Doczilla

Man I feel the love.

I'm only going by your posts.

'zilla

I see Dust like Lt. Dan in Forrest Gump.

'zilla

Hey it makes it where I can tolerate you.

Actually, I had haldol in mind for you.

'zilla

Back on topic with the misguided zombie hunter.

It is not illegal to possess any med prescribed for him by a physician (or other appropriate licensed prescriber), even dangerous ones like concentrated injectable morphine. Any of the following constitutes felony diversion of narcotics:

Possessing or obtaining a controlled substance not prescribed to you by a doctor.

Administering, selling, or supplying to someone else a controlled substance that was prescribed to you.

On our end, it's illegal to prescribe controlled substances for anyone with whom we don't have a physician-patient relationship. This generally has to have some proof such as a chart/documentation, billing, or a contract.

'zilla

If it's a comedy, I think I can handle another EMS show without taking it too personally, just as I wouldn't take Scrubs personally if I was a doctor (I think).

I don't take Scrubs personally. It's the most accurate medical show on television, no joke. The one show where everyone does pretty much... what they do.

Every other show has an ER doc doing cardiac caths, or a general surgeon doing neurosurgery, or the nurses either being useless or performing emergent surgical crics.

'zilla

"Temporal something" and "problem with the arteries" and "could rupture" is not much to go on. Here is the short list of life-threatening causes of headache that I can think of that does not include tumor, acute stroke, or meningitis:

Temporal arteritis (not life-threatening so much as vision-threatening). An erythrocyte sedimentation rate and c-reactive protein, both blood tests, can rule this out. If positive, a biopsy is done. It does not rupture, but can cause blindness.

Others:

Carotid artery dissection

Berry aneurism

Sagittal venous thrombosis

Cavernous venous thrombosis

MRI/MRA can rule these out.

'zilla

I believe the statement about my own systematic approach wasn't meant for praise. I was introducing how I am now questioning my own method. No where in paramedic school or the training of my agency was the afore mentioned literature mentioned or taught. Until now I hadn't seeked the evidence-based result. Basically I am calling myself negligent for not knowing more.

Which I brought attention to it. It's an important epiphany for prehospital providers reading this forum to understand.

PM inbound.

'zilla

Our system has approved of medics using benadryl in the past to treat dystonic reactions or extrapyramidal symptoms, but we lack a specific protocol. Can anyone give me examples of systems that have a specific protocol for this?

'zilla

There is no magic to clearing a c-spine in the field or in the ER. Some basic questions and a rudimentary exam work as well outside in the rain as it does in the hospital. There is not some year long class in nonradiographic c-spine assessment in medical school.

With NEXUS and the Canadian C-spine Rule and the subsequent follow-up studies, there is a staggering body of evidence that these clinical decision rules work. The thing is that you have to follow the clinical decision rule. The concept of the blogger's statement "I have developed my own systematic approach to these trauma patients" is ridiculous. Why use your own clinical gestalt when there is substantial literature that has developed a system for you? Granted, he's using many the same criteria as NEXUS or CCR, so there is probably little harm in him patting himself on the back for it. The point is, it's much easier to stand up in court and say that you adhered to a clinical decision rule that has been examined and validated with tens of thousands of patients rather than saying what you like to do in your own limited experience.

I'll wait for part II before I comment further.

'zilla

I agree. Stupid doesn't even begin to describe it. Absolutely no concept of what constitutes realistic lifesaving treatment in an austere environment.

'zilla

There are times when a cause of death will be assigned by a physician who does not see the patient. Someone with an extensive medical history who arrests in the field or in the hospital will frequently not undergo autopsy, and the family physician will sign the death certificate. While this does not determine cause of death with CSI precision, it is adequate in most cases. If there is foul play suspected, or if the cause of death is due to trauma, then the coroner will take the case.

Interestingly, I had a patient in her mid 50s from the nursing home come into the ER in full arrest. As per the NH, she had increasing respiratory distress and hypoxia, so EMS was called. Upon their arrival, she was profoundly bradycardic and arrested shortly thereafter. She was in the NH for PT and rehab from a bimal ankle fracture, and due to her obesity and already considerable difficulty ambulating, as well as COPD and respiratory failure that necessitated a prolonged hospital stay. She was non-weight-bearing on that leg, and given her presentation, we felt a PE was the most likely cause of death, with an alternative or secondary cause being COPD. She had been on appropriate anticoagulation.

I spoke with the treating physician, who agreed to sign the death certificate. The coroner did not release the body and slated her for autopsy, which I thought was odd until he explained it to me. Since we suspected PE, and the PE would be related to her immobility, which was related to her fracture, then her proximate cause of death was traumatic in nature.

'zilla

It looks retarded.

Looks like an EMS version of "LA Firefighters", if you can remember how awful that was.

Have they not figured out that people don't buy it anymore? Medics kneeling over someone telling them to "fight! C'mon, breathe!" Or that nobody can save anyone without deviating from protocol and risking their jobs? Or that they are all some stereotype of either a really normal overworked loving parent or a personality disorder? Folks have seen the real thing on "Trauma: Life in the ER" and "Paramedics" and "Cops" (I say "real thing" with some irony. Plenty of those folks were hamming it up for the camera). When will the studios learn that this overblown tripe pales by comparison? If you want a willing suspension of disbelief, you've got to make it come somewhere near what the audience imagines to be true.

Look at what "Law and Order" and "NYPD Blue" did for cop shows. They did it by ramping DOWN the hyperbole, not ramping it up. That's not to say that they were all that realistic (for some reason, no season of "Homicide" could conclude without a cop being shot), but they made it LOOK realistic.

I don't give it a full season.

'zilla

Anthony-

PM inbound once you clear out your inbox.

'zilla

We have to know what we're talking about here. "Trauma arrest" comes in many flavors, and whether or not you work it, and what interventions are applied, need to be decided based on a host of factors. Blunt or penetrating trauma? Is the bleeding controllable/controlled? Did the patient possibly arrest *before* they wrecked the car? What is the relative state of health of the victim? How far are we from someone that can do a thoracotomy? How long until extrication? When did they arrest? Prior to EMS arrival or after? Is there a potentially reversible cause like tension pneumothorax, airway compromise, or volume depletion that I can fix in the field?

I can't agree with the statement that putting ACLS drugs in them will just make them bleed faster. Like ERDoc said, I'll take the heart that is pumping blood (out) over the one that isn't pumping. We know how the latter one works out. ACLS is a lot about maintaining hemodynamic parameters such as preload and afterload, and so it has a role in trauma management.

I think there are many trauma arrests that should be worked, but obviously not all of them. I don't think a blanket answer of "yes" or "no" fits all traumas, as there are clearly ones that will benefit from care. The key thing is capturing those who will. We have some of those answers, but even the trauma physicians are trying to figure out which patients will benefit.

'zilla

Now for your question about the iodine being a problem with infiltration. My guess would be that it could cause some damage since it is a cleaning solution and has chemicals to kill bacteria. Warnings on the box say no for internal use. Most likely, depending on how much was there and not properly taken care of, could have some necrotic effects, and inflammation but don't quote me on that. It is a very interesting question and I would like to see a better answer than my own. I will look it up myself to see what I can find and report back if no one else does.

If you don't know what you are talking about, don't post.

Iodinated contrast material that extravasates typically causes nothing more than some local swelling. Serious complications such as skin necrosis are extremely rare, and usually result from the volume of contrast injected into a closed space. When it happens, protocol dictates that the radiologist and the ordering physician are notified and a heat pack applied. I have never applied nor needed to apply any other treatment.

For reference:

Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections.

Frequency and effects of extravasation of ionic and nonionic CT contrast media during rapid bolus injection.

Local reactions after injection of iodinated contrast material: detection, management, and outcome.

'zilla

Man, some folks are testy today.

I learned something. And considering that EVERY patient in the ER is watching House on Monday nights, (an irony I am sure to point out to them), I've got to stay ahead of Dr. House so I don't look stupid.

'zilla

I was impressed to see both the officers immediately apply the rescue blankets to prevent hypothermia. That's probably something a lot of first responders would not immediately think to do. I thought they handled things pretty well. In retrospect, perhaps it would have been better to keep the girl in the red from getting up the second time, and pin her to the ground before she got out of contact. The way she ended up fighting, though, it may not have lasted long.

As soon as she got into a fighting stance, a taser would have been nice to have. I appreciate the officer's hesitation to use force (she mentions batons) on someone so recently injured, but as soon as you're up and fighting, I don't care how "injured" you are; we're going to end the fight. That's a difficult mental transition to make in the face of the rapidly evolving situation with little info, especially after witnessing her get hit by a car.

'zilla

1. Should EMS have a completely hands-off policy (read: regulation) regarding animal care?

If management believes this to be a violation of standards of compassionate care, then yes.

2. If there is no official hands-off directive applying to EMS, is that not prima facie approval?

No, but I agree that it is a shitty agency that would discipline a crew for this if there is no policy prohibiting it.

3. If animal care is not prohibited, and is to be considered a possibility, should this not be addressed by the veterinary community, with education and protocols?

Yes, along with an arrangement to obtain online veterinary medical control at any hour if necessary.

4. Should not any law enforcement agency with a K9 programme have this formally worked out between their veterinary advisors and the EMS agency?

Absolutely. Such an arrangement will decrease confusion on the medics part and allow them to treat the K9 patient without doubt or regret. It also reinforces to the officers that they can count on EMS to provide care to their K9 officers, and this is good for interdepartmental relationships.

Has anyone here ever been told OFFICIALLY that they cannot provide care to animals? Has anyone here every been OFFICIALLY told that they could provide care to animals? Has anyone here ever had any FORMAL training in animal care as part of their EMS training (as opposed to something you sought on your own)? Has anyone here ever been approached by law enforcement about planning for animal care?

Our flight service has a clear policy that they will not care for or transport K9s, including K9 officers. I discussed this with their medical director, and there are practical considerations that led to this policy. I have given direction to our SWAT team medics that they are to treat K9 officers and transport if necessary by any means available. We have done some K9 medicine courses. We have visited our 24 hour emergency veterinary hospitals, and the vets there have said they are available and comfortable providing telephone consultation. Medics who work on teams with K9 resources (including search and rescue teams) should be expected and trained in how to care for them.

Dwayne raises a good point about priorities. We do have to balance our desire and ability to care for animals with our resources. I don't think we will see medics intentionally neglecting patients to care for an animal. However, it is certainly a possibility that we could unintentionally tie up limited resources on animal care when they are critically needed for a human being elsewhere.

There's another practical consideration here. The K9 officer represents a substantial investment in money, time, and training for the department. Add to this the emotional bond between a K9 and his handler, and NOT caring for an injured dog may impair operational effectiveness of the officer, at least temporarily. I don't think that EMS should be called for just any animal suffering a medical emergency. As others have said, that's really not what we do. But I do believe that the working dog is a special exception to this.

'zilla

You guys are frakkin' awesome. This is exactly what I need.

'zilla

Personally, I think scripting radio reports is not the best of ideas. Sure, in the perfect world we will all give the best reports and receive the best reports. Sadly though, more often than not, providers give horrible reports. They leave out info, give you wrong info from them doing a bad assessment, or you just can't understand them. I am not saying everyone is like this, and it sucks there some are. They are out there though!

We're using the scripts as a starting point for the training. As you've noticed from the examples here, there are different styles to radio reports. With the number of EMS systems that transport to our facility, we see great variability, even within those systems. I'm trying to train the residents to listen for that which is truly relevant to us in the report. What do we need to know in order to approve an order? What do we need in a notification that makes a difference? Is there something buried in the report that makes this a CAT 1 trauma instead of a CAT 2? I'm going to modify the scripts to snip some information (maybe important info) so they will have to ask for it. So I'm going to make some of these into crappy reports.

The reason we're using scripts is that we need it to be interactive. If there is a piece missing, the residents need to know to ask for it. If an order is requested, the residents need to know how to give it. This will require a live person on the other end.

'zilla

I'd be happy to do it, but I think our reporting is quite different. Our radio reports when en route are usually under 30 seconds and just include CTAS, chief complaint, vitals if noteworthy, and tx if noteworthy. But if you need someone to record one for you let me know.

That sounds like just what I'm looking for.

'zilla

Ladies and Gents-

On Wednesday, I'm helping to conduct our medical control base station course for the second year emergency medicine residents. We've changed some things around this year, and now instead of listening to recordings of call-ins, I wanted to make it more interactive. I was working on some scripts for the medic calling in to read over the phone, but thought that y'all (my expert panel) would have some pretty good ideas along those lines as well. So if you are willing to help me out, here's what I need:

A script for a brief radio or telephone report that a medic would give to the medical control hospital or physician while on scene or enroute to the hospital. They should be complete with vital signs, treatment provided, etc. I will make any necessary changes to reflect our local system guidelines or learning points that I want to illustrate. It would be nice to have a some scripts where the medic has to ask medical control for orders and the resident has to figure out whether or not to give the order. I'll also cut out some information so the residents will learn to ask for certain vital information if not given with the original report. Crappy reports are also welcome, since the resident will have to try to make sense of perhaps incomplete or jumbled prearrival information. So can you help a brother out?

Thanks!

'zilla

So a query zilla:

So just how with this very "scanty" information presented in this hypotherical senario could or would affect the treatment in any way to an EMS provider in the field ?

These are not ER MD's, these are Paramedics and EMTs capable of supportive care ONLY and no where near close to definitive Dx or treatment unless life threatning situation occurs ie ABCs ... sounds far more of a dog / instructor chasing its tail, instead of clearly pointing out and factoring in all the possible diff Dx.

If one read's the OP's following post he "went to the books" to differentiate between Meningitis vs Strep not the entire gambit of febrile paeds patho ... heck zilla your right, but it could be Malaria or Cow Pocks too just saying the instructor failed to make his point clear and I have a sneaking suspicion the OP chose to use the horses vs zebras as a title for the tread.

I guess I was in error attempting to introduce some teaching i.e. meningeal signs and cardinal signs of Strept Throat

Okay, I'll bite. As has been demonstrated in several scenarios here on EMTCity, you can't diagnose a patient without looking at them. With the two pieces of information given by the OP (presumably all that was given by the instructor), you can't diagnose strep, or meningitis, or carotid artery dissection, or peritonsillar abscess, or anything. My point was more regarding the general approach to patients by emergency care providers. Perhaps these were the points the instructor was trying to get across.

How could this affect the care provided? What if the medic told them it was just strep, and was wrong? The patient (or parents, in this case), based on that assumption, decide not to go to the ER tonight. Care could be delayed, and harm could result. Many patients do, in fact, look to EMS for medical advice rather than just transport. Considering the possible life-threatening diagnoses will help the provider to guide the patient to the right decision.

You weren't in error adding some teaching on meningitis vs. strep throat. You and I were talking about totally different things here.

'zilla

To clarify, a "zebra" is not just unlikely, it's unlikely and rare. And this statement is common among internists but not emergency physicians.

Emergency medicine is patently different from other specialties in how we approach a complaint and form a differential diagnosis. Most specialties look at what is "most likely" the cause of the patient's symptoms. As the "health care safety net", emergency care providers are the last chance many patients have to catch a potentially life-threatening disease. Our ability to perform an intense, broad evaluation in a very short period of time lends us the ability to quickly diagnose something that may take a primary care physician (if the patient even has one) much longer, and perhaps too long, to find. We can't afford to say that the burning retrosternal chest pain is probably GERD and leave it at that. We have to make sure it isn't something far worse, like MI, or TAD, or PE, or pneumonia, or pericarditis. Speaking from experience, there are few feelings worse than finding out later that your diagnosis was incorrect and you missed something dangerous. The hair stands up on my neck anytime one of my partners says, "Hey, you remember this patient you saw the other day..."

When confronted with a diagnostic dilemma (and they are all dilemmas until you think through it), think about not only what is most likely, but what is perhaps less likely but potentially lethal. It is our job to consider the potentially life-threatening cause of every complaint. Nausea? You'd better think about MI. Back pain? AAA should be somewhere in your mind. That's not to say that every patient with nausea gets an admission for serial enzymes and a stress test, but you've got to think about it. That's also not to say that every kid with a fever should get an LP, but it should be considered even if just briefly.

While you might be correct that ultimately the patient will turn out to have a non-worrisome diagnosis, your instructor's point is a good one.

'zilla

In, I think, the early 1970s, a sniper took up position with high powered rifles, in the Texas Tower. In TV movie reconstruction of the incident, they showed commercial armored trucks driving over GSW victims (high ground clearance vehicles), popping open the rear doors, PD jumping out and grabbing the victims, throwing them inside, and then getting them out of harms way for treatment, or transport to the temporary morgue.

Anybody have some similar arrangement with local armored car services?

The Texas Tower Incident August 1, 1966. Charles Whitman took position on a clock tower at UT Austin and commenced shooting at passersby after killing his wife and mother. An armored car was used to access the wounded.

http://en.wikipedia.org/wiki/Texas_tower_shooting

The LAPD SWAT team commandeered an armored car during the North Hollywood shootout (2/28/97) to retrieve the wounded as well.

http://en.wikipedia.org/wiki/North_Hollywood_shootout

The History Channel show Shootout! does a very nice job of detailing the NHS with 3D reconstructions and interviews.

'zilla

One team I work with has 2. The other has none, but has mutual aid agreements with other agencies to borrow theirs. Both agencies have mutual aid agreements with armored car companies to borrow their armored delivery trucks (similar to what was done in the North Hollywood shootout).

'zilla