croaker260

Here is our hospital destination protocol. It covers a wide variety of situations. I hope it helps. http://www.adaweb.net/LinkClick.aspx?fileticket=eJD2Vbo%2f46Q%3d&tabid=798 REGARDING Pregnant Patients This note is important too:

Never apologize for taking care of your family. Just dont buy off on the fire-jihad/red is the only color/if you aint fire you aint sh*t mentality, and keep thinking like a medic and you will be fine. Keep in mind that you should probably keep your head down for a good while. I know more than a few excellant medics who almost had their career ruined when they went to fire and began to speak up on a number of clinical issues. Apparently its a novel concept in the fire service when a new paramedic tells a captain who is an EMT to do something on a callthat needs to be done. Even when they are right..they are still wrong. But then again perhaps your department is different.......

uhm..both...easier to interact with kids AND parents. Harder to deal with after the fact. Also harder to deal with the normal parental fears. For me , its the fear of my kids drowning and getting hit/run over by a car in a parking lot or street. I am sure others have their own special phobia's by proxy from this job.

Hmmm, define "the usual"? Distraction, play, music, singing, conversation are all useful. I am not sure that there is anything that will make IV access more comfortable for a small kid. In fact, I usually take a small kid that is compliant and just lets me do anything I want as a very bad sign. For older kids (4 +, kids you can communicate with....) , from experiences with my own kids, I find the unknown and the poorly understood are far more scary that the procedure itself. Letting them know that: 1- I wont do anything without warning them first is VERY VERY Important. 2- Telling them what I am going to do, and telling them the truth about it ("It will hurt a little bit honey, but we need to do it to make you feel better") is also essentential... 3- telling them that the hurt/scary part of the procedure will be over (have an "end" and wont be "forever") is often overlooked. Especially for small kids, the cant see past the next scary step. Telling them it will not last long and be over soon takes away a huge part of the anxiety. Also, at all times, let them know they are loved and that they wont be alone at any time. This also takes a lot of the scary away. For use it seem obvious, but for a young kid...these are legit fears they may never let you know about.

Simple comfort and familiarity for the kid., takes a touch of the stress of the situation off the kid. I should clarify that this does not apply to kids in booster seats, or to critical kids.

We have the pedi mates, but I prefer to use a car seat secured to the cot..though it depends a lot on the condition and cleanliness of the car seat. For immobilization we have pediatric immobilizers, large vacuum splints, and KED's as needed.

WOW, I have absolutely no recollection of even typing that, much less those spelling errors. Yeah, long shift the night before followed by doing crap all days, gives me a little dementia I think

We have ours made at a custom shop here in town. We secure them behind a small gun safe ( www.gunvault.com) until needed, in wich wehave no problem taking them into the scene with us. We keep Versed, Dilaudid, Morphine, Fentanyl, Valium..and soon..ketamine... in the pouch.

Every time I even think about taking that chance....I remember this call from my hometown (no I wasnt involved). Not only did the LT in charge pay with her life, but because her crew looked to her to make the right decision, (wich she clearly did not make) , they almost did to. As did the transport crew that pulled right into the line of fire thinking it was safe because they trusted the first in crew to make a good descision. http://www.hultgren....owan/index.html http://www.emsworld....nt-crime-scenes I am sometimes willing to risk my life...but am I willing to risk my partners lives, or those who come in to bail me out of a stupid situation I should have never been in to begin with? How is that fair to them? Food for thought. Our job is risky enough , without us making it STUPID-RISKY.

it may be an interpretaton of the minimize inturruptions to CPR to less than 10 seconds guideline. The thought may be that it may takeyou longer than 10 seconds to switch leads, etc. No not a rule, but an unussual intepretation of a difenet rule. But that i sjust a guess, coming from an ACLS instructor.

Amen ! Dwayne had another good point, what is the research behind it, and how does it correspond to predict mortality/morbidity, or with other interventions. If it has a verified validity (such as MOI did before cars got on the "safety bandwagon"...damn engineers ) then I think it may indeed be useful in triage. Especially with the growing concern behind prehospital recognition of septic shock and triage of same patients to specialty center..... It also may be a good approach/concept to incorporate into at least the new AEMT , the old EMT-I. Perhaps even tot he EMT level depending on hours. SO, not "shit" at all. Just curious on the research.

Actually you can be sued for literally any reason what so ever. The question is can you be succesfully sued. Unfortunatey, civil court in the US isnt about truth, or justice, or right vs wrong. its simply who tells the best story in many cases. And even being unsuccessfully sued can bankrupt the average american.

Well, you and I may have a different concept here, but I think it should be mandatory for any EMS provider to bve aware and consider the "worst case scenario" as a matter of routine. I am not saying this induce paralysis of action, but its part of critical thinking and decision making. When the space shuttle blows up, its a tragedy. When it blows up due to a reasonably foreseeable event or simple failure to think things through, its criminal. Ironically , it was our own docs who facilitated this protocol, and encourage its use with and with out analgesia. A patient who has not been medicated can be sent in POV, be triaged, admitted, and in and out of the fast track side with an xray and a referal, having received an evaluation, in under an hour. They technically dont have to go to the ER, and can follow up with the clinic. By contrast, A patient who has received narcotics get an IV, a full ALS evaluation, and an ambulance ride that can only take them to an ER (the most expensive place on earth to get medical care) where they require a monitored bed, and typically 4 hours observation time minimum, and the resources that can /should be used for more ill patients. That's assuming nothing goes wrong. On this you and I agree. This is where you and i are miscommunicating. I am not putting them in pain, they are already there. I am saying we have a less invasive, less complex, more cost effective, less resource intensive option than doping the patient, that is QUICKER. It is not an option for all patellar reductions, but many of them. Again, I am all for pain management. Liberal pain management. Every day. And Twice on sunday. But I have seen both approaches work out , and think its mono-optic and dogmatic to not to consider them both. You and I are in agreement on the lack of BLS pain management options. But I think that the BLS levels need more educatio to go along with it. But I think they need more education period. Well I have. I have been fortunate enough not to be lead on them, and have learned from the mistakes. But the biggest lesson is the horrible feeling that you get when you know the patient is worse off because of something you did that you really didnt have to do. I will leave that discussion for another time. Again, I am very for liberal pain relief. And I have medicated patella dislocations previously as well. At my service we literally use more morphine than albuterol and Zofran combined, or any other drug. And I have had several ortho injuries, and also kidney stones. (BTW, kidney stones are worse...) THese experiences have taught me the importance of targeted interventions patient specific interventions, not just shotgun interventions. But 22 years has also given me a perspective of multiple approaches, and sometimes the best approach, isnt the obvious approach. Anyway, perhaps this is one topic you and I can agree to disagree and still respect each other in the morning. Respectfully submitted Steve

A2L: RE: Succs and RSI/MAI : Having about 14 years experience using a variety of induction agents in RSI.MAI, I can tell you the reality can be far worse that what words on paper can portray. Its like anything else in airway management... its easy to do...until it aint. And when it "aint"...its a nasty furball. This statement isnt specific to succs, but to the whole process. You may do RSI a hundred times without problem, or once. You never know. I remain a huge proponent of RSI/MAI, dont get me wrong. But until you have seen it screwed up by well meaning and well educated providers who are doing everything right...and things still go wrong...its just something thats hard to convey over a forum. RE: you comment on narcotic antagonists: OK, this is a pet peeve of mine... a HUGE pet peeve. SO bare with me. But if any of my paramedic students, my interns, or my FTEP newbies...... EVER implied that they werent worried about giving too much of an opioid because they had narcan, they wouldn't be pushing any meds at all until they could adequate relate and articulate all the potential "Oh SHIT" situations from such a calvalier approach to medications. And as strongly as I feel about that, I feel DOUBLY so regarding Romazicon (A benzo antagonist). I know that you didnt mean to come a across as cavalier, but its a hot button of mine. RE: Versed. Its not that I cant manage the respiratory sedation, its that it doesnt meet the risk vs. benifit analysis in my descision process in many of these cases.. As a side note- I would use Valium instead...better anti-spasm properties and all that and less respiratory depression, even though it lasts longer than versed, its simply better for this situation. Assuming you want to actually reduce the injury easily. If you just want to manhandle it back into place but not have the patient remember it, then I guess versed is better. But thats not the point. The point is that you can safely , humanely , and promptly reduce a (recently injured in the prior 15 minutes) patellar dislocation without the risks of medication administration, as well as the complicating after effects. This allows a more cost effective, less resource intensive, and a more targeted treatment specific to the patient. This is a HUGE deal in back country.. because it can mean the difference in a patient limping out on a goat trail, and being carried out with a multi-tiered robe rescue evolution or a short time...both of wich are more risky. Its also a huge deal with any patient in routine EMS operations. Sure you can knock down every patient that has a sprained ankle to splint..and some you probably should. but not all of them. Imagine explaining to the doc why your patient aspirated when they had an atypical response to the benzo, and then due to unanticipated issues you were unable to control the airway, when you gave the benzo for a relatively painful but otherwise minor and non-life threatening injury to begin with. Its the whole risk vs. benefit thing. Sometimes it makes sense to medicate...most of the time in these situations it does not. In otherwords..always pretend Mr. Murphy (as in Murphy's Law) is peaking over your shoulder waiting for you to slip up. Cross paths with Murphy only when you absolutely need to. (and when you do, have some Paramedic Voodoo in your back pocket...)

OK, here is the short version of the infamous snickers bar story: Many Many Years ago, in the late 80's, early 90's, a group of paramedics were rafting north of us here is Idaho. A little background is in order to put this in perceptive: Depending on where you were on the river it was HOURS for BLS to get to you on the river, and longer for ALS to get to you via helicopter. If you were lucky. So...One of these medics is a diabetic, and has a hypoglycemic event due to fun in the sun. These other medics were well educated, and knew the medics history, and could make a reasonable guess to the crisis even without the availability of a glucometer (this was long enough ago there were still using urine strips). So..no medical gear to speak of, no IV's, no oral glucose, and the fellow medic is unresponsive. but...they have a snickers bar. Hmmmmmmmm...... Yep, you guessed it. 1 snickers bar, PR! Apparently it took a bit but it worked quite well. To this day they have never said who drew the short straw to administer the snickers bar.

Please see the related topic on dislocated patella .

Interesting thoughts , and on paper your statement seems legit. I respectfully submit that the reality (and my experience having done a fair amount of these) is different. As you may or may not recall I am a huge fan of pain control for most orthopedic injuries. But I ask you to consider this: Patellar dislocations themselves are EXTREMELY painful. The reduction, by contrast, is only more painful for about 20 seconds of the actual reduction itself, FOLLOWED by RAPIDLY DECREASING PAIN and relief. This results in a very unique situation in EMS pain control. A patient without significant pain, but whom we have giver some relatively potent CNS depressants, and now faces related issues. I have found that in the patients that I have medicated prior to reduction, post reduction (after the pain is resolved) respiratory depression is a concern since they no-longer have the painful stimuli, but still have the narcotics in their system. Not impossible to manage, but clearly avoidable in many (not all) cases. The only way to avoid this paradox is by using conscious sedation techniques with extreemely short acting medications (i.e. propofol or etomidate) , with IMHO do not meet the risk - benefit analysis for field reduction, not to mention availability (well , we do carry etomidate). So, in this situation, based on a case by case evaluation taking into consideration multiple factors (length of time of dislocation prior to EMS contact being a huge one), starting a line and pushing meds is seldom needed. Besides I can typically have the basic assessment done, and the patellar reduced and the patient well on the way to non-pharmacological relief (ICE, support, etc) , well before my partner has the line set up and the IV started, much less having the medications drawn up. Yes there are times in which I have medicated the crap out of a patient for reduction, but with analgesia comes risks. Easily mitigated, easily controlled, and easily screened risks, but risks none the less. We have a duty as paramedics to chose the best treatment for the patient, and anticipate all potential outcomes, and not treat just based on a protocol. In our cases, our protocols give us liberal options, and the ability to decide the best route. So, in reply, I understand your statement, and agree with the sentiment, but disagree with it ALWAYS being needed in this situation. From a risk/benefit analysis, Rapid (uncomplicated) non-medicated reduction trumps delayed medicated reduction with all the potential risks that entails, especially considering the immediate relief that follows. Respectfully submitted Steve

Well, we have a mix of urban, suburban, and rural, with occasional frontier when we respond out of county or forr our Tech Rescue team. Plus huge difference between winter and summer here. The following is "off the cuff" as I dont have our yearly report readily available.... Typically (say 90% of calls) our transport times vary between 5 and 30 minutes. I dont know the average, but I am guessing 15-20 min mark. that can double in the winter. Depends on the unit though. So...not really all that long. But remember, it is mandatory for the patient to go in for evaluation, just not by ambulance.

Just food for thought... :Boss-Holzach-Matter self-reduction method ANyway, A trick a ski patroller actually showed me many many years ago is to use a sling, a pillow, and two slathes. the first swath holds a blanket roll or a pillow in place against the body under the affected shoulder next to the chest wall. The second one actually slings and swaths/stablilizes the arm over the blanket/pillow, but stabilizing/ keeping it in a position away from the body. I dont know if this makes sense, I used to have a picture but I cant find it currently.

If you really want to gove a medicaion via a mucosal route...for what ever reason, then there is one route where you can give large volumes and NOT worry about aspiration.... Seriously though, it can be done. Just ask me about the PR Snickers Bar....

Just to point out, since we in EMS tend to get the patient within 15 minutes of the injury, I would say that 99% of the time IMHO, we never sedate at all, the reduction is quick and minimally painful, it remains a BLS call, and the patient then goes in via POV to the ER for follow up. By the time an ER doc gets to the patient, orders the propofol, and meets what ever institutional requirements for conscious sedation his hospital requires......it is easily 45 plus minutes after the call, and by then you likely need sedation to reduce the injury. Not bashing you at all Doc, just providing a little different perspective.

That sounds like a PATELLAR dislocation, not a true KNEE dislocation, and yes we see them. We have a protocol for Patellar reduction, and depending on the time frame involved, frequently treat and release them. True KNEE dislocations are a different matter, and are limb threatening. TRUST ME, you would know the difference. For my fellow EMS'ers out there.....Here is the link to our protocol for this. http://www.adaweb.net/LinkClick.aspx?fileticket=j1J9gJ5SK7I%3d&tabid=798

Actually, there have been some area's that have indeed seen an increase in ROSC of up to 20% and increase at 30 days as well. Hell, a few years ago KCM1 even broke the 50% mark for VF ROSC. That hasnt been done since the 50's with the original MICU study out of Ireland. The places that dont show improvement either (a) arnt taking CPR/ROSC seriously on a system wide level, or ( have factors they havent overcome yet (like response times in rural settings.) GRANTED, these improvements are MULTI-FACTORIAL, but there is no doubt that the re-emphasis on CPR/CCR is part of the solution. Hypothermia, public awareness, and other factors also play a part.

OK, time to steer this back on track.... Both good points, one additional one to consider: Ventilation may or may not be a priority for the first tenminutes of ARREST, but remember that arrest is not the same as rescusitation efforts. I work in a well developed system with a tiered response, and it remains quite common for the first reponder general term here) to still arrive 4 - 6 minutes after the actual arrest, assuming the calling party witnessed the arrest, had a cell phone in their pocket, and called 911 correctly the first time. If you look REALISTICALLY, We as EMS providers are arriving at the patients side (Different than when we just mark ourselvs "on scene") and starting comprssions in the 6 minute mark of arrest (or later). I would submit to you that EVEN IF you use the 10 minute mark of arrest tme as a guide for when to use advanced airway mnagement, then that is still likely only 4 minutes into your actual patent care/contact time...at best. Respectfully submitted.

I take it that the Clinical Management Group are part of your clinical guideline development committee or something similar? ALso, you didn't answer my question re: CPR