ERDoc

Here is a link to a site that has multiple stories from different sources around the time of the death. What a horrible way to go. All I am left thinking is WTF??? Did they actually put the entire strecher on the boat? http://www.lifesaving.com/news/show_articl...=news&id=72

I was watching it once and they had a guy who they had caught in a previous episode. He had set up a date and had to reschedule it because he had a court date for the 1st time he was caught. Scary sh!t out there. They also caught a few lawyers, an ER doc (no relation) and others.

Newbie, we, as a group, have come to the conclusion that you are uneducated and inexperienced and your only purpose here is to instigate. Please let this thread die and stop being so obnoxious.

Agreed. Time to move on.

A little EBM for those who are interested and FF523: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...st_uids=7741343 FF523, if you want to have an intelligent debate, please refrain from the name calling and insulting, and as always please share your education and experience.

I can't believe I'm going here again. :banghead: Newbie, you continue to flip flop. I am really begining to agree with the others that you are a new medic with an ego that exceeds your knowledge, especially since you continue to fail to list your experience. Based on your posts you seem to have little field experience but can quote a book like a freshman premed. You have said in the past that we need to control the rhythm. Not exactly, what we need to control is the rate. This can be accomplished with cardizem. You will not have any disasterous effects that you seem to be concerned with. As you have said all of the symptoms are associated with the rate. If you control the rate and allow more filling time, you will improve the BP, so the hypotension will not be an issue. This is not true CHF, since as you have said the fluid buildup is from the rate. This also does not fit the definition of cardiogenic shock. To be in cardiogenic shock you need to have a sustained hypotension, inadequate tissue perfusion and adequate LV filling pressure. This pt lacks the LV pressure sp he cannot be described as being in cardiogenic shock. If you truly feel that this pt is in cardiogenic shock, why have you not started him on Dobutamine? I will ask again for all of those involved, what is your level of education and field experience? :banghead:

When all else fails, you can always give this a try: http://1strespondernews.com/webpages/news/...65-36940e51e95d

Let's face it, in medicine there is no one correct way to handle things. This case probably has at least 3 different ways to treat (though some only recognize one). Cardioversion is one possibility and for those that worship ACLS religiously is probably the right answer. Cardizem is another option that would probably work. I would probably push some CaCl with it. Obviously, treating the lungs works also. Certain people need to realize that our pts are not multiple choice tests with one correct answer. I think that is one of biggest problems people are having with Fire is the fact that he is not willing to accept that there may be a different, but not necessarily better, answer. Personally, I had a problem with him forcing his will on his pts against their wishes. There is an old saying that says if you put 10 doctors in a room and ask for how to best treat a pt you will get 15 answers. I think this is a prime example of how true that it.

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You are either flip flopping or missing the point. No one here is aruging that an unconscious pt should be treated under implied consent. You also do not need to tell them what you are doing, though it would be nice to do if they were conscious. The point that I have been making and seems to be missed is that even a hemodynamically unstable pt can still be A&OX3 and have the capacity to make their own decision. You are ethically and legally bound to get their consent before performing a painful and invasive procedure. If they tell you no, it will suck but you will have to sit there and possibly watch them go down the drain. Welcome to the world of medicine. You are obligated to make sure that they are making an informed decision and also present other possible treatments. This should include, "Hey, when you go unconscious, can I shock you then? How about when your heart stops?" Gets straight to the point and let's them know what will happen. One of the most important things you can get from a pt before they loose the capacity to make their own decisions is what their wishes are. Whenever I have someone that is circling the drain, I will do a brief assessment and then ask them, "If your heart stops or you stop breathing, what do you want done?" You now know what you can and cannot do. This is not some Orwellian state, we do not make decisions for our pts, we let them know what is appropriate to treat their problem, what the alternatives are and what the possible outcomes are. It is up to them to make the decisions, that is the humanistic approach to medicine that you seem to lack.

You need to put your nose back in a book. The way you treat your pts is criminal. Seriously, what you are proposing is against the law. This again is where we seperate the technicians from the professionals. Your hero wanna be attitude will get you in trouble someday. You need to recheck your BLS cirriculum on implied consent (or your BLS cirriculum is incorrect which is a distinct possibility). Not one of the three cirteria you listed makes you able to use implied consent. Just because a person has hemodynamic instability does not mean that they do not have the capacity to make their own decisions. Before you begin to insult someone you should make sure your arguement is valid, because in this case your facts are incorrect and your arguement is invalid. You might be able to get by on emergency consent, but it is thin ice and you have still gone against a pts wishes. Aren't we supposed to do care for our pts and not just their medical condition/monitor?

Personally, it doesn't matter how you report them, as long as they are accurate. Most docs and nurses I know don't hear or care about the last number. We hear 210 or 120 or 70 and that's about it. You get the point.

Burn the shirt and deny everything when 50 rolls up. Otherwise, as others have said hydrogen peroxide works well.

Statements like this require evidence. "It's in my EMT book," is not evidence. I've seen old EMT books that say you should apply cervical spine traction in neck injuries. Do you still do that? While you may be right, you need to back up your statement with evidence for it to be a worthwhile arguement.

I know the conditions you work in. I was there for 10+ years prior to med school and on occasion I still get to go out into the field. They are not as dramatic as you make them out to be. A good provider will always be able to maintain a controlled environment in the ambulance if they are competent and knowledgeable (with the exception of violent situations). The pt's decision should always dictate your treatment, otherwise like I said you are taking away their autonomy and committing battery. If the pt says no, then it is no. It sucks as a provider to watch someone go down the drain, but as a professional you are required to honor the pt's wishes if they have the capacity to make their wishes known. The pts you describe obviously do not have the capacity to make their own decisions.

I admit, I missed the AMS part of this also until Laura pointed it out. I still think this pt needs some form of sedation and analgesia. Something quick on, quick off would be appropriate such as propofol or etomidate, but you do have to keep the BP in mind.

The article was in the American Heart Journal. Here is another link to the abstract: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum I think morphine should be lower on the list of meds to use. ASA, nitrates and betablockers should be priority in the field for ACS. I will give a small dose of morphine after the 3 SL ntgs if the pt still has pain, after that it is on to Tridil. Obviously the most important thing in a STEMI is the cath lab.

So you are willing to take away your pts autonomy, their right to make an informed decision and possibly commit battery? You are correct when you say that you are supposed to know what to do, but being a professional also means being able to fully inform the pt of what is going to happen in terms that they can understand and allowing them to make an informed decision. Not doing so means you are acting as a technician.

Your instructor mounted a placard on himself???? :shock: Sorry, just couldn't let this one get by. I also get the impression that several people here are suggesting that we not allow a pt to make an informed decision and give informed consent to a painful and invasive procedure. Is this what people are getting at?

The fact that you fail to recognize the complexity of this pt says a lot. Nothing I will get into here though. You contradict yourself here. So is this pt perfusing well enough or not? He is obviously not "perfusing distally" if he is hypotensive and cyanotic. As well as when a pt has CHF, COPD, asthma, pneumonia and a plethora of other things. Nope. As stated before, his heart is already maxed out. Depol/Repol is occuring as fast as it can. You could give epi and not increase the rate any further. Giving albuterol will not hurt the heart any more that the rate is and it will help open the airways. Easy to say when you are not the one that will be left paralyzed or unable to speak. If there are other available therapies that may not end with brain damage, would it not be prudent to consider them? Just because we can do something doesn't mean we should. The values that you put on certain risks and benefits may not be the same that the pt or another provider would put on them. Medicine is not black and white. There are often several ways to get to the same end. With a little more experience you may soon realize this.

I don't think that is the issue here (not to say that it doesn't happen). It wasn't like sending the pt to the ER was going to affect the clinic any, if anything it shifted the burdeon of doing a workup off of the clinic. I think this case was mismanaged from what we have been told.

Touche. I was actually referring to the actual algorhythms. The only one they put on there is Amio. I have also never seen seizures with Lido. As far as the INR, I wouldn't sweat it too much. We have ways of fixing that. :wink:

What do you mean by true MI? Are we talking STEMI, NSTEMI? Nitro works in both to relieve pain. It works better for pain in angina becaue the tissue to ischemic. It's still living, but on its way out. If you improve the blood flow and take it out of an ischemic state the pain goes away. With an MI, the tissue has actually infarcted. There is no saving it, so the pain is not as easy to relieve. I have no evidence to support this, but it intuitively makes sense to me.

I think you need to go over your ACLS updates again because there are several errors in your post. The new guidelines have actually taken lidocaine out of the algorhythms. Amio is the preferred med based on several studies. Here is a small excerpt from the guidelines published in Circulation: Evidence in support of amiodarone comes from 3 observational studies (LOE 5)28–30 that indicate that amiodarone is effective for the termination of shock-resistant or drug-refractory VT. One randomized parallel study (LOE 2)31 indicated that aqueous amiodarone is more effective than lidocaine in the treatment of shock-resistant VT. Amiodarone administration is also supported by extrapolated evidence (LOE 7) from studies of out-of-hospital cardiac arrest with shock-refractory VF/VT, which showed that amiodarone improved survival to hospital admission (but not discharge) compared with placebo32 or lidocaine.33 28. Schutzenberer W, Leisch F, Kerschner K, Harringer W, Herbinger W. Clinical efficacy of intravenous amiodarone in the short term treatment of recurrent sustained ventricular tachycardia and ventricular fibrillation. Br Heart J. 1989; 62: 367–371.[Abstract] 29. Credner SC, Klingenheben T, Maus O, Sticherling C, Hohnloser SH. Electrical storm in patients with transvenous implantable cardioverter- defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol. 1998; 32: 1909–1915.[Abstract/Free Full Text] 30. Helmy I, Herre JM, Gee G, Sharkey H, Malone P, Sauve MJ, Griffin JC, Scheinman MM. Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias. J Am Coll Cardiol. 1989; 12: 1015–1022. 31. Somberg JC, Bailin SJ, Haffajee CI, Paladino WP, Kerin NZ, Bridges D, Timar S, Molnar J. Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardiol. 2002; 90: 853–859.[CrossRef][Medline] [Order article via Infotrieve] 32. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999; 341: 871–878.[Abstract/Free Full Text] 33. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002; 346: 884–890.[Abstract/Free Full Text] Administering either one guarantees admission. If a pt needs either one, they are not going home. What golden palace do you work at where a hospital admission costs $300,000? They can be expensive, but that's a little excessive. I think you need to check your facts a little more before posting, there have been a few posts where you have gotten the info wrong.

You're right young padawan, they don't have the resources, so the pt should have been sent to the ER where the resources are available. We have a middle aged AA male. Right there increases the risk for ACS and silent MIs. Based on the history, I doubt this pt has no hx, but just hasn't been diagnosed yet. He probably has not seen a doctor in years if he is getting his follow up from a free clinic. For all we know, his cholesterol is 1000 and he's got a 90% stenosis of his LAD. We have a recent EKG for comparison and see ST elevations in continuous leads. This yells ACS/STEMI until proven otherwise. He needs an ER, enzymes and stress/cath.