EVIDENCE: show me evidence oxygen as being given by EMS is harming people.

[mycrofft]

So we have clincial and scientific evidence that in a lab and in a hospital it is strongly likely that over-oxygenation is bad. But field conditions and intervening treatment bar field measures' similar scientific evaluation.

I"ll buy that, with concern aboutr lumping-together short-term with longer-term treatment, and the likelihood that the patients most likely to die anyway were also more likely to be on higher (and still-increasing) oxygen doseage (% mix, peak opressure, etc).

Do "we" toss out field oxygen (including the bystander 6 LPM rule), or is it relatively innocuous for most prehospital instances and might help some? If "some", then what percent and when would we withold?

PS: to get sidetracked, conservative practitioners point back to many instances where the new thing turned out to be wrong...then fight too hard whe the next good thing comes along. That's why we need SCIENCE. Remember being taught field oxygen to COPD pts wold "shut them down", so NO O2 ever?

PPS: Another sidetrack: does your oxygen mask have an elastic band? Is it certified rubber-free? How about the flapper valves in the BVM's, and handpowered suction devices....

 

[NYMedic828]

#2: But be very very careful that you really are a clincian before you decide to act like one...say by going to school and getting a degree then pass some boards, for instance?

#1: THAT was the original intent of EMT-Ambulance (now "Basic"), get as many TECHNICALLY trained people out there and everywhere by using rules and protocols through medical control of some sort.

#3: Yes, if your medical control or supervisor doesn't fire you for making too many exceptions, no matter how well-grounded in EMTLIFE info they are.

#1. The times have changed. The medical world has evolved exponentially and EMS refuses to change.

#2. Clinician: 1.:censored:a physician or other qualified person who is involved in the treatment and observation of living patients, as distinguished from one engaged in research.

I obviously didn't mean it in the literal context of a physician. That term is used for more things than a synonym for the word "doctor." But you knew that and just like to break balls. :blush:


#3. Then I am sorry but your agency sucks. You should be offered a chance to defend your case to the medical director before any action is taken on you. Odds are your supervisor isn't a very competent person to begin with.

 

[Veneficus]

Do "we" toss out field oxygen (including the bystander 6 LPM rule), or is it relatively innocuous for most prehospital instances and might help some? If "some", then what percent and when would we withold?....

Oxygen only helps avery small population of patients.

Oxygen is a medication. We do not give medications people do not need because "it won't hurt them."

Giving a medication that is not indicated is a medical error. A medication error to be exact.

Not only would I toss it out, but I have specifically ordered prehospital people not to initiate it. On the last few emergency patients I saw, neither of them got oxygen. They simply didn't need it.

I think it is important to recognize a change in paradigm. When tech level EMS was created the idea was to do something we thought would help to people who never got help before from illnesses we didn't understand.

Now we understand the illnesses.

We understand what helps and what doesn't. More importantly what harms exponentially better than the people who started EMS.

PS: to get sidetracked, 1. conservative practitioners point back to many instances where the new thing turned out to be wrong...2then fight too hard whe the next good thing comes along. That's why we need SCIENCE.3 Remember being taught field oxygen to COPD pts wold "shut them down", so NO O2 ever?.

1. While ignoring they were wrong more often.

2. It is my experience that "conservative" is a personality trait. You could show them evidence the world was round, but if they are not willing to believe it, no amount of evidence will save them.

3. Yes and no. I remember being told that in EMS, and immediately always followedby the caviat never deny oxygen somebody needs. However, I personally questioned the idea of hypoxic drive and the realitiy and practicality. I spent 2 weeks on a pulmonary ward where it was identified and demonstrated to me.

The issue is that it exists in a specific patient population. That many EMS providers will never see in their careers. (because they are already hospitaized) EMS has a way of oversimplification to erroneous and then overcompensating.

I suspect it stems from lack of education and experience rather than the desire to do the right thing.

 

[mycrofft]

#1. The times have changed. The medical world has evolved exponentially and EMS refuses to change.

#2. Clinician: 1.:censored:a physician or other qualified person who is involved in the treatment and observation of living patients, as distinguished from one engaged in research.

I obviously didn't mean it in the literal context of a physician. That term is used for more things than a synonym for the word "doctor." But you knew that and just like to break balls. :blush:


#3. Then I am sorry but your agency sucks. You should be offered a chance to defend your case to the medical director before any action is taken on you. Odds are your supervisor isn't a very competent person to begin with.

#1: Times are always changing, and at its thick wide base (IFT), AMBULANCE practice hasn't warranted much change. Employers resist change because it's expensive and uncertain. Machiavelli said change is uncertain because of lukewarm support and motivated resistance (paraphrase) .

#2. A clinician is a clinician, and too many EMTECHNICIANS want to start making clincial decisions instead of following their protocols. I've done it, we all have. When it goes sour, it suddenly becomes apparent how shallow and narrow EMTECHNICIAN training is. The patient pays the price. EMTs are practitioners (they practice) but not clinicians (professionals who have attended many types of patients and have broader and deeper knowledge than technicicans, who are trained and practiced in technique...not decisions). Parallel: a good lab tech will spot something and bring it to the MD's attention, but never presume to order more tests or treatment.

#3. Totally in agreement. How prevalent do you think that is?

 

[mycrofft]

Oxygen only helps avery small population of patients.10-4

Oxygen is a medication. We do not give medications people do not need because "it won't hurt them." nod

Giving a medication that is not indicated is a medical error. A medication error to be exact.Actually that is called poisoning

Not only would I toss it out, but I have specifically ordered prehospital people not to initiate it. On the last few emergency patients I saw, neither of them got oxygen. They simply didn't need it. nod. How did they take that?

I think it is important to recognize a change in paradigm. When tech level EMS was created the idea was to do something we thought would help to people who never got help before from illnesses we didn't understand. fist pump

Now we understand the illnesses. OK, but we thought so in 1970 as well. Gotta go with the latest and best, and remember hubris.

We understand what helps and what doesn't. More importantly what harms exponentially better than the people who started EMS.About friggin time!



1. While ignoring they were wrong more often.

2. It is my experience that "conservative" is a personality trait. You could show them evidence the world was round, but if they are not willing to believe it, no amount of evidence will save them.Ah, true believers! It's that "science" thing that divides obstructionists from cautionists.

3. Yes and no. I remember being told that in EMS, and immediately always followedby the caviat never deny oxygen somebody needs. However, I personally questioned the idea of hypoxic drive and the realitiy and practicality. I spent 2 weeks on a pulmonary ward where it was identified and demonstrated to me. THAT is an example of the diference between a technican (EMT) and a clinician! Dizzy nodding

The issue is that it exists in a specific patient population. That many EMS providers will never see in their careers. (because they are already hospitaized) EMS has a way of oversimplification to erroneous and then overcompensating. Again clinician vesus technician. Big nods.

I suspect it stems from lack of education and experience rather than the desire to do the right thing.BINGO.

Please write the preface for the next EMT manual?

 

[NYMedic828]

#1: Times are always changing, and at its thick wide base (IFT), AMBULANCE practice hasn't warranted much change. Employers resist change because it's expensive and uncertain. Machiavelli said change is uncertain because of lukewarm support and motivated resistance (paraphrase) .

#2. A clinician is a clinician, and too many EMTECHNICIANS want to start making clincial decisions instead of following their protocols. I've done it, we all have. When it goes sour, it suddenly becomes apparent how shallow and narrow EMTECHNICIAN training is. The patient pays the price. EMTs are practitioners (they practice) but not clinicians (professionals who have attended many types of patients and have broader and deeper knowledge than technicicans, who are trained and practiced in technique...not decisions). Parallel: a good lab tech will spot something and bring it to the MD's attention, but never presume to order more tests or treatment.

#3. Totally in agreement. How prevalent do you think that is?

#1. Agreed. Change I feel is warranted but isn't supported and never will be due to cost and fear.

#2. I agree but again my purpose was not literally to use that term in its absolute definition. I meant it in a way as more of an adjective for a provider who uses deeper thought process and critical thinking to decide their treatment parameters. Which we as EMS providers do. Granted it falls into a protocol, we still decide if that protocol fits and if it is warranted. The problem as you stated is people like to get carried away. Like someone who decides they are going to give NTG to acutely treat high blood pressure with no further warranting conditions. Those types of moves are absolutely reserved for real clinicians who can do essentially what they want to within their realm. If :censored::censored::censored::censored: hits the fan though, they need to justify their actions just the same.

#3. Very. I'd say more prevalent in private agencies than municipal. My FDNY medic program for example was partially taught by the medical directors themselves. (we have around 20 of them) We frequently have call reviews with them and doctor contact is a requirement to maintain your cert in NYC. If you make a no-no that is at a patient care level, you get a sit down at your station with one of the medical directors before any action is blindly taken on you. Where I volunteer, I have never once spoken with a medical director in person other than to get my paper signed to be an ALS provider for the agency. I think contact with medical directors is absolutely essential to the success of an agency at a provider level.

 

[Jambi]

Please write the preface for the next EMT manual?

This reminds me of when Bledsoe was talking about writing EMS text books. His baby was the multi-volume Brady paramedic series texts, and he was remarking on how programs wanted a single book "solution." Well, lets just say that you could hear the bitterness when talking about the changes that had to be made to fit it into one mega text...It was dumbed down text compared to the multi-volume set. Such is the march of EMS.

 

[mycrofft]

NYMED: Last point: total agreement. Does AFFF or other union help in this interface with management?

Second point: I understand your useage, and many EMTs are very professional in their demeanor and actions. However, deep thought is limited by the depth of knowledge and experience.

 

[Jambi]

#2. A clinician is a clinician, and too many EMTECHNICIANS want to start making clincial decisions instead of following their protocols. I've done it, we all have. When it goes sour, it suddenly becomes apparent how shallow and narrow EMTECHNICIAN training is. The patient pays the price. EMTs are practitioners (they practice) but not clinicians (professionals who have attended many types of patients and have broader and deeper knowledge than technicicans, who are trained and practiced in technique...not decisions). Parallel: a good lab tech will spot something and bring it to the MD's attention, but never presume to order more tests or treatment.

Thanks for the new signature material!

 

[NYMedic828]

NYMED: Last point: total agreement. Does AFFF or other union help in this interface with management?

Second point: I understand your useage, and many EMTs are very professional in their demeanor and actions. However, deep thought is limited by the depth of knowledge and experience.

I'm not actually not familiar with the AFFF?

We have a local union, 2507 under DC 37.

Our union does not get involved with you unless your employment comes under scruitiny. They also intervene in personell matters at the station to defend us against LT, CPTs and Chiefs if the need arises.

Any matters pertaining to patient care, if they are minor will receive a remediation packet that you review with your captain and both sign off stating you were remediated and won't do it again. Mid-level and higher issues are brought to the attention of a doctor. If it is a big no no, you are restricted as soon as a doctor gets wind of it and can not work on an ambulance until your case is reviewed. You do station work until you are cleared. Smaller issues are reviewed by the doctor and they will meet with you 1:1 or 1:2 (partner) to talk it over and educate you on your wrong doing in a civil manor with likely no repercussions.

We have a lot of broken aspects to our service but our QA/QI is pretty good here.

 

[Tigger]

we backboard people. why? because the books says so. we NRB everyone. why? because the book tells us to.

Does it? Or does it tell us to consider doing so if clinically indicated?

I don't doubt that there are some clinical guidelines that are not guidelines but rather a rulebook. If your protocols are written in this way, post them (I direct this at everyone).

If not, go back to using judgement and understand that your education did not end with your certification class, it was just beginning.

 

[Veneficus]

Please write the preface for the next EMT manual?

If invited to I would. But I suspect Brady doesn't want me to and the invite would have to come from Dr. Bledsoe personally.

As for dumbed down medic texts, I am very familiar with that story.

But there is currently a 7 volume medic text by Dr. Bledsoe, which is used by quality paramedic programs more often than not. So I guess that answers who was right.

I have the highest respect for Dr. Bledsoe.

But as an emergency guy, he is not keeping my director's seat warm.

 

[Veneficus]

replying to quote in text is killer.

Not only would I toss it out, but I have specifically ordered prehospital people not to initiate it. On the last few emergency patients I saw, neither of them got oxygen. They simply didn't need it. nod. How did they take that?

I was pretty calm about it, he simply put the mask away without a word. I suspect he went back to the station and told everyone there how little I know.


Now we understand the illnesses. OK, but we thought so in 1970 as well. Gotta go with the latest and best, and remember hubris.

I sincerely hope to look back 20 years from now and wonder what made us think of today's witchcraft.

3. Yes and no. I remember being told that in EMS, and immediately always followedby the caviat never deny oxygen somebody needs. However, I personally questioned the idea of hypoxic drive and the realitiy and practicality. I spent 2 weeks on a pulmonary ward where it was identified and demonstrated to me. THAT is an example of the diference between a technican (EMT) and a clinician! Dizzy nodding

The issue is that it exists in a specific patient population. That many EMS providers will never see in their careers. (because they are already hospitaized) EMS has a way of oversimplification to erroneous and then overcompensating. Again clinician vesus technician. Big nods.

I will point out that in the newest curriculum and roadmap, "EMT" was removed from the title of paramedic. I strongly suspect that was in an attempt to distinguish paramedics as clinicians. But as we are aware, what is on paper doesn't always match what happens in the real world.

 

[Jambi]

If invited to I would. But I suspect Brady doesn't want me to and the invite would have to come from Dr. Bledsoe personally.

As for dumbed down medic texts, I am very familiar with that story.

But there is currently a 7 volume medic text by Dr. Bledsoe, which is used by quality paramedic programs more often than not. So I guess that answers who was right.

I have the highest respect for Dr. Bledsoe.

But as an emergency guy, he is not keeping my director's seat warm.

You know, all the rage today is with open-source text books...

I can see the technician bonfire now.

<chanting> burn the book, he said no 02!

 

[Veneficus]

You know, all the rage today is with open-source text books...

That's nice, but I want paid.

 

[mycrofft]

Thanks for the new signature material!

Did I mention I trademarked that? (naw)

 

[Frozennoodle]

we NRB everyone. why? because the book tells us to.

Actually the book tells us to use common sense and treat hypoxia with titrated oxygen and resort to high flow immediately O2 in special critical circumstances. Basics get taught high flow O2 because they are basics and don't have the education backing them medics do. AHA even has notations all through ACLS discussing the ill effects of high flow oxygen.

 

[Jon]

Actually the book tells us to use common sense and treat hypoxia with titrated oxygen and resort to high flow immediately O2 in special critical circumstances. Basics get taught high flow O2 because they are basics and don't have the education backing them medics do. AHA even has notations all through ACLS discussing the ill effects of high flow oxygen.

And the other issue is that the text is, by nature, usually several years behind the state of the science.

One of these days I want to take a true ACLS:EP class. I've heard that it can be really awesome when presented right, with a good mix of clinician students.

 

[mycrofft]

This pretty well covered it

I doubt there are many studies focusing on pre-hospital care, because well, there just aren't very many studies involving EMS. However, there are plenty of studies covering things that happen in the hospital that we also do. Namely hyperoxygenation in cardiac arrest patients.

http://www.ncbi.nlm.nih.gov/pubmed/22971589
http://www.ncbi.nlm.nih.gov/pubmed/20516417
http://www.ncbi.nlm.nih.gov/pubmed/21385416
http://www.ncbi.nlm.nih.gov/pubmed/21606393

There were more, but they either used non-human subjects or had no abstracts.

Although I had reservations.
No"First Nations" jokes!

 

[errey]

I will point out that in the newest curriculum and roadmap, "EMT" was removed from the title of paramedic. I strongly suspect that was in an attempt to distinguish paramedics as clinicians. But as we are aware, what is on paper doesn't always match what happens in the real world.[/QUOTE]



here for paramedics the T stands for technologist