Bieber

No. I've heard of it and seen the videos, it looks pretty sweet. I think we were talking about getting bougies, but I'm not sure if that's fallen through or not.

I attended a symposium by Dr. Gordon Ewy (the physician from Arizona who spearheaded CCR) and my take from it was that while the primary cause for decreased ROSC and survival to discharge neurologically intact was insufficient time on the chest due to compressions, intubation, transport, etc, there is also the hyperoxic toxicity at play as well. As far as decreased carotid blood flow with supraglottic airways, I've heard that the combi-tube was bad about it but I haven't looked real deep into the literature myself. I can imagine how it COULD cause problems, with that massive balloon cuff, but like chbare noted, more studies are needed.

I would say to stick to ICS. In the event of an earthquake resulting in major damage, services of all kinds will be relying on the aid of allied agencies to assist in the disaster mitigation efforts, and ICS is the national language when it comes to disaster management. You don't want to rely on a protocol that allied agencies may be unfamiliar with if you need to call for aid; and you don't want your system's personnel to have to try and learn multiple protocols for every kind of disaster out there. ICS is something that every agency involved in disaster management should be familiar with, and it is flexible enough to applied to nearly every emergency (except for an alien invasion, in which case the plan is to run and scream and then get zapped).

Only numbers 5 and 1 were all that sensationalized, in my opinion--and number 1 only a bit.

That's awesome... and probably almost a hundred percent true.

Too many paramedics?! Nonsense! You can never have too many ALS providers!

I'm not sure that I would say making note of our data collection shortfalls was a waste of bandwidth, Mike. Nobody ever thought to start saving data until we realized that we lacked enough of it to make much of any claims about anything in EMS. If it gets people motivated to start looking into this matter, it may help us identify what changes need to be made to make EMS more appealing to potential employees and aid employers in figuring out how to boost retention within their own services.

Speaking of this topic, I just read this article from JEMS today that touches on educational levels and longevity of a career in EMS. http://www.jems.com/article/training/will-you-stay-or-go-are-high-p

EMS - Medicine, but without all of that science mumbo jumbo.

Dwayne, thanks for putting that much more eloquently and comprehensibly than I was able to! Just like you said, bro, resuscitation decisions should be made based on patient viability and the chances of a good neurologic outcome, not based on our perceptions of their quality of life and how that may or may not translate to their will or right to live. We resuscitate because we know based on what we have learned over the last hundred years that the cessation of the heart does not have to be the end of life if prompt action is immediately taken to restore a pulse and create an environment conducive to restoring its automaticity. Our capabilities are limited currently, but they're improving every day as the science comes around. Until we can convince people to no longer fight against the ultimately fatal clock of time, the expectation that we at least attempt to save those we can and the hope that we will improve those statistics won't change. That doesn't mean we shouldn't be scientific about our practice, and there's ways to narrow down the list of patients who receive resuscitative care to only those whom we can reasonably expect to successfully revive.

Because we are able to successfully resuscitate some people. The changes that have been made in resuscitative care have shown improvements and they'll continue to show improvements as we continue to improve our practice. I'm not saying we should resuscitate everyone that codes, and we certainly shouldn't transport those we don't get back--but for a small subset of people, survival is possible.

Kiwi, I understand where you're coming from, but to be honest, man, it seems like you're coming at this problem from the perspective of ethics and not from the numbers. And I get it, some of those people with severe illnesses have it very hard and I certainly wouldn't want to be in their shoes. But at the same time, our decision to resuscitate needs to be based on the science and their chances of survival to discharge neurologically intact--not whether or not we think their life is too hard to endure any longer even if it's possible to get them to that point. There are systems in place for people who do not want to be resuscitated, for everyone else we need to base our decisions on that single question: "How likely is it that we can get a good outcome out of this?" Whether we can or cannot achieve that--irrespective of their general state of health, which I admit will influence the answer to that question--THEN we make the decision to attempt resuscitation based on that factor and that factor alone. Just the numbers. The minute we start making our decisions based on what we individually would want done to us, or based on our own personal beliefs, we stop following the science. People have the right to a good neurologic outcome if we determine based on our objective assessment that such a thing is possible. People also have the right to refuse any outcome that includes ROSC. So what do the numbers say, man? Because if the stats say that people with all these significant co-morbidities almost never get a good neurologic outcome then I'll stand right beside you and argue against needlessly pounding on their chests. But I'll only do it for the science, I won't do it because I wouldn't want to be bed bound and unable to care for myself; that's me, that's my choice--and I can only speak for myself.

I agree in principle, but at the same time, it's a lot easier to look at someone who is pulseless and asystolic and take the studies and say "they have almost no chance of survival" than it is to look at someone who is pulseless and in V-fib, had good bystander CPR prior to arrival and a decent chance at being successfully resuscitated with full neurological function and say "well, because they've got multiple co-morbidities and a poor quality of life, we're going to call it"--especially if they aren't a DNR patient. To me, that almost crosses into the realm of euthanasia. On the other hand, I haven't looked at the actual survival rates of patients who code that have multiple co-morbidities and I would venture to guess that even if they're fresh their chances of surviving to discharge are low just because of all those co-morbidities--in which case I would be a little less uneasy about it. I'll have to look at the numbers and think about it some more. As a quick addendum, I'm not opposed to euthanasia, but I wouldn't be as comfortable with the idea of us deciding that that person's quality of life is bad enough that they shouldn't be resuscitated unless the studies indicate that even a "good" code with someone who has multiple co-morbidities has a low survivability. If it's us deciding to withhold resuscitation not because we can't get them back but because their quality of life sucks, I can't agree with it; if it's us deciding based on the science that even if they have the best chances of surviving the arrest they probably won't because of their co-morbidities, that's a different story.

The point you make about the vegetability (new word, enjoy) of asystolic code saves is a good one, Kiwi. And you're right, we probably shouldn't be bothering with them; and I don't expect we will for much longer. I've rethought my position on that one and I'll retract it; as far as the issue of persons with terminal illnesses, I'll have to think about that one for a while longer--although I think at that point we're getting into some especially murky ethical waters.

I'm uneasy about the idea of running someone for the sole purpose of harvesting their organs, though I admit I can't find a rational justification for that uneasiness.

Not necessarily, although in the future we will probably withhold resuscitative efforts for patients who present in an initial rhythm of asystole. For now, though, asystole isn't recommended by the AHA as an indication for the withholding of resuscitative efforts in se. In contrast, if we know that the patient's downtime has been at least thirty minutes, then there's obviously no chance of a meaningful survival (with rare exception) versus someone who presents in asystole who may have only been down for a few minutes.

In general, I think that resuscitation attempts should be made on scene, where the patient is found or nearby if they have to be moved for access, and discontinued if the patient fails to respond to therapy on scene. There's no scene transporting the dead, we're only killing them a little more slowly. Should a patient who is in asystole when the crew turn up be resuscitated? Without evidence of clinical death? Sure. Will we get them back? Very unlikely. Run them, call them. Should a patient who is housebound and dying from severe end stage systemic disease be resuscitated? Do they want to be resuscitated? If so, then sure, let's try. Ethically it gets tricky when we start to think about what are we really accomplishing here, but at the end of the day I think that if the patient wants us to at least attempt to get them back, we should honor that wish as long as they're viable. Should somebody in a rest home (nursing home) who has a poor quality of life be resuscitated? Again, same as before. If it's what they want and there's no reason to think that they are non-viable, let's give them the chance they want. Should you cease working on somebody who has been down for a half hour? Absolutely. There's virtually zero chance for a meaningful recovery of any kind. We need to stop thinking in terms of "getting a pulse back is our job" and realize that the ONLY thing that matters is getting a patient discharged neurologically intact; anything less is a failure. Should you be forced to work somebody because the family wants it? No. We can't bring the dead back to life, and if the family wants us to pound on a corpse's chest the only thing that does is to degraded both the patient and us. "I'm sorry, they're dead. If there was something I could do something to change that I would, but there isn't and I can't. I'm sorry."

I would say if we're going to use hand signals, we should try to use a system that already exists. My initial thoughts were aviation runway signals or military signals, but after a quick search it doesn't quite look like such a system that would be applicable to EMS or MCI's really exists. ASL is another option, but I think that the signs done in ASL aren't as full bodied and visible as runway or military signals; ASL wasn't exactly intended for long distance communication. The most important thing would be that it is universally adopted, so that providers from all agencies could "speak" the same language; meaning it would have to be FEMA adopted. There's also the issue of retention and provider adherence to the approved signals. How many times have you had a backer and they used a different signal to turn or stop than what your partner and you use? It's an interesting concept, though, Asys, and I agree that it would be helpful to be able to communicate non-verbally--even if you did have access to radios, just to keep radio chatter to a minimum. http://www.lefande.com/hands.html http://www.traron.org/docs/Marshaller%20Handsignals.pdf http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Manuals/FMSS/CombatFormations/COMBATFORMATIONSANDSIGNALS.htm

Obvious death (decomposition, rigor mortis, dependent lividity, injuries incompatible with life; i.e. decapitation, burned to a crisp, etc) as well as blunt trauma victims with no vital signs on ALS contact and cardiac arrests with an initial rhythm of asystole who do not respond to treatment with online medical consult. Our new protocols will be less restrictive.

I would suggest teaming up with some of your fellow classmates and reviewing for the National Registry exam together, or maybe even seeing if it would be possible to use your skills lab after class to continue to practice. I'd offer to help since we're in the same neck of the woods, but Wichita to KC is still a bit of a drive. I would assume that the time limit to begin ventilations starts when it becomes clinically evident that they're indicated, not necessarily within thirty seconds of starting the station. What all does it want you to do before you start ventilations?

I've been involved in one minor accident. While trying to turn down a big ass Chevy medium-duty chassis ambulance down a narrow alleyway (that I should not have been attempting to enter), I scraped a telephone pole. Knocked off the exhaust port and the hand bar for the side door. No accidents since then, though one near miss recently. I was driving behind someone on the highway going about 60 mph (following a safe distance) when the guy in front of me darted into the center lane because there was another car in front of him that was only doing about 30 mph. I had to slam on the breaks pretty hard, but we thankfully didn't hit the other car.

Preventing disease and unnecessary emergency medical care > our jobs. If we want to assure our own job security, it can't be at the expense of patient care. It's about them, remember? Also, assuring our own job security means embracing preventative care models and become proactive in this area of medicine. At the end of the day, we're already doing a lot of primary care and a little bit of emergency care on the side; what we need now is the training and education to give that primary care without unnecessary transport to the hospital being a necessary component. I foresee the future of EMS as transitioning to Mobile Health Services, where more and more we give people the care they actually need and less "magical" care; i.e. transporting a patient to the hospital for a simple lac that needs sutures as if that's the only or correct option. Currently? Maybe, maybe not. We talk a lot about how inadequate paramedics are at providing primary care, however primary care health issues are what make up the majority of our jobs. We've got the experience, now all we need is the education to pair that with; and there's no reason why a paramedic can't be adequately educated on the appropriate provision of primary medical care. In all fairness, I think many if not most paramedics already do give medical advice to their patients. I know I do.

I get that, I'm just trying to understand what you're basing your opinion on. I agree that taking someone without any training in emergent vehicle operations and putting them behind the wheel of an ambulance is a bad idea. I agree. I must have misunderstood something about what you said. If that's the case then I apologize. I know that the majority of accidents (clinical and operations) that occur in my system are mostly due to people rushing and not taking their time. Considering how little driving training we in EMS receive, in addition to a very much "we gotta go as fast as possible, it's an EMERGENCY!" mentality, I think it's a combination of insufficient training and too much emphasis on rushing to get from point A to point B. Ultimately, it's counterproductive. Like I said, slow is smooth, smooth is fast.

Ah, okay, Arctickat, I clicked that link earlier but didn't even pay attention to the name. Croaker, those are all great pieces of advice and I'll have to remember them on my next pediatric call. Pediatrics is an especially unique specialty of medicine due to the incredible challenges peds present besides their unique physiology with the emotional care that can be so much more challenging than attending to the emotional needs of an adult. For those of you who have kids, did having your own children make dealing with pediatric patients easier? Harder?

I can't wait for that movie to come out, it looks awesome. I remember watching those movies and the Predator series growing up (for the record, the Alien vs Predator movie sucked).