"You don't need all those fancy gadgets...

[Veneficus]

If the chest is going up and down, the drainage tubes are empty, and the urine bag full, then the patient is doing all right."

Was a half joking, half wise comment made by my surgical mentor, while watching me stare intently at a plethora of monitors on a post op cabg and valve repair patient.

But as I sit here today writing yet another paper on molecular biomarkers in shock detection and severity, it makes me wonder...

"Do we really need all of this crap?"

Another expensive quantitative test to detect AKI and guide treatment.

Since we know the multifactorial cause of AKI, we can reasonably suspect those at risk. Certainly the empty or discolored urine in the bag will tell us something.

In some of my yet unpublished aneurysm research, I discovered that post op survival of ruptured aneurysm patients in the 1960s was better than on the recent populations which are still being treated with guidlines from the mid 1980's. (by more than 15%)

The major difference?

In the 60's they assumed everyone needed dialysis. So every post op patient got it.

Now they look for renal indicators. The commonly used ones Creatinine and cysteine C really only measure GFR and are positive past the window where many treatments are effective.

Quantitative assessment fail in my opinion.

But in today's medical world, including EMS, there seems to be this idea that the more electronic quantitative crap is bought and used, the better the medicine is.

In EMS the latest gear is capnography. For everything from measuring the effectiveness of oxygen delivered by canula to the quality of chest compressions.

Do expert providers really need a graphic or quantitative guide to tell if they are doing quality CPR?

If oxygen therapy is working?

Did they not take a CPR course that taught the importance of high quality CPR and tested them on it?

Did ALS providers not take an ACLS class that again stressed the high quality and effectiveness of the BLS component?

What is the point of all of this diagnostic technology?

It seems to be a bandaid for under educated underskilled providers. (Healthcare practicioners outside EMS not excluded)

I picked on capnography, but in truth, there is all kinds of devices in and out of the hospital. They tell us what we know. What we should suspect.

If these numbers and gadgets are so useful, why do we have corpses with normal numbers?

Why do we need numbers to tell us somebody is dead?

I think we are making a mistake somewhere.

 

[NYMedic828]

I think a lot of it has to do with having actual numbers to document instead of your perception of a situation.

In the US, everything is done on the basis of avoiding lawsuits while providing the best care under that thought process instead of providing the highest care possible first and worrying about the repercussions second.

Only being an EMSer, I don't know much about all of the tools at your disposal in hospital (I know your favorite is the ultrasound) but to touch on what you said about capnography, I think they have gone above and beyond the original intended purpose of it.

In the ERs here they don't even use capnography, they confirm tube placement the old fashion way of just looking and listening. In the field, should my capnography fail to operate, regardless of seeing the tube pass directly through the vocal cords, I have to remove the ETT and continue on with a BVM. (this has happened to me)

Other accessories like pulse oximetry are also far too relied on for determining sufficient ventilation and oxygenation. Hell pulseoximetry doesn't even measure sufficiency of ventilation. Most people don't even know how an oximeter even works or what other uses it has. Less than 100% oh my god get them on a NRB stat!

 

[Doczilla]

Caponography in EMS stems in part from risk adversity.

"If you dont have (x and y parameters) , pull the tube."

We introduce more tools over time to compensate for the lowest common denominator.

Sometimes, they introduce tools just for the sake of it. Take the sternal I.O. all the rage in the army. Before those days though, it was fielded to a small non-transport ALS fire department, and I witnessed its use (despite perfectly viable EJ's) soley for the sake of using it.

Also interesting is paying for a Bluetooth option to transmit ECG's to receiving facilities. I know, fairly common practice in some places; but shouldn't more time and effort be spent towards bringing us up to the standard that allows us to give trustworthy interpretation?

Guess its cheaper than spending the overtime for inservices....

 

[shfd739]

I don't see much of the toys due to my employer--adding one new toy to the toy box is an expensive undertaking..

I have noticed that newer providers seem to want to throw every toy at every patient.

Even minor complaints wind with up 12 leads, capnography, IVs; .Ask the medic why and get a blank stare in reply.

Seems they don't trust their knowledge or themselves and expect the toys to give the answer.

 

[jlw]

It all comes down to money IMHO. As long as the various companies can turn a good profit selling all the various "diagnostic" equipment under the guise of providing the best and most accurate care possible then providers will continue to use the latest and greatest so as to not be labeled behind the times or risk any potential liability for not providing their clinicians with the tools "necessary.

 

[Jambi]

It seems to be a bandaid for under educated underskilled providers. (Healthcare practicioners outside EMS not excluded)

This...

During my paramedic clinicals an old ED doc mentored me. He liked to say, "stop paying attention to the gadgets and just look at your damn patient!" He was big on physical assessment and learning to "read" patients. I've tried to be a patient "reader" ever since. It's definitely a learning process.

 

[Christopher]

Caponography in EMS stems in part from risk adversity.

"If you dont have (x and y parameters) , pull the tube."

We introduce more tools over time to compensate for the lowest common denominator.

Ack...capnography is not catering to the lowest common denominator. Capnography is catering to the patient. Nothing to do with risk adversity at all.

The lowest common denominator is who fights capnography. Systems which use it for "risk adversity" probably are full of LCD's.

Sometimes, they introduce tools just for the sake of it. Take the sternal I.O. all the rage in the army. Before those days though, it was fielded to a small non-transport ALS fire department, and I witnessed its use (despite perfectly viable EJ's) soley for the sake of using it.

EJ's are not without complication. Granted, that does not excuse their behavior.

Also interesting is paying for a Bluetooth option to transmit ECG's to receiving facilities. I know, fairly common practice in some places; but shouldn't more time and effort be spent towards bringing us up to the standard that allows us to give trustworthy interpretation?

Amen.

Guess its cheaper than spending the overtime for inservices....

If you need inservicing for 3/12-Lead interpretation, you're not a paramedic by any standard that I'm aware of...but I have a biased view (and work in a system biased towards that view).

 

[Aidey]

I don't think capnography is a LCD tool. Yes, it helps with the idiots that don't recognize missed tubes, but it has uses far beyond that.

I'm also not a huge fan of transmitting 12 leads. I think that if you can't trust your medics to identify a STEMI it is better to spend the money educating them. One of our local hospitals started having us do this, and if they ever decide to refuse to activate the cath lab without a transmitted 12 lead it won't be pretty. Right now they are using the 12 transmission as an advertising point, and I'm hoping it was just done as a gimmick.

 

[Jambi]

I don't think capnography is a LCD tool. Yes, it helps with the idiots that don't recognize missed tubes, but it has uses far beyond that.

I'm also not a huge fan of transmitting 12 leads. I think that if you can't trust your medics to identify a STEMI it is better to spend the money educating them. One of our local hospitals started having us do this, and if they ever decide to refuse to activate the cath lab without a transmitted 12 lead it won't be pretty. Right now they are using the 12 transmission as an advertising point, and I'm hoping it was just done as a gimmick.

Don't come to Riverside County Ca. We're full of LCD medics and there is no direct CathLab activation. All patients go via ER, and it cannot happen without the monitor spitting out MI suspected or whatever else it wants to say. We cannot transport out of medic discretion...They also took pediatric intubation away for under 8s. etc

I just watched a medic push Atropine on a normo-tensive, good skin signs, bradycardic patient complaining of mild dizziness. I've also seen this same medic AMA an 85 year old male complaining of sudden onset unusual epigastric pain/indigestion...that's fire departments for you here in southern california...yay.

 

[Doczilla]

Again, I said part risk adversity. I'm not knocking it, but what im saying is that some services use it as a safety net for when a hospital tells you that your tube wasnt good wheb you brought them in.

Also, you would be extremely suprised about how many paragods can't distinguish between junctional and a-fib.

 

[Pavehawk]

Capnography, EKG, Glucometer, pulse ox, or any other technology is just a tool in the hand of a good clinician. When I started in EMS the only one of these tools we used in the field was a 3 lead EKG. Somehow the patients still got treated, O2 got put on, IV's got started, and ET tubes got placed. We still pushed drigs when they were needed (and some when they wern't, hello NaHCO3 for every code!!)

Now that we (EMS) have more toys I still use my clinical skills to assess a patient and determine what interventions are needed. All the toys and their data is for is to augment my skills and knowledge.

Could I run in a system that did not have capnography or SPO2 or 12 leads, or BGL at POC? Yeah, I could ( and have), but I have gotten in the habit of using the tools I have been given to do the best I can for my patient. It doesnt matter if they glow in the dark, beep, and make pretty lines on a screen, or are pink and have ten fingers, a tool is a tool.

I do dislike the LCD's in our system and it pains me to see protocols designed with that in mind, but I don't see that changing in my life time...(P>S> Im an old fart) unless we make Vene and few others like him king of EMS!!!

 

[Jambi]

Also, you would be extremely suprised about how many paragods can't distinguish between junctional and a-fib.

no I wouldn't lol, but that's for another thread.

To echo what you're saying Docz, risk adversity is what our protocols are based on. The MD cannot trust the medics in this county to perform, the powerful agencies refuse to do meaningful QA/QI, and repercussions are few because said agencies and their fire unions fight back via PR...AMR medics have also caused their fair share of problems.

And on the capnography issue, we're mandated to use both electronic/monitor and colorimetric because, and I quote the medical director on this, "it makes me feel good when I see the color change.." Sigh

 

[Jambi]

... unless we make Vene and few others like him king of EMS!!!

Lets get them to RivCO CA. We need a medical director with some :censored::censored::censored::censored: cajones

 

[Brandon O]

All I have to add is that, whenever someone says they don't need Fancy Tool X and it's only for "dumb medicine," I have this sneaking suspicion that they're not quite as good as they think.

We just had a medic of 10+ years roll a patient into the ED with an esophageal intubation because he didn't use the capnography. I'm sure he thought he didn't need it.

 

[Jambi]

We just had a medic of 10+ years roll a patient into the ED with an esophageal intubation because he didn't use the capnography. I'm sure he thought he didn't need it.

Money says he also failed to "read" is patient or check other simple things that would indicate an esophageal placement.

 

[Veneficus]

Money says he also failed to "read" is patient or check other simple things that would indicate an esophageal placement.

Or the tube was displaced while unloading. That happens from time to time. Anyone who has intubated in the field for any length of time can probably share stories where they or somebody they know actually knew the tube was in when they were pulling up to the ED, but it was in the esophagus or posterior pharanx when they got in the patient ED. How does capnography change that?

The question still remains, how much is too much?

Technology allows for some rather amazing things, but I still submit that relying on any single piece of technology is due to lack of ability.Technology will never replace ability.

Not all of this technology is beneficial outside of a lab. Some definately comes with an outrageous cost, and for the most part isn't feasable to apply to every patient, especially running a 1000 diagnostic tests on everyone. It is a compensation for fools.

We can inject radionucleotide into people and watch renal epithelial cells slough off in real time. Why don't we do it for everyone?

It is totally impractical and would cost incredible amounts of money.

That is my point. It is not antitechnology, it is wondering where the balance is. At what point do we use technology more for ourselves than for the patient?

As for my ability. It stands on its own merit.

 

[Melclin]

I don't know if I agree with the basic premise of the post.

If more toys are making us worse clinicians, that isn't the fault of the toys. Keep the toys and chuck the clinicians (or you know... train them better or something).

Of course the toys are adjuncts. I can think of a number of examples, where a number generated by one of these machines has done everything to change the way I was looking at a job. Now in each of those cases, it wasn't the number alone that changed my mind but it helped re-frame a whole bunch of reasonably non-specific information in a way that changed the ultimate diagnosis. I once had a pt in an Af of 180, hypotensive at 65/40. Both pt and wife were terrible historians. BSL of 30.3. It prompted me to ask more directed questions related to hyperglycaemia, DKA, fluid status etc. I fixed his HR and BP with fluid. Without the BSL to push things in that direction, might he have electrically cardioverted what we thought was a primary arrhythmia? Surely we all have these jobs, with reasonable frequency, where one number has opened our minds or confirmed our suspicions.

I'm about to go have some dinner and I can't be bothered digging around on a database, but I'm sure I've come across quite a few articles in the past suggesting the relative poverty of our clinical assessment compared to some of our toys. Hand on the forehead Vs thermometer, looking at the pt vs pulse oximetry. BSLs are pretty damn handy. I think we'd be giving a lot of unnecessary dextrose if we didn't have it and missing it when we should have been topping people up. I've had plenty of hyperglycaemic pts in whom the BSL reading added clarity and modified my fluid resus, choice of hospitals etc. How exactly do you monitor HR continuously with real time accuracy without a monitor when you already wish you had a few more hands. Can you diagnose a STEMI without an ECG?

Could capnography help us to stop reanimating a subgroup of cardiac arrests that have no chance of a good outcome? Maybe. Allow us to identify ROSC with minimal cessation of compressions...maybe. Waveform capnography is pretty well established as adding a real time and accurate level of safety to tube confirmation. Of course it not impossible to intubate without it, but it adds a level of safety and control to a potentially high stress procedure done in reasonably uncontrolled environments.

If you end up falling back on a lowest common denominator argument, then that is still perfectly reasonable. No large system is going to be 100% made up of clinicians who are all perfect. This idea is not at all specific to paramedics.

There are uses for all of these toys, if they're being misused the answer is not get rid of them, but to start using them properly.

 

[Veneficus]

I don't know if I agree with the basic premise of the post.

If more toys are making us worse clinicians, that isn't the fault of the toys. Keep the toys and chuck the clinicians (or you know... train them better or something).

Of course the toys are adjuncts. I can think of a number of examples, where a number generated by one of these machines has done everything to change the way I was looking at a job. Now in each of those cases, it wasn't the number alone that changed my mind but it helped re-frame a whole bunch of reasonably non-specific information in a way that changed the ultimate diagnosis. I once had a pt in an Af of 180, hypotensive at 65/40. Both pt and wife were terrible historians. BSL of 30.3. It prompted me to ask more directed questions related to hyperglycaemia, DKA, fluid status etc. I fixed his HR and BP with fluid. Without the BSL to push things in that direction, might he have electrically cardioverted what we thought was a primary arrhythmia? Surely we all have these jobs, with reasonable frequency, where one number has opened our minds or confirmed our suspicions.

I'm about to go have some dinner and I can't be bothered digging around on a database, but I'm sure I've come across quite a few articles in the past suggesting the relative poverty of our clinical assessment compared to some of our toys. Hand on the forehead Vs thermometer, looking at the pt vs pulse oximetry. BSLs are pretty damn handy. I think we'd be giving a lot of unnecessary dextrose if we didn't have it and missing it when we should have been topping people up. I've had plenty of hyperglycaemic pts in whom the BSL reading added clarity and modified my fluid resus, choice of hospitals etc. How exactly do you monitor HR continuously with real time accuracy without a monitor when you already wish you had a few more hands. Can you diagnose a STEMI without an ECG?

Could capnography help us to stop reanimating a subgroup of cardiac arrests that have no chance of a good outcome? Maybe. Allow us to identify ROSC with minimal cessation of compressions...maybe. Waveform capnography is pretty well established as adding a real time and accurate level of safety to tube confirmation. Of course it not impossible to intubate without it, but it adds a level of safety and control to a potentially high stress procedure done in reasonably uncontrolled environments.

If you end up falling back on a lowest common denominator argument, then that is still perfectly reasonable. No large system is going to be 100% made up of clinicians who are all perfect. This idea is not at all specific to paramedics.

There are uses for all of these toys, if they're being misused the answer is not get rid of them, but to start using them properly.

The basic premise of the post is how much is too much?

 

[Veneficus]

I don't know if I agree with the basic premise of the post.

If more toys are making us worse clinicians, that isn't the fault of the toys. Keep the toys and chuck the clinicians (or you know... train them better or something).

There are uses for all of these toys, if they're being misused the answer is not get rid of them, but to start using them properly.

I think there is a lot of interesting perspective here.

After giving it some thought, I think a lot of the technology isn't aimed at the experts.

It is to give the nonexperts a fighting chance.

Not to say these nonexperts are lesser clinicians, they are just not the crème de la crème of their respective disorders.

Take for example cardiac surgeons. Undoubtably experts in a handful of disease processes. For certain if you have one of these dseases, there is no other alternative provider.

Anesthesia practices bringing people to near death and then back all the time. (2 or 3 times a day usually) They are good at it.

Both of these disciplines are highly accustomed to predicting what the next step is and what to do when things don't go as planned.

EMS and by extension emergency medicne doesn't really deal with such specific diseases and treatments as often.

Some help from technology or guidlines certainly doesn't go amiss.

But it still doesn't answer the question. How much is too much?

At what point do you decide you need more experts or punt the patient to the ivory tower?

 

[Jambi]

But it still doesn't answer the question. How much is too much?

At what point do you decide you need more experts or punt the patient to the ivory tower?

As I sit here and think on this I'm surprised at myself in that I cannot even begin to frame an answer to this...

I suppose it's because I really don't know where to start. From the examples offered, these providers become expert in their own little slice of the medical pie. To me, this should translate well to the paramedic and EMS; we should be experts in prehospital emergency care. Thus the tools we are provided should have the purpose of augmenting our practice to either, (a) improve our ability to treat immediate life-threatening conditions, or (b) smooth the transition of care to receiving physicians (STEMI activation, stroke activation, etc).

Thus assuming that such technology was implemented to address the above, it can then be looked at from the point of view of when does such implementation impede such goals by delaying care, masking otherwise easily identifiable conditions, or unnecessarily complicate treatment and transport.

Is it a case of EMS trying to be too much, especially in light of the current educational standards here in the U.S.?

Is it a case of providing too much to under-prepared providers?

The point at which diminishing returns are reached is hard to define and it will be highly subjective and dependent on provider and locale.

This is another great example of why there needs to be more research done in EMS.