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And the IAFF marches on...

ADD and ADHD truly are disorders. That doesn't mean everyone who is diagnosed with ADD and ADHD has such, and some indeed simply suffer from a lack of discipline. But I believe there is a middle ground between medicating everyone who got a C and simply screaming at every kid and telling him or her he's bad or stupid when they have difficulties. There is nothing tough nor macho about screaming at a child who is having trouble learning. I know there are a whole cast of conservative pundits who just think Johnny needs to be "Taken out back behind the woodshed" and all that but its not always the case. ADD and ADHD truly are disorders. That doesn't mean everyone who is diagnosed with ADD and ADHD has such, and some indeed simply suffer from a lack of discipline. But I believe there is a middle ground between medicating everyone who got a C and simply screaming at every kid and telling him or her he's bad or stupid when they have difficulties. There is nothing tough nor macho about screaming at a child who is having trouble learning. I know there are a whole cast of conservative pundits who just think Johnny needs to be "Taken out back behind the woodshed" and all that but its not always the case.

ERDoc, the only problem with strict fee for service is the studies that show that the amount of medical procedures performed by physicians goes up drastically in fee-for-service systems as opposed to other payment systems. Yes, I know we all want to believe that all physicians everywhere would only perform procedures that are absolutely necessary, but doctors are human and humans are fallible. If medication and procedures were doled out strictly on medical science, there wouldn't be advertisements on TV for medications. While I believe capitalism is the superior system for finance, in that it promotes competition, I do not believe that free market values should be applied to the medical industry. You can't just say "caveat emptor" to patients. If you sell someone an air conditioner they may not need or the extra upholstery package for their car, that's just good salesmanship. But to have someone get an operation or take a medication because of the profit is morally and ethically wrong.

<p>ERDoc, sorry, I should have been more specific. When I said EMS I mean the entire system, including the emergency room, not just prehospital care. What you did hit on pretty much my point. If a politician wanted to move to a strict cash on the barrelhead, no pay, no play system, which would be the only alternative to subsidized health insurance, then you'd have to repeal things like EMTALA, and also institute sweeping tort reform for when a person does not get treated or assessed properly by a medical professional and suffers dire consequences. Personally I think if the government basically offered affordable (not free) health insurance to lower and middle class populations, you could do a lot without trampling on the constitution too much.</p> <div id="myEventWatcherDiv" style="display:none;"> </div>

While I swore off political and religious discussions, watching the Republican debate tonight left me wondering about something. The question about what to do with the 30 year old previously healthy person who has no health insurance and gets a catastrophic illness. Michelle Bachmann's response was "Hurrrk.... Obamacare...bad...hurrrkkk..." but Ron Paul said that it should be about choice, and if you choose to not buy health insurance, and you cannot pay for it when you need it, then you should have service denied. Fair enough. You don't plan ahead, you don't pay the price, you don't enjoy the benefits. But my question is, "So what do you do when that person calls 911?" This is a particularly valid question in that when the uninsured and underinsured stop getting healthcare, it falls on EMS to treat them. Now I fully believe health care in the States is in crisis, and I do agree that a government mandate to purchase a product is unconstitutional, though not without precedent, but the thing is, in a system that denies treatment and care to a population, the roles of primary care shifts to emergency medical services, and I can tell you that paramedics providing primary care is a heck a lot more expensive than providing primary care in just about any other capacity. Add to that the cost of treating a disease before it reaches the catastrophic level where EMS is actually needed, and you're really setting up a recipe for financial disaster. So my question is, if the Tea Party plans on denying service to the uninsured, do they also plan on cutting reimbursements to EMS services? No more Medicare or Medicaid checks to those nice people in billing? I mean, my suggestion is, they'd better, or government floated healthcare costs are going to go through the roof. If they do cut Medicare and Medicaid reimbursement, how would that sit with their supporters with names like AMR, Rural/Metro, Transcare, and the IAFF? This is really just a thought experiment. No ethical discussions. I am just talking dollars and cents.

I can't tell you the starting yearly salary, but I can tell you that starting out without overtime you'll take home about $1k every two weeks. Yep. Garbage collectors, on the other hand...

Dwayne, let me say there I don't think there has been or ever will be an award or citation or medal or pin I could ever get that would be more meaningful than what you said. Thank you. Thats going to boost my ego nicely for a couple of weeks. Lone, when you're first learning these rhythms, its sometimes useful to take one giant step back and focus on the basics. Cardiology is like an onion, you can keep pulling back layer after layer until the point you start crying. At this point, just try to focus on complex and pattern recognition and don't worry so much about things like arrhythmias arising from PE's or aberrancies, so long as you know they exist at this point and what causes them, don't worry too much about it. By AHA algorithm standards, this person was in an unstable wide complex tachycardia to begin with, the chest pain and SOB was enough and they recommend beginning synchronized cardioversion for such an unstable patient. I have my own views that someone with chest pain and SOB with an arrhythmia is more symptomatic and less invasive procedures should be tried prior to cardioversion, but again, don't complicate things. The man is unstable. He needs to be cardioverted. When he deteriorated to AMS, he was definitely, definitely unstable. For unstable patients, strictly by the AHA standards, it doesn't matter if its a ventricular rhythm or an SVT (including a-fib) with an aberrancy, the treatment is the same, cardiovert and be merry. Unstable tachycardias are easy, its cardioversion, cardioversion, cardioversion. My recommendation would be to know the standards for an unstable patient like you know your own name so that when they pop up in a scenario they jump out at you like a giant red flag, but it seems you're pretty much there already. Then you can boil a scenario down to blah blah blah blah blah chest pain blah blah blah blah wide complex tachycardia, game set and match. Probably what your instructor was getting at with this scenario is that normotensive BP should not be taken into consideration when determining the unstable vs. stable. Probably some not so bright paramedic student will say "Hey, he's not unstable, his BP is okay" and then your instructor can smugly explain the criteria for an unstable patient.

The NREMT has decided to kick things up a notch and redo everyone's certification levels. Basically, the new levels will be as such: Current Level New Level NREMT First Responder Emergency Medical Responder (NREMR) NREMT-Basic (NREMT- Emergency Medical Technician (NREMT) NREMT-Intermediate/85 (NREMT-I/85) Advanced Emergency Medical Technician (NRAEMT) NREMT-Intermediate/99 (NREMT-I/99) Paramedic (NRP) NREMT-Paramedic (NREMT-P) What I think is interesting is that basically, now, the levels of certification are nearly identical to the ones in British Columbia and other parts of Canada, FR (NREMR), EMR (NREMT), PCP (NRAMET), and ACP (NRP). I think some conservative pundits will be unamused. What it means is I'll have to scrape together some dough to do a 48 hour transition course to keep my paramedic certification. I'm not sure what this means for Intermediate-99's, though. Actually, I think these changes are a step in the right direction. Even though it may only be semantic, the changes to the paramedic level look like a step away from technician and towards recognized health care provider. Plus I can now shut those annoying BLS before ALS guys up who use to say stuff about the EMT being the most part of EMT-P. Not any more! I'm interested to see what they have planned for the transition course.

I understand that kiwi, but I can't see a that BP being low enough to cause AMS, even in a hypertensive patient. I can't quote you the exact pathophysiology, but I assume that AMS secondary to hypotension has to do with decreased cerebral perfusion pressure, which is simply the difference between the MAP and the ICP. Before the drop, the MAP was 140 mm Hg, and afterwards it was 92.7 mm hg. Yes its a significant drop but still well above the ranges where I believe you'd start to see deficiencies in end organ perfusion. I've seen 70 mm Hg as the level where you start to get into ischemic brain damage, but actually I'm curious as to what pressure will lead to the beginnings of a decrease in mental status. Any physicians on the board want to weigh in?

Don't sweat it. I'm sure you did fine.

Yeah Lone, don't let this one throw you. The wide complex tachycardia of unknown origin is a tricky one, and the AMS vs. normotensive BP is another curve ball.

I'm not sure how in depth this scenario wants you to get, but I would say the biggest concern would be if the wide complex tachycardia was atrial fibrillation with aberrancy. Post surgical patients can be at risk for hypercoagulability, which while I don't think would increase the risk of atrial fibrillation does raise the risk of clot formation. I'm also not sure if they are trying to throw you with the BP and the patient's mental state... I would think something other than a cardiac cause for the decrease in mental status if he is maintaining a normotensive pressure. While by ACLS guidelines this patient is unstable because of his decrease in mental status, I would still suggest starting an antidysrhythmic and hunting for an alternate cause for the decrease in mental status rather than going to synchronized cardioversion because of the increased risk of blood clot formation if the rhythm turns out to be a-fib with aberrancy. That's my real life answer. As for textbook answers, I would say thus: 1. Primary assessment concerns are what they always are. Airway, breathing, circulation, make sure he has an airway and a good O2 flow and SPO2. 2. Questions to ask the patient: Are you allergic and/or hypersensitive to amiodarone? Is he on a Beta-blocker, Calcium Channel Blocker, or Digoxin, who's effects may be enhanced by the drug? Does he have Wolf-Parkinson-White Syndrome? 3. The most important step? I don't know... history? I guess? 4. See my above answer for real life. Textbook answer is probably to regurgitate the ACLS algorithm for an unstable patient with a wide complex tachycardia, and move to synchronized cardioversion at 100 J, although the algorithm for the stable patient does mention moving to a calcium channel or beta blocker if you suspect atrial fibrillation with aberrancy, unless, of course he does have WPW and A-fib and then you don't want to use diltiazem. So to wrap it up, if the decrease in mental status is caused by the arrhythmia, then move to synchronized cardioversion, unless it isn't, in which case, move to amiodarone, unless its actually atrial fibrillation with aberrancy, in which you should move to a calcium channel blocker, unless he also has WPW, in which case you shouldn't. That should clear things up.

BoCat, It sounds like you performed in an exemplary fashion for your first lone cardiac arrest. When it comes to diagnostics, if something doesn't fit, sometimes its best just to throw it out. If this patient hadn't been stung by a wasp, and you found him as presented, it would be a pretty clear case of cardiogenic shock secondary to bradycardia. If as the previous posters have mentioned, there were no signs of anaphylaxis, then the wasp sting probably has little or nothing to do with the case. A 55 year old overweight male going into cardiac arrest is almost without a doubt suffering a cardiac event. I wouldn't be surprised if on autopsy it would show a significant occlusion of the right coronary artery which let to infarction of the sinoatrial node. In other words he had a heart attack and died. It happens. A lot. Especially to overweight 55 year old males. You did fine.

I think we're viewing this from different angles. The question as I understood it was if a BLS level ambulance (EMR in Canada, EMT-B in the states) in a system that does not allow off the ambulance MDI's or Nebs who has responded to a 911 call. I'm talking one with full transport capabilities and somewhere in the range of a maximum of 45 minutes to an hour of a definitive care or at least an ALS intercept. I'm not talking about being on a aircraft, or a ferry, or if you're hiking or in some other similar circumstance. In these circumstances, anything can become the proper course of action. That guy who had to saw his own arm off to extricate himself from under the rock did the proper course of action in his situation, but I don't think anyone would argue that in day to day operations, a field amputation for a person with a simple pinned extremity is the proper course of action. And yes I'm aware that field amputations do occasionally occur, but again, they are exception, not the rule. In the normal course of day to day operations, you should not be administering pharmaceuticals not prescribed by a physician to the patient unless you have the appropriate knowledge of their indications, contraindications, actions, and a general understanding of pharmacology. You further complicate issues when you start using bystander medications. This has nothing to do with litigation, that's my view of good clinical practice. In addition, the point that think is most important is that an asthmatic who is in danger of serious deterioration needs more than an MDI. I have seen far more situations where people spend time searching for an MDI as the definitive cure all for a serious asthmatic rather than calling 911, or in the case of a BLS crew, reaching for the BVM and initiating transport. I once brought an asthmatic out of a bradycardic PEA only using a BVM and an OPA. While I was doing this the family and bystanders were still trying to squirt an MDI into her mouth. Lastly, where I worked, the department of anesthesiology had the heavy hitters for the difficult crash airway in the ER. They were the ones the residents didn't want to call while insisting they knew what they were doing. That's what I was getting at.

Yeah I really should try reading the last line of articles sometime, lol.

Is there any studies about whether or not this increases the risk for DVT, pulmonary embolus, ischemic stroke, etc.?

Acute alcohol intoxication is the only contraindication/caution I've ever found for benzos in seizing head injury patient.

Thanks Brian! If you're ever in the Lower Mainland area let me know.

I think you're missing the point. An MDI will prevent further exacerbation. I'm not talking about a person with a fully equipped ALS bus. In that case, a nebulizer is the correct course of action. This isn't the situation that is being described. What is being debated is whether a non-prescribed MDI should be used in the absence of a prescribed MDI. In that case, the answer is no, the MDI is not going to have an immediate life saving effect. It will not be the difference between life and death. Now for any circumstance, you could create a scenario that would fit your needs. I'm sure if you stop an asthmatic from using an MDI, on a long enough time line, they will get into trouble. But exactly what situation are we talking about? Exactly where are you that you have many people ready to hand you an inhaler, but your transport time to the hospital is in such excess that a person experiencing asthma symptoms that at upon your arrival can be relieved with a simple MDI, but will degenerate enroute to the point of being critical? If the person is at a point where there is a real and present danger of decompensation secondary to status asthmaticus during your transport, they are going to need much more than a simple MDI, even with a spacer, to save their life. In the movies someone is in danger of dying because they can't get to their MDI. In real life its more complicated. In fact, by definition, status asthmaticus, that thing that actually kills you, is a prolonged asthma attack that does not respond to bronchodilators. Now I suppose an asthmatic could have been in an asthma attack for long enough that they have merely tired out their diaphragm and accessories, but will still respond to a bronchodilator, but again, in that case, a simple MDI is not going to make much of a difference. They're still exhausted. Now ER doc, I'm not sure what situation you're talking about where someone who need a nebulizer didn't get one because of the absence of wheezing, but if you're referring to silent chest, aren't they pretty much past the point of using a simple nebulizer? Isn't that usually when someone is making a call to anesthesia to pop down to the ER with their tools?

This discussion seems to be based on the ever popular "How far would you go to save a life" principle, i.e. would you bend or break the rules if it was to save a life. This is a philosophical discussion that involves ethical dilemmas that transcend medical, legal, and political philosophy. Its a sticky situation, along the lines of jailing a man for stealing a loaf bread to feed his family etc. etc. etc. Luckily, in this case, it is not at all relevant. At all. The reason being is because as my post mentioned before, MDI's are NOT a life saving intervention, but rather for therapeutic relief of mild asthma symptoms. In other words, if you have an asthmatic who is wheezing and improves on oxygen, they don't need an MDI immediately. On the other hand, if you have an asthmatic who is not improving on oxygen and is barely moving air, they don't need an MDI, they need a BVM and immediate transport. This should render the entire premise of this argument null and void. Unless someone can provide literature detailing the deterioration of an asthmatic on a timeline that reasonably exceeds standard transport times with only an MDI as the mediator, again, I say, this is a non-argument.

Actually tniugs I'm an international applicant and had to go through a pretty lenghty process just to get my training recognized. I'm happy to take the tests though, preparing for them has given me a great introduction into how things are done North of the border.

Just a reminder that MDI's are for symptomatic relief of minor asthmatic symptoms and aren't really a life saving intervention... I mean, they're nice and all but if an asthmatic is really in trouble they're going to need a bit more than an albuterol puffer.

I'm not going to arm chair quarterback, but it is rarely right nor ethical to perform a pain or anxiety producing procedure on an alert or conscious patient without an anxiolytic or analgesic. Obviously a life saving intervention would be one of these, but synchronized cardioversion isn't in that category. The fact she was under the influence of Ativan already may have been why medication was no given pre-synchronization. If someone needs to be cardioverted, give them the meds, give it time to work, and do it humanely. That would be my advice.

Cool. So, know any ACP's that are willing to spill?

I'm in Richmond area. You?