Your Controversial EMS-Related Opinion

[FiremanMike]

I've said it before, and I'll say it again: based on everything you have said about your department, your agency is likely in the minority when it comes to EMS providers who ride the BRT, and that's a good thing.

The last time I was part of an ALS FD was almost 20 years ago, and all of our FF/PMs had years of experience on the ambulance as PMs, usually as Senior PMs or FTOs. Many still worked for the City's EMS agency part time. Since then, I've worked with a few FF/PMs, but almost all had previous PM experience on the ambulance, and most were function as EMTs or AEMTs when on the BRT.

I know I'm biased, but there are not many suppression only EMTs, who have never worked on an ambulance, that I would trust do provide a decent assessment on a sick patient. There are even fewer suppression only paramedics, who have never worked on an ambulance, that I would feel comfortable assessing and treating at the ALS level, especially on a sick patient, if they were my family member.

I am much happier having the people on the BRTs being decent EMTs, with the ambulance people being more competent and experienced EMTs, along with a paramedic either on the truck or on a flycar, only handling ALS criteria patients.

Think of if this way: if you are putting 7-9 paramedics on a cardiac arrest, do you trust all of them to intubate the 400 lb patient with a mallampati class 3 airway, at 3 in the morning? And when was the last they those 7 to 9 paramedics intubated a live person with a difficult airway? or ran point on a circling the drain patient?

1. To be clear, my agency has issues. We have guys who have that p-card only because it's a requirement to get on, and we have guys who suck but can't get fired because it's too difficult. We also have some admin who hate EMS, but OVERALL, the culture in this area is different because EMS is nearly entirely fire based. There is a County EMS agency in an adjacent county, but otherwise, when you call 911, the ambulance that shows up will be from an FD.

2. I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.

Let's build on #2 and incorporate a counterpoint to some of the other thoughts in this thread. What happens when you put all your eggs in the basket of "one paramedic on scene", but that paramedic is a dolt and no one else on scene has enough training or education to realize that they're missing key signs that should be obvious to any ALS provider. Let's not pretend that the hiring standards for third service EMS agencies are such that only the cream of the crop can get those jobs, they have idiots who work there too who are also capable of murder through incompetence. When there isn't another ALS provider around to a. catch their mistakes or b. teach them, then the potential for disaster is high.

While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.

 

[EpiEMS]

I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..

I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.

Doing something more is better, all else equal. There's ample research out there showing that procedural success and outcomes are associated with volume per provider - and more medics means fewer procedures (all else equal) per ALS provider.

(For example, a study in Australia found that "OHCA survival to hospital discharge significantly increased with the number of OHCAs that paramedics had treated". Similarly, in one retrospective study of ETIs in PA, the authors noted a connection between "increased rescuer procedural experience and improved patient survival after out-of-hospital tracheal intubation of cardiac arrests and medical nonarrests".)

As far as RCT's, I'd be hard pressed to come up with a design that could ethically study this issue that way.

Probably true, the before/after control is about as good as we can probably get, I'd wager. And this is where the full suite of OPALS studies comes in - even if about a decade old - which suggest that ALS provision (which, at the time, included things now widespread in the BLS world) didn't do anything for trauma outcomes (not so surprising since the main skills referenced are ETI and IV fluids) or cardiac arrest but did improve outcomes for respiratory distress (seems like albuterol is a major driver here). T

Think of if this way: if you are putting 7-9 paramedics on a cardiac arrest, do you trust all of them to intubate the 400 lb patient with a mallampati class 3 airway, at 3 in the morning? And when was the last they those 7 to 9 paramedics intubated a live person with a difficult airway? or ran point on a circling the drain patient?

^This is it in a nutshell.

While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.

Plausible, but two points:

(1) Cost -- medics cost more. Do I get incremental benefit? A system can't be efficiently designed to do the most for the greatest number in such a manner.
(2) Quality -- more medics, more skill dilution, worse quality

 

[DrParasite]

2. I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.

Let's build on #2 and incorporate a counterpoint to some of the other thoughts in this thread. What happens when you put all your eggs in the basket of "one paramedic on scene", but that paramedic is a dolt and no one else on scene has enough training or education to realize that they're missing key signs that should be obvious to any ALS provider. Let's not pretend that the hiring standards for third service EMS agencies are such that only the cream of the crop can get those jobs, they have idiots who work there too who are also capable of murder through incompetence. When there isn't another ALS provider around to a. catch their mistakes or b. teach them, then the potential for disaster is high.

While the skill of intubation isn't difficult, it's a low frequency high risk skill in many systems (how many undetected prehospital esophageal intubations make the news), so while putting the tube between the cords is easy on a "routine" patient, it can have issues. Regardless, pick another high risk low frequency skill (needle decompression, dopamine drips, etc) and ask yourself: do you want someone who has done this procedure in the last week, last month, or 1 in the last 2 years?

BTW, I'm not saying 3rd service EMS agencies get the cream of the crop: I know from first hand experience that they have idiots, just like anywhere else. However, I am (maybe naively) optimistic that an 3rd service EMS agency, whose sole function is EMS, would terminate a new paramedic's credentials in their initial orientation if they could not function as a competent paramedic, as well as do mandatory competencies for people year after year... And have a robust QA/QI system to catch under performing providers. with a FD, when a department's primary missions is fire suppression, the focus on competencies is elsewhere, so if they can strech a hoseline, vent a roof, but have trouble reading that 12 lead, knowing their medication doses, well, we can work with that later in their career. Again, maybe not at your department, but I can assure you it happens at ABC Fire Dept.

While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.

Ehhhh, 7-9 medics sounds like horrible plan... skill dilution, worse quality, less experience with sick patients...

Now, do I think 1 paramedic on scene of a critical patient is a good idea? hell no. As you said, if the paramedic is a dolt, and no one else can pick up on key signs, it's a potential recipe for trouble. Those serious calls (cardiac arrests, penetration traumas, seizures/status ep, serious MVAs, etc) need to have a flycar paramedic/supervisor or second ambulance respond to the scene, to provide the second ALS provider for exactly the reasons you describe. While I do know there are some paramedics who refuse to work on a truck with another paramedic (after all, who is in charge of the patient or some other BS like that), there are times when having another ALS provider is beneficial.

 

[DesertMedic66]

1. To be clear, my agency has issues. We have guys who have that p-card only because it's a requirement to get on, and we have guys who suck but can't get fired because it's too difficult. We also have some admin who hate EMS, but OVERALL, the culture in this area is different because EMS is nearly entirely fire based. There is a County EMS agency in an adjacent county, but otherwise, when you call 911, the ambulance that shows up will be from an FD.

2. I've said it before and I'll say it again, the psychomotor skill of intubation is not that difficult, and of those 7-9 medics on scene, I'd expect several of them (but not all of them) to be excellent at intubation.

Let's build on #2 and incorporate a counterpoint to some of the other thoughts in this thread. What happens when you put all your eggs in the basket of "one paramedic on scene", but that paramedic is a dolt and no one else on scene has enough training or education to realize that they're missing key signs that should be obvious to any ALS provider. Let's not pretend that the hiring standards for third service EMS agencies are such that only the cream of the crop can get those jobs, they have idiots who work there too who are also capable of murder through incompetence. When there isn't another ALS provider around to a. catch their mistakes or b. teach them, then the potential for disaster is high.

While it may sound cumbersome to have 7-9 medics on scene, I'd argue it's convenient to have 7-9 ALS minded folks on scene who can do whatever needs to be done but can also catch mistakes or offer insight when necessary.

The counterpoint to your counterpoint is that when you greatly reduce the number of medics in a system it becomes vastly easier to train, educate, and evaluate them. You can also be much more selective over who you allow to become a medic. We shouldn’t have to rely on another medic to “catch our mistake”, the sole responsibility is for that medic to make the best decisions.

 

[StCEMT]

Yes, but NPs and PAs have significantly more training and would be more likely to recognize when something is moving past their expertise. Given the current state of EMT-Basic education, I'm not sure that applies there.

I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..

True, but depending on the structure in the background on how these dispatch, a higher level of education isn't needed. ALS isn't needed in the slightest for the majority of what we do. I'm all for the education bar going up, but it won't change outcomes for a fair bit of call volume.

Given the nationwide staffing issues, we already have delays in getting ALS providers on scene as is, my part time job has been a shining example of that. Why not buffer that with BLS units for calla that obviously don't need ALS?

 

[StCEMT]

Not true necessarily in the ED. Our NPs and PAs hit the high acuities.

I know it's a thing in some places. Locally for me, it basically doesn't exist. Only at one of about 16 or so places I go have I ever had a PA as lead on anything major.

 

[PotatoMedic]

How much do we really need paramedics when only 7 percent of our calls have interventions that are considered potentially life saving?

Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?

(2021). Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed? Prehospital Emergency Care: Vol. 25, No. 4, pp. 549-555.

www.tandfonline.com

 

[EpiEMS]

How much do we really need paramedics when only 7 percent of our calls have interventions that are considered potentially life saving?

Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?

(2021). Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed? Prehospital Emergency Care: Vol. 25, No. 4, pp. 549-555.

www.tandfonline.com

While I agree with the general point, I do question whether we are fully accounting for the other capabilities that paramedics bring. Obviously, there is opportunity to extend more capabilities further down the "clinical ladder" (Nitronox, anybody?), but pain control, sedation, etc. have unaccounted value.

The best analysis would look at a QALY, but unfortunately that is not something readily available for EMS.

 

[DrParasite]

While I agree with the general point, I do question whether we are fully accounting for the other capabilities that paramedics bring. Obviously, there is opportunity to extend more capabilities further down the "clinical ladder" (Nitronox, anybody?), but pain control, sedation, etc. have unaccounted value.

The best analysis would look at a QALY, but unfortunately that is not something readily available for EMS.

or... we can just give EMTs the ability to administer Fentanyl lollipops... that would allow them to give a little pain control medication to make the patient feel better... hard to accidentally OD on them, and even if they did, EMTs carry Narcan...

 

[DesertMedic66]

or... we can just give EMTs the ability to administer Fentanyl lollipops... that would allow them to give a little pain control medication to make the patient feel better... hard to accidentally OD on them, and even if they did, EMTs carry Narcan...

If only there was some type of gas or something that can be self administered by the patient that has a quick onset and quick half-life that has been shown to be a very good option for pain management…

 

[CCCSD]

California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police

Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.

www.foxnews.com

My “controversial option”: Fire every single FF involved in this, including the Chief, and charge them for criminal negligence and sue the city in court.

Cop deserves an award.

 

[ffemt8978]

California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police

Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.

www.foxnews.com

My “controversial option”: Fire every single FF involved in this, including the Chief, and charge them for criminal negligence and sue the city in court.

Cop deserves an award.

There's nothing controversial about your opinion there.

 

[Summit]

Sounds like they only have an acting chief who suspended everyone, called them failures, thanked the cops, and called for an outside investigation of his department.

That man's family is gonna get paid.

 

[DrParasite]

California medics refuse to enter care center to help man in cardiac arrest due to 'some COVID-19 law': police

Paramedics in Southern California refused to enter a post-acute-care facility to treat a man in cardiac arrest because of "some COVID-19 law," according to a Rialto Police Department report.

www.foxnews.com

My “controversial option”: Fire every single FF involved in this, including the Chief, and charge them for criminal negligence and sue the city in court.

Cop deserves an award.

Chief wasn't there, and likely the FFs weren't following his directions, so he shouldn't take the blame or punishment for the freelancing of these idiots. Unless he actually told them that they shouldn't enter due to COVID....

From the outside, this looks bad.... really bad... but (and here is the controversial part) I'm going to wait until the investigation completes before I say what I think should happen to all involved.

In case anyone was wondering, a FF/PM in that is paid $88,093.00 a year as their base salary, with a total pay between 150k and 240k, as per https://transparentcalifornia.com/salaries/search/?a=rialto&q=paramedic&y=2019. Single role paramedics make between 36k and $512 as their base salary. If this story is accurate, the taxpayers are not getting what they pay for, and I hope terminations are in order.

 

[DrParasite]

If only there was some type of gas or something that can be self administered by the patient that has a quick onset and quick half-life that has been shown to be a very good option for pain management…

If only this type of gas had been used prehospital since the 1980s..... and is still in use today....

Effectiveness of nitrous oxide in a rural EMS system - PubMed

Prehospital systems need a safe, effective analgesic agent for the treatment of patients suffering from pain. Recent studies have documented the efficacy of nitrous oxide in urban and rural settings. This study reviews the findings on 200 patients (157 trauma, 23 medical, 18 musculoskeletal...

pubmed.ncbi.nlm.nih.gov

Using Nitrous Oxide to Manage Pain - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News

Nitrous oxide has emerged as a medication closely in line with the tenets of modern prehospital medicine: evidence-based and noninvasive. It’s a medical gas that possesses both sedative and analgesic properties, and has been used extensively in hospitals and clinics worldwide for many years...

www.jems.com

https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322118/prehospital-pharmacology-nitrous-oxide

https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222945/nitrous-oxide-prehospital-analgesic

No laughing matter: Nitrous oxide reappears in US ambulances

Normally used in dentist's offices and hospitals, laughing gas is starting to turn up again in ambulances in some rural areas.

www.statnews.com

Nitrous oxide an alternative to opioids on ambulances

In some Vermont communities ambulances are now equipped with nitrous oxide to help patients deal with pain as opposed to opiates.

www.wcax.com

 

[EpiEMS]

If only this type of gas had been used prehospital since the 1980s..... and is still in use today....

Effectiveness of nitrous oxide in a rural EMS system - PubMed

Prehospital systems need a safe, effective analgesic agent for the treatment of patients suffering from pain. Recent studies have documented the efficacy of nitrous oxide in urban and rural settings. This study reviews the findings on 200 patients (157 trauma, 23 medical, 18 musculoskeletal...

pubmed.ncbi.nlm.nih.gov

Using Nitrous Oxide to Manage Pain - JEMS: EMS, Emergency Medical Services - Training, Paramedic, EMT News

Nitrous oxide has emerged as a medication closely in line with the tenets of modern prehospital medicine: evidence-based and noninvasive. It’s a medical gas that possesses both sedative and analgesic properties, and has been used extensively in hospitals and clinics worldwide for many years...

www.jems.com

https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322118/prehospital-pharmacology-nitrous-oxide

https://www.hmpgloballearningnetwork.com/site/emsworld/article/1222945/nitrous-oxide-prehospital-analgesic

No laughing matter: Nitrous oxide reappears in US ambulances

Normally used in dentist's offices and hospitals, laughing gas is starting to turn up again in ambulances in some rural areas.

www.statnews.com

Nitrous oxide an alternative to opioids on ambulances

In some Vermont communities ambulances are now equipped with nitrous oxide to help patients deal with pain as opposed to opiates.

www.wcax.com

I will say I have read a lot of state and regional protocols and I see nitrous offered less often than I would like. It really ought to be an EMT-level skill as it is.

 

[DrParasite]

The only issue I see with Nitrous is accountability (if that even is an issue). with Fent lollipops, you can count how many you have, and track their usage, just like you would any other medication; can't do the same with a gas.

But I wouldn't be against nitrous being offered as an EMT level skill.

 

[EpiEMS]

The only issue I see with Nitrous is accountability (if that even is an issue). with Fent lollipops, you can count how many you have, and track their usage, just like you would any other medication; can't do the same with a gas.

But I wouldn't be against nitrous being offered as an EMT level skill.

Fair point on that. VT has some recommendations: https://www.healthvermont.gov/sites/default/files/Nitrous Start Up Guide 17-05-30 rev.pdf

Or maybe Penthrox? I think they have approved it recently in the US?

 

[E tank]

Read a lot about N20 used in the pre-hospital setting, but I've been surprised about not a single mention of contraindications like pneumothorax or bowel obstruction, pts with vitreoretinal surgical histories...stuff like that...was it there and I just missed it?

 

[silver]

Read a lot about N20 used in the pre-hospital setting, but I've been surprised about not a single mention of contraindications like pneumothorax or bowel obstruction, pts with vitreoretinal surgical histories...stuff like that...was it there and I just missed it?

Or mention of the environmental impact. Meanwhile other settings are limiting its use if possible.