Let's just take oxygen out of standing orders.

[NYMedic828]

Circulating neutrophils increase 100%.

I meant to say they double and for some reason typed 50%.

Sorry.

My fault.

Entire post is now invalid. You are going to have to explain it all over again.





On a more serious note thanks for that, very informative as always.

Unfortunately, the lowest common denominator, even the mid-range common denominator is often far too set in their ways to change. The second problem is the information you posted will never reach them because those who instruct, often instruct wrongly.

In my experience, the people I work with are quite honestly a lost cause. (both volunteer and paid) There are those few great people who enjoy reading journals and forums but for the rest it is just a paycheck. They think because they can already perform the skill, it makes them as good as a doctor who can do the same. They don't care to understand why or how it works they just want to be told they are awesome because they can do it.

The standards of EMS quite honestly seem to get lower and lower. (I believe it is actually the only form of medical provider that can physically administer real treatments that does not require a single college credit in many areas)

I don't like picking on people, but the posts in this thread by "leoemt" are a prime example of how low EMS is falling. Someone comes into a thread, states blatantly that they are new and learning and then writes an essay length response to justify the fact that they are right, and we are wrong because their inexperienced and incompetent EMT class instructor told them otherwise. The "i know everything" mindset is too widespread in EMS at this point to be reversed.

As I have said before, EMS will die. Not today, not tomorrow, but eventually. Some would say this is a harsh statement but I see it as a completely plausible reality evidenced by the fact that healthcare costs continue to rise, EMS services are costing municipalities money instead of profiting in many areas and the biggest factor being that the medical world is advancing at speeds far beyond that which is fathomable by the base level EMS provider to keep up with. Once it all comes crumbling down, and it will, we can rebuild with an entirely new set of plans all together.

 

[the_negro_puppy]

See the problem lies with Clinical freedom. A few pages back I posted out protocols for Oxygen therapy. If we don't follow that chart and can justify why, management are happy as long as there is a clinical reason behind it. From what I read here, failing to follow 'protocols' exactly in other services could lead to your termination. When I first started nearly 3 years ago, we used oxygen more; on all chest pains etc. Now it is rarely used. The last 2 times I have used it were on COPD patients, one with a LRTI leading to exacerbation that required supplemental 02. Even then it was titrated to effect.The other was for a severely hypoxaemicCOPD pt with influenza A and losing the battle.

 

[RocketMedic]

Veneficus, how do you feel about supplemental oxygen in hyperventilation with associated hypocarbia?

 

[Veneficus]

Veneficus, how do you feel about supplemental oxygen in hyperventilation with associated hypocarbia?

I am not sure what to think of it actually.

I see mixed results in the trauma studies I saw.

Edit: but I do favor the studies that claim hyperventilation would likely induce brain ischemia. There are 2 logical mechanisms for that I can think of.

 

[NYMedic828]

I am not sure what to think of it actually.

I see mixed results in the trauma studies I saw.

Edit: but I do favor the studies that claim hyperventilation would likely induce brain ischemia. There are 2 logical mechanisms for that I can think of.

I assume the first mechanism is cerebral vasoconstriction from hypocapnia?

What's the second reason if you don't mind explaining?


Also, has a nonrebreather been shown at all too help with reinhalation of CO2, regardless of it being a "non" rebreather? I imagine O2 cranked to 15 liters would quickly displace exhaled CO2 but maybe titrated to a specific flow rate would provide a happy medium?

 

[Veneficus]

I assume the first mechanism is cerebral vasoconstriction from hypocapnia?

That is the first.

What's the second reason if you don't mind explaining?

Alveolar vascoconstriction comes immediately to mind.

I could probably make a pretty good case for hemolysis and bradycardia too.

Also, has a nonrebreather been shown at all too help with reinhalation of CO2, regardless of it being a "non" rebreather? I imagine O2 cranked to 15 liters would quickly displace exhaled CO2 but maybe titrated to a specific flow rate would provide a happy medium?

Shown?

Not that I know of, but it stands to reason if you put a piece of plastic over somebody's mouth and nose, they probably will not inhale or exhale much.

In TBI and other neurosurg, hypercapnia to some degree is demonstrated as theraputic, so I really don't know what anyone would hope to acheive doing exactly the opposite.

temporary hyperventilation can reduce ICP, but that does not stipulate hyper oxygenation.

I also read 2 studies on this today that show this hyperventilation is less effective than both mannitol and craniotomy.

 

[NYMedic828]

That is the first.





Alveolar vascoconstriction comes immediately to mind.

I could probably make a pretty good case for hemolysis and bradycardia too.




Shown?

Not that I know of, but it stands to reason if you put a piece of plastic over somebody's mouth and nose, they probably will not inhale or exhale much.

In TBI and other neurosurg, hypercapnia to some degree is demonstrated as theraputic, so I really don't know what anyone would hope to acheive doing exactly the opposite.

temporary hyperventilation can reduce ICP, but that does not stipulate hyper oxygenation.

I also read 2 studies on this today that show this hyperventilation is less effective than both mannitol and craniotomy.

A few people have told me that hyperventilation is not truly that effective in reducing ICP and you are better off just effectively managing the airway and providing whatever other treatments that may be indicated.

 

[Veneficus]

A few people have told me that hyperventilation is not truly that effective in reducing ICP and you are better off just effectively managing the airway and providing whatever other treatments that may be indicated.

The reduction is temporary, for a few minutes.

It was meant to be a presurgical procedure, not a prehospital one.

 

[Sandog]

Now the argument becomes "why was it written into protocol?" Because it was written by people who had no idea of this stuff at the time or simply didn't care because they thought just like you do. "As long as they don't die here, then we didn't kill them."

Don't presume to know what I think. I asked my question to gain understanding.

 

[Veneficus]

Don't presume to know what I think. I asked my question to gain understanding.

Sorry,

I have heard that argument so many times over the years, I figured I would just pre-empt it.

 

[Sandog]

Sorry,

I have heard that argument so many times over the years, I figured I would just pre-empt it.

No worries, I was not making an argument, rather I presented my level of understanding and requested JP to elaborate in order to improve my knowledge.

 

[JPINFV]

Based on what you say, I would think the best we can do is understand airway management, base our findings on current level of training, use visual indicators such as difficulty in breathing, perhaps vitals for further diagnostics, even pinch the nail for perfusion. Use the tools we have been given, and then follow our protocols. I think the protocols are pretty clear as to when O2 is indicated. I am unclear as to what you mean "when not indicated". Surely the protocols do not indicate O2 for a broken arm, but they do indicate for shortness of breath and blue lips.

Not trying to be a wise guy, rather, seek enlightenment.

Shortness of breath and blue lips? Sure. The problem is that many students are taught, and is reinforced by the NREMT medical practical, that the indication for supplemental oxygen is "ambulance." Furthermore, a lack of understanding on the difference between ischemia and hypoxia. Hyperoxygenating blood isn't going to relieve ischemia since the oxygen/blood isn't reaching the tissue anyways (think stroke and ACS). Compound this with a lack of understanding of how oxygen is transported, and the issues involved with oxygen (i.e. reactive oxygen species, vasoconstriction, etc) and you get the "give everyone oxygen for any complaint because it "can't hurt" lie.


Now, yes, oxygen is relatively safe to give when not indicated, and if there was some over use then it really wouldn't be an issue (think narcan as a comma cocktail when everything that can be ruled out is ruled out... like hypoglycemia). The problem is that oxygen is the EMS equivalent of duck tape in frequency of use, with the efficacy of using chewed gum as an adhesive the vast majority of the time.


As an aside, I once did have someone post a protocol that called for oxygen for every single patient... period. I never saved the link and that was years ago.

 

[Sandog]

Copy that, and thanks.

 

[Undaedalus]

I'm just dropping through to post an observation, relevant or otherwise, that I have made in regards to one Mr. leoemt and his arguments concerning EMT field diagnosis and O2 administration.

The tired rubric that EMTs do not diagnose in the field is as worn as the concept of universal O2 administration irrespective of clinical impression. Both ideas are dogma perpetuated by lazy EMS instructors who would rather pass along dated ideas for the sake of ease, than teach concepts like titrate to effect, and judgement. EMTs make diagnoses in the field every damn day. Whether you are diagnosing the symptom or the cause is a separate issue, and apparently one that is lost on some. The observation of signs/symptoms and use of diagnostic tools, along with the accumulation of as good of a Hx as possible leads a clinician towards a diagnosis of the cause of the complaint, and hopefully some kind of care plan. This is the biggest step a progressing EMT makes.. moving away from cookbook/checklist protocol and towards experiential field judgement.

 

[Veneficus]

Both ideas are dogma perpetuated by lazy EMS instructors who would rather pass along dated ideas for the sake of ease, than teach concepts like titrate to effect, and judgement..

I would just like to point out that most EMS instructors can't teach these concepts because they do not know them.

Many, I would say "most" EMS instructors are simply teaching what they were taught and what they do.

One of the things being developed for the recent curriculum changes by publishers specifically marketed at instructors is pre-made lessons on subjects that were formerly not part of the paramedic curriculum.

The ones I have seen actually have handouts to give students with the instructor copy having a few words on each bullet explaining why it is relevant to EMS.
(You know it is going to go horribly wrong when the teacher needs to be told why something is relevant next to the bullet point they are teaching)

I have even seen teachers hand out these documents and then tell students that they need to know the information for registry but it is not useful in the field. Then go right into a lecture about the usefulness of the coma cocktail in the USA in 2011.

Educated, knowledgable instructors are in the vast minority. Just as rare are ones who will admit they don't know something and get a content expert or consult their medical director as to why something is important enough to teach.

This same problem is repeated during field training. Many FTOs are promoted to such by seniority, not ability or education. This practice further perpetuates old practices. If you deviate from the FTO, you are considered insufficent and may face termination.

Some agencies don't even have formal field interships. They just put you with a senior member (usually one that has espoused the very values of agency tradition) who arbitrarily decides if you are fit for duty or not. (Usually decided favorably if you do what they do)

The problems of US EMS education are many and not easily solved.

I agree it will probably have to be redone from scratch. I still advocate it would be better served by being absorbed by nursing.

 

[JMorin95]

In the state Maine our EMS protocols state that we only have to titrate for an SPO2 of 95% better. Most likely if a patient is in between 95-100 we will not administer oxygen. If the pt. has COPD then the number to try and get is 85% or better, if a pt is on home oxygen at 2 lpm and is at 85% oxygen will not usually be administered unless there is stroke or severe hemorrage/shock of any kind.