Spock

Recently, one of our crews responded to a 30 year old female seizing. Upon arrival, they found she was one week postpartum and they called me for backup. We worked her up as eclampsia and gave six mg of magnesium and ten mg of versed but she never stopped seizing. They had initially suctioned her and assisted respirations with a BVM but when I arrived she was breathing and I had the paramedic student keep the BVM sealed and do a jaw thrust. Sat was 100% and ETCO2 was 40. I did not want to intubate her without RSI drugs so we maintained her for the 15 minute transport. Turned out she had a brain tumor with a malignant biopsy result. Sad in more ways than one. Remember what Doc said: Paralysis does not stop the seizure, you just can't see it. Good second line drugs are keppra and propofol. Of course keppra isn't found prehospital and if you use propofol, you better intubate. Spock

With all of my DMAT deployments over the past 12 years I can safely say that working in the austere environment is a bigger challenge than all of the thoracic cancer patients I see every day in the operating room. My top five would be: Epinephrine 1::1,000 Aspirin Benadryl Ancef Toradol Good question and the other posts all have merits but I would't have any RSI drug nor would I have any scheduled opioids. When we set up a clinic in Texas for Harvey, we immediately posted a large sign in triage that said we would not refill opioid prescriptions. Saw a lot of people do an immediate about face when they saw the sign. We still treated over 600 in a week. Spock Honorary Gator

WOW! Dust may have passed into the great unknown but his legacy is alive and well when you realize he has prompted vigorous discussions so many years later. I never met Dust personally but I did have several off line conversations with him and I can only say I thought he was one of the most perceptive and caring persons I ever encountered. He really wanted everybody in EMS to excel and fools and idiots were not tolerated. Sadly every profession has far to many fools and idiots. Dust was an icon and everyone should strive to attain the pinnacle he set and be satisfied to only reach 70% of his stature. The RN versus paramedic argument needs to be put to rest but I suspect this will never happen. Each has a different job and one does not automatically transfer to the other. Nurses are paid more but they also have more education (not enough in my mind) and have employers that with better financial resources. In Pennsylvania, critical care nurses can take the state paramedic exam only after they complete an EMT course and jump through many hoops. PA uses the National Registry exam for initial certification but not for recertification. After passing the exam, RNs are certified as Prehospital RNs and not paramedics. I was a paramedic (nationally registered in 1990) before I was an RN and only had to fill out some forms to obtain PHRN status while maintaining paramedic status with PA. Dust is smiling upon us from above knowing that once again he has ticked somebody off and made them post heart felt opinions sparking new conversations. We can never improve unless we are challenged. RIP Dust and thanks for the memories. Spock May the tube be with you.

Sorry I am so late to respond to this topic but I just saw it and have a unique background. My first career was as an athletic trainer and I worked at the high school, university and professional football levels and I have maintained my license to this day. I am also a paramedic, registered nurse and certified registered nurse anesthetist so I can say with complete certainty that EMS providers of any level and registered nurses are NOT qualified to make return to play decisions. Every youth sports team should make provisions for medical care during practices and games and certainly cost is a factor but isn't the safety and well being of the athletes more important? Relying on parents that are health professionals is done frequently but it is not always a wise choice. You pay the officials so why don't you pay the health care provider? Paying a local EMT or paramedic to attend games is reasonable as long as you recognize you are only getting somebody who can intervene in life threatening conditions and access EMS more readily than calling 911. My service is paid to provide one EMT or paramedic for youth football games and who ever works takes one of our response vehicles and can immediately summon a medic unit if needed. Frequently, they treat minor orthopedic injuries with a splint of some sort and the parents transport to the DEM for evaluation after signing a refusal form. Easy gig that pays OT so there is competition for the shifts. EMS folks who work sporting events should always say no when asked to make return to play decisions because as soon as the coaches realize you will always say no, they will quit asking. The best way to provide medical care for sporting events on any level is to hire a licensed athletic trainer. Yes, I am biased. Spock May the tube be with you.

I'm not going to weigh in on this topic either way because although I have worked as a paramedic and a firefighter, I never had to depend upon either profession to pay the bills. That said, I almost peed myself laughing over the comments by Van. Troll to be sure but I did find it funny in a sarcastic sort of manner. Choose a profession that allows for growth and a new challenge every day otherwise you will wither and fade into the dust. Spock May the tube be with you.

I am certainly not an expert on billing but the face sheet from the hospital is automatically imported into our computerized charting system. Our biggest problem is the insurance companies write the check to the patient and not the service so some folks see this as a windfall and never pay the EMS bill. Screwed up system to be sure. Spock May the tube be with you.

Completely agree with Mike. It is NOT a sign of weakness to ask for help no matter what some folks in medicine may say. EMS may not be an option for you but a good counselor will steer you in the right direction. Mike is also correct that it may take a few counselors to get you straight but don't give up quickly. Good luck and the City hopes the best for you. Spock

The issue is not how many intubations you have, but how many airways did you manage successfully? The vast majority of EMS calls require no active airway management skills so you could say you were were mostly successful. I ask is MOSTLY good enough? Five times the number of years experience equals 135 which is a slow three months for me. Ruff is good people but we have to be realistic about our capabilities and recognize that practice and every day training is vitally important for good patient care in all areas of medicine including but not limited to airway management. Ruff was correct in calling out our training colleagues to examine the issue and take proactive steps to prevent problems. It is easy to apply remediation for a medic that comes into the DEM with an esophageal intubation but a better approach is to have good training protocols in place to prevent the problem from occurring. Spock Let the tube be with you. Trust but verify. Capnography and bilateral equal breath sounds.

OK, I think I am a reasonably intelligent person but when it comes to computers, I am a Neanderthal. I couldn't read the original petition or any data but since I am not on Face Book the reason should become clear. One of these days I am going to invent my own anti-social network called "In your Face" and I bet it would be a hit. But I digress. I presume this is in response to the proposal to remove endotracheal intubation (ETI) from the paramedic scope to practice. This has been bounced around for quite some time and the literature I have read is conflicting. First, the original literature from the late 70's and early 80's was poorly constructed and suspect. I say that knowing full well the research was conducted in Pittsburgh and I personally knew some of the authors. Second, Dr. Henry Wang published a study in 2005 which found 39% of all paramedics in Pennsylvania had ZERO intubations for the year studied and the average number of intubations per paramedic was TWO. Now Dr. Wang is a nice guy, he is no friend of EMS or paramedics and he left Pittsburgh a few years ago which was probably in his best interests since the City of Pittsburgh medics were out for blood. But the point is, how proficient can you be with a procedure done only twice a year? My EMS agency responds to around 10,000 calls a year and the number of intubations is 50-60. We have had medics retire after 25 years who have NEVER intubated a patient. Anecdotal to be sure but you have to scratch your head and wonder about it. The advent of superglottic airways (SGA) such as the King LT-D, LMA, and i-Gell have revolutionized airway management. I did not mention the combitube because I think it should go the way of the T-Rex and is an instrument of death. Now the literature regarding the SGA versus the ETI in cardiac arrest is conflicting so the answer is yet to be determined as to which is best. And let's face it, most prehospital intubations are in the cardiac arrest patient and not the patient that is breathing spontaneously. It is my understanding there is a multi-city and country study under way right now that may answer this question of SGA versus ETI. As it stands now, I am not in favor of removing ETI from the paramedic scope of practice but we really do need to examine the issue and come to a conclusion based upon good research studies. As long as the patient arrives at the hospital oxygenated and ventilated, it doesn't matter how that was accomplished. Spock May the tube be with you

The Pittsburgh School District once had a Public Safety program where students took classes in law enforcement, fire suppression, and EMS while also completing the standard reading, writing and arithmetic classes. It was successful in supplying the city with good candidates for those professions but was eventually discontinued due to low enrollment. Wish I could help with classes in Texas but I would encourage you to keep looking. Any 17 year old that wants to pursue this type of thing is special. Go for it! Live long and prosper. Spock

Off Label has a great post. I really do believe that obese patients that fall and can't get up for an extended period of time will exhibit signs and symptoms of crush injury. How long does that take is unknown but I suspect it depends upon BMI and the amount of tissue compressed. I've had patients with crush injuries from traditional causes (building collapse) and medical causes and they are very challenging. Prehospital concerns are acidosis, hyperkalemia, low BP, and pain. A crushed extremity that does not hurt is a very bad sign and will result in amputation and possibly death. Saw far to much of that in Haiti. May the tube be with you. Spock

Crush injuries are well documented in the literature. They are usually caused by trauma but can be from medical conditions such as the diabetic patient that passes out and lays on the floor for days before being found. Glucose levels are through the roof and the patient is in DKA. We saw a lot of crush injuries in Haiti after the 2010 earthquake and amputated many limbs. Biggest concern for crush injuries is the sudden release of toxins when the offending structure is removed from the patient. They become acidotic and will crash as fast as you can say boo. Have the bicarb and calcium ready along with plenty of fluid. The PA Department of Health has a decent crush injury protocol but I am biased because I wrote it. Most of my references were from the Israeli military since they have more experience than most. Actually, the first SAR teams to arrive in Haiti were from Mexico, Israel, and Turkey. Compartment syndrome, renal failure, and gangrene are some of the more dire results of crush injuries. If this helps to lead you on the correct path for writing a paper then I hope it helps. There are many good search engines for medical conditions and you should avail yourself of all except Wikipedia which can be written by any knuckle head. Spock May the tube be with you.

Plagiarism is a major problem in academia and can never be tolerated. I'm not accusing anybody of this but one must be careful and any publisher worth their salt would be all over this type of thing. I have worked with two friends and our third text went to the publisher this week which meant we went out and had dinner and MANY drinks to celebrate! Our current book is similar in topic and is titled "True Stories from the Athletic Training Room." We collected stories from colleagues and came up with some real doozies including many that dealt with interactions what EMS but all are credited to the authors. Our publisher has already given us a new topic and we are just starting to work on the proposal. This type of thing is fun but it certainly doesn't pay much and does require some work. Education is the acquisition of knowledge. Knowledge is familiarity gained with experience. Wisdom is the possession of experience and knowledge. Obviously I am not smart enough to have thought this up and I wish I could give credit to the author but I don't know where I first read this except to say I did not dream it up. Does that clear me from plagiarism charges? Live long and prosper. Spock

Low dose dopamine is notorious for causing tachycardia and it has been seen in higher doses also. CPAP can drop the BP because of the increased inter-thoracic pressure causing a drop in preload. Let's face it, this patient scenario is a nightmare for ANY health care provider and if you get your patient to the hospital or to the end of your shift with a pulse, then you did a great job. A puzzlement to be sure. May the tube be with you. Spock

I'm going to tackle this one without consulting some text books which may be a major error since I am decades removed from basic sciences of physiology. You are presuming normal ventilatory patterns which is nice except you won't have a patient with these parameters because they would not have called EMS in the first place. Yes, CO2 diffuses into the void but so does nitrogen. Don't forget, most of the air inhaled is nitrogen and CO2 is produced internally and not externally. Oxygen displaces nitrogen which is one reason we pre-oxygenate patients with 100% oxygen prior to intubation in order to prevent hypoxia during the apnea normally seen during intubation. CO2 is involved with acid-base calculations but just because nitrogen is inert doesn't mean it is unimportant. Clear as mud? Sorry. Spock May the tube (and ETCO2) be with you.

Tough problem but you are young and have time to work it out. Decide what is most important to you and your family and develop a strategy to improve your situation. The strategy may involve moving to a different area or gaining a new level of education and moving to a new career. Many years ago, I was an athletic trainer in the NFL and many thought I had it made but I was bored. I switched careers and went into nursing and the nurse anesthesia and couldn't be happier. I have lunch on occasion with some athletic trainer friends and they complain of low pay and long hours and I think: "Boy, isn't it nice to get time and a half for anything over 40 hours!" Point is, nobody can tell you what to do or how to do it. Figure out what you are passionate about and then pursue that dream. You may have some rocky moments but the end result will be worthwhile. Good luck. Spock May the tube (and future) be with you.

I would recommend "Anybody can intubate" if it is still in print. Good luck with school. Spock May the tube be with you.

Pump failure requires an inotrope and epinephrine is your friend. A great heart surgeon I worked with (he usually just yelled at me) had a prescient saying: "Dobutamine is a great inotrope when you don't need one". Dopamine is a possibility if an epi drip is not possible. My service used to carry dobuatmine and dopamine but discontinued the dobutamine because it was never used and now the docs are always ordering epi drips or epi bolus if the transport time is short. We dilute epi into a 10 cc syringe (10 mcg/cc) and use that to bump up the pressure until arrival. Our transport times are rarely over 20 minutes so longer transports would benefit from a drip. Complex problem and all have suggested excellent interventions but I would have used a steel vasopressor (laryngoscope) to help the pressure. OK, as a CRNA, I'm biased. Clearly BiPap or CPAP is preferable to intubation when considering mortality and morbidity. Spock May the tube be with you.

Cyanide poisoning is hypoxia at the cellular level. Hydroxocobalamin is the best treatment since it is a precursor to vitamin B-12 and combines with cyanide to form B-12. The other treatments try to eliminate cyanide by other mechanisms but less effectively. Hydroxocobalamin is expensive and not always readily available for prehospital services. The Paris Fire Brigade did some of the early work on its use for patients with altered LOC after smoke inhalation and also with patients pulled from a fire scene in cardiac arrest. The Advanced Hazmat Life Support text book is a fantastic reference for hazmat medicine although it is expensive. Hazmat medicine has moved into the Hot Zone and should not remain in the cold zone. Early treatment is essential for survival and the attitude of my hazmat medical team is to enter the hot zone and apply airway, antidotes and tourniquets to the injured. Airway is the King LTD (although we may switch to the i_Gel), antidotes are the Duo Dotes, and tourniquets are the CATS. We have a process for transitioning the airway from the hot to the cold zone and have a variety of difficult airway devices available not to mention the appropriate drugs. Our medical team also can serve as the RIT for the regular hazmat teams. Hazmat isn't for everybody and only those with specialized training should get into the mix. My days as a fire fighter are long past and I wouldn't think of entering a burning building now but suiting up in level A hazmat is second nature. To each his or her own. Spock May the tube be with you. Sorry chbare, I didn't see your excellent post before I chimed in. My humble apologies. Spock

My field experience was with the same preceptor throughout my training but that was for complicated political reasons. It was actually very valuable for me but it is not the norm around here. Students go to several services and have different preceptors at each one. I think they rotate every 2-3 months but since I don't precept, I'm not certain. May the tube be with you. Spock

Well I'm sure everybody on the City wishes you the best of luck with Paramedic school. You have a great advantage over some of the EMTs I see in my area that go into the paramedic program immediately after finishing EMT school. The have no concept of what really happens in the back of the truck and they struggle to be good medics. You on the other hand, have a wealth of experience in the field and precepting should be easy. The real problem you will have is adapting to the classroom because any paramedic program worth its salt does not "keep it simple" because medicine and the credentialing bodies are complex. Don't spend time before class trying to get a head start since that will only make what is presented more complex than necessary. Take the assignments given and keep up on them in a timely fashion. Last year, I completed my doctorate and I found the best way to keep up with my academic work was to block out a specific part of the week when I did nothing but my school work. For me, that was Sunday afternoon but it could be different for everybody. The point is, stay on top of your classroom work and don't get frustrated and NEVER tell an instructor they are wrong based upon your significant field experience. In other words, DON'T piss off the person that grades your tests! That will be your biggest challenge! Good luck and check back on occasion. Spock May the tube be with you.

I can think of any number of drugs to give this patient and none of them include NTG or ASA. ERDoc is certainly correct in that this is rate related and with the a SBP of 110, the patient leans toward stable rather than unstable although that may not be the case for very long. Diltiazem is the drug of choice here followed by beta blockers, amiodarone, and perhaps verapamil. My service carries diltiazem and amiodarone but not beta blockers or verapamil. I wish we carried a beta blocker such as esmolol, lopressor, or labatelol. The last patient I had go into AFIB with RVR was under general anesthetic and already in a lateral position for a video assisted thoracoscopy. When prepping the patient, I had placed the defib pads on him because he was sicker than crap. Just before incision, the rate took off into the stratosphere and the BP as measured by my arterial line dropped like a rock. The last numbers I saw was a rate of 180 and a SBP of 50. I sync cardioverted with 200j and knocked him into sinus rhythm. The surgeon was quite happy and we finished the case after cleaning the infection out of his chest. He had a rocky ICU course but survived. The risk of cardioversion is dropping a clot into the brain and stroking out but there really was no choice here. May the Tube be with you Spock

I'm sure CCMEDIC didn't know Dust passed away some time ago but you do have to admire his passion and I hope he does return to the city at some point. He may be to embarrassed at this point but I hope he reconsiders since it might spark the kind of debates that Dust really loved. May the Tube be with you Spock

WOW! I can't believe what I have just read. Dust was truly an icon on the City and he was taken from us much to soon. I had several off line conversations with him and he was a special human being. I'm sure he has a special place in the hereafter and he is probably grinning from ear to ear knowing he got somebody that mad so many years after he passed away. RIP Dust. Spock

Agree with the transected cords and I've seen two in my career. The first was when I worked as an athletic trainer and a defensive back ducked his head when he made a tackle. The second was in the trauma bay at the level one trauma center where I worked for 16 years and the city medics brought in a guy that had been robbed in a downtown parking garage and even though he willing gave up every thing he had, the knuckleheads shot him in the neck. He was conscious and alert when they moved him over onto the hospital cot. The medics gave a report and finished up by stating almost incidentally that the patient couldn't move his arms and legs. You could have heard a pin drop in the room. Spock