chbare

First, be patient. Next, Google may help you find your answer. Third, an EMT City search may help you find your answer. Finally, you may have people question the way you articulate on this forum. Take care, chbare.

I am suprised Ventmedic does not have us all saying "Denitrogenation" instead. Take care, chbare.

http://www.casualtycareresearchcenter.org/ You could simply shoot an email to the link provided if you need additional information. Tak care, chbare.

You could use a competitive NMBA; however, then you have prolonged paralysis. I agree that nasal intubation would be a much better option. Take care, chbare.

Pre-treatment for hyperkalemia would not be indicated unless you have evidence of cardiac conduction problems related to hyperkalemia. I would look for the typical ECG changes prior to considering giving medications. Typically, your serum potassium will have to be quite high before you start developing cardiac conduction abnormalities. (6 Meq/L or higher in my experience.) I can appreciate your thinking on this matter and having CaCl- and NAHCO3 within reach would not be a bad idea. I would also expect a degree of Rhabdo in this patient. The risk of renal failure is a concern and fluid therapy if the patient can tolerate, would help "flush out" muscle death by-products and maintain renal perfusion. At some point, a foley cath will be needed as well. I know some people advocate NAHCO3 for Rhabdo; however, I really hesitate to administer bicarb without a better clinical picture. (Labs, etc) Take care, chbare.

I agree with your first statement. However, why put a King in a dead person? I simply do not agree with the whole "well it can't hurt so let's do it" concept. Even the AHA is deemphasizing the whole airway management concept for good chest compressions. I think I understand your point as such: the only situation where BLS providers will place a rescue airway is in an unresponsive patient without a gag reflex. I would agree that most patients who meet this criteria without chemical intervention will not have a pulse. Perhaps I am incorrect in my thinking? I still cannot see how the King used as the sole airway for these patients will help, if in fact good CPR seems to be much more important to the outcome in the arrest patient. I like the fact that you want evidence to backup claims; however, some things are quite obvious. For example, you see a pile of steaming hot poop on the floor. The smell causes you to gag and looking at it causes your stomach to churn. A research grant followed by a study is really not needed to prove that it will taste bad. However, I would not be surprised if such a study exists. This concept is my point. There are patients who simply cannot be managed with supraglottic airway devices. Look at an asthma patient with peak pressures of 50 or more, or perhaps a liver failure patient who is 18 months pregnant with fluid and has the highest portal pressures you have ever seen. Then notice the massive amounts of blood that they are spewing from their mouth. This is why I think simply taking intubation and RSI out of the ALS providers scope and substituting "alternative airways" would set a dangerous precedent. Take care, chbare.

It is a sad day when we look at patients as cadavers IMHO. Look, we have two kinds of arrest patients. Either we have somebody who we think is viable and may benefit from our care, or we have a dead person. If you are dead, then a King, ETT, or whatever simply will not help. If you are a potentially viable patient, then you should receive appropriate care. I do not understand the, "well the guy is already dead so this really will not hurt him anyway" argument. I can only assume it is simply about letting somebody perform a cool guy skill. Are rescue airways appropriate care? Much depends on how you define appropriate. However, simply taking away the only option that is considered a true definitive airway and replacing it with a method that is not definitive sets a dangerous precedent IMHO. I understand many ALS providers may not do many field intubations. The company clinical coordinator should ensure that paramedics are getting tubes. I understand the difficulty with getting into the OR; however, companies must be much more proactive and advocate for their ALS provides. Otherwise, the company sucks. Take care, chbare.

Try the following link. The studies may be a bit biased however. http://www.kingsystems.com/EDUCATION/Clini...21/Default.aspx Take care, chbare.

Hmm...a few questions if I may? What was the transport time to the nearest appropriate hospital? Were the EMT's able to effectively manage the airway with BLS techniques? I understand the pulse oximetry reading was 92% after placement on a NRB without the use of airway positioning or adjuncts? I have a difficult time understanding why the EMT's opted to go with RSI even with several reliable indicators of a difficult airway? One one hand the patient has persistent trismus, while in another statement there is limited jaw movement and the EMT's are able to suction the airway. I am having a hard time getting a true picture of the patients actual airway situation. While RSI is not contraindicated with the difficult airway, the person intubating must be confident and a double backup must be in place prior to going down that route. It seems that there was some discussion among the crew about performing the RSI? Were both members confident RSI was the proper route? Were alternative strategies discussed? In addition, why was pulse oximetry not constantly monitored throughout the procedure. Were the EMT's able to provide effective BVM ventilations between intubation attempts and after the aborted attempt at placing the ETC? I second the possibility of hyperkalemia r/t Succ admin. I understand the presenting rhythm was NSR; however, were the T waves Tall and pointed? During the RSI were any other changes noted other than sinus brady that went to asystole? Was a sine wave ever noted during the procedure? Another possibility to consider would be beta blocker OD; however, the presenting rhythm was not bradycardia, and the bradycardia seemed to develop during the procedure. Take care, chbare.

http://www.emedicine.com/MED/topic2417.htm Take care, chbare.

Wow..I..uhh... :dontknow: Take care, chbare.

In addition, many people strongly caution against using adenosine when an underlying A-Fib or Flutter is present. With a rate of 310 and WPW, I will assume A-Fib until proven otherwise and avoid using adenosine. Check out this reference for additional information: http://www.emedicine.com/emerg/topic644.htm Take care, chbare.

I agree. It seems there is still confusion regarding the patient's status. Remember, you can be symptomatic and remain stable. Symptomatic and unstable are not synonyms. In a patient with stable hemodynamics, intact neurological status, and minimal symptomology, why would we not consider a trial of medication? With that said, I understand that some people will interpret the current guidelines differently. In addition, I agree that a medication such as amiodarone would be a good choice for this type of tachycardia. I would also like to add that any medication that specifically targets the AV node such as adenosine should not be used in any patient where you suspect A-fib or A-flutter pre-excitation. I think the pathology behind the problems associated with this practice have already been discussed. Take care, chbare.

True enough; however, living in a third world country..eh..far southern state that borders on a third world country will be much cheaper compared to living in California. (Generally speaking.) You can visit California during your assignments then bring that money back home while saying "I am sure glad I do not live there." Take care, chbare.

Better yet, get out of California, move to a cheap state, hook up with a travel company, make killer wages traveling to California, and bring the loot back to your cheap ass home. IMHO. Take care, chbare.

$$$ Take care, chbare.

Consider relocation? Take care, chbare.

Why not go for your RN? You can knock out the Excelsior in several weeks if you really wanted to put in the time and effort. I know a medic who blew threw it by taking a test a week. Take care, chabre.

Actually, Dustdevil has been the most consistent with his arguments. In a sense, it is one way discrimination if you will. EMS workers can prevent somebody with one of these diseases from joining their ranks; however, the same standard does not apply to the patient, even when considering the safety aspect of the argument. So far, the evidence that I have seen indicates that actual exposure incidents and transmission of a disease is more likely to occur between an infected patient and uninfected EMS worker. Not the other way around. So, for the sake of discussion, Dustdevil's argument is valid. Nothing personal people, it is all about meaningful discussion from where I stand. I liken this to Vs-eh's God/transformer thread. You do not have to agree; however, meaningful discussion occurred. IMHO Take care, chbare.

Hard to say without all of the information. The medic's decision was based entirely on his assessment of the 12 lead? I wonder if there were other factors to consider? In addition, a s/p cardiac transplant patient experiencing typical chest pain from an AMI would be a little unusual. Remember, the heart is not directly linked to the nervous system. In many cases, transplant patients will not know they even had an MI. Signs and symptoms of CHF (dyspnea, activity intolerance, etc) would be of concern however. Not to discredit your concern, just additional information for consideration. Take care, chbare.

Take care, chbare.

The idea may be filled with the best intentions; however, I am not talking about idea. I simply want people to look at the results or potential results. Making a law that prevents people with these diseases from working EMS is fine and dandy until we really consider the consequences. Would it be hiding information or lying to their employer? Would it be considered wrong? I really do not care. I still maintain that proceeding down this road could open a can of unintended consequences that will only complicate the problem and cause additional problems. I am not looking at this with my heart on my sleeve or with any significant emotional attachment. I am simply considering the pit falls of such a move. I do not see any great benefit to the patient or the provider when considering the potential consequences. Take care, chbare.

Ok then. Allow me to throw out a question? What makes you so sure prohibiting people with these diseases from working EMS will make your job so much safer? I fail to see how this will significantly improve patient safety. In fact, I suspect placing restrictions will only galvanize people into hiding their medical history or not seeking proper treatment because they do not want to loose their job. Somehow, I fail to see how this makes my work situation safer. From what I gather, somebody had some kind of incident at work and now they are entertaining the idea that somehow restrictions would have created a safer environment? Regardless of our feelings and opinions, we need to carefully consider the sequelae of our actions. look at the big picture if you will. In addition, we need to face the fact that these diseases are not going away and I cannot see a simple solution. Please correct my thinking; however, I do no think the solution is as cut and dry as some people seem to think. To answer the question asked earlier. Yes, cutting my hand in an environment filled with blood and gore would be cause for concern. I am unsure how this relates to the topic at hand however. Take care, chbare.

I agree, elevated sugars related to steroids are not uncommon related to physiology discussed above. To answer the question regarding fluids and sugars. In many cases fluid replacement is crucial in patients with highly elevated sugars. (HHNKC and DKA) Remember, these patients are in a state of hypovolemic shock and usually critically volume depleted. Most patients will receive isotonic volume resuscitation long before insulin. In fact, I had a DKA patient a few nights back with a sugar of about 820 mg/dl. He had the typical metabolic acidosis, wide anion gap, increased BUN to Creat ratio, + serum ketones, hyperkalemia, etc. In the first hour, we gave two liters of NS and his sugar fell to 600 mg/dl simply from fluid replacement. Then, we started an insulin gtt, and gave two liters of NS with 20 KCL over the next few hours. Finally, we hung D5NS with 20 of K and gave him a couple of liters. No ICU beds, so I had him all night. In 12 hours he received over six liters of fluid, and finally had his insulin DC'd in the am with BGL's in the 200's and an anion gap that was closing. So, yes, fluids are in fact very important when talking about some diabetic emergencies. Take care, chbare.