Unable to gain intravenous access in a pt bleeding out, what's the next step?

[Lawsonc]

---

Members do not see this ad.

For the sakes of conversation I will try to find the source of where I read this...

My thoughts on lytics in the field is straightforward, but mostly in agreement with what has been said so far...strokes are pretty much out of the question, even with my training being well below medical school, I know a CT is a must (that may have been a lapse of memory in the previous post)...

As far as AMIs go, I think time constraints are a big issue. We should be transporting to a PCI capable facility. During that transport, I want O2, ASA, nitro, morphine, 2 EKG's showing ST elevation, and any arrythmia specific treatments that are indicated...this in itself should take up most of the transport time.

I wouldn't be down for lytics because of the lack of any available blood work...ckmb, troponin, myoglobin, GPBB...

Back soon with some links to the studies/reports

Edit:
Think SDN would publish me if I did a freelance article?

Isn't that what the portable I-stat, a cell phone for consult, and radio ECG transmission are for?

 

[EMS5]

I would venture as far as to say that most agencies don't have I-Stat available. It costs in the range of $10,000. Even if they did, the currently available cartridges test for CK-MB and troponin l, which peak at about 12 hours a piece. This means that although there may be an infarction actively occurring, it may very well not show up in the first hour or two.

Granted, I could call the online doc and ask, but what do I do if the pt has an unidentified coagulopathy? I'm up **** creek without toilet paper. As far as radio ECG transmission, yeah it's good to have, but STEMI is one thing that is drilled into our brains in medic school. If I can't identify a STEMI, I REALLY shouldn't be giving lytics in the field.

 

[deleted109597]

What on earth would an iStat help you with for a STEMI?

Just so you guys know, you can have a STEMI without bumping your troponins, if you have reperfusion fast enough. So if you're not going to give lytics based on a test that doesn't mean anything, then go right ahead.
I give lytics based on the EKG, since that's what its there for.

 

[Lawsonc]

I would venture as far as to say that most agencies don't have I-Stat available. It costs in the range of $10,000. Even if they did, the currently available cartridges test for CK-MB and troponin l, which peak at about 12 hours a piece. This means that although there may be an infarction actively occurring, it may very well not show up in the first hour or two.

Granted, I could call the online doc and ask, but what do I do if the pt has an unidentified coagulopathy? I'm up **** creek without toilet paper. As far as radio ECG transmission, yeah it's good to have, but STEMI is one thing that is drilled into our brains in medic school. If I can't identify a STEMI, I REALLY shouldn't be giving lytics in the field.

I know of a few agencies that have I-stat, predominately rural and hospital based EMS. No doubt a STEMI is a STEMI, putting clinical findings, symptoms, and history together, dare I say that even in the field I think it fair to assume. That being said, I like the idea of transmissions just to give a heads up and get the hospital ready. In one of the systems I interned in, it was policy in order to open up the cath lab to have serial 12 leads transmitted before arrival.

I am all for consulting with the MD (and not just giving a nurse report) at the facility we are going to on cases that either are going to require additional resources or support. (Patients that will need vents in the ER, STEMIs, trauma alerts, etc) Even though most hospitals (not all) will throw the doc on the line on big calls anyways. Its not mother may I, its team work.

 

[Lawsonc]

What on earth would an iStat help you with for a STEMI?

Just so you guys know, you can have a STEMI without bumping your troponins, if you have reperfusion fast enough. So if you're not going to give lytics based on a test that doesn't mean anything, then go right ahead.
I give lytics based on the EKG, since that's what its there for.

I get you, but using that logic why do 12 leads when you have NSTEMI. (My argument is not aimed at the use of lytics, rather just the clinical findings) the one agency I know of that use Istat do not have lytics, but rather use it as another tool, based on their long response and transport times.

 

[Rendar5]

I get you, but using that logic why do 12 leads when you have NSTEMI. (My argument is not aimed at the use of lytics, rather just the clinical findings) the one agency I know of that use Istat do not have lytics, but rather use it as another tool, based on their long response and transport times.

EKG is to determine if there is a STEMI or not. If there is no STEMI, then there is no STEMI. If it's a STEMI, then initial troponin plays no role in it.
If it's an NSTEMI, then troponin is useful for trending, but lytics play no role in it. In addition, if it's an NSTEMI, there is no role for emergent catheterization, immediate resource mobilization, etc.

 

[deleted109597]

I get you, but using that logic why do 12 leads when you have NSTEMI. (My argument is not aimed at the use of lytics, rather just the clinical findings) the one agency I know of that use Istat do not have lytics, but rather use it as another tool, based on their long response and transport times.

Uh, you do the 12 lead to make sure it isn't a STEMI. Unless your EMS is so advanced they have ESP.

 

[Lawsonc]

Uh, you do the 12 lead to make sure it isn't a STEMI. Unless your EMS is so advanced they have ESP.

No, that is SOP (standard operating procedure) code named ghostbuster.


My post was not related to the lytics, but rather in questioning why not use the Istat for values, it is just one more value we can provide to you (hospital), in order to paint a bigger picture.

 

[Hamhock]

As far as radio ECG transmission, yeah it's good to have, but STEMI is one thing that is drilled into our brains in medic school. If I can't identify a STEMI, I REALLY shouldn't be giving lytics in the field.

That's right: you "really shouldn't be giving lytics in the field."

Thinking that identifying a STEMI is easy shows a lack of training and knowledge.

...other reasons for ST elevations...clinical picture/chest pain story...etc.

HH

 

[deleted109597]

No, that is SOP (standard operating procedure) code named ghostbuster.

My post was not related to the lytics, but rather in questioning why not use the Istat for values, it is just one more value we can provide to you (hospital), in order to paint a bigger picture.

That's not what you said. You said

I get you, but using that logic why do 12 leads when you have NSTEMI.

Again, you do 12 leads because it is a protocol, and lets you identify STEMI vs NSTEMI. It is purely binary. Troponin is not.

On scene troponin doesn't help you. If it's positive then its an NSTEMI (or renal failure) and they don't get lytics. If it's negative it can still be an NSTEMI, and they still don't get lytics. However, it does serve your intended purpose of hanging around on scene instead of getting in the damn ambulance and driving to the hospital.
After all of this, I hate to say it, but you're at a point where you know just enough to be dangerous. You don't know what you don't know. You think CVLs are safe in the field. You don't think people need much training to intubate. You think performing labs in the field is helpful.

 

[Lawsonc]

That's not what you said. You said

Again, you do 12 leads because it is a protocol, and lets you identify STEMI vs NSTEMI. It is purely binary. Troponin is not.

On scene troponin doesn't help you. If it's positive then its an NSTEMI (or renal failure) and they don't get lytics. If it's negative it can still be an NSTEMI, and they still don't get lytics. However, it does serve your intended purpose of hanging around on scene instead of getting in the damn ambulance and driving to the hospital.
After all of this, I hate to say it, but you're at a point where you know just enough to be dangerous. You don't know what you don't know. You think CVLs are safe in the field. You don't think people need much training to intubate. You think performing labs in the field is helpful.

The Istat requires a small amount of blood, of which after starting an IV phlebotomy is performed with a 12cc syringe. I am sure while your riding in the back, it is not to difficult to put a drop on the strip and let the machine do its magic. (I know some of the earlier models could not be used during transport) but this is not the case with the newer ones.

Will it change what I do to treat a 10/10 chest pain, STEMI or NOT? Probably not. Will some systems require it as part of the job, yes. Does it bother me to do it if "I" have the time? Not at all, is it something that could be usefull for the hospital staff? Someone thinks so otherwise they wouldn't be handing out expensive equipment, or mandating that agencies purchase them.

I may not have been clear, in regards to my comment about 12 leads and NSTEMI. My point was (putting aside the use of lytics, you commented on how it was useless on a STEMI), why not get a troponin value if possible? Just because it might not show anything, its no different then a 12 lead not showing ST elevation, you don't know what is going on until you do the 12 lead and or use the Istat.

This is not an argument I want to run off with, as I have no care in the world to carry an Istat. Someone mentioned obtaining lab values in the field, I explained some agencies carry the Istat, personally it does not bother me either way.

Just to make it clear as well, I have no opinion on using thrombolytics in the field. Believe it or not I just may have a little humility and will admit I don't know enough about it to say either way. I also don't see it being used where I am anytime soon.

 

[deleted109597]

Will it change what I do to treat a 10/10 chest pain, STEMI or NOT? Probably not. Will some systems require it as part of the job, yes. Does it bother me to do it if "I" have the time? Not at all, is it something that could be usefull for the hospital staff? Someone thinks so otherwise they wouldn't be handing out expensive equipment, or mandating that agencies purchase them.

It's a way to keep getting grant money from the government, and for the companies making the products to earn money. Just like ultrasound in the field. Neither has a place prehospital.

I may not have been clear, in regards to my comment about 12 leads and NSTEMI. My point was (putting aside the use of lytics, you commented on how it was useless on a STEMI), why not get a troponin value if possible? Just because it might not show anything, its no different then a 12 lead not showing ST elevation, you don't know what is going on until you do the 12 lead and or use the Istat.

The difference being that if the EKG shows a STEMI, you act differently. They go directly to the cath lab/get lytics, regardless of any other testwork. If the troponin is positive, and they're stable, it isn't going to help you in the ambulance. And since it will have to be repeated at the hospital, it won't change inpatient management either. Thus, a useless test.

 

[future_dr_house]

IMO I think istats in the field serve little purpose and may not be justified because of their expense.

Here's how I think istats and lytics fit in the picture:
EKG with elevation and >60-90 min from a cath lab (and >20-30 min from a tertiary hospital)? Call the ED, radiotransmission of EKG if possible (to assess for pericarditis, etc), and after all agree...MONA + Lytics.
< 60-90 min? Cath lab
No st elevation? Then do the istat if deciding whether or not to go code. If + then go code. Otherwise don't go code.

I personally would feel better as a patient going code b/c I've been burned in the department with istats, but of course that's N=1 experience and a whole other discussion.

I also don't think central lines have any business in the field. IO is just too perfect for this situation after peripheral venous access has been attempted.

 

[Lawsonc]

In regards to ultra sound in the field, is that based on user experience or conditions. I am not trying to sound defensive, and I will explain my reasoning and rationale as well as why I am curious you are against it.

If its user experience, I would tend to agree, if it was due to conditions I disagree.

While maybe not on every truck in the county, or being used on every patient with abdominal pain, there is a place for it.

There have been plenty of documented cases of ultrasound being used by doctors/medics/nurses, etc in air medical transport, as well as on the ground in MCI type incidents. The findings have aided in triage and ultimately transport destinations.

 

[deleted109597]

No st elevation? Then do the istat if deciding whether or not to go code. If + then go code. Otherwise don't go code.

Faulty logic. The inverse would probably actually be more appropriate. By the time troponins are elevated the cat is out of the bag. Negative troponins (especially one set) does not nor ever will mean no disease. Period. Just ****ing drive to the hospital already.

If its user experience, I would tend to agree, if it was due to conditions I disagree.
While maybe not on every truck in the county, or being used on every patient with abdominal pain, there is a place for it.
There have been plenty of documented cases of ultrasound being used by doctors/medics/nurses, etc in air medical transport, as well as on the ground in MCI type incidents. The findings have aided in triage and ultimately transport destinations.

Mass casualty is different. However, in the vast majority of EMS calls, it is one truck for one patient. In the vast majority of systems, you go to one hospital (closest). Differences are for stroke centers/heart centers, and if you listen to Jerry Hoffman, you will understand why this is bad for medicine in general. All hospitals should give good care, not just the "centers of excellence". Trauma criteria should not include ultrasound. FAST exam is indicated for one reason, and that is the hypotensive patient. Fluid in belly=OR, no fluid in belly=no OR. Thus, if they're a trauma, they go to trauma center, regardless of US. US is not perfect even in the hands of ED physicians, it is orders of magnitude worse in pre-hospital. And above all, it prevents you from doing the things we've been talking about this entire time. Just start driving.


Thankfully my hospital lost their first trimester vag bleed center of excellence standing when they stopped delivering babies. I'm more than happy to be out of that loop.

 

[Lawsonc]

Faulty logic. The inverse would probably actually be more appropriate. By the time troponins are elevated the cat is out of the bag. Negative troponins (especially one set) does not nor ever will mean no disease. Period. Just ****ing drive to the hospital already.


Mass casualty is different. However, in the vast majority of EMS calls, it is one truck for one patient. In the vast majority of systems, you go to one hospital (closest). Differences are for stroke centers/heart centers, and if you listen to Jerry Hoffman, you will understand why this is bad for medicine in general. All hospitals should give good care, not just the "centers of excellence". Trauma criteria should not include ultrasound. FAST exam is indicated for one reason, and that is the hypotensive patient. Fluid in belly=OR, no fluid in belly=no OR. Thus, if they're a trauma, they go to trauma center, regardless of US. US is not perfect even in the hands of ED physicians, it is orders of magnitude worse in pre-hospital. And above all, it prevents you from doing the things we've been talking about this entire time. Just start driving.


Thankfully my hospital lost their first trimester vag bleed center of excellence standing when they stopped delivering babies. I'm more than happy to be out of that loop.

In regards to the "center of excellence" I am going to assume you mean regionally designated centers, trauma, cardiac, stroke, etc. My assumption, is just to make sure I am clear.

Are you able to present any literature, or at least point me in the direction (links? Medical Journals?) I am interested in this opinion as it is not something I have heard of before.

I have also been under the assumption that regional centers are the way to go. Number one it provides for experienced faculty, that specialize. Number two, many of these specialties are a burden and not sustainable financially, so by allowing one institution (predominately teaching) to run the show, you don't run into smaller hospitals that bite off more then they can chew and perform sub standard care.

 

[deleted109597]

I have also been under the assumption that regional centers are the way to go. Number one it provides for experienced faculty, that specialize. Number two, many of these specialties are a burden and not sustainable financially, so by allowing one institution (predominately teaching) to run the show, you don't run into smaller hospitals that bite off more then they can chew and perform sub standard care.

That assumption is because CMS and others have decided to make it that way. Once again, it is all about money. People do better in stroke centers not because they get better CTs or tPA or whatever but because they get better rehab. People do better at cardiac centers because those places have cath labs, and cath labs have been shown to be beneficial. People to better at trauma centers because there are trauma surgeons there. It isn't a magical process. You go where the stuff is.
Trauma does lose money, but neuro and cardiac in general do very well. Also, most centers of excellence/distinction/regional whatever are not teaching hospitals.

 

[FDNewbie]

Eastern Oregon, Central/Eastern Washington, Parts of Idaho and Montana- To name a few places with greater then 90 minutes. We are talking hours, to a cath lab, trauma center, etc, by both air and ground.

Note to self: don't ever live there...

 

[deleted65604]

If its user experience, I would tend to agree, if it was due to conditions I disagree.

In order to be used in the field, and ultrasound would have to be one of the really small ones. The smaller the machine, the worse the images and the harder to make clinical decisions. The brighter the ambient light, the harder it is to visualize structures. This makes portable ultrasound on rigs nearly useless even for an experienced ultrasonographer.

I'm also against giving EMS more money or equipment. They are already a massive waste of money. An ultrasound machine on each rig would just collect dust for 99.9% of rigs. Hundreds of thousands of EMS personnel are watching porn, making more money than they are worth and collecting exorbitant pensions. Paramedics on an individual basis have so little patient contact, that they can never become proficient at more than ACLS, basic ATLS, BLS, and IV access. That is what they should focus on, not ultrasound skills.

 

[xaelia]

In order to be used in the field, and ultrasound would have to be one of the really small ones. The smaller the machine, the worse the images and the harder to make clinical decisions. The brighter the ambient light, the harder it is to visualize structures. This makes portable ultrasound on rigs nearly useless even for an experienced ultrasonographer.

I'm also against giving EMS more money or equipment. They are already a massive waste of money. An ultrasound machine on each rig would just collect dust for 99.9% of rigs. Hundreds of thousands of EMS personnel are watching porn, making more money than they are worth and collecting exorbitant pensions. Paramedics on an individual basis have so little patient contact, that they can never become proficient at more than ACLS, basic ATLS, BLS, and IV access. That is what they should focus on, not ultrasound skills.

Our institution has a research pilot project in place where aeromedical crews carry blood, are FASTing incoming trauma patients and initiating transfusion prior to ED arrival if certain conditions are met.

Should be interesting.

 

[Lawsonc]

In order to be used in the field, and ultrasound would have to be one of the really small ones. The smaller the machine, the worse the images and the harder to make clinical decisions. The brighter the ambient light, the harder it is to visualize structures. This makes portable ultrasound on rigs nearly useless even for an experienced ultrasonographer.

I'm also against giving EMS more money or equipment. They are already a massive waste of money. An ultrasound machine on each rig would just collect dust for 99.9% of rigs. Hundreds of thousands of EMS personnel are watching porn, making more money than they are worth and collecting exorbitant pensions. Paramedics on an individual basis have so little patient contact, that they can never become proficient at more than ACLS, basic ATLS, BLS, and IV access. That is what they should focus on, not ultrasound skills.

That is so far from the truth it makes me laugh, I can't even bother arguing that. The national average is under 35,000 a year, I dont see how that is exorbitant.

 

[deleted65604]

That is so far from the truth it makes me laugh, I can't even bother arguing that. The national average is under 35,000 a year, I dont see how that is exorbitant.

I didn't say their wages are exorbitant. I said their retirement packages are. These guys retire after 20-30 years, getting a job after a few months of training directly after high school. At 45-50 years old, they are on their second career, doubling their income. This means they wil often collect a pension for 4-5 decades. Therefore, they don't have to worry about saving their money. They can live pay-check to pay-check and have side-jobs to earn extra money. The pay is greater than any other job one can get for so little training, that has such minimal job duties.

I've spent a lot of time hanging around EMS, before medical school, during medical school, and during residency. My experience is that they spend 75%-95% of their time doing nothing...nothing, at all. In each firehouse is tens of thousands of dollars worth of exercise equipment, weight machines, and full kitchens. Hundreds of thousands of specialized equipment lies idle. Rows of Lazy-Boy chairs sitting in front of big-screen TVs, with 100's of cable channels. I don't advocate dismantling the program, I'm just pointing out that there is a lot of fat that could be trimmed.

Ultimately, what irritates me more than anything, is the culture of risk-aversion that has facilitated the over-building and over-staffing of these facilities. Cities and counties constantly call for more and more funds and urge the construction of more and more firehouses. Why? Because they don't want their city to be on the national news as having some mass-casualty cituation that they couldn't handle. Because the public demands it, not realizing their taxes are paying for all this. This gives the public a false sense of security that bad things will never happen to them. Dad can drive drunk and cause a multi-car pileup, and if the ambulance isn't here in the next few minutes to cut us out, we are suing the city for everything they have. Grandma will die, but the medics will be here in 3 minutes to raise her from the dead and wisk her mottled corpse away so we don't have to look at it. Risk aversion is killing our country, and literally, transforming it into something unrecognizable.

Not to mention the hospitals that are fed by these vast networks of firestations are viewed by the public as too expensive, while the government actively plans to starve those hospitals of funds.

 

[Lawsonc]

I didn't say their wages are exorbitant. I said their retirement packages are. These guys retire after 20-30 years, getting a job after a few months of training directly after high school. At 45-50 years old, they are on their second career, doubling their income. This means they wil often collect a pension for 4-5 decades. Therefore, they don't have to worry about saving their money. They can live pay-check to pay-check and have side-jobs to earn extra money. The pay is greater than any other job one can get for so little training, that has such minimal job duties.

I've spent a lot of time hanging around EMS, before medical school, during medical school, and during residency. My experience is that they spend at 75%-95% of their time doing nothing...nothing, at all. In each firehouse is tens of thousands of dollars worth of exercise equipment, weight machines, and full kitchens. Hundreds of thousands of specialized equipment lies idle. Rows of Lazy-Boy chairs sitting in front of big-screen TVs, with 100's of cable channels. I don't advocate dismantling the program, I'm just pointing out that there is a lot of fat that could be trimmed.

Ultimately, what irritates me more than anything, is the culture of risk-aversion that has facilitated the over-building and over-staffing of these facilities. Cities and counties constantly call for more and more funds and urge the construction of more and more firehouses. Why? Because they don't want their city to be on the national news as having some mass-casualty cituation that they couldn't handle. Because the public demands it, not realizing their taxes are paying for all this. This gives the public a false sense of security that bad things will never happen to them. Dad can drive drunk and cause a multi-car pileup, and if the ambulance isn't here in the next few minutes to cut us out, we are suing the city for everything they have. Grandma will die, but the medics will be here in 3 minutes to raise her from the dead and wisk her mottled corpse away so we don't have to look at it. Risk aversion is killing our country, and literally, transforming it into something unrecognizable.

Not to mention the hospitals that are fed by these vast networks of firestations are viewed by the public as too expensive, while the government actively plans to starve those hospitals of funds.

Still nowhere near the truth and purely regional, not everywhere is fire, not everywhere are medics out of highschool. Paramedic school is a 5-6 year Bachelors level in some parts of the west (have to include 2 years of EMT experience), at least associates degree with a few crappy certificate courses littered in some states.

I can comfortably say the majority of Paramedics are not involved in a pension plan, maybe 401K, as I am going to take a shot in the dark and using my gut say majority work for private companies (just based on the size of these agencies in bigger cities) (I can get back to you with literature on this if you would really like to know)

I am sorry you have had to deal with departments like such, reminds me of my time in California, sounds alot like what parts of Texas have been described to be, and could be the reason why there has been a clash of ideas here. Not all EMS systems are like such.

What you need is minimal medics with maximum exposure, and EMTs littered across the coverage area to initialize care, because even I will admit (like has been said) Good BLS is where its at.

 

[Lawsonc]

Ultimately, what irritates me more than anything, is the culture of risk-aversion that has facilitated the over-building and over-staffing of these facilities. Cities and counties constantly call for more and more funds and urge the construction of more and more firehouses. Why? Because they don't want their city to be on the national news as having some mass-casualty cituation that they couldn't handle. Because the public demands it, not realizing their taxes are paying for all this. This gives the public a false sense of security that bad things will never happen to them. Dad can drive drunk and cause a multi-car pileup, and if the ambulance isn't here in the next few minutes to cut us out, we are suing the city for everything they have. Grandma will die, but the medics will be here in 3 minutes to raise her from the dead and wisk her mottled corpse away so we don't have to look at it. Risk aversion is killing our country, and literally, transforming it into something unrecognizable.

Not to mention the hospitals that are fed by these vast networks of firestations are viewed by the public as too expensive, while the government actively plans to starve those hospitals of funds.

This I will agree with, in terms of the social atmosphere which has its effects on all of us, not just hospital or pre-hospital. Once again to solve your initial issue, and this one all in one- what we need is less medics, but better medics.

 

[deleted65604]

This I will agree with, in terms of the social atmosphere which has its effects on all of us, not just hospital or pre-hospital. Once again to solve your initial issue, and this one all in one- what we need is less medics, but better medics.

Good points. I agree wholeheartedly.

 

[Lawsonc]

Good points. I agree wholeheartedly.

This is nothing new as well, it just differs from location to location and ideology, when I lived in California there were more jack in the box medic schools in the San Francisco bay area alone, then there are in the whole state of Washington. (population density aside, you still don't need that many medics)

 

[pseudoknot]

I've spent a lot of time hanging around EMS, before medical school, during medical school, and during residency. My experience is that they spend at 75%-95% of their time doing nothing...nothing, at all. In each firehouse is tens of thousands of dollars worth of exercise equipment, weight machines, and full kitchens. Hundreds of thousands of specialized equipment lies idle. Rows of Lazy-Boy chairs sitting in front of big-screen TVs, with 100's of cable channels. I don't advocate dismantling the program, I'm just pointing out that there is a lot of fat that could be trimmed.

Ultimately, what irritates me more than anything, is the culture of risk-aversion that has facilitated the over-building and over-staffing of these facilities. Cities and counties constantly call for more and more funds and urge the construction of more and more firehouses. Why? Because they don't want their city to be on the national news as having some mass-casualty cituation that they couldn't handle. Because the public demands it, not realizing their taxes are paying for all this. This gives the public a false sense of security that bad things will never happen to them. Dad can drive drunk and cause a multi-car pileup, and if the ambulance isn't here in the next few minutes to cut us out, we are suing the city for everything they have. Grandma will die, but the medics will be here in 3 minutes to raise her from the dead and wisk her mottled corpse away so we don't have to look at it. Risk aversion is killing our country, and literally, transforming it into something unrecognizable.

Not to mention the hospitals that are fed by these vast networks of firestations are viewed by the public as too expensive, while the government actively plans to starve those hospitals of funds.

I agree with all of the above [and was present for the key parts of…oh wait nevermind].

I think something else that drives this is the idolization of response times as the only easily measurable number associated with EMS performance. Does response time matter? Yes, for 1% of calls. But the MBA types don't want to be bothered by complexity, so we have millions of dollars wasted putting paramedics on every street corner, who then do nothing all day and don't have the skills they need when it hits the fan.

 

[deleted92121]

Been a medic for about seven years working both is a busy service with a large service area and in a bustling level II trauma center along with educational gigs and more. In this time, the most pressing issue (that can be addressed/fixed) is the amount of time crews spend on a scene screwing around trying to play cowboy. The concepts of "stay and play" versus "load and go" have been lost. Many medics simply want to play around as much as possible. The more procedures or whatnot they can do, the better job they think they do. Frustrating in my opinion.

Medics need to be able to utilize protocols as a tool, not as a cut and dry, black and white set of dogma. Cookbook medics get in trouble. Utilize medical command when questions or trouble arise. Most command docs will be willing to listen to their medics and trust their clinical judgement, aiding them and working with them. That is the whole point. But I don't know many docs that will support delaying care in the ED so the medic can play out in the field.

In the field, keep it simple. BLS skills followed by ALS if needed. Do you really need an EKG? IV? Justify why you are doing it and why it is necessary, not just because you want to. Are you really going to give NTG and ASA to a patient c/o CP even though the CP started immediately following an MVC where the seatbelt left an impression across his chest? Where palpation reveals tenderness and bruising is present? According to my one colleague, ASA and NTG are indicated because the CC was CP!!!

Oh and to answer the original question, in the field I use IO on all arrests unless contraindicated. And I don't believe a central line is ever useful in the pre-hospital setting unless you have an hour transport to the nearest hospital in the snow, uphill, and blood needs given. Even then, I may say it is still unnecessary. Yeah that is my answer, no central lines in the field. Peripheral lines, EJs, IOs. That's the ticket!