WelshMedic

Onnea äitisi!

Your presence is only a threat to those that don't really feel confident enough as a practitioner, the good people will see you as an asset.

Carry on the good work, and don't let the b*astards get you down!

WM

My first call was so long ago that we went to it in a horse and cart.... I do, however, vividly remember that it was a cardac arrest in a forest with a (retrospectively) huge down time. Yes, I worked it and no, she didn't survive.

How we laugh at our baby steps in EMS....

WM

Hello all,

I am firmly in agreement with Phil here. If we were to save just one life with this film then all the moral indignation on the planet would have been worth it. Let's not forget that today's kids are far more worldly-wise than we ever were. The outside influences such as tv and the internet make that the vast majority have already been exposed to far worse than anything we saw in this film.

WM

Hi all,

Is it just me or is there anyone else out there wondering what a powerful anesthetic drug like propofol is doing in the hands of a personal physician? Here it's only licences for use in hospitals and in a few cases, by EMS.

Still, at least I now know why it's restricted......

WM

You are right in assuming the catastrophic consequences of esophageal intubation. However, don't be too hard on yourself right away, everyone has to learn. That's the whole point of the rotation.

My own personal 5 point checklist usually stands me in pretty good stead (no failed intubations in the last 4 years):

1)Visualize the tube passing the chords

2)Note the "fogging"of the tube (not absolute, by the way...before anyone jumps on me!)

3)Listen for the absence of breath sounds over the stomach

4)Listen for breath sounds on both sides of the chest in at least 4 different places

5)Attach end-tidal capnometry for tube confirmation and maintenance

After intial intubation:

1)Use a good quality tube holder

2)Manually fixate the tube during any movement

3)Re-check breath sounds after said movement (eg. moving the pt. from the bed to the cot)

4)Place an OPA next to the tube as a bite block

5)Always assume the worst when a significant drop in etCO2 occurs.

Good luck!

WM

Will,

First of all, congratulations on the save! You've already had some great answers to your question, but I thought I'd also weigh in with an answer.

I suspect that you were witnessing the pre-arrest phase, something which we don't tend too see that much as EMS providers. The weak carotid pulse does seem to suggest a form of (barely perfusing) ventricular tachycardia. The epileptiform seizure activity is a short pre-cursor to unresponsiveness as the brain is starved of oxygen. It's actually a pretty scary sight: I have seen it a few times myself, you just know you're in for some fast action..

A witnessed arrest is, of course, the best type to have. You were right on top of it and that's why the pt. became responsive again. His hypoxic episode was short and sweet, leading to a quicker recovery. My one abiding memory is of the 44 yr ols that arrested in my truck who was given a succesful pre-cordial thump. He was awake again in a matter of seconds and said: "Man, why did you have to go and hit me like that?".

Good call!!

WM

Heck NO! That place is way to upscale for EMS hooligans. The Subway Inn or Port 41 is where it is going to happen. That or the last car of the F train to Coney Island with an oversized boom box (must have dual tape decks) and concealed beverages . Any other place is unacceptable.

I guess that makes me an upscale hooligan...........

WM

Over here it's reduction with midazolam/alfentanyl if time allows, otherwise it's just reduction.....Ouch!!!!

WM

Hello all,

Unfortunately I can't attend due to being 4,000 miles away at home

I do however want to offer a tip, if you are meeting in Manhattan: meet up here. It's the best beer bar in town and has a really nice relaxed atmosphere too.

I'll be coming in september, if it's a success then maybe it can be repeated........

WM

Whilst the study is promising in terms of cortico-steroids in the pre-hospital arena, I'm not yet ready to hang out the flags. The trial is of limited value due to it's size and the number of enrolled patients. I do think, however, that it is statistically significant that the steroids were given within a far shorter mean time in EMS than in the ER.

Terri also makes a good point, this study does not include (nor did it intend to, to be fair) the majority of patients in this category by virtue of the fact that it excludes COPD. I deal with far far more COPD pts than juvenile asthma. I am willing to suggest that pre-hospital cortico-steroids are of benefit here too, but this study does not address that.

It is also a few years old. Are there any more recent studies that back this up? (I know, I'm lazy; I should look it up myself).

WM

No, I don't but I do have inside information, as it were... Ik will send you a PM.

WM

I'm not going to comment on NJ as i have very limited experience. You may, however, consider Delaware and the following people:

http://nccde.org/ems/home/webpage1.asp

You couldn't wish to meet a better bunch of people and they are also not fire-based. The distance may be a little far to commute, depending on your location, but southern NJ is a stone's throw away.

WM

What a wonderful find!

I took part in this sketch (albeit very passively). I am sitting on the round table behind the pregnant lady as a fellow diner in the "restaurant". It was, indeed, hilarious and so much fun to do. The guy with breathing difficulties is Fran Hildewine, a friend of mine. He's better known as the JEMS's new products columnist.

Such great memories, that day!!! Thank you for this find!

WM

Doc,

I'll kick off then, shall I?

Firstly, an interesting article on a subject that is important but that does not get discussed as often as it should do.

However, I did miss one vital aspect in the study. How did the dosage errors affect mortality and morbidity. It's OK to tell us that we got it wrong, but I'd like to know what the consequences were too.

I suspect that the epinephrine dosage errors did not contribute significantly to mortality rates as pediatric arrest outcomes are generally appalling anyway. Still, it would have been nice to know how much difference it makes.

One statement did stick out though, and I will certainly be mindfull of it the next time I give pediatric drugs:

Although overall error rates in the treatment of adult and pediatric patients are similar, it is estimated that errors with potential to cause harm are 3 times more likely to occur among pediatric patients.

WM

COngrats there, Ruff!

Welcome to the world of fatherhood!

WM

CB,

Good call! A dystonic reaction is not something you'll see a lot of, I've only seen it two or three times in 18 years.

The second time was actually quite funny: a had an EMT partner that was always ribbing me about being an RN. He would bemoan the fact that I was paid more when we worked as a team. It was usually just said in a joking way, so I never really minded.

We got a call to a 17 yr old with what the GP called "neurological deficits". Upon arrival we had exactly the same symptoms as your case with a little drooling thrown in for fun. It's usually a very frightening experience for all concerned as it looks grotesque. Everyone looked at one another and wonderd what we were going to do. I asked immediately what meds he was on. I got as an answer: "He started haldol 2 days ago". Bingo!

I asked my partner to draw up our equivalent of Benadryl and gave it. The pt was asymtomatic within a few minutes. I then turned around to my partner and said: "That's why I get paid more than you do".

He has never mentioned the subject of pay since!

WM

I can assure you all that I would never defend any system that treats it's EMS as a poor stepchild. However, I do think it's fair to point out that this was a test to see where the problems were. That was the whole point, surely? Let them do their worst and we'll build from there.

These people probably haven't been back in the classroom since graduation with such a high volume system. This, to me, was a shoddy bit sensationalist journalism. Paul Werfel should never have participated, being such an influential person (apparently?).

Yes, they have major problems over there, but is it truly right to stamp on our peers from a great height with so little facts?

WM

Treating and releasing in the field - a recipe for success or disaster?.

EMS and PCI, the battle against heart disease.

The Golden Hour and other myths in trauma care.

Slightly further outside the box:

Shift patterns in EMS and it's effect on patient care.

ALS vs BLS: does the medic really save more lives?

Intergrating EMS into the primary care system, flight of fancy or an acheivable goal?

That 's a couple of ideas off the top of my head.

WM

Sod this lot, Aaron! Just send me a copy for my teaching practice, it sounds like a pretty cool teaching instrument...

WM

Say hello to Grant Gamble for me!

WM

Erin,

As a parent I can't even begin to imagine how that was for you. It's almost cruel to state it like this, but I think you "win" hands down on this topic.

That's why I feel that it's run it's course and maybe it's time to put a lock on it. It's not about the sensation of someone's "saddest call" but how we deal with it.

You are in my thoughts.

WM

Here's what I started with in 1993:

And here's what I have now:

As you can see, Mercedes is a popular brand here.

WM

I know of a very experienced anesthetist that is trained in EMS and he managed to inject the BIG into his thumb! I can happen to the best of us.

My personal preference is the EZ-IO. (I have used the BIG). It's fast, easy and leads to a better result than the BIG.

One thing we do need to remember is that the placement of an EZ isn't painful but infusion therapy sure as hell is! That's why we flush with 2% lidocaine first.

WM

I'm still reeling from the fact your Medcom thinks that 4mg of Versed will knock them out enough to facilitate endotracheal intubation!

It's very much a question of experience combined with science but I will not even attempt such an intervention until I've given a minimum of 10 mg combined with either fentanyl or alfentanyl.

I agree, however, with Dust. Such potentially dangerous procedures shoudn't be attempted by cook-book practitioners. You need years of practice before giving these drugs safely. Intubating a pt with 2mg of Versed on board will generally lead to all sorts of problems, starting with an enormous ICP rise.

WM

This is indeed not new. A pt with a drop in BP will ultimately already be decompensating to some degree. There are more subtle signs to watch for before this happens: a raised respiratory rate, restlessness, diaphoresis.

This should be the basics but I guess some folk need reminding, so a good article all-round.

WM