Paramagic

I probably shouldn't continue to engage in a battle of wits with an unarmed opponent, but I just can't help myself today. I'm not sure what this has to do with the transport of bariatric patients, but your grasp on logic seems to be as strong as you grasp on EMS. The patient's weight is almost irrelevant to the problem, if it weren't for the fact that it is the factor which means they cannot be properly restrained. There are hundreds of papers on the risk of death to unrestrained passengers in motor vehicle collisions. If a person with a healthy weight is at a significantly increased risk (around 75% more likely to die) in a motor vehicle collision, what makes you think that an overweight patient isn't? It's simple common sense (at least I thought it was). If you would like some proof that unrestrained passengers are more likely to get hurt or killed, you could try here or here, it really isn't that difficult. Oh boy, here we go again. I will type this really slowly, try to keep up. If the patient has a time critical illness or injury that we know has a high probability of resulting in death if left untreated (such as a STEMI, dissecting aorta, whatever) then it is the risk involved with transporting the patient unrestrained may be less than the risk of sitting around waiting for a bariatric unit to arrive. I don't know how to make it any clearer than that. My friends 7 year old understands that concept, I hope you can too. I see, so there has to be published data that shows something is safe or not? Ok, putting aside the hundreds, if not thousands of publications that show the increased risk to unrestrained passengers in collisions, this one I am happy to go with. You have a son right? Well, what say that I bring him a live rocket launcher for Christmas. You will undoubtedly be happy to let him play with it, as there are no published reports of children being killed in the home in the US with a live rocket launcher. Therefore, according to your "logic" it is perfectly safe. See how that works? Not very well right?

Right, I have to call absolute bullshit. You are either trolling, or actually retarded. There is no way on god's green earth that anyone who has any idea about medicine, EMS, or indeed life, can be so utterly ignorant of the concept of risk versus benefit. Every single day, everything we do, in EMS and in life, is based on a risk/benefit assessment, whether we actually think of it in those terms or not. We decide on the risk versus the benefit when we give anyone a drug, from aspirin or oxygen to suxamethonium or ketamine. We decide if the benefit is worth the risk to drive emergently or not with a patient in the back. We decide if the benefit is worth the risk to push through that orange while running late to work. We decide if the benefit outweighs the risk when we park in the no standing zone to run into the bank. We decide if the benefit outweighs the risk when we go back inside to answer the phone, leaving the kids on the swing unattended. If you genuinely cannot understand this incredibly simple and pervasive concept, you should probably be working in a sheltered workshop and having 24/7 care, because you are clearly incapable of surviving day to day life otherwise. Amen to that!

You're forgetting the important part: safety. It is important you maintain the high level of safety at all times, so you should dispense with the ratchet straps, remove all but 2 bolts holding the axle on the trailer, weld some random pieces of sharp, angular steel around the superstructure, store lots of flammable liquid on the trailer, and have a policy that the driver travels at no less than 20MPH over the speed limit, with one eye shut. (Do not question the policy! The policy is right! The policy is perfect! All Hail the Policy) And maybe add some snakes. This will make it as safe as a modern ambulance. I've seen youtube.

Oh come on! Now you're just being silly! Every ambulance made? Let's not turn this into any more of a farce than it already is. Currently 4 with another 2 coming on line next year. We are also trialling lifting equipment for our regular rigs, not for dealing with bariatric patients per se, merely to ensure safety for our staff every day when lifting patients.

Wow what? Wow, you have realised that there is such a thing as risk versus benefit? Or just Wow, I refuse to alter my worldview, therefore I won't engage in any of the discussion taking place, except to reiterate my position, or to mount ad hominem attacks using strawman arguments?

No, you're not, because that is not the case. Our rigs have stretcher and harness systems designed in conjunction with a university based engineering department that specialises in crash testing and investigation. They have been shown in exhaustive testing to be effective in frontal, rear and roll over incidents, and this has been borne out in real life as well. If your organisation is too cheap and nasty to invest in the safety of their staff, then you may have a point. Never. If a patient is backboarded, it is because I have a genuine suspicion that they have a spine or spinal cord injury, therefore they get a second rig, because I cannot safely care for two spinal cord injury patients by myself. In fact we don't even have a squad bench. Nonetheless, you keep carefully constructing straw-man arguments that have no bearing on the issue at hand, and that keep getting shot down. Do you really not understand risk/benefit? Can you honestly not see where you would accept a higher level of risk in transporting, because the benefit of getting to definitive care is greater than the risk? It really doesn't matter what 'policy' is, the decision ultimately has to lie with the provider who is a the scene. Not even the military accepts their soldiers blindly following orders without weighing up the situation for themselves, yet you expect your staff to do exactly this. It scares me that someone who identifies themselves as a paramedic appears so completely unable to see the world in anything other than black or white.

Do you find it stressful to see the world in black and white whilst trying to negotiate the grey of everyday medicine? Usalsfyre has said it over and over: what part of risk/benefit do you not understand? How on earth do you cope as an alleged paramedic and alleged manager if you cannot weigh up risk versus benefit on a case by case nature? Goodness me! Strawman much?

PIPs isn't that important with regards to what is being transmitted to the lung, it is not an accurate representation of what is happening at an alveoli level, just the circuit and larger airways Plateau pressure is what the alveoli is seeing and you want that under about 30mmH20 (off the top of my head, I could be wrong) Most ventilators have an inspiratory hold button that will get you your plateau pressure when you hold it down.

Not at all, I am certainly not discounting your experience. I have not had a similar experience, so have no frame of reference for it, hence my trouble with the concept. Anecdote is not really the spawn of the devil (despite my tag line), it is, as you point out, fundamental to shaping our practice in medicine. I certainly don't think less of you, or anyone else for recounting and referring to experience. I try to use the "evidence" as much as I can, but let's face it, there is precious little of that around, so we have to practice medicine some other way. I also appreciate a rational, civilised conversation; I think it is beneficial to all parties, thank you.

That is an excellent presentation from the DHMC Bieber, especially the first couple of slides. Thank you.

I really don't understand how some pain relief is worse than no pain relief. Can you explain how reducing pain, in a setting where immediately eliminating it is impossible, is less desirable than not treating pain at all? I'm not advocating the homeopathic doses of morphine that some services restrict their medics to, but surely some pain relief is better than none?

A sales rep for a drug that is out of patent and extraordinarily cheap? Try again. Yep, it can raise BP and heart rate slightly. Which is worse in this patient, dropping the BP or raising it slightly? We are not talking gross hypertension here. The serious effects, particularly apnea and laryngeal spasm are typically related to the speed at which the drug is pushed, hence my comment above about administering it slow IV push. The serious adverse effects are rare, and when we are considering a hemodynamically unstable patient, it is a clear choice between a histamine releasing opiate and ketamine. Yes I have seen emergence phenomena, which are more common when using larger doses for procedural sedation or anaesthesia, and are usually attenuated with a small dose of a benzodiazepine. However in my experience they are rare when using ketamine in analgesic doses. I'm not trying to make ketamine out to be anything other than what it is: a safe and very effective analgesic agent for the type of patient we are discussing.

There's no bravery at all. Ketamine has no effect on blood pressure or respirations, so I don't have to be worried about either of those things. The coarse basal crackles don't bother me much at all, I would not be surprised if that is her baseline finding. Even fentanyl would be relatively safe.

I can only go by what you have told me. I assume she is hypotensive secondary to blood loss from her pelvis. Coarse basal crackles in a bed-bound COPD patient do not worry me that greatly, but they obviously need watching. IV access, some fluid, TKVO at this stage, although it may be appropriate to give some small boluses depending on what happens with her blood pressure. 0.5mg/kg of ketamine, slow IV push, repeat as needed. No effect on BP, no effect on respirations, fantastic effect on pain. If ketamine is not an option, then fentanyl, probably starting around 25mcgs every minute or two, and keeping an eye on blood pressure, although obviously there is less histamine release with fentanyl than morphine, so that shouldn't be a major issue (although some people report a terribly itchy nose with fentanyl) If fentanyl isn't an option then an antihistamine to begin with to mediate the adverse effects (hypotension) of morphine that are primarily histamine mediated, then small boluses of morphine as with fentanyl. Further fluid may be required, but we are obviously going to be cautious due to a CHF history and the desire not to replace lots of red stuff with clear stuff. I agree that small doses of analgesia are not always optimal, but I fail to follow the reasoning of: small doses aren't great, so I'll give none. Something is better than nothing, and some explanation of why you are treating them they way you are, along with a bit of diversion if possible, should make them realize that you are acting in their best interests.

I don't really see the benefit in having unrelieved pain in either of those patients. In the first vignette I presume that the concern is the low BP? In which case some ketamine, or small aliquots of fentanyl would be appropriate. In the second scenario there is no reason for pain not to be treated either. The concern over 'masking' neurological signs by sedating the patient just means that you don't use large doses of a sedating analgesic. Fentanyl again is a good option due to it's short duration of action which will allow unhindered neurological examination when the neuro people see her (although lets face it, she will be getting a CT and CTA, possibly an MRI also, so it;s a bit like the abdominal pain myth) Or you could use NSAIDs, or some inhaled analgesia.

Yes, really. What kind of patient benefits from being in pain?

I treat multi-system trauma aggressively with analgesia. Ketamine is my preferred agent, but fentanyl is great too. It doesn't matter if they are altered or not, injuries hurt. Even if they don't recall or can't tell you about the pain, all those fractures still cause a physiological pain response that is detrimental to the injured patient. There's never a good reason to withhold pain relief.

Good stuff. The CRASH-2 study certainly looks like a compelling reason to start carrying tranaxemic acid. Cheap, easy to use, appears safe, easy to store: it almost seems too good to be true! I'm sure that some of the more progressive civilian services will be looking at this before too long.

Except less drugs is not good when the purpose of those drugs is to both ensure optimal intubating conditions AND to minimize secondary brain injury, resulting in better functional outcomes from pre-hospital RSI in traumatic brain injuries, as demonstrated by Bernard et al. And I have to second usalsfyre re: etomidate for ongoing sedation... huh?

It's really not (or shouldn't) be a matter of reversal agents being available for particular drugs. RSI is something you are doing because you have determined a clear need. If you are dicking around half-way through thinking about "revesing" it, then I suggest that the need wasn't there in the first place. It's no excuse for medical directors to implement half-baked protocols that are likely to cause more harm than good. Educate your medics, trust your medics or don't: there's no half way.

It's threads like this that should be compulsory reading for every skill-monkey who thinks that we are overeducated in the first place. Every day I wake up worrying that I don't know enough to do my job well, and then I confirm that by reading this sort of thread!

It depends on the patient. Generally speaking acidosis is better tolerated than alkalosis. If you have an elderly COPD patient who normally has a high baseline PaCO2 (although you would again need an ABG to confirm this) you probably won't want to bag the hell out if them to get their EtCO2 down as you run a number of risks. For asthmatic patients I basically don't worry too much about the EtCO2. I want to oxygenate them well first of all, then ventilate. I have seen EtCO2 up around 180mmHg in acutely unwell, intubated asthmatics. You will bring that number down, but you need to be careful when doing it. Hypoxia kills, hypercapnia happens. If you try to chase numbers too quickly you will end up breath stacking, causing barotrauma, popping blebs and generally causing all kinds of mischief. Slow and steady is the key here, these aren't the same as the metabolic acidosis patients first described and they will tolerate that acidosis well for some time.

Indeed, I guess when I said "simple physics" what I really meant was fiendishly complex and poorly understood fluid dynamics, but really for the purposes of understanding some airway resistance stuff, it's a reasonably good concept. If you have something better or simpler to describe resistance to flow, I would love to hear it!

You have protected the airway, but you have also increased work of breathing. Flow is proportional to the fourth power of the diameter, and inversely proportional to length (Poiseulles law) When we place the tube we have decreased the diameter of the airway, and we have increased the length of the airway, so to have the same flow the workload must increase: it's simple physics. And this is just the tube, it's not taking into account any increased deadspace from the circuit. Indeed; my point was that to increase minute volume to ensure adequate ventilation we need to increase the rate, not the tidal volume, in order to avoid lung injury. I hope it doesn't bite back too hard!

I have to disagree with intubating and leaving the tube open to air. You have just increased the work of breathing significantly in someone who is already demonstrating a presumed compensatory mechanism to acidosis. This is setting this patient up for imminent respiratory failure and potentially cardiac arrest as his acidosis increases. This patient needs inspiratory support to reduce his fatigue (and acid production and PEEP to improve ventilation to ensure that CO2 gets out of there. EtCO2, in the absence of in-field ABG is indeed what we should be using as a target for post-intubation ventilation management, with an understanding that there are going to be differences between EtCO2 and PaCO2. However this gradient is dynamic, so again, without ABG we just have to make an educated guess and get on with it. Respiratory rate is not of tertiary concern, it is one of your primary concerns in this patient as RR is what dictates ventilation, and ventilation in this patient is of paramount importance. We don't increase ventilation by increasing tidal volume; all that does is cause lung injury. If we want to improve oxygenation with just a BVM, we have 2 options: an FiO2 of .21 or an FiO2 of 1. Not ideal, but if that is what we have to work with, then we just have to make the best of it. I'm not sure what the 'dangers' of positive pressure ventilation are. Sure, there are some downsides, like a decrease in venous return from the increased intra-thoracic pressure affecting perfusion, but this can be remedied with some fluid and/or pressors. The dangers of leaving this patient breathing on his own are much greater. If you had a PEEP valve on your BVM and could try to synchronise some support with their respirations you may be able to support them, but I have always found this to be rather difficult.