Anything could of done differently with this call?

EpiEMS

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If I can’t give an opioid, at least give me methoxyfluorane!
 

DrParasite

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Are you suggesting that EMT's are just as equipped to manage respiratory failure as paramedics are? "But paramedics can safely give fentanyl, and EMT's have mostly the same tools for managing respiratory failure as paramedics, so why can't EMT's give fentanyl?" seems to be an accurate paraphrase of what you are getting at, and I kind of doubt you really mean that. It seems unlikely that if a family member of yours were experiencing a serious respiratory event, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available.
a narcotic-induced respiratory failure? I will ask the same question, what will a paramedic do that an EMT can't (other than intubation, which I think we can agree that there are better ways to manage a narcotic OD, at least at first)? Are you talking about a respiratory failure due to an accidental OD, or due to another medical cause? Because I know people are prescribed and self-administer fentanyl every day, and they don't have a paramedic standing by just in case.

So to answer your question of "if a family member of yours were experiencing a serious respiratory event, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available" the answer, of course, is absolutely not. That's stupid, and I never said anything like that. Send me a paramedic who can push a bunch of meds to fix what is going on (at least until they get to the ER), and intubate if needed.

However, if you are asking me "if a family member of yours were experiencing respiratory depression due to too much of a narcotic medication, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available" if BLS is closer, than absolutely send me two ambulance drivers or hose draggers with narcan and a BVM. Start ALS on the way too, but if the BLS crew gets the person breathing, and can transport my family member, I do not want them waiting for ALS, provided they are managing the condition appropriately.
A more experienced / highly trained provider is more likely to notice early signs of impending respiratory failure and not let it get the point that intervention is needed.
Gonna have to throw the BS flag there. In theory, you are correct, however, the evidence shows that "highly trained providers" have put the patient into resp failure due to too much narcotics. here is one example:
If intervention does become necessary, a paramedic is likely to be more skilled at whatever interventions become necessary than is an EMT, not to mention having more treatment options, such as titrating small doses of naloxone rather than pushing 2mg, placing an LMA, possibly even intubating if it comes to that, etc.
EMTs don't have to push 2mg... NC's protocols (which, if I'm mistaken, is the state you are located in) say titrate up to 2mg (although our city PD can only give 4mg doses, but they aren't EMTs, so that's another story). EMTs can also place SGAs (we use Kings instead of LMAs), and if anyone is intubating a patient who they gave narcotics too, they messed up big time, and really really really missed the warning signs
 

silver

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I'm not disagreeing with you that you just made the situation worse, and bagging and narcan are not 100% benign (are you suggesting that EMTs shouldn't be bagging or administering Narcan to this patient?), however the statement was

so what would a more educated provider do in this situation? meaning, how is a CCT/flight/tactical/<insert advance knowledge> paramedic going to deal with a "potential decreased respiratory drive", which a "under educated" EMT is unable to do?

Is the implication that only an under-educated provider can cause iatrogenic respiratory failure? Because I think we can both agree that paramedics and doctors have done it too.
A BVM and narcan is not the end all be all. What do you do when you can't ventilate adequately with your BVM? One shouldn't be giving fast acting opioids to an opioid naive patient without someone immediately available who is educated in advanced airway interventions and ACLS. EMT curriculum doesn't cover enough pharmacology, respiratory and cardiac pathophysiology.

And its important to make a distinction between an iatrogenic event and a patient who you are called to who ODed. Failure to rescue after you give fentanyl because you can only bag and give IN/IV narcan to isn't the most defensible.
 

Carlos Danger

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a narcotic-induced respiratory failure? I will ask the same question, what will a paramedic do that an EMT can't (other than intubation, which I think we can agree that there are better ways to manage a narcotic OD, at least at first)? Are you talking about a respiratory failure due to an accidental OD, or due to another medical cause? Because I know people are prescribed and self-administer fentanyl every day, and they don't have a paramedic standing by just in case.

So to answer your question of "if a family member of yours were experiencing a serious respiratory event, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available" the answer, of course, is absolutely not. That's stupid, and I never said anything like that. Send me a paramedic who can push a bunch of meds to fix what is going on (at least until they get to the ER), and intubate if needed.

However, if you are asking me "if a family member of yours were experiencing respiratory depression due to too much of a narcotic medication, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available" if BLS is closer, than absolutely send me two ambulance drivers or hose draggers with narcan and a BVM. Start ALS on the way too, but if the BLS crew gets the person breathing, and can transport my family member, I do not want them waiting for ALS, provided they are managing the condition appropriately.

Gonna have to throw the BS flag there. In theory, you are correct, however, the evidence shows that "highly trained providers" have put the patient into resp failure due to too much narcotics. here is one example:

EMTs don't have to push 2mg... NC's protocols (which, if I'm mistaken, is the state you are located in) say titrate up to 2mg (although our city PD can only give 4mg doses, but they aren't EMTs, so that's another story). EMTs can also place SGAs (we use Kings instead of LMAs), and if anyone is intubating a patient who they gave narcotics too, they messed up big time, and really really really missed the warning signs
I find it hard to believe that you really think EMT's are adequately trained in resuscitation of respiratory failure. You must recognize that just because two providers each possess similar tools doesn't mean they have the same expertise or even basic competence. But if not....to each his own.

The article you linked to doesn't help your argument, though. All it does is illustrate the potential hazards of fast-acting opioids in opioid-naive patients. If that can happen in an ED with physicians and nurses who are far more experienced with potent opioids and resuscitation than most EMT's, then there you go.
 
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GMCmedic

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I find this conversation interesting simply because nursing has fought so hard to protect their scope, and half of us want to give ours away.
 

EpiEMS

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I’ll freely admit fentanyl might be a bridge too far but something better than ice packs and acetaminophen would be awfully easy - and consistent with the rest of the Anglosphere.
 

EpiEMS

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I find this conversation interesting simply because nursing has fought so hard to protect their scope, and half of us want to give ours away.

Nursing is much more politically savvy and protective. (To the detriment of the public, in the main.)
 

Carlos Danger

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Nursing is much more politically savvy and protective. (To the detriment of the public, in the main.)
This is probably a topic for another thread, but I'd be interested in hearing you expand on this.
 

EpiEMS

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This is probably a topic for another thread, but I'd be interested in hearing you expand on this.

Happy to! My thesis is basically that nursing protects scope via professionalization and EMS has not yet professionalized hence challenged to protect scope. We can see this mainly in cross country comparisons - see the UK vs. US.
 

DrParasite

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I find it hard to believe that you really think EMT's are adequately trained in resuscitation of respiratory failure.
I find it hard to that you, as a CRNA, really think Paramedics are adequately trained in the resuscitation of respiratory failure.

But the reality is there will always be someone more educated who doesn't think anyone who has less training can handle an emergency.
You must recognize that just because two providers each possess similar tools doesn't mean they have the same expertise or even basic competence.
you must have worked with a lot of really incompetent EMTs. Maybe the EMTs that I have dealt with are just more competent, due to having worked in an area where they don't always have a paramedic telling them exactly what to do? Whatever, to each his own.
The article you linked to doesn't help your argument, though. All it does is illustrate the potential hazards of fast-acting opioids in opioid-naive patients. If that can happen in an ED with physicians and nurses who are far more experienced with potent opioids and resuscitation than most EMT's, then there you go.
I see you missed the point... it shows that even ED doctors and nurses can accidentally cause an OD, and they have waaay more education than most EMTs. Simply stating it doesn't happen to more experienced and more educated provided due to their experience and education is wrong. But, if you can provide some actual studies that show that EMTs have a higher rate of causing accidental ODs compared to more educated providers, I would gladly reconsider my position.
 

DrParasite

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I'm not necessarily for fighting tooth and nail to protect the Paramedic scope of practice.
back in the day, only a paramedic could defib someone. back in the day, only a paramedic could give epi. today in NJ, only a paramedic can give over-the-counter Benedryl for an allergic reaction. back in the day, EMTs were forbidden from using an SGA (some places/medical directors still won't allow it). Back in the day, paramedics couldn't do a lot of things, unless they called the doctor who told them exactly what to do. Back in the day, only a paramedic could give narcan to reverse an overdose, and albuterol could only be given by ALS.

I'm not saying there is no difference between an EMT and a paramedic (in fact, there are a plethora of situations where I would prefer a paramedic to an EMT), however how much of the fear of "we can't trust EMTs to do that" is unfounded? back in the day, paramedics fought tooth and nail to not allow EMTs to do many things... and since they have been granted the ability to do them, I haven't heard of any negative impact on public health. In fact, defibs are now public access, and narcan is given out to anyone by pharmacies. So are certain people looking out for the best interests of the general public, or just trying to act in their own best interest, at the expense of the general public?
 

Carlos Danger

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I find it hard to that you, as a CRNA, really think Paramedics are adequately trained in the resuscitation of respiratory failure.

But the reality is there will always be someone more educated who doesn't think anyone who has less training can handle an emergency.

you must have worked with a lot of really incompetent EMTs. Maybe the EMTs that I have dealt with are just more competent, due to having worked in an area where they don't always have a paramedic telling them exactly what to do? Whatever, to each his own.

I see you missed the point... it shows that even ED doctors and nurses can accidentally cause an OD, and they have waaay more education than most EMTs. Simply stating it doesn't happen to more experienced and more educated provided due to their experience and education is wrong. But, if you can provide some actual studies that show that EMTs have a higher rate of causing accidental ODs compared to more educated providers, I would gladly reconsider my position.
I would agree that paramedics should have more training in airway management, and I don't know many who would argue otherwise. But that has absolutely nothing to do with the discussion at hand. Nor does the fact that your google search was able to turn up an article about a poor outcome that was (apparently) related to inadequate monitoring in a hospital. And I would not say that the EMT's that I've worked with have been mostly incompetent, but most of them have very little formal training and even less actual experience with performing airway interventions.

Lets lay out your position in the form of a deductive argument:
  1. Bad things can happen in the hospital setting when patients aren't adequately monitored following the administration of potent opioids, despite hospital staff having the highest levels of training.
  2. Paramedics could use more training in the resuscitation of respiratory failure.
  3. Therefore, we should allow providers with much less training than either hospital staff or paramedics to administer potent opioids.
- Premise one is objectively true.
- Premise two could be debated, but most would probably agree it is true.
- The conclusion does not in any way follow the two premises.

If you think EMT's should be allowed to give fentanyl in any form, that's fine. Advocate for that. Make arguments in favor of it. But you will never ever convince anyone that THE REASON they should be allowed to give fentanyl is because more highly trained providers sometimes get it wrong themselves.
 

Carlos Danger

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Happy to! My thesis is basically that nursing protects scope via professionalization and EMS has not yet professionalized hence challenged to protect scope. We can see this mainly in cross country comparisons - see the UK vs. US.
No argument there. Nursing defined itself as a "profession" many years ago and standardized its educational requirements and role.

But how is that a detriment to the public?
 

medichopeful

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No argument there. Nursing defined itself as a "profession" many years ago and standardized its educational requirements and role.

But how is that a detriment to the public?
I'm confused by this as well.
 

DrParasite

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If you think EMT's should be allowed to give fentanyl in any form, that's fine. Advocate for that. Make arguments in favor of it. But you will never ever convince anyone that THE REASON they should be allowed to give fentanyl is because more highly trained providers sometimes get it wrong themselves.
That's not what I said.... nor was that my reason for why they should be able to. And your "deductive argument" that you claim is based on what I said is completely incorrect. you assumed many facts that are not in evidence, drew incorrect conclusions, and used that information to very poorly (and incorrectly) describe my position. in fact, you are wrong on all level. maybe you should reread it, and see if you can come up with a position that is anywhere near close to what I actually said, based on what I actually said, instead of that malarkey that you attempted to tie to me
 

silver

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But the reality is there will always be someone more educated who doesn't think anyone who has less training can handle an emergency.
I'd like to clarify this isn't an "emergency" before the provider pushed fentanyl, and this is a very known, extremely common, and expected adverse effect. That provider (or if a system is designed like ED, rapid response/code, ICU team etc) is responsible for doing all that can be done, within reason, to save that patient. If no one is available with the skills you shouldn't be giving fentanyl. In fact, I get called by non-procedural/ED/ICU/PACU RNs in the hospital frequently as they don't feel comfortable giving whatever IV opioid and will go push it myself.

I see you missed the point... it shows that even ED doctors and nurses can accidentally cause an OD, and they have waaay more education than most EMTs. Simply stating it doesn't happen to more experienced and more educated provided due to their experience and education is wrong. But, if you can provide some actual studies that show that EMTs have a higher rate of causing accidental ODs compared to more educated providers, I would gladly reconsider my position.
Its not about causing accidental ODs. As someone who gets called by others to treat acute pain I believe that Im not treating pain aggressively enough unless I'm occasionally giving narcan to my patients.
 
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EpiEMS

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No argument there. Nursing defined itself as a "profession" many years ago and standardized its educational requirements and role.

But how is that a detriment to the public?
The detrimental effects are a direct consequence of nursing as a profession (as well as nursing as a lobby): Since the early 20th century, nursing has grown into a self-regulated profession (on a national scale, let's say around 1970) and has been very politically successful - due to the public trust in nurses - at expanding scope. I don't have a problem with this by any means, particularly because there's no widespread evidence of harm (except maybe from a cost or broad public health perspective like overprescribing abx vs. physicians and ordering more imaging), but despite this experience being pushed down, nursing as a field broadly construed has taken their scope and grasped it tightly (individually rational but societally suboptimal, namely for consumers). For example, in Texas, the Texas ENA pushed absent evidence to keep paramedics out of the hospital setting - blatantly a grasp to keep wages up and avoid competition. There's no reason paramedics should be kept out of the hospital setting -- it's the same logic some physicians use to try and keep nurse practitioners & nurse anesthetists "in their lane" (to protect their compensation), it's a plea to public safety absent evidence. Another great example is the push for nursing staff minimums without strong evidence (we saw this in New York fairly recently) - yet the 2004 California law showed no broad based benefits to patients despite huge costs. It's a similar story for BSN mandates - the literature is far from conclusive, yet there is a push for mandates under broad claims of benefit to patients, when the story is equally a story of trying to restrict supply.

In short, nursing is doing exactly what Dr Parasite talked about below...but everybody does that, so it's not a "blame" but an objective observation. I don't ascribe any morality (or lack thereof) to it, but a bit of careful manipulation of information to try and drive compensation up.
I haven't heard of any negative impact on public health. In fact, defibs are now public access, and narcan is given out to anyone by pharmacies. So are certain people looking out for the best interests of the general public, or just trying to act in their own best interest, at the expense of the general public?
 

FiremanMike

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For example, in Texas, the Texas ENA pushed absent evidence to keep paramedics out of the hospital setting - blatantly a grasp to keep wages up and avoid competition. There's no reason paramedics should be kept out of the hospital setting -- it's the same logic some physicians use to try and keep nurse practitioners & nurse anesthetists "in their lane" (to protect their compensation), it's a plea to public safety absent evidence.
Hey, I know it’s not really the topic of this discussion but I just wanted to quickly address this statement. I spent 20 years believing the same thing, that medics could (and should) step in and do in-hospital nursing work and that nurses didn’t really know that much more than medics….. Then I hit RN school.… It’s just an entirely different ballgame, and the depth of knowledge is astounding.
 

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