# Going Beyond The Minimum: Paramedic or Ambulance Driver?



## RocketMedic (Aug 18, 2013)

Here is a question that is simple with a lot of nuances and massive grey areas.

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency? 

Here, I have noted that our management tends to embrace patient care and comfort performed, not simply tradition, with a reasonable acceptance of new options and expansions of trust in field personnel. There are some people everywhere who embrace changes and advances, others who follow a well-marked trail, and some who refuse to modernize. Outcomes and core medicine rarely change, but the "extras" do- for instance, a progressive medic may provide pain management for a severe laceration or use true BiPap on the complicated ventilator with true customization of settings, whereas a regressive medic may simply bandage and go or use CPAP or a BVM or something. 

Why the difference?


----------



## DesertMedic66 (Aug 18, 2013)

RocketMedic said:


> Here is a question that is simple with a lot of nuances and massive grey areas.
> 
> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?



Personally I think it is a mix of all the above. 

I feel that my agency is very open to change (we are always making changes). I am also very open to change as long as it's for the better.

For my area there really is no incentive to get further education (aside from patient care). There is no EMS agency involvement aside from writing protocols.

There are a lot of incompetent medics in my area. Since there is no real involvement with the county EMS office the incompetent medics are still able to work without issues. It's hard to keep track of and make changes when there are well over 1,000 EMTs/Medics that the county is in charge of.


----------



## EpiEMS (Aug 18, 2013)

This is a great question to pose!



RocketMedic said:


> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?



I see the biggest issues as educational, evidence-related, and medico-legal.

1) Most EMS personnel are not educated to the level that would be optimal.
2) Evidence: there's not enough pre-hospital evidence based medicine, and, often, when there is evidence, it doesn't find its way into protocol fast enough because...
3) EMS personnel don't operate under their own licenses. There ought to be a greater degree of independence from the medical director, at least, insofar as possible -- something like the UK's "Health Professions Council".


----------



## RocketMedic (Aug 20, 2013)

One of our materials employees posed the question "why not the minimum for your patient?"

Why not?


----------



## DrParasite (Aug 21, 2013)

I'm a transporter, with dreams of the system transforming us into clinicians.

I've seem so much abuse of the EMS system, where all I am is a taxi driver (not even horizontal, the patients are completely ambulatory but cabs require payment before services).  I realize that their are limitations to what I can do in the field, but I do wish we could help people more.

I would LOVE to see a bachelors degree where it's 100% focused on paramedicine and patient care.  And I still like tiered systems, where the BLS providers are competent enough to perform assessments and know when ALS is needed vs not needed (I know, that's apparently a rarity in the US for reasons I don't want to go into).

I think anything a civilian can do or be taught to do an EMT should be able to do.

I think if we get the FD out of EMS, let EMS become a full career not just a job or stepping stone, and people in EMS want to be in EMS not just be in EMS until something better comes along, it will improve EMS.

And we need active medical directors who want to be there, who go out in the field on a routine basis, have prehospital experience, and know the paramedics they supervise and write protocols so, so they can trust that they know what they are doing.

But back to what you said, I'm an ambulance driver, in a world where providers hands are tied by archaic protocols, medical directors who don't want to do the job and will not let crews do things to help the patient, other than VOMIT, and there are too many idiot EMTs and paramedic who I have no idea how they passed their tests or even got hired.


----------



## sir.shocksalot (Aug 21, 2013)

RocketMedic said:


> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition?


I think it is truly a mix of everything above. I have seen paramedics justify things for any and all of the above reasons. Usually the excuse is "It's our protocols" or "it's not in our protocols", "leave that stuff for the hospital", "our job is to get them to the doctor". Complacency and laziness are the true honest reasons why we avoid things that are difficult or new.



RocketMedic said:


> How amicable is your agency to change? How about you in your own practice?


My agency? Very minimally, if at all. As soon as the Denver-Metro medical director group expectorate a new set of protocols we will quickly adopt them but we, as field providers, have little to no influence on these decisions. Me personally? If I read about a new treatment modality or assessment tool and I have read sufficient evidence to find it believable I may implement it immediately. Titrated D50? Oxygen? permissive hypotension? Compression focused resuscitation? All of these things I put into practice when and where I can, I don't wait for the protocols to change since I can reasonably implement these things without throwing any flags. The hold up usually is when there is another paramedic on scene who is less amicable to newer concepts.


RocketMedic said:


> On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?


I see myself as a clinician, occasionally this requires me to transport people and I'm okay with that. Sometimes I will transport people for lack of a better option or because telling them to go to an urgent care or MD office would be highly questionable in court or in front of my supervisor's desk. Actually I think I transport more often than not, I have found that trying to convince people to take themselves in to a physician is a far slipperier slope than simply giving them a ride. I would like to see things changed to allow for alternative destinations or to be able to triage people to an office or urgent care instead of an ER, but that may be a long way off yet.


RocketMedic said:


> Here, I have noted that our management tends to embrace patient care and comfort performed, not simply tradition, with a reasonable acceptance of new options and expansions of trust in field personnel. There are some people everywhere who embrace changes and advances, others who follow a well-marked trail, and some who refuse to modernize. Outcomes and core medicine rarely change, but the "extras" do- for instance, a progressive medic may provide pain management for a severe laceration or use true BiPap on the complicated ventilator with true customization of settings, whereas a regressive medic may simply bandage and go or use CPAP or a BVM or something.
> 
> Why the difference?


Because people are different and they come into this field with different aspirations and expectations. While you and I might get excited to medicate a stable hip fracture others might view this as a waste of time and not "exciting". You and I might see tweaking ventilator settings as an exciting mental challenge, others view it as tedious and boring.

I think the larger issue at hand is the attitudes and expectations of those aspiring for this career. We constantly portray this image of exciting life saving and lights and sirens when the reality might be the raisin rodeo or drunk herding. There is an image of us as "emergency workers" instead of healthcare providers. We should be changing how we portray ourselves, we should appear to be healthcare providers who work in the field with emergency workers and may occasionally act as emergency workers ourselves.

You are certainly fortunate to have an employer that values modern medicine and trusts in it's employees to provide modern and compassionate care to patients. Many employers of EMS workers have a very different opinion and completely distrust those they employee, occasionally for good reason, but mostly out of ignorance.


----------



## unleashedfury (Aug 21, 2013)

I'm a huge advocate for advancing and improving pre-hospital medicine, training and education standards. as well as newer treatments available. 

I know in my workplace, the management feels as if we still rocked the Cadillac and just got them where they needed to go with no supplies or equipment used they would be ok with that. And that's were we run into a problem. Using supplies on a call means money we have to spend. money we have to spend to do business cuts into the bottom line. and thus the reason why our "benefits and pay isn't much higher" 

I'd deal with not having a pay raise because my patient needed supplies and equipment to improve their condition. rather than I can't give you any treatment its gonna cut into my paycheck.


----------



## RocketMedic (Aug 24, 2013)

Today, I ran into an Ambulance Driver. I had literally worked with a team of professional paramedics and EMTs (OCFD and my partner) to stabilize and start to correct a fairly acute COPD exacerbation. As you could imagine, I elected to use our ventilator. BiPap, albuterol, atrovent, methylprednisone (fairly generic COPD call). Afterwards, as we were packing up, another medic came in. I expressed my pleasure at the success of our therapy and the surprising success I have had with our vents- by my conservative count, I have avoided a dozen or so intubations and really helped twenty or so patients with early, aggressive application of BiPAP. I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion. Anyways, this guy flat-out says that he refuses to use it, no matter the circumstance. His rationale was that it had "strangled" two of his patients, and he attributed their deaths to the ventilator. One was apparently a full arrest, the other was unknown. His attribution of their deaths to the vent boiled down to user error within a few seconds of listening to him; or he was making it up. Either way, he simply refuses to use them in any case. "You can bag them better always, that's what I do."

Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks _and_ provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.

After this medic left, the charge RN looked at me and told me "That's why you make $15 an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot." He is literally leaving a lifesaving tool on the shelf because he is more comfortable thinking that a BVM provides PEEP or that it's preferable to intubate a patient than it is to simply BiPap them.

Ambulance drivers can be found at all cert levels.


----------



## Carlos Danger (Aug 24, 2013)

RocketMedic said:


> Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks _and_ provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.



Which vents do you use?


----------



## Clipper1 (Aug 24, 2013)

RocketMedic said:


> Today, I ran into an Ambulance Driver. I had literally worked with a team of professional paramedics and EMTs (OCFD and my partner) to stabilize and start to correct a fairly acute COPD exacerbation. As you could imagine, I elected to use our ventilator. BiPap, albuterol, atrovent, methylprednisone (fairly generic COPD call). Afterwards, as we were packing up, another medic came in. I expressed my pleasure at the success of our therapy and the surprising success I have had with our vents- by my conservative count, I have avoided a dozen or so intubations and really *helped twenty or so patients with early, aggressive application of BiPAP. I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion. *Anyways, this guy flat-out says that he refuses to use it, no matter the circumstance. His rationale was that it had "strangled" two of his patients, and he attributed their deaths to the ventilator. *One was apparently a full arrest, the other was unknown. His attribution of their deaths to the vent boiled down to user error within a few seconds of listening to him; *or he was making it up. Either way, he simply refuses to use them in any case. "You can bag them better always, that's what I do."
> 
> Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. *We can both effectively ventilate and transport patients *who are really vent-dependent without setting their therapy back by weeks _and_ provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.
> 
> ...



If a patient is in cardiac arrest with CPR being performed, you probably should bag because the ventilator will end the cycle with a chest compression and will be out of sync during chest compressions. This means the patient will not be ventilated even with the ETT. Yes, that will not help with achieving ROSC and might prevent it from happening.

A "BIPAP" mode is also not to be used on someone who is not spontaneously breathing (agonal is not) and who can not maintain their airway. 

You do not need to worry about "setting back" their therapy with a short transport or even a long one. Chances are these patients will change modes for sleeping and procedures all the time. If the patient is having an acute breathing problem you must place them on the appropriate ventilator mode and settings rather than worry about "setting them back". Being dead will set them back more.

If you don't have the appropriate meds which might even include giving a paralytic along with lots of sedation and pain relievers you might not be able to ventilate a patient effectively. Every time the machine cycles off due to high pressure, the patient is not getting effectively ventilated.  This can also lead to arrhythmias and death. 

The patient might just feel like they are being suffocated by the ventilator. Some ventilators do not have a high demand flow rate which could be because of generic settings or by machine design. EMS medical directors are usually not CCMs or Pulmonologists so their knowledge of ventilators are limited. They will have to write for generic protocols. 

*All* alarms on a ventilator serve a purpose. If something is alarming you have either set if inappropriately or something needs to be addressed with the patient. I have yet to see a transport ventilator which has too many alarms and most do not have enough.

Most of the transport ventilators function with single limb technology and an external PEEP valve rather than a continuous end flow. Most do not have a compressible volume feature so you do not know don't know how much tidal volume they are getting.  Most transport ventilators do not give a Plateau Pressure. There might be a way to achieve it for the experience practitioner but for the inexperienced it is not advised.  

Your transport ventilator might have a lot of "knobs to turn" but that does not always make it the appropriate ventilator for all patients especially in acute situations.

You will also seen in the ER an RT or experienced RN kicking the usual standby portable vent into a corner and having the ICU ventilator wheeled over because they noticed something by bagging which will require a better ventilator. They already know it would be stupid of them and probably harmful to the patient to place them on an inadequate machine.  In some cases bagging is definitely better than placing them on a machine that won't adequately ventilator the patient. If those transport ventilators would do the job the ICUs would probably use them instead of the big vents which take up a lot of room.

That being said, hospital staff will try to use transport ventilators to move patients from one area to another. A couple of the ICU machines can be switched to being mobile. But, hospital staff will have known values for ABGs and a CXR. The RNs and RTs work with many ventilators everyday and all day. With a few known values and the appropriate medications which also are often not available in EMS, they have the expertise to manipulate the transport ventilators to get through a short transport. 

Not knowing the limitations of your ventilator, using it inappropriately like BIPAP to "ventilate" a nonbreathing patient and believing your transport ventilator is life saving in all situations would make you look more like a lessor provider to those with experience and expertise with ventilators. Notice I also said expertise since some do what they believe to be a lot of ventilator transports on an ambulance but keep making the same mistakes over and over.  

How much training did you get for the the ventilator you are using AND how much education and training did you get for ventilation, oxygenation and disease processes as it applies to ventilator principles?


----------



## RocketMedic (Aug 24, 2013)

Halothane said:


> Which vents do you use?



Impact 731.


----------



## RocketMedic (Aug 24, 2013)

@ Clipper1: Good, but with proper customization, the Impact-731 can literally do all of those things. We've got BiPap, CPAP and three modes of true ventilation (pressure target, timed, and SIMV). Obviously, some people need more invasive airway management than a mask. Agonal respirations would tend to fit that description. But even then, dependent on the reasons for that condition, a ventilator could absolutely be useful.

I'm by no means a vent expert, but I do not discount it. The BVM has not entirely left my truck, but it is not my first choice for a lot of patients that do not particularly benefit from it. What made me angry was the casual dismissal of such an important piece of our jobs by a person who was too lazy to learn it.

If someone is too lazy to learn to use a ventilator or too stupid to realize that they need to be trained on it, why should they be working with etomidate, ET tubes, levophed and a host of other potentially-lethal things?


----------



## shfd739 (Aug 24, 2013)

RocketMedic said:


> Impact 731.



Yeah those arent that hard to use and use well.


----------



## Clipper1 (Aug 24, 2013)

RocketMedic said:


> @ Clipper1: Good, but with proper customization, the Impact-731 can literally do all of those things. We've got BiPap, CPAP and three modes of true ventilation (pressure target, timed, and SIMV). Obviously, some people need more invasive airway management than a mask. Agonal respirations would tend to fit that description. But even then, dependent on the reasons for that condition, a ventilator could absolutely be useful.


This ventilator can do all of those modes but should you? What is "true" ventilation? 

Pressure and timed are how the ventilator cycles or terminates flow.

SIMV is a mode whose cycle can be also be determined by pressure and time just like AC and PC. 

BIPAP is not to be used on an apneic unresponsive patient who can not maintain their airway for many reasons such as in the cardiopulmonary arrest. One is aspiration. If the person is in cardiac arrest you probably would up an OPA to open the airway. If a person can tolerate an OPA, they should not be on NIV with BiPAP.  Second, the BiPAP can be set by pressure and time. When you are delivering chest compressions, you dramatically change chest compressions. If you are trying to deliver 20 cmH2O of pressure to achieve adequate ventilation, what happens when a chest compression is performed to the tidal volume or "pressure" you think you are delivering.

Not all ventilators are the same. Even the big $50k ICU ventilators might have the same "labeling" for setting but their methods of achieving those settings may be very different.  It doesn't matter how pretty the knobs look or that some of the same labels on the portable ventilator looks just like those on the $50k ventilators. The way they are designed are very, very different.  Too many are fooled by the packaging and have never read their users manual or the reviews. You might also look up the questions the FDA posed to the manufacturers of the 731. 

A ventilator is no doubt useful but only if you have a good understanding about its limitations and how your ventilator works. You also must have the ability to pharmacologically assist the patient and ventilator synchrony. This is where most lack. They might be able to sedate but then forget they also must support blood pressure. 

You also will not find very many who will just pop a patient on a ventilator without squeezing the BVM a few times and listening to breath sounds. It would be reckless and stupid to not have a baseline for the patient for pressure, volume and chest rise.


----------



## Clipper1 (Aug 24, 2013)

shfd739 said:


> Yeah those arent that hard to use and use well.



Define use well? How do you determine how effective your ventilator is? Some have been so proud of their ventilator's performance only to find they have a pH of 7.0 and a PaCO2 of 80. Sometimes they got that by chasing their ETCO2 without understanding or knowing the disease process or anything about V/Q mismatching.


----------



## RocketMedic (Aug 24, 2013)

Clipper, I'm not claiming that the Impact is a panacea, nor is it a fix-all. With that being said, it is a powerful tool when used correctly. I was commenting on a person's stubborn refusal to use it in all circumstances as opposed to learning how to use it.


----------



## firetender (Aug 24, 2013)

*Things me and my paramedic peers were saying in 1978*

RocketMedic's original post asked: 



> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?
> 
> On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?


 
The responses were a trip back in Memory Lane for me, and painted a very interesting picture of the nature of EMS, then AND now.



> For my area there really is no incentive to get further education (aside from patient care). There is no EMS agency involvement aside from writing protocols.
> 
> There are a lot of incompetent medics in my area. Since there is no real involvement with the county EMS office the incompetent medics are still able to work without issues.
> desertEMT66


 


> Most EMS personnel are not educated to the level that would be optimal.
> There ought to be a greater degree of independence from the medical director, at least, insofar as possible
> epiEMS


 


> I'm a transporter, with dreams of the system transforming us into clinicians.
> 
> I've seem so much abuse of the EMS system, where all I am is a taxi driver
> 
> ...


 


> we, as field providers, have little to no influence on these decisions. (regarding protocol)
> 
> The hold up usually is when there is another paramedic on scene who is less amicable to newer concepts. (regarding implementing newly learned modalities or ways of treatment)
> 
> ...


 


> I know in my workplace, the management feels as if we still rocked the Cadillac and just got them where they needed to go with no supplies or equipment used they would be ok with that. And that's were we run into a problem. Using supplies on a call means money we have to spend. money we have to spend to do business cuts into the bottom line. and thus the reason why our "benefits and pay isn't much higher"
> unleashedfury


 


> Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size.
> 
> (quoting an observant nurse) "That's why you make $15 (then, it was $5.00 - my note) an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot."
> 
> RocketMedic


 
Why hasn't anything changed in 35 years?

Something that really hit me was the pay being $15.00 an hour! Who is allowing that to be so?


----------



## Clipper1 (Aug 24, 2013)

RocketMedic said:


> Clipper, I'm not claiming that the Impact is a panacea, nor is it a fix-all. With that being said, it is a powerful tool when used correctly. I was commenting on a person's stubborn refusal to use it in all circumstances as opposed to learning how to use it.



I was attempting to show you that maybe you should re-examine your own understanding of that ventilator before calling this other guy lazy, dumb, stupid and an idiot.  

It doesn't sound like your company has provided much training and education  about ventilators.  There should have been some type of competency where all Paramedics with access to the ventilator could show their skill and knowledge as well as have time to ask questions or have additional practice. Calling someone an idiot for something which is probably not really his fault but kudos to him for realizing the inadequacies but still trying to not be too humiliated probably by those who probably have less understanding about vents than him but don't know it.

The 731 is also not a popular ventilator among CCT and Flight teams or the FDA.  Given those circumstances I don't blame someone for bagging the patient.  Lack of knowledge and a  limited ventilator with a few quirks especially with PS can do a lot of harm.


----------



## RocketMedic (Aug 25, 2013)

So your alternative is to endorse single-handedly remove a therapy as useful as CPAP/BiPAP based on imagined failures caused by user error?

Heck, plenty of people have used the Impact to effectiveness. To dismiss it entirely as this medic did is folly.


----------



## Carlos Danger (Aug 25, 2013)

RocketMedic said:


> Impact 731.



I'm not familiar with that one. I've transported patients on the Parapac, Impact 754, LTV 1000, LTV 1200, and Maquet servo-i. Most of my experience is with the LTV-1200.




Clipper1 said:


> I was attempting to show you that maybe you should re-examine your own understanding of that ventilator before calling this other guy lazy, dumb, stupid and an idiot.



First of all, it's pretty clear you are missing the overall point of this thread. He was simply using an example to draw a parallel between those who reject advancements in patient care with those who try to embrace them. The intent was not to critique his knowledge of transport vents. 

Secondly, the other guy in the story _did_ sound like an idiot. "That dumb newfangled automatic breathin' box dun strungled twice uh muh patients" vs. someone trying to use some more progressive technology and somewhat of an advanced intervention to benefit their patients is the point.

FWIW, I didn't see anything in Rocket's post that indicated a lack of understanding of how to use his vent. I don't think he gave nearly enough information to assess his knowledge base. And again, that wasn't the point here, anyway.

OK, I'm not sold on using it in arrest either (especially in a non-invasive mode), but he's not the only one who does it. I assume it's in his protocols and it's what he was taught to do. Even if I think something someone does is wrong or not ideal, I try not to criticize individuals who are just doing as they were taught or as their protocols instruct.


----------



## Carlos Danger (Aug 25, 2013)

RocketMedic said:


> Here is a question that is simple with a lot of nuances and massive grey areas.
> 
> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, *a desire for simplicity above fractional improvements in effectiveness,* familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?
> 
> ...



OK, to get back on topic:

First, the part I bolded I think is the most interesting part of your post. I don't think that is necessarily a negative; I think that in the field, there is a lot to be said for the K.I.S.S. principle in general. I am a huge advocate for increased education for paramedics, and increased ability to do diagnostic and interventional stuff _in some cases,_ but as my own experience and education has increased, one of the things I've learned over and over is that less often is more

Cultures vary significantly from region to region and organization to organization (and also from individual to individual, of course). I was very early in my EMS career (<1 year) when I already saw that I wasn't going to be able to advance like I wanted to with my current position, so I changed things. 

The problem is the basic market forces that affect EMS. As much as we dislike it, the lowest common denominator will always rule. Or, at least, it have a lot of influence. As long as reimbursements for transport (and, in turn, salaries) are low, educational / entry standards will remain low. As long as educational standards remain low, there will be lots of those "lowest common denominator" types. "Exciting work as a healthcare / public safety professional" that requires a minimum of education will always mean plenty of applicants for positions, and as long as there are plenty of qualified applicants, the employers have exactly zero incentive to increase compensation or to support increased educational standards.


----------



## Clipper1 (Aug 25, 2013)

RocketMedic said:


> So your alternative is to endorse single-handedly remove a therapy as useful as CPAP/BiPAP based on imagined failures caused by user error?
> 
> Heck, plenty of people have used the Impact to effectiveness. To dismiss it entirely as this medic did is folly.



No. I suggest you get access to the manual and read it. Then I suggest your company get a qualified clinical representative to go through how to use this machine appropriately and not just however you "think" it might be okay. 

It is in inappropriate to dismiss someone using it in a way which is known to not be useful or even harmful.


----------



## Clipper1 (Aug 25, 2013)

Halothane said:


> First of all, it's pretty clear you are missing the overall point of this thread. He was simply using an example to draw a parallel between those who reject advancements in patient care with those who try to embrace them. The intent was not to critique his knowledge of transport vents.
> 
> Secondly, the other guy in the story _did_ sound like an idiot. "That dumb newfangled automatic breathin' box dun strungled twice uh muh patients" vs. someone trying to use some more progressive technology and somewhat of an advanced intervention to benefit their patients is the point.
> 
> ...



No. I am not missing the point at all.  
I get the advancement part but that must come with the appropriate education and training. Just because you have the "technology", it does not mean you should just use it however and whenever if not appropriate. 

How many codes how you worked where someone has put the patient on BiPAP rather then using the BVM or establishing an airway, either supraglottic or ETT?  Do you understand why BIPAP or CPAP is not used on patients who are unresponsive and cannot maintain an airway? This is basic and should have been covered with the simple CPAP machines. The same safety principles apply to BIPAP. Do you also understand why compressions would make any breath given by the machine useless?   

I think this BIPAP example is a good one and a biggie. If someone knows they have gotten crappy training and have seen it used inappropriately probably because of crappy training, they should not be criticized. Those who think they have something mastered and continue to make the same mistakes over and over but somehow believe they are "changing" EMS is exactly why EMS is still in the same state it has been for 40 years.  Just adding another skill with out the appropriate or adequate information to go with it is NOT advancement.  

I think the other guy's  comments should be more closely examined. He may have a point or several points especially if he has seen some major f***ups by others who believe the ventilator is for everything and are obviously using it outside of its intended purposes.  If protocols are written for NIV on a cardiac arrest, then that medical director should be questioned as to why and be shown the manual. But, when some are just given generic protocols to "turn the knob to this and we always use this mode only", then that shows there is probably a deficiency in education with the medical director trying to get away with cookbook protocols just to show how "advanced" his agency is.  That is still not advancement. Maybe the person who some believe to be an idiot is actually the one who knows there is more to the story.  But, when you have peer pressure from all of those who say they have enough training on the vent it still is just like 6 months is enough for Paramedic training.


----------



## RocketMedic (Aug 25, 2013)

Clipper, do you actually know what the capabilities of the ventilator are? It is entirely capable of providing invasive positive-pressure ventilation via ETT or a supraglottic airway. There are literally modes dedicated to that. I have no idea how you can pull "slips on Bipap masks instead of intubates" out of what I've posted. 

I use the vent when I can in an appropriate mode for the situation.


----------



## Clipper1 (Aug 25, 2013)

RocketMedic said:


> Clipper, do you actually know what the capabilities of the ventilator are? It is entirely capable of providing invasive positive-pressure ventilation via ETT or a supraglottic airway. There are literally modes dedicated to that. I have no idea how you can pull "slips on Bipap masks instead of intubates" out of what I've posted.
> 
> I use the vent when I can in an appropriate mode for the situation.



Yes I do know. You still do not see how limited this ventilator is by the specs, the FDA report and all the other sources available is rather concerning.
An old Elder valve can push air into an ETT. 

What you essentially are stating is knobology.  Yep the knob says SIMV so it must be the same as all the SIMV modes in delivery. If you read the FDA reports you would have noticed the concern about the PS. The Newport HT-50 also has similar concerns which is why many who were well versed in ventilators avoided SIMV when using that transport machine. 

Let's say you have a small car like a Volkswagon which has "Drive", "Reverse" and "Park" on the shifter. Do you believe you will get the same pulling power as you would from a Porsche with the same "labels"? 

Not all vents are designed the same. The reason the LTV1200 is so popular is the design of the internal turbine which some can hear kicking in. It also makes the machine a little warm but it is very powerful. 

What about sensitivity? Have you look at the specs and reviews on it? How about the demand flow? The valving for delivery? What about flow termination? What is the max flow? Acceleration?  You do not just judge a ventilator by its pretty knobs. 

EMS providers are probably the easiest to sell ventilators or other advanced technology to by just dropping  a few buzz words.  Say stuff like "SIMV" is great because "it let's the patient breathe spontaneously" but forget to tell them all modes allow spontaneous breaths in 2013.  The old IMV hasn't been around for over 25 years. The fact that they can take advantage of this for a sale should be an indication EMS has not advanced it education enough.

The sentence you used before the one below stated BiPAP instead of intubation. This one is very inaccurate. The volume delivered will depend on opening the airway and if chest compressions or being done. Even without chest compressions, it is crap shoot for tidal volume with BIPAP or CPAP. Look at any hospital ventilator or BIPAP machine which measures volumes. You will see each breath may vary even under the best circumstances unless the patient is on a paralytic which you would not do on BIPAP or CPAP.


> *I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion.*



How many times have Paramedics gotten away doing procedures like RSI or taking equipment like ventilators or IABPs or "monitoring" drips they probably had not been adequately trained or prepared for and some call themselves CCTs?   Some are lucky and some know they are protected by immunity laws.  Some just don't follow up to see the damage done by their actions.


----------



## RocketMedic (Aug 25, 2013)

And some will choose to flail at a BVM in the forlorn hope that it will somehow provide the function that a modern ventilator can provide.


----------



## shfd739 (Aug 25, 2013)

I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well. 

We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing. 

Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.


----------



## RocketMedic (Aug 25, 2013)

This conversation is getting sidetracked. This is about going beyond the minimum, as Halothane pointed out. So, Clipper...are you a paramedic, or are you an Ambulance Driver?


----------



## RocketMedic (Aug 25, 2013)

shfd739 said:


> I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well.
> 
> We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing.
> 
> Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.



Do you have the old CPAP units then?


----------



## shfd739 (Aug 25, 2013)

RocketMedic said:


> Do you have the old CPAP units then?



Old CPAP? We use the CPAP mode on the vent for interfacility. 911 calls get Boussignac masks for CPAP. 

I do agree with Rockets assessment about so many EMS folks acting like ambulance drivers and see the same problem here. There isn't a drive to improve and move beyond the 20 years of tradition. Nearly every shift I run into first responders that believe in back boards for all trauma, that O2 for all is a good thing and look at me like I'm crazy when I do otherwise. 

Slowly our employees are catching on but its gonna take awhile. I think it needs to start with improving the education of medics. The standards and prerequisites to go into a medic school need to be higher. I really think there needs to be a top down overhaul of education and systems.


----------



## Clipper1 (Aug 25, 2013)

RocketMedic said:


> This conversation is getting sidetracked. This is about going beyond the minimum, as Halothane pointed out. So, Clipper...are you a paramedic, or are you an Ambulance Driver?



I definitely have more ICU and ventilator knowledge than you along with a few years in the ICUs, CCT and flight as well as NICU team.  But, I have the utmost respect for professional ambulance drivers who can get an EMT or Paramedic and their patient safely to a destination.  I think going beyond would mean much more attention being given to emergency vehicle driving rather than making that term so hated to where some are ashamed to be seen at an "ambulance driving" class.  Being a PROFESSIONAL ambulance driver should be encouraged.  All the Paramedic skills will not help you drive an ambulance better or safely. That "skill" can keep you safer or keep you from killing someone and maybe ending up in jail.



RocketMedic said:


> And some will choose to flail at a BVM in the forlorn hope that it will somehow provide the function that a modern ventilator can provide.



Define modern ventilator. Do you realize that hospitals use different ventilators depending on the goal. Again if the simple little $3000 ventilator could do everything the big machines can, why spend a million on just a few ventilators.

*My point again as related to the discussion is...what you have described is not advancement. It is just getting a new gadget with a minimum amount of training to think you know what you are doing.  *


----------



## Clipper1 (Aug 25, 2013)

shfd739 said:


> I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well.
> 
> We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing.
> 
> Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.



If you read the Flight forums you will find that not all teams are happy with the 731.  We tried it for short transports or backup and junked it when the LTV1200 arrived.

If you only have 3 units then that might be too few transports to really notice something wrong. We do have the advantage of doing the iSTAT on long transports and will get another ABG on arrival.  

*Rocketmedic*

With all the different modes an ICU machine can do, it is rather strange to hear someone just matching the settings. The numbers might look the same but the way those numbers are achieved with the smart technology, the little transport vents won't come close.  Very few ICUs use SIMV just as the "SIMV" you might have read about or what the 731 claims to do. Without a good PS, which is the 731's downfall, I would not consider that mode.

But again, *education, education, education*.


----------



## RocketMedic (Aug 25, 2013)

Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!


----------



## VFlutter (Aug 25, 2013)

RocketMedic said:


> Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!



I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!


----------



## RocketMedic (Aug 25, 2013)

Chase said:


> I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!



15 is for little girls, our regulators go to 25!


----------



## Clipper1 (Aug 25, 2013)

RocketMedic said:


> Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!



Sometimes that is what must be done even in the hospital while a MORE APPROPRIATE ventilator is brought in.   

Failing to realize limitations is why I emphasize education.  Not knowing the limitations of that ventilator or willing to listen and learn makes you more dangerous than the person you consider to be an idiot because he will not just do something with very little training. He probably has seen the mistakes of others.  Just because you can does not mean you should.  That applies to intubation, RSI, ventilators, multiple drips and IABPs. I think crics are also in that category since many have not reviewed the procedure since Paramedic school.   

Master the basics and what is common in your profession before trying to go with the cool gadgets. If you can't use a BVM, don't do RSI or touch a ventilator. If you can't provide the needed pharmacological support to maintain a patient on the ventilator, you have just screwed the patient.  Ventilator management is more than just a few knobs. You either have the knowledge to do it effectively or just rely on what you should know best until your agency can give you the education and protocols to do the package.


----------



## VFlutter (Aug 25, 2013)

RocketMedic said:


> 15 is for little girls, our regulators go to 25!



My HHFNC goes up to 40L/min. Winning.


----------



## Clipper1 (Aug 25, 2013)

Chase said:


> I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!



Pulmonary fibrosis in 15 minutes?  

In the ICUs we try to get patients off the oxygen clock quickly but may have to use nitric oxide, Flolan, proning, HFOV or even ECMO.  Most prehospital providers can not initiate those.  So, oxygen might be necessary. I can assure you if a patient is short of breath and needs oxygen, 15 L/m is not going to "cause pulmonary fibrosis" in a short ambulance ride. Hell even in the ICUs a patient might be taken off BIPAP and placed on a NRB or Oxymask  at 15 L for up to an hour for procedures.  



RocketMedic said:


> 15 is for little girls, our regulators go to 25!



What equipment do you have to run 25 L through? I hope not a regular NC or face mask.   The LTV1200 can run a low flow through it for a low FiO2 while depending on the internal compressor.

Again, it's all about the education.


----------



## Clipper1 (Aug 25, 2013)

Chase said:


> My HHFNC goes up to 40L/min. Winning.



Ours goes to 60 L/min but with a kickass humidification system.

I do not recommend those in EMS trying this without the proper equipment, education and lots of Oxygen along with air tanks and a blender or we'll be back at the high flow O2 conversation but with an FiO2 of 1.0.


----------



## VFlutter (Aug 25, 2013)

Clipper1 said:


> Pulmonary fibrosis in 15 minutes?
> 
> In the ICUs we try to get patients off the oxygen clock quickly but may have to use nitric oxide, Flolan, proning, HFOV or even ECMO.  Most prehospital providers can not initiate those.  So, oxygen might be necessary. I can assure you if a patient is short of breath and needs oxygen, 15 L/m is not going to "cause pulmonary fibrosis" in a short ambulance ride. Hell even in the ICUs a patient might be taken off BIPAP and placed on a NRB or Oxymask  at 15 L for up to an hour for procedures.



Sarcasm is lost on you. Is that what they do in the ICU? Who knew. I need to find me one of those fancy ICUs to work in. Oh wait....


----------



## RocketMedic (Aug 25, 2013)

Clipper, you clearly have no idea what I am talking about.


----------



## Clipper1 (Aug 25, 2013)

Chase said:


> Sarcasm is lost on you. Is that what they do in the ICU? Who knew. I need to find me one of those fancy ICUs to work in. Oh wait....



No.  But on this forum you will have those who take your word and do stupid things while defying some very carefully written protocols from their medical directors.

Fancy ICUs?  Seriously? The things I mentioned have been around for at least 2 decades. HFOV is from the 1980s. Flolan has been around for about 15 years. Nitric Oxide became popular around 1990.  Most ICUs have some type of big ventilators. I don't know of any ICU which relies on a transport ventilator.  There are transport teams who can take mobile ECMO for both adults and kids.  None of this stuff is new or fantasy or even "fancy".

Education, Education.


----------



## Clipper1 (Aug 25, 2013)

RocketMedic said:


> Clipper, you clearly have no idea what I am talking about.



I read your post which was more about criticizing someone for not doing what you were doing which may not have been correct. 

I see you miss my point about education before going with all the "fancy" stuff to use Chase's word.


----------



## VFlutter (Aug 25, 2013)

Clipper1 said:


> Fancy ICUs?  Seriously? The things I mentioned have been around for at least 2 decades. HFOV is from the 1980s. Flolan has been around for about 15 years. Nitric Oxide became popular around 1990.  Most ICUs have some type of big ventilators. I don't know of any ICU which relies on a transport ventilator.  There are transport teams who can take mobile ECMO for both adults and kids.  None of this stuff is new or fantasy or even "fancy".
> .



Again, it was a joke. We occasionally use Flolan and Nitrox but our CCPs are not really found of HFOV.


----------



## RocketMedic (Aug 26, 2013)

Clipper, although I respect your knowledge of vents and all, we have them for a reason. They work fairly well. What you fail to comprehend is that we should be learning more about them, when to use them and where they are weak, not throwing them with the KED and mast pants as a "never-use" type of intervention. The mentality of "I don't understand it, it must be bad" is stifling needed changes. 

You do realize that these things actually do work well and save lives when properly applied?

By your logic, we should literally just drive the ambulance.


----------



## shfd739 (Aug 26, 2013)

RocketMedic said:


> Clipper, although I respect your knowledge of vents and all, we have them for a reason. They work fairly well. What you fail to comprehend is that we should be learning more about them, when to use them and where they are weak, not throwing them with the KED and mast pants as a "never-use" type of intervention. The mentality of "I don't understand it, it must be bad" is stifling needed changes.
> 
> You do realize that these things actually do work well and save lives when properly applied?
> 
> By your logic, we should literally just drive the ambulance.



What he said. Im done in this thread.


----------



## Clipper1 (Aug 26, 2013)

Chase said:


> Again, it was a joke. We occasionally use Flolan and Nitrox but our CCPs are not really found of HFOV.



Where are you at that you are using Nitrox?  Don't their CCP protocols have pain management by other means?  It also depends on if the pt is tubed as to whether Flolan is drug of choice for transport. Both nitric and Flolan are not that good for exposure. I will take non tube nitric pts if 20 ppm or less.
Our teams have RNs and RTs who can provide other ventilator support like the.Bronchotron or the Servo I.


To Rocket and sffd.
Wouldn't it still be better to ensure all Paramedics have advanced their base education before adding more complex skills?  I think everyone should at least have 2 college level a/p and a pathophys class. All other health care professions require education before skills. If you only have skills without the education  you are still considered a tech. EMS still is caught up in the "most skills wins" game. Some just don't get it that if you have the education behind you it is so much easier to gain skills.


----------



## chaz90 (Aug 26, 2013)

Clipper1 said:


> Where are you at that you are using Nitrox?



I feel like much of this confusion stems from not realizing that Chase is an RN in an ICU...


----------



## VFlutter (Aug 26, 2013)

Clipper1 said:


> Where are you at that you are using Nitrox?  Don't their CCP protocols have pain management by other means?  It also depends on if the pt is tubed as to whether Flolan is drug of choice for transport. Both nitric and Flolan are not that good for exposure. I will take non tube nitric pts if 20 ppm or less.
> Our teams have RNs and RTs who can provide other ventilator support like the.Bronchotron or the Servo I.



ER/ICU. CCP = Critical Care Physician (who are all pulmonologists). I forget that CCP refers to critical care paramedics as well. And I meant iNO not Nitrox, that is probably causing confusion.


----------



## Pavehawk (Aug 26, 2013)

Clipper1 said:


> Where are you at that you are using Nitrox?  Don't their CCP protocols have pain management by other means?



Nitrox is not used for pain management, I think you may be thinking of nitronox which is the trade name for the 50/50 mix of N2O (Nitrous oxide) and O2.


----------



## Akulahawk (Aug 26, 2013)

Clipper1 said:


> Where are you at that you are using *Nitrox?  Don't their CCP protocols have pain management by other means*?  It also depends on if the pt is tubed as to whether Flolan is drug of choice for transport. Both nitric and Flolan are not that good for exposure. I will take non tube nitric pts if 20 ppm or less.
> Our teams have RNs and RTs who can provide other ventilator support like the.Bronchotron or the Servo I.
> 
> 
> ...


You're thinking of nitronox. Different animal. Nitrox is a mixed gas, usually with a higher oxygen percentage than air, in the breathing gas. Is anyone using (or knows of a facility) Heliox?


----------



## Carlos Danger (Aug 26, 2013)

Clipper1 said:


> No.  But on this forum you will have those who take your word and do stupid things while defying some very carefully written protocols from their medical directors.
> 
> Fancy ICUs?  Seriously? The things I mentioned have been around for at least 2 decades. HFOV is from the 1980s. Flolan has been around for about 15 years. Nitric Oxide became popular around 1990.  Most ICUs have some type of big ventilators. I don't know of any ICU which relies on a transport ventilator.  There are transport teams who can take mobile ECMO for both adults and kids.  None of this stuff is new or fantasy or even "fancy".
> 
> Education, Education.



Floridamedic / Ventmedic / Clipper1:

I know you have a lot of knowledge and transport experience. You are, after all, an experienced paramedic, RRT, CCT transporter, and paramedic instructor.

After all that, you'd think one would not be so insecure as to have to constantly deride others?

You'd also think that if you really cared about education - which you constantly crow about - you'd find a way to provide it in a less condescending and negative way.

No wonder you keep getting kicked off of forums.


----------



## RocketMedic (Aug 26, 2013)

Bravo, Halothane. Thank you.


----------



## STXmedic (Aug 26, 2013)

Halothane said:


> Floridamedic / Ventmedic / Clipper1:
> 
> I know you have a lot of knowledge and transport experience. You are, after all, an experienced paramedic, RRT, CCT transporter, and paramedic instructor.
> 
> ...


----------



## Clipper1 (Aug 27, 2013)

Halothane said:


> Floridamedic / Ventmedic / Clipper1:
> 
> I know you have a lot of knowledge and transport experience. You are, after all, an experienced paramedic, RRT, CCT transporter, and paramedic instructor.
> 
> ...



Where are the posts of the others? You forgot Vene. Have others mentioned education before? 
Why is it that some in EMS continue to argue for more skills and not education to do the skills.  

Kicked off? You ha e not kicked me off. But I suppose when the theme of a forum is more skills less education  someone pro education would be unpopular. I think those I have met thru the education programs know I am not the enemy if you want to learn.


----------



## Carlos Danger (Aug 27, 2013)

Clipper1 said:


> Where are the posts of the others? You forgot Vene. *Have others mentioned education before? *
> Why is it that some in EMS continue to argue for more skills and not education to do the skills.
> 
> Kicked off? You ha e not kicked me off. But *I suppose when the theme of a forum is more skills less education  someone pro education would be unpopular.* I think those I have met thru the education programs know I am not the enemy if you want to learn.



No. No one has ever mentioned education on this forum before. Ever. 

You keeping trying to justify your rudeness and condescension by pointing out how "wrong" and "poorly educated" we are. But being more knowledgeable than others does not compel or give you the right to be rude. As an educator, you should know that better than anyone. 

You are far from the only clinician on this forum who has training well beyond paramedic school, yet you are the only one who is consistently condescending and rude to those whose knowledge doesn't match your own. This forum is frequented by several physicians, medical students, PA students, ICU RN's, RRT's, flight RN's, an AA, at least one CRNA student, and probably several other advanced clinicians that I am not aware of. Every one of them is pretty disappointed (if not disgusted) with what passes for "education" in EMS. But somehow, they all manage to do what you don't: interact with those who have less training and education then them, without treating those people like crap.

Education is actually a frequently discussed topic on here, if you hadn't noticed. The paramedics and EMT's here know well that their education sucks compared to that of other clinicians, and do not need to be beat over the head with that fact. Many of them are smart, motivated folks who do what is in their power to fix things, by asking questions and discussing things on here, seeking educational opportunities for themselves, and advocating for increased educational standards. What the hell more do you want?

You keep claiming that there is a big problem here with the "Mongo want be able do more stuff to his patients, but Mongo no waste time on book learnin" mindset, but you are really just making crap up as justification for your rudeness, because that stuff is actually almost non-existent on this forum. The people here, for the most part, really want to learn.

You keep spouting about education, but you don't educate. You have lots of opportunities on here to explain and teach in a helpful and constructive way, but instead you just make a sport of constantly, rudely pointing out how inferior other's understanding of things are. I get pretty tired of seeing it, but I will challenge you every time I do.


----------



## RocketMedic (Aug 28, 2013)

There is no such thing as a professional EMT. There are only paramedics and ambulance drivers. This is a controversial and inflammatory statement, but please, bear with me. This is not a slight against those who hold EMT certification, nor is it dismissing your service. Today, approximately seventy percent of American EMS workers are EMT's of some permutation, and your efforts are absolutely vital to our current operations. With that being said, we have a serious problem in our industry, and it starts with our facination with titles and our notions of what they should be. I offer this observation of truth from the perspective of a self-identified new paramedic. Many will hate me for it, many will accuse me of being an elitist and a 'paragod', there will be much protest. But ask your doctors, your corporate leadership, your lawyers, your enlightened non-ambulance-driving leadership. Ask Kelly Grayson, Skip Kirkwood or the JEMS regulars. They will likely agree with the sentiment. 

Ambulance drivers are pretty easy to recognize- they are those of us who ignore advances and "evidence-based" medicine in favor of anecdote, who do things "because that's the way they're done" or out of a desire to use skills for their own sake instead of patient outcomes. They're the people who withhold pain medication when it is indicated, who claim "we don't diagnose", who educate us with war stories and mantras. They are the people who bucket along with vocational educations and refuse to accept that we can offer and provide more. These people are the ones who shirk responsibility for their own careers by blaming our employers for low pay, long hours and poor treatment. They place responsibility for substandard care on their limited educations and scopes of practice and the protocols written for the lowest common denominator, yet are the first to claim credit for positive outcomes. Worst of all, they are the ones who accept that we cannot do something. Look on our social media sites- there are thousands of ambulance drivers there, arguing that they cannot provide good care, telling people to "suck up" abusive employment scenarios, or defending the virtues of noble ignorance. Most ambulance drivers are going to be insulted by this. 

Being a paramedic is not a certification level or an authorized skill list or even an education, it is a mindset. There are plenty of people I would readily call "paramedics" who wear white patches, and plenty of gold-patched ambulance drivers. What differentiates the two? The answer to that is multifaceted and is one of the reasons we are largely volunteers or paid far less than we would like. A paramedic is many things- they are responsible for patient care, they are responsible for the proper application of protocols, they are responsible for the operation of their ambulance. They are responsible, quite literally, for human life. With an eye toward that, those paramedics also realize that they are not educated to the mastery of all things, and continuously work to improve their practice, their knowledge base and (if they are great) their profession, on both a personal and a group level. This could mean college classes, professional expansion into other allied fields, or mentoring new providers. I am hesitant to extend this to "training", because that is a requirement that everyone should complete- I would say that participation in training only really matters if the students want to learn from it. Paramedics are those who seek "better" and actually work for it. On a personal level, I will advance an anecdote: I once spoke with a human-resources officer from a major EMS corporation on a flight. She told me that she evaluated candidates based on a number of factors, to include time as an EMT. When I expected to hear her speaking positively of 'street experience', she was actually very opposed to it. "If someone has been an EMT for a decade, I don't leap to experience. I think that they're lazy. I think that they're a professional ambulance driver uncomfortable with responsibility. I don't trust them with money, with medicine, and have to think hard about any job beyond driving an ambulance." As a new paramedic, this deeply influenced me- a hiring manager, a person of responsibility, trusted someone like me at 21 with a crisp new cert and little experience over an experienced EMT. 

It is not realistic to propose that we go to an all-paramedic model, nor will we. There will always be an entry-level into EMS, and it will functionally be an EMT or AEMT. With that being said, we should neither glorify that level or seperate it by title and job function. When our customers see us, they are not thinking "EMTs". They think of paramedics or ambulance drivers. Which one is something that we control with the services we offer. Those who offer basic services only are Ambulance Drivers. Those who treat their patients are Paramedics. Our customers have already made the differentiation. In the not-so-distant future, we are going to need to justify our financial existence. Those who think that our communities will continue to fund lavish lifestyles for fire departments, pay well for non-fire paramedics and pay for ambulances and their crews that offer what we do now are optimistic at best. In a future where we can realistically expect decreasing reimbursements, increasing costs and higher overall standards of care, there is very little place for those who want to do "what doctors do, but at 70mph" on a vocational education justified by anecdote and laying responsibility at someone else's door. We are going to become one of two things- literal medical transport or true professionals providing world-class medical care in the field with the ability to transport patients if needed. If we continue to revel as an industry in the noble ignorance of self-imposed limits, we are setting ourselves up to be a medical transport service with as much of the job security as our delivery drivers enjoy. Our scopes of practice will remain stagnant, our pay low and our workforce ignorant. If we want to avoid that fate, if we want to change our paradigm, we need to accept that increased educational standards, diversification of services offered and a more customer-oriented approach are going to be needed. 

Don't believe me- look at nursing. Fifty years ago (one complete working generation), nurses stood at this same crossroads. Slowly, and with much wailing and gnashing of teeth, they made the collective decision to progress professionally. Wages climbed, acceptable scope of practice increased, and professional respect increased. Fifty years ago, a young man who wanted to be a nurse was a fool foregoing a profession. Today, it's a solid decision recognized as an entry to a profession in its own right. They too had their stay-behinds- the LPN, LVN, the CNAs, the nebulous "nurse's aide". Their lot in life has not changed- they lack the education to progress, and their stagnant practice makes them the menial hell-jobs of health care for all but a few who genuinely enjoy classic nursing. Their opportunities are limited. 

We stand today in a world with more technology, knowledge and potential for service than at any time in history. We are on the edge of a demographic crisis that will see my generation caring for two large generations of very, very sick people for fairly long times. We can already see our political leaders and financiers preparing for inevitable changes in how we fundamentally operate. We can already see the hospitals, the ambulance corporations, the insurers pulling out of fiscal quagmires and the shocked reactions of communities finding out that change is coming. Hospitals that do not get paid for patients are going to demand that those patients go somewhere else or simply refuse to see them, or they will be drowned in debt and numbers. We are going to see more distributed care, more in-facility care, more nursing homes, more palliative care and more opportunities. We are not going to become doctors or offer full-service hospitals on wheels in my professional lifetime, but we are not going to remain as strictly "emergent medical transport" as we are, unless we accept limited employment and professional stagnation. I forsee a day when an old woman who falls and calls 911 does not only receive an assessment, but also treatment for an injury that does not require an ER, a hand off of her floor, and a referral to a doctor or other support structure who can help her adapt to her aging. Perhaps we could even come back to her home in a week to remove the sutures a paramedic placed. I foresee a day when a nursing home is not sending a patient out for 'weakness', but for a genuine health crisis that has not been corrected by their own treatments. I dream of a day when our professional social media is not overrun with fools who would withhold medication based on superstition, ignorance and fear. I dream of a day when our labor is not disposable, when our entry-level workers can support their families without welfare and food stamps, where we enjoy the protection of professionalism. I dream of a day when our average patient can be treated at home, our sick patients receive better care than a Stare of Life, and our extraordinary patients receive the same acute care that we provide today with transport to an appropriate facility, with labs, ECGs, and preparation for definitive care reliably completed. I foresee a day when a paramedic can respect a family's wishes and not forcibly resuscitate a patient with a terminal illness. All of these things will require changes. As an industry, we are not yet capable of assuming these roles, but that will change quickly when the first steps into that field become profitable. 

What, then, should we call our EMTs? We have titles for a reason, to denote competencies, certifications, and to organize ourselves based on our jobs and responsibilities. Someone needs to be in charge at all times, today that's the paramedic. In most places, it's whoever is providing patient care or has the highest certification or seniority. "Ambulance driver" is a little insulting. EMT is useful, but limiting. "White patch mafia" or some of the Facebook memes are just plain inappropriate for a profession, as accurate as "asswipe" for CNAs. I offer that we should simply call our partners paramedics. That's what they are, just with smaller scopes of practice and less education. They are an integral part of the patient-care team we form and should be treated as such. 

Those who wish to remain Ambulance Drivers can be just that, or perhaps Medical Transport Specialists. Frankly, I don't care what they do.


----------



## VFlutter (Aug 28, 2013)

Bro, use the return button every now and then :blink: But awesome post otherwise.


----------



## RocketMedic (Aug 28, 2013)

Chase said:


> Bro, use the return button every now and then :blink: But awesome post otherwise.



Edited it, the copy-paste from Polaris kinda sucks.


----------



## NomadicMedic (Aug 28, 2013)

You took a beating from the protocol monkeys on PoF though...


----------



## Wheel (Aug 28, 2013)

DEmedic said:


> You took a beating from the protocol monkeys on PoF though...



Link? It'll probably upset me, but oh well.


----------



## PotatoMedic (Aug 28, 2013)

PoF?


----------



## Anonymous (Aug 28, 2013)

Halothane said:


> Floridamedic / Ventmedic / Clipper1:



Did I miss something? Is Clipper1 VentMedic?


----------



## STXmedic (Aug 28, 2013)

Anonymous said:


> Did I miss something? Is Clipper1 VentMedic?



We'll just say they have very similar personalities, posting styles, and education.


----------



## PotatoMedic (Aug 28, 2013)

Wheel said:


> Link? It'll probably upset me, but oh well.



Found it...


----------



## Medic Tim (Aug 28, 2013)

wow, I am floored at the number of people who completely missed the point of what was said.


----------



## RocketMedic (Aug 28, 2013)

I'm not. That's why I try very hard to improve our profession.


----------



## RocketMedic (Aug 28, 2013)

This has taken off like a rocket on Facebook.


----------



## chaz90 (Aug 28, 2013)

It seems to have hit a sore spot on both sides of the "debate." Believe me, I use that term loosely. For the next episode in Mindless Cretins 'R Us, check out the comments on the IV Cath picture. Comments of "Go Big or Go Home" and drunk punishing outnumber sanity 3:1.


----------



## VFlutter (Aug 28, 2013)

chaz90 said:


> It seems to have hit a sore spot on both sides of the "debate." Believe me, I use that term loosely. For the next episode in Mindless Cretins 'R Us, check out the comments on the IV Cath picture. Comments of "Go Big or Go Home" and drunk punishing outnumber sanity 3:1.



Some of my favorite comments so far...

"Oh and if you go for the A/C first you suck. Go be an RN."
"Go big or go home I am embarrassed to even document a 20"
"IOs are for *****es who can't start IVs." 

I can not even fathom how someone can claim to be a medical professional and then brag about purposefully harming patients. Especially on the internet displaying your full name.


----------



## STXmedic (Aug 28, 2013)

Chase said:


> Some of my favorite comments so far...
> 
> "Oh and if you go for the A/C first you suck. Go be an RN."
> "Go big or go home I am embarrassed to even document a 20"
> ...



Alright. I had to go join this page. I need to join in on hurting the feelers.


----------



## STXmedic (Aug 29, 2013)

STXmedic said:


> Alright. I had to go join this page. I need to join in on hurting the feelers.



I immediately regret this decision. Holy crap. Are there no sane minds...


----------



## shfd739 (Aug 29, 2013)

STXmedic said:


> I immediately regret this decision. Holy crap. Are there no sane minds...



My thoughts as well. It hurts to read.


----------



## Medic Tim (Aug 29, 2013)

STXmedic said:


> I immediately regret this decision. Holy crap. Are there no sane minds...


----------



## RocketMedic (Aug 29, 2013)

My dad is super-concerned that I'll get blacklisted by AMR for what I said. 

If I get canned, how does Acadian look on people like me?


----------



## DesertMedic66 (Aug 29, 2013)

RocketMedic said:


> My dad is super-concerned that I'll get blacklisted by AMR for what I said.
> 
> If I get canned, how does Acadian look on people like me?



What did you say..


----------



## STXmedic (Aug 29, 2013)

RocketMedic said:


> My dad is super-concerned that I'll get blacklisted by AMR for what I said.
> 
> If I get canned, how does Acadian look on people like me?



Lol what did I miss?!

Their kool-aid is watermelon flavored


----------



## Jim37F (Aug 29, 2013)

Chase said:


> Some of my favorite comments so far...
> 
> "Oh and if you go for the A/C first you suck. Go be an RN."
> "Go big or go home I am embarrassed to even document a 20"
> ...



Is it sad that reading some of those comments makes me want to start carrying a DNR around?

(Kidding kidding)


----------



## DesertMedic66 (Aug 29, 2013)

Jim37F said:


> Is it sad that reading some of those comments makes me want to start carrying a DNR around?
> 
> (Kidding kidding)



I've pretty much already decided that if I ever have to call the ambulance for myself I am refusing all medical treatments until I get to the hospital. If they don't let me refuse the treatment, I will have their cert.


----------



## RocketMedic (Aug 29, 2013)

DesertEMT66 said:


> What did you say..



Nothing at all about any companies, fire departments or anything, but I am the source of the bonfire on PoF and TMIACITW. The "Paramedics or Ambulance Drivers" thing.

I think it's within policy, and I ran it past a few AMR folks to make sure, but my old man is still hyperconcerned.


----------



## DesertMedic66 (Aug 29, 2013)

RocketMedic said:


> Nothing at all about any companies, fire departments or anything, but I am the source of the bonfire on PoF and TMIACITW. The "Paramedics or Ambulance Drivers" thing.
> 
> I think it's within policy, and I ran it past a few AMR folks to make sure, but my old man is still hyperconcerned.



I stopped following TMIACITW a while ago. I'm still on PoF just to make myself feel smart by reading the comments haha


----------



## PotatoMedic (Aug 29, 2013)

I saw nothing in there that I feel would be termination worthy.  Maybe you have ruffled a few feathers... but other than that, not much.


----------



## DesertMedic66 (Aug 29, 2013)

FireWA1 said:


> I saw nothing in there that I feel would be termination worthy.  Maybe you have ruffled a few feathers... but other than that, not much.



Same thing, after I got done reading the worlds longest Facebook post


----------



## Anonymous (Aug 29, 2013)

RocketMedic said:


> but I am the source of the bonfire on PoF



you posted that on Plenty of Fish? :unsure:


----------



## shfd739 (Aug 29, 2013)

I think you'd be fine here. You might wanna lay low for a bit though


----------



## RocketMedic (Aug 29, 2013)

Lets hope it doesnt come to that. EMSA itself is a great place where I really enjoy my work, my partners and our patients. I can help people here. Id hate for a few angry people to ruin it.


----------



## TechYourself (Aug 29, 2013)

Went to PoF.


Pretty sure I now have cancer.:glare:



I'll admit that the "Paramedic vs Ambulance Driver" manefesto had me a little pissed off.

That was until I got to the last few paragraphs.
It's funny what reading the entire post will do...


As for the IV cath size debate, I'm pretty sure that this is the reason EMTs shouldn't start IVs.

With attitudes like that it's a wonder that some Med Directors let anyone in EMS start lines.:glare:


----------



## PotatoMedic (Aug 29, 2013)

It is interesting the completely different response that it got on Nocturnal Medics...


----------



## VFlutter (Aug 29, 2013)

RocketMedic said:


> I think it's within policy, and I ran it past a few AMR folks to make sure,.



Would it be against policy to openly admit, and even brag, about using large bore IVs to punish annoying or intoxicated patients? Or just poor taste?

Just curious.


----------



## Carlos Danger (Aug 29, 2013)

Chase said:


> Would it be against policy to openly admit, and even brag, about using large bore IVs to punish annoying or intoxicated patients? Or just poor taste?
> 
> Just curious.



I think that depends partly on whether you have a "nurse habit". 

Seriously, no one should ever again wonder why paramedicine is stuck where it is. If you really need a reminder, just look at PoF.

In one 5-minute glance this morning, I saw the ignorant reaction to Rocketmedic's diatribe, a thread espousing the physical assault of patients and insulting those who question the practice with accusations of being a "nurse", the normal, self-congratulatory "paramedics: doing the same thing as doctors at 60 mph" - type sentiments, and another discussion about why it would be so much better if we all followed statewide or even national protocols.


----------



## TechYourself (Aug 29, 2013)

Halothane said:


> I think that depends partly on whether you have a "nurse habit".



I know exactly what thread that is on PoF.



You have given yourself away


----------



## Wes (Aug 29, 2013)

And now y'all know why some of my posts have been so negative about the state of EMS.  I need to remove most of those EMS Facebook groups from my news feed on Facebook.


----------



## RocketMedic (Aug 29, 2013)

Chase said:


> Would it be against policy to openly admit, and even brag, about using large bore IVs to punish annoying or intoxicated patients? Or just poor taste?
> 
> Just curious.



That's street credit and commendations for you from your coworkers!


----------



## Bullets (Aug 29, 2013)

RocketMedic said:


> Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition?



Agencies avoid new things for all these reasons. With the rise of actual science in our treatments, i feel there is reluctance to implement new things without a proven benefit on a large scale. SMR is something that 100% of providers deal with, and changing the national view will be important and makes sense to most people once shown the evidence. Things like IN Narcan for BLS may not be as readily adopted because not everyone deals with those patients on a consistent basis (like my agency) so it would sit in the truck and expire again and again, costing the agency money.





> How amicable is your agency to change?



Somewhat. We are a new (2 years old in December) PD-based system, but our director is a lifelong volunteer. He is an excellent guy, but myself and our clinical coordinator have had to drag him kicking and screaming into the 21st century. Regionally, my county is still 85-90% volunteer, so as a whole, not much change is going on there. Some individuals are good, but most haven't picked up an EMS document since the class. 

Our tactic for changing things is basically bludgeoning the department heads with scientific evidence. Thankfully our medical directors attitude is "If you guys can prove it and support it, ill support you"  



> How about you in your own practice?



Im here arent i?






> On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?


I try to be a clinician, especially as i gain more education the closer i get to the NCLEX and i understand this stuff more. My peers are improving, because we email and leave relevant articles and studies around the station. Some are more receptive to this than others, but everyone improves because those that do a lot of research improve them by osmosis. 

Unfortunately, our clients view us as transporters




> Why the difference?




Im going to say it, intelligence, and by extension, education. Those that poses the education, even if it isnt in EMS or medicine, are more open to the science and rational of improving and changing. I posses a BA in History, my clinical coordinator got his first BA in Psychology (MS in Homeland Security), our director has a BS and MS in Accounting. The guys i work with who are most resistant have Associates degrees or less. This is the same across all levels of providers. I know some really stupid Paramedics.

EMT should at least be an Associates of Science, Paramedics should be at least a Bachelors of Science.


----------



## Bullets (Aug 29, 2013)

Akulahawk said:


> You're thinking of nitronox. Different animal. Nitrox is a mixed gas, usually with a higher oxygen percentage than air, in the breathing gas. Is anyone using (or knows of a facility) Heliox?



The hyperbaric chamber uses it for dive emergencies when they know the divers used Nitrox or Heliox. Pretty much the only time iver ever seen Heliox was on a SCUBA Divers back



FireWA1 said:


> Found it...





STXmedic said:


> I immediately regret this decision. Holy crap. Are there no sane minds...









Ok my God, thats painful


And i want to add to the whole "Ambulance Driver" thing. People always take offense, but your damn right im an ambulance driver. Im a professional driver and i good at it. How many people can drive a 42ft 102in bus down a 106in chute into a hotel casino convention center? Even within my department i have guys who cant or wont drive the heavies or trailers. I drive for a living, and it may be an ambulance, a evacuation bus, a heavy rescue, or MCI trailers. I can put them anywhere and everywhere. Take pride in being a professional driver.


----------



## Akulahawk (Aug 29, 2013)

Heliox is some very interesting stuff. I'm not referring to tri-mix like you'd find on a _really_ deep diver's back or in their surface supplied air for long-term saturation dives. It's a mixed gas, but basically you're mixing helium and oxygen. There's no nitrogen there. While it's good for helping to remove nitrogen from the body, heliox also has a low resistance to flow. In other words, you can get it to flow in lungs that won't ventilate well using air or nitrox mix. It's possible to use a standard ventilator with heliox, but they may be _only_ calibrated for air, and thus you'd need to correct for that. 

I don't know if heliox is used much, but it certainly can be useful.


----------



## Bullets (Aug 29, 2013)

Akulahawk said:


> Heliox is some very interesting stuff. I'm not referring to tri-mix like you'd find on a _really_ deep diver's back or in their surface supplied air for long-term saturation dives. It's a mixed gas, but basically you're mixing helium and oxygen. There's no nitrogen there. While it's good for helping to remove nitrogen from the body, heliox also has a low resistance to flow. In other words, you can get it to flow in lungs that won't ventilate well using air or nitrox mix. It's possible to use a standard ventilator with heliox, but they may be _only_ calibrated for air, and thus you'd need to correct for that.
> 
> I don't know if heliox is used much, but it certainly can be useful.



Most times ive seen Heliox and Trimix are the deepest dives, as stage bottles. They are sunk to the anchor and divers switch them out when the reach the bottoms

One local dive outfit has begun experimenting with Argox as a deco bottle, they hang it at around 4m and is only used for emergency ascents in an OOA situation. Its a small red pony bottle, but its very new. Something we just covered in their dive emergency class at the hospital


----------



## VFlutter (Aug 29, 2013)

Akulahawk said:


> I don't know if heliox is used much, but it certainly can be useful.



I have seen Heliox used a few times in the ER for status asthmaticus as a last ditch effort prior to intubation and once for a kid with Croup. I heard they sometimes use it when attempting to wean mechanical ventilation however I have never seen it personally.


----------



## Clipper1 (Aug 29, 2013)

Chase said:


> I have seen Heliox used a few times in the ER for status asthmaticus as a last ditch effort prior to intubation and once for a kid with Croup. I heard they sometimes use it when attempting to wean mechanical ventilation however I have never seen it personally.



It should NOT be a last ditch effort. When you wait too long you have to then hope the ventilator is compatible with heliox.  Weaning? No..it is an attempt at life saving. Asthma is no joke and some ER are just not equipped which can also explain the high mortality rate especially for children.


----------



## Hockey (Aug 30, 2013)

lol there is talk around my work about that post.  People totally missed the point of it


----------



## DesertMedic66 (Sep 3, 2013)

And now this topic is posted once again on PoF and on EMS1.


----------



## PotatoMedic (Sep 3, 2013)

Rocket, you really know how to poke the hornets nest!  It was interesting to read kelly's take on it though.  The question is how do we turn ems from a vocation to a profession?  I know the fire unions will battle any change to the emt b.  IE making it an AA or something.


----------



## DesertMedic66 (Sep 3, 2013)

FireWA1 said:


> Rocket, you really know how to poke the hornets nest!  It was interesting to read kelly's take on it though.  The question is how do we turn ems from a vocation to a profession?  I know the fire unions will battle any change to the emt b.  IE making it an AA or something.



In order to make EMTs have an AA then medics need to also have at least an AA.


----------



## PotatoMedic (Sep 3, 2013)

I was thinking EMT poof!  AEMT an AA and Medic a BA (or BS).  How can we get past the "we can train them" mentality and have more of the we can educate them mentality?  I really see the "50 years of tradition uninhibited by progress" coming into play.  And how will us becoming a profession impact how EMS is delivered?  What changes will occur and how can we bring management on board?


----------

