triemal04

Fair winds and smooth sailing. Rest in peace.

Yep. In all honesty, I think it would be in a departments best interests if they were ALL on the fence about this until they took a good, hard look at their particular area and capabilities. Giving it to cops is one thing; they have zero ability to ventilate a person and may be on scene for several minutes before anyone who can shows up. Better withdrawal (if it was packaged in a 2mg dose) than an anoxic injury or death. For EMT's...depends. How well can they use a BVM? How long would they be with the person before a paramedic arrived? How often would this actually be needed? Worth thinking about. Where I am there isn't really a need; the majority of EMT's are proficient enough with a BVM to ventilate an apneic person (and let's not forget that many, many narcotic OD's are not apneic and can be temporarily managed with supplemental oxygen) and are usually only alone for a few minutes. So...no need for them to have it. In other places, in fact probably the majority, where EMT's are not proficient with a BVM...have to consider it. Maybe. Or if the lag time until a paramedic arrives is very pronounced. I think there is a "need" for this...but it's not as large as it's being made out to be, the solution will probably be done in a piss poor way, and will be done, in part, to allow a little more strut in the steps of EMT's.

Sarcastic? Absolutely. Sadly though, there was more truth in it than there should be. Get to that in a minute. For you, I'd suggest that you actually learn a bit about pharmacology and the in's and out's of narcotics, narcotic withdrawal, and narcotic antagonists instead of just parroting a textbook. Because as I said, giving someone 0.4mg of narcan, or even 0.8mg if it's needed is not going do all those nasty, dirty things you mentioned. And even the lowest common denominator can be taught how to dry up 1cc of liquid and inject it into the deltoid or thigh. Now, given that the sarcastic part of my post was far to true, it is still very likely that many EMT's won't be given 0.4mg vials of narcan, but some type of autoinjector that has a much larger dose and WILL precipitate withdrawal. Sad but true. Just like to many EMT's will look at the addition of this as a supercool special thing that makes them uber highspeed low drag. Really, it comes down to this: is it going to be better to manage someone in withdrawals or someone who is dead? Given the admitted piss poor training of EMT's, expecting them to effectively ventilate someone with a BVM and not inflate the stomach is asking to much for most. Personally, if EMT's are taught how to draw up and inject a small dose of narcan I don't have any major issue with this, though how needed it is will depend on each specific area. If EMT's are only given large doses of narcan...a much more thorough look needs to be taken at a given area before implementing this.

What effects are you talking about? The ones that won't exist if this is done using more than 2 brain cells? Just because an EMT can administer narcan does not mean they need to be giving a large dose; 0.4 or 0.8mg is all that is needed in probably 95% all all narcotic OD's, especially if paramedics are also responding. I know there is talk of developing an auto-injector ala the epipen, but a much easier thing to do would be to give EMT's a 3cc syringe, 18g needle, alcohol wipe, and a 0.4mg vial of narcan. Just like they give to junkies is some places. Of course, this being EMS I do understand that 2 brain cells will not be used when implementing most programs like this and dem bad ass lifesava EMT's are gunna be savin dem sum lives with dat der 2mg narcan thingy!

http://jama.jamanetwork.com/article.aspx?articleid=1778673 I'm sure you already saw this. Retrospective analysis vs randomized trial...132 patients vs 1359... Therapeutic hypothermia isn't necessarily dead, but I think (based on other info) that just keeping them from getting hyperthermic or even slightly cool is plenty.

I got sent this recently so I can't take any credit for writing it. And while I have some minor quibbles with some of them, all in all I think it's a pretty decent list. Observations of and old paramedic 1) When you sew on a new patch, you’re not an expert. It just means that some governing body has authorized you to learn your job. 2) Never, ever, ever fight with someone for the opportunity to help them feel better. 3) We don’t save lives, we postpone death. 4) Documentation serves 3 purposes: it informs the ER what you saw and what you did about it, it gives the business office the opportunity to keep your pay check from bouncing, it prevents you from looking like a fool should you be called to testify. 5) Eat when you can, pee when you can, sleep when you can. 6) The most important skill a medic can learn is when to do nothing. 7) Never mistake continuing education for expanding your knowledge base. 8) Even the most routine transfer is a learning opportunity. 9) Your protocol was written for the dumbest guy you work with. 10) Documentation is an art. Writing too much gives the plaintiff’s attorney a bigger target, writing too little makes you look look incompetent or lazy. Lots of words is a waste of time and ink. Writing things that are already mentioned elsewhere on your PCR doesn’t improve your documentation. 11) To quote Lt Col Henry Blake, “Rule number one is that young men die. Rule number two is that doctors [paramedics] can’t change rule #1.” 12) You’re the guy who has the opportunity to make someone’s worst day better. 13) “The patient isn’t the problem, the patient HAS a problem.” Norma Henry, RN 14) Quit thinking that you’re better than the RN. You aren’t. You do a different job. 15) Read. I’ll say it again, Read. Seek knowledge, 16) Never trust a single vital signs measurement. It means nothing, especially if it was measured by a machine. Trends matter, snapshots don’t. 17) Patients don’t tell the truth. 18) You can discover many things that the patient can’t tell you by looking at their meds. 19) Bad outcomes don’t indicate bad care if you’ve done your job right. 20) That annoying rookie used to be you. 21) Stupid is ubiquitous. Get used to it, 22) Recertifying as a basic should require an explanation and a waiver. 23) You’re not in charge if it isn’t about patient care. Your partner is your equal. 24) It is rarely the worst case scenario. 25) It really can be the worst case scenario. 26) Never ignore that knot in your gut. 27) Hyperventilation syndrome and panic attack are true medical emergencies in the patient’s perspective. 28) 29) Look at the patient, not the machine. Bad roads can make healthy people look very sick. 30) Be aggressive when you have to, but understand that caution and re-assessment often leaves fewer dead bodies. 31) Smooth and controlled is always better than fast. 32) If you say, “Because I can,” or, “It isn’t gonna hurt,” expect me to punch you right in the mouth. 33) EMT’s don’t save paramedics. 34) If they don’t walk through their own front door, it isn’t a save. 35) “I’ve seen it all” should only be said at a retirement ceremony and even then should be taken with a grain of salt. 36) A college degree is a measure of persistence, not intelligence. That being said, education has value. From Steve Pike

Junkies don't call 911 as often as they should, or stick around to help the patient (CPR in someone in respiratory arrest or severe respiratory depression works people) as often as they should...but a lot of times they do. The cops...unless someone there is being a douchebag or something blatantly bad is going on (the 16 year old girl laid out in a roomful of dirtbags...not that that EVER happens... ) or you work in some small place where a heroin OD is such a big bad thing...most cops are not going to waste their time busting someone for a couple bags of heroin. It's a pain and waste of time for them and the vast majority I've seen would rather be doing something better. There's even some states that have passed laws so that if you call 911 for an OD you CAN'T be arrested on drug charges.

I think it was Boston EMS that did something like this years ago...and then scrapped it because it wasn't making a difference. Really, given the increasing controversy over when tPA should be given, or even if it should be given for most eligible strokes, this really just shows how out of touch EMS is with both current trends in medicine, and where medicine is going. Maybe someday people will actually realize that there is a point where trying to do more and more and more passes the point of diminishing returns, and that, even in targeted systems, a lot of the patients that get treated by paramedics would also have the same outcome if they just got a ride to the hospital and treatement there.

Yes. A degree in buisness admin' (or a MBA if you actually went that far) would be very beneficial in both the fire and EMS worlds. Not at the base level though. Having a bachelors might help you get a job, but as a line paramedic or firefighter you won't use it much. However...if you ever decide to promote or move into the administration side of things, then it will be very helpful, especially the higher up you go.

And you know that you are not afraid of blood and guts...how? Even disregarding the fact that "blood and guts" is a very, very small part of being a paramedic and is one of the less disturbing things that you will see, your implication that you can handle the unpleasant parts of the job is true because...why? I'm sorry, but being able to make decisions while playing a very simple game with very set rules and expectations does not mean that you will be able to think quickly, accurately, and objectively under duress in the real world, especially in the medical field. There. Now that THAT is out of the way... Finish highschool. If you have the option of taking chemistry and biology classes, especially more advanced ones, do so. Physics and english composition courses would also be beneficial, along with psychology, but at the highschool level those would be less helpful. Look into what options for paramedic school are available to you (this also means considering how bad you want it). Find out what the medical field, and EMS actually is, and more importantly, what it ISN'T. You can do this by visiting multiple (yes, many many many would be best) departments and doing ride-alongs (if they'll let you at your age) and talking with the EMT's and paramedics about what it is they do, how they do it, what they don't actually do, what they like and dislike, how much they really know about medicine (that'll be hard for you to evaluate), what the career path is in different types of services, what is beneficial to know, what is detrimental to do and so forth. Beyond that...don't do anything. Finish highschool, have some fun and enjoy yourself. You have lots and lots of time to get into the field, so don't worry about rushing it.

What about it? There's really nothing to say other than to dispel some myths; no, you won't lose your certification, no, you won't be held responsible for not performing a paramedic-level intervention if your job description is that of an EMT, no, it is not illegal in ANY state (I dare anyone to try and prove me wrong on that one ), yes, there are places that require this for various reasons, yes, a company can hire someone with a paramedic cert to work as an EMT. Depending on why a particular department does this and how it is set up it can certainly be a good thing, a bad thing, or an indifferent thing. Kind of just depends on specifics.

Yes. And it's very easy to understand why people will market shit like this, AND why people will buy/use it. One, because it's always such an ego boost to be able to tell people you are using all these fancy toys that nobody else is...because, you know...you CARE about people and are such a GOOD department. Two, because to actually change things to make a difference in cardiac arrest requires some effort. And fuck effort, ain't nobody got time for that! King County used to stand out with very high resuscitation rates (using Utstein criteria); for the last few years more departments have been getting up to very similar levels; Rochester MN, I believe Wake County, and several others that slip my mind right now. Generally, all these places like to announce that they've reached such a level (justifiable in my opinion), and when they do they also tend to mention HOW they reached that level. Anyone want to guess how? It wasn't with a bunch of bullshit toys. Citizen CPR programs. Early dispatcher CPR. Major emphasize and strict adherance to quality CPR with very limited interruptions. High level care post resuscitation also matters, as does getting the patient to the right hospital, but any department that can do the second two things, or better yet all threee, will see a jump in the survival rate, overall, and using Utstein. Any department that wants to invest in flash and toys instead of what actually matters deserves nothing more than contempt.

Aaaaaaand? Come on, this was actually an interesting situation...

Well he's certainly having a bad day. I'd still like to know what your total door to door time will be. What resources does the hospital have immedietly available? ie is anesthesia and ENT in house and available? Start by moving the BP cuff and pulse ox to the left arm and recheck the values. If the sat is still only 95% it's very likely that you are either missing a pneumo/hemo or blood flow to the lungs has been compromised. I would still be very concerned for additional injuries, or damage to major vessels that has been missed due to the other internal bleeding; unfortunately, there isn't a lot you can do right now. If the BP is still low with a low pulse I would say it's a combination of blood loss, and with the description of the hematomas have to wonder if they aren't directly impinging on the heart and/or the aorta and impeding flow, OR putting enough pressure on the carotid bodies to trick the body into thinking it's hypertensive and needs to compensate; either way the treatment will be the same. The condition of the right arm...with those injuries and the hematomas that's to be expected; nothing to be done until you get to a vascular surgeon. What about his right leg, and the whole right side of his body? TXA would good, blood would be very good; he does need volume and blood would be best. An epi drip would also be good. Now the hard part...keen or not, look the doctors square in the eye and remind them that this is a patient with a KNOWN compromised airway who is KNOWN to be a difficult (potentially very difficult) intubation. Ask them if they really, really want to take a person like that and put them into a small, cramped plane where the emergent crich that will be needed if nothing is done now will be very difficult to do. Or just tell them that he has to be intubated...like yesterday. If anesthesia and ENT are available I would confer with them and think about deferring to them; if the anesthesiologist can do an awake intubation, or a fiberoptic intubation that would be best. His crichoid membrane needs to be marked and ENT (if available) needs to be standing by with a scalpel if anything goes wrong. If they aren't available...make your plan and be ready for a bad failure. Have a backup ready (LMA and bougie), if you are good with video laryngoscopy go with that to start, if not then go with DL. Have someone available to assist with manipulating the larynx, again, have the crich marked and a designated person standing by with a scalpel. Go with sux and a very small dose of ketamine. If you can't intubate but the LMA works try passing either a bougie (or tube if it's and intubating LMA) through it; if you can't do that you still have to cut, but the pressure is off somewhat. So to recap: TXA, blood and pressors for support, a tube in the trachea by intubation or crich, keep him sedated with fentanyl (that'd help with any potential withdrawal too) ketamine, and rocuronium if it becomes neccasary. Take only this guy; your hands are going to be full.

What actually happened to the patient? When did it happen? Other than a CT what other interventions and tests, if any, have been done? What has been the trend in his vitals? What size plane do you have? What will your door to door travel time be? Start with your own exam; any other injuries or abnormalities to the entire body? Chest injuries? Lung sounds (and review the x-ray if it was done; 95% on a NRB isn't right)? If you are good at ultrasound pulling that out might be nice, but really that can wait until you are airborne. What is the injury to his hand? How much is it bleeding, and how much has it bled? Is it possible to staunch the flow with proper wound packaging, or can you clamp off individual vessels (if you can see them) or maybe a tourniquet if needed? What is the patients medical history, including meds? Is there something on board keeping his pulse that low, or is that due to the carotid injury and other damage to the neck? Are there any neuro deficiets? A shear force strong enough to cause that type of damage may also have damaged the spinal cord, not to mention the loss of blood to the brain will cause problems eventually. Not that it's going to matter in a minute, but can the patient lay flat? If they CT'd him he must, but how did he react when that happened? To recap: you have a patient with known major vascular injury to the neck, a compromised airway and hemodynamics, and possible unfound injuries (lung damage, spinal damage, the hand injury, other traumatic injuries to the body). Confirm you have patent, appropriate lines in place (or place your own), give a single fluid bolus to start (if this has been done hold off for now) Sedate, paralyze, and intubate. The bleeding into the neck is already causing swelling; with that and circumferential bruising you should be very concerned about losing the airway on the flight, AND this being a difficult intubation. So do it, but be well prepped and have all your backups ready. Have epi drawn up in a push dose concentration (10-20mcg/ml); the changes in pulse and BP could be due to the neck trauma; this would be the best way to intially fix that, especially during the intubation. If you have a plane that could potentially take 2 patients (one of whom will be supine and another who should be) maybe take a quick look at the other guy, but if it can't this patient is still the priority. That should be enough to start.