Protocol Changes

Veneficus

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Do you really think that outside people like some of the ones who post here on this forum, the average EMT spends all his waking hours thinking about EMS? .

They do if they want to earn enough to pay rent and eat ;)

I can't remember the last time I had less than 2 jobs and often landed with 3 to meet ends meet.

I can see your point with the unfair swipe at volunteers, but I think what he was trying to say, at least the way I read it, wasn't what he wrote.
 

Bullets

Forum Knucklehead
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Interesting. Titrate according to what?

To relief, instead of giving a patient 15L NRB for chest pain or breathing problem, we can start at 4L NC and increase flow until patient gains relief or we hit 15L NRB
 

Veneficus

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To relief, instead of giving a patient 15L NRB for chest pain or breathing problem, we can start at 4L NC and increase flow until patient gains relief or we hit 15L NRB

ummm....

While I see this as a step in the right direction, I don't think it is going to help with most chest pains or breathing problems.

If a patient does not have a pathology requiring increased oxygen, giving oxygen will not help.
 

Nervegas

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We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.
 

Veneficus

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We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.

That is sad, I like dopamine. It is my pressor of first resort.
 

tacitblue

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Sorry,

But the idea of a mid level provider serving where physicians are not available has since been perverted; now they are running around academic facilities providing no better care than a paramedic following protocols (and often with the same attitude).

Always with an ego that rivals any surgeon I have ever met. But when they are called upon to actually do something, they are not comfortable or have some other excuse.

I do not agree with anyone who promotes the philosophy, "better than nothing."

Physicians are medical providers, not medical managers overseeing a plethora of protocol monkies who just add extra layers and extra cost which is unsustainable.

If you want to practice medicine, go to medical school, spare me the excuses as to why a person cannot. It is not that they cannot, it is they are not dedicated enough to.

I usually find you to be interesting and insightful. This post, however, demonstrates a profound ignorance on the education and roles of midlevel providers. Excluding the current "doctor of nurse practice" crap (which is so ridiculous I don't even need to touch it), PAs and NPs are more than capable of of doing what they do.

I am an adult with congenital heart disease (double chambered right ventricle and VSD, both repaired but with remaining residua). When physicians see the zipper scar on my chest, they are not confident in managing me and do not understand the physiology of my condition. I have had emergency physicians and primary care physicians admit to me that they were out of their comfort zone. I am seen at a major academic center on the west coast for follow up with an adult congenital heart disease program. There exists only a handful of doctors in the United States who are qualified or even interested in seeing adult CHD patients; and there are now more living adults with CHD than children. Many of these people are lost to care and have serious and complex illness that require expert followup. Do you know who I see most of the time? A nurse practitioner.

Two NPs practice in the program and I cannot even begin to say enough good things about them. They are kind and compassionate, and they have an expert understanding of the complicated issues we face. Most importantly, they extend the reach of expert followup for a growing and vulnerable and patient population. And they do it well.
 
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Nervegas

Forum Lieutenant
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That is sad, I like dopamine. It is my pressor of first resort.

I agree, as it is my first choice as well, however, we now only have NS bolus's and if that doesn't work, contact MC for orders to mix up an epi drip.
 

DrankTheKoolaid

Forum Deputy Chief
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re

We are losing Dopamine, gaining Post ROSC Hypothermia. Updating to the new ACLS guidelines and streamlining some of the protocols and breaking others off into their own page instead of being all lumped together. Mostly housekeeping rather than broad changes this year.

Talk about a contradiction. AHA just stated Dopamine is an acceptable alternative to TCP. Has to be more to the story with it being removed, provider misuse maybe.
 

Nervegas

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Talk about a contradiction. AHA just stated Dopamine is an acceptable alternative to TCP. Has to be more to the story with it being removed, provider misuse maybe.

Don't know about why its being removed, I heard due to cost/waste from underusage. Our protocol covers 6 fire departments and a large Air/Ground EMS service, I would hope that it isn't due to misuse. I do know that for Brady, our MD prefers TCP > Dopamine, it was only used for hypotension in our protocol before this year.
 

Veneficus

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I usually find you to be interesting and insightful. This post, however, demonstrates a profound ignorance on the education and roles of midlevel providers. Excluding the current "doctor of nurse practice" crap (which is so ridiculous I don't even need to touch it), PAs and NPs are more than capable of of doing what they do.

I am an adult with congenital heart disease (double chambered right ventricle and VSD, both repaired but with remaining residua). When physicians see the zipper scar on my chest, they are not confident in managing me and do not understand the physiology of my condition. I have had emergency physicians and primary care physicians admit to me that they were out of their comfort zone. I am seen at a major academic center on the west coast for follow up with an adult congenital heart disease program. There exists only a handful of doctors in the United States who are qualified or even interested in seeing adult CHD patients; and there are now more living adults with CHD than children. Many of these people are lost to care and have serious and complex illness that require expert followup. Do you know who I see most of the time? A nurse practitioner.

Two NPs practice in the program and I cannot even begin to say enough good things about them. They are kind and compassionate, and they have an expert understanding of the complicated issues we face. Most importantly, they extend the reach of expert followup for a growing and vulnerable and patient population. And they do it well.

Thanks for the kind words, but let me just point something out.

Unless I am much mistaken, it was a doctor who diagnosed and initially came up with a treatment plan.

It is an NP (or a couple) who manage and follow up that plan.

I am not saying they do not know something about the very narrow field they operate with, in the same way a paramedic does the same thing in a different field.

The fact there are not enough doctors in any given field is a consequence of the American medical system, not the lack of doctors. I can assure you there are many many qualified doctors interested in all aspects of care who would move to America in a heartbeat and be more than able and willing to treat/manage you.

But you yourself said that these providers only extend expert follow up.

That is a "better than nothing" argument.

What you have may seem like gold not knowing what you could have.
 

Veneficus

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Talk about a contradiction. AHA just stated Dopamine is an acceptable alternative to TCP. Has to be more to the story with it being removed, provider misuse maybe.

or lack of use.

Why keep restocking a med that is never used?
 

18G

Paramedic
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Don't know about why its being removed, I heard due to cost/waste from underusage.

That sucks dopamine is being taken away. Hope those CHF'ers who really decompensate improve with a 250cc bolus of NSS and aren't overloaded to began with from eating to many McDonalds fries!

Vene, I used dopamine just the other day :)
 

RocketMedic

Californian, Lost in Texas
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PAs and NPs are needed. Do you really need ten years of education to order an X-ray, proscribed a medication to treat an uncomplicated patient, or suture? These are paramedic-level skills, or could be. Why not have a PA doing this?
 

JPINFV

Gadfly
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The trick isn't the uncomplicated patients, but the complicated ones. Especially the complicated ones pretending to be uncomplicated.
 

RocketMedic

Californian, Lost in Texas
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Agree, but do we really need to dump mid level providers? I don't think so.
 

Veneficus

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PAs and NPs are needed. Do you really need ten years of education to order an X-ray, proscribed a medication to treat an uncomplicated patient, or suture? These are paramedic-level skills, or could be. Why not have a PA doing this?

The problem is not treating, it is knowing what you are looking at to start treating properly.

Organ systems are connected, your heart problem causes renal and liver problems, and they all have to be explored in order to come up with the best treatment options.

Then there is the issue of not knowing what you don't know. A problem very obvious in EMS.

Infact I just a saw a patient a few days ago who was being managed by a medic for his injuries for 16 days on flexeril and motrin. Back pain was still there, and when I ran his kidney function labs, they were all out of whack.

Why did I run his renal function tests? Because I know ibuprofin affects renal function in high dose. I also understand volume of distribution and pharm kinetics. So I equate long term usage with high dosage.

Paraspinal backpain is rather easy to manage. Sometimes you must change or escalate treatment. Medicine is not one size fits all.

Along the same line, I saw a patient who fell down the stairs, who was managed by a PA for 7 days on the same treatment regiment. WHen I saw him, I reduced his dislocated shoulder, found his clavical fracture, and the intercapsular injury to his wrist.

It was not that the PA made a terrible mistake, he was doing the best with what he had and knew.

I have and know a little bit more. :)

But it doesn't change that he would have been better off coming to me first. Laying 7 days in your bed with pain, a fx, dislocation, and likely second fx which is not diagnosable until bone healing is seen on x-ray weeks later, taking 800mg motrin, the PA as the provider of first resort is simply not good enough. (especially when he thought it was just a muscle-skeletal injury)

Like I said, the PA did his exam, started following his normal management routine, and didn't even know about the specifics of the wrist injury. He cannot be faulted.

(Those are the most recent stories, but I have many more.)

Simple is not always as simple as it looks.

Another true story, pt diagnosed with topical dermatitis, managed appropriately for such condition without improvement for years.

Final diagnosis when symptoms failed to resolve? Follicular Muscinosis, a precursor legion to T-cell lymphoma.

Do you think that changes treatment and severity?

I can train any paramedic to treat simple problems, it doesn't require a "mid level" provider. That makes them an unecessary expense. But I cannot "train" somebody to critically think about conditions and complications they have never heard about. Similarly a person cannot be trained to think about unusual presentations or unknown origins unless they have extensive understanding on the workings of the whole body.

That is a body of knowledge unique to medical education.

When a PA or NP Dx renal stenosis as a cause of HTN (a rather common problem) you know the treatment?

Refer to physician.

Then treatment begins.

In such cases, and there are many more, the mid level provider is just a waste of time and money before the patient sees a doctor.
 

the_negro_puppy

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They have started opening family medicine clinics staffed primarily by NPs here, its only slightly cheaper to see them. I would never go- when I can pay slightly more to see a physician who's scope of prescription, practice and education inst limited.
 

tacitblue

Forum Crew Member
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Thanks for the kind words, but let me just point something out.

Unless I am much mistaken, it was a doctor who diagnosed and initially came up with a treatment plan.

It is an NP (or a couple) who manage and follow up that plan.

I am not saying they do not know something about the very narrow field they operate with, in the same way a paramedic does the same thing in a different field.

The fact there are not enough doctors in any given field is a consequence of the American medical system, not the lack of doctors. I can assure you there are many many qualified doctors interested in all aspects of care who would move to America in a heartbeat and be more than able and willing to treat/manage you.

But you yourself said that these providers only extend expert follow up.

That is a "better than nothing" argument.

What you have may seem like gold not knowing what you could have.
I don't disagree; I think mid levels extend the care of physicians. I would never go to a solo NP clinic for follow up on a complex issue or even a simple one. But when they are acting within their ability to be a force multiplier, I don't think it's much of a problem.

As for primary care and EM, you present an interesting point about PA/NP not having the level of education for the sheer breadth of these specialties. The NP at the CHD center can focus all her energy in learning from her expert attendings how to manage heart defects but can she diagnose the zebra masquerading as a common complaint in a primary care clinic. I don't think we disagree much, it just seems you may be a little unduly harsh towards the idea of PAs and NPs.
 
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R99

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Here in NZ we have strongly resisted the "mid level" as you call it; we do not have PA, nurse anaesthetist etc. We have a tiny number of NPs (about forty) and the majority work in community diabetes care or hospital. To give NPs the extremely limited prescribing rights some do have was horrendous exercise that took years.

A small pilot of PA in Auckland has been fiercly disdained by Medical and Nursing Councils. We have approaching a big shortage of anaesthetists but the College of Anaesthetists has ruled out a nurse/PA anaesthetist provider, even if "supervised" by a physician who might float across several theatres likr in Sweeden.
 

RocketMedic

Californian, Lost in Texas
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Venificus, you sound like a...hmmm...paramedic at one point who is now a doctor and used to be a Doc? Good guess?
 
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