Paramagic

Double post, sorry.

I'm with chbare. By intubating this patient, who is presumably demonstrating a compensatory respiratory alkalosis to deal with severe metabolic acidosis (like a DKA or salicylate toxicity) we have increased their work of breathing significantly. So in someone who is presumably already acidotic, we are then adding to that by working their respiratory muscles even harder, producing more lactate and fatiguing them to the point of failure. I will generally try to ventilate at 6-8ml/kg, with 5cmH2O PEEP as a starting point, and maintain the EtCO2 where I found it before intubation, as a "normal" number will kill them. If I have a decent ventilator I'll use A/C to take the bulk of the work of breathing off the patient; if I'm using a BVM I'll consider paralysis to achieve the same ends as I find it tricky to synchronise my bagging with their breathing at the higher rates.

I think I might have to start a campaign: Three Lettered Acronyms - Just Say No! Except that would become TLA:JSN and we would be back to square one. 

I believe that OEC + EMTB = OMG and WTF. Seriously though, what on earth are you on about?

Go easy on the poor little spammer doc, he can't help being a firefighter, it's just the chromosomal defect he was born with. Good fireman! You go put the wet stuff on the hot stuff! Good boy! Good boy!

And those results are? Seriously, what is your big claim to fame with regards to being a "pioneer" and "bringing results"? So far all I have seen is either a quite sad little insecure person with absolutely no insight, or a troll. I haven't decided which yet.

You seriously lack insight into your behaviour if you don't think that anyone would handle that situation in a different manner, even after being told by everyone how they would handle it sensibly. That goes beyond funny and into downright scary.

In that case, I'm sure you could talk to Tony Smith about something like this. I believe he is burning the candle at both ends at the moment with taking on a role at RPA over the ditch, but he is a very approachable guy and very pro ambulance and ambulance education. He may be able to provide some direction or assistance with you quest.

It IS a fact! Not just the rare scene, or a small number of scenes, but in fact the MAJORITY of scenes start out safe but end up deadly! Just last night I went to an assisted living facility for a fall with a possible fractured neck of femur. There I was having a chat to the 85 year old little old lady who was on the floor, getting ready to place and IV and give her some pain relief when BAM! She pulls out a Saturday night special and starts busting caps in my direction! Fortunately I have 100+ hours of combat training also, so I quickly disarmed her with a roundhouse kick which knocked the gun from her hand. I jumped on her, got her in a Darce choke which put her out pretty quickly (thanks pre-existing carotid stenosis!) but to be on the safe side, I hit her in the face a couple of times with my extendable BrutalMatic Tactical Baton (in mat black, with low radar reflection coating and the optional Teflon coaing to prevent blood staining) Don't want her getting up to try that shit again! Her husband looked like he wanted to start something after that, so he got a face full of OuchMaster 5000 Extreme Burn OC Spray (one on my belt, another in my left cargo pocket) After that he fell out of his wheel chair, and would not comply with my demands that he back the f**k up, so I tazed him good. You just never know when shit is going to go down... Seriously though, I suspect that the only people for whom scenes turn deadly are the patients you turn up to.

What ERDoc is describing sounds exactly like what you are after Celticcare. Things may have changed downunder, but there were never many cross trained nurse/paramedic staff in days gone by. However this would necessarily be a problem, education can occur anyway. I assume you don't work in Auckland?

I appreciate that this is something that could be beneficial to your working relationship with the nursing stuff, but I wonder if it actually requires a permanent position per se? Would it be possible to help the cross education of staff with some in-service education. I assume that you have some kind of ongoing education requirements, and that the nursing staff have time set aside each week or month for lectures. Would it then be possible to arrange with the Nurse Educator to present an in-service on Ambulance operations and clinical guidelines? Maybe it could be a regular event, say every time you guidelines are updated? I would imagine that if the choice for your employer is between funding a full (or part) time position or allowing a day or two for in-service, the cheaper option would be more likely to win. We don't have so much to do with the nursing staff, however we do have a good relationship with the medical staff in our ERs and ICUs. We have an open invitation to attend the M&M meetings, PCI audits, continuing education sessions and special lectures that the Hospital arranges, which is great for fostering that relationship.

Goodness me! To steal a quote from another forum: I carry my wallet, my keys and the chip on my shoulder...

I find it incredible that busy areas still run, or are allowed to run, 24 hour shifts. I forget the exact numbers, I will hunt the references down later, but being without sleep for about 17 hours has the same effect on your cognitive and motor skills as having a blood alcohol content of 0.05. Now, we would all, quite rightly, be absolutely apalled if someone turned up to work having had a few drinks because it would impair their judgement and so on. However we seem to be happy to allow someone to work with the same level of impairment from fatigue. Does not compute...

So long as the truck is checked off, clean and ready to go, and whatever regular duties you have are attended to, I can't see any point in making people stay awake. This is especially true on ridiculous shifts like 24s or 48s There is ample research into the effects of fatigue on cognitive and physical abilities. I personally would rather have a well rested paramedic attempting to make life-saving/life-altering decisions and carry out complex fine motor skills than one who has been awake for a prolonged period. I also think we need to remember that EMTs are people too. They may have had a bad night with a sick kid that kept them up, poor sleep from worry about financial or other issues, they may have to work more than one job to pay the mortgage, who knows? Cut them some slack.

I'm not a plumber or an electrician; I practice medicine, I'm responsible for peoples lives, health, comfort and well being, not a backed up toilet. I believe that education is of the utmost importance to ensure that I practice to the highest possible standard. As to what kind of education, that obviously depends on what you want to do. If you have any contact with patients the obviously clinical education and training is vital and my personal belief is that a degree should be the bare minimum to look after patients. After that, the sky is the limit.

^^^^^^What he said^^^^^^^ It either needs to be done properly, or not at all.

Interesting. It certainly is an irritant when it gets into places where it shouldn't be (like the brain for instance, think of subarachnoid hemorrhage and the fever that often develops) What did this medic think caused the rigidity? EDIT: Missed Dustdevil posting, but agree. If volume alone is causing rigidity 1) it won't be true rigidity like we are discussing and 2) that's your entire blood volume plus, well, a hell of a lot. Consider the massive amounts of fluid that can be tapped off someone who has ascites.

Irritation of the peritoneum by free hemoglobin. Rigidity will not necessarily be present depending on the level of free hemoglobin following hemorrhage.

Oh, Hi Johnboy! Speaking of giving people wrong information, have you come back to explain how hypoglycemia eliminates spinal reflexes? I look forward to your explanation... Waist Waste

Haha! I've never met a jaw stronger than my arm or teeth stronger than a laryngoscope wielded in anger! Fentanyl, versed, then sux (would prefer roc, but I use what I have), morphine and versed for ongoing sedation/pain relief, pancuronium for ongoing paralysis if required (not always, or even that often)

Actually the suppression of emergence phenomenon with benzodiazepines is a myth. There are two direct studies into this, neither found a difference in the emergence phenomenon when midazolam was adminstered concurrently. Well, one did, but it was not powered to detect a significant difference. Certainly midazolam is recommended if emergence occurs, but it won't stop it occurring. Wathen JE, Roback MG, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double blind randomized controlled emergency department trial. Ann Emerg Med 2000;36:579-588. Sherwin TS, Green SM, Khan A et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized double blind placebo controlled trial. Ann Emerg Med 2000;35:229-238. McCarty EC, Mencio GA, Walker LA, Green NE. Ketamine sedation for the reduction of children's fractures in the emergency department. J Bone Joint Surg Am 2000;82-A:912-18 Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97 Green SM, Johnson NE. Ketamine sedation for pediatric procedures. Part 2: review and implications. Ann Emerg Med 1990;19:1033-46. Green SM, Kuppermann N, Rothrack SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35:35-42.

On my iPhone so quoting is a bit if a pain, so I'll just do my best. Regarding SpO2 in patients with opioid analgesia on board, it really depends on what you want it to tell you an how it is used. If you are using it to identify hypoventilation, you will be well behind the 8 ball by the time the SpO2 starts to fall as the sats will hold for a remarkably long time in most patients who are hypoventilating or even apneic. In some circumstances it may be useful, but it is no substitute for eyeballing the patient. However, it doesn't really matter, it's non-invasive and cheap so as long as the limitations are recognized it is fine. Anti-pyretics don't really have any role to play in the management of true sepsis. For a polytrauma patient who is 'unstable' fentanyl is a good option for pain relief as it comes without the hemodynamic compromise associated with morphine.

That's a good point, being able to point to AHA recommendations will carry a fair bit of weight for your argument.

Good work pushing for change. I agree that small steps are probably a good start, pick a topic, research it carefully and present it well. I would suggest picking one that has a really good evidence base, and that other services have demonstrated can be used without exposing the service to greater risk. C-Spine might be a good way to go, there is a lot of evidence for this. MOI is a very poor predictor of injury, it's a good one to at least downgrade. I suspect you will never get rid of it entirely, but at least minimize the sillyness that goes with "OMG look at that MOI!!" There is a reasonable amount of evidence for how bad MOI is at predicting anything. I don't know what code yellow means, I assume it is some type of triage category? If so, just doing an ECG or starting an IV should not be a reason for upgrading a triage category, that is just ridiculous! However I suspect you will not be able to find papers on this, so maybe leave it until you have been able to effect change elsewhere and maybe gained the trust of your MD. As above, absurd, but if it's ingrained it will be hard to change. If a 22 year old basketballer lands akwardly and fractures his ankle, I will give him opioid analgesia, but why would I need to monitor his EKG or SpO2? Those are just surrogates for good patient care and monitoring by the provider. There is actually a lot of research into the futility of transporting cardiac arrests to hospital, and there are papers that address specific criteria for field termination. However, this is perhaps an emotive issue, so maybe hang back as well on this one. I think it should change, it's futile, dangerous and absurd, but establish your "credentials" first. I'm not aware of any data on doing PCI during cardiac arrest, everything I have read is regaring PCI after successful resuscitation, so I would like to see some papers also. Sorry, I strongly disagree on this one. If a patient is hemodynamically unstable it doesn't mean that they shouldnt get pain relief, it just means that you should adjust either how you give pain relief or what you give. Ketamine is ideal. Witholding pain relief to anyone who needs it is criminal in my opinion. Carl already touched on this, but there is ample evidence of the deleterious effects of untreated acute pain in the long term. More options are always good I won't flog this dead horse further but good luck! Definitely do a fair bit of research for this, what you find may surprise you. Treatment of fever in pediatrics is quite possibly for the parents benefit than the childs. Anti-pyretics don't do much good for kids, they don't reduce the likelihood of febrile convulsions and should possibly only be given to patients who are actually distressed. Even then it is not clear that the fever is actually the culprit, rather the myalgia or other issues that accompnay or cause the fever. Don't forget that fever is a normal, healthy response. A worthy aim, good luck.

Ahh, johnboy, glad I coaught you, that other thread is getting bogged down and I was hoping you could help me out some more. I'm still struggling with two things 1) How does IN glucagon work better than IM glucagon? The last reference you posted was with regards to centrally acting medications where IN is very handy due to the rapid absorption into CSF and the brain, but glucagon doesn't really fit this model, so I was wondering how it works? 2) How is it that hyopglycemia eliminates even spinal reflexes? Thanks for your help Paramagic.