Off Label

https://www.ncbi.nlm.nih.gov/pubmed/26024432

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665872/

To the OP, there is some evidence that challenges the directives you posted. Here are just two, the first being just an abstract, sorry. You very well may have a point in the extremely conservative use of the drug in the pre-hospital setting. People are prescribed NTG and walk around with it in their pockets every day.

The problem is that when an agency writes a policy or directive, they own the problems with it and must justify the difficulties with it. I'm with you in principle. At the very least, as an antihypertensive in the setting of subendocardial ischemia, NTG, if it is all there is, is pretty valuable.

5 hours ago, NBPCP said:

  So a number of us are asking, should Nitro be given more importance in prehospital settings and is this a shared theme across different EMS jurisdictions to downplay the efficacy of Nitro?  With your training, experience, do you think Nitro increases survival rates, in the 'microcosm' of prehospital emergency care?

Since you put it that way, NTG should be used in appropriate patients in the appropriate setting by the appropriate personnel. It doesn't matter what anecdotal evidence anyone can offer...all anyone is able to go on are randomized controlled studies and meta-analyses that control for very specific variables so that some sort of coherent conclusion can be made. Even then, great caution has to be taken with the conclusions.

2 hours ago, NBPCP said:

here are a few FAQ quotes from our medical director who is a physician, whose license we practice under.  Again this seems to be a reoccurring theme in correspondence from our governing body that less emphasis should be put on Nitro as it is merely symptom 'pain' relief drug...

Question: Are Advanced Care Paramedics expected to perform 15 Lead ECG’s in the field to

rule in/out RVI?

Answer: Not necessarily. Many variables may be present affecting any Paramedic’s ability to

complete certain tasks. The presence of an inferior STEMI alone is enough to support

withholding NTG.

REMEMBER: Nitroglycerin is a “Symptom Relief” drug….not a “Life Saving” drug. ASA is the only

medication in your arsenal that has been proven to improve survival from myocardial

infarctions.

Question: Really? PCPs shouldn’t patch with a BHP for patients with no previous use of

Nitroglycerin and no IV?

Answer: Yes. Again, NTG is a “Symptom Relief” medication only. The Medical Directives are clear

that if a patient does not meet the conditions they should not receive the medication or

treatment.

. 

Understand that this is a very superficial context in which to view the use of NTG. Pre-hospital care is a microcosm and an entire universe of care exists beyond the ER. In a world of tight protocol and directives where  one size must fit all, as is  totally appropriate for the setting, NTG apparently cannot not be used to it's full potential (see my post above). 

Just know that it's use in the same patients that you transport for care in the ER for myocardial ischemia is far more multidimensional once that patient gets upstairs.

15 hours ago, DMGroup said:

Is an emt qualified to make "return to play calls" at youth football games? I was told that they would be acting above there certifications if they made this kind of decision?

No, he's not.

Well even if it were just for pain, why is that not of therapeutic value? Pain causes distress which causes sympathetic discharge which causes, among other things hypertension and tachycardia which increases O2 demand and consumption in the circumstance of a pathologically impaired blood supply.

Beyond that, say for example, the NTG unloads the heart and causes a diastolic pressure of 100 to become 88. That is a direct positive effect on LV subendocardial perfusion. Will it be enough? Who knows? But that by definition is therapeutic. I'm sure you could think of other examples as well.

Do you really hear that all of the time? You gotta pick different people to hang around!

2 hours ago, Ruffmeister Paramedic said:

Well take out the thought process of you cannot have a patient with a bp without a pulse and if those 4 meds were the 4 answers you had to work with, the what would your answer be? 

It's my understanding that they want you to answer the question with what you have.  Take away all the extraneous stuff and just answer the question - you have a patient without a pulse.  What's the most appropriate drug to give to someone without a pulse and the only 4 answers are the meds listed?  

Get away from the thought process of thinking - he has a BP and RR of 18 so I wouldn't give him any drugs,  they want you to give him a drug for being pulseless so which one would you give??  

Now answer the question with that thought process!!!

Which one would you give.  

Good advice about getting into the multiple choice question frame of mind... taking these tests is a skill over and above mastering the subject matter.

I do feel the OP's pain though... if a question like that were a deliberate curve ball and not just an error (they do happen), you'd really have to question the quality of the question writers. Can't have a pulse pressure of 40 without a pulse. Questions that contradict themselves don't muster a lot of confidence in the rest of the exam.

I suspect, though, it was a typo...

I'm amazed at how articulate and seemingly intelligent some folks are that are not able to pass these exams after two or three times despite intense and diligent study. My advice as a next step would be to be assessed for an occult learning disability. Plenty of very intelligent adults suffer from these but never have them assessed.

Go here for a start:

https://ldaamerica.org/

The SF Bay Area has several cities that have that set up. Marin and San Francisco are two exceptions but San Mateo, Alameda and Contra Costa, to name 3 have  non fire  EMS agencies. Google them.

As a new member on this forum, I'm pretty reticent to give advice of this magnitude to someone I don't know. But from what I've read of your posts, you seem to be a pretty experienced dude that has some respectable chops. And a stand up dude to boot. So take this with a grain of salt and an open mind.

5 years is a really long time. It's only my opinion, Ruff, but were I you I'd seek a precepted couple of months with a busy service before going back. I say this for a couple of reasons. Firstly, it's a PRN spot where your exposure to bona fide emergencies is limited. They don't know you and credibility is a big deal. Nothing you don't already know, I get that.

Second, as you kind of implied, stuff changes so quickly in medicine. What might be second nature to you now has been old news for a while in some services. Lastly, when folks in my business leave for that long and come back,  they are welcomed with open arms as they do a precepted stretch on the job. These are people that have intubated thousands and thousands of time in the operating room under ideal conditions, let alone on a rainy highway in the dark. If I take two weeks off, I'm all thumbs when I get back.

It's just a safe way to go and make a good impression. It would make for a really smooth transition back, IMHO.

Best of luck.

On ‎9‎/‎5‎/‎2016 at 2:25 PM, SWA_EMT said:

Here's my $0.02.

While a BGL is necessary, the next of kin/responsible party is irrelevant. The pt is 18, which means she has to make the decision for herself.

That being said, I'm not necessarily concerned about the elevated pulse & respiration rates. She was just biking, of course she's going to be elevated. Along that thought process, chances are she may also be an avid cyclist/athlete, which means she may have a low BP normally. Now, while the lack of memory for the event as well as date/time is concerning, we cycle (see what I did there? ) back to the necessity for a BGL.

Now for the heart of the matter: Do we allow this pt to refuse tx & xport? This is where you need to do a really good focused H&P on the pt. Find out if those vitals are normal, if she has any known medical issues, etc. After performing that H&P, if everything checks out..we can start down the refusal pathway, whereas if there are issues found, things would need to take a different turn. If after everything we do & find, she still wants to refuse, it is still ultimately her decision. So here's what we do: explain the risks of refusal (possibility of unseen/UNK injuries & explain that the possibility that there is a chance those injuries could lead to more serious events [to coin the phrase: SZ, coma, death]). My next move would be to explain that I work under a MD's license, & I would need to contact him/her to explain the situation, & that I would express to that MD the pt's wishes to refuse tx & xport. If my MD is ok with the pt refusing, then by all means she can, but if not - I would need to xport the pt.

Given the above, if the pt is allowed to refuse: I would explain that refusing right now does NOT mean that tx &/or xport can't be sought later. I would HIGHLY encourage the pt to seek further medical tx on her own, or contact EMS if her S/Sx change or worsen. One thing I would explain to the pt is that at the moment, she still has a lot of adrenaline pumping through her system due to the events & that once that adrenaline wears off, she's likely to experience increased pn or other S/Sx, which would then be an indication of the need for further medical tx. After that point, I would ensure that the pt signs my refusal form, as well as grab a witness (non-family, non-EMS) signature if possible.

So what do we take away from this? The bigger question in this scenario is: What caused the pt to crash on her bike? Was it an underlying problem such as a low BGL, or did the memory lapse come after the event? The biggest assistance we can provide as EMS professionals is not getting sidetracked by surface level problems; we MUST dig deep, think critically, & be all inclusive in our exams & tx's.

So you do your due diligence and find exactly what the OP describes....a disoriented 18 year old with a bike and some scrapes that wants to refuse care. And a normal blood sugar.

The real danger here is making it way more complicated than it is. Given this set of circumstances, she can't be left alone. So, finding a responsible next of kin/party (roommate, boyfriend, parent etc) can ensure she gets potentially life saving care by familiar and friendly encouragement to seek attention. At the very least, she might go to the hospital with that person. It would also avoid getting the cops involved.

Based solely on what the information given is, leaving her alone is the wrong answer.

Did you not post this identical question in another forum on this site and get at least one answer?

Have cops find next of kin or responsible party while I check a blood sugar.

...where to begin? Don't know what the ratio of deaths to active shooter events is, but there is no way it is high enough to justify what the author is proposing. If there were demonstrable data that showed somehow that a significant number would be saved relative to the number of events, I'd say don't even do it then. Not so some medics could go on suicide missions. The cops weren't even going in at Orlando.

 Also, if he thinks a ballistic helmet and vest is any kind of protection, I question what if any expertise he actually possesses in terms of this topic.

Hero complex indeed...

I will say that it wouldn't be unreasonable to expect the ratio of LODD to active shooter to rise if that is something that is tracked.

4 hours ago, ambodriver said:

the reason wages are so low, is because retards in this profession don't know a damn thing about unity, sticking together or forming a union.  

 

 

I think there might be other factors in play as well....

On ‎7‎/‎31‎/‎2016 at 7:26 AM, kohlerrf said:

I am stumped?

We all know that we inspire roughly 79% Nitrogen and 21% oxygen at one atmosphere of 760mm/hg. Leaving water vapor out of the mix for now this brakes down to partial pressures of  600.4 mm/hg of Nitrogen and 159.6 mm/hg Oxygen. In a homeostatic body with a proper pH we normally absorb roughly 5% of that oxygen and none of the nitrogen leaving a "partial pressure" void of 5% which is commonly filled by C02 creating the value  we know as End Tidal CO2.  In addition our O2 sat has risen to 100% because our pH has become more alkolotic causing a left shift in the oxy-hemoglobin curve resulting in greater affinity for hemoglobin to bind with oxygen

The numbers may be a little off here but bear with me.

If CO2 diffuses to fill the void in the partial pressure, in a state of hyperventilation where our CO2 levels drop what files the void to maintain a partial pressure of 760 mm/hg in our exhaled air? Do we just absorb less Oxygen because the Hemi sites are full and we have saturated the plasma?

This is a really good question.

I think the answer lies in the increased alveolar ventilation relative to oxygen uptake at the alveoli. If a patient is hyperventilating, by definition it is not for the purposes of increasing oxygen delivery because there isn't an increase in demand. So instead of exhaling the usual (about) 16 % oxygen, he is exhaling something closer to the inhaled 21%.

While more oxygen per minute is reaching the alveoli because of the hyper ventilation, there isn't an increased demand and uptake so there is more left over to be exhaled.

On ‎7‎/‎30‎/‎2016 at 9:09 AM, DartmouthDave said:

Hello,

 

Very interesting.  In my region, as far I know, ECMO has not been used for out-of-hospital cardiac arrests.  

Off Label, in the case with the young women and the PE, did they try fibrinolysis first?

Cheers

Negative...she came to us in full arrest.

Well, devil's advocate here, wouldn't that just cause a large increase in the number of medics and drive down salaries? More medics would probably mean less quality as schools had to re-tool and turn out more medics to stay open. Less experienced would be more likely to settle for lowered wages in the circumstance of more competition for a single job.

A narrow gate isn't always a bad thing, IMO....I have no idea what the thread is about, just responding to you, Ruff...

11 hours ago, rock_shoes said:

Just throwing this out there. Most services with high ROSC rates still use a plain old ET tube. Seattle and BCAS (within Metro Vancouver) come to mind. They also try to maintain a paired, tiered, and targeted ALS response within metro zones.

Overall skill retention/proficiency haven't been shown their due over the years and it shows. Don't get me wrong, the King is a great back up airway, but it feels like their is an appetite to solve the problem with toys instead of what's really missing; education.

Also at issue are high stakes, high skills burden procedures. For real proficiency in procedures like advanced airway security, there is just no substitute for doing it a lot. Just how that happens is another question.

ECMO is a game changer. Time was that it was only really practical in the pediatric/ neonate population, but with technological advances adults now benefit as well. I've participated in two quite thrilling saves of patients who wouldn't have had a chance of survival at all. One was a young lady in her late 20's with a PE and the other was a 50 yo sudden death/ occult severe left coronary artery dz. 

5 hours ago, Ruffmeister Paramedic said:

I think what Off Label was meaning was that it was amazing that she suffered minimally.  To suffer a cardiac arrest, go on bypass, slowly rewarm, and survive.  She was able to walk out of the hospital and return to school and not have missed any days, and all you got out of it that you were glad she didn't miss any school????  

 

I think you missed the entire forest for that Seqouia that your bus hit head on.  

 

The amazing result was that she didn't miss any days of school. In the not too distant past, she would have missed months and months of school and had to relearn everything she had ever learned if she had survived, but that she survived and didnt miss any school and was able to return to school is the amazing part of it all, all because of what they were able to do for her with medical advances in care.   

Well, I think the comment brings up an interesting point and that is why do we do what we do in the first place. People usually come up with lofty answers like "to serve humanity" or "make the world a better place", but ultimately we all do what we do to restore our patients to the level of functioning that existed just prior to the event that got us involved. That is how we should measure what we do, I think, and that is all patient's can expect of us, given the circumstances.

The bar is set pretty high in some cases and not so much in others but at the end of the day, if someone can go back to school or a job or being a parent intact, it was a three point landing.

Her co-workers are d***heads too. Unless that's the way she treated them and couldn't get anyone to cover. It'd be odd for such a "star" employee, but there are two sides to every story.

On ‎7‎/‎9‎/‎2016 at 1:20 PM, rock_shoes said:

It's actually an interesting debate. One of the more pronounced signs of an opiate overdose is a decreased level of consciousness. Minus any of the other classic signs (hypoxia, respiratory depression, pinpoint pupils etc.) is a trial of naloxone worthwhile after ruling out other immediately treatable causes? Many services have exactly this type of protocol in place (often referred to as an Unconscious Not Yet Diagnosed protocol). Typically an unconscious NYD would include rhythm, vitals, blood glucose, patient ventilation prn and BLS airway intervention. In the absence of hypoglycemia and arrhythmia a small starting dose of naloxone would be administered IM or SC (0.4 to 0.8mg).

I can't speak to the number needed to treat to demonstrate any benefit from such a protocol. The number needed to cause harm at such low dosing is extremely high. The thought process with such protocols seems to be that it's worth a go because the results from a successful treatment are so positive while the results of an unsuccessful treatment are of little consequence.

My own personal opinion is that, in the cases it has been shown beneficial, there were most likely other signs of opiate or polypharmacy overdose that the provider missed.

I don't disagree here at all. But I think the term "diagnostic" is a misnomer in this regard. Before the days of finger stick glucose, the above described patients would get a stick of D50, not for diagnostic reasons but for therapeutic ones, in the event the altered patient were suffering from you-know-what. Not too many downsides of doing that either. A little narcan  isn't going to make matters worse.

The fact of the matter is that there is a wide disparity of skill and experience among providers and this type of protocol is a low stakes way of mitigating that situation and making sure something isn't missed.

The reality  that 3rd party payers, ie Medicare, are looking for any excuse no matter how trivial, to not pay you for the care that you've provided. If that means simply not including non-pertinent information, then don't. You should know what Medicare et Al will flag for non reimbursement and that should come from the employer.

This is not falsifying anything... it's not recording unneeded information.

1 hour ago, scubanurse said:

True, I'm not talking about the extremes or rare cases here though.  I'm talking about the 80 year old who's spouse woke up and found them not breathing.

This would indicate they got pulses back though, correct?  Therefore they would not be transporting a dead person.

Oops...ya got me! Good job!

On ‎5‎/‎19‎/‎2016 at 7:18 PM, JTEMS said:

In school I learned someone is not dead until they are warm and dead! I'm still in EMT school though, so I'm not the most qualified to answer.

They're not dead until they're warmed after their therapeutic hypothermia!