rock_shoes

No. I'm implying it hurts like a motherfucker when you infuse fluids lidocaine flush or not. Just because you can do it doesn't always mean it's the best thing, or right thing, to do.

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.

Chest x-ray

Lung sounds

Current chem-7

Current CBC

Current ABG

Initial chem-7, CBC, and ABG

How much fluid did she initially recieve, and how much was she given over the last 3 days?

What is the levophed running at, for how long, and has the rate had to be adjusted?

When and why were the chest tubes inserted (symptomatic or did they find the pneumo on x-ray?

What are the vent settings, and have they been adjusted?

What are the drip rates for her sedatives?

Any urine output? If so, how much per day since admission?

What type of venous access is there?

Home medications?

Medical history?

There are things that need to be done and/or changed, but I'd like that info first.

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

I got into EMS for all the hot chicks and fast driving. I found out that hot chicks are few and far between and besides, my wife's way hotter than any of those in EMS.

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

I'm a bit confused about the responding system in this state. How comes 2 units are dispatched in the same time? From what I understood there was and ALS and a BLS int he same time, right? Then, isn't there a protocol for those 2 units to work together, given they both have a specific role to play? Or am I missing something?

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.

Here's some non sensicle annecdotal evidence form someone who does not intubate, though i do work with people who have that skill set and assist with the procedure from time to time.

A lot of guys here incorporated this into their practie when Weingart put that on his podcast and from my many conversations with them they have had very very few desaturations and when they do they desaturate a lot slower than pre-oxygenation with BVM alone. I dunno what its work but from what I've seen I'm pretty much sold on it for the future.

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.

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.

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.

Best guess? You don't know either.

What about the COA/COG?

That's find you want to keep the scenario moving forward. But it can't really move if people don't know what other people are talking about.

And honestly? Right now, I'm more curious what the abbreviations really stand for than I am in the scenario.

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.

well doc if he fell out of the unidentified 777 then he is triple screwed.

But seriously, we need more info before we start down any road of SMR, I mean SMR is normally reserved for the Stepwise multiple regression of the Superficially Medically Refined in a Super Macho Resistence. I mean SMR AMR PMR EMR IMR vmr and that's my story and I'm smr'ng to it.

ok, it's late and I'm tired.

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

Lets talk ABC's. Does he have a pulse? Or am I working a trauma code?

How far did he fall? What was he doing before he fell?

Anyone of the bystanders know his past medical hx?

I would also start with a rapid trauma assessment:

COG: is he COA now or still unconsious/unresponsive?

Head: What do I see? PERLA? Normocephalic? Blood and CSF leaking from ears?

Neck: JVD? Trachea midline? Back of the neck have injuries? What are they? Bruising/swelling?

Chest: Symetrical? Breathing normally or do I have paradoxical movement? Lung sounds equal in all fields?

Abd: soft, non-tender or distended and painful?

Pel: any bruising, swelling or crepitous noted? Priaprism?

EXt: any obvious injuries to extremities x 4?

Back: injuries? Bruising/swelling/crepitous?

SMR will be initiated. IV, O2 and rapid transport.

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.

Until something happened and you are crucified for using a machine that was never intended to be used for these patients.

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.

No, I wouldnt as the lowest setting on the IVENT is for 10kg, but you have to ask how many infant/ventilator patients did you transport last year ? If you had a significant amount, then consider it, but I am guessing most of us did not have any. In my area, the childrens hospitals and the major trauma center have pediatric and neonatal transport (not to mention helicopter ambulance service), so they handle these transports --- maybe i am lucky.

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.

Either the forum's glitching or I am, as I'm having trouble using the quote function today, but...

You have a rotary wing operator, based in a neighbouring province. It's previously run operations in Nova Scotia. It's recently expanded aggressively into Saskatchewan and Manitoba. In at least one instance, it's been introduced without a competitive tender process. It's a "not-for-profit", run with minimal provincial funding. It collects a large percentage of it's revenue from corporate donations, and fund raising. It already flies missions in your own province.

Let's say you're responsible for medical oversight, and have developed (arguably) a Cadillac system in your own province. But, and I'm just guessing here -- probably an expensive system, if every new hire is going through a government funded 18 month training program, while receiving a full-time wage from the employer?

And you're not threatened by the possibility that in these days of social services cutbacks, your own system might get replaced by the cheaper option from next door?

I'm sure Dr. Wheeler is a very ethical man, whose primary interest is patient care. It's hard to argue against anyone who wants to raise the standard of training and education. Many of his criticisms may well be valid. But the conflict of interest here should be obvious, and it should be clearly stated. This doesn't render his conclusions invalid, it just makes everyone aware that it may be difficult to be completely impartial in this situation.

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.

I think it's probably fair to say that Dr. Wheeler is an expert, based on his credentials. But, as you've pointed out, he is only one expert. There is also a clear and obvious conflict of interest here, in that he runs the BCAS program, which has a coverage area that overlaps with STARS bases in Alberta. To some extent, these services are in competition, and the potential for STARS to expand further can't have been overlooked.

I haven't met a lot of people from the BCAS CCT, or from ON ORNGE CCP programs. I'm sure they're excellent people, and it sounds like their training programs are very rigorous. I have met a lot of people from AB STARS, interacted with them on calls, and benefited from training programs offered from them. I found them to be extremely well-trained, knowledgable and competent, and have learned a lot from them.

Of course, my opinion is somewhat meaningless, as I am not an expert. It's also hard to compare the training between the different locations without having taken the training. There are a lot of unanswered questions here, that make it difficult to present an informed opinion.

-----------------------------

On another note entirely, the US audience may be interested to see that the discussion here is revolving around the provision of a single RW to a geographic area roughly the size of Texas (*albeit very sparsely populated), and whether this is even beneficial versus FW. Not a narrative likely to be explored stateside any time soon.

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!

Wheeler’s recommendations:

· STARS should redesign its training program and certification process for its crews in line with other Canadian provinces and immediately supplement its crews with experienced flight personnel for a minimum of six months.

· STARS should review its pediatric training with an emphasis on airway assessment and management.

· STARS should be limited to transporting pediatric patients only in trauma scene responses.

· STARS should have on board medical personnel from Children’s hospital for all pediatric inter-facility transfers.

· STARS Manitoba and Manitoba dispatch Centre should establish a pediatric medical oversight model for triaging and dispatching pediatric patients.

· Further intensive training of STARS crews in advanced airway management should be done immediately.

· Video laryngoscopy should be included in STARS skill set for crews.

· Until STARS has well-trained crews, physicians should be onboard all missions with airway and ventilation issues.

· STARS should limit its transport of pediatric patients to trauma scene responses, and not carry out routine patient transfers between facilities, while it reviews its pediatric training. Emphasis should be on pediatric airway assessment and management.

· STARS should review its physician orientation process to increase the understanding of the advantages of different transport modalities.

· STARS orientation should include a set number of fly-alongs with crews.

· A dedicated, local Quality Improvement director should be established.

· STARS should express its commitment to be a quality organization and back up its commitment with action and accountability.

· STARS should develop a Crew Resource Management culture.

· All dispatching of air medical transports should go through central provincial dispatchers who will determine the most appropriate mode of transport.

· The patient should go by the faster means possible.

· A feasibility and cost analysis of building hospital helipads should be done for all Southern Manitoba hospitals.

· A comprehensive maintenance of competencies program should be established and monitored for STARS crews.

· STARS crews should be rotated through more high volume programs including other STARS bases and Manitoba Lifeflight.

· Quality control must improve because “overall, an emphasis on creating and maintaining a culture of quality is missing.”

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.

We just covered this last week in class, basically we do not have the stats to make the argument for video over direct laryngoscopy as our success rates equal those of emergency department physicians already. The other thing is the cost, we would need 130 something units.

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.

I do not support giving Narcan to the general public and here is why. Narcan or Naloxone HCL is indicated in the treatment of narcotic overdoses. Narcan can have some serious side effects including vomiting with rapid administration, ventricular dysrthymias and also acute withdrawal. Narcan requires that you have the ability to manage the patients airway and that you have the ability to monitor and treat complications. " Narcan is like a band aid" It does not fix the person or their wounds. Instead of wasting money on Narcan lets instead put funds into education and mental health care.

In a narcotic overdose situation Narcan is a life saving rescue intervention not a band aid. Think of it like giving an epi pen to someone anaphylactic to peanuts or some other common allergen. The side affects you mention are extremely unlikely when you take into account the dosage and route of administration for these public access kits are restricted. Administration is either intra-nasal or via IM auto-injector. The doses are 0.4 to 0.8 mg.

I absolutely agree with you these patients require education and mental health. The problem is, they will never be able to access those things if they die of an overdose. This is an opportunity to reduce the number of overdose deaths. The next step is making the education and mental health services these people require available when they're ready to accept them.

We all admit that there are risks involved with having EMTs/medics/FFs/cops/homeboy EMS give narcan. Given the benefits (preventing death) I think we can say that the benefits outweigh the risks in this case, even when given by street pharmacists and well meaning family members.

Bingo!

BC was actually one of the first places to take on this harm reduction tactic when they began allowing PCP (think EMT- I/85) level providers to administer naloxone to suspected overdoses. The downtown east side of Vancouver is a world class city's dirty little secret. It's the poorest neighborhood in all of Canada with incredibly high rates of drug addiction (heroin in particular).