Mateo_1387

...This is a classic example of the need of two paramedics on an ambulance at all times so all the pressure is not on one person. ... In the case you describe the paramedic had no one of equal certification to fall back on when trouble arose which may have actually contributed to the tunnel vision and perceived mistakes.

I do not think that dual medic would have helped overall in this case. From the Original Poster's comments the medic appeared to be very nervous. On top of the he also does not appear to be on top of things. I think this is where a dual medic system can be a bad thing. It is easy to get reliant on another medic to pick up slack. As a single medic provider you are forced to be on top of the game and be proficient at skills.

From reading through this post for the first time this is what I see and think.

For the first argument about intubations at 70 seconds taking too long I don't think it is a problem, that is only in cardiac arrest. The newest CPR standards, for lay persons, is to do continuous compressions without ventilations, if so desired by the lay person doing CPR. So provided we have effective CPR and extended time of 70 seconds to get a "golden airway" to me should not be a problem. For a patient not in cardiac arrest who is apneic or near apneic 70 seconds for intubation would not be acceptable (example. Pulmonary Edema, trauma, RSI).

Check this link out

http://emscapnography.blogspot.com/2006/08...hould-know.html

On this link find the LP12 about half way down, and three strips below that is a strip showing the gas exchange with CPR alone.

Here is my second thought.

One skill I have seen incorrectly done on every call I have been to where it involved a patient being BVM'd, the skill was done improperly. This is a so called "basic" skill that is essential to master. Using a BVM is a fairly simple skill, just done improperly a majority of the time. Multiple instructors I have had, and anesthesiologist in the OR have told me that it is a skill done improperly most of the time. I am also sure everyone reading this post has been to numerous calls where a person using the BVM is doing the skill improperly.

So now that we have it established that BVMing is mostly done improperly, why in the world do we want to give the KING to basics when what the patient needs first is proper BVMing and an ET tube? Same goes for medics, why would you want to use a King when you should have the skills down to do an ET tube. I think King would make a good backup device in a dire situations, but I think it should be a device that is rarely if never used.

I never attended one of those things that I thought was a waste of time or a disappointment. Of course, these days I get even more of the same kind of benefits out of EMT City, so I don't feel as compelled to go as I used to.

I have thought about attending a convention, but just never got the strong urge to. Now with the information that I can get it all in the City I'll probably never make it ! :hiding:

I was thinking more along the lines of one of the Emperor's Club girls in a librarian's outfit, but hey, whatever floats your boat.

LOL, Yea, that works too !

Man did I f*** up!

Yea, for real !

Sounds like me playing the game, except I curse with a lot more anger ! And then I get frustrated and quit. I would never last as long as he did.

Favorite quotes

"This s**t is f^%$#$g worse than Panic At The Disco, f**k"

"I did the correct input there Mario, you f*&^ed up !"

"This is worse than Ann Coulter!"

Side note from the BLS provider: Where I am, the protocol this patient would fall under would be "Non-traumatic CP", where technically by protocol I am required to give ASA to someone who's been coughing for 3 weeks straight and has worsening CP on inspiration/expiration and the lung sounds like you're listening to a puddle of cowpies, or to the guy who has acid reflux who calls at least twice a week for chest pain. My protocol states "Chest Pain", not "Cardiac-related CP". Why on EARTH would I NOT give ASA to this pt unless s/he meets the ABCD's of ASA contraindications? By my book, ASA, ask for medics, if he has a hx of angina and a sys. BP > 120 (and his own nitro with the 6 rights) an NTG, note to the nearest (hopefully a STEMI center, but then I can't do an EKG as a BLS here) and hope for the best.... If the new heart already has ONE MI, why can't it have another? Then again if everything around it indicates epigastric pain.... my tx still doesn't change. And I'm sure as hell ruling out MI.

~MBC

Whaaa :?: :shock:

:arrow: You would follow the cookbook by doing the Chest Pain protocol even if you know that it is not indicated? Even if you feel like you must always follow the cookbook, why not call a doctor and explain to it your patient's condition? Come one guys, we have to be thinkers and do what is right for our patients, not CYA because of what the cookbook says.

:arrow: on another note after the third sentence where you started to ramble about aspirin and medics and stemi centers and abcd's I lost you. Could you clear it up and explain what you were meaning?

Do you have a link to the story? I would be interested in what the charges are. Also makes me wonder how old the kids are.

Well, let the litigation's begin. How many epiphyseal growth plates problems do I foresee?

R/r 911

I cannot find any information where an IO has caused damage to the epiphyseal growth plates in adolescents or younger. It is more likely for the person to have infection, fat emboli, and compartment syndrome versus damage to epiphyseal growth plates. The most common adverse effect seens with IO use is extravasation. It seems like a great tool when other means of vascular access are not available. My agency uses them all the time. We have not had any problems with placements that I am aware of. Our problem with them has been that some medics have put needs used to drill back in the case they came in instead of placing them in the sharps container.

Only you can prevent bad grammar.

There should be a poster with smokey and that quote on it !

That is GREAT !

Hypovolemic cardiac arrest for another.

No fluid volume to pump, so do you really want to increase the amount of work the heart is doing without having anything to contract against?

I can see that epi for some body in hypovolemic arrest is not necessarily warranted.

You wouldn't want to chemically induce a maximal effort from ischemic tissue when you don't have an adequate oxygen supply would you? You not only worsen the ischemia, but you also create the possibility of myocardial rupture through the ischemic tissue.

But I do not see that epi is bad for someone who goes into cardiac arrest due to a MI. Maybe I am way off, but if somebody is in cardiac arrest due to MI they obviously do not have enough oxygen to support the function of the heart. The heart does not have any beta stimulation at this point. Also the brain is not being perfused. So I can see that epi's strong alpha and beta effects will cause vasoconstriction, increased inotropic, chronotropic, and dopaminergic effects to the blood vessels and heart, exactly what the patient's heart currently lacks. We have to increase the oxygen demand of the heart in order to make it function. Even if we watched a patient code in front of us, did two minutes of cpr, shocked once, and got return of pulses there is a good chance you will have to hang a drug like dopamine because the patient will be unstable.

Am I thinking way wrong? If so please explain.

Nice broad strokes you are painting with there. Did you bother to ocnsider that there are a number of situations that would not respond favorably to the strong beta effects that epinephrine will exert?

The cookbook seems to be getting to easy to follow for people to actually think anymore.

Please elaborate how strong beta effects that epi exerts on the heart is not desirable for someone in cardiac arrest?

Thanks Mateo_1387,

Well hell. Now I'm going to have to rethink the whole dang issue.

What got me thinking along these lines is my first preceptorship.

She asked for the EKG finding for IWMI, which I knew, but not the treatment. So I guessed, Vitals, ASA, IV, Nitro(if vitals to support it)...etc. To which she said, "Great, you just killed you patient!"

She ranted about the preload/afterload (She always ranted...I'm pretty sure she didn't possess a conversational tone of voice)

Anyway, I said, "But if we establish two large bore IVs and sit on the bags we should be able to support the pressure while improving perfusion, right?"

To which she said, for the hundreth time, "You wouldn't even make a decent basic, you have no business dealing in theoretical medicine!!!" At which point I dragged her by the hair out into traffic and danced around gleefully while she was turned into a puddle. (OK, I didn't really do that. but I did learn not to aske these kinds of questions as her grasp of A&P was too weak to be able to participate in any intelligent conversation)

Anyway. That's why this question intrigues me. I hate the "You did X and now s/he's dead!" Speaking of my past preceptor, not anyone here.

It seems to me that everything in medicine is give and take. Nothing is free. And on the flip side I don't see many "instant death" choices that aren't obvious.

Sorry, I notice I'm wandering. I just wanted to make it clear that I'm not arguing my point of view (As should be ovious from the bonehead mistakes from my previous couple of posts), only that I like the question, and appreciate the feedback.

Dwayne

I am all about knowing as much as you can, it definantly makes a medic more confident in his treatment.

So do you get the same preceptor for a set amount of time?

I know a lot of times in class our patients "die" when we do improper treatments, but I can't image that it happens every single time in the real world. I don't think it helps things, but it doesn't always "kill" them. Of course in class our scenarios are a lot of times based on the patient being on the verge of dying anyways

I can't really see much in ems that is x leads to y leads to z, and so on and so forth, all I see is a bunch of grey area.

Rid, I'm certainly not arguing with you, but would like to run my logic by you for your thoughts.

I understand that we need to manage preload/afterload, as Starling's law is much more important now than it is normally. But if the LAD is blocked, and if there is significant right sided involvement we know it must be blocked pretty high, wouldn't the heart benefit from the arterial dilation that "might" (I have no idea if this is logical or not) at least move the block lower in the artery so as to effect smaller protions of the myocardium?

Just thinking out loud...

Also, on the EJ. The medic I ride with put an EJ in a gunshot victim that was bleeding badly from the right bicept. Fire had attempted 4-5 IVs in one arm, we were attempting to get one in the leg...all of them blew out almost immediately! 8-9 attempts, all unsuccessful. (In the trauma bay they also made, I think, 6-7 attempts before getting a 20g started. I never heard the theories on what was going on with this guy's vascular system.) So the AMR medic got an EJ. After, I asked him about getting an EJ on a patient that was awake as the protocols say this "shouldn't" be done. He told me, "He needed an IV, not an excuse. You DO NOT want to go to our medical director and explain to him that you couldn't practice medicine because "the protocols said so", not if you want to continue to practice under his license." I love this system...

My opologies for the distraction in the thread, but I've found that many people have many different ideas on this, so perhaps it isn't a terrible sin...

Dwayne

Dwayne, just me thinking out loud here too.....

I would imagine that this patient is having a RCA occlusion. If he is having a massive Right sided MI I would just guess it would be his RCA with posterior involvement. But I guess we will not know unless emtgirl84 post the 12 leads that she has. The fluids provided for this MI is the keep the patient perfusing the brain. Ultimately, he needs PCI. We give the Nitro so that it reduces workload of the heart, and give the fluids to keep the patient perfusing. As far as his blockage it will most likely be due to "junk" building up on the walls of his coronaries.

From everything I have read and learned in school nitroglycerin has minimal effects on coronary dilation. Its main effect is on peripheral veins thus reducing preload and afterload. I have also been taught in school that the nitroglycerin increases collateral blood flow thus helping with the ischemia. As far as giving nitro without an IV, I have seen and heard different things. I have had a medic while at clinical go ahead and give the nitro to a patient with an inferior MI without an IV. I asked later why she did this and she told me that the drug was very beneficial and that there was no reason to prolong giving it since his blood pressure was good. It made sense to me. The patient did become hypotensive, if I remember correctly in the high 80's low 90's but we later established the IV, but most importantly took him to get his PCI. Then on the other side I know medics that would withold nitro until an IV is established. I guess this will be a call on experience. How comfortable someone feels giving the med based on what they have seen and experienced.

ECC stands for Emergency Cardiac Care, and is pretty much everything you do in ACLS (save airway stuff) that is not CPR. Just another acronym to remember, really.

http://circ.ahajournals.org/content/vol112/24_suppl/

I'm not sure what AZECP is getting at here either. Some quotes from the AHA ECC guidelines:

It seems that much of the research shows that there is very little difference between the two drugs as far as patient outcome, so I suppose it makes sense that the drugs may be used interchangeably (according to the guideline).

Thanks, great information !

This reeks of "cookbook" providers.

What reeks of "cookbook" providers?

By using vasopressin "just like it was epi" you are not following the recommendations from the manufacturer or the current ECC guidelines.

Who exactly is the ECC?

Beside not allowing the drug to work, have you had any success following this regimen?

How does giving an epi three minutes after a round of vasopressin not allow it to work? Vasopressin is used to cause vasoconstriction. As far as I know there is nothing that epi does to stop vasopressin from working. Two different MOAs between epi and vasopressin.

Is this outlined in your protocols? Did your medical direction sign off on this?

Yes this is in our protocols. Yes this is what our medical director signed us off to do. Our success rates in Wake County for Vfib/Vtach cardiac arrest is 34%. This is of course in conjunction with induced hypothermia for ROSC.

While I think that is hilarious, I bet the arsehole cops would never write a fire department or another cop for the same thing. Double standard hypocrites.

And since when is it illegal to leave keys in a vehicle?

In my system we just started using AVL (Automatic Vehicle locator). This is so they can dispatch the closest ambulance to a call. Ambulances still have stations, but they do post in certain areas when other trucks are out. Ambulances do not move after 2300 to post. Paramedics are allowed to mark out of service at shift change if they ran a late call and want to get home. That is so they do not get stuck at a call near the hospital when they are ready to go home. But they can answer the call if they want to, and administration encourages us to answer if it seems like a priority call.

I can't say that this system is the best system, but I think it is a good system overall. They response times would also improve if we had medics to fill spots. Daily we have numerous trucks mark out of service due to staffing.

In my agency everything goes in. This includes first in bag, monitor, and oxygen. Depending on the nature of the call LSB equipment is taken in. The only time this policy does not apply is if the patient is seen from the ambulance and is in close proximity.

That medic is only thirty?

He looks at least fifty!

What the hell is Lee County doing to you guys?

The text says he is 30 years old. The video says hes been doing emergency services for 30 years. So he probably is 50, with 30 years experience.

In what situation would you give vasopressin in 3-5 mins but wait 10 mins to redose epi?

Dwayne

Sorry for the confusion. Here we give a dose of vasopressin just like it was an epi. It is either the first or second dose followed three to five minutes later by an epi. Some texts say that vasopressin can be given and then ten minutes later start pushing epi.

Well you should follow your protocols for one on use of the medications.

Anyone tell you why they are reluctant to use vasopressin?

As far as how we use them here the epi is usually given first because it is easily given via bristojet. Vasopressin here is supplied in vials, so it is usually the second medication pushed. We just replace the vasopressin with either the first or second round of epi. We also give it within 3-5 minutes or an epi, we don't wait a full ten minutes.

What do you mean by a suggestion of each?

I'm working on a college degree, and overall I will spend about $3,000. This figure was including books.

Ever consider the East Coast? Wake County EMS may be somewhere for you to consider. It is the county that Raleigh is located. They are aggressive, high volume, and seem to treat their people well. Just PM me if you have any questions.