"Is Prehospital EMS (PHEMS) a Profession?"

[usalsfyre]

Igels and LMAs aren't as good as ET for a lot of things. Here they're intermediate or arrest airways.

They are infinitely better than a misplaced or poorly placed endotracheal tube.

Another mistake is defining it as an "intermediate airway". I am a paramedic because I have a unique body of knowledge about prehospital medicine, not because I can perform direct laryngoscopy.

We have seriously considered removing DL from the skill set of our lowest level on the clinical ladder due to competency issues.

 

[EpiEMS]

What do UK paramedics earn?

Looks like paramedic salaries start at around $33k, up to $43k for more senior folks, and then capping out at $53k as a "senior paramedic," which seems a lot like a PA, almost. Also, seems like all levels can make up to 25% more if they work odd hours or overtime — so a medic with some seniority could make as much as $66k. Nurses are on the same salary schedule, but max out at a higher level ($105k), seemingly.

Compare that to $35k for physicians in their first year of residency.


Found on:
http://www.nhscareers.nhs.uk/details/Default.aspx?Id=132 and http://www.nhscareers.nhs.uk/details/Default.aspx?Id=553 and
(Why? Cause comparative heath systems is interesting )

 

[RocketMedic]

That's roughly comparable(ish) to most large 911 services here.

 

[RocketMedic]

They are infinitely better than a misplaced or poorly placed endotracheal tube.

Another mistake is defining it as an "intermediate airway". I am a paramedic because I have a unique body of knowledge about prehospital medicine, not because I can perform direct laryngoscopy.

We have seriously considered removing DL from the skill set of our lowest level on the clinical ladder due to competency issues.

Not disagreeing, but I don't think a UK-style absolute prohibition on paramedic DL and intubation is a good idea, nor should it be legally regulated to only anesthesiologists. Restricting it within companies and agencies to trained, competent providers via operational policy and protocols? Absolutely. Taking it away from competent, trained providers who use it appropriately now? That's dumb. The arguments against prehospital ETT are mostly solved by giving us new paramedics appropriate training.

ETI may not belong in some situations (cardiac arrests, if these new studies pan out), but it's still an important tool in our kits. Every technique has its uses. Should we toss 1:1000 epi amps in favor of Epi-pens simply because there's less in the way of possible mistakes, to carry the same logic forward?

 

[St George]

Looks like paramedic salaries start at around $33k, up to $43k for more senior folks, and then capping out at $53k as a "senior paramedic,"

Correct, depending on the current exchange rate of course!

Nurses are on the same salary schedule, but max out at a higher level ($105k), seemingly.

True but for nurses to be earning close to this level they would have to include a large managerial component into their jobs OR be a clinical specialist. Remember PA's do not exist in UK medicine - this role is incooperated into the jobs of specialist nurses or other specialist healthcare professions.

L]] Also, seems like all levels can make up to 25% more if they work odd hours or overtime

Yes but the 25% is added to the yearly salary and taken evenly each month on top of regular pay. So for example a paramedic will earn the same in a month of weekends and nights as a month of nice and easy 9 to 5 monday to friday shifts.

 

[systemet]

I'm not sure why the sudden interest in what UK medics make, but bear in mind the cost of living is quite different, if you're trying to compare the UK and the US.

 

[mycrofft]

Corporals talk tactics, Majors talk strategy, Generals talk logistics

 

[TatuICU]

All nurse care is subject to medical control by a MD. If I screw up a vital sign or bandage change a MD can ream me out, or yell at my nursing boss, who then calls me in to pas it on. Can you see a nurse reaming out a surgeon for sending pt to his/her floor with a badly placed drain or a haemostat sticking out of their ear or whatnot?

Nursing protocols are required at least in Calif to be approved if not written by a MD. And "nursing care", as defined by nurses (and management), is less and less about bedside nursing.
.

Funny story, but my ICU director is probably the meanest B-i-t-$-h you'll ever meet and she actually did go to one of our Dr's lounges and chew a cardiologist's *** up one end and down the other for hanging up on a nurse who wanted to stop an amiodarone gtt because of a prolonged QT interval. She chewed his *** right there in front of everyone and he just sat there and took it, then got wrote up, then had to go before an in house peer review board composed of other docs, admins, and nurses, then had to write a letter of apology to the nurse he hung up on. There have also been times where she has called and chewed out docs for various other reasons including telling a CV surgeon that his art line which he specifically wrote (and quite rudely told) we were supposed to go by to titrate several pressors was quote " a piece of sh*t" and "if he thought her nurses were going to titrate vasoactive drips based on a poorly placed art line with a whip the size of Texas in it, then he needed to go back to whatever half-assed school let him escape with a degree." Of course she has a PhD in something or another to go along with her MSN and various other credentials and she was brought in from out of state by the company that bought our hospital to "turn things around."

None of that is relevant to this discussion and I am only trying to add a bit of levity here. I thought it was fairly humorous at the time.

 

[TatuICU]

This patient is going to die, probably from low output failure, and a tube in his throat you are blowing oxygen through is not going to change that.

If the highdose lasix isn't working and you have nothing stronger to reduce the peripheral resistance, then you have may also have a renal insult as well.

In any even, he is going to die, but you could try pacing as a palliative effort or in the absense of a pacer, perhaps some epi for b1 stimulation.

Uh, epi in decompensated heart failure? Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?

If you're looking to specifically increase CO/CI you would begin looking at dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI. Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances.

And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.

I also believe the term is CHF exacerbation, not exasperation, and lungs typically have 5 lobes, not four quadrants.

 

[CH100]

Not true, grasshopper!

Nurses do a lot more than administer drugs and treatments prescribed by MDs, and they are not supervised or evaluated by MDs - it's always other nurses.

And there is a whole additional body of "stuff" that nurses handle with no orders and no physician involvement.

Heck, in 14 states now, nurse practitioners don't even need a physician to diagnose and prescribe!

Nurses depend upon MD's for their protocols and have to have their work approved and signed off by physicians. For one. Or two.

 

[usalsfyre]

Uh, epi in decompensated heart failure? Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?

My guess is because your not going to find dobutamine or milrinone on a 911 ambulances?

If you're looking to specifically increase CO/CI you would begin looking at dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI. Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances.

I have a feeling he's going to be aware of this. My question to you is this. What's your strategy when neither (or for that matter an IABP) is unavailable? The true test of a CCM provider(to me) is their ability to provide CCM level care in the proverbial mudhut.

And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.

Or we could get the afterload off and see if that increases LV clearing and the effectiveness of the CPAP, thereby avoiding a tube and all the complications that come with it.

I also believe the term is CHF exacerbation, not exasperation, and lungs typically have 5 lobes, not four quadrants.

I'll give a pass of exasperation as autocorrect fail has done the same thing to me.

 

[Veneficus]

Uh, epi in decompensated heart failure? Where is this happening? Why would you even consider something that will increase afterload in a patient with a faulty pump?.

I suggested it because most US EMS agencies I am aware of do not carry digoxin to increase contractility. They do carry epi.

The studies on dig not improving mortality are based on long term usage. But there is disputably some short term benefit.

The idea of using epi in desperation would be to mimic that effect with stronger contractile force. (No I don't think it would work very well, if at all, which is why I suggested it would be desperation)

The primary treatment is to lower peripheral resistance. However, if your high dose diuretic, CPAP, and all the other treatments originally listed are not working, I still don't think the tube is going to be the solution.

More therapies could be tried in hospital depending on the patient's cardiac function, in order to further reduce peripheral resistance, but in a patient in such extremis as described, I stand by my statement, the tube will most likely not make anymore difference.

If you're looking to specifically increase CO/CI you would begin looking at dobutamine or even primacor, as they both have a gentle vasodilative effect along with its inotropic profile that can increase CI. Also remember that in very diseased hearts, it is not uncommon to see some beta down regulation so using something that is cAMP mediated ( like a PDEI) may be more efficacious in some instances..

If you have them. I have only ever heard of critical care units with dobutamine available.

I have not encountered a prehospital or interfacility service with milrinone.

I have seen many interesting treatments for CHF, including CVVHFT, but I have never heard of that being available on an ambulance.

And yes, this patient would need intubation and mechanical ventilation to promote effective oxygenation, inotropic support, and diuresis.

55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do?

Think about this for a bit and get back to me. Do you really think intubation is going to be the magic bullet that makes everything all right after all else has failed?

But please consider, if this is a 55 y/o female, in such extremis, then she is definately in a world of hurt. Either she had a recent untreated MI, or she has some chronic pathology that is not going to be easily correctable with the finest of facilities, much less on a 911 ambulance.

and lungs typically have 5 lobes, not four quadrants.

Pointless to this discussion. 4 lung fields have been adequete for auscultation in many environments for many years. I think without a lateral xray, ct, or ultrasound, it would be very difficult to narrow physical findings down to the particular lobe of the right lung.

 

[TatuICU]

My guess is because your not going to find dobutamine or milrinone on a 911 ambulances?

Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.

I have a feeling he's going to be aware of this. My question to you is this. What's your strategy when neither (or for that matter an IABP) is unavailable? The true test of a CCM provider(to me) is their ability to provide CCM level care in the proverbial mudhut.

My strategy is to first do no harm and epi would worsen this patient's condition. As you say, the true test is the ability to critically think and move on to a an inotrope that you DO have available, not to just give epi for the sake of giving it and increasing afterload thereby worsening a patient in decompensated heart failure.

Or we could get the afterload off and see if that increases LV clearing and the effectiveness of the CPAP, thereby avoiding a tube and all the complications that come with it.

huh? You want to lower SVR by giving a drug that's going to increase afterload? The situation has already assumed that Lasix has been ineffective. I'd love to avoid a tube in this situation as well, and while CPAP can help to restore functional capacity, I think a patient in this situation is probably going to wind up intubated anyway. Pts can fail on CPAP, happens every day during extubation efforts. It would be cool if CPAP would work for this patient, but I just don't see it happening. Why not get them intubated, get in control of their airway, and know that you are effectively ventilating at least if not necessarily effectively oxygenating yet?

I'll give a pass of exasperation as autocorrect fail has done the same thing to me.

You're right, I stand corrected.

 

[Handsome Robb]

Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.

We don't carry it. Dopamine, which we do carry, could work in this situation, you'd just need to watch your dose. I'd pick somewhere in the 5-8ish range for inotropic effects while also trying to avoid the vasoconstrictive effects of a higher dose.

Lasix sure, in the Hospital setting, but in the acute prehospital setting I'd be looking for my NTG first to drop the afterload along with the inotropic effects of the dopamine plus the increased airway pressures from the CPAP to try and ward off the ETT demon.

edited to fix my wonderful grammar

 

[46Young]

Who doesn't carry dobutamine? Primacor ok, but dobutamine? For real? And I know of zero ambulance that don't carry dobutamine which could be used as well.




My strategy is to first do no harm and epi would worsen this patient's condition. As you say, the true test is the ability to critically think and move on to a an inotrope that you DO have available, not to just give epi for the sake of giving it and increasing afterload thereby worsening a patient in decompensated heart failure.




huh? You want to lower SVR by giving a drug that's going to increase afterload? The situation has already assumed that Lasix has been ineffective. I'd love to avoid a tube in this situation as well, and while CPAP can help to restore functional capacity, I think a patient in this situation is probably going to wind up intubated anyway. Pts can fail on CPAP, happens every day during extubation efforts. It would be cool if CPAP would work for this patient, but I just don't see it happening. Why not get them intubated, get in control of their airway, and know that you are effectively ventilating at least if not necessarily effectively oxygenating yet?



You're right, I stand corrected.

Here in the U.S. I've yet to see a 911 ambulance that carries dobutamine. I've worked in NY, VA, WV, and SC. For that matter, I don't know of any IFT ambulances that carry dobutamine, either. We just get it from the sending facility. I suppose ambulances in your country carry much more than ours.

As far as treating cardiogenic shock on the average 911 ambulance, the only things we have besides airway management are epi, dopamine, NS, pacing, and atropine.

I remember usalsfyre mentioning juggling ntg and dopa in lieu of dobutamine, which is not typically carried on our ambulances.

Really, at the point of cardiogenic shock, on a 911 bus, it's either a NS bolus for presumed rt sided failure, or pressors otherwise (or both). Pressors or pacing for the bradycardia bears mentioning. We have epi and dopa, and that's about it. What else do you suggest we do in that situation?

Edit: apparently NVRob likes dopa/NTG as well. Strong work.

 

[TatuICU]

I suggested it because most US EMS agencies I am aware of do not carry digoxin to increase contractility. They do carry epi.

The studies on dig not improving mortality are based on long term usage. But there is disputably some short term benefit.

I wouldn't use Dig either. I don't know of anyone in or out of a hospital that would use Dig for this instance first line especially since, according to this scenario, Lasix has been ineffective suggesting that perhaps there are some serious renal issues happening.

The idea of using epi in desperation would be to mimic that effect with stronger contractile force. (No I don't think it would work very well, if at all, which is why I suggested it would be desperation)

The primary treatment is to lower peripheral resistance. However, if your high dose diuretic, CPAP, and all the other treatments originally listed are not working, I still don't think the tube is going to be the solution.

Epi is not a hail mary in this instance. Epi will worsen this patient's condition. The increase in afterload even at a lower dose would increase SVR and offset whatever increase in contractile force it would provide, which would probably not be very much, because as a patient with a heart this diseased probably has an LV that's as stiff as a board.

Who said the tube would be a solution? I'm saying that a tube is most likely the most effective therapy in which to assure adequate ventilation. And nothing is going to matter if you don't fix your pump problem (long shot here from the scenario described.)

If you have them. I have only ever heard of critical care units with dobutamine available.

I have not encountered a prehospital or interfacility service with milrinone.

Most units I've seen or worked on do carry dobutamine and every unit carries dopamine which could also be used here for inotropic support. Milrinone, you're right.

Think about this for a bit and get back to me. Do you really think intubation is going to be the magic bullet that makes everything all right after all else has failed?

But please consider, if this is a 55 y/o female, in such extremis, then she is definately in a world of hurt. Either she had a recent untreated MI, or she has some chronic pathology that is not going to be easily correctable with the finest of facilities, much less on a 911 ambulance.

I detect an air on condescension here, any particular reason why? Again, who said anything about intubation being a "magic bullet?" Please show where in my post that I suggested intubation was going to be the intervention to correct this patient's condition and I will certainly go back and edit it out. Intubation is not going to be the magic bullet for this patient and in fact there is no pathology that I know of where intubation is a magic bullet that fixes anything. Intubation is a therapy, and in this case I feel an appropriate one, to insure adequate ventilation for this patient. You're also assuming that a patient in this extremis is able to protect their airway.

Pointless to this discussion. 4 lung fields have been adequete for auscultation in many environments for many years. I think without a lateral xray, ct, or ultrasound, it would be very difficult to narrow physical findings down to the particular lobe of the right lung.

That wasn't the point. In this instance you would probably not even need to lay a stethoscope to this patient to hear your problem.

 

[DrankTheKoolaid]

Dont forget that Calcium can also be used for its inotropic effect, which you likely do carry. Both in cases of hypocalcemia and in normal levels, 1g CA will act to increase inotropy.

 

[TatuICU]

Here in the U.S. I've yet to see a 911 ambulance that carries dobutamine. I've worked in NY, VA, WV, and SC. For that matter, I don't know of any IFT ambulances that carry dobutamine, either. We just get it from the sending facility. I suppose ambulances in your country carry much more than ours.

As far as treating cardiogenic shock on the average 911 ambulance, the only things we have besides airway management are epi, dopamine, NS, pacing, and atropine.

I remember usalsfyre mentioning juggling ntg and dopa in lieu of dobutamine, which is not typically carried on our ambulances.

Really, at the point of cardiogenic shock, on a 911 bus, it's either a NS bolus for presumed rt sided failure, or pressors otherwise (or both). Pressors or pacing for the bradycardia bears mentioning. We have epi and dopa, and that's about it. What else do you suggest we do in that situation?

Edit: apparently NVRob likes dopa/NTG as well. Strong work.

That last bit in the first part you quoted should've said dopamine, my mistake. Epi is not a treatment because it will worsen this patient's condition.

The only the thing you can do is insure adequate ventilation, try to improve CO/CI with inotropic support, and start diuresis. And drive real fast?

Also I don't know how one can determine LAsix to be ineffective after 20 minutes, particularly in an instance where renal insult is suspected?

 

[Handsome Robb]

Dont forget that Calcium can also be used for its inotropic effect, which you likely do carry. Both in cases of hypocalcemia and in normal levels, 1g CA will act to increase inotropy.

You present an excellent point salesman.

 

[usalsfyre]

Dopa is going to be only slightly less harmful than epi, although I would use it at moderate doses before epi.

My choice is to start dopa or epi and then load as much IV NTG on board as the MAP will allow. As you note, get the afterload off. While this is certainly an inelegant solution, it's using commonly available agents.

Finally, why are we so hell bent on diuresing this patient? While probably needed eventually, this isn't going to help us out short-term very much.