rock_shoes

I have major concerns regarding bias potential of the study presented. 1) Proficiency of the intubator. Are the providers included all bark and no bite so to speak (i.e. great didactic without any practical experience). 2) Techniques used. Was CPR interrupted for airway placement? Was airway placement given greater priority than treatable causes at any point? 3) Algorithm bias. As previously mentioned early ROSC is a well-known indicator of likely survival to discharge. If ROSC comes early in the resuscitation it's less likely that the patient be intubated. It must therefore be considered that intubation could be an incidental finding in failed survival to discharge as opposed to a causal factor. As for supra-glottic devices, the very design of them should be suspect to anyone with knowledge of vascular anatomy. The early evidence gathered thus far indicates they impair cerebral circulation. Shocker! Let me tamponade your throat and see how long you stay conscious. These devices by nature of design have the potential to do exactly that from the inside out. Not exactly ideal for an already circulation starved brain.

Her GCS ranged between 7-8 from one minute to the next. We did make use of lidocaine spray, so once it had a chance to take full effect she wasn't fighting the tube. Like I said far from ideal for intubation. My conundrum with this particular patient really came from how limited my pain management and sedation options are right now. I have morphine and midazolam without any paralytics; both of which are relatively vaso-active and on my serious no no list for a patient who just had no blood pressure at all. A little more follow up. After arrival at hospital ED staff continued with the pressor drip and pacing. A central line and transvenous pacer were placed with ROSC maintained for at least the next couple of hours. When I stopped in to check on her progress she was still intubated but awake and communicating with a BP of 110/70 and paced transvenously. Survival to discharge I don't know, but I do know she's 85 and we gave her the opportunity to say goodbye to her family.

Ask and ye shall receive. With the initial presentation I elected to go a little bit old school and make an attempt at pacing. I was able to achieve excellent electrical capture but was unable to obtain sufficient mechanical capture to produce a palpable pulse. The first attempt of pacing was ceased and continuous CPR maintained (stopping to analyse a rhythm q 2 minutes. My service is currently participating in a 30:2 versus CCC ROC trial). Once vascular access was obtained it was straight into the epinephrine q3 minutes (admitedly access took longer than I would have preferred but when doesn't it in a code situation?). Also an epinephrine infusion was initiated at 3mcg/min between the second and third round of epinephrine 1mg. After the third round of epinephrine the patient had converted into a wide complex PEA (third degree block) at 26 BPM. At that time I elected to make a second attempt at pacing with success (ROSC paced at 70 BPM with 140 mA). The patient was intubated at that time with what I would refer to as "brutane" by my partner (wishing I had ketamine and paralytics on my truck for this one believe me). ROSC, pacing, and the epi infusion were maintained to hospital. The epi infusion was bumped up to 6mcg/min when the patient's BP dropped to 72/26. Sedation was relatively minimal (2.5mg IV midazolam) unfortunately because we only have relatively vaso-active agents available to us right now (morphine/midazolam). Ketamine is on its way but not yet available. I wish I had a 12-lead to share with you but I didn't do one. I was actively pacing the patient making a diagnostic 12-lead impossible at the time. I'll add a little more regarding patient follow up later on. You would. The risk vs. reward ratio for this patient of trying to move her prior to some stabalization (ie. ROSC) is pretty clear in my opinion. The numbers don't lie. CPR on the move is not nearly as effective.

I suspect that call is forever in the memory banks as being one of the most interesting you've ever had! Why are you transporting a dead body as an ALS provider? I understand why Arctickat did in the past working BLS (now he would probably pace that patient and bring him in for a pace-maker). If her heart isn't circulating any blood she is in fact dead and her brain just doesn't know it yet. At that point in time the only thing keeping this patients brain alive was high quality CPR. Why would I want to risk compromising that by trying to transport prior to ROSC? Interesting thought. I had a very similar thought a little further into the arrest (I'll explain shortly). Standard ACLS doesn't address this particularly well.

What province are you in? Knowing your general location will really help us to tailor our responses. The pathways still vary significantly province to province. Sent from my SGH-T989D using Tapatalk 2

This is a patient I recently dealt with while working targeted ALS. It was a highly unusual situation and I think it's well worth throwing out for the EMTCity local to play with. Let's start with how you would manage this patient and go from there. I'll chime in with what I actually did and the outcome later on. Initial dispatch info: 85 y/o female patient, Chest Pain with SOB. Initial Contact: BLS (PCP crew so think EMT-I) arrived first to patient with declining LOC, Bradycardia, SOB, Pale, diaphoretic. Patient arrested in BLS presence with CPR, PPV, AED applied immediately (one non-shockable rhythm analyzed prior to our arrival). We arrived to BLS crew working the arrest 4 minutes into the resuscitation. The patient patient was found to be in an asystole with absent pulses. The kicker (pun intended) is that the patient was also combative with good CPR (kicking, pulling at the BVM, I'm talking a 2-2-5 total of 9 GCS). That's all I'm giving up for now. GO!

This should give you some idea of what to expect in Canada. http://en.wikipedia.org/wiki/Paramedics_in_Canada This is the Wiki write up for BC, the province I currently work in as an ACP. http://en.wikipedia.org/wiki/BCAS I read through them both. They're relatively accurate overall. I'm also registered in Alberta as an EMT-P which actually includes the majority of the CCP SOP minus the additional education (Alberta doesn't currently have a defined CCP level so EMT-P's currently fill that hole with additional in house training from their respective employers).

Alive and well working targeted ALS in the GVRD. Sent from my A500 using Tapatalk 2

I came into Alberta from BC. It was quite simple for me, but Alberta and BC have interprovincial agreements in place. It sounds a little crazy but it might actually be easier for you to license in BC first, then register in Alberta. Agreement in trade exists but it's not always fair between provinces. For example, I transferred back to BC with an ACP license after registering in Alberta as an EMT-P. I could not have gone the other direction with a BC ACP license. I would only have qualified for an EMT registration. Sent from my SGH-T989D using Tapatalk 2

At first I thought I might have stroked out when I read the headline and it was actually April 1st. Then I read the article and found the headline is accurate. I can't say I'm likely to still be in EMS when I hit 93. I expect to burn out long before then. Sent from my SGH-T989D using Tapatalk 2

One provider might improve patient care overall but it will do nothing for response times if their driver is being paged in from home as a volly. Sent from my SGH-T989D using Tapatalk 2

Um, more like $9.13/hour. Two providers per shift, two shifts per day (12 hour shifts), 365 days per year. This simple calculation doesn't factor in vacation or benefits cost so keeping things at the 160k mark would mean making less than $9.13/hour. Not exactly what I would consider well paid, but compensation rates state side don't really compare to what we see in Canada. Sent from my SGH-T989D using Tapatalk 2

Seriously, listen to what ERDoc is saying if you haven't already. I do however expect that you've had proper follow up and are now posting it as a case study. In my experience you can be stubborn but you're not a complete dumbass and would follow up appropriately. In the interest of aiding the differential, any recent cough, cold, flu, or vaccinations (generally any potential exposure to an infective process be it viral, bacterial, parasitic, or even fungal)? Any relevant family history (CAD, diabetes, arrhythmias, etc.)? How about heart tones? Everything lubbing and dubbing the way it's supposed to? You didn't happen to have a monitor to throw yourself on while this was happening did you? How about vitals during the episode? Sent from my SGH-T989D using Tapatalk 2

10gtt and 60gtt. Easy math and zero issues with hospital system compatibility. Sent from my SGH-T989D using Tapatalk 2

Working conditions, security, equipment/supply availability, expatriate kidnapping likelihood/policy, compensation. That's what immediately springs to mind for me. I'm sure others will have more to add. Sent from my SGH-T989D using Tapatalk 2

All the best to you and your family as you go through the healing process. I have an excellent relationship with my own Dad and can only imagine the array of feelings your progressing through. Sent from my A500 using Tapatalk 2

Cheater! Sent from my SGH-T989D using Tapatalk 2

Hand over the diaphragm. Sent from my A500 using Tapatalk 2

That would certainly be my suggestion. In my experience remote mines often run a 2-3 weeks on, 2-3 weeks off type rotation. Less remote mines (no on site crew housing) frequently run a 4 days on, 4 days off rotation (any medic who usually works ambulance will be familiar). Sent from my A500 using Tapatalk 2

You need to talk to Squint. Last time I provided private ALS coverage I was making $625/day based on a 12 hour day. 24 hour a day coverage would obviously require a commiserate increase in compensation. Are you looking at an expanded scope situation? IE suturing, antibiotics etc. with telemedicine available. Sent from my A500 using Tapatalk 2

If you plan on staying in Ontario all that matters is that the program be accredited by your regulatory body. If you want the option of working in other provinces I strongly advise you to choose a CMA accredited program. It really is that simple. Sent from my A500 using Tapatalk 2

Captain please tell me this jackass was fired. Sent from my A500 using Tapatalk 2

I've looked at them personally. Great idea. That one I need to pitch to medical programs before product procurement. I start my new full time ALS position in Vancouver next week. That'll probably be when I first mention it. Put the bug in, then push more if that's not enough. Sent from my SGH-T989D using Tapatalk 2

The simple solution would be to merge the threads. Mods? Grumpy old timer. Sent from my SGH-T989D using Tapatalk 2

Hello, my name is "insert name" with "insert service." This is my partner "insert name." Your name is? What brings us to see you today "insert patient name?" Sent from my A500 using Tapatalk 2