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Showing content with the highest reputation on 10/21/2009 in all areas

  1. I can't believe you still have the "be all and end all" instructors in these days. Would you really be thrown off the class for correcting the mistake? I mean seriously, being an instructor I welcome comments and criticism. As a student paying for the course (?) you have the right to getting the (correct) information that you are paying for.
    2 points
  2. Hey man, That is an easy one, Just send me her email, and I will be happy to educate her for you. Sorry, you have to go through this my friend.... Let me know, JW
    2 points
  3. WOW. First, I cannot believe that this instructor is so ignorant to the fact your research into the definitions is wrong. Any instructor that's worth their salt should percieve this as 'feedback'. Question that I have, is the National Registry still going to test this level or drop it before your class is completed? Who knows, as this process has been ongoing for some time now. The main thing that the instructor should be following in the standard curriculum and teaching from that, using the book as a supplement. You, confronting the instructor with supporting evidence should taken as a very caring and passionate response to what your goal is, to obtain this level of certification. You want to learn, but you want to learn the right information. I will wait for further responses to add to this topic's subject matter. You follow the course objectives, and if problems continue, it is your prerogative to take it to the next level, ie. the medical director for the course (as every EMS class should have a medical direction through the training facility).
    2 points
  4. I wanted to discuss a topic that I am kind of struggling with. Whether sedating a patient to intubate them, or maintaining sedation during a transfer/procedure, the standard round these parts is Fentanyl/Versed. For simplicity I would like to keep the discussion within the limits of a average weight, normotensive, adult patient with no previous medical Hx, that needs sedated deep enough to maintain intubation for whatever reason. So, like I said, most of my education/experience is about 5.0mg Midazolam, Start at (varies) 3mcg/kg Fentanyl then paralytics if needed, or more fentanyl in the absence of paralytics. Continued sedation is usually 2.5mg doses of Versed, and 100mcg of Fentanyl. My "struggle" is that being out here in the sticks I would rather have an infusion to maintain a steady state of sedation, than the highs and lows of redosing. Unfortunatly, the agents used in infusions are not-so common prehospitally in my area, and I am not sure why (although I did see a doc hang a Versed drip). I am really interested in hearing some views on Propofol infusions and Ketamine, along with other agents.
    1 point
  5. EMS workers routinely treat patients that carry infections. There is no way of predicting what germs you may encounter when treating a patient or what illness they will have. What precautions are you taking to protect yourself from the unknowns of your everyday job?
    1 point
  6. Let me give a description of the events then I ask you for your thoughts. I received the call via our Control room asking me to do the inter-hospital transfer of a 2month old, premature (born 2months prem) baby from. We could not get more details as this child was laying at one of the local government hospitals. So off we go, ready to transfer this child to one of the private hospitals. The only thing we know for sure is that the father of the child wants us to transfer him. The current treating doctor sees no reason for the transfer. Normally we will not oblige something like this as it's against company policy to transfer a patient without the treating doctor doing the necessary paper work. Upon arrival at the paediatric ward, we are greeted by a somewhat uncaring nurse. I do the normal "Hello Sister, how are you?" bit only to be pointed in the direction of the doctor with a grunt. This is when I feel the air temperature, and decide it might be a good idea to zip up my jacket. The doctor walks me into a room filled with about 20 babies, I might as well have walked into a freaking freezer! I get to the side of the bed and find a small, blue skinned little boy on CPAP. The doctor start talking and explains the child was born two months prem, two months ago and admitted a week ago with pneumonia. I look at the IV and all I can see is a Saline on a dail-a-flow. No meds, no antibiotics. Just that one IV. Asking the Doctor if what meds the child had I am told the Saline. I ask again, just to make sure I ask specifically. "Has the patient received any medication?" To which I am told:"No, just the saline". I connect my monitor to check vitals and find the following: HR: 67 Sats: 56% (on CPAP) To this I ask the DR if the child has always been this brady. The reply will shock you:"He's sleeping, so it's normal". At this point I feel like killing this DR but, decide to rather do what I am paid to do. I sedated the child and tubed him, with the bagging the HR goes up to 120 and the stats increases to 93% where it sticks. I can't get it any higher, so we leave and transport to the receiving hospital. I inform the control centre to let them know that we are inbound and need an ICU bed and no longer a normal bed as arranged. At the receiving hospital, they take chest x-rays which reveals a complete collapsed left lung.... How would you deal with this?
    1 point
  7. With all the bashing of the new show Trauma, who remembers in 2006 when TNT came out with a short lived TV shock called Saved starring Tom Everett Scott and Elizabeth Reaser. The show focused on a medical school drop out, paramedic with tons of issues and baggage. In the first episode he is having sex in the back of the rig with his ex who is a resident in the Emergency Department. Now fast forward 3 years and NBC gives us about the same thing with a bigger budget. Some of the medicine in Saved was spot on, some was way out in left field. Trauma has it's problems but we need to remember that the people writing and creating these shows are not medics, have no medical background and are not looking to give a real world view of EMS (if they did they would not make any money). As someone who works in EMS but has also worked in theater and film on the production side, I think that both of these shows are a lot better than they would be if nobody in EMS was involved at all, advisors on have limited input on projects like a TV show (who would tube the medic or the EMT, what is the name of a drug to give someone with this problem, how many people work on a truck at a time, when do you call a chopper, etc.). Why waste time judging the slip ups in a work of fiction and getting all worked up about something that has no effect on you at all. Saved and Trauma are not intended to be a training tool, they are intended to be entrainment. Personally I enjoy watching some medical shows that are way out in left field at times (ER, Trauma, House, Saved, etc...) I don't see why people have to go looking to bash a work of fiction to the degree that has been going on this site with this show.
    1 point
  8. Sounds like instead of Bachelor of Science, it's Bu** Sh** in paramedicine for her. Follow the leads of my and the other posters. You want the best, and it sounds like you are not being provided what you request. Work the chain, but get it done soon or this will fester like a zit on her arse. Make sure that this is not a personality issue, but just the instructional issue you are dealing with. Tread, but don't stomp until the facts are evident. Take care and good luck with the rest of your class.
    1 point
  9. Apparently you still need some more of your legal pain killing stuff (BTW, what labels do you get there?), you're still sharp as ever. I will most certainly be watching this topic.
    1 point
  10. Is the War on Drugs the only War (Police Action) the they believed they could win & well didnt?
    1 point
  11. No problem guys, we will talk about individual concepts, then hopefully put it together into a cohesive format. So Far we know: 1000 mEq = 1 Eq, 1 Eq = Mole/charge, Mole = Avagadro's number or 6.02 * 10 ^23 atoms/molecules Further explanation: 6.02 * 10^23 is what we call scientific notation. When numbers are too small or large for conventional context or understanding, we put them into this format. We essentially make a smaller decimal number and use a factor of 10 to describe how many times we multiply that decimal or whole number by ten to reach the actual number. For example: 1,000 would equal 1.0 * 10 ^3 ( If we multiply by ten, three times, or move the decimal to the right three spaces, we have the actual number) Likewise: 0.001 would equal 1.0 * 10 ^ -3 ( Very small numbers less than one use a negative value, or we move the decimal to the left to obtain the actual number. Therefore, you can see the 6.02 * 10^23 is so incredibly large that understanding it in a conventional context and writing the entire number out is unreasonable and inherently difficult, if not impossible for most people. The next thing to describe is the concept of charge? Take care, chbare.
    1 point
  12. LMAO...Thanks :-) Seriously though, I would be more than happy to send her an email, keeping your name completely anonymous of course, and providing her with correct FACTUAL documentation to support both your premise, and to show her conclusions are erroneous. Just send me a PM... Respectfully, JW
    1 point
  13. Question.....What sort of credentials does this instructor have? What current EMS level are they at? How long have they been teaching this course? Have they ever been a provider at the level you are being taught? Are they a moron or not????? (Oh, I guess we might already know this one)
    1 point
  14. It's in your right as a student to want the correct information. Going about getting the right information that is being presented to you incorrectly should be taken up with the EMS Education Board (the people who gave her the certification/rights to instruct these classes). I would also bring it up to the course adviser, program director and even the dean. This is your education, for treating patients who need your help and may be dying without your help. Having the right information in your head is paramount. Just be more tactful about it. If you DO go and make a big stink about it, and nothing happens, surely the instructor would have an idea of who started it. You mentioned before that you confronted her before about this stuff. It's not a good idea to get on her bad side, since they have a way of weeding people out. So, be careful. If Jwade starts thrashing into her, your class might end up like a Harvard Medical school program... he would set her straight.
    1 point
  15. True, I did entitle it that way and I did ask for your thoughts. I simply disagree with the postings on deciding when to give the child the benefit of the doubt because of quality of life. We all know babies (especially girls) have more fight in them than adults hence the decision to "terminate" would be easier on adults than infants. My question would be, who teaches you to decide on what acceptable quality of life and what not? There's no universal accepted standard for quality of life? Is it based on your specific area where you live and make a living? The one thing this thread did emphasise is that there are huge gaps in the way we do things all over the world (a gap that does not seem to be closing at all). The gap in training and equipment availability is just as huge and ever increasing. I enjoy this type of conversation, it's borderline "getting personal and confrontational" and still teaches at the same time. Like probably 99% of the people on this site, I enjoy the expressions of views and interest in cases and scenarios like this. Update on the patient: According to the treating paediatrician rehydration is doing the trick and the process of re inflation of the lung has started with the vitals and saturation looking better.
    1 point
  16. Additionally, I would like to emphasize that yes etomidate is well known to cause transient adrenal suppression after one dose. However, I am unaware of any evidence that definitively says etomidate leads to poor outcomes in patients where this may be a problem. There are studies and allot of talk; however, the fact remains that etomidate is still a viable agent. While some providers has started to stress dose people with steroids, I am unsure if this practice actually improves outcomes. The thought that steroids lead to up regulation to adrenergic receptors in septic patients appears to be falling out of favor and may not be effective. Regarding "waking"people up to allow for negative pressure. It is a good thought in that the ultimate idea is to liberate the patient from the ventilator as soon as possible. Clearly, spontaneous "awake" trials are performed in the hospital prior to the decision to liberate and ultimately extubate. However, the transport environment is tricky. I think the practice of keeping patients light needs to be considered carefully. If you have even the slightest patient/ventilator dys-harmony, having an awake patient who is not interacting well with the ventilator is a setup for disaster. Many of the transport ventilators are simply not able to physiologically meet the needs of many patients, and many providers are not keen in this area of management. In conclusion, good concept with the caveat of having a capable provider and ventilator, therefore it is not as applicable in the transport environment. Additionally, many patients who are intubated at point of care have conditions where physiological strain could be quite harmful. Head injuries, cardiogenic shock, and septic shock are all conditions where you do not want a patient awake with increased oxygen consumption and demand. Therefore, I tend to keep my point of care patients rather heavily sedated with liberal analgesia. I am aware of my limitations as a provider and the limitations of my equipment and feel this approach is safer than attempting to keep my patient "light" while attempting to setup perfect patient/ventilator interaction with a crossvent four. Take care, chbare.
    1 point
  17. While I take all views into consideration and understand the views of everyone here. I do not agree with some of the postings related to this case. The sad reality here is that the government hospitals are severely under resourced as is the government / city run ambulances. Small things such as c-collars, vacuum mattresses, even transport incubators are non existent. If at all possible, I would have taken photo's or a video or something to show you that state of this and other government run hospitals in Africa. I am by no means trying to make excuses for what I have done (whether it be right or wrong). What I am saying is assuming that this baby has had any type of decent medical care while spending the week in the hospital or that the doctor has in anyway communicated with the parents what is being done would be very very optimistic to say the very least. I have learned the hard way to expect your worst nightmare come true when you get called to transport any patient from the government run hospitals in Africa. More often than not, the patient was taken there by the family on loaded onto the back of the police pick up truck (the government ambulance service isn't available). The casualty department (don't even try and think your trauma units) has seen the patient, decided they are not up to working today and this patient will be fetched by us shortly so they just don't do anything. Neither quality nor value of life is taken serious here. For most medical staff in these facilities it's a salary, nothing more and nothing less. In a recent newspaper article (I will try and find it) this same gvt hosp made the news for not seeing to a 2year old child resulting in the death of the child. As explained by the paper "The child was put to bed by her mother, the mother went into another room of the house and heard the child cry. When she entered the room she found a cobra on the bed with the child having been bitten on the head. A neighbour killed the snake, loaded the child and mother into a taxi (no ambulance available) and rushed them to said hospital. Upon arrival they explained the situation to casualty staff and showed them the snake. The mother was told to join the queue of 30+ people and wait their turn. When the child started haemorrhaging from the ears and nose, casualty doctors realised the child was sicker than they though. However, it was to late and the child died". Value of life is my foremost and only concern in this country. Unless there's a specific DNR I will give my patient (regardless of age) the benefit of the doubt. If you have not learned in the first 3 years of this business that doing your best with every patient might just change their life, then you never will. Sure there's cases where a resus has to be called which I do and cases where starting a resus is plain and simple not even a viable option any more. However, if for any reason I feel the patient might still have a chance, I will give him / her that chance. I did not spend the money nor time on becoming a Paramedic and all the other abbreviations to stand "play God over life or death". I did this because I wanted to be a paramedic and wanted to give all people the chance at life *let the flaming begin*. Cliché as it might sound, but that's my view on this patient and every other patient I have and will see in the future. I will post an update on this case later today as I am going to the hospital for a follow up.
    1 point
  18. I love this way of thinking ^..... It never even crossed my mind. Anyone else have any imput on this quote? Did not really think of that either. Ya, one infusion rate may be adequate for a certain hwy, but turn onto the secondary road and the stimulus of a rough ride may be enough to arouse them.... (not that kind of arouse).
    1 point
  19. Saved was a decent summer cable drama, and "trauma" is on the up as a primetime drama. Also, thanks to whoever is turning my reputation points back positive.
    1 point
  20. I suspect you did not read Seb Wongs reply and the advisor Paramedic quit the show and because of the inaccuracies. Must disagree the general public believes what they see on TV is the truth, time for true professionals to stand up and call crap when they see it.
    1 point
  21. I agree there is no reason to check the mental status on a copd. I may have not been clear enough. I never fully wake the patient, as you pointed out this could cause unsafe fluctuations in ICP as well as other problems you also point out. I try essentially just to lighten them up to a state where the rate and depth of respiration voluntarily increase to like a level 2 dream state. Here is where Propofol would be great. I currently use versed, of the three it has the most rapid onset (some argue Ativan is faster). We monitor End tidal CO2 , respiratory rate and pulsox , pulse and BP when I see the numbers begin to rise I "check in" and then re-bolus with versed the pt goes down for another 10 min and never regains consciousness. I find it important to do this, as it allows the thorax to return to a negative pressure inspiration assisting blood return to the heart and maintains well perfused muscles of respiration making it easier to eventually wean the patient off the tube.
    1 point
  22. Dixie McCall, RN, was never in conversations indicating either if, or who, she was sleeping with, on staff at Ramparts General, or at LACoFD Station 51. "Nancy" on the other hand, doesn't even seem to be upset that her colleagues are making cash bets as to when she'll sleep with the newbie EMT. I emphasize, WHEN, not IF! "Chet" was intended as a part time comic relief, and when called on, always came through in a good "Fire Fighter assisting Paramedics" way. I have not yet decided if he has a counterpart on "Trauma". Chet's only brush with pushing his own fame came when he attempted to photograph the Station 51 crew doing a rescue, but got beat out by another Fire Fighter from another station, who photographed the Station 51 crew doing a rescue, INCLUDING Chet in the picture!
    1 point
  23. I treat the patients based on whats going on (s/s's). We have numerous choices so I can choose based on time to definitive care which may not be my hospital, type of injury, illness, etc. I use versed or other for sedation in combination with one of the choices of paralytics, based on patient event, HX, etc. What types of patients? Race plays no part. Their past medical HX does play a part and while I know certain illnesses happen more in certain races I never presume that just because they are a race they have that problem as it could cause me to miss the actual problem. As to drug seekers. Not my job to decide who is faking. I don't push enough narcotics to worry about being considered a user, as mentioned earlier we are rural and most of you guys push more in a week than my entire service does in a month probably. Plus as far as Pee test I used to think my name was random.
    1 point
  24. I rather liked Saved. It died after one season... or a half season.
    1 point
  25. So true. If nothing else, this incident is something to mention to others in all our respective agencies, as something to be attentive to, even if there is no official policy yet. Simple as telling 2 friends, who tell 2 friends, who tell 2 friends, etc. It's a first step, if nothing else.
    1 point
  26. Firstly wherever possible we reverse in so we drive out. This is so there is an extra set of eyes on reversing. We also have reversing cameras in vehicles. Secondly this means that when we get into the drivers seat (remember we drive different vehicles to you, ours are a forward control mercedes van) I can see to the bumper of the van. I also would have noted any people around & made allowances accordingly. No, I am not perfect, but to hide behind 'apparantly was no policy to do such a thing for that service' is a cop out. Do we only do things because there is a policy? If there was no policy to say that if there is an explosion in the building, would everyone just sit there? Come on Ruff. They dont need a policy, they need a kick in the ass strong enough to send waves through all EMS & if they are the ones to be made an example of, then so be it. Make everyone across the US realise that we are here to help them, not hurt them. We do that in all of our actions. Especially in the most visible one of all, driving an ambulance.
    1 point
  27. Ruff, i respect you & your opinion, however, in this case it is all about vision. What if it was a child sitting there playing? Kids are always in a place they shouldnt have been. The fact this was an adult lying down is not relevant. The relevance is their inability to see that there is a potential risk, expecting that the siren would clear the way & driving off. All for the sake of how many seconds????????? The reality is ALL EMS is risk vs benefit. Doesnt matter if it is drug therapies, high speed driving or leaving the station. They demonstrated a complete lack of understanding in this case. Driving is the most fundamental skill we in EMS have. It is second nature to us. We have to be able to demonstrate we can make appropriate decisions, if we cannot control our emotions, & adrenaline rush, then we need to look at more than remedial driving. That does not control the lack of though process that has gone on here.
    1 point
  28. Ruff, I do not suffer fools well. Their actions show the need for self control & the ability to think, even when the adrenaline is flowing. They have proven they do not have this capability. If they cannot demonstrate it in the most fundamental part of EMS, driving, then how are they with the administration of drug, the prudent use of lights & sirens. This is a poor display of what is needed in emergency services, not just EMS. This profession, yes profession, does not & never will need people like this who are too lazy to check what they should. The reliance on the siren as a sole warning is misguided. If vision is impaired, then the second officer should be ensuring the WHOLE departure way is safe. I stand by my comments Just an additional thought, isnt the first rul of EMS "First do no harm"? The problem is you cannot train against stupidity
    1 point
  29. Well said Dust. Thy need to be made an exaple of, stupidity cannot be countered, this was negligent stupidity. Lets get them out of EMS, revoke their licences as well. If they havent got enough brains to operate a vehicle in the safety of themselves & the general community, why the hell should they be trusted to assist the sick & infirmed???????????
    1 point
  30. Hey guys, I also want to emphasize SA is talking about care in an environment so far removed from what we know in the United States, that making a comparison is nearly impossible. If you have never experienced the horrors of some of these places, you really cannot adequately appreciate the profound differences. Therefore, I am not sure I would go so far as to call the doctor in question incompetent as much as simply not having access to resources? Then again, the patient was placed on CPAP, so the hospital in question had access to this resource. I tend to agree with Vent that the prognosis for this kiddo is quite poor. I understand what you mean SA, I was forced to leave patients to die a miserable death during my time over seas because of lack of resources, qualified providers, and cultural beliefs that punish even the most innocent kids. Take care, chbare.
    1 point
  31. I have no idea what the doctor told the parents. I arrived at the hospital finding the mother who does not speak, read or write any language myself or my crew understands. In South Africa we have excellent facilities to manage this type of case, sadly in Namibia there's none. I'm awaiting the phone call to tell me to fly this child the 4 hours required to South Africa, which I will most probably refuse to do.
    1 point
  32. Apologies for the delay in my reply, Monday's at the office is at best a day to have rather stayed in bed. Also apologies for not giving more information on this case, I was slightly more than a little pissed at the initial medical treatment and facility. Starting at the beginning (and I wish I could show you this medical facility and it's staff). The only information we had at the time of dispatch was that the child (male) was born 2 months prem and is now 2 months old. The parents were unhappy with the current treatment being given at the Government facility and wished to have the child transported to the private facility 5min down the road. On arrival I found the following: 1) Baby weighing 1.2kg (slightly less than 3lbs)on CPAP, 2) Severe dehydration (evident by the loss of tugor on the abdo and calves) 3) Cyanosis (particularly evident in cranial area and the chest) 4) On palpation the child was cold (to the extent of my sats probe did not detecting anything, warming the baby with the warmer blanket helped) 5) The baby was not crying nor showing any normal / expected response from being examined 6) Auscultation revealed a rub of right and no audible air entry in left (PDA question: No murmur audible) 7) Resp: Rapid (-> 60/min) with deep suprasternal retractions 8) Pulse rate: 67 (as mentioned in initial post) 9) SATS: 56% on CPAP (as above) 10) IV insitu ® arm. 11) BP 50 systolic 12) Lymph nodes small and palpable No labs nor any xrays were available (according to the treating doctor and nurse) The treating doctor informed me that the child was admitted with pneumonia and has received no medication / antibiotics to treat the infection. The only treatment that was confirmed would be the CPAP and IV (as mentioned). This is when I decided to intubate with a 2.5 tube and ready for CPR. I confirmed (as required) tube placement via auscultation (still no audible air entry left) and started bagging. With the stats going up and the HR increasing it was evident that no compressions would be needed. Thus we transported to the receiving facility while informing them that we are inbound and need an ICU bed. As mentioned earlier, chest x-rays were taken at the receiving facility revealing the pneumothorax of the left lung. I have not had the time yet to follow up with the paediatrician but will update you as soon as I have had the chance. In reply to CH - True, we have three levels of qualification in SA. 1) BAA (EMT- which is a one month course or 3 months part time 2) AEA (EMT-I) Three months full time (only attainable if you have 1000 pt care hours documented, passed the entry exam and obviously the course) 3) CCA (EMT-A) 12 month full time (only attainable if you have documented 1000pt care ILS hours, passed the entry exam and the course itself) The CAA / Paramedic course has changed in recent years allowing a school leaver to do a National Diploma via the Univ. No road experience required, yet after 4 years you walk out a Paramedic. You can then go and do B-Tech, M-Tech and D-Tech in Emergency care. The first two levels have a "under supervision" license whereas the rest have a "unsupervised" practitioners license. No doctor needed, nor any medical consult needed before administering meds / drugs as per protocol. In reply to Kaisu - I am in Namibia, how does a situation like this develop? Probably the same way a doctor flies a pt to my city indicating she had a CVA that's visible on the ECG! I do a check and low and behold, she's had an anterior infarc (I will scan the 3lead print out when I remember). In reply to Vent - I hope we use the same abbreviations here as you do over there. PDA question, see above for answer Probe was post ductal as you will no doubt have noted from my post above. PMI - Apical Pulse? If so, there was a shift to the right Sadly we do not have the "paediatric specialist" we can call to jump on our vehicles, nor am I allowed to ask for a x-ray to confirm tube placement. It's a resource that's bolted to the floor of the Govt hospital (some do not even have x-ray facilities). I so wish I had the facilities and resources you have across the waters. We still have to tube, confirm tube placement via auscultation, stabilize, load and go. This makes for interesting conversation though and helps keep me on my toes and dreaming. Keep it coming
    1 point
  33. Actually, you pointed out what I missed. If there was no immediate follow up CXR after intubation at the original hospital, there is little to say but the intubation could have caused the lung collapse. Not knowing the full extent of the baby's medical history and anomalies, this intubation may only prolong the inevitable and/or the baby may have to be trached and pegged. That is not always a good thing especially in remote areas that lack in home care. Quite possibily without knowing the intent of the original hospital/doctor and if they were just waiting for the family to come to grips with realty, this may now have caused the baby and family to be put through several more weeks of torture. Again, not enough information about the prognosis of this baby.
    1 point
  34. I am going to give SA the benefit of the doubt here. Knowing what I know about some of the government run facilities in South Africa. Take care, chbare.
    1 point
  35. It would depend on the type of PNA as to whether antibiotics would be warranted. When you say collapsed lung, do you mean atelectasis or a pneumothorax? Did you point out absent breath sounds on the collapsed side or what this already know and they were using CPAP to re-exapand the lung? Did you note the PMI which should have been done as part of your assessment? Did you transport the baby on CPAP? If so, what machine did you use? Is it possible that if the collapse was a pneumothorax, could you have caused it in transti? Heart sounds? Did the baby still have a PDA and was your pulse ox pre or post ductal? Congenital heart defects? What was the prognosis of the baby? Any other anomalies? Was this baby even considered viable at birth due to other defects? Did the doctor inform the parents of the chances of severe deficits and was trying to coax them toward a non aggressive route? We often see family members who can not deal with the word "futile" and will often request an ambulance privately to move their loved one to the ED of another hospital since no other doctors will accept a transfer. Often the other hospital will tell them the same thing. You have not provided enough information about the baby for any conclusions to be drawn. However, I will tell you a little story about one of the reasons why Paramedic students are no longer allowed in our neonatal ICU. We had a little baby that looked cute and normal but had anomalies that were not compatible with life. The decision was made with the parents involved to terminate life support. The Paramedic student went to the parents and told them we committed murder by not giving the baby a chance. Thus, if you came in with a "save the world" attitude, you would probably get more than a cold reception. Sometimes nature will still win.
    1 point
  36. Government hospitals are completely government owned, run and funded. These hospitals in most cases would be on of those places where I would grab my IV stand and ride it to a PVT facility. Mostly due to slack staff and shortage of equipment. Private hospitals as exactly that. Privately owned and funded by the medical insurance of those that get admitted. The doctor's here are mostly GPs and Specialists (who coincidently does hours at the Govt Hosp) with the nursing staff being old Govt employees wanting a cleaner facility to work in as well as higher salaries. Although, not always the sharpest knives in the drawer either....
    1 point
  37. I have used the following medications for prehospital sedation: 1. Valium + Morphine (Patient Assisted Intubation), 2. Valium + Nubain, 3. Versed + Morphine, 4. Versed alone.
    1 point
  38. Remote Controlled doors are not the issue. The issue is these guys were just too excited to get a job. Common sense says that you should look at what is happening around you, If they cant see the sidewalk, then what else do they miss on the road? Problem is that you can teach common sense. No matter what you do, they will find a way to get themselves into a position of stupidity (they are firemen after all). The only way to ensure this doesnt happen is proper screening prior to employment, for EMS & Fire. Yes employment, take the whacker out of it & that will resolve part of the problem.
    1 point
  39. Actually, it is the other way around in my area of the world. We almost exclusively utilize etomidate for pre-hospital RSI. My choice of diazepam & fentanyl is personal and rather anecdotal. First, I have had sudden hemodynamic changes with conservative doses of midazolam. This is not something a person with a head injury, altered hemodynamic status, or altered cardiac status likes very much. Unfortunately, these three patient compose many of my RSI's. Not that I actually perform RSI that frequently. Therefore, I typically use diazepam and liberal doses of fentanyl. Most of my ketamine experiences are with conscious sedation for procedures. Typically, we will follow the dose of ketamine with doses of analgesics and benzodiazepines. Clearly, benzodiazepines blunt the possibility of an emergence reaction. Ketamine actually has both analgesic and sedative like effects by its self. However, there are many pitfalls to consider: -Ketamine is a cardiovascular stimulant: perhaps not a good consideration in patients in heart failure or MI. -Theoretical potential to cause harmful increases in ICP; rather dodgy evidence and in fact evidence that supports potential cerebral-protective benefits. However, it is still considered head injury taboo in the United States. -Emergence reaction and psychological harm if you allow the person to "wake up" without the benefit of benzos. -Increased secretions. Therefore, choosing ketamine requires additional agents and considerations. You will most likely need to combat secretions, monitor for adverse cardiovascular effects, and prevent emergence. While emergency may not be a big consideration for RSI, how are you going to know if you quickly push your NDNMB after the intubation and neglect to follow up with a benzo? At this point, I still advocate for etomidate as the quickest acting agent with less pitfalls than other agents on the market. Take care, chbare.
    1 point
  40. Something to ponder within this topic - it's a good read and really breaks down the pain med options and their durations, actions, etc (thanks Dr. Bledsoe) http://www.bryanbledsoe.com/data/pdf/mags/Analgesia.pdf
    1 point
  41. Ditto to the above responses. I too have administered analgesics upon arriving at the ER and have also given them while waiting for a bed while extended at the ER. Most local facilities around here do not complain as they are aware their personal perceptual opinions are irrelevant to our treatment and that we will stand behind our argument that any competent physician can appropriately assess a patient with analgesia on board. Most of the decent agencies around Houston have very liberal (i.e. unlimited) pain protocols. My current guidelines allow for analgesia prn for as long as the patient can maintain consciousness and their own airway. If your patient reports pain, it needs to be addressed in the appropriate fashion. Personally, I wouldn't concern myself with comparison statistics to other medics nor the impulsive concerns from a receiving RN. Beneficence can and should go a long way!
    1 point
  42. Or we could look at agents that are much better for the task of RSI induction agents. Currently, no better agent than etomidate exists. It acts very quickly (one arm brain cycle essentially), has a predictable duration (100 seconds for every 0.1 mg/kg dose), and it has no effect on hemodynamics. The next best would be ketamine IMHO. We must remember that sedatives such as Diprivan and diazepam do not provide analgesia. Sedation and analgesia are different topics. So, I typically use etomidate, then follow up with diazepam and fentanyl. Take care, chbare.
    1 point
  43. try doing divided doses. Yes it takes a bit longer, but giving like 4 at a time and seeing how he responds may have helped. I've seen some patients be able to adjust with smaller divided doses given than with a large bolus and you still get the effect of sedation. You certainly don't want to have a patient tank out because of a large bolus and then have to work to get it back up. Just something to consider Mobey.
    1 point
  44. As far as versed's utilization for RSI I've actually had pretty decent luck with it. It is really patient dependent as you said and obviously if they have any type of benzo tolerance they are going to require higher doses. I have found though in combo with fentanyl that you do well with the sedation. I don't even go with paralytics until I am certain the patient is adequately sedated. I certainly don't want them remembering anything. Everything has to be titrated as you said taking into account their hemodynamic status and adequate maintenance of it. Point well taken though CH - sadly we call it RSI, however there isn't much rapid about it if done right unless you do it as a crash airway.
    1 point
  45. We use Ketamine for the intitial sedation of pedi's and bronchspasm patients. 1-2mg/kg IVP. Otherwise its Etomidate 0.3mg/kg and Fentanyl 1-5mcg/kg. Induction is with Sux, Roc, or Vec, Roc being my personal preference. If the transport is greater than 30ish minutes, then I'll start an infusion of either the NMBA or the benzo depending on the patient. If we pick them up on Propofol, then we'll keep them on it blood pressure permitting. Flexibility and individuality is the key.
    1 point
  46. IFT sedation is something the RN or MD would be in control of; our ALS are not used like that for transfers. As far as sedation and analgesia we have ketamine and midazolam. Midazolam was orginally used alone for RSI when we first got it in 2005 at a dose of up to 5mg but we now use ketamine and midazolam combination. Our starting dose of ketamine for analgesia is 20mg (if no morphine has been given) so I would immagine the dose of ketamine for RSI is quite larger but it's not in our guidelines because it is a specialised procedure only taught to select Advanced Paramedics so I don't know the exact dose. We maintain the sedation with 1-2mg of midaz prn but our transport times are not really that long to require it I'd immagine
    1 point
  47. That is actually a very small dose for the purpose of RSI. You may skate by with a minimum of 0.1 mg/kg. However, this will still be ~7mg in the "average" adult. With that, the slow onset and hemodynamic implications of midazolam do not make it a very good candidate for RSI. Take care, chbare.
    1 point
  48. As far as intubation, if you are going to administer paralytics, you must administer sedation along with it. That is without question. Having said that standard "induction" doses to sedate a patient is betwee 4-6 mg versed though I have seen some patients require a bit more and 100mcg fentanyl. Etomidate is also an option with typical dosing being around 20mg (however remember etomidate does not have analgesic qualities). This typically will do well, however you should titrate doses to patient's respone and vital signs. For maintenance infusion of versed which is preferable in the transport environment to propofol with common dosage for sedation being between 2-5 mg/hr. I have struggled on many transports as due to all the stimulation in the transport environment with propofol and found you have to continuously adjust it to maintain the level of sedation that's adequate for the patient. It's preferable to midazolam or other sedatives in that it is quick on / quick off so evaluation of neuro status at receiving facility is easier than the extended time it takes for versed or others to wear off which is a positive in their eyes. However, the longer maintained sedation is preferable in the transport environment so I am partial to versed. However, propofol is quite popular in hospital and seems to do well within that realm. I've not seen a versed drip used in hospital, but have used it several times in transport. I'm sorry but I do not have any experience with Ketamine and cannot help you. Perhaps one of the people from down under can assist you better as it seems to be used more frequently there.
    1 point
  49. Unfortunately, an initial dose of 5 mg of midazolam for a 70 kg patient is rather suboptimal. A typical recommended dose for midazolam induction is 0.3 mg/kg. How many people do you see giving 21 mg of midazolam IVP? Therefore, many patients are being under-medicated. In addition, 21 mg can effect hemodynamics in the most "stable" patient. Of course, if we are looking at RSI, how "stable" is our patient? One area we often overlook is good ventilator management. We frequently run for the drugs when out patient even twitches. However, we need to ensure we are meeting our patients needs prior to going down the route of halcyon dreams and neuromuscular blockade. One thing I have seen and have attempted to correct is inadequate flow. We are taught an I:E of 1:2 is "optimal." Therefore, I have seen providers run adult vented patients at flows as low as 17 lpm to ensure they have that perfect 1:2. Therefore, meeting your patients demand and attempting to facilitate good patient to ventilator interaction is paramount. Infusions are a consideration and guidelines are all over the place. I have run midazolam infusions at 10 mg/hour and given fentanyl boluses as needed with good success. Mixing 10 mg in 100 ml makes for easy math. Ketamine is a consideration; however, you will need continuous infusions for prolonged transport and secretions along with increased sympathetic tone are considerations. Fentanyl infusions of say 1 mcg/kg/hr with boluses as needed are considerations. Some services carry diazepam and lorazepam for this purpose as well. Diprivan is a very fickle medication and precipitous drops in blood pressure are common. Additionally, you typically have to give very large doses in the stimuli rich environment of the transport environment. As it is, I have take care of many ICU patients who required vasopressor infusions to maintain blood pressure because of the high doses of Diprivan. It is also thick, milky, and loves to make bubbles that drive our minimed IV pumps crazy. I typically use diazepam and fentanyl. For a typical 30-45 minute flight with the "generic" otherwise healthy adult patient, it is not uncommon for me to give 300 mgc of fentanyl in divided doses (of 100 mcg) IVP and 20 mg of diazepam (in doses of 10 mg) IVP. Take care, chbare.
    1 point
  50. You see, they dont have intelligence tests to be a smokey, just the ability to watch reruns of rescue me.
    1 point
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