WelshMedic

Yeah, but Jim Kerr did sing: "Dont, dont you forget about me". So he got his wish, didn't he? WM

Hello everybody, I appreciate everyone's input on this subject. To comment on a few suggestions made here: ERDoc, it wsan't one flight of stairs but three. Pre-oxygenating him wouldn't have done it, he would have been very hypoxic by the second stairwell. Intubation shouldn't be taken lightly but I think it's a little inflammatory to mention death as a result of it. I'm well aware of the consequences of misplacement. That's why we have a 5 point-check before going a step further, including EtCO2 (recognized as the gold standard when it comes to tube placement and monitoring, especially in this particularly tricky case). Elvis, the truth is that I'm just not very experienced in using Narcan. I'm an experienced medic with 10 years service, but an opiate OD I've seen maybe once or twice. Despite Holland's reputation with regards to the coffeshops in Amsterdam and the "illegal" substances they sell, hard drugs (heroin, cocaine, crack) are just not a problem here like they are in the States. The Dutch tend to keep it to alcohol. This meant that I didn't want to overdose him and have a very pissed pt who was fighting us all the way down the stairs, plus I was genuiely concerned about the morphine kicking in again and having to start all over again. Regards, WM

And that's what makes it so beautiful to work in........ But seriously, no nitro at a pressure under 110 mmHg? Seems a bit draconic..... I was reading an article today about new insights into CHF care. Basically it stated that furosemide should take a back seat mainly because of misdiagnosis (pts with pneumonia were getting lasix and becoming even more dehydrated, for example). I know there's a grey area out there when it comes to diagnosing SOB, but are we really that poor in diagnostics? My gut-feeling tells me no. Any thoughts? WM

Hi Scat, I think your contribution has a lot to do with the original post. That's the point, long-acting oral morphine is much more difficult to reverse than a "quick shot". WM

I will admit that a Narcan bolus would have been prudent, but it was a text book intubation and we were able to carry out the extrication in a controlled fashion. All in all I may well do things differently next time, but I don't think this particular patient came to any real harm. I wasn't able to check up on his status tonight as we've had a hammering tonight and didn't get back to this particular hospital. WM

My motto: "If the legs are working, they're walking" I do tend to agree AZCEP, I felt indeed that any Narcan was going to be hit and miss in this situation. We had no idea how much he had taken and when. WM

Doc, Exactly, I did wonder that myself. The stairs really were a pain though and I didn't want him going off on me halfway down. That's why I decided to intubate BEFORE going down. I also agree that intubation shoudn't be taken lightly, but having to bag him if he'd gone off again really wasn't an option. I am glad that we use capnography though, I could monitor tube position throughout the whole difficult stair experience. Terri, How are you? Thanks for your reply, maybe I should have given him the Narcan in the back of the rig. The problem is that I'm on my own (Dutch EMS in nothing like the States) and didn't really have a spare pair of hands. But I suppose I could have stopped. On balance, I don't think I did him any further harm but I mightn't necessarily do it the same way next time. I'll let you know how things go. Carl.

Hi, Just wanted to run a case past you lot to see what you think. It's real, and happened to me yesterday. We were called to a townhouse in a rather run-down part of town. There we found a 45 jr old man who had a respiratory rate of 4. He was prescribed a slow release oral morphine preparation. This wasn't an intentional overdose, he just wasn't very compliant with his medication scheme and took it whenever he felt like. This had been developing over a number of days. He was lying in a bedroom at the back of the house and the stairs were extremely narrow and partially blocked by a chairlift. I decided to intubate after pre-oxygenating for a few moments, this was extremely easy as he had no gag reflex whatsoever. After a while we had the following parameters: EtCO2 4.3 kPA, Spo2 100%, ECG: sinustach 108, BP: 100/63. We strapped him to a backboard and lifted him with difficulty downstairs. The transport time was 10 minutes. That's the background information. Now here's the dilemma: you'll have noticed that I haven't mentioned Narcan anywhere in the post. I decided not to give it for the following two reasons 1) it was a sub-chronic overdose and so even if it had been effective then I would have had the same problem again in 15 or so minutes because of Narcan's very short half-life. And 2) because I felt that waking him up and probably making him combative would increase the risk to everyone when getting him downstairs. I just can't help wondering if I should have tried the Narcan and what the reaction would have been. At the hospital he was admitted directly to the ICU and as I was leaving they were drawing up the Narcan. I'll find out how thigs went on my nightshift tonight.

Hi, The above post beggars belief in my eyes. It also raises some important questions (well, they are to me anyway ); What's dispatches role in dispatching for this call? What did she tell them? That she wanted to post some bills? Aren't you able to refuse transport in such obvious cases of misuse? It would drive me crazy to pander to every whim of these sorts of people. This is one of the reasons why EMS is, in some cases, in such a financial mess. Shameful! WM

Stefan, Check your mailbox, I've sent you a PM. Carl.

Maybe this guy is the best thing that ever happened to you. He's pushing you to broaden your practice and know more about your patient. That can never be a bad thing, despite his own motivation. Just remember that knowledge is definitely a good thing in our work. I push my students as well; I'm not nasty or vindictive but I do expect a certain level of commitment and theoretical knowledge if you want to get through your rotation with me. The ones that end up crying on me usually don't last very long.....those who stay are, for the most part, very grateful. You don't get that badge with a packet of cereal.....you earn it. WM

Hi all, Is there such a thing as the perfect drug? Experience taught me that different drugs are preferable in different situations. Morphine - a great drug, but causes nausea in majority of patients. It's use should be combined with an anti-ametic, preferably ondansetron (Zofran). The reality is that not many services carry Zofran because of the cost aspects - one dose costs $40. Fentanyl - quick onset but misses the potency of true Morphine. Has less effects on hemodynamics, in my experience. (And i'm not mean with it either, Dust :wink: ) Alfentanyl (Rapifen) - a great drug and would be my first choice. However, very very potent and needs to be used with great care in larger doses. Ketamine - not bad for short term sedation (although it's not true sedation, just disassociation) but they tend to wake up as mad as hatters if you don't give enough Versed with it. Other than that it can be useful in certain situations, such as entrapments where intubation is not an option. Diclofenac (Voltarol) - NSAID - very good for musculo-skeletal pain, also useful in episodes of renal colic but obviously misses the sedative and euphoric effect of an opiate. These are the drugs we have in EMS here in the Netherlands. It's not a bad choice, but again, it's not exhaustive. There are other options out there. Carl.

Hi Doc, The latter study you mention looked at the combination of Fentanyl with Droperidol. This WAS a commonly used preparation in the treatment of ACS here in Europe a few years ago. It was marketed under the name Thalamonal.The thinking was that you could relieve pain and anxiety at the same time with this product. I personally never thought very highly of it. Then some research was published to suggest that the droperidol component led to ECG changes that could precipitate ventricular arrythmia's (can't remember exactly what the problem was, sorry). The drug was taken out of our protocols in 2001 and was replaced by fentanyl and low dose midazolam, if required. I only read the astract, but I do wonder whether the neuroleptic component in this study was the cause of the problems, as opposed to fentanyl. Take Care Welsh Medic

No worries cobber! WM (a pommie, of course)

This article makes interesting reading, but leaves me with more questions than it actually answered. 1) How was it carrried out? Was it a retrospective literature review? 2) Is it not the case that those receiving opiates are, by definition, sicker and therefore more likely to die? This issue wasn't addressed in the article 3) Is it Morphine specific? How do the synthetic opiates such as fentanyl fare? Anybody any answers? WM

As you can see from my profile, I'm a bit too far away to be able to comment on the volly v. professionals debate. Volunteer EMS doesn't exist in my neck of the woods. However, I do still think it's to the detriment of everyone's working relationship if blanket statements are made upon subjects that one has no personal experience of. Asys doesn't know anybody in the company involved and still choses to make offensive statements about how they do their business. That's my point here, not whether there's an element of truth there. I have a friend somewhere in the Eastern United States who's been on the receiving end of this sort of old boy politics within a volunteer organization. As it happens, I don't think volunteerism has a place in EMS, there's just not enough accountability or skill retention. Have a good day all. WM.

Dust, It's the difference between respect and collegiality. Yes I respect the man who serves me my midday meal as well, but it's a FD (or PD, for that matter) colleague that I expect to look out for me during an incident, and he may expect the same from me. WM

With Combivent you'll never really know, will you? I suspect it's effect will be more in teh long-term. WM

Cricket is for middle class, public school educated tossers........

At a guess, I think it's something to do with the predominantly male culture that prevails in EMS. Look at an autoshop where there are "girlie" calenders on the walls. I personally think it's a matter of choice. At our station we have digital cable with all sorts of channels including ones that show porn. I'm not a prude, I've watched in the past, but at the end of the day I'd rather watch a good Discovery documentary. The thing is with porn, is that it's so brain-numbingly boring after a while. It's like watching paint dry..... WM. PS - I wouldn't worry about the preacher either, if recent reports are anything to go by, he's the one who's watching the most.

This is a terribly emotive subject upon which there will never be a complete consensus. I'm lucky to have two healthy children and since I've had a vasectomy, there isn't much chance that I'll have to face this decision as a parent. However, I do not think it's good medicine to treat a premature baby at 22 weeks. In my mind it can never be the right decision to put a child through unnecessary suffering when the outcome is so bleak. It's not a question of economics, it's a question of compassion. Of the very rare cases where a child has survived, then I'd also be inclined to question the gestation- mistakes happen more frequently than we realise. WM

What was the mechanism of injury? how fast was the car travelling? Did she wear a seatbelt? How much damage was done to the rest of the car? These are all factors that play a role here. However, she was alert and orientated and WASN'T complaining of pain. I realise that within the claim culture that exists in the US, there's a potential for over-treating someone but surely we can think for ourselves, can't we? I don't think the roof would have come off with me as it would be a waste of time and resources as well as potentially wrecking an otherwise perfectly good car. Can't someone sue you for wrecking the car if they find out they have no lasting C-spine injury? (A genuine question?) Carl.

Why didn't he go the whole hog and suggest good 'ol Bretylium as well? Methinks this is one teacher that should hang up his gown pretty soon. (I'll never forget that great line in the film " Flatliners" - "No, don't give him Bretylium; he'll fry". Why didn't someone ask: " How you want him, medium rare?") WM