CivilDefense2002

Thought I might try one of these scenarios. Don't laugh at me too much! :shock: Seems to me to be acute angle closure glaucoma. We can see already that she's got ocular HTN from the buldging iris, plus swelling and tearing. All classic signs. The angle has been blocked or closed, and aqueous humor has and is building up. Not much I could do to treat this. Finish the H/P, V/S, maybe with some O2 via NC. Definitely start a line and draw labs for the ER. Interestingly enough, the eye patch is making the IOP worse by causing pupillary dilation. I'd remove that immediately. The optho people call acute angle closure glaucoma a true emergency, and I've heard them say we should transport emergent. However, since this has been going on for several days already, an extra two minutes delay with a safer, non-emergency transport wouldn't hurt as I see it. We'd be delayed even more if we got in an accident. More info here: http://www.emedicine.com/emerg/topic752.htm CivilDefense2002

Uhh, I wasn't talking about you and your posts. I was talking about the anecdotes I have heard that MTV's were useful in CHF and other pulmonary edema situations as a "poor man's CPAP." I came hear seeking information and research - positive or negative - that showed anything about MTV's utility in pulmonary edema. I couldn't find a thing on it, and nobody I talked to could give me anything more than "I don't know" or anecdotal evidence. It is obvious from the complete lack of research on the subject (I was concerned it was just my PubMed and google-fu that was at fault), that it is unlikely there is any proven benefit. Whether or not there is one would require testing, but the discussion here of the mechanism by which demand valve operates shows me it would be at most a marginal benefit. Nothing like the anecdotes I had heard "promised." Whether or not demand valve is effective for ventilating apneic patients is a whole 'nother discussion. One which has already been decided at my agency due to the overwhelmingly positive research on the subject (found on PubMed and elsewhere by the way), the new AHA guidelines, and the experience of our own local "elders." I wouldn't mind presenting what I've found on the topic, and discussing the pros/cons vs. BVM, but wanted to stay on the subject I started. Thanks again, your links were especially useful. -Nick

Opinions and links to research on the anecdotes I've heard about its use in PE was what I was looking for. From the lack of any research, and the great info posted here, seems like those anecdotes are just that. Thanks for all the help. CivilDefense2002

Yeah, I can see that providing PAP during inspiration wouldn't be anywhere near a replacement for CPAP. Maybe a slight benefit, but the collapse of the airways during expiration would probably make it negligable. Might be something to do a research study upon in the future. I'd be interested to know if it does do anything of utility. I still feel the research shows demand valve is the way to go over BVM. I think it'll also save us a lot of money over the long-term. A BVM costs $25 each generally. Demand valve $400. You only need to use 16 BVMs to equal to the cost of the demand valve. You also have to factor in the oxygen savings due to having continous flow in a BVM, and demand flow with the MTV. On the other hand, the demand valve needs to be serviced at least yearly, and costs for that need to be factored in. But, the big thing for me is that I find them way easier to use than BVM, it's therefore simpler to gain proficiency with (especially important for the new first responders and EMTs in my service), and most importantly the research shows better results with their use than BVM... Seems like the obvious best choice, even if it does end up being slightly more expensive. CivilDefese2002

Really... Hmm. I need to research triggering more then. Interesting that the Eagle doesn't have the better trigger system, just about all the critical care teams I know use it or the LTV1200. Thanks for the reference, looks like its got a lot of background. I will of course be looking into CPAP more. I must admit I am not up to speed on "resistances and retards," but I will make sure I am. 4cmk6: I am looking seriously at UOE, and I like their products. But, they are actually somewhat more expensive. Their single tank demand valve/inhalator/aspirator unit is functionally identical to the LSP kit you describe, but UOE charges $874 and the LSP set is $839 at EMP. The dual-tank system is $1164. Notice also that the UOE kits don't come with acylinder, while the LSP kit does. That's another $100 per tank. I must say that UOE has much better customer service though. I haven't gotten a response from LSP after e-mailing two weeks ago. I'm not sure what I'm going to go with. I might buy the UOE dual-tank case and the unusual dual-tank regulator, and get the aspirator and MTV from O-Two. Not sure. Much research still needs to be done on what the best buy would be. I also need to work out how much benefit would be had from the double tank system. Premie facie it seems like it'd be a benefit for a code that needed both ventilation and the use of the aspirator (it'd be a backup to the Impact 326 we've got), administering O2 to two patients (one on demand valve, one on NRBM, for example), and of course if we go with a CPAP the generator drains a single tank quick... Lot more work ahead of me with the calculations on that one... CivilDefense2002

AZCEP and VentMedic: Thanks for your replies. I completely agree, anecdotal evidence is not evidence at all. A comprehensive literature review on the use of MTV's consistantly shows lower peak airway pressures, lowered gastric distention, and increased tidal volume. The abstract to one of the more interesting recent in vivo studies comparing demand valves and BVM ventilation I have found thus far can be found at http://www.ncbi.nlm.nih.gov/sites/entrez?c...p;dopt=Abstract . There's a bunch of in vitro type studies as well, but that one is the only decent n-value study involving EMS providers and actual patients. Please also note the AHA 2006 ECC Guidelines now says demand valves may be used in non-intubated apneic patients. This is a reversal of the opinion in the 2000 Guidelines to discontinue their use until more research could be done. I am willing to give the MTV devices a chance in light of what the research is saying. I have found some case studies indicating traumatic pneumocephalus, overventilation, pneumos, etc. but these mostly refer to the use of the 160 LPM demand valves available before 1986, with the introduction of the 40 LPM units. This of course is only my analysis of what I've been able to dig up, but my purpose here wasn't to research the use of demand valves in apneic patients. There seems to be plenty of studies on that, just nothing I've found on their utility on spontaneously breathing patients. That's what I'm looking for before we go out and buy "cool toys" with nothing to back up their efficacy. I am not an RT, but I believe I have a decent understanding of CPAP. I did read the other thread, by the way. I hadn't considered that since you'd only be providing flow during inspiration, you'd be allowing atelectasis during expiration. I was thinking this might be a benefit as you wouldn't have to actively "fight" the continuous flow of a CPAP generator, but I can see how providing flow only during inspiration and not expiration would allow collapse of the alveoli. While BiPAP provides lower pressure during expiration, it still keeps some amount of pressure on to keep the airways open. I'm sure this "half CPAP" would probably be beneficial in some amount, but how much so? Has there been any studies on this? Can't find any myself. Lastly, in looking at all the different models, all of them trigger at -5 cm H2O, not -20. Again, not an RT, but I do know the default trigger sensitivity on the UniVent Eagle 754 is -2 cm H2O. They allow it to be set up to -6 cm H2O. With no experience in setting trigger sensitivity, I can only guess that -5 cm H2O would be doable for most alert, spontaneously breathing patients. Am I off base? 4cmk6: I actually have UOE's catalog. Now my staff can carry the same resuscitator case that Gage and DeSoto had on Emergency!. Might just buy the carrying case just for the cool factor. Gotta let the "inner wacker" out eventually. Not so sure about their products though. Haven't really been able to get good specs out of them, nor Allied/LSP. Seems O-Two Technologies is the only company I've been able to find who believes in spec sheets and educational materials. :? CivilDefense2002

My agency is currently looking at the options for ventilation and O2 delivery. It was decided the MTV/FROPVD/Demand Valve resuscitator was the way to go instead of BVM. This being in light of the new AHA guidelines recommending two-handed mask seal, and the studies showing demand valve to cause less gastric distention. I have heard about the utility of demand valve resuscitators in pulmonary edema. I've been told that it was the "prehospital CPAP" before the commercial units came available. Plenty of anecdotes from the "old school" medics I've talked with. I'm looking for any research on the efficacy of the demand valve for spontaneously breathing patient with APE. It'd be especially useful to find something comparing it to commercially available CPAP units. Only demand valve research I've been able to find is for ventilating apneic patients. Seems to me that the demand valve would provide a fair amount of inspiratory PAP during inhalation with the 160 LPM demand flow, and none on expiration. Considering the extra work of breathing needed to overcome CPAP flow during expiration, this lack of flow/pressure during expiration with the demand valve might even be a plus. Kinda a bit like BiPAP I imagine. Maybe it would be better to just use the demand valve and not bother with also keeping a CPAP generator too. Thoughts? CivilDefense2002

Asysin2leads: I am not passing judgment on anyone's knowledge. My apologies if you thought so. I am glad to hear you have good training. I have been doing my research, thank you. RADEF is most of what I am doing at the moment. At the Federal/State level there is the TEPP program from DOE, the "radiological series" (now just one class) from FEMA, courses from USDOJ-ODP, and of course local training. I know what's available around here locally, but I was curious as to what others have. You could say just another part of my research. In any event, glad to hear you believe you are ready. Thanks for the clarification. CivilDefense2002

Medic2588: I am quite sure that they can detect radiation. I am not even doubting their ability to detect very small amounts. The problem is that the vast majority of "rad pagers" being sold and used by EMS, fire, and police are TOO sensitive. You'd think that wouldn't be a problem, but I'd say it is. What happens when emergency services has to operate in a situation where they cannot just run away from the situation. Dr. Allen Brodsky, the former head of the Health Physics Society's Homeland Security committee, wrote an awesome article on the problem of emergency response guidelines that reflect overzealous regulatory standards rather than reality. Check out his article at http://www.radpro.com/RPMfront-22-4.pdf under letters to the editor. CivilDefense2002

Medic2588: You are correct, the preparedness under the civil defense initiative during the Cold War would have ensured fairly decent preparedness for emergency responders in the event of a radiological incident of any kind. Most emergency personnel who worked in the 1970s seem to vaguely recall an 16-hour class where they played with yellow boxes. Problem was, that in 1996 the "peace dividend" supposedly applied to the civilian world as well. FEMA cut funding to all civil defense programs, including RADEF. The vast majority of states ended their programs that year, and shipped their instruments to be sold at massive FEMA auctions. The remainder of states pretty much followed soon after. KS just ended theirs year before last. Besides MA, IA, FL, and OH, I know of no states which continued their programs, let alone expanded it like it needed to be. Granted, it was nowhere near where it needed to be, but it was a far better situation than there is today. You are right. With a decent amount of training, some routine practice and occasional refresher classes, there is no reason any cop, fireman, or medic can't be fully ready for the threat of radiation emergencies. Equipment is a modest investment as compared to many other expenditures, and sometimes grants are available. With a little TLC and annual calibration, they'll work when you need 'em to. Trouble is that getting this very modest effort is like pulling teeth, often times... Richard B, the EMT: That sounds all good and well in some type of vacuum where nothing else is going on. What if it alarms while you are walking up to an obvious severely injured pt at an MVA? What about approaching the thyroid cancer pt who just had radioiodine thyroid ablation? Do we run away and leave them to their deaths until the "mop and glow men" show up in a few hours? What I want to know is how "the powers that be" who buy these things think that somehow they do anything more than cause more confusion and problems than they even begin to solve. Why haven't they trained you - in a real class - at what dose and dose rate you will have to worry about breaking intentionally deflated regulatory limits, worry about increased risk of cancer 30 years down the road, or worry about acute radiation injury that can kill your fast-replicating cells and cause anemia and leukopenia in the short term? What's safe to go through to save property? To save lives? To save a school bus full of tiny schoolchildren and nuns? 8) Quick question, what brand and model "page" did they get you. Some "know-it-alls" have been trying to convince everybody out there that a $1600 pager-type device that reads only up to 3.8 mR/hr and has an esoteric 0-10 numerical display that relates to nothing is somehow one of the best choices. Supposedly they think it's better than the $400 Canberra UltraRadiac - which not only registers very low levels, but also up to 500 R/hr for serious emergency response in a radiological incident. Apparently the second or two more it takes for the UltraRadiac to alarm at the 2 mR/hr control line the regulatory pencil-pushers want as a turn-back is worth three times the cost and nowhere near the functionality... Sigh... On a related note, just like Medic2588 offered, feel free to pm me and I'll see what I can do to help in regards to RADEF preparedness. My specialty is instrumentation really, outside of that I can only point you in the right direction to someone who can. Not to pimp my own state too much, but we've got an innovative program here whereby we have a custom made circuit board and other components to completely rebuild the old 1962 vintage CD V-700 low-range instruments into an instrument rivaling - or better than - any other low-range "Geiger counter" type instrument you can buy today. There is a little assembly required, but just about any monkey with a soldering gun, drill press, and spray paint can do it - myself included. Best part is total cost ends up to be half-price of buying new "new" stuff. CivilDefense2002

medic2588: I apologize if you feel my questions are of a sensitive nature. It is not my intent to reveal any classified information, of course. However, I have yet to encounter much in the way of classified or sensitive material in the emergency preparedness or civil defense field. The standard operating procedures, forms, and other documents for the DOE's Federal Radiological Monitoring Assistance Center (FRMAC) - arguably one of the more sensitive RADEF institutions - are available online. Richard B, the EMT: I noticed one thread on people carrying radiation pagers where the FDNY pagers came up. I'm wondering what kind of training came with the issuing of the instruments. A lot of agencies seem to buy new toys and never teach their guys how to use it. Many only know that it's "bad" if it alarms, but I haven't met anyone who can tell me what type of dose or dose rate they can remain in for lifesaving, etc. A lot of guys will say they will never go near an incident scene for any reason, even lifesaving, due to perceived risks. On the other hand, you've got the case where a state police agency encountered a wrecked radiopharmaceutical van and decided to monkey around it until hazmat came. If there is interest, I can provide some sources for some really good training materials - in my opinion. For example, FEMA came out a few months ago with a neat video aimed especially at EMS, discussing the principles of contamination control in the ambulance. For example, they suggest treating the pt. completely out of jump bags, as they can be thrown away if necessary, unlike rummaging through (and possibly contaminating) the compartments. CivilDefense2002

Did a search and it doesn't seem this has been discussed before - if it has, my apologies for weak search-fu. I'm just curious how radiological preparedness is handled in other areas. Being both a paramedic and interning with the state civil defense cal lab has given me a unique perspective. I can tell you the state of FL is one of the most prepared states in the country, but there's still a lot of problems. The civil defense instrument program in the Div. of Emergency Management was almost killed in 1996 when FEMA cut funding, but the Dept. of Health picked it up. Unfortunately, the only funding source is the nuclear utilities, so all of the counties not in the EPZ for a power plant are mostly out of luck. Add onto this the fact almost all agencies - police, fire, or EMS - are very apathetic about the possibility. Police and EMS will generally say it's fire's job, yet PD is generally on scene first (blue canaries, I'm told), and EMS has to transport contaminated patients. The fire guys then say it's the hazmat team's job. Bottom line is nobody's going to know what to do when they pull up to the burning semi-truck with a trifoil on the side. Let alone be ready to handle contamination monitoring on thousands of evacuees from a power plant accident. Don't even go there with the WMD issue... Training is available from the state, but few seem to take advantage of it. Most fire departments seem to be barely interested in awareness-level stuff for their guys, let alone getting anybody who's going to use instruments through the bare-bones 16-hour G-346 "Fundamentals Course for Radiological Monitoring" class. Those that are lucky enough to have instruments seem to have this idea that it's just "turn them on and they work, right?" Somehow they're then expecting that everyone will somehow magically know to use to the gear when they time comes. It's like saying somebody's qualified to use a LP12 on some kind of inherant knowledge. :roll: G-346, now the highest level anyone off a hazmat team gets, was originally the first step in a series of three classes up to the level of Radiological Officer, FEMA killed the upper level classes due to the fact they couldn't get anyone into the first level in the first place. Instruments are also a mess. Instrument kits keep coming back that were due for calibration years ago. I checked in with the county OEM I help out last week, and they didn't have a single calibrated CD V-777-1 kit in its inventory of 30 kits. :shock: I was able to get the kits in their EOC exchanged, but all the kits that were deployed with the fire dept's were due for calibration a full year ago. Often kits seem to have been left outside in the rain, smell like they've been soaked in diesel, or had their contents looted. Worst thing is all the instruments where people left the batteries in and filled the case with acid... Some counties and departments are buying their own stuff, but that's few and far between. Most have generally purchased well, but I've heard horror stories from other states... How is it in your area? 1. Do you have instruments? If so, are they on a calibration schedule? 2. Is your state still active with a Radiological Instrument Maintenence and Calibration facility? 3. Does your state make training available? If so, does anyone go? 4. Does police and EMS involve itself in radiological preparedness, or is it only fire? 5. Are there procedures for handling radiological emergencies and contaminated patients? Has it been agreed where contaminated patients will be transported to? CivilDefense2002

Hey, let me continue to delude myself that I'll be young forever. I'm trying to pare down the numbers of crap. I realized long ago I cannot prepare for the plane crash that also somehow involves a schoolbus full of children and nuns. Or maybe I'll just overfill it intentionally for the exercise. I can tell you I'm stunned by the size of the external pockets on the ALS Ultra as compared to the old ALS. They HUGE!! I could probably fit 20 multi-traumas in just those two pockets for heaven's sake! In all seriousness, the problem is the standbys, the vast majority of the work at the moment, until the ambulance we got donated arrives and all of the paperwork goes through. Anyway, you've got 300 people all clamoring for those lovely little ACE bandages. Realized quick I'll need to carry a few spares of dressings and crap so at the end of the day I still have enough for my own use in a call. As to the O2 cylinder, I hope aluminum's what they keep in the county pool... You hit the nail on the head. The large amount of treat and release I've encountered worries me. Most of the pt's so far have been "hey, do you have an ACE bandage?" A few fx's and some other "fun" stuff, but otherwise... Portable suction unit will be carried (by someone else hopefully!), but is too big to be put in the bag. I'm considering putting a V-vac or something in the pack, but I know that they don't "suck" like you'd hope... Unfortunately, I believe these are out of scope for BLS providers in this state. Going to have to check with the MD to make sure. I tell you, it's a real wet blanket to have your medic patch and not be able to practice at it. Sigh. Something I'm hoping is able to be changed. There are several options I have heard of to solve the problem, but I doubt there'll be a change. Oh well, at least there's pt. contact, way more experience than I'd be getting otherwise. Yup, AED is available, also carried separate. They aren't buying us a new one unfortunately. We're getting a "hand-me-down" from the transporting agency, a First-Medic 510 I believe. :shock: Seen one before, big huge unit as I recall. I miss my LP12 already.... As I see it now, the EMT with me will end up carrying the suction and AED, and me the Thomas with everything else. Thanks! irlemt: Thanks for the link! -Nick

Same as I do. I do not wear EMS shirts all the time, carry a jump bag in my car, tell everyone I'm a medic, have a sticker on the car, or anything else. I am proud of being a medic, but I have no desire to push it in everyone's face, as I assume you believe as well. My only lean towards the "wankerism" is that I ocassionally wear the funny Zoll t-shirt I picked up as a freebie from the rep. No, that would be illegal, even at the BLS level. In my meet and greet I discussed my affiliations. Here I only asked for people's experiences with stocking these things so I could get some ideas. That was all. I am certainly affiliated, and am happy besides the crappy budget that only covers disposable supplies at the moment, requiring me to buy my own bag. But then again, another branch of the University is paying for the pack anyway. The EMS agency that I am affiliated with for this situation is BLS only, and my pack will originally be stocked for this potential. However, the medical director knows of my medic status, and there is now a possibility I will be authorized to perform at the ALS level. Notice though, it hasn't happened yet, and may not for some time - or may not at all. Hence the fact the ALS compartments will be empty. Maybe I'll find something else to place in there, but probably not. No need to overload. I thank you for your interest. I am always willing to consider advice. It may amuse you to know that my ultimate goal was to become a paramedic. I never even thought of being a physician. However, those whom I respected as my mentors, paramedics themselves, urged me to go to college, medical school, and become a physician. I resisted for a while, I just wanted to be a medic in the field, but they were right. In many ways it would be easier to stick it out right here with my medic cert already, but I have firmly believed in getting the best knowledge and education I can. As a physician, I will have more freedom to practice in the field, and will be better able to positively affect the situation in my area through the writing of protocols, QA, etc. Medical school was then the logical choice, and especially so considering the full scholarship I received. I believe I will be better prepared for the field at the physician level, and as a paramedic I will be able to continue working in the field until I have MD after my name. And yes, I intend to keep my medic cert even after I have my MD. I am proud of being a medic, it is not something I intend to cheapen. Granted, the agency here is only first response, but considering my schedule, it is the best thing going for me. I plan on working at the on-campus ER and a third service back home, but this BLS service is all I have for consistant field experience. I know you are against BLS, but at the very least I am getting patient contact. I believe you would be even more opposed to me only working over summer and breaks and the occassional weekend, giving myself plenty of time to lose proficiency with skills or decision-making. And I thank you for your input. I understand the offense that EMTs and medics have when premed students take EMT just to "get out there." It offends me somewhat as well. But, as I hope I have explainted, that is not me. I do not believe you have a grasp on my situation, and have made a reaction to something you have encountered so many times before. I can tell you I'm probably a situation not so often encountered. I love EMS, and may very well be happier as "just" a paramedic. This is not something to do for a few years, this is what I honestly want as my career. I just intend to do it as a physician: in the ER, as a medical director, and perhaps one day at a helicopter program. Emergency medicine, especially in the field, is what I love most. I hope I am only myself reading into this post that you take issue with the fact I am "moving on" to medical school from being a paramedic. I do not consider it so much moving up as much as finding another niche where I can learn more, perform more, and have a more positive effect upon EMS. With this said, I hope you better understand me and my motivations. If they still offend you, I am disappointed and sorry to hear that. And, if possible, I'd of course love your input as to whether I'm carrying too much or too little "crap" in my pack. That was the reason I posted, and the reason I registered even. I want to hopefully learn from the experience of others with stocking these packs. P.S. I'd like to mention I hold no malice towards you Dust, I understand your motivations for challenging me. -Nick

The University, and yes. But I'd do it for free anyway just for the chance to get experience. Why do you ask? I'd appreciate your input. Did I miss anything above? -Nick