Jwade

Physician Resident work hours have been curtailed in the recent years. On November 1, 2002, the 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association (AOA). The decision also mandates that The trainee shall not be assigned to work physically on duty in excess of 80 hours per week averaged over a 4-week period, inclusive of in-house night call. The trainee shall not work in excess of 24 consecutive hours inclusive of morning and noon educational programs. Allowances for inpatient and outpatient continuity, transfer of care, educational debriefing and formal didactic activities may occur, but may not exceed 6 hours. Residents may not assume responsibility for a new patient after working 24 hours. The trainee shall have on alternate weeks 48-hour periods off, or at least one 24-hour period off each week. Upon conclusion of a 24-hour duty shift, trainees shall have a minimum of 12 hours off before being required to be on duty again. Upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided. All off-duty time must be totally free from assignment to clinical or educational activity. Rotations in which trainee is assigned to Emergency Department duty shall ensure that trainees work no longer than 12 hour shifts. The trainee and training institution must always remember the patient care responsibility is not precluded by the work hour policy. In cases where a trainee is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved. The trainee may not be assigned to call more often than every third night averaged over any consecutive four-week period. There have been some BIG NAME institutions that have gotten nailed for not following these rules........ Respectfully, JW

Vent, I would like to think even new EMT-P's, RN's, RRT's would still be doing a complete assessment regardless of the situation. As this thread has finally come full circle to illustrate that, YES, one has to eventually treat any and all underlying acute conditions, which is exactly what I said in my first posts.....Albeit a little too basic for some of the brain trust in here! Respectfully, JW

Not sure your post clears much up, sorry.... In my 18 years of experience, most ROSC have weak pulses and low bp to start with, so this is nothing out of the ordinary. Again, the heart muscle is irritated to say the least, so I would expect potentially weird things to go on from time to time. 1. What EXACTLY is the time frame in seconds you watched this run of " VT"? 2. Here is what I would NOT do. My guess is his BP is low, hence the dopamine drip you are attempting to initiate. Giving a bolus of LIDO could further drop his BP, so that is clearly out until I have a decent BP to work with. 3. Again, one should not get so tunnel visioned on RATE. VT @ 120 or 200 is still VT. The question you have to ask is STABLE or UNSTABLE! I was not there, so I can not say for sure. 4. In the context of your information and the scenario given, I would have NOT cardioverted right away. I would have given the patient a few minutes to get his BP somewhat stable, and see if his heart " calms " down a bit......Chances are things would change on you again. 5. I would have the AMIO or LIDO ready and avail should i need it later on for sure. 6. Remember, BP = Brain Perfusion. Runs of VT are fairly common sometimes. You would be amazed at some of the stuff you see in an EP lab. Respectfully, JW

Excellent questions that need answered for sure.... One question with regard to the highlighted area above. Can you explain your rationale for pretreating with LIDO for cardioversion? Respectfully, JW

Well, 1. You can use a 3 lead to see what is happening in more than lead II, so a 12 lead while nice, is not an absolute necessity and you have to be able to interpret the 12 lead based on what you see, not what the nice little printout on the top says. 2. Let's discuss indications for cardioversion. a. V-tach with pulse - Stable = Meds / Unstable = Cardioversion / then if continued refractory to meds, cardioversion is indicated. b. You fail to mention if you have qualified your patient as stable or unstable? 3. What was LOC? ( I am making the assumption of unconscious), What was his BP? What did he or she look like clinically? People do some really weird crap post-resuscitation, so, my initial reaction is to say NO, i would not have cardioverted, but I don't have all of the info yet. Respectfully, JW

Yep, That is because they are parking them in the ground routinely.......

Vent, 1. So, curious, what exactly do you say to those people when you hear the above highlighted responses? Yes it does.......I have no problems asking her opinion. Why would I? Cardiac Physiology background, Medical School, Anesthesia Residency, managed the TICU.....Deals with Respiratory Physiology every day of the week! .Wealth of knowledge. I know where my comfort zone is and where it is not.....( NICU is not ) That is why they have NICU nurses and RRT's! I respect those professionals immensely.... Respectfully, JW

Tniuqs, Well stated, Excellent reply.. I do not have a degree(s) either, However, I did sleep at a holiday inn express last night! That has to count for something right? Respectfully, JW

OK, First, I really do NOT need any lecture on from an RRT on physiology, as I have an entire 4 years of undergrad dedicated to this. Second, I am well educated in all of the modalities in which you took such time and effort to belittle me with....I really know all those nice little calculations and while certainly useful in an ICU setting, they are pretty pointless in the majority of EMS calls..... I was initially speaking from a very basic point of view, and in the scenario HERBIE presented, the H& H ideally should be dealt with first. I even ran this thread by the SICU Trauma Surgeon / Intensivist today, and he said, " 1. The Placebo effect is unknown, 2. Eventually you are going to HAVE to fix the H&H regardless of what other modalities you try." While, I have no doubt from your well written information you are highly educated on the subject, and as an RRT, I would hope so, however, I think I am going to stick with the advice of the SICU Trauma Surgeon and my wife who used to run a Thoracic ICU. Sorry....Will just have to agree to disagree. :-) My respects for the loss of your mother. Never easy. Respectfully, JW

I did misread what CHBARE post, as it was 2 am and my ambien was already working too well...My fault... However, the bottom line here is, going back to what HERBIE stated, taking an anemic patient and sticking O2 on them without fixing the underlying issue is going to have relatively little effect. Just spoke to my wife, Board Certified MD ( Anesthesia). You have to fix the underlying hematocrit issue first and foremost.....You can start splitting hairs like some of the posters above have started doing, however, real world application is going to do very little to help anyone... Good Discussion Respectfully, JW

Mobey, YES, while technically what you said can " potentially" happen, there is NO way sticking someone on a NRB @ 15 liters will increase their PO2 enough to " Benefit the patient who is ANEMIC and already has a low HCT & HGB" As someone else suggested, you would need at a minimum Hyperbaric chamber to help.....and you would still have to fix the anemia issue regardless.....So, I think your answer, while theoretically possible, real world application is not statistically significant. Respectfully, JW

Herbie, Can you please explain your rationale for the statement outlined in red please? How is a person who is anemic going to benefit from inhaling O2? The basis of anemia is lack of red blood cells, hemoglobin is found inside the RBC, and as you know carries O2 everywhere, if you have a lack of RBC's and therefore a lack of hemoglobin carrying capacity, adding O2 is pointless. The O2 must have something to bind with to be effective. Respectfully, JW

Welcome to the forums. You stated an AAS in pre-PT, are you planning on a bachelors degree and then paramedic school? What are your ultimate end goals? I am a long time Flight Paramedic, and just finishing a double masters degree. IF I were your age again, I would do things a little differently for sure.... I am also a Pilot myself. ( Fixed Wing) What ratings do you hold? In a perfect world, I would graduate high school again, blow through a Bachelors degrees ASAFP, and then go fly Jets in the Air Force, or Apache's in the Army! I realized way too late that flying was a passion....Now, at the ripe old age of 36, sadly, I cannot qualify for a flying spot in the military..... Good Luck on your choices...Let me know if you have any questions I can answer... JW

Army, Good point, I had thought about stating this during my initial response, but I probably wrongly assumed that vital sign trending was obvious when deciding whether or not cushing's is involved. Respectfully, JW

Brandon, YES, Pretty much an ACLS thing, although, when i teach BLS to healthcare providers, I will go over it as well.. I am an AHA BLS/ACLS/PALS instructor, and I find there are quite a few ambiguous areas unfortunately. ACLS standard for symptomatic brady is , atropine .5-1mg IVP ( Unless a 3 degree AV block exists), Transcutaneous Pacing, and CPR if none of that works or no pacer available. Your only other alternative is to sit and watch them progress from bradycardia to asystole by doing nothing. Take your pick? PS. AND you must make sure you have ruled out any reversible causes. 6h's and 5t's Respectfully, JW

Brandon, Hopefully, I can clear some of this up for you. 1. When delivering a baby, NRP recommends the oropharynx to be suctioned first, followed by the nares. The theory behind this, stimulation of the nares may cause the infant to gasp and aspirate secretions which are present in the oropharynx, ( Meconium being one of them). Also, remember not to suction too vigorously, no more than 100mm HG of negative pressure to avoid common injuries. Also, too much rigorous suctioning could overstimulate the vagus nerve and thus produce profound bradycardia.. 2. Adult SYMPTOMATIC Bradycardia can be treated with the following options. Atropine ( unless 3 degree AV block), Pacing, and finally CPR.......SO, YES, you can do CPR on an adult in this situation.... 3. Cushing's Triad is when you have an increase in ICP ( Inter-cranial Pressure, ) which causes compression of the cerebral blood vessels causing ischemia to the brain. This may be represented by Increase in Blood Pressure / Decrease in HR / Decrease in Respiratory Drive. This is a real event that you can easily witness in the field, as I have seen it many times both in the field and during my days First Assisting in the Operating Room... Hope this helps. Respectfully, JW

Anthony, Which AHA publication specifically states one to check a pulse to gauge CPR adequacy? Thanks JW

Tniuqs, Ahh, Ok, that explains more to me now...Thank you for the clarification. JW

Medic One, Can you please explain to me why you check pulse while doing CPR? Which pulse are you checking? How are you assessing skin temp? OR, do you mean checking CORE temp? Thanks in advance JW

Thank you I feel bad because, this is the kind of information being taught in school as the gospel, when in fact, nothing could be further from the truth......Probably not her fault, as she is just regurgitating what some " Instructor" told her..... But, she definitely needed to be corrected, and hopefully she can learn something to help provide better care to her patients. Respectfully, JW

P, Not trying to make anything you say unsubstantiated, I just literally wanted to know how you were coming to your conclusion of cooperation? Thanks for the info. Respectfully, JW

WOW.......Where to even start this reply..... First, Where in Detroit are you working? As this is my old stomping grounds as well.... Second, I truly hope you don't seriously rely on ANY of the above information you just gave to the masses..... Here are a few lessons you should probably learn quickly.... 1.Pulses Clinicians frequently try to palpate arterial pulses during chest compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system produce femoral vein pulsations.8 Thus palpation of a pulse in the femoral triangle may indicate venous rather than arterial blood flow. Carotid pulsations during CPR do not indicate the efficacy of coronary blood flow or myocardial or cerebral perfusion during CPR. 2.Oximetry During cardiac arrest, pulse oximetry will not function because pulsatile blood flow is inadequate in peripheral tissue beds. But pulse oximetry is commonly used in emergency departments and critical care units for monitoring patients who are not in arrest because it provides a simple, continuous method of tracking oxyhemoglobin saturation. Normal pulse oximetry saturation, however, does not ensure adequate systemic oxygen delivery because it does not calculate the total oxygen content (O2 bound to hemoglobin + dissolved O2) and adequacy of blood flow (cardiac output). Tissue oxygen tension is not commonly evaluated during CPR, but it may provide a mechanism to assess tissue perfusion because transconjunctival oxygen tension falls rapidly with cardiac arrest and returns to baseline when spontaneous circulation is restored. 3.End-Tidal CO2 Monitoring End-tidal CO2 monitoring is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients. During cardiac arrest CO2 continues to be generated throughout the body. The major determinant of CO2 excretion is its rate of delivery from the peripheral production sites to the lungs. In the low-flow state during CPR, ventilation is relatively high compared with blood flow, so that the end-tidal CO2 concentration is low. If ventilation is reasonably constant, then changes in end-tidal CO2 concentration reflect changes in cardiac output. Eight case series have shown that patients who were successfully resuscitated from cardiac arrest had significantly higher end-tidal CO2 levels than patients who could not be resuscitated (LOE 5).2,22–28 Capnometry can also be used as an early indicator of ROSC (LOE 529,30; 4. I would really study up on the Dissociation Curve...... 5. Relying on a Pulse OX is the worst thing you could be doing for your patient....Before you go losing your mind about what you were taught in Paramedic school, there is a saying, You don't know, what you don't know. This is what separates the Critical Care providers from the population mean. You might want to read through ALL of VENTMEDIC's posts and learn. Respectfully, JW

CH, YES, he did say " seems " initially....But then his second statement was made as a statement of fact.... I fully agree that his whole premise of his position will be based on nothing more than anecdotal information, HOWEVER, this was my point of asking him how he was qualifying and quantifying his statement......That was something he never answered....I was curious from an MBA perspective if he could provide any factual data that would support his conclusion. Respectfully, JW

Respectfully, That is NOT what you stated.....You stated specifically " Point is that it is working in my area"......Now you say it " SEEMS" to work..... There is a HUGE disconnect between those two statements..... I asked you how you are qualifying and quantifying the first statement.......Anecdotal hypotheses don't support the statistical facts of the HEMS industry as a whole.... Again, I will agree, there are a few companies and areas doing it right......I simply asked you to prove your premise through facts..I have studied pretty much the entire US HEMS in MBA school, I have a good idea as to what is going on in any part of the country...Because you made such an initial blanket statement of fact, I assumed you had your own statistics to back up your assertion.... Respectfully, JW

Please explain to the masses how you are qualifying and quantifying this statement of fact? As a long time Flight Paramedic and Pilot, I have seen things from both spectrums. Coming from Michigan where you do NOT call a helicopter unless true life or limb, to my current state of Arizona, where you cannot spit without hitting a HEMS aircraft, the HEMS Industry is broken.....A few good programs doing things right here and there, but the majority are pathetic.. Before business school, I, too was probably a bit naive in thinking that we all can get along, etc.......Now, having EXTENSIVELY studied HEMS statistics and business models, I can promise you one thing....It is about MONEY, plain and simple......Safety, patient care, employee morale, is all secondary to flight volumes, and keeping the competition in check...... This lawsuit is nothing more than keeping their pockets lined with cash! JW