Asysin2leads

I know line of sight isn't always possible, especially at night, but especially in a scenario that involves hot, warm, and cold zones, usually command has a pretty good view of the area. People operating in an MCI ideally should have a buddy system, and keep in line of sight with each other. Hand signals are already used in helicopter extraction so the person on the ground can communicate with the spotter in the air. If an MCI is run according to the play book, the first arriving unit should break into two different roles. One person goes and gets a quick triage count while the other relays the incident to dispatch. Depending on the area, the communications person may have to be utilizing multiple frequencies just to get the information out, and point to point communication may not be possible. However, if the triage person can stay within line of sight, or return to line of sight, with a few hand gestures you should be able to relay the number of patients and the severity of each. Or signal "Oh crap, start the engine! run, run RUN!"

In all seriousness, given the roles and responsibilities of medical providers, even the insinuation that you keep the company of sex offenders could mean career suicide. If were in your shoes, in the middle of a paramedic program, I would have a serious discussion with your girlfriend, remind her that you intend to be in a high-profile public service, which is not compatible with having someone in his life hanging out with known felon and sex offender. It really has to be one or the other. If she persists, then you have to make the decision of whether you're going to follow through on your career goals OR (and it is a definite OR) you can flush your career down the toilet AND risk the situation I described above. If you choose the latter, just don't come crying when exactly what I said will happen, happens. Its pretty much coded in your DNA that at your age you will disregard the advice of others, and assume that your relationship is different and special and that you really know what's best. In fact, weren't you the one on the other thread who was describing risky driving in an emergency vehicle while assuring others you "knew how it was done" and such? Yeah, like I said, if you don't pay attention to any of this advice, its on you.

Hey all, here's something I'd like to think about. What would be some good universal hand signals for working at an MCI? In a perfect world, of course, everyone would have the best radios that work all the time and all agencies involved would work together in a seamless fashioned. Unfortunately, that's rarely the case. I think that EMS should add the use of hand signals for line of sight communication in case of transmission problems with radios. For instance, let's say you were doing triage, and wanted to relay your count back to the incident commander. You could point to your eyes for "I see" then make a signal for "patients", then hold your fingers up for how many, and at a hand signal for the appropriate color, red, yellow, green, or black. I think a big one would be a universally recognizable signal for "evacuate", something equivalent to what three blasts of a fire truck's air horns mean. Something that when you see it, you relay it quickly and then GTFO. What other signals could be useful?

Well, you could do nothing and allow your reputation be sullied by the impression that you are paling around with sex offenders and silently stew about it while occasionally making a snarky comment to your girlfriend about the whole deal. Even better than that, you can wait until she starts fooling around with him, and have a recurrent cycle of her coming back to you tearfully at the end of each transgression, until the point that "she's ready to move on but still wants to be friends" and then have a few months of phone calls at 3 a.m. while she sobs about what he did this time. This seems to be a popular route with the youth. If that happens, please, post the details. I want to hear about when she calls you up and cries about him stealing her credit card and asking you what you think she needs to do to "be able to reach him" because he "is really sensitive on the inside" and wants the world to see him how she does. Its more entertaining than going to the movies.

I'd choose your educational paths carefully. I know people I went to high school with who graduated from top universities who are working bagging groceries or working at Starbucks. In that context staying in EMS sometimes may be the most intelligent thing to do.

I once had to take my unit and myself out of service and take a shower with some very nasty soap because a doctor wouldn't let me call a cardiac arrest vicitim that literally had bugs jumping off of him when we exposed the chest. Why? Because he was in public view. After seeing the way the news media likes to pretty much just make up their own facts when it comes to this type of thing, I would be transporting, even if we were going to transport to the morgue.

Too everyone who says "don't transport unless there is ROSC", the scenario is at a bus stop in the middle of LA. I'm not sure what LA's guidelines are, but generally speaking, it is poor form to call an arrest in the middle of the street. Bystanders are not going to say "well, they did full ACLS procedures, I guess he wasn't viable" if you stop working this person and leave him there. Nope. They're going to say "Those paramedics left that man to DIE! They didn't even take him to the damn hospital!" If it's an obvious death, that's a different story, but generally speaking arrests in public view should be transported off scene. Otherwise it can turn into a PR nightmare. !

Eli Lilly isn't out of business, at least not that I've heard. Mag sulfate and valium shortages are due to manufacturing problems at Hospira, and should be released in late May. Etomidate apparently has problems with raw materials.

Given that this is being done on the street, getting the patient loaded into a more stable environment is one of the priorities. If I have V-tach on the monitor and we've already done one shock, this is how I would proceed. I would have two of the FF/EMTs take over CPR and ventilation and get the last one to arrange the stretcher and a scoop if necessary, and have it prepped for transport, and have him or her take the keys of the ambulance. His role will be to rotate in with the others after 2 minutes of CPR have passed. I would have my partner initiate IV access and perform endotracheal intubation. By this time we should be ready to defibrillate again, which we would do. I'd resume CPR and administer 1.0 mg Epinephrine 1:10,000 as well as 300 mg of Amiodarone. We would finish out this round of defibrillation and CPR and then as best as possible without interrupting CPR and remove him to the stretcher and get in the back of the ambulance. We would do another round or two in the back, away from prying eyes. If we wanted to work this code on the way to the hospital, one FF/EMT would drive, I'd keep one in the back with me and my partner for chest compressions, and have the last one drive their vehicle, if necessary. Then we'd be off to the hospital, repeating epi-boluses and pulling over if necessary.

I would subtly and professionally remind my partner that it is entirely possible to look, listen, and feel for breath sounds while checking the carotid. Really, just move your ear a little closer. I'm ALS. Confirm cardiac arrest, call for back up. Lower patient to the floor, do quick reassessment of airway, breathing, pulse, instruct partner to start CPR. Attach quick look EKG. If it's asystole or PEA, move to two person CPR until backup arrives, ventilating with BVM hooked to high-flow o2, switching with partner in two minute intervals. . If its V-fib, do two minutes of CPR, then defibrillate once at 360 joules, resume CPR. When back up arrives, have them take over CPR, after reassessing rhythm. Have partner start IV 0.9% NS with as large a catheter as possible, perform ETI. Do a physical exam, check lungs for proper inflation, look for signs of trauma, look for medical alert bracelets, check BGL. Question witnesses, round up the usual suspects. Did anyone see what happened? PEA or asystole, start hunting for reversible causes. Hypoxia: Check SPO2 and ETCO2 Hypoglycemia: BGL, look for medic alert bracelets Hydrogen Ion (acidosis): Maintain appropriate ETCO2 reading, bicarb if really necessary Hypothermia: It's LA. Unless he was found on the LA King's practice area this probably isn't a problem Hyper/Hypokalema: If there is a regular rhythm, check for peaked or flattened T's, look for evidence of recent dialysis, consider calcium chloride if hyperkalemia is suspected. Hypovolemia: If it's a PEA and you suspect hypovolemia, rapid infusion of NS 0.9% Thrombosis: If you get a regular rhythm or hopefully ROSC, do a 12 lead immediately Toxins/Tablets: Look for signs of OD or ingestion of a poison. Check pupils for sign of heroin OD. Check again. Then give him Narcan. Trauma: If a traumatic cause is suspected, continue CPR and have second crew prep for transport Tamponade: See above. Tension Pneumothorax: Auscultate lung sounds after airway securement when BVM is compressed, look for distended neck veins or tracheal shift. Decompress as necessary If it's V-fib, do CPR for 2 minutes and then defibrillate at 360 joules, immediately resume CPR. Keep an eye on ETCO2 for signs of ROSC. Administer amiodarone or lidocaine, Mag sulfate if it's torsades.

I realize I actually completely contradicted myself with the last post. I said at first you shouldn't divert unless there was an unmanageable airway, but as I was typing while I was reading, I then realized that the ER can provide some beneficial interventions like nitroprusside or dilantin, both of which as I found out can be used to treat pre-eclampsia. When I write things its usually me thinking kind of out loud, so if I present my rationale its not intended to teach or correct, I'm just saying my understanding of situations, which obviously can change as I learn more about certain things. Some ALS units in certain areas do indeed have some really advanced equipment, I wasn't sure what was available to your particular unit, which is why I was saying you should divert and have the ER intervene, and then have the transport go by speciality care with an RN later on, unless you happen to have access to fun things like nipride on your ambulance already. I threw super-ninja in there because a friend of mine who was a Navy Corpsman and an RN had a patch made up that said "RN: Rescue Ninja." I try to look at every question in EMS from every angle, the medical, the ethical, the medicolegal, and the operational. My crack about being called on the carpet simply meant that I could see, from a QA/QI stand point, having to sit and defend your actions to a medical director or supervisor, no matter if you decided to divert or not to divert, there are merits and drawbacks to each decision, and in a case like this, you need to be really on the ball and be ready to sit down and explain why you did what you decided to do. If your service carried labetalol, that would be helpful, but I personally wouldn't be comfortable attempting to control the seizures with IV boluses of diazepam, and using something like nitropaste or nitro-spray to control the hypertension, and attempting an RSI all at once if access to other options are available. To me that's like trying to turn a screw with a knife; you might be successful but its not really what the knife's intended use is for.

No, it's pretty clear now. It's pretty clear that's it's a toughy. I think the best protocol would be to transport to the women's center unless there are exigent circumstances. I think in this case the balls in our court, and you should only divert to the local place if you can justify it. I think though that if you are going to be transporting and risk childbirth, you should make provisions to have an extra set of hands with you in the back, even if it's just someone with FR training. Can your local ED do a breech birth or a placentia previa? If you suspected that this might be occuring could they intervene appropriately?

Flight, the only reason I think you could justify diverting to the closest ED would be either an unmanageable airway, or some wonder drug I'm missing out on that is better suited then a benzo to treat the seizure activity. It would really come down to a good faith decision on the part of the provider, and one you'd have to expect to be called onto the carpet for one way or the other and have to defend your position. I'm starting to lean towards the closest ER route, simply because even with an airway this patient is not stable, and according to another article I've read maternal hypertension is a big factor in causing stillbirth due to uteroplacental insufficiency. According to the same article, nitroprusside is in pregnancy Class C, so maybe the local ER could hook her up, as it does find use in cases of severe pre-eclampsia. Yeah, I think in this case I'm going to say benzos, Mag, and then divert to the closest ER, if they're not a bunch of morons. If everything goes according to plan they can set her up with some good drips to nipride and/or dilantin and then we can come back later with an RN and some infusion pumps and get her up to the speciality center. Unless of course you are super-ninja-paramedic-RN and have that stuff already to rock. If that's the case, set up shop and have at it.

Artickat, I can speak about some EMS and ER practices in the Northeast US, but I'm confused a little. Is your local podunk place like a medical clinic or is it an Emergency Room? According to my old medical directors, not only should any Emergency Room in the US be able to perform non-complicated delivery, any EMT-B in the United States should be able to able to do it to. This came about because of an issue with a BLS crew. The BLS crew had a woman who was crowning in the back of the ambulance. She requested to go to St. Not-the-closest where she had all of her prenatal care done. The crew on the other hand elected to go to the Our Lady-of-around-the-corner hospital. The baby was delivered in the ER of the hospital they diverted too, and was fine and healthy, but the mother still lodged a complaint. They found the crew to be at fault, as imminent childbirth, despite reasonable objections, is not a reason to divert to the closest hospital, as childbirth is something that an EMT-B is fully trained and certified to perform. I took a neo-natal resuscitation class shortly after I became aware of the incident, because as Kiwi mentioned, four hours doesn't cover very much. So, what I would need to know is do the standards of care of your area dictate that your neighborhood emergency joint be able to handle simple childbirth? I would be very surprised if they weren't, because as I said delivering a child when birth is imminent is seen in many areas as a basic skill. If that's the case, then you run into another complicated matter. On one hand, if you brought the mother to the ED, they should be able to handle it, and there would be no good reason to bypass it, but by the same token, the crew should be able to handle the childbirth, in the back, while moving, and imminent childbirth is not necessarily a reason to divert to the closest.

28 weeks is the beginning of the third trimester, and while its past the cusp of extra-utero survivability, but still young enough that some development normally still occurs, such as formation of pulmonary surfactant and the like. Teratogenic means literally, giving birth to a monstrosity, and in parlance means it can cause birth defects, such as the children born to mothers who took thalidomide being born with no arms, and babies born to mothers who came in contact with finasteride being born without genitals. At 28 weeks there's not any chance of not developing limbs or genitalia, but I imagine a teratogen could still cause you some problems in utero. From this article I found it says that after the embryonic stage at 9 weeks, "Teratogens taken during this period can result in improper organ functioning, delayed growth, but seldom result in birth defects" I fully agree that if push comes to shove we need to focus on the mother's survival, but I'm still wondering if diverting to the ER round the bend couldn't provide us with better options. I doubt it. From my better understanding of how teratogens affect development, I think the risk is fairly low to the fetus at this stage, so I'd probably start the mag as soon as the seizure started, and if it was still going on after 5 minutes or drop some diazepam and cross my fingers. Here's a link to the article I got my information from, though I should warn you that there are some pictures of birth defects that might give you the willies: http://wikis.lib.ncs...pment_in_Humans I've dealt with one full blown eclampsia case in my career and it was a doozy. The venous pressure was so high it shot the IV catheter out and the blood spray looked like something from Saving Private Ryan, and no you wiseasses, it wasn't in an artery. We did the mag and benzo routine, we were able to control the seizures and get to a specialty hospital, but I never found out how the case turned out.

I would start a mag sulfate drip if she started seizing, definitely, but now we're in another quandry. On the one hand, while she is seizing, she is effectively not ventilating, and if left to seize, the fetus and her will go hypoxic, which will be disasterous. On the other hand, benzodiazepines have potential teratogenic effects, diazepam, midazolam, lorazepam, even alprazolam are all Class D's, and from what I can tell the benzos that aren't Class D are Class X, and in my book, Class D would stand for DON'T! The question at this point is there anything the local ED could set her up with that would control the seizures without as great a risk to the fetus as our options? From what I can see the options are pretty limited. Tegretol, Phenobarb, Depakote, those are all still Class D, and maybe someone can comment if they are even useful in acute seizure activity. I think this is the day you should have called in sick.

Pre-eclampsia, I'd say. Take the ride nice and easy, no lights, no sirens, to the woman's hospital. Make very clear that if deterioration occurs, you might have to divert to the closest ER. It's a bit of a sticky situation. I would be hard pressed to justify allowing symptomatic hypertension to continue unabated for the 45 minute ride. On the other hand, there is a danger in any of the treatment modalities. Nitroglycerin can be associated with hypotension and fetal hypoxemia in pregnant females. Benzodiazepines should be approached very gingerly, as they can be associated with teratogenic effects. Some of them, such as quazepam and temazepam have even wound up in Category X for pregnancy risk. Magnesium Sulfate works well for eclamptic seizures, but I'm not sure of how much effect it will have on the BP and the symptomatic effects it is causing. It's not ethical to transport someone with 9/10 on the pain scale for 45 minutes, so, according to the literature I've read, the best bet may be a bolus of morphine sulfate for the ride. Morphine is listed as class C for pregnancy risk, which means that it should only be administered if the benefit to the patient outweighs the risk to the fetus. I personally would be comfortable in saying alleviating the pain is justifiable considering the relatively low risk to the fetus. The case is hard because the patient is just sick enough to warrant an intervention. If she was seizing it would be easy to figure out what to do, but she isn't.

At this point I would lean towards ETOH or polysubstance abuse.

Scene safety; Evidence of a violent crime? Anybody lurking? Any obvious signs of illness or injury? BSI, gloves and goggles. General impression: How is he dressed? Does he look like a commuter, or a homeless person? What state of health is he in? Does the bus driver know what led up to this event? C-spine precautions if there is a suspicion of trauma Attempt to rouse with verbal, then noxious stimuli. If no response, check for breathing and pulse.

Proper defensive driving technique is to enter a curve at a sufficiently low speed as to not require the use of the brake while in the curve. Maybe you should stick to watching what ever sequel to the Fast and Furious is currently out and leaving the driving to others.

chbare, I understand what you're saying, but if a person can hold their breath and function for 60 seconds, obviously between what's in your lungs and what's in your blood can sustain you for that long without more air. It's counter-intuitive to me that a person has a minute or so underwater and can function, but a person at 50,000 feet only has six seconds. I am guessing it has to do with the fact that at 50,000 feet whatever gas is left in your lungs exits quickly, so you don't have that reserve for your alveoli to feast on, and in addition, since oxygen exchange at the cellular level depends somewhat on a pressure gradient, oxygen exchange at the cellular level is also impaired. Or is it just that extra gas in your lungs when you hold your breath that makes all the difference?

Okay, here's a question I've wondered about. If you can hold your breath for a minute or so, why do you go unconscious in 6 seconds at 50,000 feet? Does the reduced pressure prevent cellular gas exchange or something?

Remember what we were talking about, 25 and under were at a much higher risk for deadly accidents? http://www.wset.com/story/18118682/witnesses-recount-truck-ambulance-accident-that-killed-one The driver, Justin Kidd, 25, has been charged with reckless driving.

The other thread about changes in aircraft flight made me remember this. This is a recording of an ATC conversation and management of a Learjet that lost cabin pressure at a high altitude. Listening to the manner in which the pilots speak and act is a great way to see how a patient that is hypoxia could present. Towards the end they descend to 11,000 feet and the difference in the way they interact is quite striking.

I found a couple of references to air embolism complications vis a vis altitude changes during helicopter flight, but no definitive articles. Most of them refer to people suffering decompression sickness en route to a hyperbaric chamber. According to this chart I'm looking at, an altitude of 1500 feet does show only a negligible drop in air pressure, only a difference of 38 mmHg, but with 95% the amount of oxygen present at ground level. The reason this was in my head was because at a transport job a long time ago we would once in a while take a stroke patient over a long distance by ground, as they said the changes in the air pressure could be detrimental. I think I learned something today.