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This is a convincing enough history for me to give IM epinephrine. With the benefit of hindsight, it sounds like there may have been an element of anxiety to the presentation. It would be interesting to know more about previous hx of allergy / anaphylaxis, but the reality is the patient's first presentation can be life-threatening, so such information is rarely useful. I'm surprised that you got this order. I would assume the physician was concerned about impending airway compromise, and trying to save you from a cricothyroidotomy. Was the patient really young? Was the physician aware they were hypertensive? IV epinephrine is for life-threatening symptoms, in the presence of circulatory compromise, when you're concerned that IM epinephrine is going to be absorbed too slowly to be effective. I had a guy who was apneic, cyanotic, no radials, terrible compliance with BVM ventilation, sat probe picking up 68% *for what it's worth. He gets 0.5 epi IM, his ECG shows sinus tach at 180 bpm with runs of VT, and he starts throwing hypoxic seizures. 2 x 0.1 mg 1:10,000 IV, his saturation comes up to 82% (now maybe an accurate reading), he has radials, and his BP cycles at 182/110. So we give 2.5 midazolam / 250ug fentanyl, piss ourselves in fear, intubate, give another 0.3 mg epinephrine IM, 600 ug ventolin MDI via the ETT, and things get a little less crazy, with something approaching a reasonable BP, saturations in the mid 90's. And so we drive to the ER, and give some benadryl, now we've got time. This is a cool war story... but the point is, this is the sort of patient IV epinephrine is made for. [At the time we didn't have steroids, we considered mag, but didn't want to upset the apple cart. Epi drip was also considered, but seemed unnecessary at that point, with a decent pressure and compliance]. This is probably coronary vasospasm from the IV epinephrine. With respect to the large amount of education and experience you bring to the discussion, would it not be possible that the patient has some developing laryngedema that has not caused enough closure to cause stridor? Couldn't early and judicious (i.e. IM) epinephrine, prevent this patient from worsening? This is an awesome point. Thanks for posting OP. All of us have made mistakes. And none of us were there on your call. I don't think the treatment was optimal, but I applaud the fact that you went out and looked for more input.

Just be ready for the answer, "No", and be sure you're ok with it. Because if you're just going to go on the vacation and decline the job, you should tell them about the vacation in the interview if you ever plan on working there.

Question 1: Can we observe SA activity on a standard surface ECG? Question 2: What happens to a the P wave in an SA exit block? Queston 3: Is the P wave altered in AV block? Given the above, what do you reckon? (Not trying to be difficult, I mean this in a friendly way). Question 4: What does nodal and infranodal AV block mean? Does either of these have anything to do with SA node function? Question 5: What is an SA pause? http://drsvenkatesan...is-sinus-pause/ Question 6: What is a high grade AV block? Is it possible for something to be a high grade AV block, but not a 3rd degree? Question 7: What is an escape pacemaker? Question 8: What regions of the heart are more likely to be atropine-responsive, i.e. have more vagal innervation? Question 9: Is it possible for an escape pacemaker to be atropine-responsive in a 3rd degree AV block? Question 10: What are the 2011 ECC (ACLS) guidelines for bradycardia? What are the primary factors determining treatment? Hey, it's great that you're interested in this. Keep posting.

I don't think it's unreasonable to ask what the time-line for the hiring process is during the interview. If you want the job badly, and there's a lot of competition, I don't think I'd ask about the vacation during the interview, unless you have some sort of extenuating circumstances surrounding it, e.g. terminally ill relative, family member getting married, etc. It probably doesn't give the best first impression -- and you've said you'd rather have the job than the vacation anyway. I think it gives the wrong idea, like you've assumed you've already got the job, or you've not even started yet and already want time off. I'd wait until they give you a job offer, and at that point I'd ask if you can still take the planned vacation. They're not going to rescind the job offer, based on you asking. But they may say no. In that case you just take the job. [if, on the other hand, you decide you're taking the vacation no matter what, then I'd definitely tell them in the interview, politely. I'd just say something like, look, I'm really interested in this position, but I've made commitments to my family that I can't break, so if this isn't going to work, I'd like to thank you for you time, apologise for any inconvenience I've caused, and hope that you'd be willing to consider me in the future. You don't want to wait until they've narrowed down the field, made final offers, and that say, oh, btw, I wasn't really a serious applicant. It might come back to haunt you.]

I guess this depends on whether their role involves critical care transport. If they're already doing these runs, flying, or using techniques that are covered better in the CCEMTP program than in their original training, then it's probably of great value for them to be taking the course. While I'm 100% for ongoing education and training, I would assume that the major benefit of this course is going to depend on how much "critical care" background the provider has going in, and what scope of practice and population of patients they're going to be seeing afterwards.

What should also be considered here, is that this is in 1976, so it's pre-reperfusion era. No angioplasties, no thrombolytics. In this time period, the treatment for MI is mostly wait-and-see, not unlike modern day stroke care. You either die or get better, and a lot of people end up disabled. It's really hard to generalise this sort of study to modern day care.

I think it's great that you want to further your education. Do you have a link to the on-line program(s) that you're considering? Maybe someone here has taken one, and has first hand knowledge? I haven't taken the UMBC CCEMT-P, so I can't comment on the specifics of that course, other than that 80 hours seems like a really short time to get even a cursory overview of a very complex area.

I agree that it's subtle in the inferior leads, but there is some concavity (coving?) to the ST segments / T wave.

I agree completely. I think the 90% in 9 minutes guideline stems from an old ICU study on VF and shock-conversion rates, something like 10% decrease every minute in delay. I think the idea was pre-PAD/pre-first responder defibrillation, to place an ambulance on scene before the point of futility in a cardiac arrest. There's probably also an element of the rapid transport / golden hour for penetrating trauma pseuoscience in there, too. I don't think MPDS really allows us to study this well. All the dispatch determinants are sensitive but nonspecific, and the life-threatening conditions are not very prevalent, and only a subset of those are really time-dependent. So there's so much noise that it's difficult to know what a reasonable benchmark would be. It's intuitively reasonable (a la the EBM parachute article), that there's some really sick patients that will benefit from field ALS, but it's hard to separate these from the noise when there's a rigid adherence to the idea that dispatch should be provide from a ring-binder by a lay person who's taken a 24 hour EMD course. There's also that huge litigation medicine aspect, as well. MPDS provides EMS systems with a means of largely escaping liability for making decisions regarding rapid response / slow response. If a system gets sued then a product being sold by an expert group of physicians is under attack, and this system will defend itself vociferously. I think it makes it very hard from anyone to move to a more rationally designed dispatch system. A fall without injury in a patient with a cardiac history is going to continue to get a hot response in many systems, because that's what the cards say. As discussed in another thread, I think this and the 10 minutes on scene benchmarks need to largely disappear. They're not strongly supported by EBM. I think an emphasis on short scene times for all calls / all ALS calls / all MPDS B and higher calls / any call on a day ending in "y", cripples the ability of providers to perform a thorough on scene assessment, and focuses EMS on an uneducated, rapid transport mentality. I think there's a small role for EMS on specialty teams like technical rescue, where a medic with some fentanyl and ketamine might be very useful. But for any large urban center, this just seems like a waste of time. Can you really make someone a good medic and a good firefighter in this setting? It's maybe a little different for the suburban departments where they're not as busy on the EMS side, and the fire side is dead. There's maybe an efficiency-saving there. But a lot of dual-role departments do a great job of being fire department and a poor job of doing prehospital care. Completely agree.

Just had time to quickly read the original article. For those who are interested: * The patient has had a second heart placed in the chest, on the right side, oriented 180 degrees to the normal position around the vertical axis. So the front of the donor heart faces the back, and the posterior wall faces towards the sternum. The heart is normal with respect to the horizontal axis, i.e. the apex is inferior, the base is superior (the pointy bit still points down). * The right atria of both hearts have been opened, and sewed together, so that the IVC / SVC feed the right atria of both hearts. * The PA from the donor heart has been sutured into the pulmonary trunk. * The left atria are also anastomosed, so blood enters both hearts upon returning from the lungs, and the aorta from the donor heart is joined to the aortic arch, so both eject into the aorta from the LV. In effect, there's two hearts in parallel. This patient had a AICD with biventricular pacing on the native heart. So the guy presents to the ER, complaining of dyspnea. He's tachycardic @ 130 bpm, got some signs of failure (B/L rales, SpO2 = 86%. His ABG is ok considering -- pO2 49, pCO2 31 mmHg, bicarb = 20 mmol/L, pH = 7.42. The CXR looks pretty awesome, because there's this enormous pair of hearts in the mediastinium. And they do a 12-lead, and it looks like a.flutter with a narrow response in the rightward leads (and arguably in lead I), and looks like coarse VF in most of the precordial leads, especially as you move leftwards. The authors say that they didn't perform a right-sided ECG in their patient as they initially suspected a.flutter with RVR, and didn't consider fibrillation of the native heart. As the patient was fairly healthy they gave amiodarone, and even dopamine and crystalloid (dopamine seems a strange choice in light of a suspected a.flutter? But perhaps they assumed that the hypotension was from another cause, as the rate was so slow? They're not clear about this in the paper). After an ICU admit both hearts end up fibrillating (they don't 12-lead this!) So they defibrillate, and a post-defib ECG (evidentally the electrical activity from the donor heart is preventing the AICD in the native heart from defibrillating) is obtained. Now you see a nice wide paced rhythm in the native heart, and a narrow sinus rhythm from the donor heart, that becomes more clear as you move rightward across the ECG. It appears that the pacemaker in the native heart is sensing off the sinus rhythm in the donor heart, and firing shortly (~ 200 ms) afterwards. They also copy an image from a previous paper showing VT in a native heart. Here the entire 12-lead looks pretty much like VT. But with rightward leads, you can see hints of a sinus rhythm in the donor heart in V4R-V6R. So the patient survives, and I guess he must have had an old pacemaker, as they state they "upgraded" his pacemaker to an implantable cardioverter, then discharged him. They make this interesting point at the end: "Pharmacologic cardioversion is usually ineffective because of loss of intrinsic inotropy caused by end-stage heart failure; hence, the only adequate therapy is a “synchronized defibrillation” by means of a high-powered direct current shock on the left side of the chest. In conclusion, whenever ventricular tachycardia/fibrillation of the native heart is diagnosed by ECG, immediate defibrillation is indicated, regardless of hemodynamics and clinical background." They also note in the discussion that: * This sort of transplant is good if the patient has severe pulmonary hypertension, and it's suspected that a normal donor heart won't have a strong enough RV to perfuse the lungs. * It's good if the available hearts don't match the donors body size well, because you can use a smaller heart here, that wouldn't be large enough for the patient normally. * It's becoming less common as better LVAD /BiVAD solutions are being developed. [i would assume that this might be a mixed bag in a patient with serious pulmonary problems as well? I think it might require removing some lung tissue to make space for the extra heart, or at least will result in a loss of TLC. I haven't check this though.]

Citation here: http://www.ncbi.nlm.nih.gov/pubmed?term=mugnai%20heterotopic%20heart Full text here / .pdf here, but I think you might need a university proxy. http://www.sciencedirect.com/science/article/pii/S0196064411018804 A little bit about heart transplantation here: http://www.heart-transplant.org/guide/ And here: http://emedicine.medscape.com/article/429816-overview

This is a great case study, thanks for posting. A couple of things to note here for anyone new to 12-lead: * ST depression in V1-V3 (and possibly V4) is probably due to posterior wall MI, as part of the RVI. But the ST depression in I and aVL is likely reciprocal changes from the infarct. * Note how the axis changes from the first ECG (+44 degrees), to the second ECG (-24 degrees). This is likely due to a loss of functional myocardium in the RV, resulting in a predominance of LV forces. Importantly, this isn't an LAHB. * Note the Q wave in lead III in the post-ECG. [Also, it seems like there is a small amount of persistent ST elevation in III, aVF.] ------------------------------ Other thoughts: * These guys were very lucky not to sewer the patients pressure with the nitrates. Fluid would have been a better option here. * While the 12-lead was extremely useful to the ED physician for cathlab activation, imagine how much more useful it might have been if the team were able to fax ahead, and get the cathlab notified. Or even bypass the ER straight into a cathlab suite with some LMWH and plavix on the way. There is more than enough evidence to support this practice, it's life-saving, and just requires the conjoint of (i) an EMS system management that's doing it's job, (ii) a medical director who's doing his/her job, (iii) a little amount of buy-in from cardiology, which really amounts to them just doing their job, too.

(i) Inferior thyroid artery. But, other vessels including the common carotids, innomate, and the um... aortic arch! lie close to the trachea, and either the cuff or tip of the tracheostomy/ETT can erode into these vessels. (scarey case report of a fatal tracheo-innomate fistula here:- http://www.anesthesia-analgesia.org/content/88/4/777.full) Then, of course, it can erode posteriorly into the esophagus, which could be disastrous as well. (ii) Prehospitally? With a TEF, deflate the balloon, advance the ET tube to below the fistula, reinflate, cross fingers. With a fistula involving major vascular structures... I think you would have to consider how rapid the hemorrhage is occuring and how much it's interfering with ventilation and oxygenation. Unless they're getting really hypoxic / incredibly hypercapnic, I thinkit might be best to do nothing. Deflating the cuff risks removing a potentially tamponading effect, and inflating it to increase the tamponade risks further eroding the vessel and turning a sentinel bleed into an end-of-life event. If you're getting bright red blood up the tube, it's probably too late, but we could try placing the tube more distally (with some thought to the fact that it may be the tip that's eroded. In either case, it's possible we're losing large amounts of blood into the mediastinium. Transexanamic acid? Inhospital? Some sort of ninja surgical repair grafting the injured vessel? Sorry for the delay. I had to do a little continuing education to answer this one!

I think this was probably a good decision. I was just interested to hear if anyone had any opinions about using the Bougie this way. Got to add -- I think it's great that you're using this resource to debrief some calls, and get some constructive feedback. It's also a nice way for the rest of us to learn from your experiences as well. This is a great attitude. Much appreciated.

Couple of quick questions: * How long does it take for an overinflated cuff to cause tracheal injury? * Is it acceptable to simply deflate the cuff until we can auscultate cuff leak or see the end of the capnograph drop off, then pump air in until it goes away, or is there a better method for doing this? * I know none of us like to remove functioning ETTs, especially in patient as sick as this. Any thoughts about using a Bougie introducer as a tube exchanger, or is this too cumbersome / risky?

Cool, thanks for the teaching point! I wonder how much further ahead EMS would be if more ER physicians engaged themselves in helping paramedics better understand medicine? Thanks again.

I think this depends a lot on the culture and the medical direction in a given urban system, as well. For example, in one of the urban systems I worked in, it was unacceptable to transport a potentially cardiac patient without a scene 12-lead. This was a pre-requisite for giving NTG to rule out RVI, and if STEMI was found, resulted in field lysis or ER bypass to cathlab. A 20 minute or greater scene time on an MI while faxing a 12-lead, drawing up meds, consulting with a doctor, and making the decision as to where the patient was going was common, and encouraged. I think we all probably agree that very few patients are acutely time-sensitive. If you're not saving time-to-reperfusion in the field, then all your STEMIs have to fall into that box. A small percentage of CVA patients that are potentially eligible for thrombolytics fall in there, if you have receiving centers capable of doing this (not always a possibility in rural regions without CT). Maybe a few more that are potential neurosurg candidates. Penetrating trauma to the core / neck. Breech presentations / unusual deliveries. Post-partum hemorrhage. Potentially surgical abdomens. The TAAs/AAAs. Beyond that very small percentage of calls, most things don't need to be rushed. I would say that a major difference in an urban center, is you often have the option to take your patient to a well-equipped facility that has specialty ICUs and a wide range of surgical capabilities. It makes it a little easier to hold off on some decisions. If the indication for intubating a sick patient is borderline, but you can put them in front of an ER fellow in 10-15 minutes, often you make the decision not to pull the trigger, because you know you can get them better care fast. This sometimes gets perceived as poor care from outside, but I think it's often in line with the patient's best interests (not to suggest that there aren't lazy or substandard practitioners everywhere). If you're transporting to a small community center 3 hours from an urban center, and there's maybe not going to be a physician on site because they're being called in from home, there's no surgical capability, you're lucky if they have much for blood, and maybe the physician you're getting has next to zero EM training / experience, then there's a different set of variables to consider. Often that patient isn't getting to a high level of care for a couple of hours, and you may be managing them in the "ER" long after you arrive. In that environment, if you're pretty sure the patient's going to get intubated, and you're pretty sure it's going to be you doing it anyway, then it makes sense to do it early.

Perhaps I don't understand this area well enough -- but isn't the specificity for the D dimer also pretty crappy? If you were to routinely D dimer every chest pain, wouldn't you also end up getting a ton of false-positives? I thought this was part of the rationale behind the PERC rule / Wells score systems? This was the problem when I was working in North America. And, really, you can't blame them. If they tell someone having a headache with symptoms similar to their prior migraine headaches to take an NSAID, rest, have someone responsible check on them periodically and call back if the nature of their symptoms changes, and it ends up being a CVA, then they're going to lose their house and their career. It seems like sometimes we have very strange ideas about risk management and personal responsibility.

I think the problem of EMS-initiated refusals is a smaller part of the bigger issue of medical tort reform. I think if the healthcare system was better organised, some risk might be mitigated by having physician oversight on cancellations during an initial roll-out phase, and some point-of-care testing might mitigate some risks. if you could D-dimer that high risk patient in the field, then discuss with an MD, maybe they'll feel safer with the refusal with a negative D-dimer? Then again, maybe just the fact that the paramedic has done the D-dimer provides enough evidence for a lawyer to say "Well, you guys were thinking PE", and "What's the sensitivity of a D-dimer for acute PE?". [Also, can EMS be responsible enough not to D-dimer the low-risk cases, or would we just end up transporting a lot of false-negatives for expensive V-Q scanning?] Malpractice law is a difficult area. It does protect patients, to some extent, but it also drives up the cost of the system, and results in a lot of unnecessary testing. In some countries you can chat with an RN on the phone, and they can book you an appointment with your family doctor, send you to a lower level ER, a higher-level ER, tell you not to present to healthcare, or simply book your appointment for 3 weeks time. These countries kill off a lot of atypical presenters, but do a much better job managing their resources, and provide expedient care for the sick patients with clear signs and symptoms. ----- An example of such a system here: http://www.electoral-math.com/archive/200504/20050430.html [Haven't read this blog before, it was just one of the first links on google].

Respiratory control is complicated, as chbare is explaining. Very few COPDers will stop breathing when given high concentration oxygen. When they do, it's often secondary to increased carbon dioxide retention, which may have little or nothing to do with any supression of a hypoxic drive component to their respiratory control. There may be a small percentage of patients that are dependent on a hypoxic drive, who may go apneic with supplemental O2, but even this is very controversial and hotly debated. The idea that you must avoid supersaturating COPDers because they might stop breathing has been greatly over-emphasised in EMS training. [* We should avoid supersaturating them because it's pointless.] There is some small amount of evidence that hyperoxygenating MI / CVA patients to high pO2s is associated with poor outcomes. I don't think these studies have met causality, although there's some plausible mechanisms by which high levels of oxygen could increase free radical formation and oxidative damage. This data has been sufficient for the AHA to recommend against routine oxygenation in patients without detectable hypoxia.

Just wanted to add that the effects of a DUI charge are likely to be highly dependent on your location, as are other issues like fleet insurance. Before making any decision, I'd try talking to someone who knows the specifics for your location. The registry body that licences EMTs and Paramedics in your region might be a good start. You could try contacting a training school -- but bear in mind some unscrupulous school owners may tell you whatever it takes to get you in the door as a paying customer. I'd also try making contact with a local service, and see what their hiring policies are. I think this is probably going to get you better information than asking a bunch of people who may be in different countries or geographic regions where different rules apply. Good luck. --------------------- Edit: Also, if you're looking at med school, and you have a 4.0 GPA, why not just apply with two years and see what happens? If you're grades are that good, and you've got something approaching some extracurriculars, you might have a good shot. If you're just getting an EMT-B for summer work and to pad the application, it might be worth it to do some sort of research elective instead.

Depending on where you are, this may also affect whether you can receive a license from your state / provincial / national registry body, even if you pass the course. I would check before spending a lot of money.

This is an awesome post, and I think this point is well worth remembering. I used to argue with my wife, a researcher, that her perspective on society was warped by hanging around with super-educated people in a very privileged environment. It took a little break from EMS for me to realise that while I was probably right, my perspective on society was similarly warped. When you see the results of negative, and often cruel and thoughtless behaviour on a daily basis, and deal with the sort of people that make up a large proportion of the call volume in an inner-city EMS system, you tend to think this is representative of the greater world at large. Even being aware of this, it's hard not to let the experiences you encounter doing EMS affect your greater view on life.

I don't know. That reads like, "Random EMS manager downplays staff abuse problem". Sure, the patient's recent emotional stress or underlying pathology can explain and perhaps mitigate some of the verbal abuse. But whether a patient is violent because they're hypoglycemic, psychotic, or just not a very nice person is pretty much irrelevant if a paramedic or EMT gets assaulted.

I agree that this is true, but this is also true in other countries with dramatically different tax systems and economic realities. However, just because everyone has the opportunity to succeed and advance (like most -- all? -- first world countries), does everyone have an equal opportunity to succeed and advance? Obviously this is not the case, right? People are inherently unequal, and some of us are born with advantages that others lack. There's no question that in any country, being born a child of wealthy parents conveys a greater likelihood of "success" as measured by a high income. Is everyone wealthy in the US (or anywhere else), deserving of their success? How hard has Paris Hilton worked in her life? Is everyone poor lazy or a malingerer? Or have some people just had the bad luck to be born to crappy parents, in impoverished neighbourhoods with poor schools and little potential for upward social mobility? How is social mobility affected by regional disparities in the education system, employment opportunities, or cost barriers to university education? Clearly while everyone has the opportunity, not everyone has an equal opportunity. To what degree money should be spent to equalise the available opportunity, depends on your personal political bent. But I'd argue that a large percentage or poverty and a large percentage of wealth have more to do with a person's parents and upbringing than their personal work ethical or intellectual capacity. I agree wholeheartedly with this. The poor shouldn't blame the rich for being poor, nor should the lower middle class blame the upper middle class. What we should do is take a look at the system as a whole, in any country, and ask whether this is the society we want, and whether things can be done to improve the opportunity for people in general. I'm not sure. I don't have any training in economics. I like this when it works out in my favour, but it seems like missed revenue. This seems to be continuously missed in all the fiscal responsibility debate -- that the decision to cut taxes is essentially a decision to spend. There's an opportunity cost associated with it. I think here we disagree again. I'd argue these two points: * I don't think there's a need for everyone to pay something. If someone's extremely poor, they're already paying taxes in other forms, and the best thing for them may be not to pay income tax. I would certainly agree that beyond a certain income level, there seems no reason why someone should pay a net zero tax rate. * Graduated taxes make sense. If someone makes $20,000 / year and you tax them 10%, and take away $2,000, this is a bigger difference than taking someone making $100,000 /year and taking $10,000. There's a basic level of income you need to put food in your mouth and a roof over your head. Once you start getting beyond that point it's disposable income. An individual may choose to buy a bigger house, or a second house, or a fancier car, or a bunch of electronics, but this becomes money that's no longer necessary to their survival. Why shouldn't someone benefiting more from society pay a little greater share? All the best.