DartmouthDave

Hello, Really, if your transport time is short the prudent option would supportive care until you get to the ED. Just be ready if things go down hill during the 15-20 minute transport. I am not saying 'scoop' and 'run' with everything and let the ED sort it out. But, EMS should be an extension of the ED. In the ED he would get supportive care and a work up to see what is going on. Why should the EMS standard be different? He has signs if right sided failure (edema and JVD) and signs of left sided failure (rales and pulmonary edema). Signs of a infectious process (general malaise x 5 days with a fever). Cardiac issues as well (1st degree block/bigeminy with an elevated DBP). Plus, a solid list of unknows..... Renal...what is going on? Any failure? Urine output? Lytes? K+ Mg+ Phos? et al.... Fluid status? In he dry intavascular? CBC? Hgb? LFT? Tn-I Blah...blah.... =) So, Kiwimedic.....what is going on here? Cheers, David

Hello, Looking back at the orginal post I noticed this bit of information: "The doctor is trying to find some chest films he took and it'll take a minute or two." What dose it show? Is the CXR new or old? Better yet a new and old one. So, looking back on this thread our list of possible dx are: 1. Sepsis 2. Pneumonia 3. CHF 4. Endocarditis with an effusion All solid answers IMHO. These all can be dx clinically. But, if you are wrong you could make things much worse. Supportive care and get to the ED. Do a quick U/S (FAST)and CXR. If this guy walked in to the ED it he would get supportive care and an U/S, labs, ABG, 12-lead, and a CXR done to figure out what is going on. Besides, these case studies always have Zebras lurking =) Cheers, David

Hello, This patient has constrictive pericarditis. I am sure it is exudative in nature. A histroy of feeling unwell for five days and an elevated temp. - Any treatments aimed towards AMI or acute CHF is a very bad idea here (No NTG No MSO4). Reducing preload isn't a good idea at all. Drop the RVEDP and the CO will tank. - If he is dry from being ill for 5 days Lasix is a very bad idea. Again, a big drop in RVEDP will kill this fellow. - ACE inhibitors. I am not keen on this as well. - CPAP. The PEEP and pressure support would increase the cardiac worklaod. - Dopamine. The heart can not stretch. This guy has systolic as well as diastolic failure due to the effusion. - Amiodarone. If his heart is irritable from treatment. Stop the treatment. If his heart is irritable due the effusion leave it. Keep it simple. IV, O2. maybe some fluid, and off to the ED. An echo or a FAST will give us the answer we need quickly (...effusion, valves, EF {if an echo is done}, what the myocardium is doing). If he has a bad pericardial effusion (...moving towards a tamponade...) a pericardial tap followed by a drain will (should) have a crowd pleasing effect. Improved CO and a resolution of his congestion. Oddly, as of late, we have had a trio of bad effusions come through the ICU. All looked like hell until drained. So, in effect......I am parrot here and repeating much of which has all ready been said. =) Thank you, David

Hello, Slow night here. I just put NaHC03 and CaCl togeather in a bag of NS. I am waiting to see if calicum carbonate will form in there. =) Ok....I am going to go with infective pericardia effusion. If I was in an urban or suburban area with short transport times I would put IV x 2, oxygen and transport. If I had a longer transport time I would dig deeper as to the patient's fluid status. Any N+V? Eatting? Drinking? How long he has had a fever/chiils? I would also see about end organ perfusion. Making pee? --If the SBP maintained above 90 and he was making some urine I would sit on my hands. --If the SBP maintained above 90 and he wasn't making urine I would be worried but I would still sit on my hands. A little pre-renal failure would (should) correct nicely once the cardiac issue is corrected. --If the SBP started to fall (RVEDP too low) and he made some urine I would give NS 250. Increase the filling pressure. --If the SBP started to fall (RVEDP too low) and he was anuric I would give NS 500. Increase the filling pressure. The risk/benefit here is very tight. David

Hello, Ah...brain gym at 0200hrs. Sepsis (...moving toward severe sepsis or septic shock) is a solid dx. The temp and the histroy point to this. However, the DBP is still quite good for sepsis and the pulse pressure is quite narrow as well (for both pressures given). For example, 96/86 has a tight pulse pressure of 10. Something is at play here. Add in signs of congestions and a new one set block and an angery strip. I would lean to endocarditis with a weaker inclanation towrads pericarditis (...no ST changes....not that they are always there)with a bad pericardial effusion. Jonas asked about edema and there is perpherial edema and crackes. What about JVD and heart sounds as well? Distant? Mummurs? The valuves may have taken a hit. Any odd skin leasons? Red spots on the arms, hands or feet (Roth lesions I think is the name...not sure)? Any splinter lesion in the nails? Supportive is the main treatment here. Get him to the ED and get a FAST done. Oh...a CXR as well. Thank you, David

Hello, We tend to give IV steroids if Etomidate has been given. As for the pro and cons I am not sure what to think. Up To Date (lit review was 09/2009) states this: Adrenocortical suppression — The major controversy surrounding etomidate stems from the reversible adrenocortical suppression associated with its use [26-29]. Etomidate is a reversible inhibitor of 11-beta-hydroxylase, which converts 11-deoxycortisol to cortisol (algorithm 1). (See "Adrenal steroid biosynthesis".) A single dose of etomidate causes a measurable decrease in the level of circulating cortisol that occurs in response to the administration of exogenous ACTH, although cortisol levels do not fall below the normal physiologic range. The effect does not persist beyond 12 to 24 hours [29]. Some researchers have raised concerns regarding the safety of etomidate in the setting of adrenal insufficiency related to sepsis [27,28,30]. However, no well-designed, prospective trial has shown adverse effects from a single dose of etomidate used for intubation in patients with sepsis or septic shock. A multicenter randomized trial of critically ill patients requiring emergent intubation found no difference in organ failure score, 28 day mortality, or intubating conditions between patients given etomidate for induction and those given ketamine [31]. No serious, drug-related adverse events were reported for either medication. Although adrenal insufficiency occurred at a higher rate in the etomidate group (86 percent), it also developed in approximately 48 percent of patients receiving ketamine. Other retrospective studies and small randomized trials have shown mixed results that also do not support recommendations to avoid using etomidate for induction in patients with sepsis. However, I read in Trauma (...I think this study was metioned in a JEMS magazine as well...I will look into this....at work again) that Etomidate caused higher mortality rate. As well STARS (Alberta) recently withdrew Etomidate from thier drugs box after concerns were raised local Intensivists. Cheers David

Hello, Picking on a long term care facilities is too easy. Mainly due to horrible patient-to-staff ratios and inadequate staffing mixes (RN/LPN/NA). They never can shine. Personally, working long term care is a horrible job. I couldn't do it. David

Hello, Welcome!!!! Nice picture Fireflymedic...

Hello, I use to work for a ground and air program. Now, I work in an ICU. Sigh, I miss my old job...... Ok. We used Propofol for transport (air). We ran (normally) 0-300 mg/hr with 25-50mg IV PRN. However, we have gone higher on occassion. In the ICU we use mcg/kg/min. It works well if your able to give enough to acheive your sedation goal. A RAAS 0f -3 worked well for most of our trips. Like you noted, hypotension can be an issue. So, in most cases an arterial line is essential. A second issue (our fligts were long...3 hours+) was technical. We used a 60cc syringe and a syringe set for the Minimed III pumps. At the high rates a syringe wouldn't last very long at all. Also, we rarely ran Propofol solo. We typically hung a Fentanyl infusion as well. Coffee time is over.... Pardon the typos.....trying to fire off this eamil on the fly. Cheers, David

Hello, Here is a copy of one of our sedation protocols (Part One). Cheers, David

Hello, School is an other issue in BC. The JI needs to have more ACP programs. Some logical picks would be one in Prince George, the Okanagan area for example (..along with a few others...). This would cut down on the training costs for the 'funded' BCAS students as well as making it available for experienced PCP who can not afford to take time to travel and be off work. Also, have it set up for adult learners with families. I know quite a few good PCP that would be excellent ACP or CCP but can not take the 'time off' for the JI or afford to live in the few ALS posts. BCIT has a good reputation for Critical Care Nursing and Neonatal Nursing as well (...not as good as Mount Royal...wonder where I went!). They could develop, staff and run an excellent PCP and ACP program. Something along the line of an ONT program. You become a paramedic and get a nice academic transcript full of management, leadership, pharm, and other good stuff. Like I said on my last post......look at a solid educational program that works and learn from it!!! This would be ONT. Even enhancing the BLS/PCP (I hate this term......it downgrades what is really done) standard of care in BC. For example, EKG and 12-leads. Obtaining a 3-lead or better yet....a 12-lead on chest pain or high risk patients is useful. Supraglotic airway devices (King LT, ect...) as well would be useful. Just to name a few. Also, more ALS like I said. Here is a simple example. A 50ish year-old women develops pneumonia/sepsis and is found unresponsive in her home. If I was at the U of A in Edmonton she would arrive (odds are) tubed, IVx2 and a bolus or two. Same patient where I work (no ALS sent or available) arrives with no IV or tube (EMR crew I think). Requires 2:1 care while being tube and stabilized. This 2:1 was 50% of the ER Nursing staff of the day. This example highlights two issues. First, the most important, patient outcomes. Good ALS/BLS is an extension of primary care. You start it we finish it so to speak. Two, workload. Staffing is an issues. Good EMS helps reduce the insane pressure most ER are feeling these days. However, I disagree with your point on staffing of CCT. Personally, I do not care if a paramedic model, nurse/paramedic or all nursing model is used. There are numerous examples of each that work very well. Just as long as IT works well and get the job done in a cost effective model. Because, like it or not budget is an issue. David

Hello, I think I may have to stop posting here. LOL! Nothing makes me go from calm and mellow to ranting mad man is 10 seconds is the current state of ALS coverage and ground/air CCT in BC. Because, I have seen some crazy situations with sick people stuck waiting for advanced care. If BC can host the Olympics it should be able (95% of the time...there are always unique situations) get a failed TNK patient to Vancouver. Or take less than 36 hours to move a ARDS/Sepsis patient. This is not the crew fault. You only can be in one place at a time. The answer is simple.....more planes and staff. More ALS coverage. It makes common scene to build on and improve an organization (BCAS)that has the equipment, experience, ambulances, staff and aircraft rather then trying to reinvent the wheel. If BCAS won't I think others will step in and try. Heck, where I work STARS Alberta came by to show off their simulator and 'plug' their program. "In a tight spot??" "Call us!" "Bed are tight....ICU is full? Well....let us help" Ed, I agree that thus far CCT (Hospital Based) in BC has been lack luster. Why? They cobble a team together without training or practice and say...have at it. Get the patient gone and free up a bed. No transport medicine is not the same as the ICU. When I think about hospital based programs (RN) that work well Airlift Northwest, Stollery NICU team, Vanderbuilt and Duke come to mind. Or mixed teams (RN/ACP or CCP) such as Lifeflight Nova Scotia. If a hospital wanted to make a good program they should look to these as example to follow. Or even BCAS leadership. Heck, BCAS position papers (written in the 70's....read some of it for a course I took...yawn) looked at Medic One in Seattle for idea on how to establish an ambulance service. BCAS just needs to shake things up and get back in the game again. Cheers David

Hello, "This is where I’m in total disagreement with you. Because of the existing structure of the service in BC and the fact that it’s a public not for profit entity, it is far less costly (to the hospitals and thus the tax payer) to properly fund the BCAS. Properly funded the BCAS could easily provide true dedicated transfer services. Private companies will only ever take on a service if they can make a profit in doing so. When it comes to public services it makes more sense for any profit to go directly back to the tax payer." If BCAS was properly funded and had enough ALS the hospital wouldn't have to send its staff. That is what I wanted to say. Now, a lack of ambulances and properly trained crews for ALS transfers costs hospitals money, time and staff. Not to mention effects patient outcomes. For example, a small town sent in a patient with a green BLS crew and a new grad RN with no critical care background. It was a inferior/right-sided MI. The guy was hypotensive, gray, nauseated, and barfing for the whole long ride in. On arrival his BP was 70. No interventions were made. Who fault is that.......not the wide-eyed paramedics or nurse. No, it was a funding issue for BCAS. "What air ambulance services? There are 3 dedicated day-time helicopters in the entire province and only one dedicated helicopter at night. The bird in Prince Rupert isn’t even staffed with ALS providers. It’s staffed with PCP-IV’s pulled off of a Prince Rupert BLS car for the flight. I could go on but I get the impression you’ve personally witnessed the sad state of affairs here in BC. BCAS has gone from being a provincial jewel to a pile of thorns. I’m still hoping we can get some roses out of this whole thing but it isn’t going to happen without some water and fertilizer. The soil’s getting might dry these days." Holly....do not get me started on this one. Once it took 36 hours to get a sepsis/ARDS patient transfer to us. An other time a fairy young patient with failed TNK needed a rescue angio in Vancouver. After 12 hours of hurry up and wait BC bedline broke the bank (gave a P#....bill to an other service) and Alberta came in a took the patient to Edmonton. Also, in my area STARS and other Alberta services have been doing more and more transfers for us. I do feel bad that BCAS has fallen behind from it glory days. When I think of good ambulance systems I think of Emergency Health Services Nova Scotia. Or new kids on the block with great potential like Ambulance New Brunswick and Island EMS (Prince Edward Island). Gasp...... Rant done. For now...... If BCAS funding dose not come around and transfer (ground and air) do not improve I can see each health region developing its own CCT program (the Trail boon-doggle notwithstanding). Need to run. David

Hello, I have worked in three proviances (AB,BC,NS) and one territory (YT) and I have found transfer services in BC below standard. I do not mean this as an insult to BCAS staff but rather a symptom of poor management and funding. For example, we frequently get patients transfer in with a BLS crew and a RN. Sometimes, things are well done. Sometimes, not so much. These are not short little transfers either. We have had a critically ill patient driven in for several hours away. In addition, from a hospitals point of view they are paying for the RN to go with the BCAS crew (that cost money as well). In fact, a hospital-to-hospital transfer can cost a pile of overtime and short staff then sending hospital. Second, time delays waiting for a transfer ambulance. Therefore, it makes economic scene 'contract' it out. In AB and NS this wasn't an issue. For example, a sepsis patient needs to get from the hospital A to hospital B. An ALS crew would show up, get report, load up the patient and be on their way. Again.........no slight intended for BCAS paramedics....just a symptom. Not to mention air ambulances services........ I would write more but work calls.

Hello, HB.....that is different. From my experience at a few different hospitals an infusion is always hung asap for a tubed patients with a sedation goal. Two common ones I have seen are; Richmond Agitation And Sedation Scale (RASS) http://www.icudelirium.org/delirium/training-pages/RASS.pdf Ramsay Scale (RS) http://www.aic.cuhk.edu.hk/web8/sedation%20scale.htm They are useful because you have a goal. An ARDS patient needs a RASS of -4. Want to wean..... a RAAS -1 on PSV overnight then a vacation in the AM . From my experience it prevents people in the ICU from snowing a patient too deep (to have a easy shift). Or worse, keeping a patient too light. For transport (depending on your vent) I think a RAAS of -3 or -4 would be ideal in most cases. We had a Dragger Oxylog 1000 that was ok. Then we got a LTV 1000 that was more dynamic. Cheers.... David

Hello, They also had an excellent episode about 'Community Paramedics' last year as well. I think they may have this old podcast online as well. There was also an interesting article in JEMS that talked about this as well. Cheers

Hello, I agree with Fiznat. Also, if you are stilled worried about pushing D50 through a line just dilute it in a 500 or 250 cc bag of NS. Heck, some services do not even use D50W for the very reason we are discussing. The just hand a bag of D10W. In the end, the results will be the same. Cheers, DD

Hello, I hope that my post did not sound judgmental. In reality, I was only irked by the BLS crew walking the patient to the ambulance and treating her as a nuisance call. I did a quick literature search last night at work and I found a 2005 study in the American Journal of Chest Physicians that had the following conclusions; "The use of vasopressin in CS caused, in this case series, an average increase in CI of 27.8 % and an average increase in urine output of 45.7% within the first 12 hours compared to baseline. CI decreased only when higher doses of vasopressin were used (in the range of 0.08 to 0.5 U/min)" It also noted that Vasopressin benefits diminished after 24-48 hours. So, considering her CO/CI wasn't the best and she had no urine output....it makes scenes. We do have Swans. But, nobody was available to float it in. So, in a pinch the FloTrac is a nice piece of equipment. It was an interesting patient. CS is tricky. Cheers

Hello, I have only seen Vasso used in distributive shock and a second or third agent when things are going poorly. This is why I was perplexed by their choice of Vassopressin. Here is some more information. This patient had a bad metabolic acidosis due to pump failure (pH 7.1 BE -12) mixed gas of %33 and a lactate of 7.0. After some fluid and pressors we had the ABG looking better (pH 7.3 BE -10) and a mixed gas of 55% and a lactate of 5.0. Mind you, this took awhile. We had her on Levophed of 20 mcg/min and Dopamine of 20 mcg/kg/mim and some Dobutamine 15 mcg/kg/min). We did not have a Swan. We used the Edwards FloTrac. It connects to an arterial line and gives you much the same information that a Swan will. So, we had her in an ok position. What she needs was an angio and an IABP. She looked grave but she was the best she could be all things considered. So, I was wondering why they hung Vasopressin at 0.03 and cranked up the pressores (Levophed 50/Dop 30/Dobutamine 30...and some IV Phenylephrine) I followed up with the receiving hospital. Her LV was 'fried' and got numerous stents and a LVAD (Left Ventricular Assist Device...something I know very little about). Cheers

Hello, I had a patient yesterday (50 y/o female) with a 2 day history of general malaise, nausea, emesis and weakness. Called EMS at 0500. A BLS crew arrived to find her on the floor cover in emesis with her 14 year-old daughter by her side. As per the PCR she was 'cold' 'pale' 'c/o numb arms' and 'weakness'. Past history of lower back pain (T#3 for pain) and mild HTN (no meds). She stated that when she got up everything 'went black'. So, the BLS crew makes her walk to the ambulance (VS 90/60 HR 60 Temp 35) and take her to the ED (took 45 minutes). "Eventually got of the ground and walked to the ambulance." Exact quota. On arrival a 12-lead showed ST elevation in V1 ---> V6. TNK failed and she rapidly developed Cardiogenic Shock and was medeved out for angios. She was quite unstable (BP 50/30 (Map 45-50) EKG: ugly!). Mixed gas improved form 33% to 58% on the pressor we had. Now, what I do not get is the flight crew started Vasopressin. Has anybody seen Vassopressin for Cardiogenic shock before???

Hello, I though that it may be a good idea to share some online sites that we have found to be useful. One I like is the London Health Sciences Critical Care site. It has drug references, educational briefs, et al...... CCTC Thank you, D

Hello, Here goes, 1. Ventolin 2. CaCl or CaGluconate 3. D50W with 5-10 Hum 'R' Insulin 4. Kayexalate 5. Dialysis 6. Bicarb Cheers

Hello, Interesting call. Incompleted spinal injury? I am not 100% but it could be Anterior Cord Syndrome. Too much cervical flexation during the crash (pain at base of skull) caused the loss of motor control below the waist. Or, Causa Equine from an abcess? Maybe his immune system was compromised due to his HIV? Just a few guesses made during coffee break.... Cheers

Hello, An other option is the MAP. Most NIBP cuffs will calculate this for you. In general a MAP should be 60 or greater. However, like noted above, the key is how the patient looks and feels and how this BP (SBP and DBP) compares to the normal if available. D

Hello, Sorry if I am repeating stuff. Not enough time to read the tread. I have to run soon...... A friend of mine (took his EMT-P at Thomas Jefferson University Hosp in Philly) and he got his AB EMT-P. It was a painful experience ($$$) but it can be done (not for the faint of heart). He was able to get his EMT-A from Alberta College of Paramedics first. Then, he had to do an ALS practicum with an AB school (this was the hard part). In effect, it took time and money. One thing for sure. Make sure you have your ducks lined up and everything in writing. I hope this helps. David