Doczilla

It's not nice to talk about me that way. I even bought you beer. 'zilla

"Snow" is in reference to Dr. John Snow, who was a pioneer in the early use of chloroform and later ether for general surgical anesthesia. To snow someone means to anesthetize them, though this can have varying meanings. We snow people for intubation, snow them for procedures so they will tolerate them better, or snow them with pain drugs when we don't know the cause of the pain but must reach a disposition. Each of these implies a different level of anesthesia. 'zilla

It is very difficult to look at a patient and his injuries, after all is said and done, and say whether excessive force was used (the above cited case involving a toilet plunger is an obvious exception). I think that these ER docs may be stepping out of their lane by saying so. The ER doc has no right to armchair quarterback the officer's decisions when he wasn't present for the injury any more than the press or some idiot citizen. Anyone who wasn't there should bite their tongue and let people who know what they are talking about look it over. It's like when the ICU doc comes down to the ER and says, "you told me this patient was hypotensive, but his blood pressure is fine." Yeah, jackass, because I treated it. It's easy to look at the subject after all the fight's been taken out of him and say, "he's calm, why did you taser him?" Folks are quick to shout "police brutality", but notice how when an officer dies in the line of duty, there aren't people shouting in the street that he should have shot the suspect. Use of force is a tactical decision, not a medical one. ER docs do not generally have any training on use of force unless they work with a SWAT team on a regular basis. You can't look at a bruise or broken bone and say it wasn't necessary unless you witnessed the subject's behavior AT THE TIME. All departments have a policy on review of the use of force, and the people who review these are officers who can put themselves in the arresting officer's shoes and know all the options available to the officers. 'zilla

In suspected thoracic aortic dissection, taking the BP in both arms is not only okay, it is encouraged. 'zilla

Like every business nationwide, EMS will see it's bottom line hurt by the recession, even city services. Less income from constituents equals less city tax revenue equals smaller budgets. Tighter budget for Medicare and Medicaid means that payments will be delayed to providers even longer than they are now. Less people being able to pay premiums on health insurance + poor stock market performance (that's where the insurance companies gamble your premiums) = less payouts from insurance companies. It's ugly, but not the perfect storm to destroy EMS. I wouldn't sound the death knell for the hospital based services just yet. Remember that these are designed to bring business into the hospital, particularly when there are competing hospitals around. Nobody has the bulk purchasing power, insurance power, and employee benefits power that the hospital does, and therefore nobody can do things cheaper. The ER is a money-loser for the hospital (spending more per patient than they are reimbursed), but 50-60% of admissions come through the ER. The ER is therefore a money-maker if it can attract patients. Just as the ER is now recognized as the front door to the hospital, so must they recognize EMS as an extension of that front door. We will learn to get by. That means we will probably put off the purchase of the new truck and eek another 50K miles out of the old one. We'll keep humping the old stretcher and throwing our backs out because we can't buy the new stretcher this year. We'll still wear the old jackets and throw a cheap Gall's reflective vest over it because we can't afford the new 5.11 reflective EMS coat (which is awesome, BTW). We'll shut the trucks off and bring the drugs inside with us to keep them from freezing instead of leaving the truck cranked all night. Con-ed will be done in house by senior personnel instead of sending everyone to EMS Today. Overtime will be limited, Christmas bonuses will be smaller, and the JEMS Buyer's Guide will make us drool with all the cool stuff we don't have (and have always done fine without). There is still money to be made in this business. We'll get by. 'zilla

Regarding GSA laws, there are often separately written laws for those with medical training and those without. The key difference in the laws for those with medical training is that you can act only up to the level of your training and not beyond, therefore an EMT-Basic cannot perform a cricothyroidotomy with a ballpoint pen. Pulling a person from a vehicle is hardly a medical procedure. It is not defined procedure in any textbook, not billable as a procedure, and there is no "standard curriculum" on how to do it. (Yes, we train on this, but every instructor teaches it a different way, and most of them are not wrong) Even if there was, the layperson should not be expected to know it. Do most laypeople know that cars don't explode? Not if they watch TV, where every car explodes on impact. WE know that cars don't explode, which is why we would be held to a different standard of care than a lay person. Okeefeda is right about the fact that anyone can be sued for anything, no matter what the law says, but the GSA gives the court guidance to dismiss the suit before it goes very far. It's not a prohibition on suing, just one that almost guarantees the suit won't go through. Many lawyers won't want to take a case that is guaranteed to fail, particularly if their fee is based on how much they win (what's 30% of 0?). "Gross" negligence would be an act so unconscionable that a reasonable person would know it's the wrong thing to do. Placing a plastic bag over the head of a patient with difficulty breathing, for example. "Willful and wanton misconduct" would be shown by intentionally yanking the patient out in order to induce injury, smothering her with a pillow, or kicking the wrecked car down the embankment with someone still inside. We've all seen some dumb shit done by laypeople with no medical training, but we've also seen a lot of folks get good care at the roadside, such as the off-duty EMT that tells the other bystanders NOT to pull the patient from the car, or the doctor and nurse on the plane who treat the chest pain prudently, or the ER doctor (myself) who happens upon a multiple vehicle wreck on the highway and performs triage and scene size-up. There are several dashcam videos of police officers being assaulted or shot, and the first person at their side that can radio their plight seems to usually be a bystander. The reason that this court finding is problematic is that laypeople with no medical training will not know about it. Medical providers will. And the higher the level the medical provider, the less likely they will be willing to help, since their deeper pockets make an appetizing target. Good luck getting a doctor to help you out when your grandmother hits the floor in the grocery store. So the next time you're on an airplane and your child or mother suffers a medical emergency, and you ask for help and the flight attendant asks if there is a doctor or medical professional on board, without this guaranteed protection, who will raise their hand? Whose hands will you be in instead? 'zilla

The assclowns on the CSC have clearly taken leave of their senses. The Good Samaritan statutes are designed to protect people from liability in all but "gross negligence" or "willful or wanton misconduct". Even thought this layperson was misguided in believing that the car would explode, removing the patient from the car when she believed imminent danger existed is prudent. Laypeople should not be expected to know anything about spinal immobilization. As has been said here, anyone can hire a lawyer to sue anyone for anything, but the court should have stomped this one into the ground early on. Hopefully, the defense's expert witnesses will expose this sham of an argument for what it is, and the court and jury will see the plaintiff for what she is. I will once again reiterate that there has NEVER been a reported case of spinal injury being exacerbated by movement. The CSC has done a disservice to patients everywhere by preventing more would be good samaritans (many of them trained healthcare professionals) from stopping to render aid and comfort in an emergency. Pump the brakes, Arctickat. ERDoc was making a point. 'zilla

A "donut magnet" is a round magnet that can be used to temporarily modify the function of implantable defibrillators and pacemakers. When placed over the device, it will disable the defibrillator/cardioverter function and prevent inappropriate shocks (of course, it will also prevent appropriate shocks as well). Inappropriate shocks are most commonly caused by "oversensing", which is when the AICD incorrectly senses that the heart is in v-fib or v-tach and provides a shock. For pacemakers, the magnet will convert the pacemaker from "demand" pacing mode to "fixed" pacing mode, i.e., it will pace at the set rate no matter what the heart is doing. This is to correct the most common pacemaker error, also known as "oversensing" when the pacemaker incorrectly senses impulses and interprets them as beats. Thinking that the heart is beating appropriately on its own, it doesn't provide a pacing impulse when needed. By converting to fixed mode, it will pace the heart at the set rate (which is set when it is implanted, but can be modified by a tech with a computer hooked to a magnet, usually 70 BPM). Once the magnet is removed, the AICD or pacemaker returns to its previous settings. Placement of a magnet does not permanently change the device settings. I think having a magnet on the ambulance is probably of little benefit. I apply these very infrequently, perhaps 3 times in the last 4 years. 'zilla

Hogs eat acorns? 'zilla

Use it, in a training environment where someone knows how, and you will see. 'zilla

You know, I misspoke, and after rereading the article, see what they are getting at and why. The article in JSOM indicates placement of the bougie anterograde through the incision and into the R mainstem bronchus, not retrograde as I initially indicated. The advantages of the procedure as indicated in the article are this: no need for a hook or dilator, lateral displacement of the membrane, which allows for a larger endotracheal tube than 6mm, and lateral displacement of the membrane reducing the chance of vessel injury or rescuer injury from the blade as you spread the incision. My apologies for any resulting confusion. Surgical cric is a temporizing measure, and has to be converted to another form of secure airway soon after arrival at the hospital (either tracheostomy or placement of an oral endotracheal tube under more controlled conditions.) The incision needed for bougie retrograde intubation is also much smaller than that required for a cric, so less danger of running into vessels you don't want to run into. Nice idea. Airtraq is probably cheaper, more compact, and works on the same principle. Similar idea to the Glidescope. Also not cheap, I'm sure. Same thing as above. Could this be the manufactured version of the patent shown above? Homemade Glidescope Ranger, which is currently available for purchase in the US at the bargain price of $8900. I'm a fan of the Glidescope and the Airtraq (I have no financial interest in either), and would recommend them for any agency that can afford to purchase them. The Glidescope is prohibitively expensive for many agencies, particularly with multiple trucks, but the Airtraq runs about $80, so it's a cheap piece of insurance. 'zilla

CHF is still principally diagnosed by chest xray, though BNP can help in a patient with a normal xray or abnormal xray and you can't tell what that perihilar infiltrate is exactly... (oh, and there is such a thing as unilateral pulmonary edema too. Remember that the most common cause of right sided heart failure is LEFT sided heart failure. Isolated right sided heart failure from acute MI is rare, representing only about 40% of inferior MIs. It's not that you CAN'T give nitro to these patients, you just have to be very careful about it. 'zilla

Read this thread: http://www.emtcity.com/phpBB2/viewtopic.php?t=12896 and this one: http://www.emtcity.com/phpBB2/viewtopic.php?t=4896 I work with a few medic/cops who are SWAT. They tend to be cops first and medics second (that's no disrespect to them. I would have them kick ass on my behalf any day), but the best SWAT medics I know are medics, not cops. Combining skill sets has some advantages but also some real drawbacks, the chief of which I see as dilution of the skill sets to accommodate multiple roles. 'zilla

Several EMS agencies in our area use them. There is no specific "protocol" for their use, which is left to the paramedic's discretion, just as there is no protocol which states which laryngoscope blade to use. Our tactical medics have them also for digital intubation use. I just read an interesting article in the Journal of Special Operations Medicine last night, which detailed use of the bougie to intubate in a retrograde fashion through a surgical cricothyroidotomy (night vision goggles optional). It's ike a retrograde wireguided intubation, but through an incision rather than a needle. Considering how difficult a wire is to see in the back of the airway (particularly a bloody one), this might be a little easier to see. I thought it might be a useful skill to add to the medic's toolbox. 'zilla

I do this for field terms as well as pronouncements in hospital. I confirm the following: no response to pain no pulse or breathing no central capillary refill no heart sounds pupils fixed/dilated asystole on the monitor and then leave the body alone. I'll cover them if it is clearly not an unexpected death or not a crime scene. So as not to introduce or disturb evidence, I do not cover the body unless instructed to do so by the crime scene investigator or crash investigator. 'zilla

Just because you saw them alive doesn't mean you can save them. Sudden onset CHF in a patient without a history of CHF is a very poor prognostic indicator. It means a) huge MI or blown heart valve from endocarditis or papillary muscle rupture. I've seen exactly this patient many times over, and despite positive pressure ventilation and any drug or airway device I want, they usually still die. The patient was doomed. 'zilla

This is one of those pieces of EMS dogma that gets passed down with this kind of emphatic dedication with absolutely no evidence to back it up. Not one reported case, EVER, of a patient having neurological deficit from improper c-spine precautions. And cases like this one are exactly why it is important for EMS providers to know what the real risks are, since management of the airway may be at odds with protection of the c-spine. And a LOW c-spine fracture will not cause paralysis of the diaphragm unless there is substantial cord contusion at levels above the fracture. Dust, Anthony, BEorP, JakeEMTP, akroeze, and CBEMT can tell you this after the cadaver lab. 'zilla

On the one hand, you have the theoretical risk of a spinal fracture, and the theoretical risk that not immobilizing it will do harm to the patient (never actually proven, though firmly in the dogma of prehospital and emergency medicine). On the other hand, you have evidence of compromise of airway and oxygenation, which if untreated, is always fatal. I would immobilize sitting up, or forgo it altogether if it compromised oxygenating the patient. 'zilla

Dust, Anthony and I closed down the Pub at the Greene last night, then froze our asses off in the parking lot for a while. And Anthony was drinking a tiny little beer. It was nice to meet you fellas and raise a glass and have a loud, spirited (in more ways than one) debate about the various reasons that Canada sucks. Glad y'all enjoyed the class. 'zilla

Yes. And she's like a little sister to all of us. Not only can we kill you, but we can sign the death certificate. 'zilla

We have a spy among us... :glasses1: 'zilla

When are we drinking beer? 'zilla

Having one paramedic asking her questions and performing procedures while the other calls in a radio report to the hospital (even if you only hear snippets of it) will allow for some exposition regarding her injuries and what they know of what happened to her. My recommendation is to go to your local paramedic training program, talk to the instructors, and ask them to run a simulated call with you as the patient. That will probably give you more information than anything else, and can help you set the tone for the scene. 'zilla

It's not at the hospital, but at Wright State University. This hotel is convenient for driving, but about 20 minutes from the University. Look at hotels near the Fairfield Mall, 675 exit 17, the Nutter Center. And while y'all are here, budget some time to see the Museum of the US Air Force. It's free, and huge. 'zilla

Those aren't hip fractures in the xrays. Those are pelvic fractures. Isolated hip fractures should not get a compression wrap. That would cause lots of pain. 'zilla