JPINFV

I might be a bad person to review the book actually because of my volunteer experience and education. Most of the information was either too basic (i.e. the 3 cardiac rhythms covered were asystole, v-tach, and v-fib. These were the exact same rhythms covered during the AED portion of basic class) or too generalized (most specifically for me was the DNR section. While I know what they were LOOKING for with the question about family members requesting EMS personal to withhold resusctation [i.e. they can't], local policy where I'm at allows them to).

I've read ACLS for the EMT-B. Biggest crock of poop ever. It was too simplified to be of any true help.

School and Eve-Online... I really need a girl friend...

^ What I was trying to get at with that last part is that most gurneys do not do a true trendelenburg (at least not the Fernos or Strykers that my company uses). Most (all?) just lift the legs instead of tilting the whole body.

That happens all the time in stage 1 or stage 2 drug studies. Why do drug studies on healthy volunteers if you can't use the data collected to determine dosing (frequency of administration, amount per administration, and maximum dose) for sick patients? If trendelenburg doesn't increase cardiac output, but increases blood pressure then what mechanism does it do so by? Blood pressure is simply (warning: generalization, viscosity and concentration also affects a patient's blood pressure, but there is no reason for these to change because of patient positioning) a combination of the volume of the liquid and the volume of the container in the systematic arteries. Volume is added by the heart (stroke volume) at high pressure and leaves via the capillaries at low pressure. The volume of the container can change too depending on the patient (sympathetic and parasympathetic nervous system activation) and drugs given (nitro, epi). While it is at least my understanding that, ignoring homeostasis (but if BP is a problem then the body is failing to self correct anyways), BP does not change a patient's stroke volume, but venous return (always low pressure) does. 1. Is there any prehospital gurney that offers true trendelenburg (entire body tilt), or do all prehospital gurneys only lift the legs. 2. Spock, do you know if CVAs have been known to develop in patients while being prepped due to increased intracranial pressure?

^ Why not treat the problem (hypoxia) instead of the symptom (tachycardia)? If you don't fix the hypoxia then you won't decrease sympathetic nervous activity. If you don't decrease the sympathetic nervous activity then the patient would just reenter tachycardia.

Just in general actually. I've seen bad things happen else where. College BBS+unsecured computers that are difficult to log the account off of=fun times in the neighborhood.

^ At least it wasn't as bad as other posts I've seen when people forget to log out of an open computer.

Well, you could use something like this, , that connects with the IV tubing between the patient and the bag and heats the fluid there.

My company is too lazy to switch to snow tires in winter.... 8) Strangely, so am I.

Why does this remind me of the shower scene with Hot Lips in MASH.

Don't defend intermediates than. I'm a basic and I sure as hell don't support the level of education that basics are currently at. As far as these so called "uniforms,' is it really that hard to get changed into actual clothes? Hell, I hate walking to my car when I need to move it out of an unused overhead (stupid apartment in a college town only giving each apartment 1 general use permit and 1 reserved overhead bay) in my PJs. I could never imagine showing up to work in them. Besides blood+thin clothes=not good. I had to buy a lab coat for microbio lab this year and half (key word half) thinking about wearing that because at least lab coats can be autoclaved if needbe.

No Canadian Tire Money?

^ Ahh, but if trendelenburg doesn't work on normotensive patients than why would it work for hypotensive patients? Also, in the study with 11 patients, 9 patients saw a decrease. At least 2/3rds of the hypotensive patients saw their blood pressure decrease. Now there's the problem with the study involving 8 patients who saw an increase in BP without an increase in cardiac output. To understand the importance of this we need to understand how trendelenburg is supposed to work. The idea (Starling's effect) is, simply put, that the more blood that reaches the ventricles (venous return), the more blood that will be pumped (stroke volume). If you raise the legs of a patient/subject then more blood should be returning to the heart because of gravity. This increases venous return which increases stroke volume via Starling's. Now how does stroke volume relate to blood pressure. Cardiac output=(stroke volume)(heart rate). (Cardiac output)(total peripheral resistance)=Mean arterial pressure=(2/3 diastolic blood pressure)+(1/3 systolic blood pressure) at high heart rates. (stroke volume)(heart rate)(total peripheral resistance)=(2/3 diastolic blood pressure)+(1/3 systolic blood pressure) Hence stroke volume is directly proportional to blood pressure. Now the problem that the study showed was that you do not have this increase in stroke volume with the supposive increase in venous return from the legs. If this is true AND the trendelenburg works, then a different mechanism exists for it to increase the blood pressure besides Starlings. Now let's throw in the cons. The blood is not going to just increase venous pressure at the heart, but also a the brain. Increase intracranial pressure might be worse for the patient in the long run by causing more damage. Researchers have seen an increase in difficulty breathing because the diaphram now has to lift the abdominal organs while decreasing intrathoracic pressure.

Sure about that one? Besides, just because everyone has an opinion doesn't mean that all opinions are created equally. Saying, "Well, everyone has one" doesn't help anyone out.

To be honest, I don't see a point for EMT-B field guides. The scope of practice truely isn't large enough to allow for critical thinking. Yes, critical thinking is good, but when you're limited to O2, oral glucose, and activated charcol (using NREMT scope), than you shouldn't have a problem with choosing treatments. A PDR is helpful for that "is this overdose truely dangerous" questions and you can use it to look up more medication info than you will ever get in a field guide.

^ Part of the problem is that if you give nitro and the pressure bottoms out then you will have a harder time starting the line. Furthermore, the risks to the patient's health from hypoprofusion are more time senstitive then the damage from an MI. You can't replace brain or heart tissue, but I'd rather have heart damage than brain damage.

Define "assisted." Did he "assist" in the same way patients with acute psych problems and are on a hold are given a "choice" to come (i.e. they don't really have a choice, but being polite and respectful will get a good number to come with you peacefully)? If he didn't do anything when "assisting" and the crew got him peacefully to the hospital, than score 1 for the crew. Are they responding to calls in their PJs?

I was doing a Google Scholar search to see just how dangerous using the buccal route in AMS patients would be when I drug this up. http://jama.ama-assn.org/cgi/content/abstract/240/15/1611 I'll see if I can get the full text sometime tomorrow.

Strange, I could say the same thing about a good number of college professors that I've had. Powerpoint lectures=sleep time. I've never understood how people can't figure out that a visual aid is supposed to aid a lecture, not be a lecture. Side note, I love this picture from LAFD's website. Sure, it's a promo picture, but I love the entire no O2 to the NRB (empty bag) and the medic in the back using the radio with gloves on. All of this, of course, done in turnout gear.

Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service John Woodall1, Molly McCarthy2, Trisha Johnston2, Vivienne Tippett1 and Richard Bonham 1 Australian Centre for Prehospital Research, Brisbane, Queensland, Australia 2 Queensland Health, Brisbane, Australia Correspondence to: J Woodall Australian Centre for Prehospital Research, GPO Box 1425, Brisbane, Queensland 4001, Australia; jwoodall@emergency.qld.gov.au Revision received 31 October 2006. ABSTRACT Background: Prehospital research has found little evidence in support of advanced cardiac life support (ACLS) for out-of-hospital cardiac arrest. However, these studies generally examine city-based emergency medical services (EMS) systems. The training and experience of ACLS-skilled paramedics differs internationally, and this may also contribute to negative findings. Additionally, the frequency of negative outcome in out-of-hospital cardiac arrest suggests that it is difficult to establish sufficient numbers to detect an effect. Purpose: To examine the effect of ACLS on cardiac arrest in Queensland, Australia. Queensland has a population of 3.8 million and an area of over 1.7 million km2, and is served by a statewide EMS system, which deploys resources using a two-tier model. Advanced treatments such as intubation and cardioactive drug administration are provided by extensively trained intensive care paramedics. Methods: An observational, retrospective design was used to examine all cases of cardiac arrest attended by the Queensland Ambulance Service from January 2000 to December 2002. Logistic regression was used to examine the effect of the presence of an intensive care paramedic on survival to hospital discharge, adjusting for age, sex, initial rhythm, the presence of a witness and bystander cardiopulmonary resuscitation. Results: The presence of an intensive care paramedic had a significant effect on survival (OR = 1.43, 95% CI = 1.02 to 1.99). Conclusions: Highly trained ACLS-skilled paramedics provide added survival benefit in EMS systems not optimised for early defibrillation. The reasons for this benefit are multifactorial, but may be the result of greater skill level and more informed use of the full range of prehospital interventions. Abbreviations: ACLS, advanced cardiac life support; BLS, basic life support; EMS, emergency medical services; ETI, endotracheal intubation; ICPs, intensive care paramedics; OHCA, out-of-hospital cardiac arrest; QAS, Queensland Ambulance Service Early access to advanced cardiac life support (ACLS) is the final link in the "chain of survival" for out-of-hospital cardiac arrest (OHCA).1 ACLS generally includes interventions such as endotracheal intubation (ETI), intravenous cannulation and cardioactive drugs. As all levels of prehospital responders now commonly use defibrillation, it is more appropriate to consider it a basic life support (BLS) skill. There has been limited research support for improved outcomes from ACLS delivered for OHCA. Previous studies have generally found no difference in survival to hospital discharge for patients treated by BLS paramedics versus ACLS-skilled paramedics.2–5 However, a number of studies have demonstrated that ACLS-skilled paramedics improve the likelihood of patients arriving at hospital with a spontaneous pulse.6–8 The largest and most recent study of the effect of ACLS-skilled paramedics in the treatment of OHCA has been the third phase of the Ontario Prehospital Advanced Life Support study, which examined the incremental effect of ACLS in an emergency medical services (EMS) system with an optimised rapid defibrillation programme.9 The study demonstrated that survival rates for patients were not significantly affected by the introduction of an ACLS program. These findings, combined with the findings of previous studies, seem to add weight to the conclusion that there is no additional benefit of ACLS interventions in survival from OHCA, and that defibrillation remains the definitive treatment. Studies examining the effect of the ACLS interventions themselves are equally pessimistic. Few studies demonstrate any positive effect on survival for ETI or adrenaline.10–12 It has been suggested that this may be because such treatments are generally used for patients who have not initially responded to defibrillation and who have a prolonged resuscitation, making them markers for a subset of patients with a poorer prognosis.13 However, some positive findings for ACLS have been reported. It has been found that two-tier systems with both defibrillator-equipped BLS and ACLS-skilled paramedics report higher survival rates than those that operate one-tier defibrillator-equipped BLS systems alone,14–16 although the dispatch model also seems to moderate survival.17 Additionally, a positive effect on survival for time to ETI has been demonstrated, with patients who were intubated within 12 min having better outcomes than those intubated afterwards.18 Comparisons of outcomes from these studies are problematic. Interventions utilised and the extensiveness of training differ widely across EMS systems. ACLS training courses range from 10 to 75 weeks, and prerequisite experience or training is rarely specified. Secondly, studies have difficulty in disentangling the effect of greater skill and experience from the effect of the interventions themselves. Thirdly, there can be a systematic bias in two-tier EMS systems, in which ACLS-skilled paramedics are often called for the most severe cases and are therefore treating patients with poorer prognoses. Finally, only a small subset of the total treated population has a genuine prospect of successful resuscitation. As a result, improvements in patient outcome can be small and difficult to detect. Although the Ontario Prehospital Advanced Life Support study examined the incremental effect of ACLS in an already optimised rapid-defibrillation EMS system, many EMS systems do not meet this study’s benchmark of defibrillating 90% of patients within 8 min. It is important to examine the effect of ACLS in systems that do not have an optimised rapid-defibrillation programme, as in these cases ACLS may provide some incremental value. The purpose of the current study was to examine the effect of ACLS-skilled paramedics on survival from OHCA in the context of a statewide EMS. METHODS Design The study was a retrospective, observational design and examined data from all patients who were treated for OHCA by the Queensland Ambulance Service (QAS) for the years 2000–2. Data collection and management Data were collected according to Utstein guidelines.19 Only those cases where resuscitation was attempted were included in the analyses. Patients <18 years of age and patients with a cardiac arrest of non-cardiac aetiology were excluded from the study. Cardiac aetiology was presumed for men >40 and women >50 years of age when determination of aetiology was not possible from the available information. For each case of cardiac arrest, ambulance records were uploaded from a centralised database and audited for accuracy against a hard copy of the ambulance report form. The ambulance report form collects information in both a code-based and a narrative script format. In addition, a specific cardiac arrest form is completed to capture core Utstein variables. By comparing these sources of information, the auditing process is able to produce high levels of data accuracy and completeness, allowing for correction of coding errors and capture of missing information. Although there is some variation in the data provided on these capture forms, they typically give a detailed account of the incident. Where multiple crews attend the same patient, case details are recorded on one form. Paramedics use a time stamp on the dispatch system to record times, which are later recorded manually on the ambulance report form. Therefore, information regarding time intervals is synchronised throughout the service and is generally accurate and reliable. Ambulance records were linked to hospital records, using probabilistic matching, to ascertain survival to discharge information. Data collection and analyses were performed as part of routine ambulance monitoring and quality assurance procedures. Therefore, ethical approval was not required. Ethical approval was obtained for linkage of ambulance data with hospital data to determine survival outcomes. Population and setting The setting for the current study was the state of Queensland, the second largest state in Australia. Queensland has a population of approximately 3.84 million people, covers an area of 1 734 513 km2, and is geographically diverse.20 Most of the population is scattered along the eastern seaboard; however, over half the state’s population resides in the capital city. There are 13 cities across the state with populations in excess of 50 000. EMS system The QAS is a statewide service. For the purpose of the current study, paramedic skill level was dichotomised with intensive care paramedics (ICPs) classified as ACLS-skilled paramedics and all other levels classified as non-ACLS-skilled paramedics (or non-ICPs). ICPs may deliver the full range of OHCA pre-hospital interventions including ETI and a range of cardioactive drugs. Other skill levels may provide CPR, defibrillation and basic airway care including oropharyngeal and laryngeal mask airways. All QAS crews are equipped with defibrillators and trained in their use. For the purposes of this research, the skill level required for each case was that of an officer with the highest skill level on scene. In Queensland, paramedics must have 2 years of field experience after their initial 3 years of paramedic training to be eligible to apply for ICP training. The ICP course is a one-year, full-time course that combines university-based classroom education, placement in hospital emergency departments and operating theatres, and extensive field experience. During their training, intensive care students also work alongside an ICP mentor in real patient care settings. The programme not only engages paramedics in psychomotor skill rehearsal of advanced clinical interventions but also heavily emphasises the use of clinical judgement and reflection in the use of these interventions. ICPs and non-ICPs operate within a two-tier EMS system in Queensland. In some urban areas, this means ICPs are floating and are often second to the scene of an arrest. Current dispatch protocols automatically deploy an ICP to a suspected arrest if one is available. No allowance is made for the likely prognosis of the patient, as this cannot be accurately predicted by the dispatcher. ICPs are assigned to ambulance stations according to regional directives, and, therefore, there is an uneven dispersion of ACLS providers across the state. Consequently, the two-tier system might be optimised in certain areas, and in other areas with less ACLS providers the two tiers may operate more as a one-tier system, with ACLS providers called to attend the nearest incident regardless of its severity. Data analyses Preliminary analyses examined the relationship between the key explanatory and outcome variables, and demographic and prehospital factors, using {chi}2 analyses. Arrests witnessed by paramedics were excluded from the analyses as they were seen to constitute a distinct group of patients who have a much better prognosis and are more likely to respond to BLS. The primary analysis examined the relationship between skill level (ICP v non-ICP) and survival to hospital discharge, using logistic regression. RESULTS Over the 3 years of the study period, a total of 8833 adult patients received treatment by QAS for an OHCA. Of these, 3054 patients met the inclusion criteria for this study (resuscitation attempted by paramedics, arrest of presumed cardiac aetiology, arrest not witnessed by paramedic). Matching with hospital data was unsuccessful in 79 (2.6%) cases, leaving a total sample size of 2975. ICPs attended 1687 (56.7%) of these cases; 1288 (43.3%) patients were treated without ICP attendance. Figure 1Go presents these data. Figure 1 View larger version (12K): [in this window] [in a new window] Figure 1 Utstein template of all study cases in 2000–2. {chi}2 analyses compared patients treated by ICPs with those treated by non-ICPs in terms of age, sex, initial rhythm, witnessed arrest and bystander CPR. Table 1Go shows these results. View this table: [in this window] [in a new window] Table 1 {chi}2 results of demographic and prehospital factors of those treated by intensive care paramedics and non-intensive care paramedics Table 2Go presents results of {chi}2 analyses comparing survival between patients treated by non-ICPs and those treated by ICPs. View this table: [in this window] [in a new window] Table 2 {chi}2 results examining the relationship between intensive care paramedics and non-intensive care paramedics and survival Transportation and admission to hospital The rates of transportation and admission to hospital for the two groups were compared using {chi}2 analyses (table 3Go). View this table: [in this window] [in a new window] Table 3 {chi}2 analyses examining rates of transport and hospital admission for intensive care paramedics and non-intensive care paramedics Skill level and survival In the main analysis, binary logistic regression analysis was used to model the probability of survival to hospital discharge in patients attended by ICPs compared with those not attended by ICPs (referent group) after adjusting for age, sex, initial rhythm, presence of a witness and bystander CPR. Secondary analyses included only those transported to hospital to exclude those patients with a very poor prognosis, and from among patients admitted to hospital. Table 4Go shows the odds ratios and 95% confidence interval for skill level adjusted for sex, age, initial rhythm, presence of a witness and bystander CPR for these three analyses. In all models, the contribution of skill level was significant (p<0.05) when assessed using the likelihood ratio {chi}2 test. View this table: [in this window] [in a new window] Table 4 Logistic regression analyses examining the effect of skill level on survival to hospital discharge Presence of ICP and time intervals Response time was defined as the time from receiving the call to arrival at scene. On-scene time was defined as the interval between arrival at patient and departure from scene. Time to defibrillation was calculated from the time of receiving the call to the time of first shock by paramedics. This analysis was conducted only on those cases that presented with an initial shockable rhythm (ventricular fibrillation or ventricular tachycardia). Time to shock interval could not be calculated in 152 (11.1%) cases because of missing data on time of first shock. It has been reported that defibrillation outcomes are optimised if the first shock is delivered within 4–6 min of arrest.21,22 Therefore, an additional between-group analysis was conducted to compare the number of patients shocked within 5 min. Table 5Go provides the results of these analyses. View this table: [in this window] [in a new window] Table 5 Key time intervals for intensive care paramedics and non-intensive care paramedics DISCUSSION The finding that the ACLS-skilled paramedics significantly improve a patient’s likelihood of survival in a statewide EMS system is noteworthy. To the authors’ knowledge, this is one of the few studies to find a significant positive effect for advanced skill level on survival to hospital discharge. The effect increases markedly when examining only those transported to hospital. This, along with lower rates of transport for ICPs, suggests that ICPs are better able to select those patients for whom resuscitation is viable. As ICPs are able to provide a comprehensive range of ACLS interventions on scene, they can elect not to transport patients unresponsive to these treatments. Cases not attended by ICPs do not have the benefit of this knowledge, and so must decide on the appropriateness of transport based on case history and response to defibrillation and other BLS measures. As such they transport more patients, including some with a poor prospect of recovery. The patients in the admitted patient subgroup are assessed independently by hospital staff and may be thought of as having equivalent viability. Even in this cohort, patients treated by an ICP show an enhanced survival effect. This suggests that the survival effect seen cannot be attributed to differing resuscitation protocols. This study made no attempt to disentangle the effect of advanced skill level and ACLS interventions. Previous research has failed to demonstrate an increase in survival associated with prehospital endotracheal intubation or adrenaline.10,23 This suggests that the improvement in survival seen here is not due to the advanced procedures used. Greater levels of education and training received by ICPs in Queensland may enable them to deliver both BLS and ACLS interventions more effectively. A study of intubation in an American EMS system found that tubes were incorrectly placed as much as 25% of the time.24 It seems plausible that an increased level of training would reduce the occurrence of such errors and improve ACLS delivery. Alternatively, when ICPs and a BLS crew attend the same case, the full range of interventions could be performed with greater efficiency and effectiveness owing to the number of trained personnel on scene. The detrimental effects of interruptions to chest compressions on coronary perfusion pressure are well known.25 In cases where more paramedics attend the patient, it is likely that the frequency and duration of interruptions to chest compressions will be reduced. The finding that cases attended by ICPs had longer on-scene time was expected, and is probably due to either the primary crew delaying transport while awaiting ICP back-up or the time required to perform ACLS procedures. The results presented here show that those patients who had longer scene times had a better outcome. This suggests that when highly skilled paramedics are available, full resuscitation at the scene may be preferable to rapid transport, as delay to ACLS is minimised. However, if the patient does not respond to treatment at the scene, rapid transport is unlikely to improve the outcome. This argument is supported when we consider that although a substantial number of patients among the non-IC group arrive at hospital pulseless and go on to be admitted, few of these patients survive to hospital discharge. These patients may have been admitted after initially responding well to ACLS procedures performed in the hospital emergency department, but the low survival to discharge rate suggests that this effect is transitory. This finding provides support for ACLS as a critical component of enhanced survival, most effective when it is delivered early. An unexpected finding was that cases attended by ICP crews had a significantly reduced time to first shock. As response times between the groups did not differ significantly, it seems that the reduced time to shock is a function of paramedic behaviour after arrival on scene. This time difference is unlikely to result of faster rhythm recognition or defibrillator activation by ICPs, as non-ICP crews will often deliver the initial shock before the arrival of the ICP crew. Although the difference in defibrillation interval is statistically significant, it seems unlikely that the size of the difference would have a noticeable effect on patient outcome. An interval of around 5 min to defibrillation has been suggested as a critical period.21,22 Cases attended by ICP crews were not significantly more likely to deliver shocks within this 5-min interval. Therefore, it is unlikely that the differences in time to first shock would account for the difference in survival observed. The finding that bystander CPR was significantly associated with the presence of an ICP is interesting, and cannot be explained by clinical protocols or dispatch methods. Had no bystander CPR been performed, the BLS crew may have ceased resuscitation sooner and the ICP crew may not have been dispatched. However, when the presence of bystander CPR was controlled for, the presence of an ICP still significantly increased the likelihood of patient survival. Consequently, bystander CPR alone cannot account for the improvement in survival observed in this study. The purpose of this paper was to examine the effect of ACLS-skilled paramedics in the context of a statewide EMS system. The finding that ACLS-skilled paramedics have a positive effect on survival suggests that advanced training in areas where defibrillation cannot be delivered within optimal time frames is critical to improving survival rates. The more extensive training and education of ACLS-skilled paramedics not only allows effective ACLS intervention but may also optimise the effectiveness of BLS interventions. Due to the observational and retrospective nature of this study, we cannot draw firm conclusions about what produced the increase in survival for those patients attended by ICPs. We are unable to determine what specific effect ACLS treatments had on patient outcome. Nor can we separate the effect of the intervention from the skill level of the paramedic providing it. Therefore, the survival effect seen may be due to a function of paramedic skill, the treatments provided or another uncontrolled factor. A number of alternative explanations could be proposed for our findings. ICPs tend to be deployed in areas of higher population. Although the results seen here might be influenced by a function of population density, the intuitive markers for such an effect, rates of witnessed arrest and response time did not differ significantly between the groups. The survival effect probably cannot be explained by differing resuscitation protocols related to skill level. Both study groups are bound by the same criteria for the commencement of resuscitation. ICPs do have more scope to discontinue resuscitation at the scene, and this is reflected in the lower transport rates for this group. More experienced paramedics are probably more skilled at recognising cases of obvious death, and so when an ICP is first on scene, he or she may be less likely to begin resuscitation. It is not clear whether such an effect would have influenced the results here, as frequently ICPs arrive on scene after the primary crew has begun resuscitation. Finally, this study did not control for post-resuscitation or in-hospital care, both of which may have affected the outcome. Further research is required to disentangle the effects of ACLS from the effects of advanced training alone. The impact or added benefit of ACLS in EMS systems that are decentralised or geographically dispersed, and where optimal defibrillation time frames cannot be met, warrants continued attention. FOOTNOTES Competing interests: None. REFERENCES 1. Cummins RO, Ornato JP, Thies WH, et al. Improving survival from sudden cardiac arrest: the "chain of survival" concept: a statement for health professionals from the advanced cardiac life support subcommittee and the emergency cardiac care committee, American Heart Association. Circulation 1991;83:1832–47.[Free Full Text] 2. Nguyen-Van-Tam JS, Dove AF, Bradley MP, et al. Effectiveness of ambulance paramedics versus ambulance technicians in managing out of hospital cardiac arrest. J Accid Emerg Med 1997;14:142–8.[Abstract] 3. Guly UM, Mitchell RG, Cook. et al Paramedics and technicians are equally successful at managing cardiac arrest outside of hospital. BMJ 1995;310:1091–4.[Abstract/Free Full Text] 4. Mitchell RG, Guly UM, Rainer. et al Can the full range of paramedic skills improve survival from out of hospital cardiac arrests? J Accid Emerg Med 1997;14:274–7.[Abstract] 5. Rainer TH, Marshall R, Cusack S. Paramedics, technicians, and survival from out of hospital cardiac arrest. J Accid Emerg Med 1997;14:278–82.[Abstract] 6. Mann CJ, Guly H. Paramedic interventions increase the rate of return of spontaneous circulation in out of hospital cardiac arrests. J Accid Emerg Med 1997;14:149–50.[Abstract] 7. Soo LH, Gray D, Young. et al Influence of ambulance crew’s length of experience on the outcome of out-of-hospital cardiac arrest. Eur Heart J 1999;20:535–40.[Abstract/Free Full Text] 8. Kriegsman WE, Mace SE. The impact of paramedics on out-of-hospital cardiac arrests in a rural community. Prehosp Emerg Care 1998;2:274–9.[Medline] 9. Stiell IG, Wells GA, Field B, et al. Ontario prehospital advanced life support study group. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647–56.[Abstract/Free Full Text] 10. Bur A, Kittler H, Sterz F, et al. Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest. Intensive Care Med 2001;27:1474–80.[CrossRef][Medline] 11. Maheshwari A, Mehrotra A, Gupta AK, et al. Prehospital ACLS—Does it work? Emerg Med Clin North Am 2002;20:759–70.[CrossRef][Medline] 12. Wang HE, Kupas DF, Paris PM, et al. Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resuscitation 2003;58:49–58.[CrossRef][Medline] 13. Adams JN, Sirel J, Marsden K, et al. Heartstart Scotland: the use of paramedic skills in out of hospital resuscitation. Heart 1997;78:399–402.[Abstract/Free Full Text] 14. Nichol G, Stiell IG, Laupacis A, et al. A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1999;34:517–25.[CrossRef][Medline] 15. Persse DE, Key CB, Bradley RN, et al. Cardiac arrest survival as a function of ambulance deployment strategy in a large urban medical services system. Resuscitation 2003;59:97–104.[CrossRef][Medline] 16. Nichol G, Detsky AS, Stiell IG, et al. Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: a meta-analysis. Ann Emerg Med 1996;27:700–10.[CrossRef][Medline] 17. Pepe PE, Abramson NS, Brown CG. ACLS—Does it really work? Ann Emerg Med 1994;23:1037–41.[Medline] 18. Shy BD, Rea TD, Becker LJ, et al. Time to intubation and survival in prehospital cardiac arrest. Prehosp Emerg Care 2004;8:394–9.[CrossRef][Medline] 19. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. Ann Emerg Med 1991;20:861–74.[CrossRef][Medline] 20. Australian Bureau of Statistics. National regional profile- Queensland. Cat no. 1379.0.55. 001 Australian Government in Canberra, Australia 2003. 21. Cone DC. The eight-minute defibrillation response interval debunked: or is it? Ann Emerg Med 2003;42:251–5.[CrossRef][Medline] 22. Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA 2002;288:3035–8.[Free Full Text] 23. Nolan JP, de Latorre FJ, Steen PA, et al. Advanced life support drugs: do they really work? Curr Opin Crit Care 2002;8:212–18.[CrossRef][Medline] 24. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban medical services system. Ann Emerg Med 2001;37:32–7.[CrossRef][Medline] 25. Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation. Circulation 2002;105:645–9.[Abstract/Free Full Text]

:mumbles something about using accronyms: PCT at atleast 1 hospital locally is a patient care technician, better known as a CNA. That said, I believe they are talking about the good ol' thump.

^ http://www.dot10.state.pa.us/pdotforms/veh...e/chapter31.pdf

^ Meh, lights and sirens don't cure or protect stupid. There's a difference between being legally able to do something (i.e. you won't get a ticket for running a red with your l/s on) and being protected from liability.

At least that doesn't happen in California