EMS is always evolving. we struggle to keep up. So if you are like US and want to provide the best for your community, we may have something for you, or you may have something for us!
Rural BLS systems
One of the hardest things in Rural EMS is to remember how big your tool box is! If you are a BLS service, push hard for Advanced Airway devices and then train with them, quarterly, monthly. Just don't be a once and done team.
Rural ALS Systems
Rural can mean a lot of things. It can mean it's a small service about 35 miles from The Nebraska Medical Center in Omaha, or it can mean a 2 ALS truck service in North Central South Dakota, 2 hours from any trauma II center. Advocate hard for being a part of the standard. Sam always says, "In rural EMS you should never be trying to create the standard in evidence based EMS, you should be trying to be a part of the standard, helping other rise up to that standard.” A service with fewer than 2000 calls a year shouldn't be initiating a prehospital trial alone. Team up with a nearby service and share information.
If you ever want to discuss a more sour subject in rural EMS, it could be medication Ketamine. Ketamine, some of you who read this are going to be like, "ok what's the big deal? We give it all the time". So let me explain the complication. There are hundreds, if not thousands, of EMS services across the US that are using protocols and medications from the late 90's. We are approaching 2020. Lets act like it. There is so much substantial evidence on Ketamine for the use of RSI, sedation of both excited delirium patients and agitated patients, pain control, and the treatment of Asthma exacerbation. The best part is that it is a bronchodialtor, and it doesn't effect pressures like most sedatives or analgesics do. I have compiled an entire page of Ketamine resources Ketamine. I'm not saying Ketamine needs to be in use at every ALS service, but it would be irresponsible to not even consider it.
Hospital Based Systems
These are some of the hardest and/or most rewarding services to work for. Hospital-based ambulance services can provide resources that are typically not found in other systems. Whether you're an employee, supervisor, or manager/director, the two things to watch for will be the dynamic between EMS and the hospital, and are we doing what's best for our community. Let me give you a fantastic point of view. Read my letter I submitted to a hospital service I worked for for a while.
WOW! RSI has been an interesting issue in EMS. There are many, who discuss the "should medics RSI? or should they not RSI?. What so many agencies don't realize is how much schooling Paramedics go through. We should be considered specialists in prehospital medicine. We are more than transport personnel. We are emergent cardiac, respiratory, IV specialists. So I'll make this simple: RSI is a combination skill of medications, preoxygenation, anatomy recognition, and practiced technique of ET placement with waveform and ETC02 confirmation. Anybody can argue the drugs. See our approach to RSI medications here. Simply put, if we fall into the old school practice of sedate, paralyze, tube, sedate, paralyze, sedate, paralyze, now its someone else's problem. We are being irresponsible and could be harming the patients.
Vent management is a whole other ball game. We can consider the basics, advanced, or critical care approach to vent management. I'd highly recommend checking out Eric Bauer's Ventilator Management. But never ever forget, we can always go back to basics.
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From all of us,
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