Bieber

I'm pretty much going to quote Dwayne here and reiterate what I've already said a hundred times about the need for EMS to mandate at the VERY minimum an Associate's degree and ideally at least a Bachelor's; or at least have it a viable option nationally instead of only at a couple handful of universities throughout the country. I would however like to add a couple of things. First of all, if it's a deficit in education that is making medical directors hesitant to put us in those roles of providing preventative medicine, then I would suggest that they take a proactive approach within their own services (along with all physicians who deal with EMS as well) by implementing advanced educational programs, classes, what-have-you that WILL give us the knowledge and the skill to deliver this facet of care which, in all honesty, would arguably make a bigger impact on patient survival (and more importantly, quality years of life), and on decreasing recurrent hospital admission. I don't claim to know what's best for everyone, and when in doubt, I will always advise my patients to go to the hospital by EMS, but at the same time I am a tremendous advocate of not transporting folks who don't need to go by EMS, and in counseling and educating patients. I like to give my patients as much information as possible as to what we are finding in our assessments, what we think is going on (or if we have no clue), and what they can expect at the hospital; and for those patients who don't need EMS, I first of all always tell them that we're more than happy to take them if they want us to bring them in (because we cannot currently refuse transport), but I also make sure that they know what they can expect from us (i.e. a taxi ride if that's all their condition merits), and what I think the hospital will probably do for them. I also like to let them know what other alternative options there are (i.e. going POV if that's what they want, "staying and playing" and calling us back if something changes and otherwise following up with their family doc, etc). One thing I've noticed is that we in the medical profession do an absolutely TERRIBLE job at telling our patients what is going on, and I think that a lot of the time we can ameliorate much of our patient's concerns simply by bringing our knowledge of medicine to their aid when it comes to their medications. I may not know the medication, but I can probably understand the medical jargon on the label or in their discharge instructions and if nothing else I can try to explain it to the patient in a way they can understand if they have concerns about it. In that sense, I think that we are capable of counseling patients about their medications to a certain degree, and I've done it before with a patient who was just having an anxiety attack because she read all of the side effects her medication can cause and it got her worried that she was going to suffer any or all of those side effects.

Dwayne, my understanding is that the hypotension associated with fentanyl is minor at best and arguably a complete non-issue. Furthermore, reducing pain (primarily but not solely in abdominal pain patients) can actually have an increase in blood pressure because the patient will no longer be tensed up and overstimulating their vagus nerve. As for the second patient, I have never heard of a stroke being a contraindication for pain management, but I would think that decreasing pain would facilitate a proper neurological assessment; the only concern being the risk of dropping their blood pressure (and thus their cerebral perfusion pressure) if it's a hemorrhagic stroke which, with fentanyl, shouldn't be an issue.

Great responses everyone! How about the rest of you? Can we get someone with an MD or a DO behind their name to weigh in on this? Or even better, how about some peer-reviewed research studies? Does anyone have anything supported by any major organizations or substantiated scientifically that supports appropriate pain management for multi-systems trauma patients? What about your own individual services? Are you allowed to provide pain management when you think it's appropriate? If not, how come? Are you trying to get that changed?

Hey I know that place! They have great videos covering a wide variety of topics (mostly science). They definitely helped to make me more knowledgeable about the science of biology. Thanks for sharing that, Dwayne.

Wow, great article, Dwayne! I've never heard it put that way, but this is the concept I've referred to as "investing in ourselves". Just like the article says, if we want quality medical care, EMS services along with ANY medical provider has got to invest in itself and its employees. And I've seen what happens when organizations don't invest in themselves and their employees and the results aren't pretty. In short, patients are best served when their medical providers themselves are best served. This kind of business model isn't uniquely effective to medicine either but is something a lot of progressive businesses have begun adopting, such as Google. Wow, great article, Dwayne! I've never heard it put that way, but this is the concept I've referred to as "investing in ourselves". Just like the article says, if we want quality medical care, EMS services along with ANY medical provider has got to invest in itself and its employees. And I've seen what happens when organizations don't invest in themselves and their employees and the results aren't pretty. In short, patients are best served when their medical providers themselves are best served. This kind of business model isn't uniquely effective to medicine either but is something a lot of progressive businesses have begun adopting, such as Google.

Well, while I haven't found a whole lot with regards to multi-systems trauma, I CAN tell you that the research is one hundred percent in favor of administering pain management for abdominal pain, and that the top folks in pain management have said time after time that pain management for any disease process is not only not going to foul up the physical exam, but that it may in fact have tangible benefits on the patient's physical condition. +100. We're expecting a major protocol update courtesy of our new medical director, and I'm anxiously hoping that we will get a dedicated pain/nausea protocol. Currently, we have to call for pain management for multi-systems trauma and I've never done it before but I know there's a big anti-pain med culture around here. ...yeah... if only.

All right, folks. I went through and searched for pain management and only found two threads relating to it. TWO. For one of the very most effective treatments we provide, and for one of the few treatments we have that has been definitely proven to do good, that is just not enough discussion about it. So, I want to talk about pain management in the setting of multi-systems trauma. I've been trying for a couple of weeks now to find some definitive research on it as well as the stances held by trauma organizations and other medical associations throughout the country and world, but my search hasn't been especially fruitful. I know that in my PHTLS book, it recommends AGAINST giving pain management in the setting of multi-systems trauma, however speaking with other medical providers from paramedic up to physician, I have noticed that there are a lot of folks who are strongly in favor of pain management for multi-systems trauma patients. Aside from the obvious of watching their blood pressure and respiratory drive (both of which some narcotic analgesics such as fentanyl have a very minimal effect), I'm not finding any strong contraindications for pain management in the setting of multi-systems trauma. So, what is it? Am I missing something? Or is this a situation where we simply decided a long time ago that patients with multi-systems trauma deserve to be in pain more than patients with isolated trauma? What do your protocols say with regards to this? What research have you found/done on it and what do the leading organizations find? Thanks! -Bieber

I don't claim to know all of the complexities behind the high cost of healthcare, and I won't try to make you think otherwise, but I do think that there is a lot of wasteful spending in medicine especially with regards to unnecessary administrative costs. I know even where I am there is a ton of money just sitting around waiting for someone to free it up by streamlining the system and making it more efficient. ERDoc, while I do think that the system should maintain a system for rewarding hard work, I'm not sure if it necessarily has to remain the status quo in order to accomplish that. I also think that, from an EMS perspective, we ought to be rewarded for clinical excellence as well--something which does not currently occur at the service I work for. We are rewarded for times, and skill competency as well to a certain degree; and while I do believe that maintaining competency in the psychomotor aspect of our job is important, I also think that we ought to be graded based on the other aspects of our job as well including the affect and the didactic portions as well. I would agree with you on a two tier system that protects our citizens who do not have the ability to afford private health insurance. I strongly believe that healthcare is something we ought to provide for our people, and that it will in the end be something that benefits everyone else as well--including the insured. We all know that the cost of emergency medical services (including EMS and the ER) practicing general medicine for people without a family doctor is much higher than if those people had a family doctor to begin with. And whether it's right or wrong and whether we like it or not, that cost gets shifted to the rest of us when those people are unable to pay for their medical expenses. It is because of this that I think EMS should expand its role and transition to "mobile health services" and provide (and charge for) more services for people with general non-emergent complaints, because as much as our job ought to be restricted to true emergencies, between the tremendous number of uninsured individuals and the fact that we spent the last forty years telling people to call 911 for any and every reason under the sun, we're not going to soon eliminate the reality that we are being increasingly called on to provide primary care. Either the government is going to have to provide some sort of safety net for the uninsured and set them up with family practitioners, and/or we in the emergency medical field are going to have to come up with a solution to the problem of people calling on us for problems that could either have been treated with appropriate preventative care or requires only primary care treatment. One thing is clear, though, "just take them to the ER" is NOT going to be a viable solution if our goal is to decrease the costs of healthcare both in the short and long term. And while I'm not as familiar with other specialties in medicine and the problems they face, I am sure that everyone in gastroenterology, nephrology, anesthesiology, family practice and every other specialty that exists would all say that there are problems within their own realm of medicine that need to be fixed, abolished, or added in order to help streamline medical care and reduce unnecessary spending.

Starting paramedic salary with FDNY is $43,690, from http://www.nyc.gov/html/fdny/html/community/ems_salary_benefits_042607.shtml Median household income for New York City is $54,554 in 2009, per http://quickfacts.census.gov/qfd/states/36000.html Enjoy! Oh wait, I just saw that you specifically wanted overtime. Sorry, couldn't tell you that, I'm a long way from New York. The impression I've always got, however, is that while EMS in se is not an especially lucrative career, the disparity in pay becomes a more pronounced nuisance in the cities with a much higher cost of living...

I was surprised to find that there are going to be transition courses for paramedics. Not quite sure what it will entail, but I guess we'll just have to wait and see. Haven't heard yet when there's going to be some transition courses.

While I agree with most of what you say, I think I have read some studies that say that while ACLS drugs don't increase survival to discharge they do increase return of spontaneous circulation. Maybe the error is not the drugs so much as the post-resuscitation care, which we are beginning to see has been woefully inadequate in EMS. Thankfully that does seem to be changing slowly but surely. Also, I just read a recent study where sodium nitroprusside (in pigs) showed a tremendous increase in survival rates from cardiac arrest. Maybe we're just not giving the right drugs, maybe there is no right drug, either way, the more we study medicine, the more we'll be able to tailor our treatments and provide more effective care. Probably the most important take home lesson from this surge in evidence-based medicine is that how we treat our patients today is probably not how paramedics will be treating them a century from now. If backtracking our treatments and simplifying them is what works, then that's what we need to do; if they say five years from now that we need to further advance our treatments with new or different medications, a new or different kind of airway, or whatever else, we're going to have to be receptive to those changes as well. Medicine is dynamic and we really can't say what the best way to resuscitate patients in cardiac arrest is until the science reaches the point where we can successfully resuscitate all salvageable patients (those in whom resuscitative efforts of any kind will be futile; i.e. the truly dead). And the same is true for all treatments. I for one look forward to seeing where we will be when I end my career in EMS; I have a notion it is going to look nothing like the medicine I'm practicing now.

Don't know too much about the payment system regarding that, but like ERDoc said, the patient has to make that decision themselves. With hospice patients (and really any patient), I think that we have a duty and obligation to inform them of their options, encourage them to go to the hospital if they need to go to the hospital, and in general do our best to give them the power to make an informed decision and unfortunately sometimes the answer is "I don't know". Erring on the side of caution is always a good bet to make, though.

I believe we have to call for benzos for head injuries too, though I'm not sure. Technically we can use two protocols as appropriate, but they are extremely fussy about us doing pretty much anything besides an IV and fluid therapy as indicated for multisystems trauma. No pain management, no nausea control, etc, etc. I've only ever had two head injuries so far, and neither of them seized on me.

We use the EZ IO, and in fact I got to use it yesterday for the first time on a code blue. As for how it or any of the other wonderful tools find their way into our supply lockers, that's above my pay grade...

Can I put "still learning" as my certification? Haha.

It's all about times these days, it seems. I know at my service we have ten minute target scene times on traumas, and the majority of our evaluations are based on our times. Like everyone else has said, instead of focusing on times that for the VAST majority of patients mean nothing, how about we start focusing on clinical excellence and increasing our education?

It's too narrow to be ventricular, I see no discernible P-waves, and it is bradycardic. I'm going to call it a junctional rhythm. I've actually had a patient with a rate around 35-40 before, however due to his blood pressure being stable with no signs of cerebral hypoxia and because I suspected that the bradycardia might be due to an infarct (patient's 12 lead was non-diagnostic but he had a significant cardiac history), I didn't give any treatment and just kept an eye on him. No fluid, either, due to--as one person's already said--the risk of inducing heart failure.

I've always taken positive orthostatic changes as a BP change of 20 or a heart rate change of 10 bpm. Although I was taught that you were supposed to wait a couple of minutes between taking vital signs. Honestly, I haven't used it as much as I probably should. Here's another question I have for you guys, when do you decide to give fluids to a patient you suspect is dehydrated?

I would probably just monitor the patient and bring him in for the reasons listed above.

Hm, I think you're right, Dwayne, I was a little hasty there. Let's reassess first, and increase that O2 to 15 LPM by NRB if we haven't already.