Based on the research I have done and studies on post-intubation sedation. The majority advocate strongly for analgesia and seem to recommend fentanyl as the initial drug of choice given it's good hemodynamic profile. That's not to say nothing else is superior or can work just as well. I'm definitely not saying that at all.
I posed the question about how to best manage post-intubation in an IFT environment with the drugs and scope of practice we have as Paramedics. I admit I am still new at managing these patient types which is why I am desiring the knowledge from you guys. Everything I read on the subject says very strongly analgesia is not really an option and needs to be provided, yet ED practice around here foregoes the analgesia so I am confused as to why that would be. I'm gonna have to ask next case I get.
And not much talk on use of a paralytic agent. What are common practices in the IFT world when deciding to use paralytics for intubated patients?
If I could offer some perspective?
First off, evidence based medicine is BS. Rather, our implementation is BS. Some things simply cannot be studied. Some things have so few studies that when the subject is taken as a whole, there is no conclusive evidence. But the very worst of it is, most of the common practices are based off of expert opinion and there is a larger evidence requirement to change those expert opinion practices than there was to institute them.
When researching IFT, emergency medicine especially, and in general all forms of medicine, you must remember that none of these experts talk to each other regularly.
This means nepho has things figured out than anesthesia doesn't and every combination of disease and specialty falls into this category. Without being derogatory of EM, I have noticed when looking at it from the outside, that they are guilty of the exact same sins as many paramedics. They don't think anyone else understands emergent patients or nothing done outside of the emergency realm applies.
This type of thinking is dangerously wrong. Principles of medicine do not change because of environment.
If you are truly interested in what is best practice, in therory or practice, you must investigate what others are doing and know that may be related.
Said simply, you cannot do or conclude what is best by reading and listening only to EM. The type of medicine they practice is not exclusive and not comprehensive. It is the jack-of-all trades master of none. So you must look at what the masters say too.
Otherwise, you hold as gospel "best practice" without knowing what else is out there to really draw that conclusion.
As you further add restrictive criteria, you limit your knowledge, effectiveness, and usefullness.
an example:
Making sure patients are not in pain>making sure patients in ED are not in pain> making sure IFT patients are not in pain> making sure emergent patients are not in pain> making sure patients in your area are not in pain> making sure your patients in your area are not in pain based on your previous local practices.
If you really to get to the bottom of pain management, rather than looking at EM which has a culture or not managing pain properly, I really suggest you look to anesthesia or PM&R as that is their very focus. With a culture of making sure the patient is not in pain.
Is it your job to research and make recommendations to your medical director on managing pain? Some will say yes, some no. But isn't it your job to do what is best for your patient? Isn't that why they put their trust in you?
What is best for them may be academic. It may be administrative. It may be doing the leg work so all of your future patients have better care than previous ones.
A professional constantly seeks to improve. A tech seeks to master what is currently being done.
Which do you want to be? How about both?
The drugs and scope you have is easily changed. The obstacle is breaking down the barriers to change.
As a perfect example,
perhaps you have been on a 911 call to a Dr. office. Said doctor may not know or want you to perform certain treatments, which you know will help and your medical director has standing orders for.
So when you get in the truck, the patient becomes indirectly that of your medical director. In absence of doctor to doctor consultation, i will bet my last $ you will follow your medical director's orders if you believe that treatment in the best interest of said patient.
In this discussion, if your medical director has authorized you to use propofol, there is nothing stopping her from ordering it at a more effective dose. If the transfering ED has an issue with it, as soon as the patient is in your care, they are in the care of your medical director, and her orders apply unless there is an extenuating circumstance or patient presentation.
I have heard of states that restrict paramedics from using certain medications. But I have never heard of any state restricting a dose.
Also specialty critical care transport falls under different guidlines than emergent EMS, which is what most state guidlines are for.
