# Protocol Changes



## exodus (Dec 28, 2011)

Anything new coming for you in 2012? What's gonna be different?


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## Smash (Dec 28, 2011)

Ketamine for all, not just the fly-boys.  About bloody time!  Probably some other stuff, but that is the one that excites me.


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## Veneficus (Dec 28, 2011)

Smash said:


> Ketamine for all, not just the fly-boys.  About bloody time!  Probably some other stuff, but that is the one that excites me.



Sure...

Rub it in...

I just used versed and morphine for conscious sedation, might as well use a leech and hot poker too.


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## akflightmedic (Dec 28, 2011)

Veneficus said:


> Sure...
> 
> Rub it in...
> 
> I just used versed and morphine for conscious sedation, might as well use a leech and hot poker too.



Why not Versed and Fetanyl??  We have heaps of it and I like it better.


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## DrankTheKoolaid (Dec 28, 2011)

*re*

Not sure if you got a chance to look at the California Paramedic proposed protocol changes but the public comment has ended already.  Lots of exciting things were included.  Sure hope we get moved out of the stone age.  Would be even better if the rest of the state can separate itself from SoCal in the way of protocols.


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## JPINFV (Dec 28, 2011)

Corky said:


> Not sure if you got a chance to look at the California Paramedic proposed protocol changes but the public comment has ended already.  Lots of exciting things were included.  Sure hope we get moved out of the stone age.  Would be even better if the rest of the state can separate itself from SoCal in the way of protocols.



Saw it, wrote a blog post on the implication of some of the APP proposed changes that represents a lot of what is wrong with EMS.


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## DrankTheKoolaid (Dec 28, 2011)

*re*

That over on your page? I must have skipped past it.  I'll scan it again and give it a read.

I found it


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## JPINFV (Dec 28, 2011)

Corky said:


> That over on your page? I must have skipped past it.  I'll scan it again and give it a read.


Here's the link:
http://emtmedicalstudent.wordpress.com/2011/09/25/independentjudgement/

Basically I had a short rant on how the APP is specifically including "perform digital and nasotracheal intubation" and how the scope of practice for paramedics should be "intubation" and let paramedics use their professional judgement to determine how to actually proceed with putting the plastic tube in the slightly larger flesh tube. Additionally, if "digital and nasotracheal intubation" requires a specific line authorizing it for APPs, does that mean that paramedics who aren't APPs can't perform digital or nasotracheal intubation? Note, I'm not saying that those should be used as a standard, but having options open are a good thing.


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## DrankTheKoolaid (Dec 29, 2011)

Yeah agreed, but then again it seem CA writes it's protocols to the lowest common denominator....... SoCAl who has so many documented screw ups it effects the rest of us in Northern California.  I think what needs to happen is a standard set of protocols and then let the LEMSA directors water them down based on history of performance of the practitioners.

Not a perfect solution I admit, but at least it is a bridge to get the protocols established and give the lower functioning a chance to increase their knowledge.  If that doesn't happen it's time to remove their paramedic cert and drop them to AEMT.

Digital intubation certainly is a needed skill especially for the Tactical Medics among us. ( Yay! Palm Springs in 3 weeks! ).  If you look at the protocols already in use in some of the CA LEMSA's they are already practicing at the APP level and up here in far Northern CA CCP is more accurate


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## DesertMedic66 (Dec 29, 2011)

Corky said:


> Yeah agreed, but then again it seem CA writes it's protocols to the lowest common denominator....... SoCAl who has so many documented screw ups it effects the rest of us in Northern California.  I think what needs to happen is a standard set of protocols and then let the LEMSA directors water them down based on history of performance of the practitioners.
> 
> Not a perfect solution I admit, but at least it is a bridge to get the protocols established and give the lower functioning a chance to increase their knowledge.  If that doesn't happen it's time to remove their paramedic cert and drop them to AEMT.
> 
> Digital intubation certainly is a needed skill especially for the Tactical Medics among us. ( Yay! Palm Springs in 3 weeks! ).  If you look at the protocols already in use in some of the CA LEMSA's they are already practicing at the APP level and up here in far Northern CA CCP is more accurate



Stay away from anything with a rainbow flag in palm springs... Haha. We joke around and say we are Rainbow Warriors haha


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## DrankTheKoolaid (Dec 29, 2011)

firefite said:


> Stay away from anything with a rainbow flag in palm springs... Haha. We joke around and say we are Rainbow Warriors haha



LOL, Yeah ill be at the International School of Tactical Medicine for 2 weeks.  Don't plan on doing any sight seeing while down there though.  Pretty much a business trip, but ill keep that in mind if we do get some time to venture out!


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## Smash (Dec 29, 2011)

Veneficus said:


> Sure...
> 
> Rub it in...
> 
> I just used versed and morphine for conscious sedation, might as well use a leech and hot poker too.





akflightmedic said:


> Why not Versed and Fetanyl??  We have heaps of it and I like it better.



Versed and fentanyl has been the standard for a long time for induction, with morphine and versed for maintenance, and honestly, it works well most of the time.  However, if I had to pick one drug to have, it would be ketamine.  The slightly disturbing thing is they are talking about doing away with morphine altogether.  While I am a fan of fentanyl, I prefer more options, rather than fewer.

And don't be too hard on leeches, I hear they have made a comeback along with maggots in wound care and the like!   And I can certainly think of a few people to whom a hot poker could be gainfully applied...



Corky said:


> Yeah agreed, but then again it seem CA writes it's protocols to the lowest common denominator.......



That is the way of it with all protocols, everywhere.  They are essentially written to establish a minimum acceptable standard.  They aren't written for those of us who get text books for Christmas and read them for fun, or who get excited when a new journal gets published, or who listen to podcasts in the car on the way to work, or who lie awake at night running through cric scenarios in their head, terrified because they haven't done one in anger yet.  They are written for Joe Shmoe who got a pass mark, and turns up every (most) day(s) because the alternative is harder work swinging a hammer or something and no flashy lights.

The trouble really arises when something written as a minimum standard, becomes the maximum standard.

It took me a long time and a lot of frustration to realise this.  I still have the frustration, but at least I understand why the world is as it is.


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## DrankTheKoolaid (Dec 29, 2011)

*re*



smash said:


> that is the way of it with all protocols, everywhere.  They are essentially written to establish a minimum acceptable standard.  They aren't written for those of us who get text books for christmas and read them for fun, or who get excited when a new journal gets published, or who listen to podcasts in the car on the way to work, or who lie awake at night running through cric scenarios in their head, terrified because they haven't done one in anger yet.  They are written for joe shmoe who got a pass mark, and turns up every (most) day(s) because the alternative is harder work swinging a hammer or something and no flashy lights.
> 
> The trouble really arises when something written as a minimum standard, becomes the maximum standard.
> 
> It took me a long time and a lot of frustration to realise this.  I still have the frustration, but at least i understand why the world is as it is.




+1,


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## Veneficus (Dec 29, 2011)

akflightmedic said:


> Why not Versed and Fetanyl??  We have heaps of it and I like it better.



Couldn't find it.


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## JPINFV (Dec 29, 2011)

Smash said:


> The trouble really arises when something written as a minimum standard, becomes the maximum standard.



The problem is all too often they are the maximum standard.


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## akflightmedic (Dec 29, 2011)

Veneficus said:


> Couldn't find it.



It is next to the ketamine!  

Just poking ya mate, no worries...


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## Veneficus (Dec 29, 2011)

akflightmedic said:


> It is next to the ketamine!
> 
> Just poking ya mate, no worries...



let me guess...


locked in the house?


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## R99 (Dec 29, 2011)

Lortadine, fentanyl and ceftriaxone are new

Midazolam and amiodarone move to ILS from ALS


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## usalsfyre (Dec 29, 2011)

Pending finishing writing the d@mn things and OMD approval..

Propofol, ketamine, droperidol, phenylephrine, dobutamine, NTG infusions, nicardipine, fosphenytoin fentanyl and midaz infusions, arterial lines, IJ and fem lines, tube thoracostomy, retrograde intubation and escharotomy. 

The only reason we're going this wide open is <10 paramedics will be credentialed at this level.


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## Veneficus (Dec 29, 2011)

usalsfyre said:


> Pending finishing writing the d@mn things and OMD approval..
> 
> Propofol, ketamine, droperidol, phenylephrine, dobutamine, NTG infusions, nicardipine, fosphenytoin fentanyl and midaz infusions, arterial lines, IJ and fem lines, tube thoracostomy, retrograde intubation and escharotomy.
> 
> The only reason we're going this wide open is <10 paramedics will be credentialed at this level.



Intending no disrespect, but when do you plan to use this stuff? I worked in a regional burn center for years and seen an escharotomy for circumferential burns twice.


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## usalsfyre (Dec 29, 2011)

Very honestly on chest tubes and escharotomy? Not often to never.

The issue I'm having is this. Things such as escharotomy are going to be extremely rare. That said, if marketed how we're aiming at we're looking at hour plus ground transports on "weather" days for HEMS in this area. So it puts our providers in a difficult spot. Take a patient you know is going to crash 25 minutes in or refuse the transport? Those two procedures in particular are intended for that environment. The concern of course is keeping a level of competency, with a small group I think that can be accomplished.

The most common procedure on that list I expect to see used? Art lines. We've run into a rash of patients on heavy duty pressors coming out of small EDs and rehab facilities with no pressure monitoring.


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## Veneficus (Dec 29, 2011)

usalsfyre said:


> Very honestly on chest tubes and escharotomy? Not often to never.
> 
> The issue I'm having is this. Things such as escharotomy are going to be extremely rare. That said, if marketed how we're aiming at we're looking at hour plus ground transports on "weather" days for HEMS in this area. So it puts our providers in a difficult spot. Take a patient you know is going to crash 25 minutes in or refuse the transport? Those two procedures in particular are intended for that environment. The concern of course is keeping a level of competency, with a small group I think that can be accomplished.



honestly, if you arrive at an ED or hospital, they should have a physician or surgeon who can provide those procedures. If they can't, then they should probably not call themselves an ED.


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## usalsfyre (Dec 29, 2011)

Veneficus said:


> honestly, if you arrive at an ED or hospital, they should have a physician or surgeon who can provide those procedures. If they can't, then they should probably not call themselves an ED.



Would I hope? Yeah. Do I know of at least three rural EDs that routinely transfer patients to large hospitals in our area that run single coverage NP or PA at night and on weekends in the ED many of whom won't perform this procedures? Also yeah...

There's some scary, scary small facilities around here. It's not unusual for the crew showing up for transport to have the most experience with critical patients of anyone there.


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## EMSLaw (Dec 29, 2011)

Veneficus said:


> honestly, if you arrive at an ED or hospital, they should have a physician or surgeon who can provide those procedures. If they can't, then they should probably not call themselves an ED.



Can you call yourself an ED without any doctors present?  I'd think that if someone rolled into a hospital, at any time of the day or night, they'd expect to find an MD in the place somewhere.  

I'm now curious.


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## Veneficus (Dec 29, 2011)

usalsfyre said:


> Would I hope? Yeah. Do I know of at least three rural EDs that routinely transfer patients to large hospitals in our area that run single coverage *NP or PA at night and on weekends in the ED many of whom won't perform this procedures*?



The solution there is not to pay those people.


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## the_negro_puppy (Dec 29, 2011)

Getting:

Fentanyl IN
Zofran (no wafers though)
Atrovent (for imminent arrest only <_< )
capnography
chest needle decompression on consult
Vitamin B12 for cyanide poisoning :rofl::rofl: wtf lol?
Magnesium sulfate for envenomation only

hydrocortisone (for pt's with specific management plans i.e adrenal insufficiency


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## R99 (Dec 29, 2011)

EMSLaw said:


> I'd think that if someone rolled into a hospital, at any time of the day or night, they'd expect to find an MD in the place .



The doctor might very well be a first year house officer who has just graduated and has less experience with sick people than the ambulance crew


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## JPINFV (Dec 29, 2011)

R99 said:


> The doctor might very well be a first year house officer who has just graduated and has less experience with sick people than the ambulance crew



Not in this day and age as interns don't have an unrestricted license to practice medicine yet. 1st year residents are neither going to be moonlighting or working single coverage in an ED.


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## usalsfyre (Dec 29, 2011)

JPINFV said:


> Not in this day and age as interns don't have an unrestricted license to practice medicine yet. 1st year residents are neither going to be moonlighting or working single coverage in an ED.



Nope, but in this state an FNP who got their degree online can .


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## EMSLaw (Dec 29, 2011)

usalsfyre said:


> Nope, but in this state an FNP who got their degree online can .



Though theoretically that NP or PA is under the supervision of an MD with an unrestricted license.  I say 'theoretically' because depending on the state, that can just mean that the MD reviews the charts every so often, and/or is available by telephone.



JPINFV said:


> Not in this day and age as interns don't have an unrestricted license to practice medicine yet. 1st year residents are neither going to be moonlighting or working single coverage in an ED.



Moreover, even a PGY1 has two years of clinical time in medical school.

I still think, though, that if there isn't an MD present - be it house doc ('hospitalist' now days, I guess), attending, or resident - your ED is now an urgent care clinic that really isn't capable of providing acute care.


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## Devilz311 (Dec 29, 2011)

We can finally give Narcotics under standing orders...


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## Veneficus (Dec 29, 2011)

JPINFV said:


> Not in this day and age as interns don't have an unrestricted license to practice medicine yet. 1st year residents are neither going to be moonlighting or working single coverage in an ED.



no offense, but a doctor who cannot function in their first year out of school, but a PA or NP can, sounds like a terrible failure of education and administration.


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## JPINFV (Dec 29, 2011)

Just a quick pedantic note. A "house officer" (archaic term for a resident) is not the same as a hospitalist (a fully licensed physician generally specialized in internal medicine). 

PA and NP run EDs are the EMS volunteers of emergency medicine. Is it appropriate? Generally no. Are there places where they're the best we can do? Unfortunately yes. Can they handle the vast majority of cases? Yes, but generally not the ones that really count.


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## JPINFV (Dec 29, 2011)

Veneficus said:


> no offense, but a doctor who cannot function in their first year out of school, but a PA or NP can, sounds like a terrible failure of education and administration.



That's how it's set up. I'm offering no judgement at this point at whether it's appropriate or not and just saying that most physicians aren't fully licensed until their second year of residency based on how most state laws are set up and because Step 3 isn't taken until sometime during PGY-1.


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## Veneficus (Dec 29, 2011)

JPINFV said:


> PA and NP run EDs are the EMS volunteers of emergency medicine. Is it appropriate? Generally no. Are there places where they're the best we can do? Unfortunately yes. Can they handle the vast majority of cases? Yes, but generally not the ones that really count.



I like you.


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## JPINFV (Dec 29, 2011)

Veneficus said:


> I like you.


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## Veneficus (Dec 29, 2011)

JPINFV said:


>



perfect


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## R99 (Dec 29, 2011)

JPINFV said:


> Just a quick pedantic note. A "house officer" (archaic term for a resident) is not the same as a hospitalist (a fully licensed physician generally specialized in internal medicine).
> 
> PA and NP run EDs are the EMS volunteers of emergency medicine. Is it appropriate? Generally no. Are there places where they're the best we can do? Unfortunately yes. Can tthey handle the vast majority of cases? Yes, but generally not the ones that really count.



A house officer/ house surgeon is not the same as your resident (registrar) they are a first year graduate with no formal training beyond medical school, unfortunately they sometimes get left sole charge in some small EDs overnight with the surgical registrar on call as their backup.

My mates daughter is in her HO year at one of the hospitals up northland, poor thing, they have a bunch of missed meningococcocemia complaints  against them, at least they can do something right!

ED here must, absolutely must have a doctor, even if its a first year house surgeon


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## JPINFV (Dec 29, 2011)

I believe we're dealing with different medical education systems and different meanings of the same term used to describe different levels. "Registrar physician" and "consultant physician" are not terms used to describe resident vs attending in the US. Similarly, a house officer/house staff in the US and used elsewhere (specifically the UK, and by connection I imagine most commonwealth countries) may have different meanings.

Similarly, a "first year graduate with no formal training beyond medical school" is generally referred to as a first year resident in the US (post graduate year-1), along with the term "intern."


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## STXmedic (Dec 29, 2011)

the_negro_puppy said:


> Getting:
> 
> Fentanyl IN
> Zofran (no wafers though)
> ...



We use hydroxocobalamin here for cyanide poisonings (people pulled out of fires) and have already had two saves. In essence, it's "super B12"


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## Brandon O (Dec 29, 2011)

Totally did not realize that was your blog JP.

No love for midlevel providers round here


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## Veneficus (Dec 29, 2011)

Brandon Oto said:


> Totally did not realize that was your blog JP.
> 
> No love for midlevel providers round here



none at all and the sooner the US wakes up and figures out they are a complete waste of money, the better.


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## JPINFV (Dec 29, 2011)

Brandon Oto said:


> Totally did not realize that was your blog JP.
> 
> No love for midlevel providers round here




Actually, the entire reason I started that blog was because I got sick of writing out the same arguments over and over again here. It's much easier to just post a link when someone complains about how paramedics don't diagnose or asks how to write a narrative. 

I can accept a use for midlevels as a force multiplier. I cannot accept midlevels as an independent practitioner.


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## Brandon O (Dec 29, 2011)

You guys are going to hurt my feelings. (But it's okay, because PhDs and DOs aren't real doctors either  neener neener)


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## Medic Tim (Dec 29, 2011)

My area will be getting ACP (EMT-P) protocols (hopefully). I am licensed but still working as a PCP(EMT-Intermediate), as they are still working on a scope of practice. I am told we are the last place in North america that doesn't have some form of ALS.


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## EMSLaw (Dec 29, 2011)

JPINFV said:


> PA and NP run EDs are the EMS volunteers of emergency medicine. Is it appropriate? Generally no. Are there places where they're the best we can do? Unfortunately yes. Can they handle the vast majority of cases? Yes, but generally not the ones that really count.



Oh, c'mon now, JP, did you have to go there?


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## JPINFV (Dec 29, 2011)

EMSLaw said:


> Oh, c'mon now, JP, did you have to go there?




You go to the emergency room with a life threatening emergency. Do you want a board certified emergency physician treating you or a PA or NP treating you?

You call 911 with a life threatening emergency. Do you want someone who does EMS on the side and who has to respond from home to the ambulance before responding to your emergency, or do you want someone who has made EMS their profession who can respond immediately?

So, yes, I think that single coverage EDs covered by mid-levels is an apt comparison to EMS volunteers when looking clearly at the level of care provided. Would you like to provide a counter? I'm more than happy to hear how, in the sense of care provided, I'm missing the mark with this analogy.


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## Tigger (Dec 29, 2011)

Trauma Point of Entry Plans for Massachusetts are supposedly going in to effect for real come the new year. Technically it's been in place since September but apparently there is going to be a bigger push for it's use. this trauma flow chart is supposed to tell you if your patient needs a trauma center (ACS level III or better). Kinda sucks if you work on the southcoast or cape, where there aren't any accredited trauma centers, or in western mass where there are three for like two thirds of the state.


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## Tigger (Dec 29, 2011)

JPINFV said:


> You go to the emergency room with a life threatening emergency. Do you want a board certified emergency physician treating you or a PA or NP treating you?
> 
> You call 911 with a life threatening emergency. Do you want someone who does EMS on the side and who has to respond from home to the ambulance before responding to your emergency, or do you want someone who has made EMS their profession who can respond immediately?
> 
> So, yes, I think that single coverage EDs covered by mid-levels is an apt comparison to EMS volunteers when looking clearly at the level of care provided. Would you like to provide a counter? I'm more than happy to hear how, in the sense of care provided, I'm missing the mark with this analogy.


The fact that someone is responding from home is not an indication of the quality of care you are going to receive, so I don't really see how these are similar. There are plenty of places where the staffed EMS department provides only BLS care.


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## Bullets (Dec 29, 2011)

For NJ EMTs

Ability to titrate via NC
Aspirin administration for non-traumatic chest pain
Move TKs up in the bleeding control
Clarify  spinal immobilization algorithm
Adopt PHTLS as trauma treatment standard


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## Bullets (Dec 29, 2011)

Tigger said:


> The fact that someone is responding from home is not an indication of the quality of care you are going to receive, so I don't really see how these are similar. There are plenty of places where the staffed EMS department provides only BLS care.



If you called 911 in my town, you could get any of the following "volunteers": 3 paramedics, a trauma PA,  4 NPs, an orthopedist, an ER MD, all of which started as EMTs and still actively volunteer, so dont judge a persons skills based on where they come from


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## exodus (Dec 29, 2011)

Bullets said:


> If you called 911 in my town, you could get any of the following "volunteers": 3 paramedics, a trauma PA,  4 NPs, an orthopedist, an ER MD, all of which started as EMTs and still actively volunteer, so dont judge a persons skills based on where they come from



I would have to say that your town is a very small minority in the quality of unpaid providers. 


---
I am here: http://maps.google.com/maps?ll=33.821368,-116.521211


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## Brandon O (Dec 29, 2011)

Bullets said:


> Ability to titrate via NC



Interesting. Titrate according to what?


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## Veneficus (Dec 29, 2011)

Brandon Oto said:


> You guys are going to hurt my feelings. (But it's okay, because PhDs and DOs aren't real doctors either  neener neener)



Sorry, 

But the idea of a mid level provider serving where physicians are not available has since been perverted; now they  are running around academic facilities providing no better care than a paramedic following protocols (and often with the same attitude). 

Always with an ego that rivals any surgeon I have ever met. But when they are called upon to actually do something, they are not comfortable or have some other excuse.

I do not agree with anyone who promotes the philosophy, "better than nothing."

Physicians are medical providers, not medical managers overseeing a plethora of protocol monkies who just add extra layers and extra cost which is unsustainable.

If you want to practice medicine, go to medical school, spare me the excuses as to why a person cannot. It is not that they cannot, it is they are not dedicated enough to.


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## Brandon O (Dec 29, 2011)

Fair enough.


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## EMSLaw (Dec 29, 2011)

JPINFV said:


> You call 911 with a life threatening emergency. Do you want someone who does EMS on the side and who has to respond from home to the ambulance before responding to your emergency, or do you want someone who has made EMS their profession who can respond immediately?
> 
> So, yes, I think that single coverage EDs covered by mid-levels is an apt comparison to EMS volunteers when looking clearly at the level of care provided. Would you like to provide a counter? I'm more than happy to hear how, in the sense of care provided, I'm missing the mark with this analogy.



This is an old canard here, the whole volunteer vs. paid debate, and I'm sure that we're not going to cover any new territory.  But, here we go...

A physician is a different level of care from a mid-level provider.  A paid EMT and a volunteer EMT have exactly the same training.  As it happens, when you call 9-1-1 in my community, the volunteer agency does respond immediately, because we stay at our station.  So there is absolutely no difference in response time or level of care. 

You're making sweeping generalizations about volunteer agencies that are not universally applicable.  Sure, there are volunteer agencies that aren't up to snuff.  There are also paid ambulance services that are fly-by-night operations that I wouldn't trust to care for my worst enemy.  

And just because a provider is paid doesn't mean they've made EMS their full-time profession.  Or is the newly-minted Per Diem EMT who rides one shift a week quantifiably better than a volunteer simply because he receives a paycheck?  If paid EMS /is/ quantifiably better, show me the study, because I certainly haven't heard of it.


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## Veneficus (Dec 30, 2011)

I don't know what JP has in mind obviously, but the way I understood it is a matter of dedication and time spent. 

For those who study medicine. (aka doctors) it is all consuming. It occupies just about every waking hour. (it occupies about 14 hours of every one of my days when I am not vacationing in an outpatient clinic here )

That is not likely to change in the next 10 years. 

The abstract of volunteer vs. paid, compared to "mid level" providers and physicians has little to do with actual transfer of monies, but of dedication.

I don't particularly like the PA position, mostly from my overwhelmingly negative personal interactions with those providers. My opinion on NPs is much better, as I understand not only why they are needed but that they are not playing doctor.

I don't care if you are old, don't want to take on debt, spend more time with your family, don't see a pay/education benefit, etc.

If you want to practice medicine, you need to be a doctor, or you are lesser. How much lesser doesn't really matter. In a race, you either won, or you lost.

In this case, you either are dedicated or you are not.


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## EMSLaw (Dec 30, 2011)

Veneficus said:


> I don't know what JP has in mind obviously, but the way I understood it is a matter of dedication and time spent.



I can understand that, I suppose, though I think, with all respect, that it's a bad argument in this case.  A NP or PA may be completely devoted to their chosen career.  What they lack is the long period of formal learning that a doctor has.  In the case of the NP, they also lack the doctor's focus on medicine, as differentiated from nursing.  

But that's the same reason that I think the comparison between paid and volunteer providers in this case is a false analogy.  Do you really think that outside people like some of the ones who post here on this forum, the average EMT spends all his waking hours thinking about EMS?  We've often decried the educational standards and the lack of motivation in higher learning from the average EMT on the street.  

The argument JP is raising is a straw man.  "Would you prefer to have a professional, trained, dedicated EMS practitioner, or a (slovenly, untrained, undedicated) volunteer."  It ignores the possibility of the volunteer being just as dedicated, or the 'professional' being a sub-par anything but.  In my experience, there are very professional, highly motivated, well-trained persons in both areas, just as there are people who are nothing more than mouth-breathers with a patch and a pulse.

I'm sorry, but JP's analogy to me reads as an unfair swipe at volunteers.


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## JPINFV (Dec 30, 2011)

EMSLaw said:


> But that's the same reason that I think the comparison between paid and volunteer providers in this case is a false analogy.  Do you really think that outside people like some of the ones who post here on this forum, the average EMT spends all his waking hours thinking about EMS?  We've often decried the educational standards and the lack of motivation in higher learning from the average EMT on the street.



Do I think that the average paid EMT spends every waking hour thinking about medicine? No. However the average full time EMT is going to be taking calls 40 hours a week on average and be in systems that, on average, take more calls than the average volunteer service. Is there overlap between the two? Sure. Are there outliers that makes the analogy less than perfect? Yes. However are you seriously going to tell me that you'd rather have a volunteer than a full time EMT treating you? Sure, the initial training may be the same, but how to you quantify and qualify the experience factor? 



> The argument JP is raising is a straw man.  "Would you prefer to have a professional, trained, dedicated EMS practitioner, or a (slovenly, untrained, undedicated) volunteer."  It ignores the possibility of the volunteer being just as dedicated, or the 'professional' being a sub-par anything but.  In my experience, there are very professional, highly motivated, well-trained persons in both areas, just as there are people who are nothing more than mouth-breathers with a patch and a pulse.



It ignores outliers. It focuses a lot on experience. No where did I mention slovenly as being a factor, unless you're going to argue that the volunteer services, on average, has a volunteer crew manning an ambulance 24/7.


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## JPINFV (Dec 30, 2011)

Veneficus said:


> I don't particularly like the PA position, mostly from my overwhelmingly negative personal interactions with those providers. My opinion on NPs is much better, as I understand not only why they are needed but that they are not playing doctor.



The DNP would like to have a word with you, as long as the cute language like substituting "collaboration" for "supervision."


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## Veneficus (Dec 30, 2011)

EMSLaw said:


> Do you really think that outside people like some of the ones who post here on this forum, the average EMT spends all his waking hours thinking about EMS? .



They do if they want to earn enough to pay rent and eat  

I can't remember the last time I had less than 2 jobs and often landed with 3 to meet ends meet.

I can see your point with the unfair swipe at volunteers, but I think what he was trying to say, at least the way I read it, wasn't what he wrote.


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## Bullets (Dec 31, 2011)

Brandon Oto said:


> Interesting. Titrate according to what?



To relief, instead of giving a patient 15L NRB for chest pain or breathing problem, we can start at 4L NC and increase flow until patient gains relief or we hit 15L NRB


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## Veneficus (Dec 31, 2011)

Bullets said:


> To relief, instead of giving a patient 15L NRB for chest pain or breathing problem, we can start at 4L NC and increase flow until patient gains relief or we hit 15L NRB



ummm....

While I see this as a step in the right direction, I don't think it is going to help with most chest pains or breathing problems.

If a patient does not have a pathology requiring increased oxygen, giving oxygen will not help.


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## Nervegas (Dec 31, 2011)

We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.


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## Veneficus (Dec 31, 2011)

Nervegas said:


> We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.



That is sad, I like dopamine. It is my pressor of first resort.


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## tacitblue (Dec 31, 2011)

Veneficus said:


> Sorry,
> 
> But the idea of a mid level provider serving where physicians are not available has since been perverted; now they  are running around academic facilities providing no better care than a paramedic following protocols (and often with the same attitude).
> 
> ...



I usually find you to be interesting and insightful. This post, however, demonstrates a profound ignorance on the education and roles of midlevel providers. Excluding the current "doctor of nurse practice" crap (which is so ridiculous I don't even need to touch it), PAs and NPs are more than capable of of doing what they do.

I am an adult with congenital heart disease (double chambered right ventricle and VSD, both repaired but with remaining residua). When physicians see the zipper scar on my chest, they are not confident in managing me and do not understand the physiology of my condition. I have had emergency physicians and primary care physicians admit to me that they were out of their comfort zone. I am seen at a major academic center on the west coast for follow up with an adult congenital heart disease program. There exists only a handful of doctors in the United States who are qualified or even interested in seeing adult CHD patients; and there are now more living adults with CHD than children. Many of these people are lost to care and have serious and complex illness that require expert followup. Do you know who I see most of the time? A nurse practitioner. 

Two NPs practice in the program and I cannot even begin to say enough good things about them. They are kind and compassionate, and they have an expert understanding of the complicated issues we face. Most importantly, they extend the reach of expert followup for a growing and vulnerable and patient population. And they do it well.


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## Nervegas (Dec 31, 2011)

Veneficus said:


> That is sad, I like dopamine. It is my pressor of first resort.



I agree, as it is my first choice as well, however, we now only have NS bolus's and if that doesn't work, contact MC for orders to mix up an epi drip.


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## DrankTheKoolaid (Dec 31, 2011)

*re*



Nervegas said:


> We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.



Talk about a contradiction.  AHA just stated Dopamine is an acceptable alternative to TCP.  Has to be more to the story with it being removed, provider misuse maybe.


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## Nervegas (Dec 31, 2011)

Corky said:


> Talk about a contradiction.  AHA just stated Dopamine is an acceptable alternative to TCP.  Has to be more to the story with it being removed, provider misuse maybe.



Don't know about why its being removed, I heard due to cost/waste from underusage. Our protocol covers 6 fire departments and a large Air/Ground EMS service, I would hope that it isn't due to misuse. I do know that for Brady, our MD prefers TCP > Dopamine, it was only used for hypotension in our protocol before this year.


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## Veneficus (Dec 31, 2011)

tacitblue said:


> I usually find you to be interesting and insightful. This post, however, demonstrates a profound ignorance on the education and roles of midlevel providers. Excluding the current "doctor of nurse practice" crap (which is so ridiculous I don't even need to touch it), PAs and NPs are more than capable of of doing what they do.
> 
> I am an adult with congenital heart disease (double chambered right ventricle and VSD, both repaired but with remaining residua). When physicians see the zipper scar on my chest, they are not confident in managing me and do not understand the physiology of my condition. I have had emergency physicians and primary care physicians admit to me that they were out of their comfort zone. I am seen at a major academic center on the west coast for follow up with an adult congenital heart disease program. There exists only a handful of doctors in the United States who are qualified or even interested in seeing adult CHD patients; and there are now more living adults with CHD than children. Many of these people are lost to care and have serious and complex illness that require expert followup. Do you know who I see most of the time? A nurse practitioner.
> 
> Two NPs practice in the program and I cannot even begin to say enough good things about them. They are kind and compassionate, and they have an expert understanding of the complicated issues we face. Most importantly, they extend the reach of expert followup for a growing and vulnerable and patient population. And they do it well.



Thanks for the kind words, but let me just point something out.

Unless I am much mistaken, it was a doctor who diagnosed and initially came up with a treatment plan.

It is an NP (or a couple) who manage and follow up that plan.

I am not saying they do not know something about the very narrow field they operate with, in the same way a paramedic does the same thing in a different field.

The fact there are not enough doctors in any given field is a consequence of the American medical system, not the lack of doctors. I can assure you there are many many qualified doctors interested in all aspects of care who would move to America in a heartbeat and be more than able and willing to treat/manage you.

But you yourself said that these providers only extend expert follow up. 

That is a "better than nothing" argument.

What you have may seem like gold not knowing what you could have.


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## Veneficus (Dec 31, 2011)

Corky said:


> Talk about a contradiction.  AHA just stated Dopamine is an acceptable alternative to TCP.  Has to be more to the story with it being removed, provider misuse maybe.



or lack of use.

Why keep restocking a med that is never used?


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## 18G (Jan 1, 2012)

Nervegas said:


> Don't know about why its being removed, I heard due to cost/waste from underusage.



That sucks dopamine is being taken away. Hope those CHF'ers who really decompensate improve with a 250cc bolus of NSS and aren't overloaded to began with from eating to many McDonalds fries!

Vene, I used dopamine just the other day


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## RocketMedic (Jan 1, 2012)

PAs and NPs are needed. Do you really need ten years of education to order an X-ray, proscribed a medication to treat an uncomplicated patient, or suture? These are paramedic-level skills, or could be. Why not have a PA doing this?


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## JPINFV (Jan 1, 2012)

The trick isn't the uncomplicated patients, but the complicated ones. Especially the complicated ones pretending to be uncomplicated.


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## RocketMedic (Jan 1, 2012)

Agree, but do we really need to dump mid level providers? I don't think so.


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## Veneficus (Jan 1, 2012)

Rocketmedic40 said:


> PAs and NPs are needed. Do you really need ten years of education to order an X-ray, proscribed a medication to treat an uncomplicated patient, or suture? These are paramedic-level skills, or could be. Why not have a PA doing this?



The problem is not treating, it is knowing what you are looking at to start treating properly.

Organ systems are connected, your heart problem causes renal and liver problems, and they all have to be explored in order to come up with the best treatment options.

Then there is the issue of not knowing what you don't know. A problem very obvious in EMS. 

Infact I just a saw a patient a few days ago who was being managed by a medic for his injuries for 16 days on flexeril and motrin. Back pain was still there, and when I ran his kidney function labs, they were all out of whack. 

Why did I run his renal function tests? Because I know ibuprofin affects renal function in high dose. I also understand volume of distribution and pharm kinetics. So I equate long term usage with high dosage.

Paraspinal backpain is rather easy to manage. Sometimes you must change or escalate treatment. Medicine is not one size fits all.

Along the same line, I saw a patient who fell down the stairs, who was managed by a PA for 7 days on the same treatment regiment. WHen I saw him, I reduced his dislocated shoulder, found his clavical fracture, and the intercapsular injury to his wrist.

It was not that the PA made a terrible mistake, he was doing the best with what he had and knew. 

I have and know a little bit more. 

But it doesn't change that he would have been better off coming to me first. Laying 7 days in your bed with pain, a fx, dislocation, and likely second fx which is not diagnosable until bone healing is seen on x-ray weeks later, taking 800mg motrin, the PA as the provider of first resort is simply not good enough. (especially when he thought it was just a muscle-skeletal injury)

Like I said, the PA did his exam, started following his normal management routine, and didn't even know about the specifics of the wrist injury. He cannot be faulted.

(Those are the most recent stories, but I have many more.)

Simple is not always as simple as it looks.

Another true story, pt diagnosed with topical dermatitis, managed appropriately for such condition without improvement for years. 

Final diagnosis when symptoms failed to resolve? Follicular Muscinosis, a precursor legion to T-cell lymphoma.

Do you think that changes treatment and severity?

I can train any paramedic to treat simple problems, it doesn't require a "mid level" provider. That makes them an unecessary expense. But I cannot "train" somebody to critically think about conditions and complications they have never heard about. Similarly a person cannot be trained to think about unusual presentations or unknown origins unless they have extensive understanding on the workings of the whole body. 

That is a body of knowledge unique to medical education.

When a PA or NP Dx renal stenosis as a cause of HTN (a rather common problem) you know the treatment?

Refer to physician.

Then treatment begins. 

In such cases, and there are many more, the mid level provider is just a waste of time and money before the patient sees a doctor.


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## the_negro_puppy (Jan 1, 2012)

They have started opening family medicine clinics staffed primarily by NPs here, its only slightly cheaper to see them. I would never go- when I can pay slightly more to see a physician who's scope of prescription, practice and education inst limited.


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## tacitblue (Jan 1, 2012)

Veneficus said:


> Thanks for the kind words, but let me just point something out.
> 
> Unless I am much mistaken, it was a doctor who diagnosed and initially came up with a treatment plan.
> 
> ...


I don't disagree; I think mid levels extend the care of physicians. I would never go to a solo NP clinic for follow up on a complex issue or even a simple one. But when they are acting within their ability to be a force multiplier, I don't think it's much of a problem. 

As for primary care and EM, you present an interesting point about PA/NP not having the level of education for the sheer breadth of these specialties. The NP at the CHD center can focus all her energy in learning from her expert attendings how to manage heart defects but can she diagnose the zebra masquerading as a common complaint in a primary care clinic. I don't think we disagree much, it just seems you may be a little unduly harsh towards the idea of PAs and NPs.


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## R99 (Jan 1, 2012)

Here in NZ we have strongly resisted the "mid level" as you call it; we do not have PA, nurse anaesthetist etc.  We have a tiny number of NPs (about forty) and the majority work in community diabetes care or hospital.  To give NPs the extremely limited prescribing rights some do have was horrendous exercise that took years.

A small pilot of PA in Auckland has been fiercly disdained by Medical and Nursing Councils.  We have approaching a big shortage of anaesthetists but the College of Anaesthetists has ruled out a nurse/PA anaesthetist provider, even if "supervised" by a physician who might float across several theatres likr in Sweeden.


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## RocketMedic (Jan 1, 2012)

Venificus, you sound like a...hmmm...paramedic at one point who is now a doctor and used to be a Doc? Good guess?


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## Veneficus (Jan 1, 2012)

Rocketmedic40 said:


> Venificus, you sound like a...hmmm...paramedic at one point who is now a doctor and used to be a Doc? Good guess?



The details of my resume are not for public consumption, it is considerable, expands now 5 countries and multiple states in the US.


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## Veneficus (Jan 1, 2012)

tacitblue said:


> it just seems you may be a little unduly harsh towards the idea of PAs and NPs.



I reserve a special place in my heart for people who give a hard time to medics but basically practice glorified cookbook medicine in a narrow specialty with a few more pathways to follow on their treatment protocols.


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## Outbac1 (Jan 1, 2012)

We are having many of our medical protocals changed to guidelines.  A much less rigid structure. Instead of "Do this, this and this" It will now be "Consider this, this and this". Thus allowing the paramedic to think and do what they think is best for the patient.


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## exodus (Feb 7, 2012)

Our protocols are no longer going to be guidelines. They are now going to be directions to apply treatment as medically indicated. WHICH THOUGH, means we can use a drug for something not on our protocol, but we simply need to get an order first.


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## DesertMedic66 (Feb 7, 2012)

exodus said:


> Our protocols are no longer going to be guidelines. They are now going to be directions to apply treatment as medically indicated. WHICH THOUGH, means we can use a drug for something not on our protocol, but we simply need to get an order first.



Looks like I'm gonna start using morphine on BLS haha


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## exodus (Feb 7, 2012)

firefite said:


> Looks like I'm gonna start using morphine on BLS haha



There was also another line that said we had to stay within our SOP


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## DesertMedic66 (Feb 7, 2012)

exodus said:


> There was also another line that said we had to stay within our SOP



I take the class next Thursday so I guess I'll find out


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## exodus (Feb 7, 2012)

firefite said:


> I take the class next Thursday so I guess I'll find out



Be sure to be prepared to do a NREMT medical / Trauma assessment. A few people failed and had to re-test the skills station again.


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## DesertMedic66 (Feb 7, 2012)

exodus said:


> Be sure to be prepared to do a NREMT medical / Trauma assessment. A few people failed and had to re-test the skills station again.



Not a problem at all seeing how I am a NREMT skills instructor up at college. Thanks for the heads up tho.


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