rock_shoes

64/40 (MAP 48) isn't going to cut it. Start a second 500mL fluid fluid challenge and switch to a NRB for the time being. What do you have available to you for pressors Chris? What's the patients heart history? Specifically do they have any history of valve incompetence/replacement? Here's hoping the receiving hospital has ECMO available. They might need it to buy enough time to give this patient a shot at surviving this episode.

Firstly, if the patient crumps you're going to cardiovert immediately and how painful the procedure is is superseded by the patient's care needs. Secondly, not all of us work 10 minutes from hospital. I don't know if you noticed but the people who suggested considering an IO are from Alberta. One hour plus transport times are not uncommon there. Personally I would probably consider going to the external jugular with this patient before IO but IO is perfectly reasonable deployed appropriately.

It's not a lidocaine flush per se. It's an incredibly slow push of lidocaine 40-50mg IO prior to any flush to anesthetize the affected nerve endings (I'm talking half a lidocaine pre-load over 2 minutes slow). After waiting 4-5 minutes for the lidocaine to take affect hammer home a 10cc flush to create a sort of pocket in the marrow space. If the lidocaine has been administered properly and given an appropriate amount of time to take effect, the flush is not a whole lot more painful than initiating a large bore IV. I've done this procedure with a number of patients and it works. The problem most paramedics have is that they push the lidocaine too quickly, and or don't wait long enough to slam in the pre-infusion flush.

Looks like a great starting point to me. As soon as Dave returns we should be off to the races.

I can't say the same. My fiancé is another paramedic.

No you're not missing anything. I work in a targeted ALS system. Any call where two units are dispatched means that the patient is assessed by ALS then transported to hospital by either ALS or BLS depending on the patients care needs. Only patients who don't require ALS intervention and are not expected to need ALS intervention over the course of the transport go with the BLS crew.

I'm right there with your co-workers Bushy. This is something I have incorporated into my airway management practice and I've noticed marked improvement with respect to de-saturation rates. The practice came to my attention as part of this CME course I participated in last year. AIME: Airway Intervention and Management in Emergencies http://caep.ca/cpdcme/roadshows-current-cme/aime The primary text for the course was Airway Management in Emergencies http://www.amazon.com/Airway-Management-Emergencies-2nd-ED/dp/1607951045 AIME was hands down the best CME course I have ever attended. The information presented was first rate and directly applicable to paramedic practice in the field. BC Ambulance has chosen it as one of our "pillars" for continuing education with the most up to date version of it available to us every three years.

Things I wish I knew prior to diving headlong into EMS: 1) The degree to which night shifts kick your rear end is directly proportional to your age. 2) Working targeted response advanced life support (ALS) isn't all gravy. Some nights I assess 15+ patients and don't transport a single one of them to hospital (BLS crews take those patients to hospital after I assess) When a call is dispatched as "highest level available" it just means I have to assess them. I only transport a patient when there is something I can provide that patient the BLS crew can not. I go lights and sirens to every single call because according to AMPDS If the call justifies my response it should be a lights and sirens response. 3) AMPDS (Advanced Medical Priority Dispatch System) is complete and utter crap. The old method where paramedic dispatchers assembled the caller's information and sent an ambulance according to their assessment of the priority level is documented to have had a significantly lower triage error rate. The triage error rate would probably be lower if we just let callers/patients decide whether or not we should show up lights and sirens. In fact, I would be all over a study to that effect. 4) Working targeted ALS in a high demand system does not mean you will have the best tools at your disposal. I would have significantly better pharmacology available to me if I worked in non targeted Alberta than what I have in BC. Being registered in both places is extremely frustrating when it comes to some of these items. What I can do in one place I can't in the other. Part of me wishes for a national practice standard, the rest of me is worried the overwhelming Ontario ethic would come into practice (I'm talking about calling for online medical control to give ASA to a STEMI patient level of ridiculous). 5) I would have fast tracked my education beyond being a paramedic a little sooner. I'm in the process of completing a bachelor of health science now. How far I go beyond that depends on my future relationship with admissions.

It's trying to do too much at once. They should have bought two of them. One MCI bus for large events and one mobile operating theatre with 2-3 beds ICU capacity.

The STARS saga continues. Manitoba broke rules with STARS contract: auditor general http://www.cbc.ca/news/canada/manitoba/manitoba-broke-rules-with-stars-contract-auditor-general-1.2578041 http://www.documentcloud.org/documents/1094024-manitoba-auditor-generals-report-on-stars.html#document/p3 I managed to find a couple more little tid- bits regarding flight costs in BC and Ontario Average cost per rotary flight in BC = $8,146.14 Average cost per rotary flight ORNGE = $7933.99 You can find the cost comparison breakdown on page 15 of the Manitoba Auditor General's report aimed at STARS. I'm not sure why they included Manitoba Lifeflight as it is solely a fixed wing service provider.

Fill your boots. https://www.coastalvalleysems.org/entry/updated-spinal-motion-restriction-treatment-guideline.html http://stedmansonline.com/webFiles/Dict-Stedmans28/APP06.pdf

Best guess would be Spinal Motion Restriction. I realize most providers use an excessive number of acronyms, but it isn't entirely unruly to use common acronyms within a case presentation thread directed at other Emergency Medical Service (EMS) providers. My usual tact is to write out the full title the first time I use an acronym with the acronym in brackets immediately after the full title. This seems to eliminate any confusion when I use said acronym later on. In the end I feel the acronym debate would be better left to its own thread instead of it rearing up almost every time someone tries to present a case. I suspect it prevents a number of people from participating in a case they could have benefited from.

Point made. Now let's stop derailing the original poster's thread and allow the case to run its course.

Hold on there turbo. Let's assess whether or not SMR is indicated before we decide to do it. I agree with doing a quick trauma assessment but the trauma aspect may well be secondary to this patients primary issue. ABCs, LOC, trauma assessment, vitals (including BGL and initial rhythm), history (event and patient)... Then decide what direction we should take this.

No question it would be a nightmare call either way. Back to the vents, BCAS CCT programs use the LTV 1000/1200 series vents. Everyone seems quite happy with them and the adaptability they allow. The Infant Transport Team has another vent they use for patients under 10kg but I'm not sure which one they went with off the top of my head.

I certainly wouldn't call it best practice, but if a patient is drain circling and they require care not available at the sending facility (or it's a scene response) get that patient out. It's a matter of evaluating what the higher degree of liability is. Is it using a piece of equipment outside of the manufacturers suggested parameters or is it allowing a patient to die when you could have at least made an attempt? I strongly suspect the answer to that question is region specific.

Could you not just trick the vent if this is a rare occurrence for your service? As in drop the volume input per kilogram to make up for having to input the patient weight as 3kg greater than it actually is. Just for easy numbers let's say you have a 7 kg patient you want to ventilate with 10mL/kg. You're looking for 70mL per ventilation. If you have to input the patient weight as 10kg set the volume to 7mL/kg. That should force the machine to still do the desired 70mL per ventilation.

Here's the thing. The service next door isn't cheaper in their expansion plan. The service they provide in Manitoba is costing Manitoba tax payers huge sums of money as in "177 missions for $10 million = $56,497 per mission." STARS might be a "not for profit" but that certainly doesn't make them any cheaper. BCAS critical care operations transported patients in 2012/13 for an average cost of $6,406/patient moving 8600 patients by ground (1900), fixed wing (4800), and rotary (1900). Even if rotary operations were responsible for the entire cost of critical care transport operations (which it is not as only 1900 out of 8600 patients were moved this way) the average cost per flight would come to $29,000/patient (still significantly less than Manitoba is paying per flight directly out of the taxpayer's pockets). http://www.bcas.ca/factsheets/critical-care-transport-program-factsheet/ STARS dirty little secret is out. This "not for profit" isn't any cheaper per flight than other operations and the training standard by all observation would appear to be less rigorous than other Canadian air ambulance operations.

Actually STARS and BCAS are not in any kind of direct competition. STARS flies into small strips of BC along the BC/AB border. They only do so at the request of BCAS into areas that would not otherwise have rotary services available. BCAS has the sole mandate to provide public emergency health services in BC. Other providers, in this case STARS, may only operate in BC with direct permission from BCAS. Response to private work sites is a little different in that an employer can request STARS service directly (typical on oil and gas sites in STARS service radius). With regard to training standards let me shed some light on the subject. All critical care training programs for paramedics in Canada start from an Advanced Care Paramedic candidate base. The 18 month BC CCP program is only the second in the country to be recommended for accreditation by the Canadian Medical Association. It is a rigorous process involving constant QA/QI, hundreds of hours in ICU, frequent case reviews with EPs/Intensivists, and huge volumes of didactic study. The STARS program by comparison is 10 weeks in duration with a couple of fly alongs. STARS gets away with this because most of the CCP SOP is included in the Alberta EMT-P SOP (ACP equivalent). It's simply insufficient by comparison and that's exactly what Dr. Wheeler has highlighted. Dr. Wheeler's primary recommendation is that the STARS program be brought in line with the critical care standard set in BC, Ontario, and Nova Scotia. I trained as an EMT-P in Alberta. I can run a vent if I have to. There's no way in hell I can run it as proficiently as a CCP or RT.

All I can say is wow. http://www.documentcloud.org/documents/1061486-final-report.html#document/p2 Based on Dr. Wheeler's report STARS Manitoba needs a complete re-tool from stem to stern. New training program, new dispatch criteria, new continuing competency plan, new physician training on transport criteria... Essentially the only thing Dr. Wheeler hasn't recommended is a new helicopter!

It would appear STARS Manitoba is back flying. http://news.gov.mb.ca/news/index.html?archive=&item=30120 I didn't see any mention of the results from Dr. Wheeler's service review. Here's hoping his findings actually come to light and this isn't just swept under the rug thanks to STARS PR power.

Interesting. My service also has DL success rates similar to the typical emergency department. They elected to bring them in anyway thanks to evidence based pressures from the medical leadership (first pass success being clearly linked to improved patient outcomes).

My service just started to carry the King Vision http://www.kingsystems.com/medical-devices-supplies-products/airway-management/video-laryngoscopes/ So far it has been brilliant. Medical programs is recommending its use with any anticipated difficult airway, and with all second attempts (unsuccessful first pass). The technique is somewhat different from direct laryngoscopy but quite easy to pick up. A solid afternoon with some instruction and an airway dummy is more than enough to pick up on the technique for any experienced intubator. Blades are available with or without a chanel necessitating two slightly different techniques.

Initially all the two of you are doing is feeling things out. I would give it a couple of tours and see how things develop before going in guns blazing (except for the driving thing, that's a straight up deal breaker if not remedied as soon as it's mentioned). My overall strategy at the moment is relatively simple. With regard to patient care, if the outcome is as good as can be expected for the situation I could care less how my partner arrived in that position. Accepting that their are other ways to accomplish the task at hand is a giant leap toward innovation within the industry. Regarding professionalism, either you treat patients/nurses/other staff with respect or you discuss your attitude with the appropriate supervisory body. Everything else is incredibly individual. If you're a country guy and your partner likes the dance beats it's going to be a very long 12 hours. My usual compromise is the classic rock station. Almost nobody hates the Rolling Stones. Food choices, the ambulance has wheels, nothing says you have to eat at the same place. General discussion, everyone has a different line. My line is a long ways out so it really doesn't matter to me what my partner du jour feels like dredging up. I have the luxury of working a holiday relief type schedule meaning I work full time but float between 8 different stations.in the GVRD (usually working the entire 4 days at one station then off to another station the next rotation). My work situation means I rotate through partners like underwear and never have to worry about being stuck with a dud long term. The disadvantage is that when I have a great partner I'm only guaranteed to have them for that tour.

Bag him up and do a little fluid loading at the very least. If you have a push pressor at your disposal (say phenylephrine) now is probably the time to give it a go (fill the tank, shrink the tank). The tachycardia is more hypoxia/hypotension than anything so working on those two issues should largely solve the tachycardia. When the time comes to actually intubate hopefully you've been able to pre-oxygenate a little better than you were doing passively with a mask. I'm on board with kiwi regarding paralytics. Go non-depolarizing and skirt the issue altogether (rocuronium or whatever you happen to carry). Are you blokes in the deep south carrying suggamadex yet? I'm assuming ketamine is your first choice for sedation in the land of Oz. If you're still worried about using paralytics at all you could always go super old school and hose down the airway with lidocaine spray. The lidocaine spray seems ridiculous but it works in a pinch.