fiznat

Wow that's interesting. I just did a google search for the right anterior oblique view and it looks just like this one. Here's an example: The caption is as follows: Fig. 1. Coronary angiogram in right anterior oblique caudal view shows a left anterior descending artery total occlusion (double arrow) and 80% eccentric lesion in the second obtuse marginal (single arrow). Here is the after: Nice catch! You must have seen this before, I would have never thought about such an odd view. ....Or maybe its common? I don't know... This certainly would better explain the injury pattern we see on the ECG. So - if I can wrap my brain around this - the view is coming from sortof over the right shoulder? That would make the circumflex (and it's posterior branches) appear on the left with the LAD on the right..... Wouldn't they have to have the patient flipped over on the table for that? Weird....

With all these patients claiming they've got swine flu, I thought the EMS providers of EMT City could use this highly specific and sensitive test for triage purposes: http://doihaveswineflu.org/

Well I've only been to the cath labs and seen these images a few times, but based on what knowledge I do have about the anatomy of the coronary arteries, that looks like an occlusion of the proximal circumflex. The LAD looks entirely intact. I agree that it seems difficult to reconcile this cath with the ECG, but we should probably remember that the 12 lead ECG is not that specific of an indicator for AMI. The difference we see in lead placement could have been confounded by any number of factors ranging anywhere from differences in coronary perfusion to physical placement of the leads. Good case though!

lol, nice. Anyways... This is a ridiculous argument. The "right speed" for a given response depends on so many dynamic factors that they cannot possibly be wrapped up here in one post or position. To say outright that a driver should "never" exceed the speed limit by a certain amount - save recklessness - is silly. Roads differ, conditions differ, ambulances differ, traffic differs, etc etc etc. Have I driven over the speed limit on lots of different types of roads? Absolutely. Does that mean I'm "not a safe driver?" I don't think so. I think it is fair to say that we are all in favor of safety on the road, and that we should each drive with due regard for the conditions we will face. If you strip this thread down to that, I think it is obvious that we are all pretty much making the same point.

I assume code 3 means lights + sirens etc (we call that "priority 1" here but everyone is different). I feel like driving slower than the flow of traffic (as "at the speed limit" usually is) while also using lights + sirens is a dangerous situation. You really don't want cars passing you when you're traveling like this. If you are going to drive the speed limit, just turn the lights + sirens off! I guess I'm not surprised, but I am a bit dismayed at how everyone wants to be such a strong supporter of "going the speed limit all the time," "speeding is dangerous and illegal" blah blah. Be honest. I will guarantee you all that you drive faster than the speed limit, in the ambulance, on a regular basis. I'm not talking about recklessly dangerous driving, but definitely over posted speed limits. I think anyone who says they observe the posted limits ALL the time is either 97 years old, or lying. It seems like people on here love to take the high road so often, and post as if they never do anything wrong, lazy, or something that may be conceived as either of those two. Lets be real here. You speed.

Are you people actually saying that you never exceed the speed limit? Seriously?

Its not just in the ambulance. I drive "fast" all the time. Our posted speed limit on the highways is 65, in general I keep my speed between 75 and 80 when driving my personal vehicle. I drive considerably slower in the ambulance, but that probably has a lot to do with the computerized system we have that records such indiscretions.... Whats the big deal? Are you actually turning your coworkers in for driving over the posted speed limit?

I've read the state statutes and there is no specific exception for emergency vehicles or exigent circumstances that I can find. The law is fairly clear, and it says if you are involved in a MVA you must stop, offer assistance, and provide your information to the other person involved. There may be some common (case) law that I have not yet found, though. The scenario says that it appears there are no injuries from a windshield assessment. ...Meaning you're not talking to the other driver, but everything looks fine. The other vehicle occupant still *may* be injured.

OK. Also per the hypothetical the PD are immediately on-scene. This one is interesting. Do we have an obligation to assess these patients or manage the scene in any way? If we were passing by an accident that had already occurred we would have no such obligation... Does it change since we were involved in it? The hypothetical states that your vehicle is save to drive. PD is also on scene.... Do you? You're not an available ambulance, and some might argue that there are exigent circumstances prohibiting a full scene assessment. How is getting out to talk with the other driver different from communicating through the window? Does the presence of the PD matter?

Something similar to this happened at my service, so I thought I'd throw this out there and see what you guys think. You've got a critical patient in the back, someone who you feel needs to be at the hospital as soon as possible. While transporting lights + sirens to the hospital, your ambulance is involved in a minor crash with another vehicle. Neither your ambulance nor the other car sustained much damage, mostly just transfer of paint and a few scrapes. What you know: 1. The MVA was minor and on a windshield assessment everyone is fine. No damage that would seem to prohibit driving either vehicle. 2. Police are immediately available. 3. Another ambulance is on the way but ETA is unknown. Could be anywhere between 1 and 10 minutes. 4. Your patient is critical (think trauma or severe respiratory distress). 5. Closest appropriate hospital is 2 miles away. What do you do?

Agree!

I would argue that this would depend almost entirely on the quality of the job performed by EMS... A properly boarded/collared patient should not move on the board no matter which direction you turn them. That includes padding voids, etc. In any case, in the video they are still transporting ON the board, just not strapped to it. Seems to me to be even more dangerous....

If we're talking about bedside manner, I think this is absolutely something you can learn as an EMT. Learning how to talk to patients, illicit a history, and offer just the right amount of reassurance is something that any level of provider can learn to do well. Becoming a paramedic just means that you ask different questions, not alter how you ask them. I don't think this is a long enough time. ...But hey if you are interested in abbreviating our already tragically short education and training time then that may be your prerogative. I'm completely against it. If you don't mind me asking, whats the big rush anyways? People new to this field need to be at the top within a year? Tell me, what other respectable medical career allows such a practice? There is a difference between utilizing your resources (which we all must learn to do well), and using those resources as an excuse to abbreviate our training. You suggested in your last post that "scene control" was unimportant for EMS providers to practice because other services should be doing that job. I disagree. I think scene control is an absolutely critical portion of our job and it is something that we need to learn how to do well on our own, without subcontracting that work out to a FD or PD.

This article is pretty slanted towards the grieving family, I must say. It isn't written like news, but rather a drama. Seems to me that articles of this type are trying to provoke an emotional response rather than provide information. With that in mind, maybe we should consider that all of the facts here may not have been accurately represented. I don't see how the quality of a QA/QI program could have prevented or caught this incident. Short of having a QA/QI representative on the scene of every call, there is no way that this would have been identified, except through the means that it was. Taking RSI away from this service on those grounds is a knee-jerk reaction that I'm not sure was warranted. Did these medics do the wrong thing? Probably, but I think it would be prudent of us to realize that this is the ultimate in Monday-morning quarterbacking. The fact of the matter is we weren't there, and the only information we have is that which was provided by this clearly dramatized "news" article.

Thats interesting! So you guys don't secure the patient to the board at all? Here in the US it is pretty much required if we are going to immobilize the c-spine. Do you rely entirely on the collar to prevent movement of the head/spine?

YOU COULD POKE HIS EYE OUT!!!!!!!1one

Yeah I do the eyelash thing, and the "arm drop test." They aren't legitimate examination techniques as far as I know, but I've anicdotally found them to be fairly reliable indicators of who is unconscious and who is not. I've also seen providers try the "arm drop test" and have unconscious patients whack themselves right in the face haha, so be careful with that one...

Yeah. You're probably missing the codec you need. There is a free program out there called "gspot" which will analyze the file you've got and let you know what codecs you need to run it. EDIT: here it is http://www.headbands.com/gspot/

I think what Donavan is saying is that there aspects of what we do that go beyond "medicine." The logistical operations of balancing medical care with managing a scene is something that takes skill and practice to learn how to do well. Experienced EMS people (both medics and EMTs) know how to move patients with efficiency and due regard for injuries, know how to take command of a scene and calm bystanders down so that we can do our work. Good providers can illicit a complete history and physical exam in a compressed amount of time under stress, and get five other things done at the same time so that the patient is properly packaged, treated, and presented to the hospital. You might learn about "speaking to people and patience" when you are younger, but good bedside manner is a professional skill that is learned by experience. The same goes for our other skills in the field. This isn't everyday experience- you need to have been there. Paramedics are tasked with all of the above responsibilities in addition to their advanced scope of (medical) care. A good paramedic needs to be comfortable handling the scene so that he/she can focus on the medicine. Setting up a plan of care for a really sick patient in your mind, while extricating, exposing, coordinating, and dealing with family members is not an easy task. This is why EMTs need experience in the field before they think about going back to school. You don't learn how to do this stuff well in a few months internship, and it is inappropriate to assume that other agencies (PD or FD) should handle our work for us.

The audio is pretty badly out of sync for me but it is still an interesting watch. You guys talk funny! haha I understand the show is designed for laypeople, so it is a bit frustrating for me to watch, knowing how much is being cut out. Did they ever shock the guy in VF or did he just spontaneously regain a rhythm (as depicted in the show)? Did they RSI (the medic was talking about seeing vessiculations), and if so why was he fighting the tube? For the hanging guy, it seemed like they spent a really long time on scene doing nothing, and then transported without securing the guy's head to the backboard.... I'm sure a lot of this has to do with the editing, as you don't really get a sense for what is happening in what order. I enjoyed that though. Thanks!!

We use the same prefilled lido jets that we do for codes (20mg/mL), although I have to say I've never actually started an IO on someone who wasn't in cardiac arrest (so I've never had a need for analgesic lido...).

Yeah I think those numbers are a bit fudged. ...Either that or they need to be qualified. I know that the entire 12 lead is not that sensitive for ACS, so I have a hard time believing that a single lead is such a great indicator of RVI. What MIGHT be true is IF there is a STEMI on the right side, there is a high chance it will show up in V4R. That much is possible. You still ought to post your source if you are going to quote stats like that though.

Hey DocHarris: http://emedicine.medscape.com/article/814632-overview

These are tough patients to deal with. Though there are a few other assessments that could/can be done here (ETCO2 especially), in the end it is probably impossible to know the exact cause of this patient's condition in the prehospital arena. He is a COPD/CHF/Pneumonia/ACS mess that we can't do a whole lot to definitively sort out. That said, I think you did okay. You monitored the vital signs, got a 12 lead, and kept an eye on the guy's ventilatory status. I think the decision to do or not to do a nebulizer tx in this situation depends entirely on how the patient looks to you, and whether you think he is maintaining on his own without it. The differential indicates that beta agonists may in fact worsen this patient's condition, so I don't think you were wrong in thinking twice about using them. ...Especially in a tachycardic, elderly patient that was not in extremis. It is never a good thing to give knee-jerk treatments. Just because the guy has COPD and is complaining of SOB does not mean he immediately gets a neb. You need to look at the whole picture, and I think you did a good job doing that.

haha, made me lol. I agree though. For the most part the difference between a right and left sided failure will not be obvious at the outset. There are a few physical symptoms you can look for though, even though they are neither specific nor sensitive indicators of right heart failure. Distal edema/JVD in the absence of pulmonary edema points to right heart failure. If you think about where blood goes as it passes through the heart, a failure of the right side should result in venous fluid backup. This results in distal edema and JVD. Pulmonary edema in the absence of distal edema, by the same rationale, should raise suspicion for left heart failure. There is a caveat, though. Right and left heart failure are rarely independent of eachother. In fact, the most common cause of right heart failure is left heart failure. So, often we will see mixed symptoms and these indicators above will be worth squat. They are an interesting thing to keep in mind, though. As far as treatment of the patient with right sided failure, you need to remember the Frank Starling law. The law states that stroke volume (and therefore cardiac output) is directly related to cardiac input ("preload"). It has to do with the stretching of the muscle fibers of the heart. Like an elastic band, the farther they are stretched, the more forcefully they contract. Patients with right heart failure have muscle dysfunction such that they become increasingly dependent on preload to mediate cardiac output. This is why we need to be careful with nitrates, as their primary function is to increase peripheral vascular pooling and reduce preload. Decreasing preload in a preload-dependent patient will rapidly reduce stroke volume, cardiac output, and blood pressure.