chbare

You are called to provide transport of a patient with altered mental status from a small rural hospital to a hospital with additional resources. The patient's diagnosis is "altered mental status." Take if from here. Take care, chbare.

I think much of the problem revolves around the fact that many paramedic programs are simple shake and bake medic factories that spit out medics in 12 weeks to a year. True, well developed and executed 2 year programs exist; however, as long as this disparity with entry level paramedic education exists, I cannot see how the medical community could support medics taking on roles traditionally filled by nurses. I agree that nurses have many problems regarding entry level education. However, the minimal education is a 2 year program across the board with a few exceptions. (ie: Net based programs that allow other providers to transition into nursing.) So, with a nurse, everybody on a level playing field regarding entry level education. With paramedics, you never know. I hope nobody is offended by this post. This is not an attack on any single provider, just how I currently view this situation. In addition, I will be the first to admit that my profession is in dire straits and big changes may be in order. Perhaps I should make my bed before commenting on other professions, but I really do want to see EMS succeed and develop into a formally educated and recognized profession. Take care, chbare.

Your rationale is correct regarding the fact that p waves can originate from areas other than the SA node; however, is this really the case with the patient in the scenario above? Is this really the patient's primary problem? There is a significant amount of evidence that supports the hypothesis that the tachycardia is related to the patients underlying condition. You will have to convince us that using adenosine to rule out other problems was in fact the most appropriate course of therapy with this patient. Take care, chbare.

Now that somebody else answered, this is also my diagnosis. TCA's are harmful when overdosed by three general mechanisms. 1) Cardiac Toxicity: They block fast sodium channels and you can clearly see the effect in the 12 lead. You may see heart blocks and lethal rhythms develop. 2)Anticholinergic effects: You see the altered mentation, pupil changes (dilation), fever, and many other neurological effects. 3) Alpha blockade: Hypotension. My treatment would include: -Aggressive airway management. -Sodium bicarbonate therapy. -Supportive care and seizure precautions. -Possible initiation of vasopressors. (I think norepinephrine would be the med of choice related to it's strong alpha effects.) Take care, chbare. 3)

Indeed it can, especially in this case. However, I want some of the other members to research and come up with the answer on their own. Take care, chbare.

Sdowler, look at this patients presentation, medication list, then the 12 lead. Why are the QRS complexes wide? I am chomping at the bit to say my working diagnosis, but I will refrain. Take care, chbare.

Hmmm..I have not seen this in a while. Look at her history and presentation, then the 12 lead. I think the puzzle should come together quite nicely. Unfortunately, the problems is not very nice. Take care, chbare.

Remember, in the setting of poor perfusion (Cardiac Arrest) and severe ventilation/perfusion mismatch (massive PE) , you may in fact have very low or unobtainable exhaled C02 values. In addition, it sounds like they were not using capnography, just a simple color changing device. I have had mixed results with these devices. I will not condemn the crews airway management strategies until we have an actual number of attempts at ETI. I have known a few BIG's to fail as well. A highly experienced medic that I worked with tried twice with different devices without success during a bad code. His technique was correct. Sometimes these mechanical devices fail. I am not sticking up for the team in question. However, I think we need more information about their actions prior to passing judgment or commenting on the way they handled this situation. Take care, chbare.

I understand your thinking. I would not have gone the route of adenosine with this patient; however, that is not to say you were in the wrong. Medicine is pretty complex in this way, you can arrive at a plan to treat people by taking many paths. No one path may be more or less beneficial than the others. I imagine you are starting to see this outside of school. Providers can differ in the way they look at their patients and their treatment modalities may differ as well. However, we agree on the major points: His airway and breathing was addressed and he was receiving a fluid challenge. Take care, chbare.

"A tough situation for sure, but it beautifully illustrates why you should go to paramedic school." Agreed. That aside, I think you provided excellent care within your level of training. You recognized the life threat and took aggressive measures within the BLS scope to treat the condition. You recognized the need for ALS and it sounds like you tried your best to deliver the patient to a higher level of care. It sounds like you have the BLS stuff down, all the more reason to get your butt back into school. :wink: Take care, chbare.

I agree. I am not sure adenosine would have been the best choice with this patient. When looking at tachycardias, one must consider the cause and correct if possible. If you thought his unstable condition was in fact because of his heart rate, cardioversion would have been a therapy to consider. I understand your thinking regarding ventricular filling time as it relates to decreased cardiac output with extreme cases of tachycardia; however, I think this patients tachycardia was part of a bigger picture. I applaud the fact that you are willing to put yourself on the stand in front of your peers and take both the praise and criticism. I do not see this as a recurring theme with EMS providers. Many people are too prideful and self absorbed to even think about attempting to learn from their actions, bad or good. In addition, you seem quite willing to own up to your decisions right or wrong. (Not that I am telling you that what you did was incorrect, this is simply how I viewed the situation given the information.) Take care, chbare.

NREMT-I/85 is based on the DOT 1985 NSC. It is essentially a basic with a few more hours of training and additional skills. This level is based around additional assessment skills, IV therapy, and advanced airway management. You should find that the written is actually quite basic in nature. Many of the questions are BLS in nature. You will have to answer a few IV questions and calculate a couple of drip rates. In addition, you will answer a few questions on airway management. You will only have 4 psychomotor skills stations: 1) Airway management 2) IV therapy 3) Patient assessment and management (Trauma) 4) Random basic skill NREMT-I/99 is based on the DOT-1999 NSC. The exam from what I understand is more in depth than the 85 exam. The psychomotor stations are similar to the paramedic stations. The course is a few to several hundred hours in length. The I/99 receives additional training in several areas and can generally perform more interventions than the I/85. Much of the scope of practice will depend on local policies, state policies, and medical direction however. With all of that said, I would go the route of paramedic if I had a choice between the three routes. Take care, chbare.

The first question I have to ask is why did they defibrillate asystole? Perhaps there is more to the story than you think? I wonder if the initial rhythm was shockable and perhaps she deteriorated into asystole as the code progressed. As far as working a code for 40 minutes, I cannot comment because I do not know you guidelines or the wishes of your medical director regarding cardiac arrest patients. Take care, chbare.

Poor acting, unoriginal script and situation, and full of antiquated cliches. This conclusion was formed from just watching the link from the first post. Take care, chbare.

JPINFV, thank you for the clarification. I think some of the problems faced in transport revolve around services not appreciating fully the level of care that they should provide. For example, I have very little formal education regarding the care of neonates and neonatal critical care. I would never consider transporting a critical neonate. In addition, I see allot of services flying non emergent patients, and I have to wonder if $$$ rather than appropriate level of care is the bottom line. However, I digress. Take care, chbare.

JPINFV, thank you for the clarification. I think some of the problems faced in transport revolve around services not appreciating fully the level of care that they should provide. For example, I have very little formal education regarding the care of neonates and neonatal critical care. I would never consider transporting a critical neonate. In addition, I see allot of services flying non emergent patients, and I have to wonder if $$$ rather than appropriate level of care is the bottom line. However, I digress. Take care, chbare.

What?, a CCT educated crew did not know about Flolan? As long as you know that Flolan is for pulmonary HTN, you would at least know it's not a bronchodilator! Another team did not know how to set up or use their vent? I just do not know what to say....I hope Vs-eh? does not read this. I take it these are hospital based crew members that are simply pulled from the floor when a transport is required? I wish EMS providers were more cautious in the way they think about patient management. I see allot of providers simply want to do things because "I can." Take care, chbare.

I am still a little confused. When you have a CCT, who provides the non pulmonary interventions. For example titrating gtts and medication administration? You say that a RN may or may not come along with vented patients and paramedics do not work for the service, so who provides the other interventions during a transport with a RT but no RN? Perhaps I have simply misread your original post. :oops: Take care, chbare.

Do your RT's push medications and titrate gtts in addition to vent management and pulmonary interventions? Not to say a have a problem with this practice. Does your company strictly provide CCT, or do you also provide 911 coverage in addition to CCT? Take care chbare.

That about sums the situation up. Where I work, most of my vented patients are out of an ER. Most of the patients are on some type of ATV such as the Autovent 2000 or they are being bagged. In many cases, the Vt's and rates are very large and their CO2's are very low. I have seen many patients with CO2's in the 10-17 range upon initial presentation, so it does take me a little time and some titration of the settings to obtain pressures, vital signs, and ETCO2's I feel comfortable working with. In the few cases of ICU vented patients, I find that I really do not need to make significant changes from the sending facilities settings. Most of my care is based on liberal dosing of pain medication and sedation. It never ceases to amaze me when I have an unresponsive patient on a Diprivan gtt suddenly wake up as soon as the rotor begins to turn. I really believe that the extra stimuli outside of the hospital has a profound effect on out patient. Take care, chbare.

Funny, Murse. I suppose JPINFV presents us with a valid question. Perhaps we could be more specific and ask how much interchangeability can we allow between providers? I admit I do not have the specific pulmonary education of a respiratory therapist; however, with my education, is it possible for me to take over some of the roles that the RT would traditionally fill in special situations? I am not sure of your background JPINFV; however, many flight and critical care transport companies in fact utilize RN/Paramedic teams to provide critical care transport. Can we adequately educate these providers to transport patients on ventilators safely and effectively? The second question is a bit more complicated. Much will depend on the patients condition and clinical presentation. Many hospitals in my area utilize very high Vt's and I usually end up titrating the Vt's down. The real advantage I have is continuous waveform capnography, so it allows me to titrate settings and I actually have some instant feedback regarding the ventilatory status. Take care, chbare.

This is a very complex subject. I find that it is difficult to simply go with the hospital settings. The additional stimulation and stress of the prehospital environment will usually require additional sedation, analgesia, vent changes, and perhaps neuromuscular blockade. I cannot comment on the specifics of the LTV, as I use the Crossvent 4. I would urge you to obtain as much additional education on vent management as possible. Things to consider with ventilators include: Type of ventilation: Volume vs Pressure The mode: SIMV, IMV, PS, etc. Tidal Volume: usually calculated at 6-8ml/kg of lean body weight. May vary and lower tidal volumes may be used in specific conditions such as ARDS. Rate: Will vary according to the patient condition. Flow: Flow of oxygen/air, generally adults are most comfortable when the flow is around 40 lpm, but this will vary according to patient condition. A down and dirty basic calculation is to add 6lpm per every 100ml of tidal volume. FIO2: Will vary according to patient condition. Peak Pressure: indicator of airway pressures and resistance. Generally I try to keep below 35, very high pressures can result from disease or equipment issues such as a kinked tube or obstruction. Always ensure proper connection to tubes and vent with very low pressures. Plateau pressures: Indicator of actual pressures in the lower lung tissue and indicator of specific types of air flow through passages. ( Turbulent, etc) This is a very important indicator of pulmonary damage and the development of ARDS. Try to keep below 30 if possible. PEEP: Positive pressure at the end of exhalation, used in a variety of conditions and can assist with oxygenation and recruitment of alveoli. I:E Ratio: I: amount of time spent inhaling, E; amount of time exhaling. Generally we allow for more time to exhale. If you look at a regular breath, one inhalation and exhalation. The amount of time inhaling would be similar to the I time, while the time it takes to exhale would be similar to the E time. Generally, we shoot for 1:2-1:3. Many complications and pitfalls exist with ventilator management. In addition, this all must be taken into consideration along with your patient assessment, end tidal CO2 management, labs, and vital signs. This topic is too complicated to adequately discuss on this forum. I have given you a few basic concepts to study and hopefully if you can understand these with additional education, you will begin to put the pieces of this complex puzzle together. Take care, chbare.

I am not exactly sure what you are trying to discuss on this thread. I think I can identify a few general points: 1) Explain the Basic EMT scope of practice. 2) Paramedic ego hold back BLS providers. 3) BLS providers do not need paramedics if the paramedics are stupid. 4) BLS providers are more useful than first aid trained high school students. Is there a general point of discussion to this thread? You will have to better articulate your stance and perhaps be a little more specific in your deliver or you may take a few hits from some of the other members on this board. Take care, chbare.

Upon arrival at the trauma center, the ER physician attempts to perform a cric and obtain a surgical airway without success. Surgery is called and they end up having to perform a trach to establish a definitive airway. FAST exam is + for intra-abdominal blood. The patient is taken to OR where both liver and spleen injuries are identified and repaired. In addition, a Leforte II fracture is identified along with a cerebral contusion and basilar skull fracture. No additional follow up information is available. On a side note: I suspect the high airway pressures and high ETCO2's were likely related to the fact that this patient was very large and required higher airway pressures for adequate ventilation. Many of the rescue devices will leak around the 20-30 mm/hg mark, and I suspect that the patient was receiving a less than optimal Vt and this led to retained CO2. I hope everybody enjoyed this scenario. This is a little different than my "usual" scenario, but we cannot always live in the land of Oz. Sometimes it is nice to see how people think when confronted with the same problem, hence, the title "out of the box." Take care, chbare.

Incorrect, anybody is free to participate in my scenarios and case studies. The purpose of these studies is to encourage critical thinking and produce viable discussion regarding the topic at hand. While many of my scenarios require ALS interentions, do not let this stop you from researching and joining the discussion. In addition, BLS interventions will always play a key role in any patient encounter. For example, could the provider in this scenario place an OPA if tolerated, have somebody hold cric pressure while another person holds a two hand mask seal, and continue ventilation with frequent suctioning for the entire trip to the trauma center? Perhaps a layer of surgilube over the beard would have helped ease the work of maintaining a mask seal? Do not sell your self short. The purpose of my scenarios is to help with learning and to encourage intelligent discussion. This scenario is not related to some of the other discussions on this site. Take care, chbare.