the pre-hospital setting._

*I respectfully disagree, the principles of scientific medicine are the same no matter what the environment. System or provider convenience does not make a treatment modality more beneficial to a patient. I do not accept for a second the argument of "in the field things are different."*

_ Not sure what you are getting at here, I treat pain with opiates all the time, and have never had to give Narcan to a patient that I gave opiate analgesia to._ 

*Have you not read some of the comments on this forum about people always having narcan as a backup to their analgesic administration plans?*

_I appolgize for the cheap shot, however, you are a student, and your experience as a physician level provider is extremely limited. If you tried your rant on tenured physicians you'd be laughed out of the room._

*Yes, my experience is limited, probably not as much as you think, but that is here nor there. You are not the first person here to assign my philosophical musings as a rant. Most likely not the last, nothing I can do about that, it's how I write.* 

*I often have discussions with rather highly respected physicians from around the globe, my contributions have been recognized, and that is all I am going to say on that. Never once have I been laughed out of the room and I keep getting invites. I think you are making assumptions in error based on your perception of my tone after a long day.*

*I question any and everything held as truth. In medicine and in life. Nothing is sacred and nothing is taken at face value.*


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## boingo (Apr 6, 2011)

Veneficus said:


> _I used bicarb on Sunday during my treatment of a polydrug OD with a suspected TCA, Mag is used fairly often, the inner city is full of severe asthma patients, and Atropine is used on occasion for peds induction and symptomatic bradycardia._
> 
> *So what you are saying is aside from mag, you rarely use these drugs?*
> 
> ...



Bad day as it where, my attack on your status as a student was uncalled for, and at the end of the day, I enjoyed the discussion.  Perhaps I envy you just a bit, I am happily married with two beautiful girls (karma, long story ) and couldn't ask for more.  I strive to be the best at what I do, and don't accept mediocrity from my peers, which causes me a bit of grief at work, but I'm OK with that.


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## 82nd medic (Apr 7, 2011)

Veneficus said:


> It is part of the required curriculum of all EMS education. Everyone knows about it. It is taught as mandatory curriculum in medical school as well. Sorry, no super military knowledge here. I have actually treated an organophosphate poisoning. There is not enough atropine on the truck. If there is any hope, you need to get to someplace that has a lot more before you
> 
> Show me the proof. An actual scientific study, not an anecdote. Because most of the cardiac arrest meds don't. The ones that do under a very limited scope of circumstances.



You said LAY person, and EMT is not a lay person. Let me know when atropine auto injectors start getting handed out like epi pens.

You're the one arguing against FDA approved drugs, show us an actual scientific study.


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## medicRob (Apr 7, 2011)

82nd medic said:


> You're the one arguing against FDA approved drugs, show us an actual scientific study.



Weren't you the guy who posted:



82nd medic said:


> Spinal immobilization is hazardous? Last I checked a broken bone that's stabilized poses less of a risk of further damage than one that's not. I've yet to see anything showing that it poses more of a risk than a prevention.




Only to be responded to with: 



JPINFV said:


> There's evidence that spinal immobilization decreases secondary spinal injury?
> 
> Malaysian/University of New Mexico retrospective chart review: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02615.x/abstract
> Outcome, no benefit.
> ...



Where is your research?


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## 82nd medic (Apr 7, 2011)

Never heard of discomfort being a contra indication for a potentially life threatening injury... That must have been replaced with the "pain is the patients problem if you need to keep him alive" class.

http://www.wildernessdoc.com/assets/pdfs/NAEMSP-Spinal Clearance Protocols-Jan08.pdf
There's plenty of other research articles suggesting selective immobilization.


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## JPINFV (Apr 7, 2011)

Evidence that there are clinical tools to determine populations that are at low to no risk of a spinal injury is not the same as evidence that spinal immobilization produces better outcomes. In fact, slide 7 of your link specifically says that there is no evidence of improved outcomes for patients who are immobilized.


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## Veneficus (Apr 7, 2011)

*You're new at this medicine thing aren't you?*



82nd medic said:


> You're the one arguing against FDA approved drugs, show us an actual scientific study.



Not trying to pick on you or insult you, but you seem to be rather on the naive side of this discussion.

First off the FDA does not decide what drugs are best in the treatment of patients/diseases, doctors do. There are off label uses for drugs based on their biological and chemical characteristics. The decision of when and why to use them is left open. A quick google search will demonstrate there is more than a few FDA approved drugs that are no longer on the market. Some of which are facing major legal action.

The drugs used in cardiac arrest resuscitation by the American Heart Association are classified as level IIB, the very research they present in their advanced provider and instructor manual points out directly that there is no evidence these medications do anything in arrest resuscitation. I am guessing by your post you haven't read that book yet.

You may need a bit more background before you pick a fight.

In my OP and as I quoted a few pages back, while i singled out medications, the purpose of discussion was the critical analysis of current treatments. I addressed the use of narcan, i researched more to it than the if:then indications, which are indications usually only found in new providers, or ones with so little medical knowledge that they cannot put for a rational argument except to point out that somebody else said it was a good idea.

Many EMS treatments were based off of expert opinion of the time they were formed. Dating back to the late 60's. In the last 15 years there have been more advancements in medical science than in the history of medicine. So today's expert is much more capable of making decisions than those of yesteryear.

Infact my 2 academic advisors often point out that molecular biology wasn't even a science when they went to school. Only recently has research on any of the treatments in EMS been done. Most of that research has been done by interested physicians, and in every case that comes to mind right now, has demonstrated those treatments were invalid. Spineboarding, aggresive fluid resuscitation, MAST, Tk for snake bites, to name a few.

Many formerly interested physicians no longer do this research in/for EMS as they have given up on trying to convince EMS to change. A majority of physicians I have met in both the US and abroad, consider US EMS an absolute waste of time and energy, my negative comments are rather kind compared to the average of theirs.  

That's how much respect US EMS has earned.

I would also like to bring to your attention that most EMS instructors, including many that I actually work with, have no formal education greater than paramedic class, which in a number of states, 5 years of experience is the qualification to teach at the highest level you obtained.

That means you could spend 5 years as a Basic EMT, finish paramedic school, and get a license to teach paramedic class the day after. The qualifier is chronological "experience" it is not even time in rate.

As was pointed out by one of the greater minds here, experience without education is the same experience over and over. 

You might want to consider that when touting information given to you by a US EMS instructor in '04.

Furthermore, the lower your formal education level, the more absolute the information is. It is designed that way so that lesser educated people do not make decisions which can lead to errors of intent or disasterous consequences. Many at the entry and mid level don't even know the vastness of what they don't know.

The links and information you posted have absoltely nothing to do with your positions. Did you even read them? Did you understand the material presented?

Guessing from your screen name and past posts, you are still in or recently out of the military. I would say you are like a pilgrim in an unholy land, because in medicine, what is handed down from those in a position of "authority" is always questionable. The very textbooks are written as: "this is all we know" and from your experience and knowledge you make decisons on that. That is one of the reasons why there is so much variation in medical treatment. Standards are developed to work "most of the time."

We don't always agree in our discussions, but I don't know a person here who would let a person suffer or die because that patient didn't fit into the standard for most without making every legal/reasonable effort to help them.


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## pullnshoot25 (Apr 7, 2011)

Amycus said:


> Note: I did not read the entire post, just the first few lines, but wanted to comment on something.
> 
> There's a medic I work with that I respect very much, who once went on a rant about how many medics just want to start lines/push meds, etc. His mantra is that the less he has to do, the better. Not from a laziness standpoint- but that if he doesn't HAVE to give a medication, or doesn't feel it's clinically beneficial to the patient, he won't do it. Don't overtreat, do exactly what is necessary for the patient.



Primum non nocere is my motto.


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## EMTinNEPA (Apr 7, 2011)

WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA.  If anything typed sounds like the scribblings of a crazy person, that is why.

This entire thread has made me lol.  Nothing but two sides setting up strawman after strawman against each other.

"I think Narcan is silly."  "Well then maybe we should take away every drug!"  "I bet you're the kind of paramedic who immobilizes everybody!"  "So you're saying we should just be a taxi service?"

Quite frankly the entire thing has been nauseating.  Both sides have valid points, but then again both sides have said some incredibly ludicrous things.

Firstly, just because a treatment isn't NECESSARY does not mean that it is not BENEFICIAL.  If I had the choice of administering Narcan and allowing a patient to regulate their own ventilatory status or shove a tube down their nose or throat and force air into their lungs with a bag, I would choose the Narcan every time.  Not because it's easier for me, but because it's better for the patient.

On the other hand, if a little old lady slips out of her chair, lands on her butt, lays down, and is not exhibiting ANY signs of potential spinal compromise (i.e. NEXUS criteria), and I have the choice of immobilizing her and protecting myself from lawsuit but risking negative effects such as pressure sores or hyperextension of the cervical spine or saying "forget the board", I will "forget the board" every time.  Not because it's easier for me, but because it's better for the patient.

Sometimes less is more, and sometimes more is more.  It takes clinical judgment to determine which is which.  Personally, I want every cool toy in the book.  I want RSI meds, I want video laryngoscopy, I want blood products, I want pre-hospital thrombolytics for MIs, I want everything!  I want to start definitive care in the field, because it's better for the patient!

Are bronchodilators really necessary pre-hospital?  No.  But does receiving Albuterol on scene and en route rather than 15 minutes later at the hospital provide the patient with relief faster?  Isn't that better for the patient?

What about CPAP?  Is it really necessary pre-hospital?  The part of me that's a patient advocate says yes, but an argument could be made for the opposite.  That one patient on the verge of respiratory distress that breaths easier because I put that mask on his face and doesn't need to be intubated and spend days or weeks in the ICU, but instead walks out of the ED 10 hours later makes me say that CPAP in the pre-hospital environment is absolutely necessary.

Or the patient with chest pain who goes directly to the cath lab because a pre-hospital 12-lead not only DIAGNOSED a myocardial infarction, but LOCALIZED it.

Now take that same chest pain patient.  Let's say the 12-lead DOESN'T diagnose an MI.  Would you proceed with treatment or would you dig a little deeper and perform, say, a 15-lead?  If you went with the 15-lead, you might find a right ventricular infarction, in which case you would have to be VERY careful with that Nitroglycerin.  Or you may find a posterior wall MI and thus have prevented an MI from being missed (and don't give me that non-sense about ST depression in the anteroseptal leads, because that only occurs in 8% of posterior MIs).  If you said you would just proceed with treatment and subsequently miss the RVI, you could very well kill your patient.  This would not only hurt the very person you're supposed to be protecting, but you allow people to argue that pre-hospital Nitroglycerin is detrimental and is a practice that should be ceased (I jest).

Like I said, both sides make valid points, but both sides also make some ridiculous statements and just like with most matters with two opposing views, the truth lies somewhere in the middle.  My attitude is that paramedics should be permitted a LOT more treatments and procedures than they are currently, but I realize that entails more responsibility and better clinical judgment is therefore necessary.

If you don't possess the clinical judgment necessary to make these kinds of decisions, I hear Wal-Mart is hiring.


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## usalsfyre (Apr 7, 2011)

EMTinNEPA said:


> Sometimes less is more, and sometimes more is more.  It takes clinical judgment to determine which is which.


Lack of clinical judgement is exactly why I find myself arguing against more and more treatments. Maybe it's the area I work in, maybe it's me being cynical but I'm starting to think piss poor clinical judgement is the rule rather than the exception.  




EMTinNEPA said:


> If you don't possess the clinical judgment necessary to make these kinds of decisions, I hear Wal-Mart is hiring.


Who the heck will work all the open spots?

It's not the posters on here I worry about. It's the other folks that scare me...


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## medicRob (Apr 7, 2011)

82nd medic said:


> Never heard of discomfort being a contra indication for a potentially life threatening injury... That must have been replaced with the "pain is the patients problem if you need to keep him alive" class.
> 
> http://www.wildernessdoc.com/assets/pdfs/NAEMSP-Spinal Clearance Protocols-Jan08.pdf
> There's plenty of other research articles suggesting selective immobilization.



Then show it to me. I can waltz in here and claim a whole host of things, and that I have plenty of research articles to back me up, but until I provide them, I can't back it up. 

So where are they? Give me at least 5.


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## Veneficus (Apr 7, 2011)

medicRob said:


> Then show it to me. I can waltz in here and claim a whole host of things, and that I have plenty of research articles to back me up, but until I provide them, I can't back it up.
> 
> So where are they? Give me at least 5.



Easy on the new guy killer.


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## medicRob (Apr 7, 2011)

Veneficus said:


> Easy on the new guy killer.



You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !

Fine then, I'll settle for 3.


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## DesertMedic66 (Apr 7, 2011)

medicRob said:


> You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !



Jonny Rocket? I thought it was Sue Maple


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## medicRob (Apr 7, 2011)

firefite said:


> Jonny Rocket? I thought it was Sue Maple



Shh.. that is my drag name.


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## JPINFV (Apr 7, 2011)

medicRob said:


> You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !
> 
> Fine then, I'll settle for 3.




Johnny Rocket? Maybe Johnny *Bottle* Rocket...


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## medicRob (Apr 7, 2011)

JPINFV said:


> Johnny Rocket? Maybe Johnny *Bottle* Rocket...



If I wasn't so entertained by that comment, I might strike you.


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## 18G (Apr 7, 2011)

EMTinNEPA said:


> WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA.  If anything typed sounds like the scribblings of a crazy person, that is why.
> 
> This entire thread has made me lol.  Nothing but two sides setting up strawman after strawman against each other.
> 
> ...



*Very well said... *


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## systemet (Apr 7, 2011)

EMTinNEPA said:


> WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA.  If anything typed sounds like the scribblings of a crazy person, that is why.



Just wanted to address a couple of things you said.  Nothing personal.  I totally understand sleep deprivation.



> On the other hand, if a little old lady slips out of her chair, lands on her butt, lays down, and is not exhibiting ANY signs of potential spinal compromise (i.e. NEXUS criteria), and I have the choice of immobilizing her and protecting myself from lawsuit but risking negative effects such as pressure sores or hyperextension of the cervical spine or saying "forget the board", I will "forget the board" every time.  Not because it's easier for me, but because it's better for the patient.



The other major c-spine rule out protocol, the "Canadian C-spine protocol", include age of >65 years old as an exclusion criteria, so while age may not be part of NEXUS, it is commonly used in some places.




> Are bronchodilators really necessary pre-hospital?  No.  But does receiving Albuterol on scene and en route rather than 15 minutes later at the hospital provide the patient with relief faster?  Isn't that better for the patient?



This is actually one thing that does have some evidence to support it.  You've probably heard about the OPALS study in Canada, where the system in Ontario (pop. ~ 12 million) moved from a primarily BLS system into an ALS system, and studied the outcome changes as they went.  This is commonly cited as evidence for ALS procedures having no added benefit in cardiac arrest, and as one of the many studies suggesting an association between ALS care and increased mortality in trauma.

One of the subgroups looked at the benefit of prehospital treatment of dyspnea, using the available modalities at the time.  Many of these are now a little out of favour, like lasix and morphine in acute pulmonary edema.  But they did show a significant survival benefit with ALS (even though a small percentage of patients in the BLS cohort were already being treated with ventolin).  Citation is:

Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, Dreyer J, Toohey LL, Campeau T, Dagnone E, Lyver M, Wells GA; OPALS Study Group.
Advanced life support for out-of-hospital respiratory distress.  N Engl J Med. 2007 May 24;356(21):2156-64.

This is available as a free .pdf, if you go here:

http://www.nejm.org/doi/full/10.1056/NEJMoa060334




> Or the patient with chest pain who goes directly to the cath lab because a pre-hospital 12-lead not only DIAGNOSED a myocardial infarction, but LOCALIZED it.



Perhaps I'm missing something here, but when I was working ALS, if the patient had a STEMI, it was either prehospital thrombolysis or enoxaparin + plavix, direct to cathlab.  

While localisation was important in terms of identifying right ventricular infarction, it seemed like the cardiologists decision as to thrombolysis vs. PCI usually came down to the timely availability of facilities, presence of higher risk for ICH (e.g. advanced age), and cardiogenic shock, versus anatomic localisation.  You could argue that identifying a left main occlusion could alter the balance of these factors.  But beyond changing treatment for RVI, localisation was less important for us.




> Now take that same chest pain patient.  Let's say the 12-lead DOESN'T diagnose an MI.  Would you proceed with treatment or would you dig a little deeper and perform, say, a 15-lead?  If you went with the 15-lead, you might find a right ventricular infarction, in which case you would have to be VERY careful with that Nitroglycerin.



Absolutely.  I'd withhold it unless IV nitro was available.  And even if it was, the priority would be to toss in a liter of fluid and get reperfusion therapy started.



> Or you may find a posterior wall MI and thus have prevented an MI from being missed (and don't give me that non-sense about ST depression in the anteroseptal leads, because that only occurs in 8% of posterior MIs).



I absolutely agree that an educated provider should perform a 15-lead if there strong suspicion of ACS.  But I think your number for the incidence of ST depression in posterior wall MI might be inaccurate.  

When you say 8%, this is pretty close to the number of isolated posterior wall MIs (Brady).  ST depression is present in ~80% of inferior wall MIs (Brady), and a fair percentage of both inferior wall (RCA) and lateral wall (LCX) MIs have extension into the posterior wall.  PWMI is thought to 
complicate as many as 20% of all MIs.  

The problem, as I understand it, is not that ST depression rarely happens with PWMI, more than many other things can cause anterior ST depression, e.g. reciprocal changes in inferior wall MI.

[Just in case anyone is wondering about isolated RVI, the incidence is around 2% (Porter et al.)]

Anyway, I absolutely agree that 15-lead ECG is a valuable and much underused tool.  I think I also need some sleep -- before I do that, my intent here is to provide extra information for anyone who's interested, not to criticise your post, which I mostly agree with.







Porter A, Herz I, Strasberg B.  Isolated right ventricular infarction presenting as anterior wall myocardial infarction on echocardiography.  Clin Cardiol (1997) 20, 971-973 --- read here http://onlinelibrary.wiley.com/doi/10.1002/clc.4960201115/pdf

Brady WJ.  Acute posterior wall myocardial infarction:  electrocardiographic manifestations.  Am J Emerg Med (1998) 16:409-413


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