08 April 2009

Do we need Paramedics?

I was listening to the EMS garage podcast #27 the other night, when they got into a heated discussion about Columbus, OH looking to be a Basic Life Support (BLS) only service. San Antonio Fire Department in Texas has just started running six BLS only ambulances in addition to their thirty two ALS (Paramedic) ambulances.

I work for a private ambulance service in Kentucky. I am a new paramedic with only a few months under my belt on the streets. My ambulance service does not have any 911 contracts, but we have many with nursing homes and rehabilitation centers around town. Today (like many days) was extremely slow, and the three paramedic trucks were relegated to dialysis runs and doctor appointments, all of them BLS in care level. I began to think are paramedics really needed in urban service areas?

The OPALS Major trauma study
as reviewed by Dr. Keith Wesley on JEMS.com showed that ALS intervention in major trauma patients had little to no benefit to survivability. Also it stated that when a trauma patient had a Glasgow Coma Scale (GCS) score of less then 9 and ALS intervened, the mortality rate INCREASED. Yes, this is only one study, but more and more studies are arriving showing that ALS procedures do not increase survivability for the patients. Trauma is the realm of surgeons (paramedic students are told that Trauma is a surgical disease, and the only definitive care is surgery), control the bleeding, apply oxygen and increase the diesel flow exponentially (all BLS skills by the way).

Cardiac Arrest, the American Heart Association (AHA) has been promoting more high quality CPR (cardiopulmonary resuscitation) and less time interrupting chest compressions while trying ALS interventions. Ok, I can hear the pundits (and old school medics) but we NEED an IV line and we NEED an endotracheal tube to secure the airway! Well, modern science along with a few industrious people have come up with several blind insertion airway devices, like the venerable Combitube or the King Airway. Both these devices are BLS level skills in many states (the number is growing and it should). Any decent paramedic, would not remove one of these devices as long as adequate ventilation are being performed (and you can even add capnography). What about electrical therapy? Semi-automatic External Defibrillators (SAED or AED) BLS skill. There is even a thought from Dr. Bryan Bledsoe in the recent JEMS magazine about giving too much oxygen. Summery, high quality chest compressions, not hyper oxygenation and a king airway with a bag valve mask (on room air of course), all BLS level skills.

Stroke (Cerebrovascular Accident, CVA), unless you work for a service that allows the administration of tPA (Tissue plasminogen activator) , you are just a glorified BLS transport truck trying to get the patient to a stroke center within the three hour time frame. Sure you can start and IV, but can you provide definitive care for that patient? If you could why would you be transporting them in the first place? Treat and release (yes I know this is extremely unlikely that a paramedic could EVER treat and release a CVA, but the question is still valid).

Asthma/Anaphylaxis, again modern science has given us the Epi Pen auto injector that many BLS services are now carrying. Even in the Metro are I live, BLS trucks administer albuterol nebulizer treatments. Then just transport them to hospital of choice.

Congestive Heart Failure (CHF), what about that smart ass? Again more medical directors are adopting protocols that involve less invasive treatments in the field, like CPAP (Continuous positive airway pressure). A BLS ambulance is trained to listen to lung sounds, they can identify ralse (crackles) and use the CPAP, during transport to the hospital of choice. Diuretic medications are also being studied closely, and some doctors want to stray away from excessive use of lasix in the field.

Angina and chest pain, Nitro glycerine (NTG) and asprin (ASA) along with a little oxygen and get thee to a hospital. There is talk in the EMS community of reducing the use of morphine for chest pain. Oh, you want to address the twelve lead ECG stuff also? Much of 12 lead ECG transmitting to ER's in my area is still in the pilot program stages. Yes, this can reduce door-to-balloon time but the study in my metro is still under way. If I can get a patient to the ER under 30 minutes and I did not transmit an ECG to the hospital is the door-to-balloon time really that much greater? We all act like transmitting ECGs to the ER is something new, but as I recall Johnny & Roy were doing that in the 1970's.

I believe that if your transport time is less than 30 minutes to definitive care in a hospital, then you really don't need paramedics in your service. Maybe I am just a new medic and I don't know what I am talking about, but the studies are out there. I became a medic to help people, and I find that I am just another ambulance driver. You can send your hate mail here: joelneild@gmail.com but you will only get a response if you can format a sentence correctly and use proper grammar.

04 April 2009

Speak to me

Stop what you are doing. Read this story from Ambulance Driver blog. Don't come back until you have read the whole story. I'll wait for you.

While listening to the EMS Educast episode 6, Dr. Joseph Weiner, a psycologist was talking about how to teach EMTs compassion. He had a few really good ideas, including just simply talking to the patient. Ask the patient about their life, inquire about what interests them.

During my induction to transport medicine (chuck runs), the goal was to finish all your paperwork prior to arriving at your destination. Rarely did I engage the patient in conversation (save for the few talkers we would transport, then I usually faked listening while completing paperwork). I did not consider myself as the dispationate burnt out EMT, I was just trying to get my work done. After a while I would engage the patients, try to brighten their day, or just pass the time (although I would try to multi task and I would write while talking).

Now, I find that I either don't have the time to do paperwork, or (especially after listening to the show) I just try to show a little more compassion towards my patients. Most of the people are from nursing homes and rarely do they get to talk to new people outside their circle.

I have always been interested in sociology (albiet from a distance) and the history of the individual people who live through historic times. I have been transporting these people for years now and I have only just begun to truely listen to them, and learn what I can. There are some very depressing stories. A few patients don't get to talk to anyone, until the ambulance picks them up for their dialysis appointment, and after they return to a house, void of human interaction, they turn on the TV and wait until we return.

A few stories have left me sadder for the day, but I hope that the patients gain from our short interaction.

03 April 2009

Twitter Log

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  • 06:06 Working @ OCEMS for 12 hrs.
  • 06:07 OC is next to @buckman hollar. With any luck we won't meet today.
  • 10:29 BTW I am playing BLS today. I can't be ALS at OC. They don't hire new medics. We just took a possible MI to the ER ( ALS onboard)
  • 10:36 Just FYI - use of a whizinator is a class A misdemeanor. (via @dancanon)
  • 10:39 #followfriday @weebeefire is my major at the firehouse. He's new to Twitter
  • 12:05 On the move. We're rotating back to the center of the county.
  • 12:07 Any one in Louisville taking part in the Humana Festival? Wondering which plays I should see.
  • 12:28 4 people have been shot and up to 41 people have been taken hostage at the American Civic Association in Binghamton, NY. (via @BreakingNews)
  • 14:12 RT @gfriese: welcome EMS magazine editor @NancyEPerry #followfriday (via @dengerin)
  • 14:18 URGENT: Jumping out of moving cars on the highway is not a good idea. Carry on with your day
  • 17:07 The Walt Disney Co. says it has cut 1,900 positions at its U.S. theme parks due to the slumping economy. (via @BreakingNews)
  • 17:13 That last tweet is true. Many managers lost their jobs at Disney World. Luckily my friends survived the cuts.
  • 17:18 Returning from BLS transfer from urgent care to hospital.
  • 17:28 Shameless #followfriday plug for @medic_ray he's a good read, and inventive. No power failure stops him!
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02 April 2009

Twitter Log

Follow me on Twitter
  • 04:24 Awake. 5 hrs sleep. Entire crew going to gym @ 5am. Maybe an aftenoon nap in my future!
  • 05:50 Finished workout. Waiting for the rest of the crew. Basketball last night wasn't good on my knee. It's not happy today
  • 10:39 At the sound of the tone the time will be 10:39 EDT. I've been awake for 7 hours. I get to nap now.
  • 10:42 @funambulator
  • 10:42 Nice use of negative space . @funambulator.
  • 11:03 Ok, maybe no nap just yet. Rain is coming and I need to mow the yard. I hate grass, the way it grows continuously. It's evil incarnate.
  • 12:23 RT @funambulator: If you remember or have a story about the '74 tornado, we want to hear from you today around 1:20 502-814-TALK or @soatalk
  • 12:32 RT @toddmundt: Cutting the Coax: an update bit.ly/iP6Ll (I like the concept, and we thought of dumping cable but we would miss UK BB)
  • 14:39 Watching Bottle Shock. Knee still hurts, I knew I shouldn't have played basketball last night
  • 16:23 Everyone says I'm a wise ass. I'm waching Talidega Nights, I feel my IQ lowering already.
  • 20:24 Going to sleep. Have to get up @ 4am for a shift at OCEMS
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01 April 2009

Twitter Log

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  • 06:24 When everything is wrong... I'm trying to just move along. Need mental health day off work.
  • 08:12 This day is proving to be a worthy adversary but I have won the battle thus far. The war is still being waged. More reports from the front
  • 08:36 I have to take my V02 max test again today. This FD doesn't understand that you can't really change a VO2 max number in 3 months.
  • 08:38 Technically it's not a real test. It's a mathematical estimate of what my VO2 max should be given BMI & max heart rate over time.
  • 09:34 Got 29 and change on m VO2 max test. Dept. Standard is 38. Ask me if I care.
  • 09:37 Anyone want to hire a medic full time? Prospects need good health plan and pay.
  • 09:40 I lie to the public when they ask if my job is exciting. It's not, and I wish we had more fires to fight. I'm bored
  • 10:12 I am feeling Verbose today, and this is Tweet 3000 for me. Thanks for putting up with me ;)
  • 11:09 What's worse than killing a patient? Trying to hide it: is.gd/pWUy (via @kevinmd)
  • 13:00 Training at Nortons Commons. Preplan strategies & tactics. Yawn.
  • 16:57 Back from gym. Truck washed. Last shift left us with nothing to dry the engine so it will hang on the line for an hour or more.
  • 17:05 Congradulations on the new Class. Who did you get for lead instructor?
  • 17:23 Dear Facebook iPhone App, Why can't I share links? Easy, simple add to next update. Ok, thanks.
  • 18:11 Why the Monkey? 091/365 Nortons Commons tinyurl.com/d7ef3d
  • 18:38 I have determined that the Submaximal VO2 max test is a joke. Tried to convince department to get a real VO2 Max test. No takers yet
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