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We learned to suture on pieces of chicken. Also used them for IOs. When I was working as a medic we were lucky enough to get to do cadaver lab, and practice surgical cric's, both using a scalpel and Seldinger technique commerical kits. I've seen the RTs do some cool stuff with pig lungs hooked up to a ventilator. I think they caused some sort of injury that depleted the surfactant then replaced it, and looked at pulmonary hysteresis. It looked pretty cool. I got lucky enough to go to a facility that was doing large animal resuscitation and cardiac transplantation research and see them open the chest of an anesthetised pig, watch and feel as the right heart distended post-arrest, and feel the myocardium harden as calcium entered. Watched them defibrillate it, and saw how dyskinetic the post-resus contractions were. They had an art line in place, and drew serial ABGs too, which was cool, really cool. If you had access to some reagents, you could try isolating cardiomyocytes from a freshly-butchered heart. But this is a pain, and take a couple of hours, and has a high failure rate.

Bear in mind that the argument that "asystole / PEA patient have a poor outcome so we should give drug X" could be applied to any drug on the ambulance or without. For example, "asystole / PEA patients have a poor outcome, so we should give preparation H". This. It's possible to arrest from excessive vagal tone. But it's not a common cause. On a logical level "absence of evidence of benefit", is not the same as "evidence of absence of benefit" (I'm sure Kiwi is aware of this, I just quoted him because it seemed like a natural lead in). But ACLS is being re-evaluated in an attempt to remove therapies that are based on tradition, and focus on those that have evidence to support their use. * Surprisingly antiarrhythmics are still included. I predict that amiodarone goes bye-bye in 2015. There's no evidence these drugs increase long-term survival. * There's real doubt as to whether epinephrine is beneficial. This may also be removed in time. There is now some actual evidence that it has no impact on survival.

There's a paper here that discusses the use of methadone in a pair of pediatric burn patients who are already receiving morphine: http://bja.oxfordjournals.org/content/80/1/92.full.pdf Major points seems to be: * Relatively little cross-tolerance between morphine and methadone due to structural differences (although, I'd assume pharmacodynamic downregulation affects both). * Equal affinity for morphine and the active enantiomer of methadone for the mu receptor, but greater intrinsic activity for methadone. * Non-opiod receptor mediated effects of methadone on norepinephrine and serotonin reuptake which may augment analgesia. * Less kappa effects for methadone, therefore less dose-limiting sedation. I don't know if it's useful to you, but it was interesting to me when I looked it up.

My conclusion, after watching exactly half, then getting very bored, was that if the father's intention was to generally demean himself and appear to be even less mature than his daughter, he achieved it. Edit: Watched the second half. I now feel sorry for the daughter. Also I have a vague sense of unease about the future of the human race.

This should have been "more candid", of course.

That would be / was frustrating. Most places, even as a medic, you're not pronouncing death, you're just deciding not to resuscitate, which is somehow different. Someone else, usually the coroner / medical examiner gets to sign the actual death certificate. I understand where you're coming from. I've come to peace with this over time. It's frustrating, but we're not equals, and it's unlikely we're going to have an equal voice any time soon. The guys in your part of the world have made some amazing steps towards professionalising EMS. Unfortunately a lot of other places are quite far behind. I can only dream of a time where every new paramedic in the US or Canada has a Bachelor's degree. I agree very strongly with the bolded phrase, and the general idea that those of us working in EMS, at all levels, have a responsibility to educate ourselves further and push for change. I have always worked in systems where paramedics have had self-governance (or at least the impression of it), and a professional college under various names has had the ability to manage registration / licensure, continuing education, and deal with conduct & competency issues, so I may lack perspective on what it means not to have this. But I will say that the concept of a professional college has often been better than the reality. I'm not suggesting that the alternatives are better. More that just because it exists, doesn't mean it works well, or is even remotely functional. Squint might have less candid words. All the best.

This is frustrating, but it's a consequence of multiple different organisations trying to shove a bunch of grey into a series of nice box and arrow flowchart. As EMTs and Paramedics we're not generally intelligent consumers of information. If I was king, this would change. Our practice is dictated, at least partially, by the body of available medical evidence. We should be taught how to access this, and we should be able to critically evaluate it, and we should be framing our conversations on website such as these in terms of the available data, where it applies. I believe we're moving in that direction. Personal opinions: Mosby has never published a decent textbook on any aspect of EMS that is suitable beyond the EMT level. NAEMT is useless, the only value some of their courses have are in extending the limited training most of us get at a basic level. NREMT probably serves a purpose in the US for reciprocity. I haven't worked out how it affects any of us outside of the US in any way. PHTLS / BTLS are almost skills courses. I feel that they're next to useless. They essentially tell you to immobilise unconscious/altered trauma patients, pay a brief lip service to the far more valuable issue of selective immobilisation in minor trauma, and brief discuss IO / IV access, without any reasonable discussion about fluid replacement, the use of different fluids, problems with over-resuscitation, in-hospital treatment of trauma, advanced diagnostics, or even something as directly relevant to prehospital care as RSI. Mostly we get some sort of poor variant of there's JVD, hypotension and absent lungs sounds --> needle decompression. I think a better solution is for us actually to get educated in trauma care beyond the latest children's chewable, wipe-clean, story book that NAEMT / ACS wants to put out for prehospital providers. But I understand your frustration. I'll pronounce a blunt trauma arrest without looking at an ECG. Or a high velocity round to the head. Obvious death is... obvious. The situation here is difficult to judge due to a lack of information. A small caliber entrance wound to the temple, resulting in pulselessness, isn't going to get worked by the majority of paramedics in the systems I've worked in. But this is a grey area. Some people will work these patients. Because it is possible that the bullet has only damaged higher structures, that it's just damaged the cerebrum without hitting a major vascular structure. It might be survivable. The absence of circulation strongly suggests otherwise, but I can understand how some medical directors might not like to give the ability to make that decision. Put the same wound in the thorax, and it's a workable code, for sure. I think you'll find MDs who will argue both sides of this. That's a bullshit response. But it's also why PHTLS is bullshit. The instructors are only as good as the instructor training course and selection process. This sort of situation is also why PHTLS / ITLS, if they were decent courses, would require that you had at least a resident on site to deal with these sorts of questions. Instead they're just a quixotic hoop you have to jump through every couple of years for recertification or continuing employment requirements. I think the criteria you have to use are an actual understanding of the medicine involved, hopefully received through a decent initial training program, and continuing education (I realise that this is optimistic). I think this should be supplemented by reading the research literature to get a more nuanced understanding and to appreciate areas of changing practice. And ultimately, your treatment has to be based upon protocol or medical control guideline, and the commonly accepted practices in your area. Because like it or not, we're not physicians, and we're all answerable to someone if we decide to break with current practice standards. Part of the trick to this, is knowing what you can and can't do, in your local area. It's not always clear. It's not always scientific, or consistent. But learning to navigate within these limitations is part of the process of being a paramedic. I'm not currently working in the field, so I may be a little out of touch, but I wouldn't start resuscitation on this patient.

Assuming I get to decide (and I'm not told by dispatch), it would depend a little on the distance to the rural hospital. If it's a few hundred meters from a rural ambulance station, probably not. If I'm coming from 45 minutes down the highway, I probably would. It's also a little dependent on how rural we're talking about. If I'm going to be at an academic center in an hour cold, and I can save 10 minutes driving hot on a decent highway, I'd probably do it. If it's just "rural", and this is a 20 minute trip, not so much. I remember there being quite a few studies a few years ago looking at transporting patients to "cardiac centers" versus non-PCI hospitals, and then doing secondary transfer (something in Denmark particularly, DANAMI? Wasn't there another around the same time in the states, CAPTIM?). They seemed to suggest that it wasn't that time-dependent. But I've also seen data from cardiologists showing that even for PCI, early revascularisation has much better outcomes. So I guess it depends a little on the patient, and how old this STEMI is. If it's already a few hours old, perhaps there's less benefit from a rapid response. No one's going to bother telling me until I get to the hospital, but it would be interesting to know why they've chosen to go with PCI instead of 'lytics, if they're rural. I'm assuming there's no cardiogenic shock here, so maybe we've had recent surgery / trauma / prior CVA?

Just a random thought -- have you considered getting a fasting glucose done? Could be new-onset DM.

Really? I don't have any psych, but are you sure it's "very dangerous"? To me, it just sounds inappropriate. A health provider shouldn't be pushing their religious beliefs on someone else. People that aren't qualified to counsell patients, probably shouldn't be doing that either. What are you concerned their going to do that's "REALLY DUMB"? If you're concerned they're going to harm a patient somehow, then obviously that needs to be addressed, but I don't understand why you would feel that way? Their personal beliefs sound like their business, until they start behaving in an unprofessional manner. If they're a friend, by all means talk to them, but if they're a stranger, I don't think I'd bother. Just my opinion, not intending to be rude in any way.

I'm a little confused by the first sentence, but I think we agree here. There's not a lot of good evidence, so we're mostly relying on expert opinion, with all its inherrent weaknesses. Regarding MAST and high volume resuscitation, these were practices that changed, at least partly, due to evidence-based medicine. But when we don't have high quality data, we're forced to make a decision anyway. I just think it's important to be aware of the lack of information available in such cases. I think you probably agree with this too, right? I think we agree here. The only thing I'll add is that physiological arguments are nice, and there's a lack of physiology to suggest that hyperoxia is going to confer benefits. The trouble with this, though, is we can often make plausible physiological arguments for therapies that don't work. That's why we need more data. This is reflected in some of the sources you've cited, for example: "We conclude by suggesting that there is insufficient evidence to support the routine use of high-flow oxygen in the treatment of uncomplicated MI. The balance of the limited evidence that exists suggests that the routine use of oxygen in this situation may increase infarct size and possibly increase the risk of mortality, owing to its haemodynamic effects, including a reduction in coronary blood flow. Major international guidelines do not appear to represent the current evidence base and may need revision. There is an urgent requirement for randomised controlled trials of the use of oxygen therapy in MI that are sufficiently powered to enable the risk of mortality to be assessed. " (From the first source, the Heart article that I also cited earlier). Everyone's recognising there's a lack of decent data in humans, that we need more, and that animal data is equivocal. I think you're unintentionally strawmaning me here. I've never said that it's particularly difficult to identify acute hypoxemia (although pulse oximetry certainly helps), nor that everyone should get a non-rebreather. Just that we don't have decent evidence as to whether hyperoxia is dangerous in humans, and how dangerous it is. Maybe I was unclear, but if you look back at my previous post, you can see I said "But that's not a logical argument for using oxygen empircally in every MI." All the best.

Just for general interest, it is possible to visualise SA / AV nodal activity using invasive techniques. The images below shows an electrocardiogram recorded from the right atria (HRA) and then closer to the AV node (HBE). As I understand it, which isnt particularly well, the A-H time represents AV delay, whereas the H-V time represents the time requires for conduction from the Bundle of His to the Purkinje fibers.

That's not what's being discussed here. No one is advocating withholding oxygen therapy from hypoxic patients. What's being debated is whether there's any point in routinely giving supplemental oxygen to normoxic patients with specific medical conditons, e.g. CVA, MI. The reality is, there's not a lot of evidence in either direction here. But there's a lack of a plausible physiologic mechanism by which supplemental oxygen in normoxic patients could cause benefit. There are a few suggested mechanisms by which hyperoxia could cause injury, but these aren't really supported by epidemological studies, yet. There's just a general absence of research in this area. It's likely that, in the entire history of EMS, more patients have been harmed by not receiving oxygen, than by receiving too much. Especially as we really don't know how much, if any, damage hyperoxia causes in adult patients. But that's not a logical argument for using oxygen empircally in every MI.

For more reading in this area, check out this webpage: http://missinglink.u...odule/index.htm Or this .ppt http://www.google.ca/url?sa=t&rct=j&q=pacemaker%20classification&source=web&cd=3&ved=0CDMQFjAC&url=http%3A%2F%2Fwww.coronaryheart.com%2FPowerpoint%2Fpacemaker%2520overview.ppt&ei=4rcnT7GbNeP34QShs8HpAw&usg=AFQjCNGKDiJhpgGCOhReQ8_Inofl6UFICg&cad=rja Or this: http://www.google.ca/url?sa=t&rct=j&q=pacemaker%20classification&source=web&cd=7&ved=0CE8QFjAG&url=http%3A%2F%2Fmedresidents.stanford.edu%2FTeachingMaterials%2FPacemakers%2FPacemakers%2520Handout.doc&ei=4rcnT7GbNeP34QShs8HpAw&usg=AFQjCNH4H8NUOOd8gZz9SiyAqDFHhvHNGQ&cad=rja

It's a little confusing. * In the different posts it's suggested she's left at scene, and elsewhere that they started transport with her up front, she asked (demanded?) to be let into the back, and they let her out the passenger door and then drove off. I can see refusing to transport her if he's critical. I believe this would be a mistake unless she's interfering with medical care. The only circumstances I can see leaving her on the side of the road after initiated transport under would be if the driver is concerned she is going to do something crazy like grabbing the steering wheel. This would have to be a really well-founded fear, otherwise it would be kind of a dick move. * I don't understand how them move him to the ambulance with pulse, he codes, and they d/c BLS and return him to the scene. Maybe there's a specific rule for BLS crews with a prolonged transport. One source suggests it's an hour to the ER with no medevac available. Even there, I'd expect any crew to start CPR, and run the code for a while in the absence of a DNR. My suspicion is that the available (often contradictory) information doesn't fully describe what happened in an accurate manner.

I've heard a lot of people are doing this, but have no direct experience myself. Is there any concern that we're taking a potentially aggressive patient, and giving them a close chemical cousin of PCP? It just seems a little counter-intuitive. Is there a risk of taking someone violent and making them fairly immune to pain, more disoriented, and more difficult to handle?

Great post. Just wondering if you have a source for valium being preferred over versed? Thanks.

There was this in Heart [1], but they excluded everything except 2 RCTs, one of which is the 1976 data people have mentioned [2]. The other was 50 patients, post streptokinase, who received either air via face mask or a nasal cannula at 4 LPM for 24 hours [3]. But the study was designed to investigate the occurence of hypoxemia and the ability of the physicians to recognise it clinically. So they didn't report much useful data. [1]Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M, Beasley. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart 2009;95:198–202. doi:10.1136/hrt.2008.148742 [2] Rawles JM, Kenmure AC. Controlled trial of oxygen in uncomplicated myocardial infarction. BMJ 1976;1:1121–3. [3] Wilson AT, Channer KS. Hypoxaemia and supplemental oxygen therapy in the first 24 hours after myocardial infarction: the role of pulse oximetry. J R Coll Physicians Lond 1997;31:657–61

Can a pacer firing continuously cause PEA? Well, you can have electrical capture without mechanical capture. I guess you could technically call this PEA, although it would be unnecessarily confusing. You can have "failure to sense", where a demand pacemaker doesn't recognise the patient's intrinsic complexes. This could cause a pacer to pace continuously, but this would be a rare event. In both these situations, you'd want to be careful to identify the underlying rhythm. It may be VF, and amenable to defibrillation. (Not that this would be indicated in this specific patient). * Just a quick note: Pacemakers are triggering cardiac depolarisation, they're not reducing energy consumption. They cause the cardiomyocytes to depolarise, just like an SA impulse, ion gradient's still have to be restored, ATP has to generated to allow for cross-bridge cycling, etc. They're there because there's some degree of dysfunction in the cardiac conduction system that's preventing an organised sequential and synchronous contraction.

*Back story to this post* We were dispatched for a 0.2 mile Inter-facility transfer from one ICU to another because this pt had a type of pneumonia that couldnt be handled at his existing location. We arrive there and we have the following 0.2 mile? 3 blocks? Was it downhill? Could you push him there? Just kidding. approx 65 yo male who is sedated running 3 infusions controlled by a pump norephinephrine fentanyl and a antibiotic which I cant think of at this moment Ok, so he has a pressor (norepinephrine) to maintain his pressure because he's septic, got all sorts of inflammatory mediators and bacterial toxins floating around that are dilating everything inappropriately, and possibly if he's been sick for a while, his adrenal glands aren't putting out enough epinephrine, and the endothelium is all dysfunctional, and the vessels aren't responding appropriately in any case. If there's not enough arterial pressure, the organs don't get perfused, and badness ensues. The norepinephrine is to treat/prevent this. The fentanyl is for ongoing sedation. The antibiotic is to treat the pneumonia and/or any secondary infections. I realise you're an EMT, but it's a good practice here to work out what sort of lines the patient has for access before leaving, work out where everything is running in, especially if you've got multi-lumen central lines, and get some sort of idea why each medication is being used. You want to know the drip rates, even if they're on pumps (hopefully the norepi is), in case you have a power/equipment failure. Before leaving, you should have an idea of which can be turned off if there's a power failure, or a problem with one of the pumps. In this case, the critical med to be on a pump is the norepinephrine. The antibiotic could be discontinued, if absolutely necessary, and the fentanyl could be given as a bolus dose. But the norepinephrine is the highest priority. Turn if off for any length of time and the patient becomes hypotensive, and probably dies. If it runs away on you, they probably stroke or infarct, or go into VT or VF arrest. You don't absolutely need to know this stuff as an EMT, but if you can ask a bunch of questions, and try to learn, it will help you later on. A lot of people treat transfers as a glorified taxi ride. They're not, as your call clearly illustrates. A lot of these patients, the difference between a ground transport and rotary/fixed wing is weather conditions, availability, or the fact that you're moving them between two ICUs or an ER and ICU that are in the same city. His vitals at the time of arrival Pulse 77 BP: 105/58 Spo2: 98% via 100% O2 delivered by a vent GCS: 3 (patient was sedated) Weight: approx 250 lbs. or 113.6 kg A little hypotensive, but ok. We have an auto-vent 3000 Zoll M series cardiac monitor (ETCo2 not equipped) This is a problem. Not your fault, but really, no one should be running around as an ALS truck without waveform capnography. It's a system issue if it's not there. If all you've got is quantitative cap, or a simple yellow/purple detector, this should be on the trach/in the vent system. It would make managing situations like this easier. Short after switching it the medic and myself hear this high pitch squeak come from the vent (more specifically the part where it connects to the trach or ET tub) I see there's a clear window on top of that piece and every time it delivers a respiration the sound comes back and a little green piece inside the window goes red. (sorry I dont know my terminology of the equipment) This is a problem. You should try and find a copy of the manual and read it. Whenever you get a competent partner, ask them about it. You shouldn't be altering vent settings yourself, but if you're going to be present on these calls, you should educate yourself about the equipment being used as much as possible. Any decent paramedic should also be more than willing to help you learn --- and should be proactively encouraging you to learn more about it, whether you want to or not. That's part of building a decent team environment / organisational culture. Being an EMT may limit your scope of practice, but doesn't need to limit your knowlege. I'm not familiar with this particular vent. We checked the monitor and SP02 normal with the 3 lead showing a NSR. About 2 minutes this bloody squeaking is still present and driving me and my partner nuts. I start getting this gut feeling that something is really wrong and shit is about to hit the fan. So I start checking and re-checking that monitor and I begin to see a negative trend. His spo2 is falling rapidly and his heart rate is steadily increasing. So there's a lesson here. Pulse oximetry is a poor indicator of acute changes in the patient condition. It can lag the change, e.g. apnea, by several minutes, as probably happened here. This is why we preoxygenate patients before doing an RSI, whenever possible. The first clue that something bad was happening was the warning indicator on the vent, and the squeaking sound. The story you're telling suggests this is some sort of peak pressure alarm / blowoff device. But I'm not certain. What I am certain about, is that ignoring this for two minutes was a bad idea. This was 2 minutes you had to act before the patient desaturated. This is mostly on your partner -- he's the paramedic, and most responsible. He should know much much better than to do this. But you do have a responsibility to speak up when you beleive the patient is in life-threatening danger. I have always encouraged the EMTs I work with to do this. I ask them, don't do it in front of the family, unless you're convinced I'm doing something boneheadedly stupid, but whatever you do, don't be quiet and watch me do something you know is absolutely wrong. Speak up. At this point I tell the medic somethings not right here. He looks at the monitor and yells up to the driver to go. "Yells at the driver to go?" --- were you still at the sending facility? Or is he telling the driver to drive stat now? Good on you for voicing your concerns, even if it's quite late now, but better late than never. The medic should have a better set of corrective actions than this. That moment I suggested a possible displacement of the trach. This is a possibility, especially if the trach tube is particularly long or is improvised from a cut-down ETT (unlikely in an ER transfer). It's probably more likely to be obstructed with a mucus plug (or one of the bronchi are), or a pneumothorax has occurred. There's an outside chance the tip has ended up outside of the trachea, but this isn't too likely either. This is something any competent medic should be all over. Obvious trouble-shooting steps: * As chbare, (who knows way more about this than me) already said, remove the vent from the circuit and use a BVM with a PEEP valve. This eliminates problems with the vent, and if it doesn't have a decent display, you get some sense of the compliance from the bagger. * At the danger of making the heads of chbare and other RRTs the world over explode --- run the mnemonic. This is a situation where time is critical. What's the mnemonic? DOPE. It covers immediate management in these situations. Displacement? - has the tube displaced? Capnography would probably have answered this right away. If the waveform disappears, it's probably obstructed. If the ETCO2 has shot up suddenly, there's a chance it's gone mainstem, although this is hard to do with a commercial trach. - lung sounds? epigastric sounds? Obstruction? Run a french cath down the ETT/trach. If it runs the length of the tube, it's not obstructed. If it doesn't, you either need to suction the tube to remove the obstruction, or it's time to exchange / replace the tube. Pneumothorax? If there's no air entry on one side, and the tube's at the same depth, and not obstructed, either there's a deeper mucus plug that you can't remove without a bronchoscope, or you have a pneumo / hemo. He's getting decompressed. Equipment failure? We remove the vent, and if we're not using one, we check our bagger and PEEP valve, make sure we haven't overtightened it by accident, etc. This guys vitals still deteriorating and Im thinking of pulling out my stethoscope to check but something kept me from doing it. You were probably expecting the medic to take charge, like they should have, probably afraid of doing something wrong, and probably just a little scared / surprised by a situation you hadn't encountered before. It will be easier next time. You should have. It would have given you valuable information. It might have spurred the medic into action, as well. My medic was quiet and said nothing he just was occupying himself with tasks and I didnt know what. We had no further communication. Sounds like the medic got trapped on spin cycle and shat the bed, if I may mix my metaphors. Again, this is more on him than you. I can only say that panic is infectious, and spreads rapidly. If the senior medic on a scene loses control, it becomes much harder for junior staff to regain control of the situation. That being said, when things start getting excited, sometimes it just takes one person to take the stress level down a notch and get everyone thinking again, and that can sometimes be the junior person. In this sort of situation, "Hey do you think the tube's obstructed?", "Do you think there could be a pneumo?", and "What do you think that red thing means"(about 2 minutes ago), are all good options. I have seen quite a few scenes spinning out of control, only to be rescued by someone saying, "Ok, let's sit on our hands, take a couple of deep breaths, count to five, and jump back in again". Sometimes a couple of seconds of collecting yourself enables rapid focused action. The chances are if you feel the necessity to do this, you're not being effective at that point, anyway, so you're not losing anything by taking 5 seconds to regain your cool. Remember slow is smooth, smooth is fast. If you can develop the ability to talk slowly and calmly, but move deliberately, it will serve you well in almost every situation. See something simple, like a cardiac arrest run by a good crew, and you'll see what I mean. The patient began to cough and gasp and appeared to struggle for air and at this point Im about to press the internal oh shit button cause im in the captain chair watching this guy spin down the drain before my eyes and im just sitting here. I didnt want to get in the way of my medic but at the same time I was frustrated because I keep feeling their must've been something I can do. We arrived to the hospital and I was thinking we were going to hit the ER with the way things are going with this guy. But no, we head to the elevators and begin to take this guy up. My eyes were set on that monitor fearing he was going to code right in that elevator. By now his pulse was 140 spiking at 170 and his SPo2 leveled out at 80. His skin showing it too. I don't think he likes being hypoxic. Running to the hospital because there's an airway problem, and deciding to take your time to go up to the ICU are illogical and contradictory actions. Either there's an airway issue, and you need to be in the first place that can fix the airway problem, or there's not an issue, and you're going to the ICU. This mostly isn't your fault either. Although you should, hopefully, have recognised the situation as being serious, and suggested the ER to your partner. Once up to the ICU he was transferred over. And it was clear with the amount of staff in the room he didnt fair too well on the way over to their facility. After he was on their bed I removed myself from the room and went back to the truck. Hands trembling. Adrenaline dump. Happens to everyone, becomes less of a problem over time. How do you ladies and gentlemen manage to maintain composure when a perfectly uneventful transfer spirals into a oh shit run. It's a learned behaviour, that comes from prior experience, and an understanding of the pathophysiology of the patient, the tools at your disposal, and how they apply to the situation. And even then, sometimes calls still get messed up. Talk to some ER or ICU docs and ask them about times they screwed up. It'll open your eyes. There's a lot of weird presentations and crazy situations out there that can catch you, sometimes even when you're on your A game. Do enough decent calls, and you learn that when it gets exciting, you need to slow down. This takes time, and it gets a little harder as a medic, because you can't show any fear / concern you might be feeling, because it will spread to your crew, or encourage other medics to start intervening, which is only helpful when everyone's working together. Save this experience, learn from it. Once you collect enough experiences like this, go to medic school. ------------------- Edit: Sorry for the long length and messed up formatting.

I didn't know about this until I read this thread, so thanks OP! There's a little bit of discussion about it here: http://openaccess.eprints.org/index.php?/archives/867-guid.html Right now, when the US National Institutes of Health (NIH) funds research, one of the requirements is that the finished work is submitted to Pubmed Central, where it can be read for free by anyone. So the Research Works act won't prevent indexing on PubMed, you'd still be able to search and find abstracts, but it means that NIH can't require the authors to publish the entire full text open access of Pubmed Central, or an equivalent site. This is something the journal publishers want. Because right now, when they accept NIH funded work, it gets published in their journal, but it's also disseminated via Pubmed Central. So they can't get money for reprints of the article, and no one is going to purchase a subscription to read an article that's available for free on-line. The researchers producing a given work don't make money from it directly. In fact, in some cases, they actually pay the journal publishers "page fee's" to have it printed in a journal, which can be several thousand dollars, that has to come from a grant somewhere. No matter how many times the article is cited, or downloaded, or purchased, the research group doesn't see the money. They only benefit from a publication in a good journal on their CV, which helps their reputation, and helps their scoring when they apply for new grants. So this is about making money for journal publishers, who are feeling a lot of pressure as more and more science becomes on-line and open access. Now, personally, I'm not sure why they're so interested in this, as very few people buy individual subscriptions to the different journals, as they're very expensive, consider a yearly subscription to the following journals: Nature $199 PNAS (say it as a word! Seriously, it's a real journal) $385 New England Journal of Medicine $148 (special offer) Annals of Emergency Medicine $254 Journal of Trauma and Acute Care Surgery $516 But I guess the big money is in getting private organisations, like research companies, or universities to sign up for institutional subscriptions: Nature $ probably a lot PNAS $4,000-$9,000 (to any institution actually doing research) New England Journal of Medicine $4-26,000 Annals of Emergency Medicine $3,000-$9,000 (to any institution actually doing research) Journal of Trauma and Acute Care Surgery $923 So, I guess the journal publishers feel a little threatened. Perhaps any university has to subscribe to the top tier journals. But maybe they feel that the NIH open access is making the universities less willing to pay for licences for the smaller less widely-read specialty journals. The sad thing here, is that the researchers are using public US taxpayer money, often having to pay a journal to have their work published, or best case, giving it away for free. And then the journals want to be able to make this work their private property, and charge money for it. Seems a little strange. This isn't solely a US issue, as a lot of researchers work with groups that receive NIH grants outside the States, or spend periods of time training in US NIH funded labs in the US.

In the past, I have used diazepam, midazolam, lorazepam, haldol and droperidol. The issues with haldol and droperidol tend to be that they tend to have a slow onset, can cause QT prolongation (especially droperidol), and tend to lower the seizure threshold, which can be particularly bad when the patient has coingested cocaine. Of all of these, I think my personal preference has been the sublingual ativan for patients I can convince to take it. It's nice to have someone acutely psychotic / cracked out, and be able to say, "Hey, how do you feel about taking one of these", and have things calm down a little. For the honest-to-god combative, five cops sitting on them patient, I like midazolam IV, just because it has a very rapid onset, and can be titrated nicely. [Edit: Of course, my personal preferences as a paramedic mean very very little. They're based on a small subset of patients that I've directly come into contact with, aren't controlled, etc. and are limited by the small amount of knowlege of medicine that I have, right?] I don't know what the EBM is in this area. See above. Personally, I wouldn't have an issue working without haldol or droperidol. I'm quite comfortable rendering people different degrees of unconscious with benzodiazepines. I'm surprised. I used to do this quite regularly with patients who were acutely psychotic, especially with a lot of people who'd be doing too much meth or coke/crack. I agree that many situations can be avoided by using good communication skills, and not scaring the crap out of someone with an altered sensorium (who's often already terrified) by trying to pretend to be a cop. (I think some people are far too aggressive and confrontational with these patients). But, some of these patients aren't thinking rationally, and can't be talked down. Some of them are fighting from the moment you or the cops walk through the door. They're going to end up physically restrained, and chemical restraint means you can minimise the number of times they have to get TASERed, maybe avoid them getting pepper sprayed. And it means when they're tied down to the stretcher they're not thrashing around, screaming, getting all tachycardic, and maybe sensitising their myocardium to any drugs of abuse they have circulating around. With respect, because I know you're a smart guy and you care about doing this sort of thing the right way.

This is a judgment call. I mean you have to form an opinion about whether the patient's symptoms have a strong anxiety component. It doesn't have to be right, but it would help if you're fairly sure about it. And if you feel there's a strong anxiety component, you've got to take a step back, and look at the whole clinical picture (or gestalt, to get fancy), and say to yourself, "Ok, how much of this feeling of the throat tightening is due to anxiety issues? Has she just been watching Oprah with a story about someone's anaphylaxis... etc. ?". Then you've got to think about how much of the objective signs are pointing in this direction. Is there hyperventilation? Is there carpal/pedal spasm or tremor, etc.? And maybe the call has just become anxiety / hyperventilation syndrome. But, then again, maybe any anxiety component is minor, or just masking the symptoms of the original disease process, i.e. the anaphylaxis. Benzodiazepines, particularly sublingual ativan, are effective in anxiety / hyperventilation syndrome. I think we all know that. But they present their own problems. How comfortable are you in writing up a cancellation on a patient you've just given ativan to? Most systems probably aren't going to allow that. The odd person becomes strongly sedated, although this is rare. They're also just not necessary most of the time. If you're giving ativan to more than a small percentage of your anxiety / hyperventilation patients, I think you need to step back and look at how well you're communicating with them first. Because it shouldn't be necessary most of the time. I would suggest that if this patient is becoming very anxious (something that is a direct and well-reported side effect of giving them epinephrine!) then the best treatment will probably be talking to them. In this instance, I would stay well away from opiates. These relieve anxiety as the result of pain. This patient doesn't sound like she's in pain, realistically. A long time ago, we used to give MS in CHF to control anxiety as the result of pain. We don't do this any more because it was a terrible idea, because we stole the respiratory drive from a lot of very sick patients and ended up intubating them, auto-PEEPing them, giving them a nosocomial pneumonia, and messing them up on a ventilator. Most systems still give some opiate to MI patients, even if there's a little bit of question about the safety of MS in NSTEMI. But this is to reduce the sympathetic outflow associated with pain, and hopefully decrease myocardial oxygen demand as a result. Here, I don't think they're going to have any benefits, and if you get the rare patient who reacts strongly, you've now created an unnecessarily complicated mess -- and if this patient has developing laryngedema, unless you're really, really rural, or about to fly them for an hour or something, you don't want to be having to intubate them. Both groups of drugs have the potential to generate hypertension, either by releasing vasodilatory inflammatory mediators, e.g. morphine, meperidine, or decreasing sympathetic outflow (the rest). If you felt that the anxiety absolutely had to be managed pharmacologically, then you could give sublingual ativan. I would be very reluctant, and very careful that I could justify it if the patient deteriorated later. Anaphylaxis (if this is anaphylaxis here), is scarey because it can occur is so many different presentations, and the patients can deteriorate so quickly. There's a temptation in EMS sometimes to aggressively treat every complaint the patient have, as if the more drugs we give, and the higher doses and more dangerous ways we give them makes us a better provider. I would suggest that "aggressive paramedicine", unless it's very selectively applied, is probably much more dangerous than just sitting on your hands. ------------------------------------- * Just realised I should probably add, I'm assuming we're talking about the initial presentation of the patient here. If we've just potentially infarcted the patient with IV epinephrine, then we should be giving benzo's. * Also, standard caveat, I haven't been working in the field in a couple of years, so any information / opinions I give may be a little out of date. Edit: everything below the "-----"

Perhaps I wasn't clear. What I meant was that, in general, it would be nice to know if the patient has a prior history of anaphylaxis, and how serious previous cases were. But that this wasn't particularly important, because while a history of prior serious reactions suggests the current situation may deteroirate rapidly, the absence of that history doesn't tell us much. In this patient, if they are developing laryngeal edema, that could become life-threatening. If the patient says they feel their throat is closing, I'd be tempted to give the epinephrine. I agree that the narrative doesn't give the impression that they're getting ready to check out right now. Absolutely. Could be anxiety, could be a psychiatric issue. It's difficult to know without being there. My understanding (which might be incorrect), is that stridor is a very late sign of laryngeal edema. Sure. But, then again, people sometimes get sick at funerals as well. This is a really hard judgment to make without actually being there. Obviously if you feel this is something psychogenic, then you're not going to give the epinephrine. You may be right. The trouble with these case presentations is that everyone gets a slightly different impression of the patient in their minds, and it becomes tempting to interpret the patient's condition in terms of your own past experiences, that may not relate to this particular case.