zippyRN

there has been some research on this , sadly i don't have the cite to hand, but the genral upshot was in the average class of 10 year olds most won't be able to do effective compressions while the average class of 11 year olds most would be able to do effective compressions. the techniques can be taught to under 5s - i've seen a 2 year old effectively inflate the 'lungs' of a 'baby' mannequin ... but don't expect their efforts to be effective unless the patient is a paed as well...

This contrasts quite a bit with the system we have here. My service has a contract with a local concert venue that holds a number of very large shows over the year which often top 15 and 20 thousand people. We dedicate usually 10 or 15 ambulances to this venue and the crews are always absolutely swamped with drunks who, our supervisors mandate, all get transported to the hospital. It isn't unusual to take out triple digits of patients from this place and fill up the hospital hallways with drunk after drunk after drunk. Unsurprisingly we aren't too popular with the ED nurses those days...

I wonder what the difference is between our environments that promotes such a clear difference in protocol. Is my service more worried about getting sued than yours? Does my service care more about reimbursement than yours? Are our patients simply sicker? (hah)

on this side ofthe pond you would lose that contract in a hertbeat , because the venue would be told change provider or you will not get the event licence and your alcohol licence will not be reviewed

however the national guidance i nthe Uk says that events have to minimise impact on regualr health services ...

the approach taken in the Uk to this kind of event would be to have a Senior Emergency Medicine / Immediate Care doctor on site supported by one or more additional doctors and a team of both Nursing and Paramedic staff in addition to first aiders for the crowd and circulation areas and 'EMTs' ( both ETA and QAT ) and paramedics for the 'pit' and to crew a limited number of ambulances ...

we can run 4 day 80 k attendance festivals with at most a couple of hundred off site transports over the event and fewer if we can get the necessary licences for an on site Plain film X ray facility

advanced practice paramedics will not happen in the USA until the education required to become a paramedic at least approaches that required to become any other flavour of health professional.

billing will also be an issue especially with the active exclusionary policies in place in the USA towards skill development

When you work a college town, this is part of the job.

You can give up on getting the college bigwigs to push education on the issue. Hell, they are pushing to lower the drinking age. What makes you think they care about educating the kids?

It does tie up a lot of your service and a lot of ED beds. But, there is nothing you can do. I worry less about alcohol poisoning and more about aspiration, in these Pt's!

from a right pondian persepctive where the legal age to purchase alcohol is 18 ( and 16 in certain circumstances relating to 'on licences' and serving meals ) and the legal age to consume alscohol in private is 5...

Alcohol consuption is an overt and integral part of university soial life, most of the larger residence complexes have alcohol licences and keep to 'pub hours' alcohol sales are a substantial contribution to the income of the Student's unions

because becasue alcohol consumption is legal and overt there are

1. better controls of consumption becasue if you get drunk in the SU or a residence bar you will be facing univesity discipline - so the bar staff are even more confident in enforcing the rules - and backed to the hilt by SU / uni security and in residences he duty Senior Resident / Warden (senior residents are older and usually higher up the course Under grads or post grads, Wardens are docoral students/ post docs or junior academics - the bnefits for both are boost in stipend and cheap accomodation for the cost ofshifts on duty as the face ofthe univerity )

2. less fear of contacting the emergency services as there isn't the issue of underage drinking , just the usual crime related to of legal age drinking ...

3. most 1st years will have been of legal drinking age for anything up to a year ( more if they have taken a year out) so it;s not a new ilicit freedom when out of the direct control of mummy and daddy ... e.g. my birthday is the 1stof october so i turned18 within a couple of weeks of beginning year 13 at school , so at the start of my first year of university i was a few weeks off 19 ...

4. there are cultural isues at play the leftpondians , particualry USAn is very much based on teaching abstinance ?

here's a question how old were yu when you had youfirst parentally santioned alcoholic drink ? i can't answer that becuase i don't remember - it's always been something that happens ... so id guess 4 or 5 - it would only have been a very small amount either of 'english' cider or watered red wine ...

hypoxic and tachycardic = gets a 12 lead ,

assume nothing seeing more and more MIs due to traditional causes in patients in their 30s and MIs / coronary artery spasm in younger people on the the ol' colomobian marching powder...

Hehe, thought so. Not everybody was supporting leaving people on the board.

Take care,

chbare.

true, but plenty of people suggestign the dogma was 'gold standard' and showing a complete lack of grip on anything other than following Doctor's orders ...

it's not just EMS , other parts of healthcare can be as bad, even with (supposedly) educated people in them ...

a recent discussion elsewhere about people remaining on Long Extrication Boards once they had arrvied i nthe emergency department descended into a flame fest with accusations that that people posting the none USAn dogmatic answer (even though it;s backed up by National clinical guidelines from elsewhere in the world and they have a decent evidence base) were 'dangerous', incompetent , substance abusers or mentally ill ... while thosewho espoused the USAn dogmatic veiw were 'safe' and competenent despite the fact their practice is proven to cause iatrogenic harm

the other point to add with PHTLS is that the course expects you to be familiar with equipment and 'standard' procedures before attending and expects a level of understanding of A+P etc at a health professional level , despite it's relatively wide entry gate

right pondian perspectve

paeds retrieval uses the ambulance crew primarily as drives and to make sure the kit is kept safe etc ...

a lot of the services don't use paramedics becasue it;s less expensive to use middle tier / ETA / QAT crews for this given that you are carrying nurse/ ODP and Registrar / Nurse paractitioner to actually look after the patient

nifedipine and lansoprazole are the rINNs for the drugs in question

movicol is a macrogol stool softener

RTC = road traffic collision

I believe this patient has a occluded foley cath which is causing a sympathetic crisis. he needs his foley unclogged. I don't remember the mechanism but his full bladder is causing a release of norepinephrine. The distended bladder also stimulates the vagus nerve causing bradycardia. I would contact medical control to see about flushing the cath or removing it. Then reassess him.

medical control says good call take him to whichever of the closer EDs you think will be easier becasue of the traffic ... do you want the field physician who is in the town becasue of the carnival to see the patient or are you happy to transport him

they also ask if he has any nifedipine with him ? and (skill level appropraite) to give standard dose of GTN if not

So his had fluids with nill output, c/o headache, brady and unusual spasmodic muscle contractions.

Something funky going on with his electrolyte levels?

Otherwise I'm with EMT322 on the treatment options. May also have some atropine on hand if the brady continues to decline

timmy examine your patient

empty catheter bag does not equal no urine output ...

IV saline lock. Don't need to get too excited at this point.

Possible Aneurysm???

cold

a reaonable physical examination of the patient would indicate a probable cause for his symptoms

Let's consider a brain bleed.

not yet , but a possiblity if mis managed

Any recent falls? How long ago was the accident?

no recent falls, original accident was 4 years ago

no to either , but he feels a little better when he is laid o nthe ambulancetrolley after you have assited him cacross from his chair

why do you want an IV in a normovolaemic, relatively hypertensive patient ? or just access only ...

what do you want to give for pain ? and why

you have a choice of 4 hospitals

community hospital with ED 10 minutes away - east wards through town and the carnival crowds

Levle 2 trauma centre I 20 minutes away - in the next decent sized town to the west

level1 trauma centre 30 minutes away - to the east ( this hospital saw the patient at the time of his original accident but he was transferred for spoinal injuries rehabilitation after the neuro surgeons / ortho surgeons fixed his back and lower limb fractures)

Level 2 trauma centre II 40 minutes to the west - this isthe spinal injuries centre te patient is known to andwherehe was rehabilitated following his original accident

Also, what's his skin turgor?

Urine Output?

Appearance of urine in cath bag?

he's not dehydrated he;'s had a glass of fruit juice and a mug of tea at breakfast and a 500 ml bottle of water and a '12 oz' can of pop since ...

however his urine bag is empty ... ( not leaking , emptied before breakfast - when it was nearly full )

Hmmm...

Any neuro problems?

no new neuro

Pupil reaction/size?

normal size reactive

Motor-sensory issues?

normal for him , few more spasms than usual

I'd say the headache may be caused from the hypertension.

quite possibly

How long has he been on movicol and lansoprazole for? What’s wrong with his stomach?

nearly 4 years

How long has the catheter been in for?

has hada SPC for 3 and a half years, current catheter is a 12 week one and it;s been in 9 weeks

Has he experienced any discharge/redness/swelling/tenderness around the insertion site?

insertion site, clean ,dry and not inflammed

Is he normally hypertensive?

if any thing his BP is normally on the low side

What’s his temp?

not pyrexial

What’s the ECG looking like?

sinus brady

Chief Complaint?

unwell, pounding frontal headache

Vitals (including skin temp/appearance)?

p 50 , bp 155/90 rr 16 , spo2 98%on room air t = 36.7, blood sugar 6.7 mmol

face, upper chest and arms quite flushed , lower limbs normal to pale

SAMPLE/OPQRST?

Allergies - none known

Meds

baclofen 10mg bd , movicol one sachet on, paracetamol 1 g PRN, lansoprazole 15 mg om , something else the patient can't remember as a PRN

PMH t 4 paraplegic folllwing motorcylce RTC - some lower limb fractures at the time - now all fixed reasonably , superpubic cather insertd during rehab

L - had a decent breakfast this morning, cereal, fruit juce, bacon cob, mug of tea, has had a bottle o water and a can of pop this morning while out

E - no particular events while out today - no new non trivial trauma

P - no particualr provoking factors for the pain - itl;s constant

Q - pounding / banging

R frontal headache

S 5/10

T head ache noticable about 30 minutes ago , patient;s partner noticed he looked flushed aobut 5 -10 minutes before call for help

Reason in wheel chair? Able to ambulate at all?

T4 paraplegic following motorcycle RTC 4 years ago , pretty much complete SCI can transfer can't stand without support due to near complete lesion and spasm

Check PMS of lower extrematies; compare to hx/reason in wheel chair and pt's (stated by him or family) normal PMS

no neurological changes from normal for patient

i'm with the doc on this one

this is one for all skill levels to play

you are on duty in a medium sized town, it is a pleasent bank holiday Monday and there is a Carnival / parade in town

you are called to an 'unwell male'

on arrival at scene you find a 30 something year old male who is sat in his own self propelled wheelchair

R alert

A clear self maintained,

B present normal

C present , face appears a little flushed, mildly bradycardic,

D GCS 15 /15 upper limbs normal, lower limbs very weak

<tinned meat product alert>

to the OP i presume you had permission to advertise?

it's a start

is ansi class2 is as shown in the video ???

in europe you need to wear EN471 class 3 on anything other than suburban roads ( or a combination that comes up to class3 - so sleeveless fluoresent and fluoresent and reflective on fire gear can add up ... ) class 2 otherwise , class1 is additional items ( e.g. over trousers) or just for use in evnvironments like wear houses where you have fork trucks and pallet movers ...

the easiest way to achieve class 3 is a sleeved garment ...

biggest problewm with IN morhpine is the volumes

smaller is better - in the ED i worked in before moving to Emergency Assessment unit were were giving meds In mainly diamorphine and aiming for a 02 or 0.4 ml volume - IN morphine sulphate was discussed t it was felt that the standard 10 mg / ml presentation left too great a volume

Use them as trained bystanders. They will not be able to perform any treatments beyond what you have available anyway. If they take too much control of things, wait for the transporting agency to arrive, and watch the fireworks.

sounds pretty much a fair assesment ...

i've stayed onscene and on one notable occasion had an offer to help at a (just )established scene accepted , of course ID and approrpaite PPE helps ...