Doczilla

The studies I've seen don't show any real improvements in prehospital intubation success rate with PAI. RSI, on the other hand, has been shown to increase overall success of intubation, from about 60-70% without it to >90% with it. Of prehospital failed intubations, inadequate relaxation is cited in over 50% of failures as a cause. "It scares the pants off the medical director" is the reason most often cited for why some systems don't have RSI, and it's usually followed by citation of dismal prehospital intubation success rates. p3 and Ruffems are right on. On a personal note, I like to paralyze people, because if their stomach contents do come sailing up the esophagus, I know they're not going to take a niiiccceeee big deep breath in and suck it all down in to all the remote corners of their lungs. Etomidate is now my go-to drug for sedation in RSI and in procedural sedation as well, for all the reasons scatrat mentioned. Additionally, so many people now take benzos (recreationally or for medical reasons) or abuse alcohol that Versed doesn't work at typical doses, and I'm stuck pushing more than I'm comfortable with. 'zilla

Let's not forget trustworthy, loyal, helpful, friendly, courteous, kind, obedient, thrifty, clean, and reverent. 'zilla

Well, if you're afraid to do CSM and the patient won't comply enough for valsalva... ...you could always perform a digital rectal sweep. It's an effective vagal maneuver without the drawbacks of the other methods. Of course, it has its own drawbacks. And some medical directors might frown on this. :twisted: 'zilla

I don't wear a thong. Boxer briefs, 50% spandex, 50% kevlar. 'zilla

It may not have been displaced very much until it was moved at the hospital. And if an x-ray was needed to determine the presence of a fracture, then they didn't see it either. And tell the "colleague" of yours to get back in his lane. If he had to call you to tell you about it, then he missed it too. :roll: 'zilla

Putting in all 3 is a very good idea, and is what is taught to the ER residents here for BLS management while preparing to intubate. I don't think it's excessive, and bringing a patient like that in signals to me that you are paying close attention to the airway and maximizing ventilation. The airways will not interfere with each other, and improves the available airway through which you can ventilate. The more you can get that airway wide open, the better you can ventilate with lower pressures on the bag, and reduce insufflation of the stomach. Scratrat's suggestion of "why don't you just intubate them" is fine, except that you have to ventilate them while getting ready to tube and to maximize your intubation attempt. The better you can ventilate them before the attempt, the more time you have for placing the tube. And then if you can't get them tubed on the first or second try, good BLS management will save you from having to perform a cricothyroidotomy. I see the mistake made fairly frequently by ALS providers: they concentrate so much on ALS skills like intubation, that they just don't pay that much attention to good solid BLS skills. 'zilla

Picked some up the other day. $2.61 for 2 4mg vials for injection. The ODT has also apparently gone generic as well. Thought this might be of interest to some folks. At this price, it's about as cheap as phenergan. If you want to debate the effectiveness of Zofran vs. Phenergan vs. Compazine, rather than filling up another thread, read and continue the debate here. 'zilla

When the officer on scene opens his trunk and pulls out an AR-15 patrol rifle and racks the slide. When your patient says, "I hope you have a strong stomach..." When running toward the ICU, you encounter a family of 10 wailing and running the other way. When the entire nursing station empties without a word. 'zilla

The V-Vac sucks, and not in the way that it's supposed to. I'd recommend trying out the Suctioneasy from NARP, if you're looking for a non-powered and portable unit. Simple, portable, effective, and costs about 1/3 of the V-Vac. http://www.narescue.com/NARP-Tactical-Suct...vice-P78C2.aspx 'zilla

When it's elective, it's done under ultrasound. When it's emergent, it is done without ultrasound. 'zilla

There are still times when I ask myself "WTF was I THINKING?" Then it occurs to me that no other job rules as much as this one. 'zilla

Someone hear hoofbeats? Must be zebras. Central neurogenic hyperventilation in a conscious patient without a brainstem infarct, invasive tumor, monster brain injury, or serious CNS infection is rarely, if ever, reported. In head traumas, this signals impending herniation, in which case your patient would not be conscious. Holy crap. Hypocalcemia?! NO. Look, you've got to look at common things being common, and neither of the above is common. A person on a plane who is hyperventilating with carpopedal spasm after getting a bonk on the head by a falling cane is not herniating, particularly if she's alert enough to complain of a headache. Less time Googling, more time at the bedside, Grasshopper. 'zilla

I've used it as a sort of "patient-be-gone" for the patients with intractable chronic nonspecific complaints that will not respond to any therapy known to man. That's terrible to say, but I see a fair number of people that I can't really flesh out their complaint and they won't go away until I give them something to make them feel funny. A shot of Vistaril, then suddenly the burning sensation in the middle of their forehead, or the nonspecific abdominal discomfort, or the back pain that is probably from that time I got hurt at work, or that numbness of my legs that really aren't numb at all, or that sense that I'm just smothering even though I've had a cardiac cath and PFTs and a pulmonary angiogram in the last week after 3 ER visits, or the feeling like I'm about to have a seizure even though I've never had one before, or the belief that I am getting chronic headaches because I had a vaccine once that wasn't thimerosol free, evaporates. 'zilla

Airlines contract with services that provide online medical direction from a ground-based ER in situations like this. The system is in place to hook you up with a doc on the phone that can do medical control just like you would in the field. And ultimately, that doc is in control just like your medical director is, and can authorize advanced care as needed. The medical control physician on the ground can override orders by a doc on the plane as well. The point is, you're never on your own up there, no matter what your skill level or what airline you're on. Virgin Atlantic has been installing telemetry modules on their planes to transmit vitals and other data (the module takes vitals for you, which is probably the key advantage of having it). The point was made here that the flight crew, and ultimately the captain, has the final say on what happens on that plane. No matter what kind of emergency it is, they may elect not to divert to another airport. You can provide some input, but don't really have any legal authority, so don't make a stink if they don't take your advice. The real question is whether or not to land the plane early. In a lot of situations, it won't make too much sense. On the little data that's available, most in-flight emergencies are anxiety-related. A few points to consider: 1) Planes take off loaded with fuel, but aren't built to land loaded with fuel. This means that if an emergency occurs just after take-off, the plane will have to circle to burn off fuel or dump it. Think about how much time that saves, and you may be better off just continuing the flight. 2) The airline loses about $250,000 each time it diverts a plane like that. This is important to consider in the grand scheme of things: will it really matter to get the patient to the hospital that much sooner? In the aforementioned example of the patient with a HR of 24, it might. For abdominal pain, even a ruptured appendix, probably not. 3) If a patient codes on a flight, there is no way to get them on the ground in time to make a difference. The captain will often just opt to complete the flight, since it won't make a difference anyway. 4) Planes are generally pressurized at 8000 feet. This may lead to some gasseous expanse problems (not a big deal for most unless they have a serious bowel condition), which can be a REAL problem if they have a pneumo or decompression sickness because they just HAD to go scuba diving one last time on their vacation. For this reason, oxygen is always a good idea. The pilot does have the capability to pressurize the plane to about sea level in cases like this. This can buy you time. 5) Plane first aid kits are commercially manufactured and vary by supplier. AEDs are pretty standard now by federal law. A lot have IV meds, benadryl, epi, lido. 'zilla

Asys brings up some good points here. Actually, everyone has brought up good points, and this has become a very interesting discussion. There is no right answer here, and hearing the thought process of various providers is the point. Now here I come to throw a wrench into the works... You are given this order by the physician. It is a lawful order, one that is appropriate to the patient's condition. The physician fully understands the patient's condition and diagnosis, and has given an order that represents, at least from his perspective, the standard of care. As a prehospital provider you work under the license of a physician, and technically are following orders in the form of protocol. You are now being given a direct online order by a licensed physician, one that your medical director allows to give online orders. Can you refuse it? 'zilla

Sick. Not simply feeling bad, but in real danger of a bad outcome if untreated. Sometimes SICK is evident in the vital signs, or the rhythm, or the lung sounds. Very often, it's not simply one variable that you can put your finger on, but a "feeling" that you have just on walking in the room and laying eyes on them. Despite the warnings we all receive about patients with potentially fatal disease that is lurking out of sight, most folks that are really in danger clue into these little instincts of ours. 'zilla

-5 for asking for more exam findings. PEA with sinus tachycardia, if you're curious. You don't need an alligator clip for the procedure. Nobody actually does this, despite its apperance in the procedure manuals. The monitor will show you all kinds of ugly ectopy when you hit the heart. All you need is a syringe (60cc would be good, but you can make do with smaller) and a BFN (big friggin' needle). The 14g 2.5" Angiocath that you use for chest decompression will do. 'zilla

Wanting to generate a little discussion here. You (as an ALS provider. If you're not, pretend you are for a moment.) are called for a patient with shortness of breath. Your patient is a 41 year old female with a history of Lupus (Systemic Lupus Erythematosis), an autoimmune disorder. The patient, on a scale from 1 to SICK, is most definitely SICK. She has a known pericardial effusion (a complication of SLE), and was to have it drained in 2 days in the cath lab by cardiology. She has had worsening shortness of breath for weeks, which is what prompted the diagnosis and plan for drainage of her pericardial effusion. Over the last 24 hours, her SOB has become intolerable, and she now is very symptomatic at rest. Vitals are as follows: T: 36.6 P: 138 R: 36 BP: 60/P SaO2: 88% on room air. Examination reveals rales in all fields, JVD, poor pulses. EKG shows a sinus tachycardia with electrical alternans, which is pathognomonic for pericardial effusion. Assume the rest of the exam is as bad as you think it is. No further exam findings will be provided, nor will they be helpful. You load into the ambulance and go, putting the patient on high flow oxygen and starting the IV enroute. You have successfully started the IV and are on the phone with the physician at the closest receiving facility (still 20min away) when she arrests. The physician orders you to do a pericardiocentesis, and says that he will instruct you in the procedure over the phone. You tell him have never performed one, and have never seen it done, and haven't been trained in the procedure, though he assures you that it is simple and he can talk you through it. You don't know if it is within the scope of practice for a paramedic in your state or not, and there's no time to call the State Dept. of EMS to check. It's definitely not in your protocols, at least not this procedure specifically, though there is leeway in the protocols for deviations from protocol with online order. The physician is an emergency physician, but not the medical director for your service. Chance of survival aside, do you follow the online order, or not? 'zilla

His BP doesn't seem that high for the typical "blowout" bleed. 12 hours of nosebleed that doesn't stop? I would be concerned for a coagulopathy. Among the boatload of medicines he takes could be coumadin, plavix, aspirin, or other meds that could cause coagulopathy (clotting problems) or thrombocytopenia (lack of platelets). These kinds of nosebleeds, while usually not life-threatening of themselves, often signal a serious underlying problem. Timmy, you did the right thing by calling the medics. You could have gotten away with BLS transport if it was available, or even let him go by car, but he needed to be checked one way or another. I agree that you should avoid arguing in front of a patient, but you were right to voice your concerns. The question to ask yourself now, is, was there a better way to do it? 'zilla

Not entirely true. Blackwater offers their SWAT Medic program as part of the several week "train up" for their PSD (personal security detail, i.e., protecting someone important) contractors who will deploy with them. The ALS certification is required for those who serve as medics for these teams. You can take the course without the prereq and without deploying with them. It'll just cost you some money. 'zilla

A london broil, a mousetrap, 14 tubes of toothpaste. And a box of those little frozen mini-eclaires. 'zilla

You might take care to remember that there are MDs on this site before you make a statement such as this. 'zilla

Looking at this case, I see a few issues: 1) The crew with the responsibility for transporting the child felt uncomfortable with taking him. That said, it's their call whether to involve another level of care, in this case, flight service. 2) The transporting crew, who had ultimate responsibility for the patient, acquiesced to the demands of the first responders. 3) The flight service turned out to be unnecessary. There are a few articles recently in Annals of EM on the dangerous nature of helicopter EMS, and how the death rate per 100,000 man-missions has tripled in the last decade, while number of sorties has expanded greatly. This should serve to reinforce the fact that calling for a helicopter is not a benign thing, and carries a real risk to the patient as well as the 3-4 man crew of the bird. Here, approximately 80% of patients flown to the children's hospital by the helicopter are discharged home from the ED. This is telling us that we are GREATLY over-triaging pediatric patients, allowing the sphincter-factor and our own perceived shortcomings in pediatric care to influence our transport decisions. The helicopter service is not about to dispel these myths: the flight service had $12M in operating costs last year, and generated $42M in revenues for the hospital. Flight services are a money-maker for the hospitals that run them for a number of reasons: 1) it's easy to bill for and recuperate the costs of operations, 2) it extends the reach of the hospital into areas that would be served by other, closer hospitals, giving them access to insured populations away from their city center, and 3) it's a great PR thing to show the community how high-tech and cutting-edge the hospital is. So they are more than happy to reinforce the feelings among ground services that they have procedures (RSI), training (can't argue), and speed that ground services don't have. It's up to the crews to make these decisions, and it's not an easy call to make. Really, once you factor in the time to spin up the bird, prep the landing zone, fly out, land, load the patient (with all the straps and securing systems and blankets and monitors and all that stuff that helicopters use), fly back, unload the patient, take the elevator down to the ED, how much time is really saved over loading the patient into the ambulance and driving there? Further, the golden hour is ONLY proven to be of benefit in patients who go immediately to the OR, which comprises a scant minority of patients in this day and age of advanced imaging. Is the 10 minutes of saved transport time really of benefit to the patient, in light of the CONSIDERABLE cost and additional risk? Just because a patient is very sick, even critically ill, doesn't mean they need a $3000 ride in a helicopter. Add to this the fact that many patients are paralyzed and intubated SOLELY because they are going on a helicopter (for monitoring and patient control) when they could be safely managed without this in a ground unit. Now we are exposing patients to greater medical risk by "preparing" them for transport. And is calling for a helicopter simply an attempt to relieve the anxiety ground crews feel when caring for truly ill patients? We have to re-examine our overuse of helicopter based EMS. The hospitals, for the reasons above, certainly aren't going to do it. The public, despite a rising death toll, isn't questioning it, even as we have more helicopter services and more accidents per mission. 'zilla

Hey Dust- Now that you've had some time "in country", have you made any changes to your load? Are there things you don't have but wish you did, or things that aren't as useful as you thought they'd be? 'zilla

If you wear a "tactical EMS" patch or subdued patch when you are not attached to a team or haven't taken a tactical EMT class, you will be labeled a variety of things: squirrel, nimrod, or mall ninja. And it will virtually guarantee that no team will want to have you. Could be worse. You wear a SEAL Trident or Special Forces tab without earning it, and you will die unmercifully. Being part of a SWAT team is all about THEM wanting to have YOU. And SWAT guys tend to be an insular group. If you don't have an "in", it will take a whole lot of groundwork and good will. And that still guarantees nothing. The training is a place to start. BLS providers don't provide much to the team, as the officers themselves can provide that level of care. Paramedic level training is necessary unless you are a sworn officer already that is part of the team. As far as tactical training goes, here are some courses, in no particular order: CONTOMS (www.casualtycareresearchcenter.org. Essentially the standard. This is the traditional "EMT-T" course, and they do an excellent job of it. Addresses many different aspects of tactical medicine, including preventive medicine and extended ops.) Cypress Creek (www.ccems.com/catt_team/class.html) Blackwater (www.blackwaterusa.com. A good well-rounded course which includes a good bit of basic SWAT ops and shooting.) International School of Tactical Medicine (www.swatdoctor.com, run by the docs who used to run H&Ks program) Tactical Element (www.tacticalelement.com) Global Medical Rescue Services (www.gmrsltd.com. These guys are VERY well respected in many circles. If you are going to do medicine in remote environments, I would go nowhere else but here.) Having done 2 of the above courses, and Basic SWAT at the police academy, and extensive training with the team here, I can tell you that the courses, like paramedic school, teach you just enough to be dangerous. Search the forums here and at www.lightfighter.net for more info. The question is, do you want to do this because you are interested in medical care in austere environments, or because you want to dress up and shoot people? If you want to do both, then see your Army recruiter. There you will get the best kind of tactical medic training there is. 'zilla