FL_Medic

We have had a few local news stories regarding "stupid" 911 calls flooding the system. I have some strong opinions about this. First, we don't want to scare people out of calling 911. On the other hand, it seems like when I was younger 911 was only called for emergencies. Of coarse I didn't work for EMS so I don't know if that was fact. When I respond to a call, it is their emergency. I try not to question why they didn't just drive to the hospital. I have seen some systems implement guidelines that allow the medic to better educate the patient on the use of 911. This sounds like a good idea as long as the medic doesn't take this too far. What do you think?

THE ANSWER Sinus Bradycardia with ventricular escape beats. You can see a slowing SA nodal discharge rate util no p-wave is seen. The ventricular complexes are late cycle, not premature like a PVC. The patient should not be treated with antidysrhythmics. O2, Fluid bolus, positioning. If still unresolved treat with Atropine then Pace if unchanged. The wide complexes with p-waves are fusion beats. Fusion beats are common when ectopic site fires while ventricles are already being activated from primary pacemaker. Unfortunately this patient was treated with Amiodarone.

You are right, checking a pulse during compressions is stupid. Don't know why I have been wasting those 5 seconds to feel if a pulse is present during compressions. Give me a break. It's one thing if I was choosing not to give Vasopressin, or choosing to give all my drugs down the tube. Show me the evidence that checking for a pulse during compressions is hurting patients. Just because they don't do research on it doesn't mean that it doesn't work.

I was wanting to hear from those people as well Devil. You know I started this post with the term priority dispatch just meaning what the name implies. I didn't actually mean the company of the same name. I guess at this point it doesn't matter. I am for a triaged dispatch to a point. What the parameters would be, I don't know. I just feel there should be a way to eliminate L & S responses to every call in my system. That is the main selling point so far here at least.

I guess this would just be common since and my OPINION. Why do we check for a pulse in the first place? If the patient is pulseless, and has a pulse with chest compressions I would assume at least the depth of the compressions is adequate depending on the pulse location. Not to say that if a pulse is still absent that chest compressions are inadequate.

We RSI, Etomidate, Succs, Diprivan (Fentanyl is optional). Don't know the reason, we aren't even going to titrate the temp, just 2 liters of cold saline after ROSC.

(Click to view this embedded page in a new window)

Disregard, I should have read to see that this was in the context of a post-arrest hypothermia treatment. You are correct, although our guideline will not include a non-depolarizing paralytic. For some reason, we have had an in-service training and are about to launch this protocol in our system without the use of Vec/Roc. I attended a conference by Brent Myers a couple years ago and can't wait to see what kind of outcomes we get.

what would be the point of the paralytics if you have the ETT already?

I haven't received the answer yet but I am going to post what I responded with. This was my emailed response: I don't think I am right, but why not try? Well, the first thing to ask would be if the patient has a pacemaker. Rhythm: There are at least three different morphologies that appear to be atrial, including a very wide complex, and one that appears to be ventricular. One ventricular morphology appear to have possible p waves with a very short pr-interval. One may even have the p buried in the R wave. Since the P waves vary in morphology as well I'd say this is some sort of atypical wandering atrial pacemaker. It's possible that this is an AV block but it doesn't meet any classic criteria. Side note: I think I even see some U waves in there Treatment: Treat the patient not the monitor. He is hypoperfusing. His rhythm may have PVCs but lidocaine would leave his HR far too slow. O2 would be initial treatment with continued supine/trendelenberg positioning. A 12-lead and family Hx would be good as well. I would feel for a mechanical pulse to see if those wide complexes are perfusing. It's possible that his pulse is slower than his HR and that BP is compensatory due to increased vascular resistance. I think that is probably the case, and if so, the patient should be treated per the symptomatic bradycardia guideline. Atropine, TCP, Dopamine, Epinephrine. The treatment goal here is to get the SA node back to it's position as the lead pacemaker. Hope I'm right, but if not I would treat with diesel fuel.

Good questions. I would have made something up to fit the scenario. The proximity would have been close but not touching, they were dry, no vomit. Dressed in shorts and T-shirts. I'll come up with another one soon.

maybe this will be better.

I check a pulse during chest compressions to make sure they are effective and to rule out volume issues. I check a pulse with every rhythm change unless obvious V-fib or. asystole. I find apical auscultation to be the fastest and easiest. Before I call a death in the field I listen to the heart.

My training captain has provided another one. Please provide your impressions. 87 y/o M c/o weakness & near syncope for the past 18-24 hours. Denies CP or SOB. HR matches monitor. 132/72 supine. Pale & clammy.

The brain injury could be from the hyperthermia and seizures. These patients also become acidotic pretty fast. If the seminar was a long time ago than this condition didn't exist. Well it did, but it wasn't recognized and named as it is now. Your local police officers are usually pretty well versed on this condition now. Since the hog tying was killing people.

Because running lights and sirens is dangerous. Should I be running code to a cut finger? Jellyfish sting? Domestic (where I have to wait for cops anyway)? Because I may have an ambulance closer to the stroke that just got called in that was initially responding to "abnormal lab values" at a local nursing home. There are reasons for priority dispatching, let's not make rash judgements and opinions. I would prefer evidence. Thanks Devil for the references, by the way.

This one is from 1999, I know it's old. Hard to find one done after 2005, studies take a while so maybe they are doing one now. External exponential biphasic versus monophasic shock waveform: efficacy in ventricular fibrillation of longer duration. Yamanouchi Y; Brewer JE; Donohoo AM; Mowrey KA; Wilkoff BL; Tchou PJ Abstract Ventricular fibrillation (VF) duration may be a factor in determining the defibrillation energy for successful defibrillation. Exponential biphasic waveforms have been shown to defibrillate with less energy than do monophasic waveforms when used for external defibrillation. However, it is unknown whether this advantage persists with longer VF duration. We tested the hypothesis that exponential biphasic waveforms have lower defibrillation energy as compared to exponential monophasic waveforms even with longer VF duration up lo 1 minute. In a swine model of external defibrillation (n = 12,35 ± 6 kg), we determined the stored energy at 50% defibrillation success (E50) after both 10 seconds and 1 minute of VF duration. A single exponential monophasic (M) and two exponential biphasic (B1 and B2) waveforms were tested with the following characteristics: M (60 uF. 70% tilt), B1 (60/60 uF, 70% tilt/3 ms pulse width), and B2 (60/20 uF. 70% tilt/3 ms pulse width) where the ratio of the phase 2 leading edge voltage to that of phase 1 was 0.5 for B1 and 1.0 for B2. E50 was measured by a Bayesian technique with a total of ten defibrillation shocks in each waveform and VF duration randomly. The E50 (J) for M, B1, and B2 were 131 ± 41, 57 ± 18,* and 60 ± 26* with 10 seconds of VF duration, respectively, and 114 ± 62, 77 ± 45,* and 72 ± 53* with 1 minute of VF duration, respectively (*P < 0.05 vs M). There was no significant difference in the E50 between 10 seconds and 1 minute of VF durations for each waveform. We conclude that (1) the E50 does not significantly increase with lengthening VF durations up to 1 minute regardless of the shock waveform, and (2) external exponential biphasic shocks are more effective than monophasic waveforms even with longer VF durations.

Lee County EMS protocols. http://internet.lee-ems.com/intranet/EMS/p...publication.pdf

Devil do you have references that support your statements?

Department of Emergency Medicine, UCSF-Fresno, Medical Education Program, Fresno, California. Source: Prehospital Emergency Care (PREHOSPITAL EMERG CARE), 2008 Apr-Jun; 12(2): 152-6 (20 ref) I will post the tables if interested. Obviously I can't post the whole article because of the copyright, but the abstract sums it up pretty well.

BIPHASIC DEFIBRILLATION DOES NOT IMPROVE OUTCOMES COMPARED TO MONOPHASIC DEFIBRILLATION IN OUT-OF-HOSPITAL CARDIAC ARREST Kimberly Freeman, MD, Gregory W. Hendey, MD, Marc Shalit, MD, Geoff Stroh, MD Abstract Study Objective. To compare the outcomes of out-of hospital cardiac arrest (OHCA) victims treated with monophasic truncated exponential (MTE) versus biphasic truncated exponential (BTE) defibrillation in an urban EMS system. Methods. We conducted a retrospective review of electronic prehospital and hospital records for victims of OHCA between August 2000 and July 2004, including two years before and after implementation of biphasic defibrillators by the Fresno County EMS agency. Main outcome measures included: return of spontaneous circulation (ROSC), number of defibrillations required for ROSC, survival to hospital discharge, and discharge to home versus an extended care facility. Results. There were 485 cases of cardiac arrest included. Baseline characteristics between the monophasic and biphasic groups were similar. ROSC was achieved in 77 (30.6%, 95% CI 25.2-36.5%) of 252 patients in the monophasic group, and in 70 (30.0% 95% CI 24.5-36.2%) of 233 in the biphasic group (p = .92). Survival to hospital discharge was 12.3% (95% CI 8.8-17%) for monophasic and 10.3% (95% CI 7.0-14.9%) for biphasic (p = .57). Discharge to home was accomplished in 20 (7.9%, 95% CI 5.1-12.0%) of the monophasic, and in 15 (6.4%, 95% CI 3.9-10.4%) of the biphasic group (p = .60). More defibrillations were required to achieve ROSC (3.5 vs. 2.6, p = .015) in the monophasic group. Conclusions. We found no difference in ROSC or survival to hospital discharge between MTE and BTE defibrillation in the treatment of OHCA, although fewer defibrillations were required to achieve ROSC in those treated with biphasic defibrillation. Not sure if you need a subscription but here is the link to the full article: http://web.ebscohost.com.db07.linccweb.org...40sessionmgr102

My system has been trying to implement a priority dispatching system for some time now. Is anyone currently working for or have you ever worked for a service that uses a similar system? What are the pros and cons? If you had a lot of experience with the system please message me.

Gotta do whatcha gotta do. Hope things get better.

Just think the opposite of SLUDGEM (organophosphate poisoning)

Negative... that pressure would make me have an IV prior to NTG administration. I think I would try and slow the rate down first too. Sometimes an accelerated rate can cause angina. I think that rate is pretty fast for an old lady. Why is it fast, that's the question. Not whether I'd give NTG prior to IV.