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systemet last won the day on March 16 2015

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  1. Hypertension

    The problem with these case presentations, is we each imagine a slightly different patient. I look at this and see someone hypertensive, with some mildly concerning symptoms; headache, dizziness, proteinuria, and you see the beginnings of hypertensive encephalopathy. We may both be right, but we're just visualising different patients. It's really hard to talk in hypotheticals. I think the analgesia for the headache is a little problematic here, and the best agent probably depends on the severity of the pain. If it is severe and debilitating, some morphine might be a reasonable choice, but runs the risk of obscuring the initial neuro exam, complicating and worsening any change in level of consciousness, and causing a rebound effect. Most headache situations I tend to opt for toradol, but with this hypertension, and the ACE inhibitor, there's got to be some concern about renal function, which means toradol probably isn't the best choice either. I think if you're going to treat, small aliquots of morphine might be the best. If we were to attempt to reduce MAP, labetalol seems like a good option, as you've got some alpha effects there too. I think there's got to be some respect for the history of reactive airway disease in this patient if we're going to give a better blocker, though. In years gone by, we gave nicardipine (adalat), but created some spectacular messes, as it tended to be a little unpredictable. I'm not sure what the best practice is here (hopefully ERDoc can educate us), but based on what I have available on my ambulance, if we treated, I'd expect to get orders for some IV nitroglycerin, maybe with some metoprolol to block any reflex tachycardia.
  2. Hypertension

    So, based on the initial description, I wouldn't treat this. Yes, she's hypertensive, and she has a headache and some dizziness, which could be the beginning of a CVA. That being said, she doesn't have any altered mental status, any focal neuro deficitis, any slurred speech, photophobia, nuchal rigidity, ataxia, vertigo, etc. Even if she is having a CVA, this may be the MAP she needs to autoregulate. If, and it's a big if, she's having a CVA, then our target MAP is going to be different based on etiology. I would sit on the patient, reassess, and let the ER work her up. Edited: for grammar, and to add link.
  3. ASA and NTG or no?

    So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit. * It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk. * Traditional spinal restriction results in a 20% decrease in FRC, which could become a trigger for pre-hospital RSI. * Spinal immobilisation can complicate airway management, and increases ICP. * The LSB is a relatively poor device for spinal "immobiilisation", as you're trying to force a curved structure to conform to a rigid plane. * Healthy volunteers often develop neck pain, and report moderate-to-severe pain when immobilised on an LSB, which can result in unnecessary imaging, which carries costs and risks to the patient. I think the rolls/blocks are primarily there to remind the patient not to move their head. Which is pretty much what they do on an LSB, anyway. I think we're all aware that a patient can generate substantial joint motion while immobilised. There's also the question as to how great the benefit really is with traditional techniques. Only a very small percentage of patients that are immobilised by EMS have c-spine fractures. The vast majority of these are stable fractures. Even most of the radiographicaly "unstable" fractures are not grossly unstable, as in the patient will move their head and displace their c-spine. They're unstable in the sense that it would be unwise to discharge them home, to play soccer or football without addressing the injury. Even when injury does occur in a patient that presents neurologically intact, it's difficult to know whether this is from motion during their care or the natural progression of the initial insult, e.g. cord contusion/concussion. There's a certain argument that the force required to fracture the c-spine is many magnitudes of order greater than any force the patient may apply through voluntary movement of their neck. Also, consider the care provided in the ER, where often the patient is removed from the LSB prior to radiography, and left supine with instruction not to move their head. Even after an injury is identified, it's not like the patient is immediately put back on an LSB and then halo'd. They're basically put on a soft stretcher, and told not to move their head, and log rolled by staff. That's all this really Is. It may be a change in care for EMS, but it's not really a divergence from standard care in the ER. The patients that are combative are still on the LSB --- and these are the patients the ER typically leaves on, right? Because we're using it as a restraint device as much as anything else. The patients that are intubated are still on the LSB -- they can't splint, and tube displacement is a potential disaster. The patients that are significantly altered, or who can't follow instructions due to a cognitive issue or language barrier, they're still on the LSB too. But what's happening, is there's a recognition of the limitations of the LSB, and that "immobilisation", is a fantasy -- what we're doing is restricted motion. This can be accomplished in a number of different ways, which can be tailored to the patient.
  4. ASA and NTG or no?

    Sorry. I hate it when people introduce new abbreviations without defining them. Spinal Motion Restriction. Just another way of saying "take c-spine". Implicit to the term is the idea that you can't immobilise the c-spine short of surgical fixation, just that you're trying to reduce movement, i.e. not everyone needs to be on a long board, not everyone needs to be supine, and a collar isn't a halo. Interesting discussion. I don't see the need to take this person to a center with cathlab, CT-angio, neuro-ICU or trauma services. It would be a good idea to aim towards a site with inpatient beds and a CT. There's not much information available here to guide this decision. Common things being more likely, I wonder if, in the end, our fellow might not have a touch of the pneumonia, and be a little dehydrated, weak and/or orthostatic.
  5. ASA and NTG or no?

    Re: the above; it's a gestalt, you take all available information, formulate a list of DDx, and find a working diagnosis. It's not treat the X, not the Y. It's treat both. This is a great attitude, so we should keep this discussion constructive. I think there are two questions here: (1) Was SMR indicated? and (2) How should SMR be performed? On one hand, you have a ground level fall in a 58 year old man. He's moving all four limbs without gross motor weakness. There's no obvious deformity to the c-spine. On the other hand, it's not clear how alert he is, and whether he would be able to report any paresthesia or sensory deficits that he might be experiencing. For c-spine rule-out, the first question is whether there's a potential mechanism., I would submit that a ground level fall in a 58 year old, probably isn't. But this is a matter of debate, and how you interpret this probably dependings on practice in your area. If you do feel that a potential mechanism exists, then, as indicated by ErDoc who's much smarter than me, then SMR is mandated. As to how SMR should be performed, I think the best choice would be to place the patient supine, with a C-collar on, and instructions not to move their head. If he is hypoxic, and becomes distressed while supine, they he could be placed semi-Fowlers, with the same. If he needs to be spinalled, and can't follow instructions, then you have to decide if he can tolerate being supine. If he can, a scoop or long board might be in order. My opinion, and it's just that, is that none of the ECGs attached show a.fib. I didn't see this patient, but my opinion is that I'd be unlike to placed oxygen on someone who didn't appear hypoxic, just because they have a few PVCs, and I can't get an SpO2. The question here is, are these PVCs acute or chronic? I don't see anything here that really pushes towards acute hypoxia as a cause. It seems more likely that this is a chronic exam finding for this patient. So, as others have mentioned, your ECG has a lot of artifact. Reading through it, and making my best attempt to fill in the gaps, I see a sinus rhythm with probable LAFB, with frequent PVCs (probably from high on the posterior wall of the RV), and Q waves with some very modest ST elevation in V1, V2 (and maybe V3, V4). There's also voltage criteria for LVH. I think this represents prior cardiac disease that either the patient is unaware of, or the staff are unaware of. It may or may not have been seen by a healthcare worker before (you'd need old ECGs for comparison). As this ST elevation is modest (much < 25% of the preceding Q wave), I'd suggest it's probably persistent elevation from an old infarction, versus a new acute event. Serial ECGs and troponins will be necessary to know for sure. In any case, there's no criteria for diagnosing STEMI in a background of LVH. I'm sure there's cardiologist who can do it, but I don't think it's an EMS thing. I don't see the lateral ST depression, and just want to point out that you really don't see reciprocal ST depression in V5-V6. Especially not to anterior elevation, which typically only produces reciprocal change inferiorly in the presence of lateral involvement. If it is there, another possibility is LV strain, but like I said, I don't see it. I don't think I would have put on oxygen, or attempted SMR. My primary concern here would probably be the risk of traumatic brain injury from the impact, especially if the patient is anticoagulated, and I expect they would get wound closure and maybe a CT. Then there's the question of whether there was a medical reason for the injury. It's unclear from the history whether this was a true syncopal event. If there has been a progressive functional decline, sepsis and medical change/interaction have to be high up the list of differentials. It's possible he's NSTEMI'd, or having a TIA/CVA, but I don't think there's anything definitive in the story here. Just opinions from another paramedic.
  6. Hypertension

    Thanks for posting this. I embarrassed myself very early in my career as a paramedic by withholding analgesia from a 20 year old woman who called from a very divey motel, asking for morphine for her cholecystitis. I told the staff that she seemed like she was med-seeking, because she had a vague abdominal complaint, requesting analgesia within seconds of my entering her room, had a psych history, and was unkempt and living in a dum, oh, an her heart rate was 70 and her blood pressure was normal. A resident took me aside, and instead of telling me exactly what an ignorant fool I was, took the time to explain to me that pain, especially from hollow organ injury, often comes with a vagal component, and that heart rate and blood pressure changes are insensitive and nonspecific. Some years later, I've formed the opinion that there will always be medseekers and drug addicts. Many of them will be very manipulative, and very convincing actors. And this leaves me with two choices; (1) I can try investigate all complaints of pain, and see if they qualify to meet my subjective standards for what acute pain should look like, and withhold analgesia from people with questionable histories. This comes with accepting that I will inevitably withhold analgesia from some people in acute pain. (2) I can stop judging people, and accept that pain is what the patient says it is. This comes with the risk of giving opiates/opiods to someone who is drug seeking, and potentially encouraging further system abuse. But, given the fairly trivial amounts of analgesia that I'm giving, it's unlikely anyone is getting too euphoric from 5-10mg of morphine, given that a lot of the addicts I meet are using over 200 morphine equivalent milligrams of diverted prescription opiod per day. I'm probably just easing their withdrawal symptoms. This comes with the benefit that I no longer have to be as judgmental towards my patients, and no longer run the risk of failing to provide analgesia to someone in severe pain, and giving them a label that will likely follow them through the ER, and probably into other areas of the healthcare system, all because theiir presentation doesn't meet my entirely subjective, culturally-biased and ill-educated opinion of what acute pain should look like. As a paramedic I am always appalled when I see articles like these being published:
  7. ECG diagnosis

    So..... The ECG looks nondiagnostic. There's not much information provided. I'd like to know a little more about the H&P to get an idea of whether this is potentially ACS, because a description of "chest pain" without any clarification leaves a lot of ddx on the table. It might be nice to risk-stratify this patient. If there's a reasonable suspicion of ACS, then some biomarkers might be helpful, and might direct us towards transporting to an ICU-capable site.
  8. Medic Minute Videos

    Hi, a few comments regarding the excited delirium "medic minute". First, I noticed that it was slightly longer than a minute! * The physician talks a lot. The expression "a picture is worth a thousand words" may apply here. Would it be possible to find some video footage of a patient suffering from excited delirium to add to the presentation? For example, some excellent video is available here: * Have you considered having a paramedic introduce topics regarding appropriate restraint tactics? There are few areas where we have more relevant direct exposure and clinical experience than a BCEM physician, but this is one of them. As a paramedic, it sometimes grates when a physician is lecturing about field triage (if they don't have prior military or EMS experience), or field restraint. This may result in more buy-in from your staff. * The direction to restrain the patient on an LSB so that they can be rolled if they vomit seems to contradict the general admonition not to place any restraints that interfere with respiration. While this may seem obvious, it may be wise to emphasise that the chest restraints should be placed more loosely than with conventional spinal immobilisation. * I am surprised that there is no mention of chemical restraint, or treatment of the excited delirium here. I realise local medical protocols vary, but I think a case can be made that there is great danger to both the patient and first responders here if you don't attempt to address the agitation. In my region, the immediate priority would be to get 10 mg haloperidol / 10 mg midazolam in I.M. as rapidly as possible. Are you willing to allow your paramedics to fluid bolus or give sodium bicarbonate if there's QRS widening, or ongoing severe agitation? Are they being given direction as to how to proceed if the patient's temperature is 41 C? Is ketamine an option in your service? There is obviously a cost/benefit analysis here, and there has to be a level of comfort in the paramedic's ability to continually re-assess the airway and manage it appropriately. But sometimes something done poorly, or with a lower level of skill than present in the ER, is still better than doing nothing. * This is a matter of personal taste, but the music is a little irritating. Also, on some visceral level, the images of a bunch of guys in bunker gear sitting in a pump truck annoyed me. It seemed that the consistent message of this video, was not restrain the patient prone, to avoid placing knees on the torso, and not to restrict the airway or respiration. However, there was not a lot of concrete information on how to do this. If this was something I was developing, I would look to emphasise the following things: (1) An understanding that this is a medical emergency, and a brief discussion of some of the potential complications, e.g. restraint asphyxia, arrhythmia, MH, rhabdo, etc. Make your paramedics buy in to the idea that this is potentially a critical ill patient, not simply someone with a mental health or substance abuse issue. These patients are often blamed for their pathology, which results in suboptimal care. (2) Recognising that this is a team sport. The smartest thing anyone can do in this situation, is to: * Avoid engaging, if at all possible, until a plan is drawn up amongst responding agencies. * Have EMS and law enforcement discuss how best to proceed, e.g. prepare restraints, draw up chemical restraint, briefly verbalise the risks of prone restraint (law enforcement should already be aware, but depending on your locals, they may not). * Calm any family or bystanders, and warn them that any restraint procedure is going to look violent, but your intention is to help this individual. This act more than anything else will mitigate potential legal issues later on. You want sympathetic bystanders, if at all possible. * Not rush. Sometimes your (or law enforcement's) hand is forced. But an under ideal circumstances, a brief scuffle for some IM chemical restraint, if you can, disengage, and let it have some effect. Then, a restraint procedure, likely followed by further chemical restraint, hopefully IV access for better titration, and then an assessment of life threats, e.g. 12-lead, acid-base status, hyperthermia, etc. Largely this is about having law enforcement and EMS work together. And it rarely works perfectly. Often your EMS providers will arrive to six cops sitting on a prone subject, cuffed behind their back. They need to know that their most important task here is to advocate for this patient, and make sure they're appropriately restrained. In my area, not chemically restraining someone like this would be negligent.
  9. When it sucks to use sux

    So, just to finish off a couple of thoughts: * He probably needs to be intubated, but his primary issue right now is circulatory collapse, not oxygenation, assuming there's a reasonable pleth with that pulseox, and there's no (unlikely) causes of a false high reading. * His HR of 170, producing a MAP of 50mmHg means he has no preload / stroke volume. If you switch him to positive pressure ventilation, you increase the pressure in his chest, compress the IVC/SVC/RA/RV, and risk turning that into 0/0. * Any instrumentation risks vagal afferent discharge, which is going to drop that rate. Our current pressure is not compatible with sustained life at a HR of 170. If we vagal him down to 120, we risk landing on 0/0. * His preintubation saturation places him right on the shoulder of the oxyhemoglobin dissociation curve. If you can bring his pressure up, you can probably use CPAP or BVM+PEEP to improve his oxygenation, giving you a longer safe apnea time. Paralysing at SpO2 89% is not impossible, but it would be nice to avoid. If we can improve oxygenation, we have a safer RSI. So, given the primary issue at the current time is circulatory, we should optimise hemodynamics first. I think this would be a good time to ensure we've done all our basic airway management, give a couple of liters of fluid, prep our push pressors, or, better yet, as triemal suggested, have that levo up and ready to go. I don't think you'd be wrong to push the pressure a little high pre-intubation, knowing that it's going to come down once they're tubed. This patient is very sick, and a cavalier and rushed approach to securing the airway is going to risk disaster. I feel like I'm echoing everyone else's points. I think there's been a lot of well-reasoned responses in this thread already. A couple more things to add: A ketamine-alone approach avoids some of the dangers of paralysis, but also carries some risks. There's still a chance of causing apnea -- you have to appreciate that this patient is peripherally constricted, so your peak CNS concentrations are going to be higher vs. an equivalent dose in a less shocked patient. An overaggressive or too rapidly administered dose of ketamine can cause respiratory depression or outright apnea, without the benefit of muscle relaxation. I wouldn't expect too much of a bump in pressure here with ket, as the patient's already tached out. If anything, I'd be prepared for the ket to drop his pressure. It's probably still the best agent here, although arguments can be made for etomidate, it pretty much mandates paralysis. Ketamine-alone is not generally going to give you the same intubating conditions as paralysis. Generally it's going to be inferior. So you're hoping that your ketamine doesn't worsen the patient's condition, and accepting that the intubation itself may be more difficult. This is a balancing of risks. Your hoping that you preserve respiratory drive, which should be advantageous, but you're accepting less-optimal intubating conditions, and potentially a more prolonged or repeated procedure in the hope that your patient is less likely to deteriorate. This isn't a given.
  10. When it sucks to use sux

    [my bolding in text]. I think chbare nailed this. There's a couple of things to think about here: (1) Why are we intubating this person? Clearly, having aspirated, and with a GCS of 5, they're at risk for further aspiration. Although, to some extent, that ship has already sailed, we can still make things worse if we allow the patient to aspirate further. At this point, it's probably not for oxygenation. An SpO2 of 88% is compatible with ongoing life, especially when you consider this person's probably a little acidotic and right-shifted. PEEP would be a consideration for ongoing management, but not until we raise that MAP a little. (2) How are their baseline hemodynamics, and how is RSI going to affect them? Right now, we have a SBP of 60 mmHg, with a HR of 170 bpm. Given the relation BP = CO x PVR; i.e. HR * SV * PVR ... [will return, have to run!]
  11. 3 ft fall spinal immobolization

    Thanks for the links. I should have read both of these a long time ago. Question : How many C-spine radiographs / CTs do you have to do to cause one terminal CA case, or preventable miscarriage / disabled child? I'm sure someone has looked at this. But, being a thinking sort of person, I'm just curious as to how close the danger of radiographic clearance in medium-risk patients is, compared to the benefit of identifying a potentially disabling, fatal or irrelevant injury? Also, re: statistics, the n-values seem quite large. I don't think I'll be amateur-sleuthing down that dark and tangled path. I far prefer selecting whichever arbitrary test produces significance in Statistica, Wilcoxon signed-rank test, n = 7, anyone?
  12. 3 ft fall spinal immobolization

    As a paramedic, I find this debate very interesting. There's an obvious disparity between practice in the US / Canada, and in Europe/Aus/NZ. In North America, there's a far greater percentage of patients receiving SMR, they're more likely to be transported on a backboard versus a scoop or vacuum mattress, and very unlikely to be transported in just a C-collar in semi-Fowler's, or have their spinal restriction removed prior to a physician assessment. I haven't read the studies that these numbers come from. Perhaps I should. But when I see numbers llike 99.6% and 100% being compared, I have to wonder, what are the n-values and CIs associated with each? What's the power analysis of the studies that have been performed? What is their alpha error? I do recall reading that CCSR is more sensitive versus Nexus. From a clinical perspective, I think there's a big difference between a "c-spine fracture", and an "unstable c-spine fracture". I wonder how many of these 0.4% were patients that required a halo, or surgical fixation? How many wiere at risk for cord injury? I'm sure you've seen plenty of people present several days after an injury that's resulted in a vertebral fracture without a negative outcome. In practice, using something resembling CCSR, I've always thought that the assessment of whether a potential mechanism of injury exists to be extremely subjective. If you don't have a potentially significant mechanism, then the rule isn't used. A simple ground level fall onto a soft surface might not be a major concern in a 20 year old who has syncope'd, or tripped over their own feet, but is a different issue in a kyphotic 80 year old with a hx of long-term steroid use. At what point is the process of immobilisation and clearance too cumbersome, and too inefficient a use of very scarce and expensive resources? Tort damages in the US essentially mandate very conservative practices, where some other areas have limited liability or face lesser mean damages. There is a great variance worldwide, even in industrialised nations, in how c-spine immobilisation and clearance is performed, which is interesting when one considers that ultimately everyone is trying to do their best for the patient. As an aside, I quite like this document from the UK: It seems quite progressive. I would like to hope that one day my practice could more closely resemble this.
  13. Good ways to kill patients

    Happened to me the other day. I was drawing up my ket and sux, and my EMT kept on bothering me, and I couldn't understand why, and then I realised that the patient had actually been decapitated, so it was completely unnecessary to RSI him. We had a dig around, and ultimately found his trachea and stuck a tube in it, then my EMT was bothering me again, and I realised we were blowing air out his hemisected torso. It was a bit embarrassing.
  14. EMS Diversions - what it costs

    I agree wholeheartedly. I'm surprised that the admission rate is so high, although I think we'd also agree that the majority of the admitted patients were probably not time-critical in the sense that a 15-30 minute delay would have affected morbidity/mortality. In terms of improving education, I think we need to alomst start from the beginning, and move it into a university model for paramedics, and a two year diploma for BLS.
  15. EMS Diversions - what it costs

    I think that very very few of our patients are time critical. Examples of time-critical patients probably include: * STEMI patients who have not received fibrinolysis, or whom are best served by primary PCI, or who require rescue PCI. * Suspected acute AAA / TAA. * Predicted difficult airway with anticipated need for intubation, e.g. significant laryngedema/angioedema * Suspected ischemic stroke inside fibrinolytic window, or "fairly close with good prognosticators/baseline:, i.e. anyone who might get 'lytics. * Respiratory failure / NIPPV patients continuing to decompensate * Possibly treatment-refractory status epilepticus. * A subset of sick status asthmaticus / treatment-refractory anaphylaxis * Pentrating trauma * A small subset of blunt trauma patients. And that's about it. Someone else will probably find a few things I missed. Things that aren't time critical probably include: moderate asthma / COPD exacerbations, most overdoses, including a fair few that are intubated, most blunt trauma, etc. I think when we really look at a lot of those patients, for example, the average polypharm OD -- once this person's been intubated, they can probably be driven intubated another 15 minutes with relatively low risk. Because they're probably going to sit and have their liver and kidneys, and maybe a few plasma esterases, do most of the work for the next few hours or days. Likewise, many of the "chest pain", or "suspected ACS" patients we've historically got very excited about are just going to sit and homeostase and get a couple of enzyme draws. Understand that I'm a proud paramedic, but I believe that EMS has oversold and under-delivered. Just like the ER, the majority of our work is primary care, dealing with patients that could have gone to a family medicine clinic. We do relatively little for these patients, but have a window of opportunity to direct them elsewhere. Where we see acutely sick patients, most of the time our care is primarily supportive and the best thing we do is take them to the ER -- where, at the same time, often they provide little more than supportive care until they move to ICU or whatever service is going to provide definitive care. I think, like everyone else on this forum, and very few people outside of it, that we need to raise our educational standards, and start refocusing on the bulk of our call volume. Typically we deal rather poorly with seniors and geriatric care, we are not great at mental health, or palliative care, or dealing with the social work that form much of the basis of EMS. Some of us get good at this through natural ability and a process of trial and error and repetition. These are obvious areas for improvement. While this is hardly unique, my system allows me to respond to palliative patients, liase with their palliative care physician, and give them pain control, antiemetics, bronchodilators, or arrange home oxygen, without having to take them into the ER. This is in its early stages, but has been well received. Other systems/regions have looked at developing paramedic/NP teams that are the first point of contact for seniors calling with urgent complaints from designated high volume centers. We're also starting to do a better job of accessing community resources, e.g. homeless shelters, following up on our high volume users, or patients with chronic issues, e.g. high risk seniors needing placement. I think these are areas where we can improve. Every paramedic wants to do prehospital ultrasound, start art lines and do EGDT, start central lines, etc. Relatively few people want to get better at picking grandma up off the floor. This might not be what most of us expected or wanted when we entered this field. I think many of us have been seduced by the idea that people call 911 for acute medical events, where we can meaningly intervene in the field -- and this does happen, but these calls represent a minority of the events we see. I think the lack of real depth in our initial education has led us to overestimate the severity of many of the patients we encounter, and changes in our societies have led to more urgent versus emergent calls. I think that we need to move away from a public safety role, and towards a model where we form part of the health care system and present the point of first interface with the healthcare system. . I'm not sure how well I'm making my point, and I'm certain that these ideas are far from unique or revolutionary, but this is how I see EMS moving forwards in the future.