Off Label

Junkies aren't the only people that overdose narcotics. Little old ladies after knee replacement surgery, college kids after an ACL repair.... the list goes on. Communities are awash in prescribed narcotics.

If EMT's take AED's with them, why not narcan? But, better than an EMT with narcan is an EMT that is able to mask ventilate well, IMHO.

I think we agree... at a hospital I'm familiar with, apparently there was a hiring person that wasn't at all uncomfortable with visible tattoos, odd hair and piercings of all types. The position was 'internal transport', what we used to call orderlies. There were several so adorned internal transporters. Apparently the medical staff, patients and their families disagreed with the hiring practices of said hire-er and those internal transporters are now no where to be seen. In fact, the group as a whole now could work for Disneyland, they're so squeaky clean.

Here's the thing. CO2 is not poison. A respiratory acidosis, even a screaming respiratory acidosis on it's own, is very well tolerated by most patients. It's not an ideal physiologic state but is very easily corrected, unlike a metabolic acidosis which is far less tolerated, not in small part because of the reasons it exists in the first place.

A bigger risk is inadvertently and severely hyperventilating a more elderly patient because of the effect on cerebral blood flow. By and large, giving about 8 breaths per minute looking for a gentle rise in the chest will avoid any big problems. Oxygenation is what really matters.

The primary utility of et CO2 is demonstration that the tube is thru the cords and/ or the airway is patent. That's it. All of the other stuff that goes with it is nice, but at the end of the day, it's a tube/airway check.

ughhhh......a grammar Nazi.... at least I know you read my posts carefully.

It's a cultural thing. You might have an ex navy corpsman combat veteran hiring chief who could care less about hairstyle or a play it down the line, bachelor's prepared city medic who does. For any job, in or out of EMS, employers are looking for maturity. Qualifications are what they are and lots of folks have them. They're not hard to come by. What makes people stand out to prospective employers is how much the candidate does NOT place himself in the center of the universe, among other things, of course, but that's a big one. If you come across as someone who finds his identity in tattoos, hair, piercings or whatever, and not in what it is you're interviewing for, you might be disappointed.

Employers want grownups, and that can have nothing at all with how old you are. Good luck.

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yep..no reason not too, there. Intubating sitting up, or semi fowler's makes things a little easier too.

Well, feel free to contribute to the conversation now. I'm glad I bumped it so you could see it!

Is it still valid?

Hand ventilation sitting up is more easy and effective than supine in most any patient. The problem is venous return....

A PA doing any kind of CCT would be overkill imho. Rural areas with > 1 hour transport  to a trauma center, cath lab, etc., that could make for an interesting bump in pre hospital care capability. But again, very impractical. In a big county there'd have to be a lot of PA's sitting around not doing anything if it were to make a real difference. There's a reason it doesn't happen that way now.

Interesting concept, no doubt.... but it does sound like a mobile general practice PA or NP. We've got those people now, sans wheels, already trained or in an established training pathway. Don't know if there are equivalent practitioners where you are. But perhaps putting these folks in non transport vehicles to be requested by the responding units. This at least would avoid an hour or more out of service time for suturing a laceration.

I am skeptical about the referral component of the idea, though. If, as has been talked about here, so many folks are incapable of understanding how to access health care specific to their needs apart from calling 911, I don't see how a visit from an ambulance crew is going to change that.

@‌ rock_shoes

You describe a combination physician assistant-EMT-public health nurse-social work case worker. Each one of those things requires both clinical and didactic training, let alone experience. It sounds good in theory, but the impracticality of it all is a non starter.

Putting people without that training into a position that they require it is at best unfair and at worse unsafe.

That "health education" and pre hospital care are not mutually exclusive is nothing new. All health care providers are educators to one degree or another. That doesn't mean a mandate for a change in the composition of  public health delivery exists. And reinventing the wheel by changing definitions of existing agencies like EMS is a set up for costly failure.

Community/public health nursing exists right now, let alone home health agencies, public and private. If those entities are under utilized or over burdened, it doesn't follow that an EMS agency's role is to become their replacements.

Hard to answer this question as I don't use this ventilator, but general principles apply when avoiding lung injury so I'll chime in anyway.

First, though, besides the weight class selections, what else is adjustable in terms of tidal volume, peak inspiratory pressures peep, etc.?

Great story... I'd forgotten the time I had transported a body in my ambulance.... mid 1980's too...This gentleman was dying of some mysterious, non infectious (it turns out) process that some specialists at a major San Francisco university based medical center were very interested in finding out more about. His impending death would occur in a matter of days so arrangements were made to transport the body immediately after death, lights and sirens mind you, across the bay directly to said hospital's morgue for immediate autopsy. I kid you not. We got the call on a sunny Sunday morning, put him in the rig and off we went. Security let us into the morgue and we left him there on the stainless steel table with a drain in the middle of it in the midst of knives and ladles of all sizes hanging from their wall mounted racks.

Nobody was there to meet us and I doubt any exam was done on that body before it was lying there for a couple of hours. Unforgettable.

Reading thru the scenario, a couple of things made me doubt AAA... not that it would have changed my management one way or the other... volume, analgesia as tolerated....

The first one was that he was on a transplant list. These involve extensive workup that would have included an abdominal CT which would have caught an AAA at risk of rupture.

The second was that he had no major risk factors for AAA. Non smoker, no documented peripheral vascular disease and he's early 50's. Not to say that a person like this couldn't present with a AAA, just unlikely...

Old thread, but.... sounds like this kid is headed for v/v ecmo at the big house. Clearly unstable for transport currently.

Optimize ventilation... how much of a leak is coming from the chest tubes at current tidal volume? This is not a situation where normal tidal volumes based on predicted body weight will do. No mention of peep, but 6- 10 for starters with total paralysis.... lots of things to unpack there, but moving on...

If she doesn't have an A line, she needs one and pulse pressure variation guided volume replacement started. She's in shock. Potassium should be antagonized with a gram of calcium chloride. K will probably fall with volume resuscitation, tho, no mention of glucose, a little insulin if appropriate. Norepi as required once adequate volume resuscitation underway for MAP of 65.

The CO2 is the least of my worries. Optimize oxygenation and perfusion and transport.

ha!

Vasopressin was removed in the interests of simplifying the process. A study found no difference between epi and vasopressin, so they got rid of vasopressin. That could have just meant they're equally useless in certain situations.

That said, IME, if epi can't fix dead, nothing can.

Not to put too fine a point on it.... but.... that we're still using NS at all is astounding. It was only used in war time in the mid 20th century because it was cheap, and it's anything but 'normal'. Giving it to someone who is already acidotic when something like plasmalyte or normosol (the same things) are lying around somewhere in the hospital would seem to result in chasing our tails with regard to correction of acid/base balance.

http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6008a1.htm

This is the reality according to the CDC. If  (very) roughly 10% of out of hospital arrests survive to discharge, neuro deficits not withstanding, convincing a young or not so young paramedic or physician to choose one out of the next ten they'll see to call might be a tall order.

Have not seen the particulars, but very surprised to see ultrasound in the airway discussion. With all of the video assistive devices now available, if the scramble becomes so desperate as to make someone think ultrasound, might it not be time for the surgical airway? I think I saw the vasopressin thing coming.

Edit: after reading the AHA document on the 2015 changes, I see that the use of ultrasound is only for tube placement confirmation, not placement.

I think it's far more likely that the "discussion" occurs in very busy, urban type systems that are very "deep" with experienced personnel than not. Folks who don't 'need' to manage full arrest patients and/or no longer derive professional satisfaction from them, successful or not.

Not all systems do transport those patients you describe. From the question, I'm guessing where you are there is not protocol for determining a death in the field in these circumstances?