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Who can see the future

30 posts in this topic

Posted · Report post

To PIggy Back on another current thread regarding the past.

What do you think is the future of EMS in the next 5 years?

The next 10 years?

What do you see in the next 20 years?
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Posted · Report post

RETIREMENT :wave:
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Posted · Report post

Fully taxpayer funded pensions?
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If we are talking about the US, I see bad things coming in 5-10 years as the IAFF tries to further justify its existence and take more control over EMS. I think after that we might see things start to swing the other way as the EMS subspecialty in Emergency Medicine becomes more prevalent and more board certified medical directors start to pop up and push for improvements in the field.
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Posted · Report post

yeah, the day of the mom and pop service are gone.

It's either fire based ems or the big alphabet services. One or the other and if you are lucky to be working for a small independently owned services, count yourself lucky until the alphabetasaurus sets his eyes on your company.
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I see a lot of consolidation and regionalization in the coming years.
Even the small town rural services are finding it hard to continue providing service as in the past.

Expenses go up and receivables go down,with insurance carriers wanting a fixed discount for services.
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Posted · Report post

Here in Ontario I'm really not sure. There are some exciting things in development that I hope come to fruition, but the legislation and regulatory environment makes these less than guaranteed.

1) Self-regulation. The Ontario Paramedic Association will soon submit an application to the Health Professions Regulatory Advisory Committee (HPRAC) for the Creation of a College of Paramedics. Self-Regulation will open the door to setting our own standards for education and a more adaptable scope of practise.

2) Community Paramedicine. With a publicly funded health care system finding efficiencies and novel ways of providing service is theoretically easier to justify since the system as a whole saves money. Many services are starting to explore various solutions to shift away from the transport everyone paradigm. The early stage programs mirror a lot of what's been reported in various publications: visits to frequent callers, referrals, follow-up visits, etc.

My service is exploring a few different options and have four staff devoted full time to developing community Paramedicine. The options being explored are an Expanded Scope of Practice for Paramedics, treat and release of nursing home patients with follow up by NP or MD the next day (traditionally we have transported 100% of these patients), and selecting experienced ACP's and sending them to Physician Assistant School and utilizing PA-Paramedics in the field.

The PA-Paramedic program is probably the most interesting. Details are still scarce at this point but it creates a new step in our career path. Also exciting is that the University has apparently agreed in principle to recognize the three years of College training an ACP has as meeting the usual prerequisite for two years of University in any discipline.

3) Longer injury free careers. We have had tracked stair chairs for three years, we have a very open policy for requesting lift assist, power cots have hit all the trucks and power lift is on the way in the new year. We've been aggressively pursuing no-lift policies and equipment where possible and promoting health and wellness across the board. Our service is far from the only one embracing this shift and I think that's going to be a huge career extender.

4) Longer careers. I think has already started. Since the download to the municipality in 2000 and the enhanced education requirements we have seen dramatic increases in pay and benefits. We have a great defined benefit pension. As services grow and embrace new ways of providing service new job opportunities are created away from the Ambulance which help alleviate burnout and extend careers. All in all I think the medics in the earlier stages of their careers are no longer entering with an eye to FD or PD and have a long career in mind when they sign up. I can easily see reaching retirement while still being with this employer.
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I echo the improvements of assisted cots and increased use of stair chairs. I have heard rumors of street rigs getting ISTAT machines to have a non stemi cath lab activation with troponin elevations.
BAYAMedic
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The Istats are nice but CLEA (I think, not sure of the acronym) would need to be involved to allow that since it is essentially a lab test. Hospital based EMS systems are best suited for this type of test and the rolling out of these things. Once these are rolled out in several systems and shown to be effective in patient care pre-hospital, then I would look for them to be a standard of care within the next couple of years.

They are pretty much idiot proof if the ones that I've used would be used.
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Do you see a use for any other labs in the field using a system such as the istat? If so which ones and why?
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Yes I do Doc,

Here is the Istat website with a comprehensive list of their tests.

http://www.abbottpointofcare.com/Patient-Care-Settings/Hospital/Emergency-Department.aspx

I would think that an ammonia level test would be beneficial, as well as Troponin,

Others in this link would strictly be used in the ED setting and not valid for EMS work.

One other would be a valid Alcohol level as well as a drugs of abuse test.

I think if I had my choice I would rank them in importance

1. Trop I
2. HGB/HCT
3. Drugs of Abuse
4. Alcohol
5. Ammonia (strictly a routing tool to the appropriate facility - super high ammonia gets a non general hospital but gets a specialty hospital)
6. CMP/BMP
7. Glucose(we already have the machines to do this)
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What about serum lactate and CBC for sepsis screening and early intervention? I don't know a lot about lab results but that's the first that comes to mind. Could be especially useful in an environment that begins to move away from transporting everyone.
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Posted (edited) · Report post

none of the test listed in the link have a CBC as a result so you might not get your wish Wolfman.

But it might be found from a different company, just not Abbott. Edited by Captain ToHellWithItAll
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Posted · Report post

I think the ability to run gasses on intubated patients would be helpful in addition to having the ability to run BMP's to appreciate potentially lethal electrolyte imbalances. I'm not sure I see much use for anything else on a "standard" EMS platform. Even lactate monitoring is not high on the list as many things cause an elevated lactate and many issues such as suspected sepsis complications are going to be managed and identified clinically and I'd still look at fluids and so on regardless of a point of care lactate value.
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I fully agree with the troponin level. It would definitely have an affect on destination. I would have to disagree with the ammonia level. I don't think it would add much in the prehospital setting. If you have someone with liver disease and they present with encephalopathy you pretty much have the diagnosis nailed. I think a BMP would be great. You could know if you are dealing with a potassium level pretty quick. It is something that can be rapidly fatal and is easily fixed. One issue I can see is overly zealous providers who over use the test. Think of the number of dialysis pts that EMS transports and now throw in a buff with a toy and see how many people who have a normally elevated potassium on a daily basis end up in the ER.

Some of the istats can run a cbc, or at least a hemoglobin and hematocrit. I don't think WBC or lactate will have much use in the field. If you have someone where you are concerned about their WBC and lactate level, you shouldn't be considering not transporting them. I like the alcohol level, drug screens are more interesting than they are useful. I think PT/INR would be good. If you have a pt where you are worried about an intracranial or GI bleed, you could see if they are supratherapeutic and give some Vitamin K (of course you would need to carry the vitamin k).
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I'm with wolfman: I think lactate and WBC could be very useful. Not for transport decisions, but there's a lot of literature supporting early sepsis treatment with antibiotics and aggressive fluid replacement. And this is ideally before the patient is hypotensive, so field lactate would be a great indicator along with the rest of the clinical picture before you have significant vital sign changes.
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I only threw in the ammonia level due to my friends ammonia level was so high a couple of times and his was missed (nearly fatally twice at a local small town hospital) and having that ammonia level could have directed his transport to a higher level of care than little doc in the box than the level 1 facility that he should have been at to begin with. And of the Istat's none have ammonia so it's a wish list not a requirement.

The drug test one is a good one but you don't have to have it in the field but we in our ER had them at our disposal but they were based on urine not blood so the patient had to either give you a sample or you had to catheterize them (we could do catheters in the field as well).

But I still stand by my list other than the ammonia.
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Posted (edited) · Report post

I'm going to go off topic here, but in a way it does have to deal with the future and EMS. In regards to the WBC/lactate levels, jkc brings up giving antibiotics in the field. Here in the US, the Center for Medicare/Medicaid Services (CMS) and JCAHO set our core measures. One of the is that we must give antibiotics to pts who are being admitted for pneumonia within 6 hours of hitting the door AND we must have 2 sets of blood cultures from 2 separate sites before the antibiotic are given. Meeting these core measures will determine our payments. How will prehospital antibiotics affect this? I realize there is no correct answer right now, but it's a fun mental masturbation exercise.

EDIT: drug screens are overused. They don't really provide much information that is useful. About the only reason I order them anymore is because the inpatient service or psych facility makes me do it before they will accept a pt. Sometimes it is fun to see what people are on, despite their insistence that they don't know how everything got in their urine. Edited by ERDoc
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[quote name='ERDoc' timestamp='1355254263' post='291394']
Some of the istats can run a cbc, or at least a hemoglobin and hematocrit. I don't think WBC or lactate will have much use in the field. If you have someone where you are concerned about their WBC and lactate level, you shouldn't be considering not transporting them.[/quote]

By way of context I was considering a particular patient type when envisioning istat for sepsis coupled with a new program in development where I am. I was thinking of an elderly nursing home patient with advanced directives and patient's stated wishes that they did not wish transport to hospital unless absolutely necessary. They are generally in frail condition and the call if for "generally unwell - failure to thrive. "

The new Community Paramedicine pilot envisions a partnership with the NP service that is currently available during business hours for Nursing Home patients. The goal of this partnership will be to identify 911 patients that can be better treated in their nursing home and can safely wait until the NP visits to continue care. We still know very little about how this will work yet but patients I've considered being ideal for this include skin tears, generally unwell.

My thinking for the lactate and WBC was as part of a thorough sepsis screening to ensure that these patients are identified early. In this context is this a more reasonable test or am I reaching?
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We had a big push for us to purchase Lactate monitors last year from the state EMS office. A lot of services did bite the bullet and spent serious money for them.
Well guess what?
The company that sold the monitors is no longer producing them for sale and will only have strips available for a couple of years.
I didn't buy one for our ambulance , as I couldn't see where it was going to affect our treatment or transport decisions based on a given reading.
glad I didn't waste that money!

Now giving us the ability to get a tropinin level in the field would make a difference on decision making of where to transport when used with other data from the 12 lead and history taking.
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[quote name='ERDoc' timestamp='1355248255' post='291382']
Do you see a use for any other labs in the field using a system such as the istat? If so which ones and why?
[/quote]

I think the istat is overpriced. There are many other tools out there that can provide many similar results for far cheaper. For example, do we need to spend $16 per cartridge over the cost of the device to get a quantitative cTnI result, or is it just good enough to know that it is elevated into the levels that we know myocardium damage is occurring for $13 a test?
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Sorry, I was just using istat as a generic term for the point-of-care devices since that is how we refer to them at my shop. Of everything we've mentioned I think anything that would tell you that the troponin is elevated, whether it be quantitative or qualitative, would have the most impact on prehospital care. I agree that a + or - would be sufficient since you will not be trending the level in the field.
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Thanks Doc. I've been using qualitative tests for cTnI/myo, Acetaminophen Overdoses, methanol, and my hospital likes to use 10 panel urine DOA tests for determining what meds/drugs may be on board a patient. They can't do a tox screen here.
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Posted · Report post

Quantitative test for tyelnol OD? How do you determine what is positive and what is negative?
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Qualitative. 200 µM cutoff point. 2 lines = positive.
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