systemet

Happened to me the other day. I was drawing up my ket and sux, and my EMT kept on bothering me, and I couldn't understand why, and then I realised that the patient had actually been decapitated, so it was completely unnecessary to RSI him. We had a dig around, and ultimately found his trachea and stuck a tube in it, then my EMT was bothering me again, and I realised we were blowing air out his hemisected torso. It was a bit embarrassing.

In order to answer this question you need to define the terms "profession" and "organisation". I would submit that while I have met many people in EMS whom act in a professional manner, we are a vocation and not yet a profession. Our barriers to entry at both the paramedic and EMT levels are quite low. We have little control over the direction of changes in clinical care, and ultimately report to EM/Cardiology. There may be countries where the move towards professionalisation is more advanced, e.g. some parts of Aus/NZ where Bachelor's degree entry-to-practice is becoming the norm, or the UK with their consultant paramedic and paramedic practitoner roles, parts of Scandinavia where the paramedics are essentially nurse-practitioners, or the countries where EMS is provided at the advanced level by specialist physicians. I doubt anyone would argue that an anesthetist working on a French SAMU ambulance meets the traditional definition of a professional, for instance. We talk a good game in EMS about how professional we are, but when you can become an EMT in less than six months, and most paramedics have less education than a plumber, it's not that meaningful. This isn't a slam on the vocation/occupation, more a recognition of the opportunity for growth and transformation. ** Or a slam on plumbers, who intermittently stop my house from flooding. But if all we define professional as, is someone who makes money from a specific job, then "professional paramedic" may mean little more than "professional exotic dancer".

I agree with the above. Realistically he's probably going to get intubated unless we can get the NIV working well, but he's going to have to get a decent fluid bolus or two first. Even if the pressure comes up, it wouldn't be unreasonable to have the levo hung at 0 and ready to go. It would be nice if the sending facility could run a peripheral venous sample through their ABG machine, and at least give us an idea about the bicarb and pH. They're probably both not so great. Do we have difficult BVM/Intubation/Cricothyrotomy indicators? I like the ketamine and topical anesthesia approach for intubation. I don't think we've actually been given a respiratory rate so far, but I imagine it's not good, and sux is probably out at a K of 6.2 mM. Do we have a decent vent? Any evidence of DIC? I'm guessing we don't have a fibrinogen? platelets? Cheers.

I've always found the formality in medicine a little strange. Something I've liked about EMS, is that I don't have this barrier of formality between me and my patients, I can walk in and say, "Hi, I'm <firstname>, and I'm a paramedic...", and the assumption is we're going to operate on a first name basis on the same social level, and treat each other, patient and provider, as peers. There's a certain authority I derive my uniform, my presence, and the simple fact that the patient, generally, has called for my help, but it doesn't come from the title of paramedic. I've noticed that the physicians I really respect seem to embrace that viewpoint as well. I remember one of our crews, 10 years ago, bringing in an elderly patient with a large anterior wall MI. The attending walks straight up to the wife, "Hi, I'm Andy, I'm going to be your doctor today, I realise that you probably have a lot of questions, and I'm going to come back and answer them in a few minutes, but right now I have a couple of things I have to do first, please sit here.". These are people I respect. I don't mean to tar all of medicine with one brush, but I have met too many people who hide behind a white coat (or, a paramedic uniform, or a set of scrubs), and use this as an excuse to treat people like meat. I think that, in some strange alter-universe, if I was a physician, this forced formality would irritate me. I have a friend who has a doctorate in international relations law, who like to sit in his family doctor's office, and when the nurse comes out and says, "John, Dr. Smith is ready to see you", he says, "Tell Dr. Smith, Dr Kxxxxxx is ready to see him". It's a rather uncommon last name. It's not that typical to use the title "Dr." in the academic world, as pretty much everyone has a PhD, or MD, or MD/PhD. It's largely reserved for undergraduates, or perhaps for a visiting guest. The debate here, to me, is whether a DNP introducing themself as a "doctor" is misleading towards the patient in a healthcare context. To me, there's no question as to whether they've earned the right to call themselves doctor --- they have a doctoral degree from a university. They have that title. But to use it in this context seems potentially misleading, unless it's clarified as, "I'm a doctor of nursing practice", or "I'm a doctor of pharmacy". It does seem strange to me, though, that physicians are quite willing to accept a blurring of lines between, "I'm Dr Kevorkian, a board-certified emergency medicine physician, providing care in this ER", and "Hi, I'm Dr. D'eath, a family medicine physician with a one year emergency medicine subspecialty certification", without complaining as loudly. This seems to be a bit of a double-standard. If non-MDs can provide medical care, at an acceptable standard, while working independently, let them do it. But, if they're going to do that, let them also be honest about what their background is. Either the physicians need to move towards, "I'm a physician", or "I'm a doctor of medicine", or the nursing DNPs need to clarify "of nursing practice". The patient shouldn't be left in a state of confusion as to who is looking after them.

This fellow seems a little sick. He has septic shock. By definition: SIRS : [2 or more of (i) HR > 90, (ii) RR>20 or pCO2 < 32 mmHg, (iii) T > 38 or < 26, (iv) leukocytosis or leukopenia or bandemia] Sepsis: SIRS + identified source of infection [pneumonia complicated by secondary ? nosocomial influenza, possibly H1N1]. Septic shock: sepsis + lactemia (lactate > 4mM) or hypotension. http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/ He also may not have the best baseline cardiovascular status [prior MI x 2, ? new-onset a.fib], or respiratory status (COPD). So there's a bit of a question as how other comorbidities may be affecting his presentation / clinical course. A couple of things jumping out: * SpO2 85% may not be that terrible for a COPDer. Is he on home O2 at baseline? Can we get a gas? A CO2 and a bicarb will let us see how effective his respiratory compensation is? On the same token: how is work of breathing, subjectively, is he tiring? * His temperature is concerning. Has he been febrile previously? Is he transitioning towards "cold shock/sepsis"? * I'd love to see a CXR -- does it look ARDSy? * Would be nice to have an ECG, BNP and trop, to see if there's any evidence of STEMI / NSTEMI / heart failure. Granted his trop may be high if his ARF has been prolonged? When was his last period of reasonable U/O? Do we know his baseline NYHA? His med list doesn't suggest a CHF hx. * Why is he hypomagnesemic? Is he a drinker? Is this from the lasix? How much was given? * Goals of care? He's younger, one would assume R1/ full code? Are patient and family amenable to ICU admission / ventilator management? * What's our transport time / mode? Are we going ground am for 20 mins? 3 hours? RW/FW? Helipad to rooftop -- or are we shuttling to the airport on both ends for ground transfer? Presumably our receiving center is tertiary care with full ICU capabilities? Looking forward, with influenza dx and rapid decompensation -- ECMO on site? * Level of consciousness? He sounds sick, but at points in the vignette, it seems like he's talking and alert -- could you clarify this? ------------- Moving on to intervention: (1) He needs a lot of fluid. This seems to be a clear septic shock presentation. WBC of 22 doesn't sound like a stress response to an MI. He has two sources of infection. He's tachycardic and hypotensive. We should start with 20 ml / kg, consider whether we can / should get better access --- CVC if skilled personel exist, or a larger IV. (2) We can leave the a.fib alone for now. At 120/min it's unlikely to be the cause of his hemodynamic compromise. Cardioversion while hypoxic, and a high demand state, is likely going to cause more problems than it resolves. Medical therapy with ARF / significant hypotension would be a brave (read: foolish) decision. (3) If we can bring his pressure up, we could reconsider CPAP/BiPAP, and have another go. If he just "failed" because he's anxious, then we may have time to take another stab at it. (4) If his mentation is poor, and fluids haven't brought up his MAP (55 mmHg), then we have to decide between more fluids and initiating levo, or both concurrently. (5) If we're going to intubate this patient, we need to improve baseline hemodynamics first. The decision to intubate is going to be based heavily on anticipated clinical course -- is the patient tiring, are dealing with respiratory failure? Given the length of transport, is there a high risk of airway compromise, probably better pre-empted in the sending facility? Given his CVP is probably very low, putting positive pressure in his chest without addressing volume status / PVR is going to be a bad idea.

I agree wholeheartedly. I'm surprised that the admission rate is so high, although I think we'd also agree that the majority of the admitted patients were probably not time-critical in the sense that a 15-30 minute delay would have affected morbidity/mortality. In terms of improving education, I think we need to alomst start from the beginning, and move it into a university model for paramedics, and a two year diploma for BLS.

I think that very very few of our patients are time critical. Examples of time-critical patients probably include: * STEMI patients who have not received fibrinolysis, or whom are best served by primary PCI, or who require rescue PCI. * Suspected acute AAA / TAA. * Predicted difficult airway with anticipated need for intubation, e.g. significant laryngedema/angioedema * Suspected ischemic stroke inside fibrinolytic window, or "fairly close with good prognosticators/baseline:, i.e. anyone who might get 'lytics. * Respiratory failure / NIPPV patients continuing to decompensate * Possibly treatment-refractory status epilepticus. * A subset of sick status asthmaticus / treatment-refractory anaphylaxis * Pentrating trauma * A small subset of blunt trauma patients. And that's about it. Someone else will probably find a few things I missed. Things that aren't time critical probably include: moderate asthma / COPD exacerbations, most overdoses, including a fair few that are intubated, most blunt trauma, etc. I think when we really look at a lot of those patients, for example, the average polypharm OD -- once this person's been intubated, they can probably be driven intubated another 15 minutes with relatively low risk. Because they're probably going to sit and have their liver and kidneys, and maybe a few plasma esterases, do most of the work for the next few hours or days. Likewise, many of the "chest pain", or "suspected ACS" patients we've historically got very excited about are just going to sit and homeostase and get a couple of enzyme draws. Understand that I'm a proud paramedic, but I believe that EMS has oversold and under-delivered. Just like the ER, the majority of our work is primary care, dealing with patients that could have gone to a family medicine clinic. We do relatively little for these patients, but have a window of opportunity to direct them elsewhere. Where we see acutely sick patients, most of the time our care is primarily supportive and the best thing we do is take them to the ER -- where, at the same time, often they provide little more than supportive care until they move to ICU or whatever service is going to provide definitive care. I think, like everyone else on this forum, and very few people outside of it, that we need to raise our educational standards, and start refocusing on the bulk of our call volume. Typically we deal rather poorly with seniors and geriatric care, we are not great at mental health, or palliative care, or dealing with the social work that form much of the basis of EMS. Some of us get good at this through natural ability and a process of trial and error and repetition. These are obvious areas for improvement. While this is hardly unique, my system allows me to respond to palliative patients, liase with their palliative care physician, and give them pain control, antiemetics, bronchodilators, or arrange home oxygen, without having to take them into the ER. This is in its early stages, but has been well received. Other systems/regions have looked at developing paramedic/NP teams that are the first point of contact for seniors calling with urgent complaints from designated high volume centers. We're also starting to do a better job of accessing community resources, e.g. homeless shelters, following up on our high volume users, or patients with chronic issues, e.g. high risk seniors needing placement. I think these are areas where we can improve. Every paramedic wants to do prehospital ultrasound, start art lines and do EGDT, start central lines, etc. Relatively few people want to get better at picking grandma up off the floor. This might not be what most of us expected or wanted when we entered this field. I think many of us have been seduced by the idea that people call 911 for acute medical events, where we can meaningly intervene in the field -- and this does happen, but these calls represent a minority of the events we see. I think the lack of real depth in our initial education has led us to overestimate the severity of many of the patients we encounter, and changes in our societies have led to more urgent versus emergent calls. I think that we need to move away from a public safety role, and towards a model where we form part of the health care system and present the point of first interface with the healthcare system. . I'm not sure how well I'm making my point, and I'm certain that these ideas are far from unique or revolutionary, but this is how I see EMS moving forwards in the future.

I found that terrifying to read. It's strange to see patient care quanitified in such abstract and economical terms. I realise this is a reality of health care in both public and private systems -- but doesn't this create a system of mixed incentives? One would assume that the point of diversion is to manage ED flow, and move the workload to less busy ERs, in order to provide more timely care for the patient, and avoid stacking critical patients in an overwhelmed facility. If this is economically disincentivised, then the hospitals are under duress to accept as many patients as possible, even when they're unable to provide their normal level of care. Given how few EMS patients are actually time-critical, I wonder if you'd be able to detect a meaningful outcome difference for all the noise in the stats?

I don't know why you'd use vecuronium. Roc is a superior agent if there's a contraindication to succinylcholine. RSI is an inherrently comitting procedure that can be very dangerous. While succinylcholine is fraught with risk and danger, using even longer-lasting agents takes away some of the remaining safety margin. I realise that there's discussion in anesthesia / EM about using rocuronium more commonly as an initial agent. Given the number of RSIs most providers perform, I think having multiple agents available only complicated an already potentially dangerous procedure.

This is a judgment call. There's always a risk of giving adenosine to a seemingly regular NCT and finding out later that it was a.fib. There are some theoretical risks if an accessory pathway is present, but this is difficult to identify when the rate is fast. Personally, I'd have the pads on, draw up some sedation / analgesia (probably some ketamine), and push the adenosine. If it's a.fib, I'd expect a transient slowing, and possibly to visualise some fib waves. If the patient acutely decompensates I have the option to defibrillate (if appropriate), cardiovert with sedation, and cardiovert without. If we identify a.fib after the adenosine, then I'd probably give some metoprolol if the pressure is anything close to reasonable.

I don't know how to say this without being rude, but I think you would benefit from taking a statistics course.

I think you tread gently here. The AAA is high on the list of differentials, and fluid resuscitation / 'trops / 'pressors are going to potentially worsen the situation. The patients requires assessment at a decent ER, and further diagnostics to guide treatment. Expedite transport to an appropriate facility, gain redundant wide bore IV access; zofran is a great idea. Have some ketamine and succinylcholine drawn up in case he starts dying. Have the dope or (better yet) levo primed and ready to go. Have all the airway gear ready. Then drive fast, and cross your fingers. Right now he's mentating. This might not, and probably won't last. But if we run around trying to arbitrarily normalise physiologic parameters without thought to the underlying cause, we're just going to make things worse, and expose the patient to a whole lot of risk for a poorly defined and arbitrary perceived benefit. Just an opinion. Obviously, if we feel the AAA is unlikely and the most likely primary cause is sepsis, then the treatment plan changes. Small aliquots of fentanyl are ok-ish. There's a risk of bringing down a sympathetically-driven pressure. Maybe even 25 ug is a reasonable idea, as the patient's likely vasoconstricted, and preferentially shunting their perfusion to the CNS. There's good arguments for ketamine, but my concern would be that right now, you know there's some degree of CNS perfusion, because he's GCS 15 -- but make him altered, and it's going to be hard to gauge that.

These are excellent: http://emcrit.org/lectures/vent-part-1/ http://emcrit.org/lectures/vent-part-2/

Certainly a possibility, but unequal bilateral B/Ps are a fairly insensitive / nonspecific finding. The patient's not particularly hypertensive, and the CXR is "clear". The heparin can be reversed with protamine at the receiving facility, if necessary. The lovenox seems like a poor choice if the risk of dissection is appreciated. I think you did the right thing here. Labetalol is probably a better option over metoprolol, if you're going to give something. There's a link to one registry here showing that pulse deficits were only found in ~ 15-20% of patients with dissection: http://jama.jamanetwork.com/article.aspx?articleid=192401 Hagen et al. The International Registry of Acute Aortic Dissection (IRAD)New Insights Into an Old Disease. JAMA. 2000;283(7):897-903. doi:10.1001/jama.283.7.897

I realise that I may be a little late to the party, and hope that this doesn't count as a thread necro. I'm not convinced that science and religion are incompatible. A lot of great scientists, including Newton and Einstein, were able to reconcile the two in their personal beliefs. While I'm not religious myself, I'd argue that science and religion speak to different domains. Science encompasses all that can be formed into a "testable hypothesis". The concept that "There exists a supernatural entity, undetectable by normal physical means", is not a testable hypothesis, therefore it's not a scientific belief. The tools of science are not useful in answering this question. In the same way that there's no scientific answer to questions like "What's the best way to live my life?", or "How should I treat other people?". To some extent, we can contort these into semi-scientific questions, like "How should I best interact with people in order to maximise by financial income?", or "How should I live my life in order to avoid suffering chronic disease?", but the original questions as formed fall more into some sort of "spiritual" or "religious" box. A literal interpretation of the bible certainly clashes with science, as ERDoc and others have given examples of. The ideas of resurrection, or bringing the dead to life (at least 2,000 years ago!), would require a substantial adjustment of modern science. They tend to fail "Occam's razor", the concept that the simplest given explanation that accounts for all aspects of an observed phenomenon is most likely to be correct. The hypothesis that we live in a world that's 6,000 years old which has been elaborately constructed by some form of supernatural deity to appear older than it actually is, and that this information has been preserved by a select few since antiquity, is certainly more complex than the currently accepted scientific explanation. But it also remains fundamentally untestable, placing it outside of the realm of scientific enquiry. I think that ultimately, science and religion cover different spheres of knowledge, and are different means of interpreting the world around us. THey have their inherrent limitations, but most of the problems occur when they try to encroach upon each other. To chbare - if you have a student who is losing religious faith because they're learning more about science - if this person is an adult, I don't think you have any obligation to withhold your personal opinions. If they're foolish enough to let an instructor define their world view unquestioningly, then they obviously weren't going to get very far in terms of rational enquiry. I would suggest prefacing anything you state with "this is my personal opinion", or providing an explanation as to the limits of current knowledge. I suspect that you already do this.

I think this depends on a lot of factors: * What sort of ER are you transporting to? If you've got a predicted difficult airway, and you're 5 minutes from an ER with board-certified EM physicians, that handles a decent volume of patients, and has anesthesia service, then doing an on-scene RSI probably isn't in the best interests of most patients. If it's not a crash intubation, it's better deferred and passed on to more experienced and better-trained hands. If I'm 90 mins from a trauma center, and 10 minutes from a remote "ER", that's not full-time staffed, and maybe calls in an FM doc from a local FM clinic, who might be there in 20-30 minuets, and might not be comfortable with this airway, and my patient needs trauma surgery, then doing a field RSI, and transporting 90 mins to the trauma center might be a better option than rushing to the local FM "ER", waiting for the physician to arrive, coordinating fixed wing, and taking 3-5 hours to get the patient to the trauma center. * Is what you're doing on scene actually reducing the time to definitive care? I can sit 5-10 minutes from a hospital, consult with a cardiologist and either give thrombolytics, or do an ER bypass to a cathlab. This saves time. The nearby ER might not have PCI, or might have a patient on the table, or might be on after-hours call-in. By waiting, starting adjunctive treatment, coordinating with existing resources, I will save time to reperfusion therapy in most patients. On average, upwards of 70 minutes in this region -- we don't have a lot of cathlab resources. * Is the patient actually in need of time-sensitive medical care? Because if they're not, scene time becomes largely irrelevant. If I have a palliative cancer patient, the palliative care team is unreachable or unavailable, and they've got breakthrough pain / nausea, etc., then maybe 30 minutes giving some analgesia and antiemetic, and discussing transport options with the family is time well-spent, versus hauling off an upset, scared, puking, palliative patient, in acute pain (*not suggesting that anyone is advocating this).

My assumption would be a combination of : (1) diminution of the initiating stimulus, I.e. over time as the infection reduces you have less immune activation and therefore less IL-1, TNFalpha, etc., and less release of bacterial pyrogens, e.g. LPS. (2) desensitization : over time the same stimulus produces less of a response, which could be as simple as receptor downregulation.

So we have an 87 year old in an assisted living facility in cardiac arrest, probably as the end result of a chronic disease process, and likely with minimal physiological reserve. Likelihood of successful resuscitation = near zero. Likelihood of successful resuscitation with good neurological outcome = pretty much sitting in the middle of the circle that makes a zero. The issue at hand here is whether the woman's wishes were met. It appears that there was no documentation signed that meets the legal requirements for a DNR / personal directive / advanced directive in this particular community. On the other hand, the family seems to be ok that the facility staff didn't begin resuscitation. To me, as a paramedic, this seems like an appropriate medical decision given the likely futility of resuscitation. That being said, if this person wanted to be resuscitated, then there wishes must be followed. It would seem reasonable that living in an assisted facility, that states (presumably openly) that it won't provide CPR, would seem to suggest that its quite likely this person didn't want to be resuscitated. Personally, I have a bit of venom for the facility itself, for putting its staff in this position without ensuring that the appropriate paperwork was in place. I have no love, as a first responder, for arriving to a cardiac arrest in an elderly patient with a bunch of family present saying "No, they wouldn't want to be resuscitated", without any valid documentation present. This usually ends up shifting the responsibility on to me to decide whether to start or not. For the record, if the family present seems unanimous in saying that the patient didn't want resuscitation, I will usually respect this. I realise that this places me in a position of legal risk, much like the staff member at this facility. I do sometimes diffuse this responsibility by calling and chatting with a physician. They're usually willing to provide some helpful guidance (and usually agree). The general public doesn't understand the reality of advanced life support in an 87 year old who has come to the natural end of their life. I don't blame the lady on the phone for not sounding panic. The sicker my patient is, the more clearly, slowly, and deliberately I speak. It's been my observation that many of us are like this. It doesn't mean that we don't care, just that we're controlling our emotions to prevent them from interfering with commmunication.

It's been a while since I had my last student. I try and tell people that I'm there to help them, and that the only thing that's going to get them kicked off practicum is lying to me, starting a (physical) fight with a patient, or stealing something. As long as they show an interest in improving, if they're having difficulty I'll try and get the practicum extended, but often that's up to the school and the employer. It's ultimately their attitude that's going to decide how much fun they have, and what they learn. I don't expect students to clean trucks, restock or do station duties. I appreciate when they do them, but that's their choice. The way I see it, they've paid good money to be there, and no one's paying them, so their priority is to learn, not to be an extra EMT / Paramedtic. Most of the places I've worked have had very little downtime, but I try and use it productively. I encourage the students to write their documentation with the attendant and engage the ER staff, and see if I can find them interesting things to see in the trauma bays. I also strongly emphasise call management. I don't care if the EMTs can't start an IV line. They'll get plenty of practice as new grads, and once they've started a few hundred they'll be good. The same thing with the medics. Missing a tube isn't going to fail someone -- but not being able to select appropriate patients for RSI, or verbalise a decent airway plan might, if the problem can't be resolved. I tell people I want to see that they can exercise judgment, lead and organise a group of providers to a specific goal (especially the paramedics). But this also comes from working in an environment where it's not uncommon to have multiple EMS units, fire resources, police all on the same scene. I don't judge someone harshly for making a mistake, I want to understand why they wanted to do something inappropriate, and whether they were making a logical decision, even if one of the premises was flawed.

I think it depends on the program, depends on the patient, and on the local hospitals and EMS. The closer the patient to a trauma center, and the lower the acuity, then the reward. There's probably arguments for some regions that the chopper brings more advanced skills, e.g. RSI, that might not be done well or done at all by the ground crews. In other regions the expectation might be that the chopper arrives to an intubated and paralysed patient - although maybe they bring blood products or the ability to place a chest tube. There's also a huge benefit to having a physician for transfers in from rural ERs with mismanaged critical patients - although sometimes a ground crew is quicker and almost as capable. I think there's a lot to be said for mitigating risk by having good pilots, a simulation program , twin pilot twin engine airframes and the ability to fly IFR or with NVGs.

Hi Kaisu, I think this was an excellent post, that provided novel information that could potentially impact my patient care. I'd like to thank you for posting it, and raising the level of discussion. I think I agree with some of the other points made, as well, that cardioversion remains the most appropriate choice in an unstable patient -- although there are definitely different degrees of unstable, and some of them might allow time for a 12-lead and an attempt at a Lewis lead, especially if sedation is being employed. Given the high frequeny of VT versus WCT with aberrancy in the adult population (about 9:1), I'd be very reluctant to give a beta-blocker or Ca2+ channel blocker to a WCT. The new ACLS guidelines support giving adenosine to undifferentiated WCT, and this would be my first approach if I found P waves in the WCT. This is an approach that I think has a reported 80-90% conversion rate for SVT. Unless I was looking at an extremely prolonged transport time, in the stable patient I would be tempted to withhold antiarrhythmics beyond adenosine until the ER. All the best everyone!

Is that below 40F or below -40F ? One of these is a bigger problem than the other.

http://www.nda.ox.ac.uk/wfsa/html/u08/u08_015.htm This is a nice page that speaks to the role of CO2 in cerebral autoregulation.

With a pressure like that, it might be worth getting bilateral B/Ps.

non-US, pm'd