tniuqs

Kinda forgot about this!

Ditto.

Reflecting on the call, I blamed myself for allowing him to break the CPAP, and my mngr for not having a spare available. I decided that was the reason he needed intubated.

Ah don't be so hard on yourself .. you done good, for a stuble jumper

On further research, it appears I may be wrong. I have not found literature supporting my theory that people suddenly removed from CPAP decompensate immediatly as this pt did. It appears it takes 4-6min for airway dynamics to change.

aka CRASHING ? Likely he was going to anyway, just a matter of time, "Pumped Out" a slang RT term, this is why serial ABG or and art line in ICU is so helpful in dx and knowing when to commit to a ventilator ..

Squint: No PEEP for this fella!

Good thing too .. with a pressure that labile BUT a question for you positive pressure ventilation, did you increase or decrease his mean airway pressure from the set CPAP numbers ? hmmmm .

Oh ya.... within the first 5min of being in the ICU, the tube was changed for an 8.0. How embarrasing

Ah don't beat yourself up pfft no big whoop ... the main reasons for 8.0 are for doing a bronchoscopy, ie Bronchial Alveolar Lavage (BAL) and sounds if you were having to add air to the ETT cuff it sounds like you did have a leak cuffs do that

One quick question - do you think that any of his issues with ventillation and perfusion had anything to do with the smaller ET TUbe?

Good thought but very minimal, maybe more resistance for exhalation and slightly higher PIP on high inspiratory flow rates greater than 60 lpm. The HOB up had far more to do with VQ than 1.0 of an mm tube.

As a passing comment, receiving lots of Paramedic handoffs in ER and ICU ... the vast majority of cuff pressures are WAY TOO HIGH guys and girls .

cheers

.

If you ask me, we need to refocus on hallway wait times, and long term placement.

And what has Raj Sherman been saying for over a year ?

Yes the Conservative Government has failed in delivery of public health care (or was this by intent ?)

AB is the least cost effective health care system in Canada.

But it goes beyond that just a personal example my personal MD has been off work for months ill ... so therefore I have no GP, advice from the office go to ER. This is a systemic problem EMS in hallways is just the offload, moreover just a symptom of the disease.

Perhaps we could look at dispatch again and get the patient transfer end streamlined, and forget these IFT trucks. If you are parked and on shift, you get dispatched to whatever call comes in Period!

Don't know how that works think AHS will listen to you ?

The new Health Care Minister Fred Horns response .... back away from the benzos Fred your a thrilling speaker LOL and best lose some weight or you will be holding down a Ferno/Stryker in a hallway .

So:

Build 2 new sub stations ... for what ? I don't know, if your sitting in ER what good is am empty hall ?

Strike a committee, ok who's going to speak out when the hidden faces and voice over was used in the interviews ?

Remember the signed STFU agreement !

I just cant wait for an election to be announced Period !

To be honest, I am glad Peter got it off his chest, but I do question the validity of this paintbrush effect.

Peter Who ?

I had a Calgary medic spend the weekend with me, and he says he does not know of any Calgary medics who are all knotted up like the Edmonton ones.

Of course not they are working Industrial ......$600 a day ... Duh!

When I questioned him, he thought it has been 2 yrs or more since Calgary has had a "Code red" (no units available) yet this happends almost daily in Edm.

Not the point Cow town vs Deadmonton.

I hate to see this get blown out of proportion because EMS is not where we should be focusing the publics attention. When I was in Edm 3 nights ago, I was there for 2.5hrs with the same 3 Edm ambulance crews waiting for beds. At the time they had just come off a 30min code red. Does that really sound like a Edm EMS problem?

Using the outlying areas for AHS EMS are suffering .. zip for coverage, the coined phrase AHS "improved utilization".

If you ask me, we need to refocus on hallway wait times, and long term placement. Perhaps we could look at dispatch again and get the patient transfer end streamlined, and forget these IFT trucks. If you are parked and on shift, you get dispatched to whatever call comes in Period!

So is that working smoothly ? Bravo for the dirty dozen drawing attention to a bed shortage in EDM ERs Sherman drew attention to this issue a year ago btw I was there in the Legislature, and Fred Horn called him "manic" ???

Looking forward to Fred Horn's release tomorrow twisting his way out of this one part 2 of a global EDM TV investigative reporting.

Hey Bro .. got the scope +++ just now ... and all the gack .. WOW and Nice Patch too ... lol.

Sure wish I had that ETCO2 sampler on a call back in Sept .. sure would have made my life easier.

cheers

After digesting some of the posts:

Lets discuss this NON INVASIVE part first .. any positive pressure ventilation is invasive to a degree, invasive your reversing all pulmonary mechanics and can affect Right Ventricular Output, just think of a dam in the lungs between the right and left side of the heart .. hence one can drop LV output and drop BP like a stone with higher levels of CPAP / PEEP, in fact in ACLS PEA or relative hypovolemic states can directly be attributed to Dynamic Hyper Inflation. Point being monitor BP as you increase CPAP always.. and look to ETCO2 and Sats .

(ps some patients have not read the pulmonary mechanics books )

1- A most excellent slide presentation BUT I would STRONGLY disagree with the European study, CPAP does increase WOB i.e. forced expiration and increased assessory muscle usage .. try one on for yourself in fact.

2- Yes BI LEVEL support does increase mean airway pressure but not WOB it decreases it with upper level support augmenting / supporting the inspiratory flow, but that's entirely the point (oxygenation is dependant on mean airway pressure) Dr. Neal Finer.

3- CPAP and BILEVEL, NIPPV are used in any modern day ER .. asthma, COPD, CHF, TALC LUNG +++ to stray off the tube.

The problem exists that it can be very clinician dependent in success rate and early application as opposed to late decreases "chewing on the ETT" and as a sidebar "cost efficacy" in ICU and decreased mortality morbidity.

OMG I said PEEP "splint's" terminal airways open mechanically in ICU once in front my Respirologist and 4 residents and got a new one ripped .. apparently the real definition: CPAP / PEEP matches intrinsic PEEP, some COPDers / CHFers (of which its a 50/50 deal as most COPD/CHF are the same critters, its not a matter one is a dog and one is a cat.

4- A big fat fail for AHS in choice of devices on 4 counts, a- the Boussniac is not approved for in-hospital use, b- It uses a huge amount of O2 (controversy in high vs low O2 delivery). c- inconsistent Fi02 this dependant on the Minute Volume of the Patient, d- serious lack of education during inception of a completely new therapy.

5-The one that a friend @ AAA allowed me to bench test does not deliver what it claimed to do .. goggle that POS and look at the Israeli studies a mixed bag of justifications ... you just cant replace a Visions CPAP, PB 840 or an LTV with 50 dollar device.

6- Curiously the ACoP did not have "in attendance a representative" at the AHS meeting of regulatory bodies when the topic of transport ventilation and CPAP was discussed ... WTF over ?

7- The Booooosniac it doest work like a jet turbine engine LMFAO its called the venturi effect, ok enough slamming AHS for their bean counter purchasing department follys.

8- Real CPAPok, better yet BI Level Support IMHO which is an available mode(s) on many new transport ventilators, (and education, sorry dust, my bad ?) this should be the choice for any EMS if they actually wanted to improve the system overall, then you get a bigger bang for the buck OR "buy once, cry once"

http://www.ffwdweekly.com/article/news-views/news/health-crisis-hits-albertas-ems-workers-8653/

Transition to perfection ... do you recall anyone predicting this outcome ?

cheers

To fully understand my position please understand this: I transport my patients to a small rural clinic with a few on-call GP's. There is very very little real EBM or even target based medicine go on out here.

Given we are in flu season full force, I have had quite a few of the following patients:

Elderly, Cardiac history, cough for a week or more, febrile, weakness, wheezy/crackly lungs.

Specifically I am talking the critically ill ones here. grey, Sp02 in 70/80's but not hypotensive.

For the most part I diagnose them in pulmonary edema with underlying chest infection.

As of late I have been treating with ventolin, and Nitro and having good results. The problem I am having is as soon as I get to the freaking clinic all treatment stops while the doc's start lasix therapy. There is just not enough time to clear up the edema with Nitro prior to transfer of care.

To be honest I would like to put these people on CPAP, however I have always stayed away from CPAP in suspected pneumonia patients.

Thoughts?

Many .. will have to read all 3 pages so get the gist of this thread, but what device are you using to deliver CPAP ?

Oh ya: try to resist the temptation to derail this thread into a SIRS/SEPSIS thread at least for the first page.

"I see friends shaking hands, sayin', how do you do? What they're really sayin' is "I love you..." "

WORD !

Let us know ... wasn't Phil from NSW ? I miss that twisted MOFO pervert .. I bet he knows Mike or of him.

Got your 6 ... craig ... let us know if we can support in any way, Mikes kids should know what this global EMS community is all about. Medic's beyond all borders, its a brotherhood and sisterhood and those children are welcome in my home any time for a Kanukistanian adventure (pick summer best advice)

cheers mate.

Yup Comrade Morgan and Comrade Clapton a great mix.

Sorry 2c4 im going to use the 2c4 cm anal probe ... just to be certain you know. ROFLMFAO ... I slay me.

Just a "bit of pressure" my ICU RNs would say .

cheers

As a woman who has been in EMS for nearly 20 yrs....heres some advice. STOP apologizing. Period! There has been some excellent advice given already and some important points.

1. You cant run every call. Being tired, falling asleep at the wheel will lead to a disaster that will ruin you and your service.

2. Stand up for yourself. As soon as you let this guy know that you dont HAVE to be there and you arent going to put up with his BS anymore, the quicker it will stop.

3. Being professional, whether its a volly service or paid, is a MUST. The patient and thier family dont usually remember the good you do. But they ALWAYS remember any dissent in the ranks.

I started in a volly service in NC. Then came home to NY and joined the local volly service there. There will always be someone in the company that doesnt like new people and will make thier life miserable if you let them. And you are letting him. Stop it. Now. Give him a little resistance, show him that you arent a scared, tired, little girl that is looking for respect. Earn it by refusing to bow down to him...in other words "grow a set".

From someone who has been there to someone up and coming....I promise you, once you take the advice given in all the above posts...life will get much easier for you. Good luck!

Nothing to add excellent advice from a pro ..

Try this sound bite Dwayne:

Apparently this guy came from the "hood" too and overcame the oppression.

Ok great points but your missing the question posed .. Dwayne do you use hand moisturiser ?

Damn that heathen pirate grog called egg nog <ahem> and somewhat fortified, I would love to retort but this pirate training is making me eyes blurry ..... and 2c4 "the gear head" and "vampire killer" of all time ... link to temporal scanner svp.

cheers

I don't know if 9Orange's intent was to be arrogant but I am pretty sure it was a disparaging remark against the other posters that do use alternative non technological measures to measure temperature.

Ok so just what EMS service can't cough up some means of taking a temp .. like really ?

AND Not to say touching your patient does not afford good bedside observation.

To speak of something as simple as checking skin temperature that is recommended in the AAOS literature,

Ahem did you read the links .. this thread was Dwyane making a teaching point that morphed and back to trusting your equipment, 12 Leads, Pulse Ox, NIBP, ETCO2 or last but not least the BGL thinghy, need I get into determing BP by pulse strength ... meh.

So:

Is the patient dang chilly, slimy or soggy ?

Is the patient going to start to do the funky chicken right quick ?

Point made, but my palmar surface of hand hasn't misled me too much, might I suggest some good handmoisturizer Dwayne ? ( egg nog and rhum does that to me)

as voodoo medicine shows a disdain for providers that use that method. He is almost implying that they run around killing chickens and breaking eggs on people’s heads to heal their illness that are other voodoo practices.

Crap ... frying eggs on a forehead is WRONG ... rats.

It may not have been arrogant but surely indicates certain haughtiness.

Pfft .. perhaps his way of being taken seriously ?

cheers

Your a good man Herbie1

After reflecting on the multitude of posts that flaming has made, I believe he is in need of some help from a forensic analysis's point of view, from his anger to delusions of grandeur and strong yet misplaced concerns that he will never be realistically be able to effect in the slightest.

This has nothing to do with his preferred sexual preference, as I look to other balanced EMS providers (one on this site that is a truly dedicated professional FIRST and highly respected !) It appears he has pent up and misplaced anger on a multitude of issues .. perhaps this is just his way to vent and very jaded sometimes, I can only guess about that, but that's acceptable to myself.

I myself and tongue in cheek have had an opportunity myself to take a few pot shots at the ignorance in his posts (My Bad ? )

It is more than apparent to myself that his goal as an advocate for Gays Rights in EMS that he is defeating himself with own goal(s), as the tenor of the vast majority of posts is very negative, and cant therow rocks if you live in a glass house but without a global open respectful perspective of others he shoots himself in his foot.

Personally I could give a rats ass what my partners sexuality is AS LONG AS THEY ARE DEDICATED to the PROFESSION FIRST.

It is my hope that today he has "someone" to hold and love, this is my true wish for him on this day, i certainly sounds likes he needs as this the very basic of human needs, that being human touch and compassion.

As is AK I am not a practising Christian (or anything else for that matter) but in the spirit of this day, I sincerely hope ONLY for the best for flamingemt, and the hope that all adults can change, no one what their childhood horrors may have been.

I would like to refer him to http://www.tema.ca/ that would not hurt either.

cheers

HERBIE1 ... sorry mate

I don't see arrogance at all but I do see some humour in in his post, 9orange is making a good point .. perhaps we all should be using a real thermometer(s) it is a vital sign.

<cough> There are those that do use antibiotics AND antipyretics IV as well as inducing hypothermia OR treating it in the field.

ps Don't set your sights so LOW ...... Please.

It is essential when treating hypothermia to have a rectal probe up the chute as "cold and waxy" to the touch on a patch to an MD 600 kms away on a sat phone just doest cut the mustard.

cheers

http://www.heraldsun.com.au/news/more-news/paramedic-dies-during-rescue-operation/story-fn7x8me2-1226230346541

http://news.google.ca/news/story?q=australian+search+and+rescue&um=1&ie=UTF-8&ncl=do1XaM-pU0QFCMMeWQNoLmhH6vSzM&hl=en&ei=NlP3TomjK-iRiAL5i42UDQ&sa=X&oi=news_result&ct=more-results&resnum=5&ved=0CEwQqgIwBA

For those that have experience in this area, the line is cut ONLY when the there is threat to the life of the entire crew and the bird, its something all crew chiefs understand and accept as a risk. After reading all the 81 on line posts concerning this event, a rational man is lead to believe that this sacrifice was unavoidable. I feel so deeply sorry for all those involved and it is my hope that they do not blame themselves as all these hoist rescue's come with huge risk.

Closing note:

Craig if you could be so kind as provide a link to a memorial on line page link, I am quite positive that others would be pleased to send our condolences to family and friends .

http://www.rollingst...canada-20110114

Quote from Rolling Stones article :

Ah political correctness at it finest banning music .. this song was banned 2010 by the Canadian Regulator for Telecoms, Radio and Television because one individual complained that it had the word "faggot" buried in the lyrics somewhere. It has been a hit for more that 20 years.

OMG I just realized Clapton is wearing a PINK suit ... gasp !

More gross generalizations without facts . FAIL .

Yep I agree...I have been using my forearm/wrist for years...it is more sensitive. They taught this to me way back on the early 90s....LOL

Could this be another EMS myth ? I say YES it is.

In fact is the hand has far more temperature receptors than any other part of the human body although AK is the confirmed expert in goats (well, so I have been told)

Then it was reinforced when I had kids. Arguably, I can hold my hand against something hot or cold way longer than I could my forearm.

Ok I have to ask what were you holding ?

The palmar surface of the hand also has a higher tolerance to temperature extremes .. AK you worked in the Arctic, you know that the hand with first nations folks can tolerate even colder temps and far far longer, it is a genetic tolerance developed over centuries.

This type of evaluation of temperature is all folly (not that I don't touch my patients as an indicator but moisture level is of key clinical revalance ) when a patient presents beet red and one can fry eggs on a forehead its time to get a bit more invasive.

In a primary delivery of health care education day with a present employer this topic was discussed even more depth the tympanic type thermometers can be up to + or - 4 C .. the only reliable ways of determining core temp is 10 cm probe up the chute and even oral can be affected by ambient temperatures although a less challenging method with the adult evaluation for bacterial vs viral URTI of which I see 3 to 4 patients a day.

Oh the why didn't you get the Fluviral that the clinic was offering for free and then the subsequent lecture and finger waving.

PS I would really like to bitch slap that Jenny McCarthy myself.

I have personally purchased a Infrared Probe (ps not cheap) Have bench tested the oral "mercury" tip of the thermometer (yes that's what the purchaser went to <sheesh> ) My personal evaluation is in comparison to the tip of the mercury immediately after the 3 minutes (oral) and the Infrared focused on peritonsillar area is dang close + or - . 3 C as not a lot of "takers" in the oilpatch are willing to comply with request of rectal temp probe, but your mileage may differ.

My study was a matter of do I transport a rig pig or observe for 24 hours ? This makes a big difference in where I practice.

http://www.cps.ca/english/statements/cp/cp00-01.htm

http://welchallyn.dk/documents/Thermometry/Ear%20Thermometry/Temp_Measure_in_Crit_Ill_Adults_OLC.pdf

http://ajcc.aacnjournals.org/content/9/4/254.abstract

Ok the CPAP device, what type was it ?

Second question .. so what PEEP level and did you put a flow diverter with PEEP on the BVM post intubation ?

I can tell you the patients ICP just by touching his head!

Sweet !

EDIT: I`m working on EF by laying my hand on the thorax - but I still have a 20% failure rate there...

Bummer !

Systemet, it is called experience. And I have not misdiagnosed one that I can think of in 2011, so I am batting closer to 100%, but will only claim 99% for now (in case I remember one later).

Batting 99% on diagnosis of MI ? WOW your good, can I patch to you with my next CP patient ?

I can also tell you the patient's B/P within a few points of margin just by feeling the radial pulse.

What a crock of shit .. seriously ? Man you so need help and put down the crack pipe.

What next speak in tongues and snake worship ?