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Everything posted by ERDoc

  1. ERDoc

    Trauma Care

    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).
  2. 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.
  3. ERDoc

    Trauma Care

    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.
  4. ERDoc

    Trauma Care

    I just read today that the OPALS (Ontario Prehospital Advanced Life Support) Study has shown that there is no difference in several survival endpoints for trauma pts that are treated by BLS vs ALS units. The only difference was that in pts who were intubated the outcomes were worse (although the article did not say if these pts were sicker). I'm not trying to start an ALS vs. BLS war, I was just curious as to everyone's thoughts on it.
  5. Do you have different fluids that you can give? In my area the EMS guys only have NS. They used ot have D5W for medical pts and LR for trauma, but this changed to NS for everyone several years ago.
  6. In my neck of the woods, the crews can only start lines (no locks). They can draw bloods, but I have never seen one do it, and I don't think the nurses will take it.
  7. Although I haven't had the opportunity to try it, I have seen anesthesiologist intubate a pt in a near upright position. They say that the airway is much easier to visualize and is more of a straight line. I have actually seen them jump up on the back of a hospital stretcher and do it standing about 3-4 feet off the ground. I can only assume that the airway is more patent in the sitting position, even for bagging. I have had the opportunity to bag someone in the sitting position and didn't have any problems. You just have to make sure that you bag when they inhale.
  8. ERDoc

    Jump Kits

    I set up my jumpbag after I received my first responder certification (with the usual BLS stuff 4X4s, Kling, etc). I pulled it out of my trunk the other day to use it and realized that I haven't used it in a long time. I found saline and water that expired in 1993. The 4X4s crumbled when I tried to fold them. I was getting some stuff out for my son who tried to catch a baseball with his teeth. He just looked at me like I was crazy.
  9. Just a few abstracts from a few studies that might help to enlighten the conversation a little (I know it is a little wordy, sorry about that): Resuscitation. 2005 Jun;65(3):325-8. Epub 2005 Jan 24. A comparison of CPR delivery with various compression-to-ventilation ratios during two-rescuer CPR. Hostler D, Guimond G, Callaway C. University of Pittsburgh, Department of Emergency Medicine and the Affiliated Emergency Medicine Residency, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA. BACKGROUND:: The number of chest compressions required for optimal generation of coronary perfusion pressure remains unknown although studies examining compression-to-ventilation ratios higher than 15:2 (C:V) in animals have reported higher C:V to be superior for return of spontaneous circulation and neurologic outcome. We examined human performance of two-rescuer CPR using various C:V. METHODS:: Thirty six EMT-Basic students in their final week of training performed two-rescuer CPR using C:V of 15:2, 30:2, 40:2, 50:2, and 60:2 on a recording resuscitation manikin. Compression and ventilation variables were recorded by computer while the number of pauses for ventilations and the hands-off time (time not spent performing chest compressions) were abstracted by hand. Data were analyzed by ANOVA and significant differences from the standard treatment of C:V=15:2 were assessed by Tukey's HSD post hoc test. FINDINGS:: The number of compressions delivered per minute increased with increasing C:V while the hands-off time and pauses for ventilations decreased. All comparisons were significantly different from C:V=15:2 (P<0.001). The ventilation numbers decreased with increasing C:V although mean minute volume exceeded 1l for all C:V. INTERPRETATION:: A 15:2 compression-to-ventilation ratio when performed during two-rescuer CPR results in 26s of hands off time each minute while only delivering 60 compressions. Alternative C:V ratios of 30:2, 40:2, 50:2, and 60:2 all exceed the AHA recommended 80compressions/min while still delivering a minute volume in excess of 1l. Ann Emerg Med. 2002 Dec;40(6):553-62. Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios. Sanders AB, Kern KB, Berg RA, Hilwig RW, Heidenrich J, Ewy GA. Sarver Heart Center, the Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, USA. art@aemrc.arizona.edu STUDY OBJECTIVE: The optimal ratio of chest compressions to ventilations during cardiopulmonary resuscitation (CPR) is unknown. We determine 24-hour survival and neurologic outcome, comparing 4 different chest compression-ventilation CPR ratios in a porcine model of prolonged cardiac arrest and bystander CPR. METHODS: Forty swine were instrumented and subjected to 3 minutes of ventricular fibrillation followed by 12 minutes of CPR by using 1 of 4 models of chest compression-ventilation ratios as follows: (1) standard CPR with a ratio of 15:2; (2) CC-CPR, chest compressions only with no ventilations for 12 minutes; (3) 50:5-CPR, CPR with a ratio of 50:5 compressions to ventilations, as advocated by authorities in Great Britain; and (4) 100:2-CPR, 4 minutes of chest compressions only followed by CPR with a ratio of 100:2 compressions to ventilations. CPR was followed by standard advanced cardiac life support, 1 hour of critical care, and 24 hours of observation, followed by a neurologic evaluation. RESULTS: There were no statistically significant differences in 24-hour survival among the 4 groups (standard CPR, 7/10; CC-CPR, 7/10; 50:5-CPR, 8/10; 100:2-CPR, 9/10). There were significant differences in 24-hour neurologic function, as evaluated by using the swine cerebral performance category scale. The animals receiving 100:2-CPR had significantly better neurologic function at 24 hours than the standard CPR group with a 15:2 ratio (1.5 versus 2.5; P =.007). The 100:2-CPR group also had better neurologic function than the CC-CPR group, which received chest compressions with no ventilations (1.5 versus 2.3; P =.027). Coronary perfusion pressures, aortic pressures, and myocardial and kidney blood flows were not significantly different among the groups. Coronary perfusion pressure as an integrated area under the curve was significantly better in the CC-CPR group than in the standard CPR group (P =.04). Minute ventilation and PaO (2) were significantly lower in the CC-CPR group. CONCLUSION: In this experimental model of bystander CPR, the group receiving compressions only for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved better neurologic outcome than the group receiving standard CPR and CC-CPR. Consideration of alternative chest compression-ventilation ratios might be appropriate. I think I've taken up enough space for now. Hope this helps.
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