chbare

ERDoc, you bring up a good point regarding retrograde intubation. This may have been a great choice for the patient. Unfortunately, this procedure was not approved or in the guidelines for the providers practice, so it was not even considered. P3medic, Monday it is. :wink: During transport, you are only able to keep the patients SPO2 around 49-95% and his ETCO2 stays in the upper 40's regardless of you ventilation strategy. I have my own theories as to why this occurred, but I will let other people chime in with their opinions. The patient was given a 1000ML challenge of warm saline in order to bring his MAP up due to the high possibility of a head injury. His pressure stabilizes at around 88-90/50-54 with a heart rate of 110. Pupil exam reveals a 3mm sluggish right pupil and a 5mm unreactive left pupil. Would you have done anything else? Take care, chbare.

ERDoc, I agree with your post; however, from the perspective of a field provider, identification of tamponade will be based on history/MOI and the clinical presentation. P3medic, I understand your stance. The patient continued to have a resp rate of 6 even after his airway was suctioned and cleared with BLS techniques. He was unable to maintain adequate ventilation and oxygenation and required PPV. This would have been near impossible with the patient on his side. The provider did not go the path of an awake technique (nasal), because of the difficulty encountered in clearing the airway and the very slow resp rate. RSI was chosen because he wanted to rapidly establish airway control. Right or wrong? After the second attempt, you do not feel confident that you will be able to establish an airway via oral intubation. This in essence or reality constitutes a failed airway situation. Two options are considered: 1) Rescue device 2) Surgical option You prep for a surgical airway then insert a Combitube. The tube is inserted without difficulty and you are able to ventilate through port number 1. No epigastric sounds are noted and bilat lung sounds are appreciated. You note that the sounds are diminished bilat however. You attach a wave form capnography device and note the plateau shaped wave form with an ETCO2 of 55. SPO2 remains in the 94-96% range with BVM ventilation through the Combitube. Why the Combitube versus a surgical option? You were able to perform adequate BVM and BLS airway maneuvers and wanted to try a rescue device prior to the transition to a surgical option? Would the LMA have been better as somebody mentioned? Right or Wrong? What will we do during transport? Will we resuscitate with fluids? How about ventilatory management? (Vent settings, ongoing sedation or analgesia?) Take care, chbare.

P3medic, how would you have managed this airway? This is not a challenge; however, discussing other strategies is very important with this scenario. Pyroknight, does your system allow for the use of rescue airway devices? We know that attempting a cric on this guy will be difficult. Is it reasonable to consider a rescue device with this patient? I will not disagree with your stance; however, we could take a number of paths with this patient. I think a few good points have been identified: 1) This is a difficult airway. 2) Are we confident we can successfully intubate this patient? 3) We are able to maintain effective ventilation and oxygenation with BLS maneuvers, so we are not in a "cannot intubate, cannot ventilate situation." 4) What are our options? In this case, the provider takes a second attempt. You change your blade and directs one of the EMT's to provide ELM during the attempt. You are still unable to visualize anything and must abandon the attempt after the SPO2 decreases to 92%. However, with some difficulty you are able effectively ventilate with BLS techniques and the SPO2 again rises into the mid 90's. What options are available at this point in time? What path do you choose and why? Take care, chbare.

Cardiac tamponade is very much a clinical diagnosis. 12 lead findings may indicated electrical altrans, low voltage QRS, or possible ST changes. These are not always found in tamponade and should not be used to diagnose tamponade without clinical evidence. I do not think it is unreasonable to obtain a 12 lead if thoracic trauma or tamponade is suspected, providing, interventions to secure ABC's are completed. This is however not the case with this patient. There are no external indications of thoracic trauma with this patient. This is not to say we can rule out thoracic trauma; however, I think we will have our hands full with other priorities and interventions as this time. Allow me to further quantify the use of copious. Initial suctioning brings up about 30 ML of blood and several 1 cm diameter blood clots along with several teeth. We decide to go the route of RSI. After giving whatever cocktail of medications are in our giudelines ( I will not start a discussion about defasciculation and lidocaine for head trauma. Perhaps another thread.), a flaccid and unresponsive patient is the outcome. The first attempt is unsuccessful. You suction about 20 ml of blood out of the airway, but are unable to visualize any landmarks. After about 30 seconds a SPO2 of 92% is noted, and you abandon the attempt. You are still able to maintain a seal and BVM ventilations with BLS techniques; however, it takes allot of work to do so. After about a minute of BLS maneuvers, the SPO2 is 96%. A HR is 130 is still noted and the B/P is 82/40. Go for another attempt? Take care, chbare.

Allow me to clarify the helmet issue: There is no indication that the patient was wearing a helmet. Post auricular ecchymosis is noted. The patient has an intact gag reflex, so you opt to perform BLS airway management techniques while direct pressure is applied over the flap and manual spinal precautions are maintained. A jaw thrust is performed and a two person BVM technique is utilized to provide PPV. You note facial crepitus and you also experience allot of difficulty in maintaining a face seal. In addition, the patient has a full beard. You suction the airway and not copious amounts of blood. You also note that the patient is quite obese with a very short neck. You understand that this will be a difficult intubation and if you need to transition to a surgical airway, you will have difficulty in locating landmarks. You are able to maintain a seal with much difficulty while an EMT first responder provides BVM ventilations. Your partner controls the scalp hemorrhage and obtains a set of baseline vital signs. P-130, B/P- 80/42, SPO2- 88% R/A-->94-96% with BVM ventilations. He also starts an IV lifeline and obtains a BGL of 112mg/dl. The nearest trauma center is 25 minutes by ground and 15 minutes by air. If you are looking at this scenario as a ground medic/EMT, then you have no air resources available and only you and your partner have ALS capabilities. However, your partner is a newly minted medic and appears very anxious and overwhelmed about the whole situation. If you are looking at this as a flight medic, then all people on scene are BLS and your partner is a newly minted flight nurse with rudimentary airway management experience. All advanced interventions will most likely be performed by you. (It's all you!!!) So, it appears that we are at the crux of this scenario. What path do we take to secure this patients airway? We know that this will be difficult at best. Do we take the path of RSI? Take care, chbare.

Pt found in the middle of a paved back road, no safety or access problems appreciated. The other questions have been answered in the prior posts. I am reluctant to give full signs and diagnostics such as BGL's because I think we may need to provide immediate interventions and perform addition assessments based on the primary assessment before moving on to more definitive therapies. Take care, chbare.

One vehicle and one patient involved. He lost control of the bike at a high rate of speed and was thrown around 30 feet to land on the pavement. The best guess as to why he lost control was, the patient was driving at a very high rate of speed and lost control. You initial assessment: Pt found on the pavement in a right lateral position. The patient does not appear to be wearing a helmet. He responds only to painful stimuli and a GCS of 6 is appreciated. You not obvious massive facial and head trauma. A massive profusely bleeding scalp avulsion over the right frontal and parietal area is noted. Multiple facial abrasions and contusions along with post auricular ecchymosis and periorbital ecchymosis is appreciated bilat. The eyes are swollen shut. He has gurgling respirations with a rate of about 6 per minute and irregular. He is pale and diaphoretic with a weak radial pulse of 130 that matches his carotid pulse. The rest of his physical assessment is unremarkable. Where do we go from here? Take care, chbare.

You are called to the scene of a 20 year old male who lost control of his motorcycle on a back road. Take it from here. Take care, chbare.

"Please do not become a nurse if it is not what you want to do. To be a nurse you have to have compassion and be passionate about what you do, otherwise you will not be a very good nurse and you will burn out easily. You also have to be able to deal with doctors, some of who can be pretty rough. If your heart is not into nursing this will wear on you very quickly. Nursing is a career that you need to have your heart into, if you don't you are doing yourself and your pts a disservice." That is a very good observation ERDoc. This understanding of Nursing is not well understood by many physicians. However, I would bet the same applies to physicians. I could not imagine many students make it through med school and residency without having a great deal of passion for what they do? Take care, chbare.

As I understand, many of the 2 year programs require pre/co-req classes in addition to the core paramedic program. As Ridryder911 stated, it is hard to appreciate another profession without actually being part of that profession. I honestly thought that I was a step ahead of everybody and that Nursing school was just a simple consumer of my time. I thought this because I honestly thought my EMT-B & CNA training prepared me to work as a Nurse. Heck, I even had ACLS, so I knew what color of box to open and push when presented with a strange squiggly line on the monitor. I simply did not know any better and EMS culture seems to accept and nurture this attitude in many areas. My first semester of school was long, horrific, and humbling. As I learned and matured as a provider, my views on skills changed as well. As a basic I thought "RSI, cool they taught me that in a 1/2 hour lecture in PHTlS, I can do that and cannot wait to do that." Now, many years later, when I arrive on the scene of a bad patient and think RSI, I pucker up and think "oh God, this could be bad." Why the change in thinking. I have learned to realize that medicine is complex and patients rarely present like the cool scenarios in the EMT book and act like the patients in the skills stations. A comprehensive educational experience is crucial to develop a good understanding of how the human reacts to illness and how our interventions effect the patient. Take care, chbare.

You are correct, I have been owned. In addition, PETA and Greenpeace are better organized and much more motivated to advancing their cause than most EMS providers. Take care, chbare.

I remember when I first started college many a year ago. It was the first day of my English 1010 course. We were asked a question by our instructor. What is literacy? We spent the better part of an hour attempting to describe literacy. Finally, he asked, "is literacy simple reading or writing?" Then, he asked can anybody explain the fundamental difference between liberal and conservative? The class was quiet. We were all in college to do whatever degree, and we could not even describe two very important concepts at work in our country. He made a great point regarding education, it is more than simply learning a few skills. A literate person should have a broad knowledge base to work from. A few hundred hour course of instruction will teach you skills; however, does this give you a broad base of knowledge. In addition, specialized courses related to your profession will only help you make advanced decisions and see the big picture regarding you patient. For example, I have a liver failure patient. What does my cook book say regarding abdominal pain? IV, O2, transport, possibly pain meds. What can I expect with my knowledge of A&P, coagulopathy, altered mentation, questions related to the pathogenesis of the disease. The question to ask is the following. Is education worth it? Do we want educated providers or trained monkeys. If we choose the monkeys, I say get rid of all the human medics and EMT's and replace them with chimpanzees trained to place people on non rebreather masks and drive ambulances. At least we can save a little money on wages and benefits. Take care, chbare.

My rebuttal would be to ask, "why do they have that lazy attitude?" :wink: Take care, chbare.

Depends on the type, size, and depth of the burn. You could send your patient into hypothermia if they have major burns. Take care, chbare.

And a K+ of 1.2. Take care, chbare.

Somedic, I agree and I am gland that I am not the only one with this view. It seems that the whole TOMS/TEMS concept has exploded into a full blown trend (The purple shirts are in kind of trend.) over the last few years. Take care, chbare.

From a stance of cost effectiveness, team cohesiveness, OPSEC, and overall survivability/effectiveness, would it not be easier to give the officers 60 hours of relevant tactical medical training? Then, the entire force is on the same page and all of the officers are able to provide front line interventions. I am not sure that a paramedic level provider will do much to the outcome of a violent incident. I am not sure that it really takes a paramedic to pull a wounded officer behind a car and return fire. (Honestly, the officer is better equipped to provide this level of care.) I cannot see any tactical medic intubating, pushing meds, and pacing until the threat is secured. This is not a blow to paramedics. However, I do not see ALS care taking a primary role in tactical operations until the scene is somewhat secure. Most of the interventions will be law enforcement based and BLS in nature until the scene is more secure. Please correct me if my thinking is incorrect. Take care, chbare.

More of the same really. We all know EMS is broken. Fixing the problem is a bit more complicated. I disagree with the thought that Nurses do not belong in the field. You must be careful with sweeping generalizations. I think the paramedic should be the prehospital standard of care; however, a Nurse can be a valuable asset and a good addition to the team. For example, look at the many HEMS services that utilize RN/Medic teams. I work in such an environment, and have to say that with the combined experience we are able to provide complex care in nearly every situation. I do not think every Nurse is entitled or qualified to work in the field, but there are specific individuals who can make great field providers. On a side note, I agree that paramedics do not need RN preceptors. A properly qualified and educated paramedic should fill that role. In addition, I have always supported having paramedics work within the ER. Take care, chbare.

I currently use Golden Hour. Cannot say I have much good to say about that program. Take care, chbare.

Not a problem. I love to learn and enjoy looking at how other people think. Take care, chbare.

Scottymedic, why do you think this is ventricular tachycardia? This is not a challenge; however, I am curious to see how you arrive at this conclusion. As stated earlier, right shoulder axis deviation is characteristic for ventricular tachycardia. Upon completing a 3 lead axis assessment, I do not think there is right shoulder deviation. This does not definitively disprove the ventricular tachycardia hypothesis; however, it leads me to question the actual origin of the tachycardia. Again, I am not trying to bust anybody. I love great conversation and I love to see how people arrive at their conclusions. Any follow up would be helpful. Any way to obtain a copy of the 12 lead performed at the receiving facility? Take care, chbare.

Great story and good strips to document your work. It looks like he had a massive inferior wall MI. It also looks like he hit the posterior wall as well, and I bet the right ventricle also took a hit. The bradycardia is actually quite common with this type of MI. The RCA supplies the nodes in a significant portion of the population. From the strips, it looks like the block was transient and self limiting. Take care, chbare

I would still like to know this patient's medication and medical history. From the strips, it looks like I is upright. If you do an axis assessment based on leads I,II,III, you can tell that this is not right shoulder deviation. This leads me to suspect something other than ventricular tachycardia. A 12 lead would be quite helpful. Did the receiving facility do a 12 lead? Are you able to get any follow up? Take care, chbare.

Was the patient stable? Were you able to obtain a 12 lead? An assessment of the axis would be helpful. (Right shoulder deviation.) In addition, patient history could also help. For example a history of WPW. Take care, chbare.

You can download the trial from medicalwizards.com. May I suggest looking at theresqshop.com. You can also download a trial of that software. I would highly recommend the resqshop software. Take care, chbare.