What has changed since you started?

[DrParasite]

Question for all the dinosaurs out there (and while the dinosaur criteria is typically 20 years as per https://dinosaursofems.com/, I guess any person who has renewed their cert a few time can contribute):

what changes have you seen to the general EMS practice since you started?

I'll start with a few examples:

1. when I started, all patients who received ALS care had a running IV bag of fluid hung, regardless of complaints. now ALS patients might get a saline lock, if the paramedic thinks they will be giving an IV medication.
2. when I started, BLS providers were not able to do any "invasive" skills. This includes supraglottic airways, BGL checks (because they have a needle), and Narcan was ALS only. now BLS can do all of those things, even in my former home state of NJ.
3. for any trauma alert, two large-bore IVs was the standard ALS intervention, and lactate ringers wide open. Now we realize that doing this just causes people to bleed kool-aid and permissive hypotension is the in thing

 

[NomadicMedic]

EOAs, MAST trousers. Backboards. C-collars. All were really common back when I started.

The biggest change has been the ability to justify not moving an arrest until you have ROSC. Used to be we'd scoop 'em up and do crappy CPR in the ambulance on the way to the hospital and pronounce them.

Oh yeah. Having to clean and reuse laryngoscope blades and BVMs.

 

[mgr22]

I started in 1992. Since then, the biggest changes in prehospital practice I've seen are (in no particular order):

• Reliance on cell phones for communication and data.
• Routine 12-lead EKGs.
• Awareness of bloodborne pathogens and use of PPE.
• BGL, SpO2, and CO2 monitoring.
• SGAs often used instead of ETIs.
• The focus on chest compressions during cardiac arrests.
• Narcan and defibrillators for public use.
• ePCRs.
• The switch from ETTs to IOs as alternatives to IVs.
• Specialty treatment centers.
• Ergonomic stretchers.
• Computer-based training.
• Controlled substances in EMS formularies.
• Automated BPs.
• Community paramedicine.

 

[FiremanMike]

All great answers above.

I'd add a move towards customer service. When I first started ('98), the bulk of our runs were moderate-high acuity and performing ALS care was the norm. Unfortunately, like much of public safety, we've changed from only responding to emergencies and doing emergency things to an era where more of our runs are non-emergent (at best) than emergent.

 

[johnrsemt]

Guidelines, rather than Protocols.
More and more medical directors realize we have a brain and don't need our hands held and we don't need to be told every little detail (unless you work in most of California).

 

[DrParasite]

EOAs, MAST trousers. Backboards. C-collars. All were really common back when I started.

The biggest change has been the ability to justify not moving an arrest until you have ROSC. Used to be we'd scoop 'em up and do crappy CPR in the ambulance on the way to the hospital and pronounce them.

When I started we still has MAST trousers on the BLS trucks. some agencies had gotten rid of them because ALS trucks carried them. We covered them in EMT class (when I took them in 1998), but no one I spoke to actually used them on a scene.

I forgot about scoop and run on cardiac arrest; we used to do that ALL THE TIME! the only time we didn't was if we thought the patient was going to be pronounced by ALS, because nothing sucked more than having the paramedics pronounce the patient in the back of the BLS ambulance. I have done crappy compressions in a moving truck more times than I can count, so I'm very glad to hear we work them on scene now,

I guess there are two other changes I would add: power stretchers, and stairchairs with treads. When I started, one agency was still using two-man stretchers. talk about a backbreaker.

The old school stairchairs were also common (my back still hurts just thinking of the ferno one we used), so when the Stryker introduced the Stair-TREAD system, it was truly a game-changer. We still carried the old chair on city 911 trucks as a backup, because of narrow hallways and crappy stairs, but the treads made it much easier to carry down a 300 lb patient.

 

[akflightmedic]

for any trauma alert, two large-bore IVs was the standard ALS intervention, and lactate ringers wide open.

Large bore meant 14g or 16g then....

Now it is 18g. And as we know, that is perfectly acceptable.

 

[NomadicMedic]

Either people were smaller or I was stronger when I first started.
These ferno stretchers were brutal.

They’re still 100 pounds lighter than a Stryker Power Pro XT.

 

[Fezman92]

they trained us how to use that stretcher in EMT school.

 

[Peak]

for any trauma alert, two large-bore IVs was the standard ALS intervention, and lactate ringers wide open. Now we realize that doing this just causes people to bleed kool-aid and permissive hypotension is the in thing

Large bore meant 14g or 16g then....

Now it is 18g. And as we know, that is perfectly acceptable.

Two large bore IVs (with the expectation of 14s if possible) for adults is still an expectation in some areas. It is here for trauma Red/1 and code whites.

For the patient who needs massive transfusion a 14 is going to provide faster flow over an 18, especially when you consider how much more viscous blood product is than crystalloid fluids.

 

[DrParasite]

Two large bore IVs (with the expectation of 14s if possible) for adults is still an expectation in some areas. It is here for trauma Red/1 and code whites.

For the patient who needs massive transfusion a 14 is going to provide faster flow over an 18, especially when you consider how much more viscous blood product is than crystalloid fluids.

the IV part wasn't what I was referring to; it's dumping as much fluid into them to get their BP up to a closer to normal level prehospitally.

and @NomadicMedic one of my agencies used that exact model... and upgraded to the 1st gen stryker powerlift stretchers after much debate. so much better

 

[akflightmedic]

Two large bore IVs (with the expectation of 14s if possible) for adults is still an expectation in some areas. It is here for trauma Red/1 and code whites.

For the patient who needs massive transfusion a 14 is going to provide faster flow over an 18, especially when you consider how much more viscous blood product is than crystalloid fluids.

I will try to find the study I ran across a few months back...where they demonstrated that although faster flow is a given, it is neither necessary nor possible when used with other/certain adjuncts. Basically the study renders the use of 14/16g darn near obsolete with science and math.

And another valid point was there is rarely a situation where a 14/16 can be the difference in a given situation that an 18 cannot accomplish.

I do not know what you mean by Trauma Red/1 or Code White. Never heard these terms.

 

[Peak]

I will try to find the study I ran across a few months back...where they demonstrated that although faster flow is a given, it is neither necessary nor possible when used with other/certain adjuncts. Basically the study renders the use of 14/16g darn near obsolete with science and math.

And another valid point was there is rarely a situation where a 14/16 can be the difference in a given situation that an 18 cannot accomplish.

I do not know what you mean by Trauma Red/1 or Code White. Never heard these terms.

The argument I’ve always heard is that an 18 under pressure provides similar flow to a 14 by gravity. That being said I can apply pressure to the 14 as well. Some pressure infusers cannot keep up with a 14, cordis, or RIC when pressure infusing crystalloid. That isn’t the case with blood product. I’d be happy to look at the study if you find it.

Most large trauma systems have a tiered trauma alert system. There is a lower tier for patients who meet a risk criteria (fall greater than 2 times height, ejection from a motorcycle, ATV rollover, death in the same MVC, et cetera) and a physiologic/anatomical criterial (penetrating injury to the Head/neck/t-shirt & boxer line, hypotension, abdominal trauma in pregnancy, witnessed trauma arrest, and so on); the latter of which of course being the higher acuity.

These are sometimes called as a trauma red vs trauma yellow, trauma alert vs trauma page/notification(or overhead vs later only), trauma 1 vs trauma 2, trauma stat vs trauma alert, and so on. These are variable based on the specify system, some may even have a higher level like the T10 program at St A’s.

A code white, locally at least, is an life threatening OB hemorrhage or cardiac arrest as the result of hemorrhage.

 

[akflightmedic]

The argument I’ve always heard is that an 18 under pressure provides similar flow to a 14 by gravity. That being said I can apply pressure to the 14 as well. Some pressure infusers cannot keep up with a 14, cordis, or RIC when pressure infusing crystalloid. That isn’t the case with blood product. I’d be happy to look at the study if you find it.

Most large trauma systems have a tiered trauma alert system. There is a lower tier for patients who meet a risk criteria (fall greater than 2 times height, ejection from a motorcycle, ATV rollover, death in the same MVC, et cetera) and a physiologic/anatomical criterial (penetrating injury to the Head/neck/t-shirt & boxer line, hypotension, abdominal trauma in pregnancy, witnessed trauma arrest, and so on); the latter of which of course being the higher acuity.

These are sometimes called as a trauma red vs trauma yellow, trauma alert vs trauma page/notification(or overhead vs later only), trauma 1 vs trauma 2, trauma stat vs trauma alert, and so on. These are variable based on the specify system, some may even have a higher level like the T10 program at St A’s.

A code white, locally at least, is an life threatening OB hemorrhage or cardiac arrest as the result of hemorrhage.

Ok..in the states I have worked and at the Level 1s I worked at, it either is a Trauma Alert or it isn't, those were the only options.
Thanks for explaining Code White. First for me.

 

[Peak]

Ok..in the states I have worked and at the Level 1s I worked at, it either is a Trauma Alert or it isn't, those were the only options.
Thanks for explaining Code White. First for me.

Unfortunately there isn't a lot of consistency when it comes to naming internal hospital emergencies.

Often smaller (whether by hospital size, total trauma volume, average acuity of trauma volume, or a multitude of other factors) find it easier to have only one alert rather than several. These typically do not coincided with the positions of large emergency/trauma/critical care sercitices, but that doesn't necessarily deminish the value of their roles. Likewise the avtivation criteria of various high accuity centers often crosses over between those higher and lower tiers.

 

[cruiseforever]

I started in 1992. Since then, the biggest changes in prehospital practice I've seen are (in no particular order):

• Reliance on cell phones for communication and data.
• Routine 12-lead EKGs.
• Awareness of bloodborne pathogens and use of PPE.
• BGL, SpO2, and CO2 monitoring.
• SGAs often used instead of ETIs.
• The focus on chest compressions during cardiac arrests.
• Narcan and defibrillators for public use.
• ePCRs.
• The switch from ETTs to IOs as alternatives to IVs.
• Specialty treatment centers.
• Ergonomic stretchers.
• Computer-based training.
• Controlled substances in EMS formularies.
• Automated BPs.
• Community paramedicine.

Yes to all of the above. You can also add:
adressing in the rural areas
911
Pacing
hands off defibrillation
calling codes in the field
expanded SOPs, I have a hard time remembering the last call to med control.
better designed and smoother riding ambulances
warmer and drier winter clothing
much younger partners
800 radios
CAD
prearrival info
Lucas
no more hyperventilation
Velcro restraints
adjustable c-collars
Broselow tape

 

[OceanBossMan263]

Yes to all of the above. You can also add:
adressing in the rural areas
911
Pacing
hands off defibrillation
calling codes in the field
expanded SOPs, I have a hard time remembering the last call to med control.
better designed and smoother riding ambulances
warmer and drier winter clothing
much younger partners
800 radios
CAD
prearrival info
Lucas
no more hyperventilation
Velcro restraints
adjustable c-collars
Broselow tape

Still going...
not slapping a collar and board on everyone who was within 10 feet of a vehicle collision
common sense use of medicines available OTC to our patients- aspirin, ibuprofen, tylenol

since covid (at least in NY)... the ability to tell a patient he doesn't need the hospital and justify non-transport for non-emergent situations, and finally realizing that we shouldn't be transporting dead people to the hospital to use up resources and space

 

[Carlos Danger]

I will try to find the study I ran across a few months back...where they demonstrated that although faster flow is a given, it is neither necessary nor possible when used with other/certain adjuncts. Basically the study renders the use of 14/16g darn near obsolete with science and math.

And another valid point was there is rarely a situation where a 14/16 can be the difference in a given situation that an 18 cannot accomplish.

I would be interested in seeing that study.

 

[akflightmedic]

I am digging...it was one of the many rabbit holes I fall into. I read it, and moved on. Months later, a convo pops up about it and I cannot produce it. LOL. I am re-googling trying to find the hole Alice fell into.

I do remember one small aspect mentioned which many of us do not know or fail to do...when I first started EMS, we never had saline locks. All IVs were plugged directly into catheter. Nowadays in many places, we insert catheter, connect the lock, and then flow fluids through the lock.

But if we were trying to dump high volume, as in a 18g or even a 16g, we should connect direct old school style and skip the lock.

 

[DesertMedic66]

I am digging...it was one of the many rabbit holes I fall into. I read it, and moved on. Months later, a convo pops up about it and I cannot produce it. LOL. I am re-googling trying to find the hole Alice fell into.

I do remember one small aspect mentioned which many of us do not know or fail to do...when I first started EMS, we never had saline locks. All IVs were plugged directly into catheter. Nowadays in many places, we insert catheter, connect the lock, and then flow fluids through the lock.

But if we were trying to dump high volume, as in a 18g or even a 16g, we should connect direct old school style and skip the lock.

I also recall reading this article. It pretty much said that there were limiting factors which included the IV tubing, use of saline locks, length of IV cath, and I think maybe one or two additional factors.