Less of That, More of This


Over at EMS 1, ambulance driving expert Kelly Grayson wrote an excellent column about how he became a “stand back, big picture, non-interventional paramedic.”  He describes how he would manage a crashing pulmonary edema patient at different phases of his career.  The interventions became less invasive at each phase, to the benefit of the patient.

Kelly’s column let me to reflect on my career.  The more skilled I got at the invasive skills, the less I find myself using them.  I also find myself doing more of some less war-story worthy interventions that are proven to improve outcomes.  Here are some of interventions I find myself doing less often, and some of the ones I do more.

Less Often:

1.  Intubation

I used to need a reason not to intubate someone.  Delivering a patient to the hospital with a tube in their throat seemed more important than chest compressions, ventilation, or the patient’s comfort.  Now on cardiac arrests it gets done during compressions or a short rhythm check, or else they get a Combitube.  On the rare occasion I intubate a patient in respiratory failure, afterwards I think about what could have been done to avoid it.  In the time I generally spend with head injured patients whose teeth are clenched, I’ve discovered that energy spent with with a bag valve mask and suction is more effective airway management than trying to get a tube down their throat or nose.  My goal now is to set up a nice package for the hospital to intubate instead of trying to do it myself.

2. Treating Wide Complex Tachycardias

After this call on my second day working as a paramedic on my own, I became a little obsessed with wide complex tachycardias (WCT’s).  I’m no Tom Bouthilet, but I’m pretty good at differentiating V-tach from other causes.  The more I learned though, the more I realized both how much I didn’t know about them and how harmful antiarrhythmics can be.  Now my skills in this area are utilized mostly for cases on Tom’s website.

For patients with regular WCT’s who are stable, I assume they are in V-tach but generally don’t intervene.  Instead I notify the hospital with the patient’s information so they can find an old ECG or call their cardiologist before we get there.  In case they become unstable and need to be cardioverted, I do put the defib patches on, start an IV, and have Etomidate ready.  But knock on wood, so far I’ve never had a stable WCT patient get worse before we got to the hospital.

3. Oxygen

Each of my patients used to get a NRB mask.  Then they got a nasal cannula.  Now even chest pain patients get none if their pulse-ox is above 92%.  After years of being taught not to treat the pulse-ox, now we know it’s usually okay to treat the pulse-ox.   Our protocol is to titrate oxygen to maintain their sat at 92%.  Not 100%.  Anything more than that is probably harmful  For patient’s on CPAP, now I don’t increase the FiO2 unless their pulse-ox stays low.    I still give shocky patients with normal pulse-ox a non-rebreather mask, but I’m still trying to figure out if that’s a good idea.

More Often

1. CPAP

I believe that this non-invasive intervention has done more good for more patients than any other tool we have.  I used to only use it on really bad, near respiratory failure patients.  Now I use it on any CHF or COPD patient who has difficulty speaking more than a few words.  These moderately sick respiratory patients usually don’t look sick at all when we get to the hospital and report feeling much better.

2. Pain Medication

I used to only give pain medication to people I thought were really hurting.  Peter Canning and Mike Taigman’s writing about pain medication have really changed my attitude about this.  I’ve learned that the only reliable way to tell how much pain someone is in is to ask them.  So now I usually ask patients if they’d like any.  We also switched from morphine to fentanyl a few years ago, which has fewer side effect and patients seem to tolerate it better. It also helps that we don’t need to request orders for it anymore.

3. Chemical Sedation

After a few years of sitting on combative patients on the way to the hospital, having hospital security fight with them, and having watched them receive chemical sedation in the hospital, I decided that was stupid.  Now I joke with the hospital security guards that the only time I’ll ever ask for them is when the drug bag is empty.  If verbal deescalation fails, they get 5mg of Versed up the nose.   If they’re still combative after a few minutes, I give them 5 mg IM Haldol.  Patients who were combative patients are usually sleeping when we get to the hospital.   Of course I watch their pulse-ox, airway reflexes, and respiratory rate, but have never had a problem with these.  Chemical sedation keeps everyone safe, which is good for the patient and good for us.

Steroids for Asthma

When I started working for a service that carried PO Prednisone, I thought it was something I would never use.  Then I read a study from Norfolk about how prehospital IV Solu-Medrol was associated with lower hospital admission rates in moderate-to-severe asthma patients.  Now I give PO Prednisone to most asthma patients who are able to speak in longer phrases after starting a breathing treatment.   If they can’t get out more than 2-3 words at a time, they get IV Solu-Medrol.  If we can help someone go home in a few hours instead of stay overnight at the hospital, then we made a difference.

As I enter my second decade as a paramedic, continuing to learn maintains my enthusiasm.  We don’t always need new tools or toys, we can just get wiser about when to use the ones we have.

So what do you do more or less of?

Comments

  1. Mark Rock says:

    Mr. Sullivan,

    You really need to reconsider your position on “pain medication.”

    The term has become a euphemism for narcotics, and EMS has fallen victim to the same scam that overcame the clinical community, beginning almost twenty years ago when special interests began to lobby for more aggressive “pain management.” Documents from 2007 show that the pharmeceutical industry, including Endo, Abbott Laboratories, Cephalon, Purdue Pharma, and Johnson & Johnson, all of whom manufacture narcotic pain medications, pumped millions of dollars into a campaign to make pain “the fifth vital sign.” This lobbying culminated in regulatory agencies pressuring physicians to overprescribe narcotics to patients; this in turn has led to what the CDC has termed a “public health crisis” of opiate-driven overdoses and deaths. EMS followed suit, and self-desinated “experts” like Mike Taigman led the charge to emphasize the liberal administration of narcotics in our practice. Here is a sample of Mr. Taigman’s expertise:

    “The reason I talk about suffering management and not just pain management is because from the patient’s perspective, it might not be a specific pain. It might be, ‘I’m feeling really bad. I’m throwing up, sweating, ready to pass out.’ If we give an opiate and something to manage the nausea, that might relieve their suffering” (http://www.emsworld.com/article/11079128/pain-management).

    Seriously? ” ‘I’m feeling really bad. I’m throwing up, sweating, ready to pass out.’ ” – and the solution is an opiate?

    Mr. Taigman’s sage wisdom aside, here is what the results have been on the clinical side:

    – Since 1999, the number of overdose deaths involving opioids (including prescription pain killers) has quadrupled.

    – According to the CDC, overdoses from prescription opioid pain relievers are a driving factor in the 15-year increase in opioid overdose deaths.

    – Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled – yet there has not been an overall change in the amount of pain that Americans report (https://www.cdc.gov/drugoverdose/epidemic).

    Overdoses involving opioids killed more than 28,000 people in 2014, with over half of those deaths directly attributable to opiates originating via prescription or otherwise obtained from healthcare professionals (https://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html).

    The clinical community has acknowledged, and acted to correct, this mistake:

    – In June, 2016, the American Medical Association recommended that pain be removed as the “fifth vital sign” across the board in professional standards, stating “Just as we now know (the) earth is not flat, we know that pain is not a vital sign. Let’s remove that from the lexicon.” (James Milam, MD, delegate to the American Medical Association).

    – “The Joint Commission does not endorse pain as a vital sign, and this is not part of our standards.” (April, 2016 JCAHO official statement on pain management).

    In March of 2016, the CDC called upon the medical community to stop the widespread, rampant administration and prescription of opioids. (http://www.foxnews.com/health/2016/03/16/cdc-urges-doctors-to-curb-prescribing-painkillers.html).

    Even Russell Portenoy, the “pain management specialist” who received millions of dollars from major drug companies in order to push the whole “fifth vital sign” movement, has backpedaled: “Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do.” (Russell Portenoy in The Wall Street Journal, December 17, 2012).

    How should we, as EMS providers, respond?

    There are three main points that have significant implications for EMS:

    1.) An over-emphasis on “suffering reduction” interferes with and detracts from the primary mission of EMS – to recognize and treat life-threatening conditions through the prevention and/or correction of oxygenation and perfusion compromise.

    2.) Administering narcotics and managing their significant side effects extends on-scene times, delays prompt definitive care, and creates additional risks for patients.

    3.) With our education, licensure, and recognition among the public, we lend legitimacy to any practice in which we engage or advocate for, including the frequent and lenient administration of narcotics.

    Following from these points are actions to be taken as follows:

    1.) EMS agencies and authorities need to undertake a sober reappraisal of the new focus on “pain management” and “suffering reduction”, and determine a course of action to address these concerns that does not advocate, nor condone, either in fact or through implication, the indiscriminate provision of narcotics.

    2.) The mindset regarding narcotic administration by EMS needs to be recalibrated to come into alignment with recent realizations and subsequent decisions by advisory and governing agencies.

    3.) EMS policies and protocols at the national, state, and local levels need to be revised to reflect these developments and understandings.

    It is my hope that the facts – and the reason and rationality that should follow – will prevail over the misguided ideology that has taken us astray over the past ten years.

    Mark Rock

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