ALS reduced to first aid.

[mycrofft]

In my experience, new concepts in advanced life support tend to be more "in vitro" (no Latin word for "hospital") than "in vivo" (real life). The trend is that, just as a snail's shell gets bigger and bigger, the trend is to bring more and more technology to the field in order to replicate necessary diagnostic, support, and treatment to use these methodologies.

This has a number of ramifications. One is that ambulances get bigger, exponentially more expensive to buy and maintain, and to staff. Another is that practitioners may tend to begin or try to improvise ALS measures which really are not appropriate in the abscence of the necessary support, and the pt would benefit more if they stuck to the basics until back at the hospital. (Think unnecessary or failed field needle pleural decompressions).

Thoughts?

 

[DESERTDOC]

What kind of support do you think Paramedics need? We are use to functioning alone or with minimal help. I will initiate any therapy that I feel, based on extensive training and experience, will benefit my patient.

Perhaps somethings are superfluous, but most are not. As an ALS provider of pre-hospital care, what would you remove so that the treatment process is easier for EMT-I's and Paramedics?

 

[mycrofft]

Hi DESERTDOC. I think we have mutual scenario dislocation.

My concept: Vacationing MD on a ski slope tries to do something there he does as a matter of course in-house, and has to stop at step#3 out of 7 due to no sterile supply, no xrays, etc., leaving the pt hanging and the responders with potentially another iatrogenic mess. (Think of the MD trying to do an improvised cricothyrotomy when simply repositioning the pt might do it).

Paramedics should have less trouble like that because "the latest thing" usually gets filtered and slowed through their educational and protocol approval processes (although I seem to recall a dilly regarding phosphorous burns or something like that in Texas last year). However, if the trend is to take more and more to the patient, and required materials are missing/broken/used up (and the more advanced the life support, the more materiele is required), then you are returning with a radio report of "We attempted to perform WXY but were unsuccessful due to the Hoberseeber Franginator was kerflabitzed".

Or, for example, with a short response time, why try a decompression (it could be other procedures) when simply turning the pt on the affected side and supporting in other less invasive ways poses less risk (versus benefit).

Imagine what could be done with a mobile small CT scanner, you could place catheters, reduce dislocations, etc etc, but you could afford one ALS vehicle versus two without.

That's my paradigm here.

PS: in time, many "essential" measures have been questioned and some replaced or eliminated.

 

[Shishkabob]

To be fair, there's a few things ems is much quicker to universally adopt than most others in healthcare. Hello ETCO2

Are there certain procedures that are "safer" in a hospital, such as RSI? Yes... But for the most part its been proven just as safe and successful in the field with proper education and QA QI


As time goes on, well continue to add beneficiary things to do out of hospital, like we did with rsi, ETco2 and 12 leads. Ultrasound is headed in that direction with a few agencies already doing it.

If it can be relatively safe and beneficial to the patient, why not do it in the field?

 

[Melclin]

I actually think that adding more often makes life easier. For us and the patients. I often think, oh this is a really difficult situation for me to be in, but if I had "x" in my scope, this wouldn't be a problem. Usually airway management issues of some kind.

Enough about me, in general, lets look at intubation example. Many may have thought that giving paramedics paralytics was a frightening addition, but I think its its frightening not to have them. Oh I can't pass the tube, shovel in more midaz. You do it right, or not at all.

There are people in melbourne who are walking and talking and deficit free because paramedics tubed them and tubed them properly, or so says our RSI trial. There are people who have a bunch more myocardium left because a paramedic did a 12 lead, or so says our ECG trial. Countless thousands have received adequate pain relief because every emergency ambulance in the state has some ability to provide pain relief.

Hypoventilating opiate ODs, hypoglycaemic pts, anaphylaxis, asthma...I mean, pick a guideline and I'll tell you why its important that we have what we have, and then I'll tell you what we should have but don't and how it would make a difference.

If nothing else, as well trained gate keepers, we stear people in the right direction for the care they need. We push triage nurses to give our pt that resus bed when she wasn't going too. You pick up on a subtle bit of important information and relay it to the doc. These are all important things. I mean, there's no guideline for that, nor any piece of sexy equipment, but its important and a first aider sure as s**t can't do it.

I think any care modality that can be administered empirically or on the basis of some form of POC testing, that then improves outcomes in some way, shape or form, is a modality we should have.

 

[mycrofft]

Let me pose a followup question

(Let me say that the responses so far are worth stepping into the excremento once again).

Ok, where is the limit to what should be deployed? Is it financial, clinical, practical, a training issue, frequency of use? It cannot be infinite.
(There, I've jacked my own thread).

 

[DESERTDOC]

I actually think that adding more often makes life easier. For us and the patients. I often think, oh this is a really difficult situation for me to be in, but if I had "x" in my scope, this wouldn't be a problem. Usually airway management issues of some kind.

Enough about me, in general, lets look at intubation example. Many may have thought that giving paramedics paralytics was a frightening addition, but I think its its frightening not to have them. Oh I can't pass the tube, shovel in more midaz. You do it right, or not at all.

There are people in melbourne who are walking and talking and deficit free because paramedics tubed them and tubed them properly, or so says our RSI trial. There are people who have a bunch more myocardium left because a paramedic did a 12 lead, or so says our ECG trial. Countless thousands have received adequate pain relief because every emergency ambulance in the state has some ability to provide pain relief.

Hypoventilating opiate ODs, hypoglycaemic pts, anaphylaxis, asthma...I mean, pick a guideline and I'll tell you why its important that we have what we have, and then I'll tell you what we should have but don't and how it would make a difference.

If nothing else, as well trained gate keepers, we stear people in the right direction for the care they need. We push triage nurses to give our pt that resus bed when she wasn't going too. You pick up on a subtle bit of important information and relay it to the doc. These are all important things. I mean, there's no guideline for that, nor any piece of sexy equipment, but its important and a first aider sure as s**t can't do it.

I think any care modality that can be administered empirically or on the basis of some form of POC testing, that then improves outcomes in some way, shape or form, is a modality we should have.

Word.

 

[DESERTDOC]

Let's deal with the pneumo example provided above.

If they do in fact have a tension pneumo going on, based on my assessment and subsequent diagnosis and are symptomatic, why would I not put a needle in the patients chest? It is fast, very effective, the first line treatment for tension pneumo. I do not care if I do it in the parking lot of the hospital, it is that fast and the results are equally as fast.

A simple non-tension pneumo can receive supportive care until such time as they get better or they deteriorate into a tension and become symptomatic.

 

[usalsfyre]

So first a word on the scenario above, pneumos go good lung down and needle thoracostomy is ONLY indicated for tension pneumothorax, if the medic is frequently placing needles in simple pneumothorax he's an idiot, and even with short transport times a tension pneumo may end in death without decompression. Further, needle decompression if done correctly is one of the easier and safer procedures you'll ever do.

This is where EBM earns its keep. What shows benefit if done by EMS vs waiting? If it shows benefit, can the cost be justified?

 

[mycrofft]

I knew as I was typing...

..that citing needle decompressions would go sideways.
I notice no one is defending the poor old MD on the ski slope:unsure:.

I guess the point I was trying to express is that SOME individuals (includes administrators, educators and other such overhead) bring material into the field which is not always practical outside of the milieu it was first dreamed up, SOME individuals will continue to swing for the fences without proper equipment to the detriment of the pt, and that the trend for the ALS "subspecialty" is to keep adding capability when Parkinson's Law (through budget, utilization review, lawsuits, or staffing patterns) will inevitably yank back on the rope and subsequent science and practice (or a simple conversation with a field guy over coffee) will prove the new measures no better or worse, or actually worse, (or, sometimes, better); (i.e., cricoid compression, not immersing people in cool water to lower core temp, levophed, tourniquets and incision for snakebites, ad nauseum).

OK, here we go again: automated vital sign monitors. When I first logged on here, everyone was all gaga for them, especially pulseoximetry. Now I know cardiologists who won't have them in their offices, and no one is citing how heroically they save pt after pt, mostly that they are just as wonky as before, and still in need of a trained observant caring human to make sense of them when they DO work.

What will the limits of field/street practice be?

PS: for the benefit of any EMT-B's, the affected ("bad") lung goes DOWN if the practitioner will not decompress, the good lung goes DOWN if you are going to decompress.

 

[LondonMedic]

Very difficult question.

For every paramedic who can safely anaesthetise someone there is one who can't and hundreds who say 'If only I could...' without necesssarilly understanding the rational, the physiology, the pharmacology, the anatomy, the technique, the importance of skill retention and all the other bits that are important.

To take RSI, we know (sort of) that it does save lives and it does reduce disability in a select cohort of patients. However, we also know that it's a risky procedure and that in the wrong hands it can be thoroughly disastrous. Yet, the US and Aus both have EMS systems that put RSI in paramedics' domain without adequate training, adequate equipment and without adequate experience. And that will lead to needless fatalities.

To stay on RSI for a moment, the procedure takes a good seven or eight minutes (from what I've seen in an anaesthetic job and a physician-led pre-hospital team), continuing the anaesthesia takes another two or so, setting the vent around a minute. If you're ten minutes from a hospital, where there could be an anaesthetist and ODP plus emergency physicians, nurses, techs and all the other team, you really need to think carefully about whether you're actually acting in the patient's global best interests or whether you're delaying definitive care.

Of course there are hundreds of examples where RSI could be used effectively and is 'essential' but whenever a new piece of kit or new skill is introduced we need to think carefully about the balance of risk to the patient in every way that it could be used.

On the subject of decompression, when London introduced needle decompression for paras the number of 'tension pneumothoraxes' nearly doubled. :unsure:


And finally why do these discussions usually centre around cool trauma stuff and not treating grandma's cellulitis at home?

 

[usalsfyre]

I guess the point I was trying to express is that SOME individuals (includes administrators, educators and other such overhead) bring material into the field which is not always practical outside of the milieu it was first dreamed up, SOME individuals will continue to swing for the fences without proper equipment to the detriment of the pt, and that the trend for the ALS "subspecialty" is to keep adding capability when Parkinson's Law (through budget, utilization review, lawsuits, or staffing patterns) will inevitably yank back on the rope and subsequent science and practice (or a simple conversation with a field guy over coffee) will prove the new measures no better or worse, or actually worse, (or, sometimes, better); (i.e., cricoid compression, not immersing people in cool water to lower core temp, levophed, tourniquets and incision for snakebites, ad nauseum).

You lost me here. What you describe is malpractice. For instance, I know the procedure to perform a tube thoracostomy. I know a way to do it with noting more than a scalpel, hemostats, bouige and a 7.0 ETT. Despite this, your not going to see me doing it. If there's individuals "pushing the limit" then they need to be reeducated and disciplined. There is however, NOTHING wrong with the acquisition of theroetical knowledge.

OK, here we go again: automated vital sign monitors. When I first logged on here, everyone was all gaga for them, especially pulseoximetry. Now I know cardiologists who won't have them in their offices, and no one is citing how heroically they save pt after pt, mostly that they are just as wonky as before, and still in need of a trained observant caring human to make sense of them when they DO work.

My pulseox works >95% of the time. I've never heard anyone advocate for technology to replace judgement. Clinical correlation is the catch phrase for the day.

[What will the limits of field/street practice be?

They will continually change as new technology and evidence become available. Scope may retract in some areas, expand in others. It will continually flux, because science continually fluxes. I'm really not sure what your complaint is. I'm not trying to slam, but you sound somewhat like your yearning for the 400 hour technician days when everything was set in stone because it was "protocol".

[PS: for the benefit of any EMT-B's, the affected ("bad") lung goes DOWN if the practitioner will not decompress, the good lung goes DOWN if you are going to decompress.

The good lung goes down in most cases. Let gravity help perfuse and ventilate the lung that's working. The only time the good lung goes up is if you believe the patient's weight will interfere with ventilatory effort.

 

[MrBrown]

Yet, the US and Aus both have EMS systems that put RSI in paramedics' domain without adequate training, adequate equipment and without adequate experience. And that will lead to needless fatalities.

Wrong. Australia and New Zealand (the two global leaders for Intensive Care Paramedic led RSI) have the toughtest education requirements in the world. RSI is open here only to selected ICPs (new ICPs have a Post Graduate Diploma ontop of a Bachelors Degree) who have passed a specific selection, education and assessment package for this.

We have been performing RSI since 2006 with a consistent success rate of nearly 98% and all unsuccessful intubations have been managed without cricothyrotomy.

Brown was gobsmacked (thats a medical term BTW) to learn that only some BASICS Doctors have RSI.

 

[LondonMedic]

Brown was gobsmacked (thats a medical term BTW) to learn that only some BASICS Doctors have RSI.

Perhaps that's a measure of how seriously RSI is taken over here. The only BASICS guys who do it are those who consider themselves to have the necessary experience and have a medical practice that allows them to constantly practice and maintain their skills. There's a serious argument in the UK pre-hospital world about the benefit of BASICS doctors who don't bring RSI to the party, their arguments about other skills - triage, procedural sedation, etc. - currently mean that they still go with BASICS because they do add value over and above a standard paramedic (and because they're free) but it's definitely up for discussion.

Wrong. Australia and New Zealand (the two global leaders for Intensive Care Paramedic led RSI) have the toughtest education requirements in the world. RSI is open here only to selected ICPs (new ICPs have a Post Graduate Diploma ontop of a Bachelors Degree) who have passed a specific selection, education and assessment package for this.

The last good paper I read on the subject was Bernard et.al. from Victoria in 2010. They describe training of around sixteen hours for RSI in those people (4 hours theory, 8 practical, 4 simulator). That can't be right? We don't let anaesthetists do it in hospital - with optimal conditions - until they've been gassing for at least three months (probably more than 500 hours). So it may require well qualified people to get that training, but I'm not sure that training does them justice. I'm sure there must be more to it?

We have been performing RSI since 2006 with a consistent success rate of nearly 98% and all unsuccessful intubations have been managed without cricothyrotomy.

Depends on how you measure success, the tube going in the right hole is only one (and the easy one at that).

I like the Bernard study because it actually measures outcome and some adverse events (although it makes no mention of several common complications of induction). It shows that there is a benefit to pre-hospital anaesthesia but that it's small - converting severe disability to moderate - and that the power of the study is small - one or two cases could have changed the result completely. But what's really interesting about this study is that it shows that there was a 6.3% cardiac arrest rate in the pre-hospital group compared to 1.3% in the hospital group. That is, paramedics killed nearly five times more people with anaesthetic than doctors.

I'm sure you have plenty of interesting papers that disagree, let's share.

 

[Smash]

RSI training of 16 hours in paramedics with a minimum of 2 years intubating experience (including sedation to enable intubation), with a demonstrated success rate equalling that of ER docs is a different thing to just 16 hours training. Is it enough? Well, the "tube in the right hole" data suggests that part of it is, the "functional benefit to patients" supports that (not to mention the enormous cost saving to the health system that comes from that functional benefit), but the paramedics do apparently "kill" more patients than doctors.

So, what is the answer? More training? Maybe: I'm always for more training, but there realistically has to be a line drawn somewhere. Given that Australia is committed to paramedic based EMS and could probably not afford the doctors, let alone actually find them in the system anyway, there has to a point where the training is deemed to be "enough" so long as outcomes support it. So far, outcomes do. There is not an infinite amount of money in the system for training, so as with all things in real life, the best must be made with what is available.

Back to Bernard and paramedics "killing" patients. Until such time (or if) some sub-group analysis is done on those patients who suffered cardiac arrest during the RSI trial is done, I don't know that the use of pejorative and emotive language like "killing patients" is useful. There are a raft of reasons why patients may have had a higher cardiac arrest rate in the pre-hospital arm, like survivor bias. We don't know what agents were used in the in-hospital arm of the study for induction: is it possible that hemodynamically unstable patients were inducted with ketamine rather than the fentanyl/midazolam that the paramedics were restricted to, thus sparing their perfusion further insult?

Certainly there are questions raised as well as questions answered by Bernards trial, but it is compelling that the only study to show that paramedics can carry out RSI safely (as opposed to causing patients to desaturate and so on) also showed that it is of benefit.

 

[MrBrown]

There's a serious argument in the UK pre-hospital world about the benefit of BASICS doctors who don't bring RSI to the party, their arguments about other skills - triage, procedural sedation, etc. - currently mean that they still go with BASICS because they do add value over and above a standard paramedic (and because they're free) but it's definitely up for discussion.

Of course any BASICS Doctor in their orange getup is useful, they give the newsmedia and other people at a job something sexier than Brown to gorp at

Piss taking aside, its sad how limiting the scope of practice is for UK Paramedics. No ketamine, no procedural sedation, no cardioversion, no RSI, no IV adrenaline, bloody hell with the move away from the IHCD Paramedic Award to higher education it seems unthinkable that things we have been doing for twenty years down here haven't made it to the UK.

Here (and in AU) some things like cardioversion are sub-"Paramedic" (UK nomenclature) and have been for nearly twenty years.

But then again it is sad to see the UK move away from Technician/Paramedic without a Paramedic on every ambulance to ECSW/Paramedic on every ambulance. Brown blames Call Connect, ORCON and the massive increase in workload you blokes have OMG its mental the number of 999 calls you have over there.

I'm sure there must be more to it?

Locally ours is about two days of eight hours plus some out-of-class stuff and a written, practical and viva assessment. Each RSI or potential RSI must be debriefed with our Medical Director (who is both a Consultant Anaesthetist and a Consultant Intensevist).

Depends on how you measure success, the tube going in the right hole is only one (and the easy one at that).

Intubation within two attempts of laryngascopy each lasting a maximum of 30 seconds and with visualisation of the vocal cords within 15 seconds. If first attempt is unsuccessful then after a period of oxygenation the second (and final) attempt may proceed with strong consideration to a different blade or tube size. Bougie is mandatory for all intubations including those facilitated by medicines.

That is, paramedics killed nearly five times more people with anaesthetic than doctors.

While Doctor-only-RSI cause supporting, thats a wee bit of a hyperinflated extrapolation

It should be noted we use fentanyl (1mcg/kg or 0.5mcg/kg for patients with BP <100mmHg) and ketamine for inducation. We do not use midazolam in shocked patients but do use in place of ketamine for those with neurogenic cause for coma with GCS <10 but without shock.

 

[systemet]

The last good paper I read on the subject was Bernard et.al. from Victoria in 2010. They describe training of around sixteen hours for RSI in those people (4 hours theory, 8 practical, 4 simulator). That can't be right? We don't let anaesthetists do it in hospital - with optimal conditions - until they've been gassing for at least three months (probably more than 500 hours). So it may require well qualified people to get that training, but I'm not sure that training does them justice. I'm sure there must be more to it?

It could be argued that this is the only good paper on paramedic RSI. I'm amazed they were able to get WOIC for this.

It's a given that paramedics are not going to be as skilled at airway management as consultant anesthetists or emergency physicians. The training time and educational process, and work environment just doesn't support this. The bigger question is whether paramedics are good enough? Under what conditions? At what cost? Is this an efficient use of resources?

I like the Bernard study because it actually measures outcome and some adverse events (although it makes no mention of several common complications of induction). It shows that there is a benefit to pre-hospital anaesthesia but that it's small - converting severe disability to moderate - and that the power of the study is small - one or two cases could have changed the result completely. But what's really interesting about this study is that it shows that there was a 6.3% cardiac arrest rate in the pre-hospital group compared to 1.3% in the hospital group. That is, paramedics killed nearly five times more people with anaesthetic than doctors.

This is a concern, but it's partially offset by a greater percentage of patients with a good neurologic outcome. So for every patient that died following paramedic RSI, there was more than one additional severely disabled person in the group that received deferred RSI at the hospital.

Would we rather have more patients with good neurologic outcome at 6 months, or more patients alive at six months, but with more severely disabled, and fewer with a good outcome?

It's hard not to be partisan here. As a paramedic I want to believe that paramedic RSI is feasible and beneficial.

I'm sure you have plenty of interesting papers that disagree, let's share.

I think this is a little disingenuous. There's a paucity of available data. At what point do we conclude that paramedic RSI is harmful, and remove the practice? If we do so prematurely, we risk removing a beneficial treatment.

 

[LondonMedic]

RSI training of 16 hours in paramedics with a minimum of 2 years intubating experience (including sedation to enable intubation), with a demonstrated success rate equalling that of ER docs is a different thing to just 16 hours training.

This is not about intubating, putting the tube in the hole is a mechanical skill that we could get a first aider to do with 16 hours training. This is about anaesthetising someone safely; understanding why you would do it, why you wouldn't do it and what to do when things go pear shaped. And that's much more complicated and, in my world, takes a long time to train for, to practice and to truly understand.

So, what is the answer? More training?

I think so. I think that if it's an important enough skill for paramedics to have then it's important enough that they be trained properly and kept constant. I appreciate that this costs time and money that services would be hard pressed to find but that should be the trade off with every skill - no fast driving unless you're prepared to pay to train the drivers, no defibrilation unless you're prepared to train the defibrilatorists and no RSI if you're not prepared to train your anaesthetists sufficiently.

So far, outcomes do.

Barely. I haven't seen enough data to be remotely certain of that. The Bernard study was, TTBOMK, the largest but it was underpowered to the point that one patient either way (either severe disability to moderate or vise versa would have changed the results to a significant degree.

Certainly there are questions raised as well as questions answered by Bernards trial, but it is compelling that the only study to show that paramedics can carry out RSI safely (as opposed to causing patients to desaturate and so on) also showed that it is of benefit.

But it doesn't show that. If anything, it shows the opposite. Fair point, 'killing' is perjorative but if we need to subgroup analyse the ones that arrested post induction then we also cast doubt on the validity of most of the results. On the subject though, it would be interesting to know how many patients were affected in the fifteen month lead-in to this which presumably allowed the paras in the study to get better.

 

[MrBrown]

It could be argued that this is the only good paper on paramedic RSI. I'm amazed they were able to get WOIC for this.

Brown assumes you are referring to ethical approval. If so, then here in this part of the world we are quite pro Paramedic research and have had several trials in recent years across Australasia.

With Paramedic education being in the Universities now there is an even stronger push on for prehospital and Paramedic-led research.

The bigger question is whether paramedics are good enough? Under what conditions? At what cost? Is this an efficient use of resources?

With appropriate education and the right tools in place absolutely the answer is yes.

Brown is an huge proponent of Paramedic RSI.

And no, Brown is not an RSI qualified Intensive Care Paramedic so no conflict of interest right here

 

[LondonMedic]

Piss taking aside, its sad how limiting the scope of practice is for UK Paramedics. No ketamine, no procedural sedation, no cardioversion, no RSI, no IV adrenaline, bloody hell with the move away from the IHCD Paramedic Award to higher education it seems unthinkable that things we have been doing for twenty years down here haven't made it to the UK.

I agree with all that you say here. I think that paramedicine in the UK is in a pretty sad state. The blame for that can be spread around plenty - the trusts & management, the volume of work, a medical profession reluctant to sanction new things and a significant number of paramedics (and techs) who are unprofessional and can't manage to do the basics well.

Locally ours is about two days of eight hours plus some out-of-class stuff and a written, practical and viva assessment. Each RSI or potential RSI must be debriefed with our Medical Director (who is both a Consultant Anaesthetist and a Consultant Intensevist).

In my mind that's such a short amount of training to cover most of practical anaesthesia. After two days of anaesthetic training I still hadn't touched a patient, it took me a good two months in the job before I was comfortable anaesthetising anyone on my own, let alone doing a rapid-sequence.

While Doctor-only-RSI cause supporting, thats a wee bit of a hyperinflated extrapolation

Only in the same way that the study is used to support paramedic intubation.

It should be noted we use fentanyl (1mcg/kg or 0.5mcg/kg for patients with BP <100mmHg) and ketamine for inducation. We do not use midazolam in shocked patients but do use in place of ketamine for those with neurogenic cause for coma with GCS <10 but without shock.

I would prefer to do it with Fentanyl, Etomidate, Rocuronium and Atracurium but I have used Propofol and Sux. Never used Midazolam and have absolutely no intention to try. Never used Ketamine for anything more than sedation but would be interested to anaesthetise with it.