ccmedoc

Absolutely, getting to the hospital in one piece is a huge priority...wouldn't you agree. We all know how people drive when the lights and siren come on, and an erratic driver in the drivers seat of the ambulance increases your chance of injuring yourself needlessly..When newer medics get spooked, they pucker up and drive faster. I heard some say theres no problem they can't out-drive :shock: . Other than the off chance surgical emergency, priority or lights and siren transports should be few and far between..Risk/Benefit ratio is not so good.. This patient----no lights and siren I do agree with the use of adenosine for diagnostic purposes, but as it was stated before, this patient was unstable enough for cardioversion if rate was suspected as the primary contributor to the presentation. I think other measures could have been taken in lieu of the adenosine in this instance. Another line in prep for the administration of additional fluid boluses and pressors,for instance (IO Included).. These considerations come with experience with sick patients and the system he is working in.. This is probably not the most debatable part of this case..No lights and sirens... :roll:

I cannot respond to this :shock: :roll: ](*,)

Sorry if I appeared snippy :wink: . The part you pick out indicated that normal, or individuals with healthy hearts didn't' have a problem with oxygen availability to coronary circulation with sats as low as 50% at times. It then goes to say that patients with cardiac problems or disease processes that affect cardiac function, showed vulnerability upwards of 85%. Meaning that a compromised individual may show increased cardiac ischemia with a sat of 85%. Already ischemic.This is one reason for the 90% rule in the assessment portion and determining administration. There are many physiologic factors involved in this discussion, and could go on for a VERY long time.. No simple answer. If I ramble I apologize

Anthony, if their heart is ischemic, then why would we want to administer a treatment that is being proven to increase cardiac ischemia. We seem to be talking in circles. Chest pain, as a symptom, does not indicate the need for high flow oxygen. Without respiratory distress or very low oxygen sats, less than 40% Fio2 should be adequate supplemental oxygen. Hypercapnia, simply put, is elevated levels of CO2 in the system. COPD sufferers have chronically elevated carbon dioxide levels and rely on these levels to regulate their respiratory rate, depth, etc. "Knocking out the respiratory drive" is not the worry here, as this typically takes a long time..many hours. The concern is the vasoconstriction and subsequent organ damage and failure that ensues (ie. heart, kidney, brain). I thought this was explained pretty clearly by a few people earlier. Not to be nasty, but maybe it is getting tough to sort through the BS that has " always been done this way" and the information that should be applied to practice. (edited for continuity)

Yup! That about covers it. Sounds good... =D> Hypothermic patients should be handled carefully. In the event of ROSC in a hypothermic full arrest, Jarring movements can initiate v-tach or v-fib until the patient is rewarmed adequately. Right on Fiznat

I don't believe it is side-stepping at all. Patients with compromised left ventricular function and high dependance on Hypercapnia have been shown to have a fall in cardiac output and increased PVR in less than 20 min with as little 40% FiO2, this is NC territory. Different disease etiologies could or could not further complicate this. Sounds like a long time, but once the cascade has begun, it is very difficult to stop. Factors such as tissue hypoxia and acidosis tend to complicate the situation due to a number of intrinsic factors. The body tries to protect tissue from hyperoxia due to oxygen being a natural free radical that reacts to form superoxides that, in turn may attack many double bonds in many organ systems. The chemistry can be complicated, but the research and facts about high oxygen concentration and free radicals are out there. If a lower FiO2 would be adequate in the short term, and prevent or minimize long term disability or death, wouldn't it be prudent to start there. As said earlier, if there is no respiratory distress, then why would you think you need high flow?? Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization Patrick H. McNulty,1 Nicholas King,1 Sofia Scott,1 Gretchen Hartman,1 Jennifer McCann,1 Mark Kozak,1 Charles E. Chambers,1 Laurence M. Demers,2 and Lawrence I. Sinoway1 Departments of 1Medicine and 2Pathology, Pennsylvania State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania This study showed a significant decrease in cardiac perfusion(coronary blood flow) up to 30% after 5 minutes on 100% oxygen.

1 mmol/L is approximately 18 mg/dl for this purpose. By my calc, this appears to be <72 mg/dl. As normal values are in the 70 mg/dl to 110 mg/dl (depending on institution) not many people in my experience are symptomatic at this level, but if you believe the indication is they are, then turn off the pump and treat accordingly. Just as AZCEP indicated. Very rapid drops could, in theory, cause a patient to present as hypoglycemic. I guess the next question should be how far below 4 mmol/L is the patient??

Comanche should read the research article and perhaps the first few pages of post. I doubt you will find any articles indicating increase in cardiac output with high FiO2 oxygen administration. Mostly due to the increase in peripheral vascular resistance, lowering of heart rate, and the probability of a weak heart, as noted in the article and comments in the first couple of pages of posts. Some studies may downplay the potential cardiac ischemia from increased O2 administration.. Debateable at best. If vasoconstriction is present, central and peripheral, cardiac ischemia is obviously an issue to be strongly considered. I think the biggest argument can be made as to how fast the resultant vasoconstriction comes about, but this is largely case by case and dependant on the health and Hx of the patient in question. I was not advocating going against protocol in my post, only questioning them to the appropriate officials when they are potentially harmful. It seems that most are not seeing the difference in trying to enhance treatment for patients and defying med control..

Generally speaking(generally), nurses that work in extended care, or nursing homes, are there for a reason. It "generally" is not for knowing their sh!t...not to say they don't know sh!t, just lacking the nursing sh!t:dontknow: :occasion5: If ya cant laugh at yourself.........?? :wink:

O.M.G.

Yup. We have written, practical, and oral boards with all three med control officers present. They reserve the right to insert added material relevant to protocols. Re-evaluations every two years, practical checks and, if need be spot checks on suspect providers. We do online protocol tests once a year. These are open book, but the intent is to stay familiar with the protocols, not fail people. We are trying to set up skill checks once a year as opposed to two years. On the upside, some CEUs are handled with these. :wink:

All 12 leads interpreted in the field, no thrombolytics or anti-platelet drugs, only asa, NTG, and morphine for pain. We need a 12 lead before NTG, then every 10 min for ST evaluation (improvement or degredation). We have 3 cath labs, only 2 are interventional and are opposite ends of the county. All they need is 10 min heads up, 12 lead correlated in ED, and away they go. I was told avg door to cath is <30min. The average HERN to cath was <45min..Pretty good if the medic is on the ball..the ball gets dropped from time to time.. Oh, and the 12 lead diagnostic is supposed to be turned off as not to distract the interpretation. STEMI only at the cath labs, I think this is pretty standard..

I think this would be a great idea, as long as the education is there . As you said, the scope of practice in the majority of areas in the U.S. is adequate. The frightening part is that most medics don't have more than a basic knowledge of the "new" skills they are given, let alone the possible ramifications. This makes it difficult to foresee any possible problems, let alone remedy them when an untoward event happens. I think an Associates Degree is adequate for the entry level, but a Baccalaureate is not out of the question and should be preferred. With tech the way it is and the progression of medicine, how can we give more responsibility to EMS without the requisite foundation of education??? I believe that Microbiology, Advanced A&P, Chemistry, Bio-chem, Intro. Psych, Developmental Psych, Pharmacology, Composition/Grammar, and Algebra as minimum pre-requisites..This would give the educational foundation and tools to understand the physiological rationals for what we are asked to do. Some of the "paper-medics" that get a license or cert with the sole intention of firefighting and nothing else may find this a bit much, but if a medic is going to practice as a professional, these pre-requisites should not seem out of context.. I don't understand the argument against advancing the education requirements, as they only serve to further the profession, both economically and professionally. If you (generalized "you" and no one in particular) want to be seen as a professional, then you must first act like one. Advancing education is the best place to start. The days of becoming an EMT out of boredom or nothing else to do are over, one way or another. I am very concerned by all of the references to over education. Is there such a thing??? Spank away :roll: If I got repetitive I apologize, apparently some things need to be repeated a couple of times :wink:

If you've ever had a case of a positional asphyxia during transport, the popo get a very leary when taking combative patients to the ED without medical clearance.. Of the research I have found on the subject, and it is sparse, it would appear that after a certain point, there is little that can be done for these patients due to these physiologic factors such as acidosis..There was an alarming number of deaths occurring in ALS presence, hence the need for quick assessment, intervention and appropriate transport(ie, positioning of patient). I think field sedation protocols are a start, but I am glad to see increasing education about the factors involved and proper assessment of these patients..

As sad as it is, we have had two patients this year "restrained" with clipboard sedation administered upside the skull.. :? No Joke. Both in self defense with PD present..not good huh? That is why we are trying to improve our sedation protocols, although both situations involved BLS, assaults are becoming more common around here..We have valium 10mg IM, but with med control auth. Too late in most cases by the time the call is made..I appreciate the responses, and look forward to more....

We use an ALS first response in the form of sheriff/medics. The time from call to patient contact for these guys is usually faster than some ambulance enroute times. By time Alpha transport arrives, assessment can be done and, if need be, appropriate treatment initiated. It took a while to iron out the turf problems as ambulance companies around here are private and government subsidy was an issue with the PD. After ALS arrives, patient is handed over to transport medic, and the "Echo", as they are called, continues his patrol. Generally any treatment provided by the first response is minimal, but it is available if needed..It is a great system when it works..

This is the hard truth and you cant get around it. Other than operating pure transfer cars, to and from dialysis appointments and the such, the only reason basics function as crew on emergency trucks, primary or otherwise, at all is fiscal. Throw the money card out, and you have drivers and inexpensive assists for paramedics. Truth hurts :-({|= Maybe a little of both. Given the difference in practices...apples/oranges in my book..Probably draw a fair amount of criticism for this, but so be it. We are not, nor are we expected to be, physicians. Another time, another thread.. :roll: Concerning the original post, Dustdevil is "right on the money". Excuse the pun :wink:

I fail to see why two medics are justified as "standard of care". Why do you "need" two medics on an ambulance.? I can't see how quality of care goes up the more medics you have. :?: I think this is a rather weak argument, although I hear it often. If a paramedic has to "bounce" treatment options off of their partner, then said medic needs a fair amount of remediation and additional education, IMHO :roll:

Shoulda called in sick :roll: Sounds like P** poor system, I'd look to work elsewhere!! :wink:

Ahhhhh.....the better part of the B52.. A lot closer to my comfort zone....Do you know how long this protocol has been implemented?? Any training about Excited Delerium or Cocaine Induced Delerium included?? VERY curious :-k

HA, HA, HA , HA :laughing3: :tongue9:...3 months [-X [-o<

Understandable, however,( not to be argumentative (well, maybe)), but I believe that Genesee, Wayne, Lapeer, Macomb, Oakland, and Washtenaw/Livingston counties participate in the Southeastern Michigan Regional Protocols. I do believe that this and most of the EMT protocols are similar, if not verbatim. The main variance is in ALS protocols...Just my experience. :twisted: Just Goes to show, especially in the DNR situation, know your protocols, the extent to which they apply to you, and who to call if you have a conundrum... :-k I think calling Med control would have been a safe way out in the initial question...when in doubt, farm it out [-o<

I was wondering how many have protocols allowing sedation as a restraint or as an adjunct to soft restraints in the event of combative patients. What they are (the meds), and maybe some thoughts from the gurus on the appropriateness and safety of using chemical restraint. If this has been asked before, I apologize

I'm sorry, I got mixed up...shouldn't respond that early in the morn... :oops: (it's morning for me) Bakerma was correct with this: Lone star is wrong with this, as is supported in the following Genesee county protocol:: Lonstar: Yes. Genesee County Michigan, as follows: Notice the initial sentence in which it is applicable to all agencies and personnel....I believe Basic EMT is included in this statement Again, sorry about the confusion, Bakerma you were absoltely correct! :oops:

Very true. Being a good basic isn't good for much more than being a good basic. It would most often be better if the basics went directly to a paramedic program without being spoiled, as he kinda said.. :wink: It is simply a waste of time trying to get "experience" for a paramedic program as a basic..even in an ALS system, as most medics are not the ones to garner any information from.. :roll: for numerous reasons. If you want to be a paramedic, just get into a program as soon as you are out of basic class..and I use that term loosely :twisted: