BEorP

Though it is nice to see support from the emergency physicians, the bottom line is that if these paramedics delayed transport to start an IV in a trauma patient, they were wrong. Would it have likely made a difference in outcome? Not likely, but they were still wrong to waste time on scene like this. Of course, we don't know all of the facts here and it is always easy to look back and judge, but it certainly seems like the paramedics are getting off relatively easy.

Don't delay transport to start IVs on trauma patients. If you do, you're not acting in the best interests of the patient.

They're great for inter facility transports. The first time you have to lug it up or down stairs, you will curse the day you ever considered it.

I know that some people prefer to get lug the stretcher up a few stairs instead of getting the stair chair, but I think that it is time that our habits change since the equipment has evolved. If you have a tracked stair chair to go with your powered stretcher, why would you ever lug the stretcher up or down stairs when you can glide with the stair chair instead?

Our tools are nice, they help us do our job, however it is possible to be too reliant on them. That's all I'm saying. The tools are half of it. The practioner's experience and intuition are the other half. such as the case in the op's original post. Does this SPO2 reading make sense?

Okay, so let's say you have a patient who has a low SpO2 with a good waveform. If this "doesn't make sense" with your general impression of the patient, what are you going to do?

You should not be allowed to use a pulse-oximeter until you have run at least 100 respiratory calls, and have assessed all of those properly with just your ears, eyes, and brain. You should be able to approximate a pulse-ox reading without using it, then use the pulse-ox to prove your estimation. You will be a far better clinician if you follow that advice.

Should you run 100 diabetic calls before measuring a patient's blood sugar as part of your assessment?

Should you run 100 cardiac calls before using an ECG as part of your assessment?

I can agree with that idea for something like not using an automatic BP cuff until you've run many calls without ever using one. Whether it is automatic or manual, it is essentially the same assessment and you can get the same information either way. But the use of SpO2 (and the two other examples above) is different because these are assessing things that we cannot assess without the special tools. Yes, you can do a thorough respiratory assessment, but no matter how good a clinician you are, you cannot measure someone's SpO2 without an SpO2 monitor.

1. How do YOU really know to trust your SpO2 readings?
   
2. Dwayne states in the mentioned posting, that "to many times people are/were suffering, and/or dying because providers didn't treat them because the pulse ox said that they didn't need to." How comes this? Beside true application errors (including deflective finger nails), the only real false-high reading of pulse ox I know is a CO poisoning. All other problems would give no reading (no signal) or false-low readings - how can this lead to provider's not giving oxygene? In my case#1 I decided so because of the general apperance (and was correct), a less imaginative provider may have given O2, because of low reading, but most probably this wouldn't have done any harm.
   
3. Do we really need pulse oxymeters or the SpO2 value (if we can't trust it anyway)?
   

Great questions.

1. As long as there is no reason to suspect CO and the patient doesn't have any obscure conditions that could impact SpO2 (e.g. methemoglobinemia), I trust my SpO2 when there is a good waveform. Rarely will I consider an SpO2 reading without viewing the waveform. It is a bit of a pain on the Zolls to need to go into manual mode to see this, but I think the extra information is worth the button presses. In my anecdotal experience, I do not recall ever seeing an SpO2 reading that seemed unreliable when there was a good waveform.

2. Given a properly functioning SpO2 monitor and a good waveform, I do not believe that it would be likely to get erroneously high SpO2 readings, with the obvious exception of CO poisoning (which isn't really erroneous since the hemoglobin is saturated). Without a waveform to help judge the reliability of the reading, it may be possible to get an erroneously high reading, but my experience has been similar to yours, Bernhard, in that I have only seen erroneously low readings. I certainly do not have experience with all devices or in all situations though, so Dwayne's experience could have been different.

On a related note, there was a comment made on a different forum that you wouldn't want to be the medic who withholds oxygen from a cyanotic patient just because their SpO2 is high. Sounds like a good statement to make, but when you stop to think about it, it really is not likely that we will ever see a patient like this (of course, excluding SpO2 malfunctions). The only thing we could come up with where a patient may be cyanotic with an erroneously high SpO2 reading was methemoglobinemia. These patients will often have an erroneously low reading if they have with mild methemoglobinemia and an unreliable high reading if they have high-level methemoglobinemia. There did not seem to be anything else that would normally lead to a cyanotic patient (who was actually in need of oxygen) having a high SpO2.

3. As you probably gather from my answers to the previous questions, I trust SpO2 more than some of my colleagues. Do not take this trust for SpO2 as an over-reliance on it though as it is still just one assessment of many that we should be doing when considering a patient's respiratory function. We certainly do need SpO2, but in my opinion we should only be using SpO2 monitors that display a waveform.

As one final note, it seems that the 2010 ECC guidelines are putting a bit of weight in SpO2 readings in the reccomendation for titrating oxygen based on SpO2 in ACS patients (http://circ.ahajournals.org/content/122/18_suppl_3/S787.full).

Looks like the OP hasn't had a chance to come back to give us all the final answer. From what I can tell, entity hit on it in a post earlier on:

found some info on http://emedicine.med...treatment#a1127 if anyone wants to read up on it a bit..

edit: this is too complex for my head right now so according to the above, increased O2 for these kids might not be the best thing for them because it will further decrease pulmonary vascular resistance / increase pulmonary blood flow.. so maybe it will be trying to find a balance of the correct O2 levels / not necessarily giving 100% o2?

From the link provided in that post, the key line seems to be:

"In the patient with hypoplastic left heart syndrome, decreased pulmonary vascular resistance causes increased pulmonary blood flow and an undesirable obligatory decrease in systemic blood flow."

Let's go back a bit. In most tissues, hypoxia leads to vasodilation. This makes sense, since if your tissues are hypoxic it would be good to increase the blood flow to get more oxygen to them. The exception to this is in the lungs. In areas of good oxygen supply, it makes sense to vasodilate to be able to take up more of that wonderful oxygen. In areas with poor oxygen supply, it makes sense to vasoconstrict so more blood will be directed to the areas with more oxygen to be taken up.

Now to think back to our current patient's heart for a moment. Due to the original condition, their left ventricle is no good. Thanks to the Norwood procedure, their right ventricle is pumping systemically. Normally the right ventricle only has to pump blood to the lungs, not the entire body, so it is working a lot harder. If the patient gets too much oxygen, that will get rid of the hypoxic vasoconstriction in the lungs. The vasodilation in the lungs means that there will be more flow in the lungs and essentially less blood for around the rest of the body. (I would guess that the kid would have a more difficult time compensating for this distributive issue since their right ventricle is punching above its weight to begin with.)

Someone also asked what O2 sat would be expected for a patient like this, the link above says:

"...most infants should remain in room air with acceptable oxygen saturation (pulse oximeter) in the low 70s."

In terms of actually titrating oxygen, I think this point was made but it never hurts to re-state it. As bleve suggested, a venturi is really the way to control the FiO2 that we are administering to a patient (though I don't expect that most ambulances have those). Remember that the FiO2 is the percentage of oxygen that a patient is receiving. If you are using a non-rebreather, the patient will always be breathing primarily pure oxygen from the reservoir bag so the FiO2 will be near 100%. Changing your flow rate from 15 LPM to 10 LPM (assuming the reservoir bag continues to remain inflated) will not change the FiO2.

Hopefully that helps to answer some questions for those who were left wondering. I really don't know anything more about any of this than what I've been able to read online since seeing this thread so hopefully people will jump in if I have been inaccurate in anything I've written. And hopefully when the OP has a chance they will be able to pop by and fill us all in on the final answer.

Yes, it exists. It is through a website called Trainingdivision.com. 80% of the course is done online at your own pace, and at the end of each semester, students are required to attend a 7 day hands-on skills class at the training center in Crowley, TX. After passing all the exams, we are then required to do the same amount of clinical rotations as any other program. Same books, same information, I am just presented with more of a challenge because I am basically teaching myself. This is a national program and students from all over the country travel to TX to complete the hands-on portion. I am fortunate enough to live only a few miles from the training center and can visit the instructors frequently when questions arise. I completely understand this being a questionable concept, but I can assure anyone with doubts that anyone who does not clearly comprehend the course work will not succeed. It is very difficult, but to be blunt, the program is designed to assure that no half-ass medics come out of it.

Welcome to the forum! Do you have a link or any more information about your program? I went to the website but I only saw a paramedic refresher and ended up going in circles through their site.

Me and my partner have been in argument for the last few days. I was wondering if some of you could lend your opinion.

We work on a native reservation in Northern Ontario. We were paged out sometime between 5-6am for a drug overdose. The only other info that I remember was that the patient was 37 and female. My partner insisted that we wait until the police cleared the scene before we went in. I felt comfortable going in without them. He contends that given the fact that we weren't familiar with the residence, as well as the time of day and the nature of the call (potential for hostility), it was unacceptable to enter before the police. I maintained that given the potential seriousness of the call, that decision was at the paramedic's discretion. In short, it's not a black and white, yes/no answer.

Your thoughts?

Good question and it is an important discussion to have. The first point that is important to understand is that at least some people's interpretation of Section A of the General Standard of Care in the BLS Standards indicates that we need to actually approach a scene to determine it is unsafe (rather than simply deciding that something doesn't sound right from dispatch info). Obviously this is not what happens in practice across our province, but understand that staging without having a specific concern for your safety may put you at risk if the MOH investigates afterwards (thinking specifically of the June 25, 2009 incident in Toronto).

My personal opinion is that many paramedics stage too often. The vast majority of the time that we to wait for police, we end up entering a scene that is quite tame. Surely we could be smarter about how we do it without endangering ourselves. That being said, I will never question the judgement of my partner. We have all had different experiences and they may be more knowledgable about the community. If they want to stage, we stage, even though it may not be what I would have done if it were solely my decision.

As one example of overuse of staging, it seems as though some paramedics will never enter a scene without police where a patient is drunk. I think that this is unreasonable. You need to consider all of the call details. One call that sticks out in my mind was in a rural community where we were paged out for someone who was drunk. Our supervisor suggested that we stage and wait for police, but upon getting the full story from dispatch the patient was a long time alcohol abuser who had finally agreed to get help. Yes, he was drunk. No, he wasn't entirely cooperative, but he certainly was not violent and wasn't a risk to us. And even if he got violent, his current state would have allowed him the coordination to chase after me.

This leads to my final point. If a patient or bystander gets violent, get out! It should be that simple. For some reason, it seems like time and time again paramedics end up in a fight with a patient or someone on scene after being attacked. They press the emergency button but do not make any real attempt to remove themselves from the situation. Unless they are holding you there or blocking your only route of egress, there is no excuse for not getting out.

But to get back to your initial question, I don't know your community (or how safe it typically is), but I would think that not knowing of that house is probably a good thing. So in short, I agree with you that I would be comfortable entering without police. That being said, I understand that a partner could have a concern and I wouldn't argue with them on that.

I hope it won't just be me! Anthony, let me know if you need to be picked up from the airport... I'm coming in on the 7th and planning on leaving after on the 8th.

I'll be there on the 8th. Hopefully others will be joining me!

Dwayne, it might be best to snag a spot now. Double check on the registration page, but I think they will refund if you cancel with enough notice if your availability changes.

However, I wouldn't let the BLS unit just park on the scene without staff, because they're all in the ALS unit working on two patients in confined space. That sounds like a waste of ressources, in my eyes the BLS ambulance would be perfectly able to transport one of the patients. But I understand, that legal restrictions may arise, if BLS staff is not allowed to work under expanded authorization with rendering/supervising ALS treatments as i.v. drops and else. That's what I asked for to understand. Thank you for explanation! Again, I'm glad to not have those restrictions here (which makes it not better here, just may be easier in this special case).

I agree that leaving an ambulance on scene creates difficulties and that it will be difficult to have three EMS providers and two patients in a single ambulance. That being said, if we're talking about a system where the BLS level can't give fluid (or do much), then transporting both patients in the ALS unit with one BLS provider assisting seems like the best way to get the highest level of care to the patients in this case (the other BLS crew member can take the ambulance and could possibly even continue to cover the area on a first response basis - since in rural areas this will be an important consideration).

There are a number of factors in this scenario that come together nicely to make this a feasible option in my opinion (and we surely won't always be this lucky). If that third patient were viable then there would be another challenging decision to make since someone is going to be taking two patients. The other thing that works out well in this situation is that they are both going to the same hospital without question. The final thing that works out well in this scenario is that the BLS crew on scene cannot just scoop and run with one patient since there are no other EMS providers on scene for the other patient. Another challenge that could have been added is if a supervisor/ERU/RRV/whatever you want to call the single EMS provider vehicle were on scene and then an argument could be made that the BLS providers should have scooped and run with one of the patients while the single EMS provider packaged the other patient and waited for the second ambulance to arrive.

In short, I am saying that I wouldn't always advocate for putting two patients in one ambulance when there is another perfectly good ambulance available, but it seems like a good option here (though other options could easily work as well). As I'm sure we can all see from the discussion, there are so many considerations here for what really does need to be a quick decision on scene so it is great to consider and discuss now while we have the time!

I would hope that since we're talking about rural EMS, that your ambulances are capable of taking two stretcher patients? If so, would certainly consider sending both in the ALS ambulance with the ALS provider and one of the providers from the BLS ambulance.

I'm glad we haven't worn out our welcome yet! I have gone the last three years and have found it to be a valuable learning experience each time. There is nowhere else where you can spend a day getting taught by emergency medicine specialists and residents who all have a real interest in EMS while also getting hands on experience (especially for just $40). Oh and lunch is always great as well.

This is a terrible loss. Rob provided advice on here from when I first started paramedic training, helped me with my resume when I started looking for my first job and then I had the pleasure of meeting him at the CAP Lab a few years ago. He always encouraged everyone to always strive for more. I hope he knew the impact he had and how much he will be missed.

Thanks for the Canadian version!

Incredible! I'd love to see a version with PCP in place of EMT and ACP in place of Paramedic so I can share it with Canadian paramedic friends who don't frequent US-based EMS forums.

As the other poster as mentioned, the visa issue will be the first thing to address. Then pick a province that you would be interested in and we can help give some information on how feasible it may be. There have been many threads on this before that you might be able to dig up with a bit of searching.

I love California and all their trailblazing ideas for paramedicine. Lead on, my friends!

Most med students who have never had pt contact are scared as hell of it because they respect what they don't know.

I think that that is the key benefit to the program right here. EMT clinical exposure in the pre-clinical years (or before) will surely make the patient interaction aspect of patient care easier in the beginning. The clinical aspect could also be beneficial, but I think this would depend very much on the ambulance service and whether there are experienced, knowledgable paramedics to learn from and discuss cases with. I think there may also be something to be gained by medical students "getting their hands dirty" in a position like this, but I can'r claim that doctors who were EMTs will be better doctors.

I certainly think that it is an interesting idea, but I think that from an EMS perspective it further degrades the occupation by showing just how easy it is to do a 120 hour course as a side project to any other major focus. I also have reservations about it being mandatory since there is a degree of risk involved with being an EMT, and it would be terrible for a student to become injured while doing it because they had to (though I guess if it was made clear to them during the admissions process then that is what they signed up for).

Ha. I love how they quote the guy from Ambulance Victoria as if he speaks for some unified Australian ambulance system that doesn't exist. CareFlight in Queensland had blood before Victoria did if they just got it this (Northern Hemisphere) spring.

It's different in the same way that being an NP is different than being a PA. It's bringing a different background to the table. It's advancing a field that has so much more to offer.

Imagine Paramedic Practitioners opening their own clinics. I would go to one.

I think it's inevitable. You are right about the nurses union trying to shut it down though. All good ideas are ridiculed before they are instituted.

I like your thinking, but I personally can't see things going this way for a number of reasons.

My personal opinion is that a lot could be gained by paramedics embracing the PA profession to bring it back to its roots. I feel that PAs could be strong advocates for paramedics if the majority of PAs were once paramedics and that it would provide a good avenue for advancement for experienced paramedics that would also benefit the PA profession. Unfortunately (in my opinion, at least), PA programs have largely shifted from valuing real healthcare experience to instead focusing on GPA and offering advanced degrees.

I thought there had been more replies to this thread before.... weird. Anyway, Lone Star has pretty much said it all. The only thing I would add is that if you choose to report this type of non-exposure exposure, it would vary depending on where you work. Where I worked, I would likely just put in an incident report describing what happened but not sounding any alarm bells by calling it an exposure (since it really wasn't as far as we know). This way though it is down on paper in case something does come of it (i.e. in case you didn't notice there was broken skin and something was transmitted and you get sick... all extremely unlikely).

I think that I'm beginning to understand why the ACoP is so frustrating. I have contacted both the ACoP and Lakeland College. The ACoP suggested that I contact Alberta educational providers such as Lakeland and Lakeland suggest that I contact the ACoP. It seems to make labour mobility difficult when you apparently need to have employment before being able to have the restrictions lifted. Surely an employer would always rather hire someone with an EMT rather than EMT (Restricted) certification, wouldn't they?

I do think we need to simplify things for the public, maybe such as in Canada or--what I think would be more ideal--abolish EMTs all together.

Exactly, if we want the public to actually know what to call us then we need to settle on one title first. It seems like the Ontario/Australian model where everyone is a "paramedic" of some type would be best. Internally, we know that an Advanced/Intensive Care Paramedic offers a higher level of care, but to the public we're all some type of "paramedic" and it is not wrong to refer to a provider of any level as such.

Thanks, I'll get in touch with them.