Spock

I don't know if I would go as far as that but the nuns ran the place into the ground and secular management has not been able to turn the ship around so we are merging with the university center up the street. We are the Borg. Resistance is futile. Prepare to be assimilated. Live long and prosper. Spock

I presume you are talking about Pennsylvania. PHRN's are allowed to preform any skill or administer any medication than is covered under their nursing license and is within their scope of practice as long as the service medical director has authorized it. That means as a CRNA I could give any drug or use any device I use in the operating room in the back of the ambulance as long as the medical director said OK. I rarely take advantage of this. The changes to Act 45 (the law regulating EMS in PA) provides for a prehospital PA category. The new law also provides for the EMT-I. Personally I think the PHRN and PHPA are bull and both should take the paramedic class. I have both NREMT-P and PHRN certification. Dust and Rid more than adequately answered the questions about the difference between PA and NP education. I got new information reflecting on my earlier comments about salary for the PA. PA's working for a private practice do indeed make more than 100k in this area. The PA's I work with are employed by the hospital (Catholic) so their salaries are much less. Live long and prosper. Spock

Suxs is OK to use in the first 24 hours post burn. After that it is probably best to avoid it. If you can't get an airway the possible hyperkalemia will never be an issue because the patient won't be alive. I worked a fire/rescue crew once at a dirt track and the sprint cars used methanol. We used water fire extinguishers as a first response and opened up as soon as you felt any heat or saw a 'shimmering wave". It was interesting. Live long and prosper. Spock

I use zofran to prevent post op nausea and vomiting (PONV) but has already stated it must be given before the patient vomits. I give it routinely for certain cases such as any laparoscopy procedure. It does not work very well after the fact. Promethazine is effective but causes significant tissue damage if the IV infiltrates. The University of Pittsburgh published a report in a pharmacy journal reporting several cases of over sedation in patients who had received opioids and then promethazine for nausea. Promethazine is a potent antihistamine and they had a significant percentage of patients found unresponsive and nearly apneic after receiving both. The were using promethazine because there was a shortage of compazine. Other drugs that work for PONV are dexamethazone, benadryl, anzemet, compazine, scopolamine patch, reglan, ephedrine and fluids. All have pros and cons. Many cases of PONV are related to volume depletion or hypotension. Granted this does not help in the prehospital arena but as Dust stated vomiting is seldom an emergency although the patient may argue otherwise. Patients at high risk for PONV are young females and nonsmokers. For some reason smokers have a very low incidence of PONV. A dubious recommendation for smoking to be sure. The last cost I saw for zofran was $16 for a 4mg vial. I think the nausea issue is a good reason to use fentanyl instead of morphine. Live long and prosper. Spock

I think Doczilla has summed it up rather nicely. Live long and prosper. Spock

We have a paramedic who has a below elbow amputation from birth. He has a BS in Occupational Therapy and is in a second degree nursing program and wants to be a CRNA. I was on a code with him once and I turned my back to get a medication while he was intubating. I swear I turned away no longer than 10 seconds and he had the tube in. Damn but I wanted to see how he did that! This is not a disability as far as he or anybody else in the service is concerned. Wasn't Douglas Bader the RAF Spitfire pilot who was a double leg amputee? I believe he was shot down and was a German POW in Colditz. I think he wrote a biography that I read many years ago. Live long and prosper. Spock

My experience with NP's and PA's is similar to what both Rid and Dust describe. Salaries are not the same here in Western PA. I may tell some of the PA's they need to move when I hear them complaining about their salaries again. Of course I don't think they are worth six figures but what do I know. Things may change in PA because most of the doctors finishing their residencies leave the state because we have horrible malpractice laws which won't change because our governor is a lawyer as is most of the over paid and under worked state legislature. I'm thinking of moving to North Carolina. I guess we are getting off topic. Live long and prosper. Spock

I couldn't agree more with Rid except about the 6 figure salaries. My wife was in the psych NP program and switched to a clinical nurse specialist because she didn't want to write prescriptions and psych NP's mostly just did intake physicals while the CNS could do therapy. Salaries were no where near 6 figures. The PA's I work with in the OR are always complaining of low salaries. Maybe that is just my area. Medical control of EMS means just that--a doctor. Live long and prosper. Spock

Been there, done that and didn't like it. The patient was going to arrest no matter what. The only thing I would add in addition to all the other good comments would be with an SBP of 60 you would want to give a minimal dose of etomidate. Even though etomidate is promoted as being hemodynamically stable, if you give 40 mg you will knock down a patients BP. Live long and prosper. Spock

Sorry to resurrect an old topic (at least I didn't start a new one) but I have read what was posted and found it informative and supportive of what I already suspected. Great minds think alike. Anyway, I am looking for articles in peer review journals evaluating the effectiveness of the treatments mentioned. I have to update a crush injury protocol we developed last year but medical command never considered it because my service was the only one that would use it out of the 14 EMS agencies in this command system. I strongly feel that treatment of crush injuries is very similar to the way we manage a patient during open AAA repairs and we use all the treatment modalities mentioned except albuterol. The biggest difference is the time of ischemia for the lower extremities which would be longer in the field as opposed to the OR. Thanks for the help. Live long and prosper. Spock

Darn but don't you folks come up with great questions. We don't do transplants at my hospital (thank God) so I went to Cardiac Anesthesia fourth Edition by Kaplan page 994-995. Cardiac denervation is an unavoidable consequence of heart transplantation. Long-term studies indicate that reinnervation is absent or only partial at best. Denervation does not significantly change baseline cardiac function but it does alter the cardiac response to demands for increased cardiac output. Normally, increases in heart rate can rapidly increase cardiac output but this mechanism is not available to the transplanted heart. Heart rate increases only gradually with exercise and this effect is mediated by circulating catecholamines. Increases in cardiac output in response to exercise are instead mostly mediated via an increase in stroke volume. Therefore, maintenance of adequate preload in cardiac transplant recipients is crucial. Lack of parasympathetic innervation is probably responsible for the gradual decrease in heart rate after exercise seen in transplant recipients rather than the usual sharp drop. Denervation has important implications in the choice of pharmacologic agents used after cardiac transplantation. Drugs that act indirectly on the heart via either the sympathetic (ephedrine) or parasympathetic (atropine) nervous systems will generally be ineffective. Drugs with a mixture of direct and indirect effects will exhibit only their direct effects. Thus agents with direct cardiac effects (epi or isuprel) are the drugs of choice for altering cardiac physiology after transplantation. However, the chronically high catecholamine levels found in cardiac transplant recipients may blunt the effect of alpha adrenergic agents as opposed to normal responses to beta adrenergic agents. So, (my analysis) beta blockers will work although if you use labetelol you would not get the alpha effect from it (labetelol is non-selective beta and alpha). Atropine won't work normally if at all. Not sure that this helps. I have often thought this would make a good article for a journal such as JEMS but I don't have the necessary expertise to write it. I'm going to suggest this to a fellow CRNA that does transplants at another hospital in our city. He is also active in EMS and might be interested in writing it. Great topic. Live long and prosper. Spock

Not to be picky but in the interest of correct spelling it is called a Bier block. You start a 20g IV in the dorsal hand and then exsanguinate the arm with an Eschmark elastic bandage. With the Eschmark in place, you inflate the proximal cuff of a double tourniquet. 40-50cc's of 0.5% lidocaine are then injected and the IV removed. The surgeon then has about 45 minutes to complete the procedure. If the patient complains of tourniquet pain after about 30 minutes, the distal cuff is inflated and the proximal cuff deflated. Heavy sedation with propofol can prolong the duration of the block. When surgery is completed, the cuff is deflated and inflated alternately in order to allow slow reabsorption of the remaining lidocaine. If the surgeon finishes in 5 minutes you must leave the tourniquet inflated for at least 30 minutes to allow the lidocaine to degrade. Sudden loss of tourniquet can result in lidocaine toxicity and severe seizures. Sorry but off topic. Live long and prosper. Spock

You are correct the LMA provides zero protection against gastric aspiration. The King provides protection from passive gastric aspiration but not from active emesis. The gold standard for preventing gastric aspiration is a properly placed endotracheal tube with a properly inflated cuff. I couldn't agree more with the statement that basic airway techniques must precede advanced techniques. When paramedic students come to our operating theater for intubations they must demonstrate they can bag the patient before we let them near a laryngoscope. Live long and prosper. Spock

My experience in the operating room leads me to believe the King will ventilate better than the LMA because the King seats better. The LMA can be highly positional and you can readily lose the seal when you move the patient. You can also ventilate the King at higher pressures (30cmH2O) than the LMA (20cmH2O). I have about ten years of experience with the LMA but have only been using the King for six months. Time will tell but I do like the King better and have stopped using the LMA. My experience with the combitube mostly consists of changing one for an endotracheal tube in the DEM or trauma bay. Not fun. Drawback for the King is it does not come in pediatric sizes. There have been many comments along these lines in other forum areas. Live long and prosper. Spock

Perhaps you didn't hear the instructor right otherwise he is an idiot. Lidocaine has no place in the treatment of PEA or asystole under any version of ACLS guidelines current or past. Live long and prosper. Spock

My experience with tourniquets runs along several lines. I have used the BP cuff as a tourniquet for IV starts and patients seem to tolerate it better than traditional tourniquets because of the larger surface area. When I was a student athletic trainer many moons ago our team orthopedic surgeon used a BP cuff to provide a bloodless field while he removed a piece of glass from my finger. On a more critical level, I have cared for three patients over the past 2 years with traumatic leg amputations; two were run over by trains while working in a steel mill and the other was working at a saw mill (he was cleaning a wood chipper from the inside when some idiot turned it on). All survived after long and stormy hospital stays (ARDS, DIC, ARF) . All had tourniquets applied although the saw mill patient did not get a tourniquet until the helicopter crew arrived. The ground medics did their job but just didn't think about tourniquets because it was always emphasized that tourniquets were a last resort intervention. Problem was all the IV fluid they gave ran out the bottom so it was a last resort situation. The patient had a hemoglobin of 6 after two units of blood in the helicopter on the way in. One of the guys run over by the train had a most ingenious tourniquet applied by his co-workers. They wrapped battery jumper cables around the leg and tightened it down with a broom handle! Darn contraption worked and saved the guys life. I suppose a thigh BP cuff might work in some cases but would not have been effective for these three patients because these were some very big thighs! If you need a tourniquet use a tourniquet. On the subject of post-injury neuropathy, low dose ketamine has been shown to decrease the incidence of not only neuropathy but also phantom pain. It is a biochemical mechanism which I am unable to describe in detail. Live long and prosper. Spock

Our rescue truck carries decon equipment and runs with the Hazmat team in our area. The county and city are setting up a hazmat medical team to respond with all 5 hazmat teams in our area. All team members will be trained to the hazmat technician level plus be ALS providers and have completed the Advanced Hazmat Life Support course. We are getting a trailer to hold our equipment including a hazmat drug box. The medical team will start care in the hot zone plus provide medical management for the hazmat team The process has been slow and hindered by poor funding but the county emergency management chief says he is committed to the idea. The AHLS course is run by the University of Arizona and is excellent. I have taken it twice already. And yes if you say 5 hazmat teams in our area is 4 too many you would be correct. Live long and prosper. Spock

The October issue of JEMS has a short review of the conflicting literature regarding the Autopulse. Page 50-53. It also references the associated literature. My service was one of those that received a very brief training module. We were part of the Aspire study. Live long and prosper. Spock

Thanks for the info Jake. Live long and prosper. Spock

I've had to do some work on the cost of the King LT-D since our command system just approved it. The EMS kit is $375 for ten which is $37.50 each. If you buy all three sizes the cost is more than one combitube which is a significant negative in my mind no matter how much I like the King. Hospitals can buy the airway only for $12-14. There is nothing to prevent a command hospital from buying the airways and selling them to EMS at cost. Our command hospital is doing just that. The sales rep gave me a DVD and CD for training and we should have that up and running by the end of the month. There is only one distributor for the King to EMS and I told our sales rep they are pricing themselves out of the market. He said the price is supposed to come down by the end of the year but probably not to hospital costs. I emphasized they must get the price of three Kings to under one combitube. How many people carry both size combitubes? We have not gotten samples of the new LTS-D for the hospital but I don't see how any size tube will pass through it because of the cap over the largest hole at the glottic opening. You have to see one to understand. But, as AZCEP said, why would you want to but in a tube that small? Live long and prosper. SPock

The benefit of hypothermia for management of cardiac arrest survivors has been supported in the literature for a number of years but not widely implemented. The literature only supports hypothermia for patients with a blood pressure and who are admitted to the ICU. I am aware of no literature that supports hypothermia in the prehospital phase of treatment. If you are fortunate enough to get pulses back in the ambulance, I suspect the paramedic should focus on maintaining a BP, ensuring adequate oxygenation and ventilation, treating dysrhythmias and maybe looking for a cause. Where is Wake County NC? I'm only asking because I'm thinking of moving to NC and was just looking for information. Live long and prosper. Spock

We had the Auto Pulse for about 6 months as part of a study. I used it 4 times and three of those patients arrived at the hospital with a pulse, blood pressure and spontaneous respirations. It delivers impressive CPR if used properly. The study was halted because of problems with a patient in another city so the jury is still out on its effectiveness. The comments about no improved survival rates are correct as all three of my patients expired a day or two later. All of these patients had significant medical problems and I was impressed that we got pulses back at all. There was no reason to believe that any thing other than the Auto Pulse was responsible. My experience is purely anecdotal so I would suggest searching the literature before buying because the thing is expensive. Live long and prosper. Spock

I didn't see the state medical director this weekend so I couldn't ask him about the NSS bolus. I did see a regional medical director and she wasn't aware of an NSS bolus in the protocol so perhaps this was an oversight. As I said, fluid for a stroke patient is probably not advisable unless hypotensive. The majority of stroke patients I have seen are hypertensive. Live long and prosper. Spock

I've used racemic epi in the hospital for post intubation croup in pediatric patients and it works very well. I will extubate in the OR and if I hear even the slightest stridor I will call for racemic epi and take the child to PACU. Respiratory responds immediately to the PACU and will give the treatment there. Totally agree with all the other comments about albuterol vs. epi. The PEPP (or is it PALS or both?) curriculum does say you can give nebulized epi but I've never done it. The advantage of racemic epi is it does not have the same side effects as regular epi. Chemically, racemic epi is a mirror image of regular epi (levo- vs. dextro- enantomer{sp?}). Organic chemistry at its best! Does anybody give albuterol via an endotracheal tube in the field? Live long and prosper. Spock Spock

I was going to add my two cents worth until I read tniugs posting. Nothing to add because it was covered quite thoroughly. I would just emphasize that you should use your capnography to gauge the effectiveness of your ventilations. I always shoot for an ETCO2 in the low 30's. Normal PaCO2 is 35-45 mmHg and there is a gradient between the two with ETCO2 0-5 mmHg lower than PaCO2. This difference is a reflection of alveolar dead space and can vary greatly especially in patients with lung disease. The only way to know the actual gradient for each patient is to send an ABG and compare the two. Easy in the hospital but not in the ambulance. I haven't thought of molecular shells in a very long time. My head is starting to spin and it isn't the Guinness. Live long and prosper. Spock