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  1. Kmedic82

    CRASH 3; TBI and TXA

    Let’s talk about TXA and brain injuries. Maybe we can put to rest the suspicion that TXA creates further injury in patient’s with a TBI. TXA is an amazing tool to use for our trauma patients. There has been so much success TXA that there are trials to see how effective it is for GI bleeds. As with most medications new to a service (mine has had standing orders on TXA for about a year), there are always questions and concerns. One that continually comes forward is, “does TXA create further harm in a patient with a brain injury?” Curious and in an effort to self educate, I searched and found an article on my favorite blog, EMcrit. The CRASH studies were used to see the effectiveness of TXA and the trauma patient. The CRASH 3 study was specifically a sub study for the TBI patient. It was ran as a pragmatic study. Meaning, it was a non-controlled atmosphere and based in a real life setting with unpredictable variables. Much like a bad trauma patient. “CRASH-3 was designed to further investigate using tranexamic acid for patients with traumatic brain injury. This study utilized the following inclusion criteria: Enrollment within hours of injury Either Glasgow Coma Scale <13 or intracranial hemorrhage on CT scan No major extracranial bleeding This was a massive, pragmatic, double-blind RCT involving 175 hospitals in 29 countries, with a target enrollment of 10,000 patients. Patients were randomized to receive either saline or tranexamic acid (1 gram loading dose over 10 minutes followed by a second gram infused over the following 8 hours; this is the same regimen used in CRASH-2). The primary endpoint was head injury-related death in the hospital within 28 days of injury.” The utilized saline as the placebo versus TXA. The results showed a reduced mortality rate in patient’s with non-severe TBIs. With an emergency room study such as this, the results were “not statistically significant.” The criteria for a TBI patient is vast. There are too many complications. What proceeded forward was the need to take out the obviously brain dead patients (GCS>9 and fixed pupils). The severe TBI patients would not benefit from TXA just due to the impact of their injury. More severe, the less of a chance of effectiveness. Now, the mildly injured patient’s proved effective. There was a significant increase in the decrease of mortality with in 28 days of the patients who received TXA while suffering from a brain injury. To receive the proper and fair outcome, it was just a matter realizing that some patients were too sick to save. “ Subgroup analysis shows benefit from tranexamic acid among patients with a greater hope of recovery. Specifically, tranexamic acid reduced head injury-related death in the subgroup of patients with GCS>8 and also the subgroup of patients with reactive pupils.” What were the take away and conclusions of the study? “The conclusion of this article sums things up nicely: “tranexamic acid is safe in patients with TBI and treatment within 3 hours of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.” The greatest strength of this study might be an extremely thorough evaluation for possible adverse events among 12,639 patients. Tranexamic acid was found to be safe, without increased rates of any adverse events (including thrombosis, seizure, and stroke). The primary endpoint of this study was technically negative (p-value slightly above 0.05). This likely reflects the inclusion of moribund patients, who diluted out the signal of benefit from tranexamic acid. Numerous subgroup analyses indicate that among patients with a greater hope of recovery, tranexamic acid is beneficial (figure below). As a statistical rebel, I would consider this trial to be positive, despite having a technically negative primary endpoint.” Check out the article at; https://emcrit.org/pulmcrit/crash3/ View the full article
  2. Kmedic82

    AHA BLS quiz app

    My AHA BLS quiz application was just released on Android. Check it out! https://play.google.com/store/apps/details?id=com.wBLSQuiz2019_9477418 View the full article
  3. 2,000 law suits and appeals have been pushed forward against Johnson and Johnson. The state of Oklahoma has started proceeding in regards to damages done to the state. As stated in the New York Times; ” Oklahoma had said it would need $17 billion to repair the damage done by the epidemic. About 6,000 Oklahomans have died from opioid overdoses since 2000, according to officials there.” It is about time some one has step forward and pursued dealers in this rich man drug war! View the full article
  4. There was a time I was burnt out. Well, that’s not exactly true. There was a time that every three months I was burnt to the core. I wanted to quit. I wanted to go to nursing school. Hell, I even put in an application to Fed Ex. Unfortunately, there was one time that my burn out led to injuring a patient. You see, I was burning the candle from all ends. I was going through a terrible separation with a woman who had two kids I cared for and adored. I was a supervisor of a shift that was falling apart. I worked nights, went to school during the day, and had to attend meetings in the mid afternoon (peak night shift sleep hours). I turned into the medic who would blow up about too many gloves being on the truck. Trash cans would fly across the bay floor after a mighty frustrated kick. Mop handles would shatter on the side of the ambulance like I was swinging a samurai sword. My off shift drinking was constant. My anger was out of control and would occasionally come out on a patient. My refusal numbers were rising and the end of the road was coming closer. One morning, my partner and I were called out to a patient complaining of abdominal pain. Before the call even came in, we were in the mood that this patient was going to be a refusal. We were both exhausted from outside life and had no intention of transporting. We were a dangerous crew that had lost all interest in their job. We wanted to be anywhere except on the ambulance. We arrived at the home of the patient and in all honesty, I barely remember the call. I am sure I talked her out of going. I probably made her feel stupid for calling 911. I probably took the anger of my personal life out on her. The only thing I remember was waking up in the afternoon to numerous missed calls from members of our upper leadership. The patient ended up have a ruptured appendix and was rushed to surgery after another crew, an hour after we left the residence, did their job and transported the patient. I was close to being fired. I was close to losing my license. I was having the biggest wake up call in not only my career, but my life. I hurt someone. Yes. She signed the refusal AMA form. But at what cost? And with how much encouragement? I like to share my mistakes for others to learn from. Burn out is dangerous. Burn out hurts patients. In the paper posted on Medium, the greatest cure for burn out is to regain the awe of your job, or life. “If this path to burn out is, as Aldous Huxley wrote, ‘a reducing valve’ of awareness, it’s awe that helps to open us back up. Dacher Keltner, a professior of psychology at the University of California, Berkeley, has shown that awe is tied directly to feeling of expansiveness, transcendence, and connection.” I was working too much OT and my personal life was falling apart. I had to make huge changes in my life, step down from positions, say no to projects, and budget my spending so I could say no to OT shifts. I stepped down as supervisor (surprisingly, I didn’t get demoted) and transferred myself to a county known to be strict. I wanted to remind myself why I not only got into the field, but to also get back to the basics of patient care. I was not taking care of people and most of all, I was not taking care of myself. My love for the job came with helping people. Where did my love for care go? My personal life was spiraling out of control and I was not feeding myself creatively. My tank for the awe was ran dry. “Awe doesn’t just shift the way we think, it changes our biology. According to a 2015 study in the journal Emotion, awe, more than any other positive feeling, is linked to lower loves of a molecule called Interleukin-6, which is associated with stress and inflammation.” The awe for the job came back when I chose to learn again. There is something to learn every shift. You just have to look for it. Even if I haven’t taken the chance to learn about something, I enjoy creating hilarious back stories for patient’s and their family. Everyone has a story. “Perspective allows me to see that ‘my’ world is tiny when compared to the actual world. I feel more open and energetic, and less burnt out.” It’s all about perspective and reminding myself why I got into the job in the first place. It’s the greatest way to help someone and it’s so damn interesting. Check out the article; “The natural cure for burnout is profound and utter awe” by Brad Stulberg on the site Medium. View the full article
  5. My PALS study app went live today for Android. If you are getting ready to take PALS, check it out. https://play.google.com/store/apps/details?id=com.wPALSQuiz2019_9326200 PALS Study Quiz 2019 I am new to developing and plan on making more. I would like some constructive criticism!
  6. My PALS study app just went live for android. If you are preparing to take PALS, please check it out!

    PALS Quiz 2019

  7. Kmedic82

    PALS Study App

    My new PALS study app just went live today! If you are an android and getting ready to take PALS, check it out! https://play.google.com/store/apps/details?id=com.wPALSQuiz2019_9326200 View the full article
  8. Kmedic82

    ElPaso Shooting

    apple.news/APWZMplLkQp28qw0aiF26Vw I couldn’t imagine being first on scene… prays for EVERYONE involved. View the full article
  9. @EMTconcerned, what was the outcome of the situation? Praying that the medic received help. If you'd like, please share my own situation. After an abusive/emotionally childhood, a wrecking ball twenties, a shit load of PTSD from the field, my drinking became a HUGE problem to my family and marriage. Not to mention, the cloud of anger I sat in at work. Long story short, I quit drinking and began therapy. Therapy was amazing but uncovered that there were some terrifying skeletons in my closet. I went into a manic episode and was almost successful at killing myself, twice. Once at home after trashing my house and then a second time after escaping the hospital. Needless to say, I was locked away for almost two month. My employer was amazing. Helped with FMLA paper work. Gifted my family with grocery gift certificates. Etc. They are even wanting me to start a first responder mental health class for our academy. But, if I worked at any other service, I know I would have lost my job and potentially ended my career. Coming form the patient stand point, your medic needs to address what the real problem is. It's hard. It hurts. It's painful as hell. There is a light at the end of the tunnel. These psych issues are something she will have to manage her entire life. It becomes a life style and your loved one need to educate to help your life style and call you out with you begin "spinning." Spinning is my wife's code word for "check yo self." Praying she received help and fought those demons. She was hitting a scary rock bottom. *******IF ANYONE READING THIS NEEDS TO PRIVATELY TALK TO SOME ONE ABOUT THEIR OWN ISSUES, PLEASE EMAIL ME!!! I AM HERE TO HELP FROM THE PATIENT AND PROVIDER STAND POINT. YOU DESERVE HAPPINESS LIKE EVERYONE ELSE.***********
  10. This study will have two versions written about it. This version is my “cut the fat” version I am trying encapsulate in this blog. As well, with my venture in medical free lance writing, I will have a “medical education” category for those who want the juicy morsels of dense medical language. With out further wait… here is sepsis study on a plate. Sepsis is a hot button topic in the world of prehospital medicine. There has been alot of literature put out by hospitals that declare more than 50% of in hospital deaths are due to multiple organ death (MODs), which is the ultimate deathly out come of sepsis. The problem with sepsis and EMS is not only figuring out what we are looking for, but also to relay to the ER what we are seeing. Granted, we are not allowed to fully “diagnose” a patient, but effect EMS education teaches differential diagnosis to create a “field diagnosis.” We want to start drawing the picture of what the patient will need for continuity of care. Depending where you work, ER nurses and docs alike appreciate a field diagnosis. Again, depending where you work. In order to have that continuity of care, the EMS provider has to be ready to give the facts and findings of your field diagnosis. Center stage at hospital night at the Apollo. Your are taking your patient to bay 1. There are 20 people in lead vests and gowns and goggles. You begin to speak loudly (que Eminem walking to the mic) and clearly. Then you are interrupted by questions you don’t know. The whole set falls apart. The crowd begins to boo. The doctors glare. The nurses snicker. The a clown with a long curved cane scoops you up and drags you to the ambulance bay… But never fear! Sepsis study’s for ambulances are here! For a potential Sepsis activation, you need to first understand the steps of infection and it’s relation to the human body. I’m sure many of us have had the case of chest pain that ended up being pneumonia. Productive cough? Elevated temp? Could still be cardiac but through our deferential diagnosis we know we have a higher chance or treating pneumonia instead of angina. Breathing treatment and fluid versus aspirin/nitro. Entrance into the portal of infection evil…There are three steps in the chain of fatal sepsis. First step is Systemic Inflammatory Response. This is the time when majority of people of who feel ill take tylenol and get rest. The body is giving basic signals that it is fighting an infection. Next is Sepsis. This in an untreated infection. The infection is now spreading into the blood stream (septicemia) and fluids begin shunting to organs to protect the body from shutting down. A patient can be altered, have low BP, elevated heart rate, tachypnia and elevated temperature. The blood vessels dilate, in effort to protect the organs, and the patient starts to present with signs of shock. “The situation is usually made worse by the damaging effects of the toxins on tissues combine with the increased cell activity caused by accompanying fever.” The next phase can be the deadly end. Multiple Organ Death (MODs) is when one by one the organs begin dying off. The body begins losing the battle against the infection. EMS’s mission in this equation is early recognition. Criteria for sepsis activation in prehospital is still developing. IStats. Sports medicine lactate testers. Many tools have been dropped off in our jump bags. A study performed in Albequre, New Mexico, hospitals worked along side EMS in order to start prehospital sepsis activation. The study hypothesized that, “in patients that EMS sepsis alert criteria, there is a strong relationship between prehospital ETCO2 readings and the outcome of diagnosed infection. The secondary hypothesis was that ETCO2 also predicted hospital admission, ICU admission and death.” Yup. The same tool used to treat respiratory problems and help declare ROSC can be extremely useful in alerting the hospital if your patient is about to go into septic shock. Alburqure created a field sepsis protocol. Hospital alerts were initiated if there was a suspicion of infection and certain criteria met with; temperature reading >38.3 or <36 c, heart rate greater than age expectation, hypotension, elevated lactate readings, elevated respiratory rate, and hypocapnia. This is NOT the EMS protocol. It is a visual to help understand what creates the criteria.As with any form of shock, a body that is in a sepsis state compensates to save valuable life saving organs. As vessels begin to shunt, you have standard shock symptoms included with infection symptoms. A sample sepsis protocol for preshospital.So what was the result with the study? Out of the 351 patients that met criteria over the course of a year for Field Sepsis, all patient’s MET the criteria! It worked!! EMS was successful in diagnosing sepsis in the field. Plus, they created a form of communication and trust with their local hospital. I know many of us are cardiology gurus. We love what we can fix in the field. Truly, it is amazing what we can do to the human heart for survival. Now infection is the next focus for saving lives. Study quoted: Sepsis alerts in EMS and the results of pre-hospital ETCO2; from American Journal of Emergency Medicine, 2018 Sepsis 3.0 https://www.ems1.com/ems-products/Capnography/articles/82616048-Sepsis-3-0-Implications-for-paramedics-and-prehospital-care/ PulmCrit: The surviving sepsis campaign 1-hour bundle is… back? PulmCrit: The surviving sepsis campaign 1-hour bundle is… back? From the hospital view. https://emcrit.org/pulmcrit/ssc-1-hour/ View the full article
  11. Kmedic82

    Trauma Library

    If you haven’t checked out Life in The Fast Lane, you HAVE to give it shot. This site’s ECG library helped me not only get through medic school, but also helped me learn what I was seeing on strange 12-leads my first year as a medic. I receive their email updates to keep myself informed, but it had been awhile since I’ve visited their site. They now have a library of just about any emergency medical topic you can think of. I was extremely impressed with their trauma library! Please stop by and check them out! Trauma Library View the full article
  12. Hey folks! I am hailing from the Midwest. I have been working fire/ems since 2007. Most of that time has been a paramedic. I have a ton of merit badges and a small retirement fund to show for years of service. After injuries and a ton of PTSD, it's time for me to start branching out from the truck. I am returning to school. While in school, I'll still be working PRN on the bus and am starting to blog, app develop, and attempting to get in the lecture circuit. Anyone else on the entrepreneur venture? My goal is to bring more humor into our traditionally dry education. Thank you for reading this! https://wordpress.com/view/theglorifiedtaxi.wordpress.com
  13. Glad to be of help. I am always covering topics like this on my blog. https://wordpress.com/view/theglorifiedtaxi.wordpress.com Keep up the good spirit!
  14. True story behind the title… I am a huge advocate for prehospital intubation. Though, I do strongly believe in good equipment, drugs, lots of practice (more than just simulators) and fail-safe options (iGel, etc). Every service has a different type of patient population. Every service has access to different equipment/protocols. Each patient has a different airway. Grants have helped many services obtain video laryngoscopes. Granted, less ambulances, the greater chance you will have to cool toys in your airway bag. Much like the cardiac monitor was a luxury in the past, I see these devices becoming first line airway in the future. To adapt and overcome. That’s how we survive in EMS. https://www.ems1.com/ems-products/medical-equipment/airway-management/articles/394417048-NC-county-EMS-adds-video-guided-intubation-tool-to-ambulances/ View the full article
  15. Great question! We all know that the creation of EMS is what's in the name. EMERGENCY. But what constitutes an emergency? Who's emergency is it? Why exactly was I called here? No matter where you work, majority of your transports are going to be for CYA (cover ya asses) purposes. Especially from another medical facility. If a family doc see's a chest pain patient at their clinic, documents it as chest pain, takes basic vitals, and then tells them to drive them self to the ER, that doc is at a HUGE risk for law suit. Even if everyone in a five block radius knows this person is stable, anything that happens to that patient from the clinic to the hospital will come back to that doc. The patient falls in the parking lot, finally has an MI, or even smashed by a meteor, some sleazy lawyer will come after that doc and their family. We transport 70% of our patient population for the possible 5% of terrible or nearly impossible situations that COULD happen. A lot of our job is dictated by legal and political crap. I work for a hospital based system currently (I have worked for just about any type of service) and we are up to our eye balls in this type of stuff. Especially when you reach to leadership level. It begins to haunt your dreams... *clutches pillow* I'm drowning... drowning... drowning is bull shit! To help create some peace of mind, just remember that transport is the game we play. It's how some of us get paid. It's how we all get new equipment and facilities. In order to keep working, the CYA covers YOU and YOUR family. Just keep in mind that everyone deserves a ride no matter how much BS the call is swimming in. Again, if you get that refusal, call a cab, and that patient comes into contact with any harm (no matter how small), it's going to fall back on you. Yes, you got the refusal. Yes, they understood the risks of going against medical advice. But lawyers know how to get around these things. They will pull up refusal frequencies, vital signs, destroy the grammar of your narrative, and will have what was once an agreeable patient with you scream bloody murder in the court room. *side note: jurors have to be able to read at a sixth level. Write all of your narratives at that level. It's a legal document, not a medical document.* It's a dangerous game we play for the little amount of money or volunteering hours we receive. But we keep with it for the small population that we really get to use our skills and help. Now, I am not saying this legal situation is ok. It's crap. But our society is greedy and they expect their emergency services to be faster than burger king, stronger than an athlete, the attitude of a saint, and that the bill to be free. So, keep yourself safe in a legal aspect. If it wasn't documented, it didn't happen. The patient has a legal right to transport. When the day becomes the crappy transport bus, just keep in mind why you got into this in the first place! Even on the BS calls, you can impact someone's life! Hope this dissertation helped! Longer than I expected!
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