ERDoc

I agree with the badges making you look like an FNG, or at the very least a buff. EMS does not need badges. All you need is something on your sleeve or back that states your level of training so that at a scene you can easily be identified. Just because your company requires you to have something does not mean that they are required to supply or even pay for it (at least in NYS). I worked for a company that required us to pay for our own uniforms and even our own oxygen regulators. This made many people quite mad, so an occupational lawyer was consulted and they were told that as long as the company is not asking for anything unreasonable there is nothing that can be done. Even the O2 regulator was not considered unreasonable. The only saving grace was that if you saved your receipts you could use it for your taxes.

Beating the ugly children in my neighborhood.

"Pt is in asystole with a rate of about 20." XYZ Ambulance: ABC Hospital, we are bringing you a 13y/o female with an airway obstruction. Pt is stable and breathing well. We also have a 15y/o male with a laceration. We'll give you more info when we arrive." ABC Hospital: XYZ Ambulance, could you please give us more information on the pt? XYZ Ambulance: No. ABC Hospital: We need to know what kind of equipment to set up for your arrival. Please tell us more. XYZ: You do not need anything at this time. You will understand when we arrive. Ambulance pulls in with a male on a strecher with a blanket over him with a large "bump" down by his abdomen. Sheet gets pulled back and it is his girlfriend. She was performing oral sex on him and his skin got stuck in her braces. :shock: :shock: :shock:

There are also signs of left sided failure (rales). This is probably not from a new insult (although you cannt completely rule that out), but most likely related to the missed meds. Ntg probably would not be a bad idea, but I would feel better if I saw an EKG first. To set the record straght, right sided failure is commonly caused by left sided failure, not the reverse. The most common cause of right sided failure is left sided failure as you get a backup from the left to the right.

This one makes #39!!

not postwhoring. :-)

I am

I'm just posting this so that I can get one post closer to that next square in my counter and move up in rank (yes, totally self serving).

Here are parts of the results from Phase II and III. These are not the actual articles that appeared in the literature, but a synopsis taken from the OPALS website: Phase II Results Phase II results of the OPALS Study have been published in the April 1999 issue of The Journal of the American Medical Association (JAMA)! The manuscript entitled "Improved Out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program (OPALS Study Phase II)" created a lot of media attention with it's publication in this prestigious medical journal. This study compared cardiac arrest survival from Phase I (communities with existing ambulance defibrillation programs) to Phase II (rapid defibrillation) in 19 Ontario communities. These communities implemented various strategies to optimize their EMS systems to achieve the target response criteria of call received to vehicle stopped with defibrillator in eight minutes or less for 90% of cardiac arrest cases. Many of these communities implemented fire fighter defibrillation programs, along with base paging, tiered response agreements, and roving. Provincially, changes were made to dispatching policies and procedures. The outcome of these interventions demonstrated that rapid defibrillation increases the chance of survival from prehospital cardiac arrest! In the largest prehospital cardiac arrest study ever conducted, involving over 5,000 patients, survival increased from 3.9% in Phase I to 5.2% in Phase II. This represents a 33% increase in survival. Or, to look at this another way, it represents additional 21 lives saved each year. Increased survival was also associated with bystander and first responder CPR. The results of Phase II provide evidence for communities considering the cost of CPR training and equipment ambulance services, fire departments and other agencies with defibrillators. In doing so, thousands of lives could be saved in a very cost efficient manner. For more information on media coverage, check out these web sites: JAMA - April 7, 1999 Phase III Results The first of several Phase III results have been published in the August 12, 2004 edition of the New England Journal of Medicine. The manuscript entitled “ Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest†has created a whirlwind of media attention in our national newspapers as well as several international newspapers . These results conclude that CPR, and rapid defibrillation increase cardiac arrest survival, but ALS does not. Over 5,600 patients were studied across 17 urban Ontario centers to reach this conclusion. Of those patients, 1391 were enrolled during the rapid-defibrillation phase, and 4247 during the subsequent advanced life support phase. Advanced Life Support training was introduced in Ontario several years ago as one part of a comprehensive approach to strengthening community response to cardiac arrest and improving survival rates. This training provides the paramedics with the skills to perform advanced life saving procedures such as airway management, and the administration of intravenous drug therapy. Other parts of the approach include CPR training for police officers and firefighters as well as the installation of public access defibrillators. Previous OPALS Phase I and Phase II research concluded significant improvement in survival from cardiac arrest if first responder be it citizen, police officer, or fire-fighter performs CPR, and if rapid defibrillation occurs within 8 minutes. Although ALS training does not demonstrate a change in survival rates for cardiac arrest patients, indications from our soon to be published Chest Pain and Respiratory research studies suggest ALS significantly impacts the number of lives saved each year for these patients. The underlying message from the OPALS Cardiac Arrest research is for health officials and planners to place an emphasis on citizen CPR training, and the rapid availability of defibrillation devices. And, just for completeness, here is the absract from the NEJM: ABSTRACT Background The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support to a program of rapid defibrillation. Methods This multicenter, controlled clinical trial was conducted in 17 cities before and after advanced-life-support programs were instituted and enrolled 5638 patients who had had cardiac arrest outside the hospital. Of those patients, 1391 were enrolled during the rapid-defibrillation phase and 4247 during the subsequent advanced-life-support phase. Paramedics were trained in standard advanced life support, which includes endotracheal intubation and the administration of intravenous drugs. Results From the rapid-defibrillation phase to the advanced-life-support phase, the rate of admission to a hospital increased significantly (10.9 percent vs. 14.6 percent, P<0.001), but the rate of survival to hospital discharge did not (5.0 percent vs. 5.1 percent, P=0.83). The multivariate odds ratio for survival after advanced life support was 1.1 (95 percent confidence interval, 0.8 to 1.5); after an arrest witnessed by a bystander, 4.4 (95 percent confidence interval, 3.1 to 6.4); after cardiopulmonary resuscitation administered by a bystander, 3.7 (95 percent confidence interval, 2.5 to 5.4); and after rapid defibrillation, 3.4 (95 percent confidence interval, 1.4 to 8.4). There was no improvement in the rate of survival with the use of advanced life support in any subgroup. Conclusions The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems.

Just so everone is on the same page as to the background and purpose of the OPALS study, here is a bit from their web page: In this era of health services fiscal restraint, policy makers require quality evidence to support decisions to initiate or continue funding for expensive programs. Prehospital Advanced Life Support (ALS) programs cost considerably more than community-wide defibrillation programs, yet evidence is not convincing for the effectiveness of ALS programs for critically ill and injured patients (ALS includes advanced airway management [intubation] and intravenous drug therapy by ambulance officers). This study should provide valuable evidence to Ontario communities and elsewhere, about the relative effectiveness of prehospital programs on the survival and morbidity of cardiac arrest, major trauma and respiratory distress patients. Such information is much needed for the cost-effective planning of emergency health care services. Background Survival for prehospital victims of cardiac arrest remains relatively low in Ontario communities compared to many U.S. and European communities. Optimal survival rates according to the American Health Association depend on four strong links in the "chain of survival". The relative importance of the third link, rapid defibrillation, and the fourth link, full ALS is not clearly distinguished in the scientific literature. Prehospital ALS measures are also commonly applied to trauma and other critically ill patients in U.S. centres. The Ontario Ministry of Health (MOH) was reluctant to commit the millions of dollars required for the widespread implementation of prehospital ALS programs without further research demonstrating the effectiveness of such programs in Ontario. In 1994 - OPALS Study funded by the Ontario MOH. In 1998 - OPALS Study funded by the Ontario MOH and the Canadian Health Services Research Foundation (CHSRF). Objectives To assess the incremental benefits in cardiac arrest patient survival and morbidity that results from the sequential introduction of rapid defibrillation programs. To assess the incremental benefit in survival, morbidity and processes of care that results from the introduction of prehospital ALS programs to multiple Ontario communities for patients with cardiac arrest (primary objective), major trauma and respiratory distress. To conduct an economic evaluation of ALS programs for the same patient groups by estimating the incremental cost per life saved and per quality-adjusted life year. Design This multi-phase before-after study (see OPALS Research Protocol) is being conducted in multiple communities in 11 base hospital regions and has three distinct phases involving a total of at least 10,000 cardiac arrest patients, 6,000 major trauma patients and 8,000 respiratory distress patients. Phase I represented the baseline survival status in each study community and was based on retrospective data for the most recent 36 months prior to Phase II. Phase II assessed the survival for 12 months after the introduction of rapid defibrillation and demonstrated that relatively inexpensive community rapid defibrillation programs increase survival for cardiac arrest patients. Phase III will assess survival outcomes months after the introduction of full ALS programs for 36 months for cardiac arrest patients and major trauma patients, and for 6 months for respiratory distress patients. The actual research protocol is on the website also, but is much too big to post here (insert your own size joke here).

I think making paramedics a 2 year degree would be a great idea. You can get a better understanding of sciences behind what we do. You can increase the foundation of knowledge that providers have. While there is a great deal of learning going on in the field, you need your basics to make any sense of what you are doing. I would much rather see the paramedic become a 4 year degree and EMT a 2 year degree, but I know that this is next to impossible. It would also be a way to increase the pay of what EMS makes. If you increase the pay, you can increase the competitiveness of the field and in return can increase the caliber of the providers. With a higher level of education, the doctors who write your protocols might be willing to allow you to do much more. The only problem that I can see is that rural areas where they are already desperate for ALS providers would find it even more difficult to find them. This could be off set by higher pay, but at what cost to the taxpayers? I think making EMT a 2 year degree would almost certainly bring an end to the volunteer system. What would you do with those who are already paramedics? Hungrymonkey, you said, "I have repeatedly been told that the real education starts when you get a job, and that school is to prepare you for that. If this is so, then why would it be required to have over two years of school on subjects that do not apply medically? IE social science, human relations, etc." How do these classes not apply medically? Human relations? We are in the business of human relations, to have an understanding of the basic principles behind the relationships would only make you better when you need to deal with difficult pts or families. Where I went to medical school, each year we had a course on medical ethics and human relations. Have you ever been trained how to tell a pt or their family bad news? No, you will probably never need to tell someone that they have cancer, but I'm sure you will have to tell family that their loved one is dead. To say that behavioral and social sciences plays no part in what we do is off base. vs-eh, down here in my neck of the woods a person only needs to take a 100 hr course to become an EMT. They are not required to have any ambulance experience before they get their card, only 10 hrs in the ER as an observer. They don't even need to be a high school graduate. I would venture to guess that almost 99% of the EMTs do not know what angiotensin is. The paramedic course is much more demanding, but again, I would venture to guess that 50-75% don't know what it is.

I don't think anyone is saying they are against ALS. This particular study shows that there is no difference in outcomes when pts are treated by ALS vs BLS. They are not saying that ALS kills the pt. I feel that the difference in the intubated pts is probably due to the fact that those who are being tubed are sicker in general and less likely to make it anyway. From a practical standpoint, if a pt comes into the ER with an IV line in already it frees up a nurse or two to move on to other things.

I just read today that the OPALS (Ontario Prehospital Advanced Life Support) Study has shown that there is no difference in several survival endpoints for trauma pts that are treated by BLS vs ALS units. The only difference was that in pts who were intubated the outcomes were worse (although the article did not say if these pts were sicker). I'm not trying to start an ALS vs. BLS war, I was just curious as to everyone's thoughts on it.

Do you have different fluids that you can give? In my area the EMS guys only have NS. They used ot have D5W for medical pts and LR for trauma, but this changed to NS for everyone several years ago.

In my neck of the woods, the crews can only start lines (no locks). They can draw bloods, but I have never seen one do it, and I don't think the nurses will take it.

Although I haven't had the opportunity to try it, I have seen anesthesiologist intubate a pt in a near upright position. They say that the airway is much easier to visualize and is more of a straight line. I have actually seen them jump up on the back of a hospital stretcher and do it standing about 3-4 feet off the ground. I can only assume that the airway is more patent in the sitting position, even for bagging. I have had the opportunity to bag someone in the sitting position and didn't have any problems. You just have to make sure that you bag when they inhale.

I set up my jumpbag after I received my first responder certification (with the usual BLS stuff 4X4s, Kling, etc). I pulled it out of my trunk the other day to use it and realized that I haven't used it in a long time. I found saline and water that expired in 1993. The 4X4s crumbled when I tried to fold them. I was getting some stuff out for my son who tried to catch a baseball with his teeth. He just looked at me like I was crazy.

Just a few abstracts from a few studies that might help to enlighten the conversation a little (I know it is a little wordy, sorry about that): Resuscitation. 2005 Jun;65(3):325-8. Epub 2005 Jan 24. A comparison of CPR delivery with various compression-to-ventilation ratios during two-rescuer CPR. Hostler D, Guimond G, Callaway C. University of Pittsburgh, Department of Emergency Medicine and the Affiliated Emergency Medicine Residency, 230 McKee Place, Suite 500, Pittsburgh, PA 15213, USA. BACKGROUND:: The number of chest compressions required for optimal generation of coronary perfusion pressure remains unknown although studies examining compression-to-ventilation ratios higher than 15:2 (C:V) in animals have reported higher C:V to be superior for return of spontaneous circulation and neurologic outcome. We examined human performance of two-rescuer CPR using various C:V. METHODS:: Thirty six EMT-Basic students in their final week of training performed two-rescuer CPR using C:V of 15:2, 30:2, 40:2, 50:2, and 60:2 on a recording resuscitation manikin. Compression and ventilation variables were recorded by computer while the number of pauses for ventilations and the hands-off time (time not spent performing chest compressions) were abstracted by hand. Data were analyzed by ANOVA and significant differences from the standard treatment of C:V=15:2 were assessed by Tukey's HSD post hoc test. FINDINGS:: The number of compressions delivered per minute increased with increasing C:V while the hands-off time and pauses for ventilations decreased. All comparisons were significantly different from C:V=15:2 (P<0.001). The ventilation numbers decreased with increasing C:V although mean minute volume exceeded 1l for all C:V. INTERPRETATION:: A 15:2 compression-to-ventilation ratio when performed during two-rescuer CPR results in 26s of hands off time each minute while only delivering 60 compressions. Alternative C:V ratios of 30:2, 40:2, 50:2, and 60:2 all exceed the AHA recommended 80compressions/min while still delivering a minute volume in excess of 1l. Ann Emerg Med. 2002 Dec;40(6):553-62. Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios. Sanders AB, Kern KB, Berg RA, Hilwig RW, Heidenrich J, Ewy GA. Sarver Heart Center, the Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, USA. art@aemrc.arizona.edu STUDY OBJECTIVE: The optimal ratio of chest compressions to ventilations during cardiopulmonary resuscitation (CPR) is unknown. We determine 24-hour survival and neurologic outcome, comparing 4 different chest compression-ventilation CPR ratios in a porcine model of prolonged cardiac arrest and bystander CPR. METHODS: Forty swine were instrumented and subjected to 3 minutes of ventricular fibrillation followed by 12 minutes of CPR by using 1 of 4 models of chest compression-ventilation ratios as follows: (1) standard CPR with a ratio of 15:2; (2) CC-CPR, chest compressions only with no ventilations for 12 minutes; (3) 50:5-CPR, CPR with a ratio of 50:5 compressions to ventilations, as advocated by authorities in Great Britain; and (4) 100:2-CPR, 4 minutes of chest compressions only followed by CPR with a ratio of 100:2 compressions to ventilations. CPR was followed by standard advanced cardiac life support, 1 hour of critical care, and 24 hours of observation, followed by a neurologic evaluation. RESULTS: There were no statistically significant differences in 24-hour survival among the 4 groups (standard CPR, 7/10; CC-CPR, 7/10; 50:5-CPR, 8/10; 100:2-CPR, 9/10). There were significant differences in 24-hour neurologic function, as evaluated by using the swine cerebral performance category scale. The animals receiving 100:2-CPR had significantly better neurologic function at 24 hours than the standard CPR group with a 15:2 ratio (1.5 versus 2.5; P =.007). The 100:2-CPR group also had better neurologic function than the CC-CPR group, which received chest compressions with no ventilations (1.5 versus 2.3; P =.027). Coronary perfusion pressures, aortic pressures, and myocardial and kidney blood flows were not significantly different among the groups. Coronary perfusion pressure as an integrated area under the curve was significantly better in the CC-CPR group than in the standard CPR group (P =.04). Minute ventilation and PaO (2) were significantly lower in the CC-CPR group. CONCLUSION: In this experimental model of bystander CPR, the group receiving compressions only for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved better neurologic outcome than the group receiving standard CPR and CC-CPR. Consideration of alternative chest compression-ventilation ratios might be appropriate. I think I've taken up enough space for now. Hope this helps.