Kiwiology

Whether or not to include chowdah in the scope of practice, duh

Helicopters are over rated and over used, in the overwhelming majority of patients they offer little benefit and disproportionately increase risk

No, funding is not at a level that allows them to be introduced to thousands of clinical people and hundred of response vehicles yet achieve a realistic cost/benefit ratio. The Ambulance Service has to compete with many other areas for the public health dollar. Something like CPAP is very expensive and only able to be used on a few patients; same with magnesium sulphate, while not as expensive it is only able to be used on a tiny subset of patients whereas two recent introductions on the other hand, oral ondansetron and oral loratadine, are extremely cheap and can be used on lots of patients.

A pretty awesome scenario bro As far as managing him locally with no CPAP, magnesium or "in line" nebulisers that attach to a bag mask with an unwavering SPO2 of 87% on oxygen and 30 minutes to hospital he'd have bought a tube most likely.

So this just turned up Well, that's me fucked, I used my once-in-a-lifetime shot and it fell over so I might as well crawl into a hole and rot Damn it to the bowels of bloody hell I should be living it up with fellow rednecks at the Indy 500 this weekend, not in this toxic fucking depressing shithole having spent the last ten months trying to get my massive failure of a life back together (not that I'm getting anywhere) Oh well who the fuck cares I'm off to get really fucking drunk and wasted on valiums

I wouldn't give him steroids and I am worried about the possible immunosuppression Lets get some wheels under this guy He is lucky he has EMTCity EMS treating him, you have CPAP, we do not in NZ so he would have bought some ketamine dreams and a tube by now

Trev, mate, thats $2 million after you employ me!

I was told most steroids are immunosuppressants; I am unaware of specifics however if that is true, owing the high suspicion of a COPD exacerbation and a respiratory infection should we be giving them?

Good points, we could try some fluid I suppose

I am mentally ill, please sedate me

Not sure on the fluids personally if he has CHF it's probably not going to help but we have no evidence of that so we could try a small bolus Why do you say it's going to help? Are you thinking he might have had a right ventricular infarct?

My question was more how are you getting those values pre hospitally without a lab? I share your concern but I'm not sure this guy will last the half hour transport to the hospital, he might, but he might not. I agree intubating him is not without risk and that he might severely desaturate during laryngoscopy however if we preoxygenate him well I don't think that will be a problem; local flavour here is to sit him up and tightly seal a bag mask over his face with a PEEP valve on it for 3-5 minutes. I don't think he would tolerate that awfully well so perhaps a little fentanyl premedication beforehand might settle him to allow it. True, but at the moment I don't think he is at the acute end of his life i.e. actively dying so I think we should work on him; if he has a cardiac arrest or something then he has clearly described he doesn't want to be coded so that's the end of it then

This guy needs to be in the hospital, clearly whatever problem he has we're not fixing to any significant degree and we're muppeting about when we could be getting some wheels under him I'm keen to shove an IO into his leg and intubate him, the hospital is going to do it anyway and if we have to stop on the way to do it then it's just doing nothing but delaying how long it takes him to get to the hospital

Bravo 711 calls Radio, best get me some more units up in the here right now, maybe the MCI bus or something, there about to be an ass whoopin goin down .... Hmm well they have a unique accent anyway, sounds a little Canadian

Why is that? If they are ventilating through bag mask which is a closed circuit and that circuit has a PEEP valve on it won't they still be exhaling against the resistance of the PEEP valve? Correct, patients with cardiogenic pulmonary edema are not fluid overloaded the fluid is just in the wrong place they are in fact relatively hypovolaemic. How are your Paramedic calculating pOsm? Do you not have the option of putting in a saline lock? What I should say is that his hypertension does not require treating right now, sublingual GTN will have some effect on his blood pressure obviously but that's not the same as "treating his hypertension" I couldn't have said it better myself Sigh, if only we haz teh CPAP

Sublingual GTN won't have any effect on his hypertension It could be CHF but I am not convinced For now I'll hold off on anaesthetising, paralysing and intubating him to try 0.8mg of SL GTN We don't have CPAP so it's not an option here, it'd have to be a tightly fitted bag mask and PEEP of 10 My guess is he's not going to tolerate somebody shoving a bag mask over his gob nor can we reasonably expect the ambo to tolerate doing it for thirty minutes until we reach hospital so I think intubating him is going to be the end point of this bloke anyway regardless of what is done beforehand

I have only had one bad patient experience with ketamine and that was some bad dreams at low dosage for analgesia Yes, it is well known that ketamine causes transient increases in blood pressure and cardiac work; it would therefore be contraindicated in patients where these alternations in physiology would be bad anybody who doesn't keep that in mind is a muppet who should not be allowed to administer it. No one agent is best but I certainly think we can agree the good old ambo trick of pouring midazolam into people until they are unconscious enough to accept a tube is not the way to go, as to whether propofol or etomidate or ketamine or thiopentone are acceptable it depends on the patient you have and their individual circumstances. Certainly I think in the pre hospital environment we should keep it simple; fentanyl for premedication and either ketamine or midazolam; some places are using etomidate but etomidate has some pretty bad adrenojulu attached to it So is ketamine better than midazolam? In patients who are shocked or are not deeply unconscious the answer is yes however in patients who have pathology where increased blood pressure or cardiac work would be bad the answer is no (95% CI, p < 0.00001*) * numbers made up, not validated by any actual scientific thingamagig

Like I said we don't have CPAP here in NZ so hmm I'm not sure, it could be of benefit from a physiologic standpoint

It does yes but it is an excellent anaesthetic that does not posses the cardiovascular risk profile of midazolam or propofol The common argument of emergence phenomena is not something that has been a problem here in NZ and I've never seen it

Not faulting your method but just generally I am very, very against intubating people without suxamethonium or another paralytic agent, yes it can be done, but should it? I don't think so Will they let you have ketamine? That'd be a far better anaesthetic than midazolam or propofol

If he has a chest infection most steroids are immunosuppressants so not something I'd use I've got no experience with CPAP or magnesium sulfate as neither are used here I am still very keen to intubate him

We could try adrenaline and it is indeed part of local guidance for COPD exacerbation The point about him being difficult to wean off the ventilator later is an excellent point, I didn't think of that It's also struck me that his SPO2 is abysmally low, but many COPD patients have a very low SPO2, do we know what it is normally? Like I said before, at this moment in time he is not "actively dying" (at end of life) so it's up to the daughter to decide really, I think it's the best option for right now and if he dies a day later in ICU then so be it, I mean until he is actively dying I think there is at least some moral obligation to work on him; if he was on palliative care or something it'd be different

For patients who are unconscious with poor airway and breathing (i.e. TBI, postictal state, alcohol or GHB poisoning) I don't think fentanyl and midazolam is a bad combination; as I've said I am personally biased towards using ketamine as ketamine provides profound anaesthesia at induction dosages but I'm not convinced 0.05mg/kg midazolam will produce the same level of amnesia; I guess I'm quite scared of the idea that the patient might not be properly anaesthetised. Patients without significant hypertension or physiology where transient hypertension and cardiac stimulation would be bad should receive fentanyl and ketamine. Midazolam is used instead of ketamine for patients who have significant hypertension as well as for patients with pathology where increased blood pressure and cardiac work would be detrimental Suxamethonium and vecuronium are in flavour for paralysis in these parts

LOL that would be something like "Far our cuz your dad is pretty nunngered as super crook eh I reckon we ought to shove a breathing tube down his gob cos he is getting stuff all oxygen up to his brainbox sound legend sweet as bro?" I reckon we should tube him if it's 30 minutes to hospital and his SpO2 is still abysmally low, if his work of breathing keeps up he's probably going respiratory arrest anyway either from fatigue or hypercarboxaemia

They do in Europe (NEF in DE, SMUR/SAMU in France, BASICS in UK) however, the helicopter allows for maximum coverage and to minimise response and transport times where it really is important in a subset of patients who really are very unwell