Paramagic

The side effect profile of ketamine is no more bothersome than any other analgesia in common use. The most common side effects are easily managed with commonly carried ALS drugs such as benzos or atropine (or glycopyrrolate , but I'm picking not many ambulances stock that) Knowing the side effects and having had a fair amount of experience with various analgesic options, I still think ketamine is the best drug ever.

I always find it interesting reading these threads to look at what people consider to be aggressive/appropriate analgesia. People sling around doses like 5mg, or 2mg or whatever. Does no-one else find it curious that pretty much every drug is given on a weight based formula (0.1mg/kg, 3mcg/kg, whatever) yet with morphine we come up with some arbitrary number like 5mg every 5 minutes. Personally I give 0.1mg/kg morphine as my initial bolus, followed by 0.05mg/kg after that until the pain goes away (or equivalent fentanyl doses). I will obviously change this for certain populations, dropping my initial dose or increasing my subsequent dose, or whatever, but none the less it is always a weight based approach as well. Ketamine is also, without doubt, the best drug ever, for anything, anywhere.

dd/mm/yy makes far more sense. So does the metric system for that matter. Although it seems medicine is at least catching up with the civilised world and you hear far more Doctors using centimetres and so on (although the next person I hear saying sonametre is going to get punched in the throat... I'm looking at you Weingart,..)

We use fentanyl and midazolam as our routine agents for induction (with suxamethonium for paralysis). Generally speaking they work well, however, as the others have said, midazolam on it's own (or fentanyl + midazolam without paralytic agents) is very much sub-optimal. I like the regime Kiwi describes, ketamine for anyone with hypotension or potential for hypotension, midazolam + fentanyl for people whose brain has already exploded and who have a BP of eleventybillion over 90. And rocuronium would be my choice of paralytic. Midazolam and morphine make a nice infusion for ongoing sedation and analgesia though, they are needed in lower doses so there are less issues with hypotension.

I work with a fair number of medics who take the same approach. I disagree with it. The bougie is the first step in the difficult/failed airway approach for most of us. If things go wrong it is important to change something in my technique and If I have already used the bougie I now have one less thing I can change, one less step in the failed airway route, one less chance of successfully intubating. If I am predicting a shitty airway for whatever reason, then I may break out the bougie straight away, but otherwise I want to give myself every opportunity to pass the tube successfully. I also do as zmedic does, verbalising everything, even when I am the senior medic at the scene. Intubation is a two medic job here, so I like to let the other medic know what is going on. I also like them to do the same for me, so that I know if things are going south, rather than sitting in silence, sweating, wondering if they are going to get the job done, whether I should step in, whether we should abort the attempt and so on. Doczilla also raises very important points. We have a 99% success rate for intubation, and a decent part of that is not just knowing how to intubate, but when we should intubate, or when we should leave it to someone else.

No, what we need to push for is a more evidence based approach to pre-hospital medicine, not getting more stuff to put in our bags to prop up our fragile egos. Which, funnily enough, is what the removal of atropine represents.

That is staggering. Regardless of whatever other clusterf**ks went on, no waveform capnography = no intubation. End of story.

I agree with usalsfyre and also with systemet. Quite aside from any errors that were made by the providers, there are some systemic issues that need to be addressed. It is really not appropriate to expect crews to transport sedated, ventilated patients without proper equipment. That means waveform capnography and proper ventilators. I'm not a fan of having to use a BVM in these situations, but I'm equally unhappy with having bullshit, cheap, nasty ventilators. BVM's have their place, both as an initial option when we just need to get air in and out urgently, and as part of a "failed ventilator" plan, but we really need to be more cognisant of the importance of proper lung protective ventilation strategies, both on 911 calls, and most certainly on IFT calls.

Sorry for taking so long to reply, the silly season has indeed been silly this year. Azcep, I am still unsure what you mean by reducing ectopic beats with lidocaine in an AMI. This is exactly the scenario where we used to start lidocaine infusions, with the rationale being that ectopics can lead to R on T, R on T leads to VF, VF kills people. Seems reasonable, until we found out that it didn't make any improvement to mortality or morbidity, so we stopped pouring a pro-arrhythmic cardiac depressant into people with a vulnerable myocardium. What would be your trigger to give lidocaine in someone with AMI? How many ectopics, or what type? What about re perfusion arrhythmia and ectopy, do you treat that with lidocaine? Croaker, given this is an established inferior infarct, who tend to have a high likelihood of RV involvement, and that there is no evidence that nitrates improve outcomes (if there is I would be happy to recant, but there is none that I am aware of), all there seems to me to be is a 50/50 chance that one will tank this patient's BP due to them having impaired RV function and being preload dependant. (Right sided leads not being given here, and the incidence of RV dysfunction being arounf 40-60% depending on whom you read) I could go with nitrates if you had a nice lateral or anterior with a booming blood pressure, but not for an inferior.

However, this is an established STEMI, not an anginal episode. I have no problem with using nitrates for an anginal episode to address supply/demand problems, but there is no benefit in nitrates for STEMI, only risk. Procainamide is interesting, not something that is seen often in the field, although it's the more effective drug. Does it get used often? How do you manage the issues with the infusion and potential side effects? I presume you have long transport times?

It wasn't really the lidocaine part that has me scratching my head, it's the AMI with ectopy. I agree that the evidence supporting amiodarone over lidocaine is pretty damn poor, so that doesn't bother me. However there is a vast difference between recurrent VT and ventricular ectopy. I'm sure many here will remember the days of "Holy crap, 3 PVCs and 6 second strip, start the lidocaine!" (or something similar) We used to think that ventricular ectopy was bad, and would lead to ventricular arrhythmia, via the magic of the R on T phenomenon, so we would go jumping on any PVCs as soon as we saw them. Eventually we realised that it was an absolute load of crap, so it mercifully went away. There's really no need to cause further problems by loading up on pro-arrhythmic drugs unless there is actually an arrhythmia (such as you describe above)

Ahhhh...... what? Useful how?

However the rates of survival from in hospital arrest with PEA as the presenting rhythm are statistically almost identical to those in whom the presenting rhythm is asystole (12% versus 11%). So if these patients, already in hospital, and therefore presumably getting whatever it is that they get in hospital as opposed to out in the field, are still going to do incredibly poorly, what is it that putting providers and the public at risk going to achieve? I agree that you can't sit there all day, which is why my protocols at least allow me to call off resus when a non-shockable rhythm is present and a reasonable effort has been made to resuscitate.

I don't think it's a matter of celebrating or embracing, merely acknowledging the fact of it's existence. We can accept that X exists (be it homosexuality, disease, death, so on) without applying a value judgement to it or attributing agency to it's being. If we remove ourselves, with all our cultural baggage from the equation and try to see a situation without the lens of out own value system it becomes easier to accept that what I see as the norm is not what others see as the norm, and broadly speaking there is no reason why my value should be any more important, relevant or "true" than anyone elses. Of course this (for me at least) applies to situations or events that are between consenting adults and do not cause harm to others or to society at large. Although that being said, we accept and indeed celebrate some things that do cause harm to society, such as consumption of alcohol (to excess), merely because it is an accepted cultural norm in Western society. I may be wrong, but I seem to recall reading somewhere some hypothesis on the role of homosexual behaviour in terms of evolutionary theory. I'll have to go and see if I can find that or whether I am just making that up. It's entriely possible I made it up.

Can't be long, have to go to bed, but I wanted to make a couple of comments not directed at any individuals, but just a couple of things that have crossed my mind reading this thread. Some of them have probably already been covered, sorry if that is the case (you'll have to google the studies yourselves) Homosexuality being aberrant: There is actually a large amount of homosexual behaviour in many different species, from "flings" to life-long pair bonding. So I can't really see how homosexuality can be considered to be against nature when it is so widespread in nature. It is certainly not a human only thing. Marriage being for procreation. I am a heterosexual, white male, happily married for many years. We do not have children, nor do my wife and I intend to have children. Is my marriage then not valid because it is not for the purposes of procreation? Marriage and social norms: Social norms change. We may not like it, but that is the way it is. In the same way, language changes. I hate text speak (LOL), poor grammar and so on (as I type these rambling, poorly constructed, nearly syntax free sentences ). But, language shifts and there is not a damn thing I can do about it. Ditto society shifting, societal norms changing, and so on. I wasn't particularly fond of the Reformation, but such is life; we adapt and move on. Besides the religious aspects, I really can see no reason to oppose gay marriage. If society accepted polygamy between consenting adults, I too would be fine with that. I'm sure that will be a battle for another time. Religion and education. There is a well established association between level of education and religiosity (I won't get into mental health and religiosity!) Low levels of education tends to be reflected in higher levels of religious sentiment, in particular of the evangelical type. Interestingly though, higher levels of education tend to be associated with less religion, but in some areas greater observance of religious ceremony (for example Catholicism or Judaism) Possibly the ceremony is appreciated for other aspects of it than the metaphysical or faith based aspect. Maybe more like meditation.