FlyingSquirrel

OK, why don't we approach this a little differently. As I am not a CRNA, I have absolutely no problem admitting that there is alot about propofol and other sedative/anesthetics/paralytics that I don't know about. However, I also do know that I am pretty well educated and experienced in the uses of various sedatives, analgesics, and paralytics, as well as basic and invasive airway management and the fundamentals of ventilator management. In the ED, of course we always have very competent ED MD's present, along with all kinds of other expert clinical support, like pharmacy, respiratory, anesthesia, etc. In the field however, our RN/Paramedic teams are on their own. We routinely perform RSI and maintain sedation/paralysis and mechanical ventilation without the luxury of anesthesia backing us up. I and many others have extensively used protocols which incorporate etomidate, propofol, succinylcholine, rocuronium, vecuronium, fentanyl, morphine, versed, and valium in this setting. I may not possess a anesthetist or pharmacist-level of knowledge on these meds, but I don't think that is a reasonable expectation or more importantly, necessary to there safe use. Thats what the medical directors who write our protocols and provide medical direction are for. Perhaps it is just because of my ignorance, but I am not aware of any poor outcomes ever occuring specifically because of a medication we used. So anyway, instead of just repeatedly telling us non-anesthesia people things like "you shouldn't be using this drug....it does things you aren't aware of....you don't even know what you don't know....you'll never get it.....read the package insert", why don't you instead try to have a little more respect for our capability to understand and educate us a little on what it is that we don't know? In other words, why, specifically, shouldn't we be using the drug?

OK, I see that you are one of those types who is incapable of having a productive discussion with someone who thinks or is used to doing things a little differently than you. You assume that I'm cocky and incompetent just because I'm comfortable doing something that you think I shouldn't be? That's a pretty ballsy and closed-minded assertion considering how little you know about me and my experience. No, I didn't miss that part of the insert. If I based my entire practice on the warnings listed on drug inserts I would never give anything to anybody. More than one lawyer, more than one medical director, more than one anesthesiologist, and more that one state board of nursing disagrees with your legal interpretation of that statement. I'm not the only non-anesthesiologist in the world who uses propofol and is comfortable with it.

I don't know what to tell you...the ED docs I work with are comfortable with it, the hospital administration is comfortable with it, the clinical pharmacists are comfortable with it, myself and the other nurses are comfortable with it, and frankly, I have never even heard of any problems with it. Personally, I am more comfortable with propofol than I am with large doses of versed. I can also find nothing in the package insert or my states' nursing practice act that indicates that we should not be using it or that we are using it innapropriately. You can dislike the idea of "general anesthesia" in flight all you want...I can tell you it's a very common practice. I've personally been doing it for several years now and have never had a single problem.

Propofol is a safe drug as long as it is given carefully and slowly and someone is present who can quickly perform airway management if necessary. Like ALL drugs, the person using it needs to be familiar with all of its effects. Propofol is extremely short acting and the negative effects of propofol usually wear off much more quickly than those of versed, which, in my opinion, is no more predictable than propofol. The same precautions should be taken during any CS, no matter the specific medication used. We use it routinely for conscious sedation in the ED and in flight. Granted, when we use it in flight we are usually using it for induction for intubation, but not necessarily.

These are the facts. I can easily support all of the following statements: 1) Medic 173 is FOS. His original post was meant only to inflame. And many of you fell for it. 2) Newer paramedics are VERY well educated; the clinical and classroom hours required of the new DOT curriculum is at least as extensive as that of a typical AAS nursing progam. No states require an AAS degree for paramedics yet THAT I KNOW OF, but that will likely change very soon. At any rate, most paramedics I know have well more education than the minimum that is required for the profession anyway. 3) The low pay that paramedics are forced to tolerate has nothing to do with their value; as someone else said, hospitals would pay RN's $5 an hour is they could. It's simple supply and demand, among other factors. 4) Paramedicine and nursing are very different fields. There is alot of overlap as far as the knowledge levels and skill sets that the two professionals posess, but there are as many differences as similarities. Nurses have a much broader education than paramedics, but the paramedics' is much more focused and in depth. Many entry level skills for paramedics are considered advanced skills for nurses, but nurses possess many skills that paramedics don't, as well. 5) There are few true absolute limitations to paramedic practice. It varies widely by state, but there is no universally-accepted scope of practice like the "Nurse Practice Act" that every state has. In most cases, paramedics can legally do about anything that their local medical directors train and authorize them to do. While not extremely common, it is also not uncommon for paramedics to place central lines, make referrals, give paralytics & intubate, acquire and analyze 12-leads ECG's, give thrombolytics, interpret labs, etc. Paramedics truly do practice medicine, albeit within a very narrow scope. 6) If you think about the skill set that paramedics posess, it makes good sense to try to utilize them in the ED. In a large, busy ED, a "resource paramedic" or two could augment medical and nursing staff by performing assessments, doing EKG's, starting lines, drawing labs, giving meds, acting as a liason between the ED and prehospital services, etc.

Mike, First, I want to tell you that I truly appreciate your input and the time that folks like you often take to reply to questions from folks like me. I come to forums like this primarily to learn from people who I know are much more knowledgeable than myself in their areas of expertise, but I also like to take the opportunity, when it arises, to educate other health care professionals about the challenges that critical care transport clinicians face, as well as the capabilities that many of them have. At any rate, I realize that before I can expect any more input from the members of this forum, I owe a bit of background. I am a flight paramedic/RN with a civilian helicopter EMS (HEMS) program that covers approximately 22 rural and semi-rural counties. Like most HEMS programs, we typically staff with a crew that consists of a critical care nurse and a critical care paramedic. In order to even interview for a position with us one must have, at a minimum, ACLS, BTLS, and PALS, along with several years of experience in your respective field. Most succesful candidates have multiple "extra" credentials and/or have backgrounds as instructiors in one or more pertinent areas. Our mission is to provide critical care transport throughout our service area by helicopter, a job which frequently involves stabilization of the ABC's at the scene of the accident or in the rural hospital ED. (We are not "first responders". A first responder is a person who is minimally trained to provide the most basic level of emergency medical care, such as CPR, splinting, oxygen administration via non-rebreather mask, etc. This level of EMS certification is designed for folks such as firefighters and police officers, who need fundamental ABC management skills but whose primary job is not to provide medical care.) Though we market ourselves as a "critical care transport" agency and do have that capability, our bread-and-butter is really the rapid stabilization and transport of acutely ill people, mostly trauma patients. About 60% of our calls are "scene calls", probably 30% are transports from rural ED's to tertiary facilities, with about 10% being critical care transports of ICU patients. Management of the ABC's - specifically securing of the airway - is the primary focus of our care standards and our initial and ongoing training. Though I can't quote too many stats and percentages off the top of my head, a recent review of medication usage revealed that we induce chemical paralysis on about 30% of our scene flights, and I know that roughly 90% of the patients we intubate are intubated on the first attempt at laryngoscopy and are described as either "easy" or "mildly difficult" by the intubator. Most of our intubations in the field involve the somewhat "prophylactic" intubation of a patient who is breathing adequately, but in whom we suspect a significant brain injury. Many of these patients are intoxicated. Most of these patients are pretty easy to intubate with etomidate, sux, and standard endotracheal technique, but we definitely run into our share of difficult airways as well. The difficult ones are normally due to some significant facial/neck/chest trauma, which is compounded by the need to maintain in-line cervical stabilization and the generally uncontrolled environment (strange positioning, very high- or low-light conditions, suction won't work, patient has a belly full of beer and pizza, has been mask ventilated by ground EMS for 10 minutes before our arrival, is hypoxic and/or hypotensive, etc). Our formulary includes etomidate, propofol, versed, valium, ativan, fentanyl, morphine, succinylcholine, rocuronium, and vecuronium, in addition to a full complement of ACLS and vasoactive drugs. Our airway skills repertoire includes standard ETI, nasotracheal ETI (very rarely done), bougie assisted ETI, digital intubation, combitube placement, needle cric w/ jet insuflation, retrograde intubation, and standard surgical cricothyrotomy. We used to carry LMA's but really didn't use them at all. We train on these meds, skills, and the associated clinical decision making extensively upon initial hire, and regularly after that. Our standards of care allow for any appropriate combination of the aforementioned drugs and techniques; we do not have a rigid algorithm-type protocol to follow. We use the Univent EAGLE transport ventilators, usually in the control mode. So, in response to your comment on how difficult it would be to do a retrograde on someone who is awake and combative....they never are awake. And in response to your comment on how difficult it would be to do a retrograde in the field....yeah, airway management in the field can be tough, but sometimes - even more often then in the hospital, I'm sure - less invasive techniques simply don't work for a variety of reasons. Generally, if we are at a point in managing a difficult airway where we're starting to think about having to do something invasive, we really only have two option: a retrograde or a surgical cric. Frankly, we arent too worried about placing a wire in the brain, because what are our options; not intubate the patient and let them almost CERTAINLY develop an anoxic brain injury, just because they MIGHT have a basilar fracture? What is the likelihood of a wire ending up in the base of the skull anyway, before we see it and retrieve it from the pharynx? As far as the low success rates in the hospital, I dare say the operators there probably just aren't experienced and confident with this technique.....the 0.006% tells the whole story. If were an EM doc, and I could call anesthesia or ENT every time I got a tough airway, then I would never do a retrograde either, and I would therefore probably be no good at it. If the hospitals did more retrogrades they would certainly have much higher rates of success. It appears to me that as with so many things, the problem is not with the technique at all, but with the way that it is (not) used. Just because a given tool isn't frequently used doesn't mean that it couldn't be, especially in a setting and in circumstances that are very different from that which was studied. Our clinical training and operations are overseen by a panel of 9 medical control physician, all of whom have emergency medicine, surgical, or internal medicine backgrounds. Because we don't have any anesthesia specialists to consult, our quest to find the most updated airway management info often relegates us to studying the literature and the advice provided from resources such as this forum. So thanks for the input and thanks for letting me tell a little about what we do. Sorry for being so long winded. -Allan

As stated, the benefits of a retrograde are that it is less invasive, and results in a much more definitive airway. I've never personally done one on a patient, but we practice the technique regularly on manikins and/or cadavers. A couple of the other medics I work with have done quite a few of them and have gotten so proficient with it that they can usually do one in about a minute or so...thats about how long it take me on a manikin. One of them actually uses it as his first line back-up technique, as far as I know he's never missed one. 5 minutes sounds very pessimistic to me. It shouldn't take much longer to do a retrograde than a cric, as long a you practice it occasionally and have the right equipment handy. Our "kit" just consists of a central line guidewire and a 16g angio that we keep in a ziploc bag with the rest of our surgical airway equipment. The primary disadvantage of the retrograde is simply that it's not a "sure thing", whereas a surgical cric pretty much is.

QUOTE: "The ego's in medicine always amaze me". Me too. I dont know how on earth someone could think that, just because they have a couple years experience in ICU nursing, they are prepared to function as a fully qualified paramedic the day they finish their two week bridge course. Asinine. When I was a new nurse it NEVER crossed my mind that I was a "fully qualified ICU nurse" the day I graduated school, even though I had been a paramedic for 6 years and had been doing critical care transport (with a-lines, swans, vents, etc) for 4 years. What do you think the hospital staff would have thought of me if I gave that impression and had that attitude? Thats the same thing Mr. ICU Nurse will get from his partners and medical director if he doesn't show some humility when he's a new paramedic. And that doesn't even touch on all the trouble a new paramedic will get their patients into if they don't manage things correctly. An ambulance or a helicopter is not an ICU. QUOTE: "Having been both Paramedic and Nurse, and having tought both. I can tell you the differences are not that great." I am both as well (FT as a flight paramedic/nurse and part time as an ICU and ED nurse) and I disagree that the differences are few. There is alot of overlap in the knowledge base and skill set, but there are alot of differences too. Most of the differences are ones of approach and philosophy, but they are real factors. Some skills, such as performing an RSI and successfuly manageing a truly difficult airway, takes lots and lots of preparation and practice, along with the right mindset and attitude. This is NOT stuff you can teach to sixth graders. This is not stuff you can teach anyone in two weeks. I've been involved in training alot of new flight nurses, and of course most of them adapted just fine to the prehospital role, whether they became paramedics or not. But I dont think I've ever worked with a flight nurse who didn't say something to the effect of, "when i worked in the unit I had no idea how much paramedics know and do", and also that they've "learned so much from my paramedic partners" since they started flying. Most have also said that they felt totally in over their heads when they first started picking up sick patients from scene calls, even though they were very experienced and very competent in the hospital setting. This would not have been much different even if they had taken the Creighton program right before starting with us, I assure you. There's no doubt in my mind that any good nurse can fairly easily learn to be a good paramedic - no doubt at all. And I encourage any nurse who wants to take their role as a paramedic seriously, to go ahead and do it. We need more good people in EMS and critical care transport just like nursing needs more good people. But for anyone who thinks that being a nurse makes you already qualified to work as a paramedic, you've got a rude awakening coming. If you dont believe me, give it a try your way....

QUOTE: "The skills to perform the procedures you mentioned above can easily be taught in a two week course. In fact, you could probably teach 6th graders to do these things." Not likely. Advanced airway management, for one, is not as easy as you think...how many times have seen experienced ED docs have a hard time getting a tube in a well lit ED with lots of help, lots of room, the patient in the perfect position, and everything neatly organized around them? Now have them try it in a dark muddy ditch or in the back of a noisy, swaying helicopter, or in the bright sunlight. Now have a nurse with little or no advanced airway expereince try. It is an art form that you will master only with LOTS of practice, not in two weeks. QUOTE: "The real skill comes not in performing the procedure, but knowing WHEN to perform it." Actually, its knowing WHEN NOT to do these things that is important. There is a difference... QUOTE: I believe that working 2 years in a busy ICU provides you with plenty of experience and insight to be a fully qualified paramedic after completion of a bridge course. QUOTE: "I would put money on the grads from an RN-EMT-P bridge course having better skills and knowledge than those from a traditional EMT-P course any day." On what basis do you make these claims? ICU experience is great; a good ICU nurse knows at least as much about general clinical issues than ANY paramedic. But the worlds are SO VERY different...to think that being an ICU nurse will instantly make you a great paramedic, is like thinking that being a good runner means you must swim really well, too. They are both athletic activities, but too different to compare directly. ED nursing maybe, but not ICU nursing. QUOTE: "In another note, does anybody know of any other RN-paramedic courses besides Creighton? That's the only one I could find." There are lots of them. Look harder. Some nurses do well in this type of bridge program, many do not. Attitude is way more important than where you've worked for the past few years. Going into a program like this with the attitude that "I'm a great nurse, therefore I will be a great paramedic" is almost guaranteeing you will fail. I mean, you'll probably get through the course just fine, but you will not have the respect of you peers - whose guidance you will need - and probably not that of your med control docs. You must be more professional and humble than that, no matter what your background.

As others have said, it depends on the type of program and type of calls you primarily take. However, all things being equal, if you work for the "typical" program that flies with a nurse and a paramedic, and does a good mix of scene calls and interfacilities, I'd say ICU experience is definitely more valuable for the flight nurse to have. A good mix of ICU, ED, and prehospital experience is ideal, of course....