Re: Too many paramedics?

[Guest guest]

I believe that not holding the particular paramedics actually accountable for

failure to properly ventilate their patients is the way to fix the problem.

There is not an EMT-Basic,EMT-Intermediate or Paramedic practicing that should

not use their training and knowledge to properly ventilate a patient. If that

means you ventilate by BVM because for some reason an intubation is not

attainable (for whatever the reason) it should be done.

I believe the problem occurs because some are so concerned with either a

feeling of inadequacy or have a genuine lack of skill that the patient is put

into jeopardy.

We are trained to use different methods to ventilate our patients. If

advanced techniques are not available (again for whatever the reason) basic

ventilation techniques with suction when and if needed will do. The studies and

outcomes from those studies I have seen tend to emphasize more with the fact the

patient was put into jeopardy because of the total absence of ventilation due to

inadequate intubation skills rather than because of the absence of the advance

ventilation technique itself. In other words " The EMS personnel did not

recognize the inadequacy of their ventilation and did not abandon the advanced

attempt and correct the situation with basic ventilation procedures. "

Using our " common sense " is also a skill we need to be proficient in.

ExLngHrn@... wrote:

I definitely agree that the standard of care is and should continue to be

ventilation, rather than intubation.

Many healthcare providers (not just EMS providers) are lacking in airway

management skills.

However, it's the height of absurdity (not to mention disingenous) for some

physicians to carp about paramedics not mastering intubation, then hiding behind

the ol' liabilty insurance excuse when they explain why they won't let paramedic

students practice intubation skills in their ER and OR rotations. Equally

disturbing are the EMS systems that allow minimally competent medics to practice

merely to have the vacancy filled.

Of course, this brings up one of my longstanding theories about EMS management.

My theory is that EMS managers pick one of the following four excuses when they

don't want to do something or allow it to be done:

1) We can't because our insurance won't let us.

2) Our attorneys say we can't do that.

3) HIPPA won't let us do that.

4) We can't due that because of " homeland security. "

-Wes Ogilvie, MPA, JD, EMT-B

Attorney at Law/Emergency Medical Technician

Austin, Texas

*Special disclaimer -- my ire is not typically directed at any particular EMS

system, educational program, or physician. If it is directed at a specific

entity, I'll clearly state such.*

Re: Too many paramedics?

>>> Methinks the real concern expounded by some (NOT ALL, of course)

physicians about skills degradation and such for paramedics stems as

much from turf protection as it does from patient advocacy. <<<

Wes,

I suppose there are some who would like to see intubation go away

because of turf protection, but my guess is they are in the minority.

I think most are genuinely concerned with the risk to the patient when

the intubator is not likely to gain significant experience in the

field especially given the paucity of evidence to suggest any

significant benefit.

There are safer ways to manage an airway than with an tracheal tube.

Perhaps some physicians are just beginning to see the light.

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

I believe that not holding the particular paramedics actually accountable for

failure to properly ventilate their patients is the way to fix the problem.

There is not an EMT-Basic,EMT-Intermediate or Paramedic practicing that should

not use their training and knowledge to properly ventilate a patient. If that

means you ventilate by BVM because for some reason an intubation is not

attainable (for whatever the reason) it should be done.

I believe the problem occurs because some are so concerned with either a

feeling of inadequacy or have a genuine lack of skill that the patient is put

into jeopardy.

We are trained to use different methods to ventilate our patients. If

advanced techniques are not available (again for whatever the reason) basic

ventilation techniques with suction when and if needed will do. The studies and

outcomes from those studies I have seen tend to emphasize more with the fact the

patient was put into jeopardy because of the total absence of ventilation due to

inadequate intubation skills rather than because of the absence of the advance

ventilation technique itself. In other words " The EMS personnel did not

recognize the inadequacy of their ventilation and did not abandon the advanced

attempt and correct the situation with basic ventilation procedures. "

Using our " common sense " is also a skill we need to be proficient in.

ExLngHrn@... wrote:

I definitely agree that the standard of care is and should continue to be

ventilation, rather than intubation.

Many healthcare providers (not just EMS providers) are lacking in airway

management skills.

However, it's the height of absurdity (not to mention disingenous) for some

physicians to carp about paramedics not mastering intubation, then hiding behind

the ol' liabilty insurance excuse when they explain why they won't let paramedic

students practice intubation skills in their ER and OR rotations. Equally

disturbing are the EMS systems that allow minimally competent medics to practice

merely to have the vacancy filled.

Of course, this brings up one of my longstanding theories about EMS management.

My theory is that EMS managers pick one of the following four excuses when they

don't want to do something or allow it to be done:

1) We can't because our insurance won't let us.

2) Our attorneys say we can't do that.

3) HIPPA won't let us do that.

4) We can't due that because of " homeland security. "

-Wes Ogilvie, MPA, JD, EMT-B

Attorney at Law/Emergency Medical Technician

Austin, Texas

*Special disclaimer -- my ire is not typically directed at any particular EMS

system, educational program, or physician. If it is directed at a specific

entity, I'll clearly state such.*

Re: Too many paramedics?

>>> Methinks the real concern expounded by some (NOT ALL, of course)

physicians about skills degradation and such for paramedics stems as

much from turf protection as it does from patient advocacy. <<<

Wes,

I suppose there are some who would like to see intubation go away

because of turf protection, but my guess is they are in the minority.

I think most are genuinely concerned with the risk to the patient when

the intubator is not likely to gain significant experience in the

field especially given the paucity of evidence to suggest any

significant benefit.

There are safer ways to manage an airway than with an tracheal tube.

Perhaps some physicians are just beginning to see the light.

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

Danny --

You mention using a BVM for ventilation when the intubation isn't available.

Shouldn't the standard be to use the most appropriate (and least invasive)

method of ventilation?

In my admittedly odd worldview, I view ventilation devices much as cops are

supposed to view the use of force. In other words, you use the least amount of

force (or invasiveness in our case) to neutralize the threat.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

Re: Too many paramedics?

>>> Methinks the real concern expounded by some (NOT ALL, of course)

physicians about skills degradation and such for paramedics stems as

much from turf protection as it does from patient advocacy. <<<

Wes,

I suppose there are some who would like to see intubation go away

because of turf protection, but my guess is they are in the minority.

I think most are genuinely concerned with the risk to the patient when

the intubator is not likely to gain significant experience in the

field especially given the paucity of evidence to suggest any

significant benefit.

There are safer ways to manage an airway than with an tracheal tube.

Perhaps some physicians are just beginning to see the light.

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

Danny --

You mention using a BVM for ventilation when the intubation isn't available.

Shouldn't the standard be to use the most appropriate (and least invasive)

method of ventilation?

In my admittedly odd worldview, I view ventilation devices much as cops are

supposed to view the use of force. In other words, you use the least amount of

force (or invasiveness in our case) to neutralize the threat.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

Re: Too many paramedics?

>>> Methinks the real concern expounded by some (NOT ALL, of course)

physicians about skills degradation and such for paramedics stems as

much from turf protection as it does from patient advocacy. <<<

Wes,

I suppose there are some who would like to see intubation go away

because of turf protection, but my guess is they are in the minority.

I think most are genuinely concerned with the risk to the patient when

the intubator is not likely to gain significant experience in the

field especially given the paucity of evidence to suggest any

significant benefit.

There are safer ways to manage an airway than with an tracheal tube.

Perhaps some physicians are just beginning to see the light.

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

Danny --

You mention using a BVM for ventilation when the intubation isn't available.

Shouldn't the standard be to use the most appropriate (and least invasive)

method of ventilation?

In my admittedly odd worldview, I view ventilation devices much as cops are

supposed to view the use of force. In other words, you use the least amount of

force (or invasiveness in our case) to neutralize the threat.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

Re: Too many paramedics?

>>> Methinks the real concern expounded by some (NOT ALL, of course)

physicians about skills degradation and such for paramedics stems as

much from turf protection as it does from patient advocacy. <<<

Wes,

I suppose there are some who would like to see intubation go away

because of turf protection, but my guess is they are in the minority.

I think most are genuinely concerned with the risk to the patient when

the intubator is not likely to gain significant experience in the

field especially given the paucity of evidence to suggest any

significant benefit.

There are safer ways to manage an airway than with an tracheal tube.

Perhaps some physicians are just beginning to see the light.

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

You are 100% correct. We have those that do not feel this way.

The problem is further complicated when word is spoken of taking the advance

skill of intubation away. Just like most of our advanced skills we do not use

them on 100% of the calls for our assistance, taking a skill away would not be

in the best interests of the people we come into contact with.

I believe this further makes alot of our personnel believe they must use the

skill to show #1 The skill is needed; and #2 That they are a competent medical

professional.

I have taken patients into the ER and was either asked by the RN or Physician

why an intubation was not accomplished. I have set at the work station at the

hospital to prepare my reports and actually overheard the comments made by the

respiratory technicians as to how inadequate the paramedic was because they were

unable to obtain an intubation in the field because it was easy to obtain in the

trauma room.

Very few individuals have the ability to do what is best for the patient

without worrying that something will be said about them at a later date.

Training, training and more training is the only cure for this type of thinking.

My humble opinion.

ExLngHrn@... wrote:

Danny --

You mention using a BVM for ventilation when the intubation isn't available.

Shouldn't the standard be to use the most appropriate (and least invasive)

method of ventilation?

In my admittedly odd worldview, I view ventilation devices much as cops are

supposed to view the use of force. In other words, you use the least amount of

force (or invasiveness in our case) to neutralize the threat.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

Fax

[Guest guest]

You are 100% correct. We have those that do not feel this way.

The problem is further complicated when word is spoken of taking the advance

skill of intubation away. Just like most of our advanced skills we do not use

them on 100% of the calls for our assistance, taking a skill away would not be

in the best interests of the people we come into contact with.

I believe this further makes alot of our personnel believe they must use the

skill to show #1 The skill is needed; and #2 That they are a competent medical

professional.

I have taken patients into the ER and was either asked by the RN or Physician

why an intubation was not accomplished. I have set at the work station at the

hospital to prepare my reports and actually overheard the comments made by the

respiratory technicians as to how inadequate the paramedic was because they were

unable to obtain an intubation in the field because it was easy to obtain in the

trauma room.

Very few individuals have the ability to do what is best for the patient

without worrying that something will be said about them at a later date.

Training, training and more training is the only cure for this type of thinking.

My humble opinion.

ExLngHrn@... wrote:

Danny --

You mention using a BVM for ventilation when the intubation isn't available.

Shouldn't the standard be to use the most appropriate (and least invasive)

method of ventilation?

In my admittedly odd worldview, I view ventilation devices much as cops are

supposed to view the use of force. In other words, you use the least amount of

force (or invasiveness in our case) to neutralize the threat.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

Fax

[Guest guest]

Wes,

That is one issue that I think the legislature should look at taking up...and

everyone would agree to it...(well except you lawyer types...) and that is to

take steps to protect facilities, physicians, and other practitioners from

liability in settings where paramedics could get more/better intubation

rotations...in the late 80's I was fortunate enough to get to intubate almost 20

patients in the OR setting and several more in the field...but now we are

getting medics out of school who haven't even intubated a dog, cat or pig....let

alone a human...

This problem needs some serious attention...

Dudley

Too many paramedics?

I've been discussing the topic of skills degradation off-list with a

paramedic who believes that some skills degradation that comes from

having too many paramedics competing for a finite number of ALS

interventions, even in a busy urban system.

My question for all of you is four-fold:

1) Is skills degradation caused (even in part) by a large number of

paramedics with a limited number of ALS interventional opportunities?

[] I suppose there is some truth to the saying " use it or lose

it " , but there are other ways to retain your skill level. Of course this

will require effort on the medic's part. To participate in our system,

the Medical Director requires a certain number of advanced procedures to

be performed in a six month period. This may be accomplished by direct

patient care, in a clinical setting or by formal skills assessment in a

classroom. While I agree that direct patient care may be the preferred

method, the other options can work well also. To just sit on your ass

and wait for the real deal should not be the limit.

2) Is reducing the number of paramedics a way to address this issue?

[] Reduce supply, increase demand, and you will see the work load

of many Paramedics increase. I can sit and think up many reasons why

reducing the number of medics is wrong, but instead I will just express

my opinion - No this is not the answer.

3) If reducing the number of paramedics was to happen, what additional

skills might an EMT-B need to possess?

[] The only thing you changed is the name. You move a skill from

one level to the other and you still have the initial argument - not

enough interventions.

4) On which call types does ALS intervention make a difference? Is

there empirical evidence/proof?

[]We get back to the research thing here. In my experience we make

a great deal of difference with some patients, with others we do not. I

do think we give the ill or injured patient a greater chance of

improvement by

being able to intubate, defibrillate, administer meds, pace, decompress,

crich and all the other things we do. Is this evidence, no! Just one

medic,s observation. After 28 years treating patients, I think we do

better for a patients today than we did in my first year.

There's something that seems counterintuitive about reducing the

availability of ALS to the general public, but I may well be wrong. I'm

just curious to see what the collective consciousness of EMS is

regarding this issue.

Best regards,

Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas