AZCEP

The more resources you look at the better, but the key to assessment is having a pattern to follow. Most doctors, residents in particular, are willing to teach you something. Take the opportunity to ask questions you have, and don't get offended when they tell you something you don't like. Doctors are no better, or different, from all people. Some are very good at what they do, and some not so much. They all have information that you can use, and some of it may well surprise you.

Expecting the combitube to "rescue" an airway is one of the great errors that we make. It's very design will not allow it to work very well once the friable tissue of the laryngopharynx has been traumatized by bad laryngoscope technique. Where an ETT can still be placed through vomitus, or blood, the combitube tries to seal these substances off. When they fill the area around the glottis, the combitube can't perform effectively. Yes, it is a useful tool. As long as those using it understand when it will and won't work.

I use the bougie on all intubations so that I'm prepared in advance for the difficult presentation. This way, I don't have to remove the laryngoscope, reventilate before reattempting.

I have to disagree with you, Spock. You can use the bougie, or flexible endotracheal tube introducer, under direct visualization. Placing it into the trachea prior to inserting an ET tube is the most common method that I've seen. We also pre-assemble the tube onto the introducer to speed things up a bit. Yes, it can result in a traumatic intubation if improperly used. At the 30 cm depth you mention, the coude tip should get hung up at/near the carina and not allow further advancement.

In the two SSM systems I've worked (Las Vegas and Albuquerque), you were posted with your partner, and rarely saw another crew. The only times this would happen is when you were at a receiving facility or at change of shift. In the fixed stations, I've always had more than one crew in house. Two to three crews at the station is pretty common, unless on calls.

System status management to the nth degree. Posts do not promote any kind of teamwork between crews when you never see any of your other co-workers. Every agency that I've been at that tried to use it had problems with any kind of continuity between individual crews. If you can't sit and discuss things that have happened there is no willingness to look out for each other. Theses systems tend to be busier, and there is less time at an individual post in between calls, but you have to wonder why someone would aspire to this type of system. Stations are much preferred. Even when you are not spending much time in them. Occasionally it is nice to know there is someplace where you will not be bothered for a few minutes.

The problem that I have with what you are saying, Richard, is the fact that your protocol is being followed without questioning the utility of it. If you are allowed to administer 15 liters per minute of oxygen using a non-rebreather mask, why are you not allowed to use a lesser device? Is it simply due to "this is how we've always done it"? Could it be that no one has thought to question this? I fully understand that you can only do what you are allowed, but this is not a good way to present an EMT's ability.

Good way for cardiologists to get more insurance money from their patients. Focus on prevention, instead of some new gadget.

One of the biggest problems with the demand valve is it's ease of use. The uneducated, uninitiated provider can and will over inflate the lungs causing all types of problems. If you have a choice, or a need for an alternative ventilation source, pick a good ventilator with the functions you need. Definitely more expensive on the front end, but you will get many years with fewer problems from the people using them.

Having providers and instructors buy into the dogma without critically thinking about the situation is just a part of the problem. Hopefully steph1030, you will be introduced to the critical thinking process as part of your paramedic education. There is no good reason to allow this short sightedness to continue. You are the provider(s) in the street. You have the ability to think about the situation that your protocols are trying in vain to cover. Take a second and apply what you know.

That is a problem everywhere, not just in your area. Providers are not supposed to think about what they are doing, and if it is going to have a benefit or any therapeutic value. The use of high flow oxygen needs to be tempered with the anticipated risks and benefits you are looking for. It may be a good time to discuss changing this protocol with your medical direction. More and more evidence is showing that high flow oxygen is not helping as much as we used to think.

I just wanted to illustrate the significant difference between the two. Having providers following a "protocol" because that is how it is written is a mistake. Cookbook anyone? Allowing them to follow a "guideline", or "recommendation" allows for more freedom in the decision making. I know it's a dangerous idea in some places to have providers thinking on their own, and may smack of heresy to many. For this I apologize. :roll:

tniuqs, I'm trying really I am, but I don't see how this is "Funny Stuff". Truth be told, the "system" is beginning to collapse on itself without much effort from anyone. Detroit, Philadelphia, Washington D.C., and recently Los Angeles, to name a few, have had to make some major changes just to continue with operations. Things will have to get much worse before they begin to show any sign of improvement.

ACLS is not a protocol. AHA will not tell providers that they have to do anything. They will only recommend, based on the evidence they have. The current recommendation is to provide the lowest possible flow rate to maintain an SpO2 >90%. If there are signs of respiratory distress, you can increase as needed. This has already been mentioned several times in this, and many other threads.

I'm a bit surprised that a guideline needed to be written into your protocols croaker. It seems that "provider discretion" should have been included, but I suppose you have a pretty wide base to work from with what is there.

That's a good illustration, but you are still responsible for what happens. Medical control will be the deepest pockets, but don't think for a minute that will absolve you of liability.

Can't say always. Too finite a description. If a patient does not respond to the initial treatments provided, then I will obtain a 12 lead. The ECG is already in place while treatment begins, so a 12 lead is not a big problem. Along with the 12 lead, you should consider capnography as well.

mackeydad, your situation is unique, at best. No one should be expected to allow any condition that will be unsafe to them. You may well be within your rights to not be restrained by applicable law, but that does not give you the right to place the EMS provider at risk. If you are unable to tolerate the thought of having a restraining device placed on you, how is it that you are able to be in the patient compartment of an ambulance? I do not wish to argue the point, but this is a question that I continue to come up against as I'm reading your responses. Just looking for some clarification. You have the right to refuse, and I'd be sure to document the situation thoroughly. This would not protect me from the eventuality of you becoming a lethal object in the event of an accident. Not only would I be responsible for the injuries that I allowed to happen to me, but I would also be negligent in allowing you to become further injured because I did not reasonably restrain you. I apologize now, but my safety comes well before anyone else's.

You and your associates have made a critical error in considering using the demand valve for any patients. CPAP and BiPAP are not the same mechanism, and need to be used long before a demand valve. All of the information from your "old school" peers needs to be severly discounted. Their "anectdotal" experiences have no place in the current EMS environment. The continuous pressure of CPAP is where the benefit lies. The generator creates the pressure to maintain airway patency. The demand valve will allow the airways to collapse, only to be forced back open with the next ventilation cycle. You have no way to measure the pressure that is being generated by a demand valve either. A BVM gives you a feel for compliance, a CPAP/BiPAP generator will only provide pressure to a preset level that can be monitored. The AHA guidelines recommending a two-hand mask seal are not new. They've been published since the 1996 revisions. A demand valve, by itself, is just as likely to cause gastric distension as any other ventilation device used without a secured airway.

Amiodarone wouldn't have been any better a choice than the Lidocaine. Following the defibrillation, the patient was in an AVB/bradycardia. Using any of the antidysrhythmics COULD have caused even more conduction system dysfunction.

The American flag, and those of most countries, is quite versatile. There is no specific requirement for which shoulder it goes on. The recommendation is if your service patch is on the left, the flag goes on the right. If you have the choice between the two, the flag goes on the left. Just remember, nothing goes above the flag.

In reference to #17: You may not ask the score of any sporting contest that has the scoreboard/clock clearly displayed on the screen. Leeway can be granted for information that is not clearly displayed. Everything else will constitute a violation of said law, and result in immediate removal from the venue in question by all means necessary.

No, scotty, I can't get you a deal on anything from Physiocontrol. The LP12 is just the equipment I'm most familiar with. I'd probably discuss the benefits of the Zoll, or Phillips, if I had anything more than passing information about them. Now, if you'd like to buy a bridge... :wink: For the benefits of your future patients, to no one in particular, take the time to pick the brains of every physician you come into contact with. Each will have more information, and significantly differing opinions of how to manage a given situation. You will learn more in a few minutes, with an open mind and a willingness to ask intelligent questions, than you did all through your EMS education. Many enjoy showing you what they know. Occasionally you will even be able to use the information.

Is that CPR being done in the first strip? If so, the wonders of bystander CPR show up again. If not, you must have walked in at just the right time. At the beginning of the first strip, it looks like there is a PEA showing. Maybe your third degree AVB was there the whole time. Having just the one lead (paddles) set in what is probably lead II doesn't tell you much. You might consider setting your LP12 so that it will show three leads at once. This isn't a hard thing to do, and makes the information readily available. Now for the lidocaine. I'm not entirely sure that it was necessary. You did have a period of VF, so it's indicated, but with the presence of an AVB post defibrillation, it may not be the best thing to do. A dose of atropine is somewhat useful, but the TCP would probably be my treatment of choice. Easier to control, and less damaging effects to an apparent MI. You got him back, and the cath lab fixed the problem. Hopefully his brain wasn't hypoxic long enough to cause a problem down the road. Good work.

Shane, You are right in Procainamide being de-emphasized, but it still appears for wide complex tachycardias. Just waaayyy down the list. With the new information, I'd suggest that this patient has overused their MDI and is suffering the consequences. Assuming it was albuterol, I'd suggest using some magnesium as your anti-dysrhythmic of choice. The electrolyte situation is probably contributing and it may work a bit better than a blocking agent. That aside, see if you can get the patient to perform an effective Valsalva or consider some Adenocard. With the rate where it is, I'm betting this is A Fib/flutter. I wasn't there, so I can't say for sure, but was the rate changing frequently? The strip seems to have some irregularity in it, but the rate causes the R-R interval to look constant. If you don't have 12 lead ECG's available to you, which many LP12 users don't, this single patient could be your impetus to get them. If you do have them, and had a short ETA, not doing one is reasonable. Your ETA would have to be less than 2 minutes, but that is a possibility. Don't feel that we are trying to bash your management. As Ruff stated, I too have been down this discussion route with medical control several times. Your ACLS guidelines will help to support your decision to achieve "expert consultation", but you didn't quite get all the information that you could have.