kevkei

I think someone needs to review the pathophysiology of RHF.

If you have talked someone into signing off, wouldn't you consider that the same as refusing to transport them? Coersion of a patient is not a refusal on their part.

I think this is more of a programming issue with the service, they should be able to change that. The other option is to hit the 12 lead button on the LP 12 with only the limb leads attached. It will print out I,II,III, aVr, aVl and aVf (half of the 12 lead) all in diagnostic mode for you.

Rid, I personally use it to: evaluate treatment, effectiveness of CPR, monitor for ROSC, monitor patency of ETI, sometimes to assess/confirm ETI, to maintain PETCO2 in a certain theraputic range depending on patient and pathological process. And yes I like to assess capnographic waveforms although it's not often an issue.

Unfortunately, yes.

The money that I make is largely why I continue to work where I do and do what I do. I do enjoy the profession and everything with it, but money does matter. I couldn't fathom doing this job (and really that's what it is, a job) for only $30-40k a year.

Yes we use it. Pretty standard dosing Versed 0.1 mg/kg to max of 5 mg single dose (max of 5 mg if given with fentanyl) and/or Fentanyl 3-5 mcg/kg to max of 250 mcg single dose, can be repeated prn. I think it works okay if you adequately dose the patient and if there is no underlying pathology that won't be overcome, as described earlier. I have in the past elected not to attempt to intubate because I knew it would fail for those reasons so I will scoop to the hospital and let them use their sux. Usually I'll ask the ER Doc if I can do the tube, only been turned down once, so at least I get the stat and the exposure. In the last 3 years our overall intubation success rate has been 87%, most failures from QA/QI seem to stem from failed RSS or pharmacology assisted's (as opposed to cardiac arrest), especially in trauma. Why? I'd like to assume it's a combination of poor decision making and not having the right adjuncts. Our medical director adamantly opposes the use of sux prehospitally in a larger system like ours, despite the fact that we meet or exceed every recommendation from the NAEMSP position paper.

PAI, MFI, RSS (whatever you want to call it) and RSI are for all intents and purposes the same thing with one difference, RSI utilizes paralytics- in most cases an ultra short acting agent, succinylcholine. Whetether you are using a single agent (narcotic, benzo, anesthetic, etc) or a combination of them, your goal is to get the patient to be adequately sedated. As long as we are expected to adequately capture a patients airway, there will always be a certain percentage of patients that will require paralysis to intubate them. On these patients, you will never be able to give enough versed, fentanyl, propofol, etomidate, etc. to decrease their airway tone, abate trismus, etc. Generally I agree with success rates and proficiency in intubating. The problem is, if the patient has a GCS of 3 in cardiac arrest, no one really cares about when the last time was they intubated or what their success rate is, because it needs to be done. What happens if they can't intubate that patient? Either learn from what didn't work and try again or use a back-updevice. The same can be said for RSI. Either we should expect people to do it all, or not at all. Not half assed somewhere in between. If you have a protocol for PAI (RSS, MFI), you should probably have an RSI protocol instead.

Unconscious "Butt Breathing"

Based on the above information you provided above, why then do you post the following below? How did they fail to C-collar him at all? It would be physically impossible to do this. Did he have neuromuscular defecits before he was moved?

Anecdotally I see this happen when I perform an EJV cannulation. When the only access I have is an EJV (unable to obtain peripheral access), take a quick look. If you see nothing visible, have someone grab the patients ankles while on the floor or stretcher and lift them up to the waist height of the person holding the ankles while standing upright. Whola, engorged EJV's. Although this isn't a true Trendelenberg position more of a modified Trendelenberg, I think it is probably more effective and practical in most instances in patients without concern for SMR. Unless they are on a LSB, achieving the 10 degree tilt for us is impossible and this is a good alternative that I have found works.

I agree in that I think it is a great secondary device but it is only as good as the operator. It could probably be even better if people would use it appropriately. The most common problem I have seen that leads to unsuccessful attempts is removing the laryngoscope blade prior to ETT insertion. This creates greater difficulty passing the ETT because it allows for a larger amount of soft tissue to obstruct the tube and create an obsticle course. It also works well in patients that are moderately anterior where you can see the base of the cords but can't get the tip of the tube around the tight angle despite the use of a stylette, curving the tip and trying to angle the tube up using the tongue or bottom teeth.

Anthony, on the risk of offending you, I'll be point blank. If you are going to practice on the street based on your comprehension of "law" in your area or what an instructor has told you, you are going to get hurt some day. If you are going to put the "law" ahead of your safety, you will be one of those people that runs into a shooting scene because you feel obligated to protect the patient firts. Remember what they drill into your head in scenarios SCENE SAFETY is paramount and occurs before you do anything else. This means neutrilize any potential threats. Your comprehension of a patient giving consent is based on textbook and classroom teaching and is wrong. When a patient gives consent (whether it is stated or implied) you don't need to ask, "can I feel your head?" "can I expose your chest?" "can I take your blood pressure?" for every thing you do. You need only ask once or it is implied when they willingly accept assessment, no more. Consent ends only when they voice disapproval, and not until. Because there is no law that stipulates you are allowed to search a patient does not mean this is a restricted activity. It would be encompassed in many other laws, such as those already mentioned. Based on your description of these laws and with respect to battery, we would all probably be guilty of battery on a daily basis. If you search a patient and they don't object, there is no battery. End of story. If they object, they get the hell out of my personal space and leave or deal with the police, those are their two choices. Then anything found during a search can be used against them in criminal proceedings. Go and gain some experience on the streets working in a hostile environment and then come back and talk to us about how we are being impolite to some of our patient group. Until then, I rest my case. (And this is posted with respect, not with belittling, as you appear to have some intelligence.) Remember, mothers know best, right?. Even they used to tell us to put butter on burns.

So if a patient gives consent to treat, they consent to allow you to touch their person, right? They have implied their consent to allow you to touch them (not battery). If in the course of your head to toe assessment, you do a rudimentary 'patting down' of their pockets and other hiding places all the while everything is done on the outside of their clothing. If any articles of clothing are removed from their person (coat, bags, etc) how is searching these items unlawful if all we are talking about is battery? As well, when a person gives consent to treat, it is implied that there are no restrictions and they have the right to stop the proceedings at any time. Consent is formed from the moment a person calls for EMS or they ask you for treatment. If they are a psych patient being arrested under mental health laws, they have no rights, consent is implied by the mental health law (unless your local laws say something different). Otherwise in non mental health situations, unless they specify what you can and can not do, consent is implied that your permission is global and unrestricted. For example, when the police ask if they can enter a persons home, once inside if they can visibly see anything, they have the right to broaden their search based on evidence found in line of sight. If I am searching them (I mean doing a head to toe exam) and they tell me to stop, a warning light goes off. What are they trying to hide and why? I would also be suspicious of anyone that would attempt to sue through the courts as opposed to trying to first lay criminal charges. If on your head to toe exam (search) you find an object that you feel is a concealed weapon, you should have the right to disarm them of that object (i.e a knife in their waist band) because you feel they are a threat. Bottom line is do what you need to do, with good reason, to make it home after every shift. If you have reason to believe they have something on them, let them sue. Document your reasons well, formulate your thoughts and let the trial begin. I'd find it hard pressed that any civil action will be found against you for trying to protect your safety. I would think they would be laughed out of the courthouse.

Isn't that what I said too? So because you can be sued for anything, you won't search a patient? You can be sued for not treating their pain, taking them to the wrong hospital, taking to long to respond.... The list goes on. How often does anyone you know get sued for their actions or lack thereof at work?

Re-read my post, did I direct my comments to you? Perhaps you could enlighten us as to the ability that would allow a patient to sue you for searching them? Keep in mind in your litigous society in the U.S, you can be sued for anything so how does this matter here? It will be a cold day in Hell before I worry more about the chance of being sued by a patient than protecting my welfare for doing a body search for weapons. How about your family launching a wrongful death suit after you are killed by a concealed weapon that had you taken 1 minute to look, could have been avoided.

IF you don't want me to search you before we get into an enclosed space, you can walk away and I will refuse to treat or transport you. For those of you that are nieve enough to think it is illegal to "search' someones pockets, think again. There is more than one way to skin a cat and thus, there is more than one way to search a person. You can do a cursory quick pat down and feel for potential weapons or other concealed items. If in your judgement you feel there is something there (i.e a knife) you should have the right to either: - remove it, - call for the police or - leave the scene. Two of those three options involve delaying care and/or abandoning the patient. Which makes more sense? Isolate the potential threat. Do you think a D.A would honestly try to bring charges against you for trying to protect yourself and go home to your family? Our department has SOP's on how to deal with abusive/aggressive/violent patients. We have also been issued ballistic vests and trained and certified in Pressure Point Control Tactics as a form of self defense as well as situational awareness training. What does this mean? It means our department recognizes that we often work in unsafe environments and have taken measures to help us protect ourselves.

The better of the two. :wink:

We have a partnership with one of our inner city shelters. If we have a 'patient' of this type that needs to go somewhere but not necessarily a hospital, we call them and they respond to pick them up from us. We donated one of our old units that they have converted to meet their needs by allowing them to have warm food and beverages available to serve. Basically they have a certain response area and we have a protocol that each patient has to meet in order to be down loaded to this service. It has been utilized for about 3 years and it has worked quite well and I haven't heard of any problems stemming from it's use. The only other choices were to either transport to hospital or to call the police and have them take them to cells or a shelter (but we would wait for hours for them in some cases).

I agree with this and from what I have heard and read, Amio is better as an antidysrhythmic for perfusing rhythms, especially VT compared to Lido. On the other hand, has Lidocaine itself ever been proven to be clinically effective or is it also of a VooDoo class of it's own (something that withstands the hands of time)?

I can't speak on Amiodarone, but with respect to Lidocaine, I have found it to only be regularily and quite effective in refractory VF. Everything else is a crap shoot.

Apparently because you don't seem to be able to differentiate the difference between a tracheostomy (which would be a surgical procedure done in the O.R, whice I have not yet claimed that we do) and a cricothyroidotomy (which obviously we do do). In the initiation of a crichothyroidotomy, I guess that you "stab" through the skin initially as opposed to making a vertical incision. I'd expect more from an RRT. In the initiation of a crichothyroidotomy, I guess that you "stab" through the skin initially as opposed to making a vertical incision. That aside, I've yet to see an effective rebuttle to the questions I have asked in the last few posts.

Well, I fall to my knees in envy at your superiority :? I have quoted two sources and provided a link that can be researched by anyone, both of which substantiate that the performance of a pericardiocentesis is indeed within the skill set of the Alberta EMT-P. Other than anecdotal huffing and puffing and posturing, you have not provided any data or resources to support your position. Please provide me the "legislation" that supports your position. Where have I suggested that this is something that is, or should be, performed on a regular basis? Where have I suggested that we all go out and look for someone to needle in the heart? I was simply suggesting that it is something included in our skill set (as is currently intracardiac drug administration, not to suggest it is ever used). I'd hope that you would be willing to think outside of the box enough that in a patient with a positive mechanism, clinical presentation and extremis (such as traumatic cardiac arrest), with no other options available to you, you might consider doing something that might help actually save a life. Have I claimed it has a high success rate? Have I suggested it is something that will always be effective? Even if it is effective in 1% of patients with an existing tamponade, is that 1 patient in 100 not worth it? I guess that as a last ditch effort you will sit with your hands in your pockets while you debate the merrits and validity of trying something that might actually work. Oh, by the way, you can also tell my patient from a month ago that had two holes in his left ventricle from a central stab wound that performing a thoracotomy in the ER is contraindicated because of the extremely low (1-2%) overall success rate. Because he got to walk out of the hospital and hug his daughter again less than two weeks later, I guess it was a good thing that the surgeon thought he was worth the risk despite the fact he was a statistic.

Boy, from a person in Ontario you seem to know your stuff about Alberta. As well, since you and Squirt know each other so well, I'd almost say you were the same person. As for the comments about doing a pericardialcentesis, you are correct regarding wanting to have people properly equipped to do the job. That said, if you have a patient that clinically presents to having a tamponade that is going the route of being one of the 98% mortality statistic group, is it going to hurt to attempt to intervene to become one of the 2% of survivors? Consider the risk vs benefit scenario. There is always more than one way to skin a cat. I will concede that it is a very invasive procedure but if you have an injury and a mechanism together in a patient that might benefit (live vs die) from it as a temporary measure, what is the harm? I'm not talking about doing this in an otherwise healty person, using alligator clips to confirm contact with the myocardium, it should be considered as a last resort. Kinda like a needle decompression in a tension pneumo. You know, TENSION, as opposed to a simple pneumo. If I have a patient that is hypotensive, decreasing LOC and all the other fluff and puff from obstructive shock, I'm not supposed to decompress? Again, I'm not comparing this to a simple pneumo where you have time to do a AP CXR, you base it on clinical presentation (heaven forbid we assess our patients and treat them as such) As for the AOCP document, the teaching institutions have been teaching to that level and ACP has been examining at that level since Feb 2004. Are you familiar with the current gap training? Have you had a read of the Alberta Health and Wellness Medical Control Guidelines (provincial protocol) relating to pericardial centesis in mechanical shock? It is indicated in Section II / Medical Guidelines and Drug information /- Shock/Trauma Emergencies / Mechanical Shock pp 85 - all EMR and BLS assessments and treatments should have been done prior to the following: -Auscultation of chest breath sounds symmetrical and present; yes/no -Yes- Suspect cardiac tamponade- JVD, narrowing pulse pressures, trachea midline, muffled heartsounds (Becks triad) -Consider: PATCH to physician re: Pericardiocentesis Could you please provide me with something to substantiate that pericardiocentesis is NOT within the skill set of the Alberta EMT-P other than a bunch of threats and verbal diarrhea? And, how is it that the AOCP document is nothing but making it's way into the fireplace? So I guess that the fact that I know and am friends with the editor of the document and his extensive research comparing the ACOP with the NOCP to see how we meet (sans EXCEED) it, means nothing? Perhaps you should forward your concerns to the Continuing Competency Program Coordinator continuingcompetence@collegeofp aramedics. and bring them up with him. Regarding the vacancy of the CEO/ Registrar, would it take much to be more qualified than the interim/acting CEO (former President B.C)? Squirt and Letterman, does Squirt by chance have the initials of W.M?

Hmmm, lets see, yes we carry the commercially available Cooks Cric Kit, which is an actual #6 sized trochar that is cuffed. In the absence of having this, it is a scalpel and shortened #6 ETT (sounds like a surgical [initiation of an incision] cricothyrotomy [incision through the skin and cricothyroid membrane] to me)? What does "pseudo surgical tracs" mean? Either is is surgical or it's not. Perhaps you could define the medical term that I am stumbling for. Again, lets refer to the AOCP document (available to anyone that would like to view it) Alberta College of Paramedics AOCP, pp131, if you will. Major Competency Area: I I. Patient Management Skills Priority: One Competency: I-1 I-1 Perform Airway Management A Paramedic will: I-1-1 Demonstrate knowledge and ability to perform basic airway management skills: (removed due to length) I-1-2 Demonstrate knowledge and ability to perform intermediate and advanced airway management skills including, but not limited to: • Non-visualized airways; • Nasotracheal intubation • Visualized airways; • Endotracheal intubation • Mallampati Signs – Class I, II, III, IV • Surgical airway; • cricothyroidotomy • percutaneous transtracheal jet insufflation • Tracheal suctioning; • Direct laryngoscopy with Magill forceps; • Sellick’s maneuver. FYI, The Alberta EMT-P has adopted the theory of the national CCP but doesn't include the practical (yet). Alberta does not have ACP's, nor will they ever have. I'd suggest you do a little more research and understand what is happening with the College and how we compare to the NOCP level. It is quite apperent that you don't know what you assume and try to pretend that you do. As for the comment "Now you may not know the true pmhx in alberta here as you really sound like a new grad" I'm not about comparing the size of our members in public, but my experience can be validated either through the opinions of those that know me here or would you like to contact me directly? Your "professional" responses so far reflect an appearance of your lack of experience so I will let that speak more for me.