"Is Prehospital EMS (PHEMS) a Profession?"

[systemet]

I have no doubts that the technology will rapidly advance, I was commenting more on the UK ambulance trusts not currently equipping them.

I find this odd, as apparently they're thrombolysing people. So they must have a 12-lead. Presumably they've just hobbled the machine, so that you can't use manual modes for defibrillation / cardioversion.

It's not impossible that they're using LP12, or similar, monitors but they've been programmed to prevent pacing or cardioversion.

 

[St George]

Far simplier answer guys. The have an AED and a seperate ECG machine to do 12 lead ECG.

 

[RocketMedic]

That seems redundant. Not to mention the few patients who would benefit from cardioversion and pacing are SOL...

Why not trust y'all with ETT and electricity? Do y'all have CPAP?

 

[St George]

ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf

 

[jjesusfreak01]

ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf

Are paramedics still allowed at least one decent BIAD, like a King? Doesn't make sense to phase out ETI when you don't have a decent backup.

 

[crazycajun]

ETT (I assume this is referring to intubation) is a dying art in the UK. IGels/LMA/Combis have taken over. Its only anaethetists using ETT these days, its no longer part of the paramedic skillset - its obslete. This is not without controversy. See: http://jrcalc.org.uk/intubation_paper_v4.pdf

I think the biggest problem (according to some research) in the UK is unsuccessful intubations in the field. My understanding is about a 25% success rate. That is a very low number. I also understand that the esophageal intubation rate is somewhere around 47% which is extremely high. The US has also looked at taking ETT intubation out of the national scope however there is definitive proof that ETT is a needed option in some rural areas. RSI on the other hand is a technique that should be more closely monitored. It seems more and more medics are being allowed to RSI that cold not intubate in the first place.

 

[systemet]

I think the biggest problem (according to some research) in the UK is unsuccessful intubations in the field. My understanding is about a 25% success rate. That is a very low number. I also understand that the esophageal intubation rate is somewhere around 47% which is extremely high. The US has also looked at taking ETT intubation out of the national scope however there is definitive proof that ETT is a needed option in some rural areas. RSI on the other hand is a technique that should be more closely monitored. It seems more and more medics are being allowed to RSI that cold not intubate in the first place.

Those numbers don't sound right. If you can find a source for them, I'd be interested in taking a look at them.

I doubt this is an issue that UK paramedics somehow have an inability to place tubes in the trachea. It seems much more likely that the medical direction in the UK has never allowed their paramedics to use RSI or medication-facilitated intubation, and in light of the many negative, and a few neutral studies out there, aren't about to start.

The rural regions in the US and Canada may have something to do with the wider use of RSI there. But I think a bigger reason is that both have incredibly disorganised and fragmented systems. It's not uncommon to drive an hour or two down a highway, and pass through four or five different systems, with different delivery methods, e.g. fire versus private ALS, municipal ALS, private BLS, volunteer EMR, etc., and five different sets of protocols.

While this sort of system probably isn't optimal, it leads to the use of different skills in different areas, which drives things forward. There's also a similar driving effect from fixed wing and rotary wing air ambulance that's less prevalent in the UK. I mean, if you're going to fly for an hour to land at a rural health center, staffed by an RN, to deal with some guy who got run over by a car an hour and a half ago, and then you've got to fly another hour to a trauma center, things like RSI become sort of, less risky and more desirable.

With the new UK medics getting a Bachelor's degree, and the UK Paramedic Practitioner program at the cutting edge of non-physician ALS development, it's hard to think that the reason they don't use RSI is some sort of widespread bungling incompetence.

Also, while cardiac arrest tubes tend to be pretty easy, if you look at a success rate in a system intubating with less than optimal agents, e.g. no drugs, or benzos alone, or benzos+opiates without paralytics, etc., the success rates are likely going to be lower versus using paralytics. There's a decent paper out there showing a HEMS system using etomidate alone versus the same system using etomidate + succs, and their success rate varied greatly -- which may be partially due to properties of etomidate, but nonetheless interesting.

[I feel like I could also ramble on about how intubation success rate is a poor metric, e.g. if my first attempt takes 30 minutes, I can probably approach a 99% first pass rate, but everyone will be dead.]

 

[Veneficus]

Has anyone considered the reason they don't have those tools is because the need to use them may be so low that it doesn't justify the expense?

 

[systemet]

Has anyone considered the reason they don't have those tools is because the need to use them may be so low that it doesn't justify the expense?

I've considered that. It's a possibility, right? It just seems that the variables involved are too poorly defined to be able to make a definitive statement in either direction.

* Is prehospital intubation desirable? There's not a lot out there comparing ETI to BVM. We have the Gausche pediatric ETI via BVM study in LA / Orange Counties, showing equivalence. But this almost feels like a win for ETI, because the intubation success rate was 57%, and still they didn't seem to be able to kill or vegetablise anyone at a significant rate. None of the subgroups are really large enough to identify whether particular groups were at greater risk. The San Diego trial's limited by methodology, but motivates against RSI in head injury. The Aussies have data showing an improvement in 6 month neuro outcomes in the same patients. But they're also successfully intubating 97% of their patients versus something like 88% in the San Diego trial.

* What does it cost to do well? We still don't seem to be able to agree on what an acceptable level of initial and ongoing training is. The Aussie's did well with 16 hours, 8 of which were in the OR with an anesthetist, but they started off with degree paramedics with postgraduate training, probably with substantial experience. San Diego failed on 8 hours of classroom setting, using paramedics with substantially less education. To see the benefits the Australians reported, do we need to increase initial training time for paramedics, restrict the skill to a small group, have periodic OR access, or a minimum number of tubes / paramedic / year? And what are the ongoing training requirements at + 1year, + 5years, etc.

It doesn't help matters either that much of the poor outcome seen in earlier trials has now been attributed to hyperventilation, which is at least partially a technology issue that can be mitigated by widespread use of waveform capnography, or that there's been concerns voiced about frequent displacement / unrecognised esophageal placement in other studies.

 

[Veneficus]

I've considered that. It's a possibility, right? It just seems that the variables involved are too poorly defined to be able to make a definitive statement in either direction.

* Is prehospital intubation desirable? There's not a lot out there comparing ETI to BVM. We have the Gausche pediatric ETI via BVM study in LA / Orange Counties, showing equivalence. But this almost feels like a win for ETI, because the intubation success rate was 57%, and still they didn't seem to be able to kill or vegetablise anyone at a significant rate. None of the subgroups are really large enough to identify whether particular groups were at greater risk. The San Diego trial's limited by methodology, but motivates against RSI in head injury. The Aussies have data showing an improvement in 6 month neuro outcomes in the same patients. But they're also successfully intubating 97% of their patients versus something like 88% in the San Diego trial.

* What does it cost to do well? We still don't seem to be able to agree on what an acceptable level of initial and ongoing training is. The Aussie's did well with 16 hours, 8 of which were in the OR with an anesthetist, but they started off with degree paramedics with postgraduate training, probably with substantial experience. San Diego failed on 8 hours of classroom setting, using paramedics with substantially less education. To see the benefits the Australians reported, do we need to increase initial training time for paramedics, restrict the skill to a small group, have periodic OR access, or a minimum number of tubes / paramedic / year? And what are the ongoing training requirements at + 1year, + 5years, etc.

It doesn't help matters either that much of the poor outcome seen in earlier trials has now been attributed to hyperventilation, which is at least partially a technology issue that can be mitigated by widespread use of waveform capnography, or that there's been concerns voiced about frequent displacement / unrecognised esophageal placement in other studies.

I was thinking more basic like:

If you don't have patients that meet the criteria for intubation very often, all the expense involved from intitial training to restocking expired supplies might not be worth it.

Example: If service A serving a population of 1 million people has 10 patients that even meet the indications for ETI, it probably is economically more beneficial to not have ETI.

Forget complications of ETI, successes, scene times etc.

During the little time I spent in the British system, (almost 2 weeks) there were less extreme patients less often in a hospital bigger and serving a larger population than the hospital I spent 4 years at in the US. (also a major academic medical center)

While it is possible it was a slow time, the providers indicated that my black cloud was in play and they were busier that time than usual.

I saw 1 patient that required emergent surgery for traumatic injury, and that was ortho in nature. (An open extremity fracture without neurovascular compromise.)

During the same time, the only patient in A&E I saw that needed to be intubated was the same guy for agitation.

Stands to reason if one of the most esteemed medical centers in the whole country intubates 1 patient in A&E a week, how often would a paramedic need to?

 

[systemet]

If you don't have patients that meet the criteria for intubation very often, all the expense involved from intitial training to restocking expired supplies might not be worth it.

Perhaps, but I'd respectfully submit that most things done in EMS are pretty inexpensive. The labour cost isn't that great to start with. There's a small chance that it might be driven up if the paramedics demand extra pay on the basis of having more responsibility -- but this argument has never worked that well in practice for any of us :lol: The drugs are cheap, as far as I know -- maybe there's some newer agents coming out that might cost more. I would think any cost in the ambulance would pale in comparison to the cost of just having someone sit in a bed in the ER with the correct wrist band on and have a couple of blood draws and an ECG done, each by someone with a union number.

Example: If service A serving a population of 1 million people has 10 patients that even meet the indications for ETI, it probably is economically more beneficial to not have ETI.

Forget complications of ETI, successes, scene times etc.

There's another set of problems connected to this too. What's the goal of the EMS system? We tend to assume that it's to reduce disability and "early" death, etc. But that's more the role of the health care system. In many places the EMS system is being funded by a municipal tax payer. Does the city / county / urban service area, really want good clinical outcomes, or just the appearance of professional looking bodies when the citizenry calls 911?

During the little time I spent in the British system, (almost 2 weeks) there were less extreme patients less often in a hospital bigger and serving a larger population than the hospital I spent 4 years at in the US. (also a major academic medical center)

[...]
I saw 1 patient that required emergent surgery for traumatic injury, and that was ortho in nature. (An open extremity fracture without neurovascular compromise.)

During the same time, the only patient in A&E I saw that needed to be intubated was the same guy for agitation.

Stands to reason if one of the most esteemed medical centers in the whole country intubates 1 patient in A&E a week, how often would a paramedic need to?

This is interesting. Did you come to any conclusions as to why this was the case? Were they simply not intubating patients who would have been intubated in the US, or another medical system, or was the acuity genuinely that much lower? Your response suggests the latter.

Do you think it speaks to better access to primary care? Or social factors? Was the surrounding area perhaps more wealthy, with less social problems?

I'm genuinely interested. Obviously the incidence of firearm trauma is much lower than in the US, as is the rate of obesity (although I hear they're working very hard to change both of those). Just wondering what you put it down to.

 

[Veneficus]

Perhaps, but I'd respectfully submit that most things done in EMS are pretty inexpensive. The labour cost isn't that great to start with. There's a small chance that it might be driven up if the paramedics demand extra pay on the basis of having more responsibility -- but this argument has never worked that well in practice for any of us :lol: The drugs are cheap, as far as I know -- maybe there's some newer agents coming out that might cost more. I would think any cost in the ambulance would pale in comparison to the cost of just having someone sit in a bed in the ER with the correct wrist band on and have a couple of blood draws and an ECG done, each by someone with a union number.

Perhaps not the labor itself, but when you institute a standard of care, costs can add up quickly. In modern EMS (or other parts of medicine for that matter) When you instutute an ETI procedure, you need things like laryngoscops. While that device is basically nothing more than a battery pack with a piece of shaped metal (or plastic if you are unfortunate) and a lightbulb connected, the device manufacturers seem to think it is worth considerably more.

You are also going to need to have a method of cleaning/replacement. Extra parts, batteries, etc.

Then to live up to the quantitative standards of modern medicine you are going to have a capnograph. (and it's associated costs)

Multiply this by a couple of hundred units in a capital city, and that may cut into your public access AED fund quite a bit.

Let's be honest, if you were decidfing whether to have more public access AEDs or the ability for EMS to intubate, would you suspect that intubation after EMS response would save more lives or improve more outcomes?

There's another set of problems connected to this too. What's the goal of the EMS system? We tend to assume that it's to reduce disability and "early" death, etc. But that's more the role of the health care system. In many places the EMS system is being funded by a municipal tax payer. Does the city / county / urban service area, really want good clinical outcomes, or just the appearance of professional looking bodies when the citizenry calls 911?.

I think the goal of every EMS system is to do the most good for the most people. Similar to any healthcare system.

It may sound bad, but you have to pick and choose who is going to get what help. In that situation, some people will always lose out.

My point is, that in the population I cited, those who would benefit from ETI may be so low they might be considered "acceptable loses" in the overall system.

This is interesting. Did you come to any conclusions as to why this was the case? Were they simply not intubating patients who would have been intubated in the US, or another medical system, or was the acuity genuinely that much lower? Your response suggests the latter..

I think the volume of acutity compared to where I was in the US was exponentially lower.

Do you think it speaks to better access to primary care? Or social factors? Was the surrounding area perhaps more wealthy, with less social problems?

I'm genuinely interested. Obviously the incidence of firearm trauma is much lower than in the US, as is the rate of obesity (although I hear they're working very hard to change both of those). Just wondering what you put it down to.

I think it is a combination of several factors, most of which you included. Even the comparitive individual wealth is a factor. I spent many years working in inner-city US EMS/hospitals, the level of poverty I witnessed there was much more profound than many Western European nations I have visited.

Only in Central and Eastern Europe have I seen people with worse circumstances in terms of poverty compared to the US.

If I had to choose the most profound influences based on what I observed, I would say that individual health awareness coupled with easy access and effective primary care were the most significant.

(Despite being firmly entrenched in reacting to emergencies of critical illness and injury, I think it is obvious the best outcomes and focus of treating such is prevention.)

I have also noticed in my anecdotal observations, that European males seem to be more active in seeking out healthcare than American males. (with females about the same level)

I haven't been able to account for this phenomenon, as many European societies have a culture of males being "tough"/stoic. I continue to try to figure it out though. What is more vexing about it is at least in Central/Eastenr Europe, males seem to engage in more destructive behavior and more often than in America.

I welcome any insight you have on this matter.

 

[RocketMedic]

Cost-effective or not, paramedics need to be able to intubate, among other things. If we worked on numbers, we would dry-run everyone obese, old, or with a terminal ailment or history.

What is actually taught to UK paramedics that differs from our (relatively standard) NR based on DOT curriculum?

 

[Veneficus]

Cost-effective or not, paramedics need to be able to intubate, among other things.

Why?

Did you know there are countries where the only people permitted to intubate are anesthesiologists?

What is actually taught to UK paramedics that differs from our (relatively standard) NR based on DOT curriculum?

I would like to see the curriculum too, but I am willing to bet that at the very least, university level anatomy, physiology, pathophysiology, and pharmacology.

Did you know the highest level US EMS textbooks are written at is 10th grade?

 

[St George]

Why?

Did you know there are countries where the only people permitted to intubate are anesthesiologists?

The UK for one!

Why?

I would like to see the curriculum too, but I am willing to bet that at the very least, university level anatomy, physiology, pathophysiology, and pharmacology.

Paramedics must have an accredited university degree (which takes 3 years) in order to attain state registration, which is a legal requirement.

 

[RocketMedic]

Why?

Did you know there are countries where the only people permitted to intubate are anesthesiologists?




I would like to see the curriculum too, but I am willing to bet that at the very least, university level anatomy, physiology, pathophysiology, and pharmacology.

Did you know the highest level US EMS textbooks are written at is 10th grade?

55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do?

Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school?

Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics? Where, aside from the "globally-recognized benchmark in knowing how to research things", do UK-style paramedics perform better and where are American paramedics stronger?

Why, exactly, is a simply-written textbook a poor substitute for a dense tome?

 

[St George]

Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school?

The argument is they should use an alternative such as an iGel or LMA.

Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics?

In the UK paramedic training has to be paid for by the student, not the ambulance service. Theres an advantage when you are a bean counter!

do UK-style paramedics perform better and where are American paramedics stronger?

I dont know, but that would be one hell of a reseach study!

 

[Tigger]

In the UK paramedic training has to be paid for by the student, not the ambulance service. Theres an advantage when you are a bean counter!

This is more often than not the case with US paramedics as well.

 

[Veneficus]

55 y/o F with acute CHF exasperation, rales in all four quadrants, unresponsive to CPAP and Lasix, SaO2 in the low 70s, semiconscious, crappy perfusion, 30 minutes from ER, no flight available. What are you going to do??

This patient is going to die, probably from low output failure, and a tube in his throat you are blowing oxygen through is not going to change that.

If the highdose lasix isn't working and you have nothing stronger to reduce the peripheral resistance, then you have may also have a renal insult as well.

In any even, he is going to die, but you could try pacing as a palliative effort or in the absense of a pacer, perhaps some epi for b1 stimulation.

Why not let paramedics intubate? What is gained by restricting the technique from professionals with appropriate training and tools simply because they haven't been to medical school??

Some believe that psychomotor skills require constant usuage to maintain and anesthesia does intubates more than anyone else. Additionally, there is a valid argument that knowing how to do something is less important than knowing when.

Like in the example of your patient here.

Furthermore, what exactly is the advantage of UK-style "degree" paramedics over American paramedics?Treat and release Where, aside from the "globally-recognized benchmark in knowing how to research things",Don't understand what you are saying here. do UK-style paramedics perform better and where are American paramedics stronger?I think this would depend on the benchmarks you are measuring.

Why, exactly, is a simply-written textbook a poor substitute for a dense tome?

If you have to ask, no words of mine will make a difference, but if I could make a suggestion?

Look at the shock management chapter in your paramedic text book, then compare it side by side with a Tome like Miller's Anesthesia or Fischer's Master of Surgery or Williams Obstetrics and see for yourself.

 

[RocketMedic]

Igels and LMAs aren't as good as ET for a lot of things. Here they're intermediate or arrest airways.


Most American paramedics self-pay through school, and everyone pays with school or time served.

What do UK paramedics earn?