ERDoc

Hey!! What about MD????

The MAST is still in the NYS protocols, but after every reference it says, "if available and regionally approved."

"ER Doc,"

With all respect, I said that an indicated use was for a pelvic FX as I stated when I said this; "Usually MAST is most often used "at splinting pressures" for A) an unstable pelvis B.) severe Bilat lower extermity trauma C.) any combination of A and B D.)Traumatic arrest . "

I was against it's use in an isolated hip Fx as posted by "medic RN", and "Ruffems", as further evidenced by "Ruffs" statement of

and "Medic Rn's" statement of

To repeat I think MAST is a great tool for the use of stabilizing the pelvis, and bilat/severe lower ext trauma....I guess I am abit confused with your contention with my post "ER DOC" as we agree.....

out here,

Ace844

I stand corrected. It did not register that they were talking about hip fxs. There's no purpose to use them in HIP fxs, but they are good for PELVIC fxs. The question is, how do you reliably tell the difference in the field?

Ace,

I'd be pretty impressed to see a pt come in with MAST on to stabilize a pelvis fracture. What do you think we do when a pt comes in with an open-book pelvic fracture (no, it is not necessarily an open fx)? We take a sheet, wrap it around the pelvis and apply pressure to keep the pelvis stable so that none of the great vessels are injured from the bone fragments. Sounds like a poor man's version of MAST to me (assuming you don't inflate the leg compartments). I realize that you cannot xray the pelvis in the field so you cannot tell if there is an open-book fx or not, but I don't see the problem with it (obviously you have to follow your local protocols). Sure, we'll probably take them off as soon as we get the pt, but it still stabilized the pelvis during transport. I'd like to see the literature that says that MAST is contraindicated in a pelvic fx. I don't think that you would find anyone (at least EM trained) that would have a problem with stabilizing an unstable fx.

It didn't happen to me, but it is funny none-the-less. I was working in the trauma room and one of my medic friends gives her hospital presentation as she is coming in on the helicopter. She says she has a male ped struck with an open hard palate fx. Once she gets in, my first concern was to see what kind of airway issues we had to take care of. I look in and it was worse than I thought. I reach in and pull out this 30 something year old guys fractured denture!!! The hard palate was perfectly intact. Sure enough, I had to pick on the medic a little. I would expect it from someone that was new, but she was probably a medic for at least 5 yrs. It made for good laughs that day.

On a side note, just to add a clinical pearl, if a pt is critical enough to have unequal pupils to the extent described above, they are not going to be conscious. Unequal pupils are an ominous sign that the brain is starting to herniate and the pt may be on their way to the ECU.

Where's the choice for "Who Cares?"

I never understood how racing could be a "sport" when all yo do is drive straight and turn left. But that's just me.

I do love the highlights on ESPN for the crashes though. Does that make me a bad person?

Devin

I used to feel the same way, until I started watching and realize what is actually involved. While I would not classify it as a "sport" it is just as physically intense, if not more, as most sports. Imagine driving your ambulance code 3 at almost 200mph for 500 miles. Imagine the amount of mental concentration it takes to avoid getting into one of those crashes (hey, eveyone loves to watch a good crash, anyone who tells you they don't is lying). Unlike those athletes in the traditional sports, the drivers don't get many breaks. They are running on adrenaline for hours on end. It's not like football or baseball (if you consider that a sport) where you have a few seconds of play followed by a longer lull in the action. There are no time outs, no half time show, no 7th inning stretch. Once it starts, with very few exceptions it goes till it's over. I'm not trying to convert anyone, but just respect the fact that there is more to it than just go fast, turn left and that is just as physically and more mentally demanding than traditional sports.

???????????

What's NASCAR????????

Being from Alaska I guess we can forgive you for not knowing what NASCAR is. North American Stock Car Auto Racing. It's the most popular stock car racing series in the world.

Some guy making a lot of left turns. I don't watch NASCAR.

Hey, there are two races each year where they have to make right turns. They are also making those left turns at almost 200mph with only a few inches between them and every car around them.

Ooooh you hit a good topic, ERDoc! We all know who will be the winner! TONY STEWART! YEAH! We should start a poll on it! He's gonna win though!

Grace

Alright, I started a poll. I couldn't put on everyone who is not mathematically eliminated since I could only put on 10 choices. If there is anyonenot on the list, you could always give them a write in vote.

Personally, Jr. will not make the chase. Gordon will make it in. JJ will start his usual come back soon and take the cup with Stewart coming in second and Gordon 3rd. However, I am a die hard Martin fan (hey, you can't hate the guy who drives the Viagara car) and would like to see him finally win the cup in what is supposed to be his last season.

Alright, I know this isn't the best place to put this, but I coulldn't find a better place. For all of those NASCAR fans out there, with 2 races left till the chase, who is going to win? Will Jr make it in? Will Gordon stay in?

When I figure out how to use the flatbed scanner, I'll post a picture of my badge from when EMS was NYC HHC EMS. It's a stop-sign shaped thing. That one was replaced by the "PD style" badge, which I also have.

When FDNY took us over (the "Merger"), we were told not to wear them anymore, in what was felt to be a Star Trek "Borg" maneuver to assimilate us in. "Firefighters don't wear badges, why should you EMS guys?" We were also told to get the FD Blue uniforms, and lose the Hunter Green Pants, Jackets and ties, with white shirt that had been our uniform.

As a possible proof of the assimilation, don't your officers wear a white dress cap as part of their Class A Dress Uniforms? For a long time after the Merger, the top EMS 4 Star Chief was only allowed a Blue one, with Gold Band and the "scrambled eggs" on the brim. After 5 years, EMS Captains and Chiefs finally got the "right" to wear the white hats, like their Fire Suppression side equivalents in rank.

Personally, I think losing those green pants was a step in the right direction (no offense). Those things we so 1970s. Just my opinion though.

As to the badges making you look like a FNG i know alot of veterans who have a badge in there wallet. Hell they even wear them on duty. How do you look like a FNG wearing a badge if everyone has one. Is everyone a FNG. As for them requiring you to have something and not supplying it are you at least getting a uniform allowance ?

I stand by what I said. I am not talking about wearing dress uniforms for special occasions. I am talking about when you are out in the field. You are not a cop or a firefighter, you just don't need it. You want to be treated as a medical professional or as an LEO? There is just no need for it. As I said before, put a patch on your sleeve so everyone can tell what level you are. Anything more and you are a buff. The badges imply some form of authority, which we do not have.

As for the uniform allowance, I think we might have gotten a few bucks, but it was only like 15 or 20 dollars. Cheap-ass company (sorry, did I say that out loud?).

KEDs are useless anyway, better off without them.

Show me the study!

I agree with the badges making you look like an FNG, or at the very least a buff. EMS does not need badges. All you need is something on your sleeve or back that states your level of training so that at a scene you can easily be identified.

Just because your company requires you to have something does not mean that they are required to supply or even pay for it (at least in NYS). I worked for a company that required us to pay for our own uniforms and even our own oxygen regulators. This made many people quite mad, so an occupational lawyer was consulted and they were told that as long as the company is not asking for anything unreasonable there is nothing that can be done. Even the O2 regulator was not considered unreasonable. The only saving grace was that if you saved your receipts you could use it for your taxes.

Beating the ugly children in my neighborhood.

"Pt is in asystole with a rate of about 20."

XYZ Ambulance: ABC Hospital, we are bringing you a 13y/o female with an airway obstruction. Pt is stable and breathing well. We also have a 15y/o male with a laceration. We'll give you more info when we arrive."

ABC Hospital: XYZ Ambulance, could you please give us more information on the pt?

XYZ Ambulance: No.

ABC Hospital: We need to know what kind of equipment to set up for your arrival. Please tell us more.

XYZ: You do not need anything at this time. You will understand when we arrive.

Ambulance pulls in with a male on a strecher with a blanket over him with a large "bump" down by his abdomen. Sheet gets pulled back and it is his girlfriend. She was performing oral sex on him and his skin got stuck in her braces. :shock: :shock: :shock:

There are also signs of left sided failure (rales). This is probably not from a new insult (although you cannt completely rule that out), but most likely related to the missed meds. Ntg probably would not be a bad idea, but I would feel better if I saw an EKG first.

To set the record straght, right sided failure is commonly caused by left sided failure, not the reverse. The most common cause of right sided failure is left sided failure as you get a backup from the left to the right.

This one makes #39!!

I am

not postwhoring. :-)

I am

I'm just posting this so that I can get one post closer to that next square in my counter and move up in rank (yes, totally self serving).

Here are parts of the results from Phase II and III. These are not the actual articles that appeared in the literature, but a synopsis taken from the OPALS website:

Phase II Results

Phase II results of the OPALS Study have been published in the April 1999 issue of The Journal of the American Medical Association (JAMA)! The manuscript entitled "Improved Out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program (OPALS Study Phase II)" created a lot of media attention with it's publication in this prestigious medical journal.

This study compared cardiac arrest survival from Phase I (communities with existing ambulance defibrillation programs) to Phase II (rapid defibrillation) in 19 Ontario communities.

These communities implemented various strategies to optimize their EMS systems to achieve the target response criteria of call received to vehicle stopped with defibrillator in eight minutes or less for 90% of cardiac arrest cases. Many of these communities implemented fire fighter defibrillation programs, along with base paging, tiered response agreements, and roving. Provincially, changes were made to dispatching policies and procedures.

The outcome of these interventions demonstrated that rapid defibrillation increases the chance of survival from prehospital cardiac arrest! In the largest prehospital cardiac arrest study ever conducted, involving over 5,000 patients, survival increased from 3.9% in Phase I to 5.2% in Phase II. This represents a 33% increase in survival. Or, to look at this another way, it represents additional 21 lives saved each year. Increased survival was also associated with bystander and first responder CPR.

The results of Phase II provide evidence for communities considering the cost of CPR training and equipment ambulance services, fire departments and other agencies with defibrillators. In doing so, thousands of lives could be saved in a very cost efficient manner.

For more information on media coverage, check out these web sites:

JAMA - April 7, 1999

Phase III Results

The first of several Phase III results have been published in the August 12, 2004 edition of the New England Journal of Medicine. The manuscript entitled “ Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest†has created a whirlwind of media attention in our national newspapers as well as several international newspapers . These results conclude that CPR, and rapid defibrillation increase cardiac arrest survival, but ALS does not. Over 5,600 patients were studied across 17 urban Ontario centers to reach this conclusion. Of those patients, 1391 were enrolled during the rapid-defibrillation phase, and 4247 during the subsequent advanced life support phase.

Advanced Life Support training was introduced in Ontario several years ago as one part of a comprehensive approach to strengthening community response to cardiac arrest and improving survival rates. This training provides the paramedics with the skills to perform advanced life saving procedures such as airway management, and the administration of intravenous drug therapy. Other parts of the approach include CPR training for police officers and firefighters as well as the installation of public access defibrillators.

Previous OPALS Phase I and Phase II research concluded significant improvement in survival from cardiac arrest if first responder be it citizen, police officer, or fire-fighter performs CPR, and if rapid defibrillation occurs within 8 minutes. Although ALS training does not demonstrate a change in survival rates for cardiac arrest patients, indications from our soon to be published Chest Pain and Respiratory research studies suggest ALS significantly impacts the number of lives saved each year for these patients. The underlying message from the OPALS Cardiac Arrest research is for health officials and planners to place an emphasis on citizen CPR training, and the rapid availability of defibrillation devices.

And, just for completeness, here is the absract from the NEJM:

ABSTRACT

Background The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support to a program of rapid defibrillation.

Methods This multicenter, controlled clinical trial was conducted in 17 cities before and after advanced-life-support programs were instituted and enrolled 5638 patients who had had cardiac arrest outside the hospital. Of those patients, 1391 were enrolled during the rapid-defibrillation phase and 4247 during the subsequent advanced-life-support phase. Paramedics were trained in standard advanced life support, which includes endotracheal intubation and the administration of intravenous drugs.

Results From the rapid-defibrillation phase to the advanced-life-support phase, the rate of admission to a hospital increased significantly (10.9 percent vs. 14.6 percent, P<0.001), but the rate of survival to hospital discharge did not (5.0 percent vs. 5.1 percent, P=0.83). The multivariate odds ratio for survival after advanced life support was 1.1 (95 percent confidence interval, 0.8 to 1.5); after an arrest witnessed by a bystander, 4.4 (95 percent confidence interval, 3.1 to 6.4); after cardiopulmonary resuscitation administered by a bystander, 3.7 (95 percent confidence interval, 2.5 to 5.4); and after rapid defibrillation, 3.4 (95 percent confidence interval, 1.4 to 8.4). There was no improvement in the rate of survival with the use of advanced life support in any subgroup.

Conclusions The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems.

Just so everone is on the same page as to the background and purpose of the OPALS study, here is a bit from their web page:

In this era of health services fiscal restraint, policy makers require quality evidence to support decisions to initiate or continue funding for expensive programs. Prehospital Advanced Life Support (ALS) programs cost considerably more than community-wide defibrillation programs, yet evidence is not convincing for the effectiveness of ALS programs for critically ill and injured patients (ALS includes advanced airway management [intubation] and intravenous drug therapy by ambulance officers). This study should provide valuable evidence to Ontario communities and elsewhere, about the relative effectiveness of prehospital programs on the survival and morbidity of cardiac arrest, major trauma and respiratory distress patients. Such information is much needed for the cost-effective planning of emergency health care services.

Background

Survival for prehospital victims of cardiac arrest remains relatively low in Ontario communities compared to many U.S. and European communities.

Optimal survival rates according to the American Health Association depend on four strong links in the "chain of survival". The relative importance of the third link, rapid defibrillation, and the fourth link, full ALS is not clearly distinguished in the scientific literature.

Prehospital ALS measures are also commonly applied to trauma and other critically ill patients in U.S. centres.

The Ontario Ministry of Health (MOH) was reluctant to commit the millions of dollars required for the widespread implementation of prehospital ALS programs without further research demonstrating the effectiveness of such programs in Ontario.

In 1994 - OPALS Study funded by the Ontario MOH.

In 1998 - OPALS Study funded by the Ontario MOH and the Canadian Health Services Research Foundation (CHSRF).

Objectives

To assess the incremental benefits in cardiac arrest patient survival and morbidity that results from the sequential introduction of rapid defibrillation programs.

To assess the incremental benefit in survival, morbidity and processes of care that results from the introduction of prehospital ALS programs to multiple Ontario communities for patients with cardiac arrest (primary objective), major trauma and respiratory distress.

To conduct an economic evaluation of ALS programs for the same patient groups by estimating the incremental cost per life saved and per quality-adjusted life year.

Design

This multi-phase before-after study (see OPALS Research Protocol) is being conducted in multiple communities in 11 base hospital regions and has three distinct phases involving a total of at least 10,000 cardiac arrest patients, 6,000 major trauma patients and 8,000 respiratory distress patients.

Phase I represented the baseline survival status in each study community and was based on retrospective data for the most recent 36 months prior to Phase II.

Phase II assessed the survival for 12 months after the introduction of rapid defibrillation and demonstrated that relatively inexpensive community rapid defibrillation programs increase survival for cardiac arrest patients.

Phase III will assess survival outcomes months after the introduction of full ALS programs for 36 months for cardiac arrest patients and major trauma patients, and for 6 months for respiratory distress patients.

The actual research protocol is on the website also, but is much too big to post here (insert your own size joke here).

I think making paramedics a 2 year degree would be a great idea. You can get a better understanding of sciences behind what we do. You can increase the foundation of knowledge that providers have. While there is a great deal of learning going on in the field, you need your basics to make any sense of what you are doing. I would much rather see the paramedic become a 4 year degree and EMT a 2 year degree, but I know that this is next to impossible. It would also be a way to increase the pay of what EMS makes. If you increase the pay, you can increase the competitiveness of the field and in return can increase the caliber of the providers. With a higher level of education, the doctors who write your protocols might be willing to allow you to do much more. The only problem that I can see is that rural areas where they are already desperate for ALS providers would find it even more difficult to find them. This could be off set by higher pay, but at what cost to the taxpayers? I think making EMT a 2 year degree would almost certainly bring an end to the volunteer system. What would you do with those who are already paramedics?

Hungrymonkey, you said, "I have repeatedly been told that the real education starts when you get a job, and that school is to prepare you for that. If this is so, then why would it be required to have over two years of school on subjects that do not apply medically? IE social science, human relations, etc." How do these classes not apply medically? Human relations? We are in the business of human relations, to have an understanding of the basic principles behind the relationships would only make you better when you need to deal with difficult pts or families. Where I went to medical school, each year we had a course on medical ethics and human relations. Have you ever been trained how to tell a pt or their family bad news? No, you will probably never need to tell someone that they have cancer, but I'm sure you will have to tell family that their loved one is dead. To say that behavioral and social sciences plays no part in what we do is off base.

vs-eh, down here in my neck of the woods a person only needs to take a 100 hr course to become an EMT. They are not required to have any ambulance experience before they get their card, only 10 hrs in the ER as an observer. They don't even need to be a high school graduate. I would venture to guess that almost 99% of the EMTs do not know what angiotensin is. The paramedic course is much more demanding, but again, I would venture to guess that 50-75% don't know what it is.

I don't think anyone is saying they are against ALS. This particular study shows that there is no difference in outcomes when pts are treated by ALS vs BLS. They are not saying that ALS kills the pt. I feel that the difference in the intubated pts is probably due to the fact that those who are being tubed are sicker in general and less likely to make it anyway. From a practical standpoint, if a pt comes into the ER with an IV line in already it frees up a nurse or two to move on to other things.