Capnography for EMT-B, a useful tool?

[VentMonkey]

Even if we feel like the info helps us formulate a more accurate diagnosis, what value does it really bring, if we are just going to do the same thing for the patient with or without the information?

Perhaps prevent the paramedic from not doing the same thing that they normally would.

Waiver: I have not used the in-line NC prongs in well over a year, and IIRC, Jarvis mentioned in a podcast he’d done with Tyler Christifulli how they can actually be an ineffective HFNC option.

In perhaps a more progressively perfect world (cue sappy music) it would entice the EM doc to trust the field folks’ “educated guesses” more than is the standard or norm now. Clearly, this still needs to be earned.

Will things still need to be redone, revisited, and reassessed? Absolutely, but I don’t know that I’m ready to write the device off completely quite yet.

Sure, I may not be giving Insulin to a DKA patient with an unconfirmed BGL through the roof, and an ETCO2 in the teens, or a suspected polypharm OD with an ETCO2 the same.

Is it more of a nice-to-know? At this point absolutely. Do I think it will fall by the wayside? Perhaps. Will it have any major effects on ones treatment or diagnosis? Nope, probably not.

I think the bigger problem is the tool at hand (like many, or most) falling into the average undereducated providers hands, and being frivolously employed.

Knowing that I can implement said tool, and explain why or where it helped my idex of suspicion, and treatments rendered—or not—still carries value in my opinion. I speak in general, on the whole, for the field paramedic d’jour who knows enough to know better.

 

[medichopeful]

I’m not saying EMT’s shouldn’t be allowed to understand, play with, or have ETCO2 monitoring, but perhaps a biiit more education is needed at the entry level to a basics training before this is universally adopted.

I would argue pretty heavily that a bit more education should be added to paramedic education as well regarding capnography.

Many of the medics I talk to are taught about capnography, but can’t really explain much about it. For example, many seem to think that EtCO2 = PaCO2, which is concerning.

I also don’t think people should be using EtCO2 without a basic understanding of ABGs, which also doesn’t seem to be a major topic in medic school sadly. I know we went over it a bit in medic school, but not much.

 

[medichopeful]

How would it change what you do for the patient that you wouldn't do from your physical exam?

Keeps me from having to count a RR. Clearly!

 

[VentMonkey]

I would argue pretty heavily that a bit more education should be added to paramedic education as well regarding capnography.

Many of the medics I talk to are taught about capnography, but can’t really explain much about it. For example, many seem to think that EtCO2 = PaCO2, which is concerning.

I also don’t think people should be using EtCO2 without a basic understanding of ABGs, which also doesn’t seem to be a major topic in medic school sadly. I know we went over it a bit in medic school, but not much.

I don't disagree with you. But then again, I simply wish that The States offered a clinically-driven ICP degree adapted from the Australian model.

I don't think it needs to be a full blown masters, but the desire to learn the level of training that they receive as Aussie ICP's prior to being allowed to practice is something certainly seen in a "select few" paramedics, and hardly seems to be the standard. If only...

 

[Summit]

CPAP and Narcan IM/IN are already in the state scope for EMTs. There has been a lot of talk about allowing Epi IM due to the cost of the Epi pens. ICEMA, at least during their meetings, is really wanting to expand the EMT scope to the max it can be so we are having to add in extra time/classes to the EMT program. So you have the normal EMT class and we add in HazMat FRA, bloodborne/airborn pathogens, and CPR. Now we are having to add in a 8-16 hour documentation class, 8-16 hour modified TECC/TCCC class, and a pharm/med admin class.

You throw all these things in, and have states like CO that expect every EMT to add 32 hours of IV class plus 8 hours of clinical if they want to do something besides drive a wheelchair van and you are closer to AEMT than you are to EMT in content, hours and scope. So we are asking Vent's question:

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?

 

[Summit]

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.

I think your post could be summarized with the following: slightly more important that know when to use a skill is knowing when you could but should not (because there is a better alternative). This requires critical thinking instead of linear thinking.

Anyone below Paramedic is expected to are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.

So you are only REQUIRED to use capnography on cardiac arrest patients, but you WISH your department would let you use capnography more? Do they prohibit you from using it on other non-cardiac arrest calls? Has your supervisor / medical director pulled you aside and said "Hey vince, your going to have to stop using this medical device, that we provide to you, on all non-cardiac arrest patients?"

I know a local Fire/EMS departments that said exactly that to their paramedics. Seriously.

 

[VentMonkey]

I think your post could be summarized with the following: slightly more important that know when to use a skill is knowing when you could but should not (because there is a better alternative). This requires critical thinking instead of linear thinking.

Anyone below Paramedic is expected to are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.

Mike Abernethy did a pretty solid job on a seminar that was webcasted from the CCTMC a few years back on just how fractured prehospital care truly is. It's a good listen that I wish every EMT and paramedic instructor required their overzealous students listen to.

We have much bigger problems in this field than letting abruptly-trained EMT's, firefighters, and even some paramedics "play" with capnography. The field is quite literally a smorgasbord of provider skill, education, and even talent level all being perpetuated by pennies on the dollar for transport. The amount of mixed signals that I hear, and see, almost daily makes complete sense as to why we keep shooting ourselves in the damn foot.

 

[DrParasite]

Mike Abernethy did a pretty solid job on a seminar that was webcasted from the CCTMC a few years back on just how fractured prehospital care truly is. It's a good listen that I wish every EMT and paramedic instructor required their overzealous students listen to.

do you have the location where the webcast can be found or downloaded?

We have much bigger problems in this field than letting abruptly-trained EMT's, firefighters, and even some paramedics "play" with capnography. The field is quite literally a smorgasbord of provider skill, education, and even talent level all being perpetuated by pennies on the dollar for transport. The amount of mixed signals that I hear, and see, almost daily makes complete sense as to why we keep shooting ourselves in the damn foot.

I agree; I also think that many of these issues cannot be, and will not be, solved at the provider level. So why not try to make the little changes were we can, and let the higher ups and elective officials try to fix the rest?

BTW, here is the Asthma COPD protocol from an EMS agency to the north of me:

 

[VentMonkey]

do you have the location where the webcast can be found or downloaded?

https://itunes.apple.com/us/podcast/ems-nation/id1063361753?mt=2&i=1000385734597

 

[EpiEMS]

Anyone below Paramedic is expected to are expected to treat complaints procedurally, but shouldn't follow a procedure to the point detriment. Paramedics should diagnosis and treat by guidelines.

I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)

What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.

 

[Summit]

I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)

What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.

If A do B & C is procedural
Guidelines are a looser set of options based on judgement

 

[DrParasite]

I need a social work protocol, because it seems like a good 75% of the BLS calls I take would be better handled by a social worker. (But in all seriousness, I don't have a "general malaise" protocol or "homelessness protocol," and we all probably should.)

When I was on the truck, I dealt with more drunks than homeless people. And PLENTY of "sick person" calls. and many intoxicated homeless people.

I guess my question would be, if they are homeless, why do they need an ambulance? If they have a medical complaint, treat them as appropriate and transport to the ER.

a general malaise protocol is typically a catch all, a protocol you can use when the patient doesn't fit any categories. most places I have seen try to use a more specific one, based on the patient's chief complaint.

What do you mean by "procedurally" vs. "guidelines"? I don't see much of a difference.

SOPs vs SOGs. SOPs are procedure: you WILL follow these directions. SOGs are guidelines: you SHOULD follow these guidelines, under ideal circumstances, but if you don't, be sure to document and justify why not.

It's all legal BS; the fire service went through it about 15 years or so years ago, because SOPs were viewed as too rigid in court; IE, if you didn't do something in the SOPs, you weren't following procedure, and were immediately wrong, despite having a good reason do to what you did.

 

[EpiEMS]

If A do B & C is procedural
Guidelines are a looser set of options based on judgement

If that's the case, then EMS protocols are closer to "guidelines", no? (Given that there's subjectivity in application, I mean.)

I guess my question would be, if they are homeless, why do they need an ambulance? If they have a medical complaint, treat them as appropriate and transport to the ER.

I'm exaggerating a bit, but somebody *saying* they have a medical complaint is different from *having* a medical complaint.

It's all legal BS; the fire service went through it about 15 years or so years ago, because SOPs were viewed as too rigid in court; IE, if you didn't do something in the SOPs, you weren't following procedure, and were immediately wrong, despite having a good reason do to what you did.

Fair enough. I'd be curious to see some cases to see how they described this in legalese!

 

[DrParasite]

If that's the case, then EMS protocols are closer to "guidelines", no? (Given that there's subjectivity in application, I mean.)

I would imagine it depends on how rigidly you have them enforced by your agency and medical director.

I'm exaggerating a bit, but somebody *saying* they have a medical complaint is different from *having* a medical complaint.

Been there, done that, not going to argue, but also realize that it's easier for me to transport the person to the ER than not.

Fair enough. I'd be curious to see some cases to see how they described this in legalese!

While I'm not an attorney, nor will I provide legal advice: Political and Legal Foundations of Fire Protection 32-FST-385 Legal Liability Issues of Standard Operating Procedures VS Other Titles for Guidance Documents


I'll even thrown in page 2 of this: https://www.usfa.fema.gov/downloads/pdf/publications/fa-197-508.pdf

Personally, I think its all a bunch of crap, and a good attorney can tear you to shreds regardless, but it all depends on what your agency attorney thinks, and how they are all written, but that's just my two cents

 

[Summit]

I would imagine it depends on how rigidly you have them enforced by your agency and medical director.

Yes, how they are written + how they are enforced