Asysin2leads

I am only somewhat amazed that a thread that began with a NIH study evolved to shoving candy bars up people's asses. That took a lot of skill. Well done.

There's no disrespect intended. I'm not saying that manipulation of a fracture or dislocation without analgesic is always wrong, and indeed, if your service has found a way to reduce or manage injuries and be able to do it efficiently and without negative feedback, then good on you. However, your service should be familiar with the standards for timely pain relief that JCAHO and/or Medicare expects. Speaking of worse case scenario, you have to bear in my mind you might get that one asshole patient who you did absolutely superb work on, and got them up and gone for cheaper and better, but who has a cousin who knows a lawyer who can get him a few bucks, and is able to bring in the standards of pain relief to court and show what you "should have" done. I think pain relief is the one single issue that modern healthcare screws up the most for the largest population. We under treat acute pain, both because of the limits of EMS and attitudes that haven't quite caught up with research, and we over treat chronic pain, turning somebody with a simple lower back muscle strain into a sedentary invalid knocked out on hydrocodone or carisoprodol, who needed a few days rest and then needed to stretch and exercise. I trust your medical judgement, I tend to be very aggressive on pain management much because of my own injuries. I'll be the guy who volunteers to be dropped off in the woods in the middle of the night even if its just for some pain relief on a person with a dislocated patella, because I know how much it hurts, and I don't want other people to have to go through that if it can be avoided.

You know what's funny? I've been in all sorts of bars in all sorts of different areas. The only time I was turned away was outside a nightclub, when I just wanted to say Happy Birthday to someone who was celebrating inside. I was offered the choice of getting a $500.00 bottle service or politely being on my way. I responded by suggesting the bouncer perform an anatomically impossible act. I've never felt uncomfortable or been made to feel I need to leave in a bar with a mixed clientèle or one where I was the visible minority, and I'm talking bars where you have to go through a metal detector and are patted down before entry. Maybe because I was always with someone who they knew. The only time I felt really, uncomfortably out of place was at a bar in the outskirts of New Jersey, in that area that is more West Virginia then Union County. It was a place where there were Harley Davidsons outside, and tow trucks with Harley Davidson logos on them outside, and everything else was pickup trucks. To make matters worse, I had just come from a clincial in New York City, so I had my dapper looking peacoat, leather gloves, and a nice Calvin Klein tie on. Everyone else had a cowboy hat on. Again, this was to say hello to someone I knew. When I walked in, if it was a movie, the music would have stopped and someone would have dropped a plate of dishes. I had one beer and then politely got the heck out of Dodge. The moral of this story is the only time I really felt like I needed to leave a bar was one that was full of other white people. Go figure.

I wasn't trying to be cavalier about narcotic agonists. I brought it up because in a risk/benefit analysis, it is another layer of safety. Morphine does have one of the narrower therapeutic indexes, but in the hands of a skilled provider it is can be administered fairly safely. Having an antagonist on hand is an extra layer of safety on top of that. The chance of overdosing the patient on morphine may or may not be unacceptably high, but the chance of a narcotic overdose times the chance of the antagonist not working significantly reduces the probability of having a life-threatening event. Of course I don't recommend using a simple opiate for extremely painful procedures. That's why I prefer a combination of an analgesic and a sedative/hypnotic or a sedative/amnesic. I also don't think its proper to imagine a worst case scenario, and then apply that logic to EMS operations as a whole. Sure, I can think of 100 scenarios that would necessitate a dislocation reduction without analgesia, you're example of being in the woods and unable to do anything but get the patient to the self-evacute would be one of them. Under fire in Iraq would be another. But doesn't mean that since its okay to do that in those situations, then its what should constitute general operating procedure. To answer your question, if I gave a sedative or analgesic, and the patient started vomiting, and the patient then aspirated on that vomit and caused severe complications, and I wasn't able to intubate, and I wasn't able to ventilate using BLS adjuncts, then I would say that is multiple failures on multiple levels and that even the Space Shuttle blows up sometimes. I am of the mindset that the prehospital practice should follow in-hospital practice as much as possible. I'm sure the ER attendings could think of a few scenarios that would preclude the use of analgesics during a reduction, but I'm sure they frown upon it as the general way of doing things. Putting someone in unnecessary pain because of possible risks that can usually be mitigated is not ethical nor humane. I should note that it is really only in the United States that lower levels of providers are denied any use of analgesics. Most first-world countries allow providers with lower than paramedic-equivalent training to administer some form of analgesic, even if its simply Nitrous Oxide. Its only in the US (in most places) that anyone under the care of anything less than a full paramedic gets a hand to squeeze on and not much more. I've never had an RSI go wrong, the closest I've ever had was a couple of heroin overdoses when I was working BLS and had a short transport time to the hospital. We were able effectively bag someone in respiratory arrest until we got to our destination. It wasn't easy, it wasn't something I can recommend, but it is entirely possible. I liken pain control to rappelling down a cliff. When you're at the bottom, looking up, it looks easy and not that high. Its only when you yourself clip in and start backing towards the edge that you get a full appreciation of what the experience is like. I think its very telling that providers who themselves have suffered painful orthopaedic injuries are more aggressive in pain control than those who have not. When you're in pain yourself, then it becomes clear what 10 minutes to the hospital feels like, or 20 seconds of reduction feels like, or how effective verbal techniques really are.

As person who once suffered a patellar dislocation, I can tell you that the pain is something you don't want to suffer 20 seconds with. As paramedics, we have several forms of airway control, as well as narcotic antagonists. Granted, analgesic effects can be different in pediatrics, the elderly, people with depressed liver functions, or people on either end of the BMI scale, but in general practice, if you have communication with an experience physician, the analgesics, sedatives, and amnesics that we carry can almost always be administered safely. Personally, I was given midazolam prior to reduction, and I can report that it is very effective, and its short half life is very beneficial if you are concerned with respiratory depression. You know, I had this almost same discussion with someone about the same concerns with succinylcholine. I had never given succinylcholine, but I was quite familar with its pharmacodynamics, and it always made me scratch my head about the gloom and doom warnings about being unable to intubate after giving it. In my mind, if you have a drug that wears off in 3-5 minutes, you should be able to control the airway and ventilate using BLS adjuncts for 3-5 minutes until such time. The quip the instructor made was "Yes, but that could mean that for 3-5 minutes the patient's life could possibly depend on the BVM skills of a medical student and some rookie nurses." Point taken. Anyway, with the current push in standard of care to aggressively manage pain control, I think its possible that at some point, it could be a liability issue if your service continues to reduce painful, deformed extremities without analgesic.

My apologies. Ahem. Right, mate if you wanna be gettin' that federal dena, point ya ears this way and listen up. First, you gotta put the bloke in sumpin' on the ground. Then ya gotta get some ALS fella to give him a butcher's, and some medical tucker. Don't try to pull the ol' wool on us by given us an EMT and callin' it gold. Right? How's that?

"Dr. Blair recommends homeopathic medicines to his patients. There is no scientific evidence or widely accepted theory to suggest that homeopathic medicines work, and Dr. Blair doesn't believe them to. He recommends homeopathic medicine to people with mild and non-specific symptoms such as fatigue, headaches, and muscle aches, because he believes that it will do no harm, but will give them reassurance. Consider the ethical problems that Dr. Blair’s behaviour might pose. Discuss these issues with the interviewer."

From the Medicarenhic.com website, "Ambulance Billing Guide" PDF: "Advanced Life Support, Level 1 (ALS1) Non-emergency - ALS1 is transportation by ground ambulance vehicle, and the provision of, medically necessary supplies and services including an ALS assessment by ALS personnel or at least one ALS intervention." I don't think a saline lock placed at the hospital counts as an intervention. According to the same PDF, "Advanced life support (ALS) intervention is a procedure that is, in accordance with State and local laws, required to be performed by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic. An ALS intervention must be medically necessary to qualify for payment as an ALS level of service. An ALS intervention applies only to ground transports" I still don't think if they did it at the hospital it counts as an ALS intervention. If it was, you'd need at least an EMT-I in the back. EMT-B + Saline lock + ALS1 = Medicare

Well, there's that too, but unfortunately in today's world "Because its really, really wrong" stopped being sufficient reason to stop a practice a long time ago.

Croaker, I've said plenty on my feelings on reducing injury without analgesia. A patellar dislocation is incredibly painful. Reducing it is very painful as well. Continuing the practice may put your service at the risk of liability. I know you're not the one making the decisions, but that practice needs to change.

Just a quick poll here, how many people's services have protocols, standing orders, or unwritten general operating procedures that involve placing oral glucose between the cheek and gums of a hypoglycemic patient that is not able to follow commands? I'm asking for a very specific reason. You see, when I first started out, there was this debate of whether to use the oral glucose in that fashion or not. One camp said yes, that the amount of glucose absorbed was enough to raise the BGL in a hypoglycemic patient. The other camp, of which I belonged to said no, that's not a good idea, introducing a foreign, sticky substance into the orophaynyx of an unconscious person was just asking for airway trouble. Debates were entertained. Arguments were had. Wars were waged. Through the years I have come across services that recommend this procedure for administration of oral glucose, and others that specifically forbid it. So I decided one day to see if anyone had ever done a study about its effectiveness. Lo and behold, the good people at the Journal of the American Medical Association did a study, and found that the amount of glucose absorption through the buccal membranes was less than 0.05 mg. In other words, it doesn't work. The title of the article, "Bioactivity of Instant Glucose, Failure of Absorption Through Oral Mucosa", was a big tip off. (Here's the link in case you don't believe me. http://www.ncbi.nlm.nih.gov/pubmed/691147 ) But here's the kicker: This study was done in 1978! Why in then name of all that is holy would anybody be arguing about this 30 some odd years later? How does that work? Really smart people did a lot of work and provided some conclusive evidence, some of the most conclusive evidence I've seen about a debated procedure. What hope is there for us to move into evidence based medicine when even when a conclusive study is done, the results are ignored? I don't get it.

Just a quick poll here, how many people's services have protocols, standing orders, or unwritten general operating procedures that involve placing oral glucose between the cheek and gums of a hypoglycemic patient that is not able to follow commands? I'm asking for a very specific reason. You see, when I first started out, there was this debate of whether to use the oral glucose in that fashion or not. One camp said yes, that the amount of glucose absorbed was enough to raise the BGL in a hypoglycemic patient. The other camp, of which I belonged to said no, that's not a good idea, introducing a foreign, sticky substance into the orophaynyx of an unconscious person was just asking for airway trouble. Debates were entertained. Arguments were had. Wars were waged. Through the years I have come across services that recommend this procedure for administration of oral glucose, and others that specifically forbid it. So I decided one day to see if anyone had ever done a study about its effectiveness. Lo and behold, the good people at the Journal of the American Medical Association did a study, and found that the amount of glucose absorption through the buccal membranes was less than 0.05 mg. In other words, it doesn't work. The title of the article, "Bioactivity of Instant Glucose, Failure of Absorption Through Oral Mucosa", was a big tip off. (Here's the link in case you don't believe me. http://www.ncbi.nlm.nih.gov/pubmed/691147 ) But here's the kicker: This study was done in 1978! Why in then name of all that is holy would anybody be arguing about this 30 some odd years later? How does that work? Really smart people did a lot of work and provided some conclusive evidence, some of the most conclusive evidence I've seen about a debated procedure. What hope is there for us to move into evidence based medicine when even when a conclusive study is done, the results are ignored? I don't get it.

Oh, I've seen tons of faked pain. I've seen people who exhibit drug seeking behavior call 911 for transport to the hospital many times, but I never had anyone expect EMS to respond and give them a shot of morphine when they were jonesing. I never had anyone try to steal the narcs, either. Maybe they just weren't fully aware of our capabilities. The argument that providing access to analgesia or addict mediated naloxone will somehow increase addiction rates or create 911 system abuse with the end result of provision of narcotics is just plain silly. And spurious.

If the extreme right wing has its way, then that is a distinct possibility. No more of this namby-pamby liberal modern medicine crap. Let's get back to the good old days when men were men and saws were saws. Anyway, compared to someone with multiple limb fractures being transported over rough terrain with no analgesic, cauterization with boiling oil seems down right humane. I know of a few hospitals where those odds would reduce the Morbidity and Mortality stats. It'll be an easy enough transition. The Upstate volunteers can just switch over to patches that depict a bottle of whiskey and a hacksaw instead of the Star of Life. They can use the town's budget to buy state of the art, diamond encrusted saw blades and use the finest, extra virgin-olive oil for the cauterization, because, you know, they want to go all out when its about saving lives.

From an educational and practical, I can't in good conscience justify the current EMS model. During the American Civil War, people with traumatic injuries could receive, if they were lucky enough, ether to help with pain control. Failing that, they at least got a shot of whiskey and a bullet to bite on. In many parts of the United States, 150 years later, people with traumatic injuries don't even get that. There is no excuse for that. No volunteer organization, or IAFF representative, can ever say anything to dissuade me from my notion that the lack of pain control, in of itself with no other factors, is a glaring example of why EMS in the United States needs rapid overhaul. If I had my way, EMT-B would be a non-transport title only. I mean, it would be a good title to have for people who do hiking, or for firefighters first on scene, something like that. I would add a 2 week pharmacology component to it so that at least nitrous or some other relatively benign analgesic could be administered until such time that more advanced care arrived. I would also create a separate title for IFT transport EMTs. This isn't to say that IFTs are not important, or have anything to with healthcare, I think you learn more doing IFTs than you do handing out band aids or picking up drunks, but I think a separate skill set could be developed and implemented to help beef up both the standards for IFT and 911 response. In short, I think the current standards of prehospital care in many parts of the United States do not deliver the appropriate care needed to the population. I would also implement a $50.00 fine for anyone who says "BLS BEFORE ALS!!!"

Heh, I got general surgery or pulmonology. General surgery is a little above my pay grade but pulmonology I could do. After all, I like to vent! Get it... ah nevermind.

I worked an area with one of the highest rates of drug abuse in North America. Not once did I ever have someone feigning injury in order to receive narcotics. Its not a valid argument. The number of people with horribly painful injuries that could have benefited from analgesia, on the other hand, was rather large.

I'm on the fence about whether ETs in cardiac arrest could be replaced with supraglottic airways or not. I guess I would say, probably. However, so long as there are patients that require immediate intubation, such as asthmatics or COPDers or CHFers, or those with maxillofacial injuries, then intubation should be a skill practiced by paramedics. I think the key is that intubation should stay in, but the way we think about intubation should change. Those intubations we brag about, the one under the bus, on fire, in the snow should become a thing of the past. Intubation should be considered a surgical technique, not a rescue technique. That is, it should only be performed in a relatively stable environment, like the back of the ambulance. That's my take on it.

I agree I agree. The only mistake was beginning transport in the first place. Someone should have just made the determination on scene. Going out and back is bad form.

I agree with systernet. Without ETCO2, the signs of a displaced tube come on right about when it becomes to be too late. ETCO2 and 12 leads aren't for the dysfunctions that are obvious, they are for the dysfunctions that are not readily apparent. Anyone can tell you what's happening with a 65 year old chain smoking obese male who is pale, cool, and diaphoretic and clutching his heart, but the 43 year old woman who "just doesn't feel right" is the one that we can use 12 lead diagnostically for. Its the same with ETCO2, if the person is turning blue, yeah, we know what's happening, but what about the beginning of tachycardia? We can use ETCO2 to help rule out causes.

Needles, I didn't mean to bash you either. I wasn't so much unhappy with your performance, being a transport EMT has to be one of the worst gigs ever, you're sometimes given very sick patients to deal with, with little information or direction for how to intervene. Unfortunately, with the state of EMS as it is, you sometimes are put in a very bad position by a company that is run in less than a stellar fashion. I applaud you for knowing that there was an issue that needed to be dealt with, and I hope that some of these things bounced off you can be helpful.

I worked in New Jersey for a couple of years as an EMT and recertified a couple of times. I can't ever recall seeing any physical fitness questions on the applications, and I don't know of anyone who has ever been denied an EMT certification because of one. That being said, it has been several years since I worked there and things might have changed. Mind you, this is simply talking about being certified, you can sit through a class, take the exams, pass, etc. and get your certification, but practising as an EMT may be a whole other story. OEMS for the State of New Jersey can be a little slow on the draw, but they are reasonable people and if you stay on their telephone tree long enough you usually can get through to someone.

I personally consider the level of paramedic to be just scratching the surface of the knowledge and skill set required to adequately care for and transport the sick and injured. To that end I would suggest working with a paramedic, and then being a paramedic as soon as possible. This is particularly true for EMT-B in the United States. Aside from areas of the world that are served with either a hearse or what ever closest vehicle is available, the basic level in the United States has to be one of the most inadequately trained providers in the world. I'm not saying that to be insulting, I'm saying that as the result of several years working at both levels and having suffered some bad injuries myself. I think the bar needs to be raised for EMT-B at least enough for them administer pain control, if nothing else. That would mean probably a couple week session of pharmacology. Intermediate plus some pain meds should be the lowest level for anyone who is responsible for responding to and treating patients anywhere. That's my $.02

I have this crazy notion that someone in acute pain is having a medical emergency which warrants the same response as any other life-threatening emergency. Just because someone isn't going to die in the next 10 minutes doesn't mean that they should be left in agonizing pain. In other words, when the Demerol wore off, you should have treated it as any other emergency that went beyond your scope of practice. The two options there are either call ALS, or divert to the nearest emergency room. When you saw that she was in significant pain, you should have called your company, told them the situation, and then diverted either to meet an ALS unit line of sight or to follow the nearest blue hospital signs. If she went into cardiac arrest, that would be fairly obvious to you. The concept that being in agonizing pain is just as much a medical emergency (outside of a mass casualty incident) as any other is one that is tortuously being introduced to EMS. Your company probably won't like it but doing the right thing for the patient comes first. So, in that aspect, BLS does have options for pain control. Call ALS, or divert to a hospital because your patient isn't stable enough for transport. Three hours without pain control? Not cool, man. That's Medicare comes a-knockin' type of stuff.

From the sounds of it you have rather dipshit crews running in your area. When I read the presentation the big three that popped out were eclampsia, sepsis, and PE. I was going to ask for protein levels in the blood tests but you beat me to it. The aforementioned ambulance crew were indeed dipshits. Anyone with a pulse rate of 225 with shortness of breath is textbook ACLS unstable tachycardia. If you are in an area without appropriate ALS response, then rapid transport to the hospital was clearly indicated. Not only that, but my personal feeling is that someone who has passed the hyperthermia threshold of 104.0 and into hyperpyrexia land is also a priority patient who needs to be at the hospital. The ER at least was able to recognize your tachycardia, but they get a D+ after that. If I, a simple ambulance driver paramedic, immediately thinks of underlying causes when I read the presentation, then a full physician should definitely do the same rather than just jump for the adenosine first thing. While your heart rate was rather high, I still probably would have tried a 500cc NS bolus on the grounds that its possible your heart rate and temperature were exacerbated by hypovolemia secondary to dehydration, a common presentation in the ill. After that, I would also probably started working with some adenosine. I guess all in all the ER didn't do too bad. I'm not sure what the diazepine was for, you weren't seizing, unless they thought maybe you were doing the nose candy or were preparing to cardiovert. After the labs came back with your magnesium and protein levels, I think a mag sulfate drip would have been the most appropriate course of action.