Pulling the plug on EMS

[Veneficus]

So today I was thinking about a reply to narcan in another post.

It occured to me that there really is no use for narcan in EMS.

Perhaps one of the primary things that EMS can claim to fame is the support of ventilation and circulation. If you can do that without a medication, why wouldn't that be the first choice? The only choice?

Now when I took pharmacology class, the first slide on the first day, was of the founder of pharmacology who declared "all drugs are poisons." (interestingly enough he died from complications of alcoholism)

Why do EMS providers seem to think that medication is always the best answer?

I am sure there is a training component as students are forced to memorize, under pain of being kicked out of a program, treatment regiments, which include medications and if these prescriptions are not followed it is wrong?

Some blame must go to protocols which never seem to get updated in a timely manner.

But it is not the instructor or medical director pointing a gun at providers telling them to always go to the max.

Now I know it is popular to pull out the anecdotes and the "what if's," but really, how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)

I sort of singled out medications in this post, but it is not limited to that.

Should EMS providers be prohibited from calling air medical services? Should they be banned from receiving bribes, I mean gifts and promotional materials, and "education" on the benefits and when to call airmed?

Now the point of this post isn't to pick on EMS or accuse it of negligence or substandard practice, but really. You have providers performing treatments that are often not needed, then turning around and not providing treatments in most cases that are!

That doesn't even get into treatments whos benefits are highly questionable.

Perhaps we should start taking a more minimalist approach to theraputics for pathologies, and a more aggresive approach to reducing pain and suffering?

Perhaps we need to get drastic and either remove ALS or put such restricitons on it that only hospitals would be able to provide the infrastructure to support ALS providers.

Look at the cost to maintain a quality intubation program compared to the benefits of intubation. In most areas it seems totally disproportionate. Especially in places where the hospital is so close, by the time you drop the tube you could have dropped the pt off at the hospital and been back at the station watching House and chomping on pizza.

Is it even realistic to ask EMS providers to take hubris, greed, and tradition out of the equation when deciding what treatments should be performed in the field?

When is EMS going to do more than pay lip service to the idea of what is best for the patient?

Or at least "do no harm?"

 

[46Young]

In most places, if you don't follow the whole protocol, (NYC as an example) you get flagged by the QA/QI nazis.

Medical directors, in general, aren't going to omit therapies and other interventions unless sufficient studies come out, and then many other agencies also have to be doing (or not doing as the case may be) the same thing. The don't want to be sued for restricting their dept from doing what's standard practice elsewhere.

 

[Amycus]

Note: I did not read the entire post, just the first few lines, but wanted to comment on something.

There's a medic I work with that I respect very much, who once went on a rant about how many medics just want to start lines/push meds, etc. His mantra is that the less he has to do, the better. Not from a laziness standpoint- but that if he doesn't HAVE to give a medication, or doesn't feel it's clinically beneficial to the patient, he won't do it. Don't overtreat, do exactly what is necessary for the patient.

 

[dixie_flatline]

So today I was thinking about a reply to narcan in another post.

It occured to me that there really is no use for narcan in EMS.

Perhaps one of the primary things that EMS can claim to fame is the support of ventilation and circulation. If you can do that without a medication, why wouldn't that be the first choice? The only choice?
...

Why do EMS providers seem to think that medication is always the best answer?

...

Is it even realistic to ask EMS providers to take hubris, greed, and tradition out of the equation when deciding what treatments should be performed in the field?

When is EMS going to do more than pay lip service to the idea of what is best for the patient?

Or at least "do no harm?"

Veneficus - I'm still new here, and you've obviously been around awhile and have more of a medical background than most. However, this isn't the first thread I've seen in the past few months where you just kind of throw out all these ruminations, mostly lambasting the US EMS system and the idea of protocols. From what I've gathered, you have formed some type of conclusion that EMS needs to go away, or die and be reborn maybe?

Here, you ask several questions (some perhaps rhetorically), but don't seem to reach a salient point that I can see. I thought at the beginning you were going to make an argument against the number of drugs that ALS providers can and do push, but that seemed to taper off at the middle and somehow you started talking about aeromedical services, then about intubation? By the end, you just seem to be saying "EMS providers are doing more than they should, and its not in the best interests of their patients". Am I understanding that right?

I think most of the people on these boards (the ones who are active more than looking to get a job or a license) are here to learn and discuss. We realize that EMS (perhaps especially in the US) isn't perfect, and are always interested in viable improvements. Do you have a suggestion of some kind here, even if it requires a sea change (that will never happen) which would radically alter the nature of prehospital care?

There are so many moving parts though, I think you'd need to address a lot. As you said, many of the agencies we work for here are urban. I know that to drive an ambulance for my FD, you need to know the route to no less than 7 hospitals, and I think it's really more like 10, none of which are further than probably 30 minutes. That's certainly not the case coast to coast however, and should that factor in somehow to 'protocols'? It would seem that you are arguing against intubations for my type of short-haul environment, but the paramedics in Montana and Wyoming (and even the Eastern Shore in MD) with the long rides to Anywhere probably get even fewer chances to stay sharp with all those skills (someone correct me if that's a bad assumption).

You talk about removing ALS entirely. What do the numbers say with regards to something like pt survivability/morbidity in the case of witnessed arrest or the like when you compare ALS to BLS? My hunch is that ALS isn't much more likely, statistically, to get a save than a competent Basic - but I bet that there are certain subsets of patients where an ALS provider makes a difference. The next step would be to examine and address those subsets - what are they, how often, etc. What is the threshold for adding a treatment/medication/protocol? Obviously we can't treat everything, so what gets left out?

I'm only a basic, but I'm still wondering what made you decide that naloxone is unnecessary for prehospital pts?

 

[18G]

Vene is an extremist. An extremist who claims to be for EMS yet constantly contradicts himself with rambling posts such as this one. Mostly what he spews is rhetoric and accuses others of not presenting evidence to back their positions when he rarely does so himself.

I mean come on... you couldn't pick a better battle than Narcan???? Your really going to argue against Narcan use pre-hospital??? What is wrong with you? Am I the only one your losing credibility with?

So your telling me that when we have a heroin OD were supposed to 100% of the time put in an NPA and just bag the patient the whole way to the hospital? When instead we can quickly improve the patient's own stimulus to breathe, allow them to ventilate themselves, reverse the problem, and mitigate the need to perform the continual intervention of assisted intervention and the inherent risks of doing so???

Hmmm.... lets see... bag a patient 30mins to the hospital, cause gastric insufflation, patient vomits, aspirates, and now has aspiration pneumonia? And not to mention emesis everywhere, the need to suction aggressively.... all for what? Or wait... place an NG tube to prevent all that??? why? How is this clearly better for the patient? And what if the patient is bradycardic and rate does not respond with the assisted ventilation??? Now what.. still no Narcan??? Or are you proposing we intubate these patient??? That is mostly stupid.... again, why?

When instead... you can place an NPA, bag the patient, start an IV and titrate your Narcan to adequate resp status!!! all within a few minutes! bam.... we take a respiratory arrest or damn close to it and give them the ability to breathe on their own all in under 10mins! And we accomplish this all with a very SAFE and EFFECTIVE medication.

By your own philosophy, the hospital shouldn't give Narcan either. Why should the hospital poison the patient, right? Why not just have the RRT bag the patient until the opiates wear off? Isn't that exactly what your saying?

The point of EMS is to bring a lot of the ED care to the field. The treatment priorities of a narcotic OD are the same no matter if initiated in the field or in the Hospital. So, what's the problem?

how often does your service use sodium bicarb? Mag sulfate? Atropine? (which makes me wonder why people would use it to "poison" a stable patient to improve some numbers, that have grossly overinflated safety ranges.)

So you don't believe in preparation? Being prepared to treat all emergency's despite frequency isn't appropriate all of a sudden? So, tomorrow a building collapses and someone is crushed... lets just say its you for arguments sake? Your in favor of the Paramedic unit not having calcium Cl and sodium bicarb? You wanna take the chance when your extricated all because your the only patient in the past 5yrs this has happened to?

Or lets say you have a Child with severe asthma... nothing is working... albuterol, atrovent, epi, CPAP... all fail to reverse.... your son or daughter is moving closer and closer to resp failure and arrest. hmmm... mag sulfate has been showed to work in asthma cases refractory to traditional treatments... but since your son or daughter is the only case like this in the past 3yrs we no longer carry mag sulfate and your Child has now Coded.

Think that's exaggerated??? I think not. It's real life on this planet although I'm not sure which one your living on.

What's next on your list to remove from the EMS arsenal? D50? Band-aids, 4x4's? Alcohol Swabs?

 

[JPINFV]

I mean come on... you couldn't pick a better battle than Narcan???? Your really going to argue against Narcan use pre-hospital??? What is wrong with you? Am I the only one your losing credibility with?

I think naloxone is an interest and somewhat appropriate choice. It's a drug that can be easily titrated, yet apparently all too many people push the maximum dose for no more reason than they can, if not other reasons. I've heard stories, both in real life and online, of people using naloxone as punishment for either the patient ('ruining the high'), the hospital (IV push the maximum dose right at the hospital so that the patient is puking and fighting with the ER staff), or both. Additionally, it is probably one of the most often used paramedic level medications. Finally, there seems to be an astonishing lack of understanding of it's actual role, which is probably best demonstrated by the fact that there's a JEMS Connect thread where a PALS instructor suggested using it IO.

 

[Sandog]

So today I was thinking about a reply to narcan in another post.

It occured to me that there really is no use for narcan in EMS.

Now when I took pharmacology class, the first slide on the first day, was of the founder of pharmacology who declared "all drugs are poisons."

Your quote of Paracelsus omits a key portion of the quote which paints quite a different picture.

"All things are poison, and nothing is without poison; only the dose permits something not to be poisonous."

 

[DesertMedic66]

When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed, or he just wants hospital based EMS. Down here most hospitals don't have the money for their own EMS. And people out here who are coding or unconscious don't walk into the hospital. Lol.

 

[18G]

When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed

All of the above.

 

[the_negro_puppy]

 

[DesertMedic66]

All of the above.

Alright. I just wanted to make sure I wasnt reading it wrong.

He just wants us to do the bare minimum to patients if that. If someone is having an allergic reaction to something, which one is better for the patient, walking into the ER bagging the patient because we didn't want to "poison" him with epi because we just wanted to do the bare minimum in treatment or walking into the ER with a patient who we gave the "poison" to, that is breathing perfectly and is talking to staff members? From my EMT school we were taught that communication is a type of basic treatment. If I'm only going to do the basic treatment then I will have a patient in full arrest in the back of my rig and I will be asking him how his day is going and how he is feeling. Talking to a basically dead patient isn't going to help the patient at all. He isn't going to sit up from the gurney and say "wow, thanks for talking to me you saved my life by doing the absolute basic thing you could do."

 

[HotelCo]

THRILLER!

[YOUTUBE]http://www.youtube.com/watch?v=sOnqjkJTMaA[/YOUTUBE]

 

[DrParasite]

When I first started reading the post I thought he just wanted to have all the meds removed from EMS. Then the further I got it seemed like he just wants EMS to be exactly like a Taxi (just put them in the back and take them to the hospital without anything medical being done). And then lastly it seems like he wants EMS fully removed, or he just wants hospital based EMS. Down here most hospitals don't have the money for their own EMS. And people out here who are coding or unconscious don't walk into the hospital. Lol.

yeah, you aren't the only one who picked up on that.

As a side note, my medical director was 100% in favor of EMTs administering nasal narcan for suspected opiate overdoses.

 

[Veneficus]

I think most of the people on these boards (the ones who are active more than looking to get a job or a license) are here to learn and discuss. We realize that EMS (perhaps especially in the US) isn't perfect, and are always interested in viable improvements. Do you have a suggestion of some kind here, even if it requires a sea change (that will never happen) which would radically alter the nature of prehospital care?

That is the question I think.

EMS doesn't seem to want to change anything. So I am trying to find the way in which EMS can be forced to change in a reasonable amount of time.

One of the things that I have been learning as of late is that providers must always question whether or not they are doing the right thing for the patient or a procedure to satisfy themselves or a guidline. It is not limited to EMS, but this board is not really the right place to start talking about the best forms of anesthesia during CABG.

There are so many moving parts though, I think you'd need to address a lot. As you said, many of the agencies we work for here are urban. I know that to drive an ambulance for my FD, you need to know the route to no less than 7 hospitals, and I think it's really more like 10, none of which are further than probably 30 minutes. That's certainly not the case coast to coast however, and should that factor in somehow to 'protocols'? It would seem that you are arguing against intubations for my type of short-haul environment, but the paramedics in Montana and Wyoming (and even the Eastern Shore in MD) with the long rides to Anywhere probably get even fewer chances to stay sharp with all those skills (someone correct me if that's a bad assumption).

I think this needs to be put in a larger context. The point isn't whether there is a problem with the skill, the question is, is the skill even necessary or should there be tighter controls on it than every paramedic at every service is permitted.

In most services that use RSI, it automatically trigers an audit. Why doesn't every intubation automatically trigger an audit? I have worked for services where giving 2 mg of morphine triggers an audit, but cardioverting an SVT patient didn't.

I realize in many places this comes down to the medical control, but I don't see any reason why EMS supervisors cannot conduct a preliminary audit and then send it to the medical director if there is not clear resolution.

You talk about removing ALS entirely. What do the numbers say with regards to something like pt survivability/morbidity in the case of witnessed arrest or the like when you compare ALS to BLS? My hunch is that ALS isn't much more likely, statistically, to get a save than a competent Basic - but I bet that there are certain subsets of patients where an ALS provider makes a difference. The next step would be to examine and address those subsets - what are they, how often, etc. What is the threshold for adding a treatment/medication/protocol? Obviously we can't treat everything, so what gets left out?

Actually the studies show that the primary benefit of ALS with a handful of exceptions are that they reduce hospital stay. Does the cost of EMS make up for the difference? Nobody knows.

One of the defenses of the status quo of EMS is to demand proof that ALS doesn't work. These providers are simply self serving fools. First, you cannot prove a negative, secondly they offer none of their own proof. They think spouting anecdotes and congratulating themselves somehow counts. Nobody in medicine is fooled by this. There just aren't many who care enough about EMS to "waste time" taking a critical look at it.

If providers of any level spend more time congratulating themselves on a job well done, rather than asking hard questions, improvement is impossible.

I'm only a basic, but I'm still wondering what made you decide that naloxone is unnecessary for prehospital pts?

I was thinking that the point of narc reversal is to stabilize respiratory and vascular systems. Anesthesia never seems to use narcan, titrated or otherwise, and they give narc doses far in excess of EMS on a daily basis. One of the most common heard mantra of ALS providers is they are not afraid of narcs because they can reverse them, which of course, seems like flawed clinical judgement.

I am seeing from this forum that despite talk of wanting to be healthcare professionals, it is really just piss and wind. Few actually want to do the work involved, but at the same time want all the benefits.

Physicians are constantly questioning their modalities, treatments, and decisions.

The only reason I can think it is labeled as extreme or anti here, is the lack of true professionalism. Providers just want to feel good about themselves. But believing without question is a dangerous mindset. When it is followed even more by positive reinforcement of ones actions as the best or true way, it is the sure path to extremism.

If you look closely, the people who always demand proof offer none of their own. Just feelings and anecdotes. Simple proof positive thinking.

But I am rather hoping that out of these questions, people start thinking and true leaders arise or are inspired to prove themselves in a way that is convincing to somebody outside of EMS.

 

[Aidey]

Can we just require that everyone has to read House of God before they are issued their cert?

 

[Veneficus]

Can we just require that everyone has to read House of God before they are issued their cert?

Never read it, don't have time.

 

[Sandog]

Vene, to be honest I did not quite get the point of your first post. Are you trying to say that current EMS procedures are too aggressive, and in many cases that providers need to think beyond a protocol? Is your point being that often times that less may be more? Just trying to get what you mean...

 

[Veneficus]

Vene, to be honest I did not quite get the point of your first post. Are you trying to say that current EMS procedures are too aggressive, and in many cases that providers need to think beyond a protocol? Is your point being that often times that less may be more? Just trying to get what you mean...

My point is 2 fold,

One that less is more.

The other is that EMS must start to look critically at the treatments it is performing.

I have a career full of anecdotes where the more rare EMS treatments I performed have actually probably made a difference.

But Anecdote is not evidence. Nor are the arugements of "what if" and "sometimes."

Like every other medical and healthcare provider, we must constantly scrutinize what we are doing.

Later this evening I expect to look up the exact physiological and pathophys of both opioid OD and the reversal of it to really see whether or not there is a flaw in the original theory of its use for EMS.

Withdrawing treatments that are grossly uneconomical, rarely used, or questionable in effectiveness should not be viewed as punishment or anti.

It shold be viewed as a professional behavior of people who are trusted by their patients to do the very best when trying to help.

I am always amuzed by the attempts at scaring me into accepting practices because somebody might die, or Bin Laden is coming to get me, or some such.

Truthfully, we could probably save some lives by hauling Westerners over the age of 50 into cath labs and placing stents preventatively. But that doesn't make it economical or good practice.

I tried to include some examples other than narcan to illustrate the point that other treatments/operations have alternatives which may be better.

Clearly because of the diversity of regional pathology a treatment that would be totally useless in one area or region might be the most helpful in another. (one of the reasons I think national scope might actually be a bad idea)

Questions we should be asking ourselves are.

1. Is the treatment put forth the best option?

2. Is it over/under used?

3. Is it for the benefit of the patient, the system, or the provider?

4. How to we reconcile the discrepency when the treatmnet is better for the later 2 than the former?

Consider this, ACLS arrest medications like epi and atropine have shown no benefit in decades of research trying to prove they have benefit. But they are on every ALS unit and ED in the country. Why? At what cost? Why are we spending money and time on those treatments if we can't get them to make a difference?

But at the same time, maybe we should be looking at other treatments like heparin on EMS units.

Treatments that were sound 20 years ago may not match the evolving pathology of the day. There should always be a constant critical eye on any treatment.

The feeling of helping somebody is not good enough. Actually helping them is. In many cases less is more.

 

[boingo]

I think naloxone is an interest and somewhat appropriate choice. It's a drug that can be easily titrated, yet apparently all too many people push the maximum dose for no more reason than they can, if not other reasons. I've heard stories, both in real life and online, of people using naloxone as punishment for either the patient ('ruining the high'), the hospital (IV push the maximum dose right at the hospital so that the patient is puking and fighting with the ER staff), or both. Additionally, it is probably one of the most often used paramedic level medications. Finally, there seems to be an astonishing lack of understanding of it's actual role, which is probably best demonstrated by the fact that there's a JEMS Connect thread where a PALS instructor suggested using it IO.

Toronto, Boston and others give Narcan to their junkies for self-tx, buddy tx, and guess what? They don't go to the hospital tying up EMS and ED resources.

 

[boingo]

Vene, I appreciate your passion, however you are still a student, not even a practicing physician yet. You seem to have these grandious thoughts of how hundreds of EM physicians, surgeons, anesthesiologists etc...are all wrong. Would reversing opiate OD in the ED be bad too? Should they get a tube and a MICU bed? Seriously, get your MD or DO under you belt and get back to us in a few years.