is "ALS" a lie?

[Veneficus]

In the last 2 days I have had my hands in the chest cavities of 3 patients.

If you have never been to a cardio surgery, I would really suggest making every effort to be a part of the experience.

I had a few minutes to look around at the wonder that stood before me.

There was all of the anesthesia get up. Monitors of every shape and size, a gas mixer, a ventilator, even a machine that measured real time blood clotting. Then there was the cardio bypass machine and all of its wonderous functions. More stainless steel and electronic devices than I care to describe. A team of 3 cardio surgeons, 2 anesthesiologists, 2 nurses, and a student.

The event starts out as a procedure. No different from any EMS station or service I have ever been to. You come in, have some coffee, discuss what's going on, check the equipment, get assigned a patient, prepare yourself for what you are going to do, and then, start treatment based off of a guidline that tells you how everything should go and how you should go about doing it.

Just like EMS, it doesn't always go like it should and in no time at all, you can find yourself completely off the map.

Now, when this happens, there is no research, no textbook, nobody to call. The various members of the team put their heads together to make something up. When you add it all up, this team has easily a hundred of years of education and experience. Without aid of a bar napkin, an idea is formed.

What makes this team ALS, isn't a few gadgets or gizmos. A technological solution to make up for shortcomings. It is the ability for them use all of their mental faculties, anecdotes, and scientific wild A** guesses in order to attempt to achieve a positive outcome.

So it makes me wonder...

Why is there always somebody in EMS forums who when faced with a conundrum, always posts something like: "Our protocol says" or "we must follow the protocol" or "that's not in my protocols?"

There is no lack of technology in EMS.

No lack of situations that go as far off the map as possible.

But yet only a handful seem to have the capacity to step outside the comfort zone and engage their collective knowledge and experience to attempt to improve on what has been, as well as prepare for what might be.

Does the reliance on guidline, mathmatically measurable studies, or the ability to call for help, stop EMS from being advanced? From being all that it could be?

No matter the outcome (which I am happy to report so far has been 100% positive) there is no doubt as to why these surgical people are paid. No doubt why they are funded, and certainly beyond question if they are worth it.

We talk a lot about education in EMS. Rather the lack of it. Ad nauseum.

But the last few days, I have come to the conclusion it is not the education holding EMS back. It is the attitude of many of the providers.

Not because it is antieducation, or antiadvancement. But because it is antiresponsibility. Everyone wants to be considered a hero, important, etc. But at the same time they want to be told what to do. They want all the quantities known. They do not want to be held accountable. They want it to be somebody elses problem.

It is like "hero in a can." No risk. All good, and the ability to punt on first down if need be and walk away clean.

Perhaps we should stop our focus on education, and focus more on provider attitude?

Perhaps before weeding out the minimally educated, we should weed out the minimally motivated?

Often times the earlier EMS providers didn't have guidlines that were supposed to cover it all. They were given what was deemed adequte info to make a difference, then kicked out without benefit of FTO, or senior guidance to succeed or fail.

They didn't have benefit of technology, but they somehow saved lives. They didn't have the benefit of research, but somehow managed to cultivate their expert opinions to make a difference. Many didn't exactly "fit in" to society, but then EMS didn't need people who did. They needed free thinkers. People not afraid to take what little they had and make hard choices. They faced the same problems as today. Patients with social issues, medical issues, mental issues, even no issues.

Those providers, like the surgical team weren't advanced because they had some invasive procedures. They were advanced because when the S*** hit the fan, they put their heads together and make something up. Usually more fearful they would fail the patient then get into "trouble" with the boss.

Doesn't EMS still need that?

If not, what is the value of EMS?

 

[JPINFV]

I think it's a mistake to make an argument that education isn't a cause for this. If through out your training you were told you don't diagnose, just follow the protocol, and call medical control early and often if you have any concerns at all, or even for a quick "hello," is it any wonder that EMS is where it is? Providers aren't thinking, aren't making decisions, and shrugging off as much responsibility as they can (nothing says "not a professional" to me more than the entire concept of calling medical control because of "liability." That, to me, says technician, not professional) because that's what they're taught to do from day one.

Why are we surprised when the majority of EMS providers are simply doing as they were taught during every piece of formal education they receive?

 

[Shishkabob]

Because when you DON'T follow protocols to an extent, you're walking a fine line of "practicing medicine without a license"...

Would you be fine with medics using their "mental faculties, anecdotes, and scientific wild A** guesses in order to attempt to achieve a positive outcome."?

Personally, I would, we're not all the idiots some claim we to be, and as everyone claims, patients won't fit neatly in to all protocols and each needs to be treated individually... but alas, the law and current practice don't allow it.



Think about it. I've been taught, by ED docs no less, that a good practice for opiod overdose, is get some IN Narcan in to bring back respirations, then do IM Narcan as a maintence so that when the initial dose wears off, they don't just drop out again, and it lasts longer. I asked the head of QA at my agency, his reply was "Do we have that as an order? Then don't do it"

Same with using IN Fent. We have the MAD, we have Fent, we know IN Fent works and is safe... yet we don't have it in our guidelines, so if someone wanted to, they could throw a fit and get our license revoked.

Etc etc with other drugs outside of their normal EMS use, but still in an accepted capacity.




You're saying EMS isn't useful because we can't use our brains, but at the same time, we can't use our brains because the law doesn't allow us to be flexible in that manner. I would LOVE if there was a national scope to where a Paramedic / RN doesn't HAVE to be directly working under a doctor to do certain things, but it's not like that. I would LOVE if we had a bit of autonomy in emergencies to do what had to get done. But alas, we don't.

 

[thegreypilgrim]

I agree with JP. It really is, ultimately, the education problem from which all other problems emanate.

Of course, poor motivation is tied to other things as well. Essentially, it's from people viewing being a medic/EMT as merely a "tool" in their arsenal to get a nice job on a FD somewhere. It's not seen as an end in itself but simply a means to another end (where else does this actually happen?). This is why you get medics who act very much like technicians and don't harbor any interest in medicine whatsoever as it's not really what they want, but in order to do what they want they have to do EMS.

Solving the education problem will solve this problem though. If it takes 4 years to become a medic, none of the people who currently become medics just to get on with FD will be willing to go through all that. You'll attract a wholly different and much more motivated person.

 

[JPINFV]

What if the "protocol" was something along the lines of, "Paramedics are authorized to use [list of interventions and drugs in the scope of practice without necessarilly mentioning route] in order to treat the sick and injured.

You can always follow up with a stardized playbook, so to speak, but that doesn't preclude a paramedic calling an audible.

 

[abckidsmom]

Last night I sat in a class my medical director was teaching on allergies and anaphylaxis. He said that things have changed now and he'd like to see ALL prehospital meds, especially epi in anaphylaxis, given IM now instead of SC.

I nearly lost my tongue to this same issue, Vene, when two providers raised their hands and said, "That's not in the protocol book, should we wait for the new revision (NEXT YEAR) or should we start right away?"

OMFG!!!!!!!!!!!!

I don't know why I keep on. It's people like this, who think that the way they do it in one spot or another MATTERS, who think that physiology is not a worldwide CONSTANT, that just piss me off.

Hooboy. Timely post, Vene. I completely agree.

I call medical command from time to time, and typically have a collegial conversation when I'm stumped. I learn a thing or two, I change my course (or not), and I arrive at the hospital. Mostly I call medical command to cease resuscitation, though.

 

[Shishkabob]

What if the "protocol" was something along the lines of, "Paramedics are authorized to use [list of interventions and drugs in the scope of practice without necessarilly mentioning route] in order to treat the sick and injured.

You can always follow up with a stardized playbook, so to speak, but that doesn't preclude a paramedic calling an audible.

Honestly, I would love if it was "You're a Paramedic and/or RN, you've been trained and educated on all this, you have shown competency, now have at it in any way you deem necessary, on or off duty, to save a life"

Yes, even off duty.



If something were to go wrong, look at it. Otherwise, I call it a win.

 

[Shishkabob]

Another example is the new ECC guidelines. Atropine is gone, yet if I were to withold atropine in asystole, per what science shows, it'd still be going against what MY orders are, and it'd be MY *** hung out to dry, atleast until our guidelines are revised this coming month. That's not right.

 

[JPINFV]

My one concern with allowing off duty care would be the care and maintnance of medical supplies. Ok, sure, an off duty medic would be able to provide ACLS to a patient in cardiac arrest. Now where is the paramedic going to get the supplies to do so? Similarly, I would request a somewhat low bar for gross negligence as my once concern is that too many paramedics and EMTs would see off duty care as a carte blanche to do as they please.

 

[Aidey]

I think Linuss hit the nail on the head. I will admit I have done some stuff that probably borders on that "practicing medicine" line. I have no delusions that EMS saves lives, so my goal is to help people and make them feel better if they can. That has meant treating withdrawal symptoms in an elderly female, double dosing Zofran in intractable vomiting, using fentanyl liberally, using benzos in dislocations to help with the muscle spasms etc.

The problem is that our protocols are not really written with that in mind, they are written from a saving lives and stabilization stand point. I don't think things will change until the focus shifts to actually caring for patients and not this saving lives myth.

 

[Shishkabob]

My one concern with allowing off duty care would be the care and maintnance of medical supplies. Ok, sure, an off duty medic would be able to provide ACLS to a patient in cardiac arrest. Now where is the paramedic going to get the supplies to do so? Similarly, I would request a somewhat low bar for gross negligence as my once concern is that too many paramedics and EMTs would see off duty care as a carte blanche to do as they please.

Agreed, a few things would need to be changed with it as well.



But say I'm driving down a rural road and come upon an MVC MCI, and there's a single ambulance there with a lone Paramedic and EMT. How is it right, in any fashion, to not let an off duty provider do what they can to help to save a life, advanced or not, so long as it's still within their scope?

Aside from the law, what makes a doctor any better at providing help off duty within their knowledge? I'm not saying have a medic or nurse give consults etc etc, but if there's a patient having an allergic reaction, why not let them give Epi/Benadryl/Pepcid?

I worry of the Ricky Rescues with an ambulance in their trunk that they never check, of course, but what about those that actually DO care?




Why does my knowledge, experiences, and education just vanish the moment I clock out?

 

[abckidsmom]

Agreed, a few things would need to be changed with it as well.



But say I'm driving down a rural road and come upon an MVC MCI, and there's a single ambulance there with a lone Paramedic and EMT. How is it right, in any fashion, to not let an off duty provider do what they can to help to save a life, advanced or not, so long as it's still within their scope?

Aside from the law, what makes a doctor any better at providing help off duty within their knowledge? I'm not saying have a medic or nurse give consults etc etc, but if there's a patient having an allergic reaction, why not let them give Epi/Benadryl/Pepcid?

I worry of the Ricky Rescues with an ambulance in their trunk that they never check, of course, but what about those that actually DO care?




Why does my knowledge, experiences, and education just vanish the moment I clock out?

Where do you work that this is the deal? ALL and I mean ALL the systems I've ever worked in, the medical director has given us a little speech at our getting released meeting about how, if we need to do something off duty, out of the area, to go right ahead, within reason, and just to call him as soon as possible afterward.

My husband and I once guided some woefully ignorant medics through a trauma debacle in the middle of I64 in WV, assisting with the extrication, darting the patient's chest and intubating him. While all of the home team providers were busy with the man in the car, a firefighter and I extricated the kids from the back seat.

We called Dr Ornato when we got to the next town, and he patted us on the back and said he'd followup with that agency in a day or two. He did. It was fine.

I will say that the medics on that scene would not have let us help if they weren't more clueless than anything I've seen before or since, though.

 

[JPINFV]

I think the biggest issue when it comes to protocols/scope of practice/practicing without a license is the inability of too many providers to properly articulate a thought process beyond "protocols told me to."

Take spinal immobilization. Massachusetts statewide protocol has a list of assessment/treatment priorities at the start of each disease/mechanism. For the most part, they are repeated verbatim for each topic. For spinal immobilization, the line used is, "Ensure cervical spine immobilization and stabilization, when appropriate, and treat accordingly."

For the actual spinal immobilization it reads, "When evaluating for possible spinal injury and the need for immobilization, consider the following factors as high risk:
AMS, history of spinal fracture, evidence of significant trauma above the clavicals, posterior neck pain, paresthesias, weakness, distracting injury, age under 8 or above 65, concerning mechanism (fall from over 3 feet, MVC over 30+MPH, motorcycle/bike/pedistrain vs auto, diving or axial load, and electric shock)."

To me, that protocol gives me just enough rope to hang myself. Nothing in that says that I absolutely have to immobilize anything, just to consider it. Therefore, if I can articulate that, even though the patient fell from over 3 feet (includes falls from standing height), but using NEXUS as a clinical decision tool, the patient is at low risk, I should be fine. I've articulated something past, "I don't want to" or "I did because of protocol." However, how many providers put thought into treatments past what the protocol book says?

 

[JPINFV]

But say I'm driving down a rural road and come upon an MVC MCI, and there's a single ambulance there with a lone Paramedic and EMT. How is it right, in any fashion, to not let an off duty provider do what they can to help to save a life, advanced or not, so long as it's still within their scope?

Agreed. However people working off duty need to know their place to an extent, and when on duty providers arrive, should be willing to step aside. In general physicians included. The biggest issue is insuring that people are who they say they are and have the experience necessary. Sure, here's my state EMT/paramedic/RN license, but I just got it in the mail and I haven't worked a day (I didn't include physicians because, in general, physicians aren't fully licensed until after their first year of residency, and the training license some states issue for PGY*1 wouldn't cover them for care outside of their residency program.

Aside from the law, what makes a doctor any better at providing help off duty within their knowledge? I'm not saying have a medic or nurse give consults etc etc, but if there's a patient having an allergic reaction, why not let them give Epi/Benadryl/Pepcid?

I worry of the Ricky Rescues with an ambulance in their trunk that they never check, of course, but what about those that actually DO care?




Why does my knowledge, experiences, and education just vanish the moment I clock out?

First, I'd argue that benadryl and pepcid are both OTC drugs and you could most likely get away with giving them anyways. Is a mother who gives their child an OTC drug or a friend that recommends a drug really practicing medicine without a license?

As far as the difference, I'd like to think that having 2 years of classroom work followed by 3 years (years 3 and 4 of medical school plus PGY1) before being fully licensed, and 2 additional years of full time clinicals when board certified/eligible makes the average physician better than the other providers. There's also the issue of maturity, and that's largely due to age at initial licensure. How many EMTs or paramedics have a shirt saying something along the lines of "I fight what you fear" because they're also a fire fighter? I don't know about you, but I fear C. diff. or cancer or TB more than I fear a fire. Physicians, we fight what you really fear. There's a reason that that shirt isn't made. Vanity shirts like that aren't in and of themselves immature, but a reflection of immature wackeritis.


*PGY=post graduate year. I.e. residency.


Edit: New signature playing off of the "we fight what you fear" motif.

 

[rhan101277]

Well when I come into a new scene, I try to consider as many differentials as I can as to why this problem has occurred. We all have protocols but everyone has sound clinical judgment and we are allowed to use it where I am. Every shortness of breath patient does not need an albuterol, lasix, nitro etc. This is where education and experience come into play. If you are not correct with your assessment then you may kill someone. It is a big responsibility and should not be taken lightly.

We all have an arsenal in the toolbox, you just need to know which tools to use.

Sometimes a physician contacted for med control is the best thing. If you have a doubt that what you are about to do may not be appropriate or you need a second opinion then errr on the side of caution. It is not like we are out here cooking breakfast. This is someone else's son, daughter, father, mother etc.

 

[abckidsmom]

It is not like we are out here cooking breakfast. This is someone else's son, daughter, father, mother etc.

Love this one, and will be incorporating it into my precepting. LOL.

 

[thegreypilgrim]

To me, that protocol gives me just enough rope to hang myself. Nothing in that says that I absolutely have to immobilize anything, just to consider it. Therefore, if I can articulate that, even though the patient fell from over 3 feet (includes falls from standing height), but using NEXUS as a clinical decision tool, the patient is at low risk, I should be fine. I've articulated something past, "I don't want to" or "I did because of protocol." However, how many providers put thought into treatments past what the protocol book says?

I agree with what you're saying, but can you imagine trying to defend yourself like this as an IFT medic in Los Angeles or Orange? I just can't see that flying here.

 

[JPINFV]

As an IFT medic in LACo? They have written into protocol selective spinal immobilization (EMTs have no choice). There is no such thing as an IFT medic in OC.

 

[Shishkabob]

As far as the difference, I'd like to think that having 2 years of classroom work followed by 3 years (years 3 and 4 of medical school plus PGY1) before being fully licensed, and 2 additional years of full time clinicals when board certified/eligible makes the average physician better than the other providers.

Just so you know, I meant that more as a "What makes people think we'll forget all we know when we get off the clock while a doc won't?" I highly doubt any medic or nurse leaves their job and goes "Systolic?"

Plus, what if we do something like docs do before we get our "limitedly unlimited" license to practice medicine? We spend a year or so on probation, playing by the book, and after that we can test again for more freedom?




I can't think of a single reason why, as a rule, we should not be able to stay within our scope while off duty, or give us a bit of leeway in decision making, so long as it's sound decision making.

 

[Shishkabob]

Well when I come into a new scene, I try to consider as many differentials as I can as to why this problem has occurred. We all have protocols but everyone has sound clinical judgment and we are allowed to use it where I am.

Don't get me wrong, we DO have some leeway. Heck, my current agency calls them "guidelines" instead of protocols, and Paramedics "clinicians" instead of technicians to open the door to critical thinking.

We even have a page in our guideline book that states, and I quote

"The very nature of critical and emergency care delivery outside the walls of a hospital demand some level of autonomy and flexibility. Clinician experience and judgement should be utilized to assure the best patient care... Pre-hospital providers work with great autonomy, but autonomy demands maturity. A key to maturity is recognition of the need for consultation or guidance from on line medical control"


So yes, we can deviate a bit, but we tend to be the exception.