croaker260

OK, I see your approach now. Not saying I nessessarily agree with it...just understand your point a little better. Here in the US we have too many cook book medics using the supra-glottic airways just because its eaier and the AHA says its ok, without any realy understanding of why or why not to chose one over the other. I am familier with your studies cited. Again this comes down to HOW you use your advanced airway of choice. At my service we are specifically using very close monitoring of ETCO2, resp rates, and early use of vents (as in on scene) to mitigate the hyperventilaion issue. I am not saying it doesnt still happen, just that it happens a lot less. I still belive that the risk of aspiration mandates the early use of an advanced airway, as long as you dont compromise CCR/CPR. We are also improving our focus on compressions, incuding starting the use of lucas here in a month to keep compressions strong. Though here in America we are still hammering EPi early in arrest. Quick question: when you say 5 cycles...do you mean 2 minutes, or 10 minutes? .

Three comments (respectfully) : 1- As an well respected doc told me: Lack of evidence is NOT evidence against. 2- Your argument Intubation in CPR holding no merit does not consider aspiration as a co-mobid factor. There is clear evidence that patients that develop aspiration pneumonia have a higher mortality than those who dont. A simple cause and effect shows that prevention of aspiration is esential. Therefore, when you consider the increased mortality with aspiration, some form of advanced airway control becomes mandatory. If we both agree that an advance airway should be placed of some type, the only question is WHICH option. ETT or another airway. We are talking about choices here. If we dont agree on this key point, then we may never agree. 3- Your argument against ETT only holds merit if you are not going to place ANY advanced airway. If you are going to place an advanced airway, then my argument comparing them still holds water. Please remember we are talking about the Cardiac arrest patient. Nothing more, nothing less. The discussion re: asthma, post arrest, etc are separate (and good, I will admit) discussions but not what the thread is about. ETT is less a potentially less traumatic, more cost effective, more secure airway that offers options in ventilator management that simple supra-glottic airways do not offer. It is an airway whose faults are not in the intrinsic design of the tube itself, but rather in how we as providers are using it. Remember: All of the adverse effects of the ETT in arrest come NOT from the type of airway, but from multiple attempts, prolonged and difficult placement, unrecognized esophageal placement, and stopping CPR to place ETT. Resolve these issues, the game changes. IF (big "IF"..) we change the way we use the ETT, then the previous evidence will no longer applies, and the previous detractors no longer apply, and then its efficacy over other supra-glottic airways is clear. IF we dont change the way we use ETT, then you are right, supra-glottic airways are a better choice. All of the above assumes three things... 1- We are talking about an arrest patient 2- We don’t stop CPR to place ETT, 3- You are proficient enough to reasonably expect to get it on the first attempt. If these three factors don’t apply, then supraglottic airways may be a better choice.

I cant say this is a good reason NOT to do it, because the same could be said of 80% of our interventions. It does seem to e a call for better training. for example: IF you have a patient in respiratory failure who is an asthmatic, your providers should be able to chose from several interventions based on a risk / benefit clinical analysis, and chose the right one. IF that HAPPENS to be intubation, then they should have been primed with the right education/training to monitor for adverse hemodynamic effects and adverse barometitric sequela (ie. Tension Pneumothorax). THT is a better approach than saying asthmatics should not be intubated (if I understood your statement correctly....) I can see your point, but I cant see why we would RSI and intubate live people with potentially complex pathology.... but not intubate dead floppy people who are as stable as stable gets. It comes back to my original post on intubating dead floppy people in arrest.....I still think that IF you are still STOPPING CPR AT ALL to intubate, you are indeed doing them a diservice. BUT...if we change our "style" and "approach" and intubate during CPR...there is NO reason why intubation is any worse (and some may argue BETER in the long term...) than other supra-glottic airways. Put another way……. The ONLY two advantages supraglotic airways have over ETT is ease of placement and not interrupting CPR. If you don’t interrupt CPR to intubate and are proficient in your ETT skills, then those "benefits" are negated, and since the ETT isolates the airway better…it now becomes superior airway control. If you CANT intubate during CPR for what ever reason...or you are not proficient..then the supra-glottic airway is a better choice. Simple, huh?

Here in Idaho, we currently se Zofran with Benadryl as a back up. In the past we have had Phenergan and iapsine, and one local agency also arries Zofran ODT, wich is awsome. If I had my "druthers" I would carry Inapsine (it works the best), followed by Zofran ODT and IV, followed by Benadryl as a third line. Phenergan wasnt bad really WHEN you diluted it and used it properly...but the strong sedative properties made it a problem in peds and with co-administation of opioids. A benifit of Phnergan is it i also an H1 inhibitor, so it could pull double duty....

I think its important to identify the two major problems with intibation in the arrest setting. Problem # 1: Inturruption of CPR Easily fixed. Intubate during CPR. When we STOP stopping CPR to intubate, this is not longer n issue and becomes simply an acedemic debate. Problem # 2: Missed intubation (regardless of case) This has been discussed EXTENSIVELY before. Without rescusitating that dead necrotic horse, I will simply say that this is also an easily solved problem, but must be solved at all levels. Not just OR on live patients, but realistic airway management scenrions, and realistic airway management training intially. I wuld LOVE to see an AIRWAY MEGA-CODEfor the NREMT using all types of devices in a systematic approach instead of a BS AIRWAY station that looks at unealistic intubation on a table.. I applologize for the short post, But I am between teaching. I am sure I will post more later after the flaming begins.

So...anyone else have any help on the original topic ?

+1 for big shears too!

uhmm, I think this thread has derailed....

Just curious , what text book are you using now? Did you chose this new text over another text, or are the pickings pretty slim out there? This is the book the school wants to use but I am 99% sure it wont work despite the publishers rep swearing its updated for 2012. http://www.elsevier....ion#description I am in a rather odd situation. This endeavor is on behalf of a relatively brand new community college in our area, whose campus is spread out over 6 different sights over at least 2 counties. Ugggh. Apparently they want all the EMS related programs at one location, so we will see what the cross department cooperation will be like. We do have decent facilities though, so that’s a plus. I grew up teaching in Ambulance Bays and under shade trees from time to time, so not having to bring my own screen and projector is a plus J Also, while the college does require separate A&P and similar courses for the medic level classes, I am not sure they will go for that for the AEMT class. I may have a way around that though. Since we will certainly have more applicants than available slots, I may make it know that preference will be given to those who have their A/P already. Sure , that way I am not REQUIRING it…but it will have the same result. For similar reasons any chemistry is going to be taught by me and my co-instructors in house so to speak. Definitely something we can do, just takes up time I would rather spend going over other topics. Such is life though. Fortunately, since we already have a medic program in place, I think we are dialed in there. I guess I should add that I have been teaching EMS for about 13 years myself now at all levels. Its just this new level is new to me, not the cope/breadth of the material itself, and I have fallen into this rather suddenly. I think we are limited to about 200-250 hours simply because of the summer semester block /reality we are stuck with. No offense taken. I would really appreciate getting a copy of the syllabus to look at. I believe that you and I have hung around here in EMTCITY land and IIRC the old EMSvillage “back in the day” (Is that forum even active anymore?) enough for a little cross internet cooperation, but I understand in any case. Thanks again for any help. Also, what is your opinion on this book? http://www.amazon.co...=pd_sim_sbs_b_1 We already use this series for the EMT basic level so it is an easy purchase logistically ..Thoughts welcome.

I am jumping into a teaching a college level summer AEMT course using the new scope of practice, and I have been tasked with schedule development. As this is a brand new thing in my state, I don't have any thing ready to go based on the new AEMT (our old EMT-advanced was really the EMT-I/85). Of course our State EMS doesn't have framework to help us either, saying its up to us to develop it. I am wondering if anyone out there has something I can use as a jumping off point so I dont unnecessarily re-invent the wheel. How many hours, what difficulty you encountered are all important bits of information. I am also interested in what text book you are using, and your opinion of it.

Best on the planet: bigshears.com. Had mine for 8 years and still work awesome. Worth every penny.

Actually, the technology used in the RAD-57 and the off shoot variants (for in hospital use) is fairly reliable and well studied. THe probablem with inaccurate readings, especially false highs, is typically operator error (though cigar smokers can have baseline readings up to 20% ). The problem is that many many people don't read the instructions, and don't watch for the "spoofs" that will throw it off, like high light environments against a bright background during the zero process. We had a HUGE problem with this with the local FDs when this came out. ANother common mistake is failure to zero it for each separate patient. We had this problem at a house fire with multiple patients, many false "high readings" on that one. . THe clinical research I have read shows a variable of 2% each way (above or below, if I recall correctly...its been a while) IIRC, there have been case reports of relatively high CO readings mitigated with high flow O2 in about an hour, with out hyperbaric therapy. Note to all: I am not a chemist nor a physicist, but IIRC, the fluid dynamic of CO is far more viscous than O2 and nitrogen, therefore you can have "bubbles" (probably a poor term to use. ) of CO that does not disperse evenly over a given area. It is true that it is heavier than air, so it will seep where gravity generally takes it, but it will not disperse evenly. This is why it is sometimes hard to "detect" CO with atmospheric monitors that the FD uses. If you dont find the "bubble" you wont get a reading.

Keep in mind there is a difference between underage drinking (Age 18-21) and Minor Consumption (Age < 18) (at least here). Minor in consumption will get your liscense suspended until you turn 18. Obviously this is a big deal to a teenager and is a deterrant (in theory) to many teenagers, but not all obviously. I would have been one of the latter if I was a teenager today instead of many many years ago. By contrast, Under age drinking is just a "citation" I am even not sure if it is a misdomeaner or not. I do not think it involves suspension of your driving privilages by itself. I suspect that this kid may have been a minor (liklely age 15-16) who got caught multiple times or did not do the required community service, or some similar act of teenage boneheaded ness.. and had his liscense suspended until age 18. Fair? No, but life isnt fair. Good Idea? I I think so. better to have a small gut punch as a teenager than a huge one as an adult.

Uhm, maybe. I am curious....is he just about to turn 18? Because if he is an adult and his license is still suspended, I have to call BS on this. Also, I don't know about every state, but here the suspension happens for repeated offenses. This in and of itself raises concerns. The background check may sink you. At my service it is a concern, because of the maturity /character issues, not so much of the driving. NOW.... let your boyfriend put about five years between him and this offense, with some good life choices and resume building to balance out his "youthful indiscretions" and he may have a chance. I know, life is SOOOO unfair when you are held accountable for your choices as an adult.

IF YOU ARE AN AHA instructor: I would check your PAM (Program administration manual) and your CTC (training center) policies before you give out anything. I am 100% sure (as an AHA instructor myself) that there is no temp card, and 99% sure that you have a very specific time frame to get their card to them. We give them out at end of class, so it has never been an issue. Assuming you don't personally know and trust these idgets..... if your "students" were the type to let their CPR card lapse when their job depended on it, I would be cautious giving them ANYTHING other than a card to begin with. Before you know it a photoshop version of that letter may "make the rounds" and you dont want anything to do with that. COntact your TC for options, not here. They are the final say on this. Just my 0.02

I had a very early edition of this http://www.amazon.com/DeGowins-Diagnostic-Examination-Ninth-Edition/dp/0071478981/ref=sr_1_1?s=books&ie=UTF8&qid=1331299472&sr=1-1 My NCOIC gave me at my first duty assignment. I found it very useful. I still have 1981 edition still today, though it has survived my military service, 2 marriages, a career in paramedicine, and an anxious beagle. The duct taped cover is bullet proof. Truthfully, we need a guide written for Paramedics, that isnt "Dumbed down" for paramedics, if you know what I mean.

Before you proceed, I suggest you read this article: http://www.emsnetwork.org/artman2/publish/article_28849.shtml

You mean the more you make the more your Ex wife gets to spend.

Here we are non-union and non-FF. We have decent working conditions, good benefits, good public safety retirement, and an outstanding schedule's (48 hours set schedule a week, no ROTATIONS). Starting pay for a zero experience medic BEFORE any extra OT ( 8 hours is automatic a week) is about 41 k/year. A medic with 10 years prior experiance is right around 50 k a year starting. It goes up from there. SO, not every place sucks. .... In fact, the pacific NW of the USA tends to do pretty good for medics. The wages I saw above in the 7-10/hour range is pretty typical for an EMT, but what do you expect. It is a 3 month -6 month course, and there are amillion "schools" (I use that term loosely) turning out a million new EMTS every chance they get, telling them all there are a ton of jobs out there. Its a tough world, and its tough to get your foot in the door at a good career service. Pay your dues, work some shit services and work hard to build up your resume and your reputation. In other words, work hard for what you want , get your medic if you can, and it will eventually ( several years or more) come to you. But not immediately. Too many high school kids expect to make 50 k by age 21, it aint gonna happen.

Depends on your definition of standbys... We have specific protocols for fire rehab, diabetic hypoglycemia, and follow general documentation and informed consent guidelines for everything else.

I am unaware of phenergan being black boxed, except for the pediatric warning under 6 years of age. Personally, I believe if you are giving an H1 blocker, you should be giving an H2 blocker as well.

Well, it is dose dependent, but if they consume (relatively) high enough quantities.... yes. Add the vomitus the patient will likely produce as well. But this is exceedingly rare, only heard of a few cases over the (20 plus) years. Look up detergent suicide. Far more common (still rare) but very lethal to all involved if you are not prepared.

I would like to clarify: The procedure is simple. the implementation is not. To the OP: READ THE BOOK I RECOMMENDED AND IGNORE THE < deleted the phrase I was going to use> THAT ARE TELLING YOU NOT TO WORRY. Dont let fear/worry paralyze you, but carry a healthy bit of respect for it none-the-less. There is a reason why there is a push to remove ETT from the medic nationally, because there are providers not respecting the skill and everything that goes into it. For a "simple procedure" you would think that first pass 50% success rates would be unheard of, but that is where many EMS services "Live". This is unacceptable. EDUCATE YOURSELF. Period.

While my county has transitioned from agricultural /urban to surburban sprawl/urban in the span of about 12 years....we are still a largely ag and wilderness state. Therefore, we do have real risks of organophosphates in our area. To say that we are "drinking the koolaid" is a bit uneducated...to say the least. We carry duodote on all of our rigs, enough for three administrations for three crew members, plus our mass casualty stocks. Before that we carried similar amounts of the Mark I kits and CANA kits. We also carry the "high dose" Atropine in the kits, 8 mg in 20 cc, for ETT atropine (when we still did that), and organophosphate poisonings) Cutaneous exposure is most common. We have a large migrant farm worker population in our AG industry, and mistakes are often made when the various OP is mixed for spraying. Our neighboring county had 8 in a single incident last year. Ingestion is rare, usually intentional, and VERY hazardous to all responders. The patient will continue to "off gass" the OP during resuscitation, sespire external/GI Decon. I seem to recall a case a number of years ago where the body exposed numerous responders, including the ER staff, tot he point of significant symptoms and closing an ER.

OR time, just like airway management in "the real world" is notj ust about the skill, or the tube, but about a global appreciation of the patients airway and respiratory needs. May I suggest some "recreational" reading to give you both a better understanding and better preparation? http://www.amazon.com/Manual-Emergency-Airway-Management-Walls/dp/0781784948/ref=sr_1_1?ie=UTF8&qid=1329370132&sr=8-1 Its really considered a "go-to" text.