sladey67

Good picture but those that abuse would ignore. The only education for them is us coming and after checking them telling them no.

Sure ... but at least my service is trying to educate the public. You're right though be lost on all but a few.

Are these protocols available online somewhere?

Not to the general community ... only available via our staff intranet ... I can access them but can't give you access to them.

http://www.asnsw.health.nsw.gov.au/

Ok, gonna preface this by saying I haven't read the whole thread ... only the first page and half ... that was enough.

Finding it hard to believe so many people would be attempting to resusitate (resurrect) this patient, or that your protocols are so inflexible that you are forced to.

Fortunately I work in a system where I have some latitude, I have no medical control to answer to, I have a set of protocols but can make autonomos decisions within that framework.

This lady has passed.

Like I said in another thread ... resusitation not ressurrection 8)

The dude is dead.

I'm in the business of resucitation not resurection.

DOA as far as I'm concerned. 8)

I think you will find that the APEC issue is not a strike as quoted in the media. Most of the additional staffing required for this event is being provided by officers working overtime shifts. What was being touted was officers NOT working these overtime shifts (and they can't be forced to do so) thereby placing the Ambulance Service in the embarrassing position of not being to fulfill it's APEC staffing committments.

I don't think we will ever strike. This would disadvantage the community and erode the goodwill that our profesion has generated. We can make our point just as effectively by other means.

The problem that I see with using the vasopressors (dopamine, epinephrine, Levophed) would be the effects they will have on the "constrictive" mechanism. Seems to me that the action you would want to have would be more ventricular filling, not a more forceful contraction of an empty chamber.

Fluid boluses to maintain the pressure, and transport to a cardiac center that can do a pericardiocentesis would be the best option.

I understand and accept your point, however my belief is that adrenaline (epi) in low doses acts first on B1 receptors and you only start to get the alpha effect (constriction) as the dose increases.

Adrenaline infusion is my only option for cardiogenic shock and our protocol calls for 5mcg - 15mcg/min. At this dose we are taught you're getting predominantly B1 effects - increased HR (not so good) and increased force of contraction (some good)

From the information given appears to be cardiogenic shock to me. Would be interested to see his 12 lead - acknowledge the short tx time.

I imagine the ER doc may have had difficulty accepting your diagnosis given the pts age. I bet if you'd said 76yo he'd have been more comfortable with it

My only pharmacological option would be for an adrenaline infusion (think you guys call it epi?). However with the information given not sure I would give it (always difficult not having the pt in front of you). Provided he was not deteriating (sp?) would probably do the basics (posture, O2, IV access, monitor) and get this guy to definative care quickly. Sometimes it better to not mess with what you've got - while his presentation is not ideal it could be a lot worse. I'd be a bit concerned about pushing his hr up with adrenaline.

Curious how did the hospital rx him?

Why not cardiovert consious pts?? I was taught that you could give 5 mg of valium if needed. In this case her LOC is going down fast enough that she needs to be fixed now. I say forget the 5 mg of valium cardiovert here and then give it if needed. why wait til she codes on you or goes fully unconscious???

Because it is outside our current treatment protocol.

I'm not saying that cardioversion is not the right tx, I just don't have it as an option.

I'd call that VT 8 days out of the week. I don't see where all this SVT and adenosine talk is coming from.

Looks like VT to me too.

Someone once told me ... "if it looks like VT it probably is" ... has held true in every case I've come accross.

If it were me this chick is getting 100mg of lignocaine 2% iv. We don't cadiovert conscious pts.

In scenario you said it was a cold night, just how cold was it? Was it cold enough maybe hypothermia saved her?

Sydney, Australia .... not that cold!

Seriously, folks... that crew is getting a lot of back slapping congratulations now, but had this patient not lived, they may well have been strung up by their epaulettes for violating the prime directive from school, which is to never remove impaled objects. At least in the US, they would have been. They -- and the patient -- got lucky, in that by some fluke of nature, it all worked out.

I agree they went outside the "never remove an impaled object" protocol, however, and as they stated, the patient was already in cardiac arrest. How is removing the object/s going to make this patients condition any worse?

Had they transported to hospital and the patient bled out and died the outcome would still be the same - for the patient. I think you would be able to defend these actions in that they were in the best interests of the patient. What was the alternative? Leave the patient impaled on the fence and still dead?

Let's look at this from the patients perspective, imagine you are this patient. What would you want done?

For the record, I personally would have called it based on the facts given.

Ok, so lets look at the options in my original post, and then lets see what happened ...

Option 1 - She's dead seems pretty popular, and honestly if i'd rocked up on scene to find this I'd probably have pronounced her. Not to many cardiac arrests following trauma make it as we all know.

Option 2 - Treat her insitu. Not really an option is it? She's in arrest, has no circulation and no way you can do effective cpr with her in this position. Unknown length of time for rescue and even if they were close by her prognosis is v. poor with so long without circulation.

Option 3 - Remove her from the fence and transport urgently ...

The crews on scene decided with option 3. Their rationale - the patient was already in cardiac arrest and they were not going to make her condition any worse by removing her from the fence.

The 4 officers (2 units on scene remember) lifted her off the fence in one smooth movement, while supporting her head and placed her onto their stretcher. Then, the most unexpected turn of events began. Just removing her from the fence and basic airway care (jaw thrust without head tilt for spinal precations) and the patient had the return of a spontaneous palpable carotid pulse of 100. Total scene time was 5 minutes. En-route the patient was intubated, cannulated, C-collar applied, she began to breath on her own with a respiratory rate of 8/min, her perfused improved to pink.

Full patient assessment en-route revealed:

- Absence of visible trauma to head, face and neck.

- Penetrating wounds to right anterior chest and left antero-axillar chest with surrounding contusions and minimal blood loss.

- Breath sounds noted to be decreased bilaterally.

- Abdomen was soft and non-distended.

- Limbs appeared intact.

- GCS remained at 3 throughout, no gag during intubation.

- Blood pressure was not obtained, they didn't seem to have enough hands/time, however palpable brachial pulse easily felt.

- Monitored in sinus tachycardia at 100.

- Pupils equal and reactive.

- SaO2 not obtained - again other priorities and pt was receiving 100% via the ETT.

- Hartmanns tkvo.

Transport time 10 minutes to hospital.

So would you still call her deceased?? Gives you pause for thought hey.

Following full x-rays, bilateral chest drains, infusion with 11 units of packed cells, 2 units of pooled platelets and 6 units of fresh frozen plasma in the ED, on admission to the ICU her total injuries were found to be:

- C4/C7 stable #'s of all transverse processes

- Left pneumothorax

- Right haemothorax

- # right clavicle

- # right 1st and 2nd ribs

- # left 1st rib

- Liver contusion

- Adrenal haematoma.

The only surgery she underwent was an open-reduction internal-fixation (ORIF) of her right clavicle. She was extubated 1 week later and when visited 10 days post fall she was happily feeding herself breakfast. She is neurologically completely intact but (probably fortunately) has no recall of the fall itself. She was on fentanyl PCA. She made a full recovery and was later discharged. Her only problem a decreased range of movement to her right arm following the surgery to her clavicle.

You just never know! 8)

True story! 8)

Ok, this is a real scenario that happened here in Sydney last winter. This was published in our service's Clinical News Vol. 5 Issue 1 Feb '07. I was not present at this job but will reproduce/paraphrase it here for your interest.

It is a cold, wet and miserable early winter morning and you are responded to a patient fallen outside a block of units. Nothing unusual here, until further information reveals the patient has fallen from a 2nd storey balcony and has become impaled on a metal fence ... ok we're awake now!

2 cars are responded, a primary care (BLS) vehicle and an intensive care (ALS) vehicle.

On arrival you find a slightly built female in her mid 50's, who was lucky enough to have been found by a now very animated neighbour, only minutes after she had fallen from a balcony about 9 metres from the ground. The trajectory of her fall can be traced by the many broken branches of the large tree through which she has plummeted, landing on the fence. Despite the rain, the cold and the time of day, this neighbour heard her fall and got out of bed to investigate, where he found her impaled on two metal poles of the fence surrounding the unit block. She is still in this position on your arrival, with one pole penetrating her right anterior chest and the other her left antero-axillar chest. Neither pole has exited through the other side of her chest, but the pole through the right side of her chest could be palpated under the skin around her right scapula. Her entire weight was still hanging from the poles with only her toes just touching the ground. Her head had fallen forward occluding her airway.

Her observations are: GCS = 3, pulse = 0, respirations = 0, pale, cyanosed mucosa, monitored in an idio ventricular rhythm at 40/min.

What would you do?

1. Do you call the patient deceased? They have had a considerable fall, is currently in cardiac arrest following trauma, and is still impaled on the fence. (I am unaware of other services protocols but this is permitted under ours).

2. Do you try and treat her while on the fence? Call rescue to cut the poles and transport with them insitu.

3. Do you attempt to remove her from the fence and treat/transport urgently? Going strictly by protocol (ours), impaled objects should not be removed unless intra cardiac and ecm is required!

The clock is ticking .... what would you do?

Ok, have fun, I'll be back in a few days or so to outline the course of action the officers involved took. You may be surprised what happened!! 8)

I so totally agree! They won’t let people who are willing and more than capable to learn how to give basic analgesia but there more than happy to staff a MX event with 400 riders or a major speedway meetting with level 2 first aid officers and a fishing tackle box.

Do you have any idea how hard it is to get a license to administer basic analgesia if you’re not a health care professional? Australia has things so very wrong lol

Timmy, what state/service are you a member of? I think you are generalising/stereotyping here (alot)! Australia is not as backward as you make out!!

I work in NSW and have the following analgesics at my disposal:

Methoxyflurane (Penthrane) - inhaled

Fentanyl - intra nasal

Morphine - iv or im

and for orthopaedic injuries or severe muscular pain (ie. lower back pain) can use a combination of Morphine/Fentanyl and Midazolam (iv) to achieve adequate analgesia (I know Midazolam is not an analgesic).

Very rarely will I take a patient into an ED still in significant pain.

Laura Anne,

Our procedure for Expiratory Assistance - External Chest Compressions is:

Indication:

Asthmatic patients presenting with severe dyspnoea.

- Little or no air movement

- Chest will not deflate

- Extremely high inflation pressure (required).

Method:

1. Place both hands on lower lateral chest wall. If the patient is supine, face the patient and kneel astride the patient's hips.

2. Compress medially, synchronising with the patients expiratory effort and do not compress during inspiration.

3. With IPPV, compression commences with cessation of each positive pressure ventilation.

4. Compressions should be slow, rhythmic and sustained to help force air out.

Complications:

1. Fractured ribs

2. Hypotension

We use 40mg, unless they are already on oral diuretics then they get 80mg. One repeat after 10 mins if no improvement.

Yikes. Does this procedure have a technical name? I'd like to do some reading on it.

Our protocol states ... "EXTERNAL CHEST COMPRESSIONS should be considered for asthmatics if condition is severe or extreme". We do this by placing our hands on lower portion of chest (bottom ribs) and gentle but firm posterior/medial compressions timed with pts expiratory effort. Often we might have to straddle the pt to do this!! but has been effective in many cases.

Ok mentor is good. So a preceptor would be the more senior officer, like an instructor ... kinda ??

100 mmHg systolic here.

What doses does everyone give?

Call me a dork if you must, but I enjoy messing around with photography from time to time, and with all the free time I've got in the back of the ambulance while I'm precepting

Nice pics. Given me an idea on how to fill some time

What is "precepting"? Seen it used on this site a few times, must be a US term. Dictionary definitions don't give me a clear idea - "a rule or commandment"

Might take some pics of our drug kits for you and you can see all our f***ing glass ampoules :shock:

Chill out, sladey.

Hey I'm chilled.

Your original post did not refer to an intubating LMA. The impression I got was you were using a stock LMA, sliding a bougie down and presto you were in!

I was simply trying to say (in my own weird way) that this seemed very idealistic and simplistic and not realistic.

Thank you for the info ... I'll have a read when I have a little down time.

You are supposed to pass the bougie down as far as you can. In theory they say you should hit the carina and meet resistance. You also might be able to feel the bumpy tracheal rings.

So just jam that bougie down there huh? How much trauma we doing to this guys larynx.

And what percentage will actually hit the spot ... ie. take an upward turn and through the cords? Not too many I bet. In my experience the hard plastic airway of a dummy is far different to the real thing. Have you or anyone ever tried this on a real person? with success?

The LMA cuff does not occlude the osephagus ... it just provides a seal.

By passing it throught the LMA (and into the trachea), remove the LMA, then just slide the tube (while visualizing or not) over the boogie into the trachea, remove boogie and bag.

Overactive

Hmm ... Now how do you know the boogie is in the trachea??

Passing a boogie down an LMA does not guarantee it will pass through the cords ... just means it's in the laryngopharynx ... somewhere. Could just as easily be sitting in the esophagus.