Is EMS treatment a farce?

[Veneficus]

Sounds very extreme doesn't it?

But is it?

Today I am dealing with renal replacement therapy in peds. While that may sound like something more related to the ICU than EMS, there is a common theme throughout that raises questions.

That is: Fluid overload increases mortality in critically ill children.

"Fluid overload of >20% at the time of CRRT initiation has significant increase in mortality, ventilator days, and length of hospital stay."

Says a study in the journal of critical care. (The PDF will not let me copy and paste the title)

In EMS, fluid resuscitation is a work in progress. Do we bolus? When? Do we permit hypotension? How much?

But generally, nobody looks at how much fluid.

We all know the numbers, 5,10,20 ml/kg. But absorbtion and depletion are never considered.

In all aspects of intensive care, slow changing, precision balances are the modality of most if not all treatments.

Which begs the question:

If slow precise treatments are the modality of intensive resuscitation, if EMS providers really are "experts at resuscitation" as is often claimed, especially when complaining about nurses, why are these EMS "experts" not embracing a treatment modality that all the other "experts" do?

"Because things aren't perfect in the field..."

This doesn't really seem like a good excuse to me. Isn't that ambulance bringing the hospital to the patient?

If not, then you don't need all that gear and protocols.

"it's different in the field..."

Really?

The position is whatever is done in the field no matter how imperfect can only help?

Sounds sort of silly actually.

Is it really impossible to try to be precise with fluid resuscitation? Because that would mean providers could not estimate or count very simple numbers.

That is really no different than supplemental O2. Most of us agree that slapping the 15LPM nonrebreater on a patient doesn't help. Many even catch on the the harmful mechanisms of it.

Why not with fluid? Anyone reading this who has spent time in an ICU should be nodding their head when I mention there is a lot of effort put into fluid balance.

It is not "all or nothing."

If I gave every soldier on the battlefield a needle and a liter of fluid and anytime somebody was bleeding or dehydrated they got the whole liter IV, would we call those providers "experts" at resuscitation?

Would they be equally expert if they never administered it?

Because that seems to be the approach of "Emergency resuscitation" experts.

Now I brought up fluid and oxygen, but isn't it true of most EMS treatments?

We are critical of "slamming narcan" but we are "pushing" D50. Despite the knowledge of gradual glycemic control, from 50-300 in seconds. (natutally being "careful" of infiltration)

Most EMS agencies will not let a provider "push" 10 mg of opioid, "because the patient might stop breathing." But 2 large bore IVs with fluids running wide open breaking up clots or causing brain edema is not "dangerous?"

For those not in the know, cell edema is the first stage of cell injury. Inducing injury (edema) doesn't sound like "do no harm."

So, which expert is going to put forth your argument? I want to hear your reasoning. At least your amazing excuse and reiteration you are still an expert.

 

[kindofafireguy]

I wouldn't say it's a farce, per se. I would say it's reminiscent of medicine itself in that is an evolving practice.

To begin with, I'm not trying to justify the methods used. This is merely my take on it.

Medicine itself in its early stages was dangerous and just as likely to kill the patient as it was to help. "Guaranteed to kill or cure," so to speak. EMS is in a comparable stage. This is by no means a justification, nor is it acceptable, but I feel it to be an honest truth.

EMS treatments are only now beginning to transition to an evidence based practice. However, the problem lies in part with medical direction. The volume of research is often vague and contradictory, and so protocols change on a whim.

One of the great problems is a lack of true education. EMS is still a vocation instead of a profession, and we are the root cause for this. We do not, as a whole, strive to raise our standards and become more refined as a career field. Many understand the "how" of our treatments, but all too few understand the "why."

This is our catch-22. Medical control will often not allow their medics to perform more advanced or independent care in many places because they do not trust their EMS providers. However, if we do not experience it and work towards it, there is no motivation nor incentive to become better (for many, at least). The idea that patient care is everyone's priority is a noble one, but unfortunately is often not the reality.

I don't see EMS providers as experts at anything. The phrase "jack of all trades, master of none" comes to mind. We are the bandaid that keeps them going until they reach proper care.

We are also our own greatest enemies. If we raise our own standards for practice and education, we will in time earn our place in the chain. But I believe that burden lies with us.

 

[Summit]

An explanation I have for why things go that way is that if a provider is drilled more on what to do than why to do/not do things, then providers will care more about how much they do while placing less emphasis on how they do it. Let me explain:

EMS providers are under a lot of pressure to do a ton of tasks in a very short period of time. They have a few minutes to go through initial assessment, introductions and initial interventions, more thorough assessment and treatment, starts an IV, blood sugar, do an EKG, get some more vitals, reassess, oops we are at the ED doors and dispatch wants to know why we aren't available yet??? Management wants to know how many boxes you crossed off on the treatment list so they can bill.

So, EMS providers often measure themselves on how much they can do quickly. After all, its an emergency! If they don't know why to slow down, take care, be precise, they won't. That takes time and gets in the way of the next task. So, just ignore it, slam it, call it good enough, and justify it as "field medicine."

The cause is a combination of factors mentioned by the previous poster and above. It is a combination of insufficient educational depth/breadth, the economic drivers, and misguided motivations create a culture that drives this sort of care that would get other providers written up, maybe fired, or possibly reported to their licensing board. One could also ask why there are more stringent regulations on CDL truck drivers than EMS.

 

[Summit]

Who can blame EMS providers? Slamming morphine makes blatantly apparent negative results. What happens to the patient 2 hours, 2 days, or 2 weeks later in the ICU doesn't enter the mind of providers focused primarily on the next 2 minutes because they weren't cultured to think about it much less educated on it. You hear it "I'm an EMERGENCY provider who is an Expert on short term pre hospital emergency care!" It just is not common that you hear EMS providers talking about how they effect patient outcomes beyond the ER (unless it is something dramatic). There are some who do think about it, like a Paramedic I know who actually teaches EMTs about pressure ulcers and backboards.

 

[Veneficus]

Medicine itself in its early stages was dangerous and just as likely to kill the patient as it was to help. "Guaranteed to kill or cure," so to speak. EMS is in a comparable stage. This is by no means a justification, nor is it acceptable, but I feel it to be an honest truth.

However, the problem lies in part with medical direction. The volume of research is often vague and contradictory, and so protocols change on a whim.

One of the great problems is a lack of true education. EMS is still a vocation instead of a profession, and we are the root cause for this. We do not, as a whole, strive to raise our standards and become more refined as a career field. Many understand the "how" of our treatments, but all too few understand the "why."

This is our catch-22. Medical control will often not allow their medics to perform more advanced or independent care in many places because they do not trust their EMS providers. However, if we do not experience it and work towards it, there is no motivation nor incentive to become better (for many, at least). The idea that patient care is everyone's priority is a noble one, but unfortunately is often not the reality.

I don't see EMS providers as experts at anything. The phrase "jack of all trades, master of none" comes to mind. We are the bandaid that keeps them going until they reach proper care.

So neither medical directors or EMS providers are experts at resuscitation is what you are saying?

An explanation I have for why things go that way is that if a provider is drilled more on what to do than why to do/not do things, then providers will care more about how much they do while placing less emphasis on how they do it.

So, EMS providers often measure themselves on how much they can do quickly. After all, its an emergency! If they don't know why to slow down, take care, be precise, they won't. That takes time and gets in the way of the next task. So, just ignore it, slam it, call it good enough, and justify it as "field medicine."

The cause is a combination of factors mentioned by the previous poster and above.

You say the same thing...

Does anyone who claims to be an expert want to offer a rebuttal?

 

[Summit]

I'm not an expert. Maybe I will be.
I don't think my comment addresses medical directors. I will say that in the 3 EMS agencies I worked/work for, most EMS providers never interact directly with their director.

 

[kindofafireguy]

So neither medical directors or EMS providers are experts at resuscitation is what you are saying?

I am neither qualified, nor inclined, to discuss the qualifications of medical directors. My point in mentioning them was simply to point out the lack of any true standards of care, as many protocols (while following a general pattern) tend to be subject to an MD/DO's interpretation or experience. This is neither an insult or complaint, simply an observation.

What I am saying is that there is far too often a disconnect between EMS and MC, and that this is often a contributing factor to the mindset of EMS providers.

Medicine in general loves labels, and I believe that far too often the label of "expert" is flung around with little regard for what it was meant to imply. Particularly, any one self-labeling themselves an expert should tread very carefully, for down that road lies damnation, so to speak. A little learning is a dangerous thing, as you so aptly point out in your signature.

Do experts exist? Sure. But I'm definitely not qualified to identify one.

 

[Veneficus]

I'm not an expert. Maybe I will be.
I don't think my comment addresses medical directors. I will say that in the 3 EMS agencies I worked/work for, most EMS providers never interact directly with their director.

I am neither qualified, nor inclined, to discuss the qualifications of medical directors. My point in mentioning them was simply to point out the lack of any true standards of care, as many protocols (while following a general pattern) tend to be subject to an MD/DO's interpretation or experience. This is neither an insult or complaint, simply an observation.

What I am saying is that there is far too often a disconnect between EMS and MC, and that this is often a contributing factor to the mindset of EMS providers.

Medicine in general loves labels, and I believe that far too often the label of "expert" is flung around with little regard for what it was meant to imply. Particularly, any one self-labeling themselves an expert should tread very carefully, for down that road lies damnation, so to speak. A little knowledge is a dangerous thing.

Do experts exist? Sure. But I'm definitely not qualified to identify one.

I think it is fairly obvious that if medical directors are not permitting the type of treatment that is demanded by the current realities of resuscitative medicine, then they are not expert.

Experts do not advocate outdated treatments in order to make things simple. The prudent measure is to advocate EMS providers under them either do nothing or do what is current.

Creating or supporting protocols that are knowingly outdated because you don't want to change, or trust, or whatever is just a poor excuse.

By the same measure. Providers who advocate poor treatment because it is convienient for their limited understand are not expert either.

The reason I raise this issue is because many EMS providers claim to be expert. I have seen it multiple times on the very forum over the last few weeks.

As you two pointed out, the level of knowledge and performance of EMS providers is simply not expert.

 

[VFlutter]

I think we can all agree that the majority of the posters on this forum are the "Cream of the Crop" and do not accurately represent the average medic (Or average provider in their respective field).


How can you expect the average medic to truly understand and implement fluid resuscitation when they do not even understand the basic concepts behind it? Osmotic & hydrostatic pressure, interstitial fluid shifts, cytotoxic edema, etc etc.

If you "water down" concepts and simplify it to the point we see in EMS then what do you except?

Those who are truly experts recognize the consequences of their treatments long after transfer of care.

 

[Veneficus]

I think we can all agree that the majority of the posters on this forum are the "Cream of the Crop" and do not accurately represent the average medic (Or average provider in their respective field).


How can you expect the average medic to truly understand and implement fluid resuscitation when they do not even understand the basic concepts behind it? Osmotic & hydrostatic pressure, interstitial fluid shifts, cytotoxic edema, etc etc.

If you "water down" concepts and simplify it to the point we see in EMS then what do you except?

Those who are truly experts recognize the consequences of their treatments long after transfer of care.

So your position is that while it is possible to be an expert at resuscitation as an EMS provider, it is not automatic because you are an EMS provider?

 

[Anonymous]

Modern Medicine is a Farce

Driven by profit and with faulty "Evidence Based Medicine." I don't know how anyone today can claim to be an expert. Our understanding of the body is modest at best and half of what we "know" today will likely be proven wrong in the the next half a century.

Dinosaurs were cold-blooded.

Most of the DNA in the human genome is junk.

Saccharin causes cancer and a high fiber diet prevents it.

Stars cannot be bigger than 150 solar masses.

and so on. It is almost laughable and one is left to wonder if we are not ultimately causing humanity more harm than good at times.

We have a flawed system with flawed clinicians, what does that amount to?

this is an exerpt that somewhat summarizes what I cannot seem to articulate right now.

Repair of the physical body is erroneously equated with healing.

In its quest for objectivity medicine has rejected its spiritual roots and lost sight of its humanity. It cannot be but a reflection of the culture from which it has emerged. It arrogantly rejects the wisdom of thousands of years of human history, is fragmented to the point of dissociation, devoid of common sense, preoccupied with short-term material goals, slave to its financial overlords, and utterly lacking in the requisite spiritual knowledge that would enable it to find its way out of its self-imposed foolishness.

Like some religious faiths, medicine clings ferociously to its worldview when challenged by congregants whose firsthand experiences sometimes lead them to believe otherwise. It defends its dogma with a powerful form of groupthink and is quick to lash out at heretical ideas that threaten its doctrine and its territorial interests. Like some religious movements that purport to be the one and only true path to salvation, it displays an unusual degree of intolerance when faced with nonbelievers who dare to ask questions. It is a closed belief system that does not allow innovation or new ideas. It lays claim to truth, fact, and objectivity, but exposes itself as otherwise when we closely examine its assumptions, politics, and practices.

http://www.naturalnews.com/031589_modern_medicine_scientism.html#ixzz2JOKRBNIt

 

[VFlutter]

So your position is that while it is possible to be an expert at resuscitation as an EMS provider, it is not automatic because you are an EMS provider?

Correct. Also, being able to run a picture perfect ACLS code does not make you an expert at resuscitation. How many times have you heard an EMS provider claim to be better than the ED physician because they did not follow ACLS or that EMS and hospital care is equivalent care because "everyone follows ACLS"

I am of the opinion that if an advanced provider is relying on ACLS then they are not an expert.

 

[Veneficus]

I think that is a very true and fair account of what modern medicine is.

How that defines or undefines an expert I am not sure.

Certainly the difference between healing and repair was a part of my education. I was told several times actually that we can never heal.

(which isn't really fact, it is just limited to such a minute group of diseases that for all practical purposes it is true)

Even in those cases, medicine doesn't really do the healing, it kills the pathology. The body then rights itself.

I would say an expert knows all the latest information of the day. Certainly nobody can know all the information and it is subject to change. Not only do we learn more, but the human organism changes over time.

Politics and money are certainly part of medicine, and if you want to be successful at it, important parts. However, many of the world's societies still see medicine as a way to preserve wealth, not a way to create it.

I would say that is the biggest difference between successful medical systems and self destructive ones.

Another important philosophical aspect of medicine is the perception of the patient. In the US in particular, patients have the expectation of curative medicine.

In all of the other societies I have visited or been a part of medicine in, the patients view it as more of a helping hand. They do not expect cures. They expect their life will be made better than it is or their suffering minimized.

The expectations of patients should never be underestimated.

When people refer to me as a healer, I feel compelled to correct them. I would describe my role as more of a necromancer. I can prolong your life, maybe even take away some of your pain, but I cannot make you the way you were and you will pay a price beyond money for what I offer. Whether or not you can accept that is up to you.

 

[systemet]

I think it is fairly obvious that if medical directors are not permitting the type of treatment that is demanded by the current realities of resuscitative medicine, then they are not expert.

I don't think that's logically contingent. The medical director may an excellent "resuscitationist", but lack the time, energy or support to ensure that the crews under his or her responsibility provide appropriate care.

I think that in some settings the medical director acts as damage control, enabling providers to administer some treatments with proven benefit, e.g. aspirin, salbutamol, while withholding the ability to perform others, e.g. RSI.

If the organisation that employs the medical director fails to support them with a responsive command structure, an active clinical education department, functional cQI/QA, and a disciplinary structure that enables providers to be coached and counselled, then there's only so much they can do by themselves.

Experts do not advocate outdated treatments in order to make things simple. The prudent measure is to advocate EMS providers under them either do nothing or do what is current.

I think the current approach in many symptoms is to take a middle way, where therapies are permitted because (1) they have historically been used [not logical, but commonly happens, or (2) there's a proven benefit. Typically most systems are conservative in introducing new therapies, and tend to be some years behind the times.

I think it's a matter of opinion as to whether this represents a medical director or team being cautious, prudent, advocates for patient care, or perhaps not sufficiently engaging themselves in an important area.

Creating or supporting protocols that are knowingly outdated because you don't want to change, or trust, or whatever is just a poor excuse.

I agree, to a point. Not wanting to change for sake of conservatism itself is ridiculous, but regrettably common. Not introducing a new procedure with potential for harm because you don't believe your providers are sufficiently skilled is perhaps more justifiable. Now the perfect answer would be to train your providers to perform better patient care, but this process is often outside of the hands of the medical director.

As a paramedic I often notice that my co-workers want change now. Next week, or next month. Real change is measured in years or decades. These things take time.

By the same measure. Providers who advocate poor treatment because it is convienient for their limited understand are not expert either.

Do you feel that that responsibility lies at the hands of the medical director?

I do think that the physician community is responsible for EMS, but it's a shared responsibility. If more physicians involved themselves in EMS education today, the way they did in the past, then perhaps there would be less problems? But at the same time, a medical director faces all manner of challenges, not least of which are being unable to set the length or content of their provider's training programs, or the financial realities of trying to perform ongoing education, research, or introduce new equipment or medication.

The reason I raise this issue is because many EMS providers claim to be expert. I have seen it multiple times on the very forum over the last few weeks.

As you two pointed out, the level of knowledge and performance of EMS providers is simply not expert.

I would agree with this. It would be idiotic for me, with about 3 years of specific education for my job (and a whole bunch of other stuff that wasn't required for licensure), to claim to be an expert in any area of medicine. I would imagine that the least qualification one could have to be considered a medical expert would be an MD with fellowship training, or perhaps a PhD heavily involved in biomedical research.

 

[Veneficus]

Correct. Also, being able to run a picture perfect ACLS code does not make you an expert at resuscitation. How many times have you heard an EMS provider claim to be better than the ED physician because they did not follow ACLS or that EMS and hospital care is equivalent care because "everyone follows ACLS"

I hear all the time how EMS providers are better at running codes than any physician specialty. In every EMS venue I have ever particpated in. Including here.

I am of the opinion that if an advanced provider is relying on ACLS then they are not an expert.

I have shared that thought for many years. The more I learn, the more feeble ACLS is.

 

[Veneficus]

I don't think that's logically contingent. The medical director may an excellent "resuscitationist", but lack the time, energy or support to ensure that the crews under his or her responsibility provide appropriate care.

I think that in some settings the medical director acts as damage control, enabling providers to administer some treatments with proven benefit, e.g. aspirin, salbutamol, while withholding the ability to perform others, e.g. RSI.

If the organisation that employs the medical director fails to support them with a responsive command structure, an active clinical education department, functional cQI/QA, and a disciplinary structure that enables providers to be coached and counselled, then there's only so much they can do by themselves.

At what point then does said medical director have a moral obligation to admit that he is incapable of meeting his responsibility and step aside?

"Proven" to work is a very weak standard actually. It hasbeen my experience that most EBM doesn't really prove anything except what the experiment is set up to prove.

At the same time, many "proven" treatments only help in a relatively small number of cases in a specific population.

Aspirin is the last "proven" treatment in the ACS population that even reached double digits.

Since medical directors hold not only the legal ability to limit treatment, but the ability to walk away, if doctors made a collective decision that they would not serve as medical direction unless specific conditions were met, then serivces that were not receptive to direction would quickly go away.

I think the current approach in many symptoms is to take a middle way, where therapies are permitted because (1) they have historically been used [not logical, but commonly happens, or (2) there's a proven benefit. Typically most systems are conservative in introducing new therapies, and tend to be some years behind the times..

You are correct on both accounts, but reason number one is such a pathetic excuse i will not qualify it farther.

Number 2 in my opinion is also flawed. Because many providers are reluctant to change, no amount of evidence prior practices didn't work will ever be sufficent for them. Similarly, no amount of evidence of the value of new treatments will ever meet their burdon.

At this point, they are simply obstructionists putting their own security above that of patients.

"Many people get medical degrees, few will ever be doctors" was a favorite saying of one of my mentors and I have adopted it.

Just because people are capable of entering and graduating medical school, mostly out of academic prowess, does not make them capable of being able to apply that science effectively nor does it give them the mental flexibility to constantly change their beliefs as new information is introduced.

Those things require a doctor.

I think it's a matter of opinion as to whether this represents a medical director or team being cautious, prudent, advocates for patient care, or perhaps not sufficiently engaging themselves in an important area.

I think once something has been demonstrated to be harmful more often than beneficial, continuing to routinely use it no longer can be considered any of the above.

I agree, to a point. Not wanting to change for sake of conservatism itself is ridiculous, but regrettably common. Not introducing a new procedure with potential for harm because you don't believe your providers are sufficiently skilled is perhaps more justifiable. Now the perfect answer would be to train your providers to perform better patient care, but this process is often outside of the hands of the medical director.

With this I agree.

As a paramedic I often notice that my co-workers want change now. Next week, or next month. Real change is measured in years or decades. These things take time..

I want change now. But you are right.

I would point out though, the lengthy process of change is paid for by the suffering of people today. There needs to be a better compromise about how long that process should take.

Do you feel that that responsibility lies at the hands of the medical director?

Aboslutely I do. I have a very rigid definition of personal accountability. WHen a person is in charge, they are responsible. Even for the actions of those underneath them which they have only partial control over.

I do think that the physician community is responsible for EMS, but it's a shared responsibility. If more physicians involved themselves in EMS education today, the way they did in the past, then perhaps there would be less problems?

I certainly agree with this.

It should involve all disciplines, not just Emergency Medicine specialists. As an example, emergency doctors didn't learn how to birth babies from other emergency doctors. They learned it from an OB/Gyn. The same should be with EMS. At the very least it should be one of these content experts that reviews and approves teaching directives in al disciplines. But then the political problem you run into is the only part EM would have in the process is operations.

But at the same time, a medical director faces all manner of challenges, not least of which are being unable to set the length or content of their provider's training programs, or the financial realities of trying to perform ongoing education, research, or introduce new equipment or medication.

True, but it has been my experience that medical directors often don't engage in these battles not because they cannot be won, but because of lack of interest.

Medical directors also have some very powerful tools to enforce their will. Such as state medical boards and other state government departments. They simply choose not to use them.

I would agree with this. It would be idiotic for me, with about 3 years of specific education for my job (and a whole bunch of other stuff that wasn't required for licensure), to claim to be an expert in any area of medicine. I would imagine that the least qualification one could have to be considered a medical expert would be an MD with fellowship training, or perhaps a PhD heavily involved in biomedical research.

I would settle for somebody who could just tell me why they are doing what they do and the potential mechanism behind why it might work.

 

[RocketMedic]

I'd reckon I'm probably better at *emergency* medicine than the interchangeable "MD" from the local SNFs (or it could be pure, unabashed hatred for that man and his crappy, crappy care), but I'm nowhere near ER-doc-level good at anything.

I think we let paramedics assume that we are experts at resuscitation because most of our dead patients are dead, and it's a low-risk/high-reward situation to let us have at them. Occasionally, we get one that's not quite dead yet, and sometimes we're able to save them. Kinda like the cart in Monty Python, without the euthanasia. Now we're experts. Yey!

It doesn't help that our education comes from old-school paramedics who rely almost entirely on anecdote to defend an established position and that our medical operations are essentially unsupervised.

 

[Dwindlin]

Personally I don't think its a fair question Vene. Especially considering fluid resuscitation/responsiveness is a grey area. Hell when one of the major recommendations by, what many would consider an expert on this very topic (Paul Marik), is essentially give it a try and see what happens.

For something like fluid resuscitation there is no great indicator of your end points, most good studies have shown that almost everything we use to measure it is voodoo (including most of the PE findings we associate with it).

 

[VFlutter]

For something like fluid resuscitation there is no great indicator of your end points, most good studies have shown that almost everything we use to measure it is voodoo (including most of the PE findings we associate with it).

Maybe we should equip all ambulances and train medics to ultrasound IVCs for fluid responsiveness h34r:

 

[Dwindlin]

Maybe we should equip all ambulances and train medics to ultrasound IVCs for fluid responsiveness h34r:

ICV diameter is an indirect method of measuring CVP...and CVP is garbage. Great review of fluid responsiveness on medscape. Thus far the only "monitor" that shows any integrity is pulse-pressure variation, but even this is only accurate in the extremes and only in mechanically ventilated patients (<9% or >13%).