# Capnography for EMT-B, a useful tool?



## beaucait (Jan 20, 2018)

Capnography has been said to be useful, but its not in Maine EMS protocol for basics. There is nothing wrong with reading a waveform if you are trained to do so. What do you think? Is it helpful? What scenario would you think this to be most helpful? Where do you think it would not be useful? Do you think BLS should use it every call? Could using waveform interpretations at the BLS level save medics some work? I mean we are all in this together.


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## Jim37F (Jan 20, 2018)

Considering SpO2 pulse oximetery monitoring isn't even universally in BLS protocols, I'd sooner start there vs trying to get capnogrophy added....heck there's still some BLS transport services without AEDs even!

But otherwise, it's a noninvasive monitoring system, and has value, and isn't hard to learn....so I don't see why it can't be added..


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## beaucait (Jan 20, 2018)

Jim37F said:


> Considering SpO2 pulse oximetery monitoring isn't even universally in BLS protocols, I'd sooner start there vs trying to get capnogrophy added....heck there's still some BLS transport services without AEDs even!
> 
> But otherwise, it's a noninvasive monitoring system, and has value, and isn't hard to learn....so I don't see why it can't be added..


I mean I do come from a non-transporting EMS service... we gotta have something to play with on the monitor.

I think in some situations with one should come the other. The SpO2 only measures how much of whatever is attached to the blood... whether it be CO2 or O2 it doesn't discriminate. If we added caponography it might give us an edge to determine if there is CO2 retention or not... 

but I'm just a basic what do I know?


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## Gurby (Jan 20, 2018)

beaucait said:


> The SpO2 only measures how much of whatever is attached to the blood... whether it be CO2 or O2 it doesn't discriminate. If we added caponography it might give us an edge to determine if there is CO2 retention or not...
> 
> but I'm just a basic what do I know?









Also $$$$$$$$$$$$$$$$$$$$$$$

But I agree that capnography is the bomb.


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## VentMonkey (Jan 20, 2018)

beaucait said:


> Capnography has been said to be useful, but its not in Maine EMS protocol for basics. There is nothing wrong with reading a waveform if you are trained to do so. What do you think?


Define “trained to do so”.


beaucait said:


> Is it helpful?


Yes, with the right patient it is an extremely useful diagnostic tool.


beaucait said:


> What scenario would you think this to be most helpful?


Any scenario in which ventilatory status can be indicative of an outcome, is compromised, and/ or can be utilized to guide your differential diagnosis. Since you’re the basic asking us, why don’t you tell us where _you’d_ use it?


beaucait said:


> Do you think BLS should use it every call?


Absolutely not, nor should every paramedic.


beaucait said:


> Could using waveform interpretations at the BLS level save medics some work?


Eh, no more than it saves work for hospital staff when it’s performed by paramedics.

Again, the prudent clinician realizes and appreciates its value and can allow it to guide them down the proper treatment algorithms.


beaucait said:


> The SpO2 only measures how much of whatever is attached to the blood... whether it be CO2 or O2 it doesn't discriminate.


SPO2 gives a somewhat hindered value of oxygenated Hgb. CO2 doesn’t have a whole lot to do with oxygenation, and is indicative of a patient’s ventilatory status. This may or may not be hindered by several factors (e.g., underlying medical conditions be it metabolic, respiratory, or anything in between).

SPO2= oxygenation; CO2= ventilation. A relevantly important distinction.

“Something to play with” is absolutely not the right reason to ask for an expanded scope without understanding the value of said diagnostic tool. This goes for all of us and does our respective field no justice in general.

I’m not saying EMT’s shouldn’t be allowed to understand, play with, or have ETCO2 monitoring, but perhaps a biiit more education is needed at the entry level to a basics training before this is universally adopted.


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## E tank (Jan 20, 2018)

How would it change what you do for the patient that you wouldn't do from your physical exam?


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## CALEMT (Jan 20, 2018)

I'm all for EMT's having cool tools to do the job such as capnography. But in what scenario(s) would you use this in? Would it make your treatment any different at the BLS level? I don't know your protocols and what you can and can't do for treatments. Like others have said it's a great tool to see the pt's ventilatory status and can affect treatments at the ALS level. It's a great tool thats relatively easy to learn, but an expanded knowledge of capnography and the pathophysiology behind ventilation is needed.


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## NomadicMedic (Jan 21, 2018)

I could see it being used a predictive tool for ROSC during a BLS resuscitation, but aside from that, not particularly useful in the BLS world. 

Having said that, I’d rank capno as one of te top 5 EMS innovations of the last 20 years.


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## EpiEMS (Jan 21, 2018)

Capnography is basically required for ETI, right? Wouldn’t it be necessary for SGAs? 

OP, are you guys dropping Kings, Combis?


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## VentMonkey (Jan 21, 2018)

EpiEMS said:


> Capnography is basically required for ETI, right? Wouldn’t it be necessary for SGAs?


Yep, but why not BVM as well?


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## EpiEMS (Jan 21, 2018)

VentMonkey said:


> Yep, but why not BVM as well?



Absolutely - it's  the gold standard for measuring real-time efficacy of our artificial ventilation. That said, never seen a BLS agency (without SGAs) that had ETCO2 monitoring capability.

If I were in charge (here's hoping), I'd make SpO2 and ETCO2 mandatory for BLS - it really does help us bag better! (Though I've only used ETCO2 to guide my BVM use on an intubated patient.)


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## VentMonkey (Jan 21, 2018)

@EpiEMS you’re not quite the “typical” basic.

Now- I don’t mean this as an insult, and I will readily admit that as a tech I would have been ill-prepared to understand its true value. But again, without understanding the ins and outs of both oxygenation and ventilation as well as where, how, and when to implement such tools to their fullest potential, would it be worth said agency’s investment to allow their BLS providers to carry them?

Clearly, it’s of great benefit to the patient and provider for reasons you’ve pointed out, but when it’s just seen as a “cool tool” to play with would you agree that your peers in general are ready to understand and appreciate its capabilities, let alone allow it to guide the therapies that they’d provide?

And why not in-line ETCO2 NC’s as well? But again, are—or will—they being implemented to the right patient, at the right time, for the right reasons and not just applied blindly to every patient (shakes head)?...**ahem**c-spine anyone?


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## Alan L Serve (Jan 21, 2018)

It's outside the scope of EMT Basics.


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## Alan L Serve (Jan 21, 2018)

VentMonkey said:


> SPO2= oxygenation; CO2= ventilation. A relevantly important distinction.


Go back to school and learn what ventilation vs respiration is. That is a relatively much more important distinction.


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## CALEMT (Jan 21, 2018)

Alan L Serve said:


> Go back to school and learn what ventilation vs respiration is. That is a relatively much more important distinction.



Ummmmm you are aware that SpO2 is infact oxygenation and CO2 is ventilation right?


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## Alan L Serve (Jan 21, 2018)

CALEMT said:


> Ummmmm you are aware that SpO2 is infact oxygenation and CO2 is ventilation right?


Production of CO2 is not ventilation. It's respiration. A subtle but important distinction.


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## VentMonkey (Jan 21, 2018)

For simplicity’s sake I referred to both so that the OP could keep in mind the distinction between the two: SPO2 and CO2 respectively.

While you may have a point @Alan L Serve, given your history on here I’m not feeding into your posts. And last time I checked, CO2 is a _byproduct_ of the respiratory system and their mechanics (i.e., ventilation).


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## Alan L Serve (Jan 21, 2018)

VentMonkey said:


> For simplicity’s sake I referred to both so that the OP could keep in mind the distinction between the two: SPO2 and CO2 respectively.
> 
> While you may have a point @Alan L Serve, given your history on here I’m not feeding into your posts. And last time I checked, CO2 is a _byproduct_ of the respiratory system.


CO2 is part of respiration, not ventilation. It's very surprising anyone claiming to be a paramedic would make such a novice and rookie mistake. As for your off-topic personal attacks I shall simply ignore them.


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## E tank (Jan 21, 2018)

Alan L Serve said:


> Production of CO2 is not ventilation. It's respiration. A subtle but important distinction.




Reducing cellular respiration to the production of CO2...edgy...subtle isn't the word I'd use...


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## VFlutter (Jan 21, 2018)

Alan L Serve said:


> CO2 is part of respiration, not ventilation. It's very surprising anyone claiming to be a paramedic would make such a novice and rookie mistake. As for your off-topic personal attacks I shall simply ignore them.



Semantics. Respiration does not happen to any significant degree without ventilation. Unlike oxygens ability to easily diffuse CO2 requires convection and dead space ventilation.


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## hometownmedic5 (Jan 21, 2018)

In the setting of a BLS provider that is trained to incubate or place and SGA, I can see it’s value and it should be mandatory.

Otherwise, there are so many things I’d like to see be universally equipped on all BLS trucks long before capnography that could actually advance the rank(SpO2, nebulizers, glucometers, AEDs, CPAP just to list a few)...


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## E tank (Jan 21, 2018)

hometownmedic5 said:


> In the setting of a BLS provider that is trained to incubate or place and SGA, I can see it’s value and it should be mandatory.
> 
> Otherwise, there are so many things I’d like to see be universally equipped on all BLS trucks long before capnography that could actually advance the rank(SpO2, nebulizers, glucometers, AEDs, CPAP just to list a few)...



At some point, BLS becomes ALS with all that. More stuff, at one point or another, introduces variables that more stuff is required to deal with. But maybe ALS by degrees is the way some service areas get up to speed...


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## Alan L Serve (Jan 21, 2018)

VFlutter said:


> Semantics. Respiration does not happen to any significant degree without ventilation. Unlike oxygens ability to easily diffuse CO2 requires convection and dead space ventilation.


Certainly not semantics nor can I parse why you think so. Ventilation is entirely mechanical. Respiration is physiological.


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## CALEMT (Jan 21, 2018)

hometownmedic5 said:


> CPAP



CPAP is pushing it in my book.


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## DesertMedic66 (Jan 21, 2018)

CALEMT said:


> CPAP is pushing it in my book.


CPAP is already in the book for EMTs. We are teaching CPAP this semester to the EMT students.


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## CALEMT (Jan 21, 2018)

DesertMedic66 said:


> CPAP is already in the book for EMTs. We are teaching CPAP this semester to the EMT students.



Wow, disregard then.


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## DesertMedic66 (Jan 21, 2018)

CALEMT said:


> Wow, disregard then.


Yep. This semester we are having to add in CPAP, Narcan IM/IN, and Epi 1/1000 IM to the EMT course.


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## CALEMT (Jan 21, 2018)

DesertMedic66 said:


> Yep. This semester we are having to add in CPAP, Narcan IM/IN, and Epi 1/1000 IM to the EMT course.



State changing the scope of practice for EMT's or just allowing EMT's to assist paramedics with those listed.


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## DesertMedic66 (Jan 21, 2018)

CALEMT said:


> State changing the scope of practice for EMT's or just allowing EMT's to assist paramedics with those listed.


CPAP and Narcan IM/IN are already in the state scope for EMTs. There has been a lot of talk about allowing Epi IM due to the cost of the Epi pens. ICEMA, at least during their meetings, is really wanting to expand the EMT scope to the max it can be so we are having to add in extra time/classes to the EMT program. So you have the normal EMT class and we add in HazMat FRA, bloodborne/airborn pathogens, and CPR. Now we are having to add in a 8-16 hour documentation class, 8-16 hour modified TECC/TCCC class, and a pharm/med admin class.


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## CALEMT (Jan 21, 2018)

DesertMedic66 said:


> CPAP and Narcan IM/IN are already in the state scope for EMTs. There has been a lot of talk about allowing Epi IM due to the cost of the Epi pens. ICEMA, at least during their meetings, is really wanting to expand the EMT scope to the max it can be so we are having to add in extra time/classes to the EMT program. So you have the normal EMT class and we add in HazMat FRA, bloodborne/airborn pathogens, and CPR. Now we are having to add in a 8-16 hour documentation class, 8-16 hour modified TECC/TCCC class, and a pharm/med admin class.



Funny how things change in the 5 years its been since I was in EMT school.


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## DrParasite (Jan 22, 2018)

I would love to see capnography added to the emt scope.  It would help guide treatments for asthma and other breathing problems, cardiac arrest, co poisining, and probably any other complaint involvng breathing problems.

Capnography doesnt need to require a life pack, they do sell smaller models similar to an old pulse ox device.

CPAP, IM epi, narcan, Albuterol, benedry,l SGA,  these things used to be paramedic only and now people are seeing that EMT can give them too and adding to the emt scope in several areas.  I wonder what else will be added in the future


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## Carlos Danger (Jan 22, 2018)

I have heard of systems that did not allow EMT's to use pulse oximetry. I used to think that was absurd, but I can see how a system would prefer folks with as little training as EMT's have to allow basic clinical signs (obvious dyspnea or wheezing, skin color) to guide protocol selection rather than imperfect technology. I think the same can be said for capnography. 

If a system has the resources to ensure that the EMT's are well trained in it's use, then why not. On the other hand, I can't think of any instance in which I think it would be necessary or appropriate for an EMT to use capnography to guide treatment. EMT protocols really should be "See A —> do B. See C —> do D" without a whole lot of room for diagnostic interpretation. Not to be insulting to EMT's (I've actually argued many times that I think in most systems, having well trained and equipped EMT's is more important than deploying as many paramedics as possible, and I think the research generally backs that up), but we do have to be realistic about the very limited education they get.     

Generally speaking though, I think capnography is overrated in terms of it's usefulness as a diagnostic tool in a non-intubated patient, anyway.


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## EpiEMS (Jan 22, 2018)

VentMonkey said:


> just seen as a “cool tool” to play with would you agree that your peers in general are ready to understand and appreciate its capabilities, let alone allow it to guide the therapies that they’d provide?



Most of my peers could handle it if there were enough in-services 
But seriously, I agree that we're pushing the limits of EMT knowledge with ETCO2.



DesertMedic66 said:


> So you have the normal EMT class and we add in HazMat FRA, bloodborne/airborn pathogens, and CPR. Now we are having to add in a 8-16 hour documentation class, 8-16 hour modified TECC/TCCC class, and a pharm/med admin class



You know, many folks on the board have said that AEMT should be the baseline for 911 response. With all of the additions to EMT that I see in a lot of places (CPAP, IM epi, glucometry, SGAs), I'm almost getting to the point of saying that EMT response is sufficient for the bulk of emergency calls in urban & suburban areas...


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## DrParasite (Jan 22, 2018)

in the next county over from me (actually, they are northeast, but minor details), they use ETCO2 on every asthma patient.  if the patient is wheezing, and the display shows a shark fin, give albuterol.  if it doesn't, CPAP.  Their clinical coordinator was trying to find a way to add it to their treament protocols.... so what did he do?  he added pictures to the flowcharts, and got them approved for the state DOH.  as Remi just said:





Remi said:


> EMT protocols really should be "See A —> do B. See C —> do D" without a whole lot of room for diagnostic interpretation.


If you hear wheezing and a shark fin, give albuterol.  if you hear wheezing and no shark fin, CPAP.  And both CPAP and albuterol in in the EMT's scope of practice here.

While I do think that EMT training is still lacking in many ways, many items that used to be paramedic only are now being given to EMTs.  How long ago was defibrillation a paramedic only skills?  and now AEDs are everywhere.  And yes, there are still places where EMTs aren't allowed to use a pulse ox.... but why are we handicapping providers? If it's a new tool they can use to assess, why not let them use it?


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## ThadeusJ (Jan 22, 2018)

My two cents (please forgive me)...respiration is the physiological occurrence of cellular mitochondria using an electron from an oxygen atom for the purpose of reducing ATP to ADP and energy (via Krebs Cycle, glycolysis and oxidative phosphorylation depending on certain factors and what's on the test that day).  To measure that you need a metabolic cart and a whole lot of inputs and assumptions.  In the process of respiration, CO2 is created.  ETCO2 measures the amount of CO2 being exhaled from the body and can be used to assess the body's ability to remove it via ventilation.  Those who rely on ETCO2 to measure respiration or ventilation use a series of assumptions to create the inference between the two (ETCO2 and its association to cellular respiration versus ETCO2 and its association to ventilation).  In the case of malignant hyperthermia where the cells go into overdrive, ETCO2 will indeed increase in the presence of normal ventilatory status.  Likewise, ETCO2 values will change with changes in ventilatory status.

Regarding CPAP as a BLS tool, New York has allowed CPAP with BLS crews for a couple of years now.  A study in Ontario, Canada in 2012 determined that the skill set was appropriate in primary care paramedics (not sure how that translates to all US-based BLS crews).  Regardless, if applying CPAP for indications of respiratory failure, one would think that ETCO2 (and thorough training) should be available to assess the efficacy of such therapy.


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## NomadicMedic (Jan 22, 2018)

I think the obstructive vs nonobstructive waveform morphology is a fair method for guiding treatment. Obviously a paramedic with clinical judgement and critical thinking skills will put it all together, but it can certainly help newer medics or point you in the right direction at 4am. 

We talk an awful lot about cognitive offloading and using diagnostic tools to help you make decisions without having to commit all of your focus is a great way to head down that road.


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## VentMonkey (Jan 22, 2018)

I would think that universal adoption of CPAP at the EMT level would prove to be much more beneficial than CO2 monitoring with regard to patient outcomes.

As far as the expanded formulary for EMT, it does seem much more fitting to merge the EMT/ AEMT training and education altogether. 

@DesertMedic66 are they adding extended, and more in-depth curriculum to the EMT course where you teach?


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## EpiEMS (Jan 22, 2018)

VentMonkey said:


> I would think that universal adoption of CPAP at the EMT level would prove to be much more beneficial than CO2 monitoring with regard to patient outcomes.



I'm up for anything to cut the number of field intubations.


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## DrParasite (Jan 22, 2018)

I can tell you we don't go in depth in cellular respiration at the EMT course that I teach..... and if the instructor does decide to supplement it (because it's pretty important information), most students won't pay attention because the chance of it being on an exam is low.


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## VentMonkey (Jan 22, 2018)

DrParasite said:


> I can tell you we don't go in depth in cellular respiration at the EMT course that I teach..... and if the instructor does decide to supplement it (because it's pretty important information), most students won't pay attention because the chance of it being on an exam is low.


So as an EMT instructor what do you make of all of this?

Do you think your students are, in general, ready for these added skills?

How much more training and education is needed at the EMT-level vs. when do we abolish both EMT and AEMT to create one “basic” level of provider prior to paramedic?

I like the honest answer, and quite frankly this is very much a problem with most things scholastically. We learn just enough to get by, right?


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## OREMT (Jan 22, 2018)

On our BLS truck we use ETCO2 as a diagnostic tool in our sepsis protocol. While monitoring ETCO2 won't necessarily change the care I provide this patient as an EMT-B, it does factor into my decision to request ALS or not.  If I'm already transporting, an ETCO2 of <25 mmHg, plus other signs of infection, necessitates a sepsis alert notification to the ED. In this capacity I think ETCO2 is very helpful for the BLS provider.


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## NomadicMedic (Jan 22, 2018)

While I think ETCO2 may be nice to have as a basic (more toys, yay!) I don’t belive it’s necessary and may take the EMTs focus off more important tasks. 

If you have interventions that can be steered by capno, then it’s useful. No basics I know of do. A “sepsis alert” precipitated by ETCO2 on a basic truck is next to useless. If you want to make an early call and if you’re thinking sepsis, you can clinically correlate your hunch with the Prehospital Early Sepsis Detection Score, and if you really want to get high speed, use the amended PRESEP score with glucose. 

Oh wait, you don’t know about those? You don’t know how to use critical thinking to suss out a field impression? But you want ETCO2?

Uhh, no. 

Drive to the hospital.


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## EmergencyMedicalSike (Jan 22, 2018)

This reminds me of a discussion a few of us had at our station. Nothing really stops basics from taking ACLS except maybe an ECG and pharm class and that’s pretty simple. So you have your ACLS card now and can interpret pretty basic cardiac rhythms. Does that mean EMT’s with ACLS should get to use monitors? Nope. 
Although learning the bells and whistles of how a monitor works is pretty simple and you have knowledge of rhythms as a basic, there’s nothing in your scope of practice you can do if you spot an arrhythmia or other abnormal rhythms. Just like ETCO2, you can learn how to work with it and get good at it, but your scope doesn’t allow you to do s**t with it if the pt goes bad. So giving these things to basics is essentially a waste of money in the end.


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## EpiEMS (Jan 22, 2018)

EmergencyMedicalSike said:


> but your scope doesn’t allow you to do s**t with it if the pt goes bad.



I gots' me an AED, I can fix two major problems right there.



EmergencyMedicalSike said:


> but your scope doesn’t allow you to do s**t with it if the pt goes bad. So giving these things to basics is essentially a waste of money in the end.



Sure it does. I've got a BVM, some OPAs, some NPAs...it's the rare airway problem that I can't fix for a bit. And ETCO2 helps me to make sure I'm bagging correctly.


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## NomadicMedic (Jan 22, 2018)

EmergencyMedicalSike said:


> This reminds me of a discussion a few of us had at our station. Nothing really stops basics from taking ACLS except maybe an ECG and pharm class and that’s pretty simple. So you have your ACLS card now and can interpret pretty basic cardiac rhythms. Does that mean EMT’s with ACLS should get to use monitors? Nope.
> Although learning the bells and whistles of how a monitor works is pretty simple and you have knowledge of rhythms as a basic, there’s nothing in your scope of practice you can do if you spot an arrhythmia or other abnormal rhythms. Just like ETCO2, you can learn how to work with it and get good at it, but your scope doesn’t allow you to do s**t with it if the pt goes bad. So giving these things to basics is essentially a waste of money in the end.




Or a waste of resources. A patient in Afib is not necessarily a medical emergency. I saw basics with a monitor sit on scene for more than 45 minutes with a syncope patient that was in Afib, waiting for a medic to show up. (It was Skyway, for @FLMedic311)

Patient had vagaled down after a particularly strenuous BM. As the “private ambulance EMT” (or stretcher fetcher) I sat there, twiddled my thumbs and watched the volunteer fire EMTs, who should not have put the patient on the monitor to begin with, hem and haw over an ECG that they couldn’t discern. 

No. You don’t get more toys.


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## E tank (Jan 22, 2018)

As someone with handy access to ETCO2 that mask ventilates people everyday, I have to say that I never, not ever, even look at the ET monitor. I feel the compliance of the bag, I watch the chest rise and fall, I fix any problems with mask seal and I see if an oral airway helps with either one.


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## DesertMedic66 (Jan 22, 2018)

EpiEMS said:


> You know, many folks on the board have said that AEMT should be the baseline for 911 response. With all of the additions to EMT that I see in a lot of places (CPAP, IM epi, glucometry, SGAs), I'm almost getting to the point of saying that EMT response is sufficient for the bulk of emergency calls in urban & suburban areas...


The more stuff that is added makes me want to agree and I know a ton of EMTs who would do amazing in that setting however I would want to make the EMT program more than 120 hours and only 12 hours of field/clinical time (which is the bare minimum here).


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## EmergencyMedicalSike (Jan 22, 2018)

EpiEMS said:


> I gots' me an AED, I can fix two major problems right there.
> 
> 
> 
> Sure it does. I've got a BVM, some OPAs, some NPAs...it's the rare airway problem that I can't fix for a bit. And ETCO2 helps me to make sure I'm bagging correctly.


Well rhythms aside from v-fib and pulseless v-tach which are the only ones you’re supposed to shock. And I’m sure even EMT’s should know what v-fib and v-tach looks like


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## EmergencyMedicalSike (Jan 22, 2018)

NomadicMedic said:


> Or a waste of resources. A patient in Afib is not necessarily a medical emergency. I saw basics with a monitor sit on scene for more than 45 minutes with a syncope patient that was in Afib, waiting for a medic to show up. (It was Skyway, for @FLMedic311)
> 
> Patient had vagaled down after a particularly strenuous BM. As the “private ambulance EMT” (or stretcher fetcher) I sat there, twiddled my thumbs and watched the volunteer fire EMTs, who should not have put the patient on the monitor to begin with, hem and haw over an ECG that they couldn’t discern.
> 
> No. You don’t get more toys.


Woah what? Basics with a monitor? Where is this magical county


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## DesertMedic66 (Jan 22, 2018)

VentMonkey said:


> I would think that universal adoption of CPAP at the EMT level would prove to be much more beneficial than CO2 monitoring with regard to patient outcomes.
> 
> As far as the expanded formulary for EMT, it does seem much more fitting to merge the EMT/ AEMT training and education altogether.
> 
> @DesertMedic66 are they adding extended, and more in-depth curriculum to the EMT course where you teach?


CA state mandates about 120 hours and a single 12 hour field/clinical shift. My college is currently at about 180 hours of lecture and 48 hours of field/clinical shift. With the new courses we are having to add it is going to push us over 200 hours in lecture. 

Our program director is involved pretty deeply in NREMT so we follow the national standards as a minimum. We would love to add lecture hours but have been getting some push back from the college. The college will not allow us to increase the field/clinical shifts due to insurance reasons.


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## NomadicMedic (Jan 22, 2018)

EmergencyMedicalSike said:


> Woah what? Basics with a monitor? Where is this magical county



South King County Washington. The fire EMTs had a LP12 to be used as an AED in advisory mode.


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## FLMedic311 (Jan 22, 2018)

NomadicMedic said:


> Or a waste of resources. A patient in Afib is not necessarily a medical emergency. I saw basics with a monitor sit on scene for more than 45 minutes with a syncope patient that was in Afib, waiting for a medic to show up. (It was Skyway, for @FLMedic311)
> 
> Patient had vagaled down after a particularly strenuous BM. As the “private ambulance EMT” (or stretcher fetcher) I sat there, twiddled my thumbs and watched the volunteer fire EMTs, who should not have put the patient on the monitor to begin with, hem and haw over an ECG that they couldn’t discern.
> 
> No. You don’t get more toys.



To Skyways credit, I do have to say that a few months ago they correctly identified a 3rd degree HB on a otherwise asymptomatic Pt and requested us for eval.  The initial complaint was weakness x3 days.  But to your point I totally agree that often less is more.  Also agree that ETCO2 in BLS is probably not beneficial


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## FLMedic311 (Jan 22, 2018)

EmergencyMedicalSike said:


> Woah what? Basics with a monitor? Where is this magical county



I could be incorrect on this but I believe the primary reason for the BLS units with LPs is for the voice recording feature that we utilize for review of cardiac arrests


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## NomadicMedic (Jan 22, 2018)

NomadicMedic said:


> South king County Washington. The fire EMTs had a LP12 to be used as an AED.





FLMedic311 said:


> To Skyways credit, I do have to say that a few months ago they correctly identified a 3rd degree HB on a otherwise asymptomatic Pt and requested us for eval.  The initial complaint was weakness x3 days.  But to your point I totally agree that often less is more.



Was Mace the EMT? He went to medic school with me.


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## Gurby (Jan 22, 2018)

E tank said:


> As someone with handy access to ETCO2 that mask ventilates people everyday, I have to say that I never, not ever, even look at the ET monitor. I feel the compliance of the bag, I watch the chest rise and fall, I fix any problems with mask seal and I see if an oral airway helps with either one.



That's the thing though - you do this every day.  For us mere mortals who will probably BVM fewer people in a career than you do in a month, 1-person BVM technique is not so easy.  I didn't realize how much I sucked at it until my OR time during paramedic school when I could look at the monitor and see what was going on.  

On the other hand, rather than give emt-b's monitors and ETCO2 to help them with a skill they'll never ever get enough experience with to become proficient at, the better solution is probably to just push using 2-person BVM technique and King tubes.


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## FLMedic311 (Jan 22, 2018)

NomadicMedic said:


> Was Mace the EMT? He went to medic school with me.


To be quite frank I do not remember the names of the guys that were on the crew, they seemed jam up though, we had quite a few sick calls with them that day.  I do wanna say I recall one of them having been to medic school.. that sounds familiar, but I could be making that up in my head..


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## NomadicMedic (Jan 22, 2018)

FLMedic311 said:


> I could be incorrect on this but I believe the primary reason for the BLS units with LPs is for the voice recording feature that we utilize for review of cardiac arrests



Yes. That’s what I was told too. Some of those audio recordings were great. Although, I know Physio was making simple AEDs with a voice recorder in them. I think consistency across all of the agencies was a big consideration when the ROC study was just getting underway.


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## VentMonkey (Jan 22, 2018)

Am I the only one who wonders if any of these shiny new, overzealous posters ever actually listen to the dialogue on here, and then go on to become quite the astute provider?...

I know if I had access to these sorts of forms, podcasts, and the general plethora of FOAM-ed when I was a noob I’d keep my Google-Fu, and YouTube University skills current as well.


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## Carlos Danger (Jan 22, 2018)

DrParasite said:


> if the patient is wheezing, and the display shows a shark fin, give albuterol.  if it doesn't, CPAP.



Exactly my point. It isn’t quite that simple in practice. A better approach is to go by history.


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## EmergencyMedicalSike (Jan 22, 2018)

FLMedic311 said:


> I could be incorrect on this but I believe the primary reason for the BLS units with LPs is for the voice recording feature that we utilize for review of cardiac arrests


To be honest though I wouldn’t mind being assigned a LP to practice interpreting patient’s rhythms. But then again, wasteful resources


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## NomadicMedic (Jan 22, 2018)

EmergencyMedicalSike said:


> To be honest though I wouldn’t mind being assigned a LP to practice interpreting patient’s rhythms. But then again, wasteful resources



Why? Why not just look at 6 second ECG or any of the dozens of other training tools out there.


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## VFlutter (Jan 22, 2018)

EmergencyMedicalSike said:


> To be honest though I wouldn’t mind being assigned a LP to practice interpreting patient’s rhythms. But then again, wasteful resources



Go shadow a hospital monitor tech for a couple shifts.


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## E tank (Jan 22, 2018)

Gurby said:


> That's the thing though - you do this every day.  For us mere mortals who will probably BVM fewer people in a career than you do in a month, 1-person BVM technique is not so easy.  I didn't realize how much I sucked at it until my OR time during paramedic school when I could look at the monitor and see what was going on.



I guess that's the Zen of the thing. The more advanced experts become, the more they come back to the primal fundamentals. They realized it was all  right there in front of them at the beginning and the journey was not to somewhere else but to where they started....or something.

Sorry...just started typing to see where it would lead...carry on...


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## taxidriver (Jan 23, 2018)

I’ve been a basic for a little under a year now. I believe that for most new basics, including myself, we just want to be able to do more. Since I began working I’ve gotten quite a few ALS shifts under my belt and I have come to realize just how huge the gap in education is between basic and medic. Emt classes don’t cover anatomy and physiology sufficiently enough to allow basics to do more advanced skills. Right now, I am capable of performing pulse oximetry, glucometry, SGA’s, Epi, narcan, etc. I am comfortable there. If we are to start pushing the boundaries with things like capnography then I believe that basic programs will need to be re-worked so that they cover more topics and require more clinical hours to hone in on these skills. And at that point, just get your medic license.


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## DrParasite (Jan 23, 2018)

VentMonkey said:


> So as an EMT instructor what do you make of all of this?


you want my honest opinion? the generation of ALS and BLS providers before me (who are now in management positions) scare me because of what their education was lacking in both time and content, yet people didn't die from it, and the up and coming ALS and BLS providers worry me, because they are educated more than in the past, but they don't have the experience in dealing with sick people (especially at the ALS level, because there are so many paramedics and paramedics spend time with not sick patients).  My generation has it's share of special people too, and I'm hoping we we move into the management positions, we can push for change.


VentMonkey said:


> Do you think your students are, in general, ready for these added skills?


I don't think it's complicated as you are making it out to be.  Do I think they will understand all of it?  and retain all of it?  no.  Do I think they can remember that 35 to 45 is where you want to be, if your cardiac arrest has an ETO2 of 5 when you pull up, the odds are he won't be coming back, and if the ETO2 is 60 on said cardiac arrest, than you should probably tell the firefighter to not bag as fast?  sure.  


VentMonkey said:


> How much more training and education is needed at the EMT-level vs. when do we abolish both EMT and AEMT to create one “basic” level of provider prior to paramedic?
> 
> I like the honest answer, and quite frankly this is very much a problem with most things scholastically. We learn just enough to get by, right?


That problem isn't limited simply to EMS; every educational institution has to balance how much information can be delivered, knowing (without continual reinforcement ) the students will only retain about 30% of what was taught.  

Personally, I would love to raise standards, but I know my program is limited by college rules on how many hours the course can be.  I think we are currently capped at 240 (including 24 clinical shifts), so trying to get all the topics covered as well as ensuring competency is tough.  There are only so many hours to work with, so we need to maximize the time we have, and hope that their agency fills in the gaps.


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## DrParasite (Jan 23, 2018)

Remi said:


> Exactly my point. It isn’t quite that simple in practice. A better approach is to go by history.


Last I checked, we don't treat based on history.  So if the person has a cough with a history of asthma, we don't get back to back albuterol treatments.   if the person has rales 3/4 of the way up with no history of CHF, do we not apply cpap despite the lack of history?

I know i probably gave an oversimplification of the process (and I have asked my buddy to send me a picture of the protocol to share), but isn't an objective scientific based assessment typically better than a "well, despite how their presenting, their history says we should treat them with this......."

And Orange County NC has a basic first responding fire department (with a few intermediates on the department) that has lifepak 12s.  and Cary FD are or were running a trial where they are putting lifepak 15s on every first responding apparatus, so if they suspect a STEMI, or are on a call that might be cardiac related, they are to take a 12 lead and transmit it to a doc before the ambulance arrives.  Not saying I agree with the practice, only that it's happening.


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## Carlos Danger (Jan 23, 2018)

DrParasite said:


> *Last I checked, we don't treat based on history.*  So if the person has a cough with a history of asthma, we don't get back to back albuterol treatments.   if the person has rales 3/4 of the way up with no history of CHF, do we not apply cpap despite the lack of history?



Treatment is based on assessment, a large component of which is history. 

So if someone has a history of CHF and are displaying S/S consistent with CHF exacerbation, you would be wise to treat for a CHF exacerbation. 

Albuterol would actually be a perfectly reasonable treatment for an asthmatic who is coughing, if coughing is known to precede an asthma exacerbation in that patient. Again, this would be based on history. That's actually a perfect example of where relying on capnography would lead you wrong.


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## DrParasite (Jan 23, 2018)

Remi said:


> So if someone has a history of CHF and are displaying S/S consistent with CHF exacerbation, you would be wise to treat for a CHF exacerbation.


sure, except in my scenario, there was no history of CHF





Remi said:


> Albuterol would actually be a perfectly reasonable treatment for an asthmatic who is coughing, if coughing is known to precede an asthma exacerbation in that patient. Again, this would be based on history. That's actually a perfect example of where relying on capnography would lead you wrong.


You are doing what I call "assuming facts no in evidence," and adding details to an otherwise strawman argument, to support your case.

I agree 100%, if the patient says "the last time I had ABC, DEF occurred" than it's best to over treat (IE, the last time I had chest pain that felt like this, it turned out to be an MI).  And yes, history is part of your assessment, but patient presentation is actually more important (unless, as you say, there is a clear correlation  of symptom specific to that particular patient).

I guess I should rephrase my earlier statement: "Last I checked, we don't treat based solely on history, unless the patient has a history of the same situation resulting in a known medical condition."  If they have a history of something special (like my 24 year old who complained of a spontaneous pneumo, had a history of one, and said it felt exactly the same as last time), than sure, I would absolutely err on the side of caution, and over treat and advise that based on the history, this is how you are treating it.

I'm pretty sure QA and my medical director would ask me to explain why I gave albuterol to an asthma patient who wasn't wheezing, but only had a cough.  But your MD might be different.


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## Carlos Danger (Jan 23, 2018)

error


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## VentMonkey (Jan 23, 2018)

taxidriver said:


> Right now, I am capable of performing pulse oximetry, glucometry, SGA’s, Epi, narcan, etc. I am comfortable there.


I commend your honesty and humility. Can I ask, are you comfortable with the skills themselves, or are you comfortable enough to admit when they should or should not properly be utilized (e.g., Narcan)? Also, I agree with just about everything you’ve said.

@DrParasite I’m hardly over complicating any of this. Can protocols follow “X,Y,Z” as you and @Remi have eluded to? Sure, but then again that is how many paramedic protocols are written, and look at what a mess it’s gotten our field into.

Guidelines are great for people who truly can read beyond them, but what about the other 80-90% who can’t, both EMT and medic?

As far the generational thing, each and everyone has its troublemakers. I was actually just thinking about this the other day. One of the more respected “ol’ skool” paramedics and I had a nice chat. He’s certainly from a generation before mine, and I am certainly from one before most of our current co-workers.

What I realized was that regardless of the generation, in and of itself, the more inclined you are as an individual to ambitiously pursue continuing educational opportunities, the less it hardly matters how long you’ve been on as a provider. Again, the other 80-90% though; and yes, this is applicable to just about all things in life.

Even those who wish to effect change and implement it can’t do any of it without exemplifying it firsthand; credibility is just about everything in leadership...at least good leadership.


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## DrParasite (Jan 23, 2018)

Narcan is another great example.  When I started, it was a paramedic only drug.  now it's over the counter.





VentMonkey said:


> @DrParasite I’m hardly over complicating any of this. Can protocols follow “X,Y,Z” as you and @Remi have eluded to? Sure, but then again that is how many paramedic protocols are written, and look at what a mess it’s gotten our field into.
> 
> Guidelines are great for people who truly can read beyond them, but what about the other 80-90% who can’t, both EMT and medic?


It is my personal belief (and this is only my opinion) that most EMT protocols should be If you see A, than do B.  relatively rigid, so even the best mongo fireman can follow them and not kill the patient.  Paramedics should have more leeway, because they are more educated, at least compared to EMTs.  Also remember, many of our protocols boil down to lowest common denominator (which is why smaller agencies with very active medical directors can do a lot more, because the medical director knows what the lowest common denominator (which he can keep at a high level) is for his particular group)

It's like IM zofran.  do I wish EMTs could give it to patients who feel like they are going to throw up?  Absolutely.  Are their risks in doing this?  absolutely, and IIRC, with zofran, it's a prolonged QT interval, but realistically, how frequently does it come up?  After all, doctors prescribe PO zofran, and don't need a 12 lead before it's taken, and no one in EMS has ever encountered an instance of asymptomatic issues. So do I think it will happen soon?  no..... in 5 years?  well, 10 years ago, did you think every cop and fireman would be carrying and giving Narcan?

I know I'm preaching to the choir here, but isn't that what QA/QI is supposed to do?  If people are screwing up, either ask that they explain their actions or reeducate them.  Whether it's at the agency level, medical director level, or state level.  My medical director really pushes giving people a lot of leeway in how they treat patients, but that also comes with a lot of oversight to ensure you aren't doing the wrong things.  And if people are making mistakes (it is the practice of medicine, after all), then they should be corrected on a case by case basis.


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## EpiEMS (Jan 23, 2018)

taxidriver said:


> f we are to start pushing the boundaries with things like capnography then I believe that basic programs will need to be re-worked so that they cover more topics and require more clinical hours to hone in on these skills



Those ambulance drivers think they can take blood pressures and put on MAST pants? Bunk, I say, bunk!
 - Some Doc, c. 1969

Standards change over time, and the curriculum grows. And, don't forget, you've already got skills that are more invasive and/or potentially harmful than capnography.


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## Carlos Danger (Jan 23, 2018)

DrParasite said:


> sure, except in my scenario, there was no history of CHFYou are doing what I call "assuming facts no in evidence," and adding details to an otherwise strawman argument, to support your case.



What the heck are you talking about? Providing a counter-example equates to a straw man now?

As usual, you are more focused on looking for ways to "win" the discussion than on understanding the other person's point. I think you just have no idea what I'm talking about, so you attack it.



DrParasite said:


> I'm pretty sure QA and my medical director would ask me to explain why I gave albuterol to an asthma patient who wasn't wheezing, but only had a cough. But your MD might be different.



Again, you completely missed the point. The relevance of an example that someone provides is not contingent on the fact that your agency has so little faith in your judgement. If you can't figure out how my example of the asthmatic relates to the topic at hand, then I don't know what to tell you.


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## taxidriver (Jan 23, 2018)

@VentMonkey I have gotten to use some of the more invasive treatments at my disposal such as CPAP and narcan IN. I did not feel that I was stepping outside of my comfort zone and they improved the patients condition. Can I say that I’m 100% confident in all my skills? Absolutely not. I truly believe that the only way to become comfortable with patient care is by doing it. SGA’s for example. I’ve used them in training a handful of times so I’d be lying if I said I felt comfortable with this skill. However, if I am in a situation without ALS and know that I have to drop a tube then I believe I am capable of doing so. I’m sure my hands will be a little shaky though.


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## CALEMT (Jan 23, 2018)

taxidriver said:


> I’ve used them in training a handful of times so I’d be lying if I said I felt comfortable with this skill. However, if I am in a situation without ALS and know that I have to drop a tube then I believe I am capable of doing so. I’m sure my hands will be a little shaky though.



Training is where you should gain proficiency and being comfortable enough to do a skill. For intubation I knew what anatomical structures to look for, what equipment I preferred for the task (Mac vs Mil), ways to confirm tube placement, and s/s of DOPE. I built up confidence and proficiency in skills from the first time tubing the manakin to having it be muscle memory. Now, fast forward to my OR shift in clinical. We've now graduated to live people. Shaky? Yes. Nervous? Yes. But my confidence wasn't phased by the real deal due to how much I practiced on skills days and I felt comfortable with the skill on a live person.


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## taxidriver (Jan 23, 2018)

EpiEMS said:


> Those ambulance drivers think they can take blood pressures and put on MAST pants? Bunk, I say, bunk!
> - Some Doc, c. 1969
> 
> Standards change over time, and the curriculum grows. And, don't forget, you've already got skills that are more invasive and/or potentially harmful than capnography.


I agree, and I have no problem at all seeing the scope of practice for basics expand as long as it is done right and the curriculum in basic classes expands with it. I have to admit, if SGA’s are a standing order for basics in my area then it makes sense for us to have access to capnography as well. But then I’d like to ask,  doesnt it make more sense for these skills to fall under the advanced or specialist emt’s scope of practice?. I’m clueless when it comes to the advanced emt’s scope of practice as this level of licensure isn’t recognized in my state.


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## taxidriver (Jan 23, 2018)

CALEMT said:


> Training is where you should gain proficiency and being comfortable enough to do a skill. For intubation I knew what anatomical structures to look for, what equipment I preferred for the task (Mac vs Mil), ways to confirm tube placement, and s/s of DOPE. I built up confidence and proficiency in skills from the first time tubing the manakin to having it be muscle memory. Now, fast forward to my OR shift in clinical. We've now graduated to live people. Shaky? Yes. Nervous? Yes. But my confidence wasn't phased by the real deal due to how much I practiced on skills days and I felt comfortable with the skill on a live person.


I can agree with that statement. I guess it all depends on where you took the class. I certainly did not feel like I was given enough time to practice using this skill. However, being able to practice on real people in a clinical setting is invaluable. I would have loved to have been given the oppurtunity to do that although I’m sure SGA’s aren’t as common in OR’s


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## VentMonkey (Jan 23, 2018)

I’m talking about a bit more fundamental education than just the skill itself.

Sure, Narcan can be given by any Joe Blow, but I’m willing to bet that Danny’s Dopefiend’s buddy is better versed in spotting the true signs and symptoms of his pals inevitable respiratory depression-induced OD over said firefighter or cop, or even EMT or paramedic, who “thinks” Narcan “might help”.

Not to mention D. Dopefiend telling his buddy “not to blow his high unless...”

Example- a righteously obvious heroin OD I had when we barely began switching to King airways was met by a FF asking me if I wanted to place a King in as soon as we stepped in the door.

This is what I am talking about, and again, it isn’t something some paramedics never learn from, or grow out of themselves. So, if providers at my level still struggle with basic critical thinking skills, why do EMT’s, cops, and firefighters need expanded scope? A fair question, IMO.


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## VFlutter (Jan 23, 2018)

taxidriver said:


> I would have loved to have been given the oppurtunity to do that although I’m sure SGA’s aren’t as common in OR’s



Actually many OR cases are done with LMAs. I put down a ton during my OR clinical.


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## DrParasite (Jan 24, 2018)

VentMonkey said:


> Example- a righteously obvious heroin OD I had when we barely began switching to King airways was met by a FF asking me if I wanted to place a King in as soon as we stepped in the door.


It's a new toy, and one he probably had never used before.   I don't blame him for being over eager.  Yes, some education needs to be given, but in many other resp arrest calls, wouldn't you be ok with them dropping a king?  At least this firefighter was being proactive about doing something involving patient care, or simply standing back and doing the circle of death until EMS arrived and told them what to do.  Overeager firefighter (and offers to help) vs firefighter who doesn't want to touch the patient..... hmm which is better....





VentMonkey said:


> This is what I am talking about, and again, it isn’t something some paramedics never learn from, or grow out of themselves. So, if providers at my level still struggle with basic critical thinking skills, why do EMT’s, cops, and firefighters need expanded scope? A fair question, IMO.


you can't cure stupidity, some people will never grasp the concept of critical thinking skills, and unfortunately, medic mills are pumping out new medics because there is money to be made in paramedic education, and they don't want to fail people because it looks bad for the program.

If an objective tool will help someone with their assessment, or possibly detect an issue they wouldn't otherwise see, what's the harm?  More accurately, what negative patient outcomes do you predict happening if we give BLS another assessment tool?


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## DrParasite (Jan 24, 2018)

Remi said:


> What the heck are you talking about? Providing a counter-example equates to a straw man now?


 I gave a realistic scenario.  you didn't answer it.  I'm not sure what is so unclear, other than you decided to use a strawman response to a valid question. So either you are unable to actually read my scenario, or unwilling to actually think outside of your small little box.  in either way, I'm not going to waste any more time with you.


Remi said:


> As usual, you are more focused on looking for ways to "win" the discussion than on understanding the other person's point. I think you just have no idea what I'm talking about, so you attack it.


it's not about winning, it's about being able to make a decent position based on the facts at hand, something you seem to not like.  You seem to lack the critical thinking ability to do it.


Remi said:


> Again, you completely missed the point. The relevance of an example that someone provides is not contingent on the fact that your agency has so little faith in your judgement. If you can't figure out how my example of the asthmatic relates to the topic at hand, then I don't know what to tell you.


it's a great example.... it's also completely irrelevant.  Yes, in one specific example, it applies.  but you can't arbitrarily treat people solely based on history.   Maybe you can in your current role, but most in EMS can't treat based on the patient's history, when the patient's condition doesn't warrant it. Not about faith in judgement.....

if you can't understand that, than I really wonder who you ever advanced above the EMR level.  And quite honestly, I'm done responding to you on this topic.  Not worth wasting the keystrokes or the time.


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## VentMonkey (Jan 24, 2018)

DrParasite said:


> in many other resp arrest calls, wouldn't you be ok with them dropping a king?
> 
> *It really depends on several factors.
> 
> ...


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## DrParasite (Jan 24, 2018)

*Now, to add to this. The firefighter was in fact very helpful and receptive, but what if I hadn’t caught it and the patient would have aspirated once the Narcan kicked in all because they wanted to play with a new toy?[/quote]*I was actually going to bring that up, how we all have heard stories about OD patient's being intubated, narcan being given, and then they pull the tube out.

I guess the question I would ask is would you be giving the narcan or the FF?  If you are, I would imagine you would direct the firefighter to remove the airway prior to given narcan.  if they are, well,  I see your point.

ETI vs SGA....more and more places are going to SGA instead of ETI..... and weren't you one of the people who said we shouldn't do something just to make the hospital's job easier?  And I'm not saying the FD wants to drop the king simply because it is a new toy, but if it was being recently trained as the new device, and his training said if they aren't breathing, drop the king, I can see why he wanted to, especially if they haven't had the chance to in the past.  But that's a different topic, and I will agree there should be a time when providers should and should not drop a SGA (and an opiod OD is one where I would avoid it.).


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## VentMonkey (Jan 24, 2018)

DrParasite said:


> ETI vs SGA....more and more places are going to SGA instead of ETI..... and weren't you one of the people who said we shouldn't do something just to make the hospital's job easier?  And I'm not saying the FD wants to drop the king simply because it is a new toy, but if it was being recently trained as the new device, and his training said if they aren't breathing, drop the king, I can see why he wanted to, especially if they haven't had the chance to in the past.  But that's a different topic, and I will agree there should be a time when providers should and should not drop a SGA (and an opiod OD is one where I would avoid it.).


Lol, clearly I say a lot of things. However, let me add this critical-thinking wrinkle-

Yes, SGA’s are certainly becoming commonplace in such circumstances like cardiac arrests, be it traumatically or medically-induced, but the respiratory arrested patient also has a pulse. 

They have yet to surpass that threshold and are the unique demographic that would benefit from early ETI when done properly by the most-skilled provider at the scene of their emergency.

Put another way, the patient with no obvious protective airway reflexes left, but phenomenal vital signs otherwise doesn’t need to be re-intubated in the ED further disrupting their airways if, and when, it can be done early with confidence and proficiency.

If we’re blindly placing SGA’s on patient’s who’s airway should have been managed more invasively, and we have the ability to do so in the first place, is this better or worse?

And as far as doing things for the hospitals. My words of the day at work are along the lines of: “as seamlessly proficient, and efficient as possible.”


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## Carlos Danger (Jan 24, 2018)

DrParasite said:


> if you can't understand that, than I really wonder who you ever advanced above the EMR level.



Lol, that’s pretty funny coming from a guy who is barely above the EMR level himself and so frequently uses terms like “straw man” when he clearly doesn’t even know what they mean.

Again, the relevance of an example is not affected in any way by your lack of ability to comprehend it. Just because you don’t get something doesn’t make it a logical fallacy.

Every discussion with you comes down to you attacking comments and arguments that you don’t understand. You are the only one on this forum that does this so consistently. I wonder why that is.


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## EMTlash (Mar 15, 2018)

Capnography could be great as you said if you know how to read it but it can definitely help with unconscious pt's, OD's, and almost anyone with respiratory distress.


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## NomadicMedic (Mar 16, 2018)

EMTlash said:


> Capnography could be great as you said if you know how to read it but it can definitely help with unconscious pt's, OD's, and almost anyone with respiratory distress.



Why? How would capnography make any impact on your treatment?


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## Gurby (Mar 16, 2018)

NomadicMedic said:


> Why? How would capnography make any impact on your treatment?



Pretty nice to be able to see someone’s breathing and ETCO2 in real time.  Say you’re mask ventilating an OD patient or cardiac arrest and doing a crappy job - waveform capnography will let you know in no uncertain terms.  Say you’re bagging and getting a good seal, but either going too fast or too slow - capnography will let you know.

That probably should have been an ALS call anyways though, and those rare instances probably don’t justify the cost of putting a monitor on a BLS truck, and the average EMT-B probably isn’t going to make effective use of capnography in the rare instance when it could be helpful... But theoretically it could impact treatment in some cases.


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## VentMonkey (Mar 16, 2018)

Gurby said:


> Pretty nice to be able to see someone’s breathing and ETCO2 in real time.  Say you’re mask ventilating an OD patient or cardiac arrest and doing a crappy job - waveform capnography will let you know in no uncertain terms.  Say you’re bagging and getting a good seal, but either going too fast or too slow - capnography will let you know.
> 
> That probably should have been an ALS call anyways though, and those rare instances probably don’t justify the cost of putting a monitor on a BLS truck, and the average EMT-B probably isn’t going to make effective use of capnography in the rare instance when it could be helpful... But theoretically it could impact treatment in some cases.


Me thinks _Kemosabe_ was looking to get the green horn's wheels turning...


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## Gurby (Mar 16, 2018)

VentMonkey said:


> Me thinks _Kemosabe_ was looking to get the green horn's wheels turning...



Doh!


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## VinceVega91 (Apr 9, 2018)

It's not needed on every call, but I think anytime you're placing a patient on the monitor, then yeah get a capnography reading. I wished our department let us use capnography more, we're only required to do so on cardiac arrests, but it's a much better and more useful tool than pulse ox and it can help determine what treatment is needed for respiratory patients as well as determine a patient's metabolic status. But yes, it should be a basic skill, it's practically a vital sign.


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## DrParasite (Apr 9, 2018)

VinceVega91 said:


> I wished our department let us use capnography more, we're only required to do so on cardiac arrests, but it's a much better and more useful tool than pulse ox and it can help determine what treatment is needed for respiratory patients as well as determine a patient's metabolic status. But yes, it should be a basic skill, it's practically a vital sign.


Wait... you're a paramedic right?  I just wanted to make sure I read that right

So you are only REQUIRED to use capnography on cardiac arrest patients, but you WISH your department would let you use capnography more?  Do they prohibit you from using it on other non-cardiac arrest calls?  Has your supervisor / medical director pulled you aside and said "Hey vince, your going to have to stop using this medical device, that we provide to you, on all non-cardiac arrest patients?"  

What's stopping you from using it on every cardiac and respiratory related patient?


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## VinceVega91 (Apr 9, 2018)

DrParasite said:


> Wait... you're a paramedic right?  I just wanted to make sure I read that right
> 
> So you are only REQUIRED to use capnography on cardiac arrest patients, but you WISH your department would let you use capnography more?  Do they prohibit you from using it on other non-cardiac arrest calls?  Has your supervisor / medical director pulled you aside and said "Hey vince, your going to have to stop using this medical device, that we provide to you, on all non-cardiac arrest patients?"
> 
> What's stopping you from using it on every cardiac and respiratory related patient?



Our rules and procedures are at times questionable and sometimes silly. Unfortunately we do not carry the nasal cannula capnography on our trucks, we only carry the ET tube ones. And yes they actually do prohibit us from using capnography on non-cardiac arrest calls, people have been disciplined for it even though their is scientific research that proves the benefits of it. Trust me,I don't agree with it. Our medical Director is trying to get our division to be more on board and embrace the usefulness of capnography, but it is such an exotic tool, that it is taking our division forever to do so.


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## DesertMedic66 (Apr 10, 2018)

VinceVega91 said:


> It's not needed on every call, but I think anytime you're placing a patient on the monitor, then yeah get a capnography reading.


That is really not cost effective nor beneficial. If I used capno on all those patients then I would be going through 4-10 a day for no purpose. If I’m recording a 12 lead on someone with chest pain to look for a STEMI then an EtCO2 isn’t going to be very beneficial. 

I think the only time I use capno on patients where it not really needed is on my LDTs only so that I can transmit data from the monitor and it will automatically put in BP, HR, SpO2, and RR. That’s just because I’m lazy and putting in 15 sets of vitals gets rather boring.


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## CALEMT (Apr 10, 2018)

I use it on every difficulty breathing call.


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## E tank (Apr 10, 2018)

CALEMT said:


> I use it on every difficulty breathing call.



Short ETT placement or mask ventilation, where would your decision making change as opposed to without it?


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## CALEMT (Apr 10, 2018)

E tank said:


> Short ETT placement or mask ventilation, where would your decision making change as opposed to without it?



I don't use it to make decisions. I treat my patients, not the monitor. I use it as a diagnostic tool to see how much respiratory distress the patient may or may no be in, or is it even respiratory or metabolic?


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## Carlos Danger (Apr 10, 2018)

CALEMT said:


> *I don't use it to make decisions*. I treat my patients, not the monitor. *I use it as a diagnostic tool* to see how much respiratory distress the patient may or may no be in, or is it even respiratory or metabolic?


???


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## CALEMT (Apr 10, 2018)

Remi said:


> ???



Lol I get the confusion with that contradiction. I probably should have worded it a little differently than I did.


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## Carlos Danger (Apr 10, 2018)

CALEMT said:


> Lol I get the confusion with that contradiction. I probably should have worded it a little differently than I did.


I get what you meant: even though it isn't necessarily going to change your treatment plan (you probably aren't going to give a neb to a 25 year old with no history of asthma who isn't wheezing, just because you see something resembling a shark-fin on the capno), it's more information that helps you form a more complete clinical picture. 

I think the greater point is that if an assessment tool isn't going to change our treatment, why do we do it? Even if we feel like the info helps us formulate a more accurate diagnosis, what value does it really bring, if we are just going to do the same thing for the patient with or without the information?


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## VentMonkey (Apr 10, 2018)

Remi said:


> Even if we feel like the info helps us formulate a more accurate diagnosis, what value does it really bring, if we are just going to do the same thing for the patient with or without the information?


Perhaps prevent the paramedic from _not_ doing the same thing that they normally would.

Waiver: I have not used the in-line NC prongs in well over a year, and IIRC, Jarvis mentioned in a podcast he’d done with Tyler Christifulli how they can actually be an ineffective HFNC option.

In perhaps a more progressively perfect world (cue sappy music) it would entice the EM doc to trust the field folks’ “educated guesses” more than is the standard or norm now. Clearly, this still needs to be earned.

Will things still need to be redone, revisited, and reassessed? Absolutely, but I don’t know that I’m ready to write the device off completely quite yet. 

Sure, I may not be giving Insulin to a DKA patient with an unconfirmed BGL through the roof, and an ETCO2 in the teens, or a suspected polypharm OD with an ETCO2 the same.

Is it more of a nice-to-know? At this point absolutely. Do I think it will fall by the wayside? Perhaps. Will it have any major effects on ones treatment or diagnosis? Nope, probably not. 

I think the bigger problem is the tool at hand (like many, or most) falling into the average undereducated providers hands, and being frivolously employed. 

Knowing that I can implement said tool, and explain why or where it helped my idex of suspicion, and treatments rendered—or not—still carries value in my opinion. I speak in general, on the whole, for the field paramedic _d’jour_ who knows enough to know better.


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## medichopeful (Apr 16, 2018)

VentMonkey said:


> I’m not saying EMT’s shouldn’t be allowed to understand, play with, or have ETCO2 monitoring, but perhaps a biiit more education is needed at the entry level to a basics training before this is universally adopted.



I would argue pretty heavily that a bit more education should be added to paramedic education as well regarding capnography. 

Many of the medics I talk to are taught about capnography, but can’t really explain much about it. For example, many seem to think that EtCO2  = PaCO2, which is concerning. 

I also don’t think people should be using EtCO2 without a basic understanding of ABGs, which also doesn’t seem to be a major topic in medic school sadly. I know we went over it a bit in medic school, but not much.


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## medichopeful (Apr 16, 2018)

E tank said:


> How would it change what you do for the patient that you wouldn't do from your physical exam?



Keeps me from having to count a RR. Clearly!


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## VentMonkey (Apr 16, 2018)

medichopeful said:


> I would argue pretty heavily that a bit more education should be added to paramedic education as well regarding capnography.
> 
> Many of the medics I talk to are taught about capnography, but can’t really explain much about it. For example, many seem to think that EtCO2  = PaCO2, which is concerning.
> 
> I also don’t think people should be using EtCO2 without a basic understanding of ABGs, which also doesn’t seem to be a major topic in medic school sadly. I know we went over it a bit in medic school, but not much.


I don't disagree with you. But then again, I simply wish that The States offered a clinically-driven ICP degree adapted from the Australian model.

I don't think it needs to be a full blown masters, but the desire to learn the level of training that they receive as Aussie ICP's prior to being allowed to practice is something certainly seen in a "select few" paramedics, and hardly seems to be the standard. If only...


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## Summit (Apr 17, 2018)

DesertMedic66 said:


> CPAP and Narcan IM/IN are already in the state scope for EMTs. There has been a lot of talk about allowing Epi IM due to the cost of the Epi pens. ICEMA, at least during their meetings, is really wanting to expand the EMT scope to the max it can be so we are having to add in extra time/classes to the EMT program. So you have the normal EMT class and we add in HazMat FRA, bloodborne/airborn pathogens, and CPR. Now we are having to add in a 8-16 hour documentation class, 8-16 hour modified TECC/TCCC class, and a pharm/med admin class.



You throw all these things in, and have states like CO that expect every EMT to add 32 hours of IV class plus 8 hours of clinical if they want to do something besides drive a wheelchair van and you are closer to AEMT than you are to EMT in content, hours and scope. So we are asking Vent's question:



VentMonkey said:


> How much more training and education is needed at the EMT-level vs. when do we abolish both EMT and AEMT to create one “basic” level of provider prior to paramedic?


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## Summit (Apr 17, 2018)

VentMonkey said:


> I’m talking about a bit more fundamental education than just the skill itself.
> 
> Sure, Narcan can be given by any Joe Blow, but I’m willing to bet that Danny’s Dopefiend’s buddy is better versed in spotting the true signs and symptoms of his pals inevitable respiratory depression-induced OD over said firefighter or cop, or even EMT or paramedic, who “thinks” Narcan “might help”.
> 
> ...



I think your post could be summarized with the following: slightly more important that know when to use a skill is knowing when you could but should not (because there is a better alternative). This requires critical thinking instead of linear thinking.

Anyone below Paramedic is expected to  are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.



DrParasite said:


> So you are only REQUIRED to use capnography on cardiac arrest patients, but you WISH your department would let you use capnography more?  Do they prohibit you from using it on other non-cardiac arrest calls?  Has your supervisor / medical director pulled you aside and said "Hey vince, your going to have to *stop using this medical device, that we provide to you, on all non-cardiac arrest patients*?"


I know a local Fire/EMS departments that said* exactly that *to their paramedics. Seriously.


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## VentMonkey (Apr 17, 2018)

Summit said:


> I think your post could be summarized with the following: slightly more important that know when to use a skill is knowing when you could but should not (because there is a better alternative). This requires critical thinking instead of linear thinking.
> 
> Anyone below Paramedic is expected to  are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.


Mike Abernethy did a pretty solid job on a seminar that was webcasted from the CCTMC a few years back on just how fractured prehospital care truly is. It's a good listen that I wish every EMT and paramedic instructor required their overzealous students listen to. 

We have much bigger problems in this field than letting abruptly-trained EMT's, firefighters, and even some paramedics "play" with capnography. The field is quite literally a smorgasbord of provider skill, education, and even talent level all being perpetuated by pennies on the dollar for transport. The amount of mixed signals that I hear, and see, almost daily makes complete sense as to why we keep shooting ourselves in the damn foot.


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## DrParasite (Apr 18, 2018)

VentMonkey said:


> Mike Abernethy did a pretty solid job on a seminar that was webcasted from the CCTMC a few years back on just how fractured prehospital care truly is. It's a good listen that I wish every EMT and paramedic instructor required their overzealous students listen to.


do you have the location where the webcast can be found or downloaded?





VentMonkey said:


> We have much bigger problems in this field than letting abruptly-trained EMT's, firefighters, and even some paramedics "play" with capnography. The field is quite literally a smorgasbord of provider skill, education, and even talent level all being perpetuated by pennies on the dollar for transport. The amount of mixed signals that I hear, and see, almost daily makes complete sense as to why we keep shooting ourselves in the damn foot.


I agree; I also think that many of these issues cannot be, and will not be, solved at the provider level.  So why not try to make the little changes were we can, and let the higher ups and elective officials try to fix the rest?

BTW, here is the Asthma COPD protocol from an EMS agency to the north of me:


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## VentMonkey (Apr 18, 2018)

DrParasite said:


> do you have the location where the webcast can be found or downloaded?


https://itunes.apple.com/us/podcast/ems-nation/id1063361753?mt=2&i=1000385734597


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## EpiEMS (Apr 18, 2018)

Summit said:


> Anyone below Paramedic is expected to are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.



I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)

What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.


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## Summit (Apr 18, 2018)

EpiEMS said:


> I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)
> 
> What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.


If A do B & C is procedural
Guidelines are a looser set of options based on judgement


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## DrParasite (Apr 18, 2018)

EpiEMS said:


> I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)


When I was on the truck, I dealt with more drunks than homeless people.  And PLENTY of "sick person" calls.  and many intoxicated homeless people.

I guess my question would be, if they are homeless, why do they need an ambulance? If they have a medical complaint, treat them as appropriate and transport to the ER.

a general malaise protocol is typically a catch all, a protocol you can use when the patient doesn't fit any categories.   most places I have seen try to use a more specific one, based on the patient's chief complaint.


EpiEMS said:


> What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.


SOPs vs SOGs.  SOPs are procedure: you WILL follow these directions.  SOGs are guidelines: you SHOULD follow these guidelines, under ideal circumstances, but if you don't, be sure to document and justify why not.

It's all legal BS; the fire service went through it about 15 years or so years ago, because SOPs were viewed as too rigid in court; IE, if you didn't do something in the SOPs, you weren't following procedure, and were immediately wrong, despite having a good reason do to what you did.


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## EpiEMS (Apr 18, 2018)

Summit said:


> If A do B & C is procedural
> Guidelines are a looser set of options based on judgement



If that's the case, then EMS protocols are closer to "guidelines", no? (Given that there's subjectivity in application, I mean.)



DrParasite said:


> I guess my question would be, if they are homeless, why do they need an ambulance? If they have a medical complaint, treat them as appropriate and transport to the ER.



I'm exaggerating a bit, but somebody *saying* they have a medical complaint is different from *having* a medical complaint.



DrParasite said:


> It's all legal BS; the fire service went through it about 15 years or so years ago, because SOPs were viewed as too rigid in court; IE, if you didn't do something in the SOPs, you weren't following procedure, and were immediately wrong, despite having a good reason do to what you did.



Fair enough. I'd be curious to see some cases to see how they described this in legalese!


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## DrParasite (Apr 18, 2018)

EpiEMS said:


> If that's the case, then EMS protocols are closer to "guidelines", no? (Given that there's subjectivity in application, I mean.)


I would imagine it depends on how rigidly you have them enforced by your agency and medical director.





EpiEMS said:


> I'm exaggerating a bit, but somebody *saying* they have a medical complaint is different from *having* a medical complaint.


Been there, done that, not going to argue, but also realize that it's easier for me to transport the person to the ER than not.  





EpiEMS said:


> Fair enough. I'd be curious to see some cases to see how they described this in legalese!


While I'm not an attorney, nor will I provide legal advice: Political and Legal Foundations of Fire Protection 32-FST-385 Legal Liability Issues of Standard Operating Procedures VS Other Titles for Guidance Documents


I'll even thrown in page 2 of this: https://www.usfa.fema.gov/downloads/pdf/publications/fa-197-508.pdf

Personally, I think its all a bunch of crap, and a good attorney can tear you to shreds regardless, but it all depends on what your agency attorney thinks, and how they are all written, but that's just my two cents


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## Summit (Apr 18, 2018)

DrParasite said:


> I would imagine it depends on how rigidly you have them enforced by your agency and medical director.



Yes, how they are written + how they are enforced


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