AZCEP

As reference, don't use area specific descriptions. Level zero doesn't mean anything to anyone outside of your service area. If I'm understanding the situation, you stripped your coverage area to transport a patient that should have been dealt with much earlier by other resources. Once the CFO got involved, you were screwed. No accountant on the planet is going to put area coverage ahead of the dollar signs that are pretty well guaranteed. The best thing you can do is do as you are told, and ask if they would like fries with their order. They are treating EMS like it is fast food, so return it in kind. Hope the CFO's family lives in your coverage area, and needs you while your resources are busy securing the greenbacks. Karma's a cruel mistress.

This EMT did not drop the ball near as badly as the system that they work in did by not having an ALS provider available for a patient that desperately needed one. Even the advice that was given by others in his system has been questionable. Ventilate someone at 28 bpm? Are they serious? What exactly are they trying to achieve with this? Sometimes, a patient will survive in spite of your best efforts. Given the short transport time, the RN should take the time to educate you instead of deriding you for your system's failure.

Can someone please explain to me what this rant has to do with the original topic? This is precisely what he is talking about. The system is a mess, and using "profession" to describe it is an insult to anyone that has taken the time to educate themselves beyond the first aid course that so many want to consider important. Your "education" comes into question when you suggest that the current state of EMS is a "profession", or that the basic level should be "given" anything beyond what they already have. Allow me to point out that the intermediate level has outlived it's usefulness. It was, and still is, a stopgap measure to allow smaller communities to have ALS providers without the costs required of a full paramedic. In 1999, NHTSA expanded the scope to turn this level into what many areas are using as a replacement for the paramedic without the commiserate education. It is a level that needs to be done away with. With the amount of education they have received they may well be the only providers that should be asking for more leeway in their BLS activities. This comparison has nothing to do with what you are trying to put forth. No, that is the textbook, feel-good answer when asked why we spend so much time involved in this bastardized system with little to no avenue for advancement. With few exceptions, people become involved with EMS to build a foundation for something else and become enamored with the environment that they land in. If they wanted to "help people" these same providers would be finding other ways to do it that don't involve flashing lights. This again calls into question your education and dedication to the "profession". No one is asking you to "bash" anyone or anything, but you need to realize there is plenty that you have not decided to realize yet.

Just another of many problems with the current system of education. Yes, I did go there. Due to the variety of situations we find ourselves in, we can't tell people how to manage each and every one of them. Between situational awareness, and critical thinking we've just added another year of clinical rotations before we turn people loose on the public.

To a point perhaps. The fire board responds to public scrutiny just like any other government body. If there was enough interest from the providers and the public to do something about it, the situation would not be approved. With the description you've provided, I would have to believe that there was a public meeting at some point to discuss this action. It may have been buried on the agenda, but it was there.

Are you sure you were hearing air moving in the apices? It is not uncommon to mistake no air movement for clear sounds. Just as a thought, but the extra insulation the patient was carrying around may have made for poor sound transmission as well. Good possibility that there was a combination of pathologies going on. Going from tachycardic to asystole that quickly does not bode particularly well either. The last effort of a globally hypoxic heart to keep this patient upright may have been just enough to end things.

I'm actually more concerned with the "...and then some." part. What else does this doorknob think he is going to need? :shock:

The hypoxic myocardium does not respond favorably to "maximal" beta stimulation. Prior to arrest the body will secrete huge amounts of endogenous catecholamines in an attempt to support function. When this fails the ischemia that is already present worsens. The heart fails as a pump, and is unable to provide perfusion to itself. Increasing vasoconstriction without the beta effects would be closer to physiologic neutral. The brain receives perfusion from vasoconstriction in the periphery. This can be better accomplished in the MI scenario with vasopressin because you won't worsen the ischemia. The inotropic/chronotropic/dromotropic effects are not what you should want to elicit from myocardium that has already failed from maximal stimulation. Give the heart an opportunity to recover a bit prior to forcing a maximal effort from it. Epinephrine does not have any dopaminergic effects. That is an entirely different mechanism and does not belong here. Until vasopressin became available you had to increase the oxygen demand. At present, you don't absolutely have to unless you do not have a choice between the two agents in question. In the scenario you mention, why would you restore circulation to an obviously irritable system only to worsen it by forcing more work from it. With the short time frame you are suggesting, allowing the pump to come back on its own would be much preferred. Dopamine is not necessarily recommended for someone that can maintain perfusion, as this situation probably could. There is a big difference between unstable and need to treat. You would be able to support perfusion with fluid boluses for a while, as you are watching this patient's MAP.

Cardiac arrest following an acute MI for one. You wouldn't want to chemically induce a maximal effort from ischemic tissue when you don't have an adequate oxygen supply would you? You not only worsen the ischemia, but you also create the possibility of myocardial rupture through the ischemic tissue. Hypovolemic cardiac arrest for another. No fluid volume to pump, so do you really want to increase the amount of work the heart is doing without having anything to contract against? Never mind the fact that epinephrine is well known to cause "stone heart" syndrome. http://ajp.amjpathol.org/cgi/content/abstract/95/3/745

Bury it with a shovel, then bury the shovel.

Why should they? Since they are in Australia or other parts that are not in the bass-ackwards U.S. system, maybe we should try to emulate them rather than criticizing. Nice broad strokes you are painting with there. Did you bother to ocnsider that there are a number of situations that would not respond favorably to the strong beta effects that epinephrine will exert? The cookbook seems to be getting to easy to follow for people to actually think anymore.

Start documenting everything about this situation. Even the smallest of details. Log your shift times, the number of times you are rotated to another station, the number of "unsafe" transports you are required to do, everything. At some point you will have to decide if this is where you want to continue working, but your safety has to come before anything else, including the paycheck.

Work stays at work, home stays at home. Never the twain shall meet. I do not socialize with the people I work with outside of the three days/week that I'm with them. I discourage my family from trying to contact me at work outside of the unforseeable emergency that I absolutely need to know about before I get home. Maybe it is my OCD working, but I've always been able to separate incidents at work from home. I've made some great friends over the years, but very few of them even know where I live or what I do on my off time. That is how it will remain.

Just to satisfy you tniuqs. The "common" use of NTG prior to IV access is a good way to become complacent with doing something that carries a significant amount of risk. There are occasions when it happens, and it is reasonable to do so. Doing it as "routine", is fraught with problems. If you are thinking through a scenario, and the NTG comes first while someone else is establishing your line so be it. I just wouldn't make a habit of the practice. Grunting is a bit more active than pursed lips, in my experience. Typically if the patient is producing a grunt, they are trying very hard to prevent their distal bronchi/alveoli from collapsing. Pursed lips tend to not be quite as sick, and can be turned around fairly quickly. The description you give pushes me to think this patient was having a fluid problem rather than an obstructive one.

Our interpretation of your description is weak at best. Could the sounds that were being made due to laryngospasm? Is it possible the child was having stridor, just not moving enough air to make it sound like it? An intraosseous attempt is plenty to tell you that the patient is unconscious. If they don't withdraw from it, then they definitely need it.

This incident shouldn't really surprise anyone. The department followed the response procedures that were agreed to by the bordering districts, and one family is now without. The fire department is suddenly supposed to be willing to violate their protocol to protect a citizen that is not in their own district? What do you suppose would have happened to the crew that responded if they had started working the structure fire in front of them, and their own district would have needed them for something else? They would have been hung out to dry is what. Maybe this will allow for some new procedures to be put into action, but I doubt it.

Like I said, I hadn't heard of Arlington having issues, but I am a few thousand miles and a lack of real caring away from the situation at hand so I'm probably not giving it the attention I should. I get the feeling that somewhere, someone is sitting behind a large desk laughing about how they are going to prove that they don't need ALS to have an effective EMS system in an urban environment. :roll:

Dwayne makes some good points about being clear with your description of the situation. By "vocal sounds" are you describing grunting at the end of exhalation? A bit different, but important to a differential. The appearance of the patient is relatively important as well. What do they look like? Gray? Mottled? Cyanotic? Diaphoretic? Flushed? All of these add information to what you are dealing with, and can make narrowing the differential a bit easier. I will say that the respiratory component of the situation needs aggressive management, and a standard SVN treatment is not going to be very effective with this patient's inability to move much air on their own. Because you don't describe the patient history, this could be any number of things. Was this patient on Viagra for ED, or pulmonary HTN? That by itself would alter the direction of management. The single blood pressure you describe does not make a good case for CHF. A patient that can't breathe will have an elevated pressure as a response to the problem. CPAP is probably a good call, but more information would be appreciated.

DO NOT use the nebulizer with less than pure spirits. If you absolutely must, use high grade vodka. You will be significantly impaired before you get much in your system, and the hangover isn't quite as bad.

So you take an inadequate paramedic and turn them into a peeved EMT? How exactly is this going to improve the situation? The public will have fewer providers they need, and more they have no use for. Take the responsibility away from the D.C. area altogether. I've not heard of Arlington VA, or Baltimore having these kinds of problems.

I can appreciate the thought process, but there would be issues with administration of nitrous oxide for the situation you describe. Since it is self-administered, and will reduce the FiO2 in use, it would not be realistic to expect great changes in patient condition from using it. NTG works in a similar manner, but on the capacitance vessels to allow the reduction in preload you are looking for. The pulmonary vessels really don't have enough volume to make a big difference.

Carboxyhemoglobin (CO) and methemoglobinemia (H2O) are both causes of false high pulse oximetry readings. Why would you expect a beating for bringing another cause of the problem to light?

Gurney, airway bag, cardiac monitor for every call. IVs are done in the ambulance because most of our district's housing leaves a lot to be desired in the way of cleanliness. There are very few occasions that I feel comfortable standing in these scenes, much less initiating an invasive technique in one.

I can agree with the simplification of CPR, since it is intended to result in more people being willing to do "something" when it is needed. Previous incarnations tended to intimidate the lay public with detail where the current seems to encourage action. For ACLS, I HATE the way it is being taught now. No stress, no critical thinking, no knowledge of anything beyond the magical algorithm is utter garbage. This is an advanced course in name only. The target audience is healthcare professionals that are responsible for patients that just might need them to know something. This is not a time for kinder and gentler. I do agree with expecting the participants to come to class knowing the information. The instructors should only be expanding on what is readily available to them. Our job should be refining the content to help with the critical thinking. Instead, we are introducing the concepts.

Until there is more evidence to support their use, the LUCAS and the AutoPulse both get the class IIb recommendation. That is, might help won't hurt. They lump them both under the "mechanical CPR" title since they can't support one device over another.