AZCEP

http://www.emtcity.com/phpBB2/viewtopic.php?t=3934 http://www.emtcity.com/phpBB2/viewtopic.php?t=4653 http://www.emtcity.com/phpBB2/viewtopic.php?t=4441 Just a few that have already discussed this at length.

To cover the transition, most could be run out with simple attrition. We will be around long after those that have not entered the field recently get tired of all of the young, higher educated providers telling them how things should be done. The intermediate level was created to allow the rural departments that wanted ALS to get it for less capital outlay than would be required by paramedics. The time has come to eliminate the level altogether. These same rural departments are now using the intermediate as an excuse why they should not be required to upgrade. Of course, this only applies to the few areas that still use this level. This would force these smaller areas to upgrade to paid services, as has already been discussed in great detail. Volunteer services are not helping anyone, and I will leave it at that. How exactly is it not a big deal for the urban providers? They still have to pay for their education, most don't get paid to attend classes, and even fewer get paid time off to attend. They also have to make the decision between educating themselves and providing for the "family". Yes, there are problems to be worked out, but the system must elevate itself before we can realistically expect to be treated as a profession.

Really need to look at all of the available information before you make value judgements. When you allow emotions to cloud your thinking, you only make bad decisions.

Whoops! Semantic error on my part. Pulselessness associated with tachycardia needs treated with electricity, and quickly. The way it was explained to me by Dr. William McConnell was to treat the rate, then the rhythm, then the container/volume. Local recommendations may vary.

Maybe I missed it, but I don't see any big differences with the AHA guidelines.

Wouldn't this move cause EMS to remain a bastardized service, with no real direction? True, it is probably better than the present, but I can't help but think that it would only keep things the same. Nationwide, the standards need to be the same for every provider level. The ABEM would be a good place to secure the standards. Increase the educational requirements. Perhaps an AS level degree for entry level providers, and the BS for all ALS. Of course, pay scales will have to increase accordingly. Eliminate the Intermediate level altogether. It has outlived it's utility. The rural departments that hold on to this level so adamantly, need to realize the increase to full paramedic is well worth it.

How is being married free? Most mental health providers that I have met have had their cheese slide a bit off the cracker.

This rate and presentation should have pulses, you are right. Since the patient did not read the book on how to present, we need to evaluate the possibility of what is causing this problem. Rate >175 and narrow QRS would lead me to believe hypovolemia, so a fluid bolus would be in order. Because the patient is pulseless, cardioversion would be indicated. Need to treat the rate first. Adenocard is out, as has been shown, it won't be around long enough to work. Back to causes. Hypoxia won't cause pulselessness at tachycardic rates. Acidosis is a possibility, but would be tied to electrolytes and ventilation. Hyperkalemia would cause a widening of the QRS so probably not. Hypocalcemia would tend to cause bradycardia. Hyponatremia would cause tachycardia, treating with hypertonic saline might be an option to consider. Has this patient experienced any trauma recently? Tension pneumo/Tamponade tend to show tachy-->brady progressions. Pulmonary embolus definte possibility related to history prior to arrest. Coronary thrombus could present this way, but we would see some ECG changes with it. For drug overdoses, any of the sympathomimetic drugs could cause this presentation as well. So, we haven't really narrowed down the causes too much. Hypovolemia, PE, AMI if ECG changes are present, and Hx of sympathomimetic drug use would be at the top of my list. Defib to stop the tachycardia, consider an antidysrhythmic to keep it slowed down, replace volume, look for ECG changes and drug use history.

Ditto Doc! I tend to start with an 8.0 and have one size bigger and smaller readily available. The kids get the biggest tube that will fit. For the burn patient, there is no specific guidline, other than early management as needed. If the airway looks toasty, they get the biggest tube possible.

Pulseless and tachycardic-->treat with electricity Adenosine/Cardizem/Amiodarone are intended for the more stable patient. A patient without a pulse is as unstable as they can get. None of the medications are very good at converting a rhythm by themselves. They are better suited to keep the tachycardia from returning. Convert the rhythm with electricity, then use the medications to keep it from coming back. By definition, you can consider it to be PEA, but at that point you need to treat the cause. Throwing epinephrine would probably be acceptable, but it won't do anything to fix the problem.

Nevada has two sets of certifications. One is for Clark County (Las Vegas, Laughlin, etc.) and one is for the remainder of the state. In Clark County, the levels are Basic and Paramedic.

We tried the coffee table for a while, but the patient kept rolling off of it.

Except for the fact that these devices do not secure the airway, or protect from aspiration as well as a properly placed endotracheal tube. You can cite SpO2 and CO2 numbers all day, but the fact remains that the only secured airway is a cuffed endotracheal tube. These devices work best when no other trauma has happened to the airway. If there has not been a previous attempt to place a tube in the trachea, then I am going to attempt it before I accept that a patient has a secure airway without one.

Combi-Tubes, LMA's, King LT-D, Cobra PLA's are all fine and good as initial alternatives to bag-mask ventilation, but as soon as an inexperienced operator destroys the soft tissue of the oro-laryngopharynx with a laryngoscope blade, the possibility of any of them working drops dramatically. If you are thinking you need to use one of these alternates, you really have to consider using it before you attempt to visualize the vocal cords. Waiting until you realize you can't only sets up failure. Once the airway is full of the numerous fluids and materials that are possible, none of these devices are going to work too well. The guy at the bottom of the stairs, might get a combi-tube until we can get him out, but I'm not going to leave it in place for too long. My EMT might be able to get a combi-tube placed while I am doing other things, but again, it is not going to stay in place very long.

Might I suggest we spend a little more time communicating with the living about the chances of meaningful survival instead of abusing a corpse. Yes, the newly dead are valuable learning tools that should be used when it is reasonable. No, we should not be transporting a body that is not responding to our treatment. The fact remains that the longer the heart is not pumping blood, the lower the chance of a meaningful recovery. Perhaps if we would spend more time teaching the public to perform chest compressions when they are needed, instead of pissing up the rope of wanting more ALS providers, we might make some real progress. All the paramedics on the planet won't help when the blood isn't moving for 6-8 minutes before they arrive. We don't need more ALS, we need more bystanders that are willing to move a cardiac arrest victim's sternum 1-2 inches toward the vertebral column to make an honest improvement in outcomes. Might I also mention, www.circulationaha.org, look at the information that is provided and understand that if medicine didn't change occasionally, we would still be doing brain surgery on our kitchen tables.

:shock: :shock: :shock: I don't think I like where this is headed.

Most of the AED's are able to be updated with a slight tweak of the software. I asked our Physio-Control service rep when we could expect them to do this to our equipment, and he was unaware of a need. Then he called back and said there would be no upgrades until August, so we are in a holding pattern. The changes that were made are not that big of a deal. If you are using old AED's that can't be updated, take into account how your device works and shorten the time off the chest, which is where most of the emphasis is anyway.

How did you get the new ACLS materials? We were told they wouldn't be available until October. Yes the editing was horrendous in the previous ACLS provider manual. The removal of the background information on the medications and necessary ECG's was a very bad idea. I've looked into ASHI as well, and I honestly can't see how their information is any different from AHA's. If the difference lies in how the information is presented, then a reasonable instructor should be able to make up for the deficiency. ASHI seems to only repackage the AHA material, with no real change to the information.

The jury is still out on how good this will be. If the family members will actually perform when they need to, great. If they get the idea that it will be like practicing on the "mannequin", okay.

My guess, and it is only a guess is because you can't kill s%#t.

Why do the sickest patients live the furthest from medical care? Why is every bystander at a scene a former healthcare provider of some level?

But if we don't try, can we ever hope to be as good?

Maintain blood pressure where it is, rapid transport to a vascular surgeon. US as you are wheeling to the OR. Got to agree with ER Doc, BAD-BAD-BAD.

In the absence of any other moderately heavy object to be forcibly applied to the side of the head, sure. Also works well for those that have ferrous metal near their brain--read: cousin Eddie from the Vacation movies.

You really have a 50-50 chance with either to actually convert the rhythm using only the medications. No evidence exists showing that one is better than the other. For every study that says one works, there will be another that says it doesn't or the other choice does. Can you say "crapshoot"? I knew you could.