So where does that leave us?

[Veneficus]

The first thing I found in my mailbox this morning was a rather damning assessment of fluid boluses in pediatric patients.

Not exactly surprising or news to the intensive medicine community. The addendum to the article showing short term benefit with increased long term mortality demonstrates my oft said opinions of the dangers of research in the emergency setting.

But over lunch I had one of those big picture thoughts.

High oxygen content therapies (15/10l NRB) for patients with difficulty breathing has been out of favor for at least 7 years now. Even the slow to change AHA now recommends oxygen titration much lower than what was bandied about 10 years ago.

Still some (especially here) advocate using it.

More and more influential people and groups are joining the "backboards are bad" group. The mounting scientific evidence is quite daming.

Today I get the latest in the antifluid resuscitation study, where permissive hypotension, even in extremely conservative levels is becomming more common in EMS.

Aggresive prehospital pain control campaigns are faltering, and in some cases (places) completely off the radar with an actual "anti pain control" wave sweeping throughout US healthcare.

Cardiac arrest meds have been reduced or eliminated in other first world nations and have basically been on the ropes with US experts for some time.

So it made me wonder...

With many of the "life saving therapies" showing to be at best useless and some even harmful, with the slow advancement of community based paramedicine, technological replacement of EMS skills such as CPR and electophysiological interpretaation, and time to stroke center, PCI, trauma, etc. the focus of many programs, coupled with the realization that healthcare dollars are going to be cut sooner rather than later...

What is EMS bringing to the table in 5 years? 10 years?

What is the saving grace?

What is likely the deus ex machia that will redeem EMS and make it not only viable, but valuable?

What would be the purpose of increasing education when the very therapies are failing?

I am not sure, what do you think?

 

[KingCountyMedic]

Interesting questions for sure.

What have we been doing for the past 10 years? Many parts of the country are churning out Paramedics faster than McDonalds makes Big Macs! Training is getting shorter and shorter, we continue to dumb down our profession. How many people will be transported "ALS" in the USA today? By "ALS" I mean O2, IV, EKG 4 lead monitor. I'd be willing to bet that only 30% of those people really needed a Paramedic transport. In my state almost every agency bills for transport be it private or public. If you stick an IV in the arm, put on the 4 lead ECG, and throw in 2 LPM nasal O2 you just increased the bill by $400. It's not EMS anymore its EM$!

It is amazing to watch how the times change in this profession. No O2 and no big fluid, fewer and fewer drugs. I'm excited to see what the future holds but I have a feeling this is just the begining.

Primum non nocere

 

[RocketMedic]

Apparently, I have been giving too many pain medications. 4/10 and arbitrary and vague physiologic benchmarks are the standard, and medicating pain from a 7/10 to a 0/10 is wrong. "Just take the edge off."
Strong work. Also, etoh is a near total disqualifier. if its good enough to saw of limbs in 1863, it's good enough for pain management.
your thoughts?

 

[mycrofft]

It's like weather versus climate, look back before you project to see if ths is likely a blip or a trend.

Modern EMS in America (can't speak for other countries) was a concatenation of emergency procedure lessons learned in Korea and Vietnam, the increase in the adoption of CPR for laypersons, and the upswing in deaths related to motor vehicles. TRAUMA was the reason it was started, not primary care issues like MI or diabetes, and the combination of not making the patient worse plus prompt transport to a hospital were it's goals.

The procedures we have seen proposed an disposed through the years have been half-proven hypotheses, taken as a genre. Now we are actually asking what's working and getting the feedback /correction step going.

Plus, nowadays the cost for heroic field measures leading to long convalescence and partial (it any) recovery are crippling.

I don't know for sure, there are a few pathways, but the most likely is keep throwing money and people at it, and pretend it's working. Like Vietnam.

 

[Veneficus]

I don't know for sure, there are a few pathways, but the most likely is keep throwing money and people at it, and pretend it's working. Like Vietnam.

That is a rather disturbingly true comparison.

Great insight.

 

[RocketMedic]

Got the "you are doing too much to control pain" speech today. Apparently, 4/10 is the new "trigger" and arbitrary benchmarks like tachycardia and hypertension are in, and prior ETOH should be a disqualifier

 

[Veneficus]

Got the "you are doing too much to control pain" speech today. Apparently, 4/10 is the new "trigger" and arbitrary benchmarks like tachycardia and hypertension are in, and prior ETOH should be a disqualifier

Who gave you that speech?

 

[RocketMedic]

Who gave you that speech?

QI Guy: Good dude, but hes tasked with pushing down our medical directors somewhat nebulous thoughts. Apparently I'm standing out amongst my peers when looking at narcotics use. I dont know if its a good thing or a bad thing to do right by my patients against the chance that I give pain meds unecessarily.

 

[Veneficus]

QI Guy: Good dude, but hes tasked with pushing down our medical directors somewhat nebulous thoughts. Apparently I'm standing out amongst my peers when looking at narcotics use. I dont know if its a good thing or a bad thing to do right by my patients against the chance that I give pain meds unecessarily.

So is it the QI guy or the med director, you should ask the later directly.

 

[RocketMedic]

pm sent.

 

[Christopher]

Interesting questions for sure.

What have we been doing for the past 10 years? Many parts of the country are churning out Paramedics faster than McDonalds makes Big Macs! Training is getting shorter and shorter, we continue to dumb down our profession...

Our training programs continue to get longer, most are positioning themselves to be an AAS.

But we're a State primarily without fire-based EMS.

 

[Carlos Danger]

]
Aggresive prehospital pain control campaigns are faltering, and in some cases (places) completely off the radar with an actual "anti pain control" wave sweeping throughout US healthcare.

I'm not aware of this trend. Can you give an example?

To the larger point, I don't see much changing in EMS, big-picture wise, anytime soon.

For decades now the percentage of truly emergent transports has fallen steadily, yet the entire focus of EMS training, equipment, and philosophy continues to be on life-threatening emergencies. I don't see that changing, really.

Hopefully I'm wrong and we'll see an expansion of education with more focus on primary care and treat & release / referral capability.

But that will take significantly increased levels of education (doesn't it seem we ALWAYS come back to that?), which I don't see happening anytime soon. Just not enough interest among the powers-that-be, when it comes down to it.

I see EMS continuing to plod along, becoming ever busier with non-emergent transports, but failing to really change in any way that increases value.

But I've been wrong before; hopefully I am this time.

Apparently, I have been giving too many pain medications. 4/10 and arbitrary and vague physiologic benchmarks are the standard, and medicating pain from a 7/10 to a 0/10 is wrong. "Just take the edge off."

Strong work. Also, etoh is a near total disqualifier. if its good enough to saw of limbs in 1863, it's good enough for pain management.
your thoughts?

FWIW, I think 4/10 is very reasonable trigger for acute pain with a short transport time.

Definitely don't agree with the general "anti-pain management" tone that you are getting, though.

Nor with the ETOH disqualifier. What is that based on?

 

[Veneficus]

I'm not aware of this trend. Can you give an example?

PMed

 

[mycrofft]

This thread's question is more germane than the usual "EMS is going to be disassembled, what will we do?" one.
==========

The whole deal has been like the reaction of the South when the boll weevil invaded. We have too much money invested, we have too many reputations vested, we have to much money to be made, to stop.*

I see a ray of light in the periodic and authoritative conferences which look at research and then change or maintain standards and teaching parameters. That offers insight to true practitioners.

Next: the key will be to link payment to outcomes, which will make cures rather than admissions and billing the basis for survival. Your corner office, annual growth and the ability to make payments on your new PET suite will depend on how many of your patients actually survive and thrive, not on how you donate money to campaigns or throw community fetes for major contributors.

And the only potential fulcrum to lever that is centrally paid health care. (Look to Britain and others to see how that can become warped, too).

*ironically, one of the pathfinders for a way out of the fall of "King Cotton" was a deeply religious black man, the son of slaves, at a primarily black institution...Dr George Washington Carver, at the Tuskeegee Institute. No dog in the game, as they say, so he came up with thousands of potentially profitable products using other plants. Who will be the next G.W Carver?

 

[Carlos Danger]

Next: the key will be to link payment to outcomes, which will make cures rather than admissions and billing the basis for survival.

And the only potential fulcrum to lever that is centrally paid health care. (Look to Britain and others to see how that can become warped, too).

Not a fan of public insurance.

Already, nearly 50% of the population is on public insurance of some type, and the healthcare situation gets worse and worse....it is a woefully wasteful model, for numerous reasons. Not to mention the fact that we simply can't afford it.

 

[Rialaigh]

Hate to say it but in transport times of less then 20 minutes. I don't see a place for ALS at all in the future other then interfacility critical care transport.

In business people will want to be picked up by the highest quality and educated provider possible. From a medical standpoint ALS does nothing to improve survival rates or patient outcomes at any noticeable level for short transports, they will do even less in the future.

I say make it all a taxi service.

 

[Rialaigh]

This thread's question is more germane than the usual "EMS is going to be disassembled, what will we do?" one.
==========

The whole deal has been like the reaction of the South when the boll weevil invaded. We have too much money invested, we have too many reputations vested, we have to much money to be made, to stop.*

I see a ray of light in the periodic and authoritative conferences which look at research and then change or maintain standards and teaching parameters. That offers insight to true practitioners.

Next: the key will be to link payment to outcomes, which will make cures rather than admissions and billing the basis for survival. Your corner office, annual growth and the ability to make payments on your new PET suite will depend on how many of your patients actually survive and thrive, not on how you donate money to campaigns or throw community fetes for major contributors.

And the only potential fulcrum to lever that is centrally paid health care. (Look to Britain and others to see how that can become warped, too).

*ironically, one of the pathfinders for a way out of the fall of "King Cotton" was a deeply religious black man, the son of slaves, at a primarily black institution...Dr George Washington Carver, at the Tuskeegee Institute. No dog in the game, as they say, so he came up with thousands of potentially profitable products using other plants. Who will be the next G.W Carver?

I thought about this

Problem is pay to play places just won't take patients who aren't going to have good outcomes. This was the fundamental problem that led to getting paid equally regardless of outcome. ER's will become even bigger money pits because they will be forced to accept patients who are going to die on them.

The worst healthcare will be provided to those who need the best healthcare.

The best healthcare will be provided to the patients who would have lived anyways.

The linking pay to outcomes system just encourages counter productive behavior. It is basic economics and it will result in each facility in the healthcare system converging one of two ways (to either extreme). Either you will get better and better care and be more selective about your patients (only taking those who will live so you get the best reembursment) or you will provide worse and worse care forcing you to take more patients (in number) to make up for less $ per patient ultimately landing yourself in a position where you end up at one end or the other of the spectrum.

 

[mycrofft]

Not a fan of public insurance.

Already, nearly 50% of the population is on public insurance of some type, and the healthcare situation gets worse and worse....it is a woefully wasteful model, for numerous reasons. Not to mention the fact that we simply can't afford it.

If you were t-boned by a speeding drunk tonight, I assure you, unless you have a personal fortune, that by the time you finally expired you would be broke and have been on government medical insurance money. Or you died on the scene.

Speaking as a former case manager for the medically indigent at a County level, catastrophic medical bills will bankrupt you even with a job and insurance. After that, you are derided as a leech or a whiner.

Private insurance companies are busy finding ways to keep from paying you because they have to. Government paid medical care is like passing the hat for an unfortunate neighbor.

Citation for the 50% figure? It that like the Romney 47% are on public assistance quote? Or are we including VA, military retirements and TRICARE, Social Security, Medicare?

If health care was more reasonably priced and universally available, we wouldn't need federal and state and county health except public health measures.

Rant over, return to the regular porgramming.

 

[Carlos Danger]

This is a complex issue that, frankly, I am tired of debating.

Suffice it to say that the free market (what we have now in the healthcare and insurance industries is anything but a free market) has solved far more problems at a far lower cost than government programs ever have.

Medicare / medicaid make up 21% of the federal budget, and that is growing rapidly.

Th federal government is almost $17T in debt and continues to borrow $.40 on every dollar they spend, with no end in sight. Some of our largest states are in similarly dire financial situations.

I don't know exactly what the answer is, but the mere suggestion of expanding any entitlement programs - no matter how important they are - is laughable.

 

[mycrofft]

"I thought about this

Problem is pay to play places just won't take patients who aren't going to have good outcomes. This was the fundamental problem that led to getting paid equally regardless of outcome. ER's will become even bigger money pits because they will be forced to accept patients who are going to die on them.

The worst healthcare will be provided to those who need the best healthcare.

The best healthcare will be provided to the patients who would have lived anyways.

The linking pay to outcomes system just encourages counter productive behavior. It is basic economics and it will result in each facility in the healthcare system converging one of two ways (to either extreme). Either you will get better and better care and be more selective about your patients (only taking those who will live so you get the best reembursment) or you will provide worse and worse care forcing you to take more patients (in number) to make up for less $ per patient ultimately landing yourself in a position where you end up at one end or the other of the spectrum. "


An analogy: I needed a new engine in my Nissan Sentra. The shop dithered and ran up bill after bill and wouldn't admit they couldn't do it. I didn't pay them, I cancelled their payment through my credit card company. That is what we need. Tell the truth, do good, not dither and run up the bill then send me to a skilled nursing facility with MRSA to die.
If patients are in a lethal category of diagnosis, and it is verifiable, then they won't be dinged if proper palliative care is done instead of useless serial MRI's, lab draws, and surgeries to keep from getting sued over abandonment or under-treatmen, or wring dollars out of insurance companies.

Cherrypicking isn't hard to spot. And make health care a civil right, then it will be enforced by the FBI with the support of the IRS and other federal government. Especially appealing if they are getting federal money.

As it is, no matter how poorly you are treated, they get paid. If outcomes begin to count (and let's throw in rates of nosocomial infections, surgical and pharmaceutical misadventures, falls, etc on the side of the ledger where you lose money or get decertified), the6h will have incentives to get their act together.

ER's are loss centers because federal and state medical pays .30 on the dollar sometimes. And the departments are not run to make a profit or break even, they are set up as a chokepoint to care practicing defensive medicine to the max. If the old County hospital and clinic networks were still up and running, private hospitals would not have the ED traffic they have now.