Going Beyond The Minimum: Paramedic or Ambulance Driver?

[RocketMedic]

Here is a question that is simple with a lot of nuances and massive grey areas.

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?

Here, I have noted that our management tends to embrace patient care and comfort performed, not simply tradition, with a reasonable acceptance of new options and expansions of trust in field personnel. There are some people everywhere who embrace changes and advances, others who follow a well-marked trail, and some who refuse to modernize. Outcomes and core medicine rarely change, but the "extras" do- for instance, a progressive medic may provide pain management for a severe laceration or use true BiPap on the complicated ventilator with true customization of settings, whereas a regressive medic may simply bandage and go or use CPAP or a BVM or something.

Why the difference?

 

[DesertMedic66]

Here is a question that is simple with a lot of nuances and massive grey areas.

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

Personally I think it is a mix of all the above.

I feel that my agency is very open to change (we are always making changes). I am also very open to change as long as it's for the better.

For my area there really is no incentive to get further education (aside from patient care). There is no EMS agency involvement aside from writing protocols.

There are a lot of incompetent medics in my area. Since there is no real involvement with the county EMS office the incompetent medics are still able to work without issues. It's hard to keep track of and make changes when there are well over 1,000 EMTs/Medics that the county is in charge of.

 

[EpiEMS]

This is a great question to pose!

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

I see the biggest issues as educational, evidence-related, and medico-legal.

1) Most EMS personnel are not educated to the level that would be optimal.
2) Evidence: there's not enough pre-hospital evidence based medicine, and, often, when there is evidence, it doesn't find its way into protocol fast enough because...
3) EMS personnel don't operate under their own licenses. There ought to be a greater degree of independence from the medical director, at least, insofar as possible -- something like the UK's "Health Professions Council".

 

[RocketMedic]

One of our materials employees posed the question "why not the minimum for your patient?"

Why not?

 

[DrParasite]

I'm a transporter, with dreams of the system transforming us into clinicians.

I've seem so much abuse of the EMS system, where all I am is a taxi driver (not even horizontal, the patients are completely ambulatory but cabs require payment before services). I realize that their are limitations to what I can do in the field, but I do wish we could help people more.

I would LOVE to see a bachelors degree where it's 100% focused on paramedicine and patient care. And I still like tiered systems, where the BLS providers are competent enough to perform assessments and know when ALS is needed vs not needed (I know, that's apparently a rarity in the US for reasons I don't want to go into).

I think anything a civilian can do or be taught to do an EMT should be able to do.

I think if we get the FD out of EMS, let EMS become a full career not just a job or stepping stone, and people in EMS want to be in EMS not just be in EMS until something better comes along, it will improve EMS.

And we need active medical directors who want to be there, who go out in the field on a routine basis, have prehospital experience, and know the paramedics they supervise and write protocols so, so they can trust that they know what they are doing.

But back to what you said, I'm an ambulance driver, in a world where providers hands are tied by archaic protocols, medical directors who don't want to do the job and will not let crews do things to help the patient, other than VOMIT, and there are too many idiot EMTs and paramedic who I have no idea how they passed their tests or even got hired.

 

[sir.shocksalot]

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition?

I think it is truly a mix of everything above. I have seen paramedics justify things for any and all of the above reasons. Usually the excuse is "It's our protocols" or "it's not in our protocols", "leave that stuff for the hospital", "our job is to get them to the doctor". Complacency and laziness are the true honest reasons why we avoid things that are difficult or new.

How amicable is your agency to change? How about you in your own practice?

My agency? Very minimally, if at all. As soon as the Denver-Metro medical director group expectorate a new set of protocols we will quickly adopt them but we, as field providers, have little to no influence on these decisions. Me personally? If I read about a new treatment modality or assessment tool and I have read sufficient evidence to find it believable I may implement it immediately. Titrated D50? Oxygen? permissive hypotension? Compression focused resuscitation? All of these things I put into practice when and where I can, I don't wait for the protocols to change since I can reasonably implement these things without throwing any flags. The hold up usually is when there is another paramedic on scene who is less amicable to newer concepts.

On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?

I see myself as a clinician, occasionally this requires me to transport people and I'm okay with that. Sometimes I will transport people for lack of a better option or because telling them to go to an urgent care or MD office would be highly questionable in court or in front of my supervisor's desk. Actually I think I transport more often than not, I have found that trying to convince people to take themselves in to a physician is a far slipperier slope than simply giving them a ride. I would like to see things changed to allow for alternative destinations or to be able to triage people to an office or urgent care instead of an ER, but that may be a long way off yet.

Here, I have noted that our management tends to embrace patient care and comfort performed, not simply tradition, with a reasonable acceptance of new options and expansions of trust in field personnel. There are some people everywhere who embrace changes and advances, others who follow a well-marked trail, and some who refuse to modernize. Outcomes and core medicine rarely change, but the "extras" do- for instance, a progressive medic may provide pain management for a severe laceration or use true BiPap on the complicated ventilator with true customization of settings, whereas a regressive medic may simply bandage and go or use CPAP or a BVM or something.

Why the difference?

Because people are different and they come into this field with different aspirations and expectations. While you and I might get excited to medicate a stable hip fracture others might view this as a waste of time and not "exciting". You and I might see tweaking ventilator settings as an exciting mental challenge, others view it as tedious and boring.

I think the larger issue at hand is the attitudes and expectations of those aspiring for this career. We constantly portray this image of exciting life saving and lights and sirens when the reality might be the raisin rodeo or drunk herding. There is an image of us as "emergency workers" instead of healthcare providers. We should be changing how we portray ourselves, we should appear to be healthcare providers who work in the field with emergency workers and may occasionally act as emergency workers ourselves.

You are certainly fortunate to have an employer that values modern medicine and trusts in it's employees to provide modern and compassionate care to patients. Many employers of EMS workers have a very different opinion and completely distrust those they employee, occasionally for good reason, but mostly out of ignorance.

 

[unleashedfury]

I'm a huge advocate for advancing and improving pre-hospital medicine, training and education standards. as well as newer treatments available.

I know in my workplace, the management feels as if we still rocked the Cadillac and just got them where they needed to go with no supplies or equipment used they would be ok with that. And that's were we run into a problem. Using supplies on a call means money we have to spend. money we have to spend to do business cuts into the bottom line. and thus the reason why our "benefits and pay isn't much higher"

I'd deal with not having a pay raise because my patient needed supplies and equipment to improve their condition. rather than I can't give you any treatment its gonna cut into my paycheck.

 

[RocketMedic]

Today, I ran into an Ambulance Driver. I had literally worked with a team of professional paramedics and EMTs (OCFD and my partner) to stabilize and start to correct a fairly acute COPD exacerbation. As you could imagine, I elected to use our ventilator. BiPap, albuterol, atrovent, methylprednisone (fairly generic COPD call). Afterwards, as we were packing up, another medic came in. I expressed my pleasure at the success of our therapy and the surprising success I have had with our vents- by my conservative count, I have avoided a dozen or so intubations and really helped twenty or so patients with early, aggressive application of BiPAP. I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion. Anyways, this guy flat-out says that he refuses to use it, no matter the circumstance. His rationale was that it had "strangled" two of his patients, and he attributed their deaths to the ventilator. One was apparently a full arrest, the other was unknown. His attribution of their deaths to the vent boiled down to user error within a few seconds of listening to him; or he was making it up. Either way, he simply refuses to use them in any case. "You can bag them better always, that's what I do."

Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks and provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.

After this medic left, the charge RN looked at me and told me "That's why you make $15 an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot." He is literally leaving a lifesaving tool on the shelf because he is more comfortable thinking that a BVM provides PEEP or that it's preferable to intubate a patient than it is to simply BiPap them.

Ambulance drivers can be found at all cert levels.

 

[Carlos Danger]

Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks and provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.

Which vents do you use?

 

[Clipper1]

Today, I ran into an Ambulance Driver. I had literally worked with a team of professional paramedics and EMTs (OCFD and my partner) to stabilize and start to correct a fairly acute COPD exacerbation. As you could imagine, I elected to use our ventilator. BiPap, albuterol, atrovent, methylprednisone (fairly generic COPD call). Afterwards, as we were packing up, another medic came in. I expressed my pleasure at the success of our therapy and the surprising success I have had with our vents- by my conservative count, I have avoided a dozen or so intubations and really helped twenty or so patients with early, aggressive application of BiPAP. I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion. Anyways, this guy flat-out says that he refuses to use it, no matter the circumstance. His rationale was that it had "strangled" two of his patients, and he attributed their deaths to the ventilator. One was apparently a full arrest, the other was unknown. His attribution of their deaths to the vent boiled down to user error within a few seconds of listening to him; or he was making it up. Either way, he simply refuses to use them in any case. "You can bag them better always, that's what I do."

Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks and provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.

After this medic left, the charge RN looked at me and told me "That's why you make $15 an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot." He is literally leaving a lifesaving tool on the shelf because he is more comfortable thinking that a BVM provides PEEP or that it's preferable to intubate a patient than it is to simply BiPap them.

Ambulance drivers can be found at all cert levels.

If a patient is in cardiac arrest with CPR being performed, you probably should bag because the ventilator will end the cycle with a chest compression and will be out of sync during chest compressions. This means the patient will not be ventilated even with the ETT. Yes, that will not help with achieving ROSC and might prevent it from happening.

A "BIPAP" mode is also not to be used on someone who is not spontaneously breathing (agonal is not) and who can not maintain their airway.

You do not need to worry about "setting back" their therapy with a short transport or even a long one. Chances are these patients will change modes for sleeping and procedures all the time. If the patient is having an acute breathing problem you must place them on the appropriate ventilator mode and settings rather than worry about "setting them back". Being dead will set them back more.

If you don't have the appropriate meds which might even include giving a paralytic along with lots of sedation and pain relievers you might not be able to ventilate a patient effectively. Every time the machine cycles off due to high pressure, the patient is not getting effectively ventilated. This can also lead to arrhythmias and death.

The patient might just feel like they are being suffocated by the ventilator. Some ventilators do not have a high demand flow rate which could be because of generic settings or by machine design. EMS medical directors are usually not CCMs or Pulmonologists so their knowledge of ventilators are limited. They will have to write for generic protocols.

All alarms on a ventilator serve a purpose. If something is alarming you have either set if inappropriately or something needs to be addressed with the patient. I have yet to see a transport ventilator which has too many alarms and most do not have enough.

Most of the transport ventilators function with single limb technology and an external PEEP valve rather than a continuous end flow. Most do not have a compressible volume feature so you do not know don't know how much tidal volume they are getting. Most transport ventilators do not give a Plateau Pressure. There might be a way to achieve it for the experience practitioner but for the inexperienced it is not advised.

Your transport ventilator might have a lot of "knobs to turn" but that does not always make it the appropriate ventilator for all patients especially in acute situations.

You will also seen in the ER an RT or experienced RN kicking the usual standby portable vent into a corner and having the ICU ventilator wheeled over because they noticed something by bagging which will require a better ventilator. They already know it would be stupid of them and probably harmful to the patient to place them on an inadequate machine. In some cases bagging is definitely better than placing them on a machine that won't adequately ventilator the patient. If those transport ventilators would do the job the ICUs would probably use them instead of the big vents which take up a lot of room.

That being said, hospital staff will try to use transport ventilators to move patients from one area to another. A couple of the ICU machines can be switched to being mobile. But, hospital staff will have known values for ABGs and a CXR. The RNs and RTs work with many ventilators everyday and all day. With a few known values and the appropriate medications which also are often not available in EMS, they have the expertise to manipulate the transport ventilators to get through a short transport.

Not knowing the limitations of your ventilator, using it inappropriately like BIPAP to "ventilate" a nonbreathing patient and believing your transport ventilator is life saving in all situations would make you look more like a lessor provider to those with experience and expertise with ventilators. Notice I also said expertise since some do what they believe to be a lot of ventilator transports on an ambulance but keep making the same mistakes over and over.

How much training did you get for the the ventilator you are using AND how much education and training did you get for ventilation, oxygenation and disease processes as it applies to ventilator principles?

 

[RocketMedic]

Which vents do you use?

Impact 731.

 

[RocketMedic]

@ Clipper1: Good, but with proper customization, the Impact-731 can literally do all of those things. We've got BiPap, CPAP and three modes of true ventilation (pressure target, timed, and SIMV). Obviously, some people need more invasive airway management than a mask. Agonal respirations would tend to fit that description. But even then, dependent on the reasons for that condition, a ventilator could absolutely be useful.

I'm by no means a vent expert, but I do not discount it. The BVM has not entirely left my truck, but it is not my first choice for a lot of patients that do not particularly benefit from it. What made me angry was the casual dismissal of such an important piece of our jobs by a person who was too lazy to learn it.

If someone is too lazy to learn to use a ventilator or too stupid to realize that they need to be trained on it, why should they be working with etomidate, ET tubes, levophed and a host of other potentially-lethal things?

 

[shfd739]

Impact 731.

Yeah those arent that hard to use and use well.

 

[Clipper1]

@ Clipper1: Good, but with proper customization, the Impact-731 can literally do all of those things. We've got BiPap, CPAP and three modes of true ventilation (pressure target, timed, and SIMV). Obviously, some people need more invasive airway management than a mask. Agonal respirations would tend to fit that description. But even then, dependent on the reasons for that condition, a ventilator could absolutely be useful.

This ventilator can do all of those modes but should you? What is "true" ventilation?

Pressure and timed are how the ventilator cycles or terminates flow.

SIMV is a mode whose cycle can be also be determined by pressure and time just like AC and PC.

BIPAP is not to be used on an apneic unresponsive patient who can not maintain their airway for many reasons such as in the cardiopulmonary arrest. One is aspiration. If the person is in cardiac arrest you probably would up an OPA to open the airway. If a person can tolerate an OPA, they should not be on NIV with BiPAP. Second, the BiPAP can be set by pressure and time. When you are delivering chest compressions, you dramatically change chest compressions. If you are trying to deliver 20 cmH2O of pressure to achieve adequate ventilation, what happens when a chest compression is performed to the tidal volume or "pressure" you think you are delivering.

Not all ventilators are the same. Even the big $50k ICU ventilators might have the same "labeling" for setting but their methods of achieving those settings may be very different. It doesn't matter how pretty the knobs look or that some of the same labels on the portable ventilator looks just like those on the $50k ventilators. The way they are designed are very, very different. Too many are fooled by the packaging and have never read their users manual or the reviews. You might also look up the questions the FDA posed to the manufacturers of the 731.

A ventilator is no doubt useful but only if you have a good understanding about its limitations and how your ventilator works. You also must have the ability to pharmacologically assist the patient and ventilator synchrony. This is where most lack. They might be able to sedate but then forget they also must support blood pressure.

You also will not find very many who will just pop a patient on a ventilator without squeezing the BVM a few times and listening to breath sounds. It would be reckless and stupid to not have a baseline for the patient for pressure, volume and chest rise.

 

[Clipper1]

Yeah those arent that hard to use and use well.

Define use well? How do you determine how effective your ventilator is? Some have been so proud of their ventilator's performance only to find they have a pH of 7.0 and a PaCO2 of 80. Sometimes they got that by chasing their ETCO2 without understanding or knowing the disease process or anything about V/Q mismatching.

 

[RocketMedic]

Clipper, I'm not claiming that the Impact is a panacea, nor is it a fix-all. With that being said, it is a powerful tool when used correctly. I was commenting on a person's stubborn refusal to use it in all circumstances as opposed to learning how to use it.

 

[firetender]

Things me and my paramedic peers were saying in 1978

RocketMedic's original post asked:

Do we, as paramedics, tend to avoid pain management, complex ventilators, new-type alternate airways and the like for reasons of educational or knowledge deficiency, a desire for simplicity above fractional improvements in effectiveness, familiarity with existing options or simply tradition? How amicable is your agency to change? How about you in your own practice?

On a larger level, do you see yourself as a transporter or as a clinician? What about your peers? Your agency?

The responses were a trip back in Memory Lane for me, and painted a very interesting picture of the nature of EMS, then AND now.

For my area there really is no incentive to get further education (aside from patient care). There is no EMS agency involvement aside from writing protocols.

There are a lot of incompetent medics in my area. Since there is no real involvement with the county EMS office the incompetent medics are still able to work without issues.
desertEMT66

Most EMS personnel are not educated to the level that would be optimal.
There ought to be a greater degree of independence from the medical director, at least, insofar as possible
epiEMS

I'm a transporter, with dreams of the system transforming us into clinicians.

I've seem so much abuse of the EMS system, where all I am is a taxi driver

I can do in the field, but I do wish we could help people more.

I would LOVE to see a bachelors degree where it's 100% focused on paramedicine and patient care.

I think if we get the FD out of EMS, let EMS become a full career not just a job or stepping stone, and people in EMS want to be in EMS not just be in EMS until something better comes along, it will improve EMS.

And we need active medical directors who want to be there, who go out in the field on a routine basis, have prehospital experience, and know the paramedics they supervise and write protocols so, so they can trust that they know what they are doing.

I'm an ambulance driver, in a world where providers hands are tied by archaic protocols, medical directors who don't want to do the job and will not let crews do things to help the patient, other than VOMIT, and there are too many idiot EMTs and paramedic who I have no idea how they passed their tests or even got hired.

DrParasite

we, as field providers, have little to no influence on these decisions. (regarding protocol)

The hold up usually is when there is another paramedic on scene who is less amicable to newer concepts. (regarding implementing newly learned modalities or ways of treatment)

Sometimes I will transport people for lack of a better option or because telling them to go to an urgent care or MD office would be highly questionable in court or in front of my supervisor's desk. Actually I think I transport more often than not, I have found that trying to convince people to take themselves in to a physician is a far slipperier slope than simply giving them a ride.

I would like to see things changed to allow for alternative destinations or to be able to triage people to an office or urgent care instead of an ER, but that may be a long way off yet.

There is an image of us as "emergency workers" instead of healthcare providers.

We should be changing how we portray ourselves,

Many employers of EMS workers ... completely distrust those they employee, occasionally for good reason, but mostly out of ignorance.

sir.shocksalot

I know in my workplace, the management feels as if we still rocked the Cadillac and just got them where they needed to go with no supplies or equipment used they would be ok with that. And that's were we run into a problem. Using supplies on a call means money we have to spend. money we have to spend to do business cuts into the bottom line. and thus the reason why our "benefits and pay isn't much higher"
unleashedfury

Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size.

(quoting an observant nurse) "That's why you make $15 (then, it was $5.00 - my note) an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot."

RocketMedic

Why hasn't anything changed in 35 years?

Something that really hit me was the pay being $15.00 an hour! Who is allowing that to be so?

 

[Clipper1]

Clipper, I'm not claiming that the Impact is a panacea, nor is it a fix-all. With that being said, it is a powerful tool when used correctly. I was commenting on a person's stubborn refusal to use it in all circumstances as opposed to learning how to use it.

I was attempting to show you that maybe you should re-examine your own understanding of that ventilator before calling this other guy lazy, dumb, stupid and an idiot.

It doesn't sound like your company has provided much training and education about ventilators. There should have been some type of competency where all Paramedics with access to the ventilator could show their skill and knowledge as well as have time to ask questions or have additional practice. Calling someone an idiot for something which is probably not really his fault but kudos to him for realizing the inadequacies but still trying to not be too humiliated probably by those who probably have less understanding about vents than him but don't know it.

The 731 is also not a popular ventilator among CCT and Flight teams or the FDA. Given those circumstances I don't blame someone for bagging the patient. Lack of knowledge and a limited ventilator with a few quirks especially with PS can do a lot of harm.

 

[RocketMedic]

So your alternative is to endorse single-handedly remove a therapy as useful as CPAP/BiPAP based on imagined failures caused by user error?

Heck, plenty of people have used the Impact to effectiveness. To dismiss it entirely as this medic did is folly.

 

[Carlos Danger]

Impact 731.

I'm not familiar with that one. I've transported patients on the Parapac, Impact 754, LTV 1000, LTV 1200, and Maquet servo-i. Most of my experience is with the LTV-1200.

I was attempting to show you that maybe you should re-examine your own understanding of that ventilator before calling this other guy lazy, dumb, stupid and an idiot.

First of all, it's pretty clear you are missing the overall point of this thread. He was simply using an example to draw a parallel between those who reject advancements in patient care with those who try to embrace them. The intent was not to critique his knowledge of transport vents.

Secondly, the other guy in the story did sound like an idiot. "That dumb newfangled automatic breathin' box dun strungled twice uh muh patients" vs. someone trying to use some more progressive technology and somewhat of an advanced intervention to benefit their patients is the point.

FWIW, I didn't see anything in Rocket's post that indicated a lack of understanding of how to use his vent. I don't think he gave nearly enough information to assess his knowledge base. And again, that wasn't the point here, anyway.

OK, I'm not sold on using it in arrest either (especially in a non-invasive mode), but he's not the only one who does it. I assume it's in his protocols and it's what he was taught to do. Even if I think something someone does is wrong or not ideal, I try not to criticize individuals who are just doing as they were taught or as their protocols instruct.