Doczilla

Having been Tased (voluntarily, I might add, no matter what Itku2ER might say about me), I can say from experience it does not result in impairment or control of muscles after the shock is delivered, nor have I ever heard of this from anyone who teaches/uses Tasers. The student was being a drama queen. 'zilla

Hey, now. There's no reason to insult the man. 'zilla

NPs and PAs do not generally have the critical care experience that I would want for medical control. Even PAs who have completed an EM fellowship have very limited ICU experience. Physician extenders exist in the ED setting largely to handle more minor cases, freeing the MD/DO for more critical patients, and the training of the physician extender generally reflects that. And unlike the EM residency-trained doc, none have done fellowships or had much of any training in administration of civilian EMS or legal aspects of that realm of care. There are exceptions, of course, but I have only seen them in the military setting, and their ability to oversee prehospital care usually comes from a background as a medic (91W/68W/18D) rather than from their PA training. There are some PAs and APNs who are well-trained in trauma care and are part of the trauma service here who do a good job of taking care of trauma patients. I have not seen any physician extenders in the medical critical care area. I see the only genuine need for online medical control as being for critically ill patients, questionable refusals, or the need for advice on complicated ethical issues that arise in the field. For these patients, physicians are the only ones formally trained to give out the orders and advice needed. 'zilla

I think that some of this question can be broken down like this: Who needs to go to the ED? Who needs to go there by ambulance? It's one thing to get someone to avoid going altogether and follow up with their primary care physician. Apart from the obvious (DOA, competent patient refusing), this is shaky legal ground. I would encourage EMS to contact the patient's primary care physician in the presence of the patient and touch base if possible. You can get some advice from the doc who knows them best, as well as ensure some follow-up care. Medical control can help you out here to a limited extent. It's another thing to say they don't need an ambulance ride, but ensuring transport to the ED. There are patients that certainly require care but don't need it by the ambulance (like the patients with the lacerations), or those who called 911 because that's the only ride to the hospital they have. With the case of the lacerations just brought up, you may be able to ensure transport with family or through a taxicab voucher program. This way the patient gets the care they need but isn't socked with a $400 ambulance bill. The EMS crew clears the scene and is available sooner for transports, reducing burden on the 911 system. The potential downside here is with those patients who are inappropriately released who have a life-threatening problem that will require monitoring on transport. What needs to go by ambulance? That list is long and distinguished, but basically comes down to those patients who require: Monitoring because they are at risk to rapidly decompensate Oxygen above what they normally take Immobilization of anything but an upper extremity Medications, including pain medicine Restraint Someone to make sure they get there because they are not mentating correctly Someone to make sure they get there because they have extremely poor follow-up care or compliance, and you really can't guarantee they will get to the ED or doctor's office if you don't take them. 'zilla

Yes, and in fact, it is required. You have to at least some idea of the patient's problem in order to apply appropriate treatment, as Medic26 alluded to. There are some who advocate the sole use of chief complaint or physical signs as diagnosis in the field, but "shortness of breath" just doesn't cut it if you are going to do anything to treat it. Presumed CHF? Bronchospasm? Myocardial ischemia? Pneumonia? All of these have vastly different treatments. You have to have not only a differential, but a leading suspect. Things aren't always that clear, so you have to put down a complaint in the dx box sometimes (abdominal pain of uncertain etiology, dyspnea NOS, altered mental status). But overall, you've got to have an idea of what you're treating. Otherwise, you're just throwing treatment at someone and hoping something works, and that's no way to practice. 'zilla

The ramifications of hitting someone with a Taser who is wearing a pacemaker: They wouldn't get shot with real bullets. The Tazer is part of the "force continuum", and depending on how your PD applies it, falls somewhere between being tackled to the ground and getting a beating with an ASP. It is a method of physical control which is safer for the officers and the suspect than many other methods. Tackling a combative person results in injury a large percentage of the time. Shooting them doesn't work out well for anyone. The application of the Taser, keep in mind, is to prevent people from injury that would otherwise be handled with hands-on force, impact weapons, or bullets. One British study on this cited lower injury rates to both officers and suspects with Taser use than other methods. The fact is that this issue has not been adequately studied in people with pacemakers. A large study is under way at Wake Forest University on less-lethal weapons, including the Taser. This may illuminate some issues. I found one case report of a woman with a single chamber ICD that was hit with a Taser. The ICD interpreted it as V-fib, though the Taser pulse ceased before the device discharged (it was charging up the capacitors to do so), and it aborted firing. This was discovered later on interrogation of the ICD (the patient was fine). The fibrillation threshold for V-fib in humans is roughly 15-25 times higher than the pulse delivered by the Taser, so I don't think the pulse will get carried down the wires into the heart and cause V-fib. It might, however, damage the pacemaker. Again, no studies to show one way or the other. From a prehospital perspective, a person with an implanted cardiac device should be brought to the hospital and have the device examined and interrogated by the rep (hospitals usually don't have the equipment to interrogate devices, relying on the manufacturer's rep to bring it in when called). An alternative to this would be arranging follow-up with a cardiology office to have the device examined the following day. Strongly consider taking the patient to the hospital anyway to examine the cause or comorbidities associated with the behavior that got them Tased in the first place. The real problem with asking the question is putting doubt in the officer's mind. There is usually no way to tell if a person has a pacemaker or not, and that hesitation may result in the officer using lethal force (shooting) a suspect when a Tazer may have adequately subdued them. The evidence we have thus far suggests that the few deaths reported are in subjects with "excited delirium" due to drug use or extreme emotional state. I don't think that this should be a contraindication to Taser use either; the alternatives are far more likely to result in injury or death. Application of less-lethal weapons (Tazer, impact weapons, chemical munitions) is not guaranteed to not cause death, just much less likely to do so. The officer should apply the device when the tactical situation dictates. 'zilla

Since they are 2 separate agencies, you should do your own documentation. It doesn't have to make it to the hospital, but there should be a copy filed with the rest of the PCRs for your service. This is for a number of reasons: 1) Documentation in case any actions are disputed (as mentioned) 2) Documentation in case there is any legal outcome (as mentioned). Emergency cases that go to litigation are often subject to "carpet bombing" where the plaintiff sues everyone that had their hands on the patient from the first responders on up, no matter what happened. Defendants that had nothing to do with the adverse outcome are subsequently dropped (you really can't expect to be held liable for the surgeon leaving a sponge in the patient, but you won't get dropped until the first round of depositions). 3) Call tracking, skills verification. 4) QA/QI. Medical directors, when they review run sheets, like to review the more serious calls like codes. 5) State requirements. 6) Data collection at the regional or state level. 7) Retrospective chart review for any number of reasons. 'zilla

I agree. Flying her was a good call. Sounds like the treating physicians came to the same conclusion. I don't understand a moratorium on flying medical patients. We fly MI and CVA patients all the time between hospitals. In certain field situations, it's completely appropriate. 'zilla

Sodium bicarb CAN be used in salicylate OD, but I would be reluctant to use it without a serum pH unless the patient is patently unstable (i.e., arresting). Bicarb alkalinizes the urine to enhance excretion and helps moderate metabolic acidosis. Salicylates cause a metabolic acidosis along with a respiratory alkalosis (central hyperventilation). They also cause hyperthermia by uncoupling oxidative phosphorylation (essentially, the electron transport chain spins its wheels producing heat instead of ATP). Treatment is largely supportive in the prehospital environment. Prepare for respiratory failure, GI hemorrhage, and shock. Establish large bore venous access and give isotonic crystalloid if needed. MedicRN brings up a good point about noncardiogenic pulmonary edema, so be cautious about fluid. Facilitate appropriate body temperature by cooling if necessary. As they burn through their energy stores, hypoglycemia may occur, so watch this and manage it. Dialysis is the most effective way to get rid of the salicylate. 'zilla

I'm skeptical. The inspiratory sound you describe sounds more to me like stridor (an upper airway obstruction), not wheezing (lower airway obstruction). It's also not very common to be diagnosed with true "asthma" at that age. I have yet to see anyone with even severe asthma have wheezing all day every day, even the ones who end up on a vent. If it doesn't wake her up in the middle of the night, I am even more skeptical. A lot of things can lead to upper airway obstruction. Masses, paralyzed vocal cords, strictures....the list goes on. Probably the most common thing that I see is anxiety-related. She may consider a fiberoptic bronchoscopy with an ENT doc to rule out some worrisome things. She may also undergo pulmonary function studies and possibly a methacholine challenge to test her airway responsiveness and differentiate asthma from other disease processes. 'zilla

Not really sure where you get that from. When you have malignant PVCs (coming close to the T-wave, short runs of non-sustained v-tach) that's your risk for the life-threatening v-tach/v-fib. And those should be treated with lidocaine, whether there is an MI going on or not. 12 lead will not affect your decision to give lidocaine in the setting of malignant PVCs. I think this thread has run its useful course. 'zilla

Only if his version of PEA is a pulseless rhythm that is wide complex and at a rate of 200bpm. 'zilla

This would work out to be 200-250mg of lidocaine, which shouldn't get you into trouble with toxicity unless you are doing it on a child. In recent years they have decreased the recommended dose of lidocaine for Bier blocks to 0.75-1.5mg/kg (from the previous 3mg/kg recommendation), which is the same dose you give for ventricular arrhythmias. Either way, one shot shouldn't cause seizures in an adult. 'zilla

While I respect considering the long term complications of tourniquet use, placing a tourniquet for for a couple of hours will not result in limb destruction. In the typical patient contact times seen in civilian EMS, it's quite safe. Neuropathy is a potential risk after 2 hours of application, but tourniquets can still be safely applied for up to 6 hours without loss of the limb. Tourniquets are routinely applied for 2 hours at a time in all kinds of surgery without any difficulty. If more working time is needed, the tourniquet is released, then reapplied. This is certainly something that can be done in the field. We can also apply tourniquets to quickly control bleeding while getting our stuff together to make a decent pressure dressing, then release the tourniquet and evaluate. 'zilla

It's absolutely appropriate to use a tourniquet to stop the bleeding once other methods (direct pressure, pressure points, pressure dressing) have failed. The thigh cuff makes a great tourniquet. Since it's wide, it will cause less tissue damage than a narrow piece of fabric, and you can control the pressure. Inflate until the serious bleeding stops (you'll still get a tiny bit, but just make sure it's not flowing). You may have to exceed the arterial pressure in order to do this, so don't be surprised if you have to inflate past 200 or 250 to get it stopped. Tourniquets are getting more attention lately with our combat experience in Iraq and Afghanistan, and it has forced us to re-examine the "taboo" of tourniquet use that we're taught in EMT school. There are a fair number of people who bleed to death in this country from extremities, even in the care of EMS, and that just doesn't need to be so. Tourniquets, appropriately applied for a short period of time (less than 2 hours), do not lead to massive acidosis, hyperkalemia, and cardiac arrest like we've been taught, and they save lives. 'zilla

"Somebody has to do something, and it's just incredibly pathetic that it has to be us." -- Jerry Garcia and the Grateful Dead

It shouldn't happen like that, but it will if any of the following are true: 1) They don't run a lot of bad traumas and aren't very practiced at it 2) The attending at the head of the trauma team doesn't take control, set the tone, calm everyone down, and assign jobs 3) The charge nurse doesn't thin the herd, assign jobs, and keep track of everything A given is that any trauma center should all the equipment needed and near the bedside, which many places solve by having a large rolling cart with chest tube trays, thoracotomy trays, line kits, advanced airway, sterile gloves, and a variety of other stuff. It is important that nurses and physicians know what is on this cart and where so they are not searching for it at the wrong times. You're going to have folks like radiology pushing their way to the middle to get the cxr, lab pushing in to draw the blood, registration trying to get the info to register the patient, etc. They sometimes feel the need to announce to everyone in the room that they need to do this or that or the other. This is all easier when they instead first approach the doc who's running the trauma or the charge nurse. They can decide if it is really imperative to get that cxr right now, or the charge rn can tell one of the nurses who is starting the IV to get a syringe full of blood for the lab. In either case, they can move the troops to give these other folks the room to do what they need. It is in these situations where good leadership is key just as much as good management. The head trauma doc, if there is at least one other doc to do procedures, should stand at the back of the room and take it all in, prioritizing procedures and orders and recognizing what equipment is needed, redirecting the other docs (usually residents) as needed. The charge nurse fits best in the recorder position, writing everything down on the flow sheet, requesting additional resources, calling for the x-rays, etc. and kicking people out of the room when indicated. These two folks have to set the tone for the resuscitation through tone of voice and through demeanor. If they don't look all excited, then everyone else will chill and do their jobs like they are supposed to and like they were trained to. When things are getting hectic, speak SOFTER, not LOUDER. This forces people to shut up to hear you, and discourages them from yelling also. And the overall effect is to calm everyone down. What is important to realize is that there are really 2 procedures that require INSTANT action: securing the airway, and decompressing the chest. Chest tubes are nice, but if you can decompress the chest, the chest tube isn't critical. Even central lines, particularly if there is good peripheral access, can wait. Delegation of tasks will help this whole situation. Pick someone and put them in charge of the airway. Tell them they need to get what they need and intubate, and don't bug them while they do. The thing with chest tubes is, if the person doing it has done only a few, they are probably concentrating on the procedure itself rather than the setup of the pleurevac. Put someone in charge of the chest tube, tell them to get one helper to set up the pleurevac, and let them do what they need to do. Likewise, requests from the folks who are on the patient (like for 4x4s or syringes or thoracotomy trays) are best directed at the charge rn or attending, who can make that happen by handing it to you or delegating it to someone. And every once in a while, the attending doc or rn has to tell everyone to shut up. The same principles apply to really s#itty calls in the field. Use the leadership to your advantage. As the leader, keep the big picture, and get off the patient. As one of the assistants, do what you need to do and open your mouth only when necessary. 'zilla

In the field: 2 pairs gloves steth shears little LED light 10cc syringe (can NEVER find one when I need one to mess with the ET tube, even if I was standing in the middle of a syringe factory) 14g 2.5" angio (for chest decompression, not IV) 5x9 dressing antimicrobial hand wipes pediatric reference gum In the ED 1 pair gloves steth shears little LED light Palm pilot gum 'zilla

Severe scoliosis or kyphosis from osteoporosis (what is this, Dr. Suess does ER?) may preclude putting the c-spine "in line", though you may be able to approximate its preinjury state. The attempt is not so much at "reduction" of a spinal problem but alignment with gentle traction. The need to manage the airway trumps leaving it in a severely deformed state, so there is no "contraindication" I am aware of that would lead you to leave it way out of place. 'zilla

Amiodarone is technically a class III antiarrhythmic (potassium channel blocker, like ibutilide or bretyllium), but also has class I (like Lidocaine), class II (beta blockers, like metoprolol), and class IV (calcium channel blockers, like diltiazem or verapamil) effects on the heart. The class II and IV effects are why you see can see AV block and hypotension with the drug and why it is contraindicated for AV blocks or bradycardia. And it looks like somebody got a homework assignment for paramedic class and took the easy way out. 'zilla

I'd agree about not getting in a pissing match with anyone. Smooth things over. "I'm sorry, perhaps there was a miscommunication" or "I had concerns about ______ which may not have come across in my radio report." If you err on the side of care and someone jumps your sh$t for overtreating, don't worry about it. Simply explain that at the time of presentation, things weren't as clear as they are now, or that you realize it was probably overkill, but that they can always just take them off the backboard or shut off the oxygen or whatever and do as they like. You are far less likely to get into hot water for overtreating than you are for undertreating. If you bring a patient into the ED who is blue or short of breath and doesn't have any oxygen on, or was found down in the street and you haven't backboarded him, then THAT's a real problem. Forget the minor stuff. If they won't let it drop or it looks like you might get written up, go to your medical director FIRST. I'd rather hear it from you first than get blindsided by an angry phone call from one of my colleagues on a situation I know nothing about. Part of the job of the medical director is to serve as a liason between EMS and the ED. Punt the high level diplomacy to him. 'zilla

Sorry about copying and pasting, but hey, it's my post, so I'll do what I want. Tactical EMS (or TEMS) training teaches the medic or tactical operator to provide basic medical care and injury/disease prevention in the tactical (i.e., SWAT, special operations, etc) environment. SWAT teams serve a variety of roles to include hostage rescue, high risk warrant service (you've got that drug dealer who is known to be armed and has assaulted officers in the past, you may want to send SWAT to pick him up rather than your garden variety detectives), personal security detail (PSD), and special security, such as that provided to medical teams that went to areas affected by Katrina. Some SWAT teams have medics on the team who are taught team movement and SWAT operations as a way to understand team ops and provide better care. They may or may not be allowed into a "hot zone" and may or may not be armed. A lot of these medics, particularly if they are not already law enforcement officers, may train with the team but do not go into the "stack" when making entry into a potential hot zone and may not be armed. They may wear body armor and identification but will be staged in the "warm" zone, ready to respond in as needed. Some teams have medics who are also operators, i.e., have a role in the law enforcement aspects of the operation, and therefore carry weapons and arrest suspects, etc. and will go in with the stack. Frankly, having your medic in with the stack is risking an important resource for very little benefit (my opinion, has not yet been shown in randomized prospective trials ). Many teams do not have medics as part of the SWAT cadre. These teams may stage an ambulance some distance away, ready to respond in to the scene as needed. These medics typically are not tactically trained, and are not really considered "tactical EMS". From the military standpoint, special ops medics tend to be operators and therefore armed and responsible for aspects of the mission other than just medicine. They also have a larger role in primary care and preventive medicine since the SOF teams may be far removed from definitive care, and evacuation may be impossible or may jeopardize the mission. 18D (Army SF medics) are typically trained not only in advanced trauma care, but dental care, veterinary medicine, and food/water procurement and purification as well. Medicine is an important part of some SF missions, which may involve training indiginous forces. The 18D helps to win hearts and minds by providing some basic medical care to these folks. Military medics are trained in tactical combat casualty care (TC3), which gives them tactical awareness and medical skills particular to the battlefield for rendering care while still potentially in some amount of danger. With this in mind, the best medical care is overwhelming firepower, and putting rounds downrange is often the most important thing that a medic can do in a hostile fire situation. 91W (combat medics) are trained in this. Tactical medicine is a combination of several aspects of care. TEMS medics are first and foremost first responders, and trauma care is the cornerstone of care in this environment (traumatic injuries, as you might expect, are common). There is an emphasis on care in austere environments with low light, little space, and little equipment. As the first medics in the door, they must be firmly familiar with triage for care and triage for evac (2 different concepts, really). Team wellness and preventive medicine are important as part of the more global concept of TOMS (Tactical Operations Medical Support), and in the civilian realm this equates to proper rehabilitation of operators on a long standoff and ensuring that everyone is rehydrating properly. The TEMS medic may have to deal with minor illnesses in operators while on a standoff, such as minor cuts and scrapes, headaches, dehydration, etc. The TEMS medic serves in an advisory capacity as well, recommending equipment and policy that may reduce injury among operators. For example, the medic may recommend that operators carry their own "blowout bag" that contains some dressings and other supplies so operators can treat themselves or a fellow operator when the casualty can't be immediately evacuated (due to hostile fire) or the medic can't get to them. He may also recommend rotation schedules for operators to ensure that they are rehabilitating properly, particularly in inclement weather. The medic may also train the operators on some basic self- and buddy-care. He may also make sure that everyone's tetanus shot is up to date, and should be familiar with any underlying chronic illness or injury that the operators have. The medic may be asked to get on the phone in a hostage situation to try to provide some care over the phone to hostages and suspects while negotiators are trying to end the standoff. They may be able to instruct the hostage or suspects in some bleeding control or airway maneuvers as well as basic treatment for shock. This may give the medic an idea of the number of casualties inside and their condition, enabling him to request civilian resources as needed. (I should emphasize that medics are NOT routinely negotiators.) Medics also serve as an on-site consultant to the SWAT team, recommending for or against things like tear gas or distraction devices (flash-bangs) in particular situations if there may be medical concerns with their use. Situational awareness and self defense are taught from a tactical perspective, and usually involves weapons. There may be some items to glean for civilian EMS use, but this isn't really a "self defense for the street medic" type course. Hope this sheds some light. 'zilla 62A

One more thing: don't talk smack about anyone in the ER, even if some nurse or tech invites you to commiserate. Like I said, it's an insular group, and what you say will ALWAYS get back to the person you're talking about. 'zilla

I've gotta agree on the chocolate and cookies thing. The occasional bribe goes a long way. A t-shirt for someone who was really nice will REALLY score some points, particularly if the t-shirt is funny or rude. If you're close to shift change and you and some of the guys are going to grab a beer or something, it never hurts to invite the ER staff. That is much easier if you happen to look like Brad Pitt, or your partner does. As others were saying, be professional, kind, and competent. Take an interest in your patients. If you make more than one trip to the ER, follow up with the nurse or doc who was taking care of your earlier patient to find out what they did. Feel free to stick around on a resuscitation (as long as you're not in the way). Offer to help if things are going sideways. Get in, get involved, but don't tell people how to do their jobs. Ask questions of folks, but know your audience: if the ER doc or nurse is holding 4 charts in his hand and sweating like a two dollar hooker on nickel night, now is probably not the best time to ask for an educated discussion of the use of recombinant activated protein C for septic shock refractory to vasopressors. Understand that you're not really part of the ER team, which tends to be an insular group. It will take time, therefore, to be known and liked. Understand also that some ER nurses and docs don't have a whole lot of respect for EMS, particularly at the EMT-Basic level. And, of course, there are difficult personalities in every group. Nursing (particularly ER nursing) tends to eat its own young, as some folks just like the power trip of holding themselves above others. You may make an appetizing target for those kinds of people. Sometimes it pays not to be noticed. 'zilla

Doesn't sound so much like vasovagal to me. One key thing about vasovagal is that it is transient. I wouldn't expect her to be in the bathroom with a low BP for 5 hours if that were the case unless she vagaled down again just prior to your arrival. It is possible that the oxygen helped her BP as well. It sounds as though she might have been a bit hypoxic based on the cyanosis, and with your therapy, that improved. The possible causes of her hypotension are many and varied, but with hypoxia and crappy lung sounds, that narrows the field a bit. If her pressure was better at the hospital, then she's obviously not yet in septic shock, but she may be headed that way. Your exam findings sound consistent with hypotension, so there's probably nothing wrong with your BP technique. I certainly agree with not waiting for ALS on this one, particularly considering your distance from the hospital. Also, as a general rule, asthma is not that common in this population. Other lung diseases (COPD) are, and that's generally what the inhalers are for. Asthma is a specific disease marked by airway hyperreactivity, excess mucus production, and hypertrophy of bronchial muscles (which enhances the reactivity). This is similar to but a narrower category than what we refer to as Reactive Airway Disease, a broad term to define people who have bronchospasm (wheezes) in response to certain stimuli. For example, emphysema patients can get bronchospasm that can be life-threatening, but it is not asthma. 'zilla