systemet

http://emcrit.org/podcasts/hyponatremia/ Link for the Weingart EMCrit podcast on hyponatremia. This is an excellent page to follow.

Hi, Terrible situation. Makes you really wonder what the parents were thinking, or if there's something else to the situation. A couple of quick points: * You can suspect hyponatremia prehospitally, but I don't think you can diagnosis it without point-of-care testing. * The normal priority in these patients is to restore volume if they're hypovolemic, the correct the sodium later. * Sodium correction must be done slowly (I remember reading something like 0.5 mEq/hr), otherwise rapid correction can damage myelin in the CNS (central pontine demyelination syndrome). So rapid correction probably isn't indicated prehospitally * The total amount of sodium given is based on labs, I think it's something like [Na]deficit * Total body water (or 0.6 x ideal body weight). I was under the impression 3% saline was still used, but this is an area I know almost nothing about. * I've never had protocols to treat this. * This patient is likely euvolemic, or only moderately hypovolemic, the primary problem is likely the hyponatremia from sodium loss across the dermis. * I think it would be reasonable to treat initial seizures with benzodiazepine, even if you're already aware that the sodium may be low. Scott Weingart did a good podcast on this at EMCrit. Hopefully the physicians on the forum can shed some more light on this area. All the best..

You could do this. And you'll get your paper written. But have you considered simply calling up a college that trains paramedics, and seeing if they can put you in touch with someone over the phone, or for a sit down with coffee? I'm sure lots of people here can give you an idea about what it's like to be a medic. And while I'm guessing that the core aspects of the job are the same, things like working conditions, pay, retirement, benefits, hiring prospects, promotions, etc. vary a lot from location to location. If you contact someone local, you might get a good look at the inside of a paramedic program you'd be interested in taking one day, or meet a mentor. It might also lead to employment opportunities. Perhaps you could get a ride-along somewhere? Just a thought.

The thought occurs that the one thing that might be worse than a blinding headache that makes you want to die, is tripping your balls off while having a blinding headache that makes you want to die. Just trying to be funny.

I can say from experience, that this is absolutely fantastic. Not having to be continuously fighting your circadian rhythms and being in sync with the rest of the world is incredible.

if you're looking for some similar systems for comparison, consider looking at the UK NHS ambulance system, and some of the provincial systems in Canada in British Columbia, Alberta and Nova Scotia.

I don't think it's necessarily wrong to use the bougie first. I might do this if I was intubating someone in C-spine, or a predicted difficult airway. But I used to use a styletted ETT on my first attempt to keep the skill of passing something a little wider through the cords. I didn't want to get into the habit of relying on something that one day might not be there. (Granted, it should always be there if I have a chance to check the truck, but sometimes you come on shift and walk straight into a call, or use the last one on a code, and don't get to get to restock it before hitting another call, etc.) * As usual, remember that I've not be working in the field the last little bit, so I don't claim to be current on everything.

Just from the physiology side of things, l-arginine is used in nitric oxide synthesis: Nitric oxide is an endogenous vasodilator released from the endothelium. Medications including nitroglycerin and nitroprusside act by releasing NO. [This shouldn't be confused with nitrous oxide, N2O found in entononx / nitronox setups, or the pollutant molecular nitrogen dioxide, NO2]. NO activates an enzyme called guanylyl cyclase, which then activates cGMP-dependent protein kinase (PKG), which acts to increase SR Ca2+ uptake, decrease membrane Ca2+ entry, and increase Ca2+ efflux, all resulting in a lower [calcium] inside the smooth muscle cell, and relaxation. [This can get more complicated. Some areas remain controversial.] cGMP is then broken down by phosphodiesterase. This can be inhibited by drugs such a milrinone, amrinone, sildenafil, etc.

Great post from 'zilla. I'm reluctant to even try and add anything to it. But I just wanted to say that when I do an intubation on someone with a pulse, I'm pretty anal about how I set up. * I check the suction works first, I jam the Yankauer in it's cover under the pillow * I have my tube lubed, styleted, tested; I have a tube size smaller placed on the bench. * The Bougie is out on the bench * I've taken out the backup device, checked the cuffs * The cric' kit is on the bench, or beside me * Drugs are drawn up * The patient's all wired for sound, (e.g. ECG, SpO2, NIBP) and the capnograph is on the bagger Then I take a second to let everyone know where everything is. Then I tell them the plan, e.g. "I'm going to try and intubate with a styletted 9.0, and I want you to put your hand on the thyroid and hold it there. If that fails we're going to back out, and either try with the Bougie, or place a combitube". I've had a few people react negatively to this, especially to the cric' kit. More than once I've heard "We're not going to need that!". But the reality is, you can't always predict when you're going to run into problems. If you're going to push the drugs, miss the tube, and get into a can't intubate can't ventilate situation, it's going to be easier if the kits already out and everyone knows where it is. [it's also a great way to know that everything's there, before you start.] This may not be exactly revolutionary -- I'm sure most of us do this. But I just wanted to throw it out there.

This is an interesting question as well. I don't want to argue based on a "slippery slope" fallacy, but there's got to be a consideration of what happens to the unvaccinated children if physicians are refusing to see them. Obviously they no longer have equal access to care, but would they still have enough access? Is an inevitable result of allowing physicians to refuse to see unvaccinated children that many of them won't be able to find a physician willing to manage their medical care? The potential injury to these children has to be balanced against the potential loss of freedom to the individual freedom of the physicians to interact in the marketplace with whatever customer they want. I think the comparison of physicians to lawyers isn't really valid either. I think a physician has (or should have) a responsibility to the community to provide medical care that's different from any responsibility that a lawyer might have. I don't think it's an issue of bullying either. There's a part of me that wonders whether parents shouldn't be forced to vaccinate. There's a point where the children need to be protected against the consequences of bad parenting. But this is a very tricky issue. Right now herd immunity pretty much takes care of the unvaccinated under most circumstances. The major risk is probably to the immunocompromised, and those too young to be vaccinated. This does happen in some places. I used to do a little bit of mountaineering in the national parks in Canada. If I paid for a valid pass to enter the park, any rescue operation was covered. If I snuck in, or was lazy and just paid for one day but stayed for a week, then the cost of a rescue was on me. Most travel insurance, and much personal injury insurance / life insurance doesn't cover these activities either, but the insurance companies are usually more than happy to sell you extra coverage. This is also an issue in a lot of the Alps. Often if you pay for a membership in, for example the Austrian Alpine Club http://www.aacuk.org.uk/ , then they'll cover the cost of rescue. The trouble is, a lot of people doing these activities are living in a small mountain town, making minimum wage so they can climb / ski / mountaineer / whatever on their time off. Just to completely derail this absolutely awesome thread, let me add an absolutely kick ass video:

This is a medic posting in AB http://www.healthjobs.ab.ca/Jobs.Slave-Lake.Paramedic-%282-Positions-Available%29.2012-0202.aspx (rate: $29.82-39.26 / hr) For an EMT spot in the same region: http://www.healthjobs.ab.ca/Jobs.Slave-Lake.Emergency-Medical-Technician---Ambulance-%282-Positions-Available%29.2012-0205.aspx (rate: $24.76 - 31.52/hr) For BC, there's a paygrid on the wikipedia page which is probably a little old: http://en.wikipedia.org/wiki/British_Columbia_Ambulance_Service Their EMT level is $20-26/hr, and the medic level is $27-32/hr. But I think these numbers are quite old. They also have a couple of critical care medic levels that are pretty interesting, including a neonatal critical medic level. These probably make more. Ontario EMT job (PCP): $30-32/hr http://www.thunderbay.ca//Assets/City+Government/Employment/docs/Primary+Care+Paramedic+-+City+of+Thunder+Bay+%28COM-35-12%29.pdf [*I have to point out here that the Ontario PCPs/EMTs train for two years to do BLS. So they're a little different from PCPs/EMTs in other parts of Canada who pay only train for 6 months]. Ontario paramedic (ACP): $36-38/hr http://jobs.workopolis.com/jobshome/db/peel.job_posting?pi_job_id=9608920 [i think both these jobs are posting a starting wage, not the range of their pay grid]. So it looks like there's money there.

I just want to make sure I understand what you're saying --- if someone intentionally takes organophosphates orally, enough can be excreted across the lungs / dermis to cause a hazard to the responders?

I'm not sure why it matters how much money you make. But you make close to $70 / hour on OT. Great, so your regular rate is $35 / hour and you're in Alberta. Fantastic. I'm sure you've got options to go to other places. I'm just not sure how much money you make has to do with this? Good luck.

So many opinions, so little time.... this is a great thread: * Discrimination is uh... wrong, m'key? A physician deciding not to see Afro-carribeans, HIV patients, or unvaccinated children because they dislike them based on their race, medical conditions, or personal life decisions is not ok. Especially when dealing with children, who don't get to make those decisions themselves but have them thrust upon them by their parents or the state (depending on the given country). * That being said, if you're a pediatrician, or a pediatric oncologist, as two of the physicians were in the new report cited, and you don't want to risk someone's unvaccinated child bringing in measles (or, I guess, polio, does that still happen?) or mumps, because you have immunocompromised children, or pre-vaccination age children, then I don't think this is discrimination any more than signs at an ICU saying "Please don't visit today if you're feeling unwell". I think the difference between discrimination and sound medical practice is in the intent. * In a similar vein, I hope that the physician who said "If you don't believe in the fundamental thing we believe in, then you need to go somewhere else", was selectively quoted or misrepresented. I share the frustration that people are willing to reject aspects of science / medicine and then turn immediately to it the minute there's a problem. But I think if someone who doesn't want to vaccinate their child makes the decision to seek medical help it should be provided without prejudice to their personal beliefs, as much as an individual scientist of physician might disagree with them. * I think parents who don't vaccinate their children are ill-informed. I believe the media presents the anti-vaccine crowd as more credible than they are because it feels it has to present both sides of an argument in an attempt to appear "balanced". But I can respect that they feel they're doing what they feel is in the best interests of their children, as much as I might disagree with them. The kids don't get a choice, and if their parents are already preventing them from being vaccinated, we should do our best to provide care (in situations where other children's safety isn't compromised). I think there are reasonable arguments for rejecting the parents --- but their children shouldn't be doubly punished. As an aside, I don't know the specifics of the New Zealand system, but a number of the Scandinavian countries have similar systems, such as Sweden. There are both negatives and positives to this, as I see it, it enables the medical system to determine how resources should be allocated, and reduces the injury that occurs from unnecessary blanket tests that are designed to prevent against litigation. On the other hand, I think it may increase the risk for individuals with atypical presentations. It's good to be in an overly cautious system that does a lot of unnecessary expensive procedures if they catch your stroke or MI. The compensation system also only works if you have good public disability care and medical care. It's no good to throw $50,000 at someone if they've now got to get their house retrofitted for a wheelchair, pay for a care aid for 40 hours a week, have a number of expensive follow-up procedures, deal with insurance issues, and live on poverty level disability pay. If your welfare system ensures decent disability care, decent living conditions for the disabled / long-term care, etc. it's easier to have a system like this. This is also an interesting issue here. To what extent should a parent be able to decide for their child, and to what extent should the state be allowed to intervene? The North American tradition tends to be that the child is viewed as property of the parent, and the parent is allowed to dictate and restrict the care provided to a minor based on their religious beliefs and personal preferences. In other countries, including much of Europe, the state has greater rights to intervene, and can ultimately force parents to have their children vaccinated, whether they like it or not. Both present problems. The state has the legal right to remove children from an abusive home environment, and has a moral obligation to protect them. But the parents also have a legal right to religious freedom, and a general desire to not have the state interfere in their daily lives, and those of their family. It gets very difficult where these two meet.

I don't know if this was evaluated clinically before either became illegal. LSD has structural similarities to ergot alkaloids which are commonly used to treat migraine and post-partum hemorrhage. These include ergonovine (which many EMS services used to carry for PPH), ergmetrine and methylysergide (sp?). I think these drugs are still used, although I'm not very educated on the current trends in migraine management beyond fluids, maxeran and NSAIDs. So, in the case of LSD, there might be some theoretical similarities to "effective" medications. Medications that wouldn't cause 12 hours of hallucinations and possible jail time! I'm not sure about psilocybin. It looks quite different structurally. However, I believe it also has serotonin receptor effects, which I think are what's important here. [These drugs also have effects at dopaminergic and alpha receptors, which may be relevant.]

I think that's a reasonable assessment of the situation. EMS is probably still a little ways away from being truly recognised / accepted as a healthcare field, but it seems like there's more research each year. Whether the research really belongs to EMS as in it's "its own research" is hard to say. The stuff I've seen / participated in (a few years ago now), has mostly been driven by cardiology or emergency medicine, rather than by paramedics. But that's part of a bigger problem of who owns / is responsible for EMS. I think a lot of us would like to have paramedics running large RCTs of prehospital sepsis management or resuscitation, etc. But the reality is, we don't have that expertise. The medicine is always going to be dictated by the physicians (and rightly so). But it should be done in partnership with paramedics, in a mentoring environment, even if it's an unequal partnership. Put bluntly, if we're participating in the research, we should be getting something out of it. I think the most reasonable exchange is for the physicians conducting the research to involve as many paramedics / EMTs as possible and help push forward paramedicine as a profession. I agree that there's relatively little EMS research. Change takes time, and it takes a long time to filter down to EMS. I think some of the changes now are occurring as a result of research in the field, e.g. therapeutic hypothermia, de-emphasis of antiarrhythmics. Practice just changes quicker in the ER because physicians actively read the literature and adapt their own practice. In EMS, we tend to be forced to wait for medical advisory committees to do their job and update guidelines / protocols. Some committees carry out their job with more enthusiasm and vigour than others. This is an attempt to do that in Canada: http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm I realise that the sample protocols seem very "old-fashioned" and basic, but if you click on the titles on the left side of the page you get a pretty good list of references for therapies that they haven't included.

I've worked under various guidelines. Some systems I've been in have had no mechanism to patch, and lots of drugs and toys. Others have been more restrictive and required patching for interventions that I wouldn't need to call for in others. I've heard the argument before that the patchless systems had "better paramedics" because they didn't need to call, but often it seemed like they just had less active medical directors, and were less accountable for their mistakes. (I am not intending to suggest this is the way it is in NZ". Arguably the dumbest protocol I've had required us to patch before administering adenosine. At the time there was no telemetry requirement / capability, but we were supposed to patch first because a review had shown too many a.fib patients getting adenosine. However the response didn't address this, e.g. "35 year old male, prior hx of SVT in a regular narrow compex tachycardia at 190 bpm, 4/10 ischemic pattern chest pain and a pressure of 90/60, I'd like to give 6/12/12 adenosine", etc. There was no mechanism to actually ensure that the tachycardia was narrow. The whole situation was farcical. The same protocols allowed me to cardiovert the second I judged the patient to be unstable --- and you could make an argument for that as well in this hypothetical situation. It felt insulting to have to call for a class I ACLS intervention. But then you have other situations. 60 year old male, HTN, obesity, NIDDM, suspected anginal chest pain x 2 hours, nausea, anterior wall MI on 12-lead. Standard ASA, NTG, +/- gravol +/- morphine given etc. What next? Should we go to PCI? Is there a room available? How long until the next one? Or should we thrombolyse and go to the ER? Which local center has the best resources? If we're going to wait an hour for PCI, is his risk better with thrombolytics now? Do I need to transport him to somewhere with PCI on-site in case he needs rescue angio, or do I have ICU beds at another site where they can just do secondary transfer? What if we throw in some more risk factors, or change some of the variables. Is thrombolysis going to be superior to PCI if we throw in some more co-morbidities? Are beta-blockers appropriate here? This isn't a bad time to chat with an ER doc or cardiologist, and get their opinion. Or renal patient, missed dialysis x 5 days, 3rd degree AV block w/ wide QRS response @38bpm, general malaise, nausea, vomiting, doesn't meet Sgarbossa criteria for STEMI. No clear ischemic pattern chest pain. Pressure's 98 / 50, fine rales, +1 pitting peripheral edema, and an S3 gallop. Should we pace? Is atropine a better idea? Is it better to sit on him until the ER, and let them get 'lytes. Or should we start pushing calcium and bicarbonate for a presumed hyperkalemia? This isn't a terrible time to chat with someone more educated. 19 year old female, idiopathic pulmonary hypertension, SpO2 of 86%, looks like death. What next? Who has standing orders for this situation? 60 year old male, tearing substernal chest pain, radiating to left arm, writhing in 10/10 pain, left arm pressure 230/140, right arm 180/100, 0.5 mV STE in V1, 0.2 mV aVR. Vomiting. What do we do about this? Are going to give IV nitroglycerin? SL? a patch? Metoprolol? What's our target MAP? ASA? Leave it alone? 80 year old cancer patient, 8/10 refractory pain, currently receiving 50 mg MS po bid, 2mg hydromorphone SC via 'clysis q4h, with another 1mg prn for breakthrough, and they're taking benzodiapines as well. It's 4 am, and there's a 1 hour transport, palliative care is unavailable. How much morphine should we give this patient? I guess what I'm trying to say, and perhaps my examples aren't that great, is that sometimes having the ability to contact a physician can enhance the care delivered. I strongly disagree with mandatory patching for things like airway management. I hate arbitrary restrictions on pain control, like "call if you give more than 20mg MS". Or chemical restraint. But I don't see it as a great affront to my grand total of 3 years of training to have to occasional run an idea by an ER fellow, or reach out for a little help.

You missed your foot. And identified a problem in cardiac arrest research. There's only a small percentage of people who are going to survive an asystolic arrest (the survival is much better for PEA). Part of this is that asystole often represents someone who has been in arrest for a long time period, and hasn't had bystander CPR, and it's not immediately treatable by one of our best therapies, defibrillation. If you take 200 people in asystolic arrest (which would be quite large for a cardiac arrest study), and randomise them to atropine or saline, even with good inclusion / exclusion criteria, you're looking at perhaps 0 - 6 survivors. Perhaps less if you start looking at good neurologic outcomes, or at 6 months or at 1 year. It's really hard to get decent statistics. So then you don't know if any difference you see is just chance, that one group just happened to get one more survivor than the others because of how they were randomly assigned. And then it becomes tempting to look at the large number of asystolic arrests and suggest that, maybe the statistics aren't great, but if there's a real difference it would benefit a large number of people. There was a fair controversy about this with vasopressin in asystole 5-10 years ago. There was a big article published in NEJM. It showed a small improvement in survival in asystole with vasopressin over epinephrine (I think), and urged immediate changes to the ILCOR guidelines. But if you look at confidence intervals, the 95% range included the possibility that the patient got better with vasopressin, that it had no effect, or that it killed people. [This still represents better epidemiological data that anything motivating for atropine.] So, historically, we've tended to use things because "it seemed like a good idea", because we could think of a plausible physiological reason as to why they might help, and there was maybe some animal data. This included things like high-dose epinephrine, calcium or isoproterenol. Things we now know are harmful, or neutral at best. Right now the best data suggests that drugs in cardiac arrest may not make a difference at all. With the trend toward evaluating current practice based on the available evidence, a lot of therapies are being removed. The problem right now, is you can make an argument for using atropine, in that some asystolic arrests might represent the consequence of excessive vagal tone. But I can make an argument that high dose glucagon might be good as an inotrope and adjunct to epinephrine. We just don't have good data to support either position. [There's even reasonable arguments for giving beta-blockers instead of epinephrine in VF/VT]. So what do you do? The current trend is towards removing things that lack a good evidence base.

Wow. I'm impressed. I take my virtual hat off to you sir.

This is something we should also be aware of on EMS calls. Especially in situations where the patient requires restraining. There is are worse ways to restrain people, but it's really hard for even the best restraint process to look good on video. If someone walks in half way through, it looks like a bunch of people in uniforms pushing someone around.

Granted, it's important that one person be in charge when the patient acutely decompensates and rapid corrective action is needed. I can't imagine a time when that's person's going to be an RN on a scene call. The only times that immediately come to mind, are maybe working with a NICU / PICU transport team, where a lot of the time, my job has been to pass things around and deal with logistical problems. And perhaps doing an IFT with an RN escort to manage a balloon pump. And even in that situation, I've felt like the responsibility is divided. If there's an acute problem with the balloon pump, while I have some education, it's going to be the RN taking the lead. If there's an acute airway issue, that's going to be my problem to fix. It's a team game. You have to be foolish to completely discount good information coming from another provider, especially if they have expertise in an area you don't. I've heard of situations where non-MDs have offered help saying "I'm a doctor". No reasonable person is going to do this on a 911 call. No reasonable PhD in English literature or Molecular Genetics, and no reasonable DVM, etc. is going to do this. But there are plenty of unreasonable people in the world. The thing is, when someone approaches you and wants to take over care, you get to decide whether they do that. If you don't believe they're an MD, you can ask them to prove it. And if you can't reach a reasonable compromise, you can always call PD. Almost all of these hypothetical situations are solved by calmly talking to people, showing respect, and then evaluating their responses with a little bit of critical skepticism. In most situations, this isn't that hard.

It's been removed from the PEA / asystole algorithm. It's still in the bradycardia algorithm. This is probably more based on past usage and expert opinion than any high quality epidemological research, but seems reasonable. It's still used as an adjunctive medication in intubating peds (somewhat controversial), and with ketamine (also somewhat controversial). It's also indicated as a treatment for OP / nerve agent poisoning. The "beneficial, so long as the medic uses good clinical judgment" could probably apply to a lot of things. Most things are not beneficial if the medic is using poor clinical judgment.

Might be a reasonable idea in a hanging, or someone found on the floor by the toilet, as well. Can't see it making a huge difference, but I think it would be justified. Not important. Too many people in EMS view what we do as a scope of practice or a drug list. That's not what's important. What's important is doing the best for the patient. Looking at my old service over the last five years: Drugs removed: thiamine, droperidol, lidocaine, diazepam, meperidine, lidospray Drugs added: amiodarone, succinylcholine, IV nitroglycerin, metoprolol, prednisone, dexamethasone, ketamine, haloperidol, tetracaine, metoclopramide, rocuronium, ondansetron, ketorolac, nitropatch. Looks like it was a net gain for them.

I think I understand where you're coming from. Perhaps I could word that better -- I would take the lead whenever interventions were required that were outside of their scope of practice, or when the patient's condition suggested that they would benefit from an assessment using skills or techniques that my EMT partner was unfamiliar with or less adept at. Then we can avoid the whole quagmire of what makes a patient ALS versus BLS, and whether this is a meaningful distinction.

When I worked urban, higher call volume, we used to alternate days, drive one day, attend the next. If I worked with an EMT, I'd take any ALS calls on their attend day. I'd still attend all the calls on my regular attend day, even clearly BLS calls. I figured I was making more money, so I could do a couple more calls. If I worked with another medic, this wasn't an issue. When I did rural, lower call volume stuff, we used to switch each call. I think the difference was, when you're doing higher call volume stuff, it's nice to be able to "switch off" on the drive days. If you just alternate calls, you're doing enough that you don't really get to relax for any length of time.