ncmedic309

I can definitely understand those concerns, I wouldn't want to be halfway between here and there when things decided they were going to take a turn for the worse either. It's one of those calls you just have to make and go with it. If the patient was alert and oriented on scene and able to communicate as the article mentioned he could when he arrived at the receiving facility, it's time to take that chance and go ahead get the patient to definitive care. It's kind of the same principle with a patient that needs cardiac interventions - why waste the time taking them to a facility that doesn't have the services when you can get them somewhere that does, even if it's a longer drive? It may not always be an easy decision to make, but sometimes the closest facility just doesn't cut it. I could completely understand if the patient was showing imminent signs of decompensation or becoming unstable, but the article leads me to believe otherwise. At the same time the information we're gathering from this is from the media, if it is in fact accurate then we're on the right track. I know that area is pretty cut up with waterways, etc. and I can't imagine that many ground transports are an easy trip. I just hope for the sake of the medics involved, they made a good decision based on their protocols and procedures even though ultimately it didn't favor a good patient outcome.

I agree that you shouldn't base your treatment on the MOI alone, but you should still allow the MOI to elevate your suspicions on the possibility of something more severe going on that hasn't yet manifested. In my region, it wouldn't be an issue - any facility that does not meet the trauma center classification will not accept patients with any significant MOI. I can't say that I blame them, it's to prevent cases like these from happening. There's no excuse for taking a patient with a signficant mechanism to a facility not equipped to deal with trauma services if you have other options nearby. Just because a patient appears "stable" doesn't mean we should let our guard down. All of my trauma patients that present with significant injury or mechanism will visit a level I or II trauma center, for their benefit as well as my own.

I'm not taking sides here, but just something that does concern me about the entire case... The one thing that I find most concerning is proven in the quotes above - this patient had a major mechanism of injury that was obviously known to the EMS crew on the scene. The patient was transported to a facility that was not rated as a trauma center. There were other facilities in proximity that did have trauma services and would have been better suited to care for the patient. I could understand transporting to the closest facility if you were having airway difficulties or another immediate life threatening injury that couldn't be corrected in the field but as stated in the article: ...which makes me believe that he was likely stable enough to be managed during the longer transport to the more appropriate facility. Now that's just my take on it, we know that time is of importance with trauma and we can't say that his outcome wouldn't have been better if he had been transported to the appropriate facility initially vs. the delay in definitive care. Just something else to ponder, but that alone in my opinion gives the family good reason for the lawsuit. I also want to make it clear that I don't know jack about the protocols of those providers and that they may have very well been working well within those established procedures and protocols when this incident occured. If that's the case, then they likely have little to worry about.

You're not making any sense and you should probably give up efforts to do so, you are already doing an excellent job at demonstrating your lack of intelligence. You can have all the health screenings requirements along with strict physical fitness and wellness requirements and still have unexplained deaths on the job. I've seen it first hand, even the healthiest providers with the most strict physical requirements can drop dead at any moment and leave us all pondering the reasons. Your obvious lack of respect for your fellow providers speaks volumes on your maturity and level of professionalism.

I think it's in PEA...

Alright, I must have missed something during this thread. It's been my impression that the patient was pulseless and apneic upon assessment. I know that bystanders reported having a pulse after CPR but the original poster remarked that the patient was a "code". That tells me that the patient is without a pulse and without spontaneous respirations - or better known as dead. It's obviously a different case if you have signs of life, of course you would give it your all at that point.

I agree with you on that end, if your going to make an attempt - make it a good one. But after all that effort, would you not just go ahead and transport the patient? So, let's say the patient is pulseless and apneic, you secure the airway, get large bore vascular access, start replacing volume your going down the road of troubleshooting the PEA (if it remains) and your not seeing any improvements based on your interventions. The time on the clock is obviously ticking away at this point, it's trauma, do we want to remain on scene or are we just doing all this enroute? In my opinion, if your going to make those kind of efforts, you might as well do it enroute to the ED. If your not going to transport, it's probably just the best option to leave the patient as you find them. Does my viewpoint make any sense at all?

I'm right there with you man, if we can identify something such as a tension pneumo and correct it on scene, that's one thing but otherwise we're fighting something we can't correct, no matter how much of an effort we put forth. I truly see no benefit in transporting dead patients to the ED just so the hospital staff can terminate efforts. We as providers should be secure enough with our training and abilities to make these decisions in the field, our medical directors rely on us to do so and put forth that trust in us. If it's your decision to do otherwise then so be it, but with a pulseless and apneic traumatic arrest, it's game over - damn near 100% of the time. That may be difficult for some to accept, but it's reality. I'd gladly welcome anybody out here to prove me otherwise.

In simplest form, it's cardiopulmonary arrest secondary to a traumatic etiology. It may be blunt, penetrating or even environmental. If it's blunt or penetrating it's typically pronounced on scene without attempts at resuscitation. If it's environmental, depending on the circumstances such as lightning strike or cold water drowning then all attempts are to be made at resuscitation with some variance in treatment based on the exact etiology. Does that clarify any better? Anthony: That's actually a good question - but yes - even a VFIB arrest secondary to blunt trauma would still fall into that category. I haven't seen a blunt arrest present with VFIB yet, but I have no doubt that other's likely have and that I will eventually see it as well and the urge to defib it will be strong. In regards to the pediatric patient, it's been explained to me of being more of a moral issue - "we just don't leave kids dead on scene." I'm completely fine with that, but to answer the question more specifically we haven't seen any improvements in ROSC with pediatric arrests.

Croaker: I completely understand where your coming from and respect your opinions. I don't feel that it would be wrong to give this patient a chance with resuscitation, I just feel that in most cases it will be futile even after your best efforts. It sounds like this was definitely a traumatic arrest, the bike was traveling at an estimated high-rate of speed and a large vehicle pulled into it's path causing what would appear to be a severe impact. I know that the initial picture does not paint something of massive blunt trauma, but with that kind of accident we know of the many irreversible problems that likely lie beneath, cervical spine injuries, torn aorta's, you name it... If you wanted to make an attempt to resuscitate the patient on scene and correct some of the things we can on scene, where's the harm? Let's secure an airway, gain vascular access, replace some volume, drop a couple needles in his chest and see where we stand after all that. In my position, I am not allowed to attempt ACLS with drugs on blunt or penetrating arrests so that would be out for me. But make a run at the other tricks in the toolbox and if you don't get any improvements, maybe then it's appropriate to terminate efforts and then at least be able to feel better about it, knowing that you gave him that chance. RatPack: I have yet to see a traumatic arrest secondary to a "punch" in the face, but anything's possible...

If its blunt trauma, the patient is pulseless and apneic, regardless of the rhythm on the monitor = the patient is dead. We don't attempt resuscitation on blunt trauma unless it's a pediatric patient. That's our protocol, standing order, blunt traumatic arrest is dead. Our medical director absolutely despises us for bringing dead patients into the ED for them to pronounce when it can be done in the field. If you’re uncertain, it's always your best option to attempt resuscitation. You should be certain though; a good, thorough assessment on the patient will give you all you need to know in most cases.

I apologize for the delay, I went through the process manually but also found the User Guide online that will walk you through it just the same - hope this helps... http://incenter.medical.philips.com/doclib...37%26vernum%3d1

I missed the part about "no injuries" - all I noted was just a quick look around while still sitting behind the wheel of the vehicle, that doesn't tell you much. It's one of those things where your damned either way, you don't want to delay the transport of your "critical patient" but at the same time you have an accident that you were involved in that may very well have injuries, until you find out otherwise...

Just for shits and giggles, if your referring to the NY area alone, I guess it is considered an Epidemic, but in all actuality, it's really a Pandemic.

I just saw that MSNBC is reporting that a school in NY has a possible widespread outbreak of the virus, with well over 100 possible infections. I also saw that Yahoo News is reporting the first two possible deaths from the swine flu in the United States - two men that died in LA County, California. Things are just getting started, this is going to get a lot worse before it gets any better. I give it a couple weeks and we'll start seeing widespread cases throughout the rest of the country.

There is a recall on the MRx for problems with the therapy knobs, it's my understanding that they cause the device to come on automatically depleting the batteries or fail to switch the device into the on position. We did have one battery that just crapped out on us, brand new and just completely lost it's charge - not sure what the issue was there? I'll play with the monitor tomorrow and follow up with the thread then.

I'm not at work and I don't have the device in front of me, but if you would like I can go through the process tomorrow and post some instructions. Someone else might be able to walk you through it on here, but my memory isn't that great.

Ok, so my bad, PD is already on scene - that would speed things up quite a bit. Not very realistic, as in most cases like this PD won't be anywhere nearby since you need them right away. So if PD is already at the location, what is their response to you leaving the scene right away? You shouldn't read to deep into it, doing a quick size-up to determine if there are any injuries is not breaking out the tools and performing assessments. It's fairly rapid, are you injured or not? So I ask you this, show me anywhere in writing where it clarifies that an ambulance with a patient on board is exempt from the law when it comes to being in an accident and leaving the scene without any other regard? In my state, hit and run is illegal, and being on an ambulance with a critical patient is not an exemption. In all honesty, even going as far as I did in the initial reply could still land you in hot water. I think either way your going to get a wide variety of responses from this one, there are legal obligations on both ends. You wanted to know what I would do, there you have it!

I've seen numerous lines started in the hospital, in the EDs, on the floors, doing clinical rotations with the IV Team, etc. I can vouch that there is nothing done differently in the hospital that isn't done in the field. I've seen numerous hospital providers start lines, they pop on the tourniquet, palpate the vein, give it one swipe with an alcohol prep and then stick. I've seen some palpate the vein again before the stick and not give it another swipe. I've seen the same in the field with EMS providers. The problem is, that unless your preparing a sterile surgical field each and everytime you do an IV, your not going to have a "sterile" stick, it's just not possible. It doesn't make a difference if your in the ED, on the floor or in the back of the ambulance. It's my personal opinion, that pulling a good patent line that was initiated only minutes earlier for the achievement of having a "sterile" site is ignorant and a waste of time. You've done nothing but take out a good line and inflict more pain on the patient putting in an additional line and likely increased the risk for possible infection. That's not good medicine...

Which monitor are you using? I'm pretty sure that the MRx comes standard with Bluetooth Technology and if not, it is an option to get on the monitor. Our's have it and any device in range that has Bluetooth will be detected on the monitor. Cell phones, PDAs, laptops, you name it, it works pretty well. I would consult with Philips for additional information, I'm sure you can probably find everything you need on their website.

I'm going to add a reply, without the vote due to lack of other choices... I would do the following: 1. Stop and immediately call dispatch and inform them of the accident, request an additional EMS unit along with PD - also requesting an EMS supervisor to the location. 2. Do a quick size-up, check to see if there are any injuries and see if we need any additional assistance. 3. Assess my vehicle to make sure it's safe to continue transport and if the other vehicle is able to be moved and the occupants aren't injured, have them remove the vehicle from the roadway. 4. Explain to the occupants of the other vehicle the situation, with PD and a EMS supervisor on the way and another ambulance if needed and then continue transporting the patient to the ED. I would also inform communications of the same and advise them to make sure that PD and the EMS Supervisor was also aware of the same. This of course would all be done very rapidly in a few minutes time span and then immediately resume transport. I wouldn't delay waiting on another unit to continue care and transport, but you have the legal obligations to at least evaluate the scene and act accordingly before leaving. You could easily be charged with hit and run if you just yell out the window to the other vehicles and then continue the transport. This is the way I see it...

I'm curious - last night the reports were that the traffic stop was initiated 2 to 3 miles away from the hospital and that the driver failed to pull over for the officer. I'm not longer seeing that on any of the stories today, so either the initial information was incorrect or the media is now leaving that information out of their stories. I can understand the initial behavior of the officer with trying to gain control of the situation, but after it was clarified that there was in fact an emergency in the hospital, his attitude and compassion should have changed to helping the family out in any way that he could. The harsh comments and threats during the rest of the incident were uncalled for and inappropriate and the actions of his superiors with the suspension seem appropriate at this time.

We don't have the option to RSI, we are using Diazepam to combat the shivering during the induced hypothermia. On another note, I'm not a fan of the LMA period - it's just not that great of a device for EMS providers to be using to "control" the airway. I fail to see the hypothermic protocol improving survival and neurological function when we can't even effectively manage the airway.

I just attended our monthly continuing education last night and I got the impression that the service is working towards eventually eliminating endotracheal intubation. The most notable change is our new cardiac arrest guidelines where first responders (EMTs) will be putting in the LMA and “managing” the airway while paramedics initiate vascular access and focus on ACLS and induced hypothermia should the patient meet the criteria. This is one of the first steps that I see them taking to weed out field intubations. Aside from that though, since this does appear to be around the corner for some providers, what will be the best means of managing the airway without endotracheal intubation?

That sums it all up right there...