usalsfyre

im not arguing the point that it hurts or helps but who will pay for it when training budgets are already stretched to the breaking point. Its fine and dandy for us who are already medics to say move on or get out of the way but what if the current medic was now obsolete and all the medics were told to either get the new cert or get out of the way. I would bet that you would be singing a different toon.

Could your agency afford to educate or send all your medics to the next level or can your agency afford to send all of your emts to the medic level based on the mandate proposed by the OP? Ill bet that most agencies cannot afford to send their people to enough ceus to keep their licences current let alone put them back through school to get to the medic level.

Sent from my SPH-D710 using Tapatalk 2

If the current level of medic was obsolete (and it's not far behind) it would be up to me to get the needed education. That's a "tune" I will sing consistently.

One level, what would you do with all the EMT's currently? How would you mandate moving them into the new standard that you propose to make required? How will you pay for all those EMT's to get those classes? Surely you don't expect them to foot the bill when they don't want to advance any further?

They have no intention of furthering their education and they should not be penalized by a system that now says that in order for them to continue working in their chosen career where they have always driven the ambulance and they never want to do anything else, you are going to require them to now become that new level of provider and only be a driver. The cost to them will be very high for NO increase in return of investment. That will force many out of work unless the companies they work for to pay for their increased training.

Are you going to grandfather these folks in?

No one payed to reeducate blacksmiths or typewriter repairmen.

Stay up with the times or move on. If you want to continue to work in EMS you have to be useful. The basic level is dangerously close to obsolescence. Tell us where the current level EMT-Basic really helps.

I still see the need for two levels, because for high risk/low frequency/high acuity type situations you need experienced, educated people who run these calls often. Not something your going to get from every crew.

What needs to go away is the EMT-Basic level and 700hr medic courses. I personally think AUS and NZ have well thought out systems.

Kinda late to the party, but midaz IM or especially IN (assuming you can get hold of a nostril) works wonders.

I am. Second semester out of 3. Already completed advanced airway managment COVERING VENTS!! Why the hell didnt I think it was the PEEP indicator!!! UGH whata bloddy brainfart from hell.

Than again. That BVM sure looked real shiny at that moment.

Actually not a PEEP indicator, it's a high pressure relief valve. The squealing and red is to let you know something is wrong. I believe these are set to activate at 55cm H20 on the AV series. What this likely meant is that the rather crude breath delivery of the Autovent was injuring your patient at that moment.

BVM would have been likely as inappropriate. What this guy needed was a provider with the equipment and knowledge to move critically ill patients from facility to facility, even if it is only 0.6 miles. You'd be surprised how fast you can cause acute lung injury.

There's a reason CCT has developed into a separate, subdiscipline within transport medicine, it's about far more than cool flightsuits and expensive toys.

Not your fault, but when you become a medic don't be afraid to say "we can't do this safely" on IFTs like this.

There was a local study done by the trauma council in East Texas, not sure if it was ever put out for publication, but the results were that out of roughly 1000 level 1 trauma activations, all of them came in hypothermic to some degree. Every. Stinking. One. Seems that stripping the patient, pumping in room tempature fluid and setting the ambulance climate control for paramedic rather than patient comfort was enough to overcome a couple of months of 100+ degree days.

People wonder why I insist on having blankets in the summer too. Any critical patient excluding heat stroke gets at least one blanket regardless of ambient temp.

Thiamine, vec, morphine and vasopressin are all still commonly on EMS units.

Well if that is true mike, then we should never transport pediatric codes either, as the risk is the same, but something tells me you probably do not call too many pediatric codes on the scene.

Actually I've made the decsion to both cease a pediatric resuscitation and not start resucitation at all. The providers emotions have no place here, working a code so you feel like you "did everything you could" is shitty medicine.

I don't see the reason for the apparently strong desire to transport adult cardiac arrest other than yet another way in which EMS providers want to shirk real responsibility.

To paraphrase JPINVF, why should we be respected as professionals when we punt every hard decision that comes our way?

Lidocaine-Out

Intubating cardiac arrest early-Out

Defib Paddles-Out

Jelcos-Out

Separate pulseoximeters-Out

Nasotracheal intubation-Out, then back In

Diazepam-mostly Out

Smaller ambulances-Out, now back In

Decent sized, capable HEMS aircraft-mostly Out

That's all I can think of for now, and I've only been around 10 years.

The DEA will probably be interested in why the Ketamine wasn't in a double locked container.

Other than that nothing is controlled. The etomidate would be a poor choice to get high off of, and the paralytics are obvious.

Brave flight crew. I'd have just stuck the tube and gone on, having managed a seizing patient in an aircraft it's not fun.

You'll find it's very easy to manage most patients for a few minutes longer. A 30 minute transport is not that long, but you see these patients getting flown all the time, when in reality you probably add 15 minutes to the transport by calling for air.

Well, considering there's an open conduit between you and the patient I'd say it'd be pretty flipping useless as a barrier device.

Correct me if I am wrong, but I was under the impression that Ativan is the benzo of choice for seizures because it stops the seizure activity in the brain. Valium and Versed will affect muscle activity in response to the brain seizure, but the "electrical storm" in the brain continues.

I carry Versed and have used it for sedation (during pacing, combative patient etc.) and RSI and I love the way the drug works. My medication of choice for seizure for the aforementioned reason is Ativan.

I would love to see the studies and other smarter people please chime in.

Midaz is a benzo the same as any other benzo, meaning they all affect GABA receptors similarly. My understanding of it is that by binding to and "activating" the receptor it raises the electrical threshold for neuron depolarization, meaning they all "quiet the electrical storm" in the brain. Midazolam terminates seizures as well as any othe agent, as the other thread notes the issue is duration. Midaz is a short acting agent anyway, in patients with baseline increased metabolism or, especially, patients with increased hepatic metabolism (such as patients on phenytoin) they can chew threw midazolam...quickly. I once gave an intubated 8 year old in the neighborhood of 20mgs of midaz in a 45min flight. He had recently started phenytoin and at that service midaz was all I had available. Lorazepam and diazepam's increased half life are very helpful here.

Don't forget these patients will often need long-term anticonvulsant therapy for anything other than a transport to the ED or for seizures that are refractory to benzos. Phenytoin, fosphenytoin and levetiracetam seem to be the choices in the EM environment.

The "abuse allegation" argument seems to be borrowing worry. Midaz, within it's proper dozing range, acts like any other benzodiazepine, with perhaps a bit faster onset. I've used a ton of the stuff over the years with no issues other than one can't intubate, hard to ventilate patient who ended hypotensive (why I'm so against midaz only intubation).

One if the issues I've seen is that diazepam is often underdosed in EMS protocols, meaning when given midaz at proper dosing ranges providers are often surprised at the effect the upper range if the dosage range has.

I've used midaz for seizures, RSI, post-intubation sedation, chemical restraint, pain control in conjunction with opiates and anxiety with no issues. Safe an effective med, and I love you can give it IN.

Neurologically generated trismus is one of those "ominous" signs generally associated with brain-stem lesion. Meaning, it's one of the later signs to show up and only releases when the herniation is so complete that there's NO response moving through the brainstem, i.e. mega bad juju. What your trying to do with midazolam "snow" the patient enough to stop the trismus impulse. Which you can do with suffiecent quantities. Here's the issues with that though.

1) The EMS systems involved in this halfassedry typically never prescribe enough midaz to do it. We're talking 30+mgs at times.

2)That amount of midaz in a single bolus may do nasty things to a B/P. Cererbral Perfusion Pressure is calculated as MAP-ICP. This number typically runs 60+, but in situations of hypotension and increased ICP this can run too low to perfuse properly or even into negative numbers quickly (see Monroe-Kellie doctrine).

3)You've not performed one of the other functions of RSI, which is to "take out" the skeletal muscle involved in vommiting. This is the real reason anesthesia invented RSI for the non-NPO patient.

Again, halfassedry has no place in RSI. For my money, surgical airway options are far more important than RSI. If you don't have them, get involved and lobby.

So you don't like public agencies, AMR and R/M are evil...have you considered the fact that perhaps your views are in no way objective and your refusal to see this makes them mostly invalid to other people?

I submit that by virtue of education even a two year AAS RN is a far more qualified to practice prehospital medicine than a Paramedic in the US where the Paramedic may have received as little as sixteen weeks of "education" plus a few hundred hours of clinical skills (cough Houston Fire Department cough)

Does that mean you can just throw an ICU or ED RN out into an ambulance and they will be sufficiently dexterous without additional role-specific skill consolidation? Maybe not, but maybe you never know ... I can teach a 10 year old to put a drip into somebody and even I can shove a plastic tube through the right hole fairly easily.

I'm fairly dismayed by the state of EMS education as well, but that doesn't mean we should just invite another profession to come play in our bailiwick because. How would NZ medics feel if the nurses there came up with a PHRN credential?

I have the same, or more educational background as many RNs with the exception of college level microbiology. Perhaps the 16 week medics don't care, but those of us with a college based background should.

For the record I'm not huge on quickie bridge courses either direction. Perhaps bridge courses can exist, but should include a the "core" of the education for either role. While there's considerable knowledge overlap, nurses vs paramedics application of said knowledge is hugh different. In knowledge application a paramedic is far more similar to a mid-level provider than a nurse (which highlights how undereducated we really are).

The "PHRN" just pisses me off. I want an IHEMT-P certification. If you want to play prehospitally, go get the education, the same as you argue we should have to do.

why is is so improtant to have an RN on flight?

here we have a doctor and paramedic or maybe just 2 paras...afterall the field is the area that is foreign to most RNs

In the US it's important because many paramedics have never laid hands on ICU level patients.

Hello all,

I have a question for the group somewhat related to the topic at hand. My question is related to chest tubes and hemothorax management. I am looking for people's views on clamping the chest tube if it is putting out a lot of blood (say >1500mL post placement, or >200mL/hr to use classic textbook numbers). For discussion sake a thoracotomy is not an option as the patient is being transported to a trauma facility (via ground or air depending on your background).

Looking forward to the feedback/discussion.

TS

Unless you've got blood or an autotransfuser you must clamp the tube. Even with blood or an auto transfuser I'm probably going to clamp a chest tube at way less than a liter and a half. Otherwise it's easy to end up with the patients entire blood volume in the chest drain.

The free market enforces good quality patient service? You can't back up that argument. The consumer can not be expected to be educated enough in all matters of emergency medicine to make appropriate healthcare decisions based on quality of service. Private EMS runs on the hot cocoa principle. That is, patients won't really care if your service completely f---ed up and failed to treat a routine malady and resulted in the death of one of their loved ones so long as you say nice things and bring them hot cocoa in the "quiet room". That's why your mantra is "customer service," "customer service, "customer service." Not "Quality healthcare!"

As opposed to say, DC, Detroit, Philly, SoCal, a good portion of Floridia and any other number of places that are public and known for crappy prehospital care? We can cherry pick examples all day long. I've found good medics and excellent patient care in all types of systems. I am sick an effing tired of public service providers acting superior because they happen to work for a public system. The only time I've ever been "encouraged" to doccument creatively was by an FD.

When it works is the operative word there. With a substantial lack of oversight in EMS, it relies on local entities that suffer from underfunding, disinterest, and sometimes out and out conflict of interest when it comes to those same checks and balances.

Municipalities and privates can be equally crappy. Again, see the Rosenbaum case or any other number of DC Fire screwups.

That would be "trade secrets" protected by law versus the Freedom of Information Act, now wouldn't it?

Trade secrets as opposed to the "we suck, what are you gonna do about it" attitude displayed by KCFD post-MAST takeover?

We have to evaluate a system based on it's individual merits. To condem it based solely on ownership is stupid and shortsighted.

Of course if anyone wants to know about ambulance service fraud in Texas, all they have to do is talk to the Dallas Fire Department.

Shhh, that can't get out! They settled that claim you know...

Pros:

Quite a bit more frank than other EMS forums

More people willing to say, "that's bullshit".

Diverse background, participating has made me a far better provider.

Cons:

Occassionlly there seems to be a fair amount of trolls running around, and a couple of people who use this BB to tell everyone how the world has "wronged" them because of their race/gender/orientation/species/genus/physical attributes/ect

The issue, I believe, is one of having the patient on a stretcher; and I believe it is specific to stretcher. Supposedly a person on a stretcher invites scrutiny from the public and it is this 'invasion of privacy' that would be at risk. Simply put, patients on stretchers are stared at.

Bull malarky, and whoever told you this is making stuff up to avoid doing something they don't think is right.

Crap, why didn't I think of nasal intubation? I guess I've been spoiled by spending most of my career in systems that had RSI.

HLPP, could you present a similar situation where you have had to weigh risk/benefit in airway management. With all do respect I have read your posts and am under the assumption you are a non-emergency transport service. Sure the risk is there for a potential non-emergent situation to turn emergent.

I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

I seriously doubt midaz will a)release the neurologically caused trismus and b)do anything but screw up your CPP if given in adequate amounts to release the trismus. In the scenario above I'd be holding a scalpel if RSI wasn't available.

Pharmacologic airway control should be an all or nothing proposition. Using sedatives only increases aspiration risk and sets up the can't intubate/can't ventilate scenario. Either your good enough to use it all, or your not. Halfassery has no place in airway management.