Fox800

This thread is getting good

Would you mind sharing your decision-making process for permissive hypotension vs. fluid resuscitation in GI bleeds?

Arizonaffcep, thank you for posting those links. It's refreshing to have someone back up their arguments with that much material! Although the ACG Guidelines do specify fluid resuscitation, they don't mention a specific bolus amount, cutoff point, or target BP other than "euvolemia" and stabilized vital signs. So, am I infusing 20 mL/kg, trying to reach an SBP of 100mmHg? Smaller boluses (250-500mL) and attempt to maintain the pt.'s BP where it's at in the 90's? Infusing that fluid will increase perfusion and raise BP, but certainly won't help a clot form. "The goal of resuscitation is the restoration of euvolemia and resultant stability in vital signs. Resuscitative measures include initial fluid administration via large bore intravenous catheters. The amount of transfusion of red blood cells and blood products must be individualized. There are potential adverse effects of blood transfusion; the goal of transfusion should be to minimize the risk of complications due to red blood cell loss and/or correction of coagulopathy, and not to transfuse to an arbitrary level of hemoglobin/ hematocrit."

Understood, however the considering the onset of symtpoms and the amount of blood lost is important. Losing 1.5L in 2 hours vs. 18 hours...

This is true, they aren't usually shining examples of fitness and nutrition. I could see the beta blockers explaining a HR < 100 in the face of hemorrhage. I'm also curious as to how long the patient's been bleeding. Did he notice tarry stool the night before and now this, or BAM! did it start 30 minutes ago? (Forgive me for the Emeril refernce)

It'd be interesting to see some other indicators of perfusion, though that'd be hard to get sine the thread starter wasn't on this particular call. I wonder what the pt.'s normal BP is, as well as an end-tidal CO2 measurement, skin color/condition, etc. This patient's bleed isn't something that you're going to fix in the field (Captain Obvious, I know). Seems to me that if he's mentating well, with warm/dry skin, a HR under 100, and a halfway decent BP (98/60 in the face of considerable hemorrhage), then I'm inclined to provide high quality BLS, have my IV's in place as a precaution, and mosey on over to the ER.

Agreed. You're not goint to be able to compress/stop this patient's hemorrhage. Permissive hypotension per protocol (here our goal is to maintain a SBP 70mmHG for non-compressible bleeding). Of course establish the two lines, apply high-flow O2, keep the pt. warm, etc. Flooding this pt. with saline will increase the SBP but also potentially make the bleed worse and/or blow out clots.

Yes we are required to carry them whenever we are out and about/on a call. My agency is big on safety. We also have issued ballistic vests and bunker gear for vehicle extrication. If you are injured/exposed on a call, the first question you'll get is "were you wearing your issued protective equipment?"

Bat belt syndrome is rampant at my agency. Required to carry: 2x alphanumeric pagers (1 personal, 1 assigned to your ambulance) Minitor (tones) pager ID card PPE pouch for Atropine/2PAM autoinjectors, N95 mask, fluid splash mask, Oakley safety glasses I added a key ring, ALS field guide, pocket protocol book, small notebook, 2x pairs of gloves, trauma shears, some throwaway pens/sharpies, and trauma shears. Also a Surefire G2 flashlight in a pouch.

Dinged as in had points taken off for his call evaluation. No writeup or suspension. I'll try to get the rest of the story.

I honestly don't know how old the patient was. But more to the point, would a GI bleed alone significantly alter your decision to perform a 12-lead ECG?

What are your thoughts on performing 12-lead ECG's on patients with GI bleeds? I'm not talking about "everyone gets a 12-lead just to be safe", I am looking for actual risks/concerns that would warrant a 12-lead vs. just 3-lead monitoring. A fellow coworked was dinged for not doing one and I'm left scratching my head. Assume no obvious cardiorespiratory sympyoms/history.

ALS, definitely. The wound might look minor, but there is a significant potential for decompensation (pneumo, hemorrhage) that an ALS provider is better equipped to manage.

My memory is a little fuzzy, but I'm pretty sure that he was paid.

When I was doing stuff on the fire side, our dept. had a French firefighter that came over and rode out/worked with us for about 3 weeks. Pretty sweet gig, if you ask me. I'd love to go ride out in a foreign country (the UK, Ireland, Australia). FOCUS: Have you ever heard of a program like this for EMS? Where would you like to go?

We are *required* to carry: alphanumeric pager (personal - for pages directly to you), 2nd alphanumeric pager (assigned to each individual ambulance, gives you info on runs/times/mileage), Motorola Minitor pager ("alert"/"noisemaker" pager), Motorola radio w/permanently affixed shoulder mic, PPE pouch (contains Oakley safety glasses, N95 mask, fluid splash mask, 2-PAM/Atropine IM autoinjection set). I stuff a bunch of pens/Sharpie/highlighter into the PPE pouch in the front flap. This alone requires a large utility (bat) belt just to hold up all of that crap. If that wasn't enough, I added an ID card holder (required to have on at all times, seems to get pulled off if just clipped on), Surefire G2 flashlight w/pouch, Leatherman Wave multitool w/pouch (used most often as an O2 key), and a Bianchi Accumold silent key holder. And believe it or not, there are plenty of paramedics at my job with more crap on their belts than me. It's pretty ridiculous.

I am currently in the academy at ATCEMS. If you have any questions, feel free to ask.

I work for a county 911 system that borders Harris County (Houston). As far as the City of Houston goes, they run 911 for the entire city...there aren't any private 911 EMS contracts within the city limits. Almost all of the county EMS coverage is provided by government services, either through a city (ex. Houston, Humble) or an Emergency Services District (Cypress Creek, Harris County ESD-1, Northwest Rural EMS). I can't comment on EMS pay for the privates...I'd imagine it's not too great. Houston has over 200 private EMS companies. It's gotten so bad that Medicare has a task force specifically for Houston to try and crack down on Medicare fraud. There are new companies popping up all the time. I've heard that the city is trying to pass some sort of ordnance limiting the number of private firms. Are you wanting work as an EMT or as a paramedic?

Our policy is to stop and assess the second patient only if the patient we are treating is stable. One medic will attend to each patient. If the patient we are transporting is unstable, we do not stop, just call for a second unit.

Both services to have provisions for termination of resuscitation. For a medical termination, the pt. has to have been in asystole the whole time, with 20 minutes of efforts going since the start of ALS interventions (either IV in place or ETT in place). The trauma termination protocol is for extended extrication times only. For most other trauma resuscitations, rapid transport is called for. Assume you are on a private transfer ambulance called to a nursing home the next county over (in a rural area). It is 1AM. You are walking down the hall to where your patient is. Your patient deteriorates to cardiac arrest soon after you make contact, but before you load them into your ambulance. You elect to start running the code on this patient. Your private service's HQ is about 40 miles away and the nearest hospital is 25-30 miles, so backup is out of the question (needless to say, the county gov't would not take kindly to a private service running code 3 to back you up). Your options are to work the code with your EMT-B partner and transport them with you in the back, or call the county 911 service to take the pt. The county 911 service would also have a paramedic/EMT truck, with the paramedic riding alone in the back. Needless to say, this county doesn't really have a first responder base. What would you do?

Hmm I can understand that. Would give most of our code drugs (vasopressin, amiodarone, atropine, etc) then after that the drugs would be pretty infrequent (2nd round of vaso, bicarb). Of course it would be more difficult in a traumatic arrest situation where you had to load and go very quickly. THAT would be hell to work alone in the back. The 911 service I work at has toys to make things easier if you are alone (EZ-IO, transport ventilator), but the transfer service I do PRN work for doesn't.

Luckily I have had first responders to ride along in the back on all the codes I've worked. I realize that in some systems you and your partner may be the only ones that show up to a cardiac arrest. Assuming your partner is an EMT and you are a paramedic, how are you supposed to get all of your medications pushed while doing good compressions and bagging (assuming you have no vent). Do you focus on compressions and ventilations (good BLS at the expense of getting your IV meds pushed at the right time) or do you just juggle everything and try to do it as best as you can?