Doczilla

We drop one on all intubated patients in the ER, but i don't know that it's in the scope of practice for paramedics here. It is potentially useful when the stomach is very distended from BVM ventilations and you're having a hard time getting good volumes after intubation, which would be the only "absolute" indication I could see for doing one in the field.

With regard to charcoal, I hardly ever use it anymore. Not much of a benefit in most cases, too many potential complications. We've really moved away from giving it empirically in poisonings except for certain select agents.

'zilla

One of my classmates recently returned from Afghanistan and brought to my attention a drug they have been using over there in the ANA hospitals, which is also being carried by the Special Forces medics who may be further removed from trauma care.  It is a fibrinolysis inhibitor, but I don't think they really know how it works. You can download the study free from the Lancet, July 2010.

Is anyone out there using Tranexamic acid or Aminocaproic acid in their prehospital protocols, or considering it? The recent CRASH2 study provides some interesting data to consider. I'm only now finding out about it. Of course, I have no financial interest in it or the manufacturer.

BLUF: Randomized double blind controlled multicenter international trial of tranexamic acid (TXA) in 20,000 trauma patients from 274 patients in 40 countries.

Given as a single 1g dose, followed by an additional 1g over 8 hours.

Patients who "clearly needed" it were not randomized, nor were patients who had clear contraindications.

10% reduction in all-cause mortality

15% reduction in mortality from hemorrhage

No significant differences in blood units given, or number of surgeries

Trend toward benefit when given earlier after injury

Hospital-based protocol, not prehospital

No increase in vascular occlusive events such as CVA, MI, PE, or DVT.

Shelf stable at room temperature, $9 per dose

It's a hell of a lot cheaper than rFactor VIIa.

'zilla

While many departments use PAI, it is, most times, a poor substitute for RSI when the department or medical director gets the heebie jeebies thinking about paralytics. Studies show it does not improve intubation success rate, whereas RSI does.

I have done PAI on occasion when knocking out the respiratory drive completely would be problematic. Most of these were extraordinarily difficult airways, such as angioedema or facial trauma, where the patient is actually moving some air on their own, bagging would be tough, and I expect the intubation attempt will take a while, such as with fiberoptic nasal intubation.

'zilla

In answer to the test question, the patient being flaccid after sedation is the desirable condition for intubation. OTI is not only okay at that point, but required.

Nowhere in your post do I see that you communicated your concerns with the ER staff and engaged in a discussion.

You may not agree with the patient's decision, but it is not your decision to make, either. As others have said, autonomy is at the core of medical ethics. The patient's decision does not have to be the right one, only one they are competent to make. You don't have to agree with every decision a patient (or HPOA) makes.

To whom, or what, are you protesting? Your follow up post indicates the ER staff tried to get him to stay. So who sees you stand tall against "The Man" by refusing to get in the back of the truck with the patient? Are you trying to tell the patient that you disagree so fervently with his decision that you will do nothing for him? A decision he has the eminent authority to make?

So you basically took it out on your partner by sticking him with the run. It was a crappy thing to do.

Good initiative, poor execution. Your first instinct should not be to foist the call on someone else. Your first instinct should be to shoulder that burden yourself. Share your concern with the patient and ER staff, share it with the patient, contact his family from home, or whatever. What will you do next time? Quit in protest? What will that solve?

The only time you should dump a run on your partner is a) when he has better skills and the patient is sick enough to require them, your interaction with the patient is such that you don't feel you can provide good care, like if you got into a fight with him or she accused you once of sexual harassment, or c) it's his turn.

A word on protest: it is better to change a poor system from within than just quit. People may care that you quit, but not enough to change anything. Quitting is certainly easier for you. What you did in this case, in a small way, was quit.

'zilla

Region wide protocol this year. One service is using it (kind of the spearhead), with several others planning to implement it soon.

'zilla

Oh, no you didn't.

You fly in from California, take our titanium trauma shears, shame all the Ohio medics in the airway gauntlet, drink at my pub, then fly away.

Still bought you that beer, didnt I?

Good to see you guys again.

'zilla

Don't be "that guy".

You know, the one that shows up in jeans and tennis shoes for a professional training experience. It is disrespectful to the agency and to your preceptors, and reflects poorly on the training institution as well. It speaks volumes of your attitude, professionalism, and commitment if you cannot even get a $15 pair of black pants at Target and a plain $20 pair of black boots. Invest the tiny amount of cash it takes to look like you belong there.

'zilla

We have been teaching EMTs for years that backboarding a) immobilizes the spine, and is harmless to the patient. Neither is true.

Every EMT instructor seems to know of someone who knew someone who treated someone with an unrecognized spinal injury who was neurologically intact and then turned one way and paralyzed themselves because they weren't immobilized. It has never been reported in the medical literature.

I usually have to give explicit instructions regarding not immobilizing transfers from other facilities on a LBB. C-Collar and laying them flat will do just fine.

'zilla

Hey.

couple of questions:

Do you have isoprenalin in the states ?

Are there any evidence that atropin could induce VF in AV block 3 ?

Best regards

/

Swedish-medic

We do have it. Here it is called isoproterenol, under the brand name Isuprel. We don't use this much anymore in symptomatic bradycardias, preferring instead to use dopamine, dobutamine, or epinephrine if you're going to start a drip to fix severe bradycardia. Isuprel used to be pretty common on the ambulances here, but got dropped by most places in the early-mid 1990s.

'zilla

Hey Doc, is the Doubletree Inn downtown a nice hotel and in a nice location?

I have a chance to get a room there for 64.00 or so per night so I want to jump on it if I can.

I stayed there 6 years ago when interviewing here in Dayton. It was pretty nice, and I would not hesitate to stay there again. It is right in the middle of downtown, which is actually very safe (really nobody around at night). You're close to the Oregon District, which is a great place to go hang out. So unless something has happened to the place since I was there, you should be GTG.

'zilla

Registration has been open 5 days, and we are half full.

Looking forward to seeing your mugs there. Beers once again on me (first round, you reprobates!).

'zilla

Registration opens October 15. Come to lovely Dayton, OH and play.

http://www.med.wright.edu/em/CAPLab/index.html

'zilla

New thread started in "Training" for 2010 CAP Lab.

'zilla

Except that the LMA does a rotten job of protecting the airway from aspiration. It's great if the patient has been npo for 8 hours and is being electively intubated with minimal bagging beforehand.

'zilla

This highlights an issue with prehospital intubation. The physical skill is easy to teach and to learn. WHEN to tube someone, how to look at the whole patient condition, then the whole scene, then the transport, then the ER visit, then the ICU admission, all in the blink of an eye, and translate this into a decision, instantaneously... THAT is the skill that takes so long to master.

'zilla

Honestly it looks like the issues proving problematic have more to do with the command climate in your unit than your specific MOS.

The quality of life for a medic is equally dependent on the command climate of the unit. Some units really appreciate having the medics. Others see them as "idle", and rather than pushing them to train like they should in preparation for the two way firing range, see only more warm bodies to set to all sort of menial task. Many commanders do not appreciate the value of the medic until troops start absorbing incoming fire. In a medical unit, this is less likely, though they tend to be top heavy, and that can grow tiresome if you are below the rank of O-4. Other commanders get that free time should be spent in clinic or in medical training, and this isn't a bad way to be if you're a shooter in an inf unit. The truly primo medic slots are flight medics on dustoff, or SOF, which are unlikely to go to a cherry medic straight out of whiskey school.

So my advice is, don't reclass just to get out of a shitty unit. There are plenty of shitty slots that 68W get into. 68W, like any worthwhile MOS, requires dedication and concentrated study.

'zilla

Folks-

Looking for some input on new products to use in the Cadaver Anatomy and Procedure Lab for EMS this year. While not the focus of the lab, this is when we get to try out the high speed gizmos on the cadavers and have multiple people try them side by side with other products. This has been a good opportunity for EMS providers to get their hands on some of the new stuff out there and see what they think. SOooo.... what are some of the new things out there we should add?

Here are some things we've had before and probably will again, along with stuff we've added this year:

King, combitube, cobra, salt, bougies

Grandview, Glidescope, airtrac, McGrath

Quicktrake, Nutrake, Pertrach, Melker

Fast1, ezio, big io

Ultrasound

Tpod, traction splints

What we are looking for:

Anything with the potential to enhance care that is placed on or in the patient

What we are NOT looking for:

Patient movement or packaging

Vehicles or computers

Extrication tools

Training aids, simulation

Again, the point is to educate prehospital providers about different ways of doing things. This will not become the exhibit floor at EMS Today.

'zilla

I'll add in here that the colonic prep for the procedure may cause significant fluid shifts, which may not be well tolerated in the elderly with fragile cardiovascular status. Patient may become fluid overloaded or dehydrated. Various preps include:

Golytely or colyte, which is a gallon of fluid with electrolytes and polyethylene glycol. This should be the safest with regards to fluid shift, but it can still happen.

Mix a bottle of Miralax (polyethylene glycol) with a bottle of Gatorade

Fleets phosphosoda

Castor oil

Usually a laxative such as bisacodyl (dulcolax) is included in the above regimens, and they're usually followed with enemas.

'zilla

Is giving Atropine here (given the right circumstances) probably the right thing to do? Yes.

Would it be really difficult to justify in court if something bad were to happen as a result of that choice? Hell yes.

Remember that while medicine is a "practice" and an "art," our slice of it as paramedics is extremely limited. Before you start blurring the lines, make sure you know your environment well and are acutely aware of the potential consequences of such a choice. It is naive to think that just because your choice was medically defensible that it will be supported by the powers that be when the chips fall on a call gone wrong. Worth thinking about...

Atropine is a recognized treatment for bradycardia, even that caused by heart block. ACLS teaches this nation-wide. It is part of prehospital protocols in many jurisdictions. It would not be difficult to defend in court at all.

You should be buried alive if you administer Atropine for 3rd degree block. There are cases of Atropine induced VF in 3rd degree block, and if you think about it, Atropine will increase the atrial contraction rate, thus decreasing pO2 in RCA and decreasing available oxygen for the ventricles. If you administer Atropine for 3rd degree block you are in essence malpracticing medicine, as it offers no benefit whatsoever, and causes side effects associated with Atropine, and further endangers the health of the patient.

This statement is closed-minded, dogmatic, intentionally inflammatory, and wrong. It is not malpractice, and I don't know who convinced you of that. As illustrated in previous posts, there are clinical indications for atropine in heart block.

Lets stick to Atropine. Logically speaking, we all agree that for a complete heart block, i.e no signal transduction between SA or AV node and ventricles is occuring, Atropine will have no benefit. Further, we all can agree that by administering Atropine, you allowing sympathetic nervous system to accelerate the atrium, perhaps increasing the atrial kick, which I will agree is a beneficial thing.

However, in literature I've reviewed, the Atrial tachycardia actually decreased cardiac output and blood pressure, thus decreasing perfusion to the ventricles. It was in part due to the ventricular tachycardia that followed, thus decreasing the inotropic effectiveness. In the case of a 3rd degree block, you are not affecting the ventricles, but you are increasing an atrial kick, but considering you only increasing cardiac preload, do you really benefit the cardiac output? Simultaneously you have a drop in pO2 in the RCA and in conjunction with an ischemia and ectopic centers in the ventricles you will aggravate the situation.

Bottom line is, to me, transcutaneous pacing has always been the best treatment modality. You cause pain thus increase the sympathetic response causing vasoconstriction, inotropic, dromotropic, chronotropic effects on the pump, and most importantly restore the blood flow via ventricular stimulation.

Its like a symphony of the cadence of life. It just works. Atropine, on the other hand, is a very dangerous alternative therapy. Just my humble opinion. In truth, I like to be in control. By external pacing you are taking over the functions of the SA or AV node, thus establishing yourself to be in charge, and having the pads already on the patient will let you cardiovert should the need arise. In the cases of acute MI, which can cause the heart block in question, the biggest concern is deterioration into VF/VT. Having pads already on the patient will let you rectify that possibility, and free up your hands to draw up Amiodarone or Lidocaine. To me its never about just one condition, its anticipating what will follow next and being ready for it right now and not once the condition presents itself.

Intentionally causing pain to elicit a physiological response is a draconian way of practicing medicine. If you want to increase sympathetic tone, you can administer a sympathomimetic agent, like dopamine or dobutamine or norepinephrine or epinephrine, which I see as far better than torturing the patient. Increasing sympathetic tone, by drugs or by causing pain, carries the same risks that you ascribe to atropine of increasing myocardial oxygen demand. And so will TCP. I've given quite a bit of atropine, and I do not see it as "dangerous" in the proper clinical setting, and is very well tolerated overall. TCP carries issues as well, if the patient is in such severe pain that they are trying to rip the pacer pads off their chest, then it's not "more efficient" than atropine.

That is all fine, but its not our job to sit there and figure out the diagnosis. We manage symptoms, and most efficient way to manage the bradycardia is transcutaneous pacing. You can spend an entire hour there trying to figure out H's and T's and that is fine, but its a job best left for the clinical setting.

Then why do any treatment at all? Just load them in the truck and take them to the hospital if that is the way you want to go. Your differential diagnosis must guide therapy. You have to think critically about what is causing the patient's condition and act accordingly.

'zilla

If you include ultrasound guided IV insertion, I would say the number is about accurate IF you used it for every IV, but most here would probably agree that's not necessary most o the time. I agree that it is overstated for most other indications. EFAST for trauma would have application for the critically ill trauma patient if they have hypotension to elicit the cause of the hypotension (hypovolemia, pericardial tamponade, or tension pneumo?). In a remote setting, with prolonged transport times, it may help the medic determine which mode of transport or destination would be most appropriate in a trauma patient without outward sign of serious injury (like hypotension, evisceration, etc.). Volume status in a patient with abnormal vitals might be helpful. Diagnosing appendicitis or cholecystitis or kidney stones in the field would not benefit the patient, significantly alter transport destinations, decrease time to OR, or change treatment. Same thing with diagnosis of fractures.

We taught this at the CAP Lab one year. It generated a lot more interest than we thought.

'zilla

A DNR is not absolute, and still requires some critical thinking. If an old lady with a DNR broke her hip, would you let her spend the rest of her days unable to walk, bed confined, and in pain every time she moved for want of a hemiarthroplasty? This is an invasive procedure, requiring general anesthesia, but will immeasurably improve her quality of life. Would you not treat a UTI, which is usually fairly easily done with oral antibiotics, and let her wallow with pain and fever? This measure is "artificially prolonging life", but we do it quite a bit because it is "low hanging fruit".

There are two types of DNR orders in Ohio. The DNR-Comfort Care means just that: comfort care only. This has been interpreted to include antibiotics, pain medication, artificial hydration and feeding. The DNR-CCA in its most basic form means that you do everything but CPR. There is still wide variety in what people will ultimately want done, so if it is not spelled out in an Advanced Directive, we have to decide based on information about the patient from loved ones, what the procedure or treatment will ultimately do for the patient, and prognosis of their various medical problems. It is not as cut and dry as a check box on a piece of paper.

'zilla

As the guy on the other end of the phone, I would order you to continue with resuscitation.

The patient's arrest is possibly iatrogenic in nature and potentially reversible with brief treatment. We suspend DNR orders during surgery for this reason.

DNR orders vary by individual and what treatment they had in mind. In my mind, resuscitation includes aggressive administration of iv fluids. Yet this simple measure can almost painlessly reverse a life threatening condition, and should be done as needed on patients with a DNR. Other things too; some say no anti-atrythmics in a dnr, but this case illustrates the benefit in a simple procedure that can turn the patient around and prevent death.

'zilla

The King is a good airway. I don't see great advantages over the combi except size and weight and simplicity. The US military is using the King extensively in the field. I much prefer it to the LMA.

'zilla

(gingerly sidesteps the paramedic intubation debate)

D50 is okay. The prohibition on drugs in hypothermia generally refers to proarrhythmic (epi, atropine) or antiarrhythmic (amiodarone, lidocaine) drugs because of the proarrhythmic state of the hypothermic heart. Glucose is important for heat generation once the patient is warm enough to shiver. Hypoglycemia may also contribute to the bradycardia and decreased inotropy.

'zilla

I do it. First off, I don't buy the argument that it will increase myocardial oxygen demand through unopposed sympathetic stimulation. The heart rate is TOO LOW, so you're not going to have a runaway heart rate that will extend the infarct. We use dopamine and dobutamine all the time for this sort of thing without concern for extending the infarct. The best thing you can do for the infarcting heart is improve the supply. Second, a patient with a high degree AVB due to digoxin may benefit from atropine. AVB from dig is parasympathetically mediated through increased receptor sensitivity, increased PS transmission at the AV node, and direct PS stimulation. It is not going to cause harm in the emergency setting, takes no time to do, and is a lot less painful than pacing.

'zilla