systemet

There's a page here (obviously low-quality source, and likely biased with the URL "diana speaks") http://www.dianaspeaks.info/AutopsySummary.html It suggests a chronology where the crash happens @ 0025, fire arrives at 0032, and the MICU arrives @ 0040. Apparently she was perfusing enough to be screaming in pain, and receives fentanyl / midazolam from an IV line initiated @ 0045, prior to extrication. It's unclear from this site whether this was to facilitate airway managment, or for extrication (doses unavailable in source). This was a few years ago now. I think today, the answer would probably be a small aliquot of ketamine. She arrests five minutes later @ 0050, it sounds like "during extrication". She's subsequently intubated, and they requests a transport destination w/ a surgical ICU bed at 0119, subsequently receiving direction to transport to a hospital four miles away @ 0129. She arrived with a pulse, strangely "without severe external injuries" @ 0206, which seems like an awfully long time to drive four miles. She rearrested at or before 0216. -------- Again, this source is probably very unreliable, and likely inaccurate. But based on this information, I'd assumed they'd thoracotomised her in the field, and were attempting some form of surgical correction. Apparently though, she wasn't thoracomtised until after her second arrest, where they (according to this source), found a partial rupture of a pulmonary vein near left atrium. They continued resuscitation until 0400. My suspicion is that the extrication itself chewed up a sizeable chunk of the on-scene time. But I can't account for the prolonged transport time. Also, according to this source, there was no chest tube on arrival. To me, you witness a traumatic cardiac arrest, you immediately drop both sides of the chest, intubate and bolus fluids. I would assume that a physician-led team would, at the very minimum, throw in a pair of chest tubes, and consider opening the pericardium (at least in the pre-portable ultrasound era). Of course, here the blood in the chest, and the PPV was probably doing something to tamponade the venous bleed that killed her.

Zippy, take a deep breath and read what I wrote again. We're making the same point. All the best.

This is an important point to remember. Ultimately it's a decision you may as a society -- do you want to take the risk of suffering a severe medical event, and not having coverage, and receive the benefit of lower taxation, or are you willing to have the government provide mandatory health insurance, and have higher taxation. For most first world countries, the choice is to provide healthcare as a basic right. That's just a statement, not a value judgment. But as Mikey points out, you're paying either way. The trade-off is a balance between what you're willing to accept for personal taxation versus what risk you're willing to accept from unanticipated healthcare expenses. As an aside, some countries have marginal tax rates of over 50%, but this isn't the same thing as flat income taxation of 50%. Of course, you can argue what percentage of the tax burden comes from sales tax and costs conveyed from corporate taxation.

No advantage, really? How does an extra decade of education make a worse provider? How is a paramedic better than a physician? Cheaper, perhaps, but that's about it. After racking my brain, I've got about two things I'm better at doing than the average EM doc; (1) Not getting myself killed in unsafe situations, (2) MCI Triage - not that this is particularly difficult, I've just done it for real, more than most of them have. Other than that, I can't think of anything else? Maybe I see more people with hypoglycemia? I doubt a board-certified EM doc is going to miss that one, though.

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.

Short answer, the PETCO2 may be high, normal or low. It's going to reflect respiratory compensation for an underlying metabolic acidosis, but is also dependent upon hemodynamics and pulmonary function. Changes in PETCO2 and PaCO2 are going to be very non-specific and insensitive in CO poisoning. You can expect PaCO2 to decrease in the early stages of poisoning, as the patient hyperventilates to create a compensatory secondary respiratory alkalosis. As they become obtunded, the PaCO2 is going to rise, and they'll develop a mixed acidosis. Whether these changes in PaCO2 will be reflected in the PETCO2 will depend upon hemodynamics (i.e. pulmonary perfusion), and lung function.

With respect (and this one one of those rare times, where "with respect", really does mean "with respect"), I find myself regularly physically and chemically restraining a fair number of patients. These patients are usually restrained because they are acutely psychotic, or have attacked the police or my crew members. I'm quite a nice guy, and try not to go out and provoke fights. I make a lot of money doing EMS, and quite enjoy it. In addition to being a fun and challenging job, it pays for a lot of things that are very important to me, like my house and children. Verbal abuse is nothing. It is a price of being a paramedic, or, more broadly, working in healthcare, despite what the "zero tolerance" posters in the ERs state. If someone is being verbally abusive towards me, it's rare that I care about their opinion of me. It is like water off a duck's back. Most of the time. If someone requires physical restraint for safe transport to the hospital, then to me, the humane approach is to provide physical and chemical restraint, usually with a combination of midazolam and haloperidol. This is to protect them from injuring themselves, or potentially being injured by law enforcement, as much as it is to protect me. As an earlier poster noted, it's quite important that they don't eject themselves sideways from the vehicle at high speed. I don't think this makes me a bad provider, or that I'm lacking in interpersonal skills. In fact, I'd argue that, in many cases, to physically restrain without chemical restraint would be negligent, and is probably a standard of care in most ERs. With regards to dealing with verbal abuse, something that works for me, is to ask first, "Do I really care about this person's opinion of me?", and "Why do I care?". Because most of the times, that personal tied down on the stretcher, handcuffed with cops, or sitting in a puddle of their own urine, has some pretty glaring personal issues and problems of their own. If I don't give them the power to make me feel bad, then all of a sudden a lot of the things they're saying lose their sting. All the best.

@ Cadaceus; re: Benadryl [still can't get the quote function to work on my win8 machine]. The reason that the EMTs can't give Benadryl is primarily political. Originally the EMT was conceived as a level that did not administer any medications. Over time, there's been a movement to recognise that paramedics are not always available in a timely manner, and to introduce some medications into the EMT scope. Generally these are medications that are either low-risk, or have a very high potential benefit. ASA, ventolin, and epinephrine certainly all fall into this category. Depending on the region, other medications, such as glucagon, D50W, narcan, Tylenol, atrovent, etc., might be included in this scope as well. The reason Benadryl probably isn't in most EMT scopes, is that the benefit is relatively small. It's considered an "adjunctive" medication, compared to IM epinephrine, which is life-saving, and the treatment of choice for anaphylaxis. In this situation, po Benadryl would be a poor choice. The patient is quite tachypneic and dyspneic, and may have a significant amount of airway edema. It may not be particularly practical, or comfortable for them to take a po elixir of Benadryl. They're quite distressed, and going to be breathing through a NEB or NRB mask. In addition, oral medications are poorly absorbed in shock states. The body shunts blood flow away from the digestive tract and towards the heart, lungs and brain, delaying absorption. Orally-administered meds are slowly absorbed, even under ideal conditions, and are subject to a lot of break down by the liver ("First-pass metabolism"). As a paramedic, this patient would get a dose of Benadryl and a dose of a corticosteroid, probably dexamethasone, IV. This wouldn't be a first priority, but would get done once some other things were taken care of. Many of the EMT scopes restrict medication use to specific routes, e.g. IM epinephrine, but not IV epinephrine, or for specific conditions, i.e. "You may give NTG SL to a patient with suspected ACS, with a prior prescription for NTG SL", but prohibit it's use in other conditions, e.g. congestive heart failure. Sometimes these restrictions don't make sense, as in the example of NTG for ACS (negligible benefit), versus NTG for CHF (large potential benefit, but greater risk of harm through inappropriate use). A lot of regions have a scope of practice that restricts EMTs from given meds via the IV route. A lot of these restrictions seem very arbitrary. For example, my local BLS can place a king LT tube, which has a small benefit in most circumstances, but can't use a CPAP device for CHF/COPD, which has a large benefit. It's just a reflection of the way scope of practice develops, which is often fragmented and may even require changes in the language of specific laws. As an EMT, this used to frustrate me, often. There are two competing ideas here. The first is that there are a large number of skills within the paramedic scope that could be performed by an EMT, an EMR, a first responder, a first aider, or a random member of the public. We have certainly seen many of these shifts where the skill has been performed by people with less and less training, e.g. public access defibrillation, dispatch prearrival instructions for ASA, epi-pens, narcan autoinjectors, etc. If you consider EMS, the whole history is a sequence of events whereby physicians realise that they can extend care into the community by delegating certain tasks to EMTs or Paramedics. There is often a period of resistance to change, and a concern that a lesser educated provider may cause harm. We have seen this result in changes where the skill has been withdrawn, e.g. RSI for paramedics is currently being greatly curtailed, or increased, e.g. cathlab bypass or field thrombolysis, ketamine, adult intraosseus initiation. As a paramedic, or as an EMT, the second idea, is that we are attempting to develop a profession of skilled out of hospital health care providers. That the patient is not going to receive the same level of expertise in a prehospital setting as they would from a board certified EM physician, but that we are going to try and move incrementally closer in that direction. This is part of the driving force behind developing Bachelor degree paramedic programs, and even graduate degrees in some countries. The educational training requirements in North America are woefully inadequate at both the BLS and ALS level. As a paramedic, a concern for me, is that if I lack sufficient education for what I am doing, and I believe strongly that my training programs were inadequate -- then passing on the skills that I can perform to someone with even less education runs the risk that we decrease the training standards further. Most of what I do could be done by a fairly experienced EMT, almost as well. But this is not the way to build a profession. So, it would be easy to add a lot more skills to the EMT scope. They could have antihistamines and corticosteroids. They could have antiemetics, opiod pain control, narcan, an anti-convulsant, etc. But given EMT training in my region is about 250-300 hours of didactic, with another 160 hours of ambulance practicum and 40 hours in the hospital, I think the training time would be inadequate to do this well. Just as my training level often lets me down when I need it. I think EMT training in many regions in the US is substantially shorter. Sorry if this constitutes a derail. I just want to add that I very much value my EMT colleagues, without whom nothing would get done. We are a team. This does not prevent me from wanting us to collectively increase our level of training and education.

A few thoughts: * I don't know as much about Morquio syndrome as I should. * This patient seems fairly sick. They're tripoding, using accessory muscles, tachypneic, with diminished a/e, desaturation at 91%, and a pretty marginal pressure for someone with a heart rate of 140 bpm, and post-epinephrine. I would probably classify them as somewhere between "moderate" and "severe". * On the upside, they have enough oxygenation and perfusion to remain alert enough to sit on the edge of the couch and tripod. There's no stridor, no hypotension, and no mention, as yet, of any obvious angioedema, uriticaria, no clear signs of laryngedema, and they're not yet hypotensive (although at a HR of 144, we can assume their either SV or SVR or both are pretty marginal, i.e. BP = CO x PVR). So there's a few things that would be nice to know: (1) Has there been any clear clinical improvement post-epinephrine, or have they been continually getting worse? Regardless, they can have some more epinephrine IM, even if it's been given recently -- there's a low chance of harm, and much greater risk from withholding. But it would be reassuring if there's been some improvement. (2) Previous allergic rxn / anaphylaxis and clinical course? Have they ended up in the ICU or intubated in the past? If we know this is the case, this increases our concern. (3) How far is the hospital? Are we able to move closer to the ER while moving towards ALS and meet half way? (4) Do we have more epinephrine injectors or the ability to give IM (or, worst case, SC) epinephrine? (5) What are the hospital's capabilities? Is it a small town clinic that may not have an FM MD on site, or is it a pediatric tertiary center? (6) Do we have transport times that support rotary wing? I would suggest here: * Repeat epi if possible * If transporting for RV w/ ALS or the ER, then we need to move as soon as possible * Neb ventolin (I imagine nebulised epi is out of scope, and there's probably no benefit of one over the other) * If we can't give more epi, then we need to move towards whoever can the quickest. * IV en route, large bore, and I think you can already justify hitting him with some fluid. There's a fair risk of him getting intubated by someone, he's probably on his way to losing his pressure, and his existing pressure is very low for his HR. [There are some other considerations on the ALS side. Just a note, that the King airway may not be great here -- it can't support the higher airway pressures that are likely going to be necessary if we actually need to intubate, everything will just blow past the cuff and end up in the stomach. It may worsen/accelerate any developing laryngedema, and won't prevent complete obstruction from developing.]

Re: NFPs You both raise excellent points. The ORNGE scandal was frankly depressing. The main comparisons being made here are STARS v. Manitoba Lifeflight v. BCAS, all of which, are NFPs, right? Being an NFP doesn't guarantee that money is being spent wisely, or, in some cases, legally. Re: Costs for air ambulance providers If you look at the per capita costs by province in the cbc link that AK posted, there's a huge difference in the volumes between the different sites. The 3 AB Helicopters are far busier than the two SK and single MB helicopter, which drives the net cost per capita down. I'm not sure how useful the BCAS figures are, in that they include a lot of fixed wing and ground transports, which aren't included in the statistics from the other providers. There's also some difficulty in comparing the costs from the different service providers. There has to be some caution in making sure that you're comparing apples to apples, and that the same costs are included in each budget, otherwise the comparisons may be fairly meaningless. Certainly STARS is more expensive on a per capita basis in MB versus the other province, if the figures in the CBC news article are correct. I suspect that the methodology may be a little suspect. The question raised by the CBC, as to whether this money would be better invested in rural ground paramedics is very interesting. I don't know much about ALS in MB, besides that there are very few ALS providers, even in Winnipeg. Does anyone have opinions about this?

Have used the carevent atv+ a handful of times. As I recall there's no way to manipulate i-time independent of rate / minute volume. Your pt. has their physiology and you get what you get. You can sort of get a plateau by doing a manual ventilatiin and covering the exhalation port, but I dont know how accurate or valid this really is. Not sure how good it would be on someone with a high minute volume or inspiratory flow, but I'm no expert.

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: www.youtube.com/watch?v=RGXC5h3eSIA * 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.

Either the forum's glitching or I am, as I'm having trouble using the quote function today, but... You have a rotary wing operator, based in a neighbouring province. It's previously run operations in Nova Scotia. It's recently expanded aggressively into Saskatchewan and Manitoba. In at least one instance, it's been introduced without a competitive tender process. It's a "not-for-profit", run with minimal provincial funding. It collects a large percentage of it's revenue from corporate donations, and fund raising. It already flies missions in your own province. Let's say you're responsible for medical oversight, and have developed (arguably) a Cadillac system in your own province. But, and I'm just guessing here -- probably an expensive system, if every new hire is going through a government funded 18 month training program, while receiving a full-time wage from the employer? And you're not threatened by the possibility that in these days of social services cutbacks, your own system might get replaced by the cheaper option from next door? I'm sure Dr. Wheeler is a very ethical man, whose primary interest is patient care. It's hard to argue against anyone who wants to raise the standard of training and education. Many of his criticisms may well be valid. But the conflict of interest here should be obvious, and it should be clearly stated. This doesn't render his conclusions invalid, it just makes everyone aware that it may be difficult to be completely impartial in this situation.

I think it's probably fair to say that Dr. Wheeler is an expert, based on his credentials. But, as you've pointed out, he is only one expert. There is also a clear and obvious conflict of interest here, in that he runs the BCAS program, which has a coverage area that overlaps with STARS bases in Alberta. To some extent, these services are in competition, and the potential for STARS to expand further can't have been overlooked. I haven't met a lot of people from the BCAS CCT, or from ON ORNGE CCP programs. I'm sure they're excellent people, and it sounds like their training programs are very rigorous. I have met a lot of people from AB STARS, interacted with them on calls, and benefited from training programs offered from them. I found them to be extremely well-trained, knowledgable and competent, and have learned a lot from them. Of course, my opinion is somewhat meaningless, as I am not an expert. It's also hard to compare the training between the different locations without having taken the training. There are a lot of unanswered questions here, that make it difficult to present an informed opinion. ----------------------------- On another note entirely, the US audience may be interested to see that the discussion here is revolving around the provision of a single RW to a geographic area roughly the size of Texas (*albeit very sparsely populated), and whether this is even beneficial versus FW. Not a narrative likely to be explored stateside any time soon.

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.

[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!]

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?

It sounds like you need to get Math, Biology and Chemistry or Physics. Why? Have you considered distance education, if you don't have the time to attend traditional classes? I don't know what province you're in, but in most provinces, you can challenge the final exam for 100% for most high school courses as a mature student. It sounds like you really need to take Math. And probably Biology, and Chemistry or Physics. It sounds like you really need to take academic math, and not taking it will not only "put you behind" but prevent you from your "dream career and passion". I don't know how taking a different course will help you meet your math and science prerequisites. It sounds like you need to make a couple of phone calls, to (1) the military, and (2) the college, to see if they have any flexibility surrounding their pre-requisite requirements. I doubt anyone here is going to be able to answer your questions. Another possibility, if you absolutely can't take these courses --- and I don't understand why you can't, is to see if there's another province with a PCP program that has different pre-req's. Also, you may be able to find a program that will accept you, pending successful completion of the courses by distance education, e.g. as long as you finish the courses by graduation, they'll allow you to graduate. This seems less likely. Then you need to be prepared to work and sacrifice for that dream. That's the reality here. All this stuff seems difficult, until you actually do it. Then afterwards, you forget how much work it actually was, and remember it as easier than it actually was, and wonder what you ever worried about. You will likely face more difficult hurdles during your PCP programs, practicums, actually working as a PCP, and doing it all over again for your ACP and/or CCP levels. This is an attainable goal, but no one's just going to hand it to you. All the best.

Great scenario! Thanks!

Well, I'm not sure how it makes sense here, but the ECG looks suspicious for Brugada syndrome, and shows a long QT. I had wondered about CES -- but there's no fecal incontinence / urinary retention / sexual dysfunction reported. However, this could cause renal failure and explain some / most of the symptoms. He hasn't done anything silly like trying to inject some heroin IM into his glute, instead of IV? No hx of CA? Is it lupus? Why do I feel that the answer will make me fell stupid. AAA? Conversion disorder? Exercise-induced asthma? spinal abscess?

The Germans seem to be aiming to reduce the door-to-needle time for fibrinolysis in ischemic CVA. I'm not sure if they're doing any sort of direct to neuro ICU or surgery for hemorrhagic CVA. My immediate guess, would be that you can't just roll into a neurosurgical or intensive care setting the same way you can roll into a cath lab. I imagine both centers will be publishing. The Germans certainly seem to be planning to. I'm also struggling to see the benefit here, but don't want to dismiss it without seeing the numbers. CVA patients do seem to get neglected on busy days in systems I've worked in. It's an area where there's a lot of room for patient advocacy when you have an elderly patient with a low level of baseline disability. Every sick 80 year old looks like a sick 80 year old. It can be easy to make the assumption that their baseline level of disability is more severe when they present disabled. I've given this some thought over the past little bit, and I can't see it being the first resource on scene in many situations -- but in a big city, if it's alerted at the same time as the first-in unit, I could see there being time to intercept, or meet on scene. Re: rule outs for medium-risk head trauma: I've considered this a little more, and I think one of the problems is that you can't just scan most of these patients and let them go. They're going to sit in the ER anyway for a few hours to allow any occult pathology time to declare. They're unlikely to get turfed as soon as a negative CT comes up, and probably shouldn't. Re: MVCs in 'lysed patients: I reckon my personal number is 1 collision for every 2,000 transports. Most of my recent MI patients have gone to cathlab, although a few still received lytics. In my system with 100,000 calls/year, we're looking at around 150-200 true STEMIs, with about half getting lysed. The rest are getting plavix and enoxaparin. Mortality benefit from early reperfusion can be quite large, especially in patients 'lysed in the first hour or two, and especially if there's a longer transport time to PCI. I doubt the risk of anticoagulation / thromolysis and MVC collision occuring in the same patient is very high. A very inexact estimate using these numbers would suggest that's a 1 in 1,000,000 proposition. Of course, my numbers are likely inaccurate, and there's an argument to be made that STEMI patients might be more likely to be transported stat, and be at greater risk for collision as a result (* on the other hand --- if you've pushed the TNK, where's the benefit to transporting emergently? The decision for reperfusion therapy has been made, it's been initiated, and we're going to be looking at what percentage ST resolution we've seen at 90 minutes. Unless they're acutely unstable, e.g. CHF, cardiogenic shock -- is there much of a point?). I wasn't intending to minimise the risk of vehicle collisions for EMS providers, but I still think that the scenario described is fairly unlikely.

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: http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20Spinal%20Consensus%20COMPLETE.pdf It seems quite progressive. I would like to hope that one day my practice could more closely resemble this.

Well, getting in a collision in an ambulance is almost always a bad idea, tPA or no tPA. Fortunately, it's also quite rare. There's a fair number of systems that are already assuming this risk by giving TNK and similar drugs to STEMI patients. Of course, the demonstrated benefit there is far clearer, and a better argument can be made for it outweighing the potential risk. One of the possible advantages of EMS is that we like to run with scissors. We have an ability to get a lot of things done quickly, by walking and talking. This seems to take longer in the in-hospital environment sometimes. It seems like the right person from the right union has to come and draw the blood. The right person from the right union has to do the 12-lead. It has to sit until the right physician has time to read it, etc. We 'lysed a STEMI a couple of weeks ago with a 4 minute first medical contact-to-ECG time, and 17 minute door-to-drug (52min symptom onset-needle) time, using 3 people and consulting with cardiology via cell. It can take me 17 minutes on a bad day to get my sick patient registered, with the right wristband and stickers, and on to the ER bed. tPA in ischemic CVA obviously remains quite controversial. I wonder if there's some place for using a mobile CT scanner to do rule-outs on low-to-moderate risk head trauma? Does anyone know what European physician-driven EMS systems are doing with similar technology? Here's an interesting link: http://www.jove.com/video/50534/prehospital-thrombolysis-a-manual-from-berlin Ebinger M, Lindenlaub S, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Kellner PA, Kaczmarek S, Endres M, Audebert HJ.Prehospital thrombolysis: a manual from Berlin. J Vis Exp. 2013 Nov 26;(81):e50534. doi: 10.3791/50534.PMID:24300505 [PubMed - in process]

Agreed. We draw POC troponins at my place, and would likely direct them to a site with PCI capabilities. That being said, as I'm sure you'd agree, plenty of people with NSTEMIs walk into random ERs and get secondarily transferred. My viewpoint may be skewed by working in an environment with very limited PCI capability serving a large population and a ridiculous geographic area. Where I am, at night the only two PCI capable centers are call-in, and a lot of worrisome cases are waiting for the a.m.

Thanks for the excellent scenario, Dave. A few points to add about POC troponin and STEMI / NSTEMI care: * Troponins can take a long time to bump, so a single negative troponin is not an effective cardiac rule-out * Conversely, most NSTEMI patients don't require emergent catheterisation * The presence of absence of STEMI indicates the need for emergent reperfusion therapy. If there's a STEMI pattern, they need to either be lysed or cathed, depending on their risk factors, comorbidities, the availability of cathlab, and the age of their MI. * In the first 2 hours, field fibrinolysis may actually outperform PCI (*Unless your site is basically always ready to go, and has an open suite 24-7, it is extremtly hard to actually cath someone in the first 60-90 mins of an MI -- a paramedic team can have someone lysed in 25 minutes, sometimes quicker), and has at least comparable benefit in carefully selected patients. Re: TXA * CRASH-2 is a great study because it shows that even in a broad, poorly differentiated population, there was no real increase in thromboembolic events. No one really infarcted or stroked out. The only patients who did badly were those with non-recent injuries. * MATTERS is another good study to look at; this was performed by the military, so it used predominantly younger and baseline-healthier individuals, but they were also much more severely injured. It showed a much greater mortality benefit, suggesting that some of the benefit of TXA may have been masked in CRASH-2 by a subgroup of less severely injured patients who were at little risk of dying, and little risk of benefiting from the TXA, making the effect seem smaller. * It's a very safe drug, with a pretty large benefit. More places should be using it.