# Your Controversial EMS-Related Opinion



## MMiz (Oct 21, 2021)

What controversial opinion(s) do you have about EMS?

I'll go first: those that refuse to be vaccinated shouldn't be in EMS.


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## NomadicMedic (Oct 21, 2021)

Candidates should have no more than two attempts to pass a cognitive exam.


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## E tank (Oct 21, 2021)

Fire should have nothing to do with EMS (besides carrying people down stairs and shocking people), EMS should be hospital based, HEMS should require hospital based medical control approval prior to all call departures.


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## Fezman92 (Oct 21, 2021)

Private EMS (including IFT) should not exist. Putting profit over people is wrong.


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## EpiEMS (Oct 21, 2021)

Fezman92 said:


> Private EMS (including IFT) should not exist. Putting profit over people is wrong.



I agree that private EMS is a suboptimal model, but not for ethical reasons. What’s your alternative when taxpayers don’t care?

My controversial opinion? EMS (paramedicine?) should be independently regulated by EMS providers and not under a board of medicine.


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## Fezman92 (Oct 22, 2021)

EpiEMS said:


> What’s your alternative when taxpayers don’t care?


Don’t care about EMS? Do you honestly care about where every single cent of your tax money goes?


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## GMCmedic (Oct 22, 2021)

Fezman92 said:


> Do you honestly care about where every single cent of your tax money goes?



Yes


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## Fezman92 (Oct 22, 2021)

GMCmedic said:


> Yes



1) Nice 👍 
2) For those that do care and don’t want their taxes going to EMS, they’re just going to have to deal with the fact that they’re paying for EMS.


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## DesertMedic66 (Oct 22, 2021)

E tank said:


> HEMS should require hospital based medical control approval prior to all call departures.


This is pretty much how it’s done for hospital to hospital transfers. Hospital A contacts Hospital B and gets acceptance. Doctor at Hospital A decides HEMS will be the best option.


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## E tank (Oct 22, 2021)

DesertMedic66 said:


> This is pretty much how it’s done for hospital to hospital transfers. Hospital A contacts Hospital B and gets acceptance. Doctor at Hospital A decides HEMS will be the best option.


Yeah, so if the receiving hospital makes a determination like that for an interfacility transfer, it would make sense if they did it for patients in the field as well.


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## akflightmedic (Oct 22, 2021)

Zero to hero is a bonafide and acceptable pathway.

Paramedic should be an Associate Degree entry level.

While both these positions sound contradictory, they are not. If no degree is ever required, I am absolutely ok with the first opinion under our current prevailing model.


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## DesertMedic66 (Oct 22, 2021)

E tank said:


> Yeah, so if the receiving hospital makes a determination like that for an interfacility transfer, it would make sense if they did it for patients in the field as well.


So you want a ground EMS unit to call the hospital and get the on from med control at the hospital to fly a patient? Instead of the ground EMS crew making that determination on their own?


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## VentMonkey (Oct 22, 2021)

Endotracheal intubation should be removed from the national scope of practice. It should be a system/ program choice with adequate and appropriate  (re)training. This applies to RSI as well.

All provider levels should have solid fundamental knowledge of basic airway care in the prehospital environment, EMR to paramedic.


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## Summit (Oct 22, 2021)

AEMT should be the minimum to work on a 911 ambulance.

AEMT should have needle decomp.

Paramedic should be a 2 year degree and CCP or CP should each be another year.


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## E tank (Oct 22, 2021)

DesertMedic66 said:


> So you want a ground EMS unit to call the hospital and get the on from med control at the hospital to fly a patient? Instead of the ground EMS crew making that determination on their own?


Or the flight crew themselves...for anything that would not be determined to be a reasonable lights and siren return by ground in any other circumstance.  Just 'cause the helicopter shows up doesn't mean they have to take someone, which, I know you know. But that isn't always how it plays out. 

This is the controversy thread, remember...


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## DesertMedic66 (Oct 22, 2021)

E tank said:


> Or the flight crew themselves...for anything that would not be determined to be a reasonable lights and siren return by ground in any other circumstance.  Just 'cause the helicopter shows up doesn't mean they have to take someone, which, I know you know. But that isn't always how it plays out.
> 
> This is the controversy thread, remember...


Oh I would absolutely love to land and then say “we can’t justify flying this one” and then leaving. I don’t ever see that happening unfortunately


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## E tank (Oct 22, 2021)

DesertMedic66 said:


> Oh I would absolutely love to land and then say “we can’t justify flying this one” and then leaving. I don’t ever see that happening unfortunately


Thus putting it on medical control at the receiving hospital.


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## Tigger (Oct 22, 2021)

If you arrive in ambulance, you should be able to provide pharmacological pain relief. 

If you’re intubating, you should have access to a ventilator. 

Not wearing high viz something on traffic accidents should result in some kind of discipline, period. 

The best for last:

The current tiered system is totally backwards. Sending someone with apx 120 hours of training to see if someone needs an actual assessment from a provider with formal education is backwards. You don’t know what you don’t know.


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## Tigger (Oct 22, 2021)

DesertMedic66 said:


> Oh I would absolutely love to land and then say “we can’t justify flying this one” and then leaving. I don’t ever see that happening unfortunately


The helicopters here will do that regularly. Volunteer BLS first response requests a helicopter on dispatch. Helicopter arrives, provides an assessment, and if warranted, waits until the ALS ambulance shows up and gives a handoff and flies away.


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## EpiEMS (Oct 22, 2021)

Fezman92 said:


> Don’t care about EMS? Do you honestly care about where every single cent of your tax money goes?


I care about EMS, but the optics often will be "you're raising my taxes for what?!" in many places. That said, most of the public does agree that taxes should fund EMS (see pg. 2 of Carson & Shepperd, 2020)

Public perception of EMS is fascinating as an area of research (e.g., Crowe 2016, Carson & Shepperd, 2020).


Tigger said:


> The current tiered system is totally backwards. Sending someone with apx 120 hours of training to see if someone needs an actual assessment from a provider with formal education is backwards. You don’t know what you don’t know.


I love this. It is indeed a totally backwards model. This is where fly car medics come in! That said, I do enjoy a good critical BLS call...


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## jgmedic (Oct 22, 2021)

Tigger said:


> The current tiered system is totally backwards. Sending someone with apx 120 hours of training to see if someone needs an actual assessment from a provider with formal education is backwards. You don’t know what you don’t know.


This is the justification for the LA/OC model. ALS first response with BLS transport that a medic can jump on if necessary. So while I agree in principle with you, that has been completely *******ized into what we have in SoCal today.


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## E tank (Oct 22, 2021)

Fezman92 said:


> Private EMS (including IFT) should not exist. Putting profit over people is wrong.


When you say 'people', is that patients or employees?


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## Fezman92 (Oct 22, 2021)

E tank said:


> When you say 'people', is that patients or employees?


Both.


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## MMiz (Oct 22, 2021)

Additional education (AEMT and Paramedic) should be required for all paid providers after a set period of time.

EMT-Basic > 1 year > EMT-Advanced > 1 year > Paramedic


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## jgmedic (Oct 22, 2021)

FD's should only be ALS if they can transport. The squad/ALS engine thing with BLS private ambos breed laziness and subpar EMS.


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## GMCmedic (Oct 22, 2021)

Fire departments only EMS involvement should be BLS non transport.


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## E tank (Oct 22, 2021)

Fezman92 said:


> Both.


Well, don't tell the guy that treats your kidney stones not to make a profit.


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## Fezman92 (Oct 22, 2021)

When I mean employees, I mean the CEOs and those high level jobs, not the ones doing the real work.


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## VentMonkey (Oct 22, 2021)

Fezman92 said:


> When I mean employees, I mean the CEOs and those high level jobs, not the ones doing the real work.


Would you know all of the logistics and logistical challenges that go into the specifics of even a mundane renal-rodeo IFT? I don’t, I just transport. 

Why shouldn’t those jobs exist? Please expound and your somewhat shortsighted comment.


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## Fezman92 (Oct 22, 2021)

Putting profit over everything else is wrong, when you only care about the bottom line, you put everyone at risk.


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## CCCSD (Oct 22, 2021)

Summit said:


> AEMT should be the minimum to work on a 911 ambulance.
> 
> AEMT should have needle decomp.
> 
> Paramedic should be a 2 year degree and CCP or CP should each be another year.


Needle Decomp is a BLS skill.


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## GMCmedic (Oct 22, 2021)

Fezman92 said:


> Putting profit over everything else is wrong, when you only care about the bottom line, you put everyone at risk.


Your first mistake is believing this is limited to private EMS. I assure you, nobody is in the business of EMS to lose money. Not privates, not third service, not municipal fire, nobody. 

If there is profit to be made, everyone is trying. When you're older, you'll understand.


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## EpiEMS (Oct 22, 2021)

CCCSD said:


> Needle Decomp is a BLS skill.



This is interesting - do you think risk/reward makes it so? I guess the view I have been told is that it is infrequently used enough and too risky for an EMT to perform. That said, less trained folks (that is, in terms of hours of EMS-type training) do perform it in, say, the military, right?


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## EpiEMS (Oct 22, 2021)

Fezman92 said:


> When I mean employees, I mean the CEOs and those high level jobs, not the ones doing the real work.



You don’t think administering a large business or organization is real work? Tell that to the chief of the police department or the head of an oil company or a hospital administrator. Somebody has to hire staff, make budgets, buy equipment…to do it right is hard and that means it is going to cost a bunch, likely more than the rank and file will be paid.


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## CCCSD (Oct 22, 2021)

EpiEMS said:


> This is interesting - do you think risk/reward makes it so? I guess the view I have been told is that it is infrequently used enough and too risky for an EMT to perform. That said, less trained folks (that is, in terms of hours of EMS-type training) do perform it in, say, the military, right?


It’s a monkey skill. It’s part of CLS/TCCC taught to 18 year old troops. I teach it in TECC. The reward is well worth the (minimal) risk.


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## EpiEMS (Oct 22, 2021)

CCCSD said:


> It’s a monkey skill. It’s part of CLS/TCCC taught to 18 year old troops. I teach it in TECC. The reward is well worth the (minimal) risk.



Makes sense. It was covered in TECC when I took it, but I would not want to be doing the skill unless refreshed on it/skill validated biannually (like any other), particularly because it wasn’t taught in my initial training to the degree I feel fully competent.


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## CCCSD (Oct 23, 2021)

EpiEMS said:


> Makes sense. It was covered in TECC when I took it, but I would not want to be doing the skill unless refreshed on it/skill validated biannually (like any other), particularly because it wasn’t taught in my initial training to the degree I feel fully competent.


Agreed. I ensure repeated skills testing for my students throughout the year as part of my training programs.


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## VentMonkey (Oct 23, 2021)

CCCSD said:


> Needle Decomp is a BLS skill.


A potentially lifesaving one at that.


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## FiremanMike (Oct 23, 2021)

Fire based versus hospital based versus government third service based is the red herring and almost entirely irrelevant to the care delivered.

The only thing that actually matters is the value the agency places on initial/ongoing training, quality improvement, and ensuring competency of their providers.


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## Summit (Oct 23, 2021)

Needle decomp is life saving when needed, but it is also invasive and not without serious complications, and the biggest single failure point is employing it when it is not indicated which automatically adds potential for complication. For that reason alone in a non-combat environment, I can see the argument for keeping it above the EMT level, even though the actual skill is less complex and less difficult than other things that EMTs do. But it should be in the hands of AEMT at least.


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## DrParasite (Oct 23, 2021)

1) Not every ambulance needs to be ALS
1a) requiring every ambulance to be ALS leads to poorer providers

2) paramedics don't belong on the engine; first response ALS is a waste

3) there is no evidence that degrees will make paramedics better, so why need them?
3a) if we are going to mandate degrees, then every paramedic should be required to get a degree in paramedicine with less than 3 years.

4) Private EMS companies should be banned from the 911 system
4a) every AHJ should be mandated to set up a 3rd service EMS system, funded by the taxpayers, and elected leaders should be held accountable for its performance.

5) FD should have a very limited role in EMS; cardiac arrests, MVAs, and heavy lifting.  EMS agencies should have enough EMS units to handle their call volume without the FD to stop the clock.


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## ffemt8978 (Oct 23, 2021)

We need to look at scope practice for each level compared to call volumes (rural vs urban) with an eye towards maintaining an effective proficiency.  While there are benefits to a standardized system, there are also drawbacks that are oft overlooked.


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## DrParasite (Oct 23, 2021)

Tigger said:


> The current tiered system is totally backwards. Sending someone with apx 120 hours of training to see if someone needs an actual assessment from a provider with formal education is backwards. You don’t know what you don’t know.


I haven't been in seen 120 hour EMT classes since the 90s... are you saying your state only requires 120 hours to become an EMT?


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## CCCSD (Oct 23, 2021)

Summit said:


> Needle decomp is life saving when needed, but it is also invasive and not without serious complications, and the biggest single failure point is employing it when it is not indicated which automatically adds potential for complication. For that reason alone in a non-combat environment, I can see the argument for keeping it above the EMT level, even though the actual skill is less complex and less difficult than other things that EMTs do. But it should be in the hands of AEMT at least.


What part of AEMT creates this magic zone of knowledge?


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## Summit (Oct 23, 2021)

CCCSD said:


> What part of AEMT creates this magic zone of knowledge?


AEMT is another 10-12 credit hours with clinicals past EMT so there is  a little bit of extra knowledge and experience in patient assessment and care versus a freshly minted EMT.

Needle thoracostomy would be new content to add on top of AEMTs slightly more in depth coverage of A&P and assessment (vs EMT).

Most of all, you can focus training and education a bit better on a smaller population of providers that encompasses AEMT and above versus all EMTs (there are over twice as many EMTs as there are EMS providers above the EMT level).


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## E tank (Oct 23, 2021)

Hospitals are direct beneficiaries of EMS. They should have some skin in the game. They provide medical clinic office space, personnel and capital expenditure for providers who then admit and refer patients for lucrative, billable procedures. They've been getting a pass on EMS for way too long.


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## Tigger (Oct 23, 2021)

EpiEMS said:


> I care about EMS, but the optics often will be "you're raising my taxes for what?!" in many places. That said, most of the public does agree that taxes should fund EMS (see pg. 2 of Carson & Shepperd, 2020)
> 
> Public perception of EMS is fascinating as an area of research (e.g., Crowe 2016, Carson & Shepperd, 2020).
> 
> I love this. It is indeed a totally backwards model. This is where fly car medics come in! That said, I do enjoy a good critical BLS call...


If they were even dispatched. Or if the crew on scene requests them. Or doesn’t cancel them because the patient doesn’t “look” sick to them. 120, 150, 180, whatever the number is, it’s not enough. The inability to interpret EKGs alone is troubling to me. 

At the end of the day, when you go to an ED, you’re seen by a provider. Even if it’s quick, somebody with formal education in medicine evaluates you. Whether or not that’s a paramedic is open to discussion, but it’s not an EMT.


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## E tank (Oct 23, 2021)

Tigger said:


> At the end of the day, when you go to an ED, you’re seen by a provider. Even if it’s quick, somebody with formal education in medicine evaluates you. Whether or not that’s a paramedic is open to discussion, but it’s not an EMT.


But is that the job of scene personnel? Final definitive,  accurate diagnosis and treatment (hopefully) isn't supposed to happen in the field. Isn't it the role of EMS to get the patient to where that happens? Whoever shows up...job one is getting the patient to the hospital. If there are those that don't appreciate their own limitations, that's another conversation.


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## Tigger (Oct 24, 2021)

E tank said:


> But is that the job of scene personnel? Final definitive,  accurate diagnosis and treatment (hopefully) isn't supposed to happen in the field. Isn't it the role of EMS to get the patient to where that happens? Whoever shows up...job one is getting the patient to the hospital. If there are those that don't appreciate their own limitations, that's another conversation.


Which is what concerns me. If a lower education provider doesn’t recognize a sicker patient that requires transport and allows them to refuse without any sort of education as to what is wrong, that would be bad.


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## EpiEMS (Oct 24, 2021)

Tigger said:


> If they were even dispatched. Or if the crew on scene requests them. Or doesn’t cancel them because the patient doesn’t “look” sick to them. 120, 150, 180, whatever the number is, it’s not enough. The inability to interpret EKGs alone is troubling to me.
> 
> At the end of the day, when you go to an ED, you’re seen by a provider. Even if it’s quick, somebody with formal education in medicine evaluates you. Whether or not that’s a paramedic is open to discussion, but it’s not an EMT.



No disagreement from me as a target state, with resources allocated to proper third service or hospital based EMS at the level that, say, FDs see. That said, the great bulk of research in the urban setting (OPALS, namely) doesn’t show improved outcomes from ALS care for major trauma and cardiac arrest, so I could imagine calibrating a model for urban vs suburban vs rural where you may not get medics on every call for efficiency’s sake.


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## VentMonkey (Oct 24, 2021)

Keeping ALS fly cars in the outskirts (i.e., suburban/ rural areas) where they’re more likely to make a difference ~vs.~ keeping BLS in the urban areas closer to the hospital where “life saving” interventions take precedence until definitive care?…

Pffth, common sense, how dare I…


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## DrParasite (Oct 25, 2021)

Tigger said:


> Which is what concerns me. If a lower education provider doesn’t recognize a sicker patient that requires transport and allows them to refuse without any sort of education as to what is wrong, that would be bad.


I honestly wonder if hospital providers (doctors, nurses, PAs, etc) think that most paramedics are incompetent due to their relative lack of education, in the same way, that some paramedics think most EMTs are incompetent due to their relative lack of education


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## Tigger (Oct 25, 2021)

DrParasite said:


> I honestly wonder if hospital providers (doctors, nurses, PAs, etc) think that most paramedics are incompetent due to their relative lack of education, in the same way, that some paramedics think most EMTs are incompetent due to their relative lack of education


Probably many do. I work hard to show that I am not and develop relationships with my receiving EDs. 

I don’t think EMTs are incompetent. I don’t think the level has enough education or diagnostic tools available to them to provide a thorough enough assessment.


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## Comfort Care (Oct 25, 2021)

DrParasite said:


> I honestly wonder if hospital providers (doctors, nurses, PAs, etc) think that most paramedics are incompetent due to their relative lack of education, in the same way, that some paramedics think most EMTs are incompetent due to their relative lack of education


Yes they do, especially those ED nurses. Large majority have no clue what type of training goes into EMS providers. However there a nurses,MDs, and PA's that were prior EMT/P. We appreciate you guys.


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## mgr22 (Oct 25, 2021)

Comfort Care said:


> Yes they do, especially those ED nurses. Large majority have no clue what type of training goes into EMS providers...


Kind of a broad statement, wouldn't you say? Some of my preceptors were ED nurses.


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## jgmedic (Oct 25, 2021)

Ive found its more the med surg types who are that way. ED, ICU, Flight I've always felt mutual respect.


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## NomadicMedic (Oct 27, 2021)

Convert EMT to be the new “first responder” and make the minimum level for 911 response Advanced EMT. 

Rename AEMT to primary care paremdic, rename NRP to Advanced Care Paramedic.


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## DesertMedic66 (Oct 27, 2021)

NomadicMedic said:


> Convert EMT to be the new “first responder” and make the minimum level for 911 response Advanced EMT.
> 
> Rename AEMT to primary care paremdic, rename NRP to Advanced Care Paramedic.


*Canada enters the chat*


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## CCCSD (Oct 27, 2021)

NomadicMedic said:


> Convert EMT to be the new “first responder” and make the minimum level for 911 response Advanced EMT.
> 
> Rename AEMT to primary care paremdic, rename NRP to Advanced Care Paramedic.


And who’s paying for all this?


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## PotatoMedic (Oct 28, 2021)

CCCSD said:


> And who’s paying for all this?


People who want an ambulance to show up when they call 911.


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## ffemt8978 (Oct 28, 2021)

PotatoMedic said:


> People who want an ambulance to show up when they call 911.


They don't pay now, what makes you think they'll pay for a more expensive taxi ride?


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## NomadicMedic (Oct 28, 2021)

You just said post a controversial opinion. You didn’t say anything about a funding source.


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## DrParasite (Oct 28, 2021)

ffemt8978 said:


> They don't pay now, what makes you think they'll pay for a more expensive taxi ride?


uber requires cash up front...  or at least a credit card on file...


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## EpiEMS (Oct 28, 2021)

Operating model wise, PD and EMS have more alignment than EMS and FD. If I had to combine services, I might rather combine PD and EMS rather than FD and EMS.


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## CCCSD (Oct 28, 2021)

PotatoMedic said:


> People who want an ambulance to show up when they call 911.


I’m referring to the AEMT, which is not authorized in all states.


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## jgmedic (Oct 28, 2021)

EpiEMS said:


> Operating model wise, PD and EMS have more alignment than EMS and FD. If I had to combine services, I might rather combine PD and EMS rather than FD and EMS.


When I was in medic school the instructors talked about Woodbury, MN as a place that does this and apparently it's pretty effective.


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## HardKnocks (Nov 12, 2021)

MMiz said:


> What controversial opinion(s) do you have about EMS?
> 
> I'll go first: those that refuse to be vaccinated shouldn't be in EMS.


1) An associate of mine, SWAT Officer, 40 y/o Male, life long Athlete/Runner, in excellent shape died of a Thrombotic Event withing 15 hrs of receiving the Covid Vaccine;

2) Some people, like myself have has serious reations to certain vaccines and are medically advised against the receiving Covid Vaccine;

3) Herd Immunity offers greated protection than the Covid Vaccine and is ignore due to the focus on Profitiblility;

4) If the vaccine was a real vaccine, meaning it made your body produce antibodies against the virus and prevent its spread the vaccine would be more accepted.  But Post Vaccine Patients are still testing positive and repeatedly cycling through the virus.

This Covid virus is here to stay, along with the yearly Flu virus.   Get used to it.

HK


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## mgr22 (Nov 12, 2021)

HardKnocks said:


> 1) An associate of mine, SWAT Officer, 40 y/o Male, life long Athlete/Runner, in excellent shape died of a Thrombotic Event withing 15 hrs of receiving the Covid Vaccine;
> 
> 2) Some people, like myself have has serious reations to certain vaccines and are medically advised against the receiving Covid Vaccine;
> 
> ...


Is your opinion about #3 based on anything factual, or is it just the way you feel?


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## Carlos Danger (Nov 12, 2021)

HardKnocks said:


> 1) An associate of mine, SWAT Officer, 40 y/o Male, life long Athlete/Runner, in excellent shape died of a Thrombotic Event withing 15 hrs of receiving the Covid Vaccine;
> 
> 2) Some people, like myself have has serious reations to certain vaccines and are medically advised against the receiving Covid Vaccine;
> 
> ...


This entire post demonstrates a fundamental lack of understanding of how this vaccine works and what the point of being vaccinated really is.

Plus, there’s another thread for this.


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## Summit (Nov 12, 2021)

HardKnocks said:


> Vaccine and COVID things unrelated to EMS
> 
> HK


Your post really isn't in the spirit of this thread so as Carlos suggests, I have written a thorough reply to you and placed it in the appropriate thread please see the link here: https://emtlife.com/threads/covid-vaccine-the-megathread.48751/page-43#post-706594


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## MackTheKnife (Nov 12, 2021)

Summit said:


> AEMT should be the minimum to work on a 911 ambulance.
> 
> AEMT should have needle decomp.
> 
> Paramedic should be a 2 year degree and CCP or CP should each be another year.


Agree with the degree!


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## MackTheKnife (Nov 12, 2021)

CCCSD said:


> It’s a monkey skill. It’s part of CLS/TCCC taught to 18 year old troops. I teach it in TECC. The reward is well worth the (minimal) risk.


And crics are taught in PHTLS. And ND is a monkey skill. Doesn't take a medic to do it.


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## MackTheKnife (Nov 12, 2021)

DrParasite said:


> I honestly wonder if hospital providers (doctors, nurses, PAs, etc) think that most paramedics are incompetent due to their relative lack of education, in the same way, that some paramedics think most EMTs are incompetent due to their relative lack of education


No one in my ED thinks our fantastic medics are incompetent, period, for any reason. Degrees for medics is something that needs to happen. This goes to getting better pay, for one. Everyone in the medical field, except for CNAs, have a degree requirement. My hospital requires BSNs for RNs. The more education you have, the pay is usually higher. I just wish our medics were allowed to fully operate within their scope of practice.


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## CCCSD (Nov 12, 2021)

MackTheKnife said:


> And crics are taught in PHTLS. And ND is a monkey skill. Doesn't take a medic to do it.


Chest tubes also for .MIL.


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## Fezman92 (Nov 12, 2021)

Mother in laws?


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## PotatoMedic (Nov 13, 2021)

Fezman92 said:


> Mother in laws?


I'll give you another guess.


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## E tank (Nov 13, 2021)

MackTheKnife said:


> No one in my ED thinks our fantastic medics are incompetent, period, for any reason. Degrees for medics is something that needs to happen. This goes to getting better pay, for one. Everyone in the medical field, except for CNAs, have a degree requirement. My hospital requires BSNs for RNs. The more education you have, the pay is usually higher. I just wish our medics were allowed to fully operate within their scope of practice.


And it will allow profiteering opportunists that have left patient care to line their pockets with the endless and ever expanding requirements to remain in practice! (Like is happening from the allied health level to brain surgeon). Cost of education not keeping up with remuneration in the actual job is causing folks to decide if their going to spend all the money on an expensive education, they won't do it for one they'll only do for a few years.


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## MMiz (Nov 13, 2021)

Opinion: providers should have to pass an annual physical agility test.


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## Bullets (Nov 13, 2021)

HardKnocks said:


> This Covid virus is here to stay, along with the yearly Flu virus.   Get used to it.
> 
> HK


Yeah, and i still get a flu vaccine every year



My controvesial opinion is that HEMS should be able to and encouraged to triage back to ground, and that HEMS projects should be regulated and a limit on projects should be set by a governing body. Not every hospital with a pad should be allowed to throw a bird in the air


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## fm_emt (Nov 13, 2021)

my controversial opinion? 

Not all AMR operations are bad. 

there. I said it. lol


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## CbrMonster (Nov 14, 2021)

Nurses should not teach paramedics in paramedic school, with the only exception being flight nurses, or nurses who are medics as well.

P cards should not be solely obtained to get a fire job (Cali problem) 

Firefighters should not get first dibs to medic programs especially at community colleges ..(socal problem again)


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## FiremanMike (Nov 14, 2021)

CbrMonster said:


> Nurses should not teach paramedics in paramedic school, with the only exception being flight nurses, or nurses who are medics as well.


Medics should abandon the notion that they are as smart as nurses....


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## CCCSD (Nov 14, 2021)

CbrMonster said:


> Nurses should not teach paramedics in paramedic school, with the only exception being flight nurses, or nurses who are medics as well.
> 
> P cards should not be solely obtained to get a fire job (Cali problem)
> 
> Firefighters should not get first dibs to medic programs especially at community colleges ..(socal problem again)


Can’t give enough likes!


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## VentMonkey (Nov 14, 2021)

CbrMonster said:


> P cards should not be solely obtained to get a fire job (Cali problem)
> 
> Firefighters should not get first dibs to medic programs especially at community colleges ..(socal problem again)


I don’t know that either are specific to only California.


FiremanMike said:


> Medics should abandon the notion that they are as smart as nurses....


Lol not sure if you’re joking but I’ll assume so? I’ve seen both with much left to be desired but that’s anywhere I suppose.


----------



## FiremanMike (Nov 14, 2021)

VentMonkey said:


> Lol not sure if you’re joking but I’ll assume so? I’ve seen both with much left to be desired but that’s anywhere I suppose.


Well it is the "controversial opinion" thread, but at the same time, I have been through both medic school and am in nursing school and can say without reservation that nursing school is exponentially more difficult.. it's not even in the same ballpark.  The breadth of knowledge that nurses learn, are tested on, and are subsequently responsible for knowing is not really something I realized before school.

To put it another way, medics are taught to think 2-3 steps ahead, and good medics will think 3-5 steps ahead.  Nurses are taught to think 4-8 steps ahead, and good nurses will think 8-12 steps ahead.

I feel I was at the top of my game as a medic, and while I have seen dumbass nurses do dumbass things, my experience from nursing school tells me that just the fact that they passed this gauntlet of information means they aren't actually complete morons.

As a side note - one of the more surprising things I've learned in nursing and clinical is that it isn't quite "doctor tells me what to do and I do it" as we medics liked to believe.  There are a lot of protocolized items that they can do and then notify the doc later, but then there's a ton of stuff that's like "hey doc, I know you're not here, this is what's happening, we need to do that" and they're like "yep, sounds good, make it hap'n cap'n"


----------



## NomadicMedic (Nov 14, 2021)

FiremanMike said:


> Well it is the "controversial opinion" thread, but at the same time, I have been through both medic school and am in nursing school and can say without reservation that nursing school is exponentially more difficult.. it's not even in the same ballpark.  The breadth of knowledge that nurses learn, are tested on, and are subsequently responsible for knowing is not really something I realized before school.
> 
> To put it another way, medics are taught to think 2-3 steps ahead, and good medics will think 3-5 steps ahead.  Nurses are taught to think 4-8 steps ahead, and good nurses will think 8-12 steps ahead.
> 
> ...


I think we really need to stop comparing nurses and paramedics. It’s like comparing plumbers and electricians. They both work in the building trades but the skill set is different, even though there are similarities. Do I think that nurses make good pre-hospital providers? Having seen many of them here in Pennsylvania, the answer is no. Conversely, do I think paramedics do a great job working in the emergency department? In most cases the answer for that is also no. We have very different skill sets and levels of training. Why do we keep comparing the two?


----------



## VentMonkey (Nov 14, 2021)

@FiremanMike, that’s fair re: the thread topic. And will I can appreciate your new found respect and fervor for nurses and/ or nursing school, I think the dumbassery is much less about a profession.

I can respect the level of knowledge and education that they’re exposed to, my wife’s a nurse (and a damn good one), but I think that’s beside the point of rudimentary competence outside of the school setting.

How many paramedics do we both know who aced the didactic then took a hard nose dive with clinicals?

And yes, I realize that the schooling is apples and oranges, but that’s my tie-in to the “controversy” of the thread topic as well.

I see @NomadicMedic beat me to it. Haha, my dood.


----------



## FiremanMike (Nov 14, 2021)

NomadicMedic said:


> I think we really need to stop comparing nurses and paramedics. It’s like comparing plumbers and electricians. They both work in the building trades but the skill set is different, even though there are similarities. Do I think that nurses make good pre-hospital providers? Having seen many of them here in Pennsylvania, the answer is no. Conversely, do I think paramedics do a great job working in the emergency department? In most cases the answer for that is also know. We have very different skill sets and levels of training. Why do we keep comparing the two?



That's fair, but it happens every day on both sides.. nurses think medics are dumb, medics think nurses are dumb... Both are entrenched in their own in-group and shun the outside group..

My statement was in response to the notion that nurses shouldn't teach paramedic school, but I'd argue that their broadened knowledge base serves a purpose in how deep they can teach on a topic.  This is valuable for everyone but the "just teach me how to get them to the hospital" crowd.. 



VentMonkey said:


> @FiremanMike, that’s fair re: the thread topic. And will I can appreciate your new found respect and fervor for nurses and/ or nursing school, I think the dumbassery is much less about a profession.
> 
> I can respect the level of knowledge and education that they’re exposed to, my wife’s a nurse (and a damn good one), but I think that’s beside the point of rudimentary competence outside of the school setting.
> 
> ...



I agree, but just wanted to say that I feel clinical is also more involved when compared to medic school clinical.


----------



## FiremanMike (Nov 14, 2021)

Just so I'm not a completely argumentative *** - my wife is a nurse too, and has told me countless stories of absolute ***-hattery from some of her coworkers..


----------



## VentMonkey (Nov 14, 2021)

FiremanMike said:


> Just so I'm not a completely argumentative *** - my wife is a nurse too, and has told me countless stories of absolute ***-hattery from some of her coworkers..


Without derailing too much, my wife isn’t an ER or an ICU nurse. She’s not even actively working in a hospital setting, nor has she for quite some time.

All of that said, I think she’s still a brilliant clinician in her respective role and can see how well she thinks on her feet—even still.

On the other hand, I’ve all too often heard ER nurses look down on non-ER nurses as if they’re incompetent. That really pisses me off, probably because I know damn well my wife would still run circles around many of them even in a pinch.

Back to the thread topic:

The “need” for bulletproof vests for the sole purpose of feeling tacticool is lame.

If this in fact your stance, it speaks volumes about your lack of people skills and the importance how it ties into your clinical ones as a paramedic.

If you cannot understand this, I think you’re a cretinous paramedic.


----------



## FiremanMike (Nov 14, 2021)

VentMonkey said:


> Back to the thread topic:
> 
> The “need” for bulletproof vests for the sole purpose of feeling tacticool is lame.
> 
> ...


100% agree.


----------



## Fezman92 (Nov 14, 2021)

VentMonkey said:


> The “need” for bulletproof vests for the sole purpose of feeling tacticool is lame.


You mean I don't need a bulletproof vest that has my blood type and "EMS" on it for my IFT job?


----------



## FiremanMike (Nov 14, 2021)

Fezman92 said:


> You mean I don't need a bulletproof vest that has my blood type and "EMS" on it for my IFT job?


I don’t think any of us need ballistic vests at all..


----------



## Fezman92 (Nov 14, 2021)

They also probably don't help people trust us. It might say "hey these EMS people don't trust anyone and are expecting that they could get shot on any call"


----------



## CCCSD (Nov 14, 2021)

Fezman92 said:


> They also probably don't help people trust us. It might say "hey these EMS people don't trust anyone and are expecting that they could get shot on any call"


More like: “These militarized racist fascists are withholding life saving drugs from the disenchfranchised…”


----------



## MackTheKnife (Nov 14, 2021)

FiremanMike said:


> Medics should abandon the notion that they are as smart as nurses....


Umm, is this "tongue in cheek" comment, or are you serious? Medics are as smart, if not smarter, then nurses.


----------



## VentMonkey (Nov 14, 2021)

MackTheKnife said:


> Medics are as smart, if not smarter, then nurses.


Come on, man? You have enough letters behind your name with both credentials to assure me you’re much more articulate than to use this as your retort.

Sure I get th controversy thing, but people are people. Some are more astute than others regardless of said job title.


----------



## VentMonkey (Nov 14, 2021)

VentMonkey said:


> Come on, man? You have enough letters behind your name with both credentials to assure me you’re much more articulate than to use this as your retort.
> 
> Sure I get th controversy thing, but people are people. Some are more astute than others regardless of said job title.


ETA: we’re all pretty much above this on this forum, controversy thread or not. Hopefully you too were joking @MackTheKnife.


----------



## FiremanMike (Nov 14, 2021)

MackTheKnife said:


> Umm, is this "tongue in cheek" comment, or are you serious? Medics are as smart, if not smarter, then nurses.


The breadth of curriculum of paramedic school isn’t even in the same ballpark as RN school.  Passing RN school requires an exponentially deeper knowledge of physiology, pathophysiology, and pharmacology compared to passing paramedic school.  A new grad RN has significantly more medical knowledge than a new grad paramedic.


----------



## FiremanMike (Nov 14, 2021)

Medics CAN be as smart as nurses, at least as it pertains to emergency care, but it takes dedication to the craft and a lot of hard work and self study.  The medics who do that recognize the volume of work and aren’t generally the ones pounding their chests saying they’re as smart as nurses.

The ones that are tend to be the B and C medics who are pissed off that the nurse wasn’t taking them seriously when they were giving report so they want to ***** about the nurse to protect their ego..


----------



## Summit (Nov 14, 2021)

Ballistic armor... uncomfortable, bulky, heavy, and stuffy, and I run hot.

Even if someone said here is an ultralight II or IIIA I'd be like, but why tho? And I'm thinking stab proof probably would benefit more likely to benefit providers than anything ballistic. But I'm biased/lucky... the scene could be made safe like that. But I knew VFFs who CCW'd to Fire/EMS calls. Rural CO gonna rural CO.

But that partner who is like "Well I took my SAPI plates out today."
What do you say to that? "OK, I'm glad we aren't expecting to be engaged by enemy scout snipers firing AP rounds... and that you'll be able to get the stair chair up 3 flights of stairs without hyperventilating."

I had one guy tell me armor was to protect him in case the ambulance crashed. I was like... "so, where's your crash helmet?"


----------



## OceanBossMan263 (Nov 14, 2021)

EpiEMS said:


> Operating model wise, PD and EMS have more alignment than EMS and FD. If I had to combine services, I might rather combine PD and EMS rather than FD and EMS.


My county has this arrangement as part of the system. Police Dept runs a medic service. Single medic in ambulance, met on scene by PD who is usually dispatched to aided anyway. Cop drives the bus to the hospital.

Of course, it's only one part of the disjointed system which also includes 70+ fire departments, and villages who contract with hospital-based services.


----------



## MackTheKnife (Nov 14, 2021)

FiremanMike said:


> The breadth of curriculum of paramedic school isn’t even in the same ballpark as RN school. Passing RN school requires an exponentially deeper knowledge of physiology, pathophysiology, and pharmacology compared to passing paramedic school. A new grad RN has significantly more medical knowledge than a new grad paramedic.


Thanks for stating the obvious (not being snarky). I am NOT talking about curriculum as an RN and a Paramedic I know this quite well. I am saying OVERALL a medic is as smart due to their autonomy, critical thinking, and diagnostic skills. A nurse, for the most part, couldn't operate independently as a medic can and achieve the same outcome. There are many variables, of course, such as the operating environment, which is not the same.


----------



## MackTheKnife (Nov 14, 2021)

VentMonkey said:


> Come on, man? You have enough letters behind your name with both credentials to assure me you’re much more articulate than to use this as your retort.
> 
> Sure I get th controversy thing, but people are people. Some are more astute than others regardless of said job title.


See my detailed response to Fireman Mike. I'm not talking purely education.


----------



## Summit (Nov 14, 2021)

I'm more curious as to your objection of having an RN involved with Paramedic instruction? What specifically is the objection and is it blanket or only in certain settings?


----------



## MackTheKnife (Nov 14, 2021)

Summit said:


> I'm more curious as to your objection of having an RN involved with Paramedic instruction? What specifically is the objection and is it blanket or only in certain settings?


Who's this written to?


----------



## CbrMonster (Nov 14, 2021)

FiremanMike said:


> Medics should abandon the notion that they are as smart as nurses....



I don’t think that, my wife’s a nurse she’s beat my *** if I thought that way, but nurses work very differently to medics for the most part, with the exception of nurses who are medics and flight nurses.

Nurses here don’t use cpap, and use bipap. I **** you not my partner who is in medic school has a nurse teacher who didn’t know what c pap was. Now I don’t think she’s an idiot they just a lot of the times don’t use the same meds or the same equipment. They don’t do a lot of skills we do, they’re not doing frequent iOS, not intubating, use different pain meds, ej’s ect, and it goes the same for medics doing nursing skills.

Most floor nurses with the exception of say cicu or telemetry floors don’t even need acls or know their rhythms ( this I know from working in a hospital on a floor, and I taught my wife rhythms, now she works in the er and has to have acls 


VentMonkey said:


> I don’t know that either are specific to only California.


I don’t have much info on how things work out of state, but it’s a huge problem in cali for dudes to get a p card to just become a firefighter knowing they hate running medical aids.


----------



## VentMonkey (Nov 14, 2021)

CbrMonster said:


> They don’t do a lot of skills we do, they’re not doing frequent iOS, not intubating, use different pain meds, ej’s ect, and it goes the same for medics doing nursing skills.


Most ground paramedics in my area—yes in California—don’t intubate. Fire is BLS and will have placed a SGA most of the time.

Refer to my original post on page 1 (#13). I stand hard and fast by this statement.


CbrMonster said:


> I don’t have much info on how things work out of state, but it’s a huge problem in cali for dudes to get a p card to just become a firefighter knowing they hate running medical aids.


Do a little research on The Googs. Literally, it takes minutes.

As for the P Card—>FFPM route, this is nothing new, has been a thing long before you and I, and will not be going anywhere anytime soon, but for the sake of the thread…sure, fair point


----------



## CbrMonster (Nov 14, 2021)

VentMonkey said:


> Most ground paramedics in my area—yes in California—don’t intubate. Fire is BLS and will have placed a SGA most of the time.
> 
> Refer to my original post on page 1 (#13). I stand hard and fast by this statement.
> 
> ...


I don’t doubt you, I know most counties are going to lma like igels and not intubating.

I would love to have rsi capabilities in my county it’s frustrating at times when I need to wait 20-30 minutes for a bird to have them do it. 

And that’s fair that’s your opinion my differs but to each their own.

Haven’t had the reason to research it, just didn’t want to make it a blanket statement for everywhere. I mean I also don’t think firefighters should be running medical aids, I think medic should be medics and firefighters firefighters.


----------



## Summit (Nov 15, 2021)

MackTheKnife said:


> Who's this written to?


@CbrMonster

He answered, I think that paramedics can learn quite a bit from RNs. Sure some specific skills should be specifically taught with the medic in mind, but there is more to clinicals than skills.


----------



## CbrMonster (Nov 15, 2021)

Summit said:


> @CbrMonster
> 
> He answered, I think that paramedics can learn quite a bit from RNs. Sure some specific skills should be specifically taught with the medic in mind, but there is more to clinicals than skills.


1000000% agree, if I don’t understand something I ask my wife, wealth of knowledge or I ask her to ask the Ed physicians she works with for further explanations on certain things. Sometimes she asks me when a medic does something she thinks is inappropriate or why we do things a certain way. 

But I think there’s a lot of difference between the way say a medsurge nurse works and a medic. Not saying anyone is smarter than the other but the two operate in very different ways and that’s ok. Everyone has their place in medical care from emt’s and cna’s up to doctors


----------



## EpiEMS (Nov 15, 2021)

OceanBossMan263 said:


> My county has this arrangement as part of the system. Police Dept runs a medic service. Single medic in ambulance, met on scene by PD who is usually dispatched to aided anyway. Cop drives the bus to the hospital.
> 
> Of course, it's only one part of the disjointed system which also includes 70+ fire departments, and villages who contract with hospital-based services.



Ahh, I know this fabled system. It’s one with many, many flaws - and though I love the concept of community volunteerism, I worry about its sustainability. Also, the staffing model seems risky to me, taking PD out of service for a transport + cleanup + getting back to their car. I was thinking more about using PD instead of FD as BLS first response or using shared administration.


----------



## DrParasite (Nov 15, 2021)

VentMonkey said:


> Most ground paramedics in my area—yes in California—don’t intubate. Fire is BLS and will have placed a SGA most of the time.


and there are people who wonder why paramedic first time intubation success rates suck, because places (such of California) don't have their paramedic intubating real people on a regular basis.   Here is a newsflash: if you don't practice or use a skill on a real person, the skill will atrophy, especially if the only time you use it is in a high stress life threatening situation, and you haven't actually done it in a similar situation in awhile.

As for all of the other nurse vs paramedic, who is smarter?  I know a lot of dumb nurses.  you know, the ones who aren't able to fart unless a doctors says they can?  and yes, @FiremanMike is 100% correct that nurses have standing orders and protocols, just like paramedics.  

and @FiremanMike is correct on something else he said: nursing school is much wider in it's scope than paramedic school, because they are (in theory) training a nurse who can operate in all aspects of nursing.  However, you still end up with a ton of dumb nurses; actually, that's not a fair statement, as most nurses aren't as dumb as we think they are, but the further they get from nursing school, the more they focus on their specialization.   And there are a lot of really smart nurses.  really really really smart ones.

For example: paramedics are really good are emergencies, especially ones that are related to the heart and lungs.  we use ACLS all the time, we are expected to be field cardiologists, and diagnose a stemi just like looking at the monitor.  It's what we do, and we do it well.  But are we as good at long term illness management?  or case management?  or bed management?  or fall prevention?  or wound care?  or ICU stuff, like assisting with procedures, administering IV antibiotics, lab values, or whatever other specialized stuff they do?  what do you really know about long term psychiatric care?  or home health care?

We (EMS) do stuff in the field that make some really smart nurses shudder (like giving glucagon), for good reason; we do it on the fly, while they need a doctor's order, lab values, tests, and someone to monitor trends, as well as have a specialist evaluate the case before an intervention is given.



CbrMonster said:


> Nurses here don’t use cpap, and use bipap. I **** you not my partner who is in medic school has a nurse teacher who didn’t know what c pap was. Now I don’t think she’s an idiot they just a lot of the times don’t use the same meds or the same equipment.


so they aren't stupid; they are ignorant, because they don't use it, why would they know how to us it?  Do you know what equipment an ortho nurse deals with on a regular basis?  because I don't, and I guarantee you that if you throw a cpap machine at an ortho nurse you will get a deer in the headlights response.  Similarly, if you throw a paramedic on an ortho floor, he or she won't know how to do half of the things that an ortho nurse does.


----------



## mgr22 (Nov 15, 2021)

When I was in medic school, I didn't care who was teaching us -- medics, nurses, doctors, whatever -- as long as they knew the material, knew how to deliver it, and answered questions. On practical rotations, I wanted instructors who taught me to do relevant stuff and let me do it with appropriate amounts of observation. Again, it didn't matter to me what licenses they held. The most educational rotations I had were with doctors and nurses, not medics, in psych, peds, the OR, and L&D.

I guess my "controversial opinion" is that teaching skills are more important than titles in a learning environment. Instructors who can't communicate what they know are pretty useless. That's been true for every industry I've worked in plus college.


----------



## CbrMonster (Nov 15, 2021)

DrParasite said:


> so they aren't stupid; they are ignorant, because they don't use it, why would they know how to us it?  Do you know what equipment an ortho nurse deals with on a regular basis?  because I don't, and I guarantee you that if you throw a cpap machine at an ortho nurse you will get a deer in the headlights response.  Similarly, if you throw a paramedic on an ortho floor, he or she won't know how to do half of the things that an ortho nurse does.


never once said nurses are stupid, but they operate very differently and use different equipment that they may not be well versed in, same with medications. It’s not that I don’t think nurses can be intelligent, there’s just a lot of differences. Your ortho floor is a perfect example of what I’m trying to say.


----------



## VentMonkey (Nov 15, 2021)

DrParasite said:


> and there are people who wonder why paramedic first time intubation success rates suck, because places (such of California) don't have their paramedic intubating real people on a regular basis.   Here is a newsflash: if you don't practice or use a skill on a real person, the skill will atrophy, especially if the only time you use it is in a high stress life threatening situation, and you haven't actually done it in a similar situation in awhile.


I can never tell who you’re talking to vs. at. I stand by my original post on the first page. Nationally. 

And I assure you it isn’t the state, but the agency that decides what their re-education can or will be. What does your paramedic license dictate?


----------



## CbrMonster (Nov 15, 2021)

VentMonkey said:


> I can never tell who you’re talking to vs. at. I stand by my original post on the first page. Nationally.
> 
> And I assure you it isn’t the state, but the agency that decides what their re-education can or will be. What does your paramedic license dictate?


I think along with agreeing with @DrParasite we slowly are losing everything, especially in California. 

I think more formal education and training is what’s the fix not taking away potentially life saving interventions. Hell San Diego county doesn’t even have mag… and icema(San Bernardino)? Lost charcoal when some idiot filled a patients lungs with it.


----------



## DrParasite (Nov 15, 2021)

VentMonkey said:


> I can never tell who you’re talking to vs. at. I stand by my original post on the first page. Nationally.
> 
> And I assure you it isn’t the state, but the agency that decides what their re-education can or will be. What does your paramedic license dictate?


I think it was pretty clear that I was responding to your post, which I quoted.  And whether it's at the local level, county level, state, or national scope of practice, it doesn't matter; there is a lot of discussion questioning if paramedics should be intubating, and some saying it should be taken away altogether.  and No, I'm saying saying it's your fault, but systems (in general) that operate like this are not helping the situation.





__





						NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical     journals
					

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary




					www.jwatch.org
				












						The Great Airway Debate
					

3 EMS physicians highlight the challenges that prevent a consensus on endotracheal intubation across EMS systems and the importance of case review




					www.ems1.com
				












						Should Paramedics still be intubating? - Simulaids
					

On 17th September 2020 East of England Ambulance Service NHS Trust (EEAST) announced they were removing endotracheal intubation from paramedic scope of practice. EEAST cited, “…several adverse incidents relating to Endo-tracheal Intubation that have resulted in Serious Incidents and the risk of...




					simulaids.co.uk
				












						Why Paramedics are Going to Lose Intubation
					

I’m sure the headline of this article will have many people lighting up their torches and sharpening their pitchforks, but hear me out before you burn my village down. Most of us have heard a…



					medicmadness.com


----------



## EpiEMS (Nov 15, 2021)

Skill dilution is the proximate cause, I would think. Fundamental cause is having too many medics in a system.


----------



## DrParasite (Nov 15, 2021)

CbrMonster said:


> never once said nurses are stupid, but they operate very differently and use different equipment that they may not be well versed in, same with medications. It’s not that I don’t think nurses can be intelligent, there’s just a lot of differences. Your ortho floor is a perfect example of what I’m trying to say.


Sorry, I was unclear; I didn't mean to imply that you said they were stupid... but some people (and I've been guilty of this too) will think that a person is stupid because they don't know how to deal with a situation, or manage a particular situation, because they don't have any recent experience in it.

My point was to say that they aren't stupid, but ignorant.  Similarly, if you a physiatrist, nephrologist, or optometrist in the middle of an ER, ICU, or other area, and say "here, manage this stroke patient" yes, they went to medical school, and this was covered, but they don't deal with it day in and day out, and putting them in that situation is likely setting them up for failure.  

As clearly demonstrated by this tweet: 



__ https://twitter.com/i/web/status/1240321752455999488


----------



## FiremanMike (Nov 15, 2021)

Opinion - the psychomotor skill of intubation is nowhere near as difficult as we make it out to be.


----------



## DrParasite (Nov 15, 2021)

FiremanMike said:


> Opinion - the psychomotor skill of intubation is nowhere near as difficult as we make it out to be.


while I agree, I would also add that those who can't monitor ETC02 for the duration of the treatment and transport should not be permitted to intubate.


----------



## CbrMonster (Nov 15, 2021)

DrParasite said:


> while I agree, I would also add that those who can't monitor ETC02 for the duration of the treatment and transport should not be permitted to intubate.


I freaking love etco2, I use that **** on everything, well almost everything.

I think intubating is an easy skill in the classroom it’s when someone has a **** airway that makes it a difficult skill plus add the stress of the call itself.


----------



## FiremanMike (Nov 15, 2021)

DrParasite said:


> while I agree, I would also add that those who can't monitor ETC02 for the duration of the treatment and transport should not be permitted to intubate.


The skill itself is easy, it's everything that goes into intubating that makes it hard.  But we (accreditation boards, teachers, managers) focus on "you must have XX number of intubations to be competent.  

I'd argue you must have XX exposure to stress management and critical thinking to be successful at airway management.  Shock index and acid/base balance (yes, that _is _actually important in clinical practice) can be taught in the classroom and reinforced through simulation to the point where it becomes second nature and will be easily incorporated into live airway management situations.


CbrMonster said:


> I freaking love etco2, I use that **** on everything, well almost everything.
> 
> I think intubating is an easy skill in the classroom it’s when someone has a **** airway that makes it a difficult skill plus add the stress of the call itself.


I disagree, the actual skill of intubation is not difficult in a live situation as long as you have the stress management and the wherewithal to work through any issues that come up..

There aren't really an infinite number of possibilities that can happen when you get in there, there's only a few..


----------



## VentMonkey (Nov 15, 2021)

Not exclusive to this field in particular, but ever prevalent. Defining one's self by what it is that they do for a living.

I've found this to be such a simple, yet often not easy thing for many to let go of, myself included. However, once this realization is met, the luxuries it affords are phenomenal.

Liking what you do for a living is much different than loving it. The former appears to be a much healthier approach to one's sanity than the latter. Never let a job define you, it won't love you back. Ever.


----------



## FiremanMike (Nov 15, 2021)

VentMonkey said:


> Not exclusive to this field in particular, but ever prevalent. Defining one's self by what it is that they do for a living.
> 
> I've found this to be such a simple, yet often not easy thing for many to let go of, myself included. However, once this realization is met, the luxuries it affords are phenomenal.
> 
> Liking what you do for a living is much different than loving it. The former appears to be a much healthier approach to one's sanity than the latter. Never let a job define you, it won't love you back. Ever.


I long ago stopped saying I was a firefighter/medic, now if people ask me what I do, I tell them I work for a fire department and leave it at that..


----------



## ffemt8978 (Nov 15, 2021)

Opinion: computet based training is no substitute for a knowledgeable instructor when teaching new materials...simply because computer can not change the way the material is presented to help a student understand something they are having difficulty with.


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## VentMonkey (Nov 15, 2021)

FiremanMike said:


> I long ago stopped saying I was a firefighter/medic, now if people ask me what I do, I tell them I work for a fire department and leave it at that..


So, I don’t have a problem telling people what it is I do for a living, I was meaning more along the lines of not living that paramedic life.


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## DrParasite (Nov 15, 2021)

ffemt8978 said:


> Opinion: computet based training is no substitute for a knowledgeable instructor when teaching new materials...simply because computer can not change the way the material is presented to help a student understand something they are having difficulty with.


Opinion: computer based or 100% online training has little real world value, has a much lower retention period for students than in class education, and other than satisfying a regulatory requirements (ie, checking a box to say you completed the training), provides 0 benefit to public safety or healthcare employees.


----------



## Carlos Danger (Nov 15, 2021)

DrParasite said:


> Opinion: computer based or 100% online training has little real world value, has a much lower retention period for students than in class education, and other than satisfying a regulatory requirements (ie, checking a box to say you completed the training), provides 0 benefit to public safety or healthcare employees.


This is demonstrably untrue, at least a good portion of the time. There’s quite a bit of research in support of computer based education.


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## DrParasite (Nov 15, 2021)

Carlos Danger said:


> This is demonstrably untrue, at least a good portion of the time. There’s quite a bit of research in support of computer based education.


can you provide a link to that research that backs up that claim?  because that hasn't been my experience at all....


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## Carlos Danger (Nov 15, 2021)

DrParasite said:


> can you provide a link to that research that backs up that claim?  because that hasn't been my experience at all....


It’s out there and it is easy to find.


----------



## Tigger (Nov 15, 2021)

DrParasite said:


> Opinion: computer based or 100% online training has little real world value, has a much lower retention period for students than in class education, and other than satisfying a regulatory requirements (ie, checking a box to say you completed the training), provides 0 benefit to public safety or healthcare employees.


We've benefited from an LMS platform significantly. We get training out on new equipment in a standard and quick way. Our in-service times have gone way down on everything from cardiac monitors to supply hose and we have less hiccups with everyone having a video to refer to.


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## mgr22 (Nov 15, 2021)

These are all opinions, right? They don't have to be vetted.


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## DrParasite (Nov 15, 2021)

Carlos Danger said:


> It’s out there and it is easy to find.


That's not how this works... you made a claim that you said was backed up by research... and when you are asked to provide that research, it falls to you to provide the research that you came exists.  If you want, I will say I looked and its not there... since it's that easy, why don't you share all the research that you came exists?


Tigger said:


> We've benefited from an LMS platform significantly. We get training out on new equipment in a standard and quick way. Our in-service times have gone way down on everything from cardiac monitors to supply hose and we have less hiccups with everyone having a video to refer to.


No disagreement that they are quicker, and it checks a box, but are they retaining the information?  if you were to quiz a person on a random new feature from the cardiac monitor at 3am, will they be able to explain what they learned?  Ditto your supply hose, 2 weeks later, can everyone explain what are the new features of the supply hose?


mgr22 said:


> These are all opinions, right? They don't have to be vetted.


right, unless someone claims there is research that an opinion is wrong... in that case, I think it's completely acceptable to request a vetting when someone claims that facts actually exist.


----------



## mgr22 (Nov 15, 2021)

DrParasite said:


> right, unless someone claims there is research that an opinion is wrong... in that case, I think it's completely acceptable to request a vetting when someone claims that facts actually exist.


You presented an opinion about online training. Whether I agree with it or not, you're still entitled to it. If you're ok with someone asking you to validate it, well, that's up to you.

In my opinion, there's a much bigger problem with opinions, or even wishful thinking, being presented as facts.


----------



## FiremanMike (Nov 15, 2021)

VentMonkey said:


> So, I don’t have a problem telling people what it is I do for a living, I was meaning more along the lines of not living that paramedic life.


I don't begrudge anyone who does, but for me it was an important mental separation to no longer consider myself a firefighter.. Just a dude who works at a fire department..

It came to a head for me a few years ago when I secured a pretty lucrative educational position outside of the FD, a position that was legitimately created for me and retooled several times to bring the pay to where I needed it to be.  I began having a giant amount of anxiety over "can I really NOT be a fireman anymore?"  I ultimately turned the position down for boring pension reasons..

That was the moment I realized how much of my identity was wrapped up in being a fireman, even if I didn't realize it.  So I've tried to separate myself from that mindset..


----------



## ffemt8978 (Nov 15, 2021)

Stating an opinion in this thread (or elsewhere) doesn't need to be backed up because it is just that...an opinion.  Stating something as a fact needs to be able to be backed up with more than google it for yourself.


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## NomadicMedic (Nov 15, 2021)

I believe intubation should be removed from the scope of most paramedics.


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## Tigger (Nov 15, 2021)

DrParasite said:


> No disagreement that they are quicker, and it checks a box, but are they retaining the information?  if you were to quiz a person on a random new feature from the cardiac monitor at 3am, will they be able to explain what they learned?  Ditto your supply hose, 2 weeks later, can everyone explain what are the new features of the supply hose?


It has improved it. Video based training has forced the training division to create videos and easily post reference materials that exist in perpetuity.


----------



## Carlos Danger (Nov 15, 2021)

DrParasite said:


> That's not how this works... you made a claim that you said was backed up by research... and when you are asked to provide that research, it falls to you to provide the research that you came exists.  If you want, I will say I looked and its not there... since it's that easy, why don't you share all the research that you came exists?


You are correct; a generally accepted rule of discourse (and one that I've pointed out on this forum more than a couple of times)  is that a claim of fact should be supported. However, that presumes that I am actually trying to convince you of something, which I am not. I was simply stating my position on the issue the same way that you did. Yours was based (presumably) on personal experience, where mine was based on that _and_ articles that I've read on the topic as part of my training as an educator. If you want to learn more about it, you will gain more looking for the info yourself than just looking at an article or two that I linked. If you don't feel very strongly about the topic or really care to learn more - which I assume is the case - than I would be wasting my time finding sources to share. Either way I have nothing to gain by doing homework for you, and you probably don't either. 

To be fair, there are a lot of variables involved in comparing in-person vs. computer based training (CBT). If you are comparing a great instructor to a lousy CBT, then sure, you will probably get better outcomes from the in-person instruction. But these days there are many educational programs that rely heavily on CBT and still produce good outcomes.


----------



## Carlos Danger (Nov 15, 2021)

NomadicMedic said:


> I believe intubation should be removed from the scope of most paramedics.


I'm sure I have other controversial opinions, but this is definitely the one that comes to mind the quickest.


----------



## Carlos Danger (Nov 15, 2021)

FiremanMike said:


> Medics should abandon the notion that they are as smart as nurses....


Obviously this was tongue-in-cheek and meant to spur a little controversy, which it did and always will. I hate to wade into the nurse vs. paramedic debate but I usually do because I'm dumb like that. 

I will point this out: paramedics receive a pretty in-depth education in a VERY narrow area, whereas RN's are trained less in-depth in any one area but in an immensely broader range of topics overall. There is little question that it takes more knowledge on more topics to pass the NCLEX than to pass the NRP.  There is also no question that many RN's function with more autonomy than most paramedics imagine they do.

One of the big differences also is that many paramedics seem to "peak" in their career within a year or two, whereas at that point many nurses are just getting started in what will be their specialty. I think this has a lot to do with why so many people burn out in EMS and don't stay in the field very long as compared to nursing (obviously there are other reasons as well, like compensation).

I've known great nurses and lousy ones, and great paramedics and lousy ones. Most nurses could never hop on an ambulance and do what a paramedic does without quite a bit of focused training. By the same token, practically zero paramedics could go into any specialized nursing unit and do what those nurses do, without a lot of training both broad and focused. As always, there are exceptions. I've seen a few flight nurses learn the job really quickly and get so good so quick that you'd swear they must have had prior EMS experience even though they did not.


----------



## NomadicMedic (Nov 15, 2021)

Carlos Danger said:


> I'm sure I have other controversial opinions, but this is definitely the one that comes to mind the quickest.


I absolutely believe this. And looking at stats of successful intubations, it probably should have been pulled years ago.


----------



## EpiEMS (Nov 15, 2021)

NomadicMedic said:


> I believe intubation should be removed from the scope of most paramedics.



Where should it be retained? Presume sufficient volume of intubations per medic and sufficient post-licensure education & skills verification are prerequisites for this — probably leaves a small cadre of flight, critical care, and some other specialized folks who could consider ETI in scope?


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## NomadicMedic (Nov 15, 2021)

EpiEMS said:


> Where should it be retained? Presume sufficient volume of intubations per medic and sufficient post-licensure education & skills verification are prerequisites for this — probably leaves a small cadre of flight, critical care, and some other specialized folks who could consider ETI in scope?


in a nutshell, yes.


----------



## RocketMedic (Nov 15, 2021)

EpiEMS said:


> Where should it be retained? Presume sufficient volume of intubations per medic and sufficient post-licensure education & skills verification are prerequisites for this — probably leaves a small cadre of flight, critical care, and some other specialized folks who could consider ETI in scope?


Pretty much everywhere that’s more than fifteen minutes to a hospital. Caveats~ VL should be a thing everywhere and routine training needs to be a thing.


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## NomadicMedic (Nov 18, 2021)

I thunk DanSun pictures do nothing but perpetuate the ”I’m broken and burnt out” trope.


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## E tank (Nov 18, 2021)

NomadicMedic said:


> I thunk DanSun pictures do nothing but perpetuate the ”I’m broken and burnt out” trope.


Had to Google that...some are pretty over the top...but 'trope'?


----------



## NomadicMedic (Nov 18, 2021)

Yes. We're exposed to a constant thematic storyline of "burnt out paramedics". See also, Michael Mores and "Rescuing Providence" or most facebook EMS groups. It's offputting and teaches our new people that it's expected to be salty and "broken"


----------



## E tank (Nov 18, 2021)

NomadicMedic said:


> Yes. We're exposed to a constant thematic storyline of "burnt out paramedics". See also, Michael Mores and "Rescuing Providence" or most facebook EMS groups. It's offputting and teaches our new people that it's expected to be salty and "broken"


Got that...and I think the term 'burn out' has lost its meaning if it ever had one...but you are drawing a distinction between what you cite and real, unprocessed, unresolved critical incident stress/traumatic stress injury, right?


----------



## mgr22 (Nov 18, 2021)

NomadicMedic said:


> Yes. We're exposed to a constant thematic storyline of "burnt out paramedics". See also, Michael Mores and "Rescuing Providence" or most facebook EMS groups. It's offputting and teaches our new people that it's expected to be salty and "broken"


I agree. We can't seem to find the middle ground between case-specific trauma and obligatory burnout.


----------



## NomadicMedic (Nov 18, 2021)

E tank said:


> Got that...and I think the term 'burn out' has lost its meaning if it ever had one...but you are drawing a distinction between what you cite and real, unprocessed, unresolved critical incident stress/traumatic stress injury, right?



Absolutely. I don't discount that critical incident stress is real and needs to be acknowledged... but when I see IFT EMTs bemoaning "the stuff I see..." 

Well... it's distasteful.


----------



## EpiEMS (Nov 21, 2021)

RocketMedic said:


> Pretty much everywhere that’s more than fifteen minutes to a hospital.


That reminded me of this Pew survey. I'd wager that would mean most major cities, almost every sizable suburb, and even well into the exurbs, your exceptions being true rural areas.


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## MackTheKnife (Nov 21, 2021)

FiremanMike said:


> Opinion - the psychomotor skill of intubation is nowhere near as difficult as we make it out to be.


You win the Academy Award for the Most Accurate Assessment of this topic! I couldn't agree with you more. Bravo!


----------



## MackTheKnife (Nov 21, 2021)

FiremanMike said:


> The skill itself is easy, it's everything that goes into intubating that makes it hard. But we (accreditation boards, teachers, managers) focus on "you must have XX number of intubations to be competent.
> 
> I'd argue you must have XX exposure to stress management and critical thinking to be successful at airway management. Shock index and acid/base balance (yes, that _is _actually important in clinical practice) can be taught in the classroom and reinforced through simulation to the point where it becomes second nature and will be easily incorporated into live airway management situations.
> 
> ...


Yep!


----------



## VentMonkey (Nov 24, 2021)

Categorizing a Bougie as a “crutch”, or rescue device. And, viewing alternative airways—when needed—as SGA’s as a provider being “weak” at airway management.


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## GMCmedic (Nov 24, 2021)

VentMonkey said:


> Categorizing a Bougie as a “crutch”, or rescue device. And, viewing alternative airways—when needed—as SGA’s as a provider being “weak” at airway management.


A service shouldn't allow intubation in 2021 if they don't stock bougies. 


I'll take it one further, if your service isn't spending covid money on video layrngoscopy they should no longer allow intubation.


----------



## MackTheKnife (Nov 27, 2021)

GMCmedic said:


> A service shouldn't allow intubation in 2021 if they don't stock bougies.
> 
> 
> I'll take it one further, if your service isn't spending covid money on video layrngoscopy they should no longer allow intubation.


Bougie and video or no intubations? That's pretty myopic. A Miller #3 and a stylet for most adults works fine although I'm not against bougie and video.


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## Tigger (Nov 27, 2021)

MackTheKnife said:


> Bougie and video or no intubations? That's pretty myopic. A Miller #3 and a stylet for most adults works fine although I'm not against bougie and video.


And yet little in the way of research supports this.


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## MackTheKnife (Nov 27, 2021)

Tigger said:


> And yet little in the way of research supports this.


Please elucidate. Not sure which way you research comment goes.


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## Tigger (Nov 27, 2021)

MackTheKnife said:


> Please elucidate. Not sure which way you research comment goes.


Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.


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## MackTheKnife (Nov 27, 2021)

Tigger said:


> Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.


Ok, understand now. My comment was from an experiential point of view. Again, from the same perspective, I watch doctors in the ED struggle to intubate with video and bougie and they call an anesthesiologist who directly intubates with a Mac or Miller and a stylet.


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## Tigger (Nov 27, 2021)

Most emergency medicine providers of any level have zero business comparing their skill set with anesthesia.


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## DrParasite (Nov 27, 2021)

Tigger said:


> Most emergency medicine providers of any level have zero business comparing their skill set with anesthesia.


Is that a fair comparison?  Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month.  so when it comes to airways, anesthesia is the expert, because they do it so frequently

but EM does a lot more stuff in a shift than simply airway management; in fact, if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?


__ https://twitter.com/i/web/status/1461969368342880257


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## Summit (Nov 27, 2021)

DrParasite said:


> , if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?


Extremely ****ing well in terms of airway management. What else was the point of this line of discussion?


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## Tigger (Nov 27, 2021)

DrParasite said:


> Is that a fair comparison?  Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month.  so when it comes to airways, anesthesia is the expert, because they do it so frequently
> 
> but EM does a lot more stuff in a shift than simply airway management; in fact, if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?
> 
> ...


Yea, it’s different. That’s the point. There isn’t a viable comparison, so don’t make one.


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## DrParasite (Nov 28, 2021)

Summit said:


> Extremely ****ing well in terms of airway management. What else was the point of this line of discussion?


last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift?  or did you miss that point that was clearly made?


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## Summit (Nov 28, 2021)

DrParasite said:


> last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift?  or did you miss that point that was clearly made?


Nah, I se a non-sequitur. 

The question was whether success rates for techniques used by high frequency intubators like Anesthesia are relevant to low frequency intubators who probably shouldn't be reliant on the same techniques.  Whether a high frequency intubator is good at doing non-airway things is not relevant to the original point.


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## Tigger (Nov 28, 2021)

Well I (and everyone else) thought it was pretty clear that we were talking about airway management skill sets; would you like a sign also labeling the sky as blue?


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## silver (Nov 28, 2021)

DrParasite said:


> last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift?  or did you miss that point that was clearly made?


Although airway management comes up with most patients, you realize that anesthesiologists/CRNAs do 99 other things during a day too?


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## E tank (Nov 28, 2021)

...boy I'm glad I'm not drunk right now.... 😁


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## Carlos Danger (Nov 28, 2021)

Tigger said:


> Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.


You are correct, and this has been true for years. Not every airway requires a VL but the problem is, it is impossible to know which one will until you've already pushed the NMB, at which point it is (not infrequently, in the case of an emergent tube) almost too late unless you have really strong airway skills. So if you don't have really strong airway skills to begin with (I don't think ANY OF US have airway skills as strong as we like to think), it's important to give yourself every advantage possible. The research reflects this consistently. 


DrParasite said:


> Is that a fair comparison?  Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month.  so when it comes to airways, anesthesia is the expert, because they do it so frequently


I think the fact that it isn't a fair comparison is the whole point. The rules are different for someone who does a thing an average of several times a day vs. someone who only does that thing several times a month or even several times a week. There are a few things that I do sometimes that I'm pretty good at but am not nearly as good at as someone who does them much more frequently. We shouldn't hold ourselves to the same standard in that case.


----------



## StCEMT (Nov 28, 2021)

All for bougie and VL, y'all know the McGrath X3 and a bougie is my **** even if it kinda goes against the grain a bit for common VL set up advice. 

Now I've absolutely successfully taken a bougie and Mac 3 for a DL on a person who checked 4/6 HEAVEN criteria boxes and all in all it wasn't too hard. I'd absolutely have preferred my McGrath though.


----------



## Aprz (Nov 28, 2021)

StCEMT said:


> All for bougie and VL, y'all know the McGrath X3 and a bougie is my **** even if it kinda goes against the grain a bit for common VL set up advice.
> 
> Now I've absolutely successfully taken a bougie and Mac 3 for a DL on a person who checked 4/6 HEAVEN criteria boxes and all in all it wasn't too hard. I'd absolutely have preferred my McGrath though.


I know of guidelines that don't just see HEAVEN as difficult airways, but makes recommendations based on them. DL for hypoxia, small patients (one of the extreme of sizes), vomiting, and exsanguination. They recommend VL for large patients (the other extreme of size), anatomical abnormalities, and neck mobility.


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## StCEMT (Nov 29, 2021)

Aprz said:


> I know of guidelines that don't just see HEAVEN as difficult airways, but makes recommendations based on them. DL for hypoxia, small patients (one of the extreme of sizes), vomiting, and exsanguination. They recommend VL for large patients (the other extreme of size), anatomical abnormalities, and neck mobility.


I mean I feel like that is how it should be. Gotta rehearse your solution, not just identifying the problem.


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## Aprz (Nov 29, 2021)

StCEMT said:


> I mean I feel like that is how it should be. Gotta rehearse your solution, not just identifying the problem.


On the ambulance, I used to do that. I would go DL for fluids in airway or any potential for glare outside. All other patients got VL. So I liked that I did kinda like a mini HEAVEN before I went air.


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## EpiEMS (Dec 8, 2021)

This study really is challenging my priors. I have to do a deep dive. There are multiple limitations but I hadn’t ever really considered the possibility that more than 3-4 providers would really make a difference, particularly in the era of the Lucas. 



			https://www.tandfonline.com/doi/full/10.1080/10903127.2021.1995799


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## DrParasite (Dec 8, 2021)

EpiEMS said:


> This study really is challenging my priors. I have to do a deep dive. There are multiple limitations but I hadn’t ever really considered the possibility that more than 3-4 providers would really make a difference, particularly in the era of the Lucas.
> 
> 
> 
> https://www.tandfonline.com/doi/full/10.1080/10903127.2021.1995799


1) not all of us have a lucas device on every ambulance in our system
2) "The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers."  this must include people who are there purely for muscle/compressions.  it's not saying you need 7 paramedics on scenes.    3-4 FFs on an engine, 1 ALS ambulance with an EMT & Paramedic, second ALS ambulance with EMT & Paramedic (or two units, one EMT/EMT & 1 Medic/Medic), maybe a supervisor to talk to the family, and you have more than enough people. 3) the city I live in sends 1 fire units to every cardiac arrest, and if it's a workable arrest, a second fire unit is sent (usually engine and ladder if in the the same house, or second due engine).  Apparently using fire crews is cheaper than buying lucas devices for every ambulance, especially since we rarely transport with CPR in progress, and there are few studies that have shown that a lucas device is clinically better than manual compressions (outside of vendor sponsored ones).


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## EpiEMS (Dec 8, 2021)

DrParasite said:


> 1) not all of us have a lucas device on every ambulance in our system
> 2) "The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers." this must include people who are there purely for muscle/compressions. it's not saying you need 7 paramedics on scenes. 3-4 FFs on an engine, 1 ALS ambulance with an EMT & Paramedic, second ALS ambulance with EMT & Paramedic (or two units, one EMT/EMT & 1 Medic/Medic), maybe a supervisor to talk to the family, and you have more than enough people. 3) the city I live in sends 1 fire units to every cardiac arrest, and if it's a workable arrest, a second fire unit is sent (usually engine and ladder if in the the same house, or second due engine). Apparently using fire crews is cheaper than buying lucas devices for every ambulance, especially since we rarely transport with CPR in progress, and there are few studies that have shown that a lucas device is clinically better than manual compressions (outside of vendor sponsored ones).



Agreed on your first point, I would argue it should be standard of care from a provider safety POV. Lucas has been shown to be non-inferior to hands on chest - so I’d argue it is more efficient, but reasonable people can disagree. 

I think you’re probably right - no way are you getting 7 medics (except in California), nor would you need them. The optimal mix is going to vary widely by response time, I think.


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## StCEMT (Dec 8, 2021)

It doesn't have to be better for me, just not worse. Most arrests, sure I don't really care. But especially now when I have sick patients for 30-40 miles in a very resource limited area, the Lucas is a must. If something happens on the way, I barely have 2 people most of the time (including myself) and some of the help I get may or may not be helpful at all.


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## EpiEMS (Dec 8, 2021)

StCEMT said:


> It doesn't have to be better for me, just not worse. Most arrests, sure I don't really care. But especially now when I have sick patients for 30-40 miles in a very resource limited area, the Lucas is a must. If something happens on the way, I barely have 2 people most of the time (including myself) and some of the help I get may or may not be helpful at all.



I agree. If clinical outcomes are the same but it makes operations easier, it’s a win.


----------



## Aprz (Dec 8, 2021)

EpiEMS said:


> I think you’re probably right - no way are you getting 7 medics (except in California), nor would you need them. The optimal mix is going to vary widely by response time, I think.


Even California is hurting right now.


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## EpiEMS (Dec 8, 2021)

Aprz said:


> Even California is hurting right now.



That’s what happens when you burn out 6 medics by sending them all to BLS toe pains!


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## MackTheKnife (Dec 8, 2021)

StCEMT said:


> All for bougie and VL, y'all know the McGrath X3 and a bougie is my **** even if it kinda goes against the grain a bit for common VL set up advice.
> 
> Now I've absolutely successfully taken a bougie and Mac 3 for a DL on a person who checked 4/6 HEAVEN criteria boxes and all in all it wasn't too hard. I'd absolutely have preferred my McGrath though.


Miller #3 for me.


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## StCEMT (Dec 8, 2021)

MackTheKnife said:


> Miller #3 for me.


It's been a few years since I've used that blade


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## MackTheKnife (Dec 8, 2021)

StCEMT said:


> It's been a few years since I've used that blade


Haven't tubed in awhile myself, but when I did, that was my go to except for peds, obviously.


----------



## MackTheKnife (Dec 8, 2021)

silver said:


> Although airway management comes up with most patients, you realize that anesthesiologists/CRNAs do 99 other things during a day too?


But not ED things. Again, this is specific to airways.


----------



## chriscemt (Dec 10, 2021)

EpiEMS said:


> I think you’re probably right - no way are you getting 7 medics (except in California), nor would you need them. The optimal mix is going to vary widely by response time, I think.


Johnson County, KS is probably getting 7 medics on most codes.  

Does the study referenced above make the distinction between EMT and paramedic?


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## FiremanMike (Dec 10, 2021)

EpiEMS said:


> I think you’re probably right - no way are you getting 7 medics (except in California), nor would you need them. The optimal mix is going to vary widely by response time, I think.


An arrest here gets an engine, a medic, and a battalion.  This would be 4, 3, and 1, all of whom are paramedics.

Sometimes I go as well, so potentially 9 paramedics, but always at least 8..


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## E tank (Dec 10, 2021)

FiremanMike said:


> An arrest here gets an engine, a medic, and a battalion.  This would be 4, 3, and 1, all of whom are paramedics.
> 
> Sometimes I go as well, so potentially 9 paramedics, but always at least 8..


too many cooks....


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## Jim37F (Dec 10, 2021)

Meanwhile here a code gets a single Fire company and single Ambulance. If the ambulance is one of the two BLS rigs, they'll also send one of the two medic Rapid Response suvs (or if they're the closest unit). So that's at the most, 3 medics, usually just one, maybe 2 normally.


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## FiremanMike (Dec 10, 2021)

E tank said:


> too many cooks....


I mean, sure.. I get that argument, but it only holds true if it’s a group of undisciplined medics. We train on having 1 voice be the quarterback and empower people to speak up, but only when necessary.

The other side of the coin is that it’s nice having everyone at a level where everyone can perform everything when needed.  There’s also more heads thinking at an ALS level who can identify differentials or things that are being missed.


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## CCCSD (Dec 10, 2021)

FiremanMike said:


> I mean, sure.. I get that argument, but it only holds true if it’s a group of undisciplined medics. We train on having 1 voice be the quarterback and empower people to speak up, but only when necessary.
> 
> The other side of the coin is that it’s nice having everyone at a level where everyone can perform everything when needed.  There’s also more heads thinking at an ALS level who can identify differentials or things that are being missed.


And more wasting time on scenes because…paramedics. Seven of them…


----------



## Tigger (Dec 10, 2021)

CCCSD said:


> And more wasting time on scenes because…paramedics. Seven of them…


How, given the example of a cardiac arrest, would more paramedics cause a scene delay? Please use specifics.

I read all these “BLS crews had better outcomes in trauma” articles where everyone dumps on medics. And rightfully so, but if you don’t know how to get off a scene when it matters, you’re a poor provider, level not withstanding.

Well educated paramedics are not inherently stuck staying on scene longer. And I’d argue that a smart paramedic probably recognizes more times when it’s advantageous to quickly transport a subtly presenting patient over a BLS crew who may never have been afforded the assessment skills to do that.


----------



## CCCSD (Dec 10, 2021)

Too many egos. LACFD is one good example. Why have seven people on the scene when only a few can actually process the actions needed. The rest are just bodies. I’ve watched paramedics argue about who was more qualified to handle a call. Too many cooks. Hell. Ask a group of seven paramedics which airway adjunct is best, and you’ll have 7 different opinions…


----------



## jgmedic (Dec 10, 2021)

LACo is pretty much the worst option. Next to OC.


----------



## EpiEMS (Dec 10, 2021)

chriscemt said:


> Johnson County, KS is probably getting 7 medics on most codes.
> 
> Does the study referenced above make the distinction between EMT and paramedic?



Nope - it doesn’t distinguish among the number of EMTs vs. medics on scene.


----------



## ffemt8978 (Dec 10, 2021)

If you have seven medics on one call, what happens when if three more calls come in at the same time?


----------



## DesertMedic66 (Dec 10, 2021)

ffemt8978 said:


> If you have seven medics on one call, what happens when if three more calls come in at the same time?


7 other medics respond. Some ALS fire departments are only staffed with medics.


----------



## FiremanMike (Dec 10, 2021)

CCCSD said:


> Too many egos. LACFD is one good example. Why have seven people on the scene when only a few can actually process the actions needed. The rest are just bodies. I’ve watched paramedics argue about who was more qualified to handle a call. Too many cooks. Hell. Ask a group of seven paramedics which airway adjunct is best, and you’ll have 7 different opinions…


That’s a system problem that has nothing to do with what certification level each person has.

Here, the guy in the passenger side of the medic is writing the report and in charge of patient care.


----------



## FiremanMike (Dec 10, 2021)

ffemt8978 said:


> If you have seven medics on one call, what happens when if three more calls come in at the same time?


There is no shortage of paramedics around here..


----------



## FiremanMike (Dec 10, 2021)

Ok I got one, in the theme of where this conversation has gone..

Tiered systems are only better for lazy medics who wish to passively improve their craft through ALS run volume instead of actively seeking out training and educational opportunities to broaden their horizon.

Some people have 25 years of experience, others have 1 year of experience 25 times.


----------



## EpiEMS (Dec 10, 2021)

FiremanMike said:


> Ok I got one, in the theme of where this conversation has gone..
> 
> Tiered systems are only better for lazy medics who wish to passively improve their craft through ALS run volume instead of actively seeking out training and educational opportunities to broaden their horizon.
> 
> Some people have 25 years of experience, others have 1 year of experience 25 times.



How would you address the counterpoint that volume of skill utilization improves proficiency?


----------



## jgmedic (Dec 10, 2021)

FiremanMike said:


> *That’s a system problem that has nothing to do with what certification level each person has.*
> 
> Here, the guy in the passenger side of the medic is writing the report and in charge of patient care.


Just wanted to bold this truth.


----------



## FiremanMike (Dec 11, 2021)

EpiEMS said:


> How would you address the counterpoint that volume of skill utilization improves proficiency?


I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..

I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.


----------



## Tigger (Dec 11, 2021)

CCCSD said:


> Too many egos. LACFD is one good example. Why have seven people on the scene when only a few can actually process the actions needed. The rest are just bodies. I’ve watched paramedics argue about who was more qualified to handle a call. Too many cooks. Hell. Ask a group of seven paramedics which airway adjunct is best, and you’ll have 7 different opinions…


So how does this contribute to scene delays, again?


----------



## PotatoMedic (Dec 11, 2021)

To be fair I haven't dug into this much, but BLS has better outcomes than ALS (per a study done in 2015)





__





						ACP Journals
					





					www.acpjournals.org
				




Now to try to find the full article.


----------



## StCEMT (Dec 11, 2021)

FiremanMike said:


> I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..
> 
> I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.


You're not necessarily reducing the level of care if it's staffed right. I am not needed in the slightest for the lady who had a bug in her ear. Literally any person with a driver's license could do just as good as me.

Besides, how is this concept that different from resource allocation when to comes to MD/DO vs PA/NP use? The hospitals I'm used to working with aren't ever really having the PA wait for us with the high acuity patients, it's the docs.


----------



## EpiEMS (Dec 12, 2021)

PotatoMedic said:


> To be fair I haven't dug into this much, but BLS has better outcomes than ALS (per a study done in 2015)
> 
> 
> 
> ...



This study was panned but I think it picks up on a broad truth that there is a paucity of evidence in favor of widespread ALS for survival & morbidity outcomes. OPALS is still the best we’ve got (I am inclined to believe, anyway). If you include other metrics like pain control, etc. which do matter but are probably understudied, ALS looks more attractive.


----------



## E tank (Dec 12, 2021)

EpiEMS said:


> This study was panned....


by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...


----------



## EpiEMS (Dec 12, 2021)

E tank said:


> by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...



Not saying I disagree with the conclusions but I do have methodological questions, which really just means we need to be doing research at a better level of evidence (RCTs?).

Some of the feedback - seems like mainly physicians? - was what I was referencing:









						Study: BLS patients have higher rates of survival than ALS ones
					

Research found that the patient population studied were more likely to survive if transported in a BLS ambulance rather than an ALS one




					www.ems1.com
				












						Advanced Life Support Takes Another Hit, But Is It a Fair Fight? | Emergency Physicians Monthly
					

Another JAMA study claims ALS beats BLS. But while it raises important questions, this study has too many biases to form concrete conclusions. “Patients who are having a heart attack, stroke or other serious health emergency have a greater chance of surviving if they’re taken to the hospital in...




					epmonthly.com


----------



## MackTheKnife (Dec 12, 2021)

Jim37F said:


> Meanwhile here a code gets a single Fire company and single Ambulance. If the ambulance is one of the two BLS rigs, they'll also send one of the two medic Rapid Response suvs (or if they're the closest unit). So that's at the most, 3 medics, usually just one, maybe 2 normally.


This is the problem with staffing. You don't dumb down, you smart up. A medic and an EMT on a bus, etc.


----------



## CCCSD (Dec 12, 2021)

E tank said:


> by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...


By paramedics…


----------



## E tank (Dec 12, 2021)

@EpiEMS ...thanks...a few thoughts (worth less than $0.02)

*"Their premise is flawed," said Howard Mell, a spokesman for the American College of Emergency Physicians and director of emergency services in Iredell County, N.C. He said ALS ambulances transport much more serious patients. "That's why they have much worse outcomes."*
My nomination for most clueless spokesman of 2015....was he really told that the study was randomized between ALS and BLS transports? As if a system with ALS units sitting around will just send BLS units on calls to see if their patients do better?

* As an observational study, it allows for correlations to be made with the data, but it cannot lead to conclusions of causality.*
 Doesn't mean conclusions can't be drawn from the data, otherwise observational studies wouldn't be published in journals like AIM. And with an n well exceeding a quarter million (approaching a half million), the shortcomings of observational data are pretty meaningfully mitigated.

With regard to selection bias:
*The applicability of the results is therefore limited to patients who are in the Medicare system and are therefore generally 65 or older.*
The very population most vulnerable to 3 of the 4 inclusion criteria and the largest, most frequently presenting fragile patient population.  That is not a study flaw. That's the representative group you want to pay attention to. The study would have been far less meaningful if it were limited to AAA baseball players less than 24 years old...hard to understand the criticism there.

I could go on, but this was a good paper as observational studies go. What this type of study and the tons before it don't (can't) take into account is what the hospitals are capable of providing.

 That care advances  orders of magnitude faster than what pre-hospital care can is a big confounder.  As hospital care becomes more sophisticated, pre-hospital care becomes _proportionally_ less important (not unimportant). Rural areas with less sophisticated hospital capability depend far more on ALS than urban centers do. Add prolonged travel times and it's a slam dunk for ALS. The irony is that those 'underserved' areas are greatly volunteer BLS so the point is moot.

As far as RCT's, I'd be hard pressed to come up with a design that could ethically study this issue that way.


----------



## FiremanMike (Dec 13, 2021)

StCEMT said:


> You're not necessarily reducing the level of care if it's staffed right. I am not needed in the slightest for the lady who had a bug in her ear. Literally any person with a driver's license could do just as good as me.
> 
> Besides, how is this concept that different from resource allocation when to comes to MD/DO vs PA/NP use? The hospitals I'm used to working with aren't ever really having the PA wait for us with the high acuity patients, it's the docs.


I don't think EMT to Paramedic is the same comparison as PA/NP to MD/DO.

As to your other point, true BLS runs don't need a paramedic, but on the same token I think far too many runs are blown of as BLS that really aren't..


----------



## StCEMT (Dec 13, 2021)

FiremanMike said:


> I don't think EMT to Paramedic is the same comparison as PA/NP to MD/DO.
> 
> As to your other point, true BLS runs don't need a paramedic, but on the same token I think far too many runs are blown of as BLS that really aren't..


The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.

That's not a failure of the idea though, it's a failure of how it is applied.


----------



## FiremanMike (Dec 13, 2021)

StCEMT said:


> The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.
> 
> That's not a failure of the idea though, it's a failure of how it is applied.


Yes, but NPs and PAs have significantly more training and would be more likely to recognize when something is moving past their expertise.  Given the current state of EMT-Basic education, I'm not sure that applies there.

I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..


----------



## DrParasite (Dec 13, 2021)

FiremanMike said:


> I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..


I've said it before, and I'll say it again: based on everything you have said about your department, your agency is likely in the minority when it comes to EMS providers who ride the BRT, and that's a good thing.

The last time I was part of an ALS FD was almost 20 years ago, and all of our FF/PMs had years of experience on the ambulance as PMs, usually as Senior PMs or FTOs.  Many still worked for the City's EMS agency part time.  Since then, I've worked with a few FF/PMs, but almost all had previous PM experience on the ambulance, and most were function as EMTs or AEMTs when on the BRT.

I know I'm biased, but there are not many suppression only EMTs, who have never worked on an ambulance, that I would trust do provide a decent assessment on a sick patient.  There are even fewer suppression only paramedics, who have never worked on an ambulance, that I would feel comfortable assessing and treating at the ALS level, especially on a sick patient, if they were my family member.

I am much happier having the people on the BRTs being decent EMTs, with the ambulance people being more competent and experienced EMTs, along with a paramedic either on the truck or on a flycar, only handling ALS criteria patients.

Think of if this way: if you are putting 7-9 paramedics on a cardiac arrest, do you trust all of them to intubate the 400 lb patient with a mallampati class 3 airway, at 3 in the morning?  And when was the last they those 7 to 9 paramedics intubated a live person with a difficult airway?  or ran point on a circling the drain patient?


----------



## MackTheKnife (Dec 13, 2021)

StCEMT said:


> The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.
> 
> That's not a failure of the idea though, it's a failure of how it is applied.


Not true necessarily in the ED. Our NPs and PAs hit the high acuities.


----------



## FiremanMike (Dec 13, 2021)

DrParasite said:


> I've said it before, and I'll say it again: based on everything you have said about your department, your agency is likely in the minority when it comes to EMS providers who ride the BRT, and that's a good thing.
> 
> The last time I was part of an ALS FD was almost 20 years ago, and all of our FF/PMs had years of experience on the ambulance as PMs, usually as Senior PMs or FTOs.  Many still worked for the City's EMS agency part time.  Since then, I've worked with a few FF/PMs, but almost all had previous PM experience on the ambulance, and most were function as EMTs or AEMTs when on the BRT.
> 
> ...


1.  To be clear, my agency has issues.  We have guys who have that p-card only because it's a requirement to get on, and we have guys who suck but can't get fired because it's too difficult.  We also have some admin who hate EMS, but OVERALL, the culture in this area is different because EMS is nearly entirely fire based.  There is a County EMS agency in an adjacent county, but otherwise, when you call 911, the ambulance that shows up will be from an FD.

2.  I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.  

Let's build on #2 and incorporate a counterpoint to some of the other thoughts in this thread.  What happens when you put all your eggs in the basket of "one paramedic on scene", but that paramedic is a dolt and no one else on scene has enough training or education to realize that they're missing key signs that should be obvious to any ALS provider.  Let's not pretend that the hiring standards for third service EMS agencies are such that only the cream of the crop can get those jobs, they have idiots who work there too who are also capable of murder through incompetence.  When there isn't another ALS provider around to a. catch their mistakes or b. teach them, then the potential for disaster is high.

While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.


----------



## EpiEMS (Dec 13, 2021)

FiremanMike said:


> I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..
> 
> I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.


Doing something more is better, all else equal. There's ample research out there showing that procedural success and outcomes are associated with volume per provider - and more medics means fewer procedures (all else equal) per ALS provider.

(For example, a study in Australia found that "OHCA survival to hospital discharge significantly increased with the number of OHCAs that paramedics had treated". Similarly, in one retrospective study of ETIs in PA, the authors noted a connection between "increased rescuer procedural experience and improved patient survival after out-of-hospital tracheal intubation of cardiac arrests and medical nonarrests".)



E tank said:


> As far as RCT's, I'd be hard pressed to come up with a design that could ethically study this issue that way.


Probably true, the before/after control is about as good as we can probably get, I'd wager. And this is where the full suite of OPALS studies comes in - even if about a decade old - which suggest that ALS provision (which, at the time, included things now widespread in the BLS world) didn't do anything for trauma outcomes (not so surprising since the main skills referenced are ETI and IV fluids) or cardiac arrest but did improve outcomes for respiratory distress (seems like albuterol is a major driver here). T



DrParasite said:


> Think of if this way: if you are putting 7-9 paramedics on a cardiac arrest, do you trust all of them to intubate the 400 lb patient with a mallampati class 3 airway, at 3 in the morning? And when was the last they those 7 to 9 paramedics intubated a live person with a difficult airway? or ran point on a circling the drain patient?


^This is it in a nutshell.



FiremanMike said:


> While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.


Plausible, but two points:

(1) Cost -- medics cost more. Do I get incremental benefit? A system can't be efficiently designed to do the most for the greatest number in such a manner. 
(2) Quality -- more medics, more skill dilution, worse quality


----------



## DrParasite (Dec 14, 2021)

FiremanMike said:


> 2.  I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.
> 
> Let's build on #2 and incorporate a counterpoint to some of the other thoughts in this thread.  What happens when you put all your eggs in the basket of "one paramedic on scene", but that paramedic is a dolt and no one else on scene has enough training or education to realize that they're missing key signs that should be obvious to any ALS provider.  Let's not pretend that the hiring standards for third service EMS agencies are such that only the cream of the crop can get those jobs, they have idiots who work there too who are also capable of murder through incompetence.  When there isn't another ALS provider around to a. catch their mistakes or b. teach them, then the potential for disaster is high.


While the skill of intubation isn't difficult, it's a low frequency high risk skill in many systems (how many undetected prehospital esophageal intubations make the news), so while putting the tube between the cords is easy on a "routine" patient, it can have issues.   Regardless, pick another high risk low frequency skill (needle decompression, dopamine drips, etc) and ask yourself: do you want someone who has done this procedure in the last week, last month, or 1 in the last 2 years?

BTW, I'm not saying 3rd service EMS agencies get the cream of the crop: I know from first hand experience that they have idiots, just like anywhere else.  However, I am (maybe naively) optimistic that an 3rd service EMS agency, whose sole function is EMS, would terminate a new paramedic's credentials in their initial orientation if they could not function as a competent paramedic, as well as do mandatory competencies for people year after year... And have a robust QA/QI system to catch under performing providers.  with a FD, when a department's primary missions is fire suppression, the focus on competencies is elsewhere, so if they can strech a hoseline, vent a roof, but have trouble reading that 12 lead, knowing their medication doses, well, we can work with that later in their career.  Again, maybe not at your department, but I can assure you it happens at ABC Fire Dept.


FiremanMike said:


> While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.


Ehhhh, 7-9 medics sounds like horrible plan... skill dilution, worse quality, less experience with sick patients... 

Now, do I think 1 paramedic on scene of a critical patient is a good idea?  hell no.  As you said, if the paramedic is a dolt, and no one else can pick up on key signs, it's a potential recipe for trouble.  Those serious calls (cardiac arrests, penetration traumas, seizures/status ep, serious MVAs, etc) need to have a flycar paramedic/supervisor or second ambulance respond to the scene, to provide the second ALS provider for exactly the reasons you describe.  While I do know there are some paramedics who refuse to work on a truck with another paramedic (after all, who is in charge of the patient or some other BS like that), there are times when having another ALS provider is beneficial.


----------



## DesertMedic66 (Dec 14, 2021)

FiremanMike said:


> 1.  To be clear, my agency has issues.  We have guys who have that p-card only because it's a requirement to get on, and we have guys who suck but can't get fired because it's too difficult.  We also have some admin who hate EMS, but OVERALL, the culture in this area is different because EMS is nearly entirely fire based.  There is a County EMS agency in an adjacent county, but otherwise, when you call 911, the ambulance that shows up will be from an FD.
> 
> 2.  I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.
> 
> ...


The counterpoint to your counterpoint is that when you greatly reduce the number of medics in a system it becomes vastly easier to train, educate, and evaluate them. You can also be much more selective over who you allow to become a medic. We shouldn’t have to rely on another medic to “catch our mistake”, the sole responsibility is for that medic to make the best decisions.


----------



## StCEMT (Dec 14, 2021)

FiremanMike said:


> Yes, but NPs and PAs have significantly more training and would be more likely to recognize when something is moving past their expertise.  Given the current state of EMT-Basic education, I'm not sure that applies there.
> 
> I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..


True, but depending on the structure in the background on how these dispatch, a higher level of education isn't needed. ALS isn't needed in the slightest for the majority of what we do. I'm all for the education bar going up, but it won't change outcomes for a fair bit of call volume. 

Given the nationwide staffing issues, we already have delays in getting ALS providers on scene as is, my part time job has been a shining example of that. Why not buffer that with BLS units for calla that obviously don't need ALS?


----------



## StCEMT (Dec 14, 2021)

MackTheKnife said:


> Not true necessarily in the ED. Our NPs and PAs hit the high acuities.


I know it's a thing in some places. Locally for me, it basically doesn't exist. Only at one of about 16 or so places I go have I ever had a PA as lead on anything major.


----------



## PotatoMedic (Dec 14, 2021)

How much do we really need paramedics when only 7 percent of our calls have interventions that are considered potentially life saving?









						Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?
					

(2021). Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed? Prehospital Emergency Care: Vol. 25, No. 4, pp. 549-555.



					www.tandfonline.com


----------



## EpiEMS (Dec 15, 2021)

PotatoMedic said:


> How much do we really need paramedics when only 7 percent of our calls have interventions that are considered potentially life saving?
> 
> 
> 
> ...



While I agree with the general point, I do question whether we are fully accounting for the other capabilities that paramedics bring. Obviously, there is opportunity to extend more capabilities further down the "clinical ladder" (Nitronox, anybody?), but pain control, sedation, etc. have unaccounted value.

The best analysis would look at a QALY, but unfortunately that is not something readily available for EMS.


----------



## DrParasite (Dec 15, 2021)

EpiEMS said:


> While I agree with the general point, I do question whether we are fully accounting for the other capabilities that paramedics bring. Obviously, there is opportunity to extend more capabilities further down the "clinical ladder" (Nitronox, anybody?), but pain control, sedation, etc. have unaccounted value.
> 
> The best analysis would look at a QALY, but unfortunately that is not something readily available for EMS.


or... we can just give EMTs the ability to administer Fentanyl lollipops... that would allow them to give a little pain control medication to make the patient feel better... hard to accidentally OD on them, and even if they did, EMTs carry Narcan...


----------



## DesertMedic66 (Dec 15, 2021)

DrParasite said:


> or... we can just give EMTs the ability to administer Fentanyl lollipops... that would allow them to give a little pain control medication to make the patient feel better... hard to accidentally OD on them, and even if they did, EMTs carry Narcan...


If only there was some type of gas or something that can be self administered by the patient that has a quick onset and quick half-life that has been shown to be a very good option for pain management…


----------



## CCCSD (Dec 15, 2021)

California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police
					

Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.




					www.foxnews.com
				




My “controversial option”: Fire every single FF involved in this, including the Chief,  and charge them for criminal negligence and sue the city in court.

Cop deserves an award.


----------



## ffemt8978 (Dec 15, 2021)

CCCSD said:


> California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police
> 
> 
> Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.
> ...


There's nothing controversial about your opinion there.


----------



## Summit (Dec 15, 2021)

Sounds like they only have an acting chief who suspended everyone, called them failures, thanked the cops, and called for an outside investigation of his department.

That man's family is gonna get paid.


----------



## DrParasite (Dec 16, 2021)

CCCSD said:


> California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police
> 
> 
> Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.
> ...


Chief wasn't there, and likely the FFs weren't following his directions, so he shouldn't take the blame or punishment for the freelancing of these idiots.   Unless he actually told them that they shouldn't enter due to COVID....

From the outside, this looks bad.... really bad... but (and here is the controversial part) I'm going to wait until the investigation completes before I say what I think should happen to all involved.  

In case anyone was wondering,  a FF/PM in that is paid $88,093.00 a year as their base salary, with a total pay between 150k and 240k, as per https://transparentcalifornia.com/salaries/search/?a=rialto&q=paramedic&y=2019.  Single role paramedics make between 36k and $512 as their base salary.  If this story is accurate, the taxpayers are not getting what they pay for, and I hope terminations are in order.


----------



## DrParasite (Dec 16, 2021)

DesertMedic66 said:


> If only there was some type of gas or something that can be self administered by the patient that has a quick onset and quick half-life that has been shown to be a very good option for pain management…


If only this type of gas had been used prehospital since the 1980s..... and is still in use today....








						Effectiveness of nitrous oxide in a rural EMS system - PubMed
					

Prehospital systems need a safe, effective analgesic agent for the treatment of patients suffering from pain. Recent studies have documented the efficacy of nitrous oxide in urban and rural settings. This study reviews the findings on 200 patients (157 trauma, 23 medical, 18 musculoskeletal...




					pubmed.ncbi.nlm.nih.gov
				











						Using Nitrous Oxide to Manage Pain - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News
					

Nitrous oxide has emerged as a medication closely in line with the tenets of modern prehospital medicine: evidence-based and noninvasive. It’s a medical gas that possesses both sedative and analgesic properties, and has been used extensively in hospitals and clinics worldwide for many years...




					www.jems.com
				





			https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322118/prehospital-pharmacology-nitrous-oxide
		



			https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222945/nitrous-oxide-prehospital-analgesic
		









						No laughing matter: Nitrous oxide reappears in US ambulances
					

Normally used in dentist's offices and hospitals, laughing gas is starting to turn up again in ambulances in some rural areas.




					www.statnews.com
				











						Nitrous oxide an alternative to opioids on ambulances
					

In some Vermont communities ambulances are now equipped with nitrous oxide to help patients deal with pain as opposed to opiates.




					www.wcax.com


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## EpiEMS (Dec 16, 2021)

DrParasite said:


> If only this type of gas had been used prehospital since the 1980s..... and is still in use today....
> 
> 
> 
> ...



I will say I have read a lot of state and regional protocols and I see nitrous offered less often than I would like. It really ought to be an EMT-level skill as it is.


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## DrParasite (Dec 16, 2021)

The only issue I see with Nitrous is accountability (if that even is an issue).  with Fent lollipops, you can count how many you have, and track their usage, just like you would any other medication; can't do the same with a gas.  

But I wouldn't be against nitrous being offered as an EMT level skill.


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## EpiEMS (Dec 16, 2021)

DrParasite said:


> The only issue I see with Nitrous is accountability (if that even is an issue). with Fent lollipops, you can count how many you have, and track their usage, just like you would any other medication; can't do the same with a gas.
> 
> But I wouldn't be against nitrous being offered as an EMT level skill.



Fair point on that. VT has some recommendations: https://www.healthvermont.gov/sites/default/files/Nitrous Start Up Guide 17-05-30 rev.pdf

Or maybe Penthrox? I think they have approved it recently in the US?


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## E tank (Dec 16, 2021)

Read a lot about N20 used in the pre-hospital setting, but I've been surprised about not a single mention of contraindications like pneumothorax or bowel obstruction, pts with vitreoretinal surgical histories...stuff like that...was it there and I just missed it?


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## silver (Dec 16, 2021)

E tank said:


> Read a lot about N20 used in the pre-hospital setting, but I've been surprised about not a single mention of contraindications like pneumothorax or bowel obstruction, pts with vitreoretinal surgical histories...stuff like that...was it there and I just missed it?


Or mention of the environmental impact. Meanwhile other settings are limiting its use if possible.


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## EpiEMS (Dec 16, 2021)

E tank said:


> Read a lot about N20 used in the pre-hospital setting, but I've been surprised about not a single mention of contraindications like pneumothorax or bowel obstruction, pts with vitreoretinal surgical histories...stuff like that...was it there and I just missed it?



It’s usually mentioned (in the protocols I have read and textbook references). A lot of the use cases cite isolated extremity and soft tissue trauma. For example, see VT protocols


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## FiremanMike (Dec 16, 2021)

DrParasite said:


> Chief wasn't there, and likely the FFs weren't following his directions, so he shouldn't take the blame or punishment for the freelancing of these idiots.   Unless he actually told them that they shouldn't enter due to COVID....
> 
> From the outside, this looks bad.... really bad... but (and here is the controversial part) I'm going to wait until the investigation completes before I say what I think should happen to all involved.
> 
> In case anyone was wondering,  a FF/PM in that is paid $88,093.00 a year as their base salary, with a total pay between 150k and 240k, as per https://transparentcalifornia.com/salaries/search/?a=rialto&q=paramedic&y=2019.  Single role paramedics make between 36k and $512 as their base salary.  If this story is accurate, the taxpayers are not getting what they pay for, and I hope terminations are in order.


I doubt they were following explicit orders, more likely they interpreted a directive in order to be lazy and grumpy with a nursing home that they’re tired of going to.

We had an agreement with our local places that they’d bring stable patients to the door but we’d come after unstable patients.  Every time the nurses forgot to do it, I heard about it immediately lol..

Never underestimate the capacity for being lazy in providers


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## akflightmedic (Dec 16, 2021)

DrParasite said:


> The only issue I see with Nitrous is accountability (if that even is an issue).  with Fent lollipops, you can count how many you have, and track their usage, just like you would any other medication; can't do the same with a gas.
> 
> But I wouldn't be against nitrous being offered as an EMT level skill.



Never an issue in the multiple systems I have worked where we carried it. The bottle is sealed in plastic. If you crack the plastic, you replace the bottle. That simple.

If you decide to huff on it between the plastic cracking and the replacing of the bottle, then good for you. But we were technically "not in service" until it was replaced. Supervisor was bringing you one, or you were swinging by central or your station to pick one up.


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## DrParasite (Dec 17, 2021)

akflightmedic said:


> Never an issue in the multiple systems I have worked where we carried it. The bottle is sealed in plastic. If you crack the plastic, you replace the bottle. That simple.
> 
> If you decide to huff on it between the plastic cracking and the replacing of the bottle, then good for you. But we were technically "not in service" until it was replaced. Supervisor was bringing you one, or you were swinging by central or your station to pick one up.


so it's not like an oxygen bottle, where there is an onboard or portable unit?  if it works, and you can seal it (or even seal the nitrox system with a plastic tag), and you have the manpower to be OOS until a fresh bottle is administered, awesome.  I did not know they worked like that, but sounds very doable.


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## akflightmedic (Dec 17, 2021)

DrParasite said:


> so it's not like an oxygen bottle, where there is an onboard or portable unit?  if it works, and you can seal it (or even seal the nitrox system with a plastic tag), and you have the manpower to be OOS until a fresh bottle is administered, awesome.  I did not know they worked like that, but sounds very doable.



Yes, it is a very portable unit. Comes in a small case with shoulder strap, you know, so you can administer at the patient's side prior to moving them. I love it on the old grannies who have fractured their hip and are laying between the toilet and the tub. If I am unable to get IV and medicate, or if I am delayed doing the IV and meds they can self medicate. It is great! The whole kit weighs less than 5lbs.

I said "technically" out of service as in your unit is not 100% stocked, however it is not a required item by the state to be a licensed ambo on the road. It just means you are not 100% stocked. And it is not really a manpower issue because it is no different than running out of oxygen, being low on other supplies, etc. You simply get restocked however your agency normally handles these things. And you are not using it on every single call either.

I have always worked County EMS or County/City Fire Rescue, so I have always had stations and plenty of supplies, with units and supervisors on the road, or we drive by Central which was near the hospitals or on the way from hospitals on the other end. Regardless, definitely should be a BLS skill since it is self administered. If given an option though, I still would choose Penthrane, used it overseas and loved it.

Bottle this size...


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## DrParasite (Dec 17, 2021)

akflightmedic said:


> It just means you are not 100% stocked. And it is not really a manpower issue because it is no different than running out of oxygen, being low on other supplies, etc. You simply get restocked however your agency normally handles these things. And you are not using it on every single call either.


The difference being, I have a second spare portable on my truck (with a regulator, ready to go), as well as two full bottles under the bench seat.  Plus the on board big tank (M tank?  L?  I could never remember the letter sizes).  Not only that, I can use the Oxygen until it's under 500 (or 300 in the city), it's not a one and done like you describe.  But as you said, you are low on supplies, so not OOS, but if it's not a critical or required item, you are still good to go for the next call (we used to typically have enough equipment to run 2 cardiac arrests or major traumas, back to back, so while we would be low, we could still handle another major call before needing to go OOS for critical supplies).

I'd be interested in seeing a pilot group study for a  911 system, with nitrous given to the BLS providers (either BLS ambulance or first responder), and actually seeing the data on how frequently it was used, if the administration was appropriate, and how long was a unit OOS for (if any) until the new supplies were provided.  Even more so, I'd be curious to know (in the BLS ambulance system) if having the Nitrous allowed for BLS to handle the call with just BLS providers (while giving pain management), allowing the ALS flycar/ambulance to go back in service for the next call.


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## chriscemt (Dec 21, 2021)

FiremanMike said:


> There is no shortage of paramedics around here..


That would be my take here, more or less.  

3 medics on some pumpers, and 2 on each ambulance, plus various chiefs and supervisors - all medics.


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