Spock

I missed the NSS bolus for stroke patients. I'll have to look into it and talk to the state medical director if I see him this weekend. Perhaps it is to prevent hypotension? Hypotension is very bad since it decreases cerebral perfusion pressure (CPP=MAP - ICP) and causes ischemia in unaffected areas. When I give anesthesia for acute stroke patients in the angio suite I frequently have to run a vasopressor to keep the BP up. I usually use neosynephrine to keep the BP > 150 systolic. I don't think a fluid bolus would increase bleeding by itself unless you gave a couple of liters. CPAP is a much better choice than intubating. Glad you have it up there because we can't get it down here. I think it is a good idea to require two ALS providers for the medication assisted intubation protocol. Nothing wrong with a back up plus one person can give the drugs and watch the monitor (pulse oximeter) while the other concentrates on the airway. I've done both in the back of a truck and would have appreciated having help. Live long and prosper. Spock.

I've spent some time on these protocols and have mixed feelings. The capnography requirement is a good thing but there is alot of opposition because of the cost. As I have said before, if you do not have electronic capnography you should not be intubating. Etomidate will be more effective than versed for intubation but any medication assisted intubation must be reviewed by the local, regional, and state medical directors. I think the state does not trust the local docs to keep a close eye on this protocol. Strong medical oversight and QA is important for the success of any medication assisted intubation protocol but three levels might be a bit much. The King LT has been approved and will be official as soon as it is published in the Pennsylvania Bulletin (a legal requirement) which will be before the protocols are approved. I'm on the agenda for our command system meeting next week and the medical directors support the King so we will start the training as soon as possible. I have an interest in getting the King in our trucks because I'm tired of having to change a combitube in the trauma bay. The King will be easier and safer. The last combitube I had to change was put in by a flight crew. The lasix restriction may have been caused by idiots in my area giving it to patients with pneumonia. They changed the protocol instead of educating the idiots. I would mention that nitrates are considered more effective for emergency management of CHF than lasix. You have to give the lasix eventually but NTG will help more readily. Live long and prosper. Spock

I have worked the Penn State University football games for about 8 years. We have two first aid rooms staffed ALS (one with an MD and two RN's and the other with an RN and paramedic), 5 cardiac squads (two paramedics and two EMT's with full ALS capabilities), one ALS ambulance reserved for the teams (my assignment and a cushy one it is!), two ALS and two BLS ambulances for transports to the hospital, two John Deere gators with stretchers for transport within the stadium, one EMT with an AED for the press box, two bike patrols (two EMT's with an AED each) for the parking lots, and 30 BLS teams (two EMT's each with a stairchair) which cover four stadium sections each. We have at least two if not three doctors for on site medical command not counting the doc in the first aid room. The stadium holds 110,000 and is usually full. In fact, on game day the stadium is the third largest city in Pennsylvania. Total staff numbers 80-90. Our calls are usually for acute alcohol poisoning, chest pain, seizures, falls, and diabetic problems. We average two cardiac arrests per year and until 3 years ago we had a 100% survival rate (they went home neurologically intact). We attribute that to a quick response by our BLS squads and early CPR. The only death was a 41 year old who was putting up a flag pole to mark his tailgate site for friends when he hit an over head power line with the pole and was electrocuted. I got pulses back after I needled his chest but he died about two weeks later. 50 AED's seems a bit much but I don't know the demographics of your possible patient population. We have everywhere from 18 year old freshman (drunk) to 80 year old alumni who haven't missed a game in 60 years and will skip their lasix so they don't have to go to the bathroom. Of course they wind up going to the hospital in CHF. Hope that helps. What we experience may not be what you can expect but I can say the vast majority of our calls are alcohol related in one way or another. If we treat a patient in the stands we limit our on scene time to 5 minutes. BLS squads are the first to respond and if the patient can sit up they throw them into the stairchair and move to the nearest exit where the ALS squad meets them. Cardiac arrests in the stands likewise have short scene times. CPR, defib and intubation and then into the stokes basket each ALS squad has and out the door. It is a good system and one of these days I hope to get the boss to publish some data. Live long and prosper. Spock

I couldn't agree more with the stay in school responses. There is a better future in nursing both economically and professionally. As a senior you are closer to the end than the beginning so stick with it. It is unfortunate that your school is suboptimal but when you graduate and pass the NCLEX you are still an RN with a BSN. Nursing needs more BSN prepared nurses. Just don't forget the bad experience you had when the college starts sending you requests for donations after you graduate. Live long and prosper. Spock

I wouldn't vote for somebody just because of one issue although being pro EMS would be a positive. I suspect most politicians are like the general public in that they don't know the difference between an EMT and a paramedic. They think everybody that gets off the rig is either a paramedic or an ambulance driver. We really need a grass roots public education effort in order to promote ourselves. I'm curious as to which end of the political spectrum holds most EMS'ers. Since we are all people first I think you will find us throughout the entire range of the spectrum with most centered around the middle. Extremes of anything are usually bad. Interesting way to discuss politics even if it is in generalities. Live long and prosper. Spock

Hey how about that--my 100th post and I am now a freshman! That makes me feel young again. To bad I'm at work or I'd go out and get drunk and stupid! Live long and prosper. Spock

I probably wouldn't bother with a bougie. I would put a salem sump down the esophageal lumen and decompress the stomach first; you just have to use a small one (12Fr) which won't remove any chunks just fluid. The manufacturer has a protocol for removing the combitube. I have intubated around the combitube and also removed it before intubating in the standard fashion. It is probably safer to leave the esophageal balloon inflated and intubate around the combitube as AZCEP described. The sales rep brought in the new King airway yesterday and it looks promising. You can place a 6.0 through the LT-D but not through the new model with the esophageal suction port. You can use a bougie with both. We are supposed to get some samples of the new model soon and I will let you know how the work. We are not paying any where near $35--the LT-D is $14 and the new model is only a few dollars more. They may be giving us a good price in order to build the market. Live long and prosper. Spock

I couldn't agree more with the comments regarding flumazenil. The only other thing I would have done was check a blood sugar because seroquil can cause severe hyperglcemia and hypoglycemia should always be ruled out in an unconscious patient. I probablywould have given narcan on the off chance the patient took an opioid that was unreported. Also, I would have intubated the patient as long as the teeth were not clenched. GCS < 8 means unable to protect the airway and intubation is indicated. However, I wouldn't argue with the treatment provided especially since you were vigilant about the chance for aspiration from vomiting. I'm not familiar with a PCP. Are you allowed to intubate? Live long and prosper. Spock

The suction port is just above the balloon. The idea is to prevent ventilator acquired pneumonia because this area never gets suctioned and bacteria may accumulate here and migrate around the balloon into the lungs. Not sure it has ever been proven. We tried them for a while but the cost was $12.00 vs. $1.10 per tube. Of course if you prevent one case of pneumonia you recoup the cost. I found no difference in placing the tube from a clinical standpoint. The hospital decided not to use them but the decision was made by folks above my pay grade so I don't know the logic involved (if any). Live long and prosper. Spock

I've been on both sides of this argument and don't have an easy answer. I've had paramedic students that couldn't mask ventilate a patient because of poor technique and medical students that made it clear they thought 4 intubations and 4 years of medical school made them more proficient than my 2 years of nurse anesthesia training and 4-5,000 intubations. Needless to say both picked their butts up off the floor before they touched a laryngoscope. I also had an emergency medicine resident walk into the OR once and announce he was going to do the intubation. I just chuckled while the anesthesiologist (who had served in Viet Nam as a medic) chewed him up and spit him out in little pieces. My hospital is on of the few in our area that still allows paramedic students into the OR. We are a Catholic teaching hospital and really believe that education is a basic tenet of our mission. The anesthesiologists and CRNA's in my department feel strongly that if they or anybody in their families ever need an ambulance they want a well trained paramedic to show up and if advanced airway interventions are necessary they expect competence. They know they can't expect that if they won't commit to education. My active involvement in EMS certainly doesn't hurt. Somebody said it doesn't hurt to know someone in the anesthesia dept and unfortunately that is true. We had a paramedic student from my service come to the OR one day and I made sure she had a good experience. Yes that is unfair but so is life. I think vs-eh really hit the nail on the head. You can't expect to get enough tubes in one day so plan on coming back. If I even think the airway is difficult you won't get a chance at it. Show me you can mask a patient and I'll let you touch a laryngoscope. Don't tell me you have done a dozen tubes and then go toward the patient with the scope in the wrong hand and no gloves. Demonstrate some proficiency with edentulous patients and you'll get a shot at people with teeth. There is a great deal of competition for tubes from paramedic students, flight crews, medical students, EM residents, medical resident and more so you will need to come around more than once if you expect to get a good experience. There is no doubt that I have colleagues in anesthesia who are jerks but that occurs in every profession. Frankly there are days that I am a jerk because I'm tired of every Tom, Dick and Harry walking in and expecting to intubate my patient. I'd like to do some tubes also. Personally, my priority is nurse anesthesia students first, paramedic students second and everybody else last. The anesthesiologists I work with pretty much leave the decision on who intubates up to the CRNA. Both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists have position papers that "encourage" their respective members to be actively involved in the education of paramedics with regards to airway techniques. "Encourage" still may not get you into the door so you will need the medical director of the paramedic education program to deal with the anesthesia department directly in order to improve the educational experience. Also, it helps to shower, shave and brush your teeth before you come into the OR. Believe it or not we have had trouble with this. Look and act professional and you have a better chance to be treated accordingly. Live long and prosper. Spock

The elimination half-time of diazepam is 21-37 hours, ativan is 10-20 hours and midazolam is 1-4 hours (Pharmacology and Physiology in Anesthetic Practice by Robert Stoelting). My experience with all three drugs tells me nothing is shorter acting or has a more rapid onset than midazolam. Live long and prosper. Spock

The old saying is the only difference between a medication and a poison is dosage. I have never given verapamil in the field but have given it in the hospital. As already noted it must be given very slowly or hypotension and vomiting will result. We have replaced it with cardizem in our trucks but our command doctors are pushing cardioversion as the front line treatment. I was just mentioning edrophonium under a different topic. It will slow a tachy rate if given without an anticholinergic because of its muscarinc effects. However, my ePocretes drug program says edrophonium is no longer available in the USA. Live long and prosper. Spock

This is a great brain teaser. I have also seen several patients in V-tach who were pretty much asymptomatic. A narrow complex tachycardia with abberency will look very much like V-tach but if you look very closely at the EKG strip you will see a small notch usually on the downside of the rhythm. That is your clue that the "classic" V-tach is probably a horse of a different color. Still, I would not have had the brass to give a calcium channel blocker in the field for this patient. The nice thing about amiodarone is that if you look at the ACLS text you will find is is indicated at some point for just about every abnormal rhythm except bradycardia or blocks. To bad this was not an option. Ringing in the ears after lidocaine indicates toxicity. Live long and prosper. Spock

Treatment of hyperkalemia is calcium choride, sodium bicarb and regular insulin. Basically these cause the potassium to shift back into the cell where it belongs and corrects the acidosis. Rapid correction of hyperkalemia is risky and is not usually done unless the K is > 6. You can also use lasix to treat hyperkalemia but you will have to monitor volume status. I have given calcium and bicarb in dialysis patients suffering from cardiac arrest in the field on two occasions (we don't carry insulin on the truck). Both times I almost immediately got a perfusing rhythm with a blood pressure. Both patients died later on in the hospital. Could have been a coincidence but I don't know. Atropine is given as a pretreament prior to succinylcholine in children to combat bradycardia because kids are one big vagal nerve. Atropine alone does not reverse suxs or any other neuromuscular blocking agent (NMB). I'm not sure what a succinylcholine overdose is. If you are talking about a patient with atypical plasma cholinesterase then the treatment is sedation and put them on the ventilator until the suxs wears off sometime in the next few days. If you give vecuronium or some other NMB before the suxs has worn off you can get a Phase 2 blockade in which case the treatment is the same--put them on the ventilator. This type of blockade will probably wear off in a few hours. Reversal of NMB's requires a few conditions. First the blockade has to be in the process of degrading. We place a nerve stimulator over either the facial or ulnar nerves and measure the train of four. The stimulator gives four impulses and we watch for the muscles to twitch. You must have 2 of 4 twitches before you can reverse the NMB. We give neostigmine and glycopyrrolate (robinul) to reverse the NMB. Neostigmine binds to the enzyme that degrades acetylcholine (ACH)(acetylcholinesterase) causing a rise in ACH and return to normal muscle function. Neostigmine given alone will cause profound bradycardia because of its muscarinic effects so we give the robinul along with it. Robinul is an anticholinergic like atropine but is a quaternary amine instead of a tertiary amine like atropine so it does not cross the blood brain barrier and make patients goofy as atropine can sometimes do. We give neostigmine and robinul together because their onsets of action are similar. Atropine has a faster onset than robinul so we don't use it with neostigmine. It used to be used with edrophonium (same class as neostigmine) which also has a fast onset. I was just looking at edrophonium in my ePocrates drug program and is says edrophonium is no longer available in the USA. I haven't used edrophonium and atropine since I did my anesthesia training over ten years ago. Hope this helps. Keep up the good work and education focus 911. Live long and prosper. Spock

Congratulations! Read the book cover to cover and ask questions. Study every day and apply yourself 100%. Remember that the only dumb question is an unasked question. Live long and prosper. Spock

That "supervision" issue is quite nebulous at best. I can work in conjunction with a surgeon, podiatrist or dentist in the administration of anesthesia and can function as an independent provider. The vast majority of rural hospitals in the United States have CRNA's as their sole anesthesia providers. Like I said, it is a fine line and as long as I do what is best for the patient I feel I can defend myself. Sorry to get off topic. Live long and prosper. Spock

Illogical? You cut me to the quick! Thanks for the ideas everybody and I may look into the hard case carrier for an O2 tank. I had one of those many years ago when I worked as an athletic trainer and it was very sturdy. Like I said, I don't see a need for an AED because every patrol car has one and my service will give me a D tank if I can resolve the safety issue in my own mind. I have intubated people prior to the ambulance arriving but the time ventilating with room air is very short so I'm not sure it is clinically significant. O2 would make a difference for the chest pain or resp distress patient I don't carry IV equipment because I'm not sure starting an IV alone has ever saved a life or even made much of a difference in outcomes. It is important to remember that you follow state or regional laws and guidelines when carrying equipment in your car. PA does not allow paramedics to carry ALS equipment in POV's. I get away with it because I am also a CRNA and laryngoscopes are the tools of my trade. It is a fine line and so far nobody has questioned it although I'm sure someday I'll tick off the wrong person and there will be an issue. It is interesting and as long as I am doing the best thing for my patient I'll take the risk. Again, thanks for the ideas. I'll give it more thought. I wouldn't have a problem if my local fire department would run QRS because then they could carry the O2. So far they have resisted the idea. Live long and prosper. Spock

150mg in 30cc saline is in the AHA ACLS text but I'm not sure why that isn't done more often because it might be easier than an infusion. Live long and prosper. Spock

I run most of my calls from home in my car because I live in a township farthest from our base. I carry a first in bag which has basic equipment plus a full intubation kit and my own pulse oximeter. I don't carry an AED because all of our police cars have them and I have rarely beaten the cops to a scene. I don't carry oxygen because I was also concerned about the potential for catastrophic tank failure if I was involved in a crash from behind. I have seen the AED work many times. Perhaps that is because the police are so quickly on scene and they really want to help the patient. Anybody have any thoughts on how I could safely carry an oxygen tank in my trunk? It would be helpful on all of the dozen or so calls I run each month as a first responder. Live long and prosper. Spock

I like the idea of the slow push and it makes sense. I'll try it next time even though the prehospital coordinator will say I violated protocol. Well that wouldn't be the first time. Good point about the special container. Our premixed amiodarone comes in a special plastic IV bag similar to insulin. Live long and prosper. Spock

Here's how I would vote: 1. Combitube for BLS YES 2. LMA for BLS NO 3. King LT for BLS YES 4. Intubation for BLS NO Live long and prosper. Spock

Very interesting topic which sent me to my pharmacology texts and the ACLS manual. The reason being is we mix amiodarone with normal saline for an infusion as per our protocols. We do not carry D5W in the ambulance. Our drug boxes are sealed so when we use one we replace the entire box at the hospital and pharmacy refills it. The medical directors eliminated D5W a few years ago for simplicity. I also mix amiodarone in NSS in the hospital and have never seen it precipitate and the desired effect was achieved. If fact, we mix all infusions (epi, norepi, neosynephrine, dobutamine, milrinone etc.) in NSS in my hospital. I could find nothing in the pharm text about D5W vs. NSS and the ACLS text said either was ok. In fact, I have been teaching in the ACLS class for 5 years that you mix it in NSS. I really don't think it matters but fascinating nonetheless. You guys are the best because you challenge the envelope and strive to improve. Keep it up. The future of EMS is bright! Live long and prosper. Spock

The Executive Director of our region told me etomidate will be added to the state list only after the training module has been written. The state medical director told me the training module is still under development as is the state medication assisted intubation protocol. If you folks are using etomidate out east then more power to you and you are more advanced than the west. No surprise there. Live long and prosper. Spock

I wasn't aware we were arguing here but some things need corrected. To reiterate what ACE wrote, versed is a benzodiazepine and has amnestic qualities but has absolutely no analgesic properties. Fentanyl is a synthetic opioid analgesic and is effective as an anesthetic only at high doses (around 1000mcg). RSI is a process with many steps and efficient performance usually requires more than one person. That's just the way it is. If you can't multitask then you get help or you don't do it. Now I think I'll go back up to my Ivory Tower just as soon as I take a shower and wash the mud off from the call I was just on where I had to tube the patient with only lidocaine, versed and fentanyl because PA doesn't allow etomidate or suxs. Live long and prosper. Spock

Good job AZCEP. The importance of denitrogination is not emphasized enough. Give etomidate (0.3mg/kg) before the suxs. The dose of suxs is 1.0-1.5 mg/kg but since there is 200mg in a vial I believe in the full syringe technique so give it all. You will have intubating conditions in 30 seconds. Also, the onset of morphine is to long to be useful in RSI so use fentanyl but it is optional. Lidocaine is used for head injuries but it has never been proven to be effective by research. Kids are one big vagal nerve so atropine is mandatory. Repeat doses of suxs or etomidate should be avoided. Live long and prosper. Spock