freaking paragods

[fiznat]

Argh, I just finished a really frustrating shift with an extremely cocky and abrasive paramedic. You guys must know the type, the people who insist on using unnecessary medical terminology in their daily conversations and hospital patches, refuse to involve their EMT in the care of the patient (checking out the truck today I was told "I dont want you or any EMT touching my ALS bag" even though it has BLS stuff in it as well), and have that general high and mighty attitude all day. On scene instead of having me do his 3-lead, setting up the IV stuff, checking sugar, etc like I normally do- I was instructed to go sit in the drivers seat and wait for him to do his "workup." 15 minutes we sit on scene while I wait for him to do everything by himself (transport to ED was less than 5 mins).

I cant stand these people. What is it about the paramedic license that turns so many people this way? It blows my mind how cocky so many of them are: arguing with docs and nurses, brushing off the EMTs, refusing to do scut work... I dealt with it by pretty much not talking with him, and refusing to do any of the extra helpful stuff I do for my more personable partners, but jeez- it was still a painful 8 hours.

You guys have experiences with people like this? How do you deal with it, and whats your take on where the attitude comes from?

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[southerndoc]

I prefer teamwork.

Sorry you had a bad experience. Hopefully this wasn't a New Haven paramedic. If so, PM me with his/her name.

 

[greytmedic]

I operate under the theory that paramedics save lives and EMT's save paramedics. Whoever your partner is needs a serious reminder about teamwork and communication. There is no way that one paramedic can provide proper care and treatment without relying on the ability and skills of their partner, whether they are another paramedic or an EMT. You have two options next time you work with that paramedic. One, act professionally and carry out your duties to the best of your abilities, or the more fun route and make the next shift the most frustrating shift ever without endangering any patients.

 

[Jambi]

Wow...I hope that person learns teamwork. Tell that medic his ALS equipment is nice and all but how will it help get the gurney back into the ambulance? I would refuse to work with that person again/gone home sick that day and told the supervisor about it.

I'll always give a person the benefit of the doubt but sometimes people manage to put their foot in their mouth while digging a hole and jumping in it all in one sentence.

BTW, I've refused to work with one person one time in six years. This person would literaly have tantrums and throw stuff. I actually stopped the ambulance, got out, called the supervisor, and waited for a ride. of course there was no patient. Imagine a taller Eric Cartmen. Same voice too.

 

[fiznat]

Hopefully this wasn't a New Haven paramedic. If so, PM me with his/her name.

No no, it was AMR but not New Haven. I work up here in Hartford. Thanks though .

 

[OSUdoc08]

Argh, I just finished a really frustrating shift with an extremely cocky and abrasive paramedic. You guys must know the type, the people who insist on using unnecessary medical terminology in their daily conversations and hospital patches, refuse to involve their EMT in the care of the patient (checking out the truck today I was told "I dont want you or any EMT touching my ALS bag" even though it has BLS stuff in it as well), and have that general high and mighty attitude all day. On scene instead of having me do his 3-lead, setting up the IV stuff, checking sugar, etc like I normally do- I was instructed to go sit in the drivers seat and wait for him to do his "workup." 15 minutes we sit on scene while I wait for him to do everything by himself (transport to ED was less than 5 mins).

I cant stand these people. What is it about the paramedic license that turns so many people this way? It blows my mind how cocky so many of them are: arguing with docs and nurses, brushing off the EMTs, refusing to do scut work... I dealt with it by pretty much not talking with him, and refusing to do any of the extra helpful stuff I do for my more personable partners, but jeez- it was still a painful 8 hours.

You guys have experiences with people like this? How do you deal with it, and whats your take on where the attitude comes from?

Some EMT's are incompetent and are basically just ambulance drivers. This is probably the partner he previously had, and he is cautious.

 

[12R34Y]

Some EMT's are incompetent and are basically just ambulance drivers. This is probably the partner he previously had, and he is cautious.

This may be the case.......however, being cautious doesn't require one to act like a jackrod. Sounds like a miserable human. They're everywhere unfortunatetly and in every field of work.

good luck with you next partner.

later

 

[12R34Y]

This may be the case.......however, being cautious doesn't require one to act like a jackrod. Sounds like a miserable human. They're everywhere unfortunatetly and in every field of work.

good luck with you next partner.

later

Oh, and I absolutely love the word "paragod". It can be so true at times with many medics. I use to be one. Not proud of it, but I thought I was "da bomb" back in the day.

Then I went to medical school....found out how stupid I was and immediately became humbled.

I prefer humble definately.

happens to the best of us. ha ha.

later

 

[DropkickMurphy]

I never developed the "IntermediGod" syndrome (The EMT-I service's version of Paragod syndrome), because I worked under a medical director who would not allow it. He very quickly would put back into check the ego of anyone whose head got too big for their own good (or that of their patients and coworkers). I like to think I'm the consumate professional health care provider I am today because of him.

 

[captaindargo]

I meet a lot of "paramessiahs" who like to call doctors educated idiots So I'm not sure is any doctor can stop them from believe how great they are.

 

[DropkickMurphy]

Except the one who has their license/certification pulled. Our medical director did this to one particular medic that I know of....talk about a kick in the nuts to an oversized ego...

 

[QuikClot]

I meet a lot of "paramessiahs" who like to call doctors educated idiots So I'm not sure is any doctor can stop them from believe how great they are.

Some doctors are educated idiots. And we're all idiots when we venture outside the realms of our own knowledge and experience . . . something that doctors often forget when dealing with EMS, especially under field conditions.

I have a theory as to why medics act like this (it's inexcusable and stupid, obviously). It's the same reason chess' International Masters treat chess fans like dirt; you have a talent, you turn it into a skill, but your institutional recognition is nil; bad money, bad job security, low public profile. People go nuts with this dichotomy, and they take it out on people lower on the totem pole. In my only limited experience, a little recognition can swell a person's ego, but a lack of recognition can turn people into screaming dinguses with great reliability.

My partner is like that. How many times have I had to listen to her describe how she was the first women in Oregon to graduate with Fire Science degree? How many times have I bit back a scream of frustration when an unstable patient's transport was delayed while she lectured their family on what she thought was wrong? About as many time as I have had to remind her that she isn't my boss and doesn't get to give me orders.

Then you can look at it on the flip side. She's been a medic 18 years, EMS for 26. She's been sexually harassed multiple times. She has a fair case of PTSD working. Her knees, back, shoulders, and eyes are shot. For that, she has peaked out at 55k, and she will never get another raise except that our hapless union stumbles into one.

At the bottom of the paragod phenomenon are frustrated people desperately seeking validation in the worst, most counterproductive way possible.

That, and of course some people are just ****ing tools.

 

[canjosh]

Some doctors are educated idiots. And we're all idiots when we venture outside the realms of our own knowledge and experience . . . something that doctors often forget when dealing with EMS, especially under field conditions.

I have a theory as to why medics act like this (it's inexcusable and stupid, obviously). It's the same reason chess' International Masters treat chess fans like dirt; you have a talent, you turn it into a skill, but your institutional recognition is nil; bad money, bad job security, low public profile. People go nuts with this dichotomy, and they take it out on people lower on the totem pole. In my only limited experience, a little recognition can swell a person's ego, but a lack of recognition can turn people into screaming dinguses with great reliability.

My partner is like that. How many times have I had to listen to her describe how she was the first women in Oregon to graduate with Fire Science degree? How many times have I bit back a scream of frustration when an unstable patient's transport was delayed while she lectured their family on what she thought was wrong? About as many time as I have had to remind her that she isn't my boss and doesn't get to give me orders.

Then you can look at it on the flip side. She's been a medic 18 years, EMS for 26. She's been sexually harassed multiple times. She has a fair case of PTSD working. Her knees, back, shoulders, and eyes are shot. For that, she has peaked out at 55k, and she will never get another raise except that our hapless union stumbles into one.

At the bottom of the paragod phenomenon are frustrated people desperately seeking validation in the worst, most counterproductive way possible.

That, and of course some people are just ****ing tools.

I think Farrell hit the 'ole nail on the head. I see a lot of problems arise from the way that the nursing profession elevates itself 'above' EMS providers. Nurses have no business telling medics how to do their job, and vice versa. This can often create a defensive and cocky attitude in the paramedic, which further worsens the friction. The paramedic sometimes picks up on this attitude and passes it right on down the line to his/her partner.
Case in point...I saw a job posting for an EMS educator at a local hospital. Requirements? BS or MS in nursing, XX years ED nursing, CEN certification, EMT-P certificate, etc. In TX (where I live), nurses can 'challenge' the EMT-P and get their certificate without going to paramedic school. So basically this hospital wants a nurse to 'educate' the paramedics, when the nurse probably hasn't worked a single day in the field. I resent the lack of respect/understanding, and this can brew a negative attitude about one's job.

 

[viostorm]

That is a horrible work situation. I'm going to give the what I consider the *mature* advice. The advice I rarely want to hear, and I almost never seem to follow.

Be quiet, be helpful. Try and find a way to make the relationship mutually beneficial. You are getting something positive out of it, he is getting something positive out of it. Don't talk bad about him. I know that is hard, especially at the end of the shift when you are tired. Be part of the solution, not part of the problem.

You get in a pissing contest you only end up smelling like piss.

I promise you, if he is as bad as you say, everyone knows about him and he is a joke among the other paramedics, his supervisors, and certainly the EMT's. He is a joke on the internet now too!!!!

There are some paramedics like this, but in my experience most of them are new or stupid. You really have not been doing it long enough if you think you can save the world on your own. If you have been doing it a long time, and you still think you can save the world on your own ... you are stupid.

In fact, most of the research shows that BLS care produces better outcomes then ALS. This surprising result is something that the EMS community is currently struggling with.

Your situation with EMT's/Paramedics is not unique, there are physicians that behave badly with nurses (surgeons are notorious for this), physicians treating physicians badly, nurses treating paramedics badly, EMT's treating nursing home staff badly. The longer you are in medicine, you will realize that your situation is repeated over and over again every day and night in the medical field. Learn to deal with it now because it will only get worse the more you progress in your career and more education/responsibiility you have!

 

[sanford_w/o_son]

I think Farrell hit the 'ole nail on the head. I see a lot of problems arise from the way that the nursing profession elevates itself 'above' EMS providers. Nurses have no business telling medics how to do their job, and vice versa. This can often create a defensive and cocky attitude in the paramedic, which further worsens the friction. The paramedic sometimes picks up on this attitude and passes it right on down the line to his/her partner.
Case in point...I saw a job posting for an EMS educator at a local hospital. Requirements? BS or MS in nursing, XX years ED nursing, CEN certification, EMT-P certificate, etc. In TX (where I live), nurses can 'challenge' the EMT-P and get their certificate without going to paramedic school. So basically this hospital wants a nurse to 'educate' the paramedics, when the nurse probably hasn't worked a single day in the field. I resent the lack of respect/understanding, and this can brew a negative attitude about one's job.

the general lack of respect for ems is a big factor. but there should be more to this particular story than the attitude just being passed down to emts.

not only is there disrespect toward ems in general, but most folks (and many in health care) don't know the difference between an emt and medic within ems. so i think it's an understandable tendency for the status-conscious medic to want to enforce a distinction between their work and that of their emt partner. by forbidding the emt to engage in qualified bls medical work, this medic was defining their partner's work as patient lifting and ambulance driving and their own work as life-saving, solo-practice, medical work. if good stuff happens, it's only because of the medic. any situation will turn out better than it otherwise would have, because there's no lowly emt mucking things up. in the face of widespread disrespect, this helps validate the medic as a true medical professional, and the medic can maybe even explain any general disrespect as being due to people seeing emts do bad things and not knowing the difference between them and medics. if only people would know the difference, and then recognize medics in action (saving lives) apart from emts in action (driving rigs), then the medics would get the godly respect they deserve.

so it's not so much medics passing down the attitude they get from nurses/doctors, but reacting to that attitude by trying to set themselves apart from emts with the hope that once they're recognized as the true medical professionals of ems they will get the respect they deserve.

this is just a theory. i say that the medic's actions are understandable in this regard, but i don't think they are in any way warranted. i am very thankful to have so far worked with medics who want me to be involved in pt care and are patient enough to teach me. at the same time, i think medics do get less respect to some extent due to the existence of emts, and i hope that with time people in healthcare at least will better understand the difference in training between them and give medics their props.

 

[sanford_w/o_son]

. . . EMT's treating nursing home staff badly . . .

ouch! i don't do this, but i do sometimes talk smack behind their backs.

i do feel guilty sometimes for "grilling" nursing home staff on pt history and the nature of the condition. they often get defensive, as if i'm passing judgment on the quality of their care. really, i'm just trying to get all the info i think the ed staff will need. having volunteered in an ed, i've heard ed staff too many times say about a low loc pt's medical info "we don't know--ems brought them."

 

[DocNusum]

Originally Posted by viostorm
. . . EMT's treating nursing home staff badly . . .

Sometimes... I work as a Nursing Supervisor in a SNF...
One day... I called EMS for emergent transport of a non-responsive, usually talkative, coherent, engaged 50 yr old patient...

Maybe the guys were having a bad day but...

They walked into the SNF and immediately started with the "Para-God" $hittt!
I was in the patients room assessing the patient doing interventions and when I came out to ascertain the Medics ETA... they were at the desk challenging the nurses (LPNs). I walked up... introduced myself as the nursing supervisor and escorted them to the patients room while I gave them a thorough report. I went back to the desk to get the paperwork in order (about 50 yards away).

By the time I got to the desk... one of the medics comes out of the room to the desk and says something to imply that WE nurses were "wasting" their time and that THEY had assessed the patient and didn't see a reason why WE called them!!!

It was incredulous!!!!

First I calmly explained the patients baseline LOC...
Then I pulled out my wallet and placed EVERY card I had in it on the counter and questioned why the medics would challenge a/multiple nurses that have been caring for this patient FOR YEARS... when the nurse says the patient "ain't right"!

By this time... as my voice got louder... the partner came out... heard what I was saying... saw the EMT-I, RN, FNP, PA-C, ACLS, etc cards... and only then acted appropriately!

DocNusum, FNP, PA-C

Btw... I called their medical director at home... while they were "in transport" (he is a racketball buddy of mine and we worked together regularly... me as a PA-C and Him as a EMMD)

 

[southerndoc]

You are an RN, a nurse practitioner, and a PA? What does PA add that the nurse practitioner doesn't provide? (I'm asking out of ignorance here. I know some states differ, but I couldn't see a need for going to both schools.)

 

[viostorm]

They walked into the SNF and immediately started with the "Para-God" $hittt!
I was in the patients room assessing the patient doing interventions and when I came out

I hate it when medics do this. I see this happen all the time .... there is no excuse for it.

I guess what I was saying in my previous post is it would be 'be nice' ... medicine would be a lot more fun for all of us. We all have bad days, we all get really tired, but it still is no excuse.

Just poking fun ... they really backed off when you showed them ACLS?

 

[deleted6669]

You are an RN, a nurse practitioner, and a PA? What does PA add that the nurse practitioner doesn't provide? (I'm asking out of ignorance here. I know some states differ, but I couldn't see a need for going to both schools.)

he went to stanford, one of 2 dual pa/np training programs, not 2 separate schools. the other dual program is uc davis.
if one is an rn this is probably the way to go for midlevel training as you get the best of both worlds.

 

[southerndoc]

he went to stanford, one of 2 dual pa/np training programs, not 2 separate schools. the other dual program is uc davis.
if one is an rn this is probably the way to go for midlevel training as you get the best of both worlds.

Interesting. What is the benefit of being dual certified?

 

[deleted6669]

Interesting. What is the benefit of being dual certified?

Some states have legislation which favors pa's and some have legislation that favors np's. some jobs are posted pa only, some are posted np only. a dually certified individual can apply for jobs that best fit in a given situation or work in both pa and np jobs at different places at the same time.

 

[DocNusum]

Interesting. What is the benefit of being dual certified?

Professional Latitude...!!!!!!

 

[DropkickMurphy]

I try to be respectful to nursing home RN's but a lot of them (at least around here) are at SNF's (using the acronym's definition very losely) because they are far too incompetent to be trusted anywhere else. Actually most of them need to be removed from the field, but that's another issue. At a couple of facilities, we are shocked to find a nurse who can explain anything about what's going on with the patient. I'd be thrilled to work around professional RN's at long term care facilities.....

 

[tlls13]

In fact, most of the research shows that BLS care produces better outcomes then ALS. This surprising result is something that the EMS community is currently struggling with.

Can you please provide examples of some of these studies? I am curious to see them. Thank you.

 

[OSUdoc08]

Can you please provide examples of some of these studies? I am curious to see them. Thank you.

ALS care often delays transport time, since some procedures are done on scene. I've also heard of some studies that show trauma patients have improved outcomes without IV access.

 

[Siggy]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9660286&dopt=Abstract

Advanced life support vs basic life support field care: an outcome study.

Eisen JS, Dubinsky I.

Queen's University Faculty of Medicine, Kingston, Ontario, Canada.

OBJECTIVE: To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. METHODS: A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS. RESULTS: The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. CONCLUSIONS: There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center.

http://www.merginet.com/index.cfm?pg=trauma&fn=OPALSALSvalue (Article citing 2 seperate studies based off of trauma patients)

Study 1 conclusion

Their findings revealed a shorter on scene time during the BLS phase compared with the ALS phase (a median of 15 vs. 17 minutes) but no differences in overall patient survival (82.1 percent during BLS and 81.1 percent during ALS phases) or in functional independence among discharged patients.

Study 2 conclusion

The 216 BLS-treated and 185 ALS-treated patients had similar overall rates of survival—54.4 and 54.8 percent, respectively. But some subgroups of patients fared better with ALS care....However, assessments of functional independence among the nearly 55 percent of patients who survived to discharge revealed no significant between group differences. Investigators also report no between group differences in functional independence at six months after hospital discharge.

One last one...

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=10159729&dopt=Citation

Does the level of prehospital care influence the outcome of patients with altered levels of consciousness?

Adams J, Aldag G, Wolford R.

University of Illinois College of Medicine at Peoria, USA.

HYPOTHESIS: Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers. METHODS: Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included; trauma, intoxication, drowning, shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records. RESULTS: Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the "alert, verbal, painful, unresponsive" scale (ALS vs BLS) were: "verbal" (40% vs 51%), "painful" (23% vs 23%), and "unresponsive" (37% vs 25%). The mean value for some time was 15 +/- 6 minutes for ALS versus 10 +/- 4 minutes for BLS (p < 0.001). On arrival in the emergency department, the LOC of 72 (64%) ALS patients and 58 (64%) BLS patients had improved to "alert." The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principal final diagnoses were seizure (27% ALS vs 38% BLS), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS providers had significantly shorter emergency department treatment times than did those transported by BLS providers (160 +/- 62 minutes ALS vs 229 +/- 67 minutes BLS [p < 0.005]). CONCLUSION: Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients.

Disclamer, I just grabed the first few studies that I found off of a google and google scholar search.

 

[tlls13]

Thank you for the heads-up on google scholar, I had never heard of it before and now have found lots of articles.

It is interesting to consider the differences between urban vs rural providers; there was negligible difference for trauma pts. in urban settings for ALS vs. BLS care. ALS aid would really help for the long transports of pts., especially trauma pts., in the rural setting. Also, for the cardiac arrest subset of pts., initiating ACLS protocols as soon as possible would be incredibly beneficial.


To the OP: Sorry for hijacking your thread.

I work as an EMT-B and have dealt with my share of paragods and difficult personalities, but I recognize the value of having dedicated and intelligent paramedics out in the field. In my county, we have a private ALS ambulance provider and some public ALS fire engines, depending on the city. Having two paramedics on scene is great for pt. care but, since they don't work together, there is the great potential for conflict or, as I like to think of it, "A Clash of the Paragods".

 

[viostorm]

ALS aid would really help for the long transports of pts., especially trauma pts., in the rural setting. Also, for the cardiac arrest subset of pts., initiating ACLS protocols as soon as possible would be incredibly beneficial.

I'd have to disagree with both your choices for which patients benefit from rural ALS.

1) One of the most well researched areas is "trauma patients" for prehospital ems. I can tell you in my old system which was a mix of rural/suburban the resucitation rate for trauma patients in cardiac arrest was around 0.04%. What that suggests and anecdotally I can confirm is that trauma patients who are dead, usually stay dead regardless of interventions.

The stuff that really makes a difference in trauma patients: immobilization, rapid transport are both BLS skills.

If you look at the ALS skills for trauma patients:

* Intubation: multiple studies suggest paramedic intubation increases mortality in trauma patients Just enter "paramedic intubation" into http://www.pubmed.org/ and there are plenty of results.

* Fluid resuscitation: My knowledge of the literature is more limited here, but what all trauma care for patients that are bleeding/hypovolemic comes down to is quick surgical intervention. Neither normal saline nor ringers lactate provide an oxygen carrying mechanism anywhere near as effective as blood/hemoglobin. There are new trial products like "polyheme" and other blood substitutes under trial (Denver paramedics, Richmond Ambulance) that may change this. Either way, without an effective blood substitute, the rural trauma patient will still bleed out regardless of ALS interventions.

* Needle decompression: arguably a valuable intervention at the right time for the right patient. But with all outcome based evidence you have to ask how many patients will receive chest darts unecessarily and end up having worse outcomes (pneumonia, infection) because the procedure was available versus how many will be saved

* Cricothyrotomy: Very little outcome based evidence available ... the skill is used so infrequently it is almost impossible to expect any paramedic to stay proficient in it. With all procedures, I have seen patients severe complications with cric's including a paramedic/nurse flight team cutting internal jugular vein.

* Pericardial centesis: I have seen it work once to restore a pulse, although outcome was still the same ... patient died. A flightweb discussion a while back suggested it really isn't useful even in the aeromedical environment because of the few patients that will benefit and usually they are dead from other reasons anyway.

2) ACLS Care in caridac arrest - My impression of the current thought is that survival rate is dependent on basically 1 thing: quick defibrillation ... a BLS skill. There are obvious non-vfib cardiac arrests and other factors.

In my opinion that would be useful to have in rural ALS: allergic reaction, maybe hypoglycemia, asthma

 

[leviathan]

2) ACLS Care in caridac arrest - My impression of the current thought is that survival rate is dependent on basically 1 thing: quick defibrillation ... a BLS skill. There are obvious non-vfib cardiac arrests and other factors.

In my opinion that would be useful to have in rural ALS: allergic reaction, maybe hypoglycemia, asthma

I agree. There have been numerous studies in ACLS that show the only intervention which increases the chances of patient hospital discharge is defibrillation. ACLS drugs may increase the chance of conversion to NSR, but neither intubation, IV fluids, or drugs have been shown to increase the number of hospital discharges.

 

[OSUdoc08]

I agree. There have been numerous studies in ACLS that show the only intervention which increases the chances of patient hospital discharge is defibrillation. ACLS drugs may increase the chance of conversion to NSR, but neither intubation, IV fluids, or drugs have been shown to increase the number of hospital discharges.

The only thing that confuses me about this is why is there such a "rush" to intubate and establish IV's in such patients in the ER if timing is not an issue?

An example is a patient with a 30 minute transport time vs. a 5 minute transport time.

The patient with a 5 minute transport time is brought in by a BLS ambulance, but ALS interventions are complete within 10 minutes, while the patient with a 30 minute transport time is still in transport for 20 more minutes.

Are these studied done seperately based on timing, or all they averaged together with various transport times?

 

[leviathan]

The only thing that confuses me about this is why is there such a "rush" to intubate and establish IV's in such patients in the ER if timing is not an issue?

An example is a patient with a 30 minute transport time vs. a 5 minute transport time.

The patient with a 5 minute transport time is brought in by a BLS ambulance, but ALS interventions are complete within 10 minutes, while the patient with a 30 minute transport time is still in transport for 20 more minutes.

Are these studied done seperately based on timing, or all they averaged together with various transport times?

I'd like to know the same thing. It seems pretty logical to me that early intubation and drug delivery would also help to increase the chance of survival for patients, but for whatever reason, the studies show otherwise. Maybe it's just poor research, or maybe there is something about the treatment that we're not appreaciating. Perhaps defibrillation is like the rate-limiting factor in treatment, and everything after that needs to be done quickly to ensure survival, but in the end it was only the defibrillation that made the *real* difference? In other words, for those who do have early defibrillation, medications and other ACLS interventions are going to "seal the deal" so to speak, but without early defibrillation, those interventions have little to no effective use. Just my own uneducated guess.

 

[southerndoc]

I'd like to know the same thing. It seems pretty logical to me that early intubation and drug delivery would also help to increase the chance of survival for patients, but for whatever reason, the studies show otherwise. Maybe it's just poor research, or maybe there is something about the treatment that we're not appreaciating. Perhaps defibrillation is like the rate-limiting factor in treatment, and everything after that needs to be done quickly to ensure survival, but in the end it was only the defibrillation that made the *real* difference? In other words, for those who do have early defibrillation, medications and other ACLS interventions are going to "seal the deal" so to speak, but without early defibrillation, those interventions have little to no effective use. Just my own uneducated guess.

Maybe there are too many paramedics, and thus not enough skills practice to maintain performance standards. When Lincoln, Nebraska, made its fire engines all ALS, its intubation success rate went down tremendously. There were too many paramedics and not enough patients needing intubations. The paramedics couldn't keep their skills performance levels up for lack of practice.

If you aren't good at something, chances are patients will suffer.

 

[DropkickMurphy]

If you aren't good at something, chances are patients will suffer.

This is why I have a pocket notebook I keep track of my own success rates in for various procedures- specifically IV starts and intubations in the prehospital setting and blood gases in the hospital setting.

If my first attempt success rate for IV's in a given month drops below 85% or for intubation gets below 75% I start getting practice in those procedures, including OR time courtesy of an anesthesiologist friend of mine. I'm quite proud of my latest statistics (for November 05 since I didn't take any call time in December) when it comes to intubation- 6 out of 7 intubations (85.7%) on the first attempt; nailed the 7th one on the second attempt Sorry....I'm just quite proud of myself.

 

[DropkickMurphy]

* Needle decompression: arguably a valuable intervention at the right time for the right patient. But with all outcome based evidence you have to ask how many patients will receive chest darts unecessarily and end up having worse outcomes (pneumonia, infection) because the procedure was available versus how many will be saved

I recommend going onto TraumaList and asking Dr. Mattox his opinion of this. You will get an earful. I did.

 

[viostorm]

I recommend going onto TraumaList and asking Dr. Mattox his opinion of this. You will get an earful. I did.

Is he pro or anti needle decompression? What is his point of view?

I've seen it done once for someone who had a pneumo from a car wreck, severe SOB, still conscious, absent breath sounds, chest dart relieved symptoms.

You are talking about the mailing list at trauma.org?

 

[viostorm]

I think I'll avoid his wrath ... here is what I found in an archive from trauma.org. He seems very passoniate about his hatred of the chest dart. Does anyone know him personally ... is he always this confrontational? Where does he work?

Anyone who is interested, the complete discussion link is posted, it seem coherent and a valuable read.

http://www.trauma.org/archives/needlethoracostomy.html

----------------------------

From: Ken Mattox
Date: Tue 17/12/2002 15:24

Despite numerous debates on this subject, I still strongly believe that there are basically NO indications for needle decompression of a chest in the prehospital setting, especially in air ambulance operations. I am certain that we will continue to see complications of this invasive, and non-QAed procedure, much like we now see with pericardiocentesis. Remove both from your resuscitation course curriculum

k

From: Ken Mattox
Date: Fri 20/12/2002 01:02

Please, please, provide us with whatever evidence that this outlandish statement made by you, Dr. Johnson, has any, ANY, basis in FACT. Do you have any earthly idea how many patients you have created an iatrogenic systemic air embolism on with this kind of foolish statement and maneuver? Do you even know when and where and why this chest needle decompression can and does cause fatal iatrogenic systemic air embolism? If you answer is, "no, please tell me." then you need to give an apology to every reader of this web site that you have given bad advice.

k

 

[FoughtFyr]

I think I'll avoid his wrath ... here is what I found in an archive from trauma.org. He seems very passoniate about his hatred of the chest dart. Does anyone know him personally ... is he always this confrontational? Where does he work?

He is a trauma surgeon at Parkland, and yes, he is a bit blunt in real life.

Personally, while I think he may be right about this, I still bristle at the idea of non EM physicians having such a lead role in EMS activities as he enjoys. Questions like this are the reason we really need to develop formal, accredited EMS fellowships... IMNSHO.

- H