What would you add? ALS and BLS

Fish said:
You don't have CPAP?
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No.

This was published in Clinical Matters (the ambulance clinical update) a while ago about it,

Despite what you might hear, PEEP and other means of raising pressure in the chest, such as
continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BIPAP), are not
magical cures for cardiogenic pulmonary edema. They reduce respiratory distress and might
reduce the number of patients who need to be intubated and ventilated when they get to hospital
but studies suggest they do not reduce mortality.
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Clare said:
No.

This was published in Clinical Matters (the ambulance clinical update) a while ago about it,
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Eh I don't really like the way that is written. Agreed that CPAP is not a magical cure but it is far from useless. Also, reducing the chances a patient will need to be intubated in the hospital is a very big deal. Early aggressive CPAP may be the difference between a short hospital visit and a long ICU stay with potential failure to ween and a trach.
 
Chase said:
Eh I don't really like the way that is written. Agreed that CPAP is not a magical cure but it is far from useless. Also, reducing the chances a patient will need to be intubated in the hospital is a very big deal. Early aggressive CPAP may be the difference between a short hospital visit and a long ICU stay with potential failure to ween and a trach.
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With the Medical Director being an Intensivest I would think he is well aware of that, I might ask him why we do not have CPAP.
 
Clare said:
If my suspicion is correct and we get ventilators and thrombolysis in 2013 then I don't think we need to add anything, maybe CPAP, maybe but apart from that I can think of nothing that we really need enough that justifies the expense.
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:blink: For what?
 
You know what we shouldn't do?
We shouldn't give oxygen to every single pt we see.
The education for the use of O2 needs to be far more in depth than it is.
 
To have protocols and SOP's to "treat and street" and bill insurance for certain clinical presentations: hypoglycemia, etc.
 
Clare said:
With the Medical Director being an Intensivest I would think he is well aware of that, I might ask him why we do not have CPAP.
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I think Tony is absolutely fantastic, but I vehemently disagree with his thinking on CPAP. Even if there is no mortality benefit (which I would dispute), one should consider the improvement in the work of breathing, subjective breathlessness and anxiety in much the same way as we think of pain relief. Even if it doesn't "save" the patient, it certainly reduces suffering, and that is important in and of itself. And as Chase points out, not intubating these patients is best for everyone. I have intubated a fair number of florid pulmonary edema patients prior to us getting CPAP and I have to say it is not fun for anyone.

Back to mortality benefit: Vital FMR, Saconato H, LadeiraMT, Sen A, Hawkes CA, Soares B, Burns KEA, Atallah ÁN. {Vital FMR, Saconato H, LadeiraMT, Sen A, Hawkes CA, Soares B, Burns KEA, Atallah ÁN.Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database of Systematic Reviews 2008.


NNT of 13 for mortality. That's a pretty good number.
 
Smash said:
I think Tony is absolutely fantastic, but I vehemently disagree with his thinking on CPAP.
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I doubt it is solely his thinking but with him being an ICU Specialist it is surprising. Do you know Tony? I have not had the pleasure of meeting him.
 
Smash said:
I think Tony is absolutely fantastic, but I vehemently disagree with his thinking on CPAP. Even if there is no mortality benefit (which I would dispute), one should consider the improvement in the work of breathing, subjective breathlessness and anxiety in much the same way as we think of pain relief. Even if it doesn't "save" the patient, it certainly reduces suffering, and that is important in and of itself. And as Chase points out, not intubating these patients is best for everyone. I have intubated a fair number of florid pulmonary edema patients prior to us getting CPAP and I have to say it is not fun for anyone.

Back to mortality benefit: Vital FMR, Saconato H, LadeiraMT, Sen A, Hawkes CA, Soares B, Burns KEA, Atallah ÁN. {Vital FMR, Saconato H, LadeiraMT, Sen A, Hawkes CA, Soares B, Burns KEA, Atallah ÁN.Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database of Systematic Reviews 2008.


NNT of 13 for mortality. That's a pretty good number.
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It is nice to see conversation like this here again.

I would point out that many intensivists do not like CPAP, for reasons that I do not think are even medically related.

I have encountered more than a few that believe CPAP is not an intensive care treatment, but something to be used on "stable" ward patients.

Something along the lines of "if they don't need intubated they don't need an ICU."
 
Veneficus said:
It is nice to see conversation like this here again.

I would point out that many intensivists do not like CPAP, for reasons that I do not think are even medically related.

I have encountered more than a few that believe CPAP is not an intensive care treatment, but something to be used on "stable" ward patients.

Something along the lines of "if they don't need intubated they don't need an ICU."
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So would they prefer to just intubate, diuresis, optimize cardiac function and hope for a smooth ween in a few days?

I understand that it may not directly impact patient mortality but should that be the sole deciding factor?
 
Chase said:
So would they prefer to just intubate, diuresis, optimize cardiac function and hope for a smooth ween in a few days?
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That seems to be the case.

I do not agree, but I acknowledge the philosophy exists.

Chase said:
I understand that it may not directly impact patient mortality but should that be the sole deciding factor?
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I don't think mortality/morbidity has anything to do with the decision.

I think it is a "this is what we do" mentality. With the belief that they do it because it is best.
 
since the OP is from Detroit.....

lets get the FD out of EMS, give EMS enough units to handle the call volume without needing help, give larger EMS system a career path, transitioning it from a job to long term career with one agency, give dispatch the authority to send the closest unit (AVLs in every truck, tracking where units are), MDTs for busier systems, ALS treats sick people only, BLS is educated enough to know the difference between sick and not sick, and when ALS is and isn't needed, supervisory personnel with management training, management with bachelors degrees in management areas at the minimum, and masters degrees preferred, and more focus on evidenced based medicine instead of "well this is how we have always done it, so if you don't do it this way, the QA nazis will be sent after you."

oh yeah, and more education so better documentation and fewer run-on sentences.
 
Clare said:
Myocardial infarction. It is my understanding that it is already used around the world in parts of Australia and the UK.
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Hasn't it pretty much been confirmed that indirect administration of tPa has more risks than benefits the majority of the time?
 
NYMedic828 said:
Hasn't it pretty much been confirmed that indirect administration of tPa has more risks than benefits the majority of the time?
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Depends on availability of PCI and onset of symptoms to needle/balloon times. In a rural area it may be beneficial prehospital if the closest interventional cardiology center is over 90 mins away. If your in the bush with a critical proximal LAD occlusion then it may be thromolytics or death.
 
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Here we have both CPAP and TNK. We have one cath lab and a lot of the population lives more than an hour from it. TNK has been used in the field dozens of times with good sucess. I have used CPAP several times with very good results. Even our BLS (PCP) crews can use CPAP. Mind you our PCP is considerably more educated than an US EMT-B.
A transport vent would be nice to have. As it stands we have to take an RT and vent from the sending hosp. for our CCT. The option is to bag the pt for two hours and that to me is just not good medicine.
Otherwise I would like to have more pain med choices. I only have MS and would like fentanyl and toradol.
 
DrParasite said:
since the OP is from Detroit.....

lets get the FD out of EMS, give EMS enough units to handle the call volume without needing help, give larger EMS system a career path, transitioning it from a job to long term career with one agency, give dispatch the authority to send the closest unit (AVLs in every truck, tracking where units are), MDTs for busier systems, ALS treats sick people only, BLS is educated enough to know the difference between sick and not sick, and when ALS is and isn't needed, supervisory personnel with management training, management with bachelors degrees in management areas at the minimum, and masters degrees preferred, and more focus on evidenced based medicine instead of "well this is how we have always done it, so if you don't do it this way, the QA nazis will be sent after you."
Detroit's EMS is separate from FD.
oh yeah, and more education so better documentation and fewer run-on sentences.
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:rofl:

While your plan is great, it is missing one thing, the funding.
You should watch Burn...
 
Achilles said:
:rofl:
Detroit's EMS is separate from FD.

While your plan is great, it is missing one thing, the funding.
You should watch Burn...
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ummm, no, it's not: http://www.detroitmi.gov/DepartmentsandAgencies/FireDepartment/EMS.aspx

And the first line of the site is: "The Emergency Medical Services Division of the Detroit Fire Department shall provide the highest level of pre-hospital care to the citizens, visitors, and stakeholders of the City of Detroit." While the latter part is a joke, the first part is 100% accurate.

oh yeah, funding, actually fund EMS with the $$$$ needed to do it's job without relying on any other agency to "stop the clock."
 
How do you expect to put all those additions into ems? They're not free.
I guess I was wrong about Detroit ems, thought they were different my bad.
 
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I'm going to repeat the formal name, taken from the official Detroit website "The Emergency Medical Services Division of the Detroit Fire Department." When the FD has a division called EMS, that makes EMS part of the fire department.

oh, and if case you still didn't get it, from the Detroit FD's main page:
"The Detroit Fire Department is comprised of 10 divisions:
Administration Division
Firefighting Division
Fire Marshal Division
Community Relations Division
Emergency Medical Services (EMS) Division
Apparatus Division
Communications Division
Medical Division
Research and Development Division
Training Academy"

so again, just because it's not the firefighting division, doesn't mean it's not part of the fire department.

I guess I should add reading comprehension to the BLS skillset....:unsure:
 
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