FL_Medic

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Also posted at Paramedicine101 I am bringing these back to the patient care forums. What do you think? Use the "Insert : SPOILER" tool located to the left of your reply. This will black out your answers requiring you to highlight them. Keeps the fun going for those who have yet to answer. Highlight below:

I wish you were right, unfortunately our peers aren't doing a good enough job giving them a reason to let us keep the skill. How many paramedics do you know that will say "I am no good at intubation"? Now how many studies have you seen that show a significant percentage of unrecognized failed intubations, or just failed intubations for that matter. If nobody needs improvement with the skill, and we are missing so many....? The first step to improvement is recognizing that we are the problem.... or a problem amongst many. I think this study is a good one. The argument is that BVM alone is not a secure airway. You are putting air into the belly, even with sellicks. I think I would rather have some air in my belly than none in my lungs tho.

Why do you think it is upright? What could cause this? Pushing the 12-lead button again won't change it's polarity.

Differential: - Leg pain - Muscle spasms - Seizures - Foot spasms - Muscle injury - Nerve irritation - Nummular eczema - Nerve compression - Hypocalcaemia - Electrolyte abnormality - Sciatica - Leg injury The most common cause (in my opinion) would be dehydration. You noted this as a consideration. You asked about her fluid intake, and this was good. I am slightly partial to this diagnosis because I am in South Florida, and everyone is dehydrated. If possible, I would have tried to obtain a HR while the patient was at ease. An elevated HR would also indicate dehydration. What about anxiety? Did the sight of the elevated blood sugar induce hyperventilation? Hyperventilation syndrome may lead to abnormal potassium release, causing cramping and/or numbness in the extremities. I have had patient's with anxiety induced by the sight of their blood sugar. Whatever you think the cause is, I would try and do a follow up. Usually the high priority calls are the easier ones to follow up on at a busy hospital; simply because they are the ones the nurses and docs remember. Welcome to the world of EMS, you seem like the type of EMT we are looking for. I always try to figure out what is going on with the patient by using simple rules of physiology, just don't get tunnel vision. Here is an example from my shift yesterday: Responded to 65 y/o male that was "sleeping too much" for the past 3 weeks. Wife stated that he is suppose to get a sleep study performed. She states that he is a loud snorer, and the patient looked like he could easily have sleep apnea. He was about 300 lbs. Room air O2 sat was initially 98%. The patient fell asleep frequently. All other VS, including BG was normal. We grabbed the big bag-o-meds and packaged the patient. During transport the patient's O2 saturation while awake was 91% and in the 60's when sleeping. This alerted me quite a bit. Lungs were clear. I attached ETCO2. The patient was normocapneic while awake and ETCO2 read 62 mmgh when asleep. Respirations were 22 when awake and 10 while asleep. I had damn near done my own sleep study and diagnosed sleep apnea before I looked at all his meds. Rx: Oxycontin, Oxycodone & Hydrocodone. I still withheld the Narcan, because the patient was still breathing and I was able to oxygenate him. I didn't want a kicking & screaming 300lb man in the back of my ambulance when the ER was less than 5 min. away. The ER doc concurred and administered 1mg of Narcan to an unhappy recipient. I still wouldn't be surprised if the patient has sleep apnea, but he presented with classic S/S of opiate OD. Ps. Just because there are cases of DKA with BG levels around 200 doesn't mean you will ever see it. You are right, DKA is much more common in patient's with BG levels > 400. Then again, they can have a sugar that high and not be in DKA. It is a complicated process, and every body has different levels of cellular metabolism.

Wake EMS was the third prehospital agency to start using induced hypothermia but has certainly been the leading agency to collect evidence. I saw Dr. Myers speak in Orlando in 2007 and was thoroughly impressed. I have written about hypothermia recently in my blog. Here is a link: http://paramedicine101.blogspot.com/2009/0...mia-part-i.html We are currently using our hypothermia protocol for post v-fib/v-tach arrest with ROSC.

Mentally Delayed

no no no, it is FIBROMYALGIA.

Some more recent studies on the topic of C-Spine:

haha, now that's funny.

Correction for ya, it is a lecture about ventilating TRAUMA patients. Excellent video, thanks for the link.

What's to say that you are risking further injury by not immobilizing though. I still haven't found solid research supporting spinal immobilization. I think it is just assumed that we could cause further injury by manipulating the spine. I understand the theory, but saying that you could cause further injury without any research supporting that statement isn't exactly advocating evidence-based medicine. I don't mean to jump on ya like a tree frog, but this is part of the discussion. Ps. you have a fine criteria in the protocol, pretty much exactly the same as NEXUS criteria. Which would be advocating EBM.

The second 12-lead

Strip Tease 12 20 y/o Post-Ictus from seizure

Prehospital Spinal Clearance Part III The evidence is here... You have heard me mention the NEXUS study a few times, and in this post I am going to finally explain exactly what it is and ask if its the solution. NEXUS stands for National Emergency X-Radiography Utilization Study. This study has been used in a few different aspects of emergency medicine, but has definitely shown its worth in the prehospital environment. [1] The following image is of a flowchart that utilizes the NEXUS guidelines to determine whether or not to implicate spinal immobilization. It is almost identical to the one found in my Prehospital Trauma Life Support (PHTLS) book. I know its hard to read, you can use the instructions on the right side of this page for larger viewing. This criteria has come from the results of the study and has shown to be successfully implemented in the protocols of a few EMS agencies nationwide. The criterion is very similar to the NEXUS criteria for x-ray in the emergency department. Even though the criteria was initially intended to rule out the need for an x-ray for spinal clearance, it is being used to rule out the need for spinal immobilization. The following is the intended use of the NEXUS criteria. See how this can easily be converted in to a prehospital guideline? Of coarse you can, I already showed it to you. It only makes sense that the same criteria that physicians use in their assessment to clear a cervical spine be used by EMTs/paramedics. If it can be taught to a doctor, why not us? We have all seen physicians take the cervical collars, that we have applied, off the patients that we bring in. This criteria has been questioned and compared to other studies such as the Canadian method, and I will go over a retrospective comparison of these two methods in my next post on this topic. Click here for the Michigan protocol that I mentioned in my last post on this topic. Even though they implement some of the same assessments as NEXUS, they do not cite them as a reference. Their protocol includes a rule in method. If any of the specified findings are present, they are to immobilize. Click here for the 2002 version of Maine's spinal clearance protocol. They appear to have included all of the NEXUS criteria and then some. They claim to have an increased sensitivity of spinal assessment: Finally, we have found research that was done on a large enough scale to be considered conclusive evidence to support a prehospital cervical spine clearance protocol. In fact, it is currently being used by many prehospital clinicians already. So why isn't it universally accepted? As I stated, in the next post on this topic I will go over the comparison between NEXUS and the Canadian method. Maybe we haven't reached the final answer. [1]Hoffman JR, Wolfson AB, Todd K, Mower WR: Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Annals of Emergency Medicine 2001.

Not that I need to do this, but... CLICK HERE FOR THE ANSWER PS... lets not forget the "Insert: SPOILER" option to hide your answers from those who don't want to read them yet.

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Same link gave C-spine clearance a B level of evidence.

PART 2 From paramedicine blog A closer look at the research... With the start of this topic, I thought I would get by with some easy research and criticisms. As I dove into this subject I soon realized it wasn't going to be that easy. In part one, I explained what struck the question and I began to look further into statements made by Trauma.org. The replies to my first post have given me new ideas and directions. The research is all there for me, and there isn't a need to reinvent the wheel here. There is a need however to ask some good questions and get the unbiased answers. In my next couple of posts on this subject I will try to take a look at the timeline of research and with skepticism I will provide you with the evidence I find. With the evidence out there, I don't see a reason we don't have a universally accepted guideline for clinically clearing the cervical spine in the prehospital environment. Liability is unfortunately the most-likely answer to a question like this one--not science. The 1999 study mentioned in part one listed Michigan and Maine as cohorts that implemented the criteria they studied for the use of spinal immobilization depending on mechanism of injury. After a couple go-arounds with Google, I found the 2005 edition of the Spinal Injury Assessment and Immobilization guideline of the Southeast Michigan Regional Protocol. I was able to find Maine's 2002 protocol, post NEXUS, and found it very interesting. I am going to get into those in a further post to stay chronological. I want to take a look at some literature I found from the AANS & CNS that was done just after the turn of the new century. This was done prior to the NEXUS study (I will get into this study later) so NEXUS didn't make the 101 reference list. That's right, there is really 101 references, consisting of research from 1966 to 2001. Right from the get-go[1]: In the 101 references they listed, they couldn't find enough evidence to support treatment standards or guidelines. Almost 40 years of research, no sufficient evidence--amazing! Give me time and I will go through their references, but for now lets take a further look at what this paper has to say. Options: They have insufficient evidence to support treatment or guidelines, but they promote a treatment that they have guide-lined. I am being critical of the literature so far, but this next statement gives me good reason: Okay, I agree that we should be concerned with causing further harm or injury to our patients. Where do they get their estimate from regarding post-incident spinal cord injuries? They list 6 of there citations after that statement. 3% to 25% is a big margin, and to think that a quarter of all spinal cord injuries could be caused by first responders is scary. It may not be impossible, but I feel this is very unlikely. They then state that multiple cases have been reported where mishandling of the cervical spine lead to injury; they list 4 of there references after that one. In the same paragraph the paper attributes neurological improvement of the spinal cord injured patients over the last 30 years to EMS. This conclusion was made after they state that in the 1970's, 55% of spinal cord injuries presented with complete lesions and in the 1980's, 61% had incomplete lesions. This is pretty interesting as well, and might lead to one of the answers to a seemingly easy question. It would be extremely difficult to show that without the implementation of full spinal immobilization a patient would suffer further injury. It is enlightening to read that there has been noticeable improvement since the implementation of prehospital spinal precautions. In further parts of this discussion I will revisit this question because it is a good one and deserves more than a one paragraph answer. Back to the study in question: They follow this up footnoting four of their citations and a statement regarding a triage-based criteria to determine appropriateness of immobilization. This is exactly what we are looking for. I wish they would have elaborated more in this paper though. Here is an abstract from one of the listed references[2]: I'm not going to lie, the first thing I always read in these abstracts is the conclusion. Read the conclusion to this one. Doesn't that statement contradict a couple points we just mentioned. How this same paper attributes neurological improvement to EMS, and how immobilization is a vital part of the treatment rendered by EMS. Looks like we revisited Rogue Medic's question earlier than expected. Before we do, I want to look at a few more of this paper's references to see what we can find[3]. Interestingly enough, this study contradicts statements made in a study in my first post on this subject. The research in the other study concluded that emergency physicians and EMTs disagreed on the matter of cervical spine immobilization. This is a moot point by now because it doesn't prove or disprove anything. Whether EMTs and physicians agree or not does not reflect the efficacy of a prehospital spinal clearance protocol. This next abstract is promising[4]: I'm sorry if this is turning into a post full of abstracts but this one in-particular is the first one I have read that was conducted before the year 2000 and shows positive results using a prehospital spinal clearance algorithm. This evidence was available prior to the statements made in that Trauma.org article, and could have been cited. I am going to stop criticizing Trauma.org for the rest of this discussion because I think I have proved my point. However, we have gone beyond that and into a greater discussion. So far, what I have... Prior to 2002 there has been much scrutiny in regards to the prehospital clearance of the cervical spine. There has been bold statements made by prestigious organizations to emphasize this point. There has been plenty of research on the topic, and as always, it is very contradictory. The question on why to immobilize patients in the first place has been touched on, but we haven't completely answered it yet. We also have some evidence that EMTs are capable of agreeing with emergency physicians on this subject--go figure. I have about 200 more references to sift through, and hopefully I can create a pretty elaborate timeline to show you where we have been and where we are. I have yet to share the conclusive evidence on this matter, but it is coming! Hopefully this will be developed into a universally accepted guideline, since it is somewhat accepted already by many prehospital agencies. I am also going to share some of the protocols from these agencies and hopefully some post-implemented research. I'm going to take a pause with this literature for now and I will be revisiting it in the near future because some of the other subtopics in this discussion are brought up in this paper. In the next part I am going to take a look at the infamous NEXUS study and PHTLS recommendations. To take part in a current discussion on this post please visit EMTcity.com. I list that forum a lot just because it is the one I actually enjoy posting on. Also, please provide your commentary right here if you have any. I use your comments when authoring these posts. Works cited [1]American Association of Neurological Surgeons and the Congress of Neurological Surgeons. "Pre-hospital cervical spinal immobilization following trauma. Sept 2001 [2]Hauswald M, Ong G, et al: Out-of-hospital spinal immobilization: Its effect on neurologic injury (comments). Academic Emerg Med 5:214-219,1998. [3]Brown LH, Gough JE, et al: Can EMS providers adequately assess trauma patients for cervical spinal injury? Pre-Hospital Emergency Care 2:33-36,1989. [4]Muhr MD, Seabrook DL, et al: Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Pre-Hospital Emergency Care 3:1-6,1999.

Experience is a priceless quality, but not accepting evidence-based medicine because of anecdotal evidence is pure lunacy. I cringe when I hear someone say they don't care what some study says. Fortunately this is a case where they decide to err on the side of caution. That isn't always the case though, and if we refuse to practice EBM our field will refuse to progress. The EMTs and the paramedics are the ones that have to move this field forward, in my opinion, not the docs that aren't on the ambulances. The more we know, the more we prove our competence, the further we will come. 'et al' means and others or along with others. While there is plenty of contradicting evidence, there is plenty of hard evidence out there as well. ps. nearly every treatment modality you have was once supported by a study. You probably wouldn't be doing much more than first aid if it weren't for these studies. So without the studies you would never have had your own anecdotal evidence. Thank you for your opinion, but I will have to strongly disagree with your main argument. Before ventmedic gets in here and does this: CLICK HERE

I haven't yet heard of a 100% EBM system. I think we should all strive for this, but some things never change no matter how little evidence there is to support it. While my system preaches evidence-based medicine, we are just now implementing an adequate QI/QA system. We have just removed Diprivan and finally rewritten our airway protocol, Amiodarone is suggested for WPW patients, we hold off on the Mag until our pregnant patients seize, and we still promote Trendelenburg position. Tom, all we can do is show them the research and hope for the best. Where is the proof that spinal immobilization even works??

I believe the statement about my own systematic approach wasn't meant for praise. I was introducing how I am now questioning my own method. No where in paramedic school or the training of my agency was the afore mentioned literature mentioned or taught. Until now I hadn't seeked the evidence-based result. Basically I am calling myself negligent for not knowing more.

Oh yea, there are plenty out there. In fact, since those two (1999), most of the evidence supports a guideline for clearance. This is still a controversial topic however.

Ok everyone. Check this out. tell me what you think of this. (Click to view this embedded page in a new window)

PS, before you all start quoting the NEXUS study, I will tell you that it will be the main focus point of part II on the blog. Don't hurt yourself looking for the evidence, I've got it for ya.