usalsfyre

iResQ

It wasn't easy, but it also helps prepare you to deal with the logistical challenges of finding a classroom, developing material, ect. The bonus is if you complete their curriculum, you don't have take the state exam.

Everyone knows how the typical educational scenario is structured. Intervene correctly and the patient gets better, don't and the patien gets worse. Let's face it though, patients rarely follow this game, especially I'm surgical cases. Are we creating unrealistic expectations in our students? Should we have some scenarios where the patient deteriorates and dies no matter what the student does?

Glad to be back, had to bow out for a while to study for my FP-C. With that behind me, I can be a little more active participant.

Holy thread revival Batman! That said....the whole attitude of "just wanting to pass to keep their jobs" is disturbing to me. If your commonly working with peri-arrest and arrest patients "passing just to keep your job" is unacceptable. There's no reason for it to be boot-camp, or in any way disrespectful. But the handholding of regular ACLS is a disservice to patients.

To echo everything above.. Unless your intubating for primarily "respiratory" reasons, the post-intubation ventilation target should be to match the pre-intubation ventilation status. The easiest way to do this with what's described is match ETCO2. The patient will need support, as you've significantly raised the patients WOB. To tniuqs or chbare, in the absence of a vent, would allowing the patient to breathe spontaneously through something like a Jackson Rees with a spring PEEP valve be better than trying to Ambu bag the hell out of him? My gut instinct is no, your looking at further bumping WOB because there's no inspiratory support, but stuffs not always as intuitive at it seems.

Airway management consist of more than an ETT Subtle changes are often important, the difficult part is figuring out WHICH subtle changes are important. Don't be afraid of opiates, the dangers are way overstated. It's ok to give NTG without IV access. It's NOT ok to give NTG without an EKG Take your suction to the patient. You'll use it more than you ever imagined. Very few patients can't stand a liter of fluid No matter how scared of foley caths you are, UO is a DAMN useful parameter to know.

Percom has a state accepted EMS Instructor course. I just finished it recently.

If we'd get away from 50 freaking percent dextrose it wouldn't be nearly as big of a deal...but until that day arrives...we should be avoiding the blown proximal veins AND the lower extremities.

A/Cs are fine, anyone who says different is being picky, and the folks arguing about "messing up" distal sites need to go look at a chart of collateral circulation. I pefer forearms when I can get them, but if I need a line RIGHT NOW you can bet I'm looking at the A/C. How do the folks who advocate lower extremity lines feel about introducing a wound into the lower extremeities of diabetics?

The thing that most seem to forget is "justice" works two ways, for the victimized AND for the accused. This type of stuff is why I've got outright contempt and disgust for the media at the national level. They no longer report news. They sell good stories.

Kansas City is headed rapidly towards the "catastrophic failure" category as well.

It's all medicine. As you said you can throw it in different subcategories, but at the end of the day, it's all medicine. ALS/BLS IS ridiculous. You think a physician, PA or nurse thinks "ALS before BLS"? Sometimes I can fix an airway by moving the patients head. Other times it may take pulling out a scalpel right off the bat. What "level" of care I'm providing falls nowhere in my thought process.

While I don't claim to speak for Kiwimedic, EMS is the ONLY place in medicine I've encountered the "ALS" vs "BLS" nomenclature. And it's really a pretty ridiculous division. Elsewhere it's medical care, and you do as much as your educated and credentialed to do.

We have. Seems it's not the group asking for it he has concerns about. Plus something about a controlled substance with hallucinogenic properties that doesn't show up on a standard UDS makes administration nervous...

Our state doesn't even have a state scope! Thank God...I'd be highly pissed if Dallas and Houston were considered when my scope of practice was developed. We don't need a "national scope of practice". No other allied health program has one. We need a real educational model, and involved medical directors who develop scope based on local needs.

And why I VERY much wish we carried it, among other reasons.

Wow... If you've spent a few years in "lung school" as you call it then you should know that an ETT is not a device that prevents aspiration whatsoever. Sure, it is a "better" device and reduces the chances, but it's not a secure device. Secondly, find me the study that shows a massively higher level of aspiration with alternative ariways than ETT in the cardiac arrest population. Yes and no. In any tertiary facility...sure. In the local critical access facility we transfer out of routinely, not likely, nor is it likely to find a clinician in the ED with the skill set to use a bronchoscope. Nor are you likely to find anesthesia coverage after hours. So yes I agree, a bronchoscope is the REAL rescue device, but it's not the common rescue device in certain settings. None lately, but long term ICU ventilation and a bridge therapy while hands are short isn't exactly comparing apples to apples. By extending your logic, we should be traching all these folks anyway, cause that's what they might end up with. See above. The two devices mentioned are not suitable for long-term ventilation. No, but when you see the guy in the grocery store a couple of months later it's a pretty good bet he wasn't in the "100%" mortality group. But per your thinking, it's such a quick and easy procedure it should be no big deal right? Even though I only have four sets of hands to provide good quality compressions, secure an airway, obtain venous access (better go ahead and place a PA cath while we're there, wouldn't want to subject the patient to unneeded procedures and they're going to get one of those in ICU too), administer any needed medications, figure out how to remove the patient should we get and ROSC....I'm not placing an LT because I think it's the "best of the best", I'm placing one because it's the reality of care delivery in my environment. I don't believe medicine is different in the field, but you have to acknowledge there are delivery differences at times, this being one of them. As Bernhard noted, the thing is like a "super OPA". I can have my Basic partner place it (as she is credentialed to do) and focus on other more pressing issues. As far as studies go....meta analysis is considered the best data to make policy off of for a reason. It's VERY easy to cherry pick studies that support your argument otherwise. You posted a study that compared BVM ventilation to ET intubation, in which ET intubation showed to be superior. I wouldn't have disagreed with you. The problem is that's not exactly what we're debating. The other studies you noted showed superior outcomes in the in-hospital environment, where it can be reasonably expected that CPR was started promptly, there will be plenty of hands to work and arrest and resuscitation equipment is close at hand. Not the case in my particular environment. Not to mention not one of those studies looked at ET intubation specifically anyway. I don't disagree with you about an ETT being a better airway, but again, it's the reality of my certain situation. I have things I need to do other than setting up for and placing a tube in this situation. I will pull the King and place a ETT when I get an ROSC, if the patient appears amicable to intubation. Yes it's another procedure, but it facilitates later care and is a better airway. The patient is usually well preoxygenated, and once I've got two or three minutes it's not a big deal. I've yet to encounter airway trauma from one of these devices, but we train on their correct insertion and I'm pretty maniacal about making sure they go in right (dear God don't hold the sucker down while you inflate the bulb). If it looks like the patient is going to be a difficult airway, then I will wait to a more appropriate setting. We manage aspiration fairly well as all of out King LTs have an OG placed almost concurrently hooked to suction until we stop having gastric contents come out. Please don't take offense to this...but as far as pissing the RT off? I really don't give a crap. Again, no offense but that's why your there. I've pissed nurses and ancillary staff off more than I can remember, usually because I've done something they're not used to. However I can count on one hand the number of times I've pissed off a physician (usually over pain management) and I've never pissed off any of the medical directors I've worked for.

Pretty well agree with above. Epi, nebs, steroids, consider mag, watch out for the pneumo and hold RSI if at all possible. If I have to tube him Ketamine has some nice bronchodilatory effects, keeps him "awake" and more importantly breathing on his own prior to dropping the tube, I'd consider doing it awake with a lidocaine topical as well. An ETCO2 of 32 tells me...he's got an ETCO2 of 32. Without an arterial gas it's impossible to correlate the two. He's obviously got massively impaired gas exchange. I'll bet once he opens up a bit that number rises like the national debt...

If this is the case...prove it. Yep, in fact I've flown patients on a vent after a failed ED intubation with a King in place with no problems, we simply placed an OG tube down the LTS-D. Not to mention any ED worth a crap has backup airways in the cart, just like you'll find in OR where the real airway specialist live. Anyone convinced the alternative airways cause massive tissue damage and are unsuitable for initial airway use needs to look up Dr. Darren Braude's Rapid Sequence Airway system developed at the University of New Mexico. If your routinely tearing up tissue with BIADS, your doing it wrong.

The problem in Texas is that "licensed" paramedic is actually just another level of certification (Yep, we have a certification call Licenesed Paramedic ).

Considering you can't practice in any state without a certification, and it's granted by the state, it's a defacto license (certain internet and real life hacks not withstanding). No reason to get hung up on nomenclature. The only reason we need to get away from the "certification" language is to place professional responsibility on the paramedic and get away from being beholden to the OMD system. Considering most paramedics don't want that, good luck.

BIAD during CPR, if an ROSC is achieved I'll pull it an intubate. If I have to tube during the CPR, it's while compressions are ongoing.

Tried to send my wife your way (she is a currently out-of-work MRI tech). Got the "you can't be serious, if you are don't expect sex for a while" look.

Where are all these people getting "experience alone with critical patients" as a basic? The number of BLS ambulances in many parts of the US is very low, and usually >50% transfer services. As to interview, operational integration, ect. That's all medicine in the EMS environment. Physicians don't learn just "medicine" during residency, they learn how to deliver it. Which is what any decent service should be teaching during internship. Per my anecdotal experience as an FTO it is far easier to take someone new and train them to follow the expectations of your organization than it is to undo the bad habits of someone who has idolized their turd of a lame paramedic partner for q couple of years.