AZCEP

You could have done a much better job of immobilizing the kiddo with the KED. It is almost designed with that situation in mind. Particularly, when considering the design of most vehicles, the KED is best suited for kids and hip fractures.

I find it interesting that you are still using Demerol. Most areas have taken it out of the EMS stockpile out of fear of adverse effects. What I wouldn't give to have some Toradol as an option.

That is all the education on reduction that most prehospital providers receive. "One attempt to reduce, then splint in place." Nowhere in the curriculum is it mentioned to properly align the bone ends, techniques for application, or how to best splint the injury site. "One attempt..." and move on. As I best understand it, the attempt is designed to get the bone ends back into their neutral position without damaging the vasculature. Unfortunately, the right way to perform this isn't taught very often. :roll:

Not every patient requires the same assessment. You do not need to remove the clothing from EVERY patient you see. No protocol can fit every patient, so why would we think that an assessment would. Tailor the need to expose with the presentation of the patient.

I answered no, because of the word "all". There are just too many situations that don't need managed this way. Yes, a thorough exam is important. Exposing and examining is critical to finding a good many things. Patient modesty, is also a consideration. Particularly in the public arenas that we often find ourselves. A focused examination should be able to find most things without necessarily removing all the clothing. Is it easier to do when the patient is in the buff? Definitely, but this does not mean they all should be forced to achieve it.

Aside from the manpower requirement, that sounds pretty reasonable. Thanks for sharing that information. I've never heard of such a thing, and now I'm off to see if I can find more details on the procedure. Always willing to make the envelope bigger.

Just to clarify, Etomidate, Versed, Valium do nothing for the pain. They are not analgesics and do not have that property. They are sedative/hypnotics. Meaning, they will "disconnect" the brain, but not shut it off. The patient still feels the pain, but is unable to respond to it. Versed and Etomidate are great combination agents so you don't have to use as much of either one. Less Versed is less likely to affect the hemodynamics, and less Etomidate is needed to induce a hypnotic state.

No. Advanced directives do not dictate anything. They only suggest that the patient has made a determination of the degree of care that they want, in the event they are unable to communicate it for themselves. This is the whole purpose of having it written out and notarized. Family members can revoke these "orders" at any time, and many do because they do not want to deal with the impending death of a loved one. Often I will inquire about the presence of a living will (though I can't legally follow it), or a DNR. If the patient and family tell me that one is prepared, I will make sure that everyone involved understands what it means can and cannot be done. In the living will situation, if a patient has taken the time to get this drawn up, it would be quite arrogant of me to tell them that I can't follow it. I will then make sure they understand the situation and document the bejeezus out of what they tell me. In the state of AZ, we have a "Prehospital DNR" form that must be signed/notarized/witnessed with photo ID of the patient on the form. When it started it had to be on 8.5 X 11 ORANGE paper, but this has since been removed. If the DNR is still in place, we are still somewhat obligated to notify medical control. If the patient does not have the prehospital form, but has some other type of documentation, I take this into account, and so does the receiving physician. These are not as difficult to follow as people tend to make them. Provide comfort measures, allow the patient to make decisions if possible, contact medical control with questions. Do what is reasonable for the ultimate outcome of the patient, and consider how you want to be treated in the same situation.

I wish I had Entonox available, but the weekly checks were getting out of hand. I've had similar experiences to what you relate, Dust. I have to say that I'm willing to take a lot of heat from "experts" if I can get a thank you from the patient that was in pain, and is now relatively comfortable. I've even gone so far as to try to discuss things intelligently, but those discussions usually end up in the toilet. :roll:

Yes, I think that I am able to adequately manage a patient's pain, but... I do not stay in the proverbial box for this one. There are many ways to manage pain that don't necessarily require a narcotic to do so. Limiting movement, putting the patient at ease, simple ice packs occasionally can reduce pain to a degree. IM meds can be used if needed, and I've used them for pediatric burn patients. Stops the squirming so the IV is much easier to start. We only carry morphine for specific pain relief, but I've found that a dose of Benadryl adds to the effectiveness quite nicely. Valium does nothing for pain, but it will help to reduce the CNS involvement. I've also dosed ASA for pain other than cardiac. Amazing how many times it is forgotten.

I had one of these incidents as well. Definitely a "yeah right" moment. Traumatic amputation using a Bengal tiger. Amazingly ours happened the same weekend that the entertainer in Las Vegas was attacked. We thought maybe the moon was in some special phase.

Look for IN seizure control using an atomizer for the Versed. Might have been all you needed, or maybe not. You carry an acceptable alternative to racemic epinephrine already. 1:1 000 in an SVN performs the same function as the commercially prepared solution. This patient likely would not have benefited much from it due to the lack of volume. If there was upper airway obstruction, perhaps, but not for strict asthma. Use a little epi before they code, or a lot after they do. Luckily you weren't restricted, as some are, to using vasopressin after he arrested. Live and learn.

Entertainment only. With a bit of flashing lights thrown in for effect.

Criminy Doczilla, I know I'm just a simple country paramedic, but I already said most of that. :wink: Glad to know that I wasn't pulling the information out of a dark place though.

An IV dose of Lidocaine will not "numb" anything. In order to get this effect you would have to deliver it topically. It can be done, but takes a bit longer than you would think. 4% lidocaine in an SVN will do a wonderful job of this, but most don't have it available. The use of Lidocaine for premedication in a head injured patient is still recommended, but the science doesn't really support it too well. Even if it is forgotten, the transient increase of ICP following intubation is best managed by getting the tube the first time. Adequate relaxation may be a problem using the Etomidate as well, but if you are moving toward RSI, I suppose it is a start.

It's on whenever I want to watch it. Got the DVD.

It can be done with an NG tube, but they tend to be too flexible to be very useful for this purpose. There are also oxygen supplying versions of the flexible endotracheal tube introducer on the market. They allow for the connection of oxygen supply tubing to a standard bougie, and it is delivered through the distal end. A bit pricey for the times you will actually need it, but they are out there.

So you are getting good at them then, eh :wink: With the number of treatments he took, we should not expect great results from our SVN/MDI's either

This patient does not need transported by ambulance. If other resources are available to do so, they should be considered. Because the guardian of this patient is requesting ambulance transport, then you should provide it. The matter of taking a unit out of service to do so is not the immediate concern. Because your allowed to refuse transport for those that don't need it you should have a good grasp of the liability that this presents, and it sounds like you do. This situation is a bit of a medico-legal mess. Transporting without the mother should be done only in a life threatening situation or obvious abuse, which this doesn't sound like. Transporting with this parent constitutes aiding an illegal immigrant, and could result in jail time. This argument could go on for years, and there is no clearly right answer. It is a discussion that needs to happen though.

Most places do not have the option of NTG infusions due to the volatility of the solution. It tends to not do well from a shelf life perspective in EMS. We do not have this option, but it is one that should be considered as you are working your patient's condition into a plan. It does work very well, and EMS can provide some basic treatments that will ease the transition to the infusion. http://members.ozemail.com.au/~jamesbc/pages/drugs/122.htm Obviously, the drip rate that is set will be determined by several things. The patient's condition, response to the medication, the concentration you have on hand, and the drip set used would be some of them. The site I've referenced is from Australia, so the terminology will be a bit different, but the information holds.

No, I am not a lawyer, so my responses can be trusted I only relate the information as it was explained to me by a sheriff's deputy. If you do not know the status of the patient, or can not obtain the information reasonably, you can be cited for transporting an illegal. Delaying transport to obtain the information would not be encouraged, and often it would be the agency at fault, not the individual provider.

If you are transporting an illegal immigrant, then you are breaking the law. You may not be required to notify law enforcement, but they will be glad to educate you when they find out. Yes, you are breaking the law. Scenario or not.

As an illegal immigrant, by transporting you are risking INS seizing your patient, your ambulance, your partner and you. They are empowered to place all illegal immigrants, and those that assist them in custody. No, I would not have a problem transporting the child and mother, but I'd be very careful who I broadcast the information to.

The 1994 version of any text should be used as the most general of references. Too many things have changed to make the information that it contains worth following. Current recommendations are to perform 2 minutes of compressions, hypothermia or not. An AED will also deliver a shock when it is determined a shockable rhythm is present. To the best of my knowledge, AED's do not have hypothermia considerations in their programming. They will work the same way they always do without using the presence of hypothermia as a determinant.

I'm not sure I understand your question scope. If I'm reading it right, you want information on management differences between chronic and acute right heart failure. Is this right? The chronic patient will likely already be on some degree of diuresis and possibly a long acting nitrate, like isosorbide. It would also be expected to have an ACE inhibitor or ARB in the mix. These patients are not ususally as sensitive to the preload reduction that the acute patients are, due to their body acclimating to the many different treatments that are already being used. The acute situation is quite different. These patients have not built up a tolerance to any specific treatments, and will respond much more dramatically to what you will try. Using a blood pressure number to decide to use NTG is a bit troublesome. The sensitivity of the patient to the agent will have a more significant effect than what their initial pressure is. If you start with a low pressure, but their are no signs of end organ problems, NTG may well be considered. You might pretreat with some fluids first, but don't eliminate the option based on one number. Using IV infusions of NTG is much preferred in the right side involved patient, due to the ability to titrate to effect. The signs of a right sided MI can be quite different from other chambers of the heart as well. Where anterior and lateral MI's become tachycardic and hypertensive, the right side will be bradycardic and normo- to hypotensive. The anterior and lateral areas progress to this, while the right side begins this way. The XII lead is the best tool you have to add information to your assessment for this situation. If you see signs of inferior wall involvement, consider the possibility of the right side being included.