Prehospital Chest Tube Thoracostomy

[fireresque51]

Thank you squint, the melker valve is just a fancy one way valve that we can hook suction to and speed up the inflation process, some of the air sevices locally use it and will evacuate blood our of a pneumo also, its a fairly efficient method but your still only pulling through a 12 ga 4 inch long cath so its not a replacement for the reel thing but it gets the job done until a chest tube can be placed, if i can find a link i will let ya know

[fireresque51]

hey dustdevil

well it is and it isn't. lol

Tennessee has 3 fixing to be 4 levels of licensure: EMT-B, EMT-IV, EMT-P, and starting 1/1/06 CC Paramedic.

They no longer teach the emt-b and start at the iv which is not a true intermediate, and emt-iv can start iv's, give d50 , do d-sticks, give sub-q epi, asa, ntg, and albuterol , it is definately a start but i would love to see the state adopt a true intermediate, also any NREMT who does reciprocity just has to take a 2 week course and a clinical or two and test to get the iv license to function here, we no longer license at a basic level , they only keep the class waiting for the older ones to retire or die out.

[Guest]

Squint, I don't have a problem with anything you have posted. It is obvious that you are seasoned and knowledgeable. It just adds a lot of perspective knowing where you are coming from. And simply listing the province you are from is FAR from revealing any sensitive personal information that might be crucial to your anonymity, unless you are one of maybe three medics in all of the NWT. Thanks for the info.

Dustdevil:

The reason I was a bit elusive was more in good jest, I do enjoy a bit of humour, it is the best medicine... readers digest is my favorite read in the proctologests office.

I was in the middle of composition to another forum, so apologies if I was not strait up from the get go. with my base of operation identified and other quals. it will be quite self evident to those of my countrymen this concerns me not.

I have been known to voice a opinion or two that are a touch controversial at times and occasionally the word infamous would be most suitable, but I do stand behind my words.....sometimes with a very red face I do add!

Thanks for the complement it goes without to much saying that you are well respected, I have viewed your posts prior to wading in, but the nonsense from my fellow countrymen will not be tolerated, by more than myself as of this date, perhaps to be more positive and politically correct a gentle reminder to individuals concerning...... scope of practice.

Also thanks is in order to firerescue51, this sounds like a great option as chest tube insertion is far more a complex than just punching in a trocar then a tube, have witnessed pulmonary contusions resulting in lobectomy, and an unrecognized lac of costal artery, with a very sad outcome, again another child. My preference is inserting a STERILE gloved finger, and do a 360 to assure no liver or diaphragm is going to be a complicating issue. This can be less advantageous for sterility and it does put the risk for the health care provider with blood borne disease's.

I am very pleased to learn and I too hope its true that the standard for TN is set at the EMT I level, here in Alberta upgap training will include Combitubes,"Symptomatic Rx Relief" IV fluid replacement therapy, including Glucagon, assist with NTG, Epi 1:1000, ASA, and the very important Ventolin/Albuterol not to forget ASA, these are all going to be applied standards for EMTs in Alberta hopefully in the next 6 months or so if all goes well. In saying so I do not want to see IV push drugs allowed more in depth education is required for this area in my estimation, but mostly anecdotal but all the same I love to be proven wrong.

Last but far from least, there is no NWT Paramedics, they do not have a registry, or regulatory body per say, they rely on Alberta's standards for the most part, there is a few ex forces (called PAs) but not quite certain of all the nitty gritty.

[Guest]

Opps; I that should read I have wind!

Correction after last epistle, I am full of wind!

Cheers all and a good night!

[fireresque51]

ty squint and i forgot to mention the combi tubes are an emt skill here also, i also forgot to mention we are ems only service, i do fire with my local vol dept.

[Dustdevil]

Last but far from least, there is no NWT Paramedics, they do not have a registry, or regulatory body per say...

Sounds like Heaven to me!

[kevkei]

It has been said previously, "We decide to needle a chest, they will be getting a chest tube whether we were right on our clinical assessment or not." And " As a side note, how about pericardialcentesis too? It's within our scope of practice to do it here."

Hmmm... as far as the National Occupational Competency Profiles Curriculum for Canada's Paramedics that sits in front of me, pericardicentesis is not done in Canada or any one of its Provinces or Territories. It is not approved as a paramedics scope of practice by the Canadian Medical Association or any College of Paramedics, Physicians, Surgeons or the like. Unless Dr. Kavorkian is back in business and is serving as your base hospital physician you do not want to advertise that you have a scope of practice that includes pericardicentesis. One stabb and your in the bighouse defending why you poked a patients heart as a paramedic. And how often does a paramedic come across cardicardial tampanade? And we are supposed to maintain the competency how?

Respectfully from Ontario

Letterman,

Hmmmm, apparently you aren't familiar with the Alberta Occupational Compatency Profile (AOCP) and how we are leaps and bounds ahead of the NOCP document. The following exerpt is taken from page 148 ALBERTA COLEGE of PARAMEDICS CONTINUING COMPETENCY PROFILE

EMERGENCY MEDICAL TECHNOLOGIST-PARAMEDIC (EMT-P) and can be viewed online.

Major Competency Area: I

Patient Management Skills Priority: Two Competency: I-18

I-18 Perform Pericardiocentesis

A Paramedic will:

I-18-1 Demonstrate knowledge of indication for pericardiocentesis:

• Relieve cardiac tamponade;

• Trauma

• Infection

• Neoplastic disease

• Myocardial rupture.

I-18-2 Demonstrate knowledge and ability to perform pericardiocentesis:

• Subxiphoid approach;

• Beck’s triad.

I-18-3 Demonstrate knowledge of contraindications and complications of pericardiocentesis:

• Cardiac dysrhythmias;

• Puncture or laceration of the cardiac chambers;

• Puncture or laceration of the coronary arteries;

• Hemorrhage from myocardial or coronary artery puncture.

Any questions?

[kevkei]

I am very pleased to learn and I too hope its true that the standard for TN is set at the EMT I level, here in Alberta upgap training will include Combitubes,"Symptomatic Rx Relief" IV fluid replacement therapy, including Glucagon, assist with NTG, Epi 1:1000, ASA, and the very important Ventolin/Albuterol not to forget ASA, these are all going to be applied standards for EMTs in Alberta hopefully in the next 6 months or so if all goes well. In saying so I do not want to see IV push drugs allowed more in depth education is required for this area in my estimation, but mostly anecdotal but all the same I love to be proven wrong.

Apparently you haven't read and dn't completely understand the EMT AOCP document and that EMT's won't be limited to administering only ASA, Nitro, Glucagon, Ventolin, or Epi. They have been adjusting the AOCP to allow EMT's to administer medications via almost every route- PO, IM, IV, SQ, SL, Neb, Inhaled, etc. Though true they will be limited to administering these specific medications (to be expanded in the future) on standing orders by their medical director, there is more to the skill set. This allows the EMT to be a true ALS assistant and they can administer what I ask them to in the event I am busy doing something else, eg Epi 1:10,000 IVP, Atropine, etc.

[kevkei]

[hr:f91cb73f83]

Ok Alberta lets try again, anonimity really does not give literary licence to go OVER the edge, I think you mean percutanous or pseudo surgical trach's, a cric is not intended to be surgical I hope, perhaps needle cric....maybe this is the medical term that your stumbling for.

Hmmm, lets see, yes we carry the commercially available Cooks Cric Kit, which is an actual #6 sized trochar that is cuffed. In the absence of having this, it is a scalpel and shortened #6 ETT (sounds like a surgical [initiation of an incision] cricothyrotomy [incision through the skin and cricothyroid membrane] to me)? What does "pseudo surgical tracs" mean? Either is is surgical or it's not. Perhaps you could define the medical term that I am stumbling for.

Again, lets refer to the AOCP document (available to anyone that would like to view it) Alberta College of Paramedics AOCP, pp131, if you will.

Major Competency Area: I

I. Patient Management Skills Priority:

One Competency: I-1

I-1 Perform Airway Management

A Paramedic will: I-1-1 Demonstrate knowledge and ability to perform basic airway management skills: (removed due to length)

I-1-2 Demonstrate knowledge and ability to perform intermediate and advanced airway management skills including, but not limited to:

• Non-visualized airways;

• Nasotracheal intubation

• Visualized airways;

• Endotracheal intubation

• Mallampati Signs – Class I, II, III, IV

• Surgical airway;

• cricothyroidotomy

• percutaneous transtracheal jet insufflation

• Tracheal suctioning;

• Direct laryngoscopy with Magill forceps;

• Sellick’s maneuver.

[hr:f91cb73f83]

Now, in regards to a traumatic arrest from pericardial tamponade, hmmm, Stats are, traumatic arrest in the field is 98% against resus, this blind procedure is the coupe de gras, excuse my french its poor. If you are suggesting that a pericardiocentesis is indicated from a pericarditis from a field evaluation.....frankly your scaring the crap out of me.

Now on to Chest Tubes, now if your not "RIGHT ON" with your clinical assessment, its time to do a ride along with a knowlegable Paramedic, a Tension Pneumo screams at you!!!Further not all pneumos (small) need to be decompressed, unless you have to go flying, treat with O2 they will absorb if one displaces nitrogen with O2. Now on to interpretation of CXRay it is not in CBO for an ACP in Alberta, well YET! But niether is the Critical Care level, why not billy, what are we waiting for a NEW registrar, i digress again silly me.

So without this definitive diagnostic confirmation of said pneumo/hemo to confirmation of effective placement and the evaluation of said pathology.

Now you may not know the true pmhx in alberta here as you really sound like a new grad. but during the jurrasic period Paramedics did in fact place tubes in ALTA....until someone did not recognise that one entered a 14 yr old boys liver, do I have to explain any further. now some constructive advice, use a 10 gauge for decompresion of pneumo, hemo and your crics as well, go big or go home. ps pin cushions/hedgehogs do survive hemos, pt. position is very important.

There is a real reason to push the recognition of CCP and adopt national standards, its time for Alberta to play catch up now, we cannot sit back on our asses and think we are the best, time to get at it, new leadership is the key.

FYI, The Alberta EMT-P has adopted the theory of the national CCP but doesn't include the practical (yet). Alberta does not have ACP's, nor will they ever have. I'd suggest you do a little more research and understand what is happening with the College and how we compare to the NOCP level. It is quite apperent that you don't know what you assume and try to pretend that you do.

As for the comment "Now you may not know the true pmhx in alberta here as you really sound like a new grad" I'm not about comparing the size of our members in public, but my experience can be validated either through the opinions of those that know me here or would you like to contact me directly? Your "professional" responses so far reflect an appearance of your lack of experience so I will let that speak more for me.

[Letterman]

Great come back Alberta! Kudo's to you, you saw my heart transplant and raised with an Alberta Occupational Competencies Profile (AOPC). I still think that your bluffing. The poker hand is not over though. The shame is that the AOCP has little to no relevance in the Province. It's not used in the teaching colleges, the emergency services, by the licensing college, or by the physicians that direct Alberta's medics. It's a working document that is finding its way into the fireplace. Think of it like a wish list letter to Santa that never quite made it to the north pole.

Proof of this is the Alberta Health & Wellness Standards for Regulated Ambulance Equipment and Supplies (also found on the web) that mentions the need to stock booster cables, a bed pan, urinal, portable O2, cold packs and an advanced airway kit for just such an occasion. I missed seeing the arterial line adapter, the central venous catheter, the selection of chest tubes, the pulmonary catheter, and even the pericardiocentesis needle. It's not a wish list, but a Provincial law. The previously noted intensive care items are not on the Calgary, Edmonton, Canmore, Lethbridge stock orders. Their not given to the EMS services from the regional governments or the associated hospitals. Are the medics purchasing the equipment on their own accord? That's just wrong. And if your getting paid less than the Ontario wages of 85K annually to do this stuff your getting robbed.

Take a few moments to re-consider Squints posts. He's probably been doing the job in a multiplicity of capacities when you were just a toot. He has nothing to prove, but just words of experience knowing the health and EMS system in Alberta. He's possibly even pretty well connected at the College as well. I hear the CEO & Registrar position is open, he sounds more than qualified to take that.

Does your employer and directing physician know that your ready and able to perform pericardiocentesis? You could be deemed as being overqualified to work in Alberta EMS.

Any questions?