AZCEP

If we can't get the seizure controlled, we need to look at RSI so we can provide some oxygen for the brain to use.

How long was she out of the country?

Rashes, petechia, purpura, skin discolorations?

The fact that she is taking quinine is kind of odd, isn't it?

Has she just returned from a trip overseas? Not much malaria in the U.S. is there?

If this was a strictly quinine OD, there should be some ECG abnormalities as well. Seems that would happen well before the blindness.

If you take an honest look at the curriculum, you will quickly find that it doesn't take much to turn out basic level providers. Most places the requirement is in the neighborhood of 100 hours. Usually, less than a full college semester. Heck, some even advertise, "In two weeks, we can make you an EMT!"

The next time these doorknobs bring up their pass rate, ask them how many of their students are still working EMS, and not for a fire department that will cover their mistakes with the fertilizer.

Wow! You get exposed to the bird flu, then you treat it with chicken soup? :shock:

You are a better man than I, Asys

Facial injury that can drain into the oropharynx might be a good reason to use a KED.

Don't want this guy to drown in his own blood, now do we.

As long as he can maintain his own airway, even with a little help from our friend Yankauer, he can go somewhere besides a trauma center.

Any odors of adult beverages? Can he answer your questions appropriately? Does he remember the incident, and the events preceding it?

Following the O2 admin as above, vascular access if possible, followed by the BZD of choice.

As much history as possible, BGL, list of meds/allergies/PMHx

Optic nerve compression wouldn't cause the lack of movement, but might account for the lack of vision, right?

The description of the onset of visual disturbance, going from the center of the field to the outside, made me think of a structural cause impinging the optic nerve.

Don't know why that got stuck in my head, but there it is.

Too late to go to Phoenix this year. Too hot already. And you'd have a very hard time convincing me any FD service rates up there as a shining example of excellence anyhow. Especially with the dip$hit chief they have.

Gee whiz Dust, how is 85 degrees at 4 pm too hot? Overnight lows of 50+, get here quick, but not bad at the moment. After a few sub-zero winters, it doesn't sound all that bad now does it.

As for the chief, the same could probably be said for any agency, anywhere. The folks in the streets are among the best I've ever worked near. Like I said, the medical director pushes his people very hard to be the best.

Facial droop?

Arm drift?

Slurred speech?

Doesn't quinine cause a vertical vision loss? Can she move her eyes through the four points when told to? Maybe Optic nerve impingement?

The problem as I see it is the matter of everyone wanting more space in the patient compartment, moving everything away from the provider. An individual's arms are only so long. Once they are properly restrained, the ability to access equipment/patient's is all but eliminated.

The restraining belt/harness system that Dust mentioned was tried for a while by some of the area departments, and it was a huge waste of effort. It was somewhat ad-libbed, so it wasn't destined for success to begin with. It was basically seat belt retractors mounted on the walls and ceiling of the patient compartment. Once you were tied into it, even the slightest movement would lock the retractor, and you would be held in place.

Currently, it is more likely to get yourself knocked in the head with the clasps, than it is to be restrained by it.

Good time to use your brain to think through the problem.

Vasopressin would probably not be too helpful, so it's out. The associated PEA will likely be slow, so Atropine would be considered, but Epi would be a better choice. The ventilations need a 1:2-3 inspiration/expiration time. Even timing the compressions/ventilations "might" be a reasonable thought.

In the most recent guidlines from AHA, there is a whole section on asthmatic cardiac arrest. Guess what, their recommendation is to prevent them from arresting in the first place. Who knew? Prevent the arrest, better survivability. :roll:

How about Denver or Kansas City? Both are fairly progressive, and have major airports. I'd also recommend Phoenix. The fire department runs the EMS so you would have to get past that whole situation, but their medical command is very aggressive with what they can do.

Sorry, didn't mean to get Dust started on that whole bit.

There was an article on the EMS Network a few months ago about this. The study was being done in Toronto. Look at PubMed or Medline. Google might even be able to find something.

Here is an article from Medscape that throws a different curve at the new AHA guidelines.

Cardiocerebral Resuscitation: A Newsmaker Interview With Gordon A. Ewy, MD

Laurie Barclay, MD

April 17, 2006 — Editor's Note: Cardiocerebral resuscitation (CCR) — employing chest compressions but no ventilations — improves survival of out-of-hospital cardiac arrest, according to the results of an observational study published by Michael J. Kellum, MD, and colleagues in the April issue of the American Journal of Medicine. Unlike traditional cardiopulmonary resuscitation (CPR), which was designed both for cardiac and respiratory arrest, CCR is designed only for unexpected, witnessed, cardiac arrest, which is by far more common than respiratory arrest as a cause of sudden collapse in adults.

Animal experiments showed that the most important factor determining survival after CPR is cardiac perfusion pressure, achieved by continuous chest compressions. Ventilations may actually be harmful because they interrupt chest compressions, decrease venous return to the heart, and increase intrathoracic pressure. When paramedics in Wisconsin employed the new CCR protocol, with chest compressions before and after defibrillation but no intubation or ventilations, they achieved a 300% increase in survival compared with use of traditional CPR.

To learn more about the clinical implications of this new protocol, Medscape's Laurie Barclay interviewed study coauthor Gordon A. Ewy, MD, director and pioneer of the CPR Research Group at the University of Arizona Sarver Heart Center in Tucson.

Medscape: What was the rationale behind the CCR protocol?

Dr. Ewy: The major rationale is that CPR hardly ever works. The survival of out-of-hospital cardiac arrest is dismal, averaging 1% to 3% nationwide. And in spite of periodic updates in guidelines, with the exception of early defibrillation, survival has not improved. Several experimental observations, when correlated, provide the rationale for a new approach to cardiac arrest, which we call CCR.

It is well known that in patients with cardiac arrest secondary to ventricular fibrillation (VF), early defibrillation is the most important intervention. This is why the defibrillation shock from an automated external defibrillator (AED), when promptly applied, has been shown to improve survival in selected locations such as casinos, airports, and the like.

But it turns out that this early "electrical phase" of VF arrest lasts for only about 5 minutes, and emergency medical personnel hardly ever arrive during this time frame. After this so-called electrical phase of VF cardiac arrest, the patient enters the hemodynamic or circulatory phase of VF arrest. And during this phase, applying an AED hardly ever resuscitates the patient.

During the circulatory phase of prolonged cardiac arrest due to VF, the factor critical to survival is the prompt restoration of cardiac and cerebral perfusion pressures by chest compressions. Restoration of blood flow might slowly reverse the adverse effects of cardiac arrest so that the individual will again respond to defibrillation.

Our interest in alternative approaches to the international guidelines began with the realization that most people who witness a cardiac arrest will not initiate bystander CPR because they do not want to do mouth-to-mouth resuscitation. Therefore, about 80% just call 911 and do not begin bystander CPR. By the time the paramedics arrive, it's too late.

So our original question was whether doing chest compressions alone on people who collapse is better than calling 911 and doing nothing until the paramedics arrive. Our swine studies in 1993 showed that during prolonged VF arrest, chest compressions alone are just as good as ideal, standard CPR when we took 4 seconds for the 2 recommended ventilations before each 15 chest compressions, and much better than no bystander CPR. Since 1993 we've been saying that we should encourage the lay public to do chest compressions–alone CPR on adults with witnessed, unexpected collapse. Between 1993 and 1998, we published 6 different swine studies, including one study with the endotracheal tube clamped, all showing that chest-compression alone was equal to ideal standard CPR, and dramatically better than doing nothing.

After the 2000 guidelines came out, Dr. Karl Kern, who is part of our University of Arizona Sarver Heart Center CPR research team, participated in a study with Dr. Chamberlain and colleagues from England to determine how to get lay people to remember and correctly perform CPR after they've been trained. As part of this study, they did videos on certified lay people doing rescue CPR, which showed that after they did 15 chest compressions, it took an average of 16 seconds for them to lift the chin, close the nose, take a breath, make a mouth-to-mouth seal, blow and watch the chest expand, repeat rescue breathing for a second breath and return to chest compressions. So they were pressing on the chest for only half the time that they were doing CPR.

In a subsequent swine CPR study published in 2003, we showed that when chest compressions are interrupted for 16 seconds between each 15 chest compressions, 24-hour survival after CPR was only 13% compared to an average of 70% in our swine given continuous chest-compression CPR. This is one reason why we have advocated and continue to advocate chest compression–only bystander "CPR" for witnessed sudden collapse in an adult.

The next observation was published by our colleague Dr. Valenzuela. When paramedics perform CPR following the 2000 guidelines, they spend only half the time on chest compressions because of the time they spend on other guideline-advocated activities, including intubation and ventilation. We therefore concluded that the recommended alternating chest compressions with breathing should be revised to improve coronary perfusion.

The next observation was that in Tucson, the emergency medical personnel arrived at an average of 7 and a half minutes [after collapse] — not in the electrical phase of VF arrest, but in the circulatory phase. Thus, following the guidelines which advocated immediate defibrillation and 3 series of defibrillation was deleterious, as chest compressions were interrupted for inordinate periods of time while the AED analyzed, shocked, and analyzed.

Because of these and other observations, we concluded that there is a better way to do resuscitation than the standard CPR advocated for the last 40 years. We called the new method cardiocerebral resuscitation, or CCR, to emphasize the importance of saving the brain.

Medscape: What were the findings of your recently published study in humans?

Dr. Ewy: We taught Dr. Mike Kellum and associates in Wisconsin the new method of CCR. When they implemented it, the paramedics would comment that they were having "saves" that they would never have had before. When Dr. Kellum and associates looked at the data, they found that neurologically normal survival improved from 15% with standard 2000 guidelines CPR to 48% with CCR. This 300% increase in survival in this study is almost too good to believe, but there is no doubt in our minds that CCR is definitely better than CPR.

Medscape: How does this protocol differ from standard CPR?

Dr. Ewy: One of the reasons that the CCR protocol is better than the standard CPR protocol is because it recognizes the 3-phase, time-sensitive model of VF articulated by Drs. Weisfeldt and Becker. The most important intervention in the first 5 minutes is defibrillation, which is why implanted cardioverter defibrillators and AEDs are effective. After the first 5 minutes, the fibrillating heart continues to use up its energy stores, becomes weaker, and cannot generate a perfusion pressure even if defibrillated. Studies in humans by Dr. Cobb and associates from Seattle, and Dr. Wik and associates from Norway showed that if one does chest compressions for 90 seconds to 3 minutes before defibrillation, survival is better.

Therefore, rather than immediate defibrillation, the CCR protocol incorporates 200 compressions at 100/minute before defibrillation. Equally important, it also incorporates 200 chest compressions immediately after the defibrillation, prior to rhythm analysis and pulse check. The reason for this is that in our experimental laboratory, after prolonged chest compressions for VF arrest, the shock almost always defibrillates, but defibrillates the rhythm to pulseless electrical activity and not to a perfusing rhythm. In our experimental laboratory, we are looking at the pressure waves, so we immediately restart chest compressions to perfuse the heart, and the cardiac-generated blood pressure gradually returns.

The most controversial aspect of CCR is the elimination of active positive pressure ventilations. We first delayed or eliminated intubation by the paramedics.This is a hard sell to paramedics. But this eliminated one intervention that resulted in a prolonged interruption of chest compressions.

But why not let the paramedics or emergency medical service personnel ventilate with bag-valve-mask ventilation? The rationale for our approach of placing an oropharyngeal airway, a nonrebreather mask, and high-flow oxygen without positive pressure is as follows. With normal breathing, intrathoracic pressure decreases, but positive pressure ventilating increases intrathoracic pressure and thereby decreases venous return. The result is decreased cerebral and myocardial perfusion. Thus, chest compression without ventilation results in better myocardial and cerebral perfusion pressures and increases survival.

Another important factor is that we and others have shown that physicians and paramedics are so excited during a cardiac arrest that they overventilate — an average of 37 ventilations/minute. It is very difficult to get these individuals to ventilate less, unless you do not have them ventilate at all.

Another observation that taught us the importance of cerebral perfusion was listening to a recording of a lay rescuer in Seattle doing dispatch-directed CPR. After a while, the woman returned to the phone and asked, "Why is it that every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Out of the mouths of babes! That woman learned in 10 minutes what it took us 10 years to find out. Whenever you stop chest compression to do anything, including breathing, it is bad for the brain as it reduces blood flow to the brain.

The question that I am most often asked is what happens to the blood oxygenation? My answer is that if one does adequate continuous chest compressions, the individual often gasps and this agonal type breating provides reasonable oxygenation. In the absence of gasping, the blood gases are very bad — but guess what, the individual survives. Thus, the medical and paramedical obsession with blood gases and thus ventilation, and not looking at neurologically normal survival as the most important end point, has been one of the major impediments to progress in resuscitation science.

Medscape: Why doesn't CPR work well?

Dr. Ewy: The fallacy of CPR is that it was designed for 2 totally different pathophysiological situations: respiratory arrest and cardiovascular arrest. What is beneficial for one may not be for the other. The reason for a single approach is that it was, and to many still is, thought that the lay public cannot tell the difference between a respiratory arrest and a cardiac arrest. I think they can.

If you pull someone out of a swimming pool, or if they stop breathing after a drug overdose, that's a respiratory arrest. But an unexpected, witnessed collapse in an adult is almost always cardiac arrest. The most important intervention for cardiac arrest is continuous chest compressions to perfuse the brain, to keep the brain and heart alive until you can shock it. If one can use the AED in the first 5 minutes, that's fine, but there are 2 major problems: the first is that the paramedics usually do not arrive in the electrical phase of VF, and the second is that the lay public does not use the AED. In Arizona, over 2,500 AEDs are registered, and we have knowledge of only 10 being used by the lay public.

Medscape: Are there situations in which the CCR protocol should not be used?

Dr. Ewy: For respiratory arrest, you need to breathe for the person. The new CPR guidelines should be followed: 2 breaths alternating with 30 compressions. But the major problem is that most lay people won't do mouth-to-mouth, so they just call 911, and by the time the paramedics get there, the person is dead.

Medscape: Are there any negative effects of CCR?

Dr. Ewy: Not that I know of, if it is used on adult subjects with witnessed, unexpected collapse.

Medscape: What additional research, education, and training needs to be done before this protocol is widely adopted?

Dr. Ewy: I think CCR should be widely adopted right now for unexpected, witnessed collapse in adults. In fact, I think it should have been adopted in 2003, when we did.

As for teaching, we should emphasize that CPR should be reserved for respiratory arrest. But for witnessed, unexpected collapse in an adult, we teach laypeople a 3-step protocol: first, call 911; second, start chest compression–only CCR. If another person is available, each do 100 compressions and trade off, as continuous chest compressions is hard work. Third, if there is an AED around, put it on and follow the directions. I think this approach should markedly increase the prevalence of bystander CPR, and bystander CPR significantly improves the chance of survival.

For paramedics, I think we need to do more research to determine when assisted ventilation is absolutely necessary. We are doing such studies now.

Medscape: If the protocol is widely implemented, what effect do you believe it will have on public health?

Dr. Ewy: The most common cause of death in the United States, Canada, and Europe is sudden cardiac arrest. CCR is significantly better than CPR, and if it's widely adopted, it will have a significant positive effect on public health. We now have data in humans to support what we've found in our animal experiments. Our recently published observations in humans showed a 300% improvement in neurologically normal survival in patients with witnessed out-of-hospital cardiac arrest and a shockable rhythm when the paramedics arrived. This study is almost too good to believe, but if we can improve survival even by 10%, there will be a huge benefit worldwide. I know if we follow these CCR guidelines, survival is going to be a lot better than it has been for the last 40 years.

Am J Med. 2006;119:335-340

Reviewed by Gary D. Vogin, MD

So, just when you think you understand the most recent change, along comes another set of guidelines.

The state of AZ has made this an alternative protocol for cardiac arrest. Yes, we are allowed to perform this standard already.

Haven't really noticed any huge difference in ROSC from using it yet, but it is still new.

I must say that the waveform capnograph is a good tool. Unfortunately, too many providers have been told that it will only help with the intubated patient. There seems to be a huge misunderstanding about the utility of the device.

We've recently adopted a policy where the providers print a strip before and after any time they move the patient. We have also tried to encourage eliminating movement as much as possible. Intubate after placing the patient on the gurney, instead of on the floor. Place a cervical collar and C.I.D. once the tube is in place, a tube tamer is only as good as the surface it is secured to.

With help from our medical director, we are reviewing every incident that results in a patient being intubated. We've been issued a standardized form, that covers sedated/RSI'd patients. It will work for all intubations, you just leave the medications used sections blank.

It will take a while to get everyone on the same page, but taken one step at a time, eventually we will reduce the problems.

I do wish that the ER staff was subject to the same type of reviews. I'm sure we could hear the screaming from the ER doc's if they had to answer to anesthesiology.

Yes, this is an American problem.

The 24 hour schedule is good for the smaller departments that don't run many calls. Once you hit, 10-15 calls per unit, the utility of the 24 hour day is seriously compromised. Most metro areas use a combination 8-10-12 hour schedule. These allow for more staffing during the "peak" hours. This could very well be the only good thing about system status management.

With the 24 hour routine, you tend to get more days off, but at the same time, you will spend more time recovering.

If you yelled for 8 years, 7 months and 6 days you would have produced enough sound energy to heat one cup of coffee.

(Hardly seems worth it.)

If you farted consistently for 6 years and 9 months, enough gas is produced to create the energy of an atomic bomb.

(Now that's more like it!)

The human heart creates enough pressure when it pumps out to the body to squirt blood 30 feet.

(O.M.G.!)

A pig's orgasm lasts 30 minutes.

(In my next life, I want to be a pig.)

A cockroach will live nine days without its head before it starves to death. (Creepy.)

(I'm still not over the pig.)

Banging your head against a wall uses 150 calories a hour

(Don't try this at home,maybe at work)

The male praying mantis cannot copulate while its head is attached to its body. The female initiates sex by ripping the male's head off.

("Honey, I'm home. What the....?!")

The flea can jump 350 times its body length. It's like a human jumping the length of a football field.

(30 minutes..lucky pig! Can you imagine?)

The catfish has over 27,000 taste buds.

(What could be so tasty on the bottom of a pond?)

Some lions mate over 50 times a day.

(I still want to be a pig in my next life...quality over quantity)

Butterflies taste with their feet.

(Something I always wanted to know.)

The strongest muscle in the body is the tongue.

(Hmmmmmm......)

Right-handed people live, on average, nine years longer than left-handed people.

(If you're ambidextrous, do you split the difference?)

Elephants are the only animals that cannot jump.

(okay, so that would be a good thing)

A cat's urine glows under a black light. !

(I wonder who was paid to figure that out?)

An ostrich's eye is bigger than its brain.

(I know some people like that.)

Starfish have no brains

(I know some people like that too.)

Polar bears are left-handed.

(If they switch, they'll live a lot longer)

Humans and dolphins are the only species that have sex for pleasure.

(What about that pig??)

To get reliable information, you will probably have to talk to people in the area. Try community colleges and the EMS providers nearby. You could also check with the state EMS office for upcoming classes.

Most intermediate programs will take roughly 600-800 hours of your time, then add the paramedic component for another 300-400 hours a few months later.

Nursing and prehospital care are significantly different from each other. The fact that you have had some EMS training already will make it a bit smoother for you. Most of the prehospital RN's that I am aware of, work critical care transports or on flight. In the flight situation, the RN is mainly concerned with medication administration, while the medic partner is doing the technical skills.

Nursing schools just don't teach people how to use the same tools that medics deal with. On the plus side, most of these same devices don't get used all that often anyway. Traction splints, KED, MAST suits, etc. These short comings can be handled by good interactions with other EMT's/medics on scenes, so you shouldn't have much problem with the transition.

You said it yourself Techmedic, EMS doesn't get ROSC very often. This alone would make it more reasonable to not transport the corpse. If you don't get a response, and that can be as little as organized electrical activity, There is no good reason to initiate transport.

ACEP even published a position statement in this regard. 20 minutes, with a secured airway, vascular access, and good BLS being performed is reason enough to consider termination of efforts. Most can, and more should be able to determine when a code is going to respond, and when it won't. Or at least, have the idea that, just maybe it will be futile to start.

I've got to think that even transporting a pulseless patient is a waste of time. Picking up a dead body, placing it into a vehicle, driving across town, and delivering said dead body to the hospital seems like a complete waste of resources.

I work 40 minutes from the nearest facility, and I refuse to beat on a corpse that long. I am willing to give them 20 minutes on scene, and decide from there. If we don't get a response to what we are doing, call them on scene. If we do, load them up and transport.

Good ACLS/BLS will do as much for a patient as an ER packed with doctors.

How old is the group? Are there youth programs in the area, like Explorers?

I guess it would come down to how honest you think you need to be. If you want to show the professional side, dress the part. Throw a fresh shine on the boots, get the uniform dry cleaned and pressed, basically make yourself look like a recruiting poster. Or, walk in with the puke/blood/gray matter still in the tread of your boots, bloody mess all over the shirt, hair uncombed, sunglasses in the auditorium.

Obviously the motivation will determine which direction to take this. If you are trying to recruit, look good. If you don't think any of these kids would be able to handle the workload, lay it on thick.

Providing a professional level of education to providers, while departments only want to shorten the time that their employees are in class.

As others have already said, too many get into EMS to drive fast, and make noise while they are doing it. This mindset has to be eliminated, and quickly.

We will complain to anyone who will listen, how we want to be treated like professionals, but if we don't act like one, it won't happen.

Let me add one to your list.

Absolutely, under no circumstances will the following be acceptable:

-->Failing a standardized test of any kind (NREMT, Nursing boards, etc.), then consoling yourself by telling others that you failed by "one question."

-->Unless the total number of questions makes it a mathematical certainty that you will fail by missing the proverbial "one question", you missed a lot of questions, not just "one".

-->Maybe if you would consider studying a bit more, rather than complaining about missing out on the "Girls Gone Wild" photo opportunity, you would have passed.

A bit on the garish side, but I've always liked the AZ patch.