AZCEP

Can we get some more details about the MVA? Injuries sustained, treatment received, position in the vehicle, vehicle damage, etc. Was she placed on any medications following the accident? Any other medical history?

Any family cardiac history? Finger stick blood sugar? I'm still transporting this patient ALS, due to the size of the differential that I can't nail down in the back of my ambulance.

New onset dizziness has too big a differential to allow BLS to transport if an ALS provider is available. Good possibility it is a fairly benign issue, but we are here, we have nothing better to do. Transport ALS.

Ace, Placing a "definitive" airway does not mean that the underlying pathology has been definitively managed. While you are looking for your sources, I'm willing to bet that you also came across several that stated something along the line of "EMS can just as effectively manage a ventilation issue with BLS maneuvers." An ETT does not treat the underlying ventilatory issue. Now, I will grant that in the case of an upper airway burn, that needs to be given time to heal itself, an ETT could be considered definitive. In most cases it would end up with a tracheostomy rather than oral intubation, but a cuffed tube is a cuffed tube. Likewise, an ETT is not a definitive modality for COPD, or CHF. In fact, there will be more difficulty allowing these patients to be extubated than most other groups. A cuffed ETT is a definitive treatment modality. It is not a definitive treatment of pathology.

Defibrillation for VF/VT D50 for hypoglycemia Epi for anaphlyaxis These are the only situations that I would be willing to describe our treatment as definitive.

Actually Asys, the same place in the Koran it says that Muhammad is in favor of killing the infidel with a well timed IED. :roll:

This is great stuff!! Don't let anyone tell you any different. When it comes to using it for patient management it becomes more and more clear why we need to know this inside and out. Why does shock do the things it does? Oxidative phosphorylation anyone? Why won't the cardiac arrest patient respond to medications that we dump directly into the heart? Similar mechanism. WWWWWWHHHHHHHEEEEEEEE!! GGGGOOOOOODDDDDD TTTTTIIIIIMMMMMMEEEEEESSSSS! Whoa, got a little out of control there :roll: As you were.

This is one of the medical/legal/ethics scenarios that is run through in every medic class I've ever seen. Dr. X gives you a medication order that you know is wrong. You repeat the order back to said doctor, and he repeats it without changing what he initially told you. What do you do? I've been witness to those providers that are not confident in their own knowledge follow an obviously bad order (Bicarb down the tube anyone? :shock: ) I've witnessed the same issues with drug doses (Epi 1:1 000, 1 mg SQ for asthma :shock: ) Then you have the more confident providers not willing to cause harm by doing something so blatantly ignorant get written up for not wanting to toe this insane line. My stand, and mine alone. If a licensed provider is willing to give me a bad order, and I make it very clear that I disagree with this order, then they had better be able to defend their position in a reasonable manner, and not just because they told me to do it. I refuse to put my career, my children's next meal, or my next house payment on the line for someone that only thinks they know what they are talking about.

It could be the widely held American medical control physician's belief that less time spent on scene and enroute to the hospital will limit the damage done by the un-educated providers. Those with half of a clue can get everything they need to done during transport reasonably effectively. As I already said, due to my transport times being so blasted long anyway, I shoot for less time on scene for everything.

Cellular modem to fax machine is much more common. Even cheaper is proper initial education, agreed. The biggest issue is finding cardiologists that are willing to believe the lowly field provider can actually determine what is happening.

Now that the wisest possible statement has been made, can we please end this ridiculous foray into oblivion? Admin, please, kill this bloody thread.

Finish the exposure to find the hole we missed. Plug it accordingly. I don't suppose this ambulance is "cool-guy" enough to have a radioilogy department included.

Have to agree with Rid on this one. If they spend the shift following a phleb around, they haven't really learned much. If they spend the time with the tech, they will discover how and why the numbers do the things they do. The students won't be happy about it, and chances are the lab techs won't be thrilled, but it would be a great learning tool. We recommend that our students spend time with each of the ancillary departments to help understand how the whole system works. Some with lab, some with respiratory, some with radiology, we even had a couple in PT/OT helping out. Each exposure adds to the picture that these students put together about their place in the system.

However, the most recent guidelines recommend an initial countershock at the highest possible level. The problem, as I see it, with the current research dealing with defib results is the lack of perfusion during the escalation. If an appropriately applied countershock is delivered in a shorter period of time the most common negative is a transient conduction delay. The threat is absolutely valid however. As I said, if a countershock is going to work, there should be a period of asystole following it.

I did not indicate we need the ICP or CPP only the pulse pressure to decide degree of shock Difference between systolic and diastolic = pulse pressure. When this narrows we can quickly determine that a patient is compensating for volume loss. Yes, the MAP would be nice to know, as would the pressures you describe, but for the quick and simple, just use the pulse pressure and use the fluid of choice (NS, LR, diesel) to maintain it.

Actually, MAP is better suited to obstruction related issues. We would really need to know the pulse pressure to guide treatment. Yes, I am aware that the MAP is related to pulse pressure, but the width of the pulse pressure would better guide us. The main issue is his lack of cerebral perfusion. Great he has a tachycardic, radial pulse, but not enough blood getting to the brain. We need to give enough fluid to maintain things where they are. Since we are already well behind the curve, we need to get some fluid into this patient. Figure he is lying supine, and still has inadequate cerebral perfusion = volume depletion. Heart sounds would be good to know, but I wouldn't rely on them much in the absence of JVD.

So with a pulseless patient, no blood flow, electrical system still working-or trying to-with no mechanical activity to move blood, metabolic demand remains high due to the stimulation that the heart is working under, available energy stores rapidly exhausted, rate slows down and continues into asystole. Every countershock, whether synchronized or not, should produce asystole. The hope being when the dominant pacemaker takes over it will do so at an acceptable rate. IVR would be an acceptable alternative as long as it could generate a pulse. It indicates that the subordinate pacemakers are attempting to work following the elimination of all stimuli. VF might be troublesome, but since we already have our equipment applied to fix the problem, we should be able to fix it fairly quickly. If the patient is truly in a pulseless SVT, then there is a fairly good possibility that the underlying cause is any number of hyperdynamic states. Hypovolemia would probably be the most common, but sympathomimetic toxins are a possibility as well. So while epinephrine would be indicated for the pulseless arrest, it would not be the best idea to use it in this case.

Medical direction usually wants an explanation for extended scene times, and employers usually fall into line behind them.

Dolan Springs, 40 miles from Kingman, 60--give or take--from Las Vegas. Our catchment area is one of the biggest in the state.

Any JVD? Breath sounds? Sounds like basic trauma care at this point. Continue with BVM, start two large IV's, seal the holes, intubate. Based on the information, this individual is in Class IV shock, so should probably get a bit of fluid and rapid transport. This is far too simple though, and I'm anxiously waiting for the other shoe to drop.

Location/size of wound. BVM compliance/heart rate/GCS?

It truly depends on the situation at hand. Urban/rural, short/long transport times, patient stability, system abilities, the list goes on and on. In my situation, with a 40+ minute transport time, and typically fairly sick patients, I don't like being on scene for more than 15 minutes if I can help it. 20-25 minutes is not unreasonable, but the situation has to dictate it.

"Fixin'" has nothing to do with repairs.

Not to pick at the nits, but an infant is <1 year of age. Child is from 1 year to the onset of adolesence (11-14 y/o). Everyone older is considered an adult. I tend to doubt that the test will be updated as yet. There is also a rumor of the candidates being able to choose which set of ECC guidelines they are tested on. Seeing as AHA has not gotten all of the material out yet.

Looks similar.