Things we can do nothing about?

[Anjel]

But what works in BFE doesnt in NYC.

People where linuss is have long transport times somedays. He might have a pt that needs RSI. So he has a RSI protocol.

Here I have no more than a ten minute trip to a hospital from wherever I am going L&S. We dont have or maybe dont need a RSI order.

America is huge and vastly different. So the amount of care given prehospital is different.

 

[Shishkabob]

I have NO issue with there being a state- or nation-wide MINIMUM "protocol", where everyone in the state/country can do, say Adenosine 6/12/12 for SVT without consultation of 'med control', etc etc...

But when you use state defined protocols as the ceiling, and NOT the floor... You screwed up.

 

[MrBrown]

Brown, It's only 5 years where you are? How does that work?

Two years of science and foundation of practice and two years of complex practice, plus one year as a Trainee Intern. We have structured practical clinical exposure and clinical decision making during all five years.

Once we graduate after five years we do one or two years as a House Officer (House Surgeon) then apply for Specialist Trainee positions (Registrar)

Sorry, it does when you try to go "Oh we can do it nation-wide!" when your nation is smaller in size and population than many US states.
.

Well it goes to show size is not everything then eh?

A nationwide standard is not unrealistic, the Fire Service has done it through the NFPA standards, hospitals do it through the Joint Commission, the various medical specialities set their own through their respective Board or College etc.

Brown however thinks a nationwide standing order is unrealistic given the extreme degree of fragmentation that exists however a national standard is not. State wide standing order has been implemented in several jurisdictions so it is not unreasonable.

For example a sample standard for asthma might be salbutamol, IM or IV adrenaline, hydrocortisone, magnesium etc or a spinal clearance standard or one for RSI.

This however would require a less fragmented approach to education and clinical leadership.

If we use a cookie cutter protocol, doesn't that just mean we can't micromanage to let certain people use their own judgment in whether or not to advise for going to the ER POV?

No Brown doesn't think so, plenty of places leave people at home and have a standard set of clinical guidelines such as well here obviously but also Australia (statewide guidelines) and the UK (JRCALC).

But what works in BFE doesnt in NYC.

That is very true

People where linuss is have long transport times somedays. He might have a pt that needs RSI. So he has a RSI protocol.

Here I have no more than a ten minute trip to a hospital from wherever I am going L&S. We dont have or maybe dont need a RSI order.

America is huge and vastly different. So the amount of care given prehospital is different.

Brown has to disagree here. Here in Auckland our Intensive Care Paramedics have RSI and have had for about the last five or six years. Some of them are ten minutes down the road from hospital and it has not changed their decision to perform RSI. You should perhaps reconsider the larger clinical context of being ten minutes down the road from hospital but if your patient needs it, they need it.

Somebody with traumatic brain injury or refractive status asthmaticus who is about to die infront of you needs RSI the same whether they are ten minutes or ten hours from hospital.

Brown has spent an hour on the floor at Nana's house while we gave her enough analgesia and packaged her so she was comfortable to take to hospital but hospital was only about 12 minutes away if that. Does that mean we shouldn't have given Nana any analgesia because we were only a few minutes from hospital?

 

[Shishkabob]

A nationwide standard is not unrealistic, the Fire Service has done it through the NFPA standards, hospitals do it through the Joint Commission, the various medical specialities set their own through their respective Board or College etc.?

And neither the JC or NFPA are law stating what can or cannot be done... just recommendations at what should be done. If a hospital wanted to go against the JCs recommendations, the worst that can happen is less federal reimbursement.

If a Paramedic were to go against protocols, you're facing something from losing your license up to jail time.




The nation-wide protocols are not unrealistic for one thing: The national scope of practice already states what is expected. That scope can translate into protocols nationally, and you can expand from there.

Every Paramedic is expected to be able to do a beta agonist for asthma, so that should be a national protocol... however if a certain place wants to add RSI, that's their right.

 

[usalsfyre]

The issue with national and state protocols here would be less if the background of a "paramedic" were the same through out the 50 states. However, currently it varries not only between states, but between freaking regions. I don't want to be held to the same standard as a 10 or 20 week flunkie.

 

[WuLabsWuTecH]

Brown has spent an hour on the floor at Nana's house while we gave her enough analgesia and packaged her so she was comfortable to take to hospital but hospital was only about 12 minutes away if that. Does that mean we shouldn't have given Nana any analgesia because we were only a few minutes from hospital?

I think here it becomes a time management thing. RSI takes what? 5 minutes to do including the setup of equipment, starting a line, and getting everything drawn and ready? Why would you EVER do it when you are 5 minutes to the hospital? (From our run district, we are never more than 5 minutes to the nearest hospital, usually less). You should be using that 5 minutes to do other things such as establishing a line, and doing a good initial assessment. You can have someone bagging for that time without distending the stomach too much right? And once you get to the hospital where you already have a line established and people standing by to RSI, you can now establish an artificial airway in less than a minute.

 

[usalsfyre]

I think here it becomes a time management thing. RSI takes what? 5 minutes to do including the setup of equipment, starting a line, and getting everything drawn and ready? Why would you EVER do it when you are 5 minutes to the hospital? (From our run district, we are never more than 5 minutes to the nearest hospital, usually less). You should be using that 5 minutes to do other things such as establishing a line, and doing a good initial assessment. You can have someone bagging for that time without distending the stomach too much right? And once you get to the hospital where you already have a line established and people standing by to RSI, you can now establish an artificial airway in less than a minute.

I've had the patient that I couldn't move without establishing an airway. The big consideration (for me anyway) in RSI is "is the airway/breathing so unstable that I can't wait until there are more resources and a better situation available".

 

[Shishkabob]

I think here it becomes a time management thing. RSI takes what? 5 minutes to do including the setup of equipment, starting a line, and getting everything drawn and ready? Why would you EVER do it when you are 5 minutes to the hospital? (From our run district, we are never more than 5 minutes to the nearest hospital, usually less). You should be using that 5 minutes to do other things such as establishing a line, and doing a good initial assessment. You can have someone bagging for that time without distending the stomach too much right? And once you get to the hospital where you already have a line established and people standing by to RSI, you can now establish an artificial airway in less than a minute.

Honestly, RSI still has it's use even if you're minutes from the hospital.


Who's to say that just because you're 5 minutes from the hospital that you can get the patient there in 5 minutes? Ever have an obese patient in the absolute back end of a house through a skinny hallway? I'd be happy if I got them in the sitting position in 5 minutes

 

[RealMedic]

Unless and until you get one standard across the board for EMS, we will always have these issues here in US. It's funny as heck to have the gent from north island give us US EMS folk his code brown opinions when they would fit better in his dr seus hat haw haw a bit of humor just taking a piss mate Right, so no matter what temple ya worship at here NREMT or state, we gotta get one standard educational and practice to get everyone on the same sheet of music. Unless you have they authority to say no transport (like our UK bretheren) then you will transport that stub toe like it or nor unless you go thru the CPR (conduct patient refusal) process. Ok next?

 

[JPINFV]

And neither the JC or NFPA are law stating what can or cannot be done... just recommendations at what should be done. If a hospital wanted to go against the JCs recommendations, the worst that can happen is less federal reimbursement.

Alternatively, the hospital can go to a different national or local accreditation service. The Joint Commission isn't the only game in town for hospital accreditation.

 

[JPINFV]

I think here it becomes a time management thing. RSI takes what? 5 minutes to do including the setup of equipment, starting a line, and getting everything drawn and ready? Why would you EVER do it when you are 5 minutes to the hospital?

So you're 5 minutes from the hospital. However, the time till hospital intubation is going to have the time it takes to package the patient, move the patient from the ambulance to the hospital gurney (including any time it takes to get someone's attention, which is small, but not existent, in an emergnecy), time to give report, time for the physician to examine the patient (also should be short, but not non-existent), and physician to set up for intubation, and then intubate. It's not like you show up at the hospital and an ET tube magically and instantly inserts itself.