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EMSDoc

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    Emergency/Trauma Physician

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    http://www.tac-med.org
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    Northeast US
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    Tactical and Pre-Hospital Medicine

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  1. In many areas of New York state... Nassau County PD, Rotterdam Township PD, Albany County Sheriff, and Guilderland Township PD to name a few... the police or sheriff's department filled a need for ALS by cross training police officers that either worked on an ambulance or responded in a fly/chase car. All of these agencies have since staffed these divisions with civilian personnel who work for the police agencies, but some cross trained medics/LEOs still work for these agencies. There are a number of combined public safety departments I know of in the mid-west, where all personnel are cross trained LEOs, medics, and FFs. I have heard stories of a reckless driver cutting off the fire truck only to find himself pulled over and a ticket written. As for the SVU episode... well that's just television. EMSDoc
  2. FYI... We have a discussion about arming medics over on our discussion board... http://www.tac-med.org/resources/community-forum/topic?id=12 EMSDoc
  3. Tac-Med is excited to announce that we are now hosting a new community discussion forum. You can join in on a wide range of topics including Tactical Medicine, Disaster Medicine, Medicine in Complex Environments, Traditional EMS, Medical Intelligence, and Public Health. Join the discussion by visiting: http://www.tac-med.org/resources/community-forum'>http://www.tac-med.org/resources/community-forum It's free to register, and free to join. We hope the forum will grow into a dynamic resource for all field providers. Best regards, David Neubert, MD Medical Director, Tac-Med LLC http://www.tac-med.org dneubert@tac-med.org
  4. The one time I was bringing in a nothing MVC -- minor chest wall trauma from the airbag. Patient was fine but had some ectopy on the monitor so I ran a 12 lead. I went to the local community hospital and was directed to fast track. I started to present to a nurse after dropping off the patient, and stated... "and there was some ectopy on the monitor so I ran this 12 lead which looks fine..." The nurse abruptly cut me off, started questioning where I learned medicine, and then started mumbling something about having to move the patient up to the main ED. I took a deep breath, and I walked calmly out of fast track. My EMT partner was flipping out that I hadn't chatised her, but what I would have said would not have been professional. Instead I walked to the ED doc I knew on the main side, and showed her the EKG, and told her the nurse's reaction. The doc immediately apologized, found the nurse, pulled her aside and explained to her that this was not her decision, and who she has just yelled at. Needless to say I received an apology, but it was all done without embarassing the RN (even though she certainly deserved it). Most of the time if you find a way to make your point without making a scene your message is better received and it can help build bridges instead of destroying them. If you do your best and the the person is still unprofessional... hey you can't argue with an idiot. Doesn't mean you should stoop down to their level. Play the high road, and it will serve you and our profession well. EMSDoc 8)
  5. You know, I find this thread interesting. EMS providers want to be seen as a profession, but then in a public forum on an EMS blog site is a thread where many voice their displeasure at doctors, and speak highly disparagingly of them. I ride in the field as a physican, as does 'Zilla, and I assume ERDoc. There are many dedicated physicians that not only respect EMS providers, but spend much of their free time teaching and riding along with EMS providers. Not only do doctors still make house calls, but we understand the challenges faced by EMS providers. Don't paint every doctor with the same brush here. I have had a few instances where I have showed up in my EMS uniform and received attitude from a receiving hospital that did not realize I was an MD. I did not disrepect those that "gave me 'tude" -- as that would make me just as guilty. I treated them with the respect they should have given me -- and received an apology each time. I have seen just as many EMS providers bring patients into my ER without giving proper medical care -- and sometimes also with a bad attitude. I treat them with respect as well and try to educate them on their short-falls. There is no excuse for ANY medical provider to treat a collegue (either subordinate or supervisor) with disrespect -- including in person or in a public blog forum. EMSDoc 8)
  6. I agree with you that in a dark room with a really bright bulb on the end of your blade it is at times much easier to intubate then outside on a bright sunny day. Sterile flourescent lights is what most docs are used to and they actually provide a nice backlight for tubes. Trust me, it is MUCH easier to intubate in a hospital where I have many people there to help out -- one to hold the tube, one to hold the suction, one to listen to lung sounds, one to massage my ego... just kidding :wink: All joking aside, I give field medics a lot of credit -- it's a tough job. I still work in the field as a doc to ensure I never lose my field perspective. EMS medical direction is a very rewarding part of my practice -- and my way to "give back" for all of those that helped me out along the way to my MD. EMSDoc 8)
  7. Hey all, Doczilla asked I join the discussion. We both have been posting on the ACEP listserver about this topic, so this is what I posted: A few points: 1. All agencies should be using waveform capnography as the "gold standard" to determine tube placement. With properly used waveform capnography there should be an almost zero percent missed esophageal intubation rate. This method of tube verification was advocated by a position paper from the National Association of EMS Physicians in 1999. ( http://www.naemsp.org/pdf/verificationtubeplacement.pdf ) It is a rapid and very reliable method of determining tube placement, much better than auscultation, tube fogging, colorometric CO2 detectors, etc. Why this has not become the standard of care in both the pre-hospital and ED settings is surprising, as if you ask our colleagues in anesthesia, no one is intubated without waveform capnography and it has been the standard of care in the OR for many years. 2. I believe that the current system by which we train paramedics to perform intubation is set up with the deck stacked against them. I worked as an EMT for many years before becoming a physician, and all my initial intubations were in either the OR or the ED. The first time I had to place a tube as the physician on an ambulance I was face down in a field with an anaphylactic patient deep in the woods on a very bright sunny day. It was an eye opener for me how much more difficult this was than placing a tube in the ED. Think about it -- as physicians we are accustomed to a well lit exam room, with an adjustable bed, staff to assist us, maybe anesthesia backup. Being in the middle of a field face down in the dirt without support staff is a very different experience. There is an interesting article from the Anesthesia literature in 2007 that shows that physicians that normally work in a hospital setting, when placed with a helicopter service, often had unrecognized esophageal intubations (no capnography was available) http://www.anesthesia-analgesia.org/cgi/co...tract/104/3/619 Flash to how we train our EMS providers: we place them in a sterile OR or ED, then once they get the "right number" of tubes send them out into the field to get a couple of "field tubes" and then that's it. Most never have the opportunity to come back to the ED/OR to practice, nor do we actually train them in the environment in which they work. Paramedic students should be getting many intubations using airway mannequins in real field conditions (dark rooms, bathrooms, dusty fields, etc.), and all practicing paramedics should have the opportunity (and be mandated) to continue to practice intubations both on airway mannequins, and back in the ED/OR to maintain their skills. The combination of training the medics in our controlled ED environment and then sending them into a very different field environment, coupled with the lack of continuing education/practice, I feel is the source of many of the issues that have been raised within this discussion. Then, factor in the lack of waveform capnogrpahy in many places, and this just compounds the issue. A recent article from the British Journal of Anesthesia shows intubation to be safe and beneficial for head injured patients with well trained providers: http://bja.oxfordjournals.org/cgi/content/full/96/1/67 Again training and education -- coupled with practice and good monitoring equipment -- is the key. 3. In the San Diego study that is often quoted (The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444-53.), the authors themselves noted that RSI improved paramedic success rates: "Paramedic RSI improves intubation success rates but is associated with an increase in mortality and decrease in 'good outcomes' when compared with hand-matched controls. These differences may reflect inherent inequities between the two groups, although they appeared similar on all parameters we measured. Alternatively, the increase in mortality may be related to inadvertent hyperventilation, transient hypoxic episodes, and prolonged scene times associated with the RSI procedure." As the authors noted in their last sentence, further analysis of the data showed that hypertventilation and hypoxia was a large factor in the poor outcome of the patients, not the RSI procedure itself. (http://www.ncbi.nlm.nih.gov/pubmed/15284540 ) Well trained EMS providers with appropriate monitoring (continous ETCO2 and SPO2) and all available airway tools (including intubation/RSI when necessary) is the best way to minimize these complications. In fact, if you look at the literature from Europe (i.e. Acta Anaesthesiologica Scandinavica. 50(10):1250-4, 2006 Nov. "Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury.") many trauma patients were dying from hypoxia from lack of airway control in BLS only systems, and the introduction of ALS showed a decrease in mortality for TBI patients. A follow up study in the Journal of Trauma in 2007 showed that if TBI patients maintained normocapnea after intubation by medics, they did not have an increased mortality. ( http://www.ncbi.nlm.nih.gov/pubmed/17563643 ) In addition, a study from Journal of Trauma in 2005 showed that the use of a neuromuscular blocking agents by medics, when adjusted for confounding variables, actually improves outcomes for patients with TBI. ( http://www.ncbi.nlm.nih.gov/pubmed/15824647 ) Interestingly enough, there is an article in Archives of Surgery from San Diego pre-RSI that actually shows an improvement in patient outcome with pre-hospital intubation of head injuries ( http://archsurg.ama-assn.org/cgi/content/abstract/132/6/592 ). This further suggests that it is not the intubation that was the issue, but unrecognized hypoxia/hyperventilation/hypocapnea as noted. A recent expert panel summarized this best: "The Brain Trauma Foundation assembled a panel of experts to interpret the existing literature regarding paramedic RSI for severe TBI and offer guidance for EMS systems considering adding this skill to the paramedic scope of practice. The interpretation of this panel can be summarized as follows: (1) the existing literature regarding paramedic RSI is inconclusive, and apparent differences in outcome can be explained by use of different methodologies and variability in comparison groups; (2) the use of Glasgow Coma Scale score alone to identify TBI patients requiring RSI is limited, with additional research needed to refine our screening criteria; (3) suboptimal RSI technique as well as subsequent hyperventilation may account for some of the mortality increase reported with the procedure; (4) initial and ongoing training as well as experience with RSI appear to affect performance; and (5) the success of a paramedic RSI program is dependent on particular EMS and trauma system characteristics. (link: http://www.ncbi.nlm.nih.gov/pubmed/17169868 ) 4. My opinion -- backed by a recent article in Journal of Trauma-Injury Infection & Critical Care [ "Prehospital Rapid Sequence Intubation for Head Trauma: Conditions for a Successful Program" 60(5):997-1001, 2006 May. ] -- is that RSI should be reserved for a small cadre of well trained paramedics that are available for the right cases and the sickest patients. It should not be every medic, every patient with a GCS < 8, or every CHF'er. The conclusion from their article is the same: "Prehospital RSI for trauma patients can be safely and effectively performed with low rates of complication and without significant delay in transport. This study suggests that resources for prehospital airway management should be focused on training, regular experience, and close monitoring of a limited group of providers, thereby maximizing their exposure and experience with this procedure." Best regards, EMSDoc 8)
  8. I am not a fan of the MAT. While it's simple to apply (you only need to use one hand), and you can apply it to yourself without difficulty, I have two main issues: 1. They break. We were using one in a training class and after 10 or 15 people used it the tourniquet was no longer functional. Now mind you in a tactical scenario I don't believe this would necessarily be an issue, but if I was bleeding out I wouldn't want to depend on a tourniquet I have seen fail in a tactical scenario. 2. They can release accidentally. The release button is on the side, so if you were extricating someone and you accidentally bumped up against something, the tourniquet could accidentally release. In my opinion, the CAT or the ratchet tourniquet are your best options. http://www.chinookmed.com/index.cfm/fa/pro..._Tourniquet.cfm
  9. Tac-Med LLC has a class coming up in April in SE Pennsylvania. Check out our website for more information, or our post in this forum. http://www.tac-med.org
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