Most Advanced Procedure

[VentMedic]

Ugh. Really? Procedures are fun. Should be taken seriously, but, hell, our jobs are fun. The most fun I've ever had on a call was doing a crich and then a chest tube...Sorry, I have neither documentation nor studies for procedures being "fun." Just ask old medics who *aren't* jaded. We do some cool and fun stuff. Sometimes patients live, too!

Fun? Playing with the whoo-whoo?

I take medicine rather seriously because I can not bring myself to laugh at the person who has just lost an extremity in an industrial accident or a child who can not breathe. If you find humor in the suffering and dying of others, then more power to you. When I a putting a chest tube in a baby, I really don't think of what a great time I am having doing a cool procedure especially if I can not save that child's life. There is also not much laughter in knowing that each invasive procedure you have to do will make that patient's recovery that much more difficult even though the procedures are necessary. If I have a patient that I do not have to poke any holes into their body be it an IV or a needle to their pericardial sac, I feel that is a much more "fun" time. I am by no means afraid to use my skills but I would rather not look forward to having a patient experience an event just so I can "enjoy doing some fun stuff".

Some may look forward to a cool trauma, but I like to see everyone go home safely especially on a night of celebration like July 4th. There should be no cool trauma to end a family picnic. I do not wish anyone to crash up just so someone in EMS can do some fun trauma stuff.

However, I believe that those in medicine, and that includes EMS, do some really amazing things and there should be pride in that. I am not burnt out or jaded. I have just become more realistic and have seen how one "cool trauma" can affect many people.

 

[ResTech]

some may look forward to a cool trauma, but I like to see everyone go home safely especially on a night of celebration like July 4th. There should be no cool trauma to end a family picnic. I do not wish anyone to crash up just so someone in EMS can do some fun trauma stuff.

One of my major pet peeves as well... having to listen to guys at the Station hope and wish for an entrapment accident or another "good call" just so they can get off and be entertained. Granted its inevitable, but I never sit around and hope for it.... I never fully understood that.

 

[Foxbat]

In the past, some of us on this forum have done procedures such as intracardiac epi, subclavian central lines, chest tubes and pericardial centesis. The first fell out of favor due to risk and alternative delivery methods which can also be said of the second. Chest tubes and pericardial centesis are still done by some CCPs on Flight and Specialty as well as a few ALS agencies where distance to the nearest facility or helicopter might make a difference.

What about central lines? Do medics still do them in some places?

 

[VentMedic]

One of my major pet peeves as well... having to listen to guys at the Station hope and wish for an entrapment accident or another "good call" just so they can get off and be entertained. Granted its inevitable, but I never sit around and hope for it.... I never fully understood that.

The best sight for me is to see the trauma beds empty on Christmas Eve and Christmas Day. I think that is the saddest time to tell someone their loved one has become a trauma patient or has died on that day. But then for the family, it doesn't get easier no matter what day it is. Unfortunately, there is rarely a time when those beds are empty.

 

[ResTech]

In my region... Paramedics are not permitted to initiate a central line, only access them (least in PA and MD). Given the almost universal availability of adult IO as a backup to IV access, Im not sure the risks of starting a central line in the field would be warranted. I'm sure others with more experience dealing with central lines can give greater insight.

 

[MMiz]

I've cleaned this thread of off-topic posts and those that violate our community rules. The thread is open again, but any insults or name calling will result in infractions.

 

[usafmedic45]

**redacted***

 

[medic417]

What about central lines? Do medics still do them in some places?

Yes I am aware of a few services that allow it. The medical director requires those Paramedics to take more education, do a bunch at the hospital under supervision, then pass a test written and on a live patient. All that extra time is not paid by the service the Paramedic does it on days off.

 

[Ridryder911]

Most of the services that had central lines have abolished them as the EZ I/O has made access a much safer and easier process. I even look for central lines to soon to be a thing in the past in ED's as EZ I/O makes popularity. Of course, it will not be a replacement but for emergency access and resuscitative measures.

I do NOT believe though, they should ever replace traditional peripheral insertion if veins are easily located and cannulated.

R/r 911

 

[VentMedic]

Our hospital crash carts are now stocked with IOs for emergencies if other access is not readily available.

Some flight teams and a few ALS agencies do have central line access in their protocols. Ada County, Idaho and I believe Seattle are two examples. Some Specialty teams will also have the protocols but that is usually done during IFT at a hospital. Neo teams will do UAC/UVC cannulation which is considered central.

However, I do believe all Paramedics should be educated on accessing the various venous ports that they find on their patients. There are even medics that do IFT/CCT that have little knowledge of these devices.

 

[rescuepoppy]

[/b]

I've often said, "It's not in knowing what to do and being able to do it. That's simple. Any moron can be taught that. The trick of this job, ladies and gentlemen, is in being able to do something and know when and when not to do it".

I've been caring for the critically sick and injured for over a quarter of a century. And anyone who has mastered this "trick" in that time is a better provider than I am.

Great post. In my opinion the best skill any medic can have is patient evaluation skills. I would much rather say that I have a skill at my disposal but this patient does not need it than to need it and not have it. All some patients need to stabilize them is a little bit of TLC if all you do is offer comfort to a patient to ease them then you have performed a skill. Not down playing the physical things that we do, but I will always say that the best tool we have is our brains. I would rather use that than any of the "toys" in my bag if that is all that is needed.

 

[zman]

As many have said, education is a must in our field and we should not be performing these "advanced" procedures without the knowledge of why to perform them, how they affect the body systems of the person they are being performed on and when to perform them.

All I wanted to know was how much will your MD let you do in the field to help save a persons life?.

Maybe it would be cool to start a different thread that discussed how your education has helped you stabilize your patient, or the longest amount of time you have had to stabilize a patient before reaching definitive care and how your education and training helped you accomplish that stabilization.

thanks for all the responses
-zman

 

[VentMedic]

You must also remember medicine is constantly evolving which is why intracardiac epi and field central lines have fallen out of favor. Quicker and easier methods have come about such as the IO. Trauma centers and the many hospitals have also made alot of procedures unnecessary in the field. As well, meds that were commonly given such as morphine and lasix have taken a back seat. CPAP has come to the front. Newer meds have replaced older meds. ACLS protocols have changed at least a dozen times. Meds that are no longer found to be effective or considered inappropriate have been removed from the trucks. The MAST has come and gone. Levophed, Vasopressin and Amiodarone are in popular...again.. and sometimes not.

Many adjunct airways and RSI have made airway management a little easier although some forget the essential skills that go into the process. What would be nice is if EMS medical directors would have the confidence in their providers to allow for guidelines to achieve sedation and with the use of paralytics instead of a strict recipe.

Hypothermia protocols may improve outcome but can be accomplished without the essential steps performed with proficiency to get to that point which includes airway, IV and medications. As recently mentioned in a post, evaluation and the ability to know when to stay and play or when to move as in how much is too much or how little is too little are very important factors that go along with any set of skills/protocols.

The state dictates from the broad sense of what a Paramedic is allowed to do. It is then up to the medical director as to what he/she feels his/her providers are capable of doing. It also depends on how much effort the medical director and the providers are willing to put forth. If the medical director feels the Paramedics are capable of doing more advanced skills than what the state allows, he/she can petition the state for an expanded scope. This is done for some flight and specialty teams. CA also has a very limited scope for their Paramedics so if a medical director wants the Paramedics working under him/her to do more, the proper path must be follow to allow this. Competencies with proper QA/QI must then be maintained as it should for any skill or protocol.

You can look up the scope of practice for any state and see what is normally allowed.

 

[VentMedic]

Maybe it would be cool to start a different thread that discussed how your education has helped you stabilize your patient, or the longest amount of time you have had to stabilize a patient before reaching definitive care and how your education and training helped you accomplish that stabilization.

My additional education and training has enabled me to transport complex patients thousands of miles across the borders of many countries with an RN as a partner. I have done this with Specialty transport teams by various modes of transportation and on Flight teams. Some of the transports have been over 24 hours in length with travel and stabilization time. Even for a fairly "routine" neonatal transport we may spend 2 hours stabilizing the infant before we move. We have brought the knowledge of our NICU with us and will often do exactly what would be done at our NICU to stabilize the infant.

 

[Summit]

Diagnosis is the most advanced and complicated activity in EMS

 

[Flight-LP]

Diagnosis is the most advanced and complicated activity in EMS

+5. That pretty much sums it up right there.

(Please don't let this statement turn into a further off topic discussion of how some believe we don't diagnose in EMS, thanks!!!)

 

[VentMedic]

(Please don't let this statement turn into a further off topic discussion of how some believe we don't diagnose in EMS, thanks!!!)

But for some it only takes as much effort as flipping a coin or a couple of pages in the recipe book.

 

[mycrofft]

I'm going to ignore the drift of this (as usual)...

The three most advanced procedures are as follows:
1. Figure out quickly what's wrong.
2. Decide and act upon that.
3. Grab your arse with both hands to hold yourself back from doing something whackerly, excessive, and dangerous to yourself or your victim, er, patient.

I don't care if you can make a NG decomressor and a rectal thermometer meet halfway, if I'm down, give me "calm and appropriate" every time.