Spock

I am a supervisory nurse specialist with DMAT PA-1. We are not volunteers but are federal employees with a GS rating for salary based upon your qualifications. It took me almost 7 months to go through the application process and I can tell you it was a royal pain in the butt. I have not been deployed as of yet although I did receive an alert for possible deployment to St. Louis early last week. As far as I can tell, the only part of FEMA that worked well during the Katrina disaster were the DMAT teams.

My team deployed the weekend after July 4 for a large air show at the local Air Force Reserve base. We set up our base hospital and saw all patients before transport to the hospital by EMS. The number of transports was far fewer than in the past. It was a good exercise for the team.

I joined because it occurred to me after Katrina that I should not be critical the government response unless I was willing to be part of the solution. That said, FEMA should not be a part of Homeland Security. That is as close to a political statement as I will make.

You probably need to contact someone with your regional team to get anywhere. Our team is no longer taking EMS personnel because we have more than enough. There are different levels of teams based upon the qualifications of members. PA-1 was recently upgraded to level 2 (Level 1 is the highest) but we need psych people and pharmacists. Each DMAT team is supposed to be a fully functional hospital. The Feds supply the equipment. Frankly I think my team has far to many command personnel who are prehospital and have no clue how a hospital runs. Like I said, change comes from within.

Live long and prosper.

Spock

The logic here is quite impressive. You folks must have Vulcan blood in your lineage.

Live long and prosper.

Spock

I think I can shed some light on your concerns about thrombolytics and the OR since I work as a CRNA and cardiac surgery along with trauma are my specialties. You cannot imagine the problems we have with bleeding when we do an emergency CABG on a patient that received thrombolytics. Since none of the EMS services in the Pittsburgh area carry thrombolytics the scenario is usually a patient that went to an outlying community hospital, got the clot buster and then got a helicopter ride to our cath lab. So far so good. What creates a problem is if they can't stent the occlusion or they dissect a coronary artery. Then the patient goes for emergency CABG and bleeds like stink. We have to give platelets, FFP and cryoprecipitate to control it and sometimes we even give DDAVP. It's a given the patient will get multiple units of RBC's.

Unfortunately I am a twisted and demented SOB who thinks these cases are fun. Of course that's why when one of these cases comes up the charge person assigns me to the case and if I am in charge I assign myself. I guess that makes me a masochist as well.

Back on topic. I don't believe the literature supports thrombolytics in the field unless transport times are long. Rapid transport to a hospital with emergency cath lab capabilities is the best treatment. Activation of the cath lab team after hours prior to EMS arrival at the hospital is ideal. My hospital will call in the cath lab team after hours if EMS sends a 12 lead showing an acute infarction and will send the EMS crew straight to the cath lab bypassing the ER.

Live long and prosper.

Spock

OK now time out. I agree with the importance of ETCO2 monitoring but it does not replace pulse oximetry. You need both pieces of information to assess your patient. ETCO2 measures ventilation while pulse oximetry measures oxygenation which are two different things. Pulse oximetry will drop almost immediately in patients with obstructive or restrictive lung disease or those with reduced functional residual capacity. It will stay at 100% for a young and healthy patient for a long time before dropping.

The best way to tell if your patient is apneic is to look at them. The best monitor is a vigilant health care provider.

Live long and prosper.

Spock

chbare has hit the nail right on the head. A narcotic is an opioid of either natural or synthetic manufacture and is a controlled substance. Benzodiazepines are not narcotics but are controlled substances. Some hospital pharmacy's will also consider sodium thiopental and propofol as controlled substances.

I would agree that the use of an opioid for RSI is desirable but not essential. Myalgia caused by muscle fasciculations secondary to succinylcholine administration are seen hours to days afterwards and will not be mitigated by fentanyl/morphine. Use of a defasciculating dose of a non-depolarizing neuromuscular blocking agent will obviate myalgia (either 1mg of vecuronium or 5mg of rocuronium will do the trick).

If you have any compassion at all for your patient you will give as much versed and fentanyl as their blood pressure will stand after paralyzing them.

Live long and prosper.

Spock

Interesting comments on dopamine especially those regarding its misuse as a vasopressor even though in most ER's I've been in it seems to be used for that purpose often. One side effect of low dose dopamine that I have seen is increased heart rate which would be beneficial for this patient. I sometimes use low dose dopamine for open heart patients with a mild degree of renal insufficiency (creatinine >1.5). It almost always drives the heart rate up about 20 beats/minute.

Live long and prosper.

Spock

My service was part of a study using the Autopulse. I used it 4 times and 3 of the 4 arrived at the hospital with a pulse and a BP and trying to breathe. All 3 had significant medical problems and experience suggested there was no reason to expect a return of pulses. The quality of CPR delivered by this device was impressive and was more effective than any human CPR over a period of time than I had ever seen.

Now the research doesn't seem to support my anectodal observations. As a part of the study we had to do 2 minutes of CPR prior to defibrillation which may have been a compounding factor. I don't know the answer.

Outcomes? They all died anyway so we didn't really do anybody any favors other than give families time to gather at the hospital and be with their loved ones when they ultimately died. I can't say if that is worthwhile although my wife would have handled her mother's passing a little better if she had survived to hospital admission and died later instead of just getting a phone call from the ER saying come right away because you mom is dead. Just my experience and it may not be what others agree with.

Live long and prosper.

Spock

Pulse rate was 100 and BP 160/100. Why wouldn't the pulse oximeter work? Now a different question is would you get a reading of 100% with a resp rate of 6 and a partially obstructed airway even if you were on high flow oxygen? Only if the tidal volume was about a liter for each breath! They had problems with a consistent ETCO2 while hand ventilating which tells me they were not as careful of the rate and tidal volume of each assisted breath as they would like you to believe. I think a mechanical ventilator will give a more consistant respiratory pattern than hand bagging any time.

Just because something is published does not mean it has any validity. The follow up regarding the difference between ETCO2 and PaCO2 is important because there is a gradient between the two and it can change quickly. The gradient is dynamic which is important to remember. Unfortunately the only way to record this is to draw an ABG while noting the ETCO2 and comparing the difference. Not possible out of the hospital unless you have an iSTAT and can draw ABG's.

Live long and prosper.

Spock

Hearing is one of the last senses to go and one of the first to return. I always talk to my patients in a calm voice as they drift off to sleep and I also tell unconscious trauma patients that I am going to give them something for their pain and then place a breathing tube. That is also why the operating room is supposed to be quiet during induction of and emergence from anesthesia. Unfortunately that is a problem with new nurses and surgical techs because of poor training.

Live long and prosper.

Spock

I was also wondering about the 5 person crew. If true there seems to be some serious overstaffing. My bet is the state will do nothing. Looking forward to an update on the outcome.

Hey Gul, been to Quark's lately? It's always good to run into another Star Trek fan.

Live long and prosper.

Spock

BP 80/40, junctional rate of 40 and room air sat of 80% suggest the patient is circling the drain and will arrest very soon without significant interventions. Hence my comment of no reserves left. Etomidate and fentanyl for this patient would result in intubation which may not be a bad thing. She was still awake so that was why I suggested medications prior to TCP. I realize AHA ACLS guidelines call for TCP in unstable bradycardia but sometimes you have to be more aggressive than ACLS. There are many ways to treat this patient all of which have been covered here. A good discussion overall.

Live long and prosper.

Spock

Boy there is quite a bit to discuss here and great post. This is a very difficult patient that really needed a helicopter. What was her outcome? Some thoughts:

1. Propofol does not need refrigerated. It must be used within 6 hours of opening of the vial and must be administered under strict aseptic conditions because it is a good medium for bacteria. Cost has dropped considerably since it came off patent a number of years ago.

2. My experience with ICU sedation of patients with propofol is that they never give enough. You get adequate sedation at 75-100mcg/kg/min and I rarely see this dose used outside of the OR. Propofol has no analgesic properties. It will drop the BP at these dosages and vasopressor support is usually needed. I use neosynephrine.

3. Pennsylvania does not allow a medic to transport with propofol so an RN from the hospital would have been necessary. Since there was such a long transport time it seems that giving ativan up front and supplementing it with versed and fentanyl for the trip might have worked. Also, the pt needs redosing of the paralytic agent (either rocuronium or vecuronium).

4. Hypotension is the worst possible thing for this patient since she needs a cerebral perfusion pressure of 80-90 to maintain perfusion of the unaffected brain. CPP= MAP - ICP (or CVP). A normal CVP is 10 so you need a mean pressure of 90 or better. Vasopressors are usually needed. I just did a case in neuroradiology for an acute stroke pt and was running her BP in the 160/110 range for the case. Again I was using neosynephrine. Other pressors that are possible are dopamine, epinephrine or norepinephrine.

5. A pt on nipride without an arterial line generates an incident report in my hospital. Are you able to monitor an ATL in the ambulance?

6. This would be an excellent educational opportunity through a case study discussion. Get the community DEM involved and learn of her outcome at the Level 1 center. It would be a very beneficial session.

Live long and prosper.

Spock

I think as long as the patient is ventilating adequately you should keep them doing so. Positive pressure ventilation would drop the BP even further because of the drugs used and increased intrathoacic pressure. I'm curious about the use of etomidate for sedation. This patient has no reserves left and 10mg of etomidate would put her out and you would need to tube her. I routinely use 10-12 mg of etomidate as a "stun dose" to tube patients in severe resp distress.

So many modalities to choose from but the most important one would be rapid transport to a facility with a cath lab because the patient needs reperfusion and probably a balloon pump.

Live long and prosper.

Spock

A topic like this is one of the reasons why I visit the City! This has to be one of the most difficult patients to manage and there are many different approaches. If you suspect a right sided MI (which is probable here) you don't have to take the time to put more leads on. Take your left sided 12 lead and flip it over and read it from the back.

The patient is clearly unstable but is still alert enough that pacing would be painful so I would vote for drugs. Atropine is easy to give but is not precise. Dopamine at low dose may be more beneficial because at 2-5mcg/kg/min a common side effect is increased heart rate which is what this patient needs while also increasing the BP. The chest pain may have decreased with a higher coronary perfusion pressure. Frankly, I would use epi at low doses such as 4-8 mcg boluses but that is only because of my comfort level with epi after doing quite a few CABG's. Early and frequent command consult is mandatory as well as continuous assessment. Walking the tightrope with vasodilators and vasopressors is difficult without an arterial line because you need instant feedback.

A very good heart surgeon I know once said that dobutamine is a great vasopressor when you don't need one!

Live long and prosper.

Spock

I just finished "And if I Perish" by Evelyn Monahan and Rosemary Neidel-Greenlee. It was published by Anchor Books a division of Random House in 2004. It covers the history of US army nurses who served in World War Two in the European Theater of Operations. Six army nurses were killed in action at Anzio in Italy. How they cared for soldiers and the changes in medicine and nursing based upon their experiences is fascinating. The section on anesthesia administration left me speechless which is difficult to do.

My first degree is in history so I have always been interested in how we got to where we are because I feel that is the only way we will get to where we want to be. Remember, those who do not learn from history are doomed to repeat it.

Live long and prosper.

Spock

I worked part-time on an ALS intercept unit for almost 15 years and one of my many rules was to never but never turn a call over to a BLS crew unless the EMT taking the patient was comfortable with my decision. I think the medic was wrong in his treatment or lack thereof.

Live long and prosper.

Spock

I read about this in the newspaper so my information is not scientific but the article said there was funding for a multicenter study including Canada and the USA. I was under the impression that some services in Pittsburgh were going to be part of the study but I have heard nothing since reading the article a few weeks ago. Has the study started?

We do interventional neuroradiology procedures at my hospital and sometimes use hypertonic saline. The physician is an MD/PhD and is so bloody intelligent that a normal conversation is difficulty even though he is a nice guy. I haven't done a procedure with him where he asked for hypertonic saline but if I ever do I'm going to ask alot of questions.

Live long and prosper.

Spock

Patient: Good morning doctor.

Me: Sir, I am not a doctor I am a nurse anesthetist.

Patient: What's the difference?

Me: I work for a living.

Live long and prosper.

Spock

My EMS agency covers 5 separate municipalities out of two stations. These 5 towns have a total of 11 fire departments (don't ask). We provide heavy rescue for three of those towns. We respond with an ALS ambulance (crew of 2), rescue truck (crew of 1-2) and the supervisor. Basic vehicle rescue is required of all employees and volunteers. The local fire department provides an engine company for hazard mitigation and provides additional manpower if needed. Several of our FD's run first responder vehicles and we will utilize them for manpower if needed. We can also do call backs for our employees and volunteers for the big one. We train with most of our FD's on a regular basis but a couple of them want nothing to do with EMS. You'll have that. We also use our rescue for FD rehab and hazmat response. It works for us. EMS got rescue because 30 yrs ago none of the FD's wanted it.

Live long and prosper.

Spock

We are not allowed to restrain any patient unless we get an order from medical command. Our command docs are petty good about authorizing chemical restraints and we use versed. Our police can restrain any patient they feel is violent and they do not hesitate to use the cuffs. They also transport with us if they cuff the patient. We have police responding to almost all of our calls. The police chief feels this is good PR for his department and the officers are usually very helpful even on simple calls.

In the hospital, leather restraints can be used only on the order of a physician and security places the leathers. Soft restraints can be used in the ICU but again only on a physician order which must be written every 24 hours. I think this is a JCAHO requirement.

Live long and prosper.

Spock

Pain control is a difficult problem in health care and costs our economy a phenomenal amount of money each year. JCAHO estimates this cost at over a billion dollars per year. We have an obligation to make our patients as comfortable as possible. If this means giving them fentanyl or morphine then so be it. Yes there are drug seekers out there but I think every system quickly identifies these people and once they realize we are on to them they move on.

In nursing school we were taught that only the patient can quantify their pain so if they say their pain is 10/10 then that is what it is no matter how they present. Many health care professionals (MD's, RN's & EMS) have a difficult time accepting this. I can relate to this on a personal basis. I suddenly developed flank pain one day that was very severe. I was sitting on the couch when my wife came home. She took one look at me and asked what was wrong. I told her I thought I had a kidney stone and she should take me to the hospital. She darn near had a stroke because I never complain about pain.

Upon arrival at the ED of the hospital where I work I told the triage RN my pain was 8/10. I had figured out early on in this process that if I sat still my pain would not be worse. Because I wasn't screaming or jumping around she didn't really believe me so I had to wait 2 hours before getting into the ER. Yes she was a witch. I got little pain relief until the chief of anesthesia heard I was in the ER and came to see me. When he found out how little treatment I had received he raised holy hell in the ED and I got pain meds quickly. My experience was suboptimal to say the least despite a $5,000 bill.

Yes pain is sometimes a good thing but that is not for me to say. I am aggressive in my pain management for all patients and worked very hard to add fentanyl to our EMS pain protocol and I am proud to say all of the medics with my service will do the same. Opioids (fentanyl and morphine) are the third most commonly administered medication in our service.

Live long and prosper.

Spock

I really liked the study out of Orlando and I frequently cite it.

Live long and prosper.

Spock

We have had significant problems with inappropriate administration of lasix in my area such that we now need an order from the physician before giving lasix. I disagreed with this because I thought is was more appropriate to educate the people giving lasix wrongly but I lost. Just another reason why I dislike the command system my service has.

The diagnosis of CHF versus pneumonia is not simple and requires a thorough physical exam which has been noted. What do you guys think about giving morphine for CHF?

Live long and prosper.

Spock

I agree with Rid once again--there is no distinctive waveform for CHF but hypoventilation will give you higher numbers. Great minds think alike.

Not all patients with asthma or COPD will exhibit the classic shark fin wave form. I've had many patients wheezing badly with high peak pressures on the vent and they had a normal wave form while others have had a classic shark fin with no wheezing and normal pressures. Capnography is a great tool and I still feel if you don't have it you shouldn't be intubating but we must remember that it is just one of the many tools (monitors) we use and we must always assess our patient. We treat the patient and not the monitor.

I looked briefly at that website and liked what I saw. I'll have to look at it closer. Rid--what other sites are available?

Live long and prosper.

Spock

If suxs had to go through an FDA evaluation today it would not pass. Treatment for MH involves much more than just dantrolene and you would be hard pressed to find anybody in anesthesia who would give suxs to a hyperthermic patient. Yes MH does have a genetic predisposition but nobody will take the chance on triggering MH.

Doczilla is right about the bronchoscopy. We frequently do a bronch before a thoracotomy and I routinely place a 9.0 tube because I love the look on the surgeon's face when he comes into the room and asks what size tube did you put in.

Live long and prosper.

Spock