usalsfyre

So the appropriate treatment for everything is transport? People are discharged from the ED with referrals to the appropriate services daily. You fail at understanding if medicine as a whole...

Whoever is writing your protocols needs to do some serious evaluation of the system. Either your medics are good enough to use drugs to intubate, or they aren't. Half assed stuff like this just sets you up to have an obtunded, non-breathing patient with trismus and active regurgitation. I am baffled why an opiate would be excluded from the drug sequence...

You sir are clueless... It's not leaving patients "at home to die". It's directing the patient to appropriate resources and looking after their finical well being (i.e. holistic care). The point of this is a GOOD assessment is done (no, you don't need labs or imaging) and a decision is made. If the problem is found to be somewhat benign, the patient stays at home, no need for an ED bill. If it's unclear or life threatening, it's transported. It doesn't have a damn thing to do with generation, other than old myths of I'm gonna get sued or leaving people at home to die keep creeping up. What it DOES have to do with is a whole crapload of providers who are unwilling to accept responsibility for their assessments and don't want to get the needed education to be able to do this. Your doing nothing but fear mongering and spreading misinformation.

The problem is exactly that, it makes people "feel" safer. Want to create hysteria and disrupt travel right now? Set off a few IEDs in the queues to get screened at JFK, Newark, O'Hare, Hartsfield-Jackson, DFW and LAX...

Who here is doing awake intubation with a topical and/or dissociative for suspected difficult airway?

The cases described aren't laziness, they're stupidity (political correctness be damned). Some of the laziest providers I've had the displeasure of knowing throw everyone in the truck, do as little treatment as they can get away with, and write a half assed report. The problem with leaving people at home in the US is the average medic is too uneducated to tell who can stay and who can't. Cases above happen because a lot of providers are too stupid to realize this. The "just one life/I don't want to get sued/transport is our job" crowd is keeping EMS in the dark ages. Right now EMS provides questionable benefit for expensive service that only transports to the most expensive hospital real estate per hour outside the OR. EMS in current form won't survive a real cost benefit analysis. There will be people asking uncomfortable, hard to answer questions at some point. As to price tags on human life? Like it or not, it's done daily.

I worked for the City, and it was an online order (there's no EMS supervisors per say over there). Alexandria can also RSI, or at least could when I left several years ago. Arlington and RSI is a new thing, and they took what's probably the correct approach. It needs to be a limited pool of experienced and well educated paramedics with good oversight. I would say the state of Maine blows this guys argument out of the water...

It's easy to forget how farking insane the setup in VA is... That said, I was only aware of two agencies in Northern VA that performed RSI, I worked for one and did clinicals at the other, both had less than 6 units and I's and P's operated completely interchangably at both (at least when I left). Has some one else added RSI?

Brutane and tincture of fractured teeth... :D Actually, fentanyl for premeditation, Amidate for sedative/hypnotic and roccuronium (no more MH or K+ concerns for us) for paralysis. As for the actual procedure, look up the national emergency airway algorhytms. Replace "1.5-2mgs/kg of succinylcholine" with "1mg/kg of roccuronium". You now have our RSI protocol.

What's humorous is how many people think LEOs are magically qualified to render a firearm "safe". Many LEOs are barely qualified to work their own gun, much less another make/model. In a former life, before kids and career I did a fair bit of high level competitive shooting. My family is still heavily involved, those of you watch the shows about competitive handgun shooting on the Outdoor channel, ect would probably recognize my brother. I've handled literally hundreds of different types of firearms. Making them "safe" comes down to one thing, VISUALLY ensuring no ammunition remains in the gun.

Betadine is supposed to dry on the site (out of the Brady medic books, don't have the reference handy)

Chloraprep is really best practice, if you REALLY want to follow best practices you clean with alcohol, wipe (swiped, not circular) with Chloraprep and the let air dry prior to starting the line. Usually I just wipe with Chloraprep and start the line.

Fiznat, understand your position better and I agree with those thoughts...mostly. I WOULD argue that outside of electrocution and hypothermia, ANY cardiac arrest rhythm that has been unresponsive to ACLS (especially with an ETCO2

Fiznat, I don't know your education level, but your making arguments that sound suspiciously close to "if it saves one patient...". That, quite simply, doesn't fly. The fact is the science supports terminating resuscitation on the vast majority of arrest in the field prior to transport. No lesser an authority on resuscitation than ILCOR recognizes this. We can argue about anecdotal case reports all day long, the fact is the majority of these cases are not helped last ditch, off the wall treatments like trauma room thoracotomy and centisis. At some point you have to begin weighing the cost/benefit of possible accidents in transport and the greater cost associated with inhospital resuscitation with the non-existent (statistically speaking anyway) improvement in outcomes. As far as anecdotal case reports go, I have never seen a chest opened in a trauma room for any other purpose than "let's try this" at academic centers. I've also never seen, or heard of, a patient that required a centisis surviving when the initial presentation was cardiac arrest. The ONE time I've heard of a patient surviving cardiac arrest from tampanode it was recognized prior to arrest during transport, and they were waiting with a needle. I don't know if your a field provider who's uncomfortable with terminating resus or perhaps a med-student/resident physician who is biased towards your trade. Either way, this attitude places providers and the public at risk from unneeded priority transport, subjects the patient to unneeded procedures, and subjects their estate to useless cost. None of which is good policy, good medicine, or true patient advocacy.

VA follows the I99 standard, prior to that it had a level called Cardiac Tech that in essence did the same thing. Is it absolutely insane? Yep, but the system was set up around the volunteer rescue squad/transporting FD, so that's what the state is stuck with.

Your two best bets are titrated oxygen therapy (sats >97%? That's absurd!) and transporting cardiac arrest. The AHA backs you on these issues. You might find out how many accidents have occurred in the last five years during emergency transport. If you can't get them to stop transporting cardiac arrest, at least see if they'll reduce transport priority. Carflite and MedStar in the DFW metroplex recently did this.

Me thinks if we fired everyone who has ever made a clinical judgement error you would have a very hard time finding a physician...

Maybe I'm an idiot, but to me your article citation (which you attempted to pass of as your own) fails to adequately explain how hypoglycemia prevents reaction to noxious stimulus. All it does is explain the effects of hypoglycemia on the CNS, which I'm fairly certain most here discussing this are aware of. Literally anyone can randomly cite crap off of medscape and pub med. I fail to see a true understanding of the sources your citing and the clinical significance behind them. There's a hell of a lot of smart people here trying to hit you with a clue bat. You might want to heed that. Like Dwayne said, your either trolling or very, very new to EMS, as anyone with REAL clinical experience doesn't speak in absolutes. I feel sorry for you the day your wrong.

1st semester medic students need to stay away from trying Google-Fu...

Unconscious and unresponsive are two different things bubba... I've had an "unconscious" patient who damn near levitated off the cot when we flushed the IO to start a pressor infusion. As such anyone I place an IO in that had a pulse gets lido to treat the pain associated with the increased pressure in the meduleary cavity, which is what Vidacare recommends. Unless I'm mistaken, that was the reason for the lidocaine. I'm not sure what blood pressure studies (which lido doesn't affect) and studies on poorer outcomes associated with HYPERglycemia have to do with this case. Still haven't seen a source for IN glucagon bring THE standard...

Sounds very much like your hung up on one services protocol, because from what it seems like most of the research behind it was done well before 2008 (meaning it's been going on much longer). The reason RSI isn't available to even "educated" paramedics is 1) most of them aren't that educated 2) too many paramedics think in terms if absolutes, not clinical possibilities 3) the places that need RSI rarely do enough intubations to remain proficient. I work for a service where all of our medics can RSI. Frankly I've seen some really scary stuff, even among "educated" medics.

No IN glucagon here, we deliver fentanyl, naloxene, midazolam, and lidocaine (for nasal and awake intubation) via MAD.

So I've been meaning to come back to this, have been a little busy. The Brain Trauma Foundation recommends mild hypocapniea for LIFE-THREATENING increase in ICP. Every source I've looked at also recommends it for such. It is not routine management, nor did I recommend it be. It's for when the patient is herniating in front of you. The studies your talking about are on prolonged hypocapniea, not using as a bridge to more effective therapy. I hesitate to say "safe" and "prehospital RSI" in the same statement. EMS is not really good at RSI if you haven't noticed... Agreed, but do you know the reasoning? Bet it's not what you think. Alot of systems do, and a lot of systems kill patients with paralytics too. ANY reduction is what your looking for with imminent herniation. If we can't raise the HOB, can't hyperventilate, how do you suggest treating the death associated with herniation? You do realize osmotic diuresis will make an active bleed worse right? One of the key points to make sure of with Manitol is that the patient is not actively bleeding into their head prior to administration. Just going off what our neurosugery group wants (covering a Level I and Level II trauma center that are both Primary Stroke Centers). If 28-32 is their wish, 28-32 is what I'll do. You strike me as someone who is self-educated and doesn't have a lot of experience in this area. Glad to see your expanding your knowledge though.

Maybe not hyperventilation (increased MV) specifically, but controled hypocapenia to an ETCO2 of 28-32 is a commonly used and reccomended by neurosurgeons way of managing the patient with severe ICP increase (i.e. signs of herniation) in the absence of more advanced methods.

Maybe in NYC, but considering the hour+ transports we have at times to get to a neurosurgeon, using BVM w/OPA would be very, very suboptimal to say the least. Plus, other than maintaining the head in a neutral position, what does cervical stabilization do for ICP? It's very hard to put the head of the bed at 30 degrees with the patient on a board... There IS evidence that RSI, done well with adequate pharmacology and post-intubation management is good for outcomes. Too many paramedics do RSI (and for that matter intubation)poorly for me to trust just anyone with a laryngescope. To answer the OP's question, adequate pain control (first and foremost) and sedation should eliminate any problems. However, outside of the unconscious patient with truisms, I'm not sure sedating and placing a supraglotic airway in the non-NPO patient is a good idea.