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paramatt_ last won the day on November 7 2017

paramatt_ had the most liked content!

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  1. Anyone ever done this?

    To follow on Mike's post, a lot of the issues with community based care is system based. ie a for profit system isint going to benefit from such novel ideas..again, a $$ thing. Working as part of a government funded service, it's a different story and all about value for money and keeping those out of hospital who can be treated in the comunity and trying to save ambulance resources for 'real emergencies'. We are doing this both in a call diversion program (only in its infant stages) where callers can be directed to local services and a paramedic run extended care program to deal with minor wound care / burns, epistaxis, catheter problems, some home rx for migrane, gastro, etc. The major success is that everyone benefits. And yes, major baseline education differences. And spending that extra few minutes preparing some food or having a cup of tea with a pt isn't just about doing a 'good deed' IMO, but is as much about being able to assess the daily living capacity of that person. Spending that extra 10 minutes chatting with someone and looking through the fridge can raise all sorts of red flags that might otherwise go unnoticed.
  2. Medical conditions causing crush syndrome

    Not just the obese. I recall attending a pt, elderly, frail, and quite small that awkwardly fell and landed with most of one thigh basically under her squashed against the ground in what would have been quite an impressive accomplishment if she was doing yoga...unfortunately she wasn't and was found some 8-10 hours later with marked visible discolouration (of what could be seen) to said limb. She had multiple co-morbidities including renal failure. Anyways, we treated her as per crush injury though she ended up having a cardiac arrest after being moved. ps. can we start calling you Plain? And for the OP. there was quite a good topic some time ago on suspension trauma, if you have a chance its probably worth a look.
  3. CHF & Low BP

    Perhaps the thought process was to increase venous return / "prime" the LV to subsequently increase stroke volume which can then be titrated with the fusemide to reduce the excess fluid. Definitely requires a careful balencing act. I've done similar with hypotensive inf STEMI pt's with a bit of failure (minus the fruse) with the aim of increasing preload. That's quite different to this pt though. To the OP: what treatment was done at the hospital and dId you stick around to see the outcome?
  4. CHF & Low BP

    Just out of curiosity, how many services out there carry dobutamine? Anyways, if the pt was for active treatment, I'd be going for a low dose adrenaline infusion..likely starting quite low..maybe 2mcg/min and titrating to maintain a sufficient MAP and no more. Excess catacholamines = no bueno with a history like that. Maybe if it was extended transport I'd consider lasix balancing act, but would be very vety weary in doing so. I'd also avoid CPAP with a BP like that. I suppose a ddx like dig toxicity should be considered. Wouldn't change anything in the short term but it might mean he'd be going home
  5. CHF & Low BP

    "If your heart stops would you like to be resuscitated?"
  6. Books Every Paramedic Student Should Read

    Welcome & good topic. Cases in Pre-hospital and Retreival Medicine, Ellis & Hooper Written in relation to commonwealth ambulance services, however, still relavent to north American models. Depending on your background and knowledge base, some parts might be a bit over your head, but lots of good cases to help consolodate and better approach scene control / management, differential diagnoses, and treatment goals. Lots and lots of little clinical pearls scattered throughout.
  7. Transporting to an urgent care

    This should be the norm. Granted all services are different, but generally speaking, the 'you call we haul' concept is quite archaic, or at least should be for any professional ambulance service. Speaking about my own service, we give advice to pt's based on what's best for them. During normal office hours, there's limited urgent care services (i.e. non-appointment walkins) which are mainly open in the evenings and weekends but we'll regularly call a pt's own Dr to try and squeeze them in for an urgent appointment if practical..sometimes we transport, sometimes we don't. Other times pt's are happy to sit in the hospital waiting be it. I find it a bit strange that urgent care facilities wouldn't want pt's. And I don't see how it matters if a someone comes via bus/car/taxi/ambulance/whatever unless there's something I'm missing In regards to that paper, I think having a direct phone line for high risk pt's post discharge is a great idea. There are few general nurse run health advice lines that pt's regular use, however, if someone were to mention that they were recently discharged post CABG or whatever, the call would likely get transferred to the ambulance comms regardless. Some of the other processes seem to be good as well and are definitely long overdue On a side note, a while ago I read an insightful paper written by an emergency consultant which basically stated that true emergency presentations in his department were overwhelmed by the was an interesting perspective...I'll see if I can dig it up.
  8. Looking for some help

    I'm working outside the US, but have a bit of knowledge of transfer/retrieval services. It's quite common to have lower acuity pt's that require similar transports both domestically and internationally. The first thing I'd be fuguring out what services / care is required during transport as some of the others suggested as there will obviously be additional costs depending on staffing requirements. The referring dr should be able to give guidance on that. A quick Google of 'United Sates domestic medical transfers' brought up a good list of companies that specialise in such work...once you know what he needs during transport you should be able to contact them directly for quotes. A good provider should be able to arrange all the transfers and liaison work between the the sending and receiving facilities
  9. Spinal Restriction

    Same...backboards for extrication only. Occasionally we might leave someone on if packaged up and its a very short transport time, maybe 5-10minutes max.
  10. second line seizure medications

    That's probably one of the most horrible situations you can be in, especially with a pead. I suppose if her oxygenation deteriorated you would have been looking at a surgical airway.. It sounds like you guys did a great job nevertheless, and with a favorable outcome. Good chance for a side is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations? I'm a fan of high-flow nasal cannula with lateral positioning if possible.
  11. second line seizure medications

    Thanks for the replies. I definitely agree with you Ruff that cost and potential lack of use has merits what medications are stocked. However, working for a government funded service that generally transports to government funded hospitals one would think there might be better continuity of care..which unfortunately isn't the case. Can be frustrating to see pt's with prolonged seizures or those high risk for multiple seizures get phenytoin loaded upon arrival to emerg which is probably something we could safely do (all our trucks have syringe drivers)..not meaning to digress...more interested in hearing about other services do things. DD, thanks for that resd. Very interesting information and definitely picked up some new terminology. Just briefly, although I appreciate the treatment approach and timing structure including giving an opportunity for meds to take effect, I don't know how generaliable it would outside be the hospital/icu setting. Just thinking about TBI or suspected intracranial hemorrhage pt's which I've seen go straight to GA after poor or limited effect from benzos with a goal of not only seizure control but getting prompt imaging and definitive treatment started. Looking forward to some more discussion
  12. second line seizure medications

    Hey there, new thread! Just after some anecdotal information on those providers who carry multiple or second-line antiepileptic medications, epscially non benzos. I've had a few cases over the past year or so where pts have responded poorly to treatment, including a couple of pediatric febrile status epilepticus. (we only carry midaz with weight based dosing). I've done a bit of research on the topic but just interested to know what others are actually doing/using including how often they get used and indications for use.
  13. I've used it a few times. I was able to pick up an SVT where absent P waves were hard to distinguish. With that being said, I've also had just as good, if not better, results in using V1 and turning up the gain. Intresting concept though
  14. ED Wait Times

    This continues to be problem where I work. No free beds in the wards, and things get gridlocked in emergency. Or more frequently its just busy and we’ll have a patient who is not suitable for the waiting room and not sick enough to go through to the resus area thus we end up looking after them. We’ll continue to provide care, on occasion we’ll assist by taking bloods, go with the patient to x-ray, etc. Not an ideal situation by any means. Once in a while a patient will be seen by a specialist team and get admitted while still in our care, or more commonly, be assessed by an ED doc a sent home.
  15. chest pain bad, nitrates good

    I recently attended an 89 year old patient in bed at home presenting with palpitations with associated with chest discomfort. The onset of symptoms woke him up. History of bypass surgery some 20+ years prior, AF, hypertension. Had once instance of rapid AF about a year prior that was medically managed. Recently well and reasonably healthy otherwise Meds were metoprolol, a dihydropyridine ca channel blocker, and was warfarinized. Also had a nitrate spray that was “hardly ever used” ECG showed rapid AF (ventricular rate between 130-160), hemodynamically stable and well perfused…initial SBP was 160 or so, GCS 15, no evidence of failure/pulmonary oedema, etc etc. My partner, who was treating, began treating the patient with nitrates as he had chest pain. Aside from dropping his blood pressure over the next to 10-15 minutes, he still remained adequately perfused. The pain marginally decreased. The obvious concern was that he was at risk of losing his pre-load and was in obvious need of some rate control, but what really surprised me was that the hospital emerg staff continued the nitrate regime. It never fails to amaze me how the chest pain = nitrate mentality is so strongly engrained into the mind of so many health care workers, both EMSers and non, that it’s almost primeval. I’ve lost count how many times I’ve attended a doctor surgery for a chest pain patient who has received nitrates but no aspirin. More worrying is that one of the most dangerous drugs we carry (in my opinion) can be administered by someone with 115hrs training and is host of a whole cascade of adverse reactions, whilst anti-platelet agents which have a proven benefit in ACS are not in the basic scope. Note: I work in an upsidedown non-US system with volunteers that can give aspirin but not nitriates I don’t want to turn this into a ALS vs BLS medication discussion, but just felt like ranting a bit on the topic. Other observations are most welcome