AZCEP

PVCS? PVC's are Premature Ventricular Contractions, but I don't think it was meant that way...

PVC's are more correctly Premature Ventricular Complexes. They become contractions when you feel a generated pulse by one that appears on the monitor. If you don't have a monitor, you won't feel the complex but will notice that the pause before the next beat is longer than you would anticipate. If you feel a pulse(a contraction) early you really can't say if it is atrial, junctional, or ventricular in origin.

Just semantics, but can be important.

Nasotracheal intubation is faster, and easier-with the right tools-, than most any other airway technique out there. Yes, RSI makes things OPTIMAL, but so many systems don't have it that the nasal route is all that is left. Even with a sedated patient, oftentimes they won't be down enough to allow for an oral attempt. When this happens they get a hose in the nose.

The "hurricane" spray is right handy, but not required. Some use the viscous lidocaine, but more for the lubrication than the anesthetic effect.

I will mention two things, 1)Use an Endotrol tube. The guidewire that is built into it makes things so much easier for you. 2)Invest in the BAAM whistle. This little device makes the breath sounds audible over most anything. There have even been cases where I have suspected a pneumo- by listening to the different sounds of the whistle.

If anyone is managing an airway, it is always preferrable to have more options that you know how to use, than to be limited to a couple that you aren't sure of.

The needle starts jumping when the cuff pressure is at, or below, the arterial pressure. You won't hear the pulse until the cuff is well below the arterial pressure. Use the needle bounce to give you an idea of when you should listen a bit closer. The pulse should start pounding in your ears relatively quickly after the needle moves.

Anyone that is doing an assessment is performing risk stratification, although to a lesser extent.

The 12 lead ECG and knowledge of the TIMI score are the most common tools that I use. The patient's history/medications also come into play, but again that is part of the initial assessment. I would rather "over-triage" someone to a PCI facility that isn't having the big one, than the other way around.

Keep the cardiologists in business.

It all depends on the receiving facility's ability to believe what the prehospital folks are telling them. Then of course, they have to relay the information to the cath lab in a way that information isn't lost.

To take the lazy bashing one step further:

-When a call is received in the middle of the night, and you aren't sure who should respond, DO NOT waddle into the hallway in your skivvies, scratch your head and ask me who is taking the call! I had to get up too, and I was able to get my clothes on! :evil:

-When new paramedics arrive from other areas of the country, and ask me to bail them out of the mistakes they are making. Flight crews in my area are notorious for this. They arrive on scene, don't want to listen to what I have to tell them, make a clearly wrong patient management decision, are then unable to carry out this decision, then want me to fix it for them. Uh, HELLO! If you had taken the time to listen to me in the first place, you wouldn't need my help now, jackass!

-The current educational standards are a joke. When you get done with your class, you will be a paramedic also. You should not have to ask me how a piece of your equipment works. Don't ask how you are supposed to perform a needle decompression, surgical cric, central line, sternal IO, nasal intubation, etc. You were taught this stuff in class the same way I was, or at least you should have been. If you are asking me how to do these procedures on a patient that needs them done in a time sensitive manner, you won't be the one doing them, I WILL!

I think I need to change my name.

One hippy bus overdose, one backstage party overdose, throw in a crucifixion, and several extremely violent ends.

I think I will skip the party, thanks.

Even one of my previous lives apparently was involved with helping carry those that needed it across a river. Then I slip and fall into the water, contract pneumonia and die from it.

I think I need some Tylenol. :wink: Someone better watch me. I might down the whole bottle without thinking about it. :shock:

Contact dispatch, make sure more ALS units are enroute, advise them to respond a supervisor.

Initiate triage, with the eight patients that are not in a burning fire truck. I am not a fire fighter, and will not put myself in danger to try to rescue someone.

Neo-Synephrine? Wow. That's one I haven't seen in quite awhile. What is it generally used for, spinal shock?

Also use it before nasal intubation or NG tube placement.

Tenecteplase is TNK, not tPA.

Bretylium is still on the state of AZ's drug list, but it is pretty hard to come by.

Might want to add Calcium Gluconate.

Could this be a case of not providing the optimal care in order to follow an outdated protocol?

Some patients need to have their spinal movement restricted, some don't. I feel pretty certain that most of us have been in either of the two categories at some point. The knee-jerk response of immobilizing everything is ridiculous, don't you think. A recent study in Canada showed that prehospital providers could accurately apply the NEXUS criteria to determine which patients needed to be strapped to a board, and which didn't.

For fun have yourself strapped to an LSB for a while, and see how you like it. Anything over 20 minutes without padding properly will begin to cause pressure ulcers.

I am not too worried about this problem. I just found out they are developing a trial program : "super EMT/I " (ETT. IV, Narcan, HHN nebulizer tx, epi; SQ) in my state to allow them to administer meds.... now this is supposed to be fill in at large metro' FD in lieu of Paramedics. Hmmm .... because they can administer med's until the EMS unit arrives?.... sounds fishy & looks fishy to me, especially it is endorsed by the Ambulance Operators. (Can we say cheap labor on the rise?)

This is actually very similar to the way that the EMT-I 99 has been put into use. Many places, Arizona included use this as a step between EMT and Paramedic, but then legislate it so the step from I to P is a full paramedic course. The only difference in the levels of care is the central vascular access, but the so called "Qualified IEMT" is still a lower level of care.

Where this becomes an issue is with staffing and with other providers. It is very common for the QIEMT to come on scene and think that they are educated to the same level as the paramedics that are already there. Administrators use them as substitutes for paramedics when no one else wants to work, and they can do it for less than a medic will cost.

I will now repeat the mantra that I have heard for so long, "Eliminate the Intermediate, and strengthen the Paramedics!"

APLS tends to be directed toward doctors, almost at the exclusion of anyone else. It is also pretty difficult to locate a course. Very few places are able to put the program on, and with the standards changing, the course dates keep getting postponed. Or maybe this is just happening to the courses I have tried to attend.

This has been discussed before, but to revisit the opinions is always entertaining.

PEPP and PALS were both developed by the American Academy of Pediatrics. PEPP was set up to better discuss the subjects that prehospital providers run into more often. Things like spinal immobilization, dealing with a possible SIDS case, tips for rapid cardiopulmonary assessment, and the limited treatment options.

PALS includes these topics in an optional addition to the course. It is up to the course coordinator/director to decide if the subject matter will be covered or not. PALS also goes into greater depth of treatment options that are available in the hospital setting.

When you take the course, regardless of which one, the information should be fairly consistent across the board. The biggest difference that I have seen is the style of presentation by the different instructors. PEPP instructors tend to be paramedics, PALS instructors tend to be nurses or doctors, on occasion. This slight difference often slants the presentation towards one audience or another.

In summary, PEPP is PALS in the street.

Quote:

I thought the idea of medics taking ACLS and practing ACLS was so you could bring ACLS to the patient. There is no reason that an arrest should be run any differently in the field that in the ED.

It is and it shouldn't

Now surely you aren't wanting to say that the way codes are run in an ED are the standard to be aspired to. I absolutely hate working codes in an ED. Too many people in the rooms, not enough people working on the patient is the situation that I am familiar with. I can only hope yours is different.

If the rhythm is bradycardic, why would you not try pacing? I'm reasonably certain that your protocols have pacing for symptomatic bradycardia, right?

Where I am, if the patient has been down >15 minutes(including unknown downtime), has asystole in more than one lead, and/or does not respond to 20 minutes of treatment, I call the ER for the okay to terminate resuscitation. With a transport time on the far side of 40 minutes, I'm not going to be abusing a corpse for the benefit of medical students that want to do procedures. As for the family, I have made it a habit to call everyone into the room that wants to be there when I announce that their family member is dead.

The way that I understand the process of lethal injection, an IV is started, the medications are connected to the IV tubing from inside a secured container, and the executioner pushes a button to start the sequence of drugs.

Considering the number of times that we have pushed a medication, up close and personal, only to watch a bad response to it, the most dramatic thing about this process is the starting of the IV(s).

Here, Here Dust!

Much like any of the technology that has hit the streets in the last few years, those that can afford it need it the least, and those that can't need it the most.

ALS providers, by themselves, take a big piece of the budget for the rural providers. Then we discuss adding more tools without discussing how to fund the acquisition of them. The technology that is becoming available is interesting in concept, but the actual application of it can be troublesome to the small departments/agencies.

It sounds like you have missed the point of RSI. The idea is to optimize the situation so that the intubation will proceed quickly and easily with less stimulation to the patient than just sedating the patient can accomplish. To use a sedative(etomidate, versed, fentanyl, valium, etc.) only works if the patient is depressed enough to push them over the edge. Often the patient will do things as a reaction to the sedation agent that the paralytic will keep from happening.

If you are going to do RSI, then do it correctly. Other than saving a few dollars by not using the paralytic, you aren't helping anyone by not using them.

Since the use of LR by itself requires larger volumes to acheive fluid resuscitation, can we then assume the use of Saline would cause the same dysfunction of the endothelium. It seems that using non-oxygen carrying substances is on it's way out of the mainstream of clinical practice anyway. But until the technology trickles down, it is all we have.

Currently, the biggest problem in my agency is the limited volume of patients. On a busy day we may transport 5-7 patients, on most 1-2. The most common types of calls are drug/ETOH related, and there are very few things that we would be able to control for.

Our medical director has assigned a couple of the residents to review data from the last two years in reference to intubation proficiency, so maybe there is some light at the end of the tunnel.

It seems that too many people like the current state of trauma management to look at it very carefully. Trauma is supposed to be the simple mechanism to treat. "Have a hole, plug it. Need a hole, make it." When we start injecting physiology and actual biological science into the mix, too many people tune us out.

That said, changes need to be made. One of the few good things to come out of an active conflict like in Iraq, is the military comes up with some pretty good ideas on how to manage a specific type of patient. Since there probably aren't many COPD/AMI patients being managed, trauma is what they get good at.

Prehospital Emergency Care and the American College of Cardiology journal have found permanent places in my collection. The excerpts in JEMS and EMS don't begin to cover the changes that are happening. I've found that JEMS/EMS are good for learning about new equipment/technology that applies to EMS, but the patient care issues are usually rehashed versions from the textbooks.

If these terms are the biggest problems facing this profession, then we are in real trouble.

For the most part, when I hear them, I use it as an oppurtunity to explain what all EMS providers are capable of in a time condensed form. I've found that most people appreciate someone explaining what resources are available to them should they need them.

In the late '80s/early '90s paramedics in AZ were allowed to perform tube thoracostomy using the McSwain dart. Picture a lawn dart with a shorter tip and you've got it. Several were done, and it was discovered that a pumped up individual could use the dart to secure a patient to an LSB. Yes, I am serious. Back to the 2" 14ga for you.

For pericardiocentesis, it was removed from the scope of practice at about the same time because when the state did a survey on how many had been performed, there weren't enough to justify having it.