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I think this depends on how you define properly. To do it properly, you need a tilt table and probably 15 minutes to half an hour. I imagine most people are talking about taking one set of vitals sitting and another recumbent. This probably doesn't take very long --- but it's going to be even less useful. Scene time is an issue if there's an underlying pathology that requires rapid surgical correction or medical intervention. But I'd imagine this is a very small percentage of cases.

This paper was discussed a little in a few EMS forums: http://www.ncbi.nlm.nih.gov/pubmed/20605259 There's a couple of instances where the RAD-57 failed spectacularly, for example patients with: %COHb (RAD-57) %COHb (Lab) 0 15 0 17 0 20 0 35 24 5 13 0 I've cherry-picked the outliers, but this is from a pretty small cohort (n = 121). The study reports a sensitivity of 48% for %COHb > 15%. On the other hand, despite the outliers above, it's still very specific, at least in this cohort. So maybe this weakens my argument --- as it when the RAD-57 reads high it tends to be right. It's just that a low reading doesn't mean anything more than a clean ECG for ruling out NSTEMI on a patient with horrible anginal symptoms. This seems like good advice. In the study cited above the mean difference is 1.4 %COHb units, but the standard deviation of the difference is 7.3%, or put another way, 1 in 3 of the subjects had a difference in their readings of either > +8.7 COHb, or < -5.9% COHb. So the variable is actually pretty huge. I found an article that quote a t1/2 as being about 80 minutes for 100% normobaric O2, although they note that a range of values from around 30-120 minutes have been reported in othe studies. So I guess it depends on what you'd consider "mitigated". If the half-life's about 2 hours, in the first hour you'll see about a 30% reduction in the %COHb. Without really understanding the physics, I took a look here: http://www.lmnoeng.com/Flow/GasViscosity.htm and the values seem pretty close, for viscosity. It seems like there's a slightly lighter density for CO, so it might tend to settle downwards, but I think this would offset a lot by random motion. But I can understand that it could be easy to have regions within a structure where the CO might be higher, and regions where it might be lower, and that if you test in one, it might give you a false sense of security. Me too.

No, at least, I don't think so. Perhaps I'm making the assumption that any carboxyhemoglobin is unable to participate in oxygen transport, when instead the non-CO bound sites can still deliver oxygen, even if the p50 is left-shifted. I wasn't aware of this, but it does makes perfect sense that the SpCO is going to be the same in both venous and arterial circulations. I think there's an equipment problem here. I have it hard to believe a patient with a true SpCO of 16% is in no distress, but I'd love to hear if there's a flaw in my reasoning.

I don't understand --- if you get arrested for underage drinking in the US, you can have your driver's license suspended? Out of curiousity, how much does the drinking age vary by state? Obviously, I'm not in the states, but I don't see the issue with somnone drinking underage and then doing EMS. I'm sure most of us have drank before the legal age in the regions we've grown up in, most of us have probably been lucky enough not to get caught. Why is this a big deal? I must be missing something here.

I realised that this sentence is confusing. What I meant, was --- if you consider that there's 16% dysfunctional CO-Hgb, then the patient has an effective SpO2 of 84%. If you had a chronic lung disease patient with an SpO2 of 84%, you might expect the odd patient to still be GCS 15, but they would likely be showing signs of distress at this point. If you take someone healthy and acutely drop their SpO2 to 84% they're going to be all sorts of sick. Sorry for any confusion.

I think there's a fairly poor correlation between the RAD-57 cooximetry and SpCO on ABG, so this may have been a false positive. The troube is, when you see that sort of number, you have to assume that something real is happening until you get a clean ABG. AaOX4, and in no distress, at an SpO2 of 84% doesn't quite jive, even if the patient had pre-existing pulmonary disease. So, at the very least, it's probably false-high. Any chance that you can follow up with the ER and see what they got on ABG?

You could go with vec, but roc would probably be a better choice if available, as it has a more rapid onset, slightly shorter duration at the higher dose needed for rapid onset, and undergoes hepatic metabolism. There's some risk here that the patient may also be in acute renal failure, depending on how long they've been hypotensive. A MAP of 48 mmHg isn't going to be great for renal function if the patient's been hypotensive for a prolonged period. Vec relies a lot more on renal function. Yeah, with the obvious caveat that you don't always know you can't intubate someone until you're already committed. Then you've accepted the risks of a blind insertion device, or a surgical airway. I agree that it sounds like she needs intubating, and obviously you can only use the tools you're given. In my old job, this is where I'd patch to a physician if I was going to give roc, first. I could treat any suspected hyperkalemia in this patient, if present, without consulting. If I couldn't get a doc due to technical problems, I could just go ahead and write if up later.

I think what you're saying here, is that they may have a net loss of K+ from the body due to diuresis, but their serum level is high due to cellular buffering. I think you're right. Regardless, if their serum K+ is 8 mmol/L, it might be better not to shoot for any higher!

I realise that I'm a little late to the party, but I'd urge some caution regarding RSI with the mother: * There's a strong possibility that she may also be hyperkalemic, as she's got a pretty decent hyperglycemia going on. A few minutes spending a 12-lead might be worthwhile, to evaluate for obvious changes suggestive of hyperkalemia, in which case some calcium and bicarbonate might be in order. * It might be better to avoid succinylcholine for the intubation, and use an alternate paralytic, e.g. roc, or attempt a sedation-only intubation, e.g. ketamine; or midazolam / fentanyl * 87% isn't that terrible a saturation, even if she doesn't have pre-existing lung disease, and it's survivable, especially if she's acidotic (Bohr effect). She's also likely been sick for some time, so a few minutes here or there to evaluate her thoroughly isn't going to be the end of the world. Thanks for the scenario, DartmouthDave.

Sorry, it's difficult to understand what you're saying here, but are you suggesting that only allowing them 6 years to transition to the paramedic level is unfair? I don't know Iowa, or the US in general, but that seems like a pretty reasonable period of time, doesn't it?

I realise this is a question about testing, but for what it's worth, in a real life situation, I'd far rather a BLS crew call me for an assist and end up doing nothing, than have them not call me and have the patient injured by something I could have prevented / treated / mitigated. I admit that some paramedics feel differently.

Let me start by saying that I know very little about the proper use of antibiotics, and they're also an area where my pharmacology is very poor (along with cancer chemotherapeutics!). So I'm not sure I can contribute a lot here, but: * Bear in mind, in a lot of countries, antibiotics are available without prescription and are being widely used for self-medication for minor illnesses, many of which are viral, of insufficient severity to warrant antibiotic therapy, or being treated with an inappropriate agent for too short a period of time. This doesn't make it right to compound the problem by giving them out inappropriately, but it does put it in perspective a little, I think. * The development of antibiotic resistant microorganisms is definitely bad, but I wonder how much of this is occurring in animal populations? A lot of industrial meat production occurs under very unsanitary conditions and requires routine use of antibiotics in feed. How much of the developing antibiotic resistance is due to this. Honest question. Oh, and Dwayne, you're not a douche, but this was funny, and probably applies well beyond the remote medicine environment: edit: spelling

Out of curiousity, do you know how often the average ICP intubates with RSI a year? And without? And I mean, actually holding the laryngoscope, not just being there while someone else does it? I'd just be interested to see the numbers, if you have them, and are allowed to share. I think so. I think the average prehospital intubation is likely more challenging that the average ER intubation, and not just because the providers are less skilled and have less options for backup. There's been at least one publication on this, but I can't remember the details. One of the problems with this area is that there's often an inconsistency between what we consider to be a difficult airway, or how we grade airways, compared to how physicians do it. Although balancing that, there's often a tendency to report intubations as being less traumatic or complicated than they actually are. That's fantastic. Have all the patients requiring surgical airways been managed without RSI? Or have there been no patients requiring cricothryrotomy at all? I think there's so much focus on closed head injury because those patients have been shown to be so sensitive to hypoxia, hypercapnia, hypoglycemia, transient hypotension, seizure activity, etc. so it makes sense that this is where the biggest improvement, but also the biggest risk is. It seems like there's been relatively little focus on the safety of intubating medical patients prehospitally using paramedics. I think the need to paralyse is reduced in patients without trismus, and in hypotensive patients, but it provides better intubating conditions (or at least should). Yeah, I definitely don't want to come across as suggesting that we should be running around tubing COPDers and asthmatics just because they're a little sick. But there is this point where they're not responding to medications, started to get tired and acidotic, and there's this window of opportunity to intubate them where you're going to have some sort of half-decent SpO2 for a short period of laryngoscopy, at least. I think if we had better ventilators for doing bilevel ventilation, we might be able to avoid this happening even more often. If there's a real hospital close, it makes sense for the patient to be intubated by someone with a lot more skill and familiarity, in an environment where help is readily available. Do your ICPs work as pairs, or do they respond individually? Just wondering. Do the ambulance paramedics do any form of narcotic / benzo / anesthetic facilitated intubation, e.g. drug overdoses, etc. Do they have the ability to cric'? I'm just interested as to where one scope ends and the other begins. If you have any links, I'd love to read them. It sounds like the NZ system is very well structured. Edit: quote tags

The problem is, you don't know that you can manage the failed airway until you've already successfully managed it. You can have all the tricks in the box, but you're either able to direct the Bougie into the glottis or not, you're either able to successfully BVM the patient, or not, you're either able to perform a surgical cricothyrotomy without injuring large vessels or vascular tissue or not. And you can either do these rapidly enough that the patient survives without injury, or not. And you won't know until afterwards, because there are those grade IV airways walking around. There are people who will give EM and Anesthesia nightmares. Being diligent may help us identify some of these patients first, but it's not a guarantee. It's a tricky game. Absolutely, and early intubation is a classic paramedic mistake. But some asthmatics will need intubation. If they can't breath for themselves, someone else is going to have to do it, or that cardiac arrest is going to be just as inevitable. Hypeventilation is an issue. But this is why we should be giving smaller volumes less frequently. With a nicer ventilator you can worry about airway pressures. I respect that attitude, and agree that it's never a bad idea to get some advice from someone more knowledgable. But I do want to add that sometimes these situations deteriorate rapidly, and depending on your system you might not be able to get timely advice.

Which is why we're discussing using ketamine versus using ketamine + succinylcholine, right? Agreed, with the caveat that we can't always predict which patients are at risk until after the complication occurs, and the corollary that succinylcholine is not a benign drug and that we should use it cautiously. Fair enough, and if Nana has a bunch of trismus, and rocuronium isn't an option, then we hope Nana's eyesight is ok afterwards. I'd be more worried if Nana had a penetrating injury to the eye, but despite the controversy about paramedic intubation, closed head injury is one of those situations where you're going to use RSI more often. As with everything, you have to have a back up plan if things don't work out. Is Nana going to be easy to ventilate via BVM? Is her jaw in a thousand pieces, have her dentures evaporated, is she a predicted difficult cricothyroidotomy? These might influence the decision making process. While I'm sure they don't care about my opinion, and probably shouldn't, I'd say they're right. But it is preferable to intubate them before at some point before they code. And if your transport time in an hour in a fixed wing, followed by 20 minutes by ground ambulance, then you've got to consider whether it's a good idea to intubate now. I think you should always be concerned, and you should always have a backup plan. But sometimes you are faced with difficult airways, or high risk patient encounters where it may be necessary. Fortunately having the nonvisualised airway adjuncts make these situations a little less frightening now.

I think you have to examine this on a situational basis. Succinylcholine brinks with it a number of risks, including apnea, hyperkalemia, prolonged paralysis in a few susceptible individuals, MH, changes in IOP, ICP, IGP, and an increased risk of aspiration. For a bad asthmatic, if you can preserve their ability to breath, even if their ventilation might be suboptimal, you may be presented with a few more options if you can't pass the tube.

There's some situations where it's nice to avoid paralysis. Some people might choose to use ketamine without succinylcholine for intubating a sick asthmatic, for example. But this is a function of the paralytic, not the ketamine.

Yes (to saving a life). But, in most situations, we're just part of a chain of care that functions as well as its weakest part. For example, there's several people (hopefully) still walking around today because I defibrillated them promptly when I witnessed the onset of pulseless VT / VF. I think all of them had MIs. Most of them probably wouldn't be alive if someone hadn't then gone and done an angioplasty, given thrombolysis, taken care of them in the ICU (including whoever it was that cleaned the room, or made it possible to give them a wristband or print a bunch of stickers to attach to all their lab work), or if they hadn't had good cardiac rehabilitation. Perhaps some of them are dead again now. It wouldn't be out of the question given their history. Anyone with a defibrillator could have done what I did in those circumstances, it didn't require any great skill. In fact, not doing it properly would have been quite hard, and definitely grounds for malpractice for anyone in a paid role. I know several of the people above survived to discharge because they sent me notes, or even better, food. There's been countless cardiac arrests that I've got pulses back on, only to have them die days or weeks later, or be severely disabled. Especially when we used to give much more epinephrine. Were their lives saved? Not really. Is anyone's life ever really saved? We all die eventually. I worked a teenager in a house-fire, and got pulses back long enough for him to die 48 hours later. I felt guilty for it, and thought I'd caused great harm to his family by giving them a period of false hope. They felt differently, and thanked me a year later. How would any modern city look if the sanitation department went on strike for a few months? Not so great, right? We'd be dying of infectious disease left, right and center. Are those guys saving lives? I'm pretty sure in the aggregate they do more to reduce death and disability than I have, or the departments I've worked for have. Yes. Not, in my opinion, just going to work and doing your job. I had some thoughts about this in an earlier thread. A bunch of people were kind enough to give it a "+1". A lot of other people made great points on the same thread, it's over here: http://www.emtcity.c...ex/page__st__30 I would add to this, that I believe over a long enough period of time doing the work of a police officer, paramedic, nurse, physician, respiratory therapist, school teacher, social worker, even firefighter, could perhaps be considered "heroic". I have a lot of respect for people who've done EMS for 30 years, still care about their patients, and have mentored countless new generations of paramedics and EMTs, and generally made a positive impact on the occupaton / profession, but I doubt most of them would consider themselves hero's. I might lose a bit of respect for them if they did.

There's a few problems with this: * It can be really hard to hear decent lung sounds in a status asthmaticus patient. * In kids, it's easy for sounds to be heard in distant regions, e.g. transmitted from the epigastrum to the lungs & vice versa. Auscultation is unreliable. It's much better to have the proper technology. It's just taken a while for this to get on to the trucks. The things with these stories, like all the "patient declared dead by paramedics, alive 3 hours later" stories, is everyone assumes that the guys involved were idiots. And some of the time they are. But it's also possible to have a good person having a bad day make a series of small errors, any of which on their own would be unlikely to have a substantial influence, and have them combine together to produce a tragic outcome. The real test of a mature provider is their ability to sit back, and go, "Could that happen to me?" and not immediately dismiss the idea with "Well, I graduated from Frank's school of Ambulance Driving, Haberdasheri and Goat molesting, so it's simply not possible". We need to develop a better ability to sit back, critically evaluate these situations, and think, what errors led to this outcome, and how could they have been prevented? How can I avoid doing the same thing? That being said, it's awesome to see that the site as a group isn't jumping on the people invovled. * Just want to add, I'm not attacking Bill here, I'm just talking about generalities.

They're both idiots. The judge's decision is questionable. The assailant did "assault" the doofus in the zombie suit. But I got the impression that I've been hurt worse by my two year old daughter jumping off the couch. He's complaining of being choked without any change in his voice, and a normal volume and pitch. It doesn't seem like it was too serious. I'm a little surprised that charges were pressed. The assailant should respect freedom of speech / expression. The guy wearing the zombie suit should probably realise that some people are pretty sensitive about their religious beliefs, and deliberately antagonising them might get him a friendly tickle-fight. A storm in a tea cup.

A lot of paramedics haven't had good role models as preceptors, and have been treated badly themselves as a student. Most probably haven't had any decent training on how to precept / mentor someone. As a result a lot of them model the same bad behaviours their own preceptors displayed. This is a shame. I'm wondering if you've reached out to this person and tried to talk to them about how you're feeling? You say you feel like he's not interested in teaching you, and that you're not getting enough feedback, and not feeling welcome --- are you sure he's trying to send this message intentionally? Maybe there's something not going so well in his personal life? I think you should try and avoid having an outright shouting match, but at least talk to your preceptor about the current situation. Then your next point of contact should be the practicum coordinator for your school, as others have suggested. There's a lot of people in EMS who like to push and push to see where someone's limits are, and sometimes you have to treat them like a schoolyard bully, and just stand up to them and they'll back down. But this is risky to do while you're on a practicum, as it can easily look like you created the problem. For what it's worth, when I've mentored or precepted people, I've always felt like part of my job is making them feel welcome. They've paid a lot of money to go through school, and they're almost always volunteering their time on the ambulance. It also feels pretty good to have someone come to you and say "Hey, I'm new at this, can you teach me how to do it well, because you're better than me". I feel like practicum should be fun, and the student's primary focus should be to learn and do calls. Other things like station duties and restocking the truck, etc. should be secondary to the learning. The calls have to be debriefed, and there's going to be a certain amount of negative feedback that has to happen, but there's no reason why it shouldn't be fun. Edit: illiteracy

I've never used either prehospitally. I was a little surprised people inject it, as it doesn't seem like pentazocine is that strong an opiod compared to others that I'd expect to be more available. But it seems to have been something that's gone on for years in that region, probably due to a relative lack of cheap heroin until quite recently.

Strangely some of our junkies use to inject crushed Talwin (pentazocine) and Ritalin, as a poor man's speed ball. It's possible that the expression "T+R's" stuck around after the Talwin was replaced with something else because it sounds funny if you say it really quickly a few times (as in " T and R's". However this irony seemed to be lost on the users themselves. I'm going to look and try and found out when/if they stopped prescribing it. Edit: still available in my old area. But I wouldn't be surprised if the term is being used generically for some combination of crushed pills with a stimulant and CNS depressant, much like depending who you talk to, a speedball is either heroin+coke or heroin+meth.

* Depends on what the patient's taken, and how much: Selected opiods (t 1/2) Narcan (60-90 minutes -- yes narcan is an opiod) Codeine (150-180 mins) Methadone (15 - 60 hours) Morphine ( 120-180 mins) Heroin (30 mins ) Oxycodone/percocet (3-4 hours) Fentanyl (2.5 minutes) Demerol / Pethidine (3-5 hours) Propoxyphene/Darvon (6-12 hours) Pentazocine (2-4 hours) * Narcan competes for binding with the other opiates ingested. So, theoretically, if you had an IV pump with narcan on one arm, and an IV pump with morphine on the other, you could wake the patient up and put them back to sleep at will by adjusting the drip rates. * There's going to be a certain plasma concentration of narcan that's going to treat the negative effect we're trying to prevent (e.g. apnea). The more opiate / opiod the patient's taken, the higher this level is going to be. How long the narcan lasts for will depend on how rapidly the narcan is being metabolised compared to the other opiate/opiod, and how much the patient's taken of the unknown drug. * There's wide variability in individual patient's ability to metabolise different opiods, which may be due to tolerance from repeated exposure (e.g. in addiction), genetics, renal and hepatic function (lots of these people aren't healthy) and other non-opiod medications taken that are competing for metabolism. * Other drugs will not only affect metabolism, but may have their own CNS affects. We've all probaby seen how unpredictable benzodiazepines can be when used with opiates for conscious sedation. If our patient has ingestion heroin+coke/meth, or has other depressants, e.g. alcohol, benzos, antidepressants, anticonvulsants, etc. then this may effect how long the effects of the narcan lasts. I think so. This would be my preference, and would have been supported by physician oversight in the systems I've worked in. But this does seem to vary geographically.

Can you expand a little more on what your scope is? ILS is a confusing level. I guess the trite answer would be any time the patient may potentially benefit from an intervention or assessment that ALS can use that you can't? For what it's worth, I've never had an issue backing anyone up. I'd rather have a BLS crew call for assistance and have it be an overreaction / waste of time, than to have them not call when the patient needed help for fear of "upsetting the paramedics".