Here are some ideas for additional topics or areas of focus that could be included in a paramedic program with an associate's or bachelor's degree:- Additional anatomy and physiology - A more in-depth study of body systems beyond basic A&P.- Pharmacology - A stand-alone pharmacology course to expand knowledge of medications beyond basic indications and contraindications. - Pathophysiology - Understanding disease processes and how they affect assessment and treatment. - Research methods - Learning how to critically appraise research and understand EMS studies. - Community paramedicine/public health - Preparing paramedics for expanded community roles in health promotion.- Leadership/management - Developing leadership and
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Here are some key things I would add to a paramedic program: - Increased focus on anatomy, physiology, pathophysiology and pharmacology. Paramedics need a stronger foundation in how the human body works under normal and abnormal conditions as well as how medications affect the body. - More emphasis on research methods, evidence-based practice and medical literature evaluation. This will help paramedics become better lifelong learners able to evaluate new research and treatments. - Expanded management and critical thinking courses. These help develop assessment and diagnostic skills beyond basic protocols. - Courses in public health, epidemiology and social determinants of health. These provide important context on the communities paramedics serve. -
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Here are some ideas for additional topics or areas of focus that could be included in a paramedic program with an associate's or bachelor's degree:- Additional anatomy and physiology - A more in-depth study of body systems beyond basic A&P.- Pharmacology - A stand-alone pharmacology course to expand knowledge of medications beyond basic indications and contraindications. - Pathophysiology - Understanding disease processes and how they affect assessment and treatment. - Research methods - Learning how to critically appraise research and understand EMS studies. - Community paramedicine/public health - Preparing paramedics for expanded community roles in health promotion.- Leadership/management - Developing leadership and
- 1. Future EMS
- 2. No notes, No Quiz, just Discussion
- 3. Basic Concepts • The Rogers Innovation Curve (1962) • A good overview: https://www.interaction- design.org/literature/article/understanding-early-adopters-and- customer-adoption-patterns
- 4. Basic Concepts - Dependencies Dependent Decoupling Distribution Democratization
- 5. Basic Concepts – 4 D’s of Dependencies (Examples) Dependent Decoupling Distribution Democratization Rare, Experimental, dependent on expertise and specialty resources and knowledge. Beginning to separate from specialty resources, decoupling from finite resources and expertise. Development begins independent of early innovators Use becomes more common. Standard practice. Becomes scalable and reliable. Resilient. Mainstream and accepted. Wide spread impact. Widespread distribution. Extreme distribution becomes decentralized production. Competition and imitation. Miniaturization and mass production, imitation. Refinement.
- 6. Basic Concepts – 4 D’s of Dependencies(Print) Dependent Decoupling Distribution Democratization Books were the province of the elite , the rich, and the church. Representative of both power and riches. Took months or years to make. Block Printing and then the printing press were developed. Early Mass production began. Were still fragile and expensive. Printing became affordable. Newspapers, mass paperback books, pamphlets, etc. Education and books became large scale and open to the masses Self publishing and digital books, blogs, and the internet coupled with widespread basic literacy has put the written in every ones hands. Miniaturized, Cheap, Competitive.
- 7. Basic Concepts – 4 D’s of Dependencies (The Internet) Dependent Decoupling Distribution Democratization 1960’s ARPANET Secret, Advanced, Dependant on limited framework. Closely guarded. Packet Swithching 1980’s ARPANET adopted Internet protocols for standardization (TCP/IP) BBS’s spring up. 1990’s World Wide Web becomes a “thing”. 1994 W3C is formed to develop standards and best practices. HTTP as standard coding. 1993= CERN proposes open source code- royalty free. 2009 The World Wide Web Foundation is formed. Code becomes bottom up and decentralized. Net Neutrality. The internet is everywhere.
- 8. Basic Concepts – 4 D’s of Dependencies (Blood Products) Dependent Decoupling Distribution Democratization Blood administration is cutting edge, dangerous, and the province of a few physicians and anatomists Blood administration becomes more wide spread due to war. Less dependent on specialist. Can be administered by physicians and other providers. Still rare and expensive. Blood Products become more wide spread. Blood banks, standardized best practices and guidelines. Safe(r) to administer. Supply may still be a problem. Still costly. The Future: Blood and blood substitutes are wide spread and available on demand (or dam close). Can be artificially created and/or customizable. Costs for production and storage drop.
- 9. Ask yourself, where are we: •In the innovation curve •In the 4 D’s •Where do we want to be?
- 11. POCUS Point Of Care Ultra-Sonography
- 13. But how would it change my care? • Point of Care+ In the field • Focused Assessment Sonography in Trauma (FAST) • Pneumothorax Detection? • Low Flow PEA vs. EMD? Is it really cardiac stand still? • Central Line Placement • Emerging: Fracture detection ‘Point of Care Ultrasound (POCUS) can significantly increase the accuracy of the prehospital diagnosis which will increase the accuracy of treatments.’ -Peter Bonadonna
- 14. So, where are we with POCUS? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 15. 15 Leads?
- 16. So, where are we with 15 Leads? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 17. Dual Sequential Defibrillation (DSED)
- 19. So, where are we with DSD? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 20. Not a sure thing yet…
- 21. Heads up CPR
- 24. Not sure how I feel about this…
- 27. So, where are we with Heads up CPR? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 28. The problem: Confounding Variables
- 29. Mechanical CPR + PCI?
- 30. So, where are we with Direct to PCI with sudden cardiac arrest? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 31. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
- 32. REBOA
- 33. Zones • The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies and is dependent on the individual). Balloon Landing Zones • Aortic Zone 1 – Extends from the origin of the left subclavian artery to the celiac artery (approximate vessel diameter – 20mm for young adult male) • Aortic Zone 3 – Extends from the lowest renal artery to the aortic bifurcation (approximate vessel diameter – 15mm for young adult male)
- 35. REBOA
- 38. London HEMS
- 39. Partial REBOA (pREBOA): Less is more • pREBOA looks to stabilize and limit bleeding while preventing downstream necrosis of the bowel and other organs. • Two phases: • Phase 1: Complete inflation and occlusion for 10-15 minutes • Phase 2: Partial inflation for 2 + hours to allow for minimal downstream blood flow at low pressures at about 0.5 l/ Minute • If hypotension returns, then the balloon is reinfalted.
- 40. So, where are we with Heads up CPR? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 41. ECMO-CPR
- 44. So, where are we with Heads up CPR? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 45. EMS Body Cams
- 46. Body Cams reduce Complaints
- 49. How is this different?
- 51. So, where are we with EMS Body Cams? • Where in the innovation curve • In the 4 D’s • Where do we want to be? • we want to be?
- 52. Early adaptors in 2016
- 53. Best practices are being developed.
- 54. What are your thoughts?
- 57. Drugs etc
- 58. Epinephrine?
- 59. Whole Blood and Plasma vs. Everything Else
- 60. Return of the Beta Blockers https://emergencymedicinecases.com/esmolol-refractory- ventricular-fibrillation/
- 62. Education
- 63. Why has Continuing Education for Recertification become our ONLY education?
- 64. FOAMed • Free Open Access Medical Education • If you want to know how we practiced medicine 5 years ago, read a textbook. If you want to know how we practiced medicine 2 years ago, read a journal. If you want to know how we practice medicine now, go to a (good) conference. If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM. • from International EM Education Efforts & E- Learning by Joe Lex 2012
- 65. SMACC TALK • Social Media and Critical Care • Became one of the largest and mot well received conferences 2016-2019 (Final Conference) • The mantle has spread… https://www.smacc.net.au/
- 66. Why FOAM? • “FOAM allows you to discuss clinical experience in areas where evidence doesn’t exist or in areas where evidence may send you to a path of confusion.” – Scott Weingart • Standard dissemination of new information is 10 years with adoption at 10-15 years • FOAM disseminates in 1-2 years.
- 67. Why Not FOAM? • Because primary research should never be published on FOAM • -No Peer Review, etc • Because it must be balanced with real critical review of the underlying literature AND a foundational knowledge of the underlying medicine. • Basing practice ONLY on FOAM is like basing medial opinions ONLY on the Abstracts, or political opinions only on the headlines.
- 69. Some of the best
- 70. More of the Best
- 74. Field Training Officer Programs
- 76. 2010 - 2014
- 77. Prehospital Care and Research Forum (2016- Present)
- 78. Resuscitation Outcomes Consortium 2006 - 2016 ROC is a clinical trial network focusing on research in the area of prehospital cardiopulmonary arrest and severe traumatic injury.
- 80. Growth of the Profession…
- 81. Self Direction
- 85. New Blood?
- 86. Full Disclosure – I am a member of the APA
- 87. Degrees for Paramedics “….Believe the time has come for paramedics to be trained through a formal education process that culminates with an associate degree. Once implemented a degree requirement will improve the care delivered by paramedics and enhance paramedicine as a heath profession. “
- 90. Questions to Ponder* (and my OPINIONS) • Is the current hodgepodge system working? • No. • Is an associate's degree enough? • I do not think so. The complexity of medicine seems to me to speak to a need for a BS level degree to met the needs of current and future entry level paramedics. • What is the additional costs? • Small 1-2 K increase over a certificate for an associates • Many programs springing up to pay for it. • What is the benefit? • See next page
- 91. What is the benefit? • It depends… • Need a paramedic specific degree, not just a degree for a degrees sake • Must improve our knowledge, care , and educational parity
- 92. What would you add to a paramedic program?
Editor's Notes
- https://www.interaction-design.org/literature/article/understanding-early-adopters-and-customer-adoption-patterns
- A dependency is a logical, constraint-based or preferential relationship between two activities or tasks such that the completion or the initiation of one is reliant on the completion or initiation of the other.
- A dependency is a logical, constraint-based or preferential relationship between two activities or tasks such that the completion or the initiation of one is reliant on the completion or initiation of the other.
- A dependency is a logical, constraint-based or preferential relationship between two activities or tasks such that the completion or the initiation of one is reliant on the completion or initiation of the other.
- A dependency is a logical, constraint-based or preferential relationship between two activities or tasks such that the completion or the initiation of one is reliant on the completion or initiation of the other.
- A dependency is a logical, constraint-based or preferential relationship between two activities or tasks such that the completion or the initiation of one is reliant on the completion or initiation of the other.
- https://pocusjournal.com/article/2018-03-01p6-12/ Portable ultrasound is a burgeoning technology with unrealized potential at a critical point in its evolution [1]. Francis Galton first generated ultrasound waves in 1876; however, it wasn’t until 1940 that ultrasound was first applied to clinical medicine [2]. Reaching a “tipping point”, ultrasound is being rapidly assimilated into many medical specialties beyond radiology, now in the hands of non-radiologist, non-cardiologist novel users [2]. Diagnostic medical ultrasound has been widely incorporated into emergency departments since the early 1980’s; however, machine size and cost has limited its use to the hospital setting [3]. The democratization of ultrasound to paramedicine could alter clinical decision-making, improve time to perioperative care, and enhance triage capabilities [1-3]. An augmented ultrasound physical examination would allow for treasurable clinical findings otherwise unobtainable to paramedics, revolutionizing prehospital medicine in a manner that is unprecedented by other tools in the arsenal of emergent care.
- https://rebelem.com/beyond-acls-dual-simultaneous-external-defibrillation/ Out-of-hospital cardiac arrest (OHCA) occurs in the United States at a rate of nearly 300,000 individuals per year. Even more concerning is the high mortality rate which is associated with this. The majority of OHCA is due to cardiac etiology with the most common initial rhythm being ventricular fibrillation (VF). What we all know is that high-quality, limited interruption cardiopulmonary resuscitation (CPR) and early defibrillation are the hallmarks of successful neurologic outcomes in OHCA. For many who have heard me speak about ACLS, you have heard me say that these guidelines are created for the providers who do not perform resuscitation as part of their daily routine. For those of us in the trenches of the emergency department, we have to think beyond ACLS at times. Although VF typically responds very well to the standard energies of defibrillation, maybe in patients with higher body mass index or morbid obesity we need higher energies to achieve successful defibrillation.
- How do you perform dual simultaneous external defibrillation? This procedure should only be used in refractory ventricular fibrillation after multiple attempts at defibrillation and appropriate medications have been given Using a second defibrillator, you can place a second set of external defibrillation pads next to each other, but ensure that the pads are not making contact with each other Charge both monitors (360J for monophasic and 200J for biphasic) Ensure everyone is clear of the patient Simultaneously press the shock button on both monitors Immediately resume CPR
- Am J Emerg Med. 2018 Sep;36(9):1674-1679. doi: 10.1016/j.ajem.2018.05.078. Epub 2018 Jun 1. The controversial role of dual sequential defibrillation in shockable cardiac arrest. Pourmand A1, Galvis J2, Yamane D2. Author information Abstract BACKGROUND: In the United States, over 350,000 cardiac arrests occur outside of the hospital and 209,000 occur in the hospital. Shockable rhythms such as ventricular fibrillation (VF) have a survival rate of 20-30% outside of the hospital setting. Dual Sequential Defibrillation (DSD) has demonstrated success in terminating VF that is refractory to multiple attempts using a single defibrillator. METHODS: The PubMed, and MEDLINE databases were reviewed in February of 2018 and literature reviewed on dual sequential defibrillation. The terms "dual", "sequential", "double sequential", and "defibrillation" were added in the search builder. This search was limited to English-language articles. The results and their references were assessed for relevance to the topic and implications for dual sequential defibrillation in shockable cardiac arrest. RESULT: Included search terms yielded 23 articles. Studies occurred in the emergency department and prehospital setting. There are two retrospective cohort studies and the majority of published studies are case reports/series. Sample size per study varied from 1 to 279 encounters. CONCLUSION: Studies have shown success in using DSD to treat refractory VF. However, further studies are necessary to assess the efficacy and safety of DSD compared to the standard of care treating refractory VF. Copyright © 2018 Elsevier Inc. All rights reserved.
- Inspired by the clinical question of whether patients in cardiac arrest should be transported either head-up or feet-up in a small elevator, an initial animal study was performed in 2014. In this swine model of cardiac arrest, pigs underwent five-minute periods of automated CPR with an impedance threshold device (ITD-16) in the traditional supine position, then with a 30-degree whole-body head-up tilt, and then a 30-degree whole-body head-down tilt.
- The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has become a topic of considerable interest as of late, primarily to treat non-compressible truncal hemorrhage (NCTH). However, it is beginning to expand into other causes of non-compressible bleeding. Is this REBOA thing new?! Nope. The concept and use of REBOA has been around since at least 1954, when Lieutenant Colonel Carl Hughes of the US military published an article describing one injury in which REBOA was used to treat NCTH and two other battlefield injuries in which REBOA could potentially have been used to stem the bleeding (Hughes, 1954). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used as part of damage control resuscitation for patients with non-compressible truncal hemorrhage. The next published data following this initial report was in 1986 and 1989 (Gupta et al., 1989; Low, Longmore, Rubinstein,Flores, & Wolvek, 1986) showing the use intra-aortic balloon occlusion in traumatic injuries actually leading to some individuals surviving. However, with no randomization obviously it was not possible to determine if this was due to use of REBOA, extent of injuries or something else entirely. Interestingly, following these publications the study and use of REBOA for trauma seemed to fall off the map entirely….until recently.
- The two main landing zones for REBOA placement are in zone I (intra-thoracic) for intra-abdominal bleeding, or zone III (intra-abdominal distal to renal arteries) for pelvic bleeding. Classically, placement was confirmed via x-ray/fluoroscopy, however more recent data shows either ultrasound confirmation or simply clinical assessment may be accurate.
- Who gets REBOA? As with many invasive procedures in critically ill patients (eg. ECMO), the million dollar question really is who gets REBOA. Trauma centres in both Denver (from manuscript; below) and Baltimore (below; widely available on internet) have proposed various algorithms in order to determine who gets REBOA in the trauma bay, and where REBOA should be placed (ie. Zone I vs Zone III)
- Who gets REBOA? As with many invasive procedures in critically ill patients (eg. ECMO), the million dollar question really is who gets REBOA. Trauma centres in both Denver (from manuscript; below) and Baltimore (below; widely available on internet) have proposed various algorithms in order to determine who gets REBOA in the trauma bay, and where REBOA should be placed (ie. Zone I vs Zone III)
- Why esmolol for refractory Ventricular Fibrillation? In refractory Ventricular Fibrillation there is a huge increase in sympathetic tone at least partially due to the epinephrine given, which results in increased myocardial oxygen demand, exacerbation of myocardial ischemia, and depression of the VF threshold. Esmolol is the perfect sympatholytic and it increases the fibrillation threshold. It has the fastest onset and shortest half-life of any B-blocker. What is the evidence for esmolol for refractory Ventricular Fibrillation? The evidence for esmolol in refractory Ventricular Fibrillation isn’t the greatest – no big RCTs to be certain. There are a handful of older small studies looking at other B-blockers in cardiac arrest that looked promising, but these were done in an era of cardiac arrest management that is now considered archaic. The evidence we have for esmolol in refractory VF in particular comes from 2 more recent studies performed in the latest era of ACLS management. A 2014 out of a single center in the U.S. compared 6 patients who got esmolol after usual ACLS care with 19 controls who just got usual ACLS care. All 6 patients achieved ROSC after 500mcg/kg IV bolus followed by a drip of a maximum of 100mcg/kg/minunte – with 4 of them achieving sustained ROSC. And here’s the amazing part – survival to discharge with a good neurologic outcome was 50% in the esmolol group vs 11% in the control group. Tiny study with impressive results. Then in 2016 there was another retrospective study of out of hospital cardiac arrests in Korea comparing 16 patients who got esmolol to 25 patients who didn’t. They used the same dosing of esmolol as the previous study, again after usual ACLS care – 3 shocks, 3mg of epinephrine and 300mg amiodarone – and they found similar outcomes: improved rates of ROSC and survival to the ICU. So while we’re waiting for some bigger multicentre RCTs, for now, consider esmolol after 3 shocks, 3mg of epi and 300mg of amiodarone in your refractory Ventrcular Fibrillation patients. While esmolol isn’t ready for routine use in this setting, it should be considered as part of the “kitchen sink” when nothing else is working.
- FOAM – Free Open Access Meducation – Medical education for anyone, anywhere, anytime. This page is dedicated to collating the resources that healthcare professionals and students can access to take part in the FOAM movement. The term FOAM was coined in June 2012 in a pub in Dublin, over a pint of Guinness during ICEM 2012
- n March 2013 the emergency medicine and critical care FOAM movement crystallised in a unique conference called SMACC (Social Media and Critical Care). This was followed a year later by an even more successful event held on the Gold Coast, smaccGOLD, before over 2,000 people assembled in 2015 for SMACC Chicago. Since then the conference has gone from strength to strength — with smaccDUB in Dublin (2016) and dasSMACC in Berlin (2017) — and become a community in its own right. The next SMACC will be in 2019, when it will return to its origins in Sydney, Australia. https://www.smacc.net.au/the-future-of-smacc/
- You need research, and research should never be published on FOAM. That would be crazy to have an original research topic published on a blog or podcast, because there is no peer review, there is no vetting and it doesn’t make a lot of sense. So publish in the traditional journals, but then to actually try and translate to the bedside, to make this usable, to have dissemination, the obvious channel is free open access medical education. The authors and researchers and scientists that are savvy to this are engaging with these new outlets are calling me up and saying “Hey, I just published this study, it’s right up the alley of EMCrit, can you do a show on it or have me on for an interview?” I say hell yes, because that’s what we do best. It’s taking that work and getting it out there. The standard dissemination cycle takes like ten years and we can do it in ten minutes. And then what I think my bent is, is trying to figure out is how to take the research and actually make it usable on a clinical ship or on a doc in the trenches of the ICU or an ED.
- The mission of the Resuscitation Consortium is to provide infrastructure and project support for clinical trials and other outcome-oriented research in the areas of cardiopulmonary arrest and severe traumatic injury that will rapidly lead to evidence-based change in clinical practice. The focus on prehospital and early hospitalization interventions recognizes the critical importance of this time frame and early congruence between the emergency cardiac and trauma populations. ROC Investigators will conduct collaborative trials of variable size and duration (equally directed towards the cardiac and trauma populations), leveraging the combined power of the member institutions and promoting the rapid translation of promising scientific and clinical advances for the public good.