Ridryder 911

I believe what research and most of the authoritatives have finally concluded is that there is far more to resuscitation than getting a pulse back in a patient. Sure, I have had dinner with "successes", but of those that was in aystole for > 8 minutes prior to arrival and with no CPR ? No. .. Hmm If you have had "several successes", you might want to log them. I know of several medics and they too never have had very many if any "successes of aystolic" patients, with a prolong down time past the clinical death time, especially with no measures being performed prior to EMS arrival. Should we be pro active thinking of outcomes and costs .. yes. Will it affect my initial decision no. Will it affect my decision to prolong resuscitation measures after two rounds of medications and effective CPR in an asytole rhythm.. yes. I make that based upon sound clinical evidence and history. My medical director is the one that is promoting this as well as many other well defined EMS physician groups as well as AHA. I have been involved with EMS that has been performing field termination for over 25 years, this is nothing new except allowing lower levels to perform this task. Again, why continue measures that is going to be immediately ceased and terminated upon arrival ? Even being aware and knowing that after no pharmacological responses and to continue raises an ethical question. My ICU experiences are far from negative, rather they are realistically. Compare the number of patient in "end stage organ failures with those that are neuro intact and functional... one does not have to be a rocket scientist to see which is higher. Unfortunately, many internist and other physicians are not comfortable with discussing ceasing or DNR's and depend on the nursing staff to obtain and discuss with the family. I wish more was active in this.. ACLS is great, but again we have known without prior rapid CPR it is futile. Then again if one does get a pulse back.. this does not mean it was successful. For studying diseases and a non-viable post resuscitated patient, cannot be compared. After forty years of study the outcome is the same. Until we can reverse the effects of cerebral anoxia it won't change. Part of job is to be the patient advocate. Making the best educated decision at that time. Be it treatment should proceed or the maximum treatment has occurred for that patient. Let me ask.. what is the ER going to do more for a patient in aystole, that cannot be performed in the field? It is a hot topic and controversial enough many physicians are calling EMS hearses with lights and sirens. In fact one physician (sorry cannot recall exact name) describes that resources are being wasted to transport patients only to be pronounced. There is no difference in outcomes (in fact in-hospital outcomes are lower than prehospital). I do believe we have only seen the tip of the iceberg in change of treatment modalities. For the part of the vacation.. your probably right.. :wink: R/r 911

So you would go for 6 years.. not 8 ?.. R/r 911

Yes, and so will any physician, so you better get prepared. Sorry, two AMI and a CVA and no damage.. hmm something is wrong. There is damage albeit it may not be obvious to you . But to have a true AMI there is "scar tissue" in the myocardium. A cerebral bleed (CVA).. and no damage.. hmm how do you think they diagnose CVA on CT scans... Better think this one out. Yes, because it is not like a geriatric patient, infants are primary respiratory and not cardiac in origin, hence usually are more receptive to treatment. However, if they were aystole, I would call them as well. If they met the criteria. You haven't worked in the field much .. huh? I suggest hitting the books and volunteering in the ER to see what the real world is like. You are in for a shock... :shock: R/r 911

So EMSBrian how many successful codes have you seen ? I mean successful by having patients functioning outside the hospital confines. I cancel codes all the time.. Why? They are futile. period. If one is aystole and have been down greater than 8 minutes . they are not going to respond to pharmacological agents and IF they do, they will be in a vegetative state. Have you ever taken care of a patient in a post-arrest state ? Probably not... Try taking care of one for about 2-4 weeks in ICU. The patients meanwhile will have post arrest seizures every other hour due to the anoxia during the event or the massive cerebral edema caused by hyperventilation during resuscitation. Now, if they do so happen to survive .. without drooling for the rest of their remainder lives, they will be a cardiac crippled. Confined to bed rest, so they now can get pneumonia or multiple sepsis from the decub or the other few thousand bugs out there.. to slowly go into renal failure, then organ system shut down.... then die. So before we get the "hero" syndrome, our actions or even lack of has long outstanding repercussions. Not only physical but financially as well at $3000.00 to $10,000 a day. If I was to introduce a surgery or even any medical procedure that would extend a life only 0.5% of the time.. would we preform it... NO! It would be categorized as useless and non-worthy. Unfortunately, part of this job is to look at the whole picture ... not snippits. Yes, resuscitate if there is any question but let's be realistic. Why work a code to bring expectations and enormous costs to only cease immediately upon arrival at the ER ? What did we prove and perform ? Far as the family being better in the ER .. that is B.S! I can attest working in the ER & field & being the bearer of bad news on both sides of the fence, it is much easier on the family at home. Hopefully, the ER will allow family to view resuscitation efforts (yes, it is important to them). Yes, the patient is now the family... so do your job, contact the minister, other family members, get them something to drink.. the LEO and M.E. should be able to take over by then until the other parties arrive. R/r 91

I am looking for those that have demonstrated that they have a desire to go into EMS. This can be by taking prerequisites, such as anatomy, physiology as well as English, medical terminology courses, etc.. they have discussed the pros's & con's of EMS, and truly investigated it as a career with knowledge of what the job performances are as well as usual requirements and duties. Not somebody that has watched a few TLC shows & decided to take the course. What I don't want to hear : I am doing this to get a job with the F.D. I am doing so I can get through nursing school faster I am doing this get into Med., P.A., schools To be a Flight Paramedic or better to be a helicopter pilot ? My (insert family member) has heart problems & I wanted to know what to do Finally, I failed the Fries portion at McDonald's and didn't know what else to do R/r 911

I too too thought of becoming a physician a couple of times. Many years ago when I was young it was much more difficult to enter medical school. Most of the people were "sons" of physicians and one had to display financial security before application was accepted, which "nicked" me out. Most of us at that time did not have an extra $50,000 around. When I turned 40 I decided to have a change of life and re-took my MCAT and actually did better than the first time, and was accepted at two medical schools. Several of my friends wrote letters of recommendation. What surprised me was several of those physicians took me aside and wanted to describe the down side. Out of the seven only one informed me they would re-enter medicine. Many described the overwhelming costs of school, long hours, increasing demands made by corporate and HMO's, constantly changing in billing and reimbursement as well as the acute increasing of malpractice, has totally changed their outlook of medicine. They described they felt I would make a good physician, but again if they had to all over they would not and would not recommend it to anyone. Especially an older adult because of the factors I described. So now, instead of going MD, I will be going NP. Sure, it is not as much autonomy in some aspects or pay as well but I will not owe anything as well and it will meet my personal goals. R/r 911

What I do when they pass by is to"wave" at them

I have no problem with BLS declaring death on patients if there had been no resuscitation efforts prior to arrival with time delay>4 minutes, and the above criteria has been made as well. I believe we in EMS are too mind set in performing resuscitative efforts for ourselves and not realizing that it will not matter if we do not have early intervention prior to EMS arrival. As the study describes nearly 100% fatal... that not good odds. We need to stand back and see what we are doing that is wrong and what we need to do to change outcomes. R/r 911

I agree, if used properly and having a true understanding of the use and application of capnography, one can utilize this tool much more. It has been described as ..."just as the ECG is important for hearts, the capnography is for respiratory systems"... Actually, I believe capnography is more important tool over the pulse oximetry. Since this measures the respiratory system, where as the oximetry measures the absorption of oxygen which can take up to for 4-6 minutes to change. Presentations of CHF versus Obstructive or mixture can be determined, since respiratory med's can actually cause harm or damage if not needed. (Yes, it is not wise to give nebulizers to CHF).. as well help aid in the diagnosis of DKA. The neat thing as well it can be used from neonate to geriatric age, it is not affected by movement (such as seizures) and produces no artifact. This tool as well can be used in exposure to toxic agents (such as nerve gases, etc). Unfortunately, most EMS personal do not use this tool often enough because the lack of understanding and education in capnography. R/r 911

Ditto Dust; Actually, come and work at any ER/ICU/ or even med. surgical unit from rural to a major trauma center.... Obviously, you have no "worldly experience". Sorry, I consult physicians and inform them of what I have. I am legally bound not to perform a procedure as much as do one, if I know that medication or procedure is harmful to that patient in that current condition. As well, I guess you have never heard of NP's (yes, they are nurses).. And yes, they can practice medicine many states without a "physician" license, so feel like a big boy and read up on what is current in medicine. R/r 911

Statistically, EMS can not prove themselves to be worthy no matter what level is provided. Most of EMS and especially Paramedic level is preventive medicine, as well as management. Therefore no quantitative studies are accurate to demonstrate their worthiness and value. The problem in medicine, especially EMS is most are not educated in how to read and decipher studies as well as their flaws. Most students will briefly skim through and read the final conclusion and base their opinion of that statement as gospel. When in fact, the study might have been biased, flawed, or lack enough true data to be fairly represented. Remember, anyone can manipulate statistics to get the number they want. R/r 911

You are right Dust... ask most noobies about Z-track or what deep I.M. is and really can be administered and you will get either some blank stares or stupid answers. Makes one scared to think about them giving any iron derititive as well. R/r 911

Sure they were not "cardioverting"; if this is the case, it is routinely done. Albeit one would prefer to sedate if able to. R/r 911

Vistaril given IV can cause sever phlebitis (inflammation & possible destruction of the veins) and hemolysis of RBC's (destruction of red blood cells). It has it on the label and most health care workers are drilled; one should NEVER administer it IV.. a big NO NO ! R/r 911

Good discussion, yes chances are it is nothing.. but there is always that possibility. If one has a has even a small suspicion one should listen to that small voice. I agree, treat accordingly and symptomatically and definitely try to convince others not to wear "blinders" and get tunnel vision. I too have worked adolescent AMI's .. and after seeing one, fortunately they tend to stick in your mind and thoughts forever. p.s. good H & P .. thanks R/r 911

That reminds me of a flight crew I flew with once, the Pilot was "hard of hearing" typical helo pilot, and they kept a ping pong ball they would throw towards him to get his attention when he was off headset..Quite interesting. R/r 911

If you can do a follow up that would be great. Contact the infection control, employee health nurses at the hospital they can either assist or direct you in the right direction. R/r 911

You need to be concerned, not panicky. In about 2 weeks, you need to get to get a Tb Mantoux /PPD skin test. It takes at least 2 weeks post exposure to detect if you were exposed. Unless you were exposed, (such as cough, droplets) I would not be worried, but still tested. We mandate Tb testing 4 times routinely here. R/r 911

I agree Dust. It is strange how they can criticize us while they still have their palms extended out to receive money. Truthfully, we are the foolish ones, by continuing to extend financial help while still being stabbed in the back or being hated. Let their own countries support them for a while.. I believe many U.S. citizens are getting tired of supporting and helping others, only to get criticized and attacked by those we do help in return. They appearantly do not know or understand .."don't bite the hand that feeds you!"... R/r 911

I had a case several years ago with a car versus tree. (Tree won)The patient had classic Beck's Triad and muffled heart tones, ST elevation (ischemia) and the DORF sign on his chest (DORF= FORD backwards). I notified the ER and advised of my clinical impression. Upon arrival the patient was worked up for a "hot belly" even over my screams of "he has a tamponade!" The patient was taken to surgery and emergency lap was performed and ..... no bleeding was noted. The patient was then loosely together & then flew to the local trauma center. Upon arrival to the trauma center, a pericardiocentesis was performed and the patient improved immediately. The patient had to stay for several days due to the erroneous surgery that was performed !!! A few weeks later the ER physician (whom @ the time my medical director as well) asked me , what clues led me to believe he had a tamponade instead of a bad belly? I informed of such and he admitted to me that he got tunnel vision. He later apologized and informed me he would always listen better, in which he did. About 6 months later, I presented him with a GSW with one and yes, he tapped it... I believe this is one skill that should be taught, that can possible improve patient's outcome. Yes, we would have to increase the knowledge, and yes definitely improve skill level. Ironically, we promote "chest decompression" and it too has a high danger level. R/r 911

Again, due to improper administration . Will this thread ever die? R/r 911

Very true, however if I going to stick my neck out, I want to have everything that the "text" says I will need. Although, this procedure used to be taught even in the routine ACLS as one of the skill station, it has lost favor for prehospital care. Strange, because it is a standard treatment for PEA, and should be evaluated... especially in trauma. I suppose as we started "dumbing" & diluting down our skills and education level, it away with other knowledgeable skills as well.. R/r 911

I know of many Flight crews that wear the patch.. but, technically one should avoid medication while on duty. ( all right there is my pc for the day :wink: ) R/r 911

I agree a tricky one.. but funny how many would agree to do a C-section on a traumatic arrest or decapitation. Same, principle "out of range of education". I would personally reiterate, that I am not comfortable nor have the appropriate equipment. I would then contact or have him contact my medical director. If they wanted me to pursue, I would feel better. I personally would have no problem but would not because I do not have the appropriate treatment. When I first started in the field, we performed intracardiac Epi injections R/r 911

Admin. can we lock this.. apearantly, it has involved into a culture and governmental battle. Geez.. no wonder we still fight wars! R/r 911