Kiwiology

Good point Richard It's also not really fair on a clinically qualified crew member to have to drive at the expense of their clinical ability on every job If it's by mutual agreement then thats different.

An EtCO2 of 20 says to me she is ventilating too fast i.e. expelling CO2 at a greater than normal rate but I don't know and once we get beyond the basics of this stuff I'm out of my depth; so I'm sticking to my original plan and taking her to a hospital with CT and ICU facilities

I'd imagine that has been taken care of when we intubated her, it would never hurt to check that it has not been dislodged however I do not and fully agree with you that automated ventilation should be something in the pre-hospital arena; it is used by the HEMS Doctors and the ICU flight transfer teams but it is not a tool available to Intensive Care Paramedics performing RSI. Will it be in the future? I can't say; the rationale for not introducing it here is most likely due to significant cost and low use (relative to other things)

Um, yeaaah we're gonna need you to come in on Saturday too, that'd be great, m'kay?

"Adequate" is a subjective term; in NZ people are intubated pre-hospital using RSI on average once every other day using the resources and guidelines we have in place and there have been no significant problems. Do I think we should have an automated ventilator for use on this lady if she's going to be in our care for the next hour or so on the ground and in the air en-route to the hospital? absolutely. Apparently that's now been refuted, but ... <insert studies here> Oh dear, sounds like this lady is Super CrookTM We could flog her ticker along with an adrenaline drip but I doubt that is going to do anything of any significance because her bradycardia is a physiologic response to the massive increase in ICP she has suffered Let's head to the hospital, they have a CT scanner and can do some lookey-loo'ing inside her noggin

Do a quick primary survey - if no respiration or pulse I'm going run a rhythm strip and sign the life extinct certificate right there

Excellent point mate and one I forgot to mention before. Ringing up on the belt mounted little talking box that your patient required some Advanced or Intensive Caring is all well and good but it's a good idea to say why your patient requires back up e.g. for pain relief, for antibiotics, for cardioversion etc. Typically all that is said here is "so and so calls Ambulance, status 1 / 2 patient, require R50" well that doesn't actually tell us a whole lot, it says your patient is either critically or seriously ill and that you want some back up but doesn't say a whole lot as to what is wrong with them; we know how inaccurate ProQA/MPDS is, for people who are super crookTM I'm sure your back up wants to have a ponder about what he or she is going to do when they get there. It is also an important consideration because most often back up is dispatched on a 1 with lights and siren at faster than normal road speed so it helps to determine if ALS should be on a 1 or a 2.

Bloody Germans so efficient No CPAP here, not even the Bouginec (? sp) French one which connects onto the oxygen tank so no CPAP machine is actually required

Excellent point mate, pain has a significant physiologic response as well as mental and physical aspects as well. This is why sedation (midazolam) is combined with morphine (analgesia) in our post-intubation regimen. Apologies; the dosages above were for midazolam. I respect you have substantial experience with automated ventilation and such; this is not something available pre hospital in NZ and is unlikely to become so in the near future. For now it's the trusty manual ventilator bag down here Yes this is true. Something I think is often forgotten is the trusty ambo blanket and the problems having a proper body temperature can avoid. Apparently "hypothermia" is part of the "triad of trauma death" as it has some bad coagulojuju associated with it, I've yet to adequately research it. Everybody is on about cold fluids in post-cardiac arrest and traumatic brain injury but I am curious to have a looksee about warmed fluids and severe trauma.

Both your points sort of lead to the same answer so I'll address them together Ketamine only produces general anaesthesia for around 20 minutes after which time the patient is going to wake up. Ongoing sedation ensures the patient is not awake and aware they cannot move with a tube shoved down their gob. Achieving a patient who is sufficiently sedated that we have blunted all their neuromuscular reflexes so they do not become agitated or restless and fight the tube is going to require a larger amount of sedation than a paralysed patient who needs a "don't remember" dosing. My readings around anaesthesia and intensive care generally state the first requires anywhere from 0.3 to 0.5mg/kg and the latter 0.1mg/kg. Indeed 0.1mg/kg is the dosage used here for patients who have a neurogenic cause for coma with a GCS < 10 and require RSI. Our Clinical Practice Guidelines say pretty much the same thing except for midazolam post-intubation it appears fixed bolus amounts are trendy down here; up to 3mg every 5 minutes (there are slightly lower dosages for patients who weigh <50kg). As an aside I'd be interested to see if a midazolam drip would be any better and might have a looksee around these here interwebz.

To maintain the presence of the endotracheal tube post-intubation; using paralysis in combination with sedation is likely much safer than using sedation alone; and we'll be able to use a lower dose of sedation.

I'd flip cartwheels with joy if you could work with the appropriate person (Nurse Educator or Consultant Physician etc.) to get students understanding (even if on a beginner level) things such as ... (1) Various things O/E e.g. percussion, tactile fremitus, peripheral neuro exam, cardiac sounds maybe? I can't hear A2/P2 split to save myself) (2) Basic biochemistries e.g. CBC, CKmb, Trop-T, MSU (U C+S), coag panel (3) Basics of antibiotics (even if it's a penicillin is different than a macrolide which is different from a cephalosporin) (4) Social and environment factors (e.g. beyond nana fell on the rug, why did she fall on the rug and who should we tell about it?) (5) The early in-hospital management of status 1/2 patients (post-cardiac arrest, cardiogenic shock, DKA, major trauma/RTA, CVA etc) Obviously learning the more ambo-orientated things like putting in a drip, 12 lead ECG acquisition and interpretation etc are quite important but I would also strongly argue so it taking three seconds to check somebodies fingers for signs of clubbing or palmar eryothema, or that the old bloke who fell over going to the loo five times in the last month because he has difficulty in mobility and lives alone so has to wait for the postie to find him etc needs referring to the falls team or home help or GP or something ... Imparting that the risk factors for ectopic pregnancy are non-white, previous parity, smoker, IUD/OC, multiple sexual partners, previous EP and something else I am forgetting could be of use too; why? because I find it bizzare I'll go to my grave being unable to forget the risk factors for ectopic pregnancy ever since I learnt them reading Williams' Obstetrics for part of National Diploma You may wish to talk to Brenda Costa-Scorse at AUT or Sarah Werner at St John

Suxamethonium only has a short duration ~15 minutes or there about, vecuronium is a much longer acting neuromuscular blocker

I will intubate using a Mac 4, 7.0 cuffed tube, anaesthetise with fentanyl 1mcg/kg, ketamine 1.5mg/kg; paralyse with suxamethonium 1.5mg/kg and vecuronium 0,1mg/kg If her time to hospital was not so extended I would not intubate right now and see how the LMA went No hyperventilation from me; ventilate to maintain EtCO2 30-35mmHg

This might be a good time to remind people that patients with cardiogenic pulmonary edema are often relatively hypovolaemic as all that fluid has come from the circulation. So giving frusemide is bad ju ju ... in the acute patient, it's used quite widely in management of chronic heart failure but may be loosing place to spironolactone

Frusemide is lasix; a loop diuretic i.e. increases urine output The English speel is furosemide

Oh that's a good one!

I didn't say not to say it in an empathetic manner And "acopia" is not a real medical word for lack of coping; neither is "dyscopia"

Anterior ST elevation on 12 lead ECG is classified here as status one or immediately life threatening problem as the left ventricle is often involved or at risk; this is not often well understood. Your student did nothing wrong in my opinion. It is entirely appropriate to tell the patient "we highly suspect you are having a heart attack".

Are you referring to LA County specifically or midazolam generally? In LA County nothing surprises me, but if you mean midazolam more generally it is an excellent choice for agitated patients or those in need of a little sedation and/or chemical restraint (what we in NZ use it for)

Do you mean the sole use of midazolam is not just for agitation or that it is not a good choice of drug for agitated patients?

Can we find out what sort of medical history this lady has/ what sort of meds she is on and whether she took them as indicated Are there any medication bottles around the place and if so how empty (full) are they compared to what should be on the label For right now the airway is my main concern; put in an LMA and see if that does the trick, however with that said, I have a strong preference towards RSI in this patient provided we can get it done without significantly extending the time it will take to get her to hospital; how far is the hospital anyway? Do a quick physical exam to see if there's any obvious signs of why she'd have a lowered LOC e.g. big snake bite wound or something crazy like that What are her obs/vital signs?

smear some GTN on the loo

I had to teach the swipe thing on my Android bad words

"Crook" means sick like how sick does Nana look OK so leaning forward with deep snorous respirations; what is her conscious state like? Obs?