HarryM

There's probably a 90% chance it's the same as you....unless you live in Wellington

Sorry. Never even heard of it. We use LP 12's and Philips MRx's with helicopters having LP 15's.

Have seen first hand paramedics who are horrible at pain management or have gotten jaded and because they don't think the patient is in as much pain based on previous patients (or some other reasoning), they won't give enough pain relief, or any at all. I'm only an EMT and currently completing my degree so I can become a paramedic and we are taught to have a very low threshold for pain relief, and to follow the pain ladder. So start with the lowest strength drug and move to higher strength drugs until you find one that is effective. Currently I have the ability to administer: paracetamol (acetaminophen), nitrous oxide, and methoxyflurane. I find the latter two are very good pain relievers and it's as much about selling the drug as actually providing it, so the patient is in a positive frame of mind that the stuff is really strong and is going to work. Further up the ladder we have fentanyl, morphine and ketamine as well as the option to add low-dose midazolam into the narcotics if required. Again we are currently being taught to use both morphine and fentanyl together with the fentanyl for initial pain relief and morphine as a longer term pain relief during transport. Again I've seen some paramedics give morphine in 1mg doses with obviously little effect, and some really good ones who give 5+mg at time and really get on top of pain early and hold it at bay....I'm aiming to be the latter when I finally graduate.

Well our police don't even carry guns....needless to say my position on this is very very against it. Although maybe if you work in such a hostile environment that it's needed then maybe there is arguments for it. But I don;t see Ohio being that hostile a place. Also, because they encounter "belligerent and unpredictable people" as a reason? That's been the nature of the job since pretty much forever.

WFA uses both magnesium and IV steroids for treatment of severe asthama Kiwi.

Excellent scenario! I haven't come across this before and would have been lulled into a false sense of security that as her gallbladder had been removed there would be no further complications so long after surgery. Will keep it in mind if I ever come across a similar patient. Thanks!

Something liver/kidney related? Is it possible that she has hepatitis of some sort which would cause liver inflammation? Although that doesn't quite explain the hypotension or bradycardia (I'm throwing straws out here).

Great. In that case I'd continue with another 250ml of NaCl. Does the 60mcg of Fentanyl relieve the pain? If not then I'd keep going with the Fentanyl...by which time we would be 20min in, at hospital and she is all handed over I wouldn't give 02. SPO2 was good and there is no evidence of SOB so far and RR is normal. No clinical indications for it at this stage.

20mcg Fentanyl and repeat every 3-4min up to 100mcg. Obviously stop if bradycardia or hypotension worsens. What is the effect of fentanyl administration as above as well as 500ml of NaCl? At this stage lets also ask about intentional OD or any self-harm that may have occurred.

As above for questioning. Needs an in-depth history taken. Would want to rule out AAA, cardiac conditions and any possible vaginal bleed before getting in a provisional diagnosis of exactly what sort of abdominal condition she might have...and that is realistically only going to be properly done with diagnostic equipment in ED. In terms of treatment some pain relief (would start with some Fentanyl due to hypotension), and 500 - 1000ml NaCl enroute for the hypotension. Any signs of septic shock? If so then would consider Ceftriaxone depending on distance from home to ED.

Protocol for RSI 1. IV Fentanyl (1mcg/kg) 2-3min before induction 2. It pt has shock then IV Ketamine (1.5mg/kg) and IV Suxamethonium (1..5mg/kg). If pt does not have shock then IV Midazolam (0.05mg/kg) and IV Suxamenthonium (1.5mg/kg) 3. Intubate and confirm tube placement with ETCO2 4. Give 10mg IV Vecuronium 5. Give ongoing sedation (1-3mg midazolam and 1-3mg morphine every 3-5min) Standard Intubation Follow steps 3-5 (only if pt not in cardiac arrest, otherwise just tube and ventilate then follow 3-5 if you get ROSC). Only a few select people are trained for RSI so they get a lot of practice. Only issue is that they often aren't around when you need them. Everyone else gets plenty of opportunities to tube as a general rule. Either on-road or at hospital if they want. Success rate is very high.

For sedation our preferred drug is Midaz but if you need to basically do a quick takedown for a very unstable patient who is a threat to others or themselves we can basically IM them with K using 2mg/kg up to 200mg max. Very effective. Only time I've seen it done patient became GCS 3 and maintained own airway well. No signs of respiratory depression. The issue we were having with midaz was that in patients that very highly combative due to amphetamines, you could hit with them with huge amounts of midaz with nil sedative effects but high risk of respiratory depression when you did finally get enough in to calm them down. One of the main reasons they brought in the K procedure for sedation.

Yes we were underdosing for analgesia which had the effect of being effective as analgesia as it could be, while also bringing out hallucinatory effects at lower doses. The doses aren't more sedative after the increase, although we also do use ketamine as a takedown drug for chemical sedation/restraint.

I know that in most hospitals here Ketamine would not be administered as a PCA. And even when administered as an analgesic it's usually given with a small amount of a benzodiazepine which significantly reduces the halluncinations etc effects. Other than that, ketamine only really gives that sort of negative patient reaction in smaller doses. Thus recently in our service our ketamine dosage guideline has been upped as higher doses reduce the hallucinations apparently (it's not im my personal scope of practice, but I read the memo).

Surely it's not safe to measure a patient's weight in lbs if the drug calc is based on kg...

Similar thing. We only have midazolam. Use it for serizures, sedation and pain relief. We also carry morphine, fentanyl and ketamine for pain relief and an opiate/benzo combo works wonders.

Same here. A refusal by a competent patient is a refusal. You can try to persuade them if you think they need to go to hospital (our guidelines say to use friends/family and their local physician to try to persuade them as well), but they still have a right to refuse. And as long as you read them their waiver and they sign on the dotted line then nothing should happen to a crew if patient then develops something else or becomes worse...unless of course you start calling in the question of whether they were competent enough. For eg our competency: Pt appears to understand info given to them and can recall this when asked and They appear to understand the implications of their decisions and can recall these when asked and They communicate on these issues consistently and They are over the age of 16 and They have not attempted (or expressed thoughts of) self-harm Meet those criteria, document it thoroughly with some airtight paperwork and get the patient to sign and you won't have any problems. As with anything, the thing that lets most people down is poor documentation. If you don't write it down it didn't happen.

Thanks for your replies. Bit of further info: we couldn't see any evidence of any other cardiac or respiratory related events going on - not to say that there weren't but our assessment didn't pick up any evidence of this. The lungs were clear and from what I have researched pulmonary fibrosis may produce a crackle in the base of the lobes but not always and it can be hard to hear. As for meds, my crew partner was in the back with the patient and I was driving so I don't remember off the top of my head what his meds were. Not sure what happened in ED after we left. Our PEEP is just a PEEP valve attached to a bag mask, so you put the mask over the pt and ensure a tight seal and they breathe through the mask. If breathing is inadequate then you can assist ventilations. So we don't have any CPAP as such. Basically I'm not sure if PEEP would have been helpful considering pulmonary fibrosis is not an obstructive disease, but just bouncing things around in my head to see if we get something similar in future whether it might be worth a try (if someone deteriorates before getting to hospital).

We used to only use morphine or midazolam for combative patients but recently introduced Ketamine as a take-down drug for a combative patient. 2mg/kg IM up to a maximum of 200mg.

Went to an interesting job yesterday and had an odd SOB case that I had never seen before so just wanted to check if anyone out there had had anything similar and for those that had if their treatment options may have differed. Elderly gentlemen with severe SOB from acute exacerbation of pulmonary fibrosis for 2-3 hours before calling ambulance. Patient on home O2 via nasal prongs. Arrive and patient is in a lot of distress, appears very SOB and very restless. RR 40, HR 120, BP 150/90, SPO2 78%. Only other medical history is longterm asymptomatic AF. No chest pain. No illness lately. Temp normal. Lungs both clear on auscultation. Nothing abnormal on 3-lead (apart from AF). Started him on an acute mask @ 5L and this improved SPO2 to 85% but didn't improve SOB or agitation. Moved up to a reservoir mask @ 10L and saw dramatic improvement. RR decreased, SOB virtually disappeared and SPO2 came up to 97%. He became much more relaxed and we took him through to hospital. No issues the whole transport until 2min out of hospital when his RR and SOB increased dramatically even on the reservoir mask. In ED he went straight to resus. What I was wondering is if he had deteriorated earlier would he have been a candidate for PEEP? We generally only use PEEP on conscious patients if they have pulmonary oedema so would it even help someone with pulmonary fibrosis? Edit: I just saw the Patient Care area so apologies if this is in wrong area.

Guilty. Have you ever sworn loudly in front of a patient in the back of an ambulance?

Could start up a new forum board that is all about people posting their procedures/protocols so others can compare and talk about reasoning etc?

Personally I still think it is pretty ridiculous to require L & S to every call. Our EMD system over here requires all EMD's to have a basic first aird certificate and then they are trained in Pre-Hospital Emergency Care (PHEC) which is essentially BLS. The call takers use the ProQA system with callers which automatically gives the call a priority between 1 - 4. The dispatcher then gets sent the job details and dispatches the crews via pagers. The call-taker, dispatcher (and in extreme situations) the crew itself can upgrade to L & S. For example, the other night we did 10 jobs. 2 of those were L & S and 1 of those jobs was to something that definitely didn't warrant lights and sires. A lot of the P1 jobs probably should have been non-L&S, and only very occaisonally do we get a job that comes through as no L&S that should have been L&S.

We use lights and sirens if the job comes through as Priority 1, and we only use them to get to the pt. It is extremely rare to use lights and sirens while transporting, unless the pt is in an extremely critical condition.

I wouldn't ever sue for an injury sustained through trying to help a patient. But we have a public health system so the injury itself wouldn't cost me anything. Different in US where someone actually needs to pay for the treatment costs and loss of wages. Would the firm you work for not pay for loss of wages and treatment seeing as it was a work related injury through no particular negligence of any party?