twist27896

Hey guys, I'll try and clear up some questions. In NC EMT-I's can intubate orally and nasally in many places. I honestly don't know why trismus persisted (it might have very well been rigor--I honestly don't know) although rigor didn't appear anywhere else that we could tell. The down time was heavily estimated as the arrest wasn't witnessed. We are in a transition phase with a new chief and policy overhaul and they temporarily took away the ability to terminate resuscitation unless rigor has obviously set in, DNR, or trauma inconsistent with life. The only thing we did know for sure is about the drug abuse hx. I am definitely not proud or "happy" that I did something in a grey area just wondering if anyone has ever heard of it being tried before.

We are working on being allowed to call asytole in the field but as of now we have to work it and transport for the ER to discontinue resuscitation unless obviously dead :\ We don't carry LMAs and we couldn't get the mouth open to use a normal adjunct. NPA was working and seemed to be effective. Just wondering if anyone has done this before and/or where there stance is on apneic nasal intubation. Pt was down for maybe 10 min? It was unwitnessed so it is kinda uncertain.

We don't really know the cause unfortunately. We gave the usual round of code drugs (including 2 rounds of narcan). The medic and doctors wanted a definitive airway so that was really the only reason I that I tried to get one than avoiding aspiration and reducing gastric air. As for it being a "code", it was an unwitnessed cardiac arrest in asystole. We walked into a report that the patient had "fainted".

I agree 100% that we should have our surgical airway stuff in our jump bag, but I guess due to budget constraints we only have one kit on the truck in the airway cabinet. The first responders had already placed an NPA while we were setting everything up. I am sure that the success was blind luck but my question is, should you ever try to do it in a similar situation? I mean every piece of literature, protocol, and advice says no but if it worked once and you are between a rock and a hard place, would it not be something to at least consider? As far as why the teeth were clenched we don't know unfortunately. The only history we were given was a methadone abuse and hx. of back surgery. I'm not a paramedic so I don't really know that much about RSI actually but I guess for non-code situations it might come into play? I could be missing ALOT of something here since I am not at the full Paramedic level which is what I am wondering.

Hi, So I ran into an interesting scenario today at work. We were on scene at a code and the patient presented with clenched teeth which we had no luck in intubating. We have no RSI protocol in our system... As my partner raced back to the truck to retrieve the cric kit and IO drill (we didn't know we were walking into a code) and the first responders were taking care of BLS I decided I would try the "absolutely contraindicated" nasotrachael intubation of our apneic patient (As an EMT-Intermediate I cannot do surgical airways). It went right in and functioned perfectly within about 8 seconds. My partner finally got back and was was shocked and confused about how it worked with no inspiration to guide it in. I guess I attribute it purely to luck but it got me thinking-- In classes and from talking to MDs and respiratory therapists, you cannot and should not ever try to go nasally with an ET tube on a non breathing patient (indeed I got chewed out at the ER). Does anyone else have any experience on this issue? I know the procedure is not intended for code situations, but it seemed to work so easily and quickly to be so harshly contraindicated in this situation. Obviously if other more reliable and indicated means were available (surgical procedures, RSI, etc.) that would be the better option, but what about if they are not readily at hand or a paramedic level provider is not present?

I understand that police officers as first responders need to have some basic first aid knowledge but this doesn't even seem legal. Chest decompression is an ALS skill which even in EMS and performed by educated paramedics requires medical direction (usually by standing protocol). I don't see how an average police officer can legally perform the skill without a physician director to practice under. I would also be wary becuase although, the skill can most likely be taught in a very short amount of time, the reasoning behind it may be more complex. Sure a person could probably learn how to locate a landmark and poke a needle till they hear a pop, but without assessment equipment and experience in assessing patients, I would be concerned with the procedure being used when it is not indicated. I agree that this is a disturbing thought. Afterthought: I do remember seeing at least one place where LEOs are paramedics as well. If he is talking about a case like this I could see it as reasonable.

I just got a part time job working as a "Industrial Health and Safety Technician" at a large tobacco processing plant. It is a really awesome experience because in addition to the normal medical side of safety, I have the opportunity to learn about equipment and machinery safety and help make policies, perform drug screens, run a medical clinic, etc. My question is does anyone know if any similar setups utilize ALS skills? Although I am an ALS provider with my EMS agency, at the plant I am only functioning as an EMT-B with limited drugs since we have no MD medical director. I am sure somewhere ALS providers are used in the industrial setting with a medical director, but I haven't been able to find much on the topic. Interested to see if anyone has any experience/knows more about this?

Fortunately no, the officer was busy with the girl and just took my license and information and interrogated me. My supervisor arrived very quickly and separated our crew and the officer. I guess I should have known that since I wasn't read any Miranda rights or taken to jail I probably wasn't really arrested. I was honestly too scared/confused to think that deep though. The officer did tell me that he was going to arrest me but I guess never got around to it, my supervisor talked him out of it, or didn't really intend to in the first place. The officer is apparently in some trouble for some of the comments/threats he made and refusing to let me obtain the patient's signature on a refusal form and refusing to talk to us upon trying to get him sign as a witness. He is facing a complaint of interfering with a EMS Technician. I kind of hope it goes through, but I do believe that many LEOs are unfamiliar with EMS laws : After all, they can take someone forcefully so I could see how they could assume we can too. I don't want to make too big a stir since it could potentially endanger my job and definitely relations with the police in our very small county. I am sure I will need their help sometime soon.

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Well everything somehow worked out. I spoke with someone high up in the public safety administrative ladder and he took care of it. Apparently I wasn't officially arrested but was being investigated by the officer and a charge hadn't been made yet (although that isn't what the officer told me when the incident happened). I believe the officer is in some trouble internally (not legally though) for the way he spoke to our crew as well. It is kind of scary to think that our public safety coworkers in blue would treat us this way when we should be working cooperatively. Interestingly he didn't seem to have as big a problem when my supervisor obtained the refusal...

@arctickat I was trying to say I have seen some people get so caught up in ACLS that they downplay CPR/BLS in codes (Looking back, I think i worded it weirdly). Also I am not saying that 02 cannot be harmful but that if a patient is in respiratory distress I think that potential benefits of high flow 02 would outweigh the risk of not giving it. I am not an EMS or medical expert obviously but a doctor I work with did reference some studies saying that in the short amount of time that we are with patients, it is unlikely high flow 02 will harm a patient. A similar discussion on jems takes a stab at this issue: http://connect.jems....en-and-copd-its. I do believe that in the long run too much oxygen can be a bad thing, but my rationale is that in the EMS setting it just seems much more dangerous to withhold than administer 02 when in doubt (a slight but possible risk vs the capability to greatly help the patient). Not saying that every person should be given 02, but if their condition warrants oxygen it seems more more risky too deny high flow than to give it if unsure. I personally would like to see a change in backboarding policy but so far our protocol is pretty strict and I again would rather be safe than sorry (legally) until our protocol allows more liberal clearance of cspine.

This brings into mind a recent incident. As an EMT-I I generally take direction from the higher level provider (EMT-P) On one call with a patient complaining of difficulty breathing, the paramedic scolded me for giving high flow (15 L/min NRB) to an asthmatic patient whose SP02 was in the very high 80's. He took off my NRB and gave the pt. 2 puffs on her inhaler and then 3 LPM via NC. The patients SP02 was slowly dropping into the mid to low 80's but the medic insisted on no NRB/high flow 02. He ended up driving and leaving me with patient care in the back. Due to the dropping SP02, increasing respiratory distress, and at the patient's insistence, I switched over to high flow 02 with almost an immediate (2-3 minute) improvement of SP02 and respiratory distress. In this case I did not argue with the medic but inside felt I had made the right choice against the medic's instructions. While 02 can possibly hurt a patient, it is very unlikely in the short time we treat them (in my opinion). I believe it can be extremely dangerous NOT to give 02 and mildy or arguably not dangerous to give 02. As an Intermediate level provider, I believe that ALS level technicians often forget the BLS aspects of patient care (i.e. giving 02, stopping CPR to give ACLS, not backboarding/taking CSPINE seriously, etc.)

I am sure this has been discussed MANY times but I have a question/opinion request on transport refusal. I'm an EMT-I in an county in NC and recently had a dramatic patient refusal. I was working a special event and was called to the police van for a possible rape/sexual assault. On repeated questioning/talking with the patient both in the presence and away from Law Enforcement officers, the female patient insisted that she was not raped, sexually assaulted, or the victim of any other crime. I informed the police that the patient was alert, oriented, and competent to refuse treatment and transport and proceeded to get a refusal signed from the patient after explaining why she should go to the ER. The on duty police supervisor had me arrested and charged with some random charge (I wasn't informed of the specifics) and called my supervisor to report that I was unlawfully refusing to take the patient to the hospital. My supervisor sternly warned me about going against the police but then stated that I could not have legally taken the patient against her will. I am a bit confused of what I should have done? On one hand I am facing some charge (he refused to even talk talk to me/answer questions upon arrest) from a police officer and on the other yelled at by my supervisor who ultimately stated that I did the right thing but should have obeyed the police. Has anyone had any experience in this? I am kind of apprehensive about what a court will say...

In regards to earlier posts, his BP was around 50 systolic upon arrival and decreased to the 30's enroute to the hospital (I'm not sure how accurate the monitor is on BP but we didn't have time to try and get a manual pressure with everything going on). I'm an EMT-I and was working with a paramedic. I know that we probably were able to get around 1.25L NS via 2 16 gauges (pressurized via squeezing) but I am not sure about the epi dosage-- as an intermediate it is out of my scope to use it to treat this specific situation so the paramedic handled it. I was thinking that PASG pants might have helped, too bad they took them off our trucks...

So we responded to a patient that was almost unconsciousness and it was determined that he had taken 2 doses of prescribed nitro after he had been experiencing chest pain after taking a Viagra earlier during the night. We attempted to VERY AGGRESSIVELY maintain a BP with fluid bolus and epi, placed in tredelenberg, and rushed him to the hospital. I don't know what happened to the patient, but what is there to do in a situation like this? We are taught to not administer nitro to patients on erectile dysfunction meds but not how to treat if the patient has taken the mix themselves. Is there anything that can be done at the prehospital level?