Capnography for EMT-B, a useful tool?

[NomadicMedic]

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

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

 

[VFlutter]

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

Go shadow a hospital monitor tech for a couple shifts.

 

[E tank]

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

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

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

 

[taxidriver]

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

 

[DrParasite]

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

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

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

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

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

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

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

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

 

[DrParasite]

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

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

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

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

 

[Carlos Danger]

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

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

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

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

 

[DrParasite]

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

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

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

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

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

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

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

 

[Carlos Danger]

error

 

[VentMonkey]

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

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

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

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

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

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

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

 

[DrParasite]

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

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

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

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

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

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

 

[EpiEMS]

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

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

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

 

[Carlos Danger]

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

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

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

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

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

 

[taxidriver]

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

 

[CALEMT]

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

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

 

[taxidriver]

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

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

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

 

[taxidriver]

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

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

 

[VentMonkey]

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

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

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

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

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

 

[VFlutter]

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

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

 

[DrParasite]

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

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

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

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

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