dzmohr

Not sure if this should go here or in the equipment section, so please don't yell if I am doing it wrong. California is drafting new AED regulations. Some are "interesting" in a California kind of way. If you would like to read the latest draft and their final copy here is a link: Link to California AED proposed regs and comments There is also a link to allow you to comment to the EMS Authority, but public comment section ends on 1/4/08. If this is in the wrong section please feel free to move it.

First responders were using fully automatic aed, not sure why paramedic was doing compressions. They had their monitor already hooked up but had not removed AED. They were not paying attention to the AED which had earlier given a "no shock advised" since the rhythm was not shockable. It was the medics not deep enough compressions that the machine thought was a newly developed shockable rhythm. As for the question as to my still being "on that" ... I was primarily responding because several mentioned these devices were dead or dying....and several asked if they were still making them without an answer in two threads.... they are actually being touted by CS and Medtronic as the latest new thing! They point out that just as an executioner is reluctant to flip the switch, they claim many are reluctant to push the shock button (THEY say that, not me!) Love how the equate a life restoring reset with an execution.

There is a little blame to go around here...dispatcher clearly needs re-education at best, EMS, from what I understand was to hold back for PD because of the involvement of a gun -- officer would have been wise to have his weapon at ready till he knew what he had for sure..... All that is so easy in hindsight, I think I would have been thinking suicide too. Here is a link if you want more details, it is out of Niagra County, NY Unresponsive man shooting

Keep in mind that in most systems a 911 hangup is law enforcement response, not an EMS response. If the caller collapsed before 911 answered law enforcement could shock minutes quicker. If the location is flagged violent or the 911 operator sensed or had a violent situation reprorted most systems have fire/ems stand back till cleared by law enforcement, again having an AED there quicker is better. You do get some interesting situations though! There is an officer involved shooting where he was responding to an "unresponsive man" with a shotgun by his side on the porch of a residence... Officer arrives with first aid kit and AED in hand thinking it a possible suicide. Sees movement, drops the medical gear and grabs his weapon and fires as he sees the "unresponsive" man swing his shotgun in his direction! Seems the paperboy that morning saw man sitting on the porch and asked if he was OK and the man did not answer him. Paperboy noticed a gun beside the man sitting in the chair who refused to answer when first asked if he was OK ( before the paperboy saw the gun and did not CARE if he was OK anymore).... Dispatch reported THAT as "unresponsive man with a shotgun beside him".

OK I know this is an old post, but I have not been around here for a few months and this one is important to me.... For trained responders who are likely to do resuscitations and use the machine with some frequency I like the Zoll for it's CPR feedback.... as for an overall public access defibrillator where frequency of use is reduced I have seen nothing that compares with the Heartsine PAD .... it is 300 dollars or more less then the next least expensive model, yet it is one of two that has a 7 year warranty ( Cardiac Science is the other) it is one of two that has an IP rating of 56 ( again Cardiac Science is the only other) it records up to 60 minutes of ecg, most only record 20 ... battery and pad module only costs 95 to replace where the battery alone in the Cardiac Science is 300+ and the pads for the Zoll , if you use the one piece, is 149 -- most of the batteries for the others is 150+ add another 30-159 for the pads. Heartsine has a model working toward FDA approval that will be in the 400-500 range list that is designed for home use. Phillips should have their CPR feedback model out soon from what I hear. Still looking for a bi-lingual model for public access use where appropriate. The only ones I would like to see off the market or available to professional only would be the fully automatic units regardless of the maker.... there are FDA reports on file where CPR was being done ( not deep enough for the AED to sense it but deep enough to make artifact it took for VF) and in loud environments the folks doing CPR did not hear the warning it was about to shock, so they got the full effect. Two of the reports were paramedics doing the CPR --- I fear it a matter of time before we have an issue with them.

I honestly do not know the answer to this so I am asking.... I know the pads would sense motion, i.e pt breathing or someone doing CPR ... but if somebody was doing CPR, kneels upright but with knee touching patient, no movement ...how does the machine sense human presence?

I would like to get as many opinions as I can about fully automatic AEDs ( no shock button) vs semi-automatic AEDs. I have heard a few reports about even experienced first responders not hearing the shock announcement for various reasons and if they were touching without movement being shocked. Might be an urban legend, but I am told there is an FDA link to such reports...if there is I can not find it even in MedWatch. This comes up because I have a hospital that is buying some AEDs from me for school application. I can just picture those doing CPR moving up but with knee still against patient or someone touching, or not hearing the announcement over crowd noise... Any of you have experiences with them? I have used manual defibs for many years and semi automatics ( with shock button) since 10 years but have never had any field experience with the fully automatics. They idea of them in the lay public scares me ( I know a human can still push the button with someone touching, but at least there is a human that claims to have checked and confirms they heard the shock announcement.) I have a link to the only FDA info I can find on my post here...Link to post with link to FDA docket ...

Thank you VERY much!

Sure was cool to watch a predecessor fluid in " The Abyss" though( think they were using florurosol(sp?) , with the rat breathing the stuff submerged in it! Once they get it perfected there will be some amazing uses! ( by that way, that was NOT a stunt, I have watched it done ... the feeling was they will eventually be able to do an 80% exchange transfusion of the stuff without ill effect. Needless to say the blood industry ( a multi BILLION dollar industry) is NOT impressed or in favor, not enough profit in it yet! Like so many drugs it is not that expensive to make but the R&D costs and regulatory kickbacks -- I mean costs...are thru the roof. But give them time, they will find a way, then the stuff will be readily available and well used. Sorry, don't have proof about any of the above except the rat breathing it, just feeling a little cynical tonight.

Contacting them is indeed best, if you need contact info PM me and I will send it. In all likelihood you will qualify for the test, if I knew what State you are getting your cert in I could answer with more clarity. Terminology can be a bit of a game here in the States. Only a few States are "licensed" most States "certify" as opposed to license. Everybody wants to control the medics! When California changed from certification to licensure and even endorsed the National Registry they made sure to still require county by county "acreditation". None if it had much value to us but it made for writing a LOT of different checks to all the agencies that wanted our money. Even where not required i recommend the NR, besides the fact that they have a really cool patch... I am the eternal optimist. It still represents our best chance to someday being able to practice nationally without needing a trailer to carry our certs with us. It also makes it a little easier to move around and challenge other tests ( so we can give MORE people money)

WOW!!! I was just going to say what happens in Vegus stays in Vegus but his answer was better! I have NO idea why I had to say that but it had to be said, I was sincere about it being a very good explanation though!

Actually we are teaching that test as part of the core curriculum for Red Cross, AHA and Medic First Aid now. And a NEW EMT finds themselves sitting and thinking a lot till they gain some confidence and experience, much like a new medic. I know a lot of seasoned and well educated medics who for any number of reasons still sit and think and waste too much time ( not sure if you meant it this way, but I do ...well educated does not mean they learned all that was taught ...just that they had the chance to.)

There is a LOT that goes into that decision and it is great example of why this is BOTH a science AND an art! From the science end ... you would not work a patient who had rigor, lividity and no core temp, right? Think about why not? ( It is not a trick question, you would not cause there is zero chance at reviving this patient even though you read a couple times a year it seems of someone with RTSC in the morgue or funeral home hours or days later). Not even "for the families sake" would most of us consider transporting ... though there are exceptions to every rule .. I transported a decapitated person from a freeway in LA at the request of CHP and with agreement of base station for a VERY unique set of circumstances - I would not advocate doing that often) If the call was person not breathing, and that appears to be reliable information from your observations, and it took you 8 minutes or more to get there, you put them on the monitor and they are flat line there are a growing number of folks that say you should not even begin working this patient, they have not much more chance then the patients above, many would say the SAME chance, none.. If you DO decide there is question and it is not that clear then you work the patient with ACLS -- as to what is an adequate trial, as an ACLS instructor you know that is covered in the ACLS standard...local protocol may deviate slightly but if they started dead and stayed dead they are likely dead. As noted above we do not transport the dead unless there is a chance ANY chance that we can revive them! Science tells us there is not in these cases. And most of us in the field can anecdotaly confirm the science. Now comes the art .... Babies, by definition of SIDS, do not serve SIDS. 80-90% of the SIDS kids I have had I have pronounced and explained to the family that with SIDS nothing COULD have been done, not even had an ER fill of Drs and nurses been there when it happened, that, as sad as it is, this just happens sometimes. I call pastoral care for the family, get them family support and do what I can till PD arrives or however local protocol goes for handling, but I still care for my patients!!!! I was called for the kid, but I still DO have patients so I usually am not going to be in service quickly, unless ABSOLUTELY necessary ... my patients are the family of the dead kid! Some would argue working the baby "for the sake of the family" and there have been a FEW times that I have... but running lights and siren is dangerous for me and others, so we do THAT kind of "code" very safely and conservatively as we can ... often will not do much more then a show in front of the family briefly, just BLS and once out of their sight shut down and drive to the ER. We are back in service quicker and the family has the support of the ER staff, including psych and pastoral care. HOWEVER ... I make point of letting the family know they should not have high expectations, that it appears the baby is not likely to respond to treatment, but we will take it to the hospital and see if ANYTHING else can be done. I do NOT want the family to be prepared for this babies death, accept it ( most "know" the baby is gone) and transport for MY sake!!! Cause it is easier to turf it to the ER to deliver the bad news....who wins in that case? You just gave that family the expectation that the child could survive, only to have them dashed again, plus the added guilt that "if only I had..." whatever..... Does this help any? Not transporting makes our job harder in some ways, it adds the needed skill of compassion to the list of skills we must develop and perfect... but it is the right thing. In doing QA, I never am critical...OK, RARELY am critical... of those who elect to transport dead people, I do ask them what there thinking was, why they made that decision .. if I get ANYTHING meaningful, then even though I might have done it differently, that does not make what THEY did wrong ( usually)... science and art ... it's a beautiful thing.... when it works .

Damn, Whit!!!! What's up??? Your Avatar shows some blood flow to the brain, but did you use it before you typed this?? ( Slow down, I am only teasing, though I do SEVERELY disagree with you!) You do sound a bit harsh and judgemental in a lot of posts, but then aren't we all at times. Most of us are passion driven...that is not ALWAYS bad. At least you have a position and you speak it. Let me ask you this, I am driving near your house, you and your family have just been in a MAJOR MVA right in front of me! You appear unconscious but your wife and three kids are trapped in the car trying to get out, obviously panicked and there is smoke and flame showing under the hood, do I follow your advise call 911, stay in my car and keep driving or stop, use my extinguisher and see what I can do to help your wife and kids ( leaving you alone to wait 20 minutes for the delayed response due to traffic, since that is your expressed wish from this post.)? I am not asking this to bait you, do not answer, please, without visualizing the situation I have described and answer honestly. Actually, I AM asking you this to bait you but let's see where it goes...just know I want to finish the thread when we are done as friends, I do respect your position and I am NOT advocating stopping if it is not safe to do so.

Apples and oranges---take a breath!! You are agreeing with us and I think perhaps you do not realize we are agreeing with you!!! There is HUGE difference between 8 minute response time, unwitnessed arrest, asystole no RTSC after ACLS and no transport I think few would disagree that person is dead and transporting them does NOBODY any good vs 4 minute response, unknown rhythm ( on most AEDs and even those with a visible ECG rarely have anyone trained to read them on site), and nada on ACLS with unknown down time( perhaps less then 4 minutes) and all they get is a couple minutes of CPR maybe and the EMT with an AED pronounces? Not with MY family they don't! I suspect not with yours either. Bottom line is ... these are two different studies. I think most of us ( don't we?) agree that the >8 min response, asystole, no RTSC after (fill in the blank be it time vs rounds of meds) ACLS trial should not be transported except in rare circumstances. I sincerely hope that few of us would agree that the 4 minute response, unknown rhythm,no ACLS with available ACLS not far off ( be it hospital or medics) should have a chance and not be pronounced without more then a couple days training ( 100 hours or so). I have a modified DNR ( chemical code only no vent without positive EEG) and I would want THAT benefit!

I will be traveling to Belfast for business a few times a year for a while now and I wanted to know a little about the Belfast EMS system. I know Frank Pantridge from the Royal Victoria Hospital is the Father of paramedics worldwide, and I will have the prvilidge of getting to know his partner Professor Anderson. But I know nothing about what the system is like today...any information would be appriciated, I would also be interested in knowing who to contact about a ride along if possible.

0.5% with NO ACLS trial, that is 25% of the national average save rate WITH ACLS in some places so YES , that deserves an ACLS trial, maybe still no transport without ROSC after ACLS trial but at least a trail. I do not believe in transporting those who have no chance of being revived, but I do not approve of leaving behind those that could be, and I think the families of those 4 survivors in that TINY sample of patients would agree! Kinda like saying the hypothermic patient showed no signs of life and was stiff as a board so why warm them, just pronounce...

I hope I am misreading your post, I suspect I am... but I strongly feel the converse is true, most do not think ENOUGH! I am not talking about horses and zebras I am talking about cookbook medicine and USA Today as medical research and if you have a puzzling patient or one that does not respond as you thought they "should" do you shrug your shoulders and blow it off or do you hit the books and try to understand why? I am one of those that believe we do diagnose and practice medicine even if we don't say the words .. we make decisons without a lot of advanced backup and we better be on our game. What I hope you mean, and what I suspect you do, is that a simple answer is often best. Give them a firm foundation and teach THEM to research and always encourage them to question, make sure they know that while you have to memorize much of the cookbook, most of their patients will not have read the script and my throw extra ingredients at you...so be ready for it and if you are not be ready for it the next time!

http://content.nejm.org/cgi/content/extract/355/21/2257 To the Editor: We do not believe that Morrison et al. (Aug. 3 issue)1 focused on the right question in the Termination of Resuscitation (TOR) trial. If saving lives is the issue, the question is: What can early, adequate advanced cardiac life support achieve? Basic life support — as provided in this study — will never result in "good" cardiopulmonary resuscitation, and transportation of the patient to the emergency department during basic life support is thus futile. With physician-staffed advanced cardiac life support systems, 40 to 50% of patients with out-of-hospital cardiac arrest have a return of spontaneous circulation, . . . Don't shoot the messenger! I did not write the above and I do not buy the 40-50% -- HOWEVER .... Termination in the field for no return of pulses should NOT be based on no response to BLS regardless of if it is provided by, EMTs or Drs .... now no return of circulation after an ACLS trial, that has been a good standard for many years.. What IS it with Ontario and ALS? Remember the much touted OPALS study that "proved" that patients fared better with only BLS and ALS reduced survival rates? Right, how many times has THAT been debunked. "Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients." Specificity of 90.2 percent --- four survive that met the BLS termination criteria with only BLS? Wonder what would have happened to the numbers had a round of ACLS been put in the mix early? Don't get me wrong, I have nothing against Ontario, and I have nothing against BLS not initiating resuscitation with the classic signs of obvious death. In unwitnessed arrest, no bystander CPR and greater then 8 minute response time, the studies support a dismal prognosis and invite not initiating a code. But just because they do not have ROSC with CPR only in a nonshockable rhythm is no reason to cancel responding ACLS or, if it is closer, transport to the hospital for an ACLS trial in the absence of an advance directive.

Exactly!

Why is it that when i saw this thread I envisioned Crocodile Dundee on scene hearing a medic ask for shears, seeing a standard set being offered says " Shears!!!! Those aren't shears mate ...THESE are shears!!!"

By the way, in the 80s and I believe up to the early 90s Denver General staged all their units out of the hospital ...hardly a rural system! ( Not that I ever understod the logic to it.)

Well now, THAT was an interesting read ( the whole thread, not any ONE post in particular)!!! Thru it all I never saw anybody answer your question, maybe I am not reading it right....but in case I am reading it right, here are some things to think about.... not knowing which County you speak of I will be general. If the area is VERY rural with the low call volume that comes with that, ALS skill deterioration can be a problem. The more procedures you do, the more diagnostic experience you have, the better you will be, that is what experience is all about.(That is why I find rural trauma centers, often, laughable --- you need to have a volume of experience impossible for most small and even many large hospitals but that is an entirely different thread) So often hospital systems will use medics and EMTs to work in the ER ( plus they are cheaper then nurses) and often throughout the hospital. They might assist with deliveries in the OB unit ( then assist with deliveries in the shipping and receiving department.) They might get to tube in the OR, start IVs in the ER and on the floor... Some hospitals base all their units at the hospital and respond out, though it makes more sense to me to rotate units so that some are out deeper in the county for response time and get rotated in to bone up on clinical skills. ( But remember, slave labor is cheap! So many keep ALL the units at base and working when not working.) As for first responders, don't know the specifics of your County...some first responders ARE EMTs, some are even paramedics, the term MAY just mean they respond before the arrival of the medics.... others , as you note, are trained below the EMT level and, while I wish they would make the investment in time and resources to upgrade in many places that just does not happen for any number of reasons ( most that we would not like.) The ONLY thing I will say about the urban vs rural responder, and it has NOTHING ( well not much anyway) to do with the silliness I have read in this thread is that I also have experienced both worlds and my hat is off to the rural first responder!! You guys ( and gals) do some AMAZING stuff with limited resources ( and sometimes resources that make me jealous, I am AMAZED by some of the monster medic units (Freightliners and beyond!!!) and equipment you guys have, shows how much the community loves you!!) I have to agree with Anatomy Girl ( yes I actually AM sucking up to her, I like the mental picture I have in my mind when I read her posts -- that is MY right as an American chauvinist!) -that in the rurals you have time to do more ... I may have run 22 calls per 24 hour shift average in San Diego, but I hardly ever had time to get a traction splint on while working a major trauma patient and the level of assessments you guys had time to do was pretty nice for me! And I have read enough in other threads not to talk about the times we would do, out of necessity, things that would stroke out some of the medics I have read comments from here ( exceeding scope and all...did I say that??)

Monday morning is a GREAT day to be quarterback on Sunday's games! Was the cardioversion correct? Maybe ... maybe not Was it INCORRECT ....no, not at ALL You did a great job showing that you attempted to control the airway, I especially like that you made a judgement call and determined BVM in THIS case was better then repeated failed attempts at ET that was unlikely to succeed. Have an extra medic? Have reason to believe your next attempt might work? Go for it...in this case you made a decision and I have to think that with the thinking process you demonstrate in your narrative you made a value judgement I would BET was correct for the situation. What I am confidant in is that you did your best in a horrible situation and if this guy WAS an organ donor you may have kept him viable ( CPR and cardioversion plus the injury may have made the heart less viable, much more would have been lost had he remained in decompensating VT. I doubt you could have done more to correct the hypoxia then what you were doing. What I am CERTAIN of is that if I ever needed a medic for me or my family I would want you two!!! You ran the call to the BEST of your ability and STILL question yourselves for how you could have done better!!! I did that on every call I ran, great learning experience .. even if I came up with something I could have, maybe even SHOULD have, done differently I still could sleep well knowing I did my BEST!

So many contradictory thoughts on this in my OWN mind! I agree 100% with Ruffems and others who have posted this line....however, I am working with a family in Indiana now who's 16 year old son experienced SCA while playing a High School basketball game 3 weeks ago. An AED was used, they got pulses and respirations back. He lived in CCU 11 days, last 5 on a vent. The Father called me and said he and his family were so grateful for those 11 days. They felt ( rightly or wrongly, it is not relevant which) that even though he was not conscious he was aware of his family being there with him. HE viewed the AED as resulting in a "save" and wanted to raise money to provide AEDs to the other schools that did not have them in the County. I had a young teen who had rigor in his fingers and was long flatline, we could have, and I normally would have, called the code at the scene, I do NOT believe on giving the family false hopes. But in THIS case in THESE circumstances because of how his Father was responding to his death ( there is a "rest of the story" but now is not the time) I worked the kid, had Dad hold the IV bag to "help" see if we could "get him back" but told him it was a long shot at BEST... I got a 17 page letter from the guy and his wife saying that the Father knew he "had killed" his son, and he could not have lived with that had it been "too late" when we arrived...that he had considered suicide but the fact that he had been able to "help try" to get him back ( by being a human IV pole) made him change his mind.... on the other hand I have seen TOO many times the anguish of parents that had accepted the SIDS death when police or somebody overruled my decision not to resuscitate and transported "for the family" ... they were fine with the fact that it was SIDS and if it happened in the ER nobody could have saved the child, only to be given false hope and have it dashed AGAIN! I don't know that there IS a correct answer for this ... to me "saving" a brain dead former person is the polar opposite of a "save". Short term" saves" go both ways, depending on the circumstances and family needs... everybody wants a neurologically intact walk out of the hospital save BUT.... The bottom line is we can only do our best with what we have to work with. EVERY ONE of them is going to die ( but then so are WE) eventually. In fact, every one we code HAS died, and ,as so many have observed in other threads, you can not get deader then dead... but with a little skill and a LOT of good fortune we can revive some that have died. To what extent is usually TOTALLY out of our control, we just have to use our heads, hands and hearts to the best of our abilities! An interesting aside ... one large city that was touting itself as "safest place in the world to have a heart attack" reportedly was considering ANY change in rhythm to be a save ( VF to Asystole ..hmm) Don't know if that is true or not, never bothered to check, but their save rates were SO much higher then anywhere else and later dropped back to the real world..( but has in recent weeks been reported at 48% survive to discharge!!) One would hope the do not count those discharged to the medical examiner ( I kid the City, they really DO have a great EMS system, please don't be mad at me if you are from there!)