States and EMT-B Morphine Administration

[JPINFV]

Then be a EMT-Intermediate. I know in some systems EMT-B's can't even use a glucometer. But if you want to give meds, IM is the least preferred method. Go to school and be an Intermediate or Paramedic where you can start IV's and give meds.

I think that's the big issue right there. In my perfect world, EMS would diverge from IFTs (who would be free to develop their own curriculum which better matches the needs of people with chronic illness not experiencing a medical emergency) and the entry level would be something, scope wise however with a proper education, between an I/85 and a I/99.

 

[Veneficus]

But the end result is that ILS in place of BLS results in far superior treatment skills and patient outcomes. In more rural areas, ILS is going to save more lives than BLS ever could..

I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.

 

[JPINFV]

I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.

The question, though, is "lives saved" the only metric that EMS should be concerned with? What about reduction of pain and suffering?

 

[BLSBoy]

I have seen no evidence to support such a statement. Given the studes demonstrating the "lives saved" by paramedic level practice, I do not think this is going to stand up anyway.

Where are these alleged "studies"?
They are obviously flawed.
Lets think here, CHF pt.... CPAP, NTG. Those alone can turn around a bad CHFer in 10-15 min, avoiding a tube in the hospital.

STEMIs, early detection and transport to a cath lab saves lives.

Prehospital hypothermia. My Dept had DOUBLE DIGIT percentages of people walking out of the hospital, NEUROLOGICALLY INTACT, not some vegetable that will eat our MCR and MCD money up, costing the taxpayers and insurance companies more money then they are worth.

You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.

 

[Veneficus]

The question, though, is "lives saved" the only metric that EMS should be concerned with? What about reduction of pain and suffering?

I think we should get away from the "lives saved" metric entirely. It is difficult to actually prove and only a very small portion of what EMS does on a regular basis.

I am not sure what a better metric would be under the current version of US EMS. Response times are just as bad. I would like it to be money saved by being a relatively inexpensive way to get into the heathcare system, not necessarily an emergency dept.

"we gave grandma jones a ride to her doctor's appointment this month at a cost of $100 and saved medicare a cost of X1000's for an ED visit when she goes into extremis."

"after 5 years of our community and school outreach programs, we have cut 911 calls by 60% saved the municipality millions in emergency response, and increased the quality of healthcare as demonstrated by the increase of x years of productive life."

"our community CPR outreach program has decreased the time from sudden cardiac arrest to quality cpr from 8 minutes to nearly 2"

"Our senior outreach program has helped our population over age X remain in their homes an average of Y years longer, reducing emergency calls by Z a year saving a cost of N in both emergency in longterm care"

"On average we identify X medical emergencies which get prompt transport to an emergency department, thereby reducing the number of out of hospital cardiac arrests by Z%"

"Our community health screen as well as adult health and wellness education has led to the referral and counciling of X people for earlier identification and preventative care which improves the quality of life for said population, keeps them producing longer, and saves W costs in long term care compared to last year's total of R"

Would be some things I would like to see.

 

[medic417]

fentanyl ↔ naloxone
Applies to:fentanyl and Narcan (naloxone)

.

LOL I was wanting one of the basics to catch it since they now know everything. No point in wasting time with education. Heck I think we can do an auto injector stent in the field so no need for cardiologists.

 

[medic417]

We're you beat by an angry mob of EMTs at some point in your life? Your hostility is getting a little ridiculous, you seem to hold the EMT personally responsible for the lack of education that is included in the curriculum.

We're all well aware of your opinions on the education level of the EMT, must you regurgitate at every oppurtunity?

You were once an informative poster but you've grown quite tiresome.

By the way some EMTs have been carrying nasal narcan for years.

Yes see I told you guys I was an informative poster. Now I have proof. Thanks.

Just because a system allows mediocrity does not mean one must settle for it.

 

[JPINFV]

LOL I was wanting one of the basics to catch it since they now know everything. No point in wasting time with education. Heck I think we can do an auto injector stent in the field so no need for cardiologists.

Well... if the EMTs can do it, so can the ED, which would be an additional billable procedure so... sure!

 

[medic417]

Well... if the EMTs can do it, so can the ED, which would be an additional billable procedure so... sure!

Why stop there? Let the janitor do it. Yay more toys with no more education. :wacko:

 

[Shishkabob]

I want toys :unsure:

 

[Veneficus]

Oh for shame

Where are these alleged "studies"?

There have been several OPALS studies for medical emergencies, trauma, and pediatrics. As these and other smaller studies have called into question the cost effectiveness of ALS response, I would hope that EMS providers become aware of them and attempt to demonstrate a less flawed method with a more accurate study. Until such a time, this is what there is to go by.

They are obviously flawed.

I don't dispute the metrics they used to measure ALS effectiveness are always representative of service provided, they are compiled in an ALS system that has higher standards than the current and past US system.

Lets think here, CHF pt.... CPAP, NTG. Those alone can turn around a bad CHFer in 10-15 min, avoiding a tube in the hospital.

CPAP manages an acute symptom of CHF, it is not a definitive treatment for it. It in no way reverses the disease process. It does not allow people to walk around like Darth Vader enjoying scaring the daylights of of the younger relatives when they ask them for a hug. Maybe EMS could doll out some welbutrin or prozac for that too.

Would that be the emergent 0.04 mg of NTG that lasts 3-5 minutes or the 12 hour patch that allows the unstable angina patient with CHF sit a few more days in their cardiac chair?

Avoiding a tube in the hospital for how long? A DNR avoids a tube. So does end of life care. If these patients are so turned around, why do they still need to go to the hospital? Aside from intervening in one acute crisis, which often sets off a sequely of ED, CICU, SNF, Hospice, or ED, CICU, mortgage forclosure, recurrent acute episode refer to earlier sequely, exactly how many lives would you call a save?

In strict protocol driven systems, both CPAP and NTG are basic skills. A basic is much cheaper to field than a medic.

STEMIs, early detection and transport to a cath lab saves lives.

Would it save more lives than a Basic with a LP 12 or 15 that puts on the 12 lead and takes the pt to a cathlab when it reads "possible STEMI" while they give the pt NTG and ASA?

Prehospital hypothermia. My Dept had DOUBLE DIGIT percentages of people walking out of the hospital, NEUROLOGICALLY INTACT,

Probably the only thing here that EMS does that actually saves lives in a measurable quantity.

not some vegetable that will eat our MCR and MCD money up, costing the taxpayers and insurance companies more money then they are worth.

I don't think it is accurate to say that a arge percentage of these people wind up in a SNF on a vent. I see a considerable number of them die within a few days in the ICU, DNR orders, and even a few who get "the plug pulled."

Wouldn't hurt insurance companies to lose a few bucks, and while I agree it does save a tube and those complications, it does not save a few days in the unit, so the actual savings is rather small. The fact the patient didn't die also means considerable spending for the chronic care. Ask any insurance company if they would rather fork over the cash for a few days in the ICU for a patient who dies or the 20 or 30 years of chronic care of those who survive with multiple decompensating pathology? Good death panel argument though with the cost comparison at the end compared to the earlier human argument.

If I am not mistaken the OPALS or similar study did show a slight reduction in hospitalization time in a few specific emergencies, which is a much better argument than "saving lives."

You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.

A good twist on the Mark Twain quote. But I am afraid that EMS uses equally flawed stats to demonstrate the lives they save. I have seen many over the years. From ROSC at the ED to response times, to superior/cheaper care provided by various agencies. Now the OPALS lies are cancelled out.

 

[medic417]

I want toys :unsure:

Well go look around the doctors area and tell them you can do what they do. Then take it. No education required. Have fun with your new toys.

 

[Shishkabob]

Well go look around the doctors area and tell them you can do what they do. Then take it. No education required. Have fun with your new toys.

But I'd still get some funny looks, and I don't have the self-esteem for those looks.

 

[medic417]

But I'd still get some funny looks, and I don't have the self-esteem for those looks.

Just a minute let me find it. Yes here it is self esteem auto injector. Now who needs a shrink? Wow you really don't need education.

 

[Hal9000]

LOL I was wanting one of the basics to catch it since they now know everything. No point in wasting time with education. Heck I think we can do an auto injector stent in the field so no need for cardiologists.

I do not believe that many Basics have posted in this thread. However, since it involved Basics, I did put in the BLS section, though it irked me to do so.

It seems safe to say that only one state is allowing Basics to give morphine.

 

[Meursault]

Where are these alleged "studies"?
They are obviously flawed.

You can quote studies all you want, but there are lies, damned lies, and stats. You can guess where your "studies" fall.

I'm tempted to tape my epidemiology textbook to a Clue Bat and start driving south.

Are you really arguing that massive clinical trials are either useless or in any way equivalent to your handful of stories about patients walking out of the hospital?

Here's the OPALS executive summary: http://www.chsrf.ca/final_research/ogc/pdf/stiell_e.pdf

And here's the portion dealing with trauma, which suggests that ALS is actually worsening outcomes in a subset of trauma patients: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/

Here's a separate publication on respiratory distress from the OPALS study, which shows some benefits, including a significant reduction in in-hospital mortality, during the ALS phase (though ALS providers only responded to about 60% of the relevant calls during this phase)
http://www.nejm.org/doi/full/10.1056/NEJMoa060334
Interestingly, what we consider "ALS interventions" were used in only a small number of patients and the biggest change was appreciably and significantly greater use of albuterol ("salbutamol"), which the authors say was the result of a different program.

Explain the problems you have with the study designs or shut up and stop reflexively criticizing evidence that challenges your beliefs.

 

[CAOX3]

Everyone needs more education I am not arguing that point.

That being said I love when people preach evidence based medicine, hold it as gospel and then dismiss it when it doesn't support their argument or personal agenda.

 

[Hal9000]

As it turns out, the state officials say that currently no company makes an autoinjector in 2.5mg for morphine, though there is one 10mg version that is somewhat common.

The state says that a company that makes the 10mg version will cave to demand and produce a 2.5mg one. Given that the entirety of MT has less than one million people, and also knowing that probably 200,000 of them are served by prehospital ALS, I do not see much demand for this product. I can't find a 2.5mg version myself, so perhaps it's not to be found.

Interestingly stupid or stupidly interesting, it's your pick.

 

[BLSBoy]

I'm tempted to tape my epidemiology textbook to a Clue Bat and start driving south.

Please, start driving. I'll meet you at the state border to show you a little, "Southern Hospitality".

Explain the problems you have with the study designs or shut up and stop reflexively criticizing evidence that challenges your beliefs.

The "Holy Grail" that you and everyone else clinging to it is all, "no shiite, Sherlock" stuff. ALS gets focused in on ALS procedures, and forgets all about good, high quality CPR, same with trauma. They don't need me, they need hot lights and cold steel.

MIs, respiratory distress, seizures, (to include eclamptic ones as well), and cardiac arrests with short downtimes and ROSC with good CPR, followed through with aggressive post rescusitation care (hypothermia, RSI, transport to a cath facility).

ALS doesn't save codes or trauma.
That is where we are going to be saving lives with ALS

 

[boingo]

There have been several OPALS studies for medical emergencies, trauma, and pediatrics. As these and other smaller studies have called into question the cost effectiveness of ALS response, I would hope that EMS providers become aware of them and attempt to demonstrate a less flawed method with a more accurate study. Until such a time, this is what there is to go by.




I don't dispute the metrics they used to measure ALS effectiveness are always representative of service provided, they are compiled in an ALS system that has higher standards than the current and past US system.



CPAP manages an acute symptom of CHF, it is not a definitive treatment for it. It in no way reverses the disease process. It does not allow people to walk around like Darth Vader enjoying scaring the daylights of of the younger relatives when they ask them for a hug. Maybe EMS could doll out some welbutrin or prozac for that too.

Would that be the emergent 0.04 mg of NTG that lasts 3-5 minutes or the 12 hour patch that allows the unstable angina patient with CHF sit a few more days in their cardiac chair?

Avoiding a tube in the hospital for how long? A DNR avoids a tube. So does end of life care. If these patients are so turned around, why do they still need to go to the hospital? Aside from intervening in one acute crisis, which often sets off a sequely of ED, CICU, SNF, Hospice, or ED, CICU, mortgage forclosure, recurrent acute episode refer to earlier sequely, exactly how many lives would you call a save?

In strict protocol driven systems, both CPAP and NTG are basic skills. A basic is much cheaper to field than a medic.



Would it save more lives than a Basic with a LP 12 or 15 that puts on the 12 lead and takes the pt to a cathlab when it reads "possible STEMI" while they give the pt NTG and ASA?



Probably the only thing here that EMS does that actually saves lives in a measurable quantity.




I don't think it is accurate to say that a arge percentage of these people wind up in a SNF on a vent. I see a considerable number of them die within a few days in the ICU, DNR orders, and even a few who get "the plug pulled."

Wouldn't hurt insurance companies to lose a few bucks, and while I agree it does save a tube and those complications, it does not save a few days in the unit, so the actual savings is rather small. The fact the patient didn't die also means considerable spending for the chronic care. Ask any insurance company if they would rather fork over the cash for a few days in the ICU for a patient who dies or the 20 or 30 years of chronic care of those who survive with multiple decompensating pathology? Good death panel argument though with the cost comparison at the end compared to the earlier human argument.

If I am not mistaken the OPALS or similar study did show a slight reduction in hospitalization time in a few specific emergencies, which is a much better argument than "saving lives."



A good twist on the Mark Twain quote. But I am afraid that EMS uses equally flawed stats to demonstrate the lives they save. I have seen many over the years. From ROSC at the ED to response times, to superior/cheaper care provided by various agencies. Now the OPALS lies are cancelled out.

If EMS just prolongs the inevitable, what exactly does the ED do? The ED does not fix the pathology leading to CHF either, or reverse STEMI unless they are not equiped with a cath lab. They stabilize and refer to a specialist. There is a continuem of care, from the scene, to the hospital, to home or admission with expert consultation and definitive care. I don't buy into the "ALS saves lives" crap, but nor do I dismiss the fact that without it several people wouldn't make the ED. You can argue that these interventions just prolongs the inevitable, but that arguement extends right into your hospital as well.