ERDoc

Sometimes it can be turned into a teaching moment where you can educate the layperson. We've all seen some shit but I think I have gotten to the point where it doesn't bother me much anymore. We don't see the ones that don't make it off the scene but in 10 years in the field I've seen my fair share of memorable scenes. I share the stories but leave out the ending. I make them ask about the ending. There is always hope that something good has happened and as we all know, those cases never have a happy ending. It lets them feel some of the let down that we feel when we take care of these pts. It invariably leads to them asking about the next case. After the first 2 or 3 cases, all of which end in death, they ask something like, "Wow, do you guys ever save anyone? It seems like on TV they save everybody." That's when you let them in on the reality of how life is nothing like TV and how dismal our ability to save people really is. I think it really lets the message set in.

I can't say that the question bothers me. Generally there is no malice behind it. It is just people trying to understand something they don't. I think they also try to get a sense of the kind of person it is that does this sort of thing.

How do you expect us to be able to give you advice or help you find resources when we don't have the full picture? You don't seem to want to provide the details so excuse us for being skeptical. If this is a military training, have you thought about asking the military? Surely your CO would be a better source than an anonymous internet forum. If you think people without prior military experience wouldn't understand, why would you come on a forum full of people without military experience and ask your questions? Do you see how that just doesn't make sense?

Suffolk County, NY requires their Fire/EMS dispatchers to be EMTs. http://www.suffolkcountyny.gov/Departments/FireRescueandEmergencyServices.aspx

I'm going to guess that this isn't a USMC/USN sanctioned event. If it was they would just simply say, "HM2 Jones, suit up. You've got to babysit some Marines."

I like the idea of mobile CT to r/o clinically significant head trauma. You might be on to something there, systemet. Another difference in the field vs in the hospital is that you are only dealing with one pt. The multitude of things that need to happen within minutes of a "stroke" hitting the door is taxing on even large hospitals. It does take a few minutes to get the pt registered in the computer. Nothing can happen without the pt being registered. This is a JCAHO issue. Tests (radiology/lab) cannot happen without several different ways of verifying pt identity. You also have to hope that the CT scanner is open and not being used. If we get an early enough heads-up this can usually be accomplished. We don't have big union issues so making sure the right person is there is no big deal. We have someone to get access, someone to get an EKG and someone to do the stroke scale (which has to be done within a certain time frame otherwise you get nastygrams from the higher ups who only understand what the regulations say and not how actual pt care works). Reading a head CT is much different than reading an EKG. Almost anyone can get proficient at reading EKGs, CTs are a whole other beast which is why there is a whole specialty dedicated to it. With a STEMI, you look at the EKG and see ST elevations. You make the diagnosis right away. With a stroke, if you are able to see the stroke it is too late. That is the problem. You have to make the diagnosis and administer a dangerous medication on the basis of a lack of evidence. Is this a CVA or a TIA? There are also a lot more contraindications for tPA in suspected stroke so you have to wait for labs to come back and go through their history if they are not good historians. All of this for something that is of questionable benefit and may be more harmful than useful.

tPA is known to cause head bleeds. The NINDS study showed that about 5.8% of pts that get tPA end up with bleeds and of those patients, 45% end up dying. Let's pretend we just gave tPA in the driveway and start making our way to the stroke center. Suddenly a car blows a red light and flips the ambulance. Can you imagine the potential blood bath that could come from an MVA after getting tPA? Even if there is no external trauma, there is going to be a brain bleed. Personally (with only experience and no studies to back it up) I don't think there is going to be any benefit.

I take back the 'not being skeptical' comment, lol.

I don't think anyone is being skeptical, we just can't give you an accurate answer with all of the details.

What he said, especially the part about what state you are from. Another place to turn would be your instructor.

Thanks, Mike.

Is this an official training or just a bunch of guys going out to have some fun? If it is official, I'd be careful and find out why there isn't an official medical person involved. If it is just a bunch of guys going to have some fun, I don't see a problem with it. As an EMT out in the middle of nowhere there really is nothing you are going to do beyond simple first aid. Don't be stupid and be that guy that buys a full medical kit with meds like morphine. Bring a bad with some bandages and some splints, it's nothing more than first aid.

What intervention are we talking about? tPA? Intraarterial tPA? I hate when strokes come in because there are so many phone calls that need to be made. It is not a simple as looking at an EKG and seeing a STEMI. Are they going to sit on the scene while the radiologist looks at the films? I don't see this being very useful. Full Disclosure:I didn't get to watch the video since I am in a place where audio is not available so I may not have all of the info.

That's the problem with NEXUS, a distracting injury isn't defined very well and is very subjective. How many people fall and break their arm and have no spinal injuries? I would say it would be most.

Or two grad students had a moment of ethanol-induced philosophical clarity one night and one of them remembered to write down their theory so they could present it to their department at the meeting on Monday.

I don't give my stuff up for free I will also check, but you know how my organization works, I might not be able to get it for you.

That is pretty impressive, albeit on a small scale. We might be on to something here.

Let's give this "paramedic" the benefit of the doubt and say he properly applied the NEXUS criteria (although the fact that the pt got a CT in the ER makes me doubt this), don't forget, the NEXUS criteria are only 99.6% sensitive, meaning you are going to miss that 0.4% of clinically significant spine injuries. The Canadian cspine rule has a sensitivity of 100%, so if applied properly you shouldn't miss any. Like I said in an earlier post, for the original pt, as presented NEXUS says no and CCSR says yes.

So you don't believe in clinical decision tools? Again, what criteria did your paramedic friend use to clear his pt? PS-You can't just say that studies have been done, you have to provide those studies.

When I first started, we called them prams. We had to get the pram out of the bus. LOL. They eventually just became stretchers.

What does the trauma to the head have to do with the cervical spine? What criteria did the medic use to clear the c-spine in the case?

Agree again. One of my shops does not have a cath lab and we get plenty of chest pain. Those with positive trops get sent to the big house those that don't get admitted here for rule out and stress testing. POC trops are one of the few lab tests that I think have a place in prehospital care. They can change your destination, saving pts multiple hospital visits/bills. It needs to be understood by the providers that a negative trop does not r/o cardiac pathology.

Systemet, you are correct that an istat trop is not good for a rule out, but it is good for ruling in. If you get a trop of 2, that pt should probably head to the cardiac center and not the local hospital. They may not get an emergent cath but they will get one.

Yeah, but she asked for a STRONG EMS system and the chances of meeting me are minimal

This one just came across my FB feed. I love call the cops. http://www.callthecops.net/police-chief-refuses-call-officer-doctor-earned-phd/