Camulos

Do you revert much VT with that? :roll: Stay safe, Curse :evil:

Sorry to create a misunderstanding. Damn night shift does that though I suppose :roll: In my prehospital work I have only ever used the T-piece with a BVM. Ventilator wise I was referring to my hospital work where we use the T-piece with the ventilators in ICU. I have used a few different vents in the past but we are currently using drager XL. I have never used a T-piece within a transport ventilator circuit. To be honest I actually prefer not to use our transport ventilator on critically unwell asthma pts at all if it can be helped. Prefer just to manually bag as I can then "feel" lung compliance. I guess that the other benefit of just bagging is that I don't see a waveform in front of me exhibiting how bad the pt is breath stacking and therefore I am able to remain blissfully unaware- JOKE!!!! Hope this makes sense as I really need some sleep. Stay safe, Curse :evil:

T- piece works quite well with BVM and also within a ventilator circuit. Depending on the ventilator you may have to get a bit tricky and compensate for the additional external flow. Some ventilators do have an in built nebuliser through which you can T-piece however I personally don't like them. I have used the T-piece method with salbutamol, atrovent, adrenaline and magnesium with good success in the past. Stay safe, Curse :evil:

Great question!! Although I don’t have the answer I will add that the squatting position was the one advocated by the mother’s coalition I referred to earlier. They were claiming it was far more comfortable than lying on their back. Stay safe, Curse :evil:

Damn - I was four minutes too late to get that answer in before ERDOC!!! :x

I was chatting to paramedicmike in the chat room yesterday about child birth when he told me of his paramedic rule number four – Always unload just as many pts as you loaded. I’m quite happy to go along with that and luckily have not yet managed to unload more pts than I loaded. I have never delivered a baby before and am quite keen to keep that scorecard clean. Having no real life experience I admit my answer is purely textbook. Mobey suggested an episiotomy. I guess episiotomy may work however don’t know that it would be my first line management. I’m happier to go with the supra pubic pressure on the baby’s shoulder before reaching for the scalpel. I also remember something about getting the mother to put her knees as high up on her abdomen as possible to assist delivery through the canal. Some of the mother’s that were present in this lecture laughed at this suggestion saying it could not be done. It was actually an interesting verbal interplay between the male lecturer and the vehement mother’s coalition – LOL. If this position were not possible I believe the mother should get on the ground on all fours - awaiting further assistance. Realistically I don’t know how these positions help. Definitely, and gladly, not my specialty. I don’t think I need to know the answer to this one anyway. I’ll be far too busy boiling the kettle and getting the towels when this happens Stay safe, Curse :evil:

Damn – I can’t find the full text on this article. Even going through my “secret” work access site I cannot manage to get it. Found another article by Hauswald and co on spinal immobilisation though which I have quickly perused and that seems interesting. Strangely, whilst writing my initial response on this topic I did actually think about comparing a standard industrialised Western centre approach to a “third world” (for lack of a better term) approach. I was thinking more like the African country’s as a possibility for this though. I do admit it was only a fleeting thought as I immediately saw too many detractions and am keen to see if Hauswald’s cited article managed to overcome these. Having not read the article I am hopeful that someone who has a copy could answer some questions for me. They mainly centre around the problems I envisaged in undertaking such a study. 1) Was the study prospective or retrospective? 2) Did the study have comparable # types and locations between the two centres? 3) Was overall injury severity comparable between the two pt populations? Again I have not read the study but I do assume it was not randomized as the treatment was predetermined based on which country, or medical facility, you were treated at. Please correct me if this is not the case. Being aware of a study of this type does raise some interesting possibilities though. Perhaps the whole study could be conducted in a place like Malaysia where spinal precautions are presumably not the standard. Make it prospective and randomize the spinal immobilisation. However whether we could extrapolate these results to our system may be the difficulty. I guess some good food for thought. So who wants to go to Malaysia? Stay safe, Curse :evil:

Did you ever find out what the final diagnosis was? I suppose the ED, and indeed myself, may have been more comfortable using amiodarone in the setting of the sinus tachycardia they were presented with rather than the earlier combination of sinus rhythm / VT we were originally presented with. I wonder if my choice to not administer an antiarrythmic, as you did, would have made this pt worse? It always would have been a very hard call to defibrillate this pt considering he was in such a fruit salad of rhythms. Out if interest did you administer analgesia to relieve his pain? And if so what did you use? Also keen to find out if lidocaine is your first line antiarrythmic. Great job on that case!!! A difficult one indeed. Goes to show you that not all pts fit into a nice little slot in the cookbook and sometimes we need to think outside the square. Stay safe, Curse :evil:

As far as diagnosis is concerned I have a few up my sleeve however none entirely fit the picture. The diagnoses that come to mind are Brugada syndrome – possibly made worse by the lignocaine, and R ventricular dysplasia. The inferior ST elevation threw me off track a bit and has led me to include R ventricular infarction. So following the standard 12 lead ECG let’s do a right sided one as well. Heck at least it will look like we are doing something useful for the pt. I’d need much more info to confirm any of these diagnoses though and although they may be going through my head I would never be able to conclusively diagnose this pre hospital in our current system. As an aside to this, is lignocaine, or liDocaine as you spell it, your first line antiarrythmic? Ours used to be however has now changed to amiodarone. In your last post you reported that the pt is “now in sinus tachy and waking up”. In my hopeless ability to not realise exactly what was going on with this pt his condition has luckily improved. Jeez I’m good – he he. As far as my treatment goes before we got to this point. Would I have given my first line antiarrythmic of amiodarone? Well probably not. Only because his rhythm was not sustained and was alternating between VT and sinus rhythm. Hard call to make, especially with the PVC’s, but I’m hoping my high flow O2 makes some in roads there. Would I have given magnesium? In the absence of polymorphic VT I would have to answer no. However as I said before I can’t see it doing much harm. Would I have electively cardioverted him or attempted to over ride pace? I really don’t think I’d have the balls considering his rhythm was so erratic. As such my treatment would have been the basics – O2, monitoring with a big focus on relieving this pts pain and anxiety to stop him pleading with me to help. And of course to provide good pt care – LOL. I would be careful which analgesic I used in this case – particularly with RVI on my list of potential diagnoses (no morphine). I guess I’ve been taught that if I truly don’t know what to do that I should just stick to the basics. So in this case I guess I’m going to have to concede that I’ve been beaten. So I’m gunna stick to the basics and only hope that the helicopter is a lot quicker than the 25 minutes I was told. If the pt deteriorates in that time, and goes into sustained VT, VF etc, his treatment decisions, for me anyway, actually get easier. However if any of my diagnoses above are correct and he does deteriorate we may not need that bird after all. Keen to hear the answer here and boy am I glad we have discussed this scenario here rather than me being unlucky enough to come across it in real life like you did. Maybe you deserve my nickname more than I do. Stay safe, Curse - May be retired and given to RUFFEMS!! :evil:

Very interesting article indeed!!! I suspected it was going to be a good one from the moment I read the disclaimer at the start. I have no doubt it will certainly “stimulate some debate amongst EMS practitioners”. Indeed it has inspired me to jot a few things down. Dr Jaslow points out that there is no level I evidence to support, or refute, current spinal immobilisation practices. I’m sure this is not news to most of us. There is definitely a paucity of evidence regarding many EMS practices – pick your topic. I would however be keen to know how a randomised control trial could be done in this particular pt population. To prove, or disprove, current spinal immobilisation practices, I would imagine that one group of pts with documented injury would have to be immobilised and one group would not. Good luck finding an ethics committee to approve that, let alone gaining pt or next of kin consent. So herein lies the problem. Perhaps there is no level I evidence because it is simply just not feasible for it to be conducted. If anyone can think of a way to conduct a quality RCT in this population I am very keen to hear it. Then I can steal it and take the credit when I publish it – LOL. In his column Dr Jaslow states “However, EMS practitioners, chief officers and EMS medical directors should give serious consideration to prioritization of clinical care procedures when manpower is limited given the lack of evidence that "in-line stabilization" offers any tangible benefit.” Surely this refocus would have to be predetermined, taught and documented in the cookbook. EMS practitioners and chief officers aside, I believe a reprioritisation of clinical care procedures at this level should come from medical directors. Realistically which medical director is going to sign off on that? I believe the possible medico-legal consequences are just too great – especially in the litigious society of the United States. Dr Jaslow also states “While those patients who sustain significant mechanism of injury are statically (sic) more likely to have a spinal column injury (and more likely to require a KED by "protocol") there are also no reported case series of spinal cord injuries that have been linked to failure to apply these devices in the field.” Again I believe this is very difficult to prove. If it could be conclusively proved I believe that would be very costly for the EMS agency involved with the resultant compensation payout. I guess the only way to establish failure to apply spinal precautions as a causative factor in SCI is if the pt was fine before you moved them, and then suddenly developed symptoms when they had been moved inappropriately. Now that’s a run sheet I would like to read. I am keen to hear others thoughts on this topic. It would be great to get Dr Jaslow’s further comments on this topic and to enquire if anything has changed since the publication of this article. We might have to send him an invitation to join here if not already a member. Oh yeah – I also found painting difficult. I think it has to do with that whole right brain, left brain thing. Stay safe, Curse :evil:

Given that its monomorphic VT I don't know that the magnesium mentioned earlier would have much of an effect. Mind you I don't believe it could cause much harm, providing it is administered appropriately. I do have a couple of theories going but need some more info first. I hazard jumping in too early and giving a stupid answer without gathering all the facts as I normally would. First of all I would love to see the rhythm strip. I am keen to know if it is truly VT or an SVT with abberrant conduction. However I am guessing its not an SVT as the pt loses his pulse and consciousness when it occurs. Does the pt have PVC's present when they revert back to sinus? If so looking at a similarity in the morphology of those may give a clue as to whether it is truly VT or SVT with abberration. Secondly, I would be interested to get this pt's medical history and current medications in case they are an abysmal historian. I am particularly interested whether this pt has a cardiac history. GREAT scenario by the way. One I have certainly not encountered before but this is great food for thought. Looking forward to see how it develops and what the final answer is. Stay safe, Curse :evil:

Is the VT monomorphic or polymorphic? Past medical history would also be useful. Stay safe, Curse :evil:

Short answer - NO!!! I only apply a pelvic wrap when there is pelvic instability and I want to decrease bleeding from the fractures. It does this primarily by decreasing the overall pelvic volume and therefore the potential space into which blood can escape. Has no place in this particular scenario in what seems to be an isolated hip fracture. On the SAM splint. They are pretty and work well however that cosmetic effect is not without a cost. I can acheive the same thing with a sheet and forceps and therefore believe that money could be better spent elsewhere - like my holiday fund. One can only dream!! Till next time. Stay safe, Curse :evil:

Some interesting answers on this topic. Being a newbie here I am mildly reluctant to weigh in on this one (no pun intended). But I do enjoy adventure so what the heck. Arizonazaffcep - I guess we all get frustrated by a perceived lack of appropriate care of some pts from time to time. I have certainly not been immune to this in the past. I believe frustration is good though as it shows that we actually care about ensuring best outcomes for our pts. When this occurs, one thing I have learnt is to enquire why certain treatments are / are not being done. The best person to give you this info is the decision maker themselves, so in this case I guess the cardiologist. In my past experience it has sometimes been a lack of education / understanding on my behalf and when the decision process has been fully explained to me it all falls into place. Admittedly sometimes it still doesn’t make sense after this process however I understand that medicine is just like that sometimes. But don’t be afraid to ask questions if you believe they require answers. Indeed as a pt advocate it is your responsibility. It is difficult to make a proper educated judgement on what was the best treatment for this particular pt without all the info I would normally ask for. That aside I’ll go with what I have been given. We know that this pt weighs 540lb. Not understanding pounds, we use kilos in the land of oz, my calculator tells me that is around 245kg. I note this pt is also only 5’7” tall. This equates to a BMI of 84.6!!! As such this pt would certainly cause some logistic nightmares in all of the hospitals I have previously worked in. This pt’s size alone makes him an extremely poor candidate for any invasive treatment. Let’s look at some potential problems with cardiac cath alone. Difficult femoral access due to physical size, inability to lie supine on the table due to resp compromise therefore requiring airway control, shocking anaesthetic risk at that size perhaps compounded by other premorbid health problems associated with his obesity, table and cath lab not large enough to cater for a pt of this size and I’m sure the list goes on. Don’t get me wrong, I am not advocating that this pt does not deserve treatment, only that there are unfortunately existent logistical problems at this size that may make the risks of such a procedure greater than the perceived benefits. Perhaps some of these came into play with this particular pt when the decision was made. Maybe you could enquire and let us know. The next point I notice from your initial post is that you stated that you and the RN later noted ST segment elevation in lead II. The casualty was then given lasix. Again, it is hard to make an educated decision here without all the info, but on this I would say to be very careful administering lasix to someone who is experiencing an inferior MI – characterised by ST elevation in leads II, III and aVF – without first ruling out isolated right ventricular infarction. Any elevation in the above leads mandates a right sided ECG. If an isolated right ventricular infarction is confirmed, the proper management consists of volume loading to maintain adequate right ventricular preload. Lasix in this condition could cause huge problems. If you require any further info on this please let me know. It is getting late here (0255hrs) and I am off to bed. Keen to hear others thoughts on this and also if Arizonazaffcep has had a chance to do any further follow up. Stay safe all, Curse :evil:

Pruning my bonsai whilst listening to classical music. Might sound lame to some but I don't really care because it works for me. Running and mountain biking are also great. Stay safe, Curse :evil:

Thanks for the welcome mate!!! Great site and I am looking forward to sharing my ideas with others here. Stay safe, Curse :evil:

In my book any pt who has suffered a significant enough force to cause a clinically evident flail segment in the field definitely deserves spinal immobilisation. I understand the term “distracting injury” is not well defined by the existing C-Spine clearance protocols, however I personally believe that at LEAST two ribs which have been fractured in at LEAST two places definitely qualifies as a distracting injury. And any flail that you can usually detect prehospital has to be much bigger than this basic definition to be recognised clinically. So if I see it in the field, then that pt gets a collar and board. I recognise that this has the potential to cause compromise to both airway and breathing. If so they get a tube and PPV – which will effectively treat the flail anyway. Stay safe, Curse :evil:

Grade 3 or 4 airway McCoy blade used Some obese grade 2's Suspected C-spine injury Equals Mr bougie Have also used it once successfully on a pt with a very stiff larynx who was undergoing radiotherapy Stay safe, Curse :evil:

Never heard anything about not taking a BP in the left arm due to the possibility of making the situation worse. As far as anatomy goes I suppose that theoretically the left arm BP could cause more “back pressure” on the aortic arch than a BP on the right side as the left subclavian artery has more of a direct communication with the aortic arch than the right subclavian which additionally branches with the right common carotid before entering the arch. Just a VERY wild guess though. My personal feeling is that a simple BP, left or right arm, would not cause this problem and we routinely do bilateral BP’s in pts suspected of traumatic aortic injuries. Would be great to have some actual research on this though. Stay safe, Curse :evil:

Funny things nasal intubations. In my experience with these I believe the complication rate far exceeds the benefits. Have seen them used when oral intubation was not possible secondary to trismus – and no option for RSI. Whether this particular pt required intubation or not is open to debate and is probably worthy of another topic. So considering the tube was already placed let’s take it from there. I agree with vent medics earlier sentiments that the insertion of the tube increases airway resistance. This does have the potential to cause the pt harm if their spontaneous respiratory effort is not strong enough to overcome this resistance. Placing a NRB over the top of the ETT is quite unusual. I have never seen any established protocols to support this practice. In spontaneously breathing pts you can connect the BVM to the ETT without providing the manual positive pressure ventilations. However you still have the problem of the resistance of the tube becoming an issue, particularly if a small tube was used, and have to be aware of that when adopting this practice. When doing this I always have a low threshold for providing some positive pressure support. Mind you, providing manual PPV to a spontaneously breathing pt is not without its dangers. You have to be careful not to over expand the lungs and cause barotrauma – particularly in small adults and children. That’s why it is always advantageous to use a BVM with an airway release valve. Unfortuantely these are not always available. Interested to hear others comments on this. Stay safe, Curse :evil:

The medication options for analgesia here are; 1) Entonox : Seems to work well on minor injuries. It is bulky to transport and has to be used with caution in trauma, particularly if pneumothorax or bowel injury is suspected. 2) Penthrane : Unusual drug in my experience. Seems to be no middle ground – It either works really well or doesn’t work at all. Usually works well in kids. I noted a previous comment on this thread regarding the adverse effects of penthrane – particularly its nephrotoxicity. All of these studies were done when penthrane was administered at an anaesthetic dose. When administered in its analgesic dose there have been no reports of this. The advantages of penthrane are that it is small and easy to carry to remote or difficult to access locations. You can also concurrently administer oxygen through the base of the inhaler however some services have banned this practice, particularly when administering in confined spaces. 3) Morphine : Fantastic medication!!! Works well in most situations. What more can you say. 4) IN Fentanyl : Also a fantastic medication. Studies have shown no real difference in efficacy between morphine and fentanyl. Easy to deliver, particularly if you stuff up the IV cannula and cannot give the morphine. Some prehospital services here also utilise paracetamol and ibuprofen if appropriate. I particularly like an earlier answer on this thread that highlighted that there are more pain relief options than just medication alone – splinting, positioning, ice (the cold type not the street type – LOL), reassurance etc. I believe it is important that we are all mindful of this and use everything we have available to ensure our patient’s pain is treated appropriately. Most of the studies report we do a poor job of treating pain therefore definitely an area for improvement. Stay safe, Curse :evil: