are paramedics beneficial to trauma patients?

[pseudoknot]

Wow, this forum's quiet lately. I saw some papers recently that may be of interest:

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity
http://www.cmaj.ca/cgi/content/full/178/9/1141
This examined survival to hospital discharge in major trauma patients in a large system before and after the introduction of ALS. They found that ALS did not improve outcomes and actually saw higher mortality with GCS<9 and ALS. It's reasonable to think this might be related to procedural interventions and scene time.

Note also that if I'm not mistaken, Canadian BLS providers are better trained than our EMT-Bs, so it's not an apples-to-apples comparison.

Here is an associated commentary about the above and the current evidence on prehospital intubation for trauma:
Should invasive airway management be done in the field?
http://www.cmaj.ca/cgi/content/full/178/9/1171

Here's a news story talking about the study:
http://www.medpagetoday.com/EmergencyMedicine/EmergencyMedicine/tb/9200

---

Members don't see this ad.

 

[leviathan]

*cricket*

I've heard of that study cited numerous times, but never actually read it. What would ALS be doing on a trauma with a GCS>9 that would increase their scene time over BLS (assuming the LOC is high enough to negate intubation)? IV starts are done en route to hospital for trauma, and patients are transported directly after primary survey stabilization.

Edit: I'm assuming you made a typo; the study says GCS less than 9. That would make sense if they were intubating on scene and delaying transport.

 

[docB]

It's way to early to actually advocate a change to ALS in regard to trauma patients now but for the sake of discussion how would we change the current system? My concern is that too much of this discussion comes across to EMS providers as an indictment of their training and efforts. That's just not the case. The issues being called into question here are scientific, not personel. These studies may be telling us that certain patients, in this case traumas particularly with head injuries, might do better without ALS interventions not because they're being done wrong, but because they just might not help.

I suggest that going forward the best way to approach this is to consider that we may eventually want to create protocols where ALS providers assess patients and based on criteria those patients are placed on a rapid transport, minimal intervention algorithm. If we get there it will be important to make everyone understand that we're not restricting the medics. We would be applying EBM to EMS and changing protocols appropriately. We would rely on the medics to make the proper assessments and decisions and interventions (or non-interventions) as the professionals they are.

 

[pseudoknot]

Thanks leviathan, for pointing out the typo.

And I agree with DocB that the question is whether to employ certain ALS interventions in major trauma patients, not whether to get rid of medics. Believe me, the next time a Chinese restaurant slips me some peanuts, I want an ALS crew to show up at my door!

I think I should have made the thread title something less inflammatory (change "paramedics" to "ALS procedures") but I guess I had seen too many similar wordings and posted hastily. Oops.

 

[MedicFL]

What "should" happen and what does happen are two different things. IV's are very often times started on scene by people who say we must follow protocol. ET's are being started on scene and often times takes 5-10 min to get tube. Even putting them on a backboard has been shown to decrease survival rates, the simple fact is these patients need the OR..

 

[FDGB]

There are many variables that need to be taken into account. Urban vs. suburban vs. rural environment, scope of practice in a given state, staffing configuration.

Yes there is evidence to suggest that intubation on trauma patients in an urban setting leads to greater mortality we do not have good data on suburban/rural environments. Also this is evaluating endotracheal intubation and not other airway techniques (ie LMA or combitube).

Additionally we need to consider the impact of the expanding number of ALS providers. With more providers in a given area each provider is performing few skills. With this in mind proficiency with these skills decreases which may lead to worse outcomes (delayed transport to perform skills, poorly performed skills etc).

DocB is right on the money with regards to applying EBM to EMS. Infact this is my interest area for research. In fact I'm working on a paper at the moment which I have to get back to.

FDGB

 

[leviathan]

What "should" happen and what does happen are two different things. IV's are very often times started on scene by people who say we must follow protocol.

Whose protocol advises a paramedic to start an IV on scene for a trauma patient? Are there really paramedics that sit around and play with their shiny toys and drug box on scene when somebody is hemorrhaging to death from internal injuries?

 

[deleted92121]

Whose protocol advises a paramedic to start an IV on scene for a trauma patient? Are there really paramedics that sit around and play with their shiny toys and drug box on scene when somebody is hemorrhaging to death from internal injuries?

Would you like to see some the medics in my company

dxu

 

[viostorm]

I think the ALS benefit in trauma may be pain management.

Some of this crap hurts so bad I think it is only humane to provide a mechanism for taking some of that pain away for the 20 minutes until someone can get you something in the hospital.

As many of your know, I totally disagree with intubation and RSI. I think an IV and pain meds are ok but only for the minor/moderately injured trauma patient.

 

[pseudoknot]

I think the ALS benefit in trauma may be pain management.

That's a really good point, although the systems I've seen still have a strong bias against providing pain meds in the field except for things like major fractures. Hopefully this will change with time.

 

[Siggy]

Whose protocol advises a paramedic to start an IV on scene for a trauma patient? Are there really paramedics that sit around and play with their shiny toys and drug box on scene when somebody is hemorrhaging to death from internal injuries?

I can't completely tell if this is a rhetorical question or not.

 

[MedicFL]

Whose protocol advises a paramedic to start an IV on scene for a trauma patient? Are there really paramedics that sit around and play with their shiny toys and drug box on scene when somebody is hemorrhaging to death from internal injuries?

I am not saying the protocol says to sit around and do things but does it happen, all the time. Protocol just says you should get two large bores IV's. I have been medic for 5 years and worked in several systems, and I see this happen all the time. Urban survival rates have been shown to be worse often times in trauma. As to the pain management in trauma pt's this is usually a no no unless an isolated FX. I have talked it over with neuro, and the trauma team and they like to be able to get there baseline before meds. I do often times give N2O to trauma pt's are its effects dissipate quickly and allow for a baseline exam to be done.

 

[pseudoknot]

I am not saying the protocol says to sit around and do things but does it happen, all the time. Protocol just says you should get two large bores IV's. I have been medic for 5 years and worked in several systems, and I see this happen all the time. Urban survival rates have been shown to be worse often times in trauma.

I've sat in ambulances for five minutes or more because the medics wanted to get their line before we got to the hospital...which was a few blocks away...but those were medical patients and it didn't hurt anything. I do think time on scene can be an issue with trauma patients though.

As to the pain management in trauma pt's this is usually a no no unless an isolated FX. I have talked it over with neuro, and the trauma team and they like to be able to get there baseline before meds.

I don't think the evidence supports this anymore. I'm almost positive it doesn't for the abdomen, but don't have time to find references right now. Also, most real traumas are going to be pan-scanned. Plus half of them are either AMS or EtOH so the value of the exam is questionable anyway.

I do often times give N2O to trauma pt's are its effects dissipate quickly and allow for a baseline exam to be done.

Huh. I've never heard of that being available on an ambulance before...or an ED for that matter.

 

[MedicFL]

N2O is widely used in EMS, for pain management.....I couldn't agree with you more about pain management in trauma's but that is the trauma teams thoughts around here and so our medical director goes with it. I mean we can do some pain management but it is more for isolated FX's, hips, dislocations and more straight forward things like that. Penetrating trauma's, any trauma alert, its a big no no around here... I think medics should be able to intubate still, RSI is a touchy subject I think it has its places because sometimes you really need to knock someone down. But maybe it should be held for flight teams and critical care medics as these tend to be of a higher skill set..

 

[jbar]

I don't know why trauma teams would back the administration of something short activing like Fentanyl in the field. In a lot of places that have longer transport times, like 20min, by the time the trauma team starts the assessment the drug is wearing off, but everyone is much happier during that transport.

 

[pseudoknot]

There is a brief review of prehospital fentanyl in American Journal of Emergency Medicine (2007) 25:842 if you have access. It seems promising but the pace of both research and protocol changes in EMS remains frustratingly slow.

 

[jbar]

we used it prehospital out in CO and I was pretty happy with it. Especially good for procedural sedation (we had some long transport times, so sometimes we were pulling some traction or having to get a ski boot off way out)

 

[leviathan]

I've sat in ambulances for five minutes or more because the medics wanted to get their line before we got to the hospital...which was a few blocks away...but those were medical patients and it didn't hurt anything. I do think time on scene can be an issue with trauma patients though.

Oh I'm all for IVs on scene for some medical patients (eg. hypoglycemia, some forms of non-traumatic hypotension/hypovolemia).

Huh. I've never heard of that being available on an ambulance before...or an ED for that matter.

We often use N2O for pain management here...I've also seen it used in the ED for shoulder reductions.

 

[Rogue Medic]

Paramedics will occasionally kill patients to follow the protocol.

If the protocol "requires" 2 large bore IVs, there are medics who will sit on scene with trauma patients to get their IVs. They are trying to avoid getting in trouble, but only demonstrating bad prehospital care.

The same is true for bleeding control. Some medics will avoid controlling bleeding by direct pressure, which may keep the patient alive until arrival at the hospital. Instead the medic attempts to start an IV, which will not improve survival, while the patient bleeds out. There are plenty of medics who abandon BLS treatment, when becoming medics, because they do not understand patient care. This is part of what the research starting this thread shows.

There is no good reason for not providing good pain management to every patient who has significant pain, except one - the life threatening conditions are higher priority and may prevent the medic from providing pain management.

Fentanyl is much better than morphine, because it wears off quickly. The patient should not be in as much pain in the ED as in the ambulance - fewer bumps in the road, better padding (if not on a long spine board, another treatment without any research supporting it). For a patient hyperventilating, due to pain, respiratory depression is a good thing, but if it goes to the point of hypoventilation, the most effective treatment is not naloxone, but simply talking to the patient. A talking patient is a breathing patient.

If pain management interferes with assessment, what about all of the patients who have RSI prior to assessment? How does a patient become harder to assess, when the pain can be localized, rather than being screaming "all over" pain?

Proper pain management improves the physician's ability to assess the patient.

If a medic is delaying transport of a critical trauma patient, that medic is not providing good care. IVs do not save lives. Bleeding control saves lives. Tubes do not save lives - good airway management is more than just putting in a tube. Airway management saves lives. If a medic can't understand that, there are exciting jobs in the fast food industry that the "medic" should consider.

 

[roja]

There are many variables that need to be taken into account. Urban vs. suburban vs. rural environment, scope of practice in a given state, staffing configuration.

Yes there is evidence to suggest that intubation on trauma patients in an urban setting leads to greater mortality we do not have good data on suburban/rural environments. Also this is evaluating endotracheal intubation and not other airway techniques (ie LMA or combitube).

Additionally we need to consider the impact of the expanding number of ALS providers. With more providers in a given area each provider is performing few skills. With this in mind proficiency with these skills decreases which may lead to worse outcomes (delayed transport to perform skills, poorly performed skills etc).

DocB is right on the money with regards to applying EBM to EMS. Infact this is my interest area for research. In fact I'm working on a paper at the moment which I have to get back to.

FDGB

You raise an incredibly important point regarding environment. EBM definately needs to be applied to EMS. And applicability/enviornment are also key concepts in ebm.

I personally carry a very unpopular opinion in nyc which is that there should be almost no field intubations. In manhattan, where transport times are short, and conditions are horrid for intubation, there is rarely a time when a patient can't be bagged and brought into the ED in a very short amount of time. Now, in the boonies, that is another story...

 

[leviathan]

You raise an incredibly important point regarding environment. EBM definately needs to be applied to EMS. And applicability/enviornment are also key concepts in ebm.

I personally carry a very unpopular opinion in nyc which is that there should be almost no field intubations. In manhattan, where transport times are short, and conditions are horrid for intubation, there is rarely a time when a patient can't be bagged and brought into the ED in a very short amount of time. Now, in the boonies, that is another story...

Annnnnd of course, unfortunately, the boonies do not support a call volume that would facilitate the skill maintenance of ALS paramedics, even though the boonies are where ALS paramedics are needed the most. I'm very happy that the service I work for is heavily involved in research and uses EBM to direct our treatment guidelines. But enough of me tooting my employer's own horn. They do that enough in the media already.

 

[pseudoknot]

Annnnnd of course, unfortunately, the boonies do not support a call volume that would facilitate the skill maintenance of ALS paramedics, even though the boonies are where ALS paramedics are needed the most.

In theory, simulation could bridge this gap, but it's far too expensive right now.

 

[docB]

Annnnnd of course, unfortunately, the boonies do not support a call volume that would facilitate the skill maintenance of ALS paramedics, even though the boonies are where ALS paramedics are needed the most. I'm very happy that the service I work for is heavily involved in research and uses EBM to direct our treatment guidelines. But enough of me tooting my employer's own horn. They do that enough in the media already.

The old EMS paradox. It's interesting on how many of these issues we run into that.

All of this is impacted by the great EMS paradox (a favorite subject of mine). The rural agencies with long transport times that need the advanced skills and equipment the most are the ones who can't afford it. If you have to transport to a hospital an hour away you need intubation more than the medic who is five minutes away. However, as a rural medic you are less likley to get enough tubes on a regular basis to stay as sharp as your urban counterparts.

 

[Rogue Medic]

I do not believe it is too expensive to be doing a good job of simulation in "the boonies." Several departments can cooperate (I know that is almost impossible in EMS in some places) and purchase a good simulator.

There is no good reason to believe that simulator practice is not adequate to maintain airway skills.

However, in places where skills are infrequently used, it is essential for the medical director to be making sure that the medics are maintaining their skills. Not everybody needs a medic response. If the service is not willing to pay to maintain skills, they cannot afford ALS.

NYC? Where the largest part of transport can be the move to the ambulance? Where, with the lights and sirens on, if a car pulls out of the way for you, another cuts in front of you? Too short a transport for intubation?

NYC? Where some units average a code a day and the medics have much more intubation experience than the ED physicians? These are the people who should NOT be intubating? For critical trauma they should be managing the airway appropriately, which usually should be intubation en route. OTOH, if you are carrying a patient down a flight of stairs, the ability to manage the airway is severely compromised and intubation can be the best preparation for movement. There are plenty of multi-flight residences in neighborhoods where violence occasionally happens. Sometimes it is impractical to not spend time on scene to intubate.

There are many ways to manage an airway. Intubation is only one. Using the appropriate one for the patient and the setting should be the goal.

 

[docB]

If the service is not willing to pay to maintain skills, they cannot afford ALS.

Excellent point.

NYC? Where some units average a code a day and the medics have much more intubation experience than the ED physicians? These are the people who should NOT be intubating?

I think many medics underestimate the experience of EPs with intubations. Most of us tube more than you think and are pretty good at it. In my hospitals my group does all of the tubes in the whole house except for the OR. I've done 7 in one day, 3 in 40 minutes once and I average 2 per day.

OTOH, if you are carrying a patient down a flight of stairs, the ability to manage the airway is severely compromised and intubation can be the best preparation for movement. There are plenty of multi-flight residences in neighborhoods where violence occasionally happens. Sometimes it is impractical to not spend time on scene to intubate.

There are many ways to manage an airway. Intubation is only one. Using the appropriate one for the patient and the setting should be the goal.

The point about stairs and other complicated extrications is a good one. I can't think of a way to properly do a BLS airway on stairs or in a stokes.

 

[Rogue Medic]

I think many medics underestimate the experience of EPs with intubations. Most of us tube more than you think and are pretty good at it. In my hospitals my group does all of the tubes in the whole house except for the OR. I've done 7 in one day, 3 in 40 minutes once and I average 2 per day.

That is a lot more than I would have expected. I was not suggesting that the doctors are not good at intubating, but that for the medics in this busy system, that only sends medics to certain calls, the intubation experience level is impressive. At least that is the way it used to be run. I am not familiar with the current method of dispatch.

In Pennsylvania, Dr. Wang and Dr. Yealy did a study that showed that the average number of intubations in Pennsylvania per medic in 2002 was one intubation. The most intubations by a single medic was only 23. One of the problems is that EMS in Pennsylvania is run in a way that dilutes skills performed.

Dr. Wang and Dr. Yealy do not support use of simulators to develop or maintain skills. They actually oppose this as being unproven and not traditional. They suggest that OR practice is proven - apparently because it is traditional, they believe it has been proven to be effective. Yet, they are critical of the use of intubation by medics. I have been told they are very persuasive; I would prefer logical. Some people just don't understand research, airway management, or risk management.

With appropriate oversight the NYC medics should be some of the best at intubation. Probably not the people you want to discourage from managing the airway.

 

[roja]

As was pointed out earlier, the question is not the skill level of the medic.
In fact, I am pretty sure my point never once mentioned skill. The environments that EMS has to intubate in are horrid, and they are good. Its not about good.

And LMA is a grossly underused tool and in NYC often would work.

Again, I said it was unpopular, but outcome data, while not oustanding data, shows a trend that it might not be the best thing.

 

[Rogue Medic]

As was pointed out earlier, the question is not the skill level of the medic.

When it comes to discouraging medics from intubating, that is often one of the reasons given.

I apologize for misrepresenting your position.

I agree that the LMA is not used enough. The fears of aspiration have not been backed up by the prehospital LMA research. Airway management is about having enough tools available that you can use the right tool and the understanding to use them properly. Having too many tools, so that one might not maintain competence with all of the tools is a problem, too.

One of the potential problems with the LMA is that so few tubes are placed, that it becomes difficult to maintain intubation skill. OTOH, if the only tubes that are being placed are those where the LMA is not working, and presumably more difficult tubes, perhaps that will improve intubation skill and understanding of airway management.​

 

[roja]

When it comes to discouraging medics from intubating, that is often one of the reasons given.

I apologize for misrepresenting your position.

I agree that the LMA is not used enough. The fears of aspiration have not been backed up by the prehospital LMA research. Airway management is about having enough tools available that you can use the right tool and the understanding to use them properly. Having too many tools, so that one might not maintain competence with all of the tools is a problem, too.

One of the potential problems with the LMA is that so few tubes are placed, that it becomes difficult to maintain intubation skill. OTOH, if the only tubes that are being placed are those where the LMA is not working, and presumably more difficult tubes, perhaps that will improve intubation skill and understanding of airway management.​

Its okay. I think that its easy to see that. And maybe that is what the history of criticism is. However, I remember my EMS ride out where the paramedic was lying on the floor, over a patient with no suction (because that field suction is a joke) with family hovering trying to tube a patient. Its not easy.

Paramedics, with proper training and skill building, are very capable of intubation. *I* am capable of intubating in the field. The question is "under what conditions should I be intubating?" If I can put in an LMA scoop and run and get to a hospital in a really short amount of time, I should.

If transport is going to be long, then I probably need to.

Paramedic skill isn't necessarily the argument. Its appropriateness.

 

[Rogue Medic]

Paramedic skill isn't necessarily the argument. Its appropriateness.

Yes and no.

There are plenty of places where paramedic skill is inadequate. I see this as mainly the fault of medical direction being too lax in oversight. In these places skill is a big part of the argument.

I agree that, where the medics do have the skills to intubate well, we need to be focusing on the appropriateness of intubation. We should not be limiting the discussion of appropriateness to intubation. Intubation is not the only skill that is too often reflexively done to satisfy protocol or to avoid criticism/punishment from the QA/QI/CYA department, rather than because it is in the best interest of the patient.

 

[leviathan]

Yes and no.

There are plenty of places where paramedic skill is inadequate. I see this as mainly the fault of medical direction being too lax in oversight. In these places skill is a big part of the argument.

I agree that, where the medics do have the skills to intubate well, we need to be focusing on the appropriateness of intubation. We should not be limiting the discussion of appropriateness to intubation. Intubation is not the only skill that is too often reflexively done to satisfy protocol or to avoid criticism/punishment from the QA/QI/CYA department, rather than because it is in the best interest of the patient.

I think we've hit the main issue here. Right now it seems intubation is more of a "one size fits all" procedure where GCS<8=intubate. Some people could do without intubation where the benefit of rapid transport to hospital outweighs the risks of having an unsecured airway. An LMA is better than nothing, or a combitube, or even just an oro/nasopharyngeal airway and good head positioning.

I feel like we've beaten this topic to death though!

 

[Druggernaut]

Maybe somewhat off topic, but I'm curious as to how the EMS systems are set up elsewhere. In a city of about 600,000, where private ambulance services operate all the BLS ambulances, and the fire department has only ALS, it is a part of the city protocol that a FD paramedic unit has to be called on all encounters with a list of patient conditions (most of the severe or potentially severe ones), even if the ambulance that initially responded was a paramedic squad from a private service (who, coincidentally, are allowed to carry more medications than the FD by their medical director, and are barred from using those drugs if interfacing with a FD paramedic rig is required, meaning 911 calls on that list).

Almost all areas of the city have a hospital within 10 minutes driving non-emergent. I've been in the act of settling a patient on the cot when they went unresponsive, and then had to call the FD paramedics, wait several minutes, exchange information with them for several more minutes, and have them sit on scene for 15+ minutes in their squad with the patient before transporting hot. I've also seen on scene times inside an accessible apartment building greater than one hour by their paramedics, then transporting emergently to a hospital located under five minutes away.

I understand that I'm somewhat lucky to be able to run on a private service and take 911 calls since I was fresh out of EMT-B, but is this standard operating procedure for this kind of situation?

 

[pseudoknot]

Well, I don't agree with the way your system is set up. I think it would be more sound to have your FD respond to every call and go from there. That's how it works with the hybrid systems I've seen personally (LA County FD, various cities in the LA area). I'm not a big believer in tiered dispatch, although I guess it could work if your BLS providers were well trained and cared about their jobs, but that's not really the case in the private companies I've seen.

That being said, policy is policy and if your FD is the sole ALS provider, it makes sense that your paramedics wouldn't be allowed to act as paramedics on 911 calls.

I also do not agree with the lengthy onscene times especially if code 3 transport was required, as a general rule. However, I don't want to second guess someone else's decisions in the field when I have no idea what was happening on those calls. I think most in this thread would agree that having some ALS providers play on scene too long is a real problem, but thankfully the exception rather than the rule.

Maybe somewhat off topic, but I'm curious as to how the EMS systems are set up elsewhere. In a city of about 600,000, where private ambulance services operate all the BLS ambulances, and the fire department has only ALS, it is a part of the city protocol that a FD paramedic unit has to be called on all encounters with a list of patient conditions (most of the severe or potentially severe ones), even if the ambulance that initially responded was a paramedic squad from a private service (who, coincidentally, are allowed to carry more medications than the FD by their medical director, and are barred from using those drugs if interfacing with a FD paramedic rig is required, meaning 911 calls on that list).

Almost all areas of the city have a hospital within 10 minutes driving non-emergent. I've been in the act of settling a patient on the cot when they went unresponsive, and then had to call the FD paramedics, wait several minutes, exchange information with them for several more minutes, and have them sit on scene for 15+ minutes in their squad with the patient before transporting hot. I've also seen on scene times inside an accessible apartment building greater than one hour by their paramedics, then transporting emergently to a hospital located under five minutes away.

I understand that I'm somewhat lucky to be able to run on a private service and take 911 calls since I was fresh out of EMT-B, but is this standard operating procedure for this kind of situation?

 

[Rogue Medic]

Druggernaut,

Lights and sirens are generally not helpful in reducing transport time by much and do not make the truly sick patient feel any better.

The system you describe is one where patient care is not at all a priority.

Politics, not medicine, runs things. Often, when there is a limited drug list (not that there aren't drugs that should be taken off of ambulances), it is because the medical director automatically allows anyone hired to work as a paramedic. There is nothing nice to say about the way this affects the patients. How many patients is such a medical direct complicit in harming and killing? But they have a nice addition to their CV - "big city medical director." We need to have more than just a medical director's reputation on the line when they are "responsible" for the oversight of EMS.

There are many other problems in the system you describe. Why, if there are medics on scene, do more medics need to be called? Idiocy. This policy has nothing to do with what is best for the patient. Sounds as if it has been written by a union.

If the first medics are dangerous, get them off the street, don't make them tag team with other medics. If the second medics are dangerous, do not let them treat patients, either. If there are no competent medics, good BLS is much better than bad ALS. Somebody needs to see the inside of a prison for this incompetence.

 

[Druggernaut]

Just about every EMS provider here not riding the fire department gravy train recognizes that the policy is the fire union's way of ensuring that the city's paramedics don't get edged out. I take it that elsewhere it isn't this blatant.

But is it typical that even in systems with only the fire department running 911 calls that there is this kind of protocol forcing BLS to call for ALS even when transport time is equal to or less than ALS response time? Or are most systems not run in a tiered manner, and those that are will grant BLS some say in the decision to make that call?

 

[pseudoknot]

Just about every EMS provider here not riding the fire department gravy train recognizes that the policy is the fire union's way of ensuring that the city's paramedics don't get edged out. I take it that elsewhere it isn't this blatant.

Maybe, maybe not. I don't live in your city so I don't want to second guess you too much. Then again there are other, legitimate reasons to not trust private companies. After all, your company lets EMTs fresh out of school run 911 calls

But is it typical that even in systems with only the fire department running 911 calls that there is this kind of protocol forcing BLS to call for ALS even when transport time is equal to or less than ALS response time? Or are most systems not run in a tiered manner, and those that are will grant BLS some say in the decision to make that call?

I don't want to speak to "most systems" because things are so fragmented. The real issue here is that if you have a BLS crew, whether the patient was theirs to begin with or turned over by ALS, what happens if the patient deteriorates and requires ALS care? In my opinion the only acceptable answer is that it depends on the ETA to the hospital and the ETA of the nearest ALS unit. This is a decision that should be made by the crews in the field or dispatch, but to have a blanket policy that says you always have to wait for ALS even if the hospital is closer is very stupid, perhaps negligently so.

 

[docB]

I agree with the comments about the possibility of union and political influence of protocols. In the west many FDs wanted no part of EMS early on and it fell to privates. Once the privates started making money then the FDs wanted in and used their political leverage to force the privates into secondary roles with mixed results for quality.

 

[Rogue Medic]

Being fresh out of school and running 911 has nothing to do with being a private company. Do the fire departments, hospitals, volunteer, other EMS agencies, . . . only hire experienced medics or basic EMTs? Almost everybody puts new people on the street. How you deal with that is where the separation of quality comes in. This does not appear to be a system designed with any interest in quality.

Then again there are other, legitimate reasons to not trust private companies.

There are plenty of reasons to distrust any type of EMS organization. A private company works with a budget, tries to maximize what is done with the budget, and people are rewarded for meeting or exceeding budget predictions. Is there any type of organization where this is not the case?

If you think that somebody is going to be more virtuous because they work for the government, you must believe in fairy tales, because there are regularly stories of corruption from all areas of government. A bunch of volunteer managers are facing prison time in the area where I work. They embezzled from their different volunteer agencies. Making a statement that the type of ownership - private vs government vs volunteer - makes a difference in the quality of care is silly.

This appears to be an example of a fire department that is not interested in patient care, at least not until after dealing with their union politics. Just another form of corruption.

The people who run things are what make the difference. There are excellent people in private companies and there are excellent people who work for the government. Of course, the ultimate responsibility should fall on the medical director. The medical professional who decides to go along with whatever dangerous practices government EMS or private EMS or volunteer EMS come up with.

Good EMS depends on excellent medical oversight. Someone who will not hesitate to oppose those endangering patients.

 

[pseudoknot]

I admit that I'm biased by my personal experiences. The private companies I've seen were interested only in money even at the expense of patient care, and the fire departments were generally the opposite. I understand this isn't universally the case.

Also, medical directors don't necessarily have all the power, even if perhaps they should.

 

[Rogue Medic]

Also, medical directors don't necessarily have all the power, even if perhaps they should.

That is the fault of the medical directors. There is no coordination among doctors to improve quality of care in many places. Even county EMS medical boards seem to be more about not making waves, than about improving care.

If presented with a fire department that insists that everyone on the engine has a medic card, the medical director needs to say no. There is no justification for such a ridiculous plan to dilute skills to the point where it is difficult for anyone, even in a big city, to maintain competence. The private companies that have a contract with the ambulance company and insist that all of their medics be signed off is also a problem. The volunteers who do not run enough calls to maintain competence are another problem.

None of them are able to work without a signature from the medical director. The medical director needs to act as if medical school provided some education and the Hippocratic Oath is not just something they use when it pleases them. Medical directors allow this bad care to happen. If they don't like the way things are run they can leave, they can go to the press, they can talk to all of the other emergency physicians who might be used to replace them. They have graduated from high school and have a bit of a clue, so why not use it?

 

[xavier2000]

It was my general impression that ALS had no overall clinical benefit to trauma patients. Not that a chest decompression isn't appreciated after a T-bone - but I thought that it was fairly common knowledge that the figures did not show positive outcomes in general.

 

[Rogue Medic]

Even chest decompression is not something that is likely to be needed. All of my tension pneumothoraces were transported without a needle in the chest, did not destabilize en route, and received liberal doses of pain medicine during transport. No complaints from the trauma surgeons. They didn't use a needle either, but a chest tube. The only time to needle decompress is when the patient is losing vital signs due to mediastinal shift. Until that point, you are only making things worse.

Trauma is best handled by BLS. They are less likely to delay on scene to do unimportant stuff, tube, IV, . . . . The most important ALS intervention for trauma is pain management, but that should not delay transport of critical trauma. All other trauma, stay on scene until the fentanyl makes patient movement tolerable.

 

[docB]

That is the fault of the medical directors. There is no coordination among doctors to improve quality of care in many places. Even county EMS medical boards seem to be more about not making waves, than about improving care.

If presented with a fire department that insists that everyone on the engine has a medic card, the medical director needs to say no. There is no justification for such a ridiculous plan to dilute skills to the point where it is difficult for anyone, even in a big city, to maintain competence.

Actually a system or agency medical director doesn't have the ability to prevent a department from doing something like demanding all of their FFs be paramedics. He can advise against it but he can't set department personnel policy. He is responsible for the quality of care delivered but trying to extrapolate that into arguing that he should be able to determine how many medics should be in a given dept.

None of them are able to work without a signature from the medical director. The medical director needs to act as if medical school provided some education and the Hippocratic Oath is not just something they use when it pleases them. Medical directors allow this bad care to happen. If they don't like the way things are run they can leave, they can go to the press, they can talk to all of the other emergency physicians who might be used to replace them. They have graduated from high school and have a bit of a clue, so why not use it?

So if he does this, quits, bad mouths the dept to his replacement and the press what will he really have accomplished. You've got to pick your battles.

 

[Rogue Medic]

Actually a system or agency medical director doesn't have the ability to prevent a department from doing something like demanding all of their FFs be paramedics. He can advise against it but he can't set department personnel policy. He is responsible for the quality of care delivered but trying to extrapolate that into arguing that he should be able to determine how many medics should be in a given dept.

While the doctor does not sign off on every policy the doctor can insist that things be changed if the department wants to continue with the same medical director. If the doctor is not capable of persuading people about good patient care, perhaps the doctor is in the wrong field.

So if he does this, quits, bad mouths the dept to his replacement and the press what will he really have accomplished. You've got to pick your battles.

What battles?

You encourage doing what?

If the service is engaging in dangerous behavior, why would the doctor considered to be an innocent bystander?

We have too many doctors endorsing, but not overseeing EMS. Why are doctors not considered responsible for their actions?

Of course, if the doctors don't change things, the lawyers might. That will probably be even worse.

 

[docB]

While the doctor does not sign off on every policy the doctor can insist that things be changed if the department wants to continue with the same medical director. If the doctor is not capable of persuading people about good patient care, perhaps the doctor is in the wrong field.

What battles?

You encourage doing what?

If the service is engaging in dangerous behavior, why would the doctor considered to be an innocent bystander?

We have too many doctors endorsing, but not overseeing EMS. Why are doctors not considered responsible for their actions?

Of course, if the doctors don't change things, the lawyers might. That will probably be even worse.

You've noted several times that the medical director can threaten to quit. That's true but when the department is undertaking a policy for political or economic reasons they'll cut a med director loose pretty quick. They'll find somebody who is a rubber stamp for everything.

What I mean about picking battles is that for a director to quit over something that is not clearly a bad idea, like having more medics in an agency, is just going to result in the guy who knows the issues being out and a guy who just does as he's told being the director.

You know that medics can quit over what they consider dangerous conditions too.

 

[Rogue Medic]

"If I don't do it somebody else will," is used by street corner drug dealers and other entrepreneurs of the criminal variety. Adding the comment "the person who replaces me will not do as good a job," is only relevant if such a person does replace you.

Why is it that it is considered acceptable for medical directors to oversee bad care?

It is the medical director's job to "direct" care, to protect the patients from bad care.

Yes, medics can quit, also. I have left jobs that were dangerous. A medic leaving is less likely to influence policy, but staying is only endorsing the policies of the department. Of course, the medic is not endorsing policies to the same extent the medical director is.

If there are bad medics in the department, that is the fault of the medical director who allows this to happen.

Maybe we really do need the lawyers to point this out to medical directors with criminal charges. When a medic kills a patient by doing, or omitting, something that the medical director should have known about, the plausible deniability defense should be treated with the ridicule it deserves.

But if that happens we won't be able to get anyone to work as medical directors.

No. You won't be able to get medical directors to provide non-existent oversight. The Sarbanes-Oxley Act is far from a good law, but it has made it so that members of the board of directors of companies are responsible for their actions. If we do this for doctors, that should be an improvement.

And how is having bad ALS better than just having BLS?

Or doctors could reform their own behavior and work to get rid of their own dangerous people.

Nah! Better to just ignore it and claim it is not a problem.

 

[pseudoknot]

I really don't think that our EMS system is so bad that all this scorched earth rhetoric is appropriate, but to each his own. Medical directors already assume civil liability, which is sufficient.

 

[Rogue Medic]

I've worked in a few states. Each granted immunity from civil liability.

Of course, when you give someone the tools they use to kill someone, do not provide appropriate oversight, and as will happen when you do this - the person you provided with the tools (that they would not have been able to use without your authorization) uses the tools to kill someone.

We should look at the medical director not for civil liability, but for criminal liability.

Look at the story of unrecognized esophageal tubes in Texas. High-risk EMS procedure gets a low level of oversight.

Where is the oversight?

How does the medical director not know that the medics and nurses are not checking tube placement?

This is not competent oversight.

 

[pseudoknot]

We should look at the medical director not for civil liability, but for criminal liability.

Look at the story of unrecognized esophageal tubes in Texas. High-risk EMS procedure gets a low level of oversight.

You want EMS medical directors to be subject to more severe penalties based on the actions of field personnel than they would be if they themselves committed malpractice?! OK, whatever dude.

The Texas article placed the blame more on the system itself than the individual medical directors. I certainly think medical directors should be involved but it's not their responsibility to fix everything at every level.

 

[docB]

When this tangential discussion arose we were talking about your assertion that a medical director was ultimately to blame for a policy of requiring a large number of firefighters to become paramedics. You argued that this was a bad policy because it lead to dilution of experience, for example, by cutting the number of tubes available per medic.

That is the fault of the medical directors. There is no coordination among doctors to improve quality of care in many places. Even county EMS medical boards seem to be more about not making waves, than about improving care.

If presented with a fire department that insists that everyone on the engine has a medic card, the medical director needs to say no. There is no justification for such a ridiculous plan to dilute skills to the point where it is difficult for anyone, even in a big city, to maintain competence. The private companies that have a contract with the ambulance company and insist that all of their medics be signed off is also a problem. The volunteers who do not run enough calls to maintain competence are another problem.

None of them are able to work without a signature from the medical director. The medical director needs to act as if medical school provided some education and the Hippocratic Oath is not just something they use when it pleases them. Medical directors allow this bad care to happen. If they don't like the way things are run they can leave, they can go to the press, they can talk to all of the other emergency physicians who might be used to replace them. They have graduated from high school and have a bit of a clue, so why not use it?

I think you have a point about the dilution of experience but that this policy of more medics is clearly bad care is debatable. One could argue back that more medics means more people will have access to a medic when they need one and that that’s good for the community. One could also argue that any dilution in the experiences could be addressed by training, simulation, CEUs, etc. My point is that this policy does not necessarily equate to bad care and I wouldn’t quit as a medical director to oppose it. That was what I meant by my comments about the limited power of medical directors and picking one’s battles.

In subsequent posts you seem to have concluded that since I disagree with your assessment of this policy equating to bad care and your assertion that the medical director should resign over it that I am therefore arguing in favor of bad care. That’s a big stretch. The comparison to a drug dealer is a little extreme as well.

"If I don't do it somebody else will," is used by street corner drug dealers and other entrepreneurs of the criminal variety. Adding the comment "the person who replaces me will not do as good a job," is only relevant if such a person does replace you.

Why is it that it is considered acceptable for medical directors to oversee bad care?

It is the medical director's job to "direct" care, to protect the patients from bad care.

Yes, medics can quit, also. I have left jobs that were dangerous. A medic leaving is less likely to influence policy, but staying is only endorsing the policies of the department. Of course, the medic is not endorsing policies to the same extent the medical director is.

If there are bad medics in the department, that is the fault of the medical director who allows this to happen.

Maybe we really do need the lawyers to point this out to medical directors with criminal charges. When a medic kills a patient by doing, or omitting, something that the medical director should have known about, the plausible deniability defense should be treated with the ridicule it deserves.

But if that happens we won't be able to get anyone to work as medical directors. No. You won't be able to get medical directors to provide non-existent oversight. The Sarbanes-Oxley Act is far from a good law, but it has made it so that members of the board of directors of companies are responsible for their actions. If we do this for doctors, that should be an improvement.

And how is having bad ALS better than just having BLS?

Or doctors could reform their own behavior and work to get rid of their own dangerous people.

Nah! Better to just ignore it and claim it is not a problem.

If you are concerned that your medical director is incompetent or that medical directors as a group are incompetent you can work to “fix” that problem. You can resign and/or go to the press with your claims as you stated earlier. You can complain to your licensing agency about your director and your colleagues who you feel are dangerous. I fear your assertion that your director should quit over a policy you oppose but that he probably supports will just lead to frustration.

I've worked in a few states. Each granted immunity from civil liability.

Of course, when you give someone the tools they use to kill someone, do not provide appropriate oversight, and as will happen when you do this - the person you provided with the tools (that they would not have been able to use without your authorization) uses the tools to kill someone.

We should look at the medical director not for civil liability, but for criminal liability.

Look at the story of unrecognized esophageal tubes in Texas. High-risk EMS procedure gets a low level of oversight.

Where is the oversight?

How does the medical director not know that the medics and nurses are not checking tube placement?

This is not competent oversight.

This is quite extreme. Aside from the issues of making a particular person more personally liable than anyone else in any industry this would have the effect of causing an immediate and unfillable vacancy in every medical directorship in the country. I can’t think of any policy that would get us back to the days of ambulance drivers faster than criminalizing EMS medical directorship.

It’s important to remember that medical directors are administrators in a system. We have pride in what we do and the systems we run. But we can not be hot headed about things. The systems will never be perfect, there will always be problem children and compromise will always be required. There is no way to run a successful and safe system while holding grudges, being totally inflexible and quitting over every disagreement.