Going Beyond The Minimum: Paramedic or Ambulance Driver?

[Carlos Danger]

Here is a question that is simple with a lot of nuances and massive grey areas.

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?

Here, I have noted that our management tends to embrace patient care and comfort performed, not simply tradition, with a reasonable acceptance of new options and expansions of trust in field personnel. There are some people everywhere who embrace changes and advances, others who follow a well-marked trail, and some who refuse to modernize. Outcomes and core medicine rarely change, but the "extras" do- for instance, a progressive medic may provide pain management for a severe laceration or use true BiPap on the complicated ventilator with true customization of settings, whereas a regressive medic may simply bandage and go or use CPAP or a BVM or something.

Why the difference?

OK, to get back on topic:

First, the part I bolded I think is the most interesting part of your post. I don't think that is necessarily a negative; I think that in the field, there is a lot to be said for the K.I.S.S. principle in general. I am a huge advocate for increased education for paramedics, and increased ability to do diagnostic and interventional stuff in some cases, but as my own experience and education has increased, one of the things I've learned over and over is that less often is more

Cultures vary significantly from region to region and organization to organization (and also from individual to individual, of course). I was very early in my EMS career (<1 year) when I already saw that I wasn't going to be able to advance like I wanted to with my current position, so I changed things.

The problem is the basic market forces that affect EMS. As much as we dislike it, the lowest common denominator will always rule. Or, at least, it have a lot of influence. As long as reimbursements for transport (and, in turn, salaries) are low, educational / entry standards will remain low. As long as educational standards remain low, there will be lots of those "lowest common denominator" types. "Exciting work as a healthcare / public safety professional" that requires a minimum of education will always mean plenty of applicants for positions, and as long as there are plenty of qualified applicants, the employers have exactly zero incentive to increase compensation or to support increased educational standards.

 

[Clipper1]

So your alternative is to endorse single-handedly remove a therapy as useful as CPAP/BiPAP based on imagined failures caused by user error?

Heck, plenty of people have used the Impact to effectiveness. To dismiss it entirely as this medic did is folly.

No. I suggest you get access to the manual and read it. Then I suggest your company get a qualified clinical representative to go through how to use this machine appropriately and not just however you "think" it might be okay.

It is in inappropriate to dismiss someone using it in a way which is known to not be useful or even harmful.

 

[Clipper1]

First of all, it's pretty clear you are missing the overall point of this thread. He was simply using an example to draw a parallel between those who reject advancements in patient care with those who try to embrace them. The intent was not to critique his knowledge of transport vents.

Secondly, the other guy in the story did sound like an idiot. "That dumb newfangled automatic breathin' box dun strungled twice uh muh patients" vs. someone trying to use some more progressive technology and somewhat of an advanced intervention to benefit their patients is the point.

FWIW, I didn't see anything in Rocket's post that indicated a lack of understanding of how to use his vent. I don't think he gave nearly enough information to assess his knowledge base. And again, that wasn't the point here, anyway.

OK, I'm not sold on using it in arrest either (especially in a non-invasive mode), but he's not the only one who does it. I assume it's in his protocols and it's what he was taught to do. Even if I think something someone does is wrong or not ideal, I try not to criticize individuals who are just doing as they were taught or as their protocols instruct.

No. I am not missing the point at all.
I get the advancement part but that must come with the appropriate education and training. Just because you have the "technology", it does not mean you should just use it however and whenever if not appropriate.

How many codes how you worked where someone has put the patient on BiPAP rather then using the BVM or establishing an airway, either supraglottic or ETT? Do you understand why BIPAP or CPAP is not used on patients who are unresponsive and cannot maintain an airway? This is basic and should have been covered with the simple CPAP machines. The same safety principles apply to BIPAP. Do you also understand why compressions would make any breath given by the machine useless?

I think this BIPAP example is a good one and a biggie. If someone knows they have gotten crappy training and have seen it used inappropriately probably because of crappy training, they should not be criticized. Those who think they have something mastered and continue to make the same mistakes over and over but somehow believe they are "changing" EMS is exactly why EMS is still in the same state it has been for 40 years. Just adding another skill with out the appropriate or adequate information to go with it is NOT advancement.

I think the other guy's comments should be more closely examined. He may have a point or several points especially if he has seen some major f***ups by others who believe the ventilator is for everything and are obviously using it outside of its intended purposes. If protocols are written for NIV on a cardiac arrest, then that medical director should be questioned as to why and be shown the manual. But, when some are just given generic protocols to "turn the knob to this and we always use this mode only", then that shows there is probably a deficiency in education with the medical director trying to get away with cookbook protocols just to show how "advanced" his agency is. That is still not advancement. Maybe the person who some believe to be an idiot is actually the one who knows there is more to the story. But, when you have peer pressure from all of those who say they have enough training on the vent it still is just like 6 months is enough for Paramedic training.

 

[RocketMedic]

Clipper, do you actually know what the capabilities of the ventilator are? It is entirely capable of providing invasive positive-pressure ventilation via ETT or a supraglottic airway. There are literally modes dedicated to that. I have no idea how you can pull "slips on Bipap masks instead of intubates" out of what I've posted.

I use the vent when I can in an appropriate mode for the situation.

 

[Clipper1]

Clipper, do you actually know what the capabilities of the ventilator are? It is entirely capable of providing invasive positive-pressure ventilation via ETT or a supraglottic airway. There are literally modes dedicated to that. I have no idea how you can pull "slips on Bipap masks instead of intubates" out of what I've posted.

I use the vent when I can in an appropriate mode for the situation.

Yes I do know. You still do not see how limited this ventilator is by the specs, the FDA report and all the other sources available is rather concerning.
An old Elder valve can push air into an ETT.

What you essentially are stating is knobology. Yep the knob says SIMV so it must be the same as all the SIMV modes in delivery. If you read the FDA reports you would have noticed the concern about the PS. The Newport HT-50 also has similar concerns which is why many who were well versed in ventilators avoided SIMV when using that transport machine.

Let's say you have a small car like a Volkswagon which has "Drive", "Reverse" and "Park" on the shifter. Do you believe you will get the same pulling power as you would from a Porsche with the same "labels"?

Not all vents are designed the same. The reason the LTV1200 is so popular is the design of the internal turbine which some can hear kicking in. It also makes the machine a little warm but it is very powerful.

What about sensitivity? Have you look at the specs and reviews on it? How about the demand flow? The valving for delivery? What about flow termination? What is the max flow? Acceleration? You do not just judge a ventilator by its pretty knobs.

EMS providers are probably the easiest to sell ventilators or other advanced technology to by just dropping a few buzz words. Say stuff like "SIMV" is great because "it let's the patient breathe spontaneously" but forget to tell them all modes allow spontaneous breaths in 2013. The old IMV hasn't been around for over 25 years. The fact that they can take advantage of this for a sale should be an indication EMS has not advanced it education enough.

The sentence you used before the one below stated BiPAP instead of intubation. This one is very inaccurate. The volume delivered will depend on opening the airway and if chest compressions or being done. Even without chest compressions, it is crap shoot for tidal volume with BIPAP or CPAP. Look at any hospital ventilator or BIPAP machine which measures volumes. You will see each breath may vary even under the best circumstances unless the patient is on a paralytic which you would not do on BIPAP or CPAP.

I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion.

How many times have Paramedics gotten away doing procedures like RSI or taking equipment like ventilators or IABPs or "monitoring" drips they probably had not been adequately trained or prepared for and some call themselves CCTs? Some are lucky and some know they are protected by immunity laws. Some just don't follow up to see the damage done by their actions.

 

[RocketMedic]

And some will choose to flail at a BVM in the forlorn hope that it will somehow provide the function that a modern ventilator can provide.

 

[shfd739]

I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well.

We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing.

Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.

 

[RocketMedic]

This conversation is getting sidetracked. This is about going beyond the minimum, as Halothane pointed out. So, Clipper...are you a paramedic, or are you an Ambulance Driver?

 

[RocketMedic]

I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well.

We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing.

Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.

Do you have the old CPAP units then?

 

[shfd739]

Do you have the old CPAP units then?

Old CPAP? We use the CPAP mode on the vent for interfacility. 911 calls get Boussignac masks for CPAP.

I do agree with Rockets assessment about so many EMS folks acting like ambulance drivers and see the same problem here. There isn't a drive to improve and move beyond the 20 years of tradition. Nearly every shift I run into first responders that believe in back boards for all trauma, that O2 for all is a good thing and look at me like I'm crazy when I do otherwise.

Slowly our employees are catching on but its gonna take awhile. I think it needs to start with improving the education of medics. The standards and prerequisites to go into a medic school need to be higher. I really think there needs to be a top down overhaul of education and systems.

 

[Clipper1]

This conversation is getting sidetracked. This is about going beyond the minimum, as Halothane pointed out. So, Clipper...are you a paramedic, or are you an Ambulance Driver?

I definitely have more ICU and ventilator knowledge than you along with a few years in the ICUs, CCT and flight as well as NICU team. But, I have the utmost respect for professional ambulance drivers who can get an EMT or Paramedic and their patient safely to a destination. I think going beyond would mean much more attention being given to emergency vehicle driving rather than making that term so hated to where some are ashamed to be seen at an "ambulance driving" class. Being a PROFESSIONAL ambulance driver should be encouraged. All the Paramedic skills will not help you drive an ambulance better or safely. That "skill" can keep you safer or keep you from killing someone and maybe ending up in jail.

And some will choose to flail at a BVM in the forlorn hope that it will somehow provide the function that a modern ventilator can provide.

Define modern ventilator. Do you realize that hospitals use different ventilators depending on the goal. Again if the simple little $3000 ventilator could do everything the big machines can, why spend a million on just a few ventilators.

My point again as related to the discussion is...what you have described is not advancement. It is just getting a new gadget with a minimum amount of training to think you know what you are doing.

 

[Clipper1]

I know of multiple flight services that are using the 731 with no issues. All of them are using the EMV+ flavor and have multiple vents in service at all times. We switched to the EMV+ earlier this year and have been using it with no issues as well.

We don't chase etco2. Ill carry over the hospitals vent settings and ask to see the most recent blood gas. If everything looks good I keep their settings on mine. Before switching ill watch the co2 and spo2 on the hospitals vent. If the values showing up are having a suitable blood gas result then I use those settings and maintain what they've been doing.

Our vents are strictly for CCT interfacility only and only 3 of our 20+ units have them.

If you read the Flight forums you will find that not all teams are happy with the 731. We tried it for short transports or backup and junked it when the LTV1200 arrived.

If you only have 3 units then that might be too few transports to really notice something wrong. We do have the advantage of doing the iSTAT on long transports and will get another ABG on arrival.

Rocketmedic

With all the different modes an ICU machine can do, it is rather strange to hear someone just matching the settings. The numbers might look the same but the way those numbers are achieved with the smart technology, the little transport vents won't come close. Very few ICUs use SIMV just as the "SIMV" you might have read about or what the 731 claims to do. Without a good PS, which is the 731's downfall, I would not consider that mode.

But again, education, education, education.

 

[RocketMedic]

Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!

 

[VFlutter]

Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!

I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!

 

[RocketMedic]

I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!

15 is for little girls, our regulators go to 25!

 

[Clipper1]

Well, O great lord of all the Vents, would you prefer me to simply carry a bottle of Lasix and an ET tube everywhere? How about I preemptively backboard everyone for you? I won't manage pain anymore either, it might interfere with an assessment. But I can drive the truck!

Sometimes that is what must be done even in the hospital while a MORE APPROPRIATE ventilator is brought in.

Failing to realize limitations is why I emphasize education. Not knowing the limitations of that ventilator or willing to listen and learn makes you more dangerous than the person you consider to be an idiot because he will not just do something with very little training. He probably has seen the mistakes of others. Just because you can does not mean you should. That applies to intubation, RSI, ventilators, multiple drips and IABPs. I think crics are also in that category since many have not reviewed the procedure since Paramedic school.

Master the basics and what is common in your profession before trying to go with the cool gadgets. If you can't use a BVM, don't do RSI or touch a ventilator. If you can't provide the needed pharmacological support to maintain a patient on the ventilator, you have just screwed the patient. Ventilator management is more than just a few knobs. You either have the knowledge to do it effectively or just rely on what you should know best until your agency can give you the education and protocols to do the package.

 

[VFlutter]

15 is for little girls, our regulators go to 25!

My HHFNC goes up to 40L/min. Winning.

 

[Clipper1]

I bet you give everyone oxygen @ 15Lpm too! ^_^ Oh all the pulmonary fibrosis you have caused!!!!

Pulmonary fibrosis in 15 minutes?

In the ICUs we try to get patients off the oxygen clock quickly but may have to use nitric oxide, Flolan, proning, HFOV or even ECMO. Most prehospital providers can not initiate those. So, oxygen might be necessary. I can assure you if a patient is short of breath and needs oxygen, 15 L/m is not going to "cause pulmonary fibrosis" in a short ambulance ride. Hell even in the ICUs a patient might be taken off BIPAP and placed on a NRB or Oxymask at 15 L for up to an hour for procedures.

15 is for little girls, our regulators go to 25!

What equipment do you have to run 25 L through? I hope not a regular NC or face mask. The LTV1200 can run a low flow through it for a low FiO2 while depending on the internal compressor.

Again, it's all about the education.

 

[Clipper1]

My HHFNC goes up to 40L/min. Winning.

Ours goes to 60 L/min but with a kickass humidification system.

I do not recommend those in EMS trying this without the proper equipment, education and lots of Oxygen along with air tanks and a blender or we'll be back at the high flow O2 conversation but with an FiO2 of 1.0.

 

[VFlutter]

Pulmonary fibrosis in 15 minutes?

In the ICUs we try to get patients off the oxygen clock quickly but may have to use nitric oxide, Flolan, proning, HFOV or even ECMO. Most prehospital providers can not initiate those. So, oxygen might be necessary. I can assure you if a patient is short of breath and needs oxygen, 15 L/m is not going to "cause pulmonary fibrosis" in a short ambulance ride. Hell even in the ICUs a patient might be taken off BIPAP and placed on a NRB or Oxymask at 15 L for up to an hour for procedures.

Sarcasm is lost on you. Is that what they do in the ICU? Who knew. I need to find me one of those fancy ICUs to work in. Oh wait....