WelshMedic

Hi all, Just a quick thank you for all the replies so far....although I'm still open to more information if anyone has any bright ideas. Medic One seems to be the best choice for us, it's reasonable for us to get there and they seem geared to receiving visitors from overseas (apparently the whole world and it's dog want to come and see their set-up). I hope my attempts at contacting them will prove succesful. Once again, thanks Carl.

Thanks Dust, I hadn't thought of Seattle, but it's a good one - I meant airport with the mainport thing. I'll get looking at what it costs to fly to Seattle! Carl.

Hi all. Just imagine, you're a group of 6 medics from the Netherlands; you've been a few times to the US (the JEMS conference) and had ride -alongs in the past. Now, you're getting that itch again (no rude comments about my itch, please) to go to the States and visit a service/do a ride-along. But this time you'd like to go somewhere where the protocols are very progressive, (they've been quite good so far but we want to see the best) the call-volume is preferably high (we're not coming all that way to sit on our tushes, that we can do here!) and if possible near a mainport. Where would you like to go? BTW, sorry about the title; but I wanted to get a lot of attention (I'm an exhibitionist, you see ) Carl (Welsh Medic)

It's a shame that you can't use monitoring at a basic level, I would have liked to have seen his rhythm. My hunch is that it was some kind of AV-block. He might have been smelly,but that's no excuse for neglecting your duty of care - he should never have been downgraded to BLS. Take this further! Carl.

ALS-Medic, Do me a favour and read the last few posts that you've written since you've been here. You seem to have made it a sport of blinding people with your fantastic knowledge base and then kicking them in the teeth with some snide comment. Just remember we're all here to learn something from one another, whatever level of provider you are. Your attitude, frankly, stinks. I'm sure you are a very knowledgeable person, but as long as you keep the attitude then I'm afraid not many people are going to listen you. I mentioned Korsakoff's only as a possibility, I didn't make a diagnosis, I can't do that from a PC 5,000 miles away from the patient. But I'm sure you already knew that, didn't you? WM.

Not forgetting: Korsakoff's Ascites due to end-stage liver failure WM.

It all depends on what criteria the cath labs have for primary referal.... WM

AZCEP, there are rare circumstances where a rupture can develop a tamponade. I have seen it myself......one minute a patient is alert and orientated, the next (because of movement) he's as dead as a dodo.... Carl.

First off, I think you're talking about a traumatic aortic rupture rather than an aneurysm, an aneurysm being a sub-acute problem which develops because of peripheral vascular disease and hypertension rather than trauma. My own take on the subject is that any traumatic rupture would have to have a tamponade if the patient is to survive, one would then assume that a sitting postion would be best for this very rare category of patient. Carl.

Hi all, Here's my spin on the subject: No, you can't set up a runny nose center for all patients with a rhinitis. But what about oncology centers for cancer patients, they're a good thing, aren't they? Yes, we'd all agree. Here's the thing, Cancer is the number two killer in the western world. Coronary Heart Disease is still number one. We need tertiary centers that specialize in angioplasty, but they also need the facilities to perform by-pass surgery, should it be necessary. The alternative is to put unstable patients on Intra Aortic Balloon Pumps and tranport to a facility that caters for open heart surgery. Not a particularly good prospect all in all, really. Here in the Netherlands we've reached a fairly workable compromise where we give tenecteplase to patients at home with an MI below a certain total sum of ST elevations, the rest ( the big MI's ) go directly for primary angioplasty. Our transport times never exceed an hour in total, irrespective of traffic conditions (that's the advantage of being a country about the size of New Hampshire). Greetings to all you folks from the other side of the big pond, Carl.

The causes of PEA - the 4H's and the 4 T's: Hypoxia Hypothermia Hypovolaemia Hypo/Hyperkalaemia Tension Pneumothorax Thrombo-embolic obstruction Toxicity Tamponade Carl.

Hi Para-Medic, If you're patient is bradycardic with a frequency of 10-15 beats a minute, then the likelyhood is that the MAP will be far below the required 60 and you're unlikely to feel a carotis pulse, let alone peripheral.You're more than likely dealing with a PEA arrest. So there's your answer - treat as such, a PEA arrest. Take Care, Carl.

OK Guys, This post is a bit late, but beter late than never . WHen should you commence CPR? This has to do with the level of perfusion primarily in your brain and in your body. Our bodies stop perfusing efficiently after we've dipped below a MAP of 70 mmHG (MAP- Mean Arterial Pressure),that's why we get cold extremities and suchlike. Once we start hovering aound 60 then we get into real trouble, there will be a marked change in LOC because of decreased cerebral perfusion. The goal is not to let the MAP go below 60 as then our body will shut down and we'll begin the processes that lead to MOF (Multiple Organ Failure). But how do we measure MAP? Well, the LP12 with a NIBP capability will do it automatically for you, but otherwise: (1xsystolic BP+2xdiastolic BP)x0.3. eg: with a patient that has a BP of 130/80, you'll see they have no problem: (130+160)x0.3= 87 but with someone with a BP of 60/40 it's: (60+80)x0.3= 42 Hope this helps to clarify the situation. Carl.

I'm not advocating doing nothing in a critical situation, we all have a duty of care to our patient. I do however think that we need to be very critical before unleashing the full force of ALS interventions on someone that would never have wanted it and, ultimately, doesn't benefit from it. We don't have such a culture of litigation here in Europe, so I would gladly take the time to find out the wishes of the patient and his or her family. Take an asystolic cardiac arrest, I'll ask the family what the patient would have wanted (and what they want, of course) whilst I'm bagging the patient, and depending on their answer I'll stop the attempt. Carl.

Medic, You're so right with that last comment, and that's indeed what it's all about. However we're all more likely to respect the wishes of a court of law than the wishes of a patient, and that I find sad.... Take Care, Carl

This sums up my point beautifully. Go on, read it again. And then consider a number of things that scream out to me from this piece: 1) 4 hourly signs are not the norm in any Nursing facility, if you're that ill you need to be elsewhere i.e. in hospital. I believe that's the reason why you were there. 2) So you ask for a DNR, and because the nurse in question can't produce it there and then, you decide to totally ignore him/her. Potentially also ignoring the wishes of a dying man. The man had been in that condition for some time, you could and should have waited for them to find it. I find it arrogant that you can't find the time to listen to staff at the home and felt that at that time they had no more useful input. 3)"an 18 gauge in th eleft arm and a 1000 bag wide open" Yes, but did you guys hold the man's hand and talk to him? 4) Despite the EMS heroics, the poor man died 2 hours later in a strange place full of strange faces........ This is not a personal attack, I would just like to offer a different perspective on things. I genuinely believe that the job would be made a whole lot easier if we just listened to one another instead of just bitching. There is no excuse for sub-standard care in any field of healthcare, but just because a nursing facility doesn't speak the same language as an EMS crew, it doesn't give us the right to stop listening to one another. I wish you all a very fine day from a very sunny (but oh so cold) Holland. Carl.

OK Guys, Everyone has their own horror story when talking about nursing facilities, it would seem. Most of the comments that have been made are justified, however I would like to put a few things into perspective as I also sense that there's a lot of misunderstanding between EMS and nursing facilities. Let's take the first example: Mr Brown, 89 years old, has had a devastating hemiparetic CVA that has left him unable to speak or mobilize and he is, in fact, bedridden. Over the course of time Mr Brown has also been prone to developing urinary retention, for which he now has a urinary cathether. He has already stated on a number of occasions that he does not wish to be treated in the event of a life threatening illness , however his son does not want to hear any of this and has actively blocked a DNR order. The same catheter has, this time, caused a UTI for which oral antibiotics have been prescribed, The antibiotics are not working and Mr Brown is developing dehydration caused by a lack of fluids (he doesn't want to drink any more) and persistent pyrexia. A hospital admission is arranged and EMS is called. The EMS crew is a BLS volunteer crew and they, after measuring vital signs, ask for ALS support. Why? the patient has a BP 95/60 and a pulse of 120. What then happens: Mr Brown is given a full ALS work-up and taken to hospital where he dies 2 days later. Nothing wrong there, you'd think as an EMS provider. But as a patient, I'm not so sure. You've just just subjected a dying old man to theoretically unnecessary ALS interventions and taken him out of his trusted surroundings to die in a hospital bed. Now, before anyone shouts: "yes, but we didn't call ourselves in, did we" - this I know, but there as a huge gap between respecting the wishes of a dying man and using blanket ALS interventions to prevent a lawsuit. And we all tend to choose the latter rather than the former, don't we? EMS is wonderful thing, but don't subject everyone to it's full force - it's neither dignified or particularly useful in the longterm. We should all have to right to die in a dignified manner, and that seems to have been forgotten in some quarters. Carl Ashman (for the record: RN and an ALS provider in a prehospital setting).