systemet

Sorry; i realised after that I might have been a little sensitive. I'm trying to crawl my wait out from under a pile of spreadsheets and stats, with an awesome 'flu and some pretty fun back pain. I'm a little grumpy today! I would agree that this was one of my biggest frustrations when I worked the road. We often didn't get the opportunity to know if we had treated appropriately in a given situation, and I think a lot of valuable learning experiences were missed. Diagnostic uncertainty isn't typically well taught in most paramedic / EMT programs. Most of us don't tend to come away with a good understanding of sensitivity and specificity. There's also a definite tendency to take relatively insensitive or nonspecific indicators, like the S1Q3T3 pattern and turn them into absolutes, i.e. the patient with a PE will have this finding, or because this finding is present it will be a PE. This is a failing in the educational systems that I hope can be improved one day. I realise you've worked EMS as well, and while my anecdotal experiences might be quite meaningless, I can agree with those sentiments. A pulmonary embolus is something you suspect in the ambulance from time to time, based on the patient's history, you get that occasional 40 year old female on birth control, smoker, pain between the shoulder blades presentation, that starts you thinking in that direction, but we really don't have any tools to identify which of these patients really do have emboli. I doubt any of us in EMS truely appreciate how many of our cardiac arrest patients potentially have had massive PEs. Yeah, that was what I was suspecting. I enjoy reading and learning more about ECG interpretation, (I've been working through the Mattu books, and doing a little bit of teaching), but I've always been aware that it's one thing for me to look at an ECG and say, hey that's BER, or there's borderline voltage criteria for LVH, so this ST elevation is likely secondary / spurious, but I've tried to have a low threshold for calling the clot-docs, in case I'm wrong. It's one thing for me, with 3 years of education and a paramedic licence, to say there's no STEMI here, despite the presence of ST elevation, and another thing for a board-certified EM or cardiology physician to make that call.

In a few places paramedics can start arterial lines. This is usually reserved for true critical care paramedics, and the lines are used for invasive pressure monitoring, not for med / fluid administration! If you were to have problems with peripheral IV access, and you need to give a medication desperately that can't be given by any other route than IV / IO, then the IO seems like a good solution. If for some reason this isn't an option, if your scope allows it, a central venous line would be the next obvious step. Very few places do many of these any more, as the IO works pretty well. Giving meds arterially presents a host of problems. The drug has to pass through the distal tissues before it can enter the venous tissue, and will be present in much higher concentrations there than when given intravenously / systemically. There's also a chance they get partially metabolised. Not to mention, that starting an arterial line on purpose is a lot more difficult than starting a venous line on purpose.

My guess, in order: 1. sinus tachycardia 2. new-onset a.fib 3. changes related to previous disease 10. Right heart strain 80. The much debated S1Q3T3 pattern. How did I do? * I wasn't trying to suggest that the presence of left heart strain in any way rules out a PE. I'm aware that the sensitivity and specificity of the ECG for PE is very low. * I'm not presuming to lecture an ER physician on subtleties of ECG interpretation. I'm sort of stupid but not that stupid * How would you feel if a crew faxed you this ECG, and asked about the STs? My opinion as a paramedic, which is worth exactly that, is that you probably wouldn't give me orders for TNK? Do you agree?

I think the issue here occurs more when a provider opts to go to an EJ or IO when there are other acceptable routes for medication administration, or there isn't a clear indication for the IV / IO, e.g. * pain management, which can usually be given IM or SC * to give D50W when glucagon is available but hasn't been used * to administer anticonvulsants, instead of going IM * for relatively small amounts of rehydration in a patient that isn't suffering serious dehydration * IV/IO narcan, etc. Unfortunately there are people out there who don't exercise good judgment and seem to be motivated by performing "cool" procedures.

Well, my position isn't set in stone. I'm willing to listen and be convinced otherwise. I wasn't trying to suggest that paramedics and EMTs shouldn't advocate for the growth of the field into a profession, more that to survive day-to-day, sometimes it's better to focus on aspects of patient care. If we can present a better solution, then I'm in favour of that.

A couple of points regarding the 12-lead: * The lateral leads are showing downsloping ST-segments and T-wave inversion, this is probably LV strain * The axis is borderline for LAD; * While this does meet the common voltage criteria for LVH (i.e. S wave in V1/V2 + R wave in V5/V6 > 35 mm), the R wave in aVL is sitting right at 12 mm (>12 is considered suspicious for LVH). Obviously LVH is better identified with echo. * Not sure whether I see a.fib either, it's a little hard to tell from the tracing. I would probably still fax this, although I think the ST changes are secondary to LVH. I wouldn't expect to get orders to thrombolyse this, but I'd let someone with MD after their name decide. I don't think there are ECG changes to support a PE -- starting with the caveat that the ECG is pretty insensitive here. If I was going to see something, I'd expect to see a rightward or right axis, +/- RBBB, right strain, RAA (collectively suspicious for RVH). Any follow-up on the patient? Any point-of-care testing available?

It's hard to keep up with all the directions this thread has bounced in. I think we all know that a large percentage of our patients aren't experiencing an acute life-threat. We probably all suspect that a substantial proportion could take a private vehicle to the ER without detriment, and that a fair portion of the people who end up in the ER via ambulance, or personal vehicle / public transport, probably could just wait until the morning or have no medical needs. I think it would be really hard to argue that this isn't the case. However, in North America, at least, there's a heavy burden of medical litigation, that results in our systems being designed to avoid legal liability as much as to provide appropriate care. A case in point is the awesome failure inherrent in AMPDS dispatching. If a random cell-phone caller drives by a seemingly unconscious man in a bus shelter in an area with a lot of homeless people / drug use, this becomes a cardiac arrest. But god help you if you're an elderly lady, fall and break your hip. Because this ends up being a low priority alpha response in a lot of instances. Far better to be drunk and sleeping in the bus shelter, than have a legitimate painful but verified not-immediately life-threatening extremity injury. Once contact with the medical system has been established (and EMS is increasingly becoming part of the medical system), there's a duty of care. Even if the patient's condition is trivial, it's going to be hard to convince a risk management team that the benefit of denying service outweighs the potential cost of a damage settlement for being wrong. Unless there's fundamental reform of medical tort law within the legal system, it's going to be hard to see how this changes. Us turning up to a 911 call and telling someone they don't need to go to the ER is essentially the same thing as a patient presenting at the ER triage, and having a physician take a blood pressure, do a finger-stick glucose and tell them to go home. This just isn't something that's supported within the framework of the medical systems in North America. There's just too much concern (justified or not) about liability. It's tempting to imagine how different the world might look if physicians were simply allowed to use their best judgment. When you start thinking about the uncertainty involved in EMS, it becomes even clearer that paramedic-initiated refusals of care are less likely to happen in the future. We lack the education and training of the physicians, and don't seem to be too interested in starting to close that (incredibly) large gap. And we lack their tools. How many physicians would be comfortable discharging a patient using only the tools available in the ambulance? And how many would be supported by risk management in their ED? It's not just an issue of provider training. Increased education only solves part of this problem. I think the answer in the future is likely to be referral to other agencies, which will have less liability than an outright refusal, but this is going to require upgrading the primary care skills of the average paramedic, which are lacking, as tniuqs has pointed out. In the US, the tort law is going to continue to be a problem, and in Canada the responsible agencies are going to continue acting as if the medicolegal environment is as litigious, even if it isn't. While healthcare spending is a huge political issue, I'm not sure that I'm willing to take the personal risk to try and reduce it by initiating refusals in an environment where the medical community and the woefully small amount of available research isn't going to support me. System issues seem equally difficult to handle, and seem likely to remain with us for a long time. I'm a little irritated with flaming right now. But, I think the attitude that you help the patient put in front of you, no matter how stupid or healthy or irritating they may be, is the correct one. If we want to become a profession, we must first act as if we already are one. I think that means leaving the political issues to management and the politicians, and taking a lot of no- to low-needs patients to the ER, until a better solution is presented. While some situations are blatant abuse, getting angry about them doesn't seem to offer any tangible solution, and just adds to the stress of an already difficult job. Perhaps the more survivable attitude is just to accept that the problem exists, treat the people you encounter as best you can, and let someone else agonise over it.

A few ideas: * Take a look at a good physiology textbook. Ganong's "Review of Medical Physiology", Vander, Guyton, Boron & Boulpaep -- one of the texts aimed at MD students, not paramedics or RNs. Look through the CV system areas. * Check this website, it's awesome for a whole bunch of stuff. Here's a couple of particularly relevant pages: http://www.cvphysiology.com/Blood%20Pressure/BP006.htm http://www.cvphysiology.com/Blood%20Pressure/BP022.htm http://www.cvphysiology.com/Blood%20Pressure/BP019.htm * Think about the biophysics. Consider CO = HR * SV; BP = CO * PVR = HR * SV * PVR = HR * (LVEDV-LVESV) * PVR, and think about the Frank Starling mechanism. Think about the effect that contractility has on this, consider that venous return and central venous pressure / RAP, are surrogates for preload in a healthy heart. * I think you end up with major determinants being cardiac output, volume and PVR. All of these are affected by multiple factors and aren't completely independent. If you have no volume, you have no preload, no SV, and no CO. If you have no CO, you have no blood pressure. * Laplace relates to both cardiac contraction, i.e. an overfilled ventricle has a larger radius, and requires the generation of a greater tension to produce the same pressure - this is the reason why nitroglycerin and preload reduction concerve MvO2 in MI, and to vascular function - if we have high PVR from atherosclerotic disease BP will go up. [*This also explains positive feedback in TAAs / AAAs, as the aneurysm dilates, the tension on the wall increases] * Take a look at vascular function curves here: http://www.cvphysiology.com/Cardiac%20Function/CF027.htm I realise this is a lot of information, but if you can look through it, it will really help you understand the complex relationships between the different factors.

Yeah, it's terrible. I didn't really know the details until I read that document. It's just so tragic that so many supposedly responsible adults took the easy way out and didn't pursue the matter. They basically decided that those kids were worthless. It seems like there's a lot of other people who should be shouldering some of the blame. Hopefully they're held to account.

Have you considered thinking? The spectacular and utterly disheartening series of failures of adults to protect young children that's described in that document is sickening. To compare a situation of that severity and magnitude to the episodic instances of concealment in EMS redefines the word asinine.

No problem! I was surprised when I read it, I learned a lot.

It sounds pretty clear that she was terminated for talking to the press. I know nothing about US whistleblower laws, and I'm a little surprised that these mandatory overtime situations are legal. I've never worked in a system that has formal mandatory over time. I've worked in busy systems where there's a good chance of getting a call in the last five minutes of your shift, and cycle time is over 90 minutes, then your truck is active while you return to the station, so there's a chance of getting hit again. I've put in 14 hour night shifts that have turned into 18, and in some of the places I've worked, it's just been accepted that you're going to log a few hours of OT every week. Some of this is just an unavoidable part of EMS: Much of it could be reduced by more staffing, and better system management. But there's a certain reality that unless you grey out every truck for a fixed time before the end of its shift (60 minutes? 30 minutes? Longer in rural areas perhaps?) you're going to do some OT. But I'm also surprised that it seems like a lot of people are supporting this practice. We've recognised in other industries that fatigue compromises performance. We don't let truckers drive 20 hours straight in most countries. We have limits on when pilots time-out (often we have different limits for when flight crews time out than for the medical crew). There's obvious and real risks to operating an emergency vehicle or performing patient care. I might be an idealist, but it seems like there should be a (non-punitive) mechanism for someone to turn around and say, "Look, I'm just too tired, I need to go out of service", especially if you're expecting them to pull ridiculous hours, doing things like 1800-0800 nights, then hitting OT, and still being on night shift at 1000. Obviously there's a responsibility for the staff member to show up to work well-rested and prepared to work, but there needs to be a safety mechanism to prevent accidents.

I was just thinking the same thing, then I found this: http://grammar.about.com/od/alightersideofwriting/a/mootmutegloss.htm It sounds like it originally meant a relevant point / arguable topic, but has taken on a more modern meaning (particularly in North America), that's almost opposite.

Where are you? The employment situation where you live may be very different to where some of the other posters live!

Mobey's article is a little old (1991 - discussing a cohort of patients from 1983-1974), and it's observational, i.e. there's no intervention being studied / no control group. So it's limited in what information it provides. It's inclusion criteria is also limited to patients who were admitted to a ICU who had coma following severe head trauma and remained unconscious for > 30 days, and had abnormal motor responses to painful stimuli (posturing or flaccidity). So this is a pretty unique group of patients. Firstly, they've survived long enough to be admitted, which our hypothetical (or Mobey's real?) patient might not, and then secondly, they've remained comatose for a long period of time. Of 132 patients, 72 regained consciousness following their coma. Patients more likely to recover lacked "extraneural trauma", and were more likely to have exhibited decorticate than decerebrate or no response to painful stimuli in the first week. They were less likely to have SIADH, hydrocephalus, seizures, or abnormal respirations. But it's a little unclear from the paper as to how big these effects were (i.e. odds ratios, confidence intervals), and with what degree of certainty (P values). But I imagine what Mobey was suggesting was that this group of patients was very sick. They had enough head trauma to be admitted to the neuro ICU, and remain comatose for over a month, and had abnormal motor responses yet despite this severe pathology, a large percentage of the patients with decorticate posturing survived. So we shouldn't assume that just because a prehospital patient is posturing, they're a no-hoper. At least that's what I take from it.

Wow. I am a big believer in students deserving to be treated well. They paid a lot of money to get into a program and come out on practicum, and part of my job should be to make sure that they're having a good time (while being tough when it's necessary and giving honest, constructive feedbacK). But I would react very badly to any student who didn't help clean up the mess they participated in making, or came in with an attitude like that. (I do believe that the student should be elbow-deep in everything medical, and shouldn't be cleaning / restocking the truck if there's debriefing, or clinical teaching that can be done inside the hospital. But they should pitch in when they've got spare time.) I bought doughnuts for the scrub nurses in the OR, and for less than 10 bucks, bought a bunch of intubations. Did the same thing in case room. Delivered (i.e. my hands on baby) 7 babies in 2 weeks. My preceptors would come find me and drag me to every labour and even C-section. I did my best to help clean and do whatever I could to help, and it paid off. The RNs are like the mafia. And even the MDs seemed to appreciate it. I had one Czech anesthetist hold me up as an example while he dressed down his residents for not helping the OR nurses out enough. I could feel the knives in my back from across the room. Oddly I woke up several hours later in a parking lot with my hand sewed to my left buttock. Never mess with anesthetists. Me too. I can't pretend that everyone always appreciated me being there, especially in the OR, where views ranged from "Paramedics shouldn't be allowed to intubate", to "Paramedics found touching a laryngoscope should be anesthetised, have their left hand sewed to their buttock and left in a parking lot", to "You guys should RSI with every intubation", but I learned so much, and saw so many things that we have so little exposure to in the field. I left with a lot more respect for the other healthcare professions / occupations.

Another thing that causes me physical pain is the mispronounciation of common medical words. For example, I went to an ACLS course where the director, another paramedic, told a room full of physicians that his service was soon going to have the capability to perform FAST ultrasound scans, and do meth-hemoglobin co-oximetry. (It's MET-hemoglobin !!!) Now granted, I lived in 3 different countries, seem to be completely oblivious as to how to use the "comma", and have learned both English and American pronounciations of a bunch of medical terminology in a seemingly random manner, but it's the principle of the thing. If we're going to talk about relatively complex things, and choose to use these words, then we should pronounce them correctly.

I agree that it's unethical to use information from the patient care record to contact a patient after an event. The information wasn't disclosed to you for personal use, but was given with the implicit understanding that it was to be used for treatment follow-up +/- billing purposes. Most jurisdictions have some sort of privacy disclaimer (I assume in the US this is part of HIPAA?), that describe why information is being collected, for what use, and how privacy is to be safeguarded. I also think it's unprofessional for a medic to initiate any conversation about a potential date (with the patient or a family member / random bystander) while treating a patient. It doesn't exactly promote the idea that you're focused on the patient's care at that point. There's also an issue as to whether the patient is in a situation where they can freely refuse here, if they are worried about upsetting the EMT / Paramedic, and the potential changes in their treatment that might result. I imagine a professional college would have issue with this. Dating a patient after meeting them in a non-work setting seems fine to me though. And I don't think it's unreasonable to give your number to the patient if they ask for it. But the dialogue needs to be steered back to patient care, to prevent an impression that you're no longer doing your job. I also don't think it's a problem to treat your girlfriend or wife. It's not something I would choose to do --- I know from experience that if a family member or friend is injured / sick my judgment goes out the window, and I become very aggressive in terms of treatment therapies. I'd far rather pass the call onto someone else, if it's a possibility. Just my opinion.

I wouldn't feel comfortable with doing this in most situations. I could see potentially administering a small amount of analgesia, and placing a patient in a BLS ambulance, if I knew I was going to be following them. Granted, they should be able to manage any respiratory depression that occurs, but I'm not sure that they're best equipped to identify an early anaphylaxis presentation or deal with it effectively, even if IM epi / nebulised ventolin are options for them. Of course, this is (technically) an MCI situation. There's inadequate resources to match the number of victims present and their severity. So some compromises may have to be made. I think in most of those situations the risk / benefit is going to fall on the side of withholding pharmacology if there's not going to be an ALS provider present for transport.

When I did it, it felt to me like the first year was basically teaching the EMT level how it should be taught. Most of the time was spent on Anatomy & Physiology, Pathophysiology and Pharmacology. We went over basic arrhythmia recognition, learned 12-lead interpretation (which really should be a BLS skill anyway), did our BLTS-Advanced, so we got some very cursory instruction in intubation / surgical airways. Took some of the general supporting courses, e.g. English, Research methodology, communication skills, medical terminology. Went over Obstetrics again, and took NRP. So really, there was only a handful of ALS "skills" taught. Mostly what we got was the theoretical background to practice that we were never taught well during our (6 month) BLS training. The second year was 1000 hours of ambulance practicum, 400 hours in the hospital (including a week in the OR, 2 weeks in case room, a couple of weeks in the ICUs and another couple in the ER). Then the merit badge stuff, ACLS, PALS. All the "critical care" stuff (I hate that expression). A little bit of time getting lectures about vents and ABGs, a very quick day learning to suture from an EM doc, learning to do UCs, NGs, etc. . I think it really depends on the program though. I think my program was OK. But it wasn't until I went to university, got some more physiology and pharmacology, and some cell biology, that I really felt like I got the theoretical background that I needed as a medic. I really think ALS level care should be taught in a university environment at a Bachelor's degree or higher level. I also think it needs to be science-based/focused.

I had a next door neighbour in my old city, who was 80 years old. She didn't have family in town, and her husband had Alzheimer's. He was ready to be put in long-term care, but she wouldn't hear of it. She'd seen the condition of the local long-term care / dementia wards, and realised that they really weren't going to treat him very well. She came from a generation where you just dealt with these realities and made do. So she looked after him, even when it was difficult. My neighbour wasn't particularly unique -- I think there's a lot of people like her. But I would say she's something of a hero to me. Going to work, drinking coffee, driving around town, talking to people, fixing problems -- that's how I remember a lot of EMS being. It definitely came at a personal cost. But I also got paid for doing it, and honestly, paid quite well. Most of the time when I did something particularly skilled, the patient and their family were unaware. And realistically, most of the time I was just doing what the next person with a union number and a paramedic license would have done. All that stuff that just falls under "doing your job". The things the patient's and families seem to remember are the interpersonal things. They don't know whether you did good medicine, just whether you were kind. I've never felt that EMS is a heroic calling. As someone else suggested, sanitation makes a greater impact on public health. Few people call an RN at an immunisation clinic a hero, or a PT working with cardiac patients, the average family MD, etc. These are all people who may have made much more of a difference than I ever did. I also don't believe that someone is a hero by virtue of being a cop, a firefighter, or being in the armed forces. I've met plenty of despicable people in all these occupations. There are occasionally individual heroes, but that's something that's earned in special circumstances, not just because you collect a weekly pay-cheque. I do hold some substantial respect for the volunteers. I like people who try and take care of their community, for free, and often without the best training or equipment. I like that. I feel with EMS sometimes it's hard to collect money for doing a paid job, and then claim great hardship. It's a situation voluntarily entered into for personal gain. My image of a hero doesn't quite include someone who says, I'll help you, but first I'd like an pension plan, extended health care, good dental, a certain overtime rate, and ten statuatory holiday days in lieu. I think I'm rambling again.

I think you can definitely make the counter-argument that paramedic RSI in head-injured patients is associated with poor outcomes in one historically-controlled study, and minimal benefit in the only RCT that's been performed. Furthermore, the patient appears to be oxygenating / ventilating appropriately at the current time. We know that this may be tenuous, and we know that there's likely multisystem trauma here. So there's a good argument for controlling the airway. We know that if this is done with RSI in the hospital environment that it improves outcomes. In EMS the data is less clear. The second patient is decompensating, but is still only borderline unstable, as they're GCS 15. It's also likely that this may change. Though their initial managment is going to be a fluid bolus, it's possible that pressors may be needed +/- airway control, depending on what other injuries declare themselves during transport. There's indication for ALS here. I think I still stand by my original choice, though. I think the distinction is we know we'd like to RSI the head injury. We know we'd like to give analgesia to the spinal injury. Life over limb. There's a potential the spinal cord injury may need pressors, which may be life-saving --- but we probably need to fluid bolus first, and evaluate whether there are other injuries before we proceed down that path. The problem here is that we would like to have two ALS rigs, a pair of incoming helicopters, and maybe a couple of BLS backup rigs for extra hands, and a whole ton of resources that just aren't available. Established triage guidelines allow us to declare the obvious DOA, and devote our limited resources to the two remaining criticals. But beyond that, we don't have tools to make a judgment as to which patient is going to benefit the most. As I said earlier, I think that unfortunately you end up getting judged on how well you chose based on the patient's final dispositions, which is monumentally unfair. With a decent medical director / supervisory chain, it should be enough that you can justify and motivate your choices. It's not your fault that an accident of this magnitude occurs in an area / time when there's not enough resources to manage it in an optimal manner. It sounds like by launching fixed wing you saved valuable time.

Dammit. Should read "anesthesia".

Just to add to the above, the benzodiazepines bind to the GABA A receptor, at an allosteric site. Under normal conditions they don't directly activate the channel, but instead sensitise it to other agonists, primarily the endogenous ligand, gamma-aminobutyric acid (GABA). [*If anyone notices the immediate similarity between GABA and gamma-hydroxybutyrte (GHB), this is not a conincidence, GHB was originally developed as a general anesthetic, acting as an agonist here. We've probably all seen that it can be quite effective at inducing analgesia during intentional overdose -- though not without problems, that caused it to be abandoned, including myoclonus and one hell of a synergistic effect with alcohol] The GABA receptor is pretty important in CNS pharmacology. If you click on the second link below, you can see a nice little diagram of a receptor looking all sciencey with a list of ligands. Note that these include the barbiturates (Pentothal, Phenobarbitol anyone?) and neurosteroids (this would include etomidate). Alcohol also acts here, as do a range of other drugs. Benzodiazepines are widely used because their effects tend to be limited by a relative lack of direct agonist action at the GABA receptor. This makes them much safer in large doses, compared to barbiturates and other agents that are direct agonists, and tends to limit their effects in overdose -- although at a certain point as the dose increases this becomes less relevant. Unfortunately given the patients we commonly encounter, most of them have coingested alcohol, which has a direct channel-opening effect, and in combination with benzos causes major toxicity at lower doses. Some good reviews here: (should be free access) http://www.ncbi.nlm.nih.gov/books/NBK28090/ http://www.ncbi.nlm.nih.gov/books/NBK28090/figure/A1185/?report=objectonly

I misspoke here. This should read "the drug is more potent". [Edit, pasted twice.]