Spock

I agree with Dust. Get your BSN and work in the ICU/CCU for experience. You can do EMS any time. If you really want to go big then go to anesthesia school and become a CRNA. Great job with autonomy and respect. The money isn't bad either. Good luck with nursing school. Live long and prosper. Spock

We just put the Emergent model in service last month. We went with that model because the region came up with a bunch of money and bought units for every EMS agency in the region. They bought three units for my service so we only had to buy two on our own. I liked the Whisperflow better but I do agree the Emergent is simpler. The City of Pittsburgh bought the disposable Boussniac (spelling?) units. That unit seems to have the highest oxygen consumption but is very simple. CPAP is an ALS skill in PA but some ER physicians are talking about making it BLS. We have had good results so far and Rid is absolutely correct that CPAP reduces the number of intubations and also decreases the cost of care. We intubate fewer patients in the hospital because of CPAP and BiPAP. So far the only problem we have had is getting the ER's ready to accept the patient on CPAP. We give them 10 minutes notice but that doesn't seem to be enough for them. We have short transport times so it is a problem still looking for a solution. Live long and prosper. Spock

We just started a new airway class called Advanced Prehospital Airway Management (APAM) here in Western PA. The region got a big grant to pay for the course and all paramedics are expected to complete the class over the next few years. The course is free and the instructors are well paid. It is an 8 hour class and is scenario based. Everyone that has completed it so far loves the class and they take away many useful skills as well as new insight into the decision making process involved with airway management. Live long and prosper. Spock

I've used the LMA and King airways extensively and have had to change the combitube in the trauma bay. I think the King wins hands down with the only reservation being no pediatric sizes yet. Pediatric Kings are coming as the Beta tests are underway. That said we should remember that the PALS recommendations for prehospital pediatric airway management is to use the BVM. I also do not agree with the failure at intubation is not an option. You should always have a backup plan for every airway management case. Live long and prosper. Spock

Very good point Dust. It seems the students in the classes I teach are either very experienced and bored to tears or lacking in the necessary fundamental knowledge to get the most out of the class. Neither group is well served. I'm not sure what the answer is but what we have now is not up to the task. One good thing is the emphasis on evidence based medicine for the updates every 5 years although if evidence is lacking there are often more questions than answers. Live long and prosper. Spock

I agree about the ACLS text book. It used to contain alot more information than the current 8th grade reader. The dumbing down of ACLS? Live long and proper. Spock

There are several volunteer fire departments in this area that have large banquet halls attached to their stations. They raise enough money to support their fire department operations with weddings, parties and other functions. Alcohol is purchased by the renters and firefighters work the events as bartenders and set up and clean up functions. While working the event they are not permitted to respond to fire calls and do not drink. They get paid to work the event. I don't see anything wrong with this. Otherwise alcohol in the fire or EMS station is a very bad idea. Live long and prosper. Spock

Lot of good comments here so the only thing I would add is if you thought the tube was in the goose you can always confirm placement by looking with the laryngoscope. From what I read it sounds as if the tube was in the goose from the beginning. We have a policy here that whoever intubates transports. We don't have fire department medics (all FD QRS are BLS) so I understand you have different issues. In the interest of continuity of care the FD medic should transport. I don't take anybodys word for proper tube placement especially if they are not transporting. As far as capnography, the waveform is more important than the number when confirming placement (vs-eh pointed that out). Why do you say the tube was OK when you pulled it? The positive capnography readings after soda ingestion is problematic. I have only read one study suggesting this is true and that was an animal study with a small test population. I am not at home so I can't cite the reference right now. Live long and prosper. Spock

We change the small endo tubes as soon as possible. We have had to many cases of a 6'2" 260 pound male with a 6.0 endo tube. Ventilations become very difficult over the next few days. It is best to change the tube early before the patient swells. We usually do it in the trauma bay but sometimes will wait until the patient is in the trauma/burn unit. The ER docs (residents) are usually quick to jump at intubating but they run in the opposite direction with changing a burn patient's tube. My previous post said we change the IV's within 2 hours. Sorry for the typo but I meant 24 hours. We tried the subglottic suction endo tubes for a while but the hospital decided not to use them because of the cost ($13 vs $1.50) Of course one less case of ventilator acquired pneumonia would more than make up for the increased cost but we couldn't convince the bean counters of that. Rid hit the nail on the head. If the patient survives the initial injury the burn won't kill him but the sepsis later on will. Rule of thumb: Age + % total body surface burn = mortality. Not scientific but it seems to be accurate. Live long and prosper. Spock

I've done my share of burns and agree that most do not go to the OR immediately unless the burns are so extensive that debridement can't be done in the tub in the burn unit. Avoid the burn site at all cost when starting an IV and don't try multiple times. You just use up good veins because we pull field IV's within the first 2 hours. The saphenous vein will take a 14g easily in most patients if the arms are burned. Open the fluids wide (warm fluid) and make sure you give an accurate report on how much you have infused. And always put in a normal size endo tube if you are intubating early. Another topic that has been addressed before but it is a pet peeve of mine and deserves mention again. Live long and prosper. Spock

We put the EZ-IO on our trucks about three weeks ago and so far it has been used twice. The medical director was concerned that people would jump to the IO without even looking for a peripheral. We shared his concerns and when we put them in service the training emphasized try a peripheral first (including an EJ) before going to the IO. Both times it was used on an arrest one of which was 2 month old. I was on the adult use and it ran just like a 20g which was better than I expected. The only problem was when we arrived at the ED the staff ignored the IO and as far as they were concerned we didn't have an IV so they wasted a great deal of time trying to get a peripheral before the doc called the code. They never did get a peripheral. I really do hate nurses. Wait--I saw another topic about that. It really is just another tool that must be used appropriately. Live long and prosper. Spock

We give NTG, ASA and morphine to our STEMI patients prior to command contact and transport these patients to hospitals with cath labs. The few community hospitals without cath labs will divert us to the cath lab centers. The only time we would go to the community hospitals is if the patient absolutely refused to go anywhere else even after we explain the community hospital can't treat them and will transfer them. The region is looking into establishing a cardiac divert policy similar to the trauma divert policy so we can go to the cath lab hospitals even if the patient objects. It really is in their best interest. Don't forget that the use of stents is under fire and we may see a return to primary CABG as the best treatment for the STEMI patient. When the questions concerning stents came up a few months ago we saw an increase in CABG's at the patient request. I admit my bias because I specialize in cardiac anesthesia. Time will tell how this plays out. Didn't the new AHA guidelines recommend that 911 dispatchers tell patients to take ASA if having chest pain before EMS arrival? Live long and prosper. Spock

Even better, they are working on a sewer back up! Actually, the towns I have mentioned only allow response to fire calls. EMS in those places are career based. Live long and prosper. Spock

I know of at least 3 small towns in my area that allow borough employees that are volunteer firefighters to respond to fire calls while working. This greatly helps their daytime response and they get the engine on the road faster than anybody else in their area. Live long and prosper. Spock

I have never liked the combitube because I hate having to go down to the ER to change one. The ER docs won't touch it and they always call anesthesia to change it. That feeling aside, it is a reasonable backup airway to a failed intubation. Each time I have changed one I have found the patient is adequately ventilated and oxygenated so the change to an ET tube is done slowly and carefully. Most of the combitubes I have changed were placed by flight crews on trauma patients after failed RSI. I have never changed a combitube on a cardiac arrest patient unless they get pulses back. I have said before that I like the King and have been using it in the OR since March 2006. I have quit using the LMA in favor of the King. One of our local flight services added the King and tracked the use of both it and the combitube. After 6 months they removed the combitube and use the King as the primary rescue airway. I believe the LMA would easily lose its seal when the patient is moved in the prehospital arena. The depth of anesthetic required for a King is greater than that required for an LMA which is one down side. The term conscious sedation was used in conjunction with the LMA and I would suggest this is erroneous. Conscious sedation means the patient retains their gag reflex which precludes the use of an LMA, ETT, King or combitube. Once you lose the gag reflex you move into the realm of general anesthesia for which one must be properly credentialed. I also believe that the King could be a BLS skill with proper education and training along with a close and stringent QI/QA process. If you can place an OP airway you can place a King. Live long and prosper. Spock

I'm not sure we are really disagreeing here but may just be splitting hairs. If you can see the trachea under direct visualization why bother with a bougie--just put the tube in. If you can't see the cords you can pass the bougie blindly into the trachea and then pass the endo tube over the bougie. I used a bougie the other day to replace a trach. Live long and prosper. Spock

Sorry but that quote belongs to Benjamin Disraeli Prime Minister of Great Britian circa 1850. EMS has always been the red headed step child of the fire service and I see no reason why that will change. Live long and prosper. Spock

Thanks for the information VentMedic. We are looking at the Boussignac and the Whisper flow. The Boussignac is appealing because it is completely disposable so when we arrive at the hospital we can just connect to the hospital oxygen supply and get back in service. Our crews have been calling in and asking for CPAP to be ready upon their arrival but the hospitals are slow to respond so there is significant lag time. Pittsburgh EMS added the Boussignac a few months ago. One of the biggest issues is getting the services around us to agree with one type of system. That way the hospitals to which we transport most of our patients can stock one circuit for replacement. That would cut down on the cost not to mention possible cost savings with bulk purchases. Unfortunately we have some service directors that don't even know what CPAP means. Live long and prosper. Spock

I would have to say that is unfortunate. I never realized Australia was so backwards and maybe I should appreciate what we have here in the States a little bit more. Fortunately you are still young and can work on your education because that is everything. Good luck. Live long and prosper. Spock

VentMedic--Which disposable CPAP system "isn't to bad." I've been researching this in order to recommend a system for my service. Through chart reviews I've determined that we would probably use CPAP at least once per week so we do have a need. Unfortunately my experience with CPAP is all in hospital so these prehospital units leave many questions especially oxygen consumption. Any help would be appreciated. Live long and prosper. Spock

Timmy--In the States you have to be a college graduate in order to call yourself an athletic trainer. I passed the national exam in 1976 (yes, I know you weren't born yet) and worked as an athletic trainer for 15 years including 8 years at an NCAA Division 1 university and 5 years in the NFL. I took the EMT and paramedic classes while working in the NFL. Now, I work as a nurse anesthetist and volunteer with my community EMS which is mostly paid. In fact, the only other active volunteer is the national sales manager for large lab testing company. Live long and prosper. Spock

ERDoc--Your points are well taken but please don't shoot the messenger. Don't forget, I'm in anesthesia and my response to how much opioids can I give is how much do you have! Our chief of surgery feels strongly about this and he is not old school by any means. I think his opinion is a reflection of his lack of respect for our emergency department. Part of this is based on a highly antagonistic relationship between surgery and emergency medicine at our hospital. Perhaps you have a better relationship with your surgeons than we have here. I confess that the relationship between anesthesia and emergency medicine here is not much better. I try to improve this because I know many of the ER docs as a paramedic bringing in patients. They usually chuckle when they see me. Live long and prosper. Spock

ERDoc--Your points are well taken but please don't shoot the messenger. Don't forget, I'm in anesthesia and my response to how much opioids can I give is how much do you have! Our chief of surgery feels strongly about this and he is not old school by any means. I think his opinion is a reflection of his lack of respect for our emergency department. Part of this is based on a highly antagonistic relationship between surgery and emergency medicine at our hospital. Perhaps you have a better relationship with your surgeons than we have here. I confess that the relationship between anesthesia and emergency medicine here is not much better. I try to improve this because I know many of the ER docs as a paramedic bringing in patients. They usually chuckle when they see me. Live long and prosper. Spock

I have had several conversations regarding abdominal pain and opioid analgesia with our chief of surgery. He is adamant that this is a bad idea and the only thing preventing more bad outcomes is the sophistication of imaging such as the new generation CT scanners. That said, there is a growing body of literature suggesting analgesia for abdominal pain is reasonable. Interestingly enough, the literature is mostly written by ER doctors and not surgeons. I have never agreed with the all or none philosophy and think every patient must be treated as an individual. Therefore, I would say it is reasonable to call command and ask for orders for opioids after a thorough exam. I don't support a standard order for opioids for these patients. One other consideration is if the abdominal problem requires surgery, can a patient sign an informed consent after receiving opioids? I doubt that a small amount of opioids would interfere with the decision making process but an attorney might argue otherwise. Analgesia for pain is the forgotten epidemic in all aspects of medicine and we all should strive to do a better job of helping our patients. Every time I hear somebody say "he doesn't look like he is in pain" I go ballistic. Live long and prosper. Spock

Using the bougie in any manner is still a blind technique and does not work 100% of the time. And you can cause significant damage to the trachea if you advance it to far. Any resistance is bad. I've seen considerable blood come out of the tube when the bougie went in to far. 30 cm is far enough because that is the distance of a normal endotracheal tube. When I have to change a tube I will place a bougie (tube changer) down the existing tube and then do a laryngoscopy. If I can see the tube passing through the cords I will have somebody else pull the existing tube while leaving the bougie in place. Then I will place the larger tube around the bougie, confirm placement and then remove the bougie. We have to do this frequently when medics bring in burn patients and they placed a small tube initially. Long term ventilation becomes a problem with a small tube. I addressed this issue in a previous post. Live long and prosper. Spock