rock_shoes

Oh we all know the dumbest question people ask.  "What's the worst thing you've ever seen/had to deal with?"

My usual response is that they don't want to know.

We lose too many too early. If it isn't shift work related or worsened illness it's PTSD. You will be missed Island. I knew you only through your contributions here, but based on what I've read over the years I'm certain your passing has left a giant hole in the hearts of your loved ones.

Your shift has ended. Just leave us the keys mate. We'll take it from here.

Ed

Since when is it acceptable to just rip through an intersection on a red light without clearing it first? Either the ambulance in question had a brake failure or the driver was an idiot.

I expect the Edmonton unit may have more of a positive effect than some of the other similar units because of the deployment plan. AHS plans to send this unit to intercept potential hot strokes coming in from rural areas which could make the difference for a number of patients (two units travelling toward each other at 100km/hr would equate to one unit running toward the stroke centre at 200km/hr).

I can't speak for other programs but CAMATA was included in my ACP program at SAIT. I suspect the best thing would be to approach the local schools directly and offer the ride along/practicum space for students on final practicum. Perhaps it could be an additional two tours/blocks at the end of a successful students practicum?

Intuitively the reported results make sense. In my own experience with enough epi and bicarb you can get ROSC out of a rock. That doesn't mean the person will have survival to discharge.

At this point it appears that epi is more beneficial than harmful in cardiac arrest. I would expect the next logical step regarding epi will be dosage determination. Is 1mg IV q 3-5 minutes the ideal dose? Should it be more? Less? An infusion instead of bolus dosing?

If you're starting entirely from scratch I would suggest finding a CAMATA course to put your people through. The course is fairly old and certainly due for an update but it's the best primer I know of without putting them through a full Critical Care Paramedic program (The 1-2 year Canadian version of the CCP I mean).

http://www.camata.ca/educationoverview.htm

A lot of it will come down to the basics. Teach Loading/unloading using whatever system the aircraft is equipped with; flight physiology and how you can expect it to affect you and your patients. Racking equipment for the flight environment; Modified patient assessment for the flight environment. It doesn't sound like you'll be flying any vented patients so that should make things a little easier. If you're flying psych patients BC actually has a fair amount of experience with this and a well developed sedation policy. It's a policy that has come under some heat over the years but is strongly backed by a record of zero patient harm incidents.

Island I am sorry for your loss. Preventing the drugs from ever landing on home soil is certainly a valid avenue to try and prevent addiction all together. I was speaking in reference to treatment cost reduction for those who are already addicted. Sent from my SM-G900W8 using Tapatalk

sarcasm alert

just what the world of drug addicts needs. A supervised shooting gallery where they can go & use illegal drugs in safety .

they turned to heroin because the prescription opiates got much harder to obtain after we went through a 5 year span of time where it seemed like every other call involved prescription medication overdoses. Heroin is cheaper and easier to obtain on the street than diverted prescription drugs

I say give them all the blow they can shoot snort or shove up their arse. They will be gone soon enough all on their own.

Their addictions are breeding a whole new adventure in the drug treatment centers who take them off heroin and get them hooked on suboxone that is provided legally by "professionals" who are helping to lighten the states wallet by millions $$$$$$$$$$ yearly.

Now we have a whole new culture of suboxone addicts robbing houses and people to get more illicit drugs on the street.

"Supervised shooting galleries" as you refer to them do not really assist anyone in getting off drugs. What safe injection sites do is reduce the amount these people drain out of the public system (remember Canada, and in fact most of the developed world, has some form of publicly funded health care). Safe injection sites reduce 911 responses for overdose, they reduce infection due to the sharing of dirty needles, and for a very small number they provide access to rehab facilities.

From a study in Quebec looking at the cost of caring for septic patients (a frequently occurring malady amongst the IVDU population). "The mean cost for all patients abstracted was $11,474 per episode of care ($1,064/day). The survivors had a mean cost for their treatment of $16,228 per episode of care ($877/day). The total cost per episode was $7,584 per nonsurvivor ($1,724/day). An average cost of $27,481 for survivors after day 28 through 1 year was calculated. The burden of severe sepsis was estimated to be $36.4 to $72.9 million per year, but higher if costs beyond day 28 are included."

http://www.ncbi.nlm.nih.gov/pubmed/12040548

From the CDC regarding the cost of HIV treatment "The most recent published estimate of lifetime HIV treatment costs was $367,134 (in 2009 dollars; $379,668 in 2010 dollars)."

http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/

In a country with a publicly funded hospital system the tax paying public is on the hook for Sepsis and HIV treatment cost. In the end I don't support safe injection sites because I think they help people get off the drugs. I support safe injection sites because I'm a responsible tax payer who likes seeing the impact of junkies on the public purse reduced as much as ethically possible.

I salute your inner whacker!

You however are a very rare form of whacker. You are the nearly extinct productive whacker who uses his powers of whackerism for the betterment of human kind.

I truly believe ultrasound is more beneficial than 12 lead technology for EMS (not saying we should take it away by any means here). If you do your homework and practice a handheld ultrasound can provide a FAST exam within 30 seconds, tell you in minutes why your patient is in shock, assist with IV placement, do cardiac, vessel, and fetal assessments.

Assuming of course your Paramedic crew has sufficient A&P knowledge and the willingness to learn the FAST system.

Interestingly enough we had a similar issue here recently. The patient refused to be transported by helicopter, multiple times. He was lucid and unimpaired, yet the flight crew administered 30mg Diazepam to sedate him because he was too agitated for the flight. Fortunately it wasn't sufficient and they elected to send him by ground. I wish i would have been there though, there is no way I would have allowed them to do that. Turns out as soon as he knew he wouldn't be flying he calmed right down and had an uneventful trip into the city.

Any idea what the reasoning was behind the decision to sedate and fly an unwilling but competent patient?

The situation reminds me of a STEMI patient I picked up one time. In the greater Vancouver area there are 3 Cath hospitals within a 20 km radius. My patient refused to be taken to the closest of the 3 but was otherwise a willing patient. Rather than argue with him I broke standard policy (take all patients to the closest appropriate hospital) and drove him to one of the other Cath hospitals another 10 minutes drive away. True I broke service policy, but in the end my sick patient received appropriate care instead of refusing life saving treatment. The point being, sometimes it's better to be inventive than right.

As it turned out he refused transport to the closer Cath hospital because his life partner died there due to similar circumstances. I was always prepared to defend my decision but oddly enough nobody ever questioned me on it.

What do you have available to you for blood products? What has been done with the patient thus far (ie. has the patient received TXA or perhaps octaplex)? Past medical history, allergies, medications?

Regardless, the picture you've painted so far tells me this gentleman requires a vascular surgeon yesterday.

Oh and what about the other patient? Anything to indicate the other patient may also require medevac?

What EMT skills above first aid would you feel might be used before an ambulance could arrive?

That would be my question.

I don't think it works.

http://www.ncbi.nlm.nih.gov/pubmed/21879897 [Link to free .pdf on page]

N Engl J Med. 2011 Sep 1;365(9):798-806. doi: 10.1056/NEJMoa1010821.

A trial of an impedance threshold device in out-of-hospital cardiac arrest.

Aufderheide TP¹, Nichol G, Rea TD, Brown SP, Leroux BG, Pepe PE, Kudenchuk PJ, Christenson J, Daya MR, Dorian P, Callaway CW, Idris AH, Andrusiek D, Stephens SW, Hostler D, Davis DP, Dunford JV, Pirrallo RG, Stiell IG, Clement CM, Craig A, Van Ottingham L, Schmidt TA, Wang HE, Weisfeldt ML, Ornato JP, Sopko G; Resuscitation Outcomes Consortium (ROC) Investigators.

BACKGROUND:

The impedance threshold device (ITD) is designed to enhance venous return and cardiac output during cardiopulmonary resuscitation (CPR) by increasing the degree of negative intrathoracic pressure. Previous studies have suggested that the use of an ITD during CPR may improve survival rates after cardiac arrest.

METHODS:

We compared the use of an active ITD with that of a sham ITD in patients with out-of-hospital cardiac arrest who underwent standard CPR at 10 sites in the United States and Canada. Patients, investigators, study coordinators, and all care providers were unaware of the treatment assignments. The primary outcome was survival to hospital discharge with satisfactory function (i.e., a score of ≤3 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating greater disability).

RESULTS:

Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (risk difference adjusted for sequential monitoring, -0.1 percentage points; 95% confidence interval, -1.1 to 0.8; P=0.71). There were also no significant differences in the secondary outcomes, including rates of return of spontaneous circulation on arrival at the emergency department, survival to hospital admission, and survival to hospital discharge.

CONCLUSIONS:

Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).

Bingo. I participated in this study. The ITD was of no benefit and actually had slightly worse ROSC rates in absolute numbers (not statistically significant).

I think this depends a bit on what sort of facility you're transporting to. If I'm 10 minutes from a trauma center, they'll only get intubated if they have no gag or I can't keep their sats > 90%, and they'll end up with an IV or IO. If I'm 10 minutes from a rural ER without EM coverage, I'm probably just going to stop and RSI them now, and either bypass to a bigger ER, or call for a helicopter.

Fair point. Currently I work close enough to trauma centres I no longer have to transport these patients to small local hospitals. That said, even when I did have to transport to smaller facilities I typically had time to either call in a medevac or do everything on route with the wheels turning.

They are basically comparing the two thoughts of trauma care by EMS. Which improves outcomes, stay and play or load and go? We can all make guesses about which is better and why but there is a lack of evidence to support either side, although this is starting to change. The best we have for comparison right now is to compare conventional EMS interventions (treating at the scene) to no intervention and rapid transport. The only way we have to evaluate the latter is to use data from homeboy ambulance since there is no significant data from EMS for this arm. I think OPALS came closest to making some recommendations, but I haven't kept up on it recently.

As for fiddle fucking at the scene, yes that is done since that is what protocols say. Try delivering a trauma pt to a trauma center with an unsecured airway and no IV. Best practices will require changing the thought process of both prehospital and hospital providers.

To be honest, it is extremely rare I deliver a major trauma patient without a secured airway and vascular access though it certainly isn't for lack of trying. It's tourniquet if necessary, load, and transport with everything else done on route. Our local trauma centres have been excellent about accepting that we may not have time to intubate etc. prior to arrival.

I find it comes down to the most basic of assessments. Does the patient require or potentially require hospital based interventions on a time sensitive basis? If so move your ass and do what you can with the wheels turning. I find this is something we frequently over complicate.

BCAS has had the KingVision video laryngoscope on car for a little over a year so far. It's an excellent tool when used appropriately. I've found suctioning technique is critical with video laryngoscopy. Sometimes you'll still have to go in with a mac/miller to suction first even if you are unable to obtain a cord view. I've developed a few different techniques for wet airways and have used it as a back-up (or sometimes primary) for the last year. With one technique I will go in direct with suction, leave the suction in place, then insert the video blade as I pull out the standard blade (works well with a severe fluid airway but requires a decent size mouth opening). With another technique I use a channeled blade and advance the suction just ahead of the camera lens to prevent it from being obscured (works well for moderately "wet" airways). Small mouth openings can still be difficult because the blades (both channeled and non-channeled) are a bit bulkier than standard direct blades. The McGrath appears to be a very similar design but likely somewhat higher quality.

Is a medical fixed wing flight an option? Would be much quicker and can just keep him occupied with an ipad, IV access when needed with orders for IV sedation.

This strikes me as a much safer option for all involved. Relatively few aeromedical services have specific procedures for transporting potentially volatile psych patients. Levels of sedation in the aeromedical environment can range anywhere from dimenhydrinate for air sickness/mild sedation to having the patient sedated and intubated for the flight. The level of sedation targeted is varied depending on an individual patient's needs as assessed by the sending physician, air medical transport advisor, and attending flight crew.

The following article gives a brief outline of the psychiatric air medical transport program used in BC as it was first implemented.

http://www.bcmj.org/article/criteria-sedation-psychiatric-patients-air-transport-british-columbia

The initial implementation of these procedures was heavy handed with regard to sedation levels and came under much scrutiny. As procedures have been adapted over time the levels of sedation used have become increasingly adapted to individual patients instead of a more blanket policy. It is worth noting that as of now not a single psych patient transported has been diagnosed with adverse effects attributable to being sedated for transport.

http://www.theglobeandmail.com/news/british-columbia/bc-rules-requiring-sedating-mentally-ill-for-transport-risks-lives-mds-say/article4186567/

I didn't know Greg but I know Greg. I have watched colleagues suffer as he obviously did for my entire career in the field. I have been incredibly fortunate thus far, but in the back of my mind I know I'm likely only waiting for the moment it all boils over. Recently I spoke with a colleague about his PTSD experiences. His suffering focuses primarily on a single incident but it took 18 years of further incidents to put him over the edge. 18 years of the worst of the human condition and he was doing well. He would go home to his loving family, work his beloved trap line, and sleep soundly at night knowing the value of his efforts. One day, one call, later he is a broken man completely unable to function at home or as a paramedic.

How will it strike me if it ever does? Will it be a slow building cumulative form? Will it be cumulative with a hyperfocus on a particular incident randomly set in motion by another separate incident? Will it be a single incident? We should all be asking ourselves these questions. We should all be seeking ways to mitigate these risks. Perhaps I will be the fortunate one who is never struck down by the acquired mental illness that is PTSD. Perhaps I will not be so fortunate. Regardless of my own fortune, I find it my duty to stand with my brothers and sisters who are suffering for as long as my legs will hold me.

Greg, you have my respect.

Ed

I think it depends on how the course is accelerated. Medical school at the University of Calgary is a three year program for example. It's 3 years because prior to entry applicants are expected to have completed a minimum of two years post secondary (the majority have a Bachelors) and the program itself runs straight through without taking summer semesters off (3 semesters a year instead of 2).

It's accelerated not because instructional time is less but because there is less time between instructional periods. An EMT program could do the same to some degree. Pre-read the material and have class 5 days a week for the duration instead of just on the weekends. Please don't mistake this as my defending the pitifully inadequate EMT education requirements. I'm speaking strictly in terms of delivering an equal volume of material over a shorter time frame.

As in mounting your old boxes onto a pickup instead of a van chassis? If that's the case you should see some serous benefits as long as you don't need the tighter maneuverability of a van. Pickups are easier to work on which should help reduce maintenance costs. Also if you have need for a 4x4 unit it's dramatically easier/cheaper to put it on a pickup chassis than have a van chassis modified.

I get not using a longboard; that's great and in line with current trends and knowledge.

It's this part that has me confused:

Why not just use the c-collar? It's mentioned earlier in the memo that a collar and being told to lay still provides adequate protection; why add in another piece that could, if I'm reading that right and the blocks are meant to actually stabilize the head, actually create more harm?

I was a little confused by that part myself. I think the intention is to use them as a reminder for the patient not to move their head around. Basic towel rolls add almost no mass about the patient's head so the risk of secondary injury as a result of their use is relatively low.

So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit.

* It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk.

* Traditional spinal restriction results in a 20% decrease in FRC, which could become a trigger for pre-hospital RSI.

* Spinal immobilisation can complicate airway management, and increases ICP.

* The LSB is a relatively poor device for spinal "immobiilisation", as you're trying to force a curved structure to conform to a rigid plane.

* Healthy volunteers often develop neck pain, and report moderate-to-severe pain when immobilised on an LSB, which can result in unnecessary imaging, which carries costs and risks to the patient.

I think the rolls/blocks are primarily there to remind the patient not to move their head. Which is pretty much what they do on an LSB, anyway. I think we're all aware that a patient can generate substantial joint motion while immobilised.

There's also the question as to how great the benefit really is with traditional techniques. Only a very small percentage of patients that are immobilised by EMS have c-spine fractures. The vast majority of these are stable fractures. Even most of the radiographicaly "unstable" fractures are not grossly unstable, as in the patient will move their head and displace their c-spine. They're unstable in the sense that it would be unwise to discharge them home, to play soccer or football without addressing the injury. Even when injury does occur in a patient that presents neurologically intact, it's difficult to know whether this is from motion during their care or the natural progression of the initial insult, e.g. cord contusion/concussion. There's a certain argument that the force required to fracture the c-spine is many magnitudes of order greater than any force the patient may apply through voluntary movement of their neck.

Also, consider the care provided in the ER, where often the patient is removed from the LSB prior to radiography, and left supine with instruction not to move their head. Even after an injury is identified, it's not like the patient is immediately put back on an LSB and then halo'd. They're basically put on a soft stretcher, and told not to move their head, and log rolled by staff. That's all this really Is. It may be a change in care for EMS, but it's not really a divergence from standard care in the ER.

The patients that are combative are still on the LSB --- and these are the patients the ER typically leaves on, right? Because we're using it as a restraint device as much as anything else. The patients that are intubated are still on the LSB -- they can't splint, and tube displacement is a potential disaster. The patients that are significantly altered, or who can't follow instructions due to a cognitive issue or language barrier, they're still on the LSB too. But what's happening, is there's a recognition of the limitations of the LSB, and that "immobilisation", is a fantasy -- what we're doing is restricted motion. This can be accomplished in a number of different ways, which can be tailored to the patient.

Bingo. Here's a link to the memo notifying AHS field staff of the change.

http://www.associatedambulance.com/wp-content/uploads/2014/10/AHS-Memo-Spinal-Motion-Restriction-October-2014.pdf

What the memo doesn't go into is the use of a scoop stretcher to enable easier patient removal onto a cot or hospital bed. This would be considered acceptable as a scoop (double clasp variety) is considered to be an acceptable spinal motion restriction device in Alberta. I suspect the scoop was left out of the memo because most AHS staff still use a long spine board.

Sorry. I hate it when people introduce new abbreviations without defining them.

Spinal Motion Restriction.

Just another way of saying "take c-spine". Implicit to the term is the idea that you can't immobilise the c-spine short of surgical fixation, just that you're trying to reduce movement, i.e. not everyone needs to be on a long board, not everyone needs to be supine, and a collar isn't a halo.

Interesting discussion.

I don't see the need to take this person to a center with cathlab, CT-angio, neuro-ICU or trauma services.

It would be a good idea to aim towards a site with inpatient beds and a CT.

There's not much information available here to guide this decision. Common things being more likely, I wonder if, in the end, our fellow might not have a touch of the pneumonia, and be a little dehydrated, weak and/or orthostatic.

The definitions are truly changing with regard to spinal precautions. Alberta Health Services EMS for example has pulled spine boards from continued use during transport. A spine board can be used to move the patient as needed but once on the cot the board is removed and the patient is transported on the cot mattress with a collar and head motion restriction (blocks or some other device to reduce lateral and rotational movement during transport. It's a progressive evidence based change on their part and I'm chomping at the bit to see other services follow suit.