Pulling the plug on EMS

[JPINFV]

Toronto, Boston and others give Narcan to their junkies for self-tx, buddy tx, and guess what? They don't go to the hospital tying up EMS and ED resources.

I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...

 

[46Young]

Veneficus - I'm still new here, and you've obviously been around awhile and have more of a medical background than most. However, this isn't the first thread I've seen in the past few months where you just kind of throw out all these ruminations, mostly lambasting the US EMS system and the idea of protocols. From what I've gathered, you have formed some type of conclusion that EMS needs to go away, or die and be reborn maybe?

Here, you ask several questions (some perhaps rhetorically), but don't seem to reach a salient point that I can see. I thought at the beginning you were going to make an argument against the number of drugs that ALS providers can and do push, but that seemed to taper off at the middle and somehow you started talking about aeromedical services, then about intubation? By the end, you just seem to be saying "EMS providers are doing more than they should, and its not in the best interests of their patients". Am I understanding that right?

I think most of the people on these boards (the ones who are active more than looking to get a job or a license) are here to learn and discuss. We realize that EMS (perhaps especially in the US) isn't perfect, and are always interested in viable improvements. Do you have a suggestion of some kind here, even if it requires a sea change (that will never happen) which would radically alter the nature of prehospital care?

There are so many moving parts though, I think you'd need to address a lot. As you said, many of the agencies we work for here are urban. I know that to drive an ambulance for my FD, you need to know the route to no less than 7 hospitals, and I think it's really more like 10, none of which are further than probably 30 minutes. That's certainly not the case coast to coast however, and should that factor in somehow to 'protocols'? It would seem that you are arguing against intubations for my type of short-haul environment, but the paramedics in Montana and Wyoming (and even the Eastern Shore in MD) with the long rides to Anywhere probably get even fewer chances to stay sharp with all those skills (someone correct me if that's a bad assumption).

You talk about removing ALS entirely. What do the numbers say with regards to something like pt survivability/morbidity in the case of witnessed arrest or the like when you compare ALS to BLS? My hunch is that ALS isn't much more likely, statistically, to get a save than a competent Basic - but I bet that there are certain subsets of patients where an ALS provider makes a difference. The next step would be to examine and address those subsets - what are they, how often, etc. What is the threshold for adding a treatment/medication/protocol? Obviously we can't treat everything, so what gets left out?

I'm only a basic, but I'm still wondering what made you decide that naloxone is unnecessary for prehospital pts?

If you want to see hostility and disdain towards EMS providers, you should search ventmedic's old posts.

 

[JPINFV]

I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...

Correction... I meant IO, however I doubt they're administering it IV as well...

 

[rwik123]

Correction... I meant IO, however I doubt they're administering it IV as well...

IM I believe

 

[18G]

Baltimore, MD had a program at one time where they handed out Narcan to addicts also. This was a long time ago so not sure if they still do it or not.

 

[Veneficus]

Forgive me

Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet. You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong. Would reversing opiate OD in the ED be bad too? Should they get a tube and a MICU bed? Seriously, get your MD or DO under you belt and get back to us in a few years.

But this is by far the absolute most ridiculous reply I have ever seen in any forum.

My musing are often retrospective. Applying the knowledge I received today to my past and current experiences in EMS.

As an EMS instructor, I am acutely aware of the rationale behind many of the field treatments. I have also seen so many emergency treatments thrown into question over the years in scientific study that any paramedic aspiring to be a professional should be aware of and capable of making informed conclusions and critisisms there of.

Is my past service on EMS protocol committees, and the research and discussions there not applicable because I am in the process of advancing my education?

Does the fact that I spend a considerable amount of time learning and being tested on past treatments, current treatments, and future recommendations somehow make me less capable of forming an opinon on them?

How much time do you or any paramedic spend on it?

One of my semesters is worth more credit hours than any US paramedic school in total. I am a student, but more than capable of forming an intellectual opinion on the same treatments that a practicing vocational technician is. (the same certification I also hold I might add)

It is yesterday's experts that recommended pouring crystalloid into patients until they bled cool aid. Been there, done that.

Relatively there are few physicians interested in EMS to put forth any effort to conduct studies on most of what is done. If Joe paramedic can decide what is being done is right, what makes vene paramedic less capable to question it?

Is my research above the level of any of my peers in pathophysiology somehow not worthy of consideration until after it is published or I put some letters after my name?

Tell me, what letters or publications do you claim to refute my conclusions?

How much research have you or US paramedics done to comment with any authority or knowledge on what EMS treatments are beneficial?

Let me address your questions.

Would reversing opiate OD in the ED be bad too?.

It depends on a couple of factors.

1. Are providers titrating it appropriately?
2. Are they using it punitively?
3. Are they doing it for patient benefit or their convienience?
4. If less aggresive treatment achieves the same thing, what makes acute reversal the treatment of choice?
5. What is the sequele if you induce irretractable pain or acute opioid withdrawel doing it? Is it worth that?

Should they get a tube and a MICU bed??.

This looks like a strawman argument to me, i put forth the idea that less invasive treatment may be more beneficial and you ask me if the patient should recieve more aggresive treatment? Come on.

Seriously, get your MD or DO under you belt and get back to us in a few years.

I'll play.

I will have MD after my name before you can matriculate to med school unless you start this september and a second graduate degree before you finish your second semester. Get some medical education past vocational/community college If:then statements under your belt and get back to me in a few years.

Feel better about yourself now?

 

[18G]

Seriously... come down off your trip... your not above us.

We want what's best for our patient's and question and research the same as you. What you suggest is pure BS and like your trying to be the trend setter with your rhetoric in hopes of one day being able to say, "I told you so".

I am still shaking my head that someone who is almost a Physician would promote not giving Narcan.

 

[18G]

Hmmm.... lets see... bag a patient 30mins to the hospital, cause gastric insufflation, patient vomits, aspirates, and now has aspiration pneumonia? And not to mention emesis everywhere, the need to suction aggressively.... all for what? Or wait... place an NG tube to prevent all that??? why? How is this clearly better for the patient? And what if the patient is bradycardic and rate does not respond with the assisted ventilation??? Now what.. still no Narcan??? Or are you proposing we intubate these patient??? That is mostly stupid.... again, why?

When instead... you can place an NPA, bag the patient, start an IV and titrate your Narcan to adequate resp status!!! all within a few minutes! bam.... we take a respiratory arrest or damn close to it and give them the ability to breathe on their own all in under 10mins! And we accomplish this all with a very SAFE and EFFECTIVE medication.

Scenario A or B. Which one is better for the patient, Vene? Just pick an answer.... A or B.

 

[boingo]

I'm pretty sure that they aren't self administering it though an IV or giving them selves the full dose (more than once)...

What does the route of administration have to do with the discussion?

 

[boingo]

My degree is bigger than yours? Seriously? You my friend should seriously get over yourself, I deal with internationally respected and well published doctors on a regular basis, doctors who publish and do research that you haven't a clue about and have none of the opinions you hold about EMS. Why is it you are in school in Europe, better education or lack of opportunity in the U.S.?

 

[JPINFV]

Some posters found it interesting that Vene had picked naloxone as part of the discussion and I referred to this thread about naloxone via IO.

 

[boingo]

Haven't seen your thread, I am responding to Venes current statements regarding the use of Narcan, period, not the route of administration. I'll take a look at the other one.

 

[JPINFV]

To be clear... I wasn't the original poster for that thread, I just referenced it for why I think naloxone was targeted specifically.

 

[Sasha]

Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet. You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong. Would reversing opiate OD in the ED be bad too? Should they get a tube and a MICU bed? Seriously, get your MD or DO under you belt and get back to us in a few years.

Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?

Vene is simply offering some food for thought.

People are taking this as black and white, because he thinks narcan is overused, that it means all drugs should be done away with.

It really isn't too much to ask for providers to be educated enough to know when less is more and when less is not enough.

 

[medicRob]

 

[18G]

Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?

Vene is simply offering some food for thought.

People are taking this as black and white, because he thinks narcan is overused, that it means all drugs should be done away with.

It really isn't too much to ask for providers to be educated enough to know when less is more and when less is not enough.

I always appreciate a Woman's opinion but that is not what Vene is doing.

Maybe we should also allow patient's to bleed and allow the body's own hemostatic mechanisms to stop the bleeding. After all our goal is to always do the bare minimum to care for our patients.

 

[Veneficus]

Is he seriously any different than the EMTs and EMT students who come on here and fight and tell everyone how things should be done?

Vene is simply offering some food for thought.

People are taking this as black and white, because he thinks narcan is overused, that it means all drugs should be done away with.

It really isn't too much to ask for providers to be educated enough to know when less is more and when less is not enough.

I think this sums it up well, but I do like to offer some alternative solutions as well. The trouble is when suggesting viable alternatives or worst case scenarios the defenders of the true faith seem to think it is heresy to not buy into the status quo or worship them as the divine heroes whose every intervention pulls people from the jaws of death.

I'll be back in a few, as promised, now that my real work for the day is done, I am going to go and find out the mechanisms behind the sequele of opioid overdose. So we can further the discussion on whether the pathology and circumstances matches the treatments.

 

[18G]

The trouble is when suggesting viable alternatives or worst case scenarios the defenders of the true faith seem to think it is heresy to not buy into the status quo or worship them as the divine heroes whose every intervention pulls people from the jaws of death..

You couldn't be more wrong.

 

[82nd medic]

So today I was thinking about a reply to narcan in another post.

It occured to me that there really is no use for narcan in EMS.

Perhaps one of the primary things that EMS can claim to fame is the support of ventilation and circulation. If you can do that without a medication, why wouldn't that be the first choice? The only choice?

Now when I took pharmacology class, the first slide on the first day, was of the founder of pharmacology who declared "all drugs are poisons." (interestingly enough he died from complications of alcoholism)

Why do EMS providers seem to think that medication is always the best answer?

I am sure there is a training component as students are forced to memorize, under pain of being kicked out of a program, treatment regiments, which include medications and if these prescriptions are not followed it is wrong?

Some blame must go to protocols which never seem to get updated in a timely manner.

But it is not the instructor or medical director pointing a gun at providers telling them to always go to the max.

Now I know it is popular to pull out the anecdotes and the "what if's," but really, how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)

I sort of singled out medications in this post, but it is not limited to that.

Should EMS providers be prohibited from calling air medical services? Should they be banned from receiving bribes, I mean gifts and promotional materials, and "education" on the benefits and when to call airmed?

Now the point of this post isn't to pick on EMS or accuse it of negligence or substandard practice, but really. You have providers performing treatments that are often not needed, then turning around and not providing treatments in most cases that are!

That doesn't even get into treatments whos benefits are highly questionable.

Perhaps we should start taking a more minimalist approach to theraputics for pathologies, and a more aggresive approach to reducing pain and suffering?

Perhaps we need to get drastic and either remove ALS or put such restricitons on it that only hospitals would be able to provide the infrastructure to support ALS providers.

Look at the cost to maintain a quality intubation program compared to the benefits of intubation. In most areas it seems totally disproportionate. Especially in places where the hospital is so close, by the time you drop the tube you could have dropped the pt off at the hospital and been back at the station watching House and chomping on pizza.

Is it even realistic to ask EMS providers to take hubris, greed, and tradition out of the equation when deciding what treatments should be performed in the field?

When is EMS going to do more than pay lip service to the idea of what is best for the patient?

Or at least "do no harm?"

There's a difference between taking morphine and putting yourself on high flow o2 because you have a cold and taking a medication that is life saving.
Take narcan: name a treatment that doesn't involve medication that can treat an Opiod overdose?
Same for atropine: name a treatment for a nerve agent that doesn't involve medication.
Are you seriously saying that human lives are not worth money when it comes to intubation?

We discussed European EMS in my class back in 2004: they're load and go, that's it. They don't even do spinal immobilization for car wrecks. Compared to that I think American EMS is pretty good

 

[usalsfyre]

Take narcan: name a treatment that doesn't involve medication that can treat an Opiod overdose?

Fluids, suction, an NPA and BVM?

Same for atropine: name a treatment for a nerve agent that doesn't involve medication.

True, but autoinjectors make layperson administration a real posibility

Are you seriously saying that human lives are not worth money when it comes to intubation?

I think what he's saying is EMS does a very poor job at intubation, and the cost/benefit of maintaining a proper program doesn't add up, especially considering the decreasing need for intubation.

We discussed European EMS in my class back in 2004: they're load and go, that's it.

Much of EMS in Europe is physician-based, the majority that isn't is nurse-based. Meaning it's far from load and go, and is more like to offer definitive treatment and outcome in the field.

They don't even do spinal immobilization for car wrecks.

How do patients live without this never proven to helpful, proven to be harmful, usually improperly applied, and painful treatment! Yet there doesn't seem to be a overabundance of paraplegics in continental Europe....

Compared to that I think American EMS is pretty good

I think you need to do a little more research on US EMS vs EMS abroad.