kohlerrf

I believe that the potency of morphine is a concern. I have heard that Fentanyl is substantially more potent than morphine as much as 10 times as potent. I may have to comparatively administer a substantial amount of morphine to achieve the same effect. Because morphine introduces a vasodilatory component and is irreversible and coupled with this increased dosage I don't feel morphine is a wise choice here. I agree Midazolam does have an indirect effect on blood pressure through its effect on muscle tone however its effect on blood pressure as compared with morphine I think is more subtle and certainly more short lived especially when you get into the higher doses of morphine. I am at odds with the hospital about giving us Fentanyl and I don't know why they resist I'm also trying to get rocuronium added to the truck as took vecuronium off the truck in favor of etomidate, but we have to work with the tools we are given. Sux does not sedate patients, a patient with sux alone is actually awake alert and oriented able to fully feel pain, see the practitioners around them (if their eyelids are open), hear what they are saying and smell their bad breath. What they cannot do is move, breath or respond to you, but they will remember everything that has gone on. Proper sedation is the critical component to intubation or RSI. A pt can be properly sedated with slow and shallow respiration and be non traumatically intubated very easily and wake later with no recollection of the entire event. Yes, I advocate this and one reason among many is that any breath beats no breath. Sux is a necessary drug to have on hand, however, in can have grave unwanted pharmacological side effects and in paralyzing the whole body it relaxes the Jaw and cardiac sphincter which is the only gate between you and a mouth full of bad. Intubation with proper sedation is not barbaric its merciful. Well aware of the similarity of sux to acetylcholine and we do keep atropine on hand. But there was no mention of using sux in my post and no mention of a bradycardia.

What is the advantage of Fentanyl/Midazolam over Ketamine or Etomidate? Yes, we carry Atropine but, Why would Atropine be very helpful in this circumstance?

All that wheezes is not asthma! I don't know enough about your exam of the patient and if you ruled out an MI or how well your patent was ventilating them selves Pusiox, ETCO2,pulse and resp rate (think IPI). In addition I believe Ventolin has a Beta 1 component that we would want to stay away from in the face of an MI. you would have to rule out the MI or pulmonary edema causing angina/MI before making any treatment choices. Remember if you your pulsox is greater than 95% and your ETCO2 is say 40 and your rate 10 to 20 you have time to look other places for the cause of the wheeze or difficulty in breathing. Never go down the cook book protocol page of SOB remember to step back look at you patient and use all your tools to figure out what is going on before you treat.

I'm not sure by what you mean "fentanyl/versed" I assume you mean use them together? In any event we do not carry fentanyl only morphine and I'm not sure morphine is potent enough for what you suggest. Also remember that although morphine is a narcotic and the effects of respiratory depression can be reversed with Narcan the hypo-tension that it causes is not. I am going out on a limb here but I assume that fentanyl has the same problem, please correct me if I am wrong. Lastly we have to expect in any patient that we change from a negative pressure inspiration to a positive pressure ventilation with an ET tube and a BVM will experience a drop in blood pressure, one reason for my above comment about "I would rather intubate a breathing patient". I shy away from agents that have a vasodilatory effect as they can potentiate this common occurance causing real problems. Etomidate nor versed have any vasodilatory effects that I am aware of. If you meant use either or, I know that versed alone wont do the job in many cases.

Yes you are absolutely right. I have a substantial amount of past experienced with NYC EMS and what you have to remember is that the larger the system is, with the more employees under its belt the more they have to dumb things down and cater to the lowest common denominator. Is kind of an inverse relation, the larger the system the simpler the patient care. the smaller the system the tighter the medical control the more the doctors feel comfortable with allowing the medics perform. While NYC does have other hospital running paramedics they are I believe the largest EMS employer in the city and more over they are union. The typical union civil servant while dedicated, is generally just interested in "work to rule" and not going above and beyond because frankly if he does the union contract prevents him from being compensated for it because everyone has to be paid according to the contract so why should he seek to better himself if he does not have to? This is the mentality that the medical control doctors have to expect. Although I believe life would run much smoother having one chief with many Indians i realized pt care suffers for it. I am for "patient care" and having smaller organizations with tighter medical control that perform on the razors edge of pre-hospital care. force paramedics to think rather than treat form a cook book. Lastly, I'm not bashing NYC EMS the are a great service dealing with issues other systems will never have to. NYC EMS has now and in the past had many great medics (me being one of them) but they are limited by human nature and the magnitude their atypical system and for that they do a great job.

I don't know if this is on point here however you said you wanted to learn as much about Etomidate as you could for the pre- hospital setting. I use it with every RSI and I am interested to hear it being used for conscious sedation , is seems logical. However let me talk about its role in RSI. Etomidate is a hypnotic sedative well suited for the patient about to undergo intubation. I personally advocated intubating a breathing patient if possible instead of going all the way to sux for many reasons and Etomidate works well to that end. However Etomidate has driven me as well as other medics to administer sux unnecessarily. I have done a some research on this since my event and it has changed my procedure for the better. I had a patient some time ago who was an apparently otherwise healthy 55y/o athletic male who was discovered by his wife who had just how had left to go to the corner store returning 10 minutes later to find him unconscious and unresponsive. on my arrival the pt was found to have vomited but currently had a clear airway with a GCS of 3 and had no medical history and was not on any prescription medications. Vital signs were WNL and I elected to RSI so as to protect the airway. The issue here is why did I elect to RSI but what happened next. We hooked the pt up inserted and a nasal airway and placed him of a NRB for pre-oxygenation and started and IV. The pt was pre-medicated with Lidocane because we were unable to rule out a bleed and did not want to increase ICP. We let the Lidocane circulate for 2 or 3 minutes and finished the prep for RSI. Patient Pulsox was no and had been 100% for several minutes and his ETCO2 was 44mm/hg still breathing about 10-12 per min pulse and B/P WNL. I checked the patient and although he had a loose jaw there was still too much muscle tone for me to visualize and the patient still had a gag. I sprayed the back of the throat with a little topical Lidocane and administered Etomidate. After about 1 minute the patient began to stiffen up and develop trismus. I could not open the jaw at all. There was no seizure activity and I feared the worst a possible bleed. I administered Sux paralyzed and successfully intubated the patient and all ended well. On my follow up and further investigation I sought out the advice of the anesthesiology department at our hospital and others and they all told me the same thing. Etomidate can cause "Myoclonic Seizures" manifesting in the stiffening of the body and trismus. Myoclonis is more commonly seen in leaner individuals and the way to avoid this side effect is to administer a benzo a minute or so prior to Etomidate. Had I known this I could have avoided Sux and from then on I always administer 2-5 mg of versed prior to Etomidate and I have not had that problem since. Sorry if I took your post to a different place. Hope this helps!

From my experience in this industry, although I personally have never had a DUI, I have come across many who have been in your situation or worse and , unfortunately, I can tell you this incident will have no adverse effect on your career as a EMT good luck to you sir.

Ricard, I started My career with the NYC Health and hospitals Corp in 1979 as 21-E out if Lincoln hospital got my medic in 1980 and I left in 1995 after working 35-W out of Woodhull hospital to work for the voluntary hospitals for the next 5 years...they paid better as for NYC bin there done that and believe me its not the bright center of the universe. TJZ you drive way too fast brother Your right i agree but I had to put that in for the yahoos Zippy great post thanks. I need to make this absolutely clear, I think type of thinking is the crux of the issue. RED LIGHTS AND SIRENS only request the right of way they do not demand it. There use does not absolve you of responsibility and you can be found libel if you cause injury to another while using light and sirens. regardless of their use you can only disobey traffic regs when conditions permit. There are no companies that can compel you to pass a red or run a stop sign at any time for any reason. the only reason you do is because every one else does. If your service has a slow response time they have to put on more units with shorter distances to travel, not to tell the existing units to speed up, think about it for a minute how ridiculous is that? I admit the escort thing is a bad idea I just put that in for the yahoo's but let me ask what is it your problem if someone is following you thorough traffic shouldn't you be looking in front of you while moving forward? If it really bothers you just pull over and stop and let them pass you and then proceed on your way.

Why dont we take all the lights and sirens off all the ambulances and just drive with the flow of traffic. I realize that there are some situations where you are in grid lock and lights and a siren might help but generally I have found gridlock is grid lock. More often than not the call we are dispatched to is not time critical such as a sprained ankle or a sick call or even in the case of an MI or CVA. It has been proven time and time again that driving with Lights and Sirens is not that big of a time savings over planning a smart route to the patient avoiding known traffic delays and in the late evening or early morning hours there is virtually no time saving. Does it really matter if we get there 30 seconds or a minute earlier? Just because we wont have lights and sirens does not mean on the odd occasion we need to clear traffic we cant have a police escort. Now lets think of the cost savings on and ambulance with no emergency lights inverters power packs and dual alternators or on board power management computers and in addition how the ambulance insurance costs would go down. Maybe with these cost savings we could add additional ambulances to cover the area that would cut down response time even further? Lastly, having not just suffered a harrowing ride screaming through the streets at the hand of another would we be calmer and think more clearly on the call and in turn more accurately diagnose and treat the patient? I think its worth a try.....

I'm with "Dwayne". Its a tough call to tube or not. Dwayne had a really great point though, LLR and puking into towels is key. Here is your argument to any ER staff that questions your airway control. "I am alone out there and I need to stop a potential airway problem from occurring rather than correct one that I did not otherwise prevent". I'm with "Dwayne". I think you did a great job in a tough situation. Its a tough call to tube or not. Dwayne had a really great point though, LLR and puking into towels is key. The effectiveness of simple BLS is so often underestimated. Should you decide to tube and get an argument to form any of ER staff that questions your airway control simply remind them "I am alone out there and I need to stop a potential airway problem from occurring rather than correct one that I did not otherwise prevent".

Ammonia inhalants can be a noxious stimuli and they can make my otherwise calm psycho or drunk very upset,combative and could escalate the situation . Why do I need this? Let them play possum on the way to the hospital who cares. Keep the situation calm and treat the pt symptomatically and arrive at the hospital uninjured.

Ive been a medic for some time now and if I can pass anything to you I hope it will be these 2 thoughts...1)TURN THE SIREN OFF! and 2)You cannot change the course of mighty rivers nor can you can you bend steel with your bare hands.

In the situation where I would think of narcan the pt generally would not be able to self administrate it by holding onto a nebulizer. While i have done RSI and intubated say a bad asthmatic and nebulized medication into the ET tube, considering the time it would take to set up and the onset of nebulized narcan ist use may cross over into neglagence. we currently have at our disposal IV,IO,IN and ET all of which would have a faster onset of therapudic effect. While it is interesting that narcan can be neutralized I dont see its practicality.

So let me get this straight? You denied someone expeditious transport to an Advanced Medical Facility because you diagnosed it and did not think it was necessary? What are you going to tell the prosecutor when he asks you why?

30 years ago we use to give D50 as a matter of course to any cardiac arrest patient, as well as 2 bicarbs and an amp of calcium. this treatment has since fallen out of favor because they have found bad things happen from the dumping in of d50 for no specific reason. if you sampled the blood an found the blood glucose level to be deficient by all means give d50. now a days the thinking is the to start cooling you patient while they are in cardiac arrest and not wait for ROSC. granted there are levels of hypothermia as you mentioned 86% but is it a given that just because some one is cold they are hypoglycemic? I think the primary focus is warming the body so that metabolism in general can take place and then worry about the energy stores. Remember you can only pronounce a warm body dead.

Given your options Glucagaon is a natural choice and although the dose is 3-5 mg some of that would be better than nothing. In my service we carry 4mg of Glucaagon and we also carry Vasopressin or ADH. I believe ADH works on the vasculature in a different way and would be immune the the effect of a Beta blocker. In addition ADH prevents fluid loss from the blood stream through the kidney and into the bladder. Remember we can lose 5 to 700cc of fluid into the bladder before we become aware of it and the pt becomes incontinent. Although Glucagon can negate the effect of a beta blocker you will still have to administer another drug such as epi to raise the SVR. With ADH its a one shot deal. Granted you sill may have a rate issue but in cardiac arrest I would rather get the infarcted heart back at a rate of 50bpm that 130bpm

Given your options Glucagaon is a natural choice and although the dose is 3-5 mg some of that would be better than nothing. In my service we carry 4mg of Glucaagon and we also carry Vasopressin or ADH. I believe ADH works on the vasculature in a different way and would be immune the the effect of a Beta blocker. In addition ADH prevents fluid loss from the blood stream through the kidney and into the bladder. Remember we can lose 5 to 700cc of fluid into the bladder before we become aware of it and the pt becomes incontinent. Although Glucagon can negate the effect of a beta blocker you will still have to administer another drug such as epi to raise the CVP. With ADH its a one shot deal.

Great sight thanks for sharing it...every day I learn how much more I dont know!

I havent found the need to......EVER!

Interesting question! it just so happens Im hosting a free webinar today that is reviewing actual cases our medics have had using a BVM or our Vortran Automatic Respiratprator explaining why you need to control not only your respiratory rate but also the volume you infuse with each breath. We use the End tidal CO2 and Pulsox in conjunction to determine our rate and you will learn why that is critical. The webinar is free and you and anyone else interested can log in from any computer with speakers to attend. here are the details: You are invited to attend a free Webcast titled: “Critical Control of End Tidal CO2” Summary: An introduction to the need for critical monitoring of the End tidal CO2 and a case study review comparing results of ventilated patents using a BVM as opposed to those ventilated with the Vortran Automatic Resuscitator model VAR-Plus. Date/Time: Thursday March 25th 2010 at 1pm and then again at 7pm (Log in will be accepted 15min prior to start time to adjust your settings) The Webcast is scheduled to last 1 about hour but may run longer if there are questions. Click on this URL or copy an paste it to your browser and it will direct you to the meeting. http://connectpro44528521.acrobat.com/etco2/ Please follow the onscreen instructions to enter. This is an interactive Webcast and you will have the option to ask questions by raising your hand then typing them into a text buffer of if you have a microphone you may type in the letters VP and then click to raise you hand. You microphone will temporarily be turned on and while depressing the talk key with your mouse you can address the forum. If You miss this WebCast please email me so I can tell you when the next series is schedule at robert.aguard@gmail.com Hope to see you there!

Feel free to step on toes! I have rarely seen an MD in the Er that can manage a code better than a Paramedic and interestingly enough the MD's and nurses in the local ER's realize it as well and often take second chair.

Point well taken, however if a reading is present it is a good guide but your right there is good possibility that you may not get a reading. To restate the answer, compressions should not be stopped to specifically allow for intubation.

I would agree I have never seen a bulge in the abdomen except for a herina however in many people who have a relatively flat abdomen while supine you can often see the pulsation of the abdominal aorta. Give a try and look for it and you may be surprised.

Perhaps I was not clear. I would by all means gain IV access. I would avoid administering any significant amount of fluid if I had to hang a bag and could not use a lock. The rate would be no more than KVO. This patient had no indication of fluid loss and secondly fluid administration does not provide for medication administration IV access does and the latter can be achieved with out fluid administration. In the absence of any signs of hypovolemia I am unaware of any indication or protocol that tells us to run fluids with no reason,if done this can very often lead to an adverse condition. Our fluid protocols are a little more conservative than yours but I see your point. The titrating thing is a good though process but you have no indication of a falling blood pressure? Lastly you should lobby to get blood glucose monitors on the truck. A good portion of our elderly population is living on a fixed income while expenses are rising disproportionaly. Often times the first expense to be cut out is the regular check up with the doctor, next either some of the medications "that don't do anything" ,or, food and diet. I cant tell you how many malnourished elderly home alone patients were discovered with "slurred speech unable to walk" buy the niece that came to visit just to find they were hypoglycemic from poor nutrition. Administration of D/10 and 100mg thiamine made them right a rain and able to speak to social services at the hospital to get meal on wheels or some other correction. Most of all we did not have to set the wheels in motion for a Stroke Alert which would have cost hundreds or thousands of dollars. There are companies that give you BG monitors free all you have to do is ask. Check it out I think you'll have some success here.

Fluids here is contraindicated. I also noticed you did not check the blood glucose of this AMS patient? My first option would be a saline lock, if you don't have those I'm on the fence as to whether I would start a hypotonic solution like d5w or an isotonic like normal saline. I have heard that glucose is bad for a CVA but I think that came from the day when we use to give 25 grams of D50 to all patients who had an altered mental status, but we haven't done that since I climbed down from my dinosaur. I would have started a D5 line and kept is kvo, the small amount of actual glucose she would have received would be immaterial and d5w diffuses across the membrane not contributing to increasing the b/p. Lastly if you going to hydrate someone then do it. To stand in front of your medical control doctor and explain why you gave a "little more than kvo but not enough for a fluid challenge" would be a waste of breath and a wrath coming from the doctor for my indecision would be more that I could bear. I think you made the right call not giving fluids at all.