systemet

I think that a lot of these medical advisory decisions are often made in a fairly unscientific manner, based on a couple of situations where bad outcomes have occured. The committees have a clear responsibility and duty to protect the patients, but I think they often end up restricting practice based more on a few bad incidents than a thorough and scientific evaluation of the data. Not to mention, a system has to be quite large to be seeing enough of these patients in a year to generate real statistics. Often the end result is something as useless as "Because paramedic administration of diltiazem in symptomatic atrial fibrillaton hasn't been shown to improve outcomes.....". This is a fairly meaningless statement that means a lot less than the casual read would suggest, and is entirely compatible with "paramedic administration of diltiazem in symptomatic atrial fibrillaton hasn't been shown to worsen outcomes.....", or "we made a fairly random decision based on the loudly expressed opinions of a few particularly vocal individuals, and wanted to dress it up in pseudo-academic language.". As has been noted before, it's often easier to restrict practice than it is to train individuals up to an acceptable level and run a decent QI program (not to imply that this is an issue with your service).

I think there's a few potential issues. 1. Correlation vs. causation: a stable patient given diltiazem who has no or minimal response is more likely to have their symptoms worsen in 30' than improve. Any change in condition may be attributed erroneously to the effects of the diltiazem. 2. Diltiazem is still a negative inotrope, and while "cardioselective", with a lower incidence of hypotension than verapamil, true pharmacological selectivity is a theoretical ideal more than a practical reality. So some vasodilation will occur to varying degrees in diiferent individuals. 3. Recall bias : everyone remembers (and QIs, and sends the chart to the medical director) of the guy who get diltiazem, sewers his pressure to 60/30, and then codes. No one really remembers the guy whose rate slows and rapidly improves. 4. Inappropriate patient selection: honestly, I think most of the a.fib patients I've seen / heard of getting verapamil, diltiazem, metoprolol, etc probably shouldn't have. If we givve a CCB to somone old and septic wirth a compensatory tachycardia, bad things are going to happen. 5. Unidentified or occult underlying re-entry, e.g. WPW 6. Interaction with the patients own oral AV nodal blocking meds.

This is one of the reasons why I liked being on a medic/EMT car, or being the only ALS provider on scene. In some ways it ramps up the pucker factor, as you've got no one to fall back on. But you get twice the exposure to running critical calls, and doing some of the psychomotor skills. [i won't say it doesn't often run smoother when you can just turn around to someone else and say "Can you intubate, when I do this here?", but it does mean you're doing half as much of everything.] Not all of us play nice together, and sometimes multiple ALS providers on scene, especially >2 just means someone else tries to take over, making the entire call go sideways, especially if someone on scene is perceived as junior or weak. Depending on the culture in your workplace, and how this guy is as a human being, it might be worth saying something like, "I don't know if you've noticed, but I've been having some trouble with intubations recently. Do you think next time you back me up on a critical call you can watch while I'm intubating, and give me some pointers?". I'm used to supervisors being there to be supervisors, and assist, not to try and poach skills and interfere with medical management or generally mess up the flow of things. You should also look at the circumstances of the intubation attempts. Are these failures an issue with medication? Do you have inadequate relaxation of the jaw, are you using a sedation protocol where RSI might be better? If you're intubating without paralytics, are your drug doses too low, or is the population of patients you're intubating needing particularly high doses, e.g. closed head injuries. Are you not waiting long enough for the meds to take effect? Do you still have residual jaw tension. You should consider your set up. Is the angle of the mandible aligned with the sternal notch? Is the neck flexed, head extended? Have you positioned both yourself and the patient in the best manner to succeed? Are you using the larygnoscope in a technically correct manner? Are you cranking on the jaw? Are you doing something silly, like taking a large blade, ramming in midline down the pharynx, and then pulling back to visualise --- or are you inserting it laterally, moving the tongue midline, and moving progressively deeper while identifying the structures? Are you modifying your approach to deal with poor visualisations e.g. C&L 3,4? Could you be using a Bougie in some circumstances? If using a stylet, is the tube curved appropriately? Are you doing something easily correctable, like pulling the tube back a bit as you remove the laryngoscope? Is there some commonality amongst the small group of people that you're having trouble intubating? Obese? C-spine precautions? Inadequately medicated? Could it be specific circumstances that are causing you a problem? Are you setting up well for the first attempt, and then varying your second and/or subsequent attempts based on what you see on the first pass? Or are you just repeating what didn't work the first time? I think it's worth remembering that the population of patients we see in EMS often contain a lot of difficult airways, and we often have suboptimal training and equipment. The goal should be for atraumatic intubation, without incidences of profound desaturation, hypercapnia, arrhythmias, etc. Some of the guys going around boasting high rates are technicallly proficient, but a lot of others are just refusing to return to BLS measures, or a rescue device, and are stressing the crap out of their patients just so they can mark off that they got the tube, without mentioning it was on attempt 5. Just some things to consider. I'm no expert, but perhaps something in there will be helpful. Also, I would suggest that while mannequins are not like real airways, regular practice on a mannequin is far superior to not doing anything.

Just as an aside, you can now get IGRA tests, that can differentiate between patients vaccinated with BCG, and those with latent TB infection. I think they're fairly sensitive/specific, but they throw a lot of "indeterminate" readings, in which case they're not so helpful. I'm not sure what the healthcare is like in your neck of the woods, but it might be worth looking into.

That's not proof, that's anecdote. Proof, well, "evidence" would be a better word, would be a number of research studies published in peer-reviewed journals, consistently showing that care by a physician assistant improves "outcome X" versus care by a paramedic. These studies don't exist. These "pre-requisite in the basic sciences" seem to be at least two years of university biological sciences, and a reasonable MCAT score, right? So that's already a length of study that exceeds many paramedic programs just to put yourself in a chair on day one. I think we're comparing apples to oranges. Are they? I've never taken a PA program, but I have taken a science degree from a reputable university. I remember having 3-5 hours of lectures a day, for 5 days a week, and maybe a few hours of labs spread out over the week. The actual instructional time was maybe 20 hrs / week. But you can bet I spent another 20 + (perhaps even 40+) studying after class to make sure I knew the material. This would describe many people in my paramedic program. I agree with this. The logical course of action is to then increase the educational requirements. I won't defend restrictive medical control, because it is a nightmare to reach some arbitrarily defined maximum dose of morphine and have to get on the phone to a physician and say, "I've given 20 mg of MS, my patient's still in pain from their 28% BSA partial-thickness burns, can I give more?". However, I would argue that medical consultation isn't always a bad thing. Sometimes it's in the patient's best interest for the provider to run a situation by someone with more education and training and either get some advice or a second opinion about something. For example, I had a palliative care patient once with breakthrough pain. Sick, cachexic, on lots of opiates. It seemed reasonable that this person had some tolerance issues, and I was thinking that 10 mg of MS IVP would probably be a good starting dose. Not being 100% sure about how the patient would deal with MS, as they were currently receiving dilaudid, and being concerned that they might have had issues with prior morphine toxicity, etc. I called up their palliative care physician. You know what I got for orders? 30mg of MS IVP. I'm not saying I'm awesome, because I'm not. But there's something to be said for recognising your limitations and seeking advice when you feel it might benefit the patient. If I'd have gone with 10mg IVP, I'd have waited 5, 10 minutes, maybe given 5 mg, or perhaps another 10mg, and eventually in 30-45 minutes, I might have got up to 30 mg, and started to get the situation under control.

I've taken on-line / distance and traditional university classes. I've also worked with people who've taken paramedic programs where the majority of the course delivery was on-line. Personally, I wouldn't choose to take paramedicine on-line, if I had the option for classroom education. I think some of the most valuable moments in paramedic school were when one of the instructors went off on a tangent about an atypical presentation they saw, or a time they made a mistake, or some of the common prehospital pitfalls in a given situation. There's also a danger when you do self-directed learning that you go off on a tangent learning about something really interesting, like the pharmacology of opiate metabolites, that might have some small application to prehospital care, but might represent time better spent focusing in a different area. If you have a decent program, getting to run scenarios and play with equipment and simulators on a regular, near-daily basis is also really valuable, and hard to reproduce in a distance format when you may only meet up with classmates once very couple of months for a week or two. I wouldn't say "Don't do it", if it's the only option, just that I wouldn't choose to do it as a first choice. I felt that many of the medics I worked with who had done a distance delivery course were underprepared when they first hit the road, but that the gap narrowed over a few years once everyone had a base of experience.

That sounds rough, and I can see why you wouldn't want to invest 2 years of your life doing that when you could spend the same time, come out as a diploma RN and make twice as much. No matter how I say this, it's going to sound rude, but you have my sympathy and my respect for working EMS for that sort of money. I mean that honestly. That being said, the JEMS salary survey suggests that the average medic wage is US $49,000, which seems a lot more than I was lead to beleive that the UK paramedics make. http://www.jems.com/sites/default/files/Download%20JEMS%202011%20Salary%20Survey.pdf

I've done it. I had a guy in the back of the ambulance with multiple torso stab wounds, who was refusing to take off his T-shirt in front of my female partner. i was getting quite frustrated, and angry with him, until I asked him what the issue was, and why he wouldn't take it off. Gynecomastia as a side effects of the antipsychotics he'd been taking. He didn't want my partner to see it. So we agreed she'd go up front, I'd uncover him quickly, and put a gown over the top. The gynecomastia seemed minor to me -- I don't think I would have really noticed it if he hadn't mentioned it. He just looked kind of obese to me. But there I was, getting all irritated with the world in general, because my stabbing patient wouldn't play nice, and it turned out he had a decent, understandable reason. I'm not saying that he shouldn't maybe have just accepted that my partner was a health professional, and not made a big deal about it. But I sure made an easy situation difficult for myself until I stopped to wonder where he was coming from. I felt pretty stupid afterwards.

I think this is a valid question, but at the same time we have to ask, "What evidence do we have that training of paramedics beyond 6 months or 2.5 hours, or 7 minutes 14 seconds, isn't beneficial?". As the catechsim goes, "Absence of evidence isn't evidence of absence.". There's also a philsophical issue as to who should bear the burden of proof here. Should it be those who say that additional training doesn't improve paramedic care, or those that say that additional training does improve care? For whom should the onus to produce evidence fall upon? Not to ad hominem this discussion into irrelevance, but historically a lot of those who have advocated for shorter programs have been associated with fire department EMS systems that would benefit financially and logistically from shorter training times. It would be fallacious to argue that this renders their arguments invalid, but it does suggest they may be more likely to be biased. [Of course, the converse is true, that many arguing for longer educational requirements just want to professionalise EMS and get paid more, and may be similarly biased in the opposite direction.] It's difficult to prove the benefit of something before it exists. It might be hard to show an incremental benefit of a 4-year degreed paramedic if they're working in a system alongside 6 month-trained paramedics, with the system designed to the lowest common denominator. It would be similarly difficult to compare, say the New Zealand system, with an area in the US where the majority of paramedics have 6 months of training and be able to be certain that all differences in outcomes were due to the differences in paramedic education. A number of confounders exist, not the least of which, is that most of the potential effects on outcomes will be greatly influenced by the local demographics of disease and the surrounding medical systems. Quick question -- Are you sure? Because I remember a time when the UK medics were very excited that some of them were going to start making more than £20,000 / year (at the time, around US$ 42,000, now about US$32,000 due to the utter collapse of the UK financial system). They didn't seem particularly highly paid. But perhaps this has changed? My impression (from afar) has been that the pay (and quality) of US systems varies greatly across the country, with some places playing twice as much as others.

If you need PALS or ACLS, you might want to check whether the AHA will accept it as a pre-requisite.

For what it's worth, I find it really hard as well. I'm not that great at heart sounds.

Thanks Bieber!

I think there's a few things that have to factor into the decision here: (1) Duration: Obviously this is difficult to pinpoint, as the patient may have had an asymptomatic period prior to the rate increasing and becoming symptomatic, but if you have a clear history of paroxysmal onset of symptoms, it might be easier. The longer the symptoms have been ongoing, and the less certain you are that you can pinpoint the time of onset, the greater the risk of rhythm conversion. (2) Primary versus secondary a.fib: Is the rate really our problem, or do we have someone who has a separate problem, in which a fast rate might be expected or compensatory e.g. fever, pain, dehydration, sepsis, acute MI, etc. (3) Transport time, and the center you're transporting to: are you 10 minutes from a center with board certified EM docs and cardiology? Or is it a rural hospital an hour away with the FM guy who's seeing patients at the local clinic, who might not be at the ER until some time after you arrive, even if you call first, and might not be particularly comfortable with this patient? (4) Risk of underlying WPW? Because we don't want AV nodal blocking agents here, at least not the ones we commonly carry. Honestly, I think most of the time, this is a situation where it's better to tread very lightly, especially if they're somewhat stable. Most of the time it's not the a.fib that's the problem. Regarding this, I have this potentially flawed idea that when you cardiovert you get a very fast and perhaps supraphysiologic contraction of the myocardium that could cause embolisation, that you'd lack with a chemical conversion. I was under the impression that the risk with electrical cardioversion was greater? Do you know if anyone's looked at this? Am I just hilariously poorly informed here?

A few others that come to mind: * The heuristic that a radial pulse = SBP >90, brachial > 80, femoral > 70, carotid > 60, etc. * That antiarrhythmics are beneficial in cardiac arrest * That high dose, escalating dose, huge amounts of epinephrine in a bag, or the regular 1mg epinephrine q 5 min, actually helps my cardiac arrest patients. * That the point of a code is to ram as many drugs with confusing infusion rates into the patient as rapidly as possible. * That it's ok to just walk in, ram in the laryngoscope, get the tube quickly, then start CPR * That CPR isn't important * High volume fluid resuscitation, e.g. 20 ml/kg repeated a couple of times, is good in hypotensive trauma. * That thiamine is useful. * All trauma GCS <= 8 intubate * That every intubation should be with paralytics * But, also that paralytics should be avoided at all costs unless there's trismus * Pacing asystole * Atropine, bretylium, procainamide, in cardiac arrest * That a 12-lead can rule out AMI * That 12-leads are pointless prehospitally * That EMS will never give thrombolysis * That capnography is useless * Sadly, that EMS can't affect acid-base status with overaggressive ventilation in a short transport * That helicopters are necessarily superior to ground or fixed wing * That paramedic self-governance is a panacea to everything that's wrong in EMS * That people in pain are tachycardic * That paramedics should try and distinguish fakers from patients in real pain, based on socioeconomic factors. * That you can say something nice and poetic to the family to make them suddenly feel better. * That EMS is always acute / emergent care. * That nurses are stupid. * That paramedics are like physicians.

Awesome, and a little frightening.

My opinions (bear in mind that I haven't been active in the field in a couple of years): Definitely not that one. The best advice is to start working for credits towards a degree, if it's financially / logistically possible. EMS has a horrible tendency towards weekend certification courses, like ACLS, PALS, PEPP, NRP, ITLS, PHTLS, AMLS, GEMS, PPC, AHLS, ABLS, or for that matter the CCEMTP program, that does nothing to advance the profession, and risks turning us into a bunch of badge-collecting boy scouts. Basic EMT training is so short that you probably can get some value from some of these courses, but I doubt any of them would really add to your employability, although this may vary based on where you're working. When I was an EMT I held an ITLS (at the time, BTLS) cert that the local employers wanted people to have. Most of these courses you could probably extract a large percentage of the benefit from by just purchasing a cheap second hand copy of the most recent textbook. * Reading an ACLS or PALS text, particularly the cardiac arrest sections might make you more useful to a paramedic partner during a code. The AHA (or local organisation), tend not to certify BLS providers. The course requires some very basic ECG skills. * NRP isn't a bad course. It's very simple, and very short, and almost all of it is BLS applicable. It also covers a very low frequency skillset, i.e. the resuscitation of newborns, that you may only use a few times in your career. Really, these low frequency skillsets are the ones we probably should be prioritising for refreshers, because most of the other stuff you do fairly regularly. * I thought PEPP was an ok course for BLS. It introduces a simple method for assessing pediatric patients, that would probably give you more confidence if this is an area where you're lacking in comfort/experience. * The best choice of all, might actually be some sort of driving course like CEVO or NAPD. Most employers don't want you wrapping a vehicle around a pole, and you certainly don't want that either.

A few thoughts regarding these scenarios: * The English language is particularly confusing and unhelpful in these discussions because we use the word "right" to refer to at least three completely separate concepts that are often given separate names in other languages. We can talk of "right" as in "correct", without it implying any more value judgment than that "1 + 1 = 2" is "right"; we can use it to describe the legal concept of a "right", something that is defined and enforecable by law, and it can also imply an ethical/moral judgment that a certain action is "right". I think a lot of the dissonance in this thread is because one poster is referring to what they feel is morally right, while another is referring to what is legally right. As several others have pointed out, this two ideas are not necessarily the same, nor does one necessarily imply the other. * In the countries I've worked in, I'm not aware of any special privilege given to paramedics to allow them to confiscate property or to physically remove a bystander from a scene. This means that any action I take to remove someone from the scene against their will, or to take their property from them, constitutes theft or battery. This would likely give the person who I was battering, or trying to steal from, considerable legal right to defend themselves. Any action I performed to subsequently defend myself in these circumstances might well be interpreted in a law court as a continuing act in an assault / battery that I have initiated. * Most legal systems don't afford an unconscious or severely injured patient a legal right to privacy in a public place, although they might protect against publication. However, in many countries there's a legal right to film activity occurring in a public place, providing the person doing the filming is not trespassing. So while we may be defending a perceived moral right of the patient to privacy, we are doing this while interfering with someone's legal right to film, or occupy a public space, and possibly while committing an act of theft, battery or assault. * I think that the desire to protect the patient's dignity is admirable, but you can't know what the person filming is planning on doing with the footage. They may be planning on removing any footage that identifies the patient, or shows the nature of their injuries, or exposed body regions that are taboo in the local culture. They may not be intending to actually harm the patient's dignity at all. * As a non-American, I would argue that having a legal right to film the police, in particular, is far more important to the defence of a democracy than any constitutional provision allowing the posession of firearms. I think we should be very careful about attacking these particular freedoms.

I don't think that we have much of an ability to distinguish "fake" seizures from "real" seizures. The spectrum of possible seizure disorders includes randomly staring off into space in the middle of a conversation for a few seconds ("petit mal"), suddenly collapsing to the floor ("atonic seizures" / "drop attacks"), or random crazy psych-like behaviour ("complex partial seizures" / "temporal lobe seizures"/ "psychomotor seizures"). Not everything that is a seizure is a tonic-clonic seizure. I guarantee that many of us, myself include, would be willing to write off many people exhibiting real seizure activity as having behavioural issues or being syncope of some other etiology, e.g. potentially cardiac -- especially if we haven't witnessed the event ourselves but are responding to it minutes or hours later. I'm sure plenty of emergency physicians make mistakes, and I know from talking to neurologists, that even with multiple EEGs and a lot of investigation, it's not easy to differentiate seizure activity from other syncope, unless you witness the actual event occurring. I'd say it's more important to be able to determine which patients should be receiving benzodiazepines, i.e. primarily those with generalised tonic-clonic activity, than it is to label patients as "fakers" or "not-fakers". Applying a label like this is something that may follow the patient through their stay in the emergency department and negatively affect the care they receive when they have a legitimate medical concern. It might be better to simply make a judgment as to whether benzodiazepines are necessary, collect the best history available, and let the ER / neurology sort it out.

I've typically used benzodiazepines, +/ - haldol / droperidol. Droperidol isn't commonly used anymore due to concerns with QT prolongation. Of the benzodiazepines, midazolam seemed to work best, with a rapid onset, and predictable IM absorption, if the patient's too agitated for IV initiation. Diazepam seemed fairly poor even when given IV, has a horrible half-life, and can't really be given IM. Lorazepam is a little slow-acting, but works, but has a longer half-life compared to midazolam. Because of the slow onset, I've seen people (including myself) get in trouble by giving repeat doses too quickly. In situations where someone is problematic but not actively violent, they can often be convinced to take a sublingual ativan. Droperidol / haldol are ok, but they carry some risk of arrhythmia, which might be amplified if the patient's been taking street drugs (especially droperidol). They can also cause hypotension (haldol more than droperidol), and both can lower the seizure threshold, which might not be ideal for sympathomimetic overdoses. The risk of EPS is supposed to be lower with droperidol; the n = 2 cases I've seen have responded rapidly to benadryl. Both carry a risk of neuroleptic malignant syndrome. Personal opinon -- in many cases, especially when the likelihood of stimulant ingestion is high, benzodiazepines alone may offer a similar effect with a better risk profile.

There's an article about this from 2009 here: http://www.bcmj.org/article/criteria-sedation-psychiatric-patients-air-transport-british-columbia

I think it's a good idea --- but I also think that most of us lack a really solid background in ventilator management. If you just throw in a cheap volume-cycled CMV ventilator where you just set a minute volume and a respiratory rate, the thing's going to alarm off half the time, not really be useful on a lot of sick patients, and perhaps cause as many problems as it solves, especially in inexperienced hands. My knowledge in this area is pretty weak, but I bet someone like chbare would have some good input.

Re: SpO2 and anemia, the SpO2 should read normally, i.e. it will reflect the percentage of available hemoglobin that's saturated with oxygen. In the anemic patient, by definition, the amount of hemoglobin is going to be lower than normal, resulting in a lower arterial oxygen content. CaO2 (ml 02 / dl) = 1.34 * hgb * SaO2 + 0.003 * pO2 [i hope people will forgive me for leaving out the units]. So this presents one of the major problems with pulse oximetry --- it doesn't directly measure arterial oxygen content, because it doesn't give us information about a major variable (hgb). Also, while in most situations hgb bound oxygen represents the major arterial source of oxygen, it's the pO2 that actually provides the driving force for diffusion across the cell membrane. So you can have situations, e.g. hemorrhagic shock, where the SpO2 may be 100%, but the actual arterial oxygen content is abysmal, because there's very litte hemoglobin. [These massively anemic patients are among the patients that might benefit from higher FiO2's to raise the concentration of dissolved oxygen carried in the plasma, i.e. pO2, although we've all heard recent concerns about superphysiologic pO2's, and the potential problems.] re: CO and SpO2, on most pulse oximeters, the CO-hemoglobin will be falsely interpreted as oxyhemoglobin, giving a false high, if you're considering the pulse oximter to read oxyhemoglobin.

Used that in 1997.

Thanks for the awesome scenario. Well presented! I think it's VT. I think another option is a.flutter, but the rate seems a little off for that, I think there's retrograde P waves, which, if correct, rules out a.flutter. It could also be junctional w/ aberrancy. It's really hard to measure the QRS sometimes from just the limb leads. I think this is a reasonable thing to do, but from what I remember, the evidence, while weak, is much better for mag in asthma versus COPD. I might try and do a lit search if I have time. Anecdotally, it seems like mag either works really well, or does nothing. Not sure why. I think sometimes the change in patient condition is just coincidental, and can be put down to higher FiO2 and beta-agonist / anticholinergic, and also that people really like to give mag, because it makes them feel like they're doing something. A couple of questions here, perhaps chbare can help --- (1) How good is the evidence for CPAP in reactive and/or obstructive airway disease? I can understand that it might prevent some dynamic airway collapse, but it seems like the underlying pathophysiology is very different versus CHF, (2) Would some sort of bilevel support be better here, with a lower PEEP, but a higher inspiratory support? Regarding this --- I think you're leaning towards SVT because the axis is normal and the complexes are upright in II, III, aVF. When you see textbook examples of VT, they normally give you something with a nice indeterminate axis, that looks nice and wide in the limb leads. But, of course, VT can have any axis, and look nice and positive, when it wants to. It's hard in this example to decide where the QRS begins and ends (in my opinion), and would be easier with a 12-lead with multiple options from which to measure. But if you look at the ECG, it does look suspiciously wide, but it's a bit of a judgment call. It could well be SVT, I just personally think VT is a little more likely. It's also the safer clinical decision --- if you're not sure, and if you're sure, you want to be really sure, it's better to assume VT. That's not to suggest that we should just give up every time we see something wide, just that we should bias ourselves in the direction of VT for the safety of our patients.

Uggh... That looks a little suspicious for VT. There seem to be some retrograde P waves in there, too. Could be some sort of aberrant junctional tachycardia as well. Either way, don't like it. Glad it stopped quickly. Suggests that the myocardium doesn't like being hypoxic.