Doczilla

This thread makes me miss the days when the local Dr. could fix everything. They had to be prepared for whatever came through their doors. If they didn’t have a solution they pretty well made one up. So with this in mind a good dose of pre-hospital care knowledge would possibly be advantageous to make anyone, including Drs. producing more well rounded professionals and better citizens. Don’t get me wrong, specialization gives us great benefits and greater medical bills because so many professionals do not seek diversity in their training. Well rounded may not bring them more money but in the end isn’t service what we are all about? Physicians may never need pre-hospital emergency skills but if they ever do need them. I am sure they will be glad they took the time to prepare. It shouldn’t be the backbone of a medical program but would surely add value if included in pre-med education.

In those days, medicine was far less complex than it is today. Only a fraction of the medicines we have now, few surgeries, far less technical complexity of the kind of medicine we practice these days. And much higher expectations on the part of our patients and their families. But outcomes are better, people are living longer, and staying in the hospital less.

I'm currently starting my MS1 right now and I couldn't imagine throwing in an EMT curriculum on top of everything else. There's just too much. The EMT cert would be looked at like it was a chore and the experience would be wasted I think. I'm glad I had my EMS experience before school, but I really don't think it would be worth anything at this point.

So much of the MS1 and MS2 years are a complete waste of time. I have never once in clinical practice wondered about the CD40 ligand, or Krebs cycle intermediaries, or cholesterol manufacturing pathways, or looked through a microscope at a tumor to see if it was cancer. An injection of some practical knowledge would be a good thing. Some med students who rotate through our department don't even know how to glove up in a sterile manner.

'zilla

The legislation is not for every Tom, Dick, and Harry EMT. It is for those, who by job description, necessity, and intent go where the shooting is. And before anyone puffs their chest out to talk about the shitty neighborhoods they ride the ambulance into, it is only for those assigned to a tactical team and on mission.

Richard, that would vary by team and individual. Some bring their own, some departments provide them, depending on the weapon and the individual.

The bill neither requires TEMS providers to be armed, nor is any statutory permission required to carry outside of specific locations like schools and government property.

'zilla

I'd say yes. The only physicians who get any kind of training or understanding of EMS during residency are in emergency medicine. Any physician, however, may find themselves in a disaster or other emergency in the prehospital arena, or may find themselves the first to render aid outside of a typical patient care setting. Some knowledge of basic EMT skills would be helpful. It might also cut down on some of the bitching that doctors do about prehospital care who have no idea what it's really like.

Our ER residents ride the ambulance once a month through intern year. Second year they continue their field experience but are more involved in QA, education, and meetings with the regional physicians advisory board and standing orders committees. We also put them through a medical control base station course and an extrication course. Third year, they are required to lecture EMS for con Ed, and have 8 hours of didactic training and multiple planning projects for ems. All available residents teach for te CAP Lab, and many teach for the wilderness medicine expo and hospital seminars for ems. We also provide coverage for the Dayton Air Show and X Fest. About 1/5 are on SWAT teams, and several more are associate medical directors for ems agencies.

'zilla

Article from MedCity News

Text copied below.

Bill Brady and I are on the Warren County team together, and helped craft the bill. The article is actually pretty good on the scope and intent of the bill. The byline suggests that the bill is to arm your regular EMT on the street, which it is not.

The bill addresses two main issues germane to TEMS in this state:

To be a peace officer in any capacity in Ohio, you must complete the full course of academy training (minimum 500+ hours, and typically over 700), and 5 months of full time academy is prohibitive for many physicians and other medical professionals who are working full time. There is no "reserve" or otherwise abbreviated academy in Ohio, nor "special deputy" status for anyone who has not completed the full course of training.

A lot of us do this for nothing, and there is difficulty in saying if we are municipal employees entitled to qualified immunity from litigation. Fortunately, it has never been tested.

We've had several (occasionally heated) discussions on the ACEP TEMS listserv about whether or not arming medics is a good idea, from a tactical or a legal perspective. The bill sidesteps that to some extent, leaving it up to the SWAT commander to decide if it is appropriate for their team size, op tempo, TTPs, and personnel. Citizens other than sworn LEOs are prohibited from carrying weapons in places like schools, court, government buildings, etc., and the TEMS provider would therefore be breaking the law if they stepped into that environment with a weapon. The bill would permit TEMS providers to carry a weapon openly as part of "official duties" with the SWAT team during an operation. The TEMS provider would therefore not be violating the law if they responded to an incident in a school with the team and happened to be armed. The bill does not give TEMS providers (defined as First Responders, EMTs, Nurses, and Physicians) police powers, nor does it permit them to carry wherever they like outside of a SWAT mission (this would be governed by OH CCW laws). By putting it down on paper, it helps the SWAT commander and police chief understand that by simply arming the medic, they aren't deputizing them or making them an LEO.

The second issue is that of liability. Many TEMS providers, including physicians, provide medical support on a volunteer basis, often to police departments that have no volunteers nor policies to govern them. A point brought up by many is that if we are not paid, we are not "employees", and therefore not entitled to qualified immunity. This bill would establish the qualified immunity, even if the provider is not getting paid. It is modeled off a law in Ohio that provides similar immunity to physicians who volunteer to provide medical support at scholastic sporting events.

You can see the text of the proposed bill here:

OH HB288

It would modify existing OH law. New portions proposed by the bill are underlined.

The bill will go to the public safety committee for discussion, and may undergo revision before it goes up for vote.

'zilla

7.15.11 | Brandon Glenn

EMTs with guns? Ohio bill would give some the right to bear arms

Some Ohio emergency medical technicians could get the right to carry guns under a proposal in the state’s legislature.

This seems to be an increasingly hot-button topic among EMTs, who raise the issue as they struggle to cope with rough neighborhoods, threatening onlookers, violent situations, and armed and unstable patients. Skeptics, meanwhile, point out that emergency scenes are cleared first by the police or dispatchers, and adding a gun to the EMT kit would unnecessarily expand the job and risk of emergency workers.

Ohio’s legislation takes a narrow focus. House Bill 288 would give EMTs guns only when they went with SWAT teams. The law would also treat medical personnel like police in that they would have immunity from civil suits in connection with their use of guns when working with the SWAT team, said Republican Rep. Courtney Combs, the bill’s sponsor.

“It’s a bad situation if they call the SWAT team out,” Combs said. “For the protection of the medical professionals, they should have the right to carry firearms.”

That sounds about right to Dr. James Brown, chairman of the emergency medicine department at Wright State University’s Boonshoft School of Medicine, which has a Division of Tactical Medicine to help first-responders deal with high-risk situations.

“Personally, I’m a fan of it but the concern is what’s the [EMT's] motivation for being there? Is it just so you can carry a gun?” Brown said.

Brown acknowledged that there’s some controversy in the field of tactical medicine over whether medics should be armed. Brown believes the benefits outweigh the risks.

“If they’re armed for their own personal security, then that’s a good idea,” Brown said. “If they’re not armed, then the team has to task someone to be their security. Some teams are small and that winds up being problematic.”

EMTs wouldn’t be required to carry a gun under the legislation. The decision would be left up to EMTs and the SWAT teams they work with, Combs said.

Combs said the need for such a law was brought to his attention by his son-in-law, Dr. William Brady, an emergency physician in Kettering, Ohio, who sometimes works with the Warren County SWAT team.

The Ohio State Medical Association, the state’s largest physicians’ group, hasn’t taken a position on the legislation, a spokesman said. The president of the Ohio Association of Emergency Medical Services wasn’t available for comment. Combs said he hadn’t yet consulted with the emergency services group, but plans to contact interested parties within the next few months.

It’s unclear how many, or if any, states have similar laws. A spokeswoman for the National Association of Emergency Medical Technicians said it advocates at a federal level and isn’t involved in state legislation.

The bill hasn’t been assigned to a committee and no hearings will be scheduled until Ohio lawmakers return from their break in September, Combs said.

Photo from flickr user mikejmartelli

The EMS coordinator is a hospital employee, forgot to mention.

All of the hospitals in this area have an EMS Coordinator that helps arrange followup on critical patients, manage con-ed offerings at the hospital (and at the squads), and look into issues that arise from either end. They tend to be RN+paramedic, with field experience as well as ER experience. They are typically some of the smartest people I've had the pleasure to work with.

'zilla

You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration?

With a rate of 210-220, that would be pretty hard to pick up, even on a 12 lead.

'zilla

This can happen with a preexcitation syndrome like WPW and underlying a-fib. It's not v-tach per se, but conduction of atrial impulses throughout the accessory pathway (Kent bundle). Since they depolarize the ventricle more slowly than if the impulses came down through the His purkinje system, it appears wide complex.

'zilla

Antibiotics may be useful in prophylaxis of wound infections in environments far removed from medical care. 39% of wounds sustained by US troops during the Battle for Mogadishu sustained wound infections, which was only 18 hours from beginning to arrival at medical care. For most EMS systems, they are not looking at this kind of interval to care outside of a disaster situation, so I don't believe it would be necessary.

Regarding sepsis, blood cultures change antibiotic treatment rarely, and culture results will not return for several days. One reason we don't see abx in the prehospital environment often for meningitis/encephalitis is that the diagnosis is so hard to make, and once made, it is recommended to give a dose of steroids prior to administration of the antibiotic.

I carry ceftriaxone (Rocephin) in my kit for care provided outside the normal environments. It's inexpensive, has good broad spectrum coverage, penetrates CSF well for head wounds, has decent gram negative coverage for abdominal wounds, and covers pneumonia and UTI rather well.

'zilla

The larger contractors (KBR, Dyncorp) will typically use medics to take care of their employees. They have agreements with the US government to receive routine care at US facilities (TMC, BAS, or CSH), but the company has to pay for the care provided. By using the medics, the company saves some money by filtering some of the patients that would otherwise end up in sick call. The medics will provide care for most routine medical problems, referring up to the US medical facilities if more advanced care is needed. I have also coordinated follow up care with the company medics after I saw the patient in the ER. They did follow up exams, administered subsequent rabies vaccinations (an exposure requires several shots over the course of a month), and monitored medication therapy.

'zilla

Alcohol kills bacteria fairly instantly on contact, but once it has evaporated, there is no persistent antimicrobial effect on the site.

Betadine kills by dessication. It must dry to be effective. But it keeps on killing, which is why we like it for surgical preps.

CHG is kind of the best of both worlds. This has replaced betadine for many procedures such as central lines and blood cultures in my hospital.

We use all 3 as surgical scrubs. All 3 are quite irritating to tissue.

'zilla

This is a hot button issue in areas where there is a lot of competition between hospitals and a lot of advertising.

This has nothing to do with EMTALA. EMTALA, as someone already mentioned, was written to prevent hospitals from transferring patients away or refusing to see them because of their ability to pay. As much as patients love to crow that their long wait time is because they are uninsured, or minorities, or because they've tried to sue the hospital before, it really doesn't factor in. Triage protocols are developed and externally validated, and deviating from them for personal or financial reasons is highly unethical. They are designed to detect severe underlying illness, and nurses undergo continuing training as well as QA processes to further hone their accuracy. Also, with regards to the "medical screening exam", triage by a nurse does not meet this requirement. Though we haven't defined it well in writing, it is interpreted to require an exam by some sort of provider: physician, PA, or NP.

ERs have the capability to see pediatric patients. They may not be able to admit them to the hospital, but all must have the equipment and training. Nobody can argue that a specialty pediatric hospital wouldn't do a better job of it, although through RSV season our pediatric hospital has some of the longest wait times in the city.

Contrary to an earlier statement here, hospitals do add staff at peak times, much as high volume EMS agencies do, to improve performance at the busy times and reduce cost at the slow ones. Having a rigid staff contingent when most presentations to the ER are elective and typically peak during certain hours is not really seeing the big picture. Trouble is, there are unexpected peaks and valleys in ER volume, and even astute managers who look at trends and apply formulas cannot predict when those are going to occur. It's disheartening to everyone in the ER when 30 or 40 or 50 patients walk through the door in one hour, as sometimes happens in my ER. But it is tough to say exactly when that's going to happen. You may as well say the same thing about EMS when every ambulance is out the door and calls are stacking up. Sure, if they staff more trucks, those peaks will be easier to handle, but at what cost?

A patient calling EMS from the ER waiting room does not constitute an emergency. They already have access to the emergency medical system. They have a right to be seen, and will be seen. It may just not happen in the amount of time they would prefer. Worse, you are removing the patient from an environment where there is a higher level of care. If the patient decompensates enroute, you've taken them away from somewhere that has extensive resources and personnel into an austere field environment. Now, voluntarily calling 911 to take you somewhere else does not constitute an EMTALA violation or inappropriate transfer. It is "left without being seen", and would be the same if the patient walked out of the ER and got in a cab.

We can all cite or envision cases where a patient was mistriaged and had a graver medical problem than immediately evident. But these are the exception to the rule. Circumventing the system jacks up the patient flow. If every patient had a choice, they would page a resuscitation team at triage for every one, and they would get seen instantly, labs and xrays would be expedited, and the disposition done lightning fast. Which is essentially what we are trying to do, but the reality of emergency care in this day and age is that we can't do it. So we have to rely on triage protocols. But this does not mean we should abandon the triage system, and further burden the EMS system with additional call volume. The truth is that very few of these cases are about a medical emergency. It is far more about unrealistic expectations on the part of the patient (as evidenced by the fact that they would call 911 to haul them elsewhere). The patient believes that by setting a destination of the hospital, they can utilize free transport by EMS, and that's just not so.

Don't get me started on the patients unhappy that we didn't prescribe them percocet or refill their xanax. That's clear abuse, and our medics call the police, as do we.

Crochity, I'm assuming you were talking about OR blocks, not surgeons getting blocks of time in the ER.

Keep in mind that EMS operates at a loss; you cannot adequately equip and staff an ambulance to make decent response times unless you are subsidizing the emergency care with paid scheduled nonemergency transports (which are highly efficient use of resources) or with external funding, such as through taxes or hospital revenue. This means that every transport not only costs the patient, but costs the system. The EMS system, as much as we train on customer service and satisfaction, is providing a potentially lifesaving service to those in the field, or to effect transfer to a higher level of care when it is determined that specialized services are needed. It is not there to cart the patient around town at will. It is a safety net for those who cannot get to the hospital by other means, and who require immediate stabilization even before hospital arrival. This service comes at a substantial cost, a fact that all too many cities are aware of with shrinking budgets. To utilize it solely for customer preference reduces the capability of the EMS system by one ambulance, and lengthens response times to those who need it. This margin of safety gets narrower every year as cities and companies try to do more with less. ERs suffer the same issue. You cannot recuperate the costs you incur in providing emergency medical care. Hospitals eat it because the ER is the front door for their admissions.

ER overcrowding is a national problem, not just a problem of one facility. Despite the fact that ER admissions have been steadily and rapidly climbing for the last 2 decades, the number of ER beds and inpatient beds has been declining. So we are doing more with less. Add in physician shortages in emergency medicine and internal medicine, and you have an insufficiently robust physician workforce to handle these admissions. Care now has become more complex. Gone are the days when you could simply admit every chest pain. Now you have to use complex testing algorithms and serial enzymes to arrive at a safe disposition while using as few inpatient beds as possible. And the number of primary care physicians is well short of what is needed. This is not simply an issue of payer source, since insured patients use the ER as much as uninsured patients. Massachusetts passed a law for universal health coverage, and ER visits went up, not down. Hospitals are creating committees to address the issues, and with buy in from the inpatient floors, discharge planners, skilled nursing facilities, nurses, managers, housekeeping, and just about everyone else, the problem can be attenuated, but will always be there, and will get worse.

This issue is ENTIRELY about customer service. The customer is unhappy, and wishes to go elsewhere. The problem is, now you're spending other people's money (the taxpayer's) to do it.

'zilla

My recommendation, before putting together a formal "presentation", is to look up examples of the protocols you desire in other EMS systems, as well as pull any relevant articles (looks like most of what you want is not really evidence based, but operational preference). Then, have an informal private discussion with the medical director 1 on 1. In my experience, this will allow him to get his head wrapped around it first, and he's in a good position to initiate the changes in the organization with potentially less resistance. If you go with a full on presentation to the MD and command staff all at once, then there may be other players that will want to shoot it down for various reasons such as resistance to change, desire not to do more training, concern for budgeting the training, and equipment, etc. Regarding the medical society that approves the protocols (assuming this is a panel of physicians that makes this call), let the MD handle it. That's his job, and it's better coming from another MD than from outside the panel.

'zilla

God speed, Sir, and thank you for your service.

Actually, about a third of all PREVENTABLE combat deaths are from hemorrhage from an extremity. Most combat deaths are still not preventable, being that they are grievous wounds to things we can't fix. For the hemorrhage from an extremity, that's about 9% of all combat deaths. 5% from tension pneumothorax, 1% from airway obstruction. 90% of those KIA die before they ever reach a medical facility.

Ah, crap. This should read that 2/3 of all preventable combat deaths are from hemorrhage from an extremity, not 1/3.

As for all the comments about me needing a taste of basic and the microscopic level at which my post was picked apart, no one will believe me if I bother telling you. But I've trained with PJs, Recon Marines, Seals, Sergeant Majors, and field grade officers in every branch. They're all just as ruthless as doczilla, and have taught me to do the same when necessary. But they do it for a reason, not because they feel like they can. They realize they're working with young men and women who are making the effort to go above and beyond their call, when they could be eating donuts and playing xbox.

You came here with serious questions about serious business, and I gave you a no-bullshit answer. It was filled with facts to assist your thinking and was very direct. It is the type of answer you should expect from anyone who is knowledgeable in the given areas and serious about helping you with your career goals. That you did not like what I had to say does not make my answer ruthless.

NOW, surely we're done with all that. Ak, everyone else who was trying to help, thank you. I suppose I originally made this post because I've gone though some drastic changes lately, and I'm now considering the military as a career option. However, so many people get washed out, burned out, or injured. Due to this they fall out of the military and get a job they don't truly enjoy, or that doesn't pay all too well. However, if I can get valid experience in the military as a medical professional, that's a great experience and opportunity to serve my country. After which, if I really enjoy it, I could make some money for the future and do something I really enjoy, which is working hard. I'm not out to be a mercenary, or a hotshot carrying a big gun. But..I recently read that 50% of all deaths in combat are due to uncontrolled hemorrhaging. If that's the case, how many fathers and brothers and husbands could I send home alive?

Actually, about a third of all PREVENTABLE combat deaths are from hemorrhage from an extremity. Most combat deaths are still not preventable, being that they are grievous wounds to things we can't fix. For the hemorrhage from an extremity, that's about 9% of all combat deaths. 5% from tension pneumothorax, 1% from airway obstruction. 90% of those KIA die before they ever reach a medical facility.

You've said you really like the military, but spent 1 week in PJOC and decided you wanted nothing to do with it. PJs are among, if not the, most highly trained paramedics in the service. (We can argue about 18D and other SOF medics, but pararescue is probably the closest to what a .civ paramedic does) So as I said before, ask yourself why you were so turned off by it. Was it the yelling, the physically arduous nature of the training and the work, the long hours, little sleep, the kind of medicine, what? Again, PJ is the epitome of all this you say that you want to do.

I'm seeing a lot of "I want to make money" from your posts, which as I and others have said, is not really in line with your short and intermediate term career plans with the military, medicine, and EMS.

I came here and gave you pretty much exactly the info you were looking for, and then some. You responded defensively, and with a great deal of shitty attitude.

'zilla

Just STOP. Reset the OODA loop for a minute here.

Sup folks,

Not a good way to start your first post on a professional forum.

I'm pretty young. I'm 17, but I have a lot of experience behind me and big aspirations. I've been a member of the Civil Air Patrol for six years now, and I'm currently a CNA. I had my heart set on a civilian ER nurse for quite a while, but I really am already a military man at heart. I thrive in that life style. I'm currently researching contract work overseas. One could literally retire early on that.

So the questions are:

• Aside from pararescue (because I know ALL about it, and want nothing to do with it) what emergency medicine is there in the military?

There are medics in the Army, Air Force, and Navy. The Marines are supplied medics by the Navy. There are also special operations medics, which include PJs, 18D, SEAL corpsmen, and others. The term "medic" in the military is fairly generic. All are to some extent trained to be "combat medics", i.e., work in the field as an organic part of a unit, but also may work in hospitals or clinics.

Pararescue is a specific special operations MOS in the Air Force. If you know ALL about it, and decided it's not for you, you may ask yourself why that is. If you're so geeked by the military, and want to do high speed medicine in dangerous places, PJs are essentially the epitome of that. If the arduous nature of their training concerns you, then you need to question your motives.

Do combat medics get paid more than the typical NCO?

No.

• Say I got my RN and Paramedic over the next three years, and then enlisted. What position would be ideal? Would I be better off just getting an EMTB license if I want to be a combat medic?

If you enlist and go the medic route, your EMT-B training will be provided to you in your initial training.

Which position is ideal? Depends on your goals. If you are an RN, it is unlikely that you will be used as a combat medic. There are however many positions for RNs in various military settings.

• Realistically, what are the odds of actually getting a contract in the middle east (or anywhere else) doing medic work?

They are good if you have extensive field experience or military deployment experience. CAP does not count. Without those experiences, you could possibly get a contract with a small company, but unlikely to be one with a good reputation. Very unlikely you would get a field job with Blackwater, Triple Canopy, KBR, Dyncorp, or any other sizable company with decent street cred.

• How good is the GI bill, really? I mean I've read all about it. But none of the guys I know care about college yet. Do you really just get your college paid for? I could, in theory, go play in the sandbox, make a few bucks, and then come back and get my RN degree and settle down.

Yes, you get your college paid for, but it doesn't come free. It comes at the price of service.

I dunno. I'm just sitting here realizing it's time to start thinking hard about these things. And I know what I like. Which is medical work, the military, and money. The only time those three coincide is with organizations like blackwater. (err.."UStraining")

"The military" and "money" do not go together. You will not make as much in a military occupation as you will in the equivalent civilian job. They don't call it "service" for nothing. Lacking in your post is any thought of service to your country or others.

CAP is NOT the same as being in the active duty military. You are in for a kick in the teeth when you get to basic if you think so.

Your image of PMCs is somewhat skewed. The reputation that BW has in the industry is a very good one. Despite what you might read in the mainstream media, PMC work is not the key to boatloads of cash, nor is it equivalent to the military. Pictures of PMCs wandering around in khaki 5.11s, Oakleys, with M4s might look cool, but you have to remember a few things about them. These men have cut their teeth on actual deployments, often with special operations units, already having extensive training in the given field as well as maturity. The ones who are paid well have earned it because of their qualifications. They look like mercenaries, able to do whatever they like and put boot to ass for fun, but PMC work is hot, boring, dusty, dangerous, and thankless work. It is also extremely detail oriented, and a high degree of professionalism is expected of them. The career outlook for these positions is not that good either. Folks who do it long term are subject matter experts in their given field, which comes from many years of experience, usually in the military.

There are positions overseas with PMCs that do not require this background, which do pay decent, but those are typically in support roles such as logistics and supply. And no, you will not carry an M4 and shoot bad guys.

SLOW DOWN. Focus on the 25 meter target. Finish school, get good grades. If you want to make boatloads of cash, that will not come without extensive experience and education. If you want to be an RN, go get your RN. If you want to get combat experience, then go join up in a combat arms MOS, and realize that you are still unlikely to get any.

'zilla

2nd degree type 2 AVB with junctional escape beats. Look at the pattern of QRS complexes. Some are closer together, and some farther apart (escape beats). You've got some nonconducted P waves, but the PR interval is regular on the P waves that are conducted.

The QRS itself is not particularly wide as you would see in a LBBB. It's narrow right up until the notched terminal portion of the QRS. This would be typical for early repolarization. With as slow as it is, this may be an early osborn wave of hypothermia. Although, all the osborn waves I've seen were wider than this, so I'm betting on early repol, which was probably preexisting to this presentation.

'zilla

My gut told me there was no foul play, and I thought it unlikely that both the husband and her father were conspiring to off her, although the husband was clearly driving the bus when it came to her care. There was no durable POA; we were just going by the usual OH rules regarding who makes those decisions, i.e., spouse, then parents, then grown children, then siblings, etc. Ethics committee is a good thought, but I'm not sure how we make that happen at 11pm on a weekend.

Ohio currently has two levels of DNR. A DNR-Comfort Care Arrest (DNR-CCA) simply states that no resuscitation will be undertaken in the case of a cardiac arrest. It is frequently interpreted to allow everything else, though we may modify treatment based on discussion with family. A DNR-Comfort Care (DNR-CC) means that no aggressive lifesaving measures will be taken. This is usually taken to exclude intubation, pressors, central lines, defibrillation, but not necessarily IV hydration, artificial nutrition, or antibiotics. There is legislation afoot in Ohio for the MOLST (Medical Orders for Life Sustaining Treatment), but at present the only way to express your wishes regarding specific treatments is in a written advance directive. As you can see, even here, there is room for debate, as some will say that brief life saving interventions would be permissible if the disease process is thought to be easily reversible.

Most patients I encounter do not have clear advance directives on what care they would or would not want, which complicates things for those of us in critical care and emergency environments. We often rely on family members to tell us what they know of their loved one to help us guide what we do. If they have no useful information, then we treat under the doctrine that most people would want to survive under any circumstances. Most of the time EMS is, frankly, not permitted to think beyond the written page. Only honoring a recent, signed, very explicit DNR order is perhaps medicolegally the safest way to go. This also fails to address the majority of futile resuscitation that we will perform. Of course, if the patient never said anything, we'll never know that they wouldn't want to suffer a lingering convalescence. Making this call on limited information, from sources other than the patient, is tough.

There is that critical time, the immediate resuscitation, that makes all the difference. If you can get someone through that initial issue in the ER, it is very likely the patient will survive. It could be that come patients see that respiratory arrest as an easy way out, and in fact, they are often correct, since the one intervention, intubation, at the critical time, is enough to get them over the hump, to a prolonged convalescence, which is what the patient may want to avoid if they have expressed their wishes not to be intubated. Does this change what we do if the causative issue is one that is potentially easily correctable, or iatrogenic, or self inflicted?

In the end, it was all academic. She maintained her own airway and did not require intubation in the ER. The patient was not terribly well educated on her insulin pump, and was also on a long-acting insulin, so it was thought that this, combined with a UTI, caused the hypoglycemia. She was admitted by PCC to the ICU. He made her a full code, and his documentation stated that he "was not satisfied with the documentation of her wishes regarding code status". The husband was apparently pretty unhappy about it, according to the chart. The patient fully recovered, and met with Integrative Care Management. In a well-documented conversation, the patient said she would not want to ever be intubated under any circumstances, and it appears the husband was correct. A DNR-CC form was executed, and the patient discharged home.

I bring this up because of the difficult position I was in, not just with the patient and family but with staff. The nurses taking care of her were very experienced and pretty headstrong, and they clearly would have put up a fight if something happened and intubation was medically indicated and I refused to do it. I'm not sure how that would have played out, but it likely would have involved the resource nurse, the AO, another physician from the ER, and hard feelings all around. It would have been fairly ugly. We like to think that we run the place, but when the nurses feel an ethical obligation to do something, they can, and will, stand up to us, and refuse to execute orders they feel are not in the patient's best interest.

'zilla

41 YO F presents to the ED in status epilepticus due to profound hypoglycemia. She has a history of type I diabetes as well as multiple sclerosis. She functions independently at home, but has maxed out therapy for the MS, which has been progressive.

The patient was last seen normal by her husband about 3 hours ago when he went out to run an errand. When he returned, he found her unconscious. Accucheck read "low", so he gave her 2mg of glucagon IM and called paramedics. Blood sugar read 113, though we think this may have been a spurious reading by the meter. Nothing suspicious was found such as a suicide note or empty pill bottles.

She is on an insulin pump, which appears to be functioning well and is not empty. She gets 2mg ativan IV and D50, which stop the seizures. She never regains consciousness in the ER. In fact, she requires multiple doses of D50 and a D10 drip to maintain her blood sugar.

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

I'll tell you later about what happened with her.

I got into a discussion with a couple of the nurses about what to do with her. I did not think that intubation was appropriate, as we had an (albeit old) DNR form and two close family members that said she would not want it. The nurses said that she is young, still very functional and relatively healthy, so why would we not intubate or resuscitate her if needed? I cited two chronic, progressive, debilitating diseases, although I concede she is not bed bound or demented. They brought up the fact that the husband may be stretching the truth for his own purpose, i.e., to rid himself of her. They brought up the possibility that he may have given her an intentional OD of insulin, though at the present time there is no evidence of foul play. She is currently maximized on therapy for the MS, and in fact exceeding typical doses of her medication (not illicitly, but with doctor's order) to try to slow the progression.

So, if it is medically appropriate (i.e., for airway protection, need for ventilation) do you intubate her?

I am not concerned with discussing details of her treatment right now, only the ethical question of intubating or defibrillating her if it becomes necessary.

'zilla

I agree with ER Doc to just take it off. You've got 6 hours of cold ischemic time before you have to worry about lactic acidosis that would be clinically significant.

'zilla

We put one in the other night when this drunk chic chewed a bottle of xanax right in front of us...but the crazy thing is hospitals in our area are steering away from gastric pumping and lavage...cause its so messy...that's crazy if you ask me...but they say it ain't killing them...they can just sleep it off...blew my mind!!!

Gastric lavage and charcoal are not the harmless interventions many have thought them to be. The old "activated charcoal binds everything" is not true, and it conveys benefit in a very few overdoses. When it does, it is not the single dose of charcoal we have been taught, but multi-dose activated charcoal that is given repeatedly. As per the American College of Medical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists, it should only be given for carbamazepine, dapsone, phenobarbital, quinine, or theophylline. If aspirated, the charcoal causes a horrible aspiration pneumonitis. The aspiration risk goes up if you are shoving a tube into a conscious patient's throat. The sorbitol can also cause potentially serious fluid and electrolyte shifts.

For single dose activated charcoal, this position statement from the same organizations provides some guidance: "Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within 1 hour of ingestion. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour of ingestion. There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated."

Gastric lavage has not really been shown to improve outcomes in poisonings either, and it comes with some serious downsides.

The same groups put out a position paper on gastric lavage as well. "Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnor- malities, and aspiration pneumonitis. Contraindications include loss of protective airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition."

Benzodiazepine overdose, like xanax, is typically pretty benign. In a medical setting where you can monitor their oxygenation and protect their airway if needed, there is no need to administer an counteragent (flumazenil. NEVER give this for a poisoning. You know what? Never give it.) or expose the patient to additional risk of complications from gastric lavage, whole bowel irrigation, or charcoal. There are specific cases when one or more of these may be useful.

'zilla

At this point, it means very little to the average EMS provider. This determination means that physicians may board certify in EMS after completing an EMS fellowship. This is similar to a doctor completing internal medicine residency, then doing a cardiology fellowship to become a cardiologist.

Initially many physicians will be "grandfathered" in without the fellowship if they have substantial relevant experience in EMS, but nobody knows yet what that will entail. When emergency medicine started out as a specialty, most physicians who worked in the ER were not residency trained in emergency medicine. Because the residency wasn't available when they had initially trained, and because the had a good deal of experience in the specialty, they were allowed to sit for the board exam in emergency medicine. The requirements to allow this got tighter over time, and finally was not allowed, so now you can board certify in emergency medicine only if you have completed an emergency medicine residency.

The ABMS board certification in EMS is not for your average ER doc who may give online medical control. It is more for physicians in an administrative role, usually for larger systems. It will certainly qualify physicians to do field response, though you don't see this often in your average EMS service. I don't think we will get to the point that all EMS medical directors are board certified, as the demand would far outstrip the supply. Larger cities will likely start requiring it.

There are EMS fellowships currently, but nobody can board certify until the exam is created, which requires setting forth the training requirements (not easy to put down on paper EVERYTHING you want them to learn in a year or two) and prerequisites for board certification. with no board certification, it is tough to convince a doc who has completed residency to endure another year or two of fellowship with little professional recognition on the other side of it when they could be making 4 times as much money. Therefore, many EMS fellowships can be done in conjunction with an MPH.

What I hope this will accomplish:

Better recognition of the need for specialized training for physicians providing medical direction.

Hopefully better pay for physicians doing EMS medical direction. Many EMS systems want much of their medical director, but compensate very little (if anything) for their time. It is usually seen as a "hobby" by the hospital or physician's group, discretionary and subservient to all other employee responsibilities. As a recognized medical specialty, the physician is in a better position to demand some FTEs for the work he does.

Better expectations of medical direction. Many states allow any licensed physician of any specialty to be an EMS medical director. The quality or level of involvement therefore varies greatly from one medical director to another. With board certification, the physician has dedicated substantial time to the specialty, and is less likely to be an absentee medical director.

Better funding for EMS research.

More opportunities for full time EMS medical director jobs.

'zilla

I agree with most of the other stuff here. Generally SWAT medics have substantial amounts of field experience prior to getting onto a SWAT team. Of our six medics, all have at least 5 years full time field experience, and most are lieutenants or captains on their respective departments, with 10-15 years of field time.

'zilla