Doczilla

Neither do I.

Atropine? Probably not, but the above concerns are valid.

Epi 1:1000 sometimes comes supplied in 30cc vials (30mg) in systems that use high-dose epi or mix their own epi drips. It is possible to make this mistake, and give 10cc (10mg) of epi instead of the intended 1mg. It might happen if the medic said to an unknowing or inexperienced partner "give me 10cc of epi". If his partner didn't look closely at the vial, and drew it up rather than using the prefilled 1mg/10cc syringe the medic was asking for, it might happen. This could very well be a lethal mistake.

Giving verapamil to someone in V-Tach, now that will kill someone. This may happen if the rhythm is misidentified. Verapamil treats "supraventricular" tachycardias, while lidocaine treats v-tach. Some supraventricular tachycardias have what is called a conduction aberrancy, which means the complexes appear wider than normal, sometimes mimicking v-tach. That's not a big deal if you give lidocaine (thinking they're in v-tach) to a patient in SVT, but if the medic thinks it's SVT with aberrancy and it's really v-tach, giving the verapamil is bad news. Some systems carry verapamil, though this is falling out of favor since we have cardizem.

'zilla

With regards to the 500cc IV bags, you could drain off the air and half the fluid volume from a 1000cc bag to save space and weight.

I agree on dumping the intubation kit. If you felt bad about not having one, you could go lighter with a 2AA handle and plastic disposable blades to offload some weight. Ditch the #3 Miller, since there aren't any airways you can handle with the #3 and not the #4 (it'll be long, but it'll do.). You may consider the King LT-D or LT-DS instead of the combitube to save on space and weight.

Dump the FAST 1. They're big and they rattle. Instead go with the manual driver and a couple of EasyIO needles (the powered handle is a bit heavy for a combat pack). Much lighter and a bit smaller. Alternatively, the Jamshidi or another regular IO needle isn't a bad choice. Perhaps it doesn't seem as high-speed as the FAST 1, but my success with the FAST is mixed having used it several times.

Rocephin isn't a bad way to go for a lot of stuff. Ancef is the go-to drug from the trauma and ortho guys, but the ID guys don't think it's all that great. You may want to add clindamycin (which is cheap, and available in IV and PO forms) which will cover all manner of skin infections, anaerobes included. Any hospital around should have it.

Perhaps a few little bitty LED lights? Drop me a line and I'll send you some.

Don't forget to have fun while you're out there!

'zilla

Dubin's is an excellent text, and you certainly can't go wrong there.

Another one, which is my personal favorite, is "12 Lead ECG: The Art of Interpretation" by Holtz and Garcia. TONS of full size full color EKGs, with great illustrations and explanations. EKGs each have 3 color-coded captions for different levels of understanding. If you are just starting, you read one caption. Once you've done those, you can go back and do them all over again, with the captions geared for your higher level. Once you are the sh#t, you can do them all again, reading the third caption for the most advanced level of interpretation. I'm not shilling for them or anything, but it's a great book.

'zilla

+1 on the pens. Nurses are constantly pilfering pens from anywhere they can find them. Get good pens for them, and they'll always have your number. ("Why bother looking it up? I'll just call this one right here..."). Post-it notes are also good. Clipboards are something else to consider (many facilities use these in every room. Not a bad way to make yourself a household name.).

The key to selling a business is selling the relationship. Schmoozing is a good thing, and not just admin. Like others said, remember who is placing that call to you (i.e., the nurses). Your employees should have a partnership in the success of the business. Profit sharing is one way to do this. If they have that in mind when they go to the pick-up/dropoff sites, they may be your best ambassadors. Send holiday cards and thank-you notes to patients as well as those who call you. And bringing a plate of cookies once in a while doesn't hurt either.

Also take stuff to the local ERs. We are always calling someone to pick up the patient to take them back to the nursing home. In the middle of the night, the less hassle, the better. Schmooze the employees of all shifts.

And fix the link to your website in your signature.

'zilla

You are correct in that you don't send someone home with the numbing drops (usually proparacaine or tetracaine), for the reason you stated as well as the fact that the drops impair healing. A one-time dose will not do much to endanger healing, but I wouldn't want the soldier doing it day after day. This is why I take the Alcaine with me after I do a slit lamp exam. Otherwise it seems to find its way into the patient's pocket. I set them up with plenty of anti-inflammatories and percocet because this injury truly does suck.

Also, patching is controversial. On the one hand, it serves to remind the patient not to rub the affected eye. On the other, it lessens oxygen delivery to the corneal epithelium which is healing.

In the operational environment, the mission may dictate that a soldier not be distracted by the extreme pain and watery discharge that accompanies a corneal abrasion. Numbing it up long enough to get back to the FOB means the operator will remain mission-capable and able to complete tasks and fight off the enemy rather than just tag along. The long duration of action of bupivicaine means that it won't have to be repeatedly readministered.

'zilla

Nice set-up!

That said, I would modify it a bit:

Dump the NuTrake in favor of your previously mentioned Shiley hook and scalpel. I don't think these commercial devices are much better than the old fashioned surgical approach.

I'd add some Marcaine (bupivicaine) and opthalmic antibiotic like Ilotycin (erythromycin). Nothing like a few drops of Marcaine to give you 12 hours of relief from a fresh corneal abrasion.

Marcaine is good for lots of stuff, actually. Local wound blocks, digital blocks, and nerve blocks will do much to relieve pain from just about anything.

I'd switch the 1000cc NS bags out with and equal volume of 500cc bags. Gives you more administration options.

I don't know how austere your AO is, but I would consider supplies for purifying water and making fire.

I would add a large pile of Steri-strips and some benzoin swabs. With these, you can get away without suturing a lot of stuff. They will also secure a partially avulsed fingernail.

I would carry several packets of a powdered concentrate of electrolytes for oral rehydration.

Duct tape.

I didn't see much mentioned as far as meds apart from the rocephin. You did say you're mostly set up for trauma. I think you may augment your kit without too much difficulty for certain minor medical issues. You may consider adding some epi, benadryl, and prednisone for allergic reactions, as well as drugs for pain control and sedation. A humongous supply of ibuprophen would be paramount for that population, as well as anti-emetics, anti-diarrheals, and more ibuprophen.

I agree with the Romulan cloaking device and ticket home. If you can't find those, I'd bring an M4, a shovel, and a Ranger battalion.

'zilla

One thing that many folks don't think of is that the patient may have to have a bronchoscopy in the hospital for diagnosis of some conditions. In our adult hospitals here, because of bronch equipment size, they can't get bronched through any tube smaller than an 8.0 (okay, maybe they can squeeze it through a 7.5, but the pulmonologists REALLY prefer the 8.0, and have told me that on more than one occasion).

A lot of medics reach for the smaller sizes because they pass more easily and success rate is slightly better (anecdotally). I've been encouraging my medics to use the larger sizes if possible. If physiological size, impinging mass, or airway edema makes that impossible, so be it.

'zilla

I ran this one by our ICU pharmacist. Ativan does not come supplied as a powder to the pharmacy.

'zilla

Ativan is a powder which is dissolved in polyethylene glycol and propylene glycol. I don't know if it comes to some hospital pharmacies in the powdered form or if it only comes from the manufacturer as a solution.

'zilla

I frankly don't see much clinical utility here. Honestly, what am I going to see as the doc staring at the monitor? Is the resolution good enough to provide any real clinical information? One major issue I have with these supposed technologies is that the doc is looking at a less-than ideal picture (even if it's HDTV, it's still a one-dimensional picture), and cannot palpate or auscultate anything. I still have to rely on the medic's examination skills in this regard. So what have I gained by being able to look at the patient? Furthermore, is that visual information received really going to affect care? I'm not cutting that patient loose before I can lay my hands on him and get my own history. That process would be so cumbersome and time-consuming that I see no benefit in sitting down away from my other patients to do it. Then to discharge him from care based on someone else's physical without my own physical and lab results? No way.

I'd rather spend the money on overtime to get the medics in for more regular preceptorship in the ER.

'zilla

The staff of Aesclepius (the god of medicine) has a single worm on it. Aesclepius was the son of Apollo. He was trained in the healing arts so well that he once raised a patient from the dead. Believing this should be the sole providence of the gods, Zeus killed Aesclepius. Traditionally, healers would use a small stick to extract guinea worms from the skin through an incision. The worm would be wound around the stick as it was extracted over a period of days. This is the traditional symbol for medicine which healers would use to advertise their art, still used today by the AMA and USAF medical departments.

The double serpent staff with wings represents the God Hermes, who is often associated with alchemy. This, like the staff of Aesclepius, was used as a printer's mark in the 18th and 19th centuries. Printers saw themselves as the bringers of wisdom of the gods, using these symbols of traditional knowledge. The association of the double serpent staff with medicine comes from its adoption by the US Army medical department in the early 20th century. Ironically, this is the more widely recognized and used of the two symbols.

The true location of the Aesclepian staff is a secret closely guarded by the Priory of Scion, a shady organization of interns and residents who may or may not be assassinated by creepy albino monks. (random DaVinci Code reference)

'zilla

Propofol has anti-epileptic properties. We take advantage of these when putting folks on the vent that have a high risk of seizure (closed head injury, history of seizures, etc.).

'zilla

Stocked bags invariably suck. They have plenty of crap that you pay for and don't need, and not enough of the stuff you do. My advice: buy a decent empty kit on eBay and decide what you want to carry. You will save money and space this way. Especially if you lift the supplies from the ER. (I am NOT condoning theft. Some hospitals supply their EMS folks. Some of them even know that they do.)

If it is for personal off-duty use, carry plenty of BLS stuff and skip the ALS stuff. Carry what you need to stop bleeding and manage a basic airway, as well as tend to minor wounds that won't require ambulance transport. If it's for on-duty use, I agree with Dust (as usual), your employer should be providing it.

'zilla

Hey y'all, I'm looking for a recommendation for CPAP/BiPAP machines for prehospital use. Our service is adding this to the armamentarium, and I put a great deal of stock in experiences people have had with field use (everything looks great in the box when the rep is trying to sell it to you. Doesn't mean it works.). If there is a particular device/manufacturer you have used and like or don't like, please chime in. If there is something cool and high-speed/low-drag that you have heard about, I'd like to look into that too. I am looking specifically for CPAP or BiPAP, not ventilators (though if the device does double duty, that's fine too).

I am NOT intending to open a discussion as to the various merits of prehospital CPAP use, general treatment of respiratory distress, pathophysiology of CHF, the dumbing down of the EMS curriculum, or whether or not volunteer squads should be eliminated. :wink:

Thanks for your input.

'zilla

Actually, it has very little to do with the state of things in the ER. It has more to do with how things are looking upstairs. A hospital will typically go on diversion when there are no beds available for admission (particularly ICU beds) and they have already maximized the discharges as best they can. This is not a small thing for the hospital. The number of times they go on divert is tracked, and they may have their accreditation endangered if it is too frequent. Even when the ER is horribly crowded, they will continue to accept patients, even in excess of admission capacity, if it is felt that they can open up more beds upstairs or discharges can be expedited by bed control.

The hospital cannot turn away patients at the door when they arrive via POV, as they have not met the "screening exam" requirement of EMTALA. They also cannot refuse a patient who insists on going there, though you can explain that the chances of them getting off the stretcher into a real bed for a few days is small, and that they will most likely board down in the noisy, hectic, bright, and unrelaxing environment of the ER. Nor can the hospital turn away a critical patient from EMS. If your patient is crashing and the hospital is on divert, your legal responsibility is to transport to the nearest facility regardless of diversion status.

'zilla

We just adopted it in our protocols. Looking at the studies, it has roughly equivalent onset of action as IM narcan. The chief advantages are that you won't risk introducing infection as you will with a needlestick, you don't have to wait to start an IV to get it on board, and you don't have a contaminated sharp on scene after administration. It's optional for our medics and EMTs. They can do IM narcan if the patient is somewhat awake and they are concerned about getting bitten while trying to give the IN spray.

We also use the spray for seizures, which is where this administration route really shines. Onset of action is quick, and you don't have to get the IV first on a moving target. It's standing order to give IN Versed on a seizing patient before attempting the IV.

Thus far the medics are very fond of the MAD and have anecdotally had great results.

'zilla

Wow, okay, where the hell did THIS thread go?

I'll interject one more comment here regarding the docs going L&S to the hospital, which seems to have drawn a lot of fire related to EMS responding L&S to bulls#it calls...

There is a key difference between the doc driving L&S to the hospital and EMS doing it. EMS goes hot because the patient has not been assessed by anyone but a LAYPERSON. Therefore, patient information is sketchy at best, and there is a decent chance that it is bulls#it and a chance that the person "not eating" is actually not breathing either.

The doc heading to the hospital, on the other hand, is going to see a patient who has been assessed by another doc, who has determined that there is an expedient need for specialty surgery. It's different from taking all comers in an EMS system and seeing if L&S improve outcomes. The patients the doc sees are known to have time-critical injury which requires immediate attention, and the delay in this attention is well-documented to increase (greatly) risk of death. True that the ER doc can do a certain amount of stabilization. I can manage the airway (surgically if necessary), place a chest tube, give blood (if available), even do a certain amount of local exploration to clamp a bleeder. But if the spleen is in pieces, I defer to my surgical collegues, as their skill is the only chance the patient has. And every minute the patient waits is another tick down the survival ladder.

Yes, air transfer to a surgical facility is ideal, but many places are too out of the way, frankly, and bad weather does happen.

How about an alternative: asking the police to pick the doc up at home and drive them in? The driver would be trained and experienced, in a well-marked car, and there would likely be someone close to where the doc lives to grab them. This may alleviate many of the concerns, legal and logistical, about the doc having his own means of emergency response.

'zilla

If the patient is totally upright when JVD is measured, there are several cm of the venous system that are still in the chest, so you may potentially miss a milder JVD. When the patient lies down, the entire jv is at the level of the atrium, so the whole thing will be distended. At 45 degrees, you can measure JVD almost from the level of the right atrium.

Note, though, that you don't measure along the jv. Draw an imaginary line horizontally from the end of the JVD to a point above the sternum. Measure the vertical distance between this line and the sternal angle (angle of Louis) to estimate the JVD and, by extension, the central venous pressure. There's a very nice graphic of this in the link posted by ak.

'zilla

The bicarb and lasix are geared more toward preventing/treating a spike in the potassium level in the blood when you have profound tissue ischemia/injury and release of potassium from the extracellular space. The lasix helps the kidneys offload the excess potassium if they are still functioning. The insulin and D50 are also intended to lower the serum potassium level as detailed in Rid's post. We still alkalinize the urine (through a bicarb drip) for rhabdomyolysis to try to prevent renal failure (assuming relatively normal electrolytes), but the evidence doesn't really support a benefit.

Rhabdomyolysis can induce acute renal failure, but the immediate life-threat is from hyperkalemia, which is what the prehospital protocol is treating. The renal failure, if it's going to occur, will happen no matter what we do.

I see no reason to avoid large volumes of IV fluid. Profound swelling and third-spacing of fluid is common in these types of injuries, which can rapidly lead to hypovolemia. This is independent of vascular pressure, so the mantra of withholding fluid in incontrolled traumatic bleeding goes out the window. Large volumes of IVF may also help prevent renal failure in the patient with less severe rhabdo.

For part 2.... Giving bicarb kicks the TCA off the binding sites in the heart, reducing cardiotoxicity and enhancing elimination. Alkalinization of the urine will also enhance elimination of barbiturates, though I haven't heard that it reduces toxicity in the immediate setting the way that bicarb does for TCA OD.

'zilla

Trauma centers get their trauma ratings based on what services are available in-house and what are available within "a reasonable amount of time". For level I centers, the trauma surgeon has to be in-house. Other surgical specialties, such as neurosurg, ENT, orthopedics, and optho are usually not in-house but must be able to be in-house within a given amount of time. As you work down the trauma designations, the trauma surgeons don't need to be in-house, but available in a certain period of time.

The fact is that most hospitals cannot afford to pay for in-house trauma surgeons 24/7, particularly if they don't often see trauma that requires an operation. This is the same reason that the surgical subspecialties are not required to be in-house, as they are urgently required to operate so infrequently that it just isn't cost-effective to pay them to be in-house all the time. Critical trauma patients may find their way to these hospitals because of a variety of reasons.

1) Homeboy ambulance

2) There is no other hospital close enough

3) Airway that cannot be secured

4) Loss of pulse in the field

Some may be too unstable to be transferred, necessitating on-site surgery regardless of the hospital's trauma designation.

Trauma doesn't pay. The patients are less likely to have insurance (in some places, they almost never do), and so the surgeons must either be payed by the hospital for taking care of them OR have it negotiated into their contract to do emergency and trauma cases periodically as pary their hospital privileges. This means that they have to have a full OR and office schedule in addition to covering the trauma call. If you know anything about a surgeon's life, this isn't a small thing.

I think that allowing trauma surgeons to respond with L&S to the hospital for patients meeting certain criteria is appropriate. This isn't some Ricky Rescue who red balls it to every patient who calls 911 for a sniffle. Why do we haul ass with trauma patients to the hospital? Because minutes wasted before surgery for those who need it loses lives. The data that support this are hardly controversial. Something else to consider is that there is a better medical assessment done of the patient before the surgeon puts his/her life at additional risk (and others too), as opposed to most emergency services, who by default respond with L&S to any 911 call unless it meets certain very narrow criteria.

'zilla

Asys-

I think you did fine. You appropriately assessed the patient and need for interventions that don't fall under one single protocol. Demonstrating good decision-making, you even called for online medical control for further guidance before proceeding on. The system worked here, and, I suspect, to the patient's benefit. Add to that, the patient's condition changed in front of you, necessitating a re-evaluation of the course of treatment, which you did appropriately. Key here is that you didn't get stuck in one protocol and continue down that line after the condition changed.

I don't see any specific contraindication to any of the treatments rendered. In fact, it appears that they were all indicated. I don't know the significance of the 12-lead findings, not being able to see the strip myself. "Borderline" elevation doesn't count for much. Either the elevation is there or it's not, though that's not going to change your treatment prehospital. Some change may be expected based the elevated heart rate alone.

The protocols are guidelines based on typical presentations of common prehospital problems. This patient obviously didn't read the book (darn him). The protocols are designed to teach the paramedic the thought process that the physicians have in treating these problems and how far they expect you to go on your own. They are not intended to cover every single patient that you will encounter in the prehospital setting, hence the phrase, "treat the patient, not the protocol". (last cliche, I promise). If the telemetry doc is still giving you crap, bump it up the chain of command to the actual medical director. That what we're for: to keep you from unnecessarily getting sh#t from other docs who don't know what they're talking about. And the MD can tell the telemetry doc to consume fecal matter and expire prn.

'zilla

"Hmmmm... these are some nice works here. Let's toss in a wrench..."

While the stacks of cash are irrelevant to the patient's condition (though a strong predictor of future penetrating trauma), the drugs are an important clue. Just because he has a seizure disorder doesn't mean he hasn't been doing drugs and isn't suffering an OD. I have to disagree that the differential diagnosis is one line only. Stimulants cause seizures, and the end stage of most lethal toxic exposures is "seizure, coma, death" (except benzos, which is "coma, death"). It belongs on the run report. And it will do absolutely nothing in terms of bringing the illegal activity to light, since the cops won't see the report and it would violate pt. confidentiality if the hospital said something.

Now does the apartment look like a meth lab? That's a hazmat scene. Great danger to everyone else in the building. Cops must know, canaries must go in (sorry, "Highly Trained Hazardous Materials Technicians"), and the place has to be searched and deconned.

Agree that pulling a hissy fit and screaming for 5-0 by radio is not going to do me a lot of good, especially considering that I'm wearing a nametag. I would, however, whisper something to a cop friend that they "might want to give that place a look". Sorry, but even drug dealers should know better than to call the medics to their own apartment without making at least a passing attempt to make it not look like a Quentin Tarantino movie. Geez, they're just asking to be caught. They should talk to the street level pushers and further explore the services of the "homeboy ambulance service" (door-to-er service in a stolen car, no waiting.)

'zilla

Try the following for some more reviews and resources:

www.swatmedics.org

www.lightfighter.net

www.tacticalforums.com

When going to the above forums, particularly the last two, I would read much and post very little. These guys have definitely "been there, done that" and do not suffer fools lightly.

'zilla

Probably the simplest and most economical answer would be to bring the drug box into the station, then put it in front of the door so you don't forget it on the way to a call. (THAT would be embarrassing.) If the units you're referring to are reserve units or don't see calls much, then this may be the way to go. Other solutions may include temperature-controlled cabinets or leaving the A/C or heater on all the time as the unit is plugged in. Garaged units really shouldn't have any problems (it would take so long for the bay to cool down, then the truck to cool down, then the box to cool down...) and most bays aren't much below 50 or above 80 anyway. There may be some commercial products out there for this, but I'm not familiar with them, so perhaps someone who is will chime in. You may contact some of the ambulance manufacturers and ask them what's out there.

'zilla