Spock

Good points Mike. We have seen infections from prehospital IV's. Is the number greater than that of hospital IV's? Probably not but I couldn't cite exact figures. Pulling prehospital IV's is a hospital policy. The hospital has control over IV's started in house but not over the prehospital IV's. It's not fair but that's the way it is here. Live long and prosper. Spock

I'm amazed any lab would accept blood for a type and cross that was not drawn in house. As for caps, I get rid of them and the extensions immediately and hook up the IV tubing directly to the IV catheter. The extensions can be a problem because some are 20g. Even though the catheter is 16g the 20g wins. There is something incongruent about saline locks and trauma patients but I have also seen patients get large amounts of fluid because of inattentive medics and nurses. Like anything else there is a time and place for most things. I was always taught that the smallest IV you could administer blood through was a 20g but only if something bigger was impossible. I always run blood through a fluid warmer but that is because I run it in as fast as I can. A rule in anesthesia is anything given over longer than 3 seconds is a slow IV push! Live long and prosper. Spock

Lots of good information here and all things are relative. Permissive hypotension still has its place and I routinely do it in the OR to decrease blood loss especially for orthopedic or oral/maxillary/facial procedures but I decide how low to drop the BP and tell the surgeon to go pound salt if he doesn't like it. Like Rid said, you still have to perfuse the heart and the brain. Coronary perfusion pressure (MAP - LVEDP) should be greater than 70 unless the pt has HTN or CAD in which case 80 or 90 is appropriate. Cerebral perfusion pressure (MAP - ICP or CVP) should be greater than 60 with 70 to 80 ideal for pt's with HTN. Bottom line is to keep MAP above 70 in all patients except the young and healthy. I get irritated when I see a pt arrive with 2 large bore IV's (which will get pulled) after 6 attempts. By golly the medic was going to get 2 IV's no matter how many attempts it took! What a waste. I'm not sure why your trauma doc wants 2 IV's but he must have his reasons. Better communications is definitely needed. We prefer to have one good IV and start the rest ourselves especially since we draw labs from one of the IV's we start. Live long and prosper. Spock

We don't draw labs any more and in PA medics are not allowed to draw blood for alcohol levels. The PD has to go to the hospital and watch the blood being drawn and labeled. He then takes the blood to the crime lab for testing with a chain of custody followed. Alternatively, the officer can ask the MD to order a toxicology screen and then get a subpoena for the results. I agree about the color of the tubes. Our lab changes the colors every other week it seems and I always have to ask which color tubes to draw. My hospital (level 1 trauma center) has a policy to DC all prehospital IV's as soon as possible. I just pulled two on a patient this evening. Infection is a real concern. Live long and prosper. Spock

Penn State University runs its own EMS agency out of the student health department. The have two units and staff them with 3 EMT's--two paid and one volunteer. PSU is located in State College which is a pretty rural area. The units are BLS and meet all state regulations. One unit covers the campus while the other is used for special events such as athletic events. They upgrade the service to ALS for football games and import medics from all over the state because there are not enough in the area. I've been working games for 8 years now and every game is an adventure. Beaver stadium holds around 110,000 and is the third largest city in PA on game days and I'd bet 60% of the fans are drunk by kickoff! We have around 90 people working the games including MD's, RN's, Medics, and EMT's. It's a pretty good system. There are quite a few college EMS agencies and they have an organization that meets every year. I'm not sure of the name but if you google it I'm certain you would find it. PSU offers EMT courses for college credit and the crews earn money for school. They staff one truck 24/7 including summer. ALS comes from the local hospital by a response unit. Most of their calls are BLS and I think they run 6-700 per year. They are pretty busy in the summer covering all kinds of camps and events including the 3 day Special Olympics in June. I've worked Special Olympics for going on 10 years and enjoy it every year. Live long and prosper. Spock

We have a Kindred here in Pittsburgh and a former student of mine is the CEO but I just never saw the abbreviation LTAC before. Very interesting discussion here. One thing to remember about medications is that we frequently only have theories of how and why they work even though we use them commonly. Propofol has been around for quite some time but it was very expensive so most people didn't use it until it came off patent around 1999 (not sure of the exact date). The text I cited has been updated so it may now say that propofol does have anticonvulsant properties. I suppose I should update my library. Anyway, the common perception is that it does stop seizures although benzodiazepines are the drug of choice to terminate a seizure. Propofol goes away so quickly that the seizure would easily reoccur. The tonic movements seen with propofol could easily be confused with seizures so the only way to know what is really going on is to monitor EEG during the event. My experience over nine years as a CRNA tells me that the tonic movements occur rarely because I can't ever remember seeing it. That doesn't mean it does not happen but I have just not seen it. I monitor EEG during general anesthesia with my BIS monitor which is a gauge of anesthetic depth. I usually do not apply the monitor until after the patient is asleep but I may start putting it on prior to induction and look for EEG activity consistent with a seizure upon propofol administration. Live long and prosper. Spock

What is an LTAC? The abstract Medik8 posted is indeed interesting but one item from 1994 is not an indictment of propofol. I would say that seizures from propofol are rare to nonexistent. Cocaine and seizures are very common. One other thing about propofol is that it burns very badly if given through a small peripheral IV. We usually administer lidocaine 1mg/kg just prior to propofol as a venous local anesthetic. Live long and prosper. Spock

Sorry not to have answered sooner but I've been working late recently and golfed on Sunday (my birthday!). I administer propofol almost every day I work. It is the induction agent of choice in our operating room for general anesthesia and is used as an infusion for sedation cases (we call them a MAC case). We use propofol because it is cost effective (it came off patent a few years ago) and is thought to have antiemetic effects. It wears off quicker and leaves no hang over effects that you saw with pentothal. We use etomidate for patients with impaired left ventricular heart function and fentanyl for CABG patients. Patients frequently report very pleasant dreams while receiving propofol many of them of a sexual nature. More than one patient has asked if they could take some home! I have never seen seizures from propofol. Some will use propofol to terminate a seizure but the text state it has no anticonvulsant properties. Tonic movements have been reported but I have never seen them with a bolus or infusion. A bolus of propofol is always followed by a muscle relaxant such as succinylcholine or rocuronium. The muscle fasciculations we see with suxs may also be caused by the propofol but we would have no way to differentiate. I have never seen the tonic movements when roc is given. One thing that commonly happens with propofol is a dysphoria or agitation seen when not enough is given. There is a gray area (I call it the DMZ) between sedate and unconscious that is very unpleasant for all. The pt will be wild and almost uncontrollable. The solution is to given more or less in order to get them out of the DMZ. This is adapted from Clinical Anesthesiology by Morgan and Mikhail second edition pages 144-155. "Propofol decreases cerebral blood flow and ICP. In patients with elevated ICP, propofol can cause a critical reduction in cerebral perfusion pressure (<50mm Hg) unless steps are taken to support mean arterial BP. Propofol and thiopental probably provide a similar degree of cerebral protection during focal ischemia. A unique characteristic of propofol is its antiemetic and antipruritic properties. Propofol does not have anticonvulsant properties. Induction is occasionally accompanied by excitatory phenomena such as muscle twitching, spontaneous movement, or hiccuping. Propofol decreases intraocular pressure." Propofol works by facilitation of inhibitory neurotransmission mediated by gamma aminobutyric acid. Its high lipid solubility accounts for its rapid onset. Metabolism is through the liver although clearance exceeds hepatic blood flow which means it goes away quickly. The metabolites of propofol are inactive and renal failure does not impede excretion. Propofol is not water soluble and is available in an emulsion containing soybean oil, glycerol, and egg lecithin which accounts for its milk white appearance (we call it milk of amnesia). A common misconception is that patients allergic to eggs can not receive propofol: they can. OK, sorry for the pharmacology 101 lecture. Nate, I'm not sure what happened with your patient but the seizure you saw might have been from either a contaminant or the DMZ I spoke of. Propofol has no preservative and must be drawn up and administered aseptically within six hours. Sepsis and death have resulted from contaminated propofol. Could this have been the issue or was he in the DMZ? What else was given and the same time and what were the circumstances surrounding the seizure? I understand if you can't answer these questions. Might I add it is a pleasure to converse with all the folks on EMT City. The questions and comments are for the most part very intelligent and insightful. Much better than our local forums here in the Steel City home of the Super Bowl Champion Pittsburgh Steelers! Sorry, just had to toss that in. Live long and prosper. Spock

1-EMT-P-- I'm curious to know what kind of results they are getting using fentanyl for chest pain. In the operating room we use fentanyl as an induction agent for patients undergoing open heart surgery because of its hemodynamic stability. 1000mcg of fentanyl along with 5mg of versed and anybody is asleep and not breathing. My question about chest pain arises from the position statement on prehospital pain management issued by the National Assoc. of EMS Physicians. Among other things they stated that morphine is still the analgesic of choice for chest pain. If you talk to your buddy in Maine any time soon see if you can find out. Thanks. Live long and prosper. Spock

tinman was right. The medic was scared stiff and had no idea what to do so she screamed at miniemt. Insecure and stupid; a lethal combination. To OZ! Live long and prosper. Spock

I think fentanyl is the best opioid for prehospital use. It has rapid onset and short duration. If you have long transport times you can give fentanyl and morphine together. The fentanyl will be "wearing off" when the morphine kicks in. Any of the agonist/antagonist drugs are lousy analgesics. I only use nubain in the hospital when I have a patient slow to emerge from anesthesia and I think the cause is too much opioid. It doesn't happen often because I work at a level 1 trauma center in the city and most of our patients are not narcotic naive. Our prehospital pain protocol was recently changed to include fentanyl and we are having very good results. With morphine we say a reduction in pain from 8 to 5 on the ten scale while fentanyl is showing a reduction of 8 to 3 with many patients at ZERO pain upon arrival at the hospital (we have short transport times). I've given it three times since we implemented it in January but all three were in combination with versed to put a patient down for intubation. Not what the medical directors had in mind when they agreed to add fentanyl but it was certainly on my mind when I proposed the protocol change! Live long and prosper. Spock

Can I come up to the Green Mountain State and precept the "I-tech"? That would be fun! Can you say new rectum? Live long and prosper Spock

If I had only one monitor it would be a pulse oximeter because I feel it gives you more information than any other single monitor. That said, the best monitor is a vigilant health care provider. Live long and prosper. Spock

I'm not sure why everything would be "dumbed down" as Dustdevil suggests. Why couldn't educational standards and scope of practice move to the ceiling instead of the basement. Nurses, certified athletic trainers, physical therapists and nurse anesthetists all take a national certification exams. I'll bet other health professions are the same. Why can't EMS? Live long and prosper. Spock

I'm all in favor of GOOD education and increasing educational requirements. That can only lead to fewer volunteers, more jobs and higher pay. I don't think I would eliminate the EMT altogether but I would require experience as an EMT prior to entering the medic class. Here in Pittsburgh you can start the medic class the day after you pass the EMT exam. I had to have at least one year of critical care nursing experience prior to entering anesthesia so I don't see why EMS should be different. I will say the best partner I ever had was an EMT. He was fully capable of assessing a patient and if the call was BLS he insisted on taking the call. He could check a blood sugar (EMT's in PA aren't allowed to do that) and knew enough about EKG strips that he could recognize a lethal or life threatening arrhythmia. Unfortunately cancer got him and he passed away. EMS hasn't been the same without him. Live long and prosper. Spock

It is a shame that we have such variability in the scope of practice from state to state and even within the same state. Wouldn't it be nice if an EMT (or EMT-I or EMT-P) in Florida was the same as in New York or Colorado or any of the other states or Canada? EMS is sometimes its own worst enemy. Live long and prosper. Spock

I used to teach the cardiology and respiratory sections of a community college paramedic class but stopped a few years ago. I included many things that were valuable in order to properly assess and treat patients but the students only wanted to know what was on the test because if it wasn't they weren't going to study it. I had students get angry with me for not giving them the answers to the test! Heaven forbid they should open a book, read or study. I'm afraid this is true of most education today and not just the paramedic classes. Live long and prosper. Spock

We added IN narcan to our protocol using the MAD device about a year ago but it is utilized rarely. I'm not sure why our medics don't use it because we do get alot of OD's. Perhaps we are just not in the habit of using IN anything. IN versed for the seizing patient is a great idea but again we don't use it regularly. Some folks use IN versed for sedation but it burns quite a bit so I don't think it is practical for that purpose. I'm going to have to remember IN narcan for the next OD I see. Live long and prosper. Spock

I subscribe to Annals of Emergency Medicine and am able to download any of their articles. It's the best $167 I spend each year (tax deductible of course). JEMS might be the same but I never looked. Contact them and see is you can get a reprint (it will cost you). You might ask your medical director to see if the hospital library can come up with it also. I'm a pack rat and never throw away books or journals but we moved in 2002 and I took the opportunity to thin the herd so to speak so I don't have it. It was the one about using a spine board and c-collar for all intubated patients wasn't it? Good idea. Live long and prosper. Spock

I agree with Rid on this although the two terms have become synonymous. As for the oxyhemoglobin dissociation curve I just have to say that you should never forget 2,3 DPG, the Bohr and Haldane effects and by all means keep the right shift away from the left. Just remember that saturation does not equal ventilation. Live long and prosper. Spock

If viagra comes in liquid form, does that mean you have to drink it fast to avoid getting a stiff neck? Live long and prosper. Spock

I feel your pain. We have destination command unless we want to give a controlled drug (morphine, fentanyl, versed, valium) then we have to call our command hospital and they relay the information to the receiving hospital if it is different. We also have to call command in order to get a helicopter because we have some idiots in the system that have flown people for nose bleeds! The medic on that one swore she felt a pulsating abdominal mass. A classic example of dumbing down the system because of the lunacy of a few. Luckily she is no longer a medic. Some people get around the problem by having the fire chief or police officer request a helicopter. We have so many birds in this area that they wouldn't turn down a flight no matter how inappropriate. Command knows this happens but turns a deaf ear to it. Some system isn't it! Many of our docs don't even know our protocols. We routinely get orders for ativan when we don't have it in the drug box. Live long and prosper. Spock

I agree with you guys on wave form capnography. Frankly, I feel if you do not have this technology you should not be allowed to intubate although I do realize it is expensive. However, the payment to settle the lawsuit for one unrecognized esophageal intubation would pay for the technology along with several ambulances. I recognize the use of capnography for the nonintubated patient but I'm not sure what it gets you. So the ETCO2 is high; does this mean you can put the patient down and tube him? We mandate the use of capnography for all intubated patients along with recording a strip on the LP 12 at time of intubation and time of arrival in the DEM. Our director won't get the cannulas for the nonintubated patients because of the cost and we can't do anything about a high ETCO2 anyway. We don't have RSI. Also, he said insurance won't pay for it. Using a c-collar and HID for all intubated patients is an excellent idea and has been reported in the literature. Recording an ETCO2 strip after every move is also a great idea. Here is another: upon arrival at the DEM, have the physician listen to lung sounds and confirm tube placement PRIOR to moving the patient to the hospital bed. San Diego FD does this and wrote about it in a recent edition of JEMS. The first time I did this the doc looked at me like I was a nut but she did it anyway. Wave form capnography is another example of EMS technology outpacing hospitals. We transport most of our patients to six different hospitals. Only two have capnography in the DEM: one can never find the tubing for their monitor and the other has a unit so old it takes 10 minutes to warm up. Go into most hospital ICU's around Pittsburgh and you will find intubated patients without capnography. I presume it is the same in other parts of the country. The website for the King airway is www.kingsystems.com. We are forming a Hazmat medical team in Pittsburgh to provide medical support for our 5 Hazmat teams (I know, that is probably four more than we need). We are planning on using the King as our primary airway for use in the hot zone. After decon and movement to the cold zone, we will change this out for an endotracheal tube. I also think it makes more sense to use a King or combitube for the RARE patient that needs airway procedures while entrapped. Every person I have seen with their head through the windshield was dead. Live long and prosper. Spock

I wasn't suggesting that the King should replace ETI and I agree that more experience is needed with it. I just think it is a better back up than the LMA or the combitube in the prehospital arena. Also, if an EMT can place an OP airway I see no reason why they couldn't use a King LT-D. Using a device 6 times does not make me an expert which is why I still look for cases to use it. I'm currently on the down side of a 24 hour shift. Score for today is 4 ETI's, 0 LMA's and 0 King LT-D's. Yes, ETI is still the gold standard. Time for coffee. The next surgeon that walks through the door is going to get it right between the eyes. Live long and prosper. Spock

I am as active in the field as my time permits. My local service is mostly paid but still has a few volunteers. They issued me my own radio and I respond from home on calls near me or I take a response vehicle home and run ALS backup to give the supervisors a break. EMS gets into your blood. I really think the King has advantages over the LMA. It provides a small amount of protection against gastric aspiration (the LMA provides none) and maintains a better seal when moving the patient. The first person to use the King in our OR was a first year SRNA. She put it in easily. I've used it six times so far and am always looking for a reason to use one. Most of the cases I'm assigned to are not appropriate for a King or LMA. You can also use higher positive pressures to ventilate a patient with a King as compared to an LMA. We pay $8 for a disposable LMA and $14 for the disposable King. There are three sizes based on height. I would think the King would be much better for prehospital or battlefield conditions than an LMA. Its advantage over the combitube is that with only one lumen there is no decision to make for ventilations. The King came from Germany and was approved for the US in 2005. There is a website but I have it at home and I'm at work right now. Google King. Live long and prosper. Spock