Spock

I volunteer every summer for the Pennsylvania Special Olympics State games and have run into this problem. Athletes are required to manage their own meds (and they take a bunch) under the supervision of their parents and coaches. I wear three hats working these games: nurse anesthetist, athletic trainer and paramedic and switch between them depending upon the injury. I am also an employee of the University Ambulance Service which covers the games so I am under their EMS medical director as a paramedic. I always err on the side of caution and stick to the basics. Otherwise you have already gotten some very good information from Dust and Eyedawn. I do have to agree with dust that most of the EMT's are not familiar with the significant medical conditions these athletes have and a good nurse is more appropriate. At least with the Boy Scouts you are dealing with a healthier population. Live long and prosper. Spock

Hey Rid, I wasn't bragging about anything just pointing out the facts. Actually, what's wrong with the Ivy League other than most of those players are smarter than the rest of us! I would never suggest the Big Ten is better than some other conferences after what Ohio State has done over the past few years. Live long and prosper. Spock

Penn plays in the Ivy League. Penn State plays in the Big 10. Not to be picky or anything! Live long and prosper. Spock

I have to agree with VentMedic on this one especially the part about intoxicated patients rarely needing intubation. Blind nasal intubation is a lost art. Live long and prosper. Spock

I have to side with Dust on this topic. The basic paramedic program must be more consistent across the board and the diploma mills need to go away but I would say the same for nursing diploma programs since I believe the BSN should be the entry level degree for all RN's. I wouldn't say a BS should be required for paramedics because the pay would not rise along with the degree but I see nothing wrong with an associates degree for paramedics. I wouldn't be quick to compare the US with what is done overeas. The medical and legal systems are different and comparisons are difficult. I'm not saying one system is better than the other just that they are different. Patient expectations are also different. I'm certain the US system could be improved and I suspect our colleagues overseas would say their systems could also stand improvement. Live long and prosper. Spock

Well this topic got hot and heavy pretty quickly. I won't claim to have read every post completely but I did skim slowly over them and would like to offer my opinion. 1. I don't know how old Henry Wang is but I have had several conversations with him and I am confident that he is younger than me although you can't always be sure about Asian-Americans because they don't seem to age much. Must be clean living. 2. PA paramedics averaged 2 intubations per year in 2005 according to Wang in Critical Care Medicine August 2005. With 2 per year nobody can maintain proficiency including ED doctors. 3. I had an ED resident in the OR the other day bragging that he had done 4 intubations the previous month and he really didn't need my input or advice. The departmental chairman threw him out and he won't be allowed to return. 4. Paramedics really need to police themselves and upgrade their standards. My medical director (he covers 10 services) doesn't have any idea how many tubes his medics get nor their success rates. I think he is to busy because I wouldn't want to accuse him of not caring. 5. I think medics should be allowed to intubate but I'm not sure all of them are capable. I can teach a monkey how to intubate but not when and if the monkey doesn't do it often he will never maintain proficiency. Unfortunately we don't know how many tubes it takes to be proficient. Good comments by all and it shows how excited the folks on the City can be. Keep up the good work. Live long and prosper. Spock

When I went to nursing school we had to get the immunizations on our own as Timmy said. Fortunately I was still working part time as a paramedic and my employer paid for all immunizations and a yearly physical including PFT's because we carried SCBA's. I think the employer should pay for these but it does vary from company to company. Live long and prosper. Spock

Since you decided to pick nits I will respond. The Department Of Emergency Medicine IS a standard abbreviation and is more acceptable than the emergency room because the area is bigger than a room and encompasses an entire department of a hospital. The ER is a term of the 80's while DEM is a term of the 90's. Since this is a new century it never occurred to me that an explanation of a common abbreviation was necessary. Logic would suggest--------------- Oh, never mind. Live long and prosper. Spock

We were talking about this just the other day in the cysto room. The urologist said he had several patients in his office who were incensed over this. They all were active men in their 70's and 80's and were not ready to just up and die. They wanted the testing because they wanted to know if they had prostate CA and could make an informed decision on treatment options. The jury is still out on this and prostate screening is probably still indicated for most men. Live long and prosper. Spock

I have to agree with letting the nurses do ride alongs with EMS and paying them to do it. I once worked on a hospital ALS response unit and the DEM nurse manager had all newly hired RN's do at least 2-3 shifts with the response unit. The nurses came away with a new understanding of EMS and were easy to work with because of the personal relationship they developed with even a few shifts. People (both EMS and DEM) need to understand everyones job is easier if we work together. Live long and prosper. Spock

My service is an Authority that covers five communities. We run a subscription drive every year and bill for calls. We also run a capital fund drive every year to raise money above what the subscriptions bring in. The communities do not fund the service but have always been helpful with services in kind when possible. Money has been in short supply with the cuts in Medicare so we have been tightening our belts as much as possible. I'm not sure what the future will bring but we can't sustain ourselves in the long run as we are currently constituted. Live long and prosper. Spock

I graduated from the Center in 1989. Welcome to the City. Live long and prosper. Spock

Assisting ventilations in a spontaneously breathing patient is a difficult task. If you increase the tidal volume of each spontaneous breath you will improve their ventilation and saturation although both may still be inadequate (low minute volume.) There is nothing wrong with overriding spontaneous respirations other than the patient may quit breathing altogether and you have to breath for them. That actually makes management easier and you can improve ventilation and saturation to optimal levels. I've always considered pulse oximetry to be a BLS skill with proper training although that may vary from state to state. Mask ventilation is a difficult skill to master under any circumstances. Good question. Live long and prosper. Spock

"Wrong sided surgery" still happens and is a big issue in the operating room. The surgeon is required to mark the surgery site and before incision the circulating nurse calls a "time out" and states the patients name, the surgical procedure, patient allergies and if antibiotics were given. All in the room must agree before incision is made. We still have surgeons complain that they have to mark the site. How pompous and arrogant can they be? This surgeon should be required to tell all of his future patients about this mistake. Live long and prosper. Spock

EMS has definitely become more professional in this area over the past 20 years. Crews are in station and not responding from home and they are wearing uniforms instead of tee shirts and shorts. Radio traffic is more professional as is dispatch. There are fewer volunteers and EMT's and medics are more educated. There will always be a few bone heads out there but we seem to be weeding them out of the service instead of letting them go elsewhere to practice their idiocy. We can only hope educational standards will continue to increase along with professionalism. Hopefully pay will increase along with the education. Crews still aren't paid enough in my mind. Live long and prosper. Spock

Good comments here. I would add that timing is important. You need to work with the rescue crew so that everything is in place medically before the patient is freed. By that I mean IV's in place and volume loading before releasing the patient. Also, be prepared to intubate as soon as the weight is removed since the patient may arrest or become unresponsive. If you run a bicarb gtt you can't use that line for meds because anything given with bicarb will precipitate and clog the line. I also would suggest giving one gram of calcium chloride just prior to releasing the weight. Calcium will improve cardiac contractility and help with the resultant hypotension. This situation is very similar to what we do in the operating room when we do an open AAA repair. The surgeon clamps the aorta above the aneurysm and then releases the clamp after the graft is sewn in place. The reperfusion of both legs can become interesting especially if the SOB doesn't give you advance warning and just releases the clamp. Lots of swearing then. Obviously you might be restricted by the circumstances such as how much of the patient is pinned and what body parts are available for IV's. The bottom line is lots of fluids and rapid transport. The Israeli's and the Japanese have a lot of experience with this and I have seen literature recommending urine output of 12 liters per day. That requires a lot of fluid! Diuretics are best left for the hospital. Pennsylvania just added a crush injury protocol to our state protocols. I submitted a very aggressive protocol for consideration but I didn't see the final version. I'll try to share it when it becomes available. Live long and prosper. Spock

Congratulations. I know you must be relieved to finish your training and perhaps slightly apprehensive over becoming an attending. Your posts indicate common sense which can't be taught so I'm certain you will be successful. Good luck. Live long and prosper. Spock

Not sure how I missed this topic but I was out of town for a while. I completely agree with Dust that moving the patient will easily disrupt the seal of an LMA. I won't even move a patient from the OR table to a regular bed with the LMA in place. I have lost a seal just by turning a patient's head. The LMA is not approved for prehospital use in Pennsylvania. I've used just about every airway tool out there and my first choice for a rescue airway is the King. I've said this before and after using it for over two years I'm more convinced than ever. I feel the learning curve is smaller with the King than the LMA based on my personal experience. I use the King as a primary airway in the operating room instead of an LMA. I have used it as a rescue airway in the field. We recently got some GlideScopes in the operating room and those things are amazing although at $10,000 each they are out of the price range of most EMS agencies. The most important thing for airway management is practice. As I've said before you can teach a monkey to intubate but if he won't remain proficient unless he intubates frequently. The real problem is teaching him when to intubate. Take the tools your state and service let you have and work with them on a routine basis. If you haven't looked in your intubation kit in the last month you probably should let somebody else take the airway. Live long and prosper. Spock

There was a recent article in JEMS concerning this very topic and the firefighters liked the cold towels the best. Talk to the athletic trainer at your local high school or college for more information. My 15 years as an athletic trainer working football taught me many things on heat rehab and it all relates directly to firefighters. paramedicmike is correct about the weight of the gear and football players are in better shape than firefighters for the most part. Still, the techniques used on the football field will work on the fireground or hazmat scene. You might try searching the sports medicine literature for articles on this topic. If I recall correctly, the misters never really worked all that well and created a mess. I never used them up here in the northeast but they were popular in the southeast. If your service does sports standbys at your local schools this is a perfect opportunity to develop a relationship with the athletic trainers. Just a thought. Live long and prosper. Spock

I prefer an epi drip for any patient with a lousy pressure and one step away from cardiac arrest. I mix 4 mg of 1::1,000 in a 250 bag of NSS. 15cc/hr is 4mcg/min and you can titrate up from there although once you hit 8mcg/min and have not achieved the desired effect you need to think of something else like adding levophed to the epi or going to isuprel. Live long and prosper. Spock

Lots of good comments here and it is good to see so many people are knowledgeable on this topic. I read the comments and would just add a few things. If I am repeating what somebody already wrote I apologize. Capnography is a valuable monitor but it is only one of many we use. The most important monitor is a good physical exam and a vigilant health care provider. Correlate the ETCO2 reading with everything else you do and see. Capnography will be the first monitor to show the patient either lost or regained a pulse. I use the ETCO2 as a guide for whoever is doing compressions. If it goes up then compressions are effective. Also, my experience shows if we start working a code and the first ETCO2 is single digits after intubation I know we have no chance of regaining pulses and I will stop the resuscitation. We have that ability here to call the code in the field. Medical command has always supported that and families are receptive when it is explained to them properly. There is some literature to support this but I'm not at home so I can't cite the reference. Don't forget there is a place for capnography in the non-intubated patient. It will show if your treatments are helping or not. I wrote the SOP's for my service on this and we require both SPO2 and capnography for any patient that is getting fentanyl for pain management. Capnography is your first monitor to show hypoventilation. Of course you should look at the patient first but ETCO2 is valuable in this setting. I agree the Easycaps are a poor substitute and I never use them in the field. Direct visualization is a poor means to confirm tube placement because I can't count the times a medics swears he say tube go in the trachea when it is in the goose. I believe the tube is being pulled out when the stylet is removed because medics around here don't continue visualization while somebody else pulls the stylet. Also, stylets come out more easily if they are lubricated. We've been using capnography for almost 7 years and our medics really like it. This is one piece of technology where prehospital is ahead of the hospital. Most of our ER's still don't have capnography and the staff are painfully uneducated on the subject. What a shame. Live long and prosper. Spock

MAT has at least three different P wave morphologies. If the rate is fast enough you really can't tell the difference between the three rhythms. Live long and prosper. Spock

You are correct about milrinone since it is a potent vasodilator. I can only remember one time where I gave a loading dose of milrinone and did not have to run an epi infusion. Live long and prosper. Spock

Now that is one darn good question. There are a number of studies out but I don't think any of them really answer the question. The San Diego study is frequently mentioned as a reason why medics should not use RSI but the study had serious flaws in my view. We do need research on this and the services that use RSI should think about publishing results. Retrospective to be sure but it would be a start. A double blind study would be difficult since no placebo can mimic the effects of etomidate and suxs. Live long and prosper. Spock

Your comments about bias are well taken Dust. I guess the bias is on my part. Dr. Wang's solution to problems with paramedic intubation are to remove intubation from the scope of practice instead of education and close medical control which are more difficult and requires work on the part of the medical director. Every time I read a newspaper account of failed RSI by ground paramedics the cause almost always is poor decision making and failure to follow proper procedures. I have to ask again, how wide spread is the use of RSI by ground services? Live long and prosper. Spock