mobey

I need to see/hear a medical reason for them not to walk (always with assistance btw). At risk of sounding like a "grumpy old guy", I give medical care at many levels.... but I am not a wet-nurse, I do not carry my patients thinking it is some superior care. I assist each patient to the level that they require it, sometimes they need a little encouragement to get thier drunk ass off the curb and walk, sometimes a stable yet frail elderly patient gets carried so they don't injure themselves. That is how it should be though, a case by case basis. If you are generalizing treatment of your patients, you are behind the 8-ball.

Oh J306..... I see myself 10years ago If you had a drunk girl who could stand up on her own, she likely could have walked WITH ASSISTANCE on her own. "Assistance fail" One person under each arm, and away we go. Not to get hung up on one case..... I once too held the parinoia of patients falling, and had it drilled into me "If they call 911, they deserve a stretcher". This is just so untrue. You need to be more concerned about you're longevity in this profession if you are considering EMS as a career. There are actually very few patients in areas like ours that cannot ambulate themselves to the cot, if the cot is lowered just outside the back of the ambulance, or use the side door for the lower step. You may be changing the words from you're original post, but your tone remains the same. I like the patient advocacy you are displaying, but remember, you and your partner come before the patient. You mention professionalism in your post above... here is a thought for you. Carrying patients unnessesarily holds back progression of our profession. As for power cots, in the hands of non-progressive practitioners who insist on carrying cots around like in the 80's, they are dangerous and should not be used. I have been using one for 2 years now and have never lifted it. Most practitioners just refuse to change thier traditions. Lemme run a call by you: Pick up a 65 y/o 250lb with influenza like illness. Coughing, fever, SOB, weak, dehydrated. Single level home. Walk the pt to the front door with assistance to where the cot is sitting. (or use a stair chair if you like) Have the patient sit on the cot. Push the "up button on your 125lb elec cot. Weight lifted = 0 Hook the cot onto ambulance and have your partner grab the handles with you and lift. Weight lifted = 125+250=375. 375/2=187lb. 187lb/2 people lifting=93lb each Now while your waiting in the hall and the patient has to go pee? Push the down.... Now the cot needs adjusted to unload into hospital bed..... push the buttons. Seems to me technology, when used properly, is taking away alot of the manual part of our jobs.

No one here specified to give Midaz. Why not give a benzo? you strongly disagree, yet provide no opinion, or evidence to counter. And yes.... in the patient you mention above (anxiety, hyperventilation, carpopedal spasm) I do treat them.

I am pretty quick to "light up" a group about professionalism, sounds like they could use it. The standard has been set in your classroom that giggling/immaturity and unprofessional conduct is accepted. YOU have set that standard now YOU must raise it.

Mike; The way this usually works, is you tell us what you think so we can lead your thinking path the right way through the forest. A Q&A session will warrent you nothing. Let me ask: What are potential side effects, both good & bad, of giving low dose benzo's to an anaphylaxis patient?

This is a great case to present, and I'll tell you right now, I have been on both sides of the fence. One time I had a atypical anaphylaxis (to latex..... a church girl) It was one of the first scenario's I ever posted here, and if I was smart enough I would dig it up. But I cannot find it (would be laughable by now I am sure). I have also had a severe anxiety after taking an inhaled steroid for the first time, that I thought was anaphylaxis. So here is my thoughts; A) Don't trust your ears when there is a hummingbird between them. A Patient can kill themselves, and sewer you're career with fear/drama. Don't let them do it! C) Learn to love you're EtC02. If you don't have it... Get it!. If you have a high Sp02, and low EtC02, you are probably looking at anxiety. D) Never, ever, ever, ever, let anyone ever distract you when you are trying to critique you're calls to improve patient care. Stick to you're own agenda, and those with integrity and common goals in this profession will surround you with support. Casual reading: http://www.ncbi.nlm.nih.gov/pubmed/11801981 http://www.ncemi.org/cse/cse0412.htm

Funny how my experience reflects this exactly, yet I have never put 2 and 2 together.

I tend to agree. It is quite likely that this pt's BP will normalize over the next few days as thier medication schedule gets back on track. Asymptomatic HTN is not an emergency which requires an ambulance trip to the ER, therefore, I would not force that on the patient.

OK, I'll stab. Yes. Temperature has a direct relationship with the bohr effect. Although not a major influence, a hypothermic patient will have a shift to the left, and a hyperthermic pt - a shift to the right. From what I have read, it does not have to be severe hypo/hyper, but overall temperature is one of the "lesser" important factors when dealing with oxyhemoglobin curve. That said... Hypothermia has many more reprocussions I am sure you are aware of. Warming the elderly is always a top priority for me too. In my opinion, one that is too often overlooked, especially in people who cannot shiver. http://www.ventworld.com/resources/oxydisso/dissoc.html#factors http://jap.physiology.org/content/57/2/429.abstract http://www.sciencedirect.com/science/article/pii/0167483882902096

Jump in buddy! Welcome

+1 for first poster to use Emcrit as a teaching tool! I am secure with the fact I have a man-crush on Scott W.

Ahh, you have not forgotten! Stay tuned...

Interesting snippet: (dunno why these always underline) Measured cuff pressures averaged 35.3(21.6)cmH2O. Only 27% of the patients had measured pressures within the recommended range of 20–30 cmH2O. Fifty percent of the values exceeded 30 cmH2O, and 27% of the measured pressures exceeded 40 cmH2O. Thus, 23% of the measured cuff pressures were less than 20 mmHg. Measured cuff volume averaged 4.4 ± 1.8 ml .http://www.biomedcentral.com/1471-2253/4/8 Perhaps our "standard" 10ml needs revisited. How much does a manometer cost anyway? Got to add -- I think it's great that you're using this resource to debrief some calls, and get some constructive feedback. It's also a nice way for the rest of us to learn from your experiences as well. This is a great attitude. Much appreciated. Ya, I am the only medic out here, so this is the best credible resource I have found to critique calls.

Great point Sys. I did not specify, but I would never try it without a tube exchanger. Even with that.... I was too chicken at the time

I think this may be the exact problem! No matter what the adult airway size, no matter what the tube size, it seems we arbitrarily throw 10ml into the cuff without thought. We really should be using pressure guages in this circumstance, especially with extended transport times. Well.... Let me think aloud. Vocal cords = 5mmhg CPAP = 10mmhg (boussignac discussion aside) Total pre intubation = 15mmHg. Post intubation Et Tube = 1-2? (I dunno..... not much.... ) BVM with no diverter = 0.5-1 ? (again... dunno really) So the answer is, dramatically less! Although, I will say prior to paralytic use, he was breath stacking pretty good so that counts a little!

Even better, put 2mg in 1000ml and use even numbers! Even better, put 2mg in 1000ml and use even numbers! I am also a huge fan of the "clock" method

Well of course there are. A leaky cuff means the airway has not been isolated. This pt was paralyzed so active vomiting was not an option, but passive regurgitation causing a aspiration pneumonia is a real threat. This is the reasoning behind EVAC et tubes. In the case of a leaky cuff, I am diligent to ensure frequent suctioning of the hypooropharynx, although that offers minor protection. Raising the head of the stretcher a few degrees will use gravity to keep the stomach contents down, as well as maximizing lung physics. What really needed to happen was the tube needed changed out, I am a little hesitant to do so on the road in the middle of but***k alberta though Overinflation of the cuff is just not good practice due to the consequense of tissue necrosis from the increased pressures, unfortunatly, this often becomes first line defence.

No, since I saw improvement the minute the tube went in. However, I did have to deal with a leaky cuff the whole time.

Kinda forgot about this! Thx for pointing out the obvious Dave.... ughh. Brainfart Once the pt became hyperdynamic.... 5.0mg Versed IVP w/100mcg Fentanyl. Versed drip started at 5.0mg/hr and Fentanyl IVP prn (about every 20-30min.) When the initial Versed.Fentanyl was pushed the pt's BP crashed to 60/40 MAP50ish. I fluid bolused 1000ml NaCl and the BP recovered. From that point it went fairly well. The Sp02 stayed up, EtC02 stayed acceptable and the pt was admitted to ICU. The patient spent 3 days on the vent, then biPAP, then home 3 weeks later. Reflecting on the call, I blamed myself for allowing him to break the CPAP, and my mngr for not having a spare available. I decided that was the reason he needed intubated. On further research, it appears I may be wrong. I have not found literature supporting my theory that people suddenly removed from CPAP decompensate immediatly as this pt did. It appears it takes 4-6min for airway dynamics to change. Squint: No PEEP for this fella! Oh ya.... within the first 5min of being in the ICU, the tube was changed for an 8.0. How embarrasing

To be honest, I am glad Peter got it off his chest, but I do question the validity of this paintbrush effect. I had a Calgary medic spend the weekend with me, and he says he does not know of any Calgary medics who are all knotted up like the Edmonton ones. When I questioned him, he thought it has been 2 yrs or more since Calgary has had a "Code red" (no units available) yet this happends almost daily in Edm. I hate to see this get blown out of proportion because EMS is not where we should be focusing the publics attention. When I was in Edm 3 nights ago, I was there for 2.5hrs with the same 3 Edm ambulance crews waiting for beds. At the time they had just come off a 30min code red. Does that really sound like a Edm EMS problem? If you ask me, we need to refocus on hallway wait times, and long term placement. Perhaps we could look at dispatch again and get the patient transfer end streamlined, and forget these IFT trucks. If you are parked and on shift, you get dispatched to whatever call comes in Period!

Thank you Squint for yet another great post regarding pulmonary physiology and the effects we have on it at the Paramedic level without going "over my head". Doczilla: That is quite possibly one of the most informative posts I have seen in a long time. Reminds me of the 'ol City, and I think posts like that have been lacking here over the past few years. Back to the thread: I have been taking into consideration these pt's have a hypovolemia, as I do with all patients who have been tachypnic for any amount of time. I will admit right now that I do have a very hard time distinguishing pure pneumonia, and pneumonia with CHF exacurbation in the setting of a Heart failure patient whom is febrile with crackles/wheezes. Clearly I would not be using NTG on a pure pneumonia patient on purpose. I fully understand I was missing a link in my thinking, and I will spell it out so no one else misses it. History of "unwell" with cough/fever/SOB presenting with crackles/wheezes = Presumed pneumonia Pneumonia = Volume depletion Volume depletion= decreased preaload & therefore afterload (unless some other vascular issue is causing constriction) Decreased preload/afterload = No CHF exacubation. One of my biggest concerns in CPAP use in pneumonia is clearing secretions and (for lack of better words) "Solidifying" inflammitory exudate or pus causing further complications. is this a real issue? or just something I made up? Squint, you may be pleased to know that whether i intubate or apply CPAP, I always give a fluid bolus of some size as I have effectively removed the "bellows pump" from the right heart.

Looking forward to that! Boussignac CPAP. Don't kill the messenger! It is all AHS will let us use.

I have heard discussion about this as well. The pop-cooler chat I heard was the theory of allowing a single seizure in a known epileptic continue for 5-10 mins before interveining. The idea is that a seizure may resolve and we can spare the patient from unessesary medication administration and hospitalization due to the sedative effects of those drugs. I have no evidence to solidify this, nor do I know of it being an actual practice out there. It is just something overheard from a Doc talking to a MD student.

chbare you bring up so many points I just love to debate! a) I disagree with the use of Lasix in these patients, the science just does not support it. Love to have the debate about bronchodilators in pulmonary edema with bronchospasm. I am in support, however most of the pratitioners I debate with are not. However, for this thread, I would like to hear your personal opinion/rationale for or against CPAP in pulmonary edema with underlying chest infection. I do realize the literature is less than satisfactory, and that is why I have brought it here. Thx