kohlerrf

Compressions should not be stopped.It is rarely necessary to stop doing compressions while attempting to intubate.whether you are using a NRB mask to oxygenate or a BVM to ventilate look at your pulsox while attempting and when you see the rapid drop stop your attempt and begin to ventilate again. Intubation is knoced way down the list in cpr anyway if your having that much trouble just drop an LMA. Granted there are those patients that have the hump back and the bobbing head with each compression and there you may have a problem but otherwise get prepaired suction the pharynx remove the dentures stick the blade in get a good visaulization slowley advance the tube to the glottic opening time it and push, or get all set up at the 3 minute mark and at 4 minutes when you stop for your first rhythm check then stick the tube in.

Are you saying if you transport and don't hit a pot hole you should press on their abdomen until they show signs of pain? Or how about we treat the pt on all the other facts in evidence after taking a complete history and performing a physical exam excluding abdominal palpation? If your pt was orthostatically hypotensive, tachycardia, pale and cool with or without abdominal pain how would your prehospital treatment change?

We run a Paramedic and an EMT-I on every ambulance. We split the duties based on weather it is an ALS or BLS Patient. In route to the hospital we call in to advise what we have, on arrival the ER staff is pretty good about having a bed assignment for us. Once the pt is off our stretcher and a verbal report is given to the nurse or doctor we are available! Documentation can wait but must be submitted in a timely manner and definitely before the end of the shift. Generally we are available 5 min after arriving at the hospital. There are those occasions where you have to decon the ambulance due to blood or other substance or you are critically low on supplies but by in large we are considered to always be in service, as a matter of fact, normally the dispatch center never puts us out, if another job comes up in our area they will dispatch us and if we are out of service and cant take the call we tell them to dispatch another unit....and then get on the phone with the supervisor if you know what I mean....I guess we do pretty much the same thing as "Grumpy Old Man"

I did not intend this thread to be about teaching styles, perhaps I should have been more clear about the events. Any one who chooses to ride on my truck knows me well. That is why they ride. I make it known that "your are not in Kansas any more Dorothy" Riders work on the patients on my truck and they are not mules. EMTs and Medics alike are given free reign and are also made responsible for their actions. I have ZERO tolerance when it comes to patient care and everybody respects that. Should I step in during patient contact there is no discussion, the patient is my responsibility and is treated my way and handed off to the ER. Afterwards we debrief and I explain and entertain discussions. Yes I yanked his hand away as I feared no good could come of this action and there was a remote possibility of disaster. There was no admonishment in front of the patient and care was seamless and continuous in route. The EMT continued and finished the balance of his physical exam on the patient and logged several sets of right and left B/Ps. This particular EMT, as well as many others have been back several time to ride with me again by choice because they want to learn and not just taught!

Palpating the abdomen could not rule out or rule in anything you have listed here. Your presumptive diagnosis for the above is easily obtained by taking a proper verbal history, a physical exam (excluding probing the abdomen)and a series of accurated vital signs. In additon by not delaying transport and not taking the time for auscultation palpation and percussion of the abdomen the patient will reach definitive care and feel relief sooner. Tell me sir can you yourself, through palpation, tell the differance between Gastroenteritus and Diverticulitus? Would it matter if you could? Frankly, even if I could tell the differance I would still just tell the ER the patient has an acute abdomen along with the history, signs and symptoms I had found as I would not want to be responsible of possibly misleading the Doctor causing him to miss a real problem that I may have missed on my exam. The specific diagnosis of non traumaic belly pain is far beyond my skill set and scope of knowledge.

Very lucid thinking. I agree, I too have not seen compelling evidence either way regarding palpation. I think we both agree that palpation cannot rule out this or any critical abdominal issue. Furthermore while palpation can support other findings leading to the r/o diagnosis my point is that your conclusion cannot be based on it. After all I have examined perfectly healthy individual and looked at their abdomen only to visually see the normal pulsing of the abdominal aorta. Does this runner with a twisted ankle get treated for a AAA? If we stand back and think of a AAA or hot appendix or perforated bowel, these situations have swollen distended tissue that if left unattended do in fact burst and then the patient dies in seconds. Although there is no study that I am aware of that proves pushing on a thin wall aneursym or a swollen appendix will cause it to burst it would seem a logical assumption, as I have been successful with balloons. In light of the fact that nothing we find during palpation would change our rule out diagnosis that we based on the history vital signs patient presentation etc... I see no need to take the risk because what are the chances of the patient living long enough to make it to surgery if we are wrong. By telling the ER that you suspect an acute abdomen based on history vitals etc...and not pushing and probing you may buy the pt the times he needs to see the pro's on this subject. Above all do no harm.....

On scene the patient was outwardly stable. From the history, visualization of the abdomen and vital signs this pt was potentially unstable 2 large bore were started in route, and run kvo, on arrival I advised the ER staff I was treating a rule out AAA and they confirmed it by a sono. Patient was taken to the O.R. he burst on the table but was saved. I did not palpate , auscultate or percuss in the pre-hospital setting did I harm the patient? What was a the very real possibility here had I delayed transport and started "gently manipulate, palpate, percuss and auscultate" this abdomen while the patient was sitting in his office chair? More importantly would your full abdominal exam rule out a AAA in the field? And just to set the record straight. While I did yank his hand away I did not reprimand him in front of the patient and to be more specific after the pt had been handed off it was during our debeif I asked him not to palpate the abdomen of my patients and gave him the above mentioned reasons.

Ok,All good replies, however things like "The standard of care" and "Ive always been taught to" don't really address the issue address. Yes I agree we have to present a good picture the the ER staff as part of the transference of care. As far as listening for lung sounds thats a different topic so I would like to remain on point and discuss the abdomen. Our local "protocols" do not specifically address things such as how to do a physical exam although it is in the state curriculum and the national registry. That being said I am not satisfied that the state or the national registry have all the answerers. There are many procedures we do that are contradictory to the curriculum. For example compression only CPR with no BVM or advanced airway or permissive hypothermia wich is not even addressed in the classroom and over drive pacing just to name a few. This forum should be read thinking out of the box and nothing read here is law however is may be the stuff law is made from. An EMT should be able to take a proper history(including recent bowel movements number and quality, urination frequency color and oder, nausea vomiting, fever,etc...) vital signs, visualize the abdomen for discoloration or deformity and yes even gently touch abdomen to feel for temperature or pulsation. However the additional information gained by invasively poking your fingers into the four quadrants of an acute abdomen in the pre-hospital setting can spark major problems can dramatically contribute to a poor prognosis and that can only be handled surgically. I feel the risk of the EMT pushing on a hot appendix and rupturing it, perforating an diseased bowel, bursting an abdominal aneuyrsm or causing the patient to vomit and compromise the airway to name a few, however minimal, are too great for the new information that could be potentially gained. Remember that because patients can be ticklish, rigidity, lumps or mases could easily be a reaction caused by the patients own embarrassment, or your cold hands, and as such palpation is low on the list of objectivity even in the hospital setting. Regarding auscultation and percussing the abdomen. These are probably the top 2 most objective techniques. Even if you were an expert at interpreting bowel sounds and the percussive sounds or "fluid waves" across the abdomen, these techniques cannot be done in a moving ambulance. Regardless of the findings nothing here would change your treatment in the field and delaying transport to perform these properly would only delay definitive patient care. Students are taught to palpate the abdomen to have the skill and pass the test bla bla bla. We also educate using a objective body of evidence rather than just teach chapter 6 pages 132-158 from the manual?

I was called to a 57 y/o man complaining of a sudden onset of mid line abdominal pain while sitting in his office doing some paper work. Patient has a history of hypertension and high cholesterol and is non compliant with his meds. Patient had not eaten lunch yet and tells us the pain feels as if something is "pulling apart" in his belly and lifts up his shirt to reveal an vertical 5-8cm oval lump in his abdomen just off the mid line. While in route to the hospital my EMT "ride along" placed him on oxygen, moves down and begins to palpate the abdomen? I yanked his hands up telling him not touch the any of my patients abdomens, ever! Regardless of what anyone thinks is wrong with this patient, could someone please tell me why we still teach EMTs to palpate the abdomen!

Your absolutely right, the fault here it the dam plastic ET tube, no matter what we do it just wont go in the right hole! Come to think of it I have seen CPR done poorly causing a flail chest. We have to stop doing CPR its killing people! By the way I have heard of ambulances on their own running red lights and killing people, the better thing here is to ride bicycles. Its a poor clinition that blames the equipment! If you cant tube don't do it, we carry 6 other airway adjuncts on the truck because there are times you just cant tube. If you have some ego issues your in the wrong profession. if you have another adjunct that provides better airway protection than a properly placed ET tube I'm all ears. Otherwise don't deprive the patients, take your ego outside and let a competent medic manage the airway!

5-7 this year (in the field) however we are required to have 2 separate days with anesthesia in th OR per year and 4 mandatory CME days for 8 hours each day. Regardless of the topic of the CME we all practice ETI on the manikins on those days as well. Intubation is a critical pre-hospital skill. Our industry operates in a different and unique environment. Although there are some very good adjuncts out there, and we carry many of them, ETI is still the gold standard for airway protection in our environment. I was concerned to read?.... What is the definition and "unsuccessful intubation"? Discovered at the hospital ER or discovered on the initial attempt on scene and an alternative airway was secured? ETI is hard and necessary skill to be mastered. To acquiesce and say maybe we should take the tool of ETI out of the carriculum is a shortsighted solution retarding the growth of pre-hopital care. We operate in the world of random, not a predictable hospital environment, in addition by our definition, we cannot step back and bag the pt until the attending arrives to tube the patient. We need more tools than the ER or OR because they only get the patients that we have already cleaned up!

Could not of said it better myself!

STEMI is one "indication" for the PAMI procedure.

Very good point Vent! Exactly the kind wisdom from experience that is lost on the new guard. In addition I think its a great idea to have "untrained" drivers. When I started, my partner was called an MVO for "motor vehicle operator" all she did was drive and help me carry patient or equipment. Those were the days.... PAMI=Primary Angioplasty in acute Myocardial Infarction. When we diagnose and acute myocardial infarction in the field we notify the cath lab at the hospital with a PAMI ALERT. This starts a cascade of events both pre-hospital and in hospital in order to reduce door to balloon time as this is a time sensitive procedure. Good point. we are often called by PD to an emergent situation and told to respond flow of traffic and stage. meaning, go with the normal flow of traffic and no lights and sirens than stage in th area and wait to be called in by police when the scene is safe. Yes "do nothing until the scene is safe" for all you young Bucks. Oh no!?$?%# I see another thread spawning!

I have heard of those same laws, I have read in our own SOP here that we are required to use lights on every emergency response, but I think that may be an insurance issue frankly. Come to think of it I dont know of any state or federal VTL that requires the use of Emergency lights during an emergency response as long as the vehicle is operating within the applicable local ordinance such as the posted speed limit. I do recall though, that New York State does require you to display "visual and audible warning signals while operating in discordance with the applicable traffic ordinance". You bring up an interesting point, because my service does not allow us to exceed the posted speed limit at any time, so it must be an insurance thing that we have to keep the lights on, but no where have I ever seen that the siren must be consistently sounding during a response. Every day I learn how much more I don't know!

Frankly, Yes. If it were a perfect world I don't think we should have lights and sirens on an ambulance! People often ask me what can a PARAMEDIC do that an EMT cant? my reply is " In a "non traumatic case" Paramedics can do everything the Emergency Room will do to you in the first 20 minutes of your visit. For example if you need the ambulance to take you to the hospital because you have a cold and a fever, what would the ER do in the first 20 min. Nothing but maybe take your temperature and a history, we can do that. On the other hand if you are in cardiac arrest or acute pulmonary edema, what would the ER do in the first 20 min.....Bla Bla Bla Bla....yes we can do all that too right here in your living room!" I never use lights or sirens in route to the hospital with 3 exceptions, Trauma, CVA and PAMI. I think the use of lights are still necessary because all municipalities do not allow Paramedics to operate at the same level and the training varies widely. In adtion there needs to be some pre-hospital soultiions developed for the 3 sitiuations I mentionsed but barring that since we can do everything the ER will do I firmly believe the use of lights and sirens should be the exception rather than the rule. Lastly I will submit, with the current systems I can recognize that there might be a benefit to the patient for you to use your lights and sirens to enter on coming "SLOW MOVING" traffic cautiously at a slow rate of speed to avoid senseless grid lock that would other wise unusually delay your response. Remember the easiest fastest and safest way the reduce response time is to add more ambulances to a given area and NOT TO SPEED THEM UP! There is NEVER the "Need for Speed" reducing response time yes! but never the need for speed. Either speed kills them and stopping kill you! Im curious? Does your VTL state that your siren must be "CONSISTENTLY SOUNDING" the entire time your vehicle is in motion while your emergency lights are on?

I realize that the various states "require" you t0 run lights and sirens. However I also know that more specifically in most states the law states you are required to have your emergency lights on at all times while responding to an emergency and only requires you to have your siren or "audible warning signal" when you are in violation of local traffic ordinance. in other words, if you are traveling at or below the posted speed limit although you must have your lights on you are "not" required to have a siren running. In addition if it were the case that you have to use your lights AND sirens while responding, you would be required to have your siren on while backing your truck into the driveway of at the address of the call until you put your vehicle in park? The law is very specific and this is the point of my post. ALL of us, me included, have been trained "by the senior guy" lights and sirens go together. I have found they don't. More importantly it has been proven factually in many many studies both on a closed coarse and the open road that regardless of you experience the driver will drive at a faster rate of speed if a siren is in use regardless of the type of call they are responding to. I would be interested in specifically seeing your ordinance regarding the use of an audible warning signal while responding to an emergency. The law is very specific and we on the other hand don't take time to read it putting ourselves and others at risk. After reading the specific law I think you might be pleasantly surprised!

Ill stop 3 car car lengths back and shut down the show and I will not push sombody through a light. I turn it on at the green and my partners think Im nuts, I dont understand why they dont get the concept? Unfortunately, I think there may be readers in here who arent fessing up and seeing the light! This is a really important simple cheap easy concept if you want a carrer in EMS!

Right on Brother! Lets take this situation for you gotta get there nubes still out there. You are 2 cars back behind a car stopped at a red light of a busy intersection. Mommy and baby are belted in waiting for the light to turn green. Your truck is over hanging their rear bumper blasting your air horn lights and sirens! Terrified and distracted by you, mommy wants to get her baby away from you and sees the car in front of her went through the intersection and made it. Mommy, being distracted by you a screaming baby and cross traffic in the intersection creeps into the busy intersection to get her terrified and screaming child away from you and SLAM, is broadsided by an 18year old blasting snoop dog on his base woofer in his low rider. What happens now?

In the case of the home fed asthmatic 100% FiO2 fed nebulizer will help the pt return to their baseline faster and in the case of uncomplicated sinus bradycardia with pure oxygen administration the rate will often times will increase to a sustainable 60 or 70bpm and the B/P will normalize as well. Remember a sign of hypoxia (more prominent in the very young and the very old is bradycardia)

I have been driving ambulances for some time now for paid 911, Volunteer 911 and CC transports. I am amazed at the never ending incorrect assumptions that we ambulance drivers make. To start off, nowhere have I found any law, regulation, ordinance or company policy that states, during my emergency response "REQUIRES" me to disobey the vehicle traffic law. For example I am not required to exceed the posted speed limit. I am not required to pass through a red traffic signal. Providing I am not disobeying any traffic regulation, I am not required to have an audible warning sound or siren consistently sounding from the time I put the vehicle in drive to the time I put the vehicle in park at the scene. If all this is true, and we know it is so dangerous, why do so many of us do it? and don't tell me its to get to the pt faster, I've been around that block...

melclin coodos"s great topic. this is somthing so ,new and fresh I have never heard of this, thank you! Everyday I learn how much more I dont know!