usmc_chris

If you read the drug information, the manufacturers of sublingual nitroglycerin tablets state that nitro is in fact contraindicated in the presence of an acute myocardial infarction. These people, who are, at least in theory, the experts on the drug, do not want it given in the setting of AMI While I do not have any studies in front of me, I believe that the evidence is increasingly showing that despite the theoretical benefits, there is little statistical benefit, if any. Second, as to the theory of the reduction in preload - there is a reason that you should ALWAYS obtain a 12-lead prior to NTG administration. Early aspirin is very beneficial, however, early nitroglycerin can in fact be fatal. Should the patient be experiencing an AMI with RVI, then they are probably preload dependent - and reducing this can certainly cause death. This (and the training/education to detect aortic stenosis) are the reasons that BLS should never carry their own nitroglycerin - should they assist the pt with their own pre-prescribed NTG, much, if not all, of the liability can be shifted to the prescribing physician. On the other hand, if you give your own, you would not have a legal leg to stand on if the pt received NTG, had an adverse reaction, and had one of these two conditions. Even worse, if you are an ALS tech, and you didn't bother to check/perform these simple assessments.

Hello all, I've been around for a while, reading posts, but haven't really posted (too busy with Paramedic class, will be done in a couple months!!) This post caught my eye, I thought, I might actually know what that is! Have you considered alcohol as a cause, especially in the college-age population? I wouldn't be so sure about this cause in the 18 yo with the hx of recurrent afib, but it is very common to see paroxysmal supraventricular tachydysrhythmias in otherwise healthy patients a day or so following the consumption of a large amount of alcohol. This most commonly presents as atrial fibrillation with RVR, but sometimes can be seen as a traditional SVT such as AVNRT. This would be common in the college-age binge drinking population, and and a rash of these patients are often seen in the ED following major holidays - thus the condition is termed holiday heart syndrome. These patients usually spontaneously convert back to a sinus rhythm with no treatment, however in symptomatic patient I certainly wouldn't withhold treatment. Chris

To be perfectly honest, I don't know. There was an announcement a few months that the pilot program was being terminated, and the REMAC has since removed all references to the program from its website with the exception of monthly meeting minutes. I can't even find the justification for ending the program anymore, that is what I vaguely remember as their reason. I suspect much of the reason had to do with under-utilization of the program for three reasons: 1) Laziness/apathy of some ALS providers - under the protocol, transportation to the alternative destination required the ALS provider to tech the call. Providers would say, hey, if we go to the hospital, it's BLS, and I can get my EMT partner to write the chart. So that's easier, especially on a day when you've had a lot of ALS calls. 2) Attitude of urgent care facilities. The only urgent care facility I have any experience with is also our local psych hospital, and they're not too keen on receiving psych patients by ambulance, let alone low-acuity medical patients. My best guess is they took in the patient, then called one of the commercial services to take the patient to their partnering medical hospital anyways. (We have two large commercial agencies, who do all transfers and a majority of 911 calls in the county - and these were the only two agencies participating in the pilot anyways - why take somebody to the urgent care, then turn around and take them to the hospital, when you could just take them to the hospital in the first place?) 3) I'm not sure, but I would suspect insurance compensation for ambulance transport to an urgent care is somewhat lower than to a regular hospital. Some agencies would not want to utilize the program for this reason. So, my assumption is the justification given may have been more of a "keep the peace" PC excuse rather than a legitimate explanation for the failure of the program. That being said, there could have been legitimate funding issues, but I simply don't know what they would be.

Hi, I'm new here, and have been monitoring the forums for a while, but decided to jump in on this one. In my region, they have already implemented something like this. Unfortunately, the program was abruptly terminated, I believe due to a lack of funding. Under the "Alternative Destination" pilot project, ALS providers could, with an online med control consult, decide to transport certain patients that had been EMD coded as low-priority, and assessed to have no priority symptoms, to designated urgent care facilities rather than emergency departments. It was a neat concept and it's a disappointment to see it go.