AZCEP

At least there are more and more articles being written about it. Unlike some things, that get one, intubation has had dozens that have actually looked at both sides of the issue. Hopefully we are learning from these.

The use of "renal-dose" Dopamine has never been proven to be terribly effective for increasing renal blood flow, or reducing systemic blood pressure. The interpatient variability is simply too great to suggest using it as a standard treatment without invasive monitoring capability. If you are allowed to float a Swan prehospital, you are too cool for most places. The response to Dopamine will change dramatically depending on how sick a patient is. Some will respond favorably to 1-2 mcg/kg/min, while others won't consider a response until the dose is significantly higher. The best way to consistently increase renal blood flow with Dopamine is to get into the Beta range, and use the lowest dose to get the response you want.

I think the direction Ace is coming from is that being paralyzed is a quite painful situation. One that would be lessened through the use of an opioid analgesic. Fentanyl and/or Morphine are commonly used for this purpose. Do you have this ability in your system? Benzodiazepines and even Etomidate do nothing to relieve pain. They are only able to make the CNS less able to respond to the stimuli. To quote eMedicine: In current practice, narcotic refers to any of the many opioids or opioid derivatives. In cultivation since approximately 300 BC, pure opium is a mixture of alkaloids extracted from the sap of unripened seedpods of Palaver somniferous (poppy). Opiates, such as heroin, codeine, or morphine, are natural derivatives of these alkaloids. The term opiate is often used (albeit slightly incorrectly) to refer to synthetic opiate derivatives, such as oxycodone, as well as true opiates. So in actuality BZD's are not narcotics, in a strict sense of the term.

Give it time and someone will have the revelation that they will sell more Vasopressin in a prefilled syringe than in vials. The cardiac arrest algorithm is all inclusive now. You have a dead patient, they are all included on one algorithm. Basically, if the patient is pulseless, you can use vasopressin. I for one would like to hear how well it works for you and your patients.

Doesn't exactly give you a warm/fuzzy about the system now does it. :shock: Until we start doing door-to-door checks, I guess we just have to expect the public to ask for help when they need it. Good or bad, is there any way that we could get better responses when they are needed most?

Physiology answers all questions. Some of the more detailed items that are included were a little tough to grasp. The physiology section helped to iron things out.

Whoops, ugly American there. Must have gotten hung up on what was written, and forgot where it took place. I would still like to hear some experiences of other providers to similar situations, though.

That is some great information. Maybe a bit deep on the neurophysiology, but it does help clear up some of the other issues.

I think... I think... I think... I'm glad I don't do billing, is what I think. Seems we have gotten back to the issue of how to prove we are doing a job that no one else can, and doing it well enough we can't be replaced with reduced levels of care. Whole other topic for discussion though.

Come on now, we can't think that far ahead, remember? The clippy thingy goes on the finger, no where else.

Anything that can remove the human factor from CPR is worth looking into. If I never have to do compressions going down the road again, it will be just fine with me. My safety, CPR performance, resuscitation possibilities are all much better if I don't have to do compressions for 40 minutes.

You bring some interesting points up. NTG contraindicated for inferior wall MI? RVI sure, but careful administration with inferior wall MI might respond favorably. No NTG, but okay to use Morphine? They will both have similar actions on the RVI. Morphine is easier to titrate, so you will have fewer negative effects, but you still have to be careful. Prehospital fibrinolysis isn't widely used in the States, but for those that are able, it might be a good consideration. Depending on how long it will take to get this patient to a PCI facility. Atropine would be a consideration, as mentioned previously, but I would shy away from it. The lower doses of Etomidate may very well reduce blood pressure, but if we can get the rate up with TCP, the situation resolves itself, right? The right sided leads would be considered after treatment has begun, only as additional confirmation. Good points, and glad to hear from someone not held to the same standards. These are the situations that we can all learn from.

:shock: :shock: :shock: :shock: :shock: I'm I reading that right? A physician is saying that if one group of paramedics can do it then so should another group? :shock: :shock: :shock: :shock: :shock: :shock: Did I miss something? Where am I? What happened to "paramedics can't intubate"? I feel dizzy all of a sudden. I better step away from the internet for a moment.

To quote one of our physicians, "The patient is the weak link in the chain of survival." Sicker patients can't call for help as easily. Healthier patients don't want to call for help as often. Richer patients would rather see their own doctor. Poorer patients don't want to incur a bill for services that they can't pay. Tough situation created by societal values. Do these same types of situations occur in, say Canada, where the bill is significantly reduced through government assistance? I honestly don't know enough about the Canadian system to say, but would venture to guess that they happen in lesser numbers.

So how do we justify the costs of full ALS capability? Unfortunately, the evidence doesn't support ALS being used very often. Even less when we look at each individual cost of having full ALS. Even as providers, we know that most of our transports could be handled by a BLS provider that is allowed to administer a couple of medications, and perhaps use an AED. Rare is the case that the full ALS system shows it's merits, but when they do happen nobody wants to think about the differences. Is cost effectiveness the best measure to judge a system by? Seems the ER physician, as an example, gets the same bill generated regardless of what type of patient they see, and no one is judging them by this standard. Yes, facilities have instituted PA's and NP's to supplement the physicians, but isn't that what EMS is as well-->physician extenders. Unusual to see doctors making house calls in the U.S. anymore.

Interesting case study, Ace. I'm curious how the pulse oximeter was able to give it's reading. It would appear that although this patient was in a degree of shock, they did not assess pulses manually. I'm of the opinion there is more not being said here, than is. If anyone out there has more information regarding this, or a similar case, I would like to hear about them. Feel free to PM, or start another thread. This is another topic that can't be discussed too often.

I-Olfactory cribiform plate of ethmoid nasal cavity special sensory olfactory epithelium - smell -------------------------------------------------------------------------------- II-Optic optic canal of sphenoid orbit special sensory retina-vision -------------------------------------------------------------------------------- III-Oculomotor superior orbital fissure orbit somatomotor levator palpebrae superioris superior rectus medial rectus inferior rectus inferior oblique visceromotor preganglionic parasympathetic to: ciliary ganglion (innervation of sphincter pupillae and ciliary muscle) -------------------------------------------------------------------------------- IV-Trochlear superior orbital fissure orbit somatomotor superior oblique muscle (poverty muscle) -------------------------------------------------------------------------------- V1-Trigeminal opthalmic (Major branches: Lacrimal, Frontal, Nasociliary, and Meningeal branch) superior orbital fissure orbit general sensory general sensation from skin and mucosa in region at and above orbit V2-Trigeminal maxillary (Major branches: Infraorbital, Zygomatic, Nasopalatine, and Palatine branch) foramen rotundum pterygopalatine fossa general sensory general sensation from skin and mucosa in region from orbit to mouth V3-Trigeminal mandibular (Major branches: Buccal, Auriculotemporal, Lingual, Inferior Alveolar, and Meningeal branch) foramen ovale with lesser petrosal from CN9 infratemporal fossa branchiomotor muscles of mastication tensor tympani tensor veli palatini mylohyoid anterior belly digastric general sensory general sensation from the skin and mucosa from region at and below the mouth -------------------------------------------------------------------------------- VI-Abducens superior orbital fissure orbit somatomotor to lateral rectus (best abductor!) -------------------------------------------------------------------------------- VII-Facial (Major motor branches: Temporal, Zygomatic, Buccal, Mandibular, Cervical, and Posterior Auricular) internal acoustic meatus-> facial canal-> stylomastoid foramen temporal bone branchiomotor muscles of facial expression stapedius stylohyoid mylohyoid posterior belly digastric facial canal-> middle ear-> chorda tympani-> petrotympanic fissure special sensory taste, anterior 2/3 tongue facial canal-> middle ear-> chorda tympani-> petrotympanic fissure visceromotor preganglionic parasympathetic to: submandibular ganglia (innervates submandibular and sublingual glands) greater superficial petrosal-> pterygoid canal visceromotor preganglionic parasympathetic to: pterygopalatine ganglia (innervates lacrimal gland, nasal glands, and palatine glands -------------------------------------------------------------------------------- VIII-Vestibulocochlear internal auditory meatus temporal bone special sensory hearing and balance -------------------------------------------------------------------------------- IX-Glossopharyngeal jugular foramen neck branchiomotor stylopharyngeus viscerosensory pharynx, palate, carotid sinus, carotid body and posterior 1/3 tongue special sensory taste, posterior 1/3 tongue jugular formen-> tympanic branch-> tympanic caniculus-> middle ear middle ear viscerosensory middle ear and auditory tube jugular formen-> tympanic branch-> tympanic caniculus-> middle ear infratemporal fossa visceromotor parotid -------------------------------------------------------------------------------- X-Vagus jugular foramen branchiomotor pharynx and larynx general sensory auricle, external auditory meatus viscerosensory mucosa of entire larynx visceromotor preganglionic parasympathetic to abdomen & thorax -------------------------------------------------------------------------------- XI-Spinal Accessory enters by foramen magnum-> exits by jugular foramen neck branchiomotor trapezius, sternocleidomastoid -------------------------------------------------------------------------------- XII-Hypoglossal hypoglossal canal neck somatomotor all tongue muscles (these end in ‘glossus’) are innervated by CN12 except palatoglossus Or if you would like a mnemonic: On Old Olympus, Towering Top, A Finn And German Viewed Some Hops For functions: Some Say Marry Money, My Brother Says, Bad Business, Marry Money with S=Sensory M=Motor B=Both For assessment, here is a reference card that I made up a while back: Cranial Nerve Nerve assessment I(Olfactory) Identify simple odors II(Optic) Identify letters No visual field deficit III(Occulomotor) Pupillary light reflex IV(Trochlear) Eyes follow in parallel V(Trigeminal) Contraction of masseters/Mandibular deviation Normal perception from face VI(Abducent) Eyes follow in parallel VII(Facial) Normal facial movement Symmetrical eyebrows/smile VIII(Vestibulocochlear Symmetrical hearing bilaterally IX(Glossopharyngeal) Normal gag reflex X(Vagus) Equal palate/Uvular movement XI(Accessory) Equal muscle strength head turn/shoulder shrug XII(Hypoglossal) Tongue protrudes in midline How about Brown-Sequard Syndrome?

Some people will become less than diplomatic with their interactions with us, but often times it is well within each provider's control to alleviate this problem. Some will get out of bed upset about their situation in life, and take it out on everyone they come into contact with. When we walk into a scene, and we recognize this, it makes things much easier for us, if we are able to communicate in a way that these challenges become less of a factor.

I'll bet it was caused by inadequate cleaning of the medication. No other reason for infections to present, right? A bit disconcerting from a consumer's perspective, though.

GA, If you are going to ask for evidence, the least you can do when it is presented for you is to actually read it. Any time we break the skin, or make contact with a mucous membrane, we increase the risk of infection. I notice you aren't asking us to stop establishing vascular access, or is that next? You don't propose that we stop using direct pressure with non-sterile supplies to stop active bleeding, or is that coming? There are some topics you just have to accept as part and parcel of medical care. One of them is the possibility that when we invade the body, the body will fight the invasion, and illness may become worse. Can someone please give this thread some Botulinum toxin? In other words, KILL IT. Thank you.

I hope GA is reading. Yet another way Ace has suggested to improve an EMS system. Let's see, breakfast for 70 physicians, yeah, the budget should cover that. Somebody get IHOP on the phone!

GA, You are completely ignoring the fact that the laryngoscope is not a viable route for the transmission of infection. The articles you quoted don't even support your view, and yet, you offered them as evidence. Perhaps you need to concede the point that the laryngoscope is not a great source of infection. Maybe we should look at other, more commonly used pieces of equipment. Now, as we can all see, the risk of infection is there. Good point. The problem lies with proving that EMS equipment is any more responsible for it, than hospitals. I'd wager that the prehospital equipment maintains a higher degree of cleanliness than hospitals, due to having less equipment to clean. You should also realize that the warning that was given was directed toward the healthcare providers that use the contaminated equipment, not the patients. Potential risk has to be highlighted here. NOte that most of the transmission of bacteria are related to the ventilator circuit, not the laryngoscope. There again, the problem does not carry over to EMS too well. The ventilator circuit, is commonly replaced after each use. I've yet to see one reused prehospital. Anyone that is following the recommended guidlines has done plenty to reduce the risk. Now, if we want to do more, then we will have to bring a cleaning crew with us. I don't see any other way to eliminate the risk of infection when dealing with the envirnomental challenges that we face. If we don't have a clean room to perform in, then of course we are going to increase the risk of infection. This is not something that is taken lightly, but you need to realize the limitations of the environment before making more blanket statements.

So to get these kinds of results the facilities have to believe that we know what we are doing individually. What would be the best way to get this message across? We all have worked with providers of all levels that we wouldn't let treat a sick cockroach, much less a human being, so how do we go about convincing the receiving physicians that, as a group, we can make this determination without them? This is most definitely a serious question, because we are having this issue here locally. Perhaps I'm guilty of thinking locally and acting globally, but if anyone has suggestions, I'm willing to listen.

Gee Ace, I think you made the pilot sick. :shock: And strangely no responses from GA. Hmmm, maybe he wore himself out finding the next pet cause to espouse. Just when things started getting interesting too. :?

That would lead me to believe a raging infection from somewhere. My suspicion would still be the surgery site, but the bowel would hold firmly to second place. Not uncommon to nick the bowel when knives start flashing through the abdomen. Any retraction on the bowel could also create a necrotic section. You could very well be onto something there Ace.