kevkei

it's not going to happen in the USA until you can bill for it ...

If you will take a moment to look, you will notice that I'm not from the US.

Hey all, I have an info request for you.

I am currently involved in a project that is looking at innovative and creative ways to deliver alternative forms of EMS that fall outside of the traditional scope of respond, treat and transport to a hospital.

Specifically some examples of what we are looking at:

• Expanding the scope of practice for EMT’s and Paramedics, something akin to a Paramedic Practicioner (Somewhat resembling a P.A)

• Taking the hospital to the patient in an attempt to meet the patients ‘needs’ as opposed to their wants.

o Examples of this would be access to a large referral network.

o Working with primary care and urgent care networks possibly with the ability to transport patients to areas other than a hospital E.R

Some services that we are researching are Metropolitan Ambulance Service in Melbourne Australia, the National Health Services model out of the United Kingdom, MEDIC Mecklenburg EMS Agency Charloette/Mecklengurg Co. N.C as well as Richmond Va.

Do you or your service have any experience in these areas or do you know of anyone that does? If so, I would like to hear from you. Drop me a P.M

Thanks for your consideration,

Kevin

It's probably a combination of poor planning and preparation as well as assumption.

I agree that you should pass the largest ETT size the pt will be able to tolerate. If you plan ahead and have 1 each of ETT sizes from say a 6.0-9.0 ready to go, you can perform the laryngoscopy and take a look and then decide what sized tube to pass. Typically from what I have seen, if you only open up a 6.0 from it's packaging, that is what people will use even if your view is unobstructed and there is minimal edema.

An extra 20-30 seconds worth of planning and preparation will save you in the long run and will also benefit the patient. It is value added time with exponential reward.

As for the use of Sux, if you are anticipating a difficult intubation, why not use it in the event you fail and run into a can't intubate/can't ventilate situation? How long is the serum K+ shift affected in relation to the Sux's duration of action? I understand that it is often advantageous to be 'better safe than sorry' but I think it better applies to a controlled situation with optimum conditions and if you have an acceptable alternative.

The problem that I see is people revert to "I was taught....." which doesn't neccesarily lead to the best decision making. If you have one paralytic and one oportunity to attempt an intubation, use it. I do agree that in the situation of "we prefer to use...", it demonstrates a valid thought process but shouldn't be limiting.

On another note, is there any consideration of either nebulized epi or racemic epi as a bridge in these situations?

It's easy to blame the intubation, the RSI, or whatever else.

What about considering the fact that if nothing was done at all, he would have arrested. If you consider things that way, it makes the decision to do something a lot easier.

Not to be picky but in the interest of correct spelling it is called a Bier block. ...

Live long and prosper.

Spock

Well, you are being picky and that's okay. I guess I had an episode where I was stuttering while typing.

HellsBells,

I'll beat everyone to the chase and keep it short. Treat the pt, not the pulse oximeter. The values obtained by SpO2 are very limited in their significance and are often over stated.

It's a common sense issue really. If everything else has failed to controll the bleeding, why not? If direct pressure, elevation, pressure points, etc has not had the desired effect, it is fair to assume you can sacrifice the limb to preserve life (life over limb theory).

Keep in mind, venous bleeds tend to be controlled more easily than an arterial bleed. If it is a laceration of the femoral or brachial artery, blood flow is already impaired so how is the application of a tourniquet going to hurt?

Use of a BP cuff is safe and effective as long as it can physically be applied (not effective for example if it is a stabbing located in the femoral triangle). You can more easily titrate it to desired effect than a tourniquet. It's use in hospital for surgery and exploration in the ER happens all the time, it's called a Beer block.

I think if all else fails and you can't control a bleed, you would be negligent not to try to use a BP cuff and/or tourniquet as opposed to allowing the pt to exsanguinate because you don't want to cause tissue damage?

To expand on AZCEP, There are two ways the leads can be contiguous, that is, "anatomically" in any of the leads or "numerically" in the precordial or chest leads.

If you have something showing in leads V2 - V3, this would be numerically contiguous and looks at the anterioseptal aspect of the heart. What if you have anatomically contiguous changes (ST elevation) say in leads I and V6 (or what about aVL?)? Both are looking at the lateral aspect of the left ventricle so you have enough criteria to say there is evidence of injury in two contiguous leads.

ERDoc, after the use of either RE or epi, don't you guys add a steroid like PO Dex?

That is the standard of care here, either they get Dex alone (mild-mild/moderate croup score) or after RE then are discharged moderate-severe). I thought there were studies that were able to defunct idea of the rebound effet with the added use of Dex.

Many studies have shown that there is no better efficacy with nebulized epi or racemic epi over albuterol. Considering the added potential of more significant side effects, albuterol is a better choice.

As has been stated, nebulized epi is better where you want to see the alpha effects, like in anaphylaxis (lingual or pharyngeal edema) or croup.

IM is okay if given in a large muscle mass (sub Q is a poor choice given the alpha effects it decreases it's absorption) in severe bronchospasm or when nothing else seems to be working. I've found that albuterol + Atrovent (ipatropium) repeater prn works well and if you need something extra in the moderate/severe patients, add 2 mg of Mag Sulfate IV early in your regimen. Keep in mind this is for the asthmatic, not the COPD'er.

I find it interesting that hot water is now the treatment of choice for jellyfish. Correct me if I am wrong but haven't native peoples used human urine for centuries to treat jellyfish stings? Maybe it was simply the temperature of the urine and nothing else in the urine that deactivated the toxins of the jellyfish. Interesting.

Oh and for the record if I get hit with a jellyfish please use hot water rather than pee on me. Thanks.

Actually it is the ammonia content in the urine that deactivates the toxin, not the temperature (as it would already be the same temperature of the affected area) . Heat, as hot as can be tolerated will denature the protein in the toxin and renders it ineffective.

That's why here, we don't have 'protocols' they are called Medical Control Guidelines because they recognize no call or guideline is black and white, it's all grey.

For example, we are encouraged (read, you are stupid not to) to do a 12 lead prior to administering nitro to rule out RVI and to also do a 15 lead in the presence of inferior changes and/or if elevation is present in V1.

I find it interesting to say that there is no evidence of positive outcomes from diuretic treatment pre-hospital. Personally, I do not have enough fingers or toes to count the many patients I have witnessed first hand improving from the use of various diuretic agents. I am sorry to say this, but your study is indicative of what many ED physicians do...........blame the pre-hospital folks for patients gone bad. Removing Lasix is not the answer and most of us do not have any urge to give something just because we can, again, typical ED physician's false belief. A proficient examination utilizing adjuncts available to all medics (i.e eyes, hands, ears, thermometer, stethoscope, etc.) WILL reveal the difference between CHF and Pneumonia. Citing half assed points and creating it into a study will work for some, but for the rest of us who actually know what we are doing, this is just another "study" that will fizzle off into the wind. Now using Morphine on the other hand, well that is a whole different thread..........................

One point of clarification if you may. How do you know that it was the diuresis that resulted in the improvement and not the result of concominant therapy or nitrates themselves?

LEt's say for argument's sake, he has a localized spinal injury in the lumbar region. What would be the point of applying a c-collar? Absolutely none.

I will advocate that for some people, the limited splinting of being strapped to a board may provide some relief although they are few and far between. For most, it is somehow trying to find a position of comfort. Usually it seems lying on their side with knees flexed and a pillow between is best.

Agree with both of the above.

Although, in the US, it really isn't very common for it to be applicable to a Paramedic, who work primarily from written protocols that they are not allowed to stray from. One of the most satisfying things about my current position is that I am given a great deal of latitude with my clinical decision making and can choose from a variety of medications for any given condition, based upon what I feel is best for this particular patient. But yes, that is an extremely dangerous way to go if you are not basing your decisions upon sound, research based evidence.

Dust, wouldn't you say though that more EMS protocols are being driven by evidence based medicine these days? If they aren't, they damn well should be.

Argee with Rid, tniuqs and Dust that evidence based medicine is the ONLY way to go otherwise it's all Voodoo.

I have done a few on kids and one on an infant. If you are questioning what size catheter to use, 18g or 20 g on an infant. For children, depends on their age and size. Toddlers, possibly 18 g. Older children, 14 or 16 g. Location is the same.

18g on a neonate? I hope you aren't trying to be serious. :shock:

I'm probably one of the few here that has actually been on strike.

We did too 3 years ago and ended up getting twice what they had offered. The result was due to them not bargaining at all, the offer on day one was the same as their final offer at the 11th hour (bargaining in bad faith).

In short the threat of a strike and in the end a strike itself is a powerfull tool in a unions bargaining toolbox. To those that say that we should be hung and we don't care about the people we serve I say you are foolish on a whole lot of levels. I care about the people I serve, but I care much more about the people who live under my roof that I am responsible for providing for.

I enjoy the protection of a union and to those that don't understand it; nuts to you. You will get it some day.

Agree'd. It isn't a bargaining tool if they don't think you will do it, so sometimes you have to prove them wrong. They sold it to city council and the tax payers that they had an adequate contingency plan but failed to mention they could only survive for 12 hours with half of the units we would normally have.

Using the addage about serving the patients, all they do is use that as a hostage tool. Why should we care about the patients when our employer doesn't care about us?

Keep it coming Canada! Edmonton Alberta! To all the Albertans here is another question how many people have taken a course at CCEMS?

CCEMS sucks Say hi to Barry for me.

Hello everyone! I am going to be an EMT (PCP) pretty soon here in Alberta.. if all goes according to plan... and i was thinking about getting my NREMT registration... anyone know the process?? do i have to go and do an EMT-B course?? any ideas where in northern montana would be good (closest state to me!) Any help would be greatly welcomed...

Why, why, why? Did I ask why? You would be more equivalent to an EMT-I than a basic so why would you want to?

Well that depends, there are forms of Valium that are water based/water soluble on the market now. So not all is oil based. Having said that, Versed would be a much better choice from a pharmacological perspective.

What is a toque? :?

What is a toque?

[web:7af692a29b]http://en.wikipedia.org/wiki/Tuque[/web:7af692a29b]

GAmedic1506, so are you telling me that if yo have a patient that states they took 10 tablets of extra strenght Tylenol, you are going to administer AC?

I'll tell you why it is being given less and less, because people are better understanding pharmacodynamics and pharmacokinetics. To be specific, our local ER's are now only giving it in few and very specific cases. One needs to understand the LD 50 (lethal dose) and toxic levels of a drug, then they need to understand what those effects will be. For example, if you have someone that has an isolated intentional overdose of 100 tabs of Paxil, they may have toxicity but there is no chance of it being fatal or even causing any harm to the body.

AC administration is looked at by evidence based medicine based on a risk vs benefit analysis. The FACT is, the risk typically is a lot higher than the benefit. And don't tell me that aspiration is crap. It is a given fact that charcol is bad and does nasty things to alveolar tissue.

So if you want to practice cook book medicine, go ahead. But don't try to tell a bunch of these very intelligent and well respected posters here they are out to lunch. Maybe it is you that needs to look in the mirror?

Clinically, there is no real reason to splint a suspected hip fracture or dislocation. Even for the femoral shaft, greater/lesser trochanter, etc. If you think about it, what is the recommended way to splint a suspected fracture? Splint the joint above and below the injury.

Well here you have a very stable orthopedic injury that is being splinted by very large and strong muscle groups around the joint itself. The area of the injury is not going to move. However, what will move is the areas pf the leg distal to the injury. Most pain is caused by people manipulating the leg by trying to adduct it back to the midline and then 'splint' the legs together by whatever means. This is the worst thing to do if they have evidence of internal rotation, the patient will be sure to SCREAM as to how much it hurts when you do that.

Talk to an orthopedic surgeon, they will tell you there is no real need to isolate a hip fracture/dislocation. Ususally the best method is to 'splint' by placing it in a position of comfort.

I hope my name is remembered...because I was the one who actually gave a damn and I won't tolerate a medic belittling an EMT because of lack of skill or knowledge that they do not teach us in the first place...from my understanding we are all in this together and I believe that is correct. I appriciate your comments and I respect what you had to say. But you had to be there Rid to fully understand before you accuse me of being a bitch to the medic.

I believe Ridryder was making reference to the Medic on the call and using it as an example of how to tread carefully in your workplace.

Remember, we are hearing your side of the story and are absent of the Medics side to see what he saw and thought. Don't assume that you know everything and start blaming them for being wrong. Maybe in this case you were right, but what about the future? You had better be damned sure to be 100% correct to challenge them to their face. For example, you felt they were in atrial flutter but what if the Medic said 'no, it's a-fib' and he has a history of this based on his medications (first clue is he is on blood thinners).

As for going around behind their back, it sounds to me like the guy admitted he made a mistake and attributed it to work load. Can you tell me you have never taken a short cut or not done something for a patient for personal or selfish reasons? We are only human.

To be specific, there is nothing with the first patient that screams out at me that this needs ALS intervention. Weak and dizzy is a very common complaint amongst the elderly and the majority of times it is very benign. Could also explain him being pale, 'shaky' and the elevated BP, due to the catecholamine response.

The second patient sounds very vague. In the end, what is it you expect? So if they were wrong not putting O2 on, why didn't you?

Something else to consider is, what are the ALS resources like in your area? For example, what is his train of thought to tax resources that don't absolutely require ALS in the event a cardiac arrest comes in or an MI? It's also about triaging and prioritizing.

Our system here utilizes a pilot and a co-pilot. No if's, and's or butts.