Off Label

2 hours ago, Just Plain Ruff said:

just make sure that unlike some of the services that I used to work at, have a strict policy that after use, the mast dont just get folded up and put back in the bag or box, they get a thorough cleaning.  Ever opened a mast pants box after a couple of weeks in a hot outer compartment of your ambulance and the last crew who used them on a bloody trauma didn't clean them correctly????

They'd have found a week old summer catfish in their boots...at the very least...gross.

19 hours ago, ERDoc said:

It's funny how things change.  In my days, early to mid 90s, long boards and c collars were gospel.  We drilled on standing take downs constantly.  Then again, MAST pants were still in use also.  Look at us now.

I think with the evolving understanding of crystalloid volume resuscitation and permissive hypotension in trauma, the MAST should get a second look, imo.....

All of our Stoner Ford Type II's  (mid/late 80's) had stretcher hooks you could suspend over the squad bench and put a third patient "bunk bed" style  on a scoop or flat folding stretcher over the bench patient.

epi, lido, ketamine, ancef, succs

If the police billed insurance for their services, there'd be an engine at every robbery.

Ain't no Easter without Passover!

The "good" guys and the "bad" guys aren't really hard to separate out of this conflict. In this civil war, both sides are bad guys by Western Civilization standards. The Syrian president was attempting to kill Syrian rebels which include elements of ISIS, which is a good thing, but he has no regard for innocent human life which makes you wonder what he'll be up to when he wins with the help of the Russians.

The world has stood by in the past as maniacs slaughter by the hundreds of thousands. There just comes a time when decent people need to say enough.

Helicopters, cancer treatment, treatment of rare disease...it's the conundrum. The money has to come from somewhere and someone won't be happy when it comes from wherever they are. There are a couple of hospital based programs where I am that offer memberships of maybe 100 bucks a year and medically necessary transports are covered. These memberships are also honored by services in surrounding states. NFP hospital HEMS are able to absorb rulings like this better than free standing services.

Discretion with what constitutes necessary air transport might help a little.

My 0.02

What do you expect from a group called "Ghetto Medic"? I'd be embarrassed for someone that I recognized there.

When the machine tells you. If you do it too soon, you'll just end up pausing CPR longer than need be.

This guys mom walked him down three flights of stairs and had him sit down on the lawn after she called us for his asthma exacerbation. If he was under 375, I couldn't tell. She did it before he wouldn't be able to, cause he couldn't by the time we got there. Don't know if the trip down the stairs made it worse or not, but I could have kissed that old gal.

16 hours ago, Off Label said:

That'd be some kinda lvad

Whoops...I got it. Was referring to OP of 120/80 blood pressure, not Ruff's post. Good point. LVADs are becoming so much more common around larger metro areas, not so much in "flyover" towns. Worth paying attention to, though, as people with LVAD's get into cars and drive to places far, far away from the centers that place them.

15 hours ago, ERDoc said:

LVAD?

That'd be some kinda lvad

Sounds like, lacking any ability to get the HR down, the idea was to increase myocardial O2 delivery with the nitro? Not a chance I would have been comfortable with personally given no atrial help and the fall in stroke volume from that rate.  The patient sounded like he was flirting with needing CV, but giving the NTG could force your hand in that.

I'd punt to the ER for pharm control if the transport time allowed, trying to avoid CV if possible.

6 hours ago, Ruffmeister Paramedic said:

ok, a couple of things,  10 minutes before starting cpr on a pulseless patient - the question is this "did he die?"  I'm sure he did without cpr.  But maybe not.  

Why did they give bicarb? 

 

And finally, F*** ALS if you disagree with their plan of care,

Amen, Ruff...but you identify a critical care phenomena that exists in a unique way only in the prehospital setting...and that is on scene pi**ing matches. It's as old as the hills and it is a real problem. Sure, in hospitals, surgeons and intensivists and anesthesia can bump heads about the treatment options for a given situation, but this is in another zip code entirely.

Engine medic v. 3rd service medic, fire als v. private bls on the one hand or fire bailing on the ambulance crew at the worst possible moment on the other. It really looks bad back at the hospital.

Had a patient brought in by ambulance with a pillow case over his head because he was trying to spit at the cops and the ambulance crew. Initial call was from the police for a disoriented and combative patient. He had kind of calmed down when I saw him, but was still thrashing his head from side to side...he was handcuffed to the stretcher. I told him I'd take the pillow case off of his head if he promised not to fight or spit at me and he nodded his head that he wouldn't. When I took it off, he made a herculean effort to flip his tongue back, up and out of his mouth to present a zip lock sandwich bag of  densely compressed marijuana bud.

Poor guy was choking.

That's a really cool concept. So, fire doesn't send a first responder unit where you are?

What could go into a basic EMT jump bag that he couldn't use if he were trained to use it and was certified? Meds, obviously, but I'd think he'd be more useful at least in assessment than a first aider.

Link doesn't work, Joshua.

4 hours ago, paramedicmike said:

Nice story up until the last two sentences.  Then it lost me.

Ahhhh....the melodrama of a 21 year old. I remember that...I used to make fun of guys like that and I was as melodramatic as anyone. It's one thing to exsanguinate partly into a body cavity and partly onto the side walk, but that scene must have been unimaginable, especially for a kid barely out of his teens.

I agree, heavy on the drama...but I'll give the kid a pass.

I wonder what the feed before the pasted exchange said?

6 hours ago, medicgirl05 said:

If this is something that would show up on your criminal record I would think it would be difficult to become certified as an EMT. It might depend on your state, I would certainly contact your licensing agency before taking the class to see if it would prohibit you from getting licensed.

The next thing, if it's something that would show up on a background check, but you are able to become certified...I think it would be incredibly difficult to find employment as an EMT. I know I wouldn't pass your application up the chain knowing EMT's are a dime a dozen around here and most don't have a history of sex crimes.

Sex crimes as a 13 year old? 24 years old now? That's a lot of water under the bridge. Caution? Definitely. Full disclosure? Absolutely. But I wouldn't dismiss the guy out of hand without so much as a glance. I'd worry way more about the folks you don't know about.

This type of things isn't limited to the ER in Critical Access/rural hospitals. There is a reason why these are referred to as "underserved" areas. Low reimbursement for physician services at these hospitals as compared to more "desirable" areas means that board certified specialists and sub-specialists cannot afford to live and work in these areas even if they did consider the quality of life acceptable for them and/or their families. That means what you sometimes end up with are folks that can't work in those more desirable areas because of some problematic element in their work history or younger less experienced physicians coming out of their training that are there as part as a "pay back" for financial grants for their training. They can leave after the agreed upon time frame.

It is kind of scary sometimes, but in my experience with rural access hospitals, the administrators are desperate to keep the doors open (as they should be) and if having a physician on duty is a requirement for receiving the critical access federal dollars, being able to fog a mirror may be the only other requirement for working at some places.

Good luck.

Sure it can, but hypotension isn't shock.

And we need a new word for the physiologic condition known as "shock"...There is a broad spectrum of hypoperfusion and it's consequences, if any.

21 hours ago, paramedicmike said:

  But there is nothing out there that clearly states "NTG use in prehospital ACS treatments saves lives".  If there was we wouldn't be having this discussion.  OP wouldn't be having the discussion with his/her medical director and governing body.  If there was evidence we'd be doing it with every ACS patient we encountered. 

Disappointing as that may be for all of us who have dedicated ourselves to doing the right thing, or what we thought was the right thing, for our patients we work with what the literature shows us: There is no evidence it saves lives in the field.

When what we do every day is an effort to save people's lives that idea can be a bitter pill to swallow (or let dissolve under your tongue).

I'm still intrigued by the idea of a RCT on prehospital NTG use and outcomes. 

But there's no evidence  that it doesn't, and more importantly, that, as used, that it does harm. And that is really a large part of the nature of medicine in general. Remember MAST pants and how everyone thought we were doing such a great job using them? We were also so convinced 20 years ago that we had volume resus in trauma figured out and that has been completely re-thought.

At the end of the day, though, there is a net increase in survival across the board, despite ourselves. Something is working.