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I'm not suggesting you replace the soft squishy thing between your ears. That's what will tell you whether or not you can trust the numbers. Having an end tidal certainly doesn't mean you shouldn't have a listen either. SPO2 and EtCO2 do however remain the only quantifiable numbers you're going to get on an ambulance anytime soon. If you have access to them and you refuse to use these well vetted and studied tools at your disposal your being a prat. Don't believe me? Here's one of a great many papers regarding the use of EtCO2 to mitigate unrecognized esophageal intubation. http://mastertrain.8m.com/masterimages/2013articles/The Effectiveness of Out-of-Hospital Use of Continuous End-Tidal Carbon Dioxide Monitoring on.pdf
For the love of god ventilate them first is all I ask. For you and your partner's safety. Other than that, fill your boots. I don't care if I never bring around another opiate overdose because the PCP/EMT/FR did it prior to my arrival. The part about this whole debate that makes me laugh (at least in western Canada) is what brought it about. BC and Alberta have been experiencing a rash of overdoses involving Fentanyl (either directly or laced heroin). As a result of the increased number of overdose deaths public outcry has pushed the agenda. The funny bit is the dosing. The doses given either with home kits or by responding FR's/EMT's/PCP's are too small to be effective in a true fentanyl overdose. The doses these people are giving will rouse the average heroin user who took 2 points instead of the usual 1; not a fentanyl overdose. Dealing with true fentanyl overdoses I've been having to use in excess of 6mg of naloxone to bring them around to an effectively breathing state. Many of these patients end up on a continuous naloxone infusion while the fentanyl runs its course.
This my friends is exactly what I'm getting on about with one small difference. I would advocate the development of a Paramedic Practitioner group along the lines of what has been done in the UK as opposed to a PA/NP model. It might seem far fetched state side were paramedic education varies wildly; in countries like Canada, Australia, New Zealand etc. where paramedic education involves a significant post secondary commitment, it's merely a natural progression of the profession. Interestingly enough PA programs are just starting to come to life on the civillian side of things in Canada (currently there are two producing practitioners). Presently the overwhelming majority of accepted applicants are paramedics with a smattering of RN's and RT's tossed into the mix. I can't think of a better pool to draw from when implementing a pilot program.
At no point would I ever suggest putting paramedics into such a role without education/training to match the scope of the position. Paramedic education varies wildly around the world with programs ranging from 6-12 months to 3-4 years depending on the level and country. Suffice it to say the successful programs around the world have involved providers from the more educated end of the spectrum. As I've already mentioned a large part of the role would involve directing patients toward the correct care as opposed to providing that care directly. Ie. referring the patient requiring social work directly to the social worker or referring the home care nursing patient directly to a home health assessment team. Directing patient's toward the correct care doesn't require a practitioner to be able to provide that care. It requires a practitioner to recognize when that care is required. As far as upping the educational anti is concerned, all I can really say is it's about bloody time. For example. http://kssdeanery.ac.uk/sites/kssdeanery/files/Paramedic Practitioner Presentation.pdf I'm not talking about a pack of untrained monkeys. I'm talking about educated professionals who are prepared to provide such services.
Whether you or I believe these people should be calling for currently existing home health services instead is becoming increasingly irrelevant. They're calling EMS wether we like it or not because few of them know how to access those services appropriately. The end goal shouldn't be for EMS to take over such services rather to redirect people into them as appropriate. Granny calls because she is weak due to poor nutrition (no longer cooking for herself). Rather than just toss the poor old girl on the bed, we should probably be leaving her home (provided she checks out medically) with a referral to a mobile meal service for seniors (and a sandwich until they show up). That isn't taking over another service. It's creating a new route to the appropriate service by marginally changing our assessment and referral pathways from the traditional "you call we haul." EMS has become a gateway to the health system for patients who don't know how to access the most appropriate service. Further to that, we have always been an extension of the emergency department. Little Johnny fell off his bike and needs a few stitches (no other injuries presenting). Should you as an EMS provider clean it up and toss in a few sutures with instructions to see his family physician for removal (costing the system a few hundred dollars)? Should you haul little Johnny off to the ED so a physician can provide the same service (costing the system thousands of dollars and using that physician's time for a minor task when he could be otherwise occupied with higher acuity patients)? Your total patient side time is likely going to be far less with the first option because we all know little Johnny is probably going to the back hallway to wait when you get to the ED (if you even manage to get triaged in a timely fashion). As for the paramedics making scheduled home health visits you mention, those programs typically exist in areas that don't have any other home health programs. Those will not come to be in a place like Chicago or Vancouver where home health programs already exist. Where they will come to be is in rural areas where call volumes amount to 2-3 calls a day. In between calls they can be making these visits and if a call comes in they will either leave the current visit or reschedule any visits they miss during the emergency call. The point is they won't be replacing anyone. They'll be providing a service that wouldn't otherwise exist instead of sitting on their collective ass' watching youtube at the station.
Where one stands with regard to the cost part of the issue is going to vary dramatically depending on the nature of the system in which they work. I for example work in a publicly funded system whereby paramedic services, hospital services, and specialty services are all funded by the province (with a portion of federal transfer money earmarked for healthcare costs). A paramedic crew assessment and discharge costs the taxpayers a few hundred dollars. An emergency department visit costs the taxpayers several thousand dollars. In short, the more closely paramedic services are tied to overall health services in an area, the greater the potential cost benefit to paramedic services providing non emergent care and discharge.
One of the best calls I ever did was for a newly diagnosed diabetic. He called because he was concerned his BGL was elevated and his family doctor had put the fear of god in him regarding the dangers of chronically elevated BGLs. Naturally we checked it for him and it was perfectly fine. Then we investigated a little further. The real reason he had called was because he didn't know how to use his home glucometer to check his BGL. He didn't know how to use his home device because he was functionally illiterate and unable to make any sense of the instructions. In a matter of 20 minutes we taught this gentleman how to use his home device and as a result he never accessed EMS services again for anything of a minor nature. That's community care and that's why EMS providers must accept that they have a valuable role to play within community care.
I don't see this article as a strike for or against community paramedicine. What I do see it as is a call for both appropriate education and health team collaboration. The giant culture shock that's coming for many paramedics is that they were always meant to be a health care entity. What makes us unique is the fact that we are health care workers operating in an emergency service environment.
This is a very realistic concern regarding any refugees coming to Canada also. In the end I support taking in refugees with a proper screening process but I'm concerned our own in country resources are not prepared to care for these people adequately.
To be honest I've stopped counting. I did 3 in just my last block of work (4 days on 4 days off) which is fairly common; so I'm willing to estimate a conservative 20+ this year. I work in a targeted service so I end up doing the pre-hospital intubations for an entire zone as opposed to a single unit. For those who don't have similar working opportunities, the body of evidence supporting high fidelity simulation practice and its resultant increase in first pass success is becoming quite clear. Practice, either on a manikin or a patient, breeds a higher degree of success.
Then do an IM or IN dose of an opiate to start out. An inhaled agent like entonox (50:50 mix of N2O2 and O2) is a bloody good stop gap while waiting for the IO to sit or IM/IN opiate administration to kick in (if it isn't contraindicated). If they're already in agony for whatever reason giving them one more reason to be in agony is far from a kindness. There are always options including the external jugular (assuming of course that's in your allowed SOP which I suspect it is if your doing nerve blocks and sutures).
The key is patience. Once the slow infiltration of lidocaine is complete you have to wait a solid 4-5 minutes before flushing or doing anything else. 4-5 minutes on an ambulance call seems like an eternity so very few providers wait long enough. If the patient is so crook you can't wait the 4-5 minutes you just have to accept you're going to cause significant pain. On the plus side, early administration of an appropriate benzo means the patient is unlikely to remember how much the flush sucked.
I wouldn't want anyone to feel as though they shouldn't participate just because a topic landed in a particular forum (ie. an EMT not feeling as though they could learn and participate in a topic that happened to land in the paramedic section).