usalsfyre

If the current level of medic was obsolete (and it's not far behind) it would be up to me to get the needed education. That's a "tune" I will sing consistently.

No one payed to reeducate blacksmiths or typewriter repairmen. Stay up with the times or move on. If you want to continue to work in EMS you have to be useful. The basic level is dangerously close to obsolescence. Tell us where the current level EMT-Basic really helps.

I still see the need for two levels, because for high risk/low frequency/high acuity type situations you need experienced, educated people who run these calls often. Not something your going to get from every crew. What needs to go away is the EMT-Basic level and 700hr medic courses. I personally think AUS and NZ have well thought out systems.

Kinda late to the party, but midaz IM or especially IN (assuming you can get hold of a nostril) works wonders.

Actually not a PEEP indicator, it's a high pressure relief valve. The squealing and red is to let you know something is wrong. I believe these are set to activate at 55cm H20 on the AV series. What this likely meant is that the rather crude breath delivery of the Autovent was injuring your patient at that moment. BVM would have been likely as inappropriate. What this guy needed was a provider with the equipment and knowledge to move critically ill patients from facility to facility, even if it is only 0.6 miles. You'd be surprised how fast you can cause acute lung injury. There's a reason CCT has developed into a separate, subdiscipline within transport medicine, it's about far more than cool flightsuits and expensive toys. Not your fault, but when you become a medic don't be afraid to say "we can't do this safely" on IFTs like this.

There was a local study done by the trauma council in East Texas, not sure if it was ever put out for publication, but the results were that out of roughly 1000 level 1 trauma activations, all of them came in hypothermic to some degree. Every. Stinking. One. Seems that stripping the patient, pumping in room tempature fluid and setting the ambulance climate control for paramedic rather than patient comfort was enough to overcome a couple of months of 100+ degree days. People wonder why I insist on having blankets in the summer too. Any critical patient excluding heat stroke gets at least one blanket regardless of ambient temp.

Thiamine, vec, morphine and vasopressin are all still commonly on EMS units.

Actually I've made the decsion to both cease a pediatric resuscitation and not start resucitation at all. The providers emotions have no place here, working a code so you feel like you "did everything you could" is shitty medicine. I don't see the reason for the apparently strong desire to transport adult cardiac arrest other than yet another way in which EMS providers want to shirk real responsibility. To paraphrase JPINVF, why should we be respected as professionals when we punt every hard decision that comes our way?

Lidocaine-Out Intubating cardiac arrest early-Out Defib Paddles-Out Jelcos-Out Separate pulseoximeters-Out Nasotracheal intubation-Out, then back In Diazepam-mostly Out Smaller ambulances-Out, now back In Decent sized, capable HEMS aircraft-mostly Out That's all I can think of for now, and I've only been around 10 years.

The DEA will probably be interested in why the Ketamine wasn't in a double locked container. Other than that nothing is controlled. The etomidate would be a poor choice to get high off of, and the paralytics are obvious.

Brave flight crew. I'd have just stuck the tube and gone on, having managed a seizing patient in an aircraft it's not fun. You'll find it's very easy to manage most patients for a few minutes longer. A 30 minute transport is not that long, but you see these patients getting flown all the time, when in reality you probably add 15 minutes to the transport by calling for air.

Well, considering there's an open conduit between you and the patient I'd say it'd be pretty flipping useless as a barrier device.

Midaz is a benzo the same as any other benzo, meaning they all affect GABA receptors similarly. My understanding of it is that by binding to and "activating" the receptor it raises the electrical threshold for neuron depolarization, meaning they all "quiet the electrical storm" in the brain. Midazolam terminates seizures as well as any othe agent, as the other thread notes the issue is duration. Midaz is a short acting agent anyway, in patients with baseline increased metabolism or, especially, patients with increased hepatic metabolism (such as patients on phenytoin) they can chew threw midazolam...quickly. I once gave an intubated 8 year old in the neighborhood of 20mgs of midaz in a 45min flight. He had recently started phenytoin and at that service midaz was all I had available. Lorazepam and diazepam's increased half life are very helpful here. Don't forget these patients will often need long-term anticonvulsant therapy for anything other than a transport to the ED or for seizures that are refractory to benzos. Phenytoin, fosphenytoin and levetiracetam seem to be the choices in the EM environment.

The "abuse allegation" argument seems to be borrowing worry. Midaz, within it's proper dozing range, acts like any other benzodiazepine, with perhaps a bit faster onset. I've used a ton of the stuff over the years with no issues other than one can't intubate, hard to ventilate patient who ended hypotensive (why I'm so against midaz only intubation). One if the issues I've seen is that diazepam is often underdosed in EMS protocols, meaning when given midaz at proper dosing ranges providers are often surprised at the effect the upper range if the dosage range has. I've used midaz for seizures, RSI, post-intubation sedation, chemical restraint, pain control in conjunction with opiates and anxiety with no issues. Safe an effective med, and I love you can give it IN.

Neurologically generated trismus is one of those "ominous" signs generally associated with brain-stem lesion. Meaning, it's one of the later signs to show up and only releases when the herniation is so complete that there's NO response moving through the brainstem, i.e. mega bad juju. What your trying to do with midazolam "snow" the patient enough to stop the trismus impulse. Which you can do with suffiecent quantities. Here's the issues with that though. 1) The EMS systems involved in this halfassedry typically never prescribe enough midaz to do it. We're talking 30+mgs at times. 2)That amount of midaz in a single bolus may do nasty things to a B/P. Cererbral Perfusion Pressure is calculated as MAP-ICP. This number typically runs 60+, but in situations of hypotension and increased ICP this can run too low to perfuse properly or even into negative numbers quickly (see Monroe-Kellie doctrine). 3)You've not performed one of the other functions of RSI, which is to "take out" the skeletal muscle involved in vommiting. This is the real reason anesthesia invented RSI for the non-NPO patient. Again, halfassedry has no place in RSI. For my money, surgical airway options are far more important than RSI. If you don't have them, get involved and lobby.

So you don't like public agencies, AMR and R/M are evil...have you considered the fact that perhaps your views are in no way objective and your refusal to see this makes them mostly invalid to other people?

I'm fairly dismayed by the state of EMS education as well, but that doesn't mean we should just invite another profession to come play in our bailiwick because. How would NZ medics feel if the nurses there came up with a PHRN credential? I have the same, or more educational background as many RNs with the exception of college level microbiology. Perhaps the 16 week medics don't care, but those of us with a college based background should. For the record I'm not huge on quickie bridge courses either direction. Perhaps bridge courses can exist, but should include a the "core" of the education for either role. While there's considerable knowledge overlap, nurses vs paramedics application of said knowledge is hugh different. In knowledge application a paramedic is far more similar to a mid-level provider than a nurse (which highlights how undereducated we really are).

The "PHRN" just pisses me off. I want an IHEMT-P certification. If you want to play prehospitally, go get the education, the same as you argue we should have to do. In the US it's important because many paramedics have never laid hands on ICU level patients.

Unless you've got blood or an autotransfuser you must clamp the tube. Even with blood or an auto transfuser I'm probably going to clamp a chest tube at way less than a liter and a half. Otherwise it's easy to end up with the patients entire blood volume in the chest drain.

As opposed to say, DC, Detroit, Philly, SoCal, a good portion of Floridia and any other number of places that are public and known for crappy prehospital care? We can cherry pick examples all day long. I've found good medics and excellent patient care in all types of systems. I am sick an effing tired of public service providers acting superior because they happen to work for a public system. The only time I've ever been "encouraged" to doccument creatively was by an FD. Municipalities and privates can be equally crappy. Again, see the Rosenbaum case or any other number of DC Fire screwups. Trade secrets as opposed to the "we suck, what are you gonna do about it" attitude displayed by KCFD post-MAST takeover? We have to evaluate a system based on it's individual merits. To condem it based solely on ownership is stupid and shortsighted.

Shhh, that can't get out! They settled that claim you know...

Pros: Quite a bit more frank than other EMS forums More people willing to say, "that's bullshit". Diverse background, participating has made me a far better provider. Cons: Occassionlly there seems to be a fair amount of trolls running around, and a couple of people who use this BB to tell everyone how the world has "wronged" them because of their race/gender/orientation/species/genus/physical attributes/ect

Bull malarky, and whoever told you this is making stuff up to avoid doing something they don't think is right.

Crap, why didn't I think of nasal intubation? I guess I've been spoiled by spending most of my career in systems that had RSI.

I seriously doubt midaz will a)release the neurologically caused trismus and b)do anything but screw up your CPP if given in adequate amounts to release the trismus. In the scenario above I'd be holding a scalpel if RSI wasn't available. Pharmacologic airway control should be an all or nothing proposition. Using sedatives only increases aspiration risk and sets up the can't intubate/can't ventilate scenario. Either your good enough to use it all, or your not. Halfassery has no place in airway management.