Pulling the plug on EMS

[medicRob]

yeah the UK is almost if not 100% equal in the care provided and medical procedures performed.

I agree 100%.

Does the US have some of the best teaching hospitals and care specific facilities? I would argue yes.

I agree. However, I do not agree with the thought that the US is somehow suprerior to all other nations in the practice of medicine in general. There are areas where we excel, there are areas where others take 1st place.

What I am against is blind statements such as:

"Umm.. people come to the US to receive medical care not available anywhere else. "

 

[boingo]

Certainly,

Permit me to quote part of my original post?

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 used bicarb on Sunday during my treatment of a polydrug OD with a suspected TCA, Mag is used fairly often, the inner city is full of severe asthma patients, and Atropine is used on occasion for peds induction and symptomatic bradycardia.


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

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!

Care to cite your source for over treatment in those who don't need it and under treatment in those that do?


Look at the cost to maintain a quality intubation program compared to the benefits of intubation.

Don't know what it costs, I get plenty of opportunity. Intubation isn't for everyone, if you can't get the experience you shouldn't be doing it, this goes for the doc working the rural ER too, if they intubate twice a year, they should be reaching for a supraglottic airway too, gasp!


At which point in my first reply the only mention of narcan:

I was thinking that the point of narc reversal is to stabilize respiratory and vascular systems. Anesthesia never seems to use narcan, titrated or otherwise, and they give narc doses far in excess of EMS on a daily basis. One of the most common heard mantra of ALS providers is they are not afraid of narcs because they can reverse them, which of course, seems like flawed clinical judgement.

The patient given opiates in theater are completely different than the recreational opiate abuser seen in the pre-hospital setting.


You suggest that the idea you can give narcan should be the reason not to withold analgesia?

Not sure what you are getting at here, I treat pain with opiates all the time, and have never had to give Narcan to a patient that I gave opiate analgesia to.


all the way down in post 18:

Later this evening I expect to look up the exact physiological and pathophys of both opioid OD and the reversal of it to really see whether or not there is a flaw in the original theory of its use for EMS.

next time i mentioned narcan, right after you decided your argument was to put me in my place as a student :

I appolgize for the cheap shot, however, you are a student, and your experience as a physician level provider is extremely limited. If you tried your rant on tenured physicians you'd be laughed out of the room.

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?

They should be, both in and out of hospital, it doesn't alway happen, in both venues. Punitive Narcan is an A-hole move, and happens in and out of hospital. Convenience? Perhaps. The junkie I wake up on the top floor of the projects can walk his sorry *** down as opposed to straining my back, so I'll own that. As for chronic pain pts, different animal, I don't reverse analgesia in those pts, the pts I speak of are the recreational opiate abuser.

Next was a question about my choice of education. Probably because that was the only response you could dream up after your initial attempt an an insult didn't work.

Not fair, and I appologize, I do respect your education and persuit of excellence, a bad day and your rant set me on my course.


Honestly my first choice of school was the oldest in the Western world, my wife asked me if I would consider something closer to her home and i thought given her sacrifice it was the least I could do. But looking back I do not regret my decision to come to this school and I am rather proud of it. Especially when I see what is coming out of the US schools.

Tell me, Other than trying to coatail greater minds as demonstration of your greatness What exactly is your contribution?

Day in and day out delivery of prehospital medicine. My mentors and educators are George Velmahos, Erwin Hirsch, Ron Walls, Lenworth Jacobs and Jonathan Gates, and many, many others....

somewhere in there, USA responded to a treatment question:

"Fluids, suction, an NPA and BVM?"

My next reply to narcan was the search I did on it.

So how far off topic am I?

The topic was Narcan, so your are still a ways off.

 

[rwik123]

It depends on what you call the best, compare what European students do in school, particularly in rotations to their US counterparts.

I probably shouldn't start in about teaching to the tests instead of medicine prior to residency so I won't.

Care specific is great. If you can afford it. It also depends on how you measure.

PS.

The first face transplant in the US was performed by A Polish born and trained Physician.

Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals? In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.

 

[Veneficus]

Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals?

Life is never simple.

The US imports 24% of it's physicians by need. So just because the doctor is foreign doesn't mean they are great.

The US does pay the most, often doctors laugh that it is the only place you get paid more for results that don't matter.

Some foreign doctors who are exceptionally gifted do go to the US. Some stay, some don't. We have several doctors here who worked in the US and came back, in very prestigious facilities and research, Berkly, Philly, human genome project, artifical heart, off pump bypass, etc.

In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.

I think they just stand out more. As I said, the last stat I saw was 24%.

 

[medicRob]

Ok. So would you agree upon the fact that the cream of the crop per say of medical professionals; MDs ect migrate and ultimately end up in US hospitals? In my experience there tends to be major ethnic diversity in the population of doctors..Mass General more specifically, a large number of physicians not originating in the US but either attending medical school here or coming here after they have their degree.

It is true that a significant number of the physicians in the US are from India, Japan, or other countries.. However, I am sure this is true of other areas. I believe the US and London to be pretty much equal in medical capability. I do not think one is better than the other. There are too many factors to consider.

I am sure there are just as many physicians who migrate to London from the same countries of origin as those who migrate to the US. However, I can't really speak on that as I have never been to London, and haven't researched the topic.

 

[JPINFV]

Umm.. people come to the US to receive medical care not available anywhere else. We are far from second-class world citizens.

That doesn't mean every part of the system is the best though...

 

[Veneficus]

The topic was Narcan, so your are still a ways off.

I used bicarb on Sunday during my treatment of a polydrug OD with a suspected TCA, Mag is used fairly often, the inner city is full of severe asthma patients, and Atropine is used on occasion for peds induction and symptomatic bradycardia.

So what you are saying is aside from mag, you rarely use these drugs?

Care to cite your source for over treatment in those who don't need it and under treatment in those that do?

Come on, do you really want to get into an argument about the overuse of spineboards and the underuse of pain medication in the US as a whole?

I doubt there are statistics on it anyway, but I'd like to think we have way too much respect for each other for that. Besides, do you really want to argue the opposition on that statement?

Don't know what it costs, I get plenty of opportunity. Intubation isn't for everyone, if you can't get the experience you shouldn't be doing it, this goes for the doc working the rural ER too, if they intubate twice a year, they should be reaching for a supraglottic airway too, gasp!

So my question of the global application is met with "in my service?"

The patient given opiates in theater are completely different than the recreational opiate abuser seen in the pre-hospital setting.

I respectfully disagree, the principles of scientific medicine are the same no matter what the environment. System or provider convenience does not make a treatment modality more beneficial to a patient. I do not accept for a second the argument of "in the field things are different."

Not sure what you are getting at here, I treat pain with opiates all the time, and have never had to give Narcan to a patient that I gave opiate analgesia to.

Have you not read some of the comments on this forum about people always having narcan as a backup to their analgesic administration plans?

I appolgize for the cheap shot, however, you are a student, and your experience as a physician level provider is extremely limited. If you tried your rant on tenured physicians you'd be laughed out of the room.

Yes, my experience is limited, probably not as much as you think, but that is here nor there. You are not the first person here to assign my philosophical musings as a rant. Most likely not the last, nothing I can do about that, it's how I write.

I often have discussions with rather highly respected physicians from around the globe, my contributions have been recognized, and that is all I am going to say on that. Never once have I been laughed out of the room and I keep getting invites. I think you are making assumptions in error based on your perception of my tone after a long day.

I question any and everything held as truth. In medicine and in life. Nothing is sacred and nothing is taken at face value.

 

[boingo]

I used bicarb on Sunday during my treatment of a polydrug OD with a suspected TCA, Mag is used fairly often, the inner city is full of severe asthma patients, and Atropine is used on occasion for peds induction and symptomatic bradycardia.

So what you are saying is aside from mag, you rarely use these drugs?

Yes.

Care to cite your source for over treatment in those who don't need it and under treatment in those that do?

Come on, do you really want to get into an argument about the overuse of spineboards and the underuse of pain medication in the US as a whole?

I doubt there are statistics on it anyway, but I'd like to think we have way too much respect for each other for that. Besides, do you really want to argue the opposition on that statement?

Fair enough, however there is a lot more to prehospital medicine than spinal immobilization and pain management, some do it well, others not so much, globally.

Don't know what it costs, I get plenty of opportunity. Intubation isn't for everyone, if you can't get the experience you shouldn't be doing it, this goes for the doc working the rural ER too, if they intubate twice a year, they should be reaching for a supraglottic airway too, gasp!

So my question of the global application is met with "in my service?"

No, intubation is a big deal, providers at ALL levels need to stay proficient or don't perform the procedure. We had a recent discussion about prehospital intubation at a lecture I attended recently, when I posed the question as to why we (the academic medicine community) allow junior EM residents to intubate as opposed to anesthesia, who are in house 24/7, I was told it was becuase the EM doc might be working in an environment without anesthesia back up, however when I offered the simple solution of a supraglottic airway there were a lot of silence in the audience. You can't have your cake and eat it too.

The patient given opiates in theater are completely different than the recreational opiate abuser seen in the pre-hospital setting.

I respectfully disagree, the principles of scientific medicine are the same no matter what the environment. System or provider convenience does not make a treatment modality more beneficial to a patient. I do not accept for a second the argument of "in the field things are different."

We will agree to disagree on this. The opiate abuser is a different animal than the surgical patient.

Not sure what you are getting at here, I treat pain with opiates all the time, and have never had to give Narcan to a patient that I gave opiate analgesia to.

Have you not read some of the comments on this forum about people always having narcan as a backup to their analgesic administration plans?

You don't see a safety benefit in that?

I appolgize for the cheap shot, however, you are a student, and your experience as a physician level provider is extremely limited. If you tried your rant on tenured physicians you'd be laughed out of the room.

[B]Yes, my experience is limited, probably not as much as you think, but that is here nor there. You are not the first person here to assign my philosophical musings as a rant. Most likely not the last, nothing I can do about that, it's how I write. [/B]

Fair enough. I don't know you any more than you know me, and I will assume your motives are genuine and for the benefit of the patient.

I often have discussions with rather highly respected physicians from around the globe, my contributions have been recognized, and that is all I am going to say on that. Never once have I been laughed out of the room and I keep getting invites. I think you are making assumptions in error based on your perception of my tone after a long day.

I question any and everything held as truth. In medicine and in life. Nothing is sacred and nothing is taken at face value.

Bad day as it where, my attack on your status as a student was uncalled for, and at the end of the day, I enjoyed the discussion. Perhaps I envy you just a bit, I am happily married with two beautiful girls (karma, long story ) and couldn't ask for more. I strive to be the best at what I do, and don't accept mediocrity from my peers, which causes me a bit of grief at work, but I'm OK with that.

 

[82nd medic]

It is part of the required curriculum of all EMS education. Everyone knows about it. It is taught as mandatory curriculum in medical school as well. Sorry, no super military knowledge here. I have actually treated an organophosphate poisoning. There is not enough atropine on the truck. If there is any hope, you need to get to someplace that has a lot more before you

Show me the proof. An actual scientific study, not an anecdote. Because most of the cardiac arrest meds don't. The ones that do under a very limited scope of circumstances.

You said LAY person, and EMT is not a lay person. Let me know when atropine auto injectors start getting handed out like epi pens.

You're the one arguing against FDA approved drugs, show us an actual scientific study.

 

[medicRob]

You're the one arguing against FDA approved drugs, show us an actual scientific study.

Weren't you the guy who posted:

Spinal immobilization is hazardous? Last I checked a broken bone that's stabilized poses less of a risk of further damage than one that's not. I've yet to see anything showing that it poses more of a risk than a prevention.

Only to be responded to with:

There's evidence that spinal immobilization decreases secondary spinal injury?

Malaysian/University of New Mexico retrospective chart review: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02615.x/abstract
Outcome, no benefit.

"The effect of spinal immobilization on healthy volunteersType of participants: Twenty-one healthy volunteers with no history of back disease.
Interventions: Subjects were placed in standard backboard immobilization for a 30-minute period. Number and severity of immediate and delayed symptoms were determined.
Measurements and main results: One hundred percent of subjects developed pain within the immediate observation per iod. Occipital headache and sacral, lumbar, and mandibular pain were the most frequent symptoms. Fifty-five percent of subjects graded their symptoms as moderate to severe. Twenty-nine percent of subjects developed additional symptoms over the next 48 hours.
Conclusion: Standard spinal immobilization may be a cause of pain in an otherwise healthy subject."
http://www.sciencedirect.com/scienc...35221faae7006f0e68a60164a846d51c&searchtype=a


"We conclude from our data that these devices produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G9CB76-D&_user=945451&_coverDate=09%2F30%2F1988&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467727&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=53df0436f30430badda5e47cb9251fdd&searchtype=a


"Spinal immobilization significantly reduced respiratory capacity as measured by FVC in healthy patients 6 to 15 years old. There is no significant benefit of one strapping technique over the other."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G82KTB-J&_user=945451&_coverDate=09%2F30%2F1991&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467753&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=88ea3a5b2f9bdbd0e50e6afd483bc97e&searchtype=a


So, now show me a study where spinal immobilization improves outcomes.

Where is your research?

 

[82nd medic]

Never heard of discomfort being a contra indication for a potentially life threatening injury... That must have been replaced with the "pain is the patients problem if you need to keep him alive" class.

http://www.wildernessdoc.com/assets/pdfs/NAEMSP-Spinal Clearance Protocols-Jan08.pdf
There's plenty of other research articles suggesting selective immobilization.

 

[JPINFV]

Evidence that there are clinical tools to determine populations that are at low to no risk of a spinal injury is not the same as evidence that spinal immobilization produces better outcomes. In fact, slide 7 of your link specifically says that there is no evidence of improved outcomes for patients who are immobilized.

 

[Veneficus]

You're new at this medicine thing aren't you?

You're the one arguing against FDA approved drugs, show us an actual scientific study.

Not trying to pick on you or insult you, but you seem to be rather on the naive side of this discussion.

First off the FDA does not decide what drugs are best in the treatment of patients/diseases, doctors do. There are off label uses for drugs based on their biological and chemical characteristics. The decision of when and why to use them is left open. A quick google search will demonstrate there is more than a few FDA approved drugs that are no longer on the market. Some of which are facing major legal action.

The drugs used in cardiac arrest resuscitation by the American Heart Association are classified as level IIB, the very research they present in their advanced provider and instructor manual points out directly that there is no evidence these medications do anything in arrest resuscitation. I am guessing by your post you haven't read that book yet.

You may need a bit more background before you pick a fight.

In my OP and as I quoted a few pages back, while i singled out medications, the purpose of discussion was the critical analysis of current treatments. I addressed the use of narcan, i researched more to it than the if:then indications, which are indications usually only found in new providers, or ones with so little medical knowledge that they cannot put for a rational argument except to point out that somebody else said it was a good idea.

Many EMS treatments were based off of expert opinion of the time they were formed. Dating back to the late 60's. In the last 15 years there have been more advancements in medical science than in the history of medicine. So today's expert is much more capable of making decisions than those of yesteryear.

Infact my 2 academic advisors often point out that molecular biology wasn't even a science when they went to school. Only recently has research on any of the treatments in EMS been done. Most of that research has been done by interested physicians, and in every case that comes to mind right now, has demonstrated those treatments were invalid. Spineboarding, aggresive fluid resuscitation, MAST, Tk for snake bites, to name a few.

Many formerly interested physicians no longer do this research in/for EMS as they have given up on trying to convince EMS to change. A majority of physicians I have met in both the US and abroad, consider US EMS an absolute waste of time and energy, my negative comments are rather kind compared to the average of theirs.

That's how much respect US EMS has earned.

I would also like to bring to your attention that most EMS instructors, including many that I actually work with, have no formal education greater than paramedic class, which in a number of states, 5 years of experience is the qualification to teach at the highest level you obtained.

That means you could spend 5 years as a Basic EMT, finish paramedic school, and get a license to teach paramedic class the day after. The qualifier is chronological "experience" it is not even time in rate.

As was pointed out by one of the greater minds here, experience without education is the same experience over and over.

You might want to consider that when touting information given to you by a US EMS instructor in '04.

Furthermore, the lower your formal education level, the more absolute the information is. It is designed that way so that lesser educated people do not make decisions which can lead to errors of intent or disasterous consequences. Many at the entry and mid level don't even know the vastness of what they don't know.

The links and information you posted have absoltely nothing to do with your positions. Did you even read them? Did you understand the material presented?

Guessing from your screen name and past posts, you are still in or recently out of the military. I would say you are like a pilgrim in an unholy land, because in medicine, what is handed down from those in a position of "authority" is always questionable. The very textbooks are written as: "this is all we know" and from your experience and knowledge you make decisons on that. That is one of the reasons why there is so much variation in medical treatment. Standards are developed to work "most of the time."

We don't always agree in our discussions, but I don't know a person here who would let a person suffer or die because that patient didn't fit into the standard for most without making every legal/reasonable effort to help them.

 

[pullnshoot25]

Note: I did not read the entire post, just the first few lines, but wanted to comment on something.

There's a medic I work with that I respect very much, who once went on a rant about how many medics just want to start lines/push meds, etc. His mantra is that the less he has to do, the better. Not from a laziness standpoint- but that if he doesn't HAVE to give a medication, or doesn't feel it's clinically beneficial to the patient, he won't do it. Don't overtreat, do exactly what is necessary for the patient.

Primum non nocere is my motto.

 

[EMTinNEPA]

WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA. If anything typed sounds like the scribblings of a crazy person, that is why.

This entire thread has made me lol. Nothing but two sides setting up strawman after strawman against each other.

"I think Narcan is silly." "Well then maybe we should take away every drug!" "I bet you're the kind of paramedic who immobilizes everybody!" "So you're saying we should just be a taxi service?"

Quite frankly the entire thing has been nauseating. Both sides have valid points, but then again both sides have said some incredibly ludicrous things.

Firstly, just because a treatment isn't NECESSARY does not mean that it is not BENEFICIAL. If I had the choice of administering Narcan and allowing a patient to regulate their own ventilatory status or shove a tube down their nose or throat and force air into their lungs with a bag, I would choose the Narcan every time. Not because it's easier for me, but because it's better for the patient.

On the other hand, if a little old lady slips out of her chair, lands on her butt, lays down, and is not exhibiting ANY signs of potential spinal compromise (i.e. NEXUS criteria), and I have the choice of immobilizing her and protecting myself from lawsuit but risking negative effects such as pressure sores or hyperextension of the cervical spine or saying "forget the board", I will "forget the board" every time. Not because it's easier for me, but because it's better for the patient.

Sometimes less is more, and sometimes more is more. It takes clinical judgment to determine which is which. Personally, I want every cool toy in the book. I want RSI meds, I want video laryngoscopy, I want blood products, I want pre-hospital thrombolytics for MIs, I want everything! I want to start definitive care in the field, because it's better for the patient!

Are bronchodilators really necessary pre-hospital? No. But does receiving Albuterol on scene and en route rather than 15 minutes later at the hospital provide the patient with relief faster? Isn't that better for the patient?

What about CPAP? Is it really necessary pre-hospital? The part of me that's a patient advocate says yes, but an argument could be made for the opposite. That one patient on the verge of respiratory distress that breaths easier because I put that mask on his face and doesn't need to be intubated and spend days or weeks in the ICU, but instead walks out of the ED 10 hours later makes me say that CPAP in the pre-hospital environment is absolutely necessary.

Or the patient with chest pain who goes directly to the cath lab because a pre-hospital 12-lead not only DIAGNOSED a myocardial infarction, but LOCALIZED it.

Now take that same chest pain patient. Let's say the 12-lead DOESN'T diagnose an MI. Would you proceed with treatment or would you dig a little deeper and perform, say, a 15-lead? If you went with the 15-lead, you might find a right ventricular infarction, in which case you would have to be VERY careful with that Nitroglycerin. Or you may find a posterior wall MI and thus have prevented an MI from being missed (and don't give me that non-sense about ST depression in the anteroseptal leads, because that only occurs in 8% of posterior MIs). If you said you would just proceed with treatment and subsequently miss the RVI, you could very well kill your patient. This would not only hurt the very person you're supposed to be protecting, but you allow people to argue that pre-hospital Nitroglycerin is detrimental and is a practice that should be ceased (I jest).

Like I said, both sides make valid points, but both sides also make some ridiculous statements and just like with most matters with two opposing views, the truth lies somewhere in the middle. My attitude is that paramedics should be permitted a LOT more treatments and procedures than they are currently, but I realize that entails more responsibility and better clinical judgment is therefore necessary.

If you don't possess the clinical judgment necessary to make these kinds of decisions, I hear Wal-Mart is hiring.

 

[usalsfyre]

Sometimes less is more, and sometimes more is more. It takes clinical judgment to determine which is which.

Lack of clinical judgement is exactly why I find myself arguing against more and more treatments. Maybe it's the area I work in, maybe it's me being cynical but I'm starting to think piss poor clinical judgement is the rule rather than the exception.

If you don't possess the clinical judgment necessary to make these kinds of decisions, I hear Wal-Mart is hiring.

Who the heck will work all the open spots?

It's not the posters on here I worry about. It's the other folks that scare me...

 

[medicRob]

Never heard of discomfort being a contra indication for a potentially life threatening injury... That must have been replaced with the "pain is the patients problem if you need to keep him alive" class.

http://www.wildernessdoc.com/assets/pdfs/NAEMSP-Spinal Clearance Protocols-Jan08.pdf
There's plenty of other research articles suggesting selective immobilization.

Then show it to me. I can waltz in here and claim a whole host of things, and that I have plenty of research articles to back me up, but until I provide them, I can't back it up.

So where are they? Give me at least 5.

 

[Veneficus]

Then show it to me. I can waltz in here and claim a whole host of things, and that I have plenty of research articles to back me up, but until I provide them, I can't back it up.

So where are they? Give me at least 5.

Easy on the new guy killer.

 

[medicRob]

Easy on the new guy killer.

You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !

Fine then, I'll settle for 3.

 

[DesertMedic66]

You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !

Jonny Rocket? I thought it was Sue Maple