Carl Ashman

Dont worry mate, we can have our own European reunion. You can tell me how Oktoberfest went. Gutted I still haven't had chance to visit.Carl

I think it's fair to say that a physician in EMS will have a limited scope of practice. Of course, the OP's has other options as a native English speaker. Take a look at

You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration?

Carl.

(Shakes his head sadly....) Only in America!

Come on people, this is just abuse of the system. They are already in an EMERGENCY room, full of EMERGENCY nurses and physicians. If they want to get taken elsewhere because of the waiting times then they take a cab. They are not going in my truck. Not that I would even get to see them because dispatch would refuse and ring the ER.

Is it no wonder that healthcare in the US is so broke?

I don´t normally have such strong opinions but this just goes beyond the pail to me....

Carl.

I used to live on Lou Costello Street. It was around the corner from Charlie Chaplin Drive.

No, I'm not kidding, It was called the filmstar neighboorhood.

C.

Everyone is too tired, cynical, or lazy to upset the status quo and I know that none of you on this forum wants that--if you didn't still have that drive to improve, you wouldn't spend your free time reading an EMS forum. So let's do this, let's commit ourselves every day to improving our profession, for our patients, for our services, and for ourselves.

Ouch, that is harsh. This can also be a good place to learn about how other people do things. It will give good ideas for the future. One good example, I visited the US in my capacity as EMS educator more than 10yrs ago. I saw CPAP in action and was impressed. I went home and hounded my Medical Director so long that he finally relented and we now have CPAP. Don´t underestimate the power of the net.

Other than that, you make good points. Prescribing is, however, a long way off, I fear.

Carl

We're not just dealing with emergencies, so we had better start shaping up and educating ourselves on more than just emergencies. We're taking care of people with primary care problems, and we've got to address them instead of just passing them on to the ER--because they're not primary care providers either, but at least they have the education to address primary care issues, even if it's not their forte. An EMT could transport a patient with primary care issues to the hospital and pass the problem along; it's going to take a paramedic, an evolved paramedic with more education than I currently have, to step up and manage those issues without necessitating transport to an inappropriate facility. There are lots of patients with primary care issues who only need immediate relief and counseling, not an arbitrary ride to the hospital. But until we get out of this mentality that we're only going to manage emergencies and ignore the fact that we're being called upon to adapt and overcome, and actually change the way we do business, we're going to continue to fall down the totem pull of healthcare professionals and remain disrespected, undereducated, incapable, questionably necessary, and increasingly economically scrutinized.

An excellent, well made point there Bieber. Education is a substantial part of the answer but not the whole sum. Whilst I agree that, with better and broader (degree-based) education, providers should be given more options than taking a patient "hot" to the nearest ER, there are a number of issues. Safe clinical practice dictates that in the management of chronic illness you should be able to refer your patient to a primary care provider. Now I am not about to start a debate on the entire US healthcare system but it is fair to say that a large portion of the population don't even have a primary care physician, let alone an entire support network. Therefore, here's the dilemma: it's fine to refuse transport to the mild COPD patient, but who is going to manage his care after you've left?

Carl.

As far as I know I'm neither transgender nor, indeed, the OP. That was Metal Medic.

Going somewhat off-topic here: I am however confusing things. I am better known here as WelshMedic. However, for lots of reasons (like being on forums on 3 different continents) I have decided to revert to my real name. So there.

Sorry, now on-topic.

Are you in the loop now Dwayne?

Carl.

Very cool to know it found a home with someone who appreciates it! Me mum is still proudly displaying the picture frame you gave me. Thanks!

Actually, only my broken heart is in Kalifornia now. The rest of me is back home in Texas, so I am fine with Kali falling into the ocean!

I wish I had a lot more time to spend here, but I'm taking enough drugs each day to kill both Charlie Sheen and Lindsay Lohan. Consequently, the entire Dallas Fire Department doesn't have enough Narcan to keep me awake most of the time. Anyone who says you can get addicted to oxycontin is full of shyte. I been taking it for over three years and I ain't addicted!

So anyhow, I won't be here constantly, as I once was. But I won't be far away. I spent the last week resisting the urge to reply to "Rastus", the Civil Air Patrol kid.

My family in Japan is all fine. I have about a dozen family members who are Japanese. Only two of them were here when the earthquake hit. They all live 200 miles south of Fukushima, south of Tokyo, so they're in no immediate danger. But radiation is showing up in the water there now, and shortages are widespread. It takes hours of waiting in queue to get half a tank of gas. A couple of them have fled to the far south of the country to wait it all out. The rest are just living each day as if nothing happened. Crazy.

Tniuqs, my sister just turned 26 last week. She's too old for you! Also, the plastic MRE knife still works better than a Nu-Trach!

Reaver, cool to see you again! When did you move to Colorado?

Again, I've really missed you guys, and I want to thank you so very much for your warm welcome and kind thoughts. Positive energy is always welcome here!

Hey Rob,

I've been MIA from here for a while too now.... I was wondering what you were up to, it's so quiet around here these days. Let's see if we can kick up a bit of dust (no pun intended) and let this place rock again!!!

The artist formerly known as WelshMedic.

Carl, I didn't realize you're from out of the country! That definitely makes a difference, and I can tell from that picture that your guys' safety is held in much higher regard than ours. Right now, we work the code on scene and transport (unless the initial rhythm was and has remained asystole) after getting the antiarrhythmics or the three doses of atropine in (for PEA). We also don't have automated compression devices, though I could see how transporting a code blue patient while using one of those wouldn't be an issue.

Nice truck, by the way! I really like your setup. Honestly, having never worked in a type II ambulance, I don't think it would be that much more of a pain than in a type III. I know people complain about not having easy access to the patient's right side, but even in our trucks where we do have access to that side, trying to squeeze in there to get an IV is still a pain in the butt, and I'm not a big guy.

And there's me wondering how I offended you....

I've never had an issue with type II, we just do everything on the right side. In fact, type II is relatively large here. Have a look how our other neighbour's do it:

Yes, you really are looking at a standard Mercedes with an ambulance built on top!! Now they really are a pain to work in (even if they are very comfortable and go like the wind)

Only in the sense of honoring a favorite "Dust-ism" which is...."are you hot?"

Oh, AK... it really like old times here. It's good to be back........................

Where is Dust anyway?

Carl.

Too late. I'm no longer "school age" and am no longer in my 20's (although I pass for it). Which is kind of where the push and pull comes in. I currently work 40 hours a week and attend classes part time, in addition to being a mom who decided to never get married. (I hate the "single mom" moniker as too many use it as an excuse or a pity ploy).

To put it this way, I'll still be in my 30's when my son graduates from High School.

Does that change anyone's perspective?

-MetalMedic

Edited to correct grammatical error.

Only in as much as you will find it harder to meet the demands of school versus home life. But you will get through it at the end of the day because you are determined and keen for knowledge. Besides, a little life experience can be a very positive advantage in our line of work.

Try, by the way, to aim as high as you can when going to school. Nothing less than an Associate's Degree as this provides the absolute minimum in critical thinking and reasoning skills that you will need to be a practitioner that is tuned into the individual needs of your patient. Which is the opposite of a cookbook medic.

Carl.

Okay, just to clarify, I'm well aware that septic patients don't get antipyretics as the standard care. I guess I should have said I would like to have a protocol for febrile (non-septic) patients AND a protocol for specifically septic patients.

Carl, you've offered one possible in-hospital treatment, PCI with continuous mechanical compressions. The studies I've read show that while it is possible, it's still an emerging science and I haven't seen any that directly address PCI following out-of-hospital cardiac arrests on their own. The fact is still the same that if you can't do adequate CPR while en route to the hospital, what's the point in getting them to a PCI center so they can have their heart revascularized and wake up with massive neurological deficits? I think that trying to get a return of spontaneous circulation on scene followed by PCI after transport to the hospital would hold more positive outcomes than transporting those patients before they've attained ROSC.

The second thing you've suggested is organ donation, and to be honest I'm a little appalled by that. Not because I'm against organ donation, because I'm not, but look at it this way. You want us to transport patients who are still in arrest, something which is known to greatly decrease their chances of survival, as well as put every provider in the back of the ambulance in harm's way (we, like most services in this country, don't have seating which allows providers to remain seat belted in while doing CPR), not for the purpose of saving the patient, but to save his or her organs. I'm all for organ donation, but our role is to try and save our patients, and to keep ourselves safe in the process.

Looking at it from your point of view I would be appalled too. My personal safety is of paramount importance, always. However, we work differently to you guys. The code is worked onscene according to protocol. Then, a decision is made to transport if the patient falls into the trial category (<75yrs and no other medical conditions that contraindicate) The service in question then uses an automated compression device and a transport ventilator (as opposed to a BVM). The drugs would have been drawn up before hand and would be given whilst in a belted, sitting position. The monitor is also so positioned that it can be used from a sitting position. Organ donation is not the primary aim, by the way. Of course we are far more focused upon making a save but we also realise that we can't save them all and so try and make the best of a bad situation.

Here's a pic of the inside of the vehicle for you to understand a little better what I mean:

Carl

Actually the suppression of emergence phenomenon with benzodiazepines is a myth. There are two direct studies into this, neither found a difference in the emergence phenomenon when midazolam was adminstered concurrently. Well, one did, but it was not powered to detect a significant difference. Certainly midazolam is recommended if emergence occurs, but it won't stop it occurring.

Wathen JE, Roback MG, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double blind randomized controlled emergency department trial. Ann Emerg Med 2000;36:579-588.

Sherwin TS, Green SM, Khan A et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized double blind placebo controlled trial. Ann Emerg Med 2000;35:229-238.

McCarty EC, Mencio GA, Walker LA, Green NE. Ketamine sedation for the reduction of children's fractures in the emergency department. J Bone Joint Surg Am 2000;82-A:912-18

Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97

Green SM, Johnson NE. Ketamine sedation for pediatric procedures. Part 2: review and implications. Ann Emerg Med 1990;19:1033-46.

Green SM, Kuppermann N, Rothrack SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35:35-42.

Hello Paramagic,

Thanks for talking the time to reply.

I am aware of the problem in children, that's why I tend to steer away from ketamine in this patient group. My opinion was based upon administration to adults. I have never taken part in a study, so my evidence is anecdotal, but I have never seen a serious form of re-emergenge phenomenon in subjects that have been given supplemental midazolam in the 10 years I have been using it. I have, however, seen it in patients that were given just ketamine.

Carl.

Morning all,

Well, this has turned into a great discussion on myths in EMS.

FIrst of all, Here's the link about automated compressions in PCI (not exactly convincing results, but it's a start).

To adress some other points that have cropped up during the discussion:

Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field? Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest?

I already touched on this, potential organ donation is one issue.

. I'm surprised that antipyretics don't help to reduce the incidence of febrile seizures, though. I really need to look up the standard model of care for sepsis and SIRS with regards to this protocol.

Well, actually, the jury is out on this one. There is a body of evidence that would suggest there's no benefit. One of the inital problems is that paracetamol is often used incorrectly by parents in terms of dosages. Sponging the child has proven to work faster than paracetamol but the effect of the drug lasts longer. However it's benefit lies within symtomatic relief, something which you would hard-pressed to deny a child. As EMS providers we would nood see the long-term benefit of sustained administration but it is not necessarily bad practice to iniate it. As far as anti-pyretics are concerned in sepsis, I agree, there is little benefit as these pts need far more aggressive therapies like parenteral antibiotics and fluid monitoring and management strategies (basically an ICU bed).

Ketamine would be ideal, however I don't know if ANYONE around here is using it, not even in the hospitals. I don't really think fentanyl or morphine would be appropriate for a patient who is hemodynamically unstable.

Ketamine is a great drug and I am so glad to have it in my arsenal. However, it is not good practice to give it stand-alone. Ketamine works differently to other analgesic/anesthetic agents. It's a NMDA receptor agonist. It only shuts down those receptors that are responsible for conscious thought but not all senses. It can lead to intense dreams or nightmares and the so-called re-emergence phenomenon. This is where the patient literally screams his or her way back into consciousness. However, there is good news, this effect can be greatly reduduced by a co-commitent dose of a benzodiazepine. My personal choice is midzolam. I have recently been trying new options in pain management strategies (I have a very liberal protocol with lots of room for manoeuvre and a willing Medical Director). I recently attended an MVA with a young adult with multiple fractures. With a combination of ketamine 0.5mg/kg and fentanyl 0.01mg/kg topped off with a 2mg bolus of midzolam the pain score went from 9 to zero in less than a minute. Without snowing the patient under, either. She remained reasonably stable throughout the whole process. As far as I am concerned, ketamine has a great future in EMS.

Carl.

Oh god what i wouldn't give to have ketamine in my kit bag!

Yep, got to say, I really think it's the dog's bollocks. Your patient is one minute writhing in agony and snoring gently the next...

C.

Morning Bieber,

Well, I must say that you are very ambitious. One thing you'll have to remember is that Rome wasn't built in a day. If I were you then I would pick out 2 or 3 of these subjects on focus on changing those first. My choice would be c-spine clearance, standing orders for pain management and a reappraisal of dosages in the pediatric patient. You have plenty of other relevant "burning isuues" but these would be my priority. Yours may differ, I don't know.

I'll give you my take on the rest:

MOI in trauma is a good indicator of the types of injury one might expect. Don't forget that if someone does not intially present with symptoms then it's not to say there's nothing going on. There are many cases of particularly splenic and liver injuries with late on-set presentation.

Elimination on restrictions on EKG/IV application. What do you mean?

EKG/BP/Spo2 montoring of patients that have received narcotics or sedatives is good, safe practice. Why would you want to change it? The subtle signs that monitoring shows may alert you far more quickly to a impending problem.

Eliminating transporting Code Blue patients: Here I tend to agree, to a point. We all know the importance of BLS and that massage in a moving truck is pretty ineffectual. However, there is a progression towards automated compression with a Lucas or Zoll. This changes the rules somewhat as there is a growing body of evidence that suggests PCI (angioplasty) in cardiac arrest may have some effect. Also, we are currently trialling a new protocol which indicates transport in potential organ donors.

Cardioversion as a standing order: Agreed! Clinically unstable patients that do not respond to pharmacological agents need treating stat (God, did I just say, STAT? Shoot me..). I would however advise an adjunct protocol for the administration of a benzodiazepine. Cardioversion without Versed on board..Oww!!

Pain management: agreed! Multi-system trauma should not be excluded. If anything, they have more right to be medicated. Pain is a disabilatting factor that leads to higher mortality. Pijn management protocols should be linked to the individual pain score. My personal favorite is a combination of ketamine, midazolam and fentanyl..

NSAIDS? Mmmm.. I have limited experience of these drugs in EMS. The only real benefit I saw was with diclofenac in renal colic patients. Wouldn't be my first choice. Also, there really are not many patients by which opiates are contra-indicated.

O2 therapy only to those who need it: I agree wholeheartedly! By now we all know about the effect of 02 generated free radicals in the MI patient, don't we?

A protocol for febrile patients is actually quite easy: cool em' down and give IV/rectal paracetamol titrated to weight/age.

Treat and release options: One of the problems in US EMS is that most of the ground rules are based on the lowest common denominator. Whilst you come across as being a very engaged practitioner that is hungry for new knowledge, that can't be said of everyone. Can a part-time medic with a certificate from a paramedic mill school be trusted to make that decision? EMS needs to pull up it's boot straps nd make a degree mandatory before we take that route. (Or be a nurse-led profession, but I wouldn't want to offend anyone here..)

Here is the link to a presentation I gave in Pennsylvania last year, there is a relevant section on pain mangement in the middle. You have my blessing to reproduce, should you wish...

https://docs.google.com/present/edit?id=0Adxb-ZUzuZENZGdkendqcG5fMThkenJnZDZkMg&hl=en

Good luck with your crusade!

Carl

Edited to include link

We have a program where we take BSN students on for an internship of 6 months. In that time they learn all about EMS (EMS is nurse led here) and undertake a clinical research project. I think it really raises awareness of the job. The group I'd personally like to see ride-along is the dispatchers. They'd then get for more understanding of their own job too. Currently they are required to do just 1 day during their initial training and that's it.

Carl.

Sorry if I ruffle feathers but I guess I see things a little differently. And I am unconcerned with the whole "I am a paramedic, I am the only one that can help a patient cuz I got drugs" mentality. BLS providers are a huge link in the chain of survival and without them getting there first in some cases, mortality rates in rural areas would be bigger than they are now. The old saying of "Paramedics save lives, EMT's save Paramedics" cant be truer because unless we remember where we started at? all the drugs and IV's and C-PAP and cardiac monitoring wont save a patient if we dont have the very basic skill of opening an airway.

I agree entirely. There is a very important role for EMT's in the First Responder role. But that isn't to say that they should replace paramedics because of cost issues. That's the issue, to me, that needs fixing.

Carl.

I don't see a need for either medical control or my supervisor in this situation, as it truly is relatively straight forward if you've been taught critical thinking skills.

I think that this thread is an awesome idea. As I've said many times in the past, I believe the vast majority of my most difficult decisions have been moral/ethical, not medical. And I don't think that I see a lot of this being taught, and very seldom see it practiced. I think we need a forum just for moral/ethical scenarios.

When I state that the above scenario is relatively straight forward what I mean is that if I begin at the beginning, the fact that I am there not to cover my ass, but to be a patient advocate, then forcing this woman out of her house if she's mentating properly is going to be so far down on my list of possible options that it's unlikely that I will ever get there. She has a support system in place and is healthy enough to choose to rely on it instead of going to the hospital. Educate her and the neighbor to watch the bruises as they can become a significant health risk in a pt of this age, help her to the bathroom, get her comfy, make sure her telephone is within reach, remind her that I would like nothing more than to come over and help again if she needs it, and then document the shit out the call in case something goes sideways.

Easy, right? I'm not sure at what point MC or a supervisor would have become useful unless I believed her to be significantly damaged and I couldn't change her mind about transport.

Great thread. It would be fun if everyone posted their 'weird' calls, right? So we can flex our brains a little bit down this logic path.

Dwayne

Finally someone who turns this call around to see it in perspective. Of course this lady doesn't need to go to hospital (where, at her age, she would signifcantly be at risk from all soorts of hospital-based pathogens), she needs helping up and a cup of tea. And some help and advice to the carers about preventing falls. Yes, even in this case, there is a role for preventative medicine.

Carl.

Perhaps you're reading it wrong. Our nearest medic is about 30 miles away. I ain't waiting for them to assess my patient... And I'm not following any protocol that says I can't recall the ALS provider. The people who makes these updates, clearly haven't been active in the EMS field in quite some time. However, as far as the BLS protocols. We were already full compliant a year or more ago. The subtraction of the MAST just made our cabinet look a little neater.

Yes, but why is your nearest medic 30 miles away? Because your community does not see the value in ALS. Maybe that's not the best starting point...? Once again, I have no wish to banish Basic's but I don't think they should have sole responsibility. That's why I think this amendment might not be a bad thing.

Carl

Whether or not it's a politically motivated change, I think it's a change for the better. My predecessor has already pointed out that ALS can do things for the pt. that BLS can't. Pain management springs to mind here. Not that I'm suggesting for one moment that there is no role for BLS. They are unmissable in the First Responder role and play a major part in patient care. However, at the end of the day, I would want to be looked after by someone who had a little more understanding of my condition and the treatment options.

Hope I don't ruffle to many feathers.

Carl.

Phila international airport has one dedicated medic unit (medic 30) that does about 1,500 runs a year. Terminal E is on the far north end of the airport at the furthest point from the escorted/secure entry point. PIA is at the furthest southwest point in phila as well. There are alot of unanswered questions here, and thus not enough info for any real answers. Within 15-20min of the airport are M19,M3,M37,M11,M23,M43,M14...not that only a bad night everyone could be out on calls but being in the system I havent heard anything of thia incident unless its rather old and just making the news.

Not to mention Tinicum Twp Volly EMS being about 5 minutes away. With ALS backup from Crozer-Chester at less than 15 mins..... I guess no one likes crossing boundaries. Which is pretty ironic since that's all you ever do from an airport.

Carl.

The only way to go!!! (At least you wont get confused with LEO......

Carl.

You know when you're having a bad day in EMS when your aortic dissection patient starts moaning he's going to die, his nurse escort starts vomiting due to travel sickness and your partner drving hits the central reservation on three wheels in the driving rain. (I still have no idea how I got to retell that story)

Carl.