"Is Prehospital EMS (PHEMS) a Profession?"

[Zeroo]

So it's a profession in name only?

.... I wish I could understand what you was trying to get at. Seems rather vague of a statement. Maybe I am just a dunce though. Still gonna give it a go at replying. I would consider it a profession because its something I wanna do for the rest of my life. Granted that's obviously not what makes it a profession. However I really don't care.

 

[JPINFV]

.... I wish I could understand what you was trying to get at. Seems rather vague of a statement. Maybe I am just a dunce though. Still gonna give it a go at replying. I would consider it a profession because its something I wanna do for the rest of my life. Granted that's obviously not what makes it a profession. However I really don't care.

My point is that, despite it failing to meet many of the more important criteria defining a profession (unique body of knowledge, autonomy, self governance, etc), you're declaring it a profession because you don't care about those things.

Just because you want to do something for the rest of your life doesn't make it a profession. Declaring something a profession, which given it's current state isn't, doesn't automatically confer respect or fix those aspects of the trade.

 

[Zeroo]

My point is that, despite it failing to meet many of the more important criteria defining a profession (unique body of knowledge, autonomy, self governance, etc), you're declaring it a profession because you don't care about those things.

Just because you want to do something for the rest of your life doesn't make it a profession. Declaring something a profession, which given it's current state isn't, doesn't automatically confer respect or fix those aspects of the trade.

Like I said in my post. I don't really care if it isn't officially considered a profession! So maybe it isn't. Not that big a deal.

 

[TatuICU]

I think you are misunderstanding or interpreting the original discussion.

I presented a potential course when you don't have the perfect solution. Based on what is commonly carried on a US ALS unit when after your primary treatments have failed.

The original argument was that intubation would somehow help.

Since then, I have seen an argument against what I said, based most likely off of what you have seen or assume, as I have posted the very mechanism as to why epi might be a long shot.

Giving dig to increase cardiac contractility in advanced CHF is in every medical text I have ever seen that talks about the subject.

There are several studies showing it does not improve mortality. But at least one that demonstrates a reduction in ICU admission. If it can be used chronically, it can be used acutely by the same mechanism.

I have said it many times, in medicine, it is not "what" that makes a difference, it is "why."

http://jasn.asnjournals.org/content/15/8/2195.full

http://www.ncbi.nlm.nih.gov/pubmed/21180781

and as for inciting renal toxicity, in acute kidney injury, there are treatments in order to help mitigate that as nicely explained here.

http://www.ncbi.nlm.nih.gov/pubmed?term=N-GAL: Diagnosing AKI as soon as possible

and in the full publication of this:

Ren Fail. 2012;34(1):130-3. Epub 2011 Oct 20.

Using NGAL as an early diagnostic test of acute kidney injury.

We can make the scenario as complex as you like.

Just state what you want it to be.

Why are you posting studies about efficacy of dig in chf? In any case you're the one who brought up digoxin for some reason and now you're posting studies to justify adding more treatments in the case of renal insult to give dig? Why is dig even a part of this discussion? What about posting studies to justify things everyone already knows is so fascinating?

What do I want it to be? I couldn't care less. What do you even mean?

 

[TatuICU]

Which is why I'd choose dopa over epi. I think the diuresis is going to be more about increased renal perfusion though.


So you want vasodilation from dobtamine (tied dose wise to your inotropy) but not from NTG (an independent factor you can adjust)? Which is it?

Diuresis is going to be important in say...20 minutes or so. In the next five while we're in the oxygenation death spiral its not going to help fast enough. You've got to get the afterload off and clear the LV right now to give the CPAP a chance to do its job.

Ultimately she needs a baloon pump.

Which is what? If I choose just ntg I'm not helping her cardiac status, I'm just killing her bp even more. The vasodilation fro
Dobutrex is mild and is part of its profile to help increase cardiac output. Not sure what you're gettin at here, so yes I would prefer a drug that mildly vasodilates and increases inotropy than a drug that only vasodilates. Is that what you're asking?

Diuresis will be important in 20 minutes? Ok the scenario states a 30 minute transport time not counting scene time. We can get it started. Of course airway and breathing is first which I why I said intubation I feel is more appropriate given the gravity of the situation. This doesn't sound like exac chf, it sounds like decompensated heart failure. Agree with the balloon pump

 

[RocketMedic]

could I just inquire why you have this fascination with intubation?

Its not a fascination with intubation, or any other tool. Its an example of advanced treatments we in EMS use- a low-use, high acuity skill with serios potential to harm but absolutely needed at times.
As a professional, I don't aim to use an intervention inappropriately, but at the same time, I don't believe that infrequent use or risk justifies removal of skillsets. Would you stop teaching firefighters interior attack, police officers rifle use and movement under fire, or doctors surgical intervention?

Intubation is one of the things that differentiates paramedics from technicians. Advocating removal of skillsets allowed by accepted standards of care on the basis of difficulty or infrequent use makes us technicians, not professionals. On the other hand, agency level controls on the applications of interventions make sense.

 

[Veneficus]

Why are you posting studies about efficacy of dig in chf? In any case you're the one who brought up digoxin for some reason and now you're posting studies to justify adding more treatments in the case of renal insult to give dig? Why is dig even a part of this discussion? What about posting studies to justify things everyone already knows is so fascinating?

Mostly to refute your absolute statements of what will and will not work and what is indicated and what is not.

One of the things I find more fascinating about medicine, and anesthesia in general, is there are multiple ways to achieve the same thing with not much matter in how to go about it.

As for the intubation, I don't think it helps enough in enough cases to keep it as part of a core skill in EMS.

You mentioned the epi would not work with absolute authority. Are there better things to use? Certainly. But in a fix, it epi can be used.

Do I think any EMS agency carries dig? No. But you seem to think that anyone with renal compromise was going to somehow die a nasty death by using it.

Which is not the case.

I added the other 2 studies because they talk about timely reversal of AKI for conditions where a patient maybe compromised renally, such as in CHF.

Many drugs have a narrow theraputic index like dig, but we still use them. It doesn't automatically exclude them.

Dealing with or as absolutes in medicine can make for some very long days. There is just more to it than: If-then/never.

 

[TatuICU]

Mostly to refute your absolute statements of what will and will not work and what is indicated and what is not.

One of the things I find more fascinating about medicine, and anesthesia in general, is there are multiple ways to achieve the same thing with not much matter in how to go about it.

As for the intubation, I don't think it helps enough in enough cases to keep it as part of a core skill in EMS.

You mentioned the epi would not work with absolute authority. Are there better things to use? Certainly. But in a fix, it epi can be used.

Do I think any EMS agency carries dig? No. But you seem to think that anyone with renal compromise was going to somehow die a nasty death by using it.

Which is not the case.

I added the other 2 studies because they talk about timely reversal of AKI for conditions where a patient maybe compromised renally, such as in CHF.

Many drugs have a narrow theraputic index like dig, but we still use them. It doesn't automatically exclude them.

Dealing with or as absolutes in medicine can make for some very long days. There is just more to it than: If-then/never.

But you didn't refute anything. You say yourself that neither is anywhere close to the best treatment. And who was speaking in absolutes? You're really just talking in circles at this point.

 

[TatuICU]

To answer the actual question at hand here, I feel that EMS is a non-profession that is worked mostly by very good professionals. If that makes any sense.....

 

[Veneficus]

But you didn't refute anything. You say yourself that neither is anywhere close to the best treatment. And who was speaking in absolutes? You're really just talking in circles at this point.

I wasn't aware that talking about alternative therapies was a circle?

It was you who said my epi suggestion would not help.

It was you who seemed to think the use of dig in CHF was some kind of abomination?

Especially in renal failure.

I simply provided the argument and a small amount of evidence demonstrating they were both potential treatments.

Hopefully somebody reading this found it more intellectually stimulating than you seem to.

 

[TatuICU]

I wasn't aware that talking about alternative therapies was a circle?

It was you who said my epi suggestion would not help.

It was you who seemed to think the use of dig in CHF was some kind of abomination?

Especially in renal failure.

I simply provided the argument and a small amount of evidence demonstrating they were both potential treatments.

Hopefully somebody reading this found it more intellectually stimulating than you seem to.

When did I say that use of dig, a drug used to treat chf, was an abomination in the treatment of CHF? I said that using dig as a first line tx in the scenario would be stupid, and it would be. Now youre just making things up.

And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie. Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late. Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.

What could be intellectually stimulating about this conversation? I'm arguing for what i believe is a pathophysiologically sound tx with rationale and you're telling me I'm wrong by using if-then arguments for what are situationally not first line treatments.

If you want to continue this feel free to pm me or I can give you my phone number and we can discuss it verbally so theres much less potential for misunderstandings. I'm always up to learn something since i seem to be way off base in my understanding of cardiovascular phys and pharm, and to meet others in the business.

 

[Veneficus]

When did I say that use of dig, a drug used to treat chf, was an abomination in the treatment of CHF? I said that using dig as a first line tx in the scenario would be stupid, and it would be. Now youre just making things up..

Not making things up, that's how it looked when I read it. It still looks that way. Let's not dwell on it.

And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie. Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late.

Not true, you don't need a swan, there are physical findings. I'll detail it in a PM.

Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.

I have no doubt, but it is probably more of a result of where you are rather than because it is not done.

I have read cases of cardiac bypass under region anesthesia. Never saw it, but it is happening.

What could be intellectually stimulating about this conversation? I'm arguing for what i believe is a pathophysiologically sound tx with rationale and you're telling me I'm wrong by using if-then arguments for what are situationally not first line treatments.

What you believe?

 

[RocketMedic]

Veneficis, allow me to present an analogy. In the military, we have a grenade launcher known as a MK19. For the most part, its very effective and safe. If improperly assembled or employed, you risk it detonating in your face or wiping a squad off the map. Professionals understand and analyze the risks and make appropriate decisions based on use of certain toolsets. Just having it does not justify putting it in everyone, nor does it justify wholesale removal.

My dad once used an ETT to push a piece of taffee lodged near the carina of a pediatric patient clear of the airway and allow ventilation. He's been a 911 paramedic as long as I've been alive and can tube anything. His partners and coworkers have quite a bit of experience themselves. I think you may be judging EMS by its absolute lowest provider, and you can't do that accurately.

Does a paramedic like me belong as lead on a 911 truck? Young, inexperienced, with a decent core knowledge and a desire to learn? Personally, I think so. I know my limits, I'm not afraid to ask for help, and I know what I need to do at my level for most things. I'm trying to go back to school and I'm trying to find a job that pays well enough to support myself. I'm a perfect hire for EMSA, AMR, or a lot of other places. To me, that says that I'm doing something right.

Long-term, don't delete us, empower us.

Personally, I think change starts at the instructors. I'm not proud of my medic mill, and if I'd been from a different background, I wouldn't feel safe with patients. However, that medic mill and others like it teach to a very low target standard. We must evaluate that standard and those instructors if we want positive change.

 

[TatuICU]

Not making things up, that's how it looked when I read it. It still looks that way. Let's not dwell on it.



Not true, you don't need a swan, there are physical findings. I'll detail it in a PM.




I have no doubt, but it is probably more of a result of where you are rather than because it is not done.

I have read cases of cardiac bypass under region anesthesia. Never saw it, but it is happening.




What you believe?

Responded to PM

 

[CH100]

Rocket, you sound like you have a pretty good head on your shoulders.

Much of what happens to a newly-graduated paramedic depends on where he or she lands. An organization with a strong Field Training and Evaluation Program will teach that new medic the things that he needs to be successful, give him a chance to apply that knowledge and those skills, and evaluate his ability to meet the organization's clinical and operational standards. In my experience (and my organization), that takes 6 months to 1 year with a paramedic Field Training Officer (FTO).

If a new graduate returns home to be "the only paramedic in town" or "..on the shift" or "..on the truck," he or she is in for a tough time (or, the patients are in for a rough time). Or, if he goes to work for a service where he is expected to function with an EMT partner as an emergency or critical care unit, same thing. There is a gap, between "got my state license" and "being a journeyman paramedic" that has to be filled in somehow. It is probably best filled in in an organized manner, and not just by accident.

 

[usalsfyre]

Which is what? If I choose just ntg I'm not helping her cardiac status, I'm just killing her bp even more. The vasodilation fro
Dobutrex is mild and is part of its profile to help increase cardiac output. Not sure what you're gettin at here, so yes I would prefer a drug that mildly vasodilates and increases inotropy than a drug that only vasodilates. Is that what you're asking?

I never stated give her NTG alone, you give the NTG to treat the SVR in conjunction with an inotrope to increase CO. The NTG can be as mild or as severe as the dose will allow. Granted it doesn't have the greatest effect on the arterial side of the equation, but your far more likely to find IV NTG in asture environments than say, nitroprusside.

Diuresis will be important in 20 minutes? Ok the scenario states a 30 minute transport time not counting scene time. We can get it started. Of course airway and breathing is first which I why I said intubation I feel is more appropriate given the gravity of the situation. This doesn't sound like exac chf, it sounds like decompensated heart failure. Agree with the balloon pump

Again, I'm not disputing diuresis, we've just got a crapload of other stuff to take care of before we get there.

And epi is a dangerous game to play in decompensated heart failure yet you're talking about using it as though it's no biggie. Unless you have real time data about your SVR in this situation via a Swan, by the time you figured out that the epi is in fact increasing your afterload And further decreasing your CI, it's too late. Ive never ever seen epi used for decompensated failure. Not in the ICU and not in the field.

It may seem like a dangerous game to play if you have a PA cath on the majority of patients. But I think you'd find there's a number of places where vasopressors, inotropes, ect are used on a fairly regular basis without that data, and patients aren't dying at any greater rate (trying to remember who did the data that said Swan's have no effect on outcome).

 

[usalsfyre]

Veneficis, allow me to present an analogy. In the military, we have a grenade launcher known as a MK19. For the most part, its very effective and safe. If improperly assembled or employed, you risk it detonating in your face or wiping a squad off the map. Professionals understand and analyze the risks and make appropriate decisions based on use of certain toolsets. Just having it does not justify putting it in everyone, nor does it justify wholesale removal.

My dad once used an ETT to push a piece of taffee lodged near the carina of a pediatric patient clear of the airway and allow ventilation. He's been a 911 paramedic as long as I've been alive and can tube anything. His partners and coworkers have quite a bit of experience themselves. I think you may be judging EMS by its absolute lowest provider, and you can't do that accurately.

Does a paramedic like me belong as lead on a 911 truck? Young, inexperienced, with a decent core knowledge and a desire to learn? Personally, I think so. I know my limits, I'm not afraid to ask for help, and I know what I need to do at my level for most things. I'm trying to go back to school and I'm trying to find a job that pays well enough to support myself. I'm a perfect hire for EMSA, AMR, or a lot of other places. To me, that says that I'm doing something right.

Long-term, don't delete us, empower us.

Personally, I think change starts at the instructors. I'm not proud of my medic mill, and if I'd been from a different background, I wouldn't feel safe with patients. However, that medic mill and others like it teach to a very low target standard. We must evaluate that standard and those instructors if we want positive change.

Rocketmedic, you have to choose procedures based on potential to harm and the lowest common denominator. If you want to see why, I suggest you seek to get involved in QA at a system. It's very often frightening. I was a staunch advocate for ETT. After being involved in QA and education, I can safely say the majority of paramedics I encounter have no business doing it.

 

[TatuICU]

I never stated give her NTG alone, you give the NTG to treat the SVR in conjunction with an inotrope to increase CO. The NTG can be as mild or as severe as the dose will allow. Granted it doesn't have the greatest effect on the arterial side of the equation, but your far more likely to find IV NTG in asture environments than say, nitroprusside.

I agree, all I saw that you typed was NTG. And Nitroprusside would be contraindicated in this patient anyway if you thought them to be in renal failure, unless we want to add cyanide poisoning to the equation.

Again, I'm not disputing diuresis, we've just got a crapload of other stuff to take care of before we get there.

Agreed

It may seem like a dangerous game to play if you have a PA cath on the majority of patients. But I think you'd find there's a number of places where vasopressors, inotropes, ect are used on a fairly regular basis without that data, and patients aren't dying at any greater rate (trying to remember who did the data that said Swan's have no effect on outcome).

I'm not suggesting that every vasoactive or inotropic gtt requires a PA to effectively manage, not by a long shot. We hang levo, dopa, dobu, epi, you name it without PA caths routinely in ICU and in fact Swans have been found to not be very beneficial in a lot of cases anyway. The only time you'll routinely see a swan stay in is post cardiosurgery and they're usually out the next day even then. We may balloon up, balloon down, and wedge real quick to get a PCWP in a sepsis patient if our intensivist wants it really bad but typically not. I'm saying that we shouldn't hang epi in this instance and if you were to do it, the only safe way would be to have PA cath and stop the epi as soon as your SVR trended upwards. It was less literal and more to get across my point of it not being a "meh, let's try this" drug in this scenario. You have others weapons to use before you go to something that has the potential to worsen an already horrendous condition. You don't throw a hail mary at the start of the 4th quarter. You throw it on 4th and 20 with :02 left on the clock.

 

[TatuICU]

After being involved in QA and education, I can safely say the majority of paramedics I encounter have no business doing it.

Can you give some examples of cases? Are you speaking in terms of poor proficiency?

 

[mycrofft]

Someone in another thread said something about "a trade, like plumbers". There is something to be said for that. It is a distinct branch of invaluable service, licensed, but without self-governance and its own science, drawing from civil engineering and long traditions (plus ads in the latest trade magazine).
I'm glad t hear someone say "I don' care, I think of it as a profession" as long as that sort of person continues their education and is not adverse to organizing to get better benefits and treatment.