States and EMT-B Morphine Administration

[Veneficus]

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.

Not denying that at all. My point is that advanced care doesn't equal better outcome.

But I would also like to point out data from the AHA.

Between 2000 and 2005 (according to the AHA numbers) ACLS providers put priority in advanced life support skills.

The number of unsuccesful resuscitations increased from 300,000/year to 350,000 a year. (now I understand there are some confounders to these numbers, but please bear with me)

in the 2005 guidlines, there was a refocusing on BLS (cpr) as the primary ntervention in both bystander an ACLS interventons. I cannot remember the exact number, but if I am remebering the right number, think it was an increase ~14-18%

which means that resucutation of cardiac arrest went back to near the 2000 baseline.

With the advent of AEDs and a renewed focus on CPR, (all of which are basic life support skills) it could be concluded that the BLS skills have a greater impact than ALS skills.

Now correlate that to the OPALS studies, which do point out a decrease in hospital stay from ALS in certain conditions. (respiratory and hypoglycemic again if memory serves me)

What can be logically concluded is that ALS does have a positive outcome in certain conditions.

I think we have both argued the position that there is benefit to ALS particularly in cases like pain control. My position is that it is not "life saving" in any appreciable number compared to BLS. (that also includes in the hospital)

I think we need to start being realistic about the value that ALS provides, not keep clinging to some romantic fantasy.

I would also like to point out something that was said without directing it at the person who brought it up.

Trauma does not equate to surgical intervention anymore. Those days have been over for about 20 years. It does equate to care from a trauma specialist. That can include Emergency Physicians, Surgeons (all appropriate disciplines), Interventional Radiologists, and Intensivists.

Surgical trauma requiring emergency damage control surgery in the western world is actually decreasing and has been for some time. as is our ability to nonsurgically manage injuries that once automatically meant damage control surgery. (emergent, and without regard to return to function or aesthetic value.)

Some patients in western countries will still require a surgeon to be sure, but less for life threatening injuries and more for return to near normal function.

Would all parties please stop perpetuating the dogma.

 

[LonghornMedic]

Boy, this thread sure went sideways. As far as patient outcomes in BLS versus ALS systems, I'm convinced they are better in ALS. I've worked as a Basic when I first started in a BLS system, an Intermediate in a ALS system and now as a Paramedic. Both ALS systems I've worked in were far superior to the BLS system I worked in. All EMS systems are different. It's like the old saying- "If you've seen one EMS system, you've seen one EMS system." So my experience may differ from another person's experience. My one complaint about ALS is that some Medics spend WAY too much time on scene. Especially on medical calls. Everyone seems to understand the Golden Hour when it comes to trauma calls, but medical calls seem to bring out a different perspective. I've worked with partners who just love to start everything on scene. I do everything en route. My philosophy is I am not a doctor or a ER. My job is to get them to the next highest care ASAP.

 

[JPINFV]

Golden hour as a time matrix is bunk. Your patient doesn't magically expire at 60 minutes post insult.

 

[LonghornMedic]

Golden hour as a time matrix is bunk. Your patient doesn't magically expire at 60 minutes post insult.

No. But ****ing around on scene doesn't do your patient any good either.

 

[JPINFV]

Depending on what exactly you're ****ing around doing. Not all emergencies are load and go, do everything enroute emergencies. For example, if you're going to intubate, why make the intubation harder by adding extra external noises and movement? However, if you're just sitting on scene for the sake of sitting on scene, then I agree.

 

[reaper]

Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.

Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?

No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.

 

[LonghornMedic]

Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.

Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?

No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.

Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.

 

[reaper]

Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.

You could have chose a better example to make! Why transport a working code? What will they do in the ER that is any different then what you are providing? Why not sit on scene for 30 minutes providing quality CPR and work the pt. If you do not get a change by then, think about calling it!

Does not matter if you can do it en route. If there is no need to rush, why rush? Do you know the anxiety to a pt that an IV while moving causes? I can do an IV in 30 secs. Why wait till you bouncing down the road?

Point is, the majority of medical pt's are not time sensitive, so why rush them off to the ER? Take your time, treat your pt, keep them calm and explain everything. Even if I take 10 minutes extra on scene. It will not change the out come for my pt.

 

[JPINFV]

Why sit on scene? I'm not rushing. Just the opposite. But everything I can do on scene I can do en route. 12 leads would be the exception. But I've sat on the scene of codes for 30 minutes working them(when I was an EMT-I and had to keep my mouth shut). My philosophy is I am a pre-hospital provider. My job is to get people to the hospital. I do it as quickly as possible while still providing the proper care.

...except you can't provide continuous good quality compressions while the ambulance is moving any faster than a crawl to the hospital.

 

[LonghornMedic]

You could have chose a better example to make! Why transport a working code? What will they do in the ER that is any different then what you are providing? Why not sit on scene for 30 minutes providing quality CPR and work the pt. If you do not get a change by then, think about calling it!

Does not matter if you can do it en route. If there is no need to rush, why rush? Do you know the anxiety to a pt that an IV while moving causes? I can do an IV in 30 secs. Why wait till you bouncing down the road?

Point is, the majority of medical pt's are not time sensitive, so why rush them off to the ER? Take your time, treat your pt, keep them calm and explain everything. Even if I take 10 minutes extra on scene. It will not change the out come for my pt.

Again, I'm not rushing them. I just choose to do stuff en route. My preference. The majority of the people who call us get transported. We don't turf too many. So I do an initial assessment on scene. If it's something like hypoglycemia, then we'll obviously do an IV and D-50 there.

Again, my method may vary from yours. I prefer not to sit around and do stuff when I can do it on the way. Shortens my scene time and allows me to go available for calls sooner. I've worked with guys who take an hour and a half to tech a kidney stone from call origination to available for calls. When I do it, we'll be available in 30-45 minutes. Again, that's just me.

 

[LonghornMedic]

Majority of medical pt's are not time sensitive. Medical pt's are the few that we can help in the field.

Why rush down the road, bouncing along, while providing treatment. If you are not in a time sensitive deal?

No reason why IVs, 12 leads, and meds cannot be started on scene. Provide the treatment that will benefit the pt's, in a calm controlled setting. Then transport to the ED for follow up.

A calm controlled setting is in the back of my ambulance, even if we're on scene. In a critical emergency, with panicked family, co-workers or other bystanders milling around I'd rather be in the rig doing what I need to do. Believe me, I've worked codes with hysterical family members screaming and crying. If given the choice, I just as soon be in the rig with all my equipment within reach instead of fishing through a jump bag. Just my preference.

 

[Jay]

Wrong. TN allows Subq Epi, is about to allow Narcan. Colorado already allows Narcan.

Narcan/Naloxone should really be a "common sense" drug that can be used if the proper protocols allow along with adequate training at any level. I just got done replying to another post on here where rwik123 was unsure given the following scenario:

http://emtlife.com/showthread.php?p=249067#post249067

I for the most part immediately saw the opiate OD as a possibility along with perhaps hypoglycemia as another strong possibility, but this is because I immediately recognized two of three pieces of the opioid triad. Now, granted if there was adequate training explaining the opioid, especially the "why's" than an OD that would require naloxone would be easy to treat at any level, it goes back to recognizing the symptoms and treating your patient and not just the numbers.

Now, on that note, training would also have to include what NOT to do, e.g. NOT to push narcan for a non-opiate overdose, e.g. benzos or antidepressants; teaching the theory on this would be extremely beneficial. Also, there are certain "opiates" such as Tramadol where narcan would not have a very powerful (if any) effect (due to the way it acts on two receptors and its pseudo-opiate makeup) so training on contraindications would be beneficial. This could be a 4 hour class. Or even combined with some other BLS-ALS hybrid drug administration could be a day or two even that could really make common sense situations a lot easier because they could be defused at a lower level in much less time.

 

[Basermedic159]

No state allows EMT-B to push anything.

That's not totally accurate. I'm an EMT-B in NC and I can draw up and administer EPI sq for anaphylaxis. Not auto injector.

Also Narcan via MAD device...

 

[Basermedic159]

There's a big difference between communities that can't afford and communities that won't afford the $20/person extra a month for paramedic service. In those (really rare on a per-capita basis) locations, I'm somewhat more comfortable with expanded scopes for EMTs. However, I'd rather see blind airways than ET tubes, IVs than IO, and something a little further down the schedule list than morphine. There's a big difference between someone screwing up or losing a tube or oral glucose and an auto injector of morphine, and I'd hate to be the medical director the first time an audit comes up with a missing auto injector of morphine.

Medics can steal medications just as fast as basics can. As a matter of fact, the news that i've have seen/read about, only showed medics stealing narcs. In my opinion, it is easier for a medic to snatch a drug quicker than a basic, due to the simple fact of medic being able to access narcotics more easy than a basic.

 

[Basermedic159]

Severe pain + 2mg morphine = severe pain.

What does Severe pain + nothing for pain =?

 

[Basermedic159]

Personally, I think EMT-B should be done away with. Just have EMT-Intermediate and EMT-Paramedic. Both can start IV's, manage airways, administer drugs, etc. EMT-B's are really nothing more than glorified first aid. With EMT-I's you could add morphine to their formulary, as you already have access to narcan should a reaction occur. I feel more comfortable letting EMT-I's administer morphine that EMT-B's.

Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.

You should remember whats infront of your patch Mr. *EMT*-paramedic

 

[JPINFV]

Medics can steal medications just as fast as basics can. As a matter of fact, the news that i've have seen/read about, only showed medics stealing narcs. In my opinion, it is easier for a medic to snatch a drug quicker than a basic, due to the simple fact of medic being able to access narcotics more easy than a basic.

Where in my post did I bring up theft?

 

[triemal04]

Really? I bet pt's would disagree. Especially when Firefighter/EMT's respond to the pt's before we get there. Just because *you think* a "glorified first aid" EMT gets in your way dosn't mean it dosn't matter medically to the pt.

You should remember whats infront of your patch Mr. *EMT*-paramedic

I don't think that at all. I know that in the vast majority of cases it doesn't matter medically if an EMT get's to the patient before me. Of course, in many cases it also doesn't matter if I get to the patient either; the number and types of calls where we (paramedics) will have an effect on patient mortality and final outcome are not as high as you think.

There are plenty of cases where we will be able to help with the patient's comfort and resolving some symptoms/conditions. But...there aren't many times you can say that, can you?

Before you get to pissy, think about what I'm actually saying. It isn't that EMT's and paramedics aren't needed, just that your (and my) skill set and education are often woofully inadequate to have any meaningful medical impact.

This doesn't mean that we never do; don't bother bringing up examples, everyone knows they exist, it's just that more often than not...we could take the patient to the hospital while doing absolutely nothing, and the outcome wouldn't change.

 

[RocketMedic]

No state allows EMT-B to push anything.

Not entirely true, the armed forces count as states to the NR and FedGov and allow poorly-trained EMT-Bs (68W10/20s) to administer quite a bit. Big ones on this list are morphine, fentanyl, and valium/versed.

 

[RocketMedic]

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.

We've got 2.5mg autoinjectors, but I haven't seen them in ages.