AZCEP

This is a discussion that needs to happen more and more. Too many providers want to "square-peg, round-hole" this situation and it just won't work. Increase perfusion pressure. How do we want to do this? Fluids, vasopressors, inotropes, all of the above? Increase heart rate. Which route do we take? Electricity, anti-cholinergics, sympathomimetics, a combination of all of them. Decrease myocardial workload. The options abound. From what I've seen, the only treatments we agree on are oxygen and ASA. Even these have some differences as to how much we should use. This is the stuff that class just doesn't prepare you for, and we probably should.

The lack of available personnel is entirely due to upper management. The duty supervisors learn how to do their jobs from the administrators, so what rolls down hill, etc. The people running the calls may make interpersonal cohesiveness difficult, but if you know that management has an idea of what you need to perform, then you can get by.

What if the rights of others infringe on mine? What if the work place becomes uncomfortable for me? You can't adequately argue this point when you try to cover each possibility with the broad stroke of self-righteousness. You keep to your business, and I will keep to mine. Some of the administrators that put these rules in effect are only setting their employees up to fail. Keep your personal beliefs to yourself, and this goes to everyone. It is very difficult to find anyone that wants to hear them.

Just to be clear. You are not asking about not having enough personnel, right? For the routine vehicle checks and following of SOP, if the employees don't do it, then it falls to the duty supervisor. When things don't get done, the supervisor needs to have a mechanism in place to ensure it doesn't continue.

A recent article on emsresponder.com talked about Hemopure, another oxygen carrying alternative to blood, was not going to be allowed by the FDA to be tested by the military. Polyheme is the only game in town. Guess I will have to carry a salt shaker with me on my next trauma call, eh?

Dopamine is a more titratable to effect medication than Epi is. You can increase it just enough to get the blood pressure back without increasing the heart rate too much. For bradycardia, Epi is 2-10 mcg/min and it will do a bang up job of increasing the heart rate, but it can make the blood pressure worse. Alpha and Beta effects don't always play nice with each other. The infarcted area will become much bigger as well.

Not so much shy away from the TCP, just consider that while you are using it you will be making the MI bigger, and if you turn it off, you might not be able to re-capture the heart with it. Patient comfort will also take a hit, but at this point I sure the patient wasn't feeling too well anyway. With Dopamine, you would be able to monitor the rhythm better, and treat the pressure, which is the problem in the first place. You are right about the use of electrical therapy for the unstable patient, but keep the underlying problem in mind.

I had a similar patient not too long ago. A very tense transport, I tell you what. Atropine might be a good temporizing measure, but once it is in you can't shut it off as it makes the MI bigger. Pacing should be a consideration, but it too will make the rate increase, and extend the MI. Dopamine and Epi, same problem. Was a right sided view done on the ECG? It could have given you some very useful information. The patient presentation screams cardiogenic shock, so you wouldn't really be wrong with any of the standard treatments, but they will all make things worse as well. Use Dopamine just enough to get the pressure up, and balance it with some NTG or small doses of Morphine for the pain. How good are you at walking a tight rope? That is what you are going to be doing.

Has to be some type of sympathomimetic, but his vitals don't jive. GHB is a CNS depressant, so it probably wouldn't present like this, but who knows what it was mixed with. Snow him, intubate, let the people with the sheepskins on the wall figure it out.

My scenarios tend to include knowing why something is being done. Knowing when is good, knowing how is important, but knowing why separates us from the organ grinder's monkey. I would recommend to all of the instructor/preceptor/concerned obervers to bring this up when you are watching a student struggle with a concept. Start the new thinking down this line, and they will fall back to it each time they are under pressure when they are done with you.

I have a new favorite ECG book. Advanced ECG: Boards and Beyond 2nd edition By: Brendan P. Phibbs, MD Paperback: 294 pages Saunders/Elsevier ISBN: 9781416024026 This book takes the basic knowledge that you receive from most other ECG texts and expands on it. One of the first lines in the book describes that you will never see a "basic ECG" so why would you spend time studying how to look at them. It discusses the more difficult ECG topics in a method that makes it so very easy to understand. Ectopic beats, AV blocks, Bundle branch blocks in all their variations, and MI identification with/without BBB patterns. Self assessment tools follow each section to quiz you on the newly gained information. The strips are from actual patients, so you can be assured you might actually see some of the rhythms. After you read the Bob Page 12 lead book, pick this one up for an expansion of the information. Easily 8/10 stars. I will also agree with Mike, the Emergency Airway Management book is excellent. If you learn anything from the book, you will see how it actually applies when you decide to attend the conference that goes with it. As a package book/conference 10/10, book alone: 8/10.

Good pick up on the diving issues. I'm going to spin this another way and suspect an embolus. ECG, D-dimer(we are still in our cool guy ambulance, right?), CT of the chest. Any difference in the pulse side-to-side? Upper and lower extremities?

You'll have to contact the service rep for the AED's that you are using. They are all different, and may/may not be willing to upgrade them without you spending a lot of money.

Great analogy :roll: OTC means safe? On what planet exactly? No protocol? Sounds like a medical direction issue, not the street provider. If NO ONE in the state uses it, how does it magically appear in this medic's hands. I am beginning to think that you have had first hand experience with this issue, and wish to ASSUME that everyone makes the same mistakes. Keep painting with that broad of a brush, and you will end up covering more up than you will fix.

"Learning new stuff is scary."--ARE YOU KIDDING! I didn't suggest we try to calculate the terminal airspeed velocity of an unladen swallow, for crying out loud. A standard issue assessment can determine a good amount of possible causes for this event. Hypoxia, hypovolemia, hypo/hyperthermia, hyper-/hypoelectrolytes, even the stated GHB and ephedrine can be suspected with a history. Let's not forget the other causes: trauma, tablets, thrombus(cardiac and pulmonary). These are just the most basic possibilities. If we look a little closer at this patient's history, we just might find something else. Is this something new? Do we not perform this on most of our patients?

Perfusing rhythm with good vitals, monitor as is and identify the cause of the arrest. If you find a cause, consider treating it, if not, leave well enough alone. Just because you can, doesn't mean you should.

We've had 3 ROSC with the new guidlines, none of them left the hospital so no saves. We have also focused more on the prevention of the arrest. Aggressive treatment in the peri-arrest period has done wonders to the number of codes we have to work. Amazing how the heart that doesn't arrest is easier to save than the one that does.

Distal circulation? Ultrasound of the popliteal/femoral arterial beds The temp really doesn't scream out an infection yet. Is there any streaking from the site? Red rash on one, but not the other?

First, activated charcoal is NOT an antidote. It does not reverse the effects of the toxin you are trying to treat. It is an ADSORBENT. It's entire reason for being used is to prevent the toxin from being ABSORBED by binding to it, then allowing it to move through the small intestine for excretion. Once the toxin has reached the small intestine, usually a 45-60 minute trip, the effectiveness of charcoal is greatly reduced. More than 30-45 minutes gastric lavage will be ineffective, and most poison centers discourage it's use routinely. 45-60 minutes, charcoal can work. If the contact is made with an inexact time of ingestion, charcoal use is reasonable. If the patient is symptomatic, with the threat of airway compromise, then charcoal has to wait until the airway is secured to be administered. Second, and maybe more important, more overdose patients are saved through a thorough assessment and appropriate supportive care than will ever be by using charcoal. Once there are symptoms present, charcoal is not going to help, and could very well make the situation worse. When you go on a call for an overdose contact your local poison center, and ask their advice. That is what they are there for. 1-800-222-1222 is there number, and it doesn't matter where you are. Dial the number and you will get the closest one that is open for business. Canada may have a different number, but they can use this one as well.

I can see the extrapolation coming. If one group can successfully perform RSI, then all should be able to. Flight crews can do it, why not ground medics, then why not all providers that have intubation in their scope? It won't take long to teach a couple of new drugs to people. Then everyone would be able to use it. Great idea. :roll: Using this procedure as a merit badge isn't the best idea either, but it has to be controlled somehow. How much credibility do we give this study, when there is much more against prehospital intubation, than there is for it? We can't turn a blind eye, but at the same time don't hurt yourself jumping on the bandwagon.

Okay, so for all of you that had any doubts about it, settle down. I bow to the one true para-GOD. There is simply no way to compete with the knowledge that Rid brings to the table. We are all just passing through the EMS existence that Rid has allowed us to have. Truly impressive that with the amount of information he carries with him, that he is able to get his head off the pillow.

He's a lumberjack and he's okay... Oh, wait that's a different one.

Too much sensitivity. If people are going to get their underpants in a bunch, then maybe they should pick an easier field of endeavor. Almost by definition, EMS personnel have to be opinionated and willing to hold fast in an argument. That said, more of us need to be able to integrate another viewpoint into our own thought processes. The mark of a truly educated provider is being able to accept a conflicting view while holding to your own.

Yes I have, but no we don't stock it. Time was a bottle of 80+ proof was required equipment for an ambulance in the state of AZ. Then someone found out more of the whiskey was being used for personal consumption than therapeutic effect, and it was eliminated. Volunteer departments really look at you funny when you tell them to go buy a bottle of Jack Daniel's for a patient.

If this goes as advertised, it will be a good thing.