Jim Squire

Rock_shoes, First, thanks for the response. I appreciate the time people with experience like you take to answer questions from people like me who are in the process of starting out. I have no idea why I find all this so fascinating, but I do. Unfortunately, I'm not sure I understand your point - I'm still just a student without a single ride to my name yet searching for a class that's open during COVID without much success. Can you check my analysis below and tell me if I'm right? The Monro-Kellie Doctrine (which was a new one for me; thanks!) says that if any one of the 3 volumes of brain, blood, or CSF increases then another volume must decrease and ICP will rise. That makes sense intuitively to me, and is why an intracranial bleed 2/2 head trauma would cause an rise in ICP. But why is morphine contraindicated here? I would think morphine would decrease BP, therefore decreasing cranial blood volume proportional to the brain's arterial compliance, therefore decreasing ICP, and therefore improving things. So from that, morphine is good. Cerebral perfusion pressure (yet another thing I hadn't heard of before; thanks!) says the greater the differential between the MAP and ICP, the greater perfusion. Also makes sense intuitively. From that I see that the drop in BP from morphine combined with the increase in ICP if there is a brain bleed or post-traumatic swelling would be bad; it would decrease the pressure gradient and therefore decrease neural cellular respiration. So from that morphine is bad. Combining those two things, the takeaway is that, in practice, the damage that morphine does from decreasing cerebral perfusion is worse than the improvement it does by reducing ICP, so don't use it. Is that right?

Thanks everyone! I appreciate the feedback. It's tough enough to feel comfortable in knowing what to do in a critical emergency, worse to have to juggle conflicting standards of care. But what's really worse is the feeling that it leaves us vulnerable to lawsuits if things go south. I could imagine a lawyer saying, "Mr. EMT, please read here, from the AOSS textbook, the standard in the field, about whether to provide O2 at 95% saturation. And, yet did you provide O2 anyway against this guidance? And let me ask the expert, is it possible unnecessary O2 administration could cause O2 toxicity that could result in death?" Or if the I did the exact opposite thing, the lawyer would say "Mr. EMT, please read here from your own state's scenario on a critical failure point for failure to administer O2 at 95% saturation for a patient with low glucose. And, yet did you withhold O2 anyway against this guidance? And let me ask the expert, is it possible that withholding needed O2 could result in death?" Still, I want to train and get certified. Now, if I can just find an EMT class that's open in my area this summer during COVID lockdown...

Contraindications for morphine use include (among others): head injury, decreased mental status, multiple trauma. Why? I understand why it's respiratory depression effect would make contraindicated for patients with COPD and asthmatic attacks, and why its effect on blood pressure would make it a bad choice for a hypotensive pt. But why would multiple trauma and altered LOC/head injuries make it so? I'd think head injuries would make rise of ICP an issue, one in which morphine would, if anything, help.

Thanks rock_shoes. Makes me feel like I am learning something. Although I’m a bit surprised that local protocols don’t reflect evidence based research (which is just common sense here), especially as a “critical fail” point. Well, as I said, I’m new to this.

Hi all, I've done a long career in teaching/military, and thinking about what to do with my spare time in 18 months once my kids leave the house. I did a ridealong and volunteering in the local EMS unit seems like it could be really rewarding. I don't want to take the EMT course quite yet - I want to spend the remaining time I can with my kids while they're still around - but I've found a great course offered where I teach that I'll take next year once empty nest arrives, and in the meantime I'd like to poke around and see what those with experience say about the career, especially as a volunteer. I'm a bit concerned that as a 50 yo volunteer I'll never gain the patient volume to have the experience that would make me a great provider, but my local unit has some experienced people to help me along the way.

I'm learning to become an EMT, so be easy on me for asking this newbie question, but it points to something about O2 adminstration that I don't understand. Virginia's health department posts a bunch of scenarios for EMT training like this one: http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/M003.pdf In it we find a young adult diabetic patient with a Rx for insulin, able to speak but not feeling well, alert and oriented x3 but "sluggish to respond" and a CC of "not feeling right". He has an O2 sat of 95 and respiratory rate of 14, no mention of cyanosis, vitals normal except for low glucose. Why does the grading criteria call it a critical fail to not provide O2? As a not-yet-certified EMT student with no field experience, I'd think this pt doesn't seem to be in any sort of respiratory distress; he just needs some glucose paste and continued monitoring enroute to the ER (and probably doesn't even need the ride, but I understand we are always supposed to transport everyone unless they sign waivers since there are problems that require more skill/equipment than we have to Dx.) Are we supposed to automatically provide O2 for everyone (except those in hypoxic drive), regardless of O2 sat? Just when I think I'm starting to get a handle on this...