Jumping off bridges

No, this isn't a post about the Golden Gate Bridge.

Although it could be.

More a comment a bout blind allegiance without question.

I think everyone's mother at one time uttered the phrase "If all your friends were jumping off a bridge would you do that too?" when our defense of a choice was "But all my friends are doing it!"

I was wondering recently why so many systems are running full speed towards certain treatments that have a great effect, but not necessarily pre-hospital.  If the beneficial time of application is within 3 hours of illness or injury and my average time from patient contact to hospital is 30 minutes, is that worth the investment for the system?

What if the time of application is 6 hours?

If studies show that applying treatments within 6 hours is beneficial, is that a good investment for my system?

So many systems are running towards therapeutic htpothermia and judging by the studies it is a beneficial treatment.  But do we need to be starting it immediately?  From what I can tell systems with prolonged transport times, only Intermediate Life Support, most rural areas, could see a great improvement in patient outcomes.

But in the urban settings, when even the ER could wait to apply it, is it something we need on the rigs, in our continuing education, and yes I'll go there, additional opportunity for misapplication (liability)?

When does the risk/cost outweigh the benefit?

I think it is similar to the decisions I make in starting an IV pre-hospital.  We have nifty little saline locks attached to tubing for "gaining access."  With the risk of infection in the back of my rig, or worse yet in the street, I will only take that risk if the benefit is there.  Why am I breaking the skin simply to attach tubing?  If I am not anticipating the administration of life saving fluid or medication, then why even do it?

When these pricey little guys arrived in our bags there was a training session and now 4 saline tubes and tubing are in my overflowing 40 pound bag.  In the early days someone (I don't know who...) put a little paper in the baggie with the saline lock that read:  "Peripheral venous puncture is not a benign procedure.  If you do not anticipate the administration of life saving fluid or medication, does the benefit of administration outweigh the risk of infection?"

I still don't use them and am quite within policy, protocol and the one that should be first on the list, the patient's best interests.

BUT, on the other side of the bridge jumping argument, I like to think I surround myself with people who are like minded, forward thinking individuals.  If Ted Setla, Radom Ward, Chris Montera and Jeremiah Bush jumped off a bridge I would have to ask some serious questions as to why.  Or trust my friends.

I have made some blind leaps in the past that I now find foolish, probably still a few left in my future, but a blind allegiance is the thing I want to bring to your attention.  It is said that the most dangerous person is the true believer and someone who will blindly jump off that bridge with their friends no questions asked is the same in my mind.  However, a constant doubter, someone who refuses to jump or stay, but wants to see what the majority of folks do first is equally as foolish.

So when Mom asks  "If all your friends jumped off a bridge, would you jump too?"

I'll answer:

"Well...is there a train coming?"


Slightly different corollary to apply in this or some future blog post: I found one of my kids swinging from a rope off an upper balcony in a gym - crazy insane stupid - with a bunch of friends.  In alarm, I barked at them to knock it off before they all got killed.  My kid's immediate reply: "No Dad, only one of us will get killed, then we'll stop".

I think the answer you seek is somewhere in there.

Anyway, I LMAO and awarded the kid 10 attaboys for quick wit, but still made them stop.
Wm. Random Ward said…
In my system if we are going to bill the call as an "ALS" call there are some procedures and steps which must be followed in order to receive medicare reimbursement. Remind you of a recent argument we put forth? Here's the deal, because we use ICD-9 codes to code for our billing records we have to at least apply oxygen, a monitor, and achieve veinous access (or at least attempt) in order to charge for an ALS call. Furthermore, if the patient is complaining of one of the 30 or so ALS level complaints that we have listed as per our billing process we are required to either take BLS or ALS actions and then justify it within the coding schedule. So the real question is, how much longer are we going to allow reimbursements to justify our treatment?
Rogue Medic said…
I do not do billing, and have not read the Medicare publications, but I have been told by people who are supposed to know this stuff that ALS is based entirely on whether an ALS assessment is appropriate.

IVs are not generally a part of my assessment.

In my new Pennsylvania protocols, oxygen is only indicated when SpO2 is below 94%. 

I would be violating protocol to apply oxygen to all ALS patients, even though most ALS patients do not require oxygen. 

Of course, I expect that a lot of medics in Pennsylvania will foolishly assume that oxygen cannot be harmful and apply it because it is traditional and because we can. 

Most of the local hospitals do not accept blood samples drawn by EMS, so the only reason for me to start an IV is for a route to give medication (a bolus of 0.9% saline is a medication).

I could be wrong. I am trusting some people who work in EMS - and we are often wrong about a lot of things - but I have been told by a lot of people who should know that ALS payment is based upon an ALS assessment.
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Too Old To Work said…
I don't do the billing although I do know a bit about the subject. No one from management has ever suggested that I have to apply the cardiac monitor, start an IV, or give oxygen in order for a transport to qualify as an ALS 1. I rarely start an IV on an Asthma patient unless they are so sick that I think they will need either IV medication or intubation. Or both. I never apply a cardiac monitor to a penetrating trauma patient unless I plan to intubate them and the it's mostly for SpO2 and EtCO2 monitoring. I neither give Oxygen NOR apply the monitor to hypoglycemic patients, although I usually end up starting an IV and giving D50.

Through all of these calls over the years no one has ever suggested that my course of treatment was wrong.

I think that Rogue Medic is correct.
Too Old To Work said…
So many systems are running towards therapeutic htpothermia and judging
by the studies it is a beneficial treatment.  But do we need to be
starting it immediately?  From what I can tell systems with prolonged
transport times, only Intermediate Life Support, most rural areas, could
see a great improvement in patient outcomes.

It would seem so. We do therapeutic hypothermia and not only is sooner better, but it also has the side benefit of pushing the hospitals to continue a proven therapy that they might not be inclined to otherwise use. Think about that for a minute. This is a case where EMS may not only be doing something new in terms of increasing patient survival to discharge alive and neurologically intact, but we are driving hospitals into adopting the same therapy.

That's pretty amazing if you ask me. EMS, at least my system, is ahead of hospitals in using EtCO2 in the ED and now we're ahead of them in using therapeutic hypothermia.

That right there is EMS 2.0 in action my friend.
Rogue Medic said…
I have no problem with therapeutic hypothermia by EMS if it actually improves outcomes. That is not yet clear. There is expected to be a discussion of one aspect of this on the next EMS Garage.
Too Old To Work said…
It seems pretty clear from the research that it does work. The question is when to best implement it, and the answer seems to be as soon as possible. There are other questions to be answered such as who will benefit the most, the best way to perform the cooling, and so on still need to be completely answered. We've been doing this about three years and have already modified our protocol from ROSC after VF to ROSC after any type of medical arrest.