Things EMS could do better...

[BostonEMT]

I'm looking for feedback from the SDN EM MDs, DOs, and PAs on what EMS could do better. I'm not talking about systemic problems with education, training, regulation, etc. I just mean the little things, the oft-overlooked things, the things nobody tells the EMTs and medics but everyone complains about after we leave.

What could EMS do better?

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[docB]

We frequently get patients brought to a facility even though they just had surgery or an inpatient stay somewhere else. That means we don't have their records or their doctors. The reason given for bringin them to us is the ever vague "patient request." We'll then ask the patient and they'll deny it. Usually it has to do with the fact that we are close to base and it's quittin' time. Complaints go nowhere because no one can prove what was said in the back of the rig.

I know EMS is always getting grief for their telemetry reports, too long, too short, whatever, so I say this knowing that some one out there will always want a social history in every report. I hate it when I get a med student on internal medicine type report for a non-emergent patient. "60 yo M with chest pain. Vitals stable. See ya in 5." is good enough for me unless I hear sirens in the background.

I know you have to put every quasi-trauma on a board. I know they all have to pee the instant you snap the buckels. But I can't "just clear them off the board real quick" from across the room. You put them on the board to CYA and now I've gotta follow procedure to clear them to CMA. And if I'm really busy that may be a while so they will probably need a bedpan. If they want to AMA out of the collar and board rather then use a bedpan that's cool 'cause then we're covered (sort of).

 

[leviathan]

I know you have to put every quasi-trauma on a board. I know they all have to pee the instant you snap the buckels. But I can "just clear them off the board real quick" from across the room.

Hmm, sounds like the EMS in your area should maybe be given some updates on their training on c-spine clearance.

 

[docB]

Hmm, sounds like the EMS in your area should maybe be given some updates on their training on c-spine clearance.

Dang it! I did one of those typos that completely changed the meaning of what I said. Gotta fix that.

 

[leviathan]

Dang it! I did one of those typos that completely changed the meaning of what I said. Gotta fix that.

Oh, I actually didn't see your typo and thought you said "can't"!

I was being serious, and meant that I think EMS in some areas are a little bit over cautious and should get better training in the area of c-spine clearance. I wonder if it would be overkill to suggest they learn the NEXUS criteria or the C-Spine Rule for Physicians?

 

[BostonEMT]

Massachusetts is a very backward, slow-to-adapt, state EMS-wise. I've been told repeatedly that prehospital c-spine clearance will never happen in this state, but who knows. A good idea but a lot of EMT-Bs don't even know when to give oxygen, so....

 

[leviathan]

Massachusetts is a very backward, slow-to-adapt, state EMS-wise. I've been told repeatedly that prehospital c-spine clearance will never happen in this state, but who knows. A good idea but a lot of EMT-Bs don't even know when to give oxygen, so....

Where I work we clear most c-spines as long as there is no neck pain, neuro deficits, and no barriers to proper assessment (distracting injuries, EtOH, communication problems, etc). The only exception to this is a major mechanism of injury (high-speed MVA, roll-over MVA, long falls, etc) will probably get collared even if there are no findings.

 

[BostonEMT]

That's because Canada is a more sensible place than the US.



Any experience with Vancouver EMS? I hear good things.

 

[leviathan]

That's because Canada is a more sensible place than the US.



Any experience with Vancouver EMS? I hear good things.

Yes, I work in Vancouver. It is a province-wide system though. The training is a bit different than in the US with most BLS paramedics having IV endorsement and the ability to give 10-12 different drugs, and ALS paramedics are limited to only high-priority calls so have plenty of experience intubating and seeing sick people. Lots of involvement in research studies too with the Resuscitation Outcomes Consortium (ROC). Pay is OK, about 60k/year for BLS and 70-80k/year for ALS...but that is after you work in a rural town for 5 years making $2/hour on a pager. Our latest contract we are fighting to get wage parity with police and fire services.

 

[howelljolly]

Yes, I work in Vancouver. It is a province-wide system though. The training is a bit different than in the US with most BLS paramedics having IV endorsement and the ability to give 10-12 different drugs, and ALS paramedics are limited to only high-priority calls so have plenty of experience intubating and seeing sick people. Lots of involvement in research studies too with the Resuscitation Outcomes Consortium (ROC). Pay is OK, about 60k/year for BLS and 70-80k/year for ALS...but that is after you work in a rural town for 5 years making $2/hour on a pager. Our latest contract we are fighting to get wage parity with police and fire services.

holy moley

In the northeast (US) the medics in some areas fought, and did get wage parity with RNs, as I think they should. Thats decent money.

 

[BostonEMT]

In the northeast (US) the medics in some areas fought, and did get wage parity with RNs, as I think they should. Thats decent money.

I'd bet paramedics with Boston EMS make something close to an RN's salary, but there aren't very many of them and I can't think of any other services that pay EMS personnel that well. Most join ALS fire departments and get another job or two working at private ambulance companies.

IMHO, good, experienced medics certainly should earn as much as an RN, but it is not likely to change any time soon.

 

[leviathan]

I'd bet paramedics with Boston EMS make something close to an RN's salary, but there aren't very many of them and I can't think of any other services that pay EMS personnel that well. Most join ALS fire departments and get another job or two working at private ambulance companies.

IMHO, good, experienced medics certainly should earn as much as an RN, but it is not likely to change any time soon.

I know in reality most of the guys I know working as ALS here are making over $100,000 / year with the overtime they do.

 

[howelljolly]

Parts of southern US have very low pay for medics. In Texas, medics make less than housekeeping, in at least one hospital (read that in a JEMS article a while back). I knew a CC/Flight medic out there that made about 30K. Then there are volunteer medics in some places...

Back to the topic.

I think one thing EMS can do better is ask how much oxygen you should put the patient on oxygen when they get to the ER treatment bay. Most patients who qualify for 15 lpm in the field (everyone who can tolerate a NRB), do not need that much oxygen in the ER. The patient will be ignored by the staff for a bit, and when they do see the patient, they will curse the EMTs for leaving the patient on that much gas.

 

[189362]

I live where there is a large influx of elderly pts with COPD and protocol suggests EVERYONE gets 10-15l/min high flow O2 via Non rebreather. You know how many pts stop breathing by the time they make it to the hosp. because their hypoxic drive is all out of whack.

 

[leviathan]

I live where there is a large influx of elderly pts with COPD and protocol suggests EVERYONE gets 10-15l/min high flow O2 via Non rebreather. You know how many pts are in severe resp. distress by the time they make it to the hosp. because their hypoxic drive is all out of whack.

If you meant to say they are responding to PaO2 then they would probably become apneic, not develop respiratory distress.

 

[189362]

stop breathing is equal to or greater than resp. distress

 

[howelljolly]

Apneic patients aren't always in distress. Sometimes they're just apneic.

Im sure this has been discussed elsewhere on the EMS forum, but I dont think that clinically we will see a COPD pt. going totally apneic because their hypoxic drive to breathe is obliterated by supplimental oxygen. I think, the patients respiratory rate will decrease (because of the neural control of ventilation), and the patient will get hypercapnic. Then you'll see vasomotor and mental status changes. Thats if the theory is clinically relevent.

As I understand it, it isnt that clinically relevent because chronic CO2 retaining patients do not COMPLETELY switch from the normal hypercapnic drive to the pathologic hypoxic drive. The rise in PaCO2 is also because of normal changes in the oxygen dissociation curve with increased PaO2, and an hyperacute V/Q mismatch caused by normal oxygen-induced pulmonary vasodilitation in a really sick lung parenchyma.

But whether or not the patients brain feels like he needs more oxygen, we know the patient does... go give oxygen. Thats what we tell our EMT students.

Heres some reading material
http://home.pacbell.net/whitnack/The_Death_of_the_Hypoxic_Drive_Theory.htm

 

[leviathan]

stop breathing is equal to or greater than resp. distress

Apnea is a completely separate entity from someone who is in respiratory distress, which is a subjective term indicating an increase in respiratory rate, recruitment of accessory muscles, etc.