actualparamedic

That's a good question, and I scoured the both internet and some textbooks collecting dust here at the office for a good answer. Finding nothing, and since you brought up tough and crusty, my mentor from all those years back always taught me to look in an African American's mouth under the tongue as a sign of adequate perfusion (beefy red/dark pink as the norm). Poor perfusion and you get that grey/white pallor inside the mouth as well. I still think of using the inside of the mouth as 'core circulation', I guess, and that's a late sign that you're circling the drain. Too many large vessels running nearby and close proximity to the brain to be considered 'distal' IMHO. I wouldn't use temperature of the extremities as a reliable indicator of perfusion, either. Too many environmental, BMI, co-morbidities (PVD, HTN, ID/NIDDM, etc), wiring/plumbing factors could play into that. Other thoughts, anyone?

OK, the data used in this story is that old (collected during 2002), not the newspaper story. What the article proposes as a 'new idea' has been the basis of the Medic One EMS System in King County, WA for several decades. Their working code resuscitation rate is reported to be in excess of 40%, and their ET intubation success rate is one of the best in the nation. It is not unusual for a medic to get 50 tubes a year as well, due to the high acuity of their calls. King County medics work in a system that the ALS only rolls on critical calls, there are no ALS first responders, and basic life support rigs take a huge share of the transport load. They also have a paramedic program approximately double the length of most others in the US, currently exceeding 3,000 hours. It's not exactly the 'paramedic assembly line' classes I've seen many folks on this forum bemoaning for months on end. In reading this article, many have expressed that this is statistical smoke and mirrors, and can't possibly sustain itself in the long run. Truth be told, this model has been in use for more than two decades and shows no signs of slowing down. Kudos to Boston and EMSA as well: busy systems who deserve recognition for the commitment of their skilled and competent field providers. Too bad other EMS systems can't learn from this. It reinforces, at least at face value, that a tiered BLS-ALS response system does work to provide excellent patient care with measurable outcome improvements (at least from a cardiac arrest standpoint). EMT-B personnel can and domake up an important delivery component of a 9-1-1 system. Disclaimer: I have not yet personally reviewed the study, but, seeing as how the data was already presented at a EM conference I'll take it as valid unless I hear/see otherwise.

The University of Maryland Baltimore County has a campus EMS program. Not sure what level they're functioning at, or if their website has been updated recently. http://ehs.umbc.edu/umbcems/

Medibrat and Devin are correct. There's no direct correlation between abnormal pupillary reaction secondary to brain swelling and hyperventilation. Reversal of abnormal pupils (if it occurs) parallels with the resolution of brain swelling/brainstem compression. This has everything to do with pharmaceutical or neurosurgical intervention, when indicated. Some traumatic, metabolic, CVA-related or anoxic insults to the brain will progress to brain death no matter what type of field or hospital treatment is undertaken.

Anyone from an EMS system here that has a c-spine field clearance protocol? What have your experiences been so far? I heard Central DuPage EMSS (half hour west of Chicago, busy urban-suburban system) has had a c-spine field clearance protocol in use for several years. Markers include mechanism, pain, neuromotor scoring, neuro (GCS) deficits, etc. It doesn't mean they escape spinal immobilization, it means they escape riding the backboard. Dustdevil's point about a patient's post-accident frame of mind by the time a MD performs an ED c-spine clearance is rooted in absolute truth: they're just unwinding enough to finally focus on themselves (not their car, motorcycle, cellphone, purse, children, missed job interview, etc.). I'd also like to hear how often anyone here still applies a KED for high speed trauma, or if anyone applies it regularly for MVC victims as part of policy/protocol.

Dustdevil - why don't you create a draft of your plan to establish a sweeping new EMS system and send it to NHTSA, NAEMSA, NREMT, congressional/senatorial reps, and all 50 state EMS directors and see how well it is received? A well written proposal won't be turned away by any of these organizations, especially if you have a viable funding solution in place. Don't want to send it off to all of them? Create a website with your proposal and send request for review to your targeted audience via emails and snail mail. I would be interested to see if the wheels begin to turn. If nothing else, you can create a united front with more folks who support your ideas and get them out and circulating. Just because Penna has sent out letters to "dormant" EMS providers doesn't imply that 50% of their EMS providers are not actively employed or volunteering. As a sidebar, Penna has spent a great deal of their 9-11 Homeland Security money tackling some of the very issues this thread contains. Lots of money spent on blue ribbon panels, grass roots EMS involvement/input from career and volunteer agencies - and no concrete solutions, just ideas and an honest internal assessment of the state's ability to deliver essential emergency services on all fronts. The mailing campaign and EMS recruitment website you spoke about are just two of many ideas. [actualparamedic/quote]Plus, how will you pay for this sweeping national EMS practice reform?

First of all, I want to make clear that I am not talking about rural volunteers, I was definitely talking about EMS at large. There are more EMT-B's in metropolitan/suburban areas than rural areas (on fire departments, working for tranfer services, and paid-by-the-call personnel). All of your rebuttal points are valid in their own right, but you ignore the reality. EMT-B's by and far still make up the backbone of EMS in the United States today - more than 70% based on that study from 1993. And while paramedics and EMT-I's are plentiful (and even over-concentrated in some states) they are a scarce commodity in other states. Your original post says to do away with EMT-B's and make EMT-I the new minimum standard, and that will never happen. You haven't substantiated your tossing out of the fact that more than half of the licensed/certified EMT-B's aren't actually in EMS. Where do you come up with that number? I haven't seen any literature or studies affirming that or even suggesting that. Making EMS a paid venture isn't just a consideration of dollars and cents. In some cases, compensating EMS providers leads to not professionalism but rather an atmosphere of complacency and entitlement. What about the thread on this forum regarding the decline of volunteers in New York State - down many thousands over a decade. Creating a paid EMS infrastructure will cost taxpayers according to the article some $7 billion. Talk about a taxpayer revolt! Do you think folks in metro NYC and collar counties are going to shoot this hypothethical referendum down at the polls since it addresses a need most urgent in central and upstate New York?...you betcha! I'm guessing you live in metro D-FW from some of your previous posts -- how would you feel about a $125.00 property tax levy on your house next year to support EMS down in Brazoria County or somewhere in Hill Country or maybe west Texas if it doesn't directly benefit you. If EMS was such an easy fix following this path then why hasn't it been implemented before? Also, you seem to have been around the block enough in multiple disciplines to know that functioning at a higher EMS level doesn't necessarily translate to better care for a community. Example: a dedicated, active provider who had marginal BLS skills to begin with is suddenly forced to transform into an EMT-I, passing his written and clinical exams by the skin of his teeth. He just isn't cut out to be an intermediate life support provider and after 14 months leaves EMS altogether because he can't do it well. There are no EMT-B's so he has nothing to fall back on. Good riddance? You just forced someone out of a job who was dedicated to EMS, and that won't be lost on his co-workers/co-volunteers/family. Remember, every provider level has their place in working cooperatively to effectively deliver EMS even if it's not the way or at the level you think it should be delivered. While this forum is all about exchanging ideas, spirited debate, and expressing opinions...you're shooting from the hip on this one. The suggestion of eliminating EMT-B's with a forced national upgrade to EMT-I is on the periphery at best. The logistical, training, and provider compliance issues not to mention implementation burdens by each individual state is a decade-long proposition. Plus, how will you pay for this sweeping national EMS practice reform? Don't think for even a minute the federal government will be pitching in anything!

What? :shock: I can only see this mindset as leading to the total collapse of EMS. OK, that's a little dramatic but...consider this: In 1993, granted this is old data from Tom Scott, MA via EMS Universe, Emergency Care Information Center, Carlsbad, California, USA, the breakdown of EMS providers in the US went like this: EMT-A or EMT-B - 506,000 (76.2%) EMT-I or EMT-D - 79,400 (11.9%) - including AEMT-CC, Cardiac Technician, Cardiac Rescue Technician, and EMT-I EMT-P 79,200 (11.9%) Now announce nationwide to existing EMT-B's in 2005 that they must upgrade to and maintain EMT-I by 2009 and see how many downgrade to first responder or drop their EMS certification altogether rather than take on responsibility for more training. A volunteer dominated state on the east coast went through this when bridging their EMT-A's to the new EMT-B in the mid 1990's: even with four years to make the transition a significant number of providers (primarily volunteers) dropped down to first responder rather than take the bridge course. I don't think anyone expected this type of attrition on such a large scale. Seriously think about how eliminating EMT-B's through forced upgrades to EMT-I would gut volunteerism and essentially cripple delivery of EMS services in rural areas. There's already enough trouble maintaining the status quo. Using numbers from 1993, imagine if 10% of those 506,000 EMT-B's decided to downgrade to first responder or drop EMT-B completely. That's 50,600 EMT-Basics off the street. Talk about sudden impact - that's 25,300 ambulances idled instead of running calls. Just my $.02

I'm not surprised at all. Maybe a better way to move this thread along is to attack the issue from your local or regional point of view and share ideas. There is no silver bullet solution without a national EMS system to designate/regulate every facet of EMS provider design and practice. There will never be something like this that I can see on the horizon. No one at this point has enough influence to unite EMS in a way which change can be affected uniformly on a nationwide basis without causing disruption to the daily flow of EMS. The National Scope of Practice Model is a good idea affecting only education, but has met with significant resistance from individual providers all the way up the chain to EMS associations and even state EMS offices. There are so many factors which figure into why people train to and function at the EMS level they do. There are regional EMS delivery considerations, financial constraints, geographic factors, state EMS office requirements/regulations, local medical director biases, protocol restrictions, availability of EMS education venues and the ability of those training centers to educate EMS providers all the way up to EMT-P, public attitudes towards EMS, and the list goes on and on and on. Here's a maddening example: One of the largest fire departments in the US is comprised of approximately 60 volunteer and career stations. When a career ambulance company is assigned to a call, they go out the door as a paramedic unit (EMT-P) or medic unit (Cardiac Rescue Tech). In that same fire department, when a volunteer ambulance company is assigned to a call, it may go out the door as an ambulance unit (EMT-, IV unit (IV-Tech), medic unit (Cardiac Rescue Tech) or paramedic unit (EMT-P). Volunteers are offered training to upgrade to the EMT-P level for free through the county fire academy. Yet the number of paramedics in the volunteer ranks stays constant, and every year a new crop of EMT-IV personnel appear in the volunteer ranks, rather than upgrade to EMT-P from EMT-B. Why is this? Why does the county allow this? Why do the volunteer companies allow this? Why do the citizens allow this (especially when a EMT-IV volunteer unit is dispatched to your severe trouble breathing emergency --- you'll get an IV and albuterol nebulizer but no IV/IM meds and you'll like it!)? Wouldn't it make more sense from a staffing level, instructor commitment level, financial commitment level, and level of EMS service available to the community to eliminate all EMT-IV's and CRT's, going with either EMT-B or EMT-P staffed ambulances? It all seems blatantly obvious to me...but it's just my opinion. There are obviously factors playing in to this which I can't understand, don't understand, am previously biased about or don't agree with, but it doesn't make my "brilliant" position more valid. I should also disclose that I was once part of this EMS system Ace, this thread has great potential, but needs to be steered in a new direction.