OzMedic

[quote="FL_Medic This may be another topic, but you may want to consider precautions when using high flow O2.. Stroke - high flow O2 may decrease your Pt's respiratory drive. CPAP with MI - This may worsen the MI. how should we oxygenate our head traumas?] I'm not sure if you read my earlier posts in this thread about the use of oxygen in stroke/head injury. I must say I have never heard of the theory where prehospital hyperoxia in stroke can cause a reduction in respiratory drive! If you believe this to be the case I would be most interested to hear your understanding of the mechanism involved. As for C-PAP/Bi-PAP/IPPV in AMI my understanding is that it is purely the mechanical action of the increased intrathoracic pressure causing a reduction in venous return that is postulated to be the culprit and not in any way a chemical side effect of hyperoxia. Again please correct me if I am wrong on this point also. Cheers

Merry christmas to you to Terri, If your a good girl all next year I'll be there for next christmas :santa: All the best to you and those close to you xxx Oz

The one thing that has not really been looked at in this post is the failure to apply a traction splint to the affected limb. There are varying thoughts on the utilisation of this procedure and because I am in a lazy mood today I will just post 2 contrasting opinions and a link to a JEMS article that looks at this issue. "Traction Splinting in Limb Fracture - A Vital Manoeuvre" Article from: Trauma Grapevine – Volume 1 No.7 April – June 1997 The aim of this short paper is to highlight the need for early application of traction splints in the management of femoral shaft fractures. Over the last four weeks I have been consulted as a Vascular Surgeon, to review three patients with femoral shaft fractures, in whom absent pulses have been noted below the groin. The first patient reviewed in the Emergency Department of a tertiary referral hospital had sustained a combination of chest, abdominal and right leg injuries. The acute management of the patient had been appropriate but during the secondary survey, the obviously angulated and externally rotated pulseless right leg, caused a lot of consternation in the attending staff, who asked for a vascular surgical review. Prompt application of a Hare traction splint resulted in brisk restoration of popliteal and pedal pulses. Failure of both Ambulance and Emergency Department staff to identify the need for this device in the management of a simple femoral shaft fracture was interesting. Two further cases presented within a week to Liverpool Hospital Emergency Department. In the first instance, a male motorcyclist had sustained a simple transverse fracture of the femoral shaft at the junction of the middle and distal third. This had resulted in leg shortening and external rotation of the distal leg. Emergency Department staff, concerned at the absence of pulses, were arranging for radiography and Doppler studies. A consultation to the Vascular Surgical Service was also requested. Prompt application of a Hare traction splint was all that was necessary to realign the femoral shaft and restore the pulses, avoiding unnecessary radiography or vascular studies. The final case again involved a male motorcyclist who had sustained a transverse fracture of the distal left femur with slight comminution. A transverse laceration of the popliteal fossa had resulted in degloving to the level of the gastrocnemius muscle of the distal portion of the wound. The leg was obviously deformed, the thigh shortened and grossly swollen. Two x-rays were performed to confirm the bony injury which was quite clinically apparent. Nothing had been done to restore the pulse deficit below the left groin. In this case, again, the application of a Hare traction splint resulted in prompt restoration of pulses during the interval prior to placement of a Denham tibial pin in the Operating Theatre. In all three scenarios, staff with at least moderated exposure to general principles of trauma management, failed to identify the need for application of a traction splint to restore pulses in the presence of a femoral shaft fracture. In part, their concerns related to the pain that movement of the leg would produce. Systemic analgesia with intravenous Morphine or inhaled nitrous oxide and reassurance and explanation, will usually allow the placement of traction splints. Patients usually experience significant relief from pain promptly after the leg is restored to normal alignment. The decision to x-ray prior to realignment, was made on one occasion in this trio of patients. In some ways this is analogous to x-raying a tension Pneumothorax or dislocated ankle before treating these life or limb threatening conditions. The need for application of the traction splint has higher priority than the need to image the bony deformity, which can be done with greater patient comfort and less threat to the limb, after application of the traction splint. The final observation was of the lack of familiarity of attending medical staff from two teaching hospitals with the traction devices which are available to them in their respective emergency departments. These three cases highlight the need for general awareness of first aid principles in the management of femoral shaft fractures and of the need for attending staff to be practised in the application of simple traction splints. John Crozier, Vascular Surgeon, Lecturer in Surgery Liverpool Hospital, LIVERPOOL or there was this study from Am J Emerg Med. 2001 Mar;19(2):137-40. Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols. Abarbanell NR. Department of Emergency Medicine, Baptist Medical Center, Jacksonville, FL 32207, USA. The present study was completed to establish an epidemiologic database defining the prehospital occurrence of midthigh trauma/suspected femoral shaft fractures, and the use of/need for traction splints (TS) in hope of developing recommendations for further treatment protocols. On review of 4,513 paramedic run reports for the 12-month period from January 1999 through December 1999, from a low-volume urban emergency medical services (EMS) system, 16 persons (0.35% total patients) presented with midthigh injuries. Data collected included patient chief complaint/injury, mechanism of injury, clinical findings, splint application, additional interventions, iatrogenic complications, patient age, and ambulance field time. Paramedics noted injuries suspicious for femoral shaft fractures in 5 patients (31.25% study patients, 0.11% total patients). TSs were applied successfully only twice (12.50% study patients, 0.04% total patients). Fourteen patients (87.50% study patients) were managed with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort. No sequelae as a result of such care occurred. No inappropriate use, point estimate (PE) [(0)/(16) (0.00% to 20.60%)] or unmet need, PE [(0)/(4), 497) (0.00% to 0.08%)] of care was noted. The data presented in this study suggest that given similar EMS system characteristics, prehospital midthigh injuries/suspected femoral shaft fractures occur on an extremely rare basis, and treatment with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort may constitute an acceptable course of care. Including TSs as essential ambulance equipment may be unnecessary. and the link....... http://www.swissrescue.ch/dossier/traction...splint_angl.pdf I think in this case the fact that the patients leg was described as grossly swollen might indicate the need for some traction for haemorrhage control if nothing else. In response to the original question, I am a big fan of C-spine clearance and use it often, however, if this patient has suffered a mechanism then his C-spine cannot really be cleared due to the distracting nature of his other injury. Just my thoughts

Sorry, I can't afford the airfare :wink:

mmmmmmmmmmmmmmmmmmmmm, boobies! 8)

This has happened at least once that I'm aware of in my service and was supported by management. There are so many situations like this that can arise in our occupation. I think you have to take each case as it comes. My general rule is it's better the patient dies of something you didn't or couldn't do rather than because of something you did. That being said, this patient is pretty much dead so i guess all bets are off. Like I've mentioned in a previous post the Australian legal system operates on the "reasonable man" principle where a persons actions are judged by what a selection of peers of the same level of training would do if placed in the same situation so the consensus on this forum is probably a good indication. Of course this is of no consolation if you lose your job. Would I do it? Good question.................................oops got to go, the pager went off!

With that sort of cash you might be seeing me too sometime Tim old mate!

The one smart thing that Vic are doing is offering great money for medics. How do you get a QAS ICP to drag his arse off the beach and move to freezing Victoria? Offer them 120k per year, thats how! The trick is not to go to the effort and expense of training medics, far cheaper to poach them from other states with the offer of better conditions :wink:

LOL at that, so true!

Timmy if things went down as you say they did then complaining about it on an US website is not going to help. Regardless of if the medics or you were right about the patient requiring transport the behaviour you described is cause alone to complain to the ambulance service the medics were from about their behaviour. I can assure you that all complaints are investigated and followed through. One thing that concerns me is the heated debate that you described as occurring in front of the patient. If you had any part in this then you are also guilty of unprofessional behaviour as there is never any excuse for this. This may go against you in any investigation as you will be portrayed as the instigator of said behaviour. Please don't think that I am putting you down for being a patient advocate but there are many ways of handling conflict besides arguing on front of a patient. You are young and have not had a lot of time to develop these skills yet so don't feel too bad What I am offering you here is guidance not criticism so don't take it personally. If it was me I would complain, we all need an attitude adjustment from time to time (god knows I have).

Medics in my system are valued for for far more than their on-road skills and ability to be a bum on a seat. They are the mentors, educators, QA and the testing ground for new interventions. The idea of having these guys circulating around is that they bring the standard of the whole service up by the way they lead by example and support the staff with lower clinical qualifications.

Further to Bushies frank and succinct response, if 2 medics are on the same unit by some accident of rostering then they will soon be split and partnered up with 2 ALS guys to maximise the resources. The majority of ICP's work as single responders anyway backing up ALS crews when needed.

I don't really know where to start with this one! What is with the focus on RN's in an ambulance? It's just a bizarre logic! You keep proposing that it is a higher standard of education than medic and that may be the case where you are from but placing an RN or Dr for that matter in the back of an ambulance is not achieving anything! Yes there are many highly trained RN's and other allied health people in ambulances but ask any of them and they will agree that their previous training did nothing to adequately prepare them for the intricacies of prehospital care. When guys like Dusty and others go on the road in EMS they are not doing it as an RN they are medics. As for the level of training of RN being higher that is also not the case. An RN goes to uni, earns a degree and begins to practice as an RN. In my service you earn your degree in pre-hospital care, practice for 5 years minimum and then apply for medic which is another year full time at uni plus another 6 months of placements etc to earn your post graduate diploma of intensive care paramedic practice. This is a far higher level of education in prehospital specific education than RN training. I am now completing my Masters and after that will move on to doctorate level. Prehospital care is a specialist field and the education should be reflective of this. If you dragged an RN or junior Dr for that matter from the local hospital and put them in my job for a day and told them what was expected of them most of them would wet their pants (As indeed I would if asked to perform certain specialist nursing interventions in a hospital). Remember also that RN's without any postgraduate education perform their duties in a controlled and supervised environment with plenty of checks and balances for support. Most of what they do is ordered or Ok'd by a doctor. I perform my interventions in a myriad of difficult environments often as a single officer autonomously with nobody else to ask for help or advice. If you want a higher standard of medic where you are then replacing them with RNs is not going to do it! Improving the standard of prehospital education is the only way you will achieve your goals. Along with that will come industry recognition and renumeration commensurate of the standards achieved. It is certainly the case here and I earn more than any level of nurse or junior Dr with the exception of high level management.

On plenty of occasions I have needed to get bystanders/family members to assist in cases. If they happened to be a trained medic then I can only see that as a bonus. I was once responded code 1 to a possible cardiac arrest and I noticed the address was my grandmothers house, what was I going to do? not respond because it was my grandmother? I attended the case, done what could be done and called it, the hard part was after when I had to go and tell my mother. We deal with these situations all the time so we are obviously going to handle it better when it happens to someone we know. When there is nothing left to do we can become humans again and deal with it like anybody else. Just my thoughts anyway

and some more......................... Hemodynamic effects of supplemental oxygen administration in congestive heart failure. Haque WA, Boehmer J, Clemson BS, Leuenberger UA, Silber DH, Sinoway LI. Division of Cardiology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA. OBJECTIVES. This study sought to determine the hemodynamic effects of oxygen therapy in heart failure. BACKGROUND. High dose oxygen has detrimental hemodynamic effects in normal subjects, yet oxygen is a common therapy for heart failure. Whether oxygen alters hemodynamic variables in heart failure is unknown. METHODS. We studied 10 patients with New York Heart Association functional class III and IV congestive heart failure who inhaled room air and 100% oxygen for 20 min. Variables measured included cardiac output, stroke volume, pulmonary capillary wedge pressure, systemic and pulmonary vascular resistance, mean arterial pressure and heart rate. Graded oxygen concentrations were also studied (room air, 24%, 40% and 100% oxygen, respectively; n = 7). In five separate patients, muscle sympathetic nerve activity and ventilation were measured during 100% oxygen. RESULTS. The 100% oxygen reduced cardiac output (from 3.7 +/- 0.3 to 3.1 +/- 0.4 liters/min [mean +/- SE], p < 0.01) and stroke volume (from 46 +/- 4 to 38 +/- 5 ml/beat per min, p < 0.01) and increased pulmonary capillary wedge pressure (from 25 +/- 2 to 29 +/- 3 mm Hg, p < 0.05) and systemic vascular resistance (from 1,628 +/- 154 to 2,203 +/- 199 dynes.s/cm5, p < 0.01). Graded oxygen led to a progressive decline in cardiac output (one-way analysis of variance, p < 0.0001) and stroke volume (p < 0.017) and an increase in systemic vascular resistance (p < 0.005). The 100% oxygen did not alter sympathetic activity or ventilation. CONCLUSIONS. In heart failure, oxygen has a detrimental effect on cardiac output, stroke volume, pulmonary capillary wedge pressure and systemic vascular resistance. These changes are independent of sympathetic activity and ventilation. PMID: 8557905 [PubMed - indexed for MEDLINE]

Just some more info in relation to my last post for those interested "There are several reasons for our recommendations that prehospital providers give only low-flow oxygen to stroke patients. First, no data support the administration of any dose of oxygen to acute stroke patients. The only clinical data we have (from a Swedish study) suggest that 3 L of oxygen given for the first few days after a stroke in a hospital may be harmful. The differences between oxygen and no-oxygen patients, however, were not great. Additionally, the number of patients studied was not large, so this study is not definitive. In animal models, high-flow oxygen actually worsens ischemic stroke outcome by causing oxygen free-radical formation in the ischemic penumbra (the area of still-salvageable tissue surrounding infarcted brain in the first few hours of ischemic stroke). High-flow oxygen is also associated with hyperventilating the patient and resultant hypocapnea. This decreases cerebral blood flow and can only hurt a patient with acute ischemic stroke. I know of no neurologists who advocate the use of high-flow oxygen for acute stroke patients. Unfortunately, few neurologists have been involved in the education of prehospital providers in the past. That's changing. Finally, the real controversy regarding oxygen is not high-flow vs. low-flow, but low-flow vs. nothing. EMS personnel are actually right not to give oxygen to an acute stroke patient whose O2 saturation is 92%. My personal feeling, however, is that 2-4 L of oxygen for less than 30 minutes is highly unlikely to hurt any stroke patient. Some EMS personnel may not have O2 saturation capabilities, and I'm worried about mistreating patients with stroke and hypoxia. In the hospital, if the O2 saturation stays at 92%, we can remove the oxygen." David Lee Gordon, MD Associate Professor of Clinical Neurology & Medicine Director, Emergency Medical Skills & Neurology Training Center for Research in Medical Education University of Miami School of Medicine

Let's hope not mate, lol!

There is no excuse for falsifying a run sheet! That is what I perceive as the biggest problem with this scenario. In my service an ACP can be authorised by an ICP to push drug etc under their direction. The run sheet has 2 check boxes next to each intervention with administering officer and authorising officer. Obviously it is entirely on the senior clinicians head if something goes wrong as it was their responsibility to ensure that the procedure was performed correctly. This means that you would probably not get a first year student to do it but if the person has years of experience and for instance can give other IV meds besides the one you are authorising then it is permitted. ICP's in my service are often utilised as a back-up for other crews and in this instance they are expected to assist the ACP crew with any interventions necessary without taking over the case. This allows the ACPs to maintain clinical exposure and learn about more advanced interventions increasing their knowledge base. An ICP will often drive allowing the ACP to continue patient care allowing them to monitor the situation by on-going dialog. Additionally ACP's will mentor student ACP's in the same manner as they are not authorised to do anything until they are qualified. First hand experience like this is vital for the learning process. I realise that a lot of this does not have relevance to the scenario initially presented but it may be valuable information to anybody that has a hand in driving change in the system if that is what the majority wishes. It would seem that a lot of posts on here are only against the practice because it is against the rules and not because they disagree with the concept. A few posters eluded to the medico-legal aspect of the given scenario and what would happen in court etc. Not aside from the issue of internal discipline that can sack/deregister you for going outside the guidelines a court of law may not be so black and white. aside from the falsification issue which is a slamdunk wrong often legal court proceedings are judged by the "reasonable man" scenario which dictates that put in a similar situation what would a representation of the defendants peers do to determine if it was reasonable. That means not a Dr or an EMT basic but medics of the same training and experience as the defendant. In this instance what the regulation says may have very little to do with the result (I know, your still out of a job but it's just an interesting point). Now please forgive me if this is totally not what the US legal system is like and if it is not then I'm sorry because it strikes me as quite fair. I'm sorry if this is way off the main point of this thread I guess what I'm trying to say is that delegation and education are both very important factors in being a medic in my system and to achieve either we need to allow others to practice under our authority.

As tniuqs wrote lung disease secondary to bleomycin therapy is a contraindication to oxygen therapy in my service. Bleomycin is an antineoplastic agent with potential for producing pulmonary toxicity, attributed in part to its free radical-promoting ability. Clinical and research experiences have suggested that the risk of bleomycin-induced pulmonary injury is increased with the administration of oxygen. Other research rejects this theory such as: J Urol. 1998 Oct;160(4):1347-52 Bleomycin associated pulmonary toxicity: is perioperative oxygen restriction necessary? The inappropriate prehospital administration of oxygen therapy is one of my pet peeves and a subject that interests me greatly as a research topic. One particular instance is the administration of high concentration oxygen therarpy to CVA patients. I will expand on some of my research and understanding of the issue but before I do a message to the EBM junkies out there (Bushy, that means you mate among others). Most of this stuff is theoretical and not supported by quantitative research and when you think about it why would it be? Oxygen is free, nobody owns it and there is absolutely no money to be made by researching it, especially the possible detrimental effects of it. It has been entrenched in medical practice for hundreds of years and is widely thought to be safe and benifical for almost anything. Anyway here is some information to consider: During ischaemic brain events there is a zone around the ischaemic area that is hypo-perfused that is often referred to as the penumbra of ischaemia. In head-injured patients, this penumbra is affected by CO2 concentrations, (i.e., hyperventilation may produce more ischaemia). During ischaemic events the penumbra rapidly losses its ability to adequately deliver oxygen and glucose to its neurons. Brain lactate increases and ATP stores run very low. This upsets the normal metabolic function of the mitochondria, which are responsible for producing, then reducing free radicals. Many people use the term free radical quite loosely, but essentially these are chemicals that are looking for electrons. They usually get them from the electron transport chain in aerobic metabolism. These electronless molecules are very reactive and tend to strip electrons off anything they bump into, including proteins, enzymes and especially membranes. These radicals are hydrogen peroxide, superoxides, nitric oxide and hydroxyl radicals. When free radicals interact with stuff inside of cells, they change it. Proteins and enzymes (which are 99.99 percent proteins) fold differently. Membranes have holes punched in them which leads to cellular oedema. Also during ischemia, the pH of the ischemic cell and intracellular fluid goes down. This acidosis causes excitatory amino acids (EAAs – the common excitatory neurotransmitters in the brain) to be released. EAA release causes further leakage of ions, increasing oedema. Since there is no ATP to run the ATPase pumps, the cells get worse and worse. This is a downward graveyard spiral. Along comes "Joe-EMT/Paramedic" who has been trained that oxygen is good and therefore lots of oxygen must be better. He/she gives the ischaemic patient 100% oxygen by mask without addressing the flow problem. The oxygen filters in and before the ischemic tissue can adjust, makes lots of free radicals that the cell is not able to scavenge. The free radicals trigger further activation of the inflammatory response and we get more leakage of ions, most notably calcium. At this point we run into what is known as the "oxygen-calcium paradox". Oxygen is needed for life. Calcium is needed for life. But during ischaemia, oxygen and calcium can actually damage tissues. The free radicals (caused by oxygen) cause ischaemic mitochondria to leak. Calcium rushes in and causes mitochondria to self-destruct. The final common pathway to cell death is the loading of calcium onto an ischemic mitochondria. Does all this mean we don't give oxygen to brain injured patients? absolutely not! Does it mean that we only administer oxygen to maintain SpO2 to normal levels? Maybe so. Is it a subject worth further research? I think so, what about you guys? If people are interested in any of the further info I have discovered about the effects of hyperoxia I will be happy to post it. All of this is of course superfluous to the issues of administering oxygen to certain patients with COAD. This is another area which is extremely poorly understood by most of the EMS and indeed medical profession mainly due to poor education (this whole hypoxic drive BS has got to stop). Of course all this stuff is only my understanding of the relevant issues based on research and information provided by some very smart people of which I'm sure there will be plenty that will correct any inadvertent misinformation that I have given. By the way one of my favorite EMS quotes remains "outta oxygen - outta luck" :wink:

Hey there Dust, thanks for the reply mate. I gather from your response that you have a very unique situation over there and I understand. The storage of narcotics is always a contentious issue and often inspires vigorous debate over what if's etc. While I'm sure if I was in a situation like Dust's I would probably do the same thing I feel it is not necessary to carry narcotics on your person when carrying out general EMS duties as many do. To me it's just another one of the 30 or so drugs that I carry except for the fact thats it's one of the safest. There are plenty of instances of methoxyflurane, entonox, benzodiazipine addiction amongst EMS staff, patients, their families, Dr's, nurses etc etc etc that may target our kits in those moments when we are not looking. So now I have a pocket for morphine, a pocket for methoxyflurane, a pocket for midazolam...........................hmm maybe I should consider the ketamine, haloperidol and promethazine as well. If any of these drugs goes missing there will be an investigation and as long as all the checks and balances have been carried out and you have nothing to hide then there should not be a problem. Anyway, I guess I'm just saying that I don't understand why people treat morphine as something special other than the obvious extra bit of documentation required according to local legislature. Dust, I hope everything is going ok for you over there and you get through unscathed. You have both my respect and admiration. Bushy, G'day mate! yes it has been a while. I've got a bit of breathing space between semesters to experience some freedom from the shackles of academia. Hope we can catch up soon.

Sorry Dust this may be a stupid question but why can't it just go in your kit with the rest of your drugs?

I tend to agree with Ridryder. My post was directed at services that still utilise medical control. There are, and have been for 30 years or so, excellent in depth paramedic courses around the world negating the need for medical control. My service is a minimum 5 years on-road and a bachelor degree before entry in the 1 year, full time, post graduate diploma in intensive care paramedic practice, by the time you do all the in-hospital training it stretches out to a 1 1/2 years. All practice is autonomous for ICP's once qualified. Most of the uni's here are now offering paramedic education to the doctorate level. The argument should not be about who is most qualified to direct paramedics but why they need it in the first place.

Here's a crazy idea, upgrade paramedic education to the point where medical direction is not necessary! I don't understand the concept of training people in performing interventions and stopping short of educating them when and why they should perform them. Maybe it's just me :roll:

I was just reading through this post and it seems that most people are referring to the use of promethazine as an antiemetic. While I do use it for this in some circumstances, the major reason that I utilise the drug are for it's anti-histamine effects during severe allergy. I have found it to be very effective in this area and when co-administered with hydrocortisone it will arrest and reverse a developing reaction avoiding the need the resort to the administration of adrenaline and it's undesirable side effects. My service also utilises it for co-administration with agents that have a high incidence of allergic reactions such as antivenoms. While I utilise metaclopramide as my primary antiemetic agent it is my understanding that promethazine is more effective for nausea due to disruptions within the middle ear such as motion sickness vertigo and labyrinthitis. I believe this is due to the inhibition of of signals from the vestibular apparatus to the emetic centre in the medulla. While it will potentiate the sedative effects of narcotics the belief that it enhances the analgesic effect has been refuted by some studies proposing that this practice actually results in sub-standard analgesia. Anyway, as I was initially saying I find promethazine an excellent tool for moderate to severe allergies that have not quite developed to the point of anaphylaxis negating the need to pull out the big guns. While I am well aware that there are a myriad of mediators of allergy/anaphylaxis besides histamine, I have not yet encountered a reaction that did not respond positively to promethazine.

After 20min of trying the best I got was 29 sec, after 5min my 5y/o daughter made 14sec so I immediately turned it off and sent her to bed.