croaker260

There is a TON of science behind the changes...and more every day (Thank You Cobb, Safar, and others!!!!) I do a "science behind CPR" lecture frequently (for the past 5 years) to all levels of providers, including once a year to a batch of lifegaurds. Its a little bit challanging without me to explain it slide by slide, but after 1.5 hours, even 16 year olds are EXCITED about doing ROCK STAR CPR. Here is a link to my latest version on slideshare.com. (its like a youtube of power point presentations). Ther eare a couple of new things I need to include that came out this month...but its 95% current. The formating gets a little wonky on a couple of slides but you should be able to view it just fine. If you want to chat on the phone I can proably take you through it slide by slide. Here is the presentation. I also have one expanded for ACLS as well..... http://www.slideshare.net/croaker260/importance-of-cpr-2010

I typically intubate DURING compressions. To maximise my chance of success, I go in with the Bougie on my first attempt, difficult airway or not. I tend to have good success with this approach. Intubating during compressions is recommended in the new 2010 guidelines as well as (some) renewed emphasis on ETT as at lease one study showed improved survival to hospital discharge with ETT (though no improvement in ROSC).

Remember the original poster is in Germany, so the laws are likely quite a bit different. I would be interested in hearing what other industries use this methods, such as the fire brigades, or the transportation industry over there? All in all it sounds like an accounting nightmare, as well as a moral drain on the service. As you probably already summised, in the US, in most (but not all) industries (and in most ambulance services)... hours worked equals hours paid, with anything over 40/week being overtime (though some FD's try to use the 56 hour mark instead. Thses usually get shot down when challanged legally though) You will find some privates and rural agencies try to use "sleep time " rules , but they are also generally dispised and are uncommon when comapred to the industry as a whole. Some services try to use per diem pay and/or salory pay, though this is uncommon in EMS also.

Exactly how I was tought, and this is also taught/reinforced in most PALS courses.

Also keep in mind that a significant number of "vertigo" are actually atypical CVA presentations (aneurysms) , another reason for ALS.

Not to laugh at your "ooopppsss"....because we have all been there at one time or another...but laugh I did. Good story with a lot of good points in it.

Uhmm..both? If the patients s/s are easily remedied with a non invasive intervention ...with no adverse side effects (i.e. a position of comfort that relieves or markedly reduces the s/s to a well tolorated level) ......then further intervention is not warranted in the prehospital setting. IF this is NOT effective or practical to even try (i.e. hyperemesis) then more invasive and more risky (by comparison only, its still pretty safe)interventions such as medications (anti-emetics with or without benzo's) are indicated. Its not an either /or question. Its a basics before (and side by side with) ALS solution. I hope that makes sense.

Just another follow up, the overwhelming majority of the side effects listed are seen with Tagamet, not Zantac (10% of the rate of SE compared to Tagamet)or Pepcid (even far less). Tagamet inhibits the cytochrome P450 enzyme system in the liver, wich is responsible for the metabolism of many drugs. Therefore it prolongs the metabolism of b blockers and other drugs, which may interfere with treatment of epinephrine and prolong the halflife of the offending allergen. As for comparing Pepcid and Zantac...We are actually pushing for Zantac because of the shorter time to effect when given IV.

We use benzos for "nausea/vomiting with inner ear/vertigo s/s". We have for many years and are quite comfortable with it, I cant think of any adverse situations other than the rare over-sedation...but then again we prefer Valium in this role and NOT versed.... Obviously there are huge pitfalls of releasing these on scene, the largest one being the unrecognized vestibular artery rupture/pathology....fortunately (generally speaking) the patient who receives narcotics is getting a trip to the ER so the t/r issue isnt there.

Flaming: Your missing the point of "just in time" discussion. Cardiac arrests are typically less than 1% of total call volume, and actual ROSC far less than that, yet how much training do we do to save the life of a stranger? I would argue that the lives of those we know is worth at least equal attention. Now, the purpose of this is not to boo hoo the topic, or to shock and awe a rookie into compliance with P&P, its to generate discussion in real time and among our peers followed by "critical self review". Why? Because I believe that "just in time" 10-15 minute reviews save more lives than any merit badge course or P&P out there, that small-unit peer-led training (in what ever discuise you want to take it)is as useful as a refresher course...and that hopefully these discussions will refill the "gut feeling" tank enough that someone somewhere will wait that extra second, take that extra step , that saves their ass or their partner's ass. Thats why I posted it. Now in a perfect world, we would all go back and on our next shift casually say..."Hey did you hear about that paramedic..." and see where the discussion takes you. If your an FTO, hand one of these articles to your intern and say "Hey, did you hear about..." and guide the discussion a bit If your the captain you would casually say over the breakfast table to your crews..."Hey..did you hear about"..and push the discussion a bit.. As Gordan Graham would say..."Every day a training day"

I on the other hand have seen similar situations. Usually ER wait times is not a single source or large delay its a collection of smaller, more subtle and harder to define delays. One of our local larger tertiary care hospitals tried a fast track system. The problem is that the docs and PA's working this side of the ER were doing the same time consuming test that the rest of thee ER was doing, and the total time in the ER did not go down. I have heard of an ER that actually sends a PA out into the waiting room to get some tests already started, like strep tests, while you are still waiting to be seen. I have heard that helps. One of our local hospitals is a semi-rural community hospital. It used to have horrible service. In the past 5 years it has been taken over by HCA, and scene then it has dramatically reworked its who system not only from a process point of view but a customer service point of view. BTW, in most hospitals that are not on the east coast the delays are on the floor, not in the ER. They got their staff motivated to improve the hospital, and diversion times went out the window. I recently took my son there for a medical issue, and I have never been treated so nice in the middle of the night at any hospital ever...and the staff (for the most part) did not recognize me out of uniform. I was in and out in under an hour!!! I Kid you not..and they were STEADY. This same hospital has embraced technology, but also a culture of "being nice". They started using technology to post their current (w/in 15 minutes I believe) average wait time in their ER on major billboards across town and on the interstate. A similar sized hospital nearby is the complete opposite. Both serve a high volume of uninsured and under insured people. Both are community hospitsl. It just depends on leadership ad it can be done. S

We used to have a pretty good show, "Paramedics". Produced hand in Hand with "trauma : Life and death in the ER". Both these shows died when HIPAA came around. Too much hassel to get HIPAA covered institutions and services to allow a film crew in the ER or ambulance where informed consent is already difficult to obtain.

I still stand by my statement abvove, of course cost and ease of use being BIG factors.

Our agency has wrestled with this for years. As a result you will see a wide combination of names, initials, etc on our plates and/or embrodiered on our polo's. Recently the State came out with a proposed regulation requiring First Name and Last Initial, for all providers, but I am not sure where that is going. Anyway, the issue that our departmenthas is that we are about 40% female, and have cases where some stalking like behavior has occured. Of course we deal with the DUI's and other criminal behavior that puts us at a little risk as well. We still havenet come up with a consitant policy, but in general we mainly go with First name and last initial. We have buissness cards to give out as well, but have the option not to give them to patients we are uncomfortable with. I agree that it is a false sense of security, but if your on FB you are pretty much screwed anyway. Personally I think following your local law enforcement agencies policies is a good safe and proven policy. They have much more to fear than we do, so if it works for them it shoudl work for us. Additionally, advise your co-workers to live smartly. Manage your social media privacy settings, keep your number unlisted, and just be careful (but not fearful)in general and that will do more than any ID badge policy.

The best education is done with a grin on your face. Just sayin'

Hey all, As I was perusing the internet (EMSnetwork.org) I was astounded the number of EMS assaults that made the headlines in the last 5 days alone, and even more over the past month. While most of the assaults were minor, one involved a gun and another was quite serious involving a crew getting beat with there own toughbook (A coworker of mine would claim this is another reason to go iPad). Anyway, I thought this would be a good time to review our own safety procedures on scenes and around patients of all types, as well as just raise our own situational awareness with some just in time discussion. I have enclosed just a few of the links below. As an old crusty sergeant said on Hill Street: Be careful out there. -Steve . Psych Patient Flips Out In Ambulance, Assaults EMT, Steals Car: http://gothamist.com/2011/05/16/psych_patient_flips_out_in_ambulanc.php Honolulu man charged with punching female paramedic: http://www.staradvertiser.com/news/breaking/117845823.html Drunken limo passenger punches female paramedic: http://www.newsok.com/drunken-limo-passenger-punches-female-paramedic-oklahoma-city-police-say/article/3572916?custom_click=headlines_widget Police: Man Attacked EMS Crew In Moving Ambulance: http://www.wfmz.com/web-exclusive/28085494/detail.html Man Fires Shot After Ambulance Crew Enters Wrong Apartment Pennsylvania: http://www.emsnetwork.org/artman2/publish/article_45609.shtml

RaaaaMeeennnn! And for those who are lost...here ya go: http://en.wikipedia.org/wiki/Flying_Spaghetti_Monster

The things that come to mind: 1) Cost- As medicare reimburesments decrease, and every intervention is evaluated for cost effectivenenss, cost is an issue. 2) Ease of use - In crisis situations in severe TBI...EMS manpower is often limited. If this device requires the complete attention of one of the critical members of the team for afull five minutes when other immediate priorities exist, it probably wont get used much. On the other hand if you can attach it, press a button or three, then come back to it when you get a chance, it may be useful. 3) One area that I feel it woud be of huge use, depending on ease of use, and based on what little I saw on your website, is a secondary confirmation of mental status on patients refusing care, especially since it assesses memory, cognition, etc. If this could reduce litigation by providing a more thourough assessment of those patients who should be seen but are refusing (extreme sport athletes, patents who may have some intoxication but who appear cognitive, elderly who may have some intermittant dementia issues, or as mentioned the concussive football player...) then this is an excellent tool to reduce liablility to help document capacity to refuse care. In this role I see real promise. That said, the above is simply speculation, and depends on the final product and the science/studies behind it, as well as cost.

Honestly, this and similar topics have been discussed ad nausem on the NEMSMA Google list serve. Skip Kirkwood and many other current leaders of both fire and non fire agencies are on there and are a truly great bunch of helpful professionals. You will likely not only get an answer, but an answer based on facts your own administration will understand.

Wait a bit. if you are worth a damm, your quiet professionalism will put you in a position to be asked at the right time.

Oh I am fully aware that time constraints..but I agree, if you clean your likely site before you put on the TQ, then set up your stuff, then TQ, that can take 2 minutes easy if your (like many things in EMS ) cheorograph it right.

Hmm, the little tings you learn, and the little things you overlook when you teach because you "assume: others know it too. I always used Betadine first then alcohol on the extra grubby homeless population because that was the way I was taught "back" in the day in the army. It was never explained to me then the thought process why.... and while I have heard of letting the betadine dry also, no one could ever tell me "why" for that approach either. If someone cant tell me the "why" one way is better than the other I tend to be very suspicious of it. But I digress. I consider myself a very intelligent (if grammatically challenged) Medic with a diverse spectrum of knowledge... so if I am unaware of this than I am sure 75% of the EMS world is as well. I smell a continuing educational article coming on. Of course I may be incontinent again. Damm! So...just to be clear...Alcohol with scrubing first, THEN Betadine to dry.....then IV stick?

There are a few LE agencies out there with EMS divisions. There are also a number of LEO (Sheriff mostly) ran ALS services with duo-role officers in the northern Mid west that have run successfully for years, as well as a few in california. Most of these guys do not consider themselves "public safety" oficers because they mostly do not do fire supression at all. The most common thing they have in common is that they serve very rural and very vast areas co-responding in a (typically) fly car set up with BLS agencies. Many of them also perform SAR duties as well but that is more common for sheriff agencies than you might think. While my experiance with them is very limited,the few medics I have encountered in SAR courses (back in the day when I did tech rescue) were very motivated and gung ho about medicine and SAR, and prefered the LEO culture to the typical EMS culture and Fire Culture they had in their area... The one draw back is that they tend not to have the extensve ties with the medical community that more traditional EMS's do. Again , I am speaking in generallities here. Anyway, that aside, there have been a surpising number of LEO based systems , we just never hear about them because for the most part they run in different circles than we do culturally and educationally. All in all, we generally dont hear crappy things about them in the news like some of our own brethern. While not the same thing, also remember that Boston EMS started out in the Boston PD, and are still represented (quite successfully) by the Boston Patrollmans Association (union) against the IAFF and the BFD. Also , one of the first civilian air medical services to run paramedics is the Maryland State Police Air medical system, wich got its start with the help/guidence/hardheadedness of the father of trauma medicine, R Adams Cowley himself! It still runs today, and I think they have something like 6 helicopters/bases.

Awsome thread, we need more discussions like this. Its the little things that change the culture of our profession, one dysfunctional neuron at a time. Anyway, I have two comments. Simple one first: My FT department easily does half of its training on duty training through centra-learn and other on line rescources. This usually involved it being done in the station. More complex thought second: The law enforcement community has discussed this for YEARS (decades even). Gordon Graham has a simple thought: EVERY DAY A TRAINING DAY. If the Watch SGT (or what ever the title was....) did 10 minutes of review (and documented it) of important "just in time" training with every roll call, for 4 day a week, times 52 weeks a year, that would equal 34.6 hours of training a year before the first officer stepped onto a range or into a classroom! Now the math would obviously work different for EMS and our different scheduals, but at my part time gig they do 30 minutes of web based telephonic conference call training EVERY DAY at the beginning of their shift as a shift on top of the normal training required. This equals about 52 hours of training a year for full times just through this medium. Brian Willis (another Law Enforcement training speaker) also discusses this concept, and EMS is no where as busy as LEO's typically are in major cities. My point is this: We as field providers need to do more to help ourselves, and for those of us field providers who are moving up, we can and do need to do more for our co-workers. Not every bit of training is a merit badge course (i.e. ACLS, PALS) or a refresher course or a conference. REAL training is in small groups and "just in time" and led by our PEERS and OURSELVES.

Just an update: Presented Zantac IV today and was approved by our SOCC and Medical Directors. It goes to the system wide medical directorate next month and will likely be approved. Only debate was wich would be mosr ecost effective, IV Zantac or IV Pepcid. We will likely go with one or the other.