buddha

Just out of curiosity, Rid, and to rescusitate this horse (or at least to put it on life support), do you have any research on nasal versed? The idea is much more appealing to me than rectal valium, so I asked a friend of mine (D.O.) for his thoughts. He said that versed has been tried before, like most things in medicine, and that it is hit or miss at best for the active seizure. Anecdotally, it seems to sedate some people well while others just seem to not be affected in a desirable manner. I remember a 9 year old psych patient from years ago who was given versed by the attending to sedate his rage. The more he got, the wilder he got. A paradox effect similar to meds like benadryl (which puts adults to sleep but sometimes causes kids to bounce off the walls) or ritalin (which calms kids but causes the opposite effect in young adults). Also, we recently went through a regional debate over benzos when the local psych docs lobbied the REMAC to to scrap valium in favor of ativan. The fact that none of us carry refrigerators on the busses, and the prospect of diluting this nasty drug before administration were both initially overlooked by folks who don't have to work in the streets. Valium finally won out (thank God) and has worked very well for me over the years. Is there new research that indicates versed is better?

Why are you guys making this so difficult??? The answers are simple, if you don't get caught up in the "what if's". First, look at why you are at the patient's side. You are there for SOB. What do you know about the patient? Onset acute and worsening during last few hours. SPO2 90% ambient - which is not a crisis at the moment. Put the patient on 12 lpm via nrb. Rales halfway up = acute pulmonary edema. Peripheral edema, ascites, and JVD noted = right sided failure. Right sided failure is secondary to LV failure, and when most patients suffer coronary syndromes such as A-fib or AMI they experience some degree of LV failure. Why? Because the left side has the highest workload and therefore demands the most oxygen. Treating the syndrome will usually eliminate pulmonary edema. The right sided failure, however, always remains in some degree. Now think about the possibilities in this patient. Yes, he's in A-fib, but is it symptomatic?? Not with a reasonably controlled rate and decent BP. A-fib is not the cause of this patient's current problem. Why does everyone need a 12 lead?? Think about the obvious - yes, an RVI can cause peripheral edema. Yes, NTG is bad for the RVI patient. Remember that RVI many times presents bradycardias and heart blocks (cuz the conduction system is on the right). Remember also that if you are still suspicious of RVI, you can see all you need to see with your three lead monitor. The ECG parameters to identify AMI are ST elevation greater than 1 mm in two or more anatomically connected leads - therefore, you can look at lead ll and lead lll to pretty much rule out RVI. Forget the symptoms of right sided failure and treat what you need to. Give the NTG first, because it is quick acting and should provide near immediate relief. Secure a line and give your 80 mg lasix, which will take a while longer to work ( try to time it so the patient doesn't have to pee until you get them inside the ER). Who cares if his feet are swollen as long as he can breathe??

The features you mention depend on how your machines are configured. Our M-Series are set up to record everything the machine does, and allows for a large variety of event markers which can be custom programmed by the user. All data is stored in our machines for 72 hours, unless we manually erase it. When I get to the hospital, I push the summary button on the m-series, and then print my choice of a full code summary (including strips before and after each event marker), or trend data (which lists HR, RR, SPO2, BP, and CO2) minute by minute. Having used both bug zappers in the field, I still prefer the zoll for its size, weight, and reliability.

Local fire dept. dispatched for reported utility pole broken with wires down. Command determines cable to be of the telephone variety, and notifies dispatch - requesting telephone company response. Dispatch to command "Telephone crew responding with 30 minute ETA. They are inquiring as to whether pole is back up yet." Did the phone company expect their pole to sprout and grow?

The most common emergencies include: diabetic ketoacidosis ( high blood sugar ) and hypoglycemia ( low blood sugar ). Both of these conditions if left untreated can be life threatening. So you want to play, 1-EMTP?? In 22 years, I have never seen DKA to be acutely life threatening. DKA takes days or weeks to manifest, and progresses slowly - unlike hypoglycemia, which is very acute and often ocurs without warning. These two processes are very different. How do you propose to fix DKA in the field, if it is an immediate life threat? I didn't think so. It is true that hypoglycemia can be fatal if untreated, but so can airway obstruction, cva, or toxicity. Sugar should not be given blindly on the "hunch" that a seizure is hypoglycemia related. A couple minutes without oxygen will do as much or more damage than a couple more minutes without sugar. You still gotta break the seizure first and then treat what you find.

Sorry to disagree, Asys, but the Autopulse is very much different than the thumpers you are referring to. A thumper is an oxygen powered device that is capable of producing force in only 1 dimension and at only 1 rhythym. The autopulse is programmable for 15:2, 5:1, or asynchronous compressions. The design of the Autopulse provides for even compression circumferentially around the thoracic cavity, rather than just pumping the sternum. This is just inference at this point on my part, but there must be a benefit to squeezing the chest in this manner - remember that AHA endorses hands encircling the chest for infant CPR, citing better perfusion pressure in infants. Wouldn't the same hold true regarding perfusion pressure for adults??

The choice of fluid seems to run in cycles(or circles). We carry D5W for our intermediates to treat hypoglycemia (in NY they cannot give D50), and to mix meds as needed. Remember that D5W is hypotonic, and since water follows salt, it doesn't stay in the vascular system very long (which is why it's great for mixing meds). We used LR for trauma for a while, and then we used NS, and now we are back to LR for traumatic hypovolemia. Reasoning as I recall is based on damaged organs' need for electrolytes. We currently carry all three. NS is mostly used on medical patients. Saline locks are great for gaining and maintaining IV access when you suspect a patient MAY need meds or fluids down the road.

In my earlier post, I stated that my preference would be to break the seizure first - and then follow with glucose check to confirm or rule out hypoglycemia. Ace is right - every patient should get the same thorough evaluation, regardless of what you know (or think you know) about a patient. Providing care based solely on a bracelet or on the word of a bystander will eventually get you into trouble. How many causes for seizure can you think of - hypoxia, hypoglycemia, fever, toxins, cva, tumor, etc. Evaluation done properly is a scientific method of examining all possibilities and systematically ruling them in or out. The presenting problem is an active seizure - break the seizure and then work to determine and treat the cause of the presenting problem. Remember the common test question about a driver observed operating erratically who crashes into a pole and is found acting "intoxicated"?? Are his actions the cause of the crash (medical, ETOH), or did the crash cause his current state (head trauma)?? Which came first - the chicken or the egg??

Active seizures lead to hypoxia, obstructed airway, and if untreated, death. Trying to secure good IV access for a D50 bolus in an actively seizing patient is akin to trying to shove a wet noodle up a wildcat's butt, not to mention the added potential for patient injury as you try to hold an arm secure enough to get a good line. Break the seizure and treat the hypoglycemia after. Don't forget that glucagon takes 10-15 minutes to really break enough sugar loose, which is a long time for someone to seize. Suppose you get a line and begin D50, but the patient pulls the IV while you are trying to administer - now you have to restart another difficult IV. Remember that extravasation of D50 causes tissue necrosis. Rectal or nasal benzos work just fine and are very quick onset. Breaking the seizure first will make it much easier and safer for both you and the patient.

We used to hang fluids on everyone, but that has evolved. In the past, our region required fluid up but our neighboring region would not allow fluid running without med control auth (they HAD to do locks). We have progressed to doing locks on many of our patients for the following reasons: 1) All the area hospitals use different IV tubing and pumps. It becomes much easier to unplug a line from a lock (or a j-loop) to change tubing than it would be to untape the IV site and disconnect from the catheter hub. 2) Our ALS workup requires IV ACESS and pre-IV blood draws as a standard, and all the hospitals are glad to have completed draws handed to them. We draw red x 2, green, blue, and purple. 3) Many patients already have plenty of fluid, and some have more than they need. I'd much rather place a lock in a patient with acute pulmonary edema and not have to deal with the extra fluid. 4) A patient with a lock can be much easier to handle than one with a bag dragging at the end of a six foot tube, especially during extrication from the second floor. Much harder to accidentally rip out a saline lock than it is to pull an IV by its tubing.

Our agency (in NY) provides BLS supplies for its members to stock and maintain a jump kit. We do not as a rule provide supplies to people on the street who are not members of our agency, but we do restock the first response agencies who work with us when they are on scene with us.

An interesting perspective, to say the least. Makes you think about the simple stuff. With respiratory failure, we are finding that the true measure of success in treatment lies not in how much oxygen you can load into a patient but in how well you can regulate CO2 levels - oximetry vs. capnography.

How fortunate that you have such vast resources to choose from, all of which are reputed to excellent facilities. In our corner of the world, we are not so lucky. While we have a level ll center about a half hour from home, that time changes greatly dependent on weather (or exact location within our jurisdiction). Also, different centers in our region have developed reputations for specializing in certain areas. As stated, our "local" facility is a general trauma center, and there is another just across the PA border (about 5 minutes farther by air). AOMC and Robert Packer are both fine facilities for most cases. The special trauma situations are better handled by more distant (and larger) centers which would be out of reach by ground but are well less than 1 hour away by ground. As examples, Strong Memorial in Rochester, NY and Geisinger in Danville, PA are both known for specialized pediatric trauma care. Strong, along with Upstate Medical in Syracuse, both have regional burn center designation. Strong also has a neurological ICU. Where I would want my family to go is largely dependent on the specific care they may need in a specific situation.

Actually, in NY, a student needs only to turn 18 by the last day of the month in which he/she sits for the written exam. You could take the exam at age 17, if you will turn 18 by the end of the month. Secondly, NYSDOH requires that course memorandums (rosters) of students enrolled in the class be received by the DOH at least 6 weeks prior to the written exam. This allows time for the state to order the exam and to forward tickets to the I/C ( and to assure compliance with state regs). You should have completed an application for EMS certification at the beginning of your class. As for the practical exam, students may fail up to two stations the day of the practical, and the Practical Exam Coordinator must allow any student who fails a station to make 1 attempt to retest that day. You could fail the trauma assess and the medical assess, and retest each on the same day. If you fail the retest, you must make arrangements to retest one more time (after remediation). Students who fail the second retest must then sit through a refresher class before taking the exam again. Practical exam procedures are also clearly laid out by NYSDOH, and the exam is meant to be a black and white test. Evaluators cannot freelance and fail you for items that are not specifically listed on the practical exam evaluation sheet. They are not supposed to ask questions. Evaluators are supposed to give the scenario and answer questions the candidate may have, then remain silent and evaluate the patient. All of this information is available on the NYSDOH website under "Information for Providers". Sounds like many things were not done appropriately in your class. Stick to your guns, and file the complaint. When you contact the state office, ask for Karen Meggenhoffen. If you need any further advice or help, PM me. I'm a NYS Certified Instructor Coordinator also.

Status epilepticus is as potentially fatal as hypoglycemia. Normally I would advise treatment of the underlying cause (low blood sugar) to correct the situation (seizures). But in this case I agree that without IV access your choices are limited. Glucagon takes a long time to kick in, relative to D50. What is your definition of status?? Some texts refer to status as seizures with greater than 30 minute duration, and others consider 2 or more seizures in succession without consciousness to be status. With hypoglycemia, the next step beyond seizure is probably arrest. With this presentation, I would run with Diazepam 5 mg PR to break the seizure. Follow with glucometer to confirm hypoglycemia and then go with 100 mg thiamine and D50. Our region also allows ativan, but I personally do not like the drug at all. Break the seizure as quickly as possible and then treat the underlying cause.

I also agree that EMS education is not perfect, but the point is that we need to work for change rather than sit around and complain about it. If you believe something is lacking, work to change the standards. I have been at this for more than a couple years, and feel qualified to make a couple observations. Many of the folks in here appear relatively new to EMS - not a bad thing. I am happy to see and to work with a new generation of provider. Your enthusiasm is very much appreciated and admired from my point of view. However, being new, many of you haven't had the opportunity to see where we started and how much we have truly changed as a profession over the last 25 years. The national standard curricula have changed greatly since my first EMT class, and many additions have been made. As we look forward to the National Scope of Practice model, the future holds many interesting changes in store for us. We need to support meaningful change and it starts at the curriculum - not the textbooks. I have suffered through many of those clinical rotations you guys describe, and I am glad that NY has worked at developing better clinical requirements. One thing that no one has really discussed here is the fact that many people are "book smart" but lack even a hint of "street sense". When I did Paramedic years ago here in NY, completion of clinical rotations was competency based rather than time based. My students are required to do competency based clinicals. There are certain things each student must complete to be able to sit for final exams. I always felt that we were providing good classroom training and then sending people into the field like lambs to the slaughter. My students now rave about the clinical rotations and the amount of knowledge they gain from experienced preceptors, and when they pass the certification exam, I feel like they are truly ready to go out on their own. The best changes we could make to our EMS educational program, in my opinion, would be a long term internship/clinical rotation such as the residency that doctors undergo. You can be at the top of your class, but the real test is in the field. And yes, I still learn new things every shift (as well as from my students).

Sorry to hear that the Combitube lost out to LMA in your area, Craig. After the rollout of Guidelines 2000, much discussion ensued over alternative airways. The main points that I deciphered were as follows. 1) The US is a litigious society, and the malpractice claims for bruised lips, broken teeth, vocal trauma, and etc. have hit anesthesiologists very hard. The LMA is replacing ETT in many OR procedures because of the reduced rate of complication. During my OR rotations when I was in Paramedic school (2000), this was the biggest fear/complaint among the anesthesiologists I studied under. 2) Research indicated at the time that the success rate for prehospital ET in the US was somewhere around 60-70%. Apparently we are not as good at airway management as we should be, and the AHA guidelines suggested that the LMA was easier to place and reduced traumatic complications when used by people who did not intubate on a regular basis. 3) The downside of the LMA is that, despite its ease of use, it doesn't provide a positive airway seal. The seal is marginal at best, and is very touchy to achieve. This is not a significant problem in the OR setting where patients have been NPO for hours prior to the procedure, but how many of our patients who need emergency airway management are NPO? I cannot remember one who hasn't puked. Someone above posted it correctly - LMA= Let Me Aspirate. 4) Enter the Combitube, which is another alternative airway recommended by Guidelines 2000. We carry this device, and it is intended to be strictly a "rescue airway" for use when ET is unsuccessful. The Combitube is a blind insertion device, making it simple for everyone down to EMTB level to use (depending on each state's scope of practice). Whether placed in the esophagus or the trachea, it provides a positive airway seal. It is possible to place an NG tube through the Combitube if it is in the esophagus. If you remember the EOA/EGTA that we used to use, the Combitube has the same contraindications for use (but because it doesn't rely on a mask to seal, it ventilates much better). In our area, AEMTI and above are allowed to use the Combitube if ET is unsuccessful - but no one that I know of uses the LMA prehospital. 5) Neither of these alternative airways are meant to be used long term - they are "rescue airways", and an ET can be placed around the Combitube or through the LMA (if you have the right style).

We have an explorer program at our agency that is now about 5 years old and working fairly well. We affiliated with the Boy Scouts of America to establish an explorer program in NY State. The benefits of this were help with recruiting, and the excellent insurance coverage provided by BSA. We take kids 16 and older who have an interest in the medical field. Explorers may ride from 0600-midnite once they have completed HIPAA and BBP training. New York allows First Responder certification at 16, and EMT at 18. Our explorers are allowed to practice up to their level, but only in the presence of a member (explorers do not run by themselves). We offer scholarships to active explorers who meet duty requirements and are schooling in a healthcare related field. The intent was to mold these youngsters and keep them as members when they matured, but there is a problem for us. The minimum age for membership here is 21, so most of our explorers turn 18 and leave to join a rescue squad. We have so far been unsuccessful in attempts to lower the membership requirement to 18. There is an ambulance service in VT or NH that is actually run by high school kids, but I cannot remember the name. There was recently an article in JEMS about their service. Maybe someone here knows of them.

I guess the First Amendment provides you the right to draft your own textbook, but that doesn't mean anybody will actually publish it. Those books currently in print, such as Brady and Mosby's are written around the National Standard Paramedic Curriculum and as such meet or exceed the curriculum requirements. During my years of teaching, I have found that all texts on the market contain the same basic material. The only real difference between them is the quality of graphics and the readability. I realize that you, Steve, are one of those people with MD syndrome, and I will not condemn you for that. I spend a good deal of my free time reading texts, research, articles, and even this forum to see what I can learn to improve my patient care. The same is not true of everyone - not all medics are interested in becoming pseudo-MD's. Texts need to be easy to read and interesting, or many students will not read them. If you are so unhappy with the current available texts, you should be lobbying for changes to the National Standard Curriculum. To the next point, I have not in many years seen anyone as blatantly arrogant as you. I have read many of your posts that berate people with opinions different than yours, you show little patience for the new people who come in here looking to learn from the elders, you have been downright rude on numerous occasions, and you are even so bold as to openly criticize a nationally known and respected EMS Physician. I realize this is also your First Amendment right. What you fail to understand is that we all have opinions, and they almost always differ. The most productive learning experiences come when there is an open exchange of ideas and opinions. A truly open exchange can only come with mutual respect and tolerance of opposing views. Anything less is oppressive and history tells us oppression often leads to revolution. If you feel compelled to spew your opinions, then you need to learn to accept those which differ from yours. If you can't find something good to say about someone, don't bother to say anything. Lastly, let me say that I do find many of your posts to be insightful. I do respect your knowledge, and your right to share with the rest of the community. I said it, I meant it, and it felt good.

I believe the Autopulse will be the next big thing in the world of EMS. We have had the opportunity to see one on demo, and found it to be light, well constructed, and efficient, as well as easy to use. For anyone who has seen or used a thumper, the autopulse is far superior. It is backed by strong research indicating better perfusion pressures, and can take the place of two rescuers on a long arrest transport. Zoll believes in this piece of equipment, as they have acquired the company that designed and manufactures it. Anything with the Zoll name on it is a quality piece of equipment. The drawback - PRICE! At last check, the price of a new autopulse was around $15000.00, which is extremely steep for most agencies on "fixed incomes". Is the expense worth the benefit? Maybe. I do have an autopulse on my Christmas list.

Fact is, as much as we all hate to admit it, we are not in control. Whether you choose to believe in God, or Allah, or Buddha, or the Great Spirits, Fate, or simply in the power of the Universe - you unconsciously concede that many things are beyond your control. That being said, what gives any of us the right to judge right or wrong??? The way I see it, we are merely an instrument of whatever higher power you choose to believe in. Some patients are meant to live, and we save them. Some are meant to die, and we lose them. These situations are not a reflection on us, but the natural order of life. Health care providers have become selfish - we want every patient to live, and we throw all kinds of tantrums when they don't. Modern medicine is so focused on prolonging life that millions of dollars are spent keeping the shells of people alive for years past what would have been a productive span - millions of dollars that would provide care to sick and dying children all over the world. We have become so obsessed with prolonging life that we are trying to force our will upon whatever higher being calls the shots, and that is where the trouble lies. It is easy for you to sit in judgment out here in cyberspace, but we do not know what actually transpired with this patient. Perhaps if we were there, our opinions might be vastly different. We should be at the top of our game every shift and we should give 110% of ourselves to each patient, but we should also realize that we are not in control of any patient's destiny. Whether we like it or not, who ultimately lives or dies is not our choice.

Here are a couple pics of my new ride. I am now officially a "pick-up man" again!http://i5.photobucket.com/albums/y155/buddha077776/e97081d2.jpg

Seems that we pretty much agree, Rid. Simple and effective. I was curious - does it also seem to you that the amount of crap in a provider's jump bag is inversely proportional to said provider's level of experience and/or comfort? I'm getting too old to drag the whole ambulance around on my shoulders and I've learned along the way to do more with less.

Thanks for your support. As one of those former mullet providers, I am not being facetious. Mullets are COOL!! Anyone can shave their head, and they all look the same - but a mullet is as individual as the provider sporting it.