AZCEP

If you have to ask your medical control if you can perform a procedure to secure an airway, there might be bigger problems than how you go about doing it. Here it is a protocol item. Our medical control would prefer them to the surgical cricothyrotomy, but it does take a bit longer to perform.

Retrograde intubation is not all that difficult to perform, but you don't need it very often. Most providers are capable of securing a surgical airway if needed. If they can't, then the retrograde option is a pretty good one.

The idea is more to provide a point of care view of the patient and allow the progression to be viewed. Instead of explaining a mechanism of injury, you can show a picture of it. Instead of describing the injury, you have a picture.

Like I said before, the remote agencies that use Tuscon Medical Center as their medical control are using this to help in triaging which patients need an hour plus flight to Tuscon, or can be adequately managed in a local setting. Yes a little more education would help, but the technology should be considered helpful in some cases.

I agree Rid. The FOUR point score was much more detailed, and made better clinical sense of what was happening. I don't remember reading any studies that indicated rates of morbidity/mortality from what the FOUR point score determined, but then I didn't really look either.

The system in Tuscon is directed more to the outlying agencies that use Tuscon Medical Center for medical control. I can see this as a definite benefit if, and it is a big one, the medical control physicians don't restrict providers from doing their job until they are in the back of the ambulance, where they can be monitored.

At the same time, "lipstick" cameras are available that can be pinned to a uniform that would allow constant, real time viewing of what is happening.

The biggest hurdle is the cost. If you can't convince an administrator that you need less expensive equipment, like KED's or 12 lead cardiac monitors, how in blue blazes are you going to talk them into spending five to six figures for this?

A couple of things

First, the brand/type of blood glucose monitor that you use can alter the validity of the test result. How often is it calibrated, and by who? By calibrated, I don't mean the quality control checks. I mean the actually taking the device out of service, and going through it to make sure that it's programming has not lost accuracy.

Second, depending on the manufacturer of your monitor, what type of test strips are you using? Some devices are capable of testing capillary, mixed venous, or both. It should be indicated on the bottle of your test strips. For the Accu-check brand that we use, the capillary blood strips are in a red bottle, and the mixed venous are in a blue one. Check into this.

Also, regardless of the above, there is a pretty wide variability in how reliable each finger stick/blood sample will be. The conditions under which the sample is gathered can cause changes to the value. How clean was the site? Was there any contaminant on the strip? Was there a full moon? All fairly small alterations, but enough to alter the accuracy.

A finger stick glucose level is only a ball-park number anyway. Don't allow your treatment to suffer because of one number. If your patient looks hypoglycemic, they probably are. The worst thing you can do to a symptomatic patient is withhold some sugar because you got a normal reading on your monitor.

Geez, with all of the education, I figured someone would include Level of Consciousness.

All the numbers in the world don't do you any good if you don't know what an individual patient looks like normally. SpO2 and BGL are great for documentation, but if you are unable to assess how the patient is "abnormal" the gathered information is going to be lost on you.

We have all seen this situation. Blood pressure is down because of too large a cuff being used. Altered heart rates because of psychogenic reasons. Increased respiratory rates for the same. "Normal" blood glucose levels and the patient looks hypoglycemic. Low SpO2 because the extremity is cold or the ambulance is bouncing down the road.

If your assessment determines that something is wrong, then the numbers should back this up. If not, wait a few minutes, and they will.

Dust,

I thought I did this with my last entry, if not then delete away.

They a comfortable in the knowledge that someone else is doing the work for them.

Take advantage of it by removing an item that they might need, and that they won't find if they don't check their unit. The next day when you do your check, ask if anyone found said item, because you can't find it.

Educated to a level of proficiency, trained to a degree of competency, individually acting.

Directed by physicians based on direct and indirect communication. Equipped with enough technology to allow for a cursory physical examination in the absence of direct physician supervision.

Up to 1500 clock hours of education in the U.S., significantly more in other parts of the industrialized world, for the highest levels available. Multiple classifications exist, in progression to the highest, first responder, basic emergency medical technician, intermediate emergency medical technician, and paramedic.

The descriptions are slightly different based on the jurisdiction represented, but most will have similar capabilities.

There is no consensus to determine what is the best system arrangement, though many exist. Many areas are served by volunteer organizations, responding from other activities of the members daily lives. Another significant number are a division of area fire departments, and these are usually cross-trained to serve fire suppression functions as well. Some areas have private companies providing service, and some will have a mix of all of these.

Is that more what you had in mind, Dust?

I don't want to but here it comes, Rid and Dust are correct...AGAIN.

The providers that are currently entering the field have had much of their pseudo-education given to them. This got them through school, then sets them to think that the rest of their careers will be given to them as well. Maybe it is just a generational thing, but many of the younger students I have run into seem to feel they are entitled to get whatever they ask for.

The education system has to get more strict in holding to the standards that are set. The students have to realize that while they are paying for their courses, they do not automatically get a certification/license out of sitting in class playing grab a$$.

No blood draws, the hospital labs wouldn't use the sample we provided them, so we stopped on our own.

IV's have to be restarted within 24 hours, hospital starts are restarted after 72 hours.

Two IV's is one thing, aggressively replacing fluid until the blood comes out looking like Kool-Aid, is something else entirely.

Definitely ask the question so that you can learn from those that will be supervising the care provided.

Two things:

1: Lights and sirens get old quickly

2: We don't see "blood and guts" all that often

AZ has a strange setup in my opinion.

For all initial certifications, NREMT is required as a standardized test. If you come in from outside the state with NR, you have to take a 48 hour refresher course. If you complete an AZ program, you have to take the NR test before they will certify you.

Once you are certified by the state, you can let your NR lapse without losing your certification level. As long as you keep your state card current, you are okay to work.

Another way to spend some money, but if it will increase survivability even marginally, it would be worth having.

The difficulty in changing the system is not simply a matter of making more noise about how it needs changed. Even with the latest revision to the National Scope of Practice, it was pretty obvious that legislators are unwilling to increase requirements at the expense of those that think they are adequately trained.

Most are still holding to the idea that an intermediate is adequate to provide ALS more affordably than full paramedic service. So, reduce the requirement, you get EMT-I instead of EMT-P. Education isn't as expensive, it doesn't take as long to get through class, and the reduction in care won't be readily apparent.

Now, let's say, this EMT-I decides to move to another state, or even a different part of their current state. They can't find a job that allows them to practice. The new location's medical direction doesn't recognize the intermediate level. What are they to do? They usually are given the option of dropping to the basic level or taking a full paramedic course.

Either way more money is lost. Drop to basic, accept the fact that the intermediate course you took was a waste of time/money, and take a lower paying position. Advance to paramedic, accept the fact that the intermediate level was a waste of time/money when you first took it, lay out more cash to get through class, find a paramedic level position somewhere, and not come close to recouping the lost revenue.

Not such a simple thing to fix, now is it. The fix definitely needs to happen, but until you can get more lawmakers to agree that standards need to be the same for everyone, it will never happen as it needs to.

I'll agree with Techmedic. No Sux because of the hyper-K+, and maintain renal function with fluid boluses. Probably a good idea to place a foley and monitor urine output as well.

Any indication of liver failure? Another item that would be useful to keep an eye on.

What does the ECG look like? If there is any widening of the QRS's, we would need to start thinking about treating the K+ level. Depending on the degree of acidosis, it might be reasonable to use some bicarb.

Have to get these deck chairs arranged just so.

Secure an airway. First and foremost. Bilateral IV's with enough fluid to maintain perfusion. Since we have all the toys here at Land of Oz EMS, I want a Chem panel including BGL, CBC, ABG with and without O2, CXR, and while we're at it a tox screen. It would probably also be a good idea to find out how well his liver is working.

That should keep the lab busy a while.

Serotonin syndrome?

The more critical the situation, the less likely I am to do a lot of talking to family. I will tell them just enough so they know what is going on, and what I am going to do, but I won't leave them with a warm, fuzzy feeling about it.

Ratcheting biceps tendon?

Oculogyric crisis? dystonic contractures?

25 mg Benadryl coming up.

We had an "Easy" button, but it died a tragic death of overuse. Some people just want everything easy.

The precise problem is the MINIMUM standard is too low.

If you want any other profession to provide you a service, you can rest assured that their minimums are high enough to enable them to handle a problem without inconveniencing you.

If you want someone to take your life in their hands, you don't have that assurance.

And for the record, when I took the NREMT exam, I did think that it was ridiculously easy. I had no idea that a high school or college level of reading comprehension would not be needed. For that matter, if you know how to take a standardized test, and have any idea how the body works, you can pass the NREMT exam. The requirement of attending so many class hours to qualify, only makes it appear that you need it to pass the test.

Another product of the system.

When defending the educational system for EMS providers, we all need to keep in mind that the "system" was developed to create more, not better, providers. If you send enough people through a program eventually you will have some excellent and some not so excellent individuals. The current method is only adequate to prepare you for an entrance exam. Yes, the NREMT test is that, an entrance exam. There is a reason why you will learn more in the first six weeks of field practice, than you will in a year long class.

Even if you do come out of a program with a state of the art education, when you take the NR exam, you don't need to know more than 70% of the material. Consider in each individual section of the exam, you don't need to score more than 65% on any given subject.

Airway--63%

Cardiology--61%

Trauma--63%

Medical--60%

OB/Peds--60%

EMS Operations--No minimum requirement

How can we honestly say that the NR exam is useful, when Airway management is given such a low priority. EMS was designed around managing trauma patients, but we only are required to know 63% of the material. Yes, I realize that by scoring the minimum in each category you can't pass the overall. My question would be, how comfortable would you be to know that the provider that is treating you was unable to score higher than 70% overall on an entrance test.

The end point of education can not be guided by this exam. Good starting place, horrendously low requirement for passing.

In a related story:

An Omaha nursing home reported that one of their Alzheimer's ward residents had spent several hours outside the home unsupervised and returned unharmed.

Film at 11 :shock: