croaker260

IM in eclampsia only, but lets stay on topic. I have one more day before I turn in my research. Did you vote?

Here is a better link than the crapppy training video from the site.

Anyone using or revieed this device? My agency has tasked me with reviewing it and I am trying to see what the experiance is. Are you using any similar devices? http://www.allmed.net/catalog/item/1,1528,3863,3864

Could you PM me with your agency and state, so I can reference it correctly?

I apologize, I actually thought this would be easy. We already give it, I was simply tasked with finding out what other people are doing and to see how we compare. I was anticipating a minute to complete the survey and a couple of minutes to cut and past from their protocols, I was specifically trying to avoid a lengthy discussion that might get off topic. Please feel free to send a link.

The assumption is that the two are equal in quality of CPR, both in the intial 5 minutes and for longer arrrests. Results of research are mixed, and I am not saying that one is absolutely better than another. I am saying that it stresses the importance of consitant (not just transient) high quality CPR and a team leader who is willing to ensure that.

Technically the Lucas (or to be more specific the LUCAS II as it had to be redisigned for us american fat bodies) and the Thumper are two different devices. The AHA has put them (and similar devices...I was surprised to learnthat there are quite a few knock offs outside the US) as "Mechanical Piston CPR" devices, as opposed to the Zoll Auto Pulse wich is a "load distributing band CPR" device (AKA Geezer Squeezer). The AHA discussion on various types of CPR is here: http://circ.ahajournals.org/content/112/24_suppl/IV-47.full A good overview of these is here: http://www.signavitae.com/articles/review-articles/135-mechanical-cpr-devices

I believe that TX protocols are determined by the agency you work for, not by the state.

I have been tasked with reviewing a portion of our SWO's for the delivary methods of our Mag. If you could complete the above survey and add any additional comments below. This is for mag for all uses, i.e. cardiac arrest, asthma, pre eclampsia and actual eclampsia, etc.

I want to add a point... I know CPR is dangerous in the back of the ambulance. I am not disagreeing with that. At all. But we work in a risky job, we should mitigate risk, but not hide from it. My point is this: BEFORE any discussion on the danger of transporting a code is had, FIRST WE SHOULD LOOK AT PATIENT SURVIVAL. WHAT (REALISTICALLY) IMPROVES THE CHANCE OF SURVIVAL? Because if transporting the patient upside down running code with polka music blaring in place of the siren, while covered in peanut butter and wearing clown noses actually improved ROSC...I would find a safe way to do it. Thankfully it doesn't. My point is simple...working the patient in a flat unmoving surface improves ROSC (providing you really really focus on good CPR). Transporting the patient while doing CPR, and all the pauses and cot riding and everything else that goes with that....DECREASES ROSC. All other discussions are secondary until this is addressed... ....unless someone wants to play polka music and has a jar of peanut butter. I'll discuss THAT Nope, they actually suck in American style ambulances too.

Actually...no. "Bad " CPR that does not produce at least 15 mm hg sustained coronary perfusion pressure (CPP) has ZERO (read o.o%) survival. So its just like "no CPR" So...respectfully....Do you want to improve survival in your patients, or do you just want to do what you have always done, and get what you have always gotten? (i.e. a national ROSC rate in the single digits?) Its a simple question. Improve or stay the same? ( BTW my service ROSC rate is between 36 and 41%) If you do want to improve survival, then "make your stand" where you find the patient, and work them RIGHT THERE until you have ROSC or efforts truely are futile (or you call it on scene). I think we can agree that the first 15-20 minutes of arrest are THE most important. So... MAXIMIZE your efforts for those first 15-20 minutes. THAT MEANS...work the code on a flat non-moving platform until you get ROSC or until clinical indicators indicate futile response (i.e. ETCO2 < 10 mm hg, sustained asystole in a warm patient, etc) Draw a line in the sand and "Make your stand"! (I am getting brave heart flash backs here... ) I am not going to make character or ethical judgement on this statement..in fact I can see your point......but I will leave you with this: ( OK HAPPINESS, please take the following int he respectful way it is indeed intended. ) I dont know how many years you have been working. 1 year, 5 years, or 20. But just in the past 6 weeks I have had 3 ROSCs, 3 times as many as you have seen over a presumably longer period of time. All of those have been on a flat unmoving services. I have no idea how many ROSCS I have had over the (21) years, but I do know that all but 2 were worked on flat unmoving surfaces. The only two that I didnt work like that , were witnessed VF in the back of my ambulance and shocked in under 30 seconds (read: had ROSC before the body depleted all the myocaridal ATP) , therefore CPP and CPR was not a factor. NONE of the (adult MEDICAL) arrests...NONE.. I transported doing CPR (which is what was common practice in the south where I used to work) EVER had ROSC after arrival at the hospital. NONE. BTW, I had one arrest literally in the shadow of the hospital. Despinte the angry crowd and worried FFs, I made my stand and worked him right there on a baseball field. It was ROCKSTAR CPR and not only did we get ROSC, but complete neuro recovery. Since CPR also has an effect on cerebral perfusion fI personally believe that focusing on good CPR instead of succumbing to pressure and scooping him up...is why he lives a fully productive life today. So....believe me or not. But unless you are pushing the holy grail of ROSC (50%) we all can improve and should be examining EVERY thing we do with a critical eye.

First of all, that is the ABSTRACT...I actually have an original copy of the study here somewhere, I just didnt want to scan it. Re: Pnt 1: There was mentions of the vehicle. It was an ambulance, moving at normal speeds, obeying all traffic laws, etc. So presumable a more stable platform than running "Hot", or code 3, or whatever you want to call it. Re Pnt 2: That is a big "WHAT IF" to try to give your assertion. First you are presuming a a participant or a researcher bias, yet you have been unable to demonstrate what that bias is. Second, The Prehospital Journal of Disaster Medicine is a reasonable well respected and regarded international medical journal and are not well known for publishing bogus studies. It is peer reviewed and has very high standards. Furthermore, if you have ever seen the validation process to get a study published in almost any magazine, it is rather extensive. Re; Point #3: YOU ARE MISSING THE POINT. Starting an IV in a moving ambulance has no direct effect on ROSC. If my starting an IV in an arrest patient had an effect on ROSC, I would certainly change my method, but it doesnt. HOWEVER.....CPR EFFICACY DOES HAVE AN EFFECT ON ROSC, and a moving platform has been shown to have an adverse effect on CPR (when done by human beings in adults, I am interested in someone reproducing the study with the autopulse or the Lucas II) , therefore it has an effect on ROSC. Now, if you have any research showing your version of providing CPR is unaffected by a moving platform...please feel free to post.... <crickets chirping>

Here is the study: http://www.ncbi.nlm....pubmed/10155415 Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005). CONCLUSION: A moving ambulance environment appears to impair the ability to perform closed-chest compressions. PMID: 10155415 [PubMed - indexed for MEDLINE]

RE: NTG - NTG still has benefit in STEMI, I am curious your reasoning behind the statement that there is only RISK. Not all STEMI is embolic, and even if one of the coronary arteries is indeed clogged, the resulting strain of the event on the remainder of the myocardium, as well as most the these patients have co-existing CAD, means NTG in my mind is of benefit. Comments welcome. RE: Procainimide: Our transport times are highly variable , from 5 minutes to 45, depending on weather and locations (Winter can be a b!tch in Idaho). However we work 99% of our adult codes on scene until ROSC, so transport times only come into play during the maint. infusion phase or procainimide. I wouldn't say it gets used a LOT, because the incidence of recurrent VF (as opposed to refractory) is (relatively) uncommon. Once we get ROSC we tend to be able to keep it for the next 15 minutes or so. By contrast, most of the time I give it is as a second line drug if I exhaust Lidocaine, yet their ETCO2 still indicates viability...wich is admittedly rare. But it does happen. I remember those days, though I recall it was 6/minute , non-perfusing, with agina/ACS s/s. As a side thought: I actually gave it once recently for 10-15/minute PVCs, multi-focal, with chest pain, diaphoresis, etc and a Hx of previous sudden cardiac arrest 6 months prior. I still got the beginning of an ass chewing from a doctor who is known for her (usually justified) EPIC ass chewing, but even she (reluctantly) admitted that I had a point and "at least you had a thought process". I think that was a compliment.

Lidocaine-Out NOPE, Lidocaine still OK Intubating cardiac arrest early-Out NOPE, interrupting CPR for ETT out, Intubating during CPR OK and encouraged in the 2010 guidelines. Defib Paddles-Out NOPE, Not OUT, just pads are preferred. Jelcos-Out Still use them for EJs, Needle Crics, Decompression, and up to a year ago, we still used them for central lines. Separate pulseoximeters-Out Uhm, still see separate pulse oxes, and SPO2/SPCO2 (wich is really just advanced SPO2 when you look at the technology and development history) Nasotracheal intubation-Out, then back In NEVER was out for us. Diazepam-mostly Out NOPE, not at all. There are still things we have preference for Valium over versed. Smaller ambulances-Out, now back In Region specific. Decent sized, capable HEMS aircraft-mostly Out Depends on your region, though I will agree we are starting to see reconsideration of how HEMS is used and trauma levinling in general.

Here is an old school trick... Place the patient in shock position ( legs elevated) and press firmly but gently on the liver. This produces JVD boys the hepatic jugular reflex and will increase the chance of success.

I am going to go against the flow on this one.... 1. There is no absolute contraindication against NTG....I agree to use it cautiously...but NTG is commonly used in IV form post arrest. I am confused if the patient is continueing to have the tingling or not. If he is......Since the patients tingling in the chest is considered an aginal equivalent...NTG may be considered. (that said....I do understand the idea that sometimes we should leave good enough alone as well. ) 2. Kudos on the Lido..Im a big fan myself. 3. In our protocols we not only have lido, but procainimide for recurrent VF (defined as VF that comes back AFTER termination) where we start with lido first for "persitant" VF (VF with no ROSC in between. )

The main study that I an referring to was from the 90 s and specifically looked at CPR IN AN AMBULANCE. I stand by my statement. While there are no absolutes.... I think the abundant evidence shows that working most medical codes on scene until (persitant) Aystole, ETco2 <10 mmhg, ROSC occurs is by far the best thing to do. Of you feel you must transport an arrest..then at least wait until there its no chance of of survival..because once you dink around with transport you have remove reasonable chance of survival, wierd situations aside. Spory about typos.....sending from my droid and a th tiny keyboard.

Really kinda bummed no one has commented.

Location its competly relevant. Let me explain. Several studies have shown that cpr effecacy decreases by human brings (IIRC ALL study SUBJECTS WERE CPR INSTRUCTORS) approx. 50% when on a moving platform like in the back of a rig. Since (closed chest) CPR only produces 20% +/- 6% normal cardiac output...an estimated 15 to 25 mmhg coronary perfusion pressure (CPP) IF DONE PERFECTLY...then a reduction of 50% puts CPP in the 6-15 mmhg range. Why is this important? A n absolute minimum of 15 mmhg CPP is REQUIRED to achieve ROSC. ERGO....CPR IN A MOVING VEHICLE REDUCES/ELIMINATES ROSC AND THEREFORE IS DETRIMENTAL IN ADULT CARDIAC ARREST. this has not been researched in pediatrics but given that actual diameters of the chest, actual force and depth needed, and the methods of compression ( two thumb vs palm) a well a causes of arrest are dramatically different, the results may be different to in patients with smaller body masses. But that its just thinking aloud, where the facts of adults in arrest are well studied.

See comments above. Transporting them while doing CPR removes any chance of the CPR being effective.

You know, we had a heated discussion on this back in 2008, and before that on firehouse.com in 2005 ish. Here is the link to the thrad in 2008: http://www.emtcity.c...cardiac-arrest/ Now my thoughts.. The discussion shouldnt just be about if the patient is viable or not. (I will add that ETCO2 canbe crucial in that descision, but that is a different discussion.) The discussion shouldn just be about if it is safe for providers. (We accpet some risk inthis job and make risk vs bnifit descisions every day) The discussion shouldnt just be about wasting time, $$ andresocurces. (though this is a dicussion we should have about every call in our system) I think he discussion should also include if we are actually doing HARM to the patient by transporting them before ROSC. By HARM, I mean decreasing the chances for ROSC. To illustrate, I going to qoute myself from the earlier 2008 discussion, though current guidelines and science support this as well. In addition to the "calling the code" I personally believe that transporting them at all has a detrimental effect. For medical arrest, with ALS on scene: 1- Considering that we can do most everything that will be done in the ER, including pericardial centesis, and considering that the AHA recognizes that for most cases if a patient is not resuscitated by ALS on the scene, he wont be. So why take them to the rig to be transported if there is no benefit? Work them on the scene. 2- Efficacy of medications and therapies, as well as cerebral perfusion and coronary perfusion, is DIRECTLY related to the efficacy of CPR. Several studies have shown that quality of CPR both while moving the patient and during code 2 transport drops by over 50%. Therefore if PERFECT CPR only does 30% of cardiac output, we just dropped it to about 15-20% during the move and for the duration of transport. So: Work them on the scene. 3- The new 2005 AHA ACLS guidelines have extensive discussion on the problems with interrupting CPR even briefly. Even ETT and stacked shocks are re-evaluated in this light. Simply put SUCCESSFUL resuscitation is directly linked to good and SUSTAINED CPR. Since any interruption of CPR must be weighed as benifit vs con on the overall success of the resuscitation...and as discussed above there is minimal to no benefit to working them in the rig...and some benefit to working them on scene (provided the crew is ALS with all appropriate skills and such). Therefore: Work them on the scene. In short: Transport decreases the effecacy of CPR to a point that ROSC is even more unlikely (read : detrimental to the patient). So, work them UNTIL ETCO2 is <10 mm hg and you have exhausted your protocols.

ERDoc, HIPAA is not violated if it is a mandated reporting incident, which difers by state to state. HIPAA also only applies if you are doing electronic billing for medicare/medicaid, which is not the case here, though other privacy laws may apply. The medical director issue is a part of a larger issue...does the state allow paramedics to work outside of a licensed EMS agency? Of course with unlimited $$ in a fictional world, a "shell" private EMS agency could be set up just for this. Many other allied health professions practice across state lines, Athletic trainers and Physical therapists as well as Physicians with sports teams is a prime example...so this is not out of the realm of plausibility... just very very unlikely.

1- I am a big fan of the IN route... but only as an option when traditional IV access is not practical. 2- Frequently 5-10 minutes of good proper BVM oxygenation AND ventilation will restore some respiratory function in the recreational OD. If this tactic works, then bagging them is not an issue, and neither is Narcan. 2- If aspiration has already occured, you are better off bagging or placing the advanced airway de-jour than giving narcan... Respiratory failure is likely and giving Narcan will only complicate management. 3- Without getting too sideways on Narcan, narcan in a clinical vacuum is a safe drug, narcan used on the street with all the clinical variables we find in real patients can be a time bomb if you dont understand the "why's" and "whats" going on behind the scenes, especially with poly-pharm and hypoxic/acidotic patients. 4- I see your point of rural BLS services and bagging for an hour, but I am a huge fan of alternative airways for BLS services, and there are BLS devices such as the NuMask (www.numask.com and no I am not a sales rep ) that are viable options as well. I bring this up because Narcan is one of those drugs you can cause more problems than you solve....especially if you dont have all the options for airway management (i.e. RSI/MAI and sedation) when things go sideways. If you can managem the patient with oxygenation and ventilation...often you are better off doing that. For a better explanation of my views on Narcan... look here: http://www.emtcity.c...-ems-providers/ See my comments above about bagging, oxygenation, and ventilation. I think we can all agree its a possible tool in the tool box, but I agree its bioavailability is not well understood or researched. And since ETT administration of any drug, narcan included, is regarded as unpredictable in its absorption... the (relatively) well researched 80% bioavailability of IN narcan when compared to IV narcan is predictable and acceptable. Why is this important? Because with Narcan...LESS is MORE (even more so than other drugs) . And the ability to give predictable small amounts is crucial to avoiding complications, especially in poly pharm OD's. So yes, its an interesting option in the back of your head.I agree. But I agree also with chbare that there are a lot better options usually available, including not giving it at all. Respectfully submitted: Croaker

Heres another one from when I worked just north of Nashville.... Dago Cabbage ‎2 lbs. ground beef 1 lb. hot sausage 1 lg. can tomatoes 2 sm. cans tomato paste 1 tsp. oregano 1 lg. onion, chopped Garlic salt & pepper to taste 1 lg. cabbage Cook beef, sausage and onion in skillet; drain. Chop the pulp of the tomatoes. Add them and other ingredients (except cabbage) to meat mixture. Shred cabbage and cook in small amount of water until tender. Drain and add to first mixture. Simmer all together for 20 to 30 minutes. Serve over hot cornbread. Veeerrryyy Tasty! Haven't tried this one yet, but I hear its awsome from soem EMS friends.... Not sure if its station safe.... 4 cheese smoked mac-n-cheese 1 (16 ounce) package elbow macaroni 1/4 cup butter 1/4 cup all purpose flour 3 cups milk 1 (8 ounces) cream cheese, cut into large chunks 1 teaspoon salt 1/2 teaspoon black pepper 2 cups extra sharp Cheddar cheese, shredded 2 cups Gouda cheese shredded 1 cup Parmesan cheese, shredded Directions 1. Load the wood tray with one small handful of wood chips and preheat the smoker to 225° F. 2. Cook pasta according to package instructions. In a medium saucepan, melt butter, and whisk flour into the butter. Cook over medium heat for 2 minutes, until sauce is bubbly and thick. Whisk in milk and bring to a boil. Cook 5 minutes until thickened. Stir in cream cheese until mixture is smooth. Add salt and pepper. 3. In a large bowl, combine 1 cup Cheddar, 1 cup Gouda cheese, Parmesan cheese, pasta, and cream sauce. Spoon mixture into an 11 by 9 ½-inch aluminum roasting pan coated with nonstick cooking spray. Sprinkle top with remaining Cheddar cheese and Gouda cheese. 4. Place in smoker and cook 1 hour at 225° F, until brown, bubbly and delicious.