# Most Advanced Procedure



## zman (Jul 4, 2009)

I was just intersted to see what the most advanced procedure you can perform in your area is?  I know there are some pretty progressive EMS systems out there and then there are some not so progressive, like mine.  So lets hear it, what the most advanced procedure that can be performed in your locality!

-zman


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## ResTech (Jul 4, 2009)

Most invasive here would be a cricothyrotomy.


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## medic417 (Jul 4, 2009)

Triple by pass.

Sorry EMS is not about the skills, so why try and one up each other?


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## Ridryder911 (Jul 4, 2009)

medic417 said:


> Triple by pass.
> 
> Sorry EMS is not about the skills, so why try and one up each other?



I agree. There are systems where more advanced procedures would be justified than in others. Part of the systems responsibilities though is to ensure that there is good formal education associated and linked to those skills. 

R/r 911


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## VentMedic (Jul 4, 2009)

"Skills" can be taught to almost any human and some animals, even the "advanced" ones. What should be the appropriate question is what type of patient is your agency educated for and capable of transporting? Many ALS trucks double as CCTs and transport critical patients with an LVAD, IABP, ECMO (adult), various ventilator modes, on a variety of gases, a wide assortment of lines and tubes as well as a drugstore of drips.


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## daedalus (Jul 4, 2009)

VentMedic said:


> "Skills" can be taught to almost any human and some animals, even the "advanced" ones. What should be the appropriate question is what type of patient is your agency educated for and capable of transporting? Many ALS trucks double as CCTs and transport critical patients with an LVAD, IABP, ECMO (adult), various ventilator modes, on a variety of gases, a wide assortment of lines and tubes as well as a drugstore of drips.



That gets me all sorts of excited. 

But to the OP who cares about skills. In Santa Barbara, we can do needle crics while in ventura we cannot. Both counties have the same primary provider (AMR) and the same medical director. It is all about transport times in both counties.


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## Flight-LP (Jul 4, 2009)

medic417 said:


> Triple by pass.
> 
> Sorry EMS is not about the skills, so why try and one up each other?



Only triple??????? Your agency sucks! We can do quad bypass................lol


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## VentMedic (Jul 4, 2009)

Here you go daedalus:

http://www.emtlife.com/showthread.php?t=8948&highlight=flight+scenarios

In the past, some of us on this forum have done  procedures such as intracardiac epi, subclavian central lines, chest tubes and pericardial centesis. The first fell out of favor due to risk and alternative delivery methods which can also be said of the second. Chest tubes and pericardial centesis are still done by some CCPs on Flight and Specialty as well as a few ALS agencies where distance to the nearest facility or helicopter might make a difference. 

However, it is knowing how to stabilize a patient to get them from point A to point B that really counts. One should NOT depend on the speed of the ambulance. When some EMTs make the comments about what difference can a Paramedic make in certain situations, the answer is in the stabilization. Sometimes it just takes the ability to maintain an adequate MAP for perfusion that makes the difference whether the patient has a decent chance of regaining a normal life.


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## WolfmanHarris (Jul 4, 2009)

Ridryder911 said:


> I agree. There are systems where more advanced procedures would be justified than in others. Part of the systems responsibilities though is to ensure that there is good formal education associated and linked to those skills.
> 
> R/r 911



Quoted for agreement.

Recently ground ACP's had needle cric removed from the trucks. The Ontario Base Hospital Group reviewed it's use province wide, found it had been used three times in as many years and after some discussion among the medical advisory group it was pulled. So now on a skill checklist Ontario probably looks like it's lagging behind and yet Advanced Care Paramedics still have three years of formal education.

Skills, as has been said are a poor indication of a system's quality and in fact when I see some of the extended lists of toys, to me it begs the question, when was the last time it was used? How competent are the providers? We only need to look at some abysmal ETT stats to see the dangers of including items in a skill set without ensuring mastery of the skill and ensuring adequate practice on human patients under supervision before hitting the road and as part of CME.


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## ResTech (Jul 4, 2009)

Why don't we just play along with the thread and answer the question without being so damn proper, politically correct, and exerting your own educational agenda for once. Just have fun with it. 

I think by now everyone on here knows the importance of education as a foundation to skills. Its mentioned I think in every single thread about 20 times.


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## VentMedic (Jul 4, 2009)

ResTech said:


> Just have fun with it.


 
You do realize that these procedures are not for the fun of it but are meant to save a life.  However, just as easily, they can cause death.


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## Melbourne MICA (Jul 4, 2009)

*"Advanced"*

Talking about "Advanced" procedures sounds like a way to have pissing contest if I can put it in such crude terms (and all due respect to the original poster). Ventmedics point about "stabilisation" is the best direction to take such a conversation.

"Stay and play" or "Load and go" was the old catchcry of general ambulance thinking for decades. In the past the idea was in fact pretty ludicrous when you think about it because there were so few "procedures" (read management options) that we had to stabilise pts with and hence alter outcomes favourably.

Today the situation is vastly different and changing further with each new addition to our kitbag of tricks.

There is enough evidence now from the many pre-hospital studies to demonstrate that pt outcomes have benefitted from pre-hospital practices that result in achieving haemo or homeostasis. Venty mentioned perfusion mangament as one example. I know for a fact that our rapidly improving post arrest stats here in Melbourne has resulted from aggressive ROSC interventions, arrhthymia Rx, RSI implmentation and cooling management.

So if we're going to talk about "advanced procedures" I would certainly frame the proposition in terms of a gammet of advanced procedures producing haemo or homeostasis.

MM


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## MSDeltaFlt (Jul 4, 2009)

VentMedic said:


> *"Skills" can be taught to almost any human and some animals, even the "advanced" ones*. What should be the appropriate question is what type of patient is your agency educated for and capable of transporting? Many ALS trucks double as CCTs and transport critical patients with an LVAD, IABP, ECMO (adult), various ventilator modes, on a variety of gases, a wide assortment of lines and tubes as well as a drugstore of drips.


[/b]

I've often said, "It's not in knowing what to do and being able to do it. That's simple. Any moron can be taught that. The *trick of this job*, ladies and gentlemen, is in being able to do something and know when and when *not* to do it". 

I've been caring for the critically sick and injured for over a quarter of a century. And anyone who has mastered this "trick" in that time is a better provider than I am.


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## ResTech (Jul 4, 2009)

> You do realize that these procedures are not for the fun of it but are meant to save a life. However, just as easily, they can cause death.



My point exactly! I was not referring to having fun with the procedures.. I was referring to having fun with the thread and forum in general... no need for ppl to take things so literal and be so proper. This isn't a college classroom. 

Someone asked a question to get an idea how invasive some EMS systems are. Simple question... simple answer.


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## ResTech (Jul 4, 2009)

> The trick of this job, ladies and gentlemen, is in being able to do something and know when and when not to do it".



So true...


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## Sasha (Jul 4, 2009)

ResTech said:


> Its mentioned I think in every single thread about 20 times.




Yet some people still don't get it.


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## HotelCo (Jul 4, 2009)

Massaging the heart with a gloved hand.


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## VentMedic (Jul 4, 2009)

ResTech said:


> Someone asked a question to get an idea how invasive some EMS systems are. Simple question... simple answer.


 
No it is not as simple as that. There are a few procedures that Paramedics are permitted to do but few will ever do because they are not "cool" such as foley catheters and NG/OG tubes. 

As well, there are agencies that now no longer do ETI for Peds. Several other agencies are now looking at eliminating ETI for adults. IO is still not wide spread and some agencies will not believe an EJ is considered peripheral. RSI is still controversial and with the wide variety for the mix of certs on crews, it is easy to see where safety could be an issue and I don't even have to mention education there. You have agencies that don't carry med pumps. Some agencies are very limited on the meds and may not be able to do medicated drips. Even some ALS trucks that claim to do CCT must have the RN set them up with everything they need and then all the medic has to do is stare at the pump or maybe just shut it off if the beeping annoys them.

So with so many inconsistencies in EMS with the different certs and education, it is difficult to get very excited about someone doing any advanced skill or protocol unless you hear they have accomplished the education to go with it for the entire agency. Now that is exciting.


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## usafmedic45 (Jul 4, 2009)

I am probably not that much older than most of the members of here.  When I was working in EMS, I was actually _younger_ than most of those I had under my purview. In fact, the age difference was sufficient that many of them were old enough to be my parents (I actually dated the daughter of one of my EMTs for a while).



> That doesn't mean you automatically deserve any more respect or that others deserve any less respect. You guys are great, I love reading your posts, but you do not rule the forum and your word is not law or to be taken as such.



That is not what I meant.  I do not think I deserve any more respect than the next person.  What I was trying to imply was that as professionals- whether it is you or I coming with the stance- we base our decisions (or rather we should) base them on evidence and when getting into a debate one is well advised to have that evidence at hand when beginning.  If Rid said something I disagreed with and which he could not defend, I assure you I would tear his stance apart the same as I would one proffered by a junior member here.  It has everything to do with treating the topic with proper respect and acting as professionals when acting within the profession.  Nothing more, nothing less.  Sorry for the confusion.


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## maxwell (Jul 4, 2009)

VentMedic said:


> You do realize that these procedures are not for the fun of it but are meant to save a life.  However, just as easily, they can cause death.



Ugh.  Really?  Procedures are fun.  Should be taken seriously, but, hell, our jobs are fun.  The most fun I've ever had on a call was doing a crich and then a chest tube...Sorry, I have neither documentation nor studies for procedures being "fun."  Just ask old medics who *aren't* jaded.  We do some cool and fun stuff.  Sometimes patients live, too!


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## VentMedic (Jul 4, 2009)

maxwell said:


> Ugh. Really? Procedures are fun. Should be taken seriously, but, hell, our jobs are fun. The most fun I've ever had on a call was doing a crich and then a chest tube...Sorry, I have neither documentation nor studies for procedures being "fun." Just ask old medics who *aren't* jaded. We do some cool and fun stuff. Sometimes patients live, too!


 
Fun? Playing with the whoo-whoo?

I take medicine rather seriously because I can not bring myself to laugh at the person who has just lost an extremity in an industrial accident or a child who can not breathe. If you find humor in the suffering and dying of others, then more power to you. When I a putting a chest tube in a baby, I really don't think of what a great time I am having doing a cool procedure especially if I can not save that child's life. There is also not much laughter in knowing that each invasive procedure you have to do will make that patient's recovery that much more difficult even though the procedures are necessary. If I have a patient that I do not have to poke any holes into their body be it an IV or a needle to their pericardial sac, I feel that is a much more "fun" time. I am by no means afraid to use my skills but I would rather not look forward to having a patient experience an event just so I can "enjoy doing some fun stuff".

Some may look forward to a cool trauma, but I like to see everyone go home safely especially on a night of celebration like July 4th. There should be no cool trauma to end a family picnic. I do not wish anyone to crash up just so someone in EMS can do some fun trauma stuff. 

However, I believe that those in medicine, and that includes EMS, do some really amazing things and there should be pride in that. I am not burnt out or jaded. I have just become more realistic and have seen how one "cool trauma" can affect many people.


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## ResTech (Jul 5, 2009)

> some may look forward to a cool trauma, but I like to see everyone go home safely especially on a night of celebration like July 4th. There should be no cool trauma to end a family picnic. I do not wish anyone to crash up just so someone in EMS can do some fun trauma stuff.



One of my major pet peeves as well... having to listen to guys at the Station hope and wish for an entrapment accident or another "good call" just so they can get off and be entertained. Granted its inevitable, but I never sit around and hope for it.... I never fully understood that.


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## Foxbat (Jul 5, 2009)

VentMedic said:


> In the past, some of us on this forum have done  procedures such as intracardiac epi, subclavian central lines, chest tubes and pericardial centesis. The first fell out of favor due to risk and alternative delivery methods which can also be said of the second. Chest tubes and pericardial centesis are still done by some CCPs on Flight and Specialty as well as a few ALS agencies where distance to the nearest facility or helicopter might make a difference.



What about central lines? Do medics still do them in some places?


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## VentMedic (Jul 5, 2009)

ResTech said:


> One of my major pet peeves as well... having to listen to guys at the Station hope and wish for an entrapment accident or another "good call" just so they can get off and be entertained. Granted its inevitable, but I never sit around and hope for it.... I never fully understood that.


 
The best sight for me is to see the trauma beds empty on Christmas Eve and Christmas Day.  I think that is the saddest time to tell someone their loved one has become a trauma patient or has died on that day.   But then for the family, it doesn't get easier no matter what day it is.   Unfortunately, there is rarely a time when those beds are empty.


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## ResTech (Jul 5, 2009)

In my region... Paramedics are not permitted to initiate a central line, only access them (least in PA and MD). Given the almost universal availability of adult IO as a backup to IV access, Im not sure the risks of starting a central line in the field would be warranted. I'm sure others with more experience dealing with central lines can give greater insight.


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## MMiz (Jul 5, 2009)

I've cleaned this thread of off-topic posts and those that violate our community rules.  The thread is open again, but any insults or name calling will result in infractions.


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## usafmedic45 (Jul 5, 2009)

**redacted***


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## medic417 (Jul 5, 2009)

Foxbat said:


> What about central lines? Do medics still do them in some places?



Yes I am aware of a few services that allow it.   The medical director requires those Paramedics to take more education, do a bunch at the hospital under supervision, then pass a test written and on a live patient.  All that extra time is not paid by the service the Paramedic does it on days off.


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## Ridryder911 (Jul 5, 2009)

Most of the services that had central lines have abolished them as the EZ I/O has made access a much safer and easier process. I even look for central lines to soon to be a thing in the past in ED's as EZ I/O makes popularity. Of course, it will not be a replacement but for emergency access and resuscitative measures. 

I do NOT believe though, they should ever replace traditional peripheral insertion if veins are easily located and cannulated. 

R/r 911


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## VentMedic (Jul 5, 2009)

Our hospital crash carts are now stocked with IOs for emergencies if other access is not readily available.

Some flight teams and a few ALS agencies do have central line access in their protocols. Ada County, Idaho and I believe Seattle are two examples. Some Specialty teams will also have the protocols but that is usually done during IFT at a hospital. Neo teams will do UAC/UVC cannulation which is considered central. 

However, I do believe all Paramedics should be educated on accessing the various venous ports that they find on their patients. There are even medics that do IFT/CCT that have little knowledge of these devices.


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## rescuepoppy (Jul 5, 2009)

MSDeltaFlt said:


> [/b]
> 
> I've often said, "It's not in knowing what to do and being able to do it. That's simple. Any moron can be taught that. The *trick of this job*, ladies and gentlemen, is in being able to do something and know when and when *not* to do it".
> 
> I've been caring for the critically sick and injured for over a quarter of a century. And anyone who has mastered this "trick" in that time is a better provider than I am.



  Great post. In my opinion the best skill any medic can have is patient evaluation skills. I would much rather say that I have a skill at my disposal but this patient does not need it than to need it and not have it.  All some patients need to stabilize them is a little bit of TLC if all you do is offer comfort to a patient to ease them then you have performed a skill. Not down playing the physical things that we do, but I will always say that the best tool we have is our brains. I would rather use that than any of the "toys" in my bag if that is all that is needed.


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## zman (Jul 5, 2009)

As many have said, education is a must in our field and we should not be performing these "advanced" procedures without the knowledge of why to perform them, how they affect the body systems of the person they are being performed on and when to perform them.

All I wanted to know was how much will your MD let you do in the field to help save a persons life?.

Maybe it would be cool to start a different thread that discussed how your education has helped you stabilize your patient, or the longest amount of time you have had to stabilize a patient before reaching definitive care and how your education and training helped you accomplish that stabilization.

thanks for all the responses
-zman


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## VentMedic (Jul 5, 2009)

You must also remember medicine is constantly evolving which is why intracardiac epi and field central lines have fallen out of favor. Quicker and easier methods have come about such as the IO. Trauma centers and the many hospitals have also made alot of procedures unnecessary in the field. As well, meds that were commonly given such as morphine and lasix have taken a back seat. CPAP has come to the front. Newer meds have replaced older meds. ACLS protocols have changed at least a dozen times. Meds that are no longer found to be effective or considered inappropriate have been removed from the trucks. The MAST has come and gone. Levophed, Vasopressin and Amiodarone are in popular...again.. and sometimes not. 

Many adjunct airways and RSI have made airway management a little easier although some forget the essential skills that go into the process. What would be nice is if EMS medical directors would have the confidence in their providers to allow for guidelines to achieve sedation and with the use of paralytics instead of a strict recipe. 

Hypothermia protocols may improve outcome but can be accomplished without the essential steps performed with proficiency to get to that point which includes airway, IV and medications. As recently mentioned in a post, evaluation and the ability to know when to stay and play or when to move as in how much is too much or how little is too little are very important factors that go along with any set of skills/protocols. 

The state dictates from the broad sense of what a Paramedic is allowed to do. It is then up to the medical director as to what he/she feels his/her providers are capable of doing. It also depends on how much effort the medical director and the providers are willing to put forth. If the medical director feels the Paramedics are capable of doing more advanced skills than what the state allows, he/she can petition the state for an expanded scope. This is done for some flight and specialty teams. CA also has a very limited scope for their Paramedics so if a medical director wants the Paramedics working under him/her to do more, the proper path must be follow to allow this. Competencies with proper QA/QI must then be maintained as it should for any skill or protocol. 

You can look up the scope of practice for any state and see what is normally allowed.


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## VentMedic (Jul 5, 2009)

zman said:


> Maybe it would be cool to start a different thread that discussed how your education has helped you stabilize your patient, or the longest amount of time you have had to stabilize a patient before reaching definitive care and how your education and training helped you accomplish that stabilization.


 
My additional education and training has enabled me to transport complex patients thousands of miles across the borders of many countries with an RN as a partner. I have done this with Specialty transport teams by various modes of transportation and on Flight teams. Some of the transports have been over 24 hours in length with travel and stabilization time. Even for a fairly "routine" neonatal transport we may spend 2 hours stabilizing the infant before we move. We have brought the knowledge of our NICU with us and will often do exactly what would be done at our NICU to stabilize the infant.


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## Summit (Jul 5, 2009)

Diagnosis is the most advanced and complicated activity in EMS


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## Flight-LP (Jul 5, 2009)

Summit said:


> Diagnosis is the most advanced and complicated activity in EMS



+5. That pretty much sums it up right there.

(Please don't let this statement turn into a further off topic discussion of how some believe we don't diagnose in EMS, thanks!!!)


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## VentMedic (Jul 5, 2009)

Flight-LP said:


> (Please don't let this statement turn into a further off topic discussion of how some believe we don't diagnose in EMS, thanks!!!)


 
But for some it only takes as much effort as flipping a coin or a couple of pages in the recipe book.


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## mycrofft (Jul 8, 2009)

*I'm going to ignore the drift of this (as usual)...*

The three most advanced procedures are as follows:
1. Figure out quickly what's wrong.
2. Decide and act upon that.
3. Grab your arse with both hands to hold yourself back from doing something whackerly, excessive, and dangerous to yourself or your victim, er, patient.

I don't care if you _can_ make a NG decomressor and a rectal thermometer meet halfway, if I'm down, give me "calm and appropriate" every time.


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