triemal04

It's the Tunguska Blast of 1908 all over again! Run for the hills the <insert object of whichever conspiracy theory you prefer here> are coming!

Fair points and to a large extent I agree with what you're saying. I think it's taking my points to an unintended extreme. However, what you're saying is something that needs to be pointed out and considered in a long standing and productive career in EMS.

My concern with the poster who started this tangent is that he stated the death of a complete stranger had no effect on him whatsoever. That's a little disturbing even when taking into consideration different people handle things differently. It would've been just as disturbing had he said that he becomes crippled emotionally after every single patient event.

Balance is everything. It's easier for some than others.

Kinda figured that; but it was as good an opening as any to point out that an extreme, on any end of the spectrum, is still an extreme. Which just ain't right most of the time.

Part of the problem in discussing this is that, whatever term is chosen to represent how someone feels, it's very subjective and up to the individual. I can honestly say that, for the most part, death in EMS does not bother me at all. But to me, like I said above, feeling empathy for the family or sorry that someone died (depending on the circumstances) doesn't count as being "bothered" by it.

It also helps that my motivation, as I'm sure it is for most people who make a career out of this, goes beyond feeling like I'm a big live saving hero out to vanquish that dirty foe death!

What's your motivation to try and save the person if being dead doesn't bother you? Fear of losing your job? If so, then your motivation for being involved in EMS is immediately suspect and chances are increased that you're more dangerous than helpful. Either way, my request for you to reevaluate your career choice and think about another line of work is still valid. Or are you actually motivated in trying to save a life? If the death of a complete stranger doesn't bother you, as you claim, then what's your motivation to help a complete stranger while s/he is still alive?

I'd be careful with that line of thinking. It's things like that that lead to zealotry and also to people having severe issues with this job as well. If you are only doing this because you see yourself as on some type of mission to "prevent death" or "save lives" or "rescue people" or whatever, that isn't a good thing either. Personally, I'd say if that is your only motivation then you need to get the hell out ASAP.

Death and disease are natural parts of life; just because someone isn't bothered by a death and can accept that it is a natural occurence, that, despite their interventions still happened doesn't mean that they shouldn't be doing this. There is a difference between having empathy for the dead and remaining survivors (if any) and being upset and/or bothered by it.

Your line about helping a complete stranger if flawed for the same reasons. If someone needs help, that is why we are here; to do so to the best of our abilities. I can't speak for anyone else, but I do it because I like to, and I enjoy the work. But just because we are supposed to be helping people does not mean that you need to become attached to every patient to the point that you are letting things get to you.

well I live in a state where thats a possibility. but i know my scope of practice my protocols and proper documentation. so they are welcome to try. But as long as I do my job within my training, and to the best of my abilites. they wont achieve anything. But if i dont then i truely deserve it then dont I?

You don't actually think that's true, do you? How the hell old are you and have you never paid attention to the news or what's happening to the medical field?

Just because you do everything "right" does not mean that you won't get sued, and it doesn't mean that if you do you'll win. Doing something "right" also does not gaurentee that an expert witness wouldn't testify that you were actually "wrong." Or that a judge might ignore the evidence. Or a jury go with their emotions instead of facts. Or your insurance (or hopefully your employers) won't settle to keep something out of court, even though you were "right." (if you think that doesn't matter then think again)

There is unfortunately a reason that far to many people practice defensive medicine, and the American legal system is a big part of it.

1.

I think we spend too much time valuing our jobs and existence on these patients, lets spend more time on patients that we can have a positive outcome on.

We do, probably for a variety of reasons, which are a topic for another thread, as is whether or not cardiac arrest survival should be used as a measure of how "good" a service is. Short answer would be because it's an easily measurable statistic, and, if you look at the history of paramedics and EMS, going all the way back to Dr. Pantridge in Ireland, this is why we came to be: MI's and cardiac arrest.

I am "old school" and disagree. I dont think the "device" used matters, I still believe "proper ventilation does". I can not tell you how many times I have watched Para-Gods dig in someone's throat for minutes in an attempt to get the tube in, versus just ventilating with a BVM. I do not see how the deprevation of oxygen improves anyone's survival chances. I have been around long enough to see "new studies" that prove what we have been doing for years is now somehow wrong, but the success rates never improve. I say go back to two rounds of Epi, Bicarb, and D50 for any arrest; it worked just as good as what we are doing today.

Hell, I'd say that's new school and the more appropriate mindset. Although they aren't perfect and have their own drawbacks, there are enough types of airways out there that ETI does not need to be the only one available, or the only one that someone is "willing" to do. (this is ignoring that you can easily ventilate most patient's with a BVM if you do it right). Tracheal intubation, when done correctly, is probably still the best and most efficient way, but it's not the only one, and no matter what's done, the end goal is, as you said, proper ventilation by any means.

Does anyone have access to the whole study, since it's hard to judge a study simply by the abstract. Do we know anything about their approach, say: if BVM fails --> supraglottic airway, if that fails --> ETI... which would explain the results. Assuming ETI is as good as BVM in delivering oxygen to the patient, why would there be a difference in outcome? Do we know enough about the (patho-)physiology? All we are doing is guessing.

Interestingly survival with good neurological outcome is as low as 2.9% in this study. Whereas in other systems it's as high as 10%...

Just a guess, and I doubt this is something that would be included, or even could be included in the full study, but my guess would be that the insertion of an ET tube or supraglottic caused, in at least some cases:

1- a pause in compressions

2- hyperventilation of the patient

3- caused whoever was in charge to neglect their other duties; ie defibrillation, ensuring effective compressions were happening, and medical therapies

Whether or not that would be responsible in any part for the difference I have no clue.

I don't get it really. Why do we need to stop compressions to intubate? I mean, I used it stop them years ago but then I thought..."Hey, why am I stopping when I can still see all my landmarks?" so I decided to give it a go. Since then I've only stopped compressions a couple of times, and only for about 3 - 5 seconds to pass the tube. I still intubate farther down the algorythm than the old days, but stopping CPR to do it just isn't always a requirement.

You shouldn't need to in almost every case. Part of the problem may be that it used to be/probably still is taught that compressions are held during intubation, or it's never mentioned at all. I know that many areas are advocating not stopping, but it will still take awhile before that becomes standard across the board, and as ETI is moved away from as a whole it will likely get mentioned less and less.

Also factor in that if someone is only intubating a few times a year (which I'd say is all to common in the US) they may not be thinking about that and/or have the confidence to try it.

More needs to be known about this (intubation during cardiac arrest) before a definative answer can be given. The skill level of the providers taking part in the study...the number of required attempts...how long if at all compressions were stopped for...when it was done...what was the presenting rhythm...initial downtime...CPR before arrival or not...cause of the arrest...all that and more needs to be known before a real answer is available. And to be really accurate, the variables need to be the same for each group participating.

This is an interesting study. It's huge (n = 650,000) -- compare that to something like ROC-PRIMED (n=10,000), or the San Diego RSI Trial (n = 200 trial patients, 627 controls). So it's well-powered to detect even a small difference.

* WOIC is "waiver of informed consent" -- when you do a clinical trial you have to explain what you're doing and the risks and benefits to the patients, if your patients are unconscious (or, in this case, dead, or some version of it) there's a process whereby you have to inform the community, and apply to an ethical committee to be allowed to study people without first obtaining verbal consent, which is impossible in this setting.

However, they've adjusted for this, so it's probably not a big deal.

I agree it's time for a RCT. I think it can be done, and done in a way that many of the potential variables are accounted for and removed. As for as the ethics, I doubt it'll be a problem. ROC has been doing studies that sometimes push the boundaries for awhile; the way they've got around the ethics commission is to announce in the news media in all their locations that such and such a study will be starting, and give people the ability to opt out by requesting a bracelet to identify themselves.

And given that they got approval to study the efficacy of lidocaine vs amiodarone vs saline in cardiac arrest...I think that getting approval to look into intubation wouldn't be to hard. And appropriate.

For any paramedics who are truly proficient at intubating, this is something to be concerned with. Not because of the science behind it or how the "study" was performed, but because it has been published in JAMA. A very insignifigant medical journal...

Having met and talked to a couple of Japanese paramedics and paramedic students, while this is applicable to the US system, it's not the a perfect match. Japan gives their paramedics more didactic hours than any school I've ever heard of; as far as science and theory go, they are sound and would run circles around the average paramedic. As far as physically performing clinical skills...let's just say that the clinical hours don't add up to the didactic. In essence, you have people with minimal training in intubation attempting to intubate in the worst conditions possible.

Which really isn't all that different than the average US paramedic trying to intubate a cardiac arrest patient.

When you compare this to other similar studies (data gained from PRIMED for example) what you really start to see is a much better point: if people are not truly proficient at intubation, then they should not be intubating patients. Ever. And the average US paramedic, sad to say, is far from proficient. It's not a hard thing to understand; if you aren't good at a skill that has the potential to stop chest compressions (one of only 2 things that we know truly work for cardiac arrests) you probably shouldn't be doing it. If you aren't good at something that, if done wrong, will decrease if not remove your ability to ventilate a patient (even if the need may be quite small in an arrest) then you probably shouldn't be doing it.

I haven't been a paramedic for a super long time, but the longer I do this, the more I read and learn, the more I do start to believe that intubation should be removed from the skillset of the vast majority of paramedics out there. Until both the educational system and EMS delivery model change, that is really the only thing to do.

I guess I have to ask why you would have such an issue with a funny little bird that is suffering from depression, reguardless thats not nice and you should say sorry........................we are all trying to get along in the sandbox

Because that freak is exactly that, and it bothers me for a number of reasons. I wasn't kidding in my previous post; on the 3 sites I've come across him "kiwi" has pretended to be all that and who knows what else.

I've worked very hard to get to where I am, and I take issue with some poser pretending to be anything even remotely similar. Of course I'd be bothered if he was pretending to be a lawyer, accountant, mechanic, carpenter, cook, or anything that he wasn't and had never been taught to be, had never done, likely never will do and trying to pass himself off as such and give out advice about that particular topic. The extent that this is happening in this case is insulting, disgusting, and rather disturbing as well.

I don't know what, if any, mental issues "kiwi" has, but let's think about it. Do you really think it's healthy to come to online forums and live out a fantasy? Taking an interest in something is one thing, but this is quite another and has gone far beyond that. Pretending to be something you aren't is not right, or good.

Anyway. I'm in a hurry, but that's the gist of it in a quick fashion. Seeing the sheer number of posts from this nutter whenever I check the site is aggravating, so I think I'm going to take the easy way out and put him on the ignore list (if there is one on this site; gotta check.)

Lets see here, the guy has his leg all but amputated, but doesn't want immediate care. We don't know what his reason was because the OP admits he's forgotten it. But, it's pretty fair to believe that there was no good reason. Thus, he's not making a decision competently. But, that's fine, you get to have an opinion, too,

No we don't force everyone to go against their will in our system. The other side of the coin is the I live and work in one of the most litigious states in America. So sometimes the people that make the rules are going to err on the side of caution. That's why we have someone above us in the chain who can give orders and take the liability off of us.

It's also why I took the time to make the point that other system policy's and procedures would likely vary.

Sweet holy motherfuck! Are you suggesting that because someone makes a poor decision that they are incompetant to make any decision? Are that the act of making a bad decision is a sign of mental incompetance as far determining the ability to refuse goes? Oh wow...

It doesn't matter if you work in California (or wherever); if someone is competant to refuse you can't force them. You can, and should give them every opportunity to change their minds, but in the end the choice is theirs. Document document document. And yeah. You'll still run the risk of being sued, maybe successfully. But it's better than the alternative.

Some years ago I had a patient with chest pain in the ER. Wide mediastinum on the portable chest. After a trip to the CT scanner, we had a diagnosis of an aortic dissection. After being told what was going on, the patient just wanted his/her sons to take him/her home. Several people tried their best to explain the risks, but in the end the patient signed out AMA and went home to their death. You have to respect the autonomy of a well informed, competent patient and let them make their decision. Sometimes, we as health care providers, get it in our minds that we know what is best for people. That's a slippery slope, but I'm not sure I always know what's best for me let alone a well informed, competent person making a decision about their healthcare.

Maybe a topic for a different thread, but I see that as a completely different set of circumstances. Instead of an accident you have a natural event occuring. If they decide that they don't want to ungergo surgery with the associated risks, are comfortble with their own mortality and would prefer to spend their last time at home with family...I have zero problem with that.

As before they should still have every chance to change their mind, but...depending on the person, whoes to say that wasn't the better choice for them?

Fine, then I'll say it. The kid is an idiot.

Well...yeah. And woefully uninformed about EMS.

I just took issue with who said it.

I would agree triemal, but only because I serve a relatively small service area with a low call volume and can send another ambulance if another call comes in. Also, I can be ready to respond from this scene should the need arise, and return once all is done. I've done it before. It's only gonna be a couple of hours before his wife arrives to take him in, and who knows, if he's going the same direction that we are we could still follow them, just in case she needs us. However, I will not take my ambulance and crew out of service just in case this guy crashes when there are others calling for help. I'll go to where I'm wanted and needed rather than hover over someone who doesn't want me there.

I completely agree with all of that. For the record, I'm not suggesting that while you wait you make yourself completely unavailable; if another call comes in it's time for triage...and I'm most likely leaving. But without knowing the culture I think that waiting for awhile, even if you are a bit outside your primary area is prudent. It may take you longer to respond but realistically that's not that big a deal, and again, no different than if you transported him.

Document the crap out of it no matter what, but you can't leave

Why can't he leave? Do you sit and babysit every competent and informed refusal you get?

Oh hell no. And if push came to shove heading out is an acceptable option; as long as the LN staff knows how to put a tourniquet on if the bleeding were to worsen it would probably work out fine.

My concern with leaving, at least without waiting there or in the nearby area with this particular guy is that, as the initial psychological shock of the injury wears off there's a good chance that he may change his mind, or be more open to persuasion. In which case being nearby would be good thing. Knowing the culture would play a part though; if they are as rule very stoic and stubborn then his reaction could be typical and might not change.

Anecdotally I can say I've done that successfully (and unsuccessfully) with semi-similar patients. I guess it'll come down to what each person is comfortable with. Me? I'd stay for a bit.

You said this was a non-US country so couple questions. How typical is this type of stoicism and/or refusal to admit to there being a medical/personal problem for that culture? How much does the average person there know about medicine and their countries capabilities? And realistically, based on the availability of a vascular surgeon and the amount of damage done (you said it came off after a crush type injury) how viable do you think the leg was? Personally I'm envisioning something that's not and I'd be more concerned with however much blood he lost initially and potentially could lose; usually it's CLEAN cuts that bleed less as severed vessels can retract somewhat.

Since this was a work related injury get his boss involved. If there's any coworkers/friends around, preferably someone from the same culture/area, talk to them and have them try and get through to him.

Barring that...make it absolutely clear to him what COULD be done to help him, and what could, and quite possibly WILL happen if he doesn't get quick help. Have other locals explain the same as well. And if he still refuses...you've gotta stay with him. Document the crap out of it no matter what, but you can't leave. If he drops because of blood loss you need to be there, and if he changes his mind as the gravity of the situation sets in you need to be there. Sucks if you are the only person available for a large area, but if you transported him you'd be unavailable for other calls anyway, so it's a wash.

You're an idiot, you realise that?

No. You don't get to say that. You...a mentally unbalanced admitted liar who at various times has pretended to be a NZ EMT...NZ Paramedic...medical student...doctor...flight doctor...who knows what else...going by the names Kiwimedic, Kiwiology, MrBrown, Rotors, and probably many more...who's only medical background is the ability to use Google...

You don't get to call anyone an idiot.

Don't get upset over this. It was a general message that is applicable across the board; I wasn't singling out anybody.

I tried to delete this post, but I'm not sure how. I have it from another member with much experience that my concerns were groundless. Apologies.

I wouldn't move so fast if I were you. while I'm not implying in any way, shape or form (really, I'm not) that island emt or whoever contacted you was anything less than completely honest and accurate, there are a couple issues here.

Using the word of ONE person to determine the accuracy of something/if you should go there isn't always the best idea. In this case, whatever it was, SOMETHING happened. While the news article may have not been accurate and blown out of proportion (and they often are) it'd be better to do more research instead of just using one responce.

More importantly than that, basing decisions off what one person on AN ANONYMOUS INTERNET FORUM tells you is just plain silly. People can, and do, pretend to be whatever they want, and with a bit of google-fu and intelligence it's relatively easy to do. This forum is no different than others and has at least one, and propably more lunatic posers.

Again, not implying that whoever sent you a PM wasn't being truthful, just a little piece of advice.

Once we are on hospital property, the patient is technically the hospital's patient. We are waiting inside a hallway of the ER for a room, the only equipment we have with us is the cardiac monitor (which some supervisors encouraged us to turn off once we had been triaged and were just waiting for a room, to "show" the hospital the patient was their responsibility... I refused to do that). We were not allowed to further treat the patient, as they were no longer "our" patient, and as the patient was not in an ER room and being seen by a dr, the hospital would not treat them either. On 1 call I was able to give my waiting pt additional pain medication that I had left over in the vial (was going to waste) with permission from the attending Dr, but this was an exception, not at all the norm. If we had fluids or anything running we would continue that while waiting, but not start anything new. Now typically we were not kept waiting with "critical" patients, however on occasion we have been (such as the a-fib w/ RVR patient, another patient on CPAP... both of these were at the same hospital)

Believe me, I know how bad for patient care this sounds, thats why I got out of that system as soon as possible (started my new job this month!)

Dear god that's ridiculous. Good on you for getting out of that system.

Out of curiousity, do you know what the reasoning behind that was? Was it to try and force the ER's to take over care quicker because you routinely were being parked in the hall, or some other reason?

Probably 20-30 minutes and that doesn't happen all that often. One of the lucky ones I suppose.

we were waiting the extended times with actually sick patients, who are then not getting any further treatment, as we are on hospital grounds and can no longer treat them;

Wait...what? You aren't allowed to continue treating your patient because...you are on hospital property? Even though NOBODY ELSE is treating the patient? Please explain...

That's actually pretty funny. When I started posting on EMS websites in 2007 that was more or less what I though; emtlife was for fun, emtcity was to learn something. Unfortunately, in that regard I think the difference has become smaller, due in part to the simple lack of posting here. And, while I come here less and may not be the best judge, at one time when this place was busier the amount of shittalking that went on was...awesome. The difference being that here it was allowed by all, not just some.

The harborview crowd has always thought of themselves as better than the rest of us mere mortal beings when it come to cardiac resuscitation numbers.

They have always posted numbers that are double the rest of the country.

I've always said that there are questions on how they come up with there numbers and what types of patients are being included in their data. If you only include cardiac arrest that are witnessed and have immediate CPR & defibrillation, the numbers will be better anywhere.

To openly state they don't follow AHA guidelines is just plain foolish , I can imagine a lawyer seeing that and waiting for the next non survivor to file a lawsuit.

If you read any of the published data (including the annual countywide report) what's used for the "50%" resucitation rate is the Utstein Criteria. It is a very selective criteria, based off the people who allready have the highest chance of a successful rescucitation. It's also a criteria set that ensures that every system would have worked that particular code; different places will have different thresholds for starting/withholding CPR, but pretty much everyone would start one on someone who meets the Utstein Criteria. So there may be some...selective <cough> PR <cough> data reporting going on, but it does make it easier for an accurate comparison between systems.

Of course, at this point the King County system isn't alone in pushing 50% using Utstein; it's happening in lots of places. If you look at the annual report (it's online) they're also posting a 20% survival rate (that's survival to discharge neurologically intact) for ALL non-traumatic cardiac arrests. THAT is an impressive number, but my guess is that anyone who get's close to 50% with Utstein will be getting closer and closer to that as well.

Forgot to mention that many places are taking part in, or have taken part in studies that disregard AHA reccomendations. Which are only reccomendations; like NFPA and fire departments, you aren't required to follow them.

If you look at the ROC studies, including the one that's ongoing looking at lidocaine vs amiodarone vs placebo...that's not following AHA guidleines. Yet 12 (I think; can't remember and am to lazy to check) different regions and who knows how many different services are doing so.

Or the CCR studies that were done awhile back...completely different than AHA guidelines, and never had a problem.

I post both here and on emtlife.

My guess would be the OP got banned because his website is seen as competition, or something along those lines, although that's a complete guess. The questions he was asking where a bit odd at first glance, but that's no big deal.

In all honesty I post far more there than I do here. This despite the very high number of moderators, unfairly and arbitrarily enforced rules, "family friendly" motiff, multiple instances of hero-worship among posters, and, just guessing here, a higher rate of posers.

So why do I post more there? Simple...it's far, far busier than here.

Sad but true.

(add in that the city seems to be coddling people more and more...unfortunate)

At first glance this would appear to be an MI or otherwise cardiac related...but...some other things there too.

She has had a prior hemmorhagic CVA...while it was 12 years ago this is still something to be thinking about. Add in that this was her first seizure in 12 years and her disorder was caused by the CVA in the first place...worth keeping in mind. If she is getting less responsive/lethargic and continueing to do so, very concerning. Repeat neuro exams, especially with a 2.5 hour transport are mandatory. The 12lead looks both like an acute MI, and a little like one that's been ongoing for awhile.

With the recent seizure and her history I'd be a little leery about the plavix and lovenox. Not saying I wouldn't, but a conversation with the cardiologist would be in order with my concerns expressly laid out. The tnk is definetly out.

Far as the access issue...if you can't find a peripheral vein then she get's an IO. Right away. You can try lidocaine (which is less than effective that I've seen) along with some IM fentanyl and versed, but she still get's it early. The other option, which will depend on how well you know the local doctor and what his capabilities are, is that it might be worth calling and asking if he'd be willing to start either an IJ or subclavian before you continue towards the city. If it's something he's good at it won't add much time, and with this being a high risk patient for both cardiac and neuro issues (or something else), a long transport, and the potential use of anticoagulants and/or thrombolytics, it'd be worth having.

Continue with repeat 12 leads (or 18 but since you said that's out...), repeat neuro exams and aggresively treat the nausea with your anti-emetic of choice. If the lethargy continues to progress or the vommitting becomes severe...carefully intubate.

I'll be quick, you won't feel a thing.

That's not a lie...

Oh wait...are we talking about lies told by paramedics while at work?

Oops...

It's not so much that I'm against discussing what happened, or trying to figure it out; I'm all for that and if I came across otherwise that wasn't my intent. It just seemed that, in this thread and in a few other recent ones about medical events that honestly had some questionable reporting, some posters seem to be taking what is written as gospel.

That's just one of those things that will drive me nuts when I see it, especially when you consider that most posters here are supposed to have critical thinking skills, some degree or another of medical education, and the ability to question what they read when it doesn't make complete sense.

Anyway, editorial off. Please continue.

Let's see...newspaper articles being written by people with no medical education...basing their info only off what the people who filed the lawsuit are saying (just guessing here, but I highly doubt either doctor mentioned, anyone in their practise, or the named hospital would be dumb enough to be talking to a reporter about this)...does anyone else want to consider that all the facts are so far from known that it's pure speculation at this point?

Telling someone that they need to trial a vaginal delivery before a c-section is different than flat out refusing to do one. (and since nobody here is an OB or was involved in this case...do you really want to guess what the reasoning behind that decision was?)

An epesiotomy was performed...perhaps that's where the extra "spurting" blood came from...

An "internal decapitation" would be something along the lines of an AOD as best I can figure...little different than tearing the head off the body. But which will sell more papers and earn certain people more money? "oh the horror...the horror...that evil monster doctor!"

The doc tried to "cover up" the injuries before handing the kid to the parent's...um...why is that bad? You can argue all day about what the motives may have been, but cleaning up a dead body before the family views it is par the course...at least around here. And if the head was off the body...hard to do.

There is so much about this that isn't known and so many different ways this could really have played out that it's impossible to say completely what happened right now.

I'm very curious to see if this full story on this comes out and what actually happened. But I've been in L&D during a...let's just say freaky event that, if someone with only one partial side of the story heard would have sounded just as bad, if not worse. And in that case nothing had really been done wrong...it was just what happened.