systemet

We're using this.

I agree that the issue is worthy of further study. While Hasegawa et al. suggests that there's detriment to both ETT and SGA, an issue that may relate directly to ventilation technique, it would be good to see a prospective trial that attempts to control for some of the potential confounders that were present here and in ROC-PRIMED. It would be nice to compare a planned primary SGA versus primary ETT versus primary BVM -- rather than selecting patients by the final airway technique employed. It would be nice to look at hand-on percentages, etc. There is a study going on in the UK currently, that's about to stop enrollment that might answer some of these questions: http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=11962 It's a randomised comparison of iGel versus LMA versus current practice (which I think is ETT). They're due to close on the 28th, and have n =>500 right now. This may answer some questions regarding any harm with SGAs, unless that harm is specific to a given device, i.e. for some reason the King or Combitube cause detriment but the LMA or iGel don't. Nothing I've said should be taken as being negative about the excellent work the ROC is doing. The ROC-PRIMED study did an excellent job of evaluating the usefulness of impedence threshold devices (ITDs), and comparing a short period of CPR (30-90s) before defibrillation versus a longer period (3 min). It's great that they decided afterwards to look at the difference in outcome between SGA and ETT patients -- but this wasn't what the study was designed to do, and as a result the design was suboptimal for answering that particular question. I think that's to be expected. Hopefully the UK study will answer some of these questions.

This is a valid question. They identify in the study abstract that SGAs have been used prehospitally there since 1991. ETI was then introduced for some practitioners in 2004, with a 62 hour didactic component, and 30 tubes in the OR. They discuss whether this is adequate training in the discussion, and state that it exceeds "national curriculum requirements" in the US (apparently only 5 tubes?), and in the UK (25). They quote a study that I haven't read, suggesting that 20 OR tubes are the sort of minimum number to hit a 90% success rate for paramedics. I find this numbers to be a little suspect, but I haven't bothered to actually read the sources, so I should probably reserve comment. This just wasn't described, which I think was a problem with ROC-PRIMED as well. They also seem unclear on whether some of the SGA group are patients whom they initially attempted to intubate with ETT, and then went to SGA as a rescue. Obviously these patients may have been exposed to greater and more numerous periods of interrupted CPR than a primary SGA group. This is possible. The BVM only group showed a more rapid ROSC versus the advanced airway group. I don't think that the difference was statistically significant, but if there's a group of rapid ROSC, high risk for survival patients hidden amongst a bunch of noise it could skew things. In pigs. The very limited evidence suggests that it impairs cerebral circulation in pigs. The only evidence of detriment in humans is the post hoc analysis of ROC-PRIMED, an analysis that's contradicted by this much larger, more recent study, which shows an equal detriment to both. If anyone wants a copy, pm me with an email, and I might be able to point you in the right direction.

I just want to point out that some of are / were, even some years ago.

Focus on the things that you can change, not on the things that are out of your control. Union issues, management issues, contractual issues, hospital wait times, AMPDS not working, etc. will just make you angry, unless you have power to effect change. Try and avoid the group-think. Resist the urge to compromise your values to fit in, and remember that you often have a choice, be popular and well-liked or do your job properly. Keep your head down until you've been in a position for a year. Never talk badly about someone else, because it will come back to them, and cost you. Remember that you're privileged to be in a position where you can help people, remember that you chose this occupation. Have an active and full life outside of work. Don't spend all your spare time hanging around with other EMS types. Don't judge people, just help them. You won't stop drunk people from getting drunk, or people calling 911 for frivolous reasons. Give people the benefit of the doubt.

It doesn't really work like that. I've had night shifts where I've done 10 calls and everyone's been intoxicated. I feel like I've had tours like that. Where I work, our dispatchers will stage us on shootings, stabbings, and assaults where the assailant is on scene. They can stage us if they believe the scene is unsafe, and I can stage whenever I feel like it, based on the information I get, which is often < 2 lines of text on a computer. The dispatchers don't ask, "are you drunk or high?", you generally work that out once you're there. Not to mention that a lot of people don't answer those questions truthfully. Or that sometimes all the dispatcher gets is "there's some guy lying in a bus shelter [click]". A lot of the people we see are drunk, a lot are high on a wide range of drugs, both prescription and non-prescription. A lot of people are just violent. Some people aren't perceiving reality the same way you and I do, and are acutely psychotic, whether drug-induced or "organic". Sometimes hypoxia and hypoglycemia or postictal states are a problem. A lot of people haven't had good experiences with people in uniform, and a lot of people are quite willing to hurt a stranger, especially if they appear rude or unfriendly. The best defence isn't a stab vest, judo chop, or AR-15. It's being polite to people, and remembering that you're there to help.

This is a great thread. Thanks for participating everyone!

This is an interesting study. It's huge (n = 650,000) -- compare that to something like ROC-PRIMED (n=10,000), or the San Diego RSI Trial (n = 200 trial patients, 627 controls). So it's well-powered to detect even a small difference. The majority of the advanced airway patients were SGAs (~ 85%) vs. ETT. Both advanced airway subgroups showed harm. There are potential confounders there -- it could be that there's a survival bias for patients in the BVM group, if they regained circulation prior to any airway attempts. Nowadays a lot of services are deferring advanced airway until 5-10 minutes after initiation, so if the patient regains circulation prior to that, they probably end up in the BVM group, and bias that cohort towards survival / better neurological outcome. But the magnitude of the difference is pretty big, The 95% confidence interval OR for intubation is 0.37-0.41, and for SGA 0.36-0.40, suggesting patients in the BVM group were 2.5X more likely to survive with good neurological outcome. Kiwi suggests a couple of plausible mechanisms. As the authors suggest, there needs to be an RCT for advanced airway in cardiac arrest now. One potential confounder that the researchers didn't identify was the use of epinephrine. 10.6% of the patients in the advanced airway group received epinephrine, versus 2.9% in the BVM group. Now this makes sense, as you'd assume that less of the providers using BVM would be authorised to give epinephrine -- but what if this is the variable at play, and not the method of ventilation? As they say, it's time for an RCT. Intubation vs. no-intubation in cardiac arrest. Can you imagine walking in to the patient's house, directing a couple of firefighters to move the living room table out of the way, putting the patient on the floor and going to open an envelope with an 'A' or a 'B' in it? Interesting times ahead, potentially. I wonder what the ethics of a waiver of informed consent are for this situation? ------------------------------------------------------------------------------------------------------------------------------------------- For people less familiar with research trials: * An n-value is an overly complicated way of saying how many patients were in a study. The higher the n-value, that is, the greater the number of people in the study, the more it's able to detect small differences. If we see a 3% difference in a comparison between two groups of 10 patients each, it's unlikely to be statistically significant -- it could just be chance. When we have 650,000 people, a 3% difference is often more meaningful. This is sometimes referred to as the "power" of a study. * Significance testing is a statistical tool that looks at how much data varies, and lets you estimate how much of a difference between two groups might be due to chance. The standard in most biomedical trials is that there should be a less than 1 in 20 chance that any difference observed is due to random variation (sometimes referred to as p = 0.05). * Confounders are factors that may influence the outcome of a study. If I try to investigate whether coffee causes cancer, I need to make sure that I take account of how many people in each group smoke. If I simply compare coffee-drinkers to non-drinkers, I'll find an increased cancer rate in the coffee drinking group as coffee drinkers are more likely to be smokers than people who don't drink coffee. This may seem obvious, but is frequently missed. * A confidence interval is an estimate of the precision of a number. It tells us how confident we are in a given number, so a 95% confidence interval gives us a number that is likely to be right 19 times out of 20. Sometimes you read a study that shows a 20% decrease in mortality, but then you see that the confidence interval is from -10% to 50%, i.e. there's a greater than 1 in 20 chance that the intervention may actually save the lives of 10% of the patients enrolled, there's also a more than 1 in 20 chance that the mortality effect is far worse than 20%, i.e. 50%. * An Odds ratio shows an association between two factors. If the odds ratio is 1, then there's no difference. In this study group the odds ratio for intubation was 0.40, that is if you were able to take a time machine, take 10 of the BVM patients and intubate them instead, you'd expect four of the patients that would have otherwise survived to have died. * An RCT is a randomised controlled trial, where you roll a dice, flip a coin, open an envelope or pull a number off a computer to assign patients to a control or intervention group. What the authors of this study suggest is that we take a group of patients, and randomly assign them to either have intubation / SGA insertion or to BVM-only.\ * WOIC is "waiver of informed consent" -- when you do a clinical trial you have to explain what you're doing and the risks and benefits to the patients, if your patients are unconscious (or, in this case, dead, or some version of it) there's a process whereby you have to inform the community, and apply to an ethical committee to be allowed to study people without first obtaining verbal consent, which is impossible in this setting. This is possible. They didn't capture that data, so we won't know from this study. One would assume that that would be more of an issue for the ETT group than the SGA group, but they don't describe how many intubation attempts there were, if any, before SGA insertion (I think there was a simiilar problem with ROC-PRIMED). When you look at the group compositions, the BVM group had a much higher rate of VF/VT as the presenting rhythm (20% v. 6-8%), bystander witnessed arrest (5% v. 2%), and EMS witnessed arrest (9% v. 2-3%), and a much shorter time to ROSC (6 min v.14 *although the CIs overlap here, so it's not significant). However, they've adjusted for this, so it's probably not a big deal.

I think a lot of people are making a lot assumptions about how that AAA patient is going to present, and the value of palpation as a diagnostic aid. Firstly, I'm firmly in the camp that believes that palpation of the abdomen is part of a thorough physical exam. If light palpation causes intense guarding, pain, or movement, then obviously we probably shouldn't palpate any harder, or again. The fact that light palpation elicits guarding, tenderness, pain, writhing, etc., is a potentially significant finding. Palpation as a tool for AAA is going to be poorly sensitive, and, honestly -- poorly specific. Only a small percentage of people with AAAs are going to have a palpable pulsatile mass, and we are going to be lucky to identify it based on inspection or palpation. Thus, it's a poorly sensitive finding. Many of these patients are going to identified on abdominal XR, CT, or U/S. The sensitivity must decrease as the patient's body mass increases. It may be a little more specific, perhaps. That is, if we find a pulsatile mass, the likelihood of AAA is probably a bit higher. But I bet if we try to call the subtler cases, e.g. "I feel like there's something pulsating there, but I'm not quite sure", in order to increase the number of patients we detect, then our specificity is going to plummet, i.e. we're going to call more false-positives. There's also a disconnect here between the concept of acute and chronic presentations of a pathology, in this case, AAA. There's plenty of people walking around with significant AAAs, even up into the 8cm range. These people may have pulsatile masses, but may be managed medically or waiting for nonurgent surgical correction. They may present with abdominal pain from any number of other causes, and the signs/symptoms related to the chronic AAA may distract from the acute pathology. If we consider AAA, I think it's likely that changes in the quality of the femoral or pedal pulses, or the perfusion of the lower extremities might be more useful than abdominal palpation. I'm sure one of the docs has a more educated opinion on this.

Great post! Pretty much anyone can be sued for anything. It's up to the courts to decide whether you should be liable.

Just to add my .02; Shift cycles vary greatly by location, and typically by how busy the service is. If you're working in an urban environment, you're typically on some combination of 10's, 14's, 12's or 8's, or whatever, where you get paid for the time you're there, and typically 1.5X or 2X if you end up running calls before or after your shift. Sleep at night is theoretically possible, but unlikely. In a more rural environment, you may be on 24's. Depending on your employer you may basically come into work for a few hours, then be free to go home (if you live near enough). They usually provide some sort of accomodation for out-of-towners, but this might involve sleeping on a couch, or a dorm. Some employers may provide workout equipment, television, etc. I've worked some places where you can come in for 24 hours, do nothing, have four hours where they want you in uniform, and otherwise go to sleep, work out, or watch tv for the rest of the time. On other occasions you may work 21 of 24 hours, and finish the end of shift needing to sleep for a couple of hours before heading home. Usually you're compensating for any hours beyond a certain amount as OT. The more common shift schedule I've seen is 4 days on / 4 days off. I have worked 6 on / 3 off, but this is very rare in my region now. Pay is much better in most of Canada than in the US. The other challenges with EMS, e.g. family life, critical stress, shift work, remain universal. You have to decide whether they're worth it. It's not typically a 9-5 job, unless you can find a teaching position, or some higher administrative position. Waking up at 2 am from a dead sleep to a critical call, or (sometimes worse), someone who is going to be behaviourally difficult with no obvious acute complaint, is pretty much a universal. You can do this in the city, off a five minute nap in the passenger seat of the ambulance, or you do it from home, drive to the station, get in the ambulance, etc., but it's there. And it will be a constant issue -- you choose how you deal with it.

I was going to say that at least there's not that much snow and ice on the road, then I saw the last 30 seconds. Winter, don't worry, it's just 7 months a year. What's the temperature like?

Edit: changed a single word to remove some unintentional ambiguity. Edit2: decided better not to post.

OB confuses me too. With our second child, my wife, or I guess my unborn daughter, was having some nasty deep broad decels. The midwife ( think NP - these were real medical practitioners) ran off to the gyne, and came back with a dose of terbutalinw. That, and some positioning slowed everything down nicely. Problem solved.

I think we all know that you've been doing this since before many of us were born and have a wealth of knowledge to share. I didn't intend to be disrespectful in any way, I just like talking pharm.

As an aside, levophed is still alive and well, and widely used in the ICU and even ER. It's a decent pressor, and gets a lot of use in sepsis. Unfortunately I don't have it on my ambulance, but most people I'd likely use it for need a few liters of saline first. Granted, these people are sick and have a high mortality.

If you want to make a kit to go in your personal vehicle, I think these are the things I would include: - a cell phone (or if coverage is an issue, satphone - not cheap) - a dozen ab pads and a dozen rolls of three inch gauze - two CATTs - a couple of rolls of two inch tape, something plastic that might close s sucking chest - two cardboard splints and a few tensors. - a pocket mask w one- way valve - a couple of blankets - flashlight - a couple of traffic vests - a warning triangle or two to mark an accident - a pen and notepad - a snickers bar - some ASA - chewing gum and a couple of beer.

Wow. I'm trying to work out if I like the supervisor, because he obviously held you responsible and got the team concept across --- or if I don't like him because he was aggressive in making his point, and it sounds like he dressed the medic down in front of you, and vice versa. I saw a post on one of my friend's facebook pages recently. This might be second nature to some of the management types out there, but he wrote "praise in public, correct/coach/counsell in private, otherwise you look like a ***". It resonated a little.

You may be being a little sensitive. Arctic is a nice guy, has a lot of experience as a paramedic, and has likely been in similar situations many times in the past. We get a lot of people here who try and deceive us, for whatever reason. It could, and perhaps should be talked about. The problem is that, in the current model, there's just so little time. The training is so short, and basically inadequate, and there's so much material to cover that some things have to suffer. Unfortunately, as you've just seen, the provider is often left to work things out for themselves when they hit the road. I don't want to go on a rant about educational standards, as I think it will end up hijacking your thread. Then I think both you and your friend have just learned a very valuable lesson. Human beings are fallible, and every level of provider makes mistakes. Unfortunately, in health care, the patients are often unaware of the mistakes that have been made, and health care providers often collude to cover up treatment errors, and rarely inform the patient when a mistake has been made. It is very hard to be the person who speaks up in this situation, but, ultimately someone has to. I like to hope that in EMS, we are slowly moving towards an environment where we can identify errors, and report them, without having as much fear of punitive action. Obviously poor providers need to be counselled and coached, but hopefully we can identify why errors were made, and see if there's anything we can do to prevent them from happening again. I like this. [edit: nuked some unnecessary white space].

Odd. Are you sure that coarse VF is actually on the monitor, and that you're not seeing CPR artefact? This is more commonly mistaken for VT than coarse VF. Two more bits of weirdness here: (1) If the patient has been pulseless for some 30 minutes or so, after an initial downtime of 20 mins, there's no reason to transport, this code should be called on-scene. (2) If we're working a code it's epi q5 until we stop. We don't stop giving meds. These are surprising actions for a registered paramedic. I'm a paramedic. For years, I've started every shift I've worked with an EMT I don't know with a short little speech, something along the lines of, "I like to help people, I don't get in trouble, and I don't start fights. I like to fix problems. I may spend a lot of time on scene, and I do a lot of 12-leads. If you see me doing something stupid, let me know, because there might be something I've missed. If you're in the back at any point, and the patient complains of pain or nausea, let me know, and we can pull over and take a look at it. If there's any patient, BLS or ALS, you're not comfortable with, let me know, and I can ride in. They pay me a couple of dollars an hour extra, and I can happily do a couple of extra calls. If you have a question, let me know, I love to teach.". One of my bigger fears as a paramedic is that I'll do something stupid one day because I missed a critical piece of information, or got lazy, and no one bothered to let me know. The guiding principle in all of this needs to be "first do what's in the perceived best interests of the patient". Sort of a modified Hippocratic oath. You should intervene when you know or believe that what is being done may potentially cause harm to the patient. This is part of what you're getting paid to do, regardless of your certification level. Then you need to be professional. "Sure, I can grab that atropine, but isn't that coarse v.fib on the monitor? Would you like some amiodarone instead?". It sounds like that's what you (or your friend) did. You can't really get in a fistfight over this, and try and wrestle the atropine out of his/her hands, or everyone's getting fired, and the patient's family is getting horribly traumatised, but you can politely and professionally point this out in a way that the family isn't aware of. They likely have no idea what amiodarone, atropine, or VF are. Yes, but politely, and with respect to your level of practice and the possibility that you may be wrong, and in proportion to the potential harm to the patient. If the paramedic chooses to ignore this warning, then they're fair game. Personally, I've always gone by the rule that I will never keep silent and then take an issue to management / medical direction. If it's important enough to make an issue of, then it needs to be talked about before its done. If I do my best to warn someone, and they choose to ignore that warning, then I have to protect myself, and future patients. As well. What are they going to do? Shout at you a bit? They can't take away Christmas, or dock your pay. If they're mean to you or rude, or threatening, it's only going to make your decision easier. In this situation, no. In other situations, maybe. Your paramedic may have a great reason why they're not treating someone's symptom complex involving "chest pain" with ASA and NTG. Or why they're not intubating this patient. There are things that may be provider-dependent, like pain control. Some things have lesser impact for the patient. This is not one of those situations. Granted, the patient has been dead for some time prior to your arrival, there's minimal evidence to support antiarrhythmics in general in cardiac arrest, and your patient is extremely likely to stay dead regardless of what wonder drug you push in the IV line. But, there's a clear, and bizarre med error being made here if the patient is actually in VF. If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed. And wondering why I gave atropine to VF. There is no "outranking" in EMS. You're all responsible for the patient, and will be judged as a group. That being said, as an EMT, you're at less risk than any ALS providers on this call, as this is something out of your scope. Other decisions, particularly the problem of a partner wanting to do a refusal on a patient with potential ACS symptoms will put your job at jeopardy as well, even if a paramedic is there. In this situation where an ALS med error was made, you're less likely to get disciplined. Of course, the point here isn't to not get disciplined -- it's to do the right thing for the patient. As an aside, this is one of the reasons I like working with an EMT better than another paramedic. It keeps me sharper, and ultimately I'm going to be accountable for anything done wrong, and can intervene and play the paramedic card without going through the mess of arguing with another paramedic. This is a difficult situation. Similar situations, probably of lesser magnitude, will arise again. EMS often has a very blue collar mentality where we cover for each others mistakes, let one provider run roughshod over others, and fail to report these things when they happen. As a provider you have to decide where the line is for you personally, and what's more important, doing the right thing, or being popular with your peers? In the situation described, I would talk to the paramedic after the call, and demand, first politely and then rudely, to know why atropine was given instead of amiodarone. Explain why you think amiodarone should be given -- specifically that the patient was in VF. See if they were aware of this. Give them a chance to admit their mistake, and sugget that they take it to medical direction or management instead. If they refuse to, then I would suggest dealing with it internally first, and considering a complaint to the college. Ultimately, if it's a serious enough issue, you were present, and you fail to report it, your employer, the college (who can be quite unforgiving), and ultimately the police, may come after you as well. Especially if there's been any collusion on an attempt to alter or doctor documentation. Merry Christmas.

Pretty much the same thoughts here. I have no intent to politicise this medical discussion, but I think it's terrible that you've been put into this position. My sympathies, and a very Merry Christmas to you and your family, Dwayne (and to everyone else).

Here's a copy of the form they use in Canada: http://www.rcmp-grc.gc.ca/cfp-pcaf/faq/lic-per-eng.htm Of note for the current conversation, it has sections (16/17) asking whether the applicant has been charged or convicted for a criminal code offence involving violence, improper firearm handling or storage, or drug trafficking. It also asks about whether anyone has placed a protection order against you, whether you have a recent history or mental illness or alcoholism, and whether anyone in your immediate household has been prohibited from owning weapons. In addition, it asks about recent job loss, separation, or bankruptcy. It further asks about any spouse, common-law or "conjugal" partners in the last 2 years, and requires that your spouse's contact details are given. There's a section requiring personal references too. Some of these questions may seem improper to a US citizen -- but remember that in Canada, firearm ownership is a privilege versus a right. Another major distinction is that the use of firearms as a form of personal protection / defence and concealed carry are not accepted as valid. Obviously any such form would need to be modified for a US audience, but it gives you an idea of how another nation with a similar sociocultural background has dealt with this problem. This doesn't prevent a previously-law abiding individual from going out and shooting up a school. Nor does it guarantee that someone with a mental health problem will be refused a licence. But if you consider the shooter in the recent event in the US -- would they have been able to purchase firearms if they'd had to be vetted in a similar manner? Would the family have found two reference people? Perhaps -- and it wouldn't stop him from stealing another person's weapons, but it is another extra layer of safety against people who perhaps shouldn't own firearms.

Interesting. I didn't know that there was a separate process for automatic weapons in the US. So, when you guys had the assault weapons ban, how did they choose to define assault weapons in legislation? Question: Do you guys think that there should be more background checks in place to purchase firearms in the US?

Living in a country where high capacity magazines are illegal, what typically happens is that a block of wood or something similar is placed in the magazine before sale. It's easy to later remove, but fulfills the letter of the law. In a similar manner, you may still be able to purchase an automatic that's been modified to single shot, but a kit to convert it back may be sitting next to it for sale "for collectors" or "for novelty value". Take out the piece of wood, put a bunch of rounds in, and put it in the firearm and you're now in possession of an illegal weapon that will get you jail time. Convert the weapon back to full auto, same thing. Obviously it depends on how you write the law, but it's not always a case of banning a specific weapon as much as prohibiting specific capabilities. edit: typing on phone, spelling

I think we've deviated from the original discussion a little, although this is all very interesting. I'm not from the US, but I'd like to echo the point made earlier ( by chbare, I think), that this shouldn't become a "criticise the US", bitch session. I think that there are a few reasonable steps that could be taken after this. I don't think that a ban on "assault weapons" will, by itself, prevent a similar tragedy occurring again - butt sure seems like a good idea. As discussed, the term "assault weapon" is very vague. Perhaps a better approach is to simply ban automatic weapons, defined as anything that fires more than one round each time the trigger is depressed. It seems like there's little sporting or recreational use of these weapons. The future King of England seems unlikely to invade if automatic weapons are removed. The other, is that it seems ridiculous that someone should be able to avoid a background check by purchasing at a gun show. Couldn't this loophole be closed too? From the outside, looking in, I wonder if this is a primary healthcare problem? Could something as unpopular as universal healthcare enable more potential killers better access to mental health professionals?