National EMS Scope of Practice Model Revision

[VentMonkey]

So what you are saying is America is not a developed first world nation which wants its ambulance personnel to be able to look after their patients if they are not at Paramedic or ICP equivalent levels...

I'm not not saying that.

 

[hometownmedic5]

So my issue is dog piling skills/procedures onto people without education. I see it as a half measure.

If you want basics to have an expended scope, let's just make basics intermediates and be done with it. We dont need another half rank or regional speciality certifications (emt-iv; bls intubation with a waiver and so on). If we're going do make a go of this national scope idea, let's stop playing games and get it done.

 

[VentMonkey]

@Remi I believe we share a similar thought process with regard to prehospital ETI.

That's about what I would envision as most practical. In essence you're covering airway management, and once there's a firm grasp of the entire management process from beginning to end, ETI may be taught for what it is...a skill. One that is way overemphasized as it stands now, but the "bigger picture" itself being airway management, is currently all but null and void.

We haven't earned the right to practice this as a group of clinicians, collectively IMO. We haven't even earned the right to call ourselves clinicians, let alone practitioners as a group.

I would think a "skill" like this deserves way more credit, and in turn respect, than we've given it over the past 50 or so years.

 

[EpiEMS]

So time for me to write a nice letter, I guess?

Key takeaways for me that I can find good evidence for:
- Tourniquets for everybody (a good-enough summary here, obviously I'll provide links to studies)
- Epinephrine autoinjectors for EMTs, push assisting down to EMRs, too (because it is the gold standard for anaphylaxis and is not available enough)
- Glucometry and CPAP for EMTs
- Cervical spine clearance for all levels (EMT and above)

How about that?
Anything else I'm missing? I know some folks had some suggestions at the Paramedic level....

 

[Jdog]

So time for me to write a nice letter, I guess?

Key takeaways for me that I can find good evidence for:
- Tourniquets for everybody (a good-enough summary here, obviously I'll provide links to studies)
- Epinephrine autoinjectors for EMTs, push assisting down to EMRs, too (because it is the gold standard for anaphylaxis and is not available enough)
- Glucometry and CPAP for EMTs
- Cervical spine clearance for all levels (EMT and above)

How about that?
Anything else I'm missing? I know some folks had some suggestions at the Paramedic level....

Honestly, I would love to see oral ondansetron added to the EMT scope. Probably won't happen, but one can only dream.

 

[EpiEMS]

Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)

 

[MonkeyArrow]

Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)

It got "blackboxed" by the FDA for use in pregnant women.

 

[NomadicMedic]

Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)

Works great for nausea, doesn't work very well for someone who is actively vomiting.

I use the ODT's prophylactically. "Here, please let this dissolve in your mouth. Hold this yak sak and don't puke on me."

 

[EpiEMS]

@NomadicMedic Any major risks to worry about?

 

[DesertMedic66]

It got "blackboxed" by the FDA for use in pregnant women.

It had a warning label put on it for continued use during pregnancy. Last I checked there were no studies done about single doses. We still give it for pregnant females.

 

[NomadicMedic]

It had a warning label put on it for continued use during pregnancy. Last I checked there were no studies done about single doses. We still give it for pregnant females.

Yep. And it's cautioned in a few other meds. Apomorphine is one. It also may prolong QT.
The use in pregnancy was off label and I think GSK paid a big fine for promoting the off label uses.

It's got a few issues, but still very widely used.

 

[SandpitMedic]

Regarding intubation, perhaps intubation itself is not the crux of the issue. Perhaps it is the way most paramedic students are taught to intubate.

First off, it's taught like this glorious end all be all of being a paramedic (according to newbs). It's taught in such a fashion that it is meant to be this 30 second emergency procedure. "YOU HAVE 15 SECONDS TO GET THIS TUBE OR YOU ARE A KILLER!!!" "GET THIS TUBE IN 8 SECONDS OR YOU'LL BE A WEAK PARAMEDIC FOREVER!!!?"--- ummmm... no.
So much emphasis on speed and just getting the tube...

There should be nothing fast about taking someone's airway. It should be smooth and methodically done. You should be fully prepared and ready for alternative ways to achieve the goal. Obviously, this is a time sensitive procedure, but it certainly should not be a rush procedure. First pass success should be the ultimate goal during training; preparing and setting yourself up for success the first time. In addition, I've seen too many times a second attempt the same as the first... if you didn't get it the first time (which is bad) then change something the second time...don't make the same mistake twice. There is also much much more than just "getting the tube" such as how to appropriately manage the patient once the tube is in place...

It should be taught as a smooth non-dramatic procedure. Not this life saving hero move.

And one more thing, if I had to pick one piece of equipment on the Ambulance/Aircraft that is the most underutilized it would be.... the bougie.

Use every tool you have to ensure first pass success, and don't rush it. The training needs to be changed. Also, none of us are heroes.

 

[VentMonkey]

Regarding intubation, perhaps intubation itself is not the crux of the issue. Perhaps it is the way most paramedic students are taught to approach intubation.

First off, it's taught like this glorious end all be all of being a paramedic (according to newbs). It's taught in such a fashion that it is meant to be this 30 second emergency procedure. "YOU HAVE 15 SECONDS TO GET THIS TUBE OR YOU ARE A KILLER!!!" "GET THIS TUBE IN 8 SECONDS OR YOU'LL BE A WEAK PARAMEDIC FOREVER!!!?"--- ummmm... no.
So much emphasis on speed and just getting the tube...

There should be nothing fast about taking someone's airway. It should be smooth and methodically done. You should be fully prepared and ready for alternative ways to achieve the goal. Obviously, this is a time sensitive procedure, but it certainly should not be a rush procedure. First pass success should be the ultimate goal during training; preparing and setting yourself up for success the first time. In addition, I've seen too many times a second attempt the same as the first... if you didn't get it the first time (which is bad) then change something the second time...don't make the same mistake twice. There is also much much more than just "getting the tube" such as how to appropriately manage the patient once the tube is in place...

It should be taught as a smooth non-dramatic procedure. Not this life saving hero move.

And one more thing, if I had to pick one piece of equipment on the Ambulance/Aircraft that is the most underutilized it would be.... the bougie.

Use every tool you have to ensure first pass success, and don't rush it. The training needs to be changed. Also, none of us are heroes.

I honestly didn't think that the whole "you're weak if you can't get the tube" mantra was still a thing with preceptors, and trainers, deplorable. I'm not completely surprised, and yes I agree that there needs to be more focus on how it is performed, but again, clearly we need to wipe the approach as it stands currently altogether.

As you eluded to, it's just "getting the tube", and nothing more. If we approach airway management like we should be approaching much of what we do, from a preventative standpoint, we'll be not only more educated about all of the proper procedures, options, and techniques, but we will have changed our end goal from "I'm awesome because I can put a piece of plastic between a persons vocal cords.", to "it can probably wait until we get to the hospital.", or "I should really be doing this properly to begin with because as my respiratory module indicates there's a higher likelihood of my patients hospital stay lengthening, and/ or them developing pneumonia-->ARDS is way high; maybe I should employ proper aseptic techniques and take my time so that I decrease their length of stay; this would be preventative."

That's what I mean by de-emphasizing. You're absolutely right, we're not heroes. I don't think I have ever seen, or heard a physician tout they're a hero because they had to intubate a patient they were reluctant to (in my experience the better physicians have this approach to clinical airway management). Then again, they possess the knowledge-base to understand the onslaught of susceptibility they've just opened said patient up to. What do we possess that says we should continue to be allowed such a giant responsibility?

It also may prolong QT.

This is the one I most commonly hear applicable to us about Zofran, maybe because it involves ECG's? Lol, I don't know. My understanding about the prolongation of QT intervals is that it's more prevalent with extremely high doses (e.g., perhaps what a cancer patient being treated via chemotherapy may be ingesting). It's not to say that it can't happen, but overall it appears to be mostly a benign medication, so yes, ODT Zofran could probably be added, and of benefit to the EMT scope of practice.

 

[Carlos Danger]

@SandpitMedic everything you wrote is 100% correct. Intubation is merely an intervention, and not even a complex one at that. In theory, virtually anyone can learn the skill and acquire the judgement needed to place an ET tube. Still, we still find ways to screw it up. All_the_time.

Complex or not, it does take time and resources to teach airway management, and more time and resources to maintain it. And the consequences of letting someone loose to do the intervention without having fully developed the skill are dire. When I was in paramedic school in 1997-1998, I remember talking about how we really should get a lot more/better training in airway management than we did. And now, two decade later, we are still having the same exact talk. We all recognize the importance of improving training in airway management, which is why "airway" such a frequent topic of conversation. In spite of that, there has been virtually zero progress in the area of airway training for paramedics for at least as long as I've been involved in EMS. The national curriculum is virtually the same. Paramedics are still graduating their programs with 3 or 4 live intubations (or less). I still pretty frequently see paramedics in the OR who just don't really seem to understand what is going on. The research that is unsupportive of paramedics doing RSI in the field just continues to pile up - a new study came out just a few weeks ago - I think that's the 17th or 18th in the past 20-25 years that says pretty much the same thing as the rest. Can the problem even be fixed? I don't know. Probably. I can't see why not. But whether it's because paramedic programs and EMS agencies can't or won't improve things, it just isn't happening.

A good argument can also be made that intubation by paramedics in the vast majority of cases simply isn't necessary. CPAP is everywhere now, and SGA's have improved dramatically. Many paramedics intubate less than 5 times a year, and a large majority intubates less than 10 times a year. That's probably not only well below the threshold needed to maintain competency, but it also indicates that maybe it's a skill that they don't even really need.

Are there exceptions to all the negativity? Of course. Which is why I don't think it should be removed from the paramedic scope of practice across the board.

 

[Carlos Danger]

This is the one I most commonly hear applicable to us about Zofran, maybe because it involves ECG's? Lol, I don't know. My understanding about the prolongation of QT intervals is that it's more prevalent with extremely high doses (e.g., perhaps what a cancer patient being treated via chemotherapy may be ingesting). It's not to say that it can't happen, but overall it appears to be mostly a benign medication, so yes, ODT Zofran could probably be added, and of benefit to the EMT scope of practice.

Zofran has been proven to prolong the QTI to a greater extent than droperidol did, and droperidol was effectively done away with because of the black box warning that it was slapped with for that purpose around the same time that zofran came out (conspiracy theory, anyone?). It doesn't take a large dose of zofran to prolong the QTI, either.

That said, I don't think there has ever been a case of lethal arrhythmia that was attributed to zofran, even in the really high doses. It's probably about as safe as a drug can be.

 

[NomadicMedic]

Zofran has been proven to prolong the QTI to a greater extent than droperidol did, and droperidol was effectively done away with because of the black box warning that it was slapped with for that purpose around the same time that zofran came out (conspiracy theory, anyone?). It doesn't take a large dose of zofran to prolong the QTI, either.

That said, I don't think there has ever been a case of lethal arrhythmia that was attributed to zofran, even in the really high doses. It's probably about as safe as a drug can be.

I was giving zofran to a young woman who was sick and her dad, who was there (and did not offer to drive her to the hospital BTW) was an oncologist. He asked what I was giving her and when I said 8 of zofran said, "is that enough? We give huge doses to chemo patients."

Our ED docs are like, "woah! You gave 8mg of zofran?" I'm so tired of the dark ages.

As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.

 

[VentMonkey]

"You know you're a paramedic, or EMT when..."

As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.

 

[DesertMedic66]

I was giving zofran to a young woman who was sick and her dad, who was there (and did not offer to drive her to the hospital BTW) was an oncologist. He asked what I was giving her and when I said 8 of zofran said, "is that enough? We give huge doses to chemo patients."

Our ED docs are like, "woah! You gave 8mg of zofran?" I'm so tired of the dark ages.

As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.

I named my son Laryngo Scope. You should see all the weird looks I get. Next kid I am going to name Yaunker Non-rebreather

 

[SandpitMedic]

Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, and here in my area there is a private school that does not require it.

Manikin medicine.

ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.

 

[VentMonkey]

ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.

I would consider this a sub-topic, elaborate?

Is the greater LV area absolutely flooded with paramedics? If so, do you think a system such as this, coupled with presumably short ETA's to the ED, really needs ETI in their protocols?*

*there, it's still sort of on topic.