triemal04

It is. That was the biggest thing I got from the large study from japan a couple years ago; it's not that epi is inherently bad (which was their conclusion for some reason) just that it doesn't lead to good outcomes unless it's given in a timely manner after starting a resuscitation. Strange thought, no? Small steps...hopefully one day we'll get there. Of course that really requires a cultural change more than anything medical, but maybe some day... I would think (hope) it would be something like that; have a 20cc vial and draw up either a ml of saline, or a ml of x mg/ml or y mg/ml. Be interesting to see what would happen with a drip. It's worth remembering that epi doesn't function well in acidotic environments, and given that the pH of the average arrest is something like 7.1 (I think, it was relatively low) a heavier concentration for a drip than normal might be required. Be interesting to see, but I think it'd be better to figure out just how much and when epi should be used in the first place, then look at the way it's given. Of course, given the howls that went with the ALPS study, an epi study that includes a placebo arm (which it has to) will cause a lot of blowback from some providers. Some of the press releases that went with the Paramedic2 study seemed to be aimed more at paramedics than the public... Thanks for proving my point mikey...if you want, I bet there's lots of places that would love to publish a scholarly article about your personal anecdotal experience...you should contact them.

I doubt glucagon will be studied in any large way anytime soon, but who knows. Epi, on the other hand, is worth looking at, especially since the most recent bullshit study from Japan (I honestly don't understand why those get published in the form they were in) and some other smaller, poorly run ones have come out. I think that if a true randomized study is ever done it'll probably show, not that epi is bad, but that it is most effective and has the highest benefit when given early (as the Japanese study actually showed), and most likely doesn't need to be given in the same massive doses that it's given now. That and that at some point we need to come around to understanding that a lot of people who go into cardiac arrest did so for a reason, and should be allowed to remain that way. Mikey...this is a discussion for adults. Go sit in the corner and observe.

And if you're to stupid to determine how to correlate what you find during your history and physical exam with what you find by using all dem dang ol' purty toys then you are correct, you should ignore what "machines" tell you. In fact at that point you should ignore what you find on your h&p and find a different line of work all together. Because you aren't smart enough to be a paramedic. It's unfortunate that some people are allowed to continue even when that's the case.

I think that what you'll see is either a intubation study (maybe, but if some groups dropped out that could, and hopefully WOULD kill that study) or one done on various doses of epinephrine. My personal opinion only on the latter but...wouldn't surprise me. Sure you did.

What!? You mean if you really learn how to do something in the first place, perform it on a regular basis, and continue to train on it you'll actually become good at it!? BLASPHEMER! That defies all logic! EMS logic that is... Sorry, I just couldn't resist. In all seriousness though, there are departments out there that work like that, and have published their data. I wish that was the message that people were actually taking home, not just the standard "don't do this" one.

That's LVH, not a STEMI. Most likely anyway, based of the crappy 12lead. There are some things that are odd about your exam, and good for picking up on those and following up, but you probably should have dug further, and gotten a better 12-lead. I don't see a problem with withholding ASA; I'd expect him to be on a blood thinner right now anyway. I'm not sure why a c-collar was placed. How did you present this patient at the hospital?

I think you're confusing what actually constitutes negligence (hint: this wasn't it), what level of an exam was required of this patient, and forgetting that just because you believe something should have been done a certain way, doesn't mean that is the only way. In all honesty, you need to make sure that this: isn't completely coloring your opinions of this specific situation. (I say that without knowing what those other things were, obviously) Because what you described here, without having all the facts, really isn't all that bad.

That was the entire thinking behind what used to be called "cardio-cerebral resucitation," ie CCR; it may be called something else now, not really sure. It made a decent sized splash maybe 5-6 years ago, though probably not as big a one as it should have, but it did result in some departments changing how the run a CPR and to the deemphasize on intubation by the AHA.

I don't know that I'd call it a problem, just that the results from services like that encompass more than a simple "this is good or it isn't" answer. In all honesty, for the vast majority of paramedic services, paramedics shouldn't be intubating, and it's very likely that doing so really does more harm than good, or at best has zero benefit over a different type of airway. If you first focus on services that are proficient at it, the results would show that (assuming that was the outcome) intubation is good IF it's done by people who are good at it; then it would need to be replicated at the average type of service to see if there was a difference. This was sort of seen in the last study put out by, I think, Wang; he used ROC data (from PRIMED I think) and came to the conclusion that paramedic intubation was detrimental. BUT, at the end of the study there was a brief section that went over the fact that when the data from certain high performing subgroups was analyzed the opposite was true. That is what needs to be emphasized more than just a blanket "don't let paramedics intubate." Granted, there are other confounders when you look at most high performing systems, but the best benefit of studying those systems would be to push others not to do the same skills, but to do the same skills at the same level of proficiency; that's what should be taken away from a study like that.

ROC has been kicking around doing a randomized study looking at ETI and supraglottic airways during cardiac arrest for awhile; from what I head a few months ago it may actually be in the works after the completion of ALPS. The problem is that there are a few ROC members who will catagorically refuse to be involved in this, including some that already have both high resuscitation rates, and high first pass success rates for ETI. A true randomized study absolutely needs to be done, but as with all studies on paramedic ETI, it has to first use services that are truly competant at intubation before it's studied in the average service. Depending on the study design, that may be hard to do.

Damn...I just went from reading this: to reading this: after skipping all the posts in between...let's just say I expected to see something very different when I went back and read them all...

I think Broome Doc's talked about using it for uncontrolled nosebleeds. May have been someone else though.

http://www.cardiosource.org/science-and-quality/clinical-trials/a/avoid.aspx?WT.mc_id=Twitter The link to the slides on the right has most of the actual study in it. Definetly food for thought; while the people who got O2 had a larger infarct and more adverse events (including another MI), they actually had a LOWER mortality at both discharge, and 6 months. Hmmm... I'd like to know why they choose 8lpm by facemask instead of 2-4 by nasal cannula. It doesn't make much sense; even the authors admit that what they did isn't a standard therapy.

Not super surprising; if they don't need O2, don't give them O2. I really want to see the full study though, be interesting what adverse outcome they were seeing, what they were measuring, why it wasn't related to something else, and so forth. If there actually were true detrimental events that can be conclusively (or at least with a high degree of certainty) shown to have been caused by O2, that might have a better effect than just telling people it's not needed and "might" be a problem down the road. Cool.

We don't carry it (yet). I would think that how often it gets used will be more a function of how often you see more serious traumatic injuries; if it's not common then you probably won't be using it that much. If you work in the knife and gun club...probably use it more.

They've been enrolling patients for a couple of years in your neck of the woods; any news on when they have all the patients they need? I'm sure it'll be taken into account, but be curious to see how far they break down and differentiate the different MI's; just based on location and time, or will it be based on TIMI flow? Or something else?

Community paramedics are the current hot topic in EMS for various reasons, some good, some bad. While these programs can certainly be extremely beneficial, both to patients, and to departments that implement them, there is a side to this that could have some interesting implications for EMS. At the recent ACEP conference, it sounds like several medical directors had reservations about community paramedics due to the lack of education at the paramedic level; a very valid concern. With EMS now being a subspeciality of EM, the fact that this (if reported accurately) was discussed at the annual ACEP conference should make people take note. If this type of program continues to be implemented using paramedics, more and more doctors (and not just medical directors and/or EM doctors) will become aware of the lack of education at the paramedic level. If that's the case, will this have an overall good, bad, or indifferent effect on EMS as a whole?

Acting like a dick isn't the way to get people to post more. Brown recluses are a well known problem in the southeastern part of the country (and other parts), with well known and documented results from bites. (to be clear, this wasn't directed at the OP)

To continue... Somebody is stretching and looking for someone to blame. And very likely has their own personal agenda against youth football teams. So we now have a nice "he said, she said" moment. Should be easy enough to figure out what actually happened...you know...since there were plenty of witnesses available. Not to mention the fact that the concern for getting the ambulance stuck, as already noted, is a more than valid reason to not drive onto a grass field. Combine that with the fact that it wouldn't have made a bit of difference in the outcome...someone is again stretching and looking for someone to blame. And very likely wants to fill their pockets at the same time. I'm not going to touch on the actual complaint, other than the mention yet again that this is why lawyers are seen, often rightfully so, as scum of the earth. While there may be valid complaints against the school district and/or coaching staff, the complaints levied against both the fire departments involved, and the ambulance company are, without far more facts than have been presented, nothing more than baseless shit. I refuse to be polite about it; it's shit. It is tragic that a teenager died, and there may be negligence on the parts of the school districts/coaches...but the fact that such a wide net was thrown for such bullshit reasons makes it look more like someone has an ax to grind and wants money and less like the family really wants resolution. To bad that cases like this bring leeches crawling out of the woodwork.

Well...I think it's probably one of these options. a) the parent's are still grieving and/or pissed off and looking for someone to blame. b ) they got connected with a terrible POS lawyer c) they got contacted and "counseled" by a POS with their own private agenda d) they have legitimate concerns Sadly, I think, based on this single article (which doesn't have all the facts but is all there is to go on right now) that option a and d are having the least impact on this decision. More on that later.

What are you, 12 years old? Because that's how you seem right now. Now, I can't tell if you are just trolling to stir things up (I think you're trolling; it's been a long time since I heard anything about this type of deal, though I'm not exactly omnipotent and could be wrong) or being serious, but either way, it's a poor showing on your part. If you are being serious, you need to start showing some common sense and intelligence. Right now you aren't showing either, and are contradicting yourself. You asked a question...were given an answer with several reason for that answer...and you have yet to come up with why any of those reasons are invalid. Once again, if anything I, or anyone has said is wrong, please, by all means point out how it is wrong, and what the reality is. Or you can just go on thinking that someone has been insulting military corpsmen (nobody has) and thinking that you have some mystical knowledge that nobody else has.

Wow. Touchy touchy. I'm sorry, but when you immedietly jump to a pedantic defensive posture like that you start to lose credibility. Perhaps you should exercise some...I don't know...calm critical thinking skills and try again? I think you have a gross lack of understanding in the difference between the standard training that a military corpsman recieves and the standard training that a civilian paramedic recieves. Despite what you apparently think, trauma management makes up an extremely small part of what a paramedic does, and in all reality, trauma management for a field provider is easy. There is far, far more to field care that revolves around soley medical complaints, or even more fun, a mixed problem of trauma and medical issues. As far as I know, the standard training that say, an Army 68W recieves has very little to do with that. If I'm wrong...feel free to elaborate and correct me. I hate to say it, but the fact that you think that a few physical skills equates to "critical care levels" shows beyond a shadow of a doubt that you don't understand what real critical care is. Again, if you think I'm wrong, please elaborate on what "critical care" the garden variety military corpsman provides. I'm going to be nice and not suggest that the fact that you apparently think that having to deal with someone with cancer makes you the equal of a paramedic, and that since you apparently think that whatever your own personal experiences were are the same as EVERY military corpsman marks you as an idiot. Really, I wouldn't do that. What I will suggest is that you need to stop, calm yourself, which, if you were such a high-speed provider who provided critical care under a hail of lead should be very easy for you, and think about this: If you want to compare two different groups who provide a similar service (it doesn't have to be medical related, it can be anything) you have to look at the lowest common denominator; ie the people who just barely make it through whatever certification or testing process to gain entry into that specific group. Because that is all that matters for comparison; there will always be people who go above and beyond the minimums, but what matters is the basic requirements to do that particular job. What I mean is, you can't compare the top guy from group A to the bottom guy from group B, OR the top guy from group B, because there is no standard for being on the top...theres just a standard for being on the bottom. So...knowing that, do you really think that bozo A from the military who spent their time in the states and never saw a patient beyond sick call (where they turfed the patient to the next highest level of care without doing anything) is the same as bozo B the paramedic who barely passed the NR and works for a slow, lousy service? I can tell you right now, there is a big difference in what the two will know, and be capable of doing. And a transition course is not the way to make up the difference. If you want the title, put in the time to earn in. Don't come up with some sob story to get around it, or think that by coming up with some fancy name for a new provider will make you equals.

No. Sorry, but it's a bad idea being put into place for all the wrong reasons. There is to much variability in what a "medic" in the Army, Navy, and Air Force does to make a transition course possible. Even if you looked soley at people assigned to line infantry/armor/MP/some type of combat unit there is to much variability in what 2 different people will be doing/knowing. Beyond that, there is to much variability in what a "medic" in just the Army does. The Army and Navy (not sure about AF) will come out with at least their EMT cert if not something higher...that's really all that they should get. If a process is put into place to help them reaquire an expired cert with fewer hoops to jump through that sounds like a good idea, but there is to much of a difference between what different medics will be doing to make a transition course possible. There are specific types of medical providers in all 3 services that will get, or have the opportunity to get, a higher cert than EMT as part of their training. And there are people who will get the opportunity to attend civilian EMT/AEMT/EMT-I/Paramedic classes as part of their career; this doesn't apply to them for obvious reasons.

You're asking two very different questions here. Regarding who's "better," that's completely variable from area to area, service to service, and person to person. In some areas private ambulances, even if they do not respond to 911 calls, will have very motivated, well educated providers. In some areas the ambulances that respond to 911 calls, private or otherwise, will have dumb, lazy providers. And vice versa of course. There is to much variability across the country to say definatively which is more prevalent. Nor does it really matter all that much beyond what you are dealing with in your own area. Now, if you want to talk personal opinions, that's different. Based on my own experience, in MY opinion and in MY area, generally the non-private providers are better. Of course, this is only my opinion; doesn't make it right, and since I still recognize that and understand that it very well may not be accurate in a multitude of situations...it doesn't really matter that much. As far as what you should do...that is entirely dependant upon you. If you have the opportunity to move into management, and that's something that you want to do, then you just need to decide if it's a service you want to be in that position with. You can always move back to being a field provider, and having a supervisory position on your resume is always a good thing.

My god, just stop. All you are doing is making yourself look even dumber, and even more like asshole. Replies in red. There is a time and place to treat people in a less than nice manner. There is a time and place for the equivalent of getting in someones face. But that time is when it's called for. Your little game of "stupid newbies, I'm a big bad (retired) EMT that knows all, they need to get in the corner till I say otherwise" that you pull out for every new poster is nothing more than ignorance, stupidity, and general asshattery. Your constant patting yourself on the back to the tune of "someone's gotta tell these punks how it really is" is just plain a nice excuse for acting like an asshole. Perhaps you should find some better ways to spend your time. Just as a general aside to anyone else reading this; there are no moderators here right now. Which, personally, I don't think is neccasarally a bad thing. But the problem with that is that the forum has to be self-policing, which means when crap like the above gets spouted, it needs to made clear (especially to any new posters) that it's crap, not liked, not preferred, and not the standard response. Otherwise...you get a nice dead forum. Like this this one.