croaker260

WOW, I had thought that practice died out int he early 90's. JPINV, you might want to provide the complete citiation for his use.

Hmmmm...and the hits keep on coming! http://www.wjla.com/news/stories/0409/6165...ml#commentsform

From wiki: A brief online review of literature finds numerous discussions of this reflex in mammles dating back to the early 1900's, so it is fairly well documented. Its application to anesthesia is also well documented, but (to my understanding) been replaced by more reliable methods. In my personal experiance the Blink reflex , when absent, is usually a fair (not great, but fair) and objective indicator of LOC. In absent, it is (IMHO) one of the more benign indicators of weather someone has lost their gag reflex. Far better than direct stimulation of the gag relefx via a tongue depressor wich I have seen done on several occasions. HOWEVER, the inverse is not true. When present, it does NOT indicate that the gar relfex is intact. KEY POINT: And either way an intact gag relflex does not indicate a patent or protected airway. Far better is whether a patient can swallow or cough on command.

Our own history (Medicine, that is) is full of Cause and effect assumptions based on inadiquate observation and data. Once our brain latcheds on to this, it becomes a "Bias" and is difficult to break. Example: You see "A" (Smoking pot) and shortly after, you see "B", then you assume there is not only a relationship, but a causitive relationship (A caused B ) SOmetimes you even use A and B to come up with a further thoery ..."C". i.e. Patient smoked pot (A), Patient had Siezure ( B ), I assume they must be related (A + B ) thereore the pot must be tainted ( c ). Example: Patient goes into cardiac arrest, say V-Fib. As a result of this, the patient has brief SZ activity (A) that is observed by bystander, then the patient Stops breathing ( B ) , and this is observed by the bystander , then the patient dies...Therefore the SZ caused the patient to stop breathing and therefore the death. (A + B = C), not the 40 years of smoking, hamburgers, and obesity. And if only the doctors had found his SZ disorder, then he would be alive. So, back to the pot and the syncope or SZ activity....Nevermind it could have been a hypoxic trigger on a pre-existing SZ disorder, a cardiac dysrythmia, or just good old fasioned coincidence or psychosomatic. In observational bias investigating these other possibilities...investigation is not only is not done (If it conflicts with A + B = C, then I dont want to believe it) but investigation is resisted (How dare you say I was wrong, I saw it with my own eyes!). Example: If Paramedic response is good (A), then more paramedics must be better ( B ) therefore A + B = C (Better outcomes). Overcoming this observational bias is difficult. Just look at the public resistence to reducing Paramedic first response units and improving response on critical . Sometimes there is a relationship, just not the one we assume. Example: I have a patient in pain....I give them Morphine (A) and Phenegran ( B ) and they get quiet. I assume Morphine and Phenegran together have increased analgesia(potentiation)...( c )..when actually they increase SEDATION (Z), not analgesia...but the observational bias comes into play and this (Phenergan potetiates Analgesia) is still being taught today (incorrectly) in medic schools. So my point is this...in a very rambling crazy way..... If (BIG IF) the events were what they were reported as (It really was a SZ or Syncope), chances of it being the pots fault are equal to it being any number of other enviromental or physiological factors that may or may not be related.

FYI everyone. Please take any extra precautions you need and rigorous handwashing. This is ramping up today in the national media about the potential for pandemic. This influenza strain has reported killed 60 in Mexico, all aged from 25 to 45 (our age range, not the elderly....). Fortunately no deaths reported in the US cases, but its here. The CDC is advising it is probably too late for containment, but encourage our standard use of universal precautions. Lets be safe out there. Below is a post from the NEMSMA list serve

What we are looking at is a culture of indifference to quality patient care....which is what the IG report said in review of the rosenberg death...almost verbatum.

Yep, its pretty much as whiz bang as promised....only real downside is we dont tube as much.... I liked snatching breathers from the jaws of death with an old fashioned nasal tube while the rookies were still searching for an IV line to RSI/MAI.... Ahh the good ol days... Seriously...CPAP in EMS is a true boon to pt. care. Just understand that: 1- Some people will still need a tube... 2- Hypotension risk 3- Upper GI/Gastric distention concerns 4- Importance of the face mask seal Our protocol here: http://www.adaweb.net/LinkClick.aspx?filet...d&tabid=798

I hear rumors all the time of Washington (the state, not DC) moving that way. Come 2012/2013, the majority of programs left will be ones that are ran by colleges, with a 2 year degree option. Not mandatory (unfortunately) but a step in the right direction.

Well done. Thanks.

Thats a very specific staement. Do you have a reference? Not that I disagree...just want to be "solid"....

In squarly in the courner for the Med Director From Wake County. They have been on the forefront of many good things in the past years, including Theraputic Hypothermia and Advanced Practice Paramedics. Im NOT for the FDNY. Another med director came from FDNY, to the newly founded LMEMS (Louisville) and by all acounts has allienated most of his EMS crews.

Thats an assumption, not a know fact or even a stated fact. Not defending them, but the article doesnt state what they did one way or the other. Lets make this an objective and civil discussion.... WHat are your proceedures in the situation of a GSW to the head, in order to call them in the field? Do you "HAVE" to put on an ECG? (We dont...). Do you "HAVE" to call med control on "catastropic injuries"? What is the minimum you "HAVE" to do, and is there anything extra you do do?

Actually you leave V1 and v2 in place, moving just V3-V6 (although I recently saw a text that just moved V4-V6...not sure if there is any real difference there). This gives you views of the right side of the heart through the right side of the chest. Similar to moving your leads around for V7 through V15 will give you your posterior view instead of hoping for riciprocal changes in V1-V2. Remember your precordial (V) leads are UNIPOLAR, looking only from their specific locaion, where your "limb Leads" (I, II, III, AVL, AVR, AVF) are BiPolar, meaning they need two leads to assess their "view". This is why moving your V leads can be useful. Any-who....Moving your V3-V6 over to look at V3r thu V6r will enable you to assess for ST elevation or other signs of Ishemia/infarction specific in location to the right side of the heart. Just a thought, but with out going back to the OP, you do understand your lead groupings, vectors, and such in 12 leads? I know you said something about having the "basics" down, but different people view the "basics" as different things....no offense intended....

Well, good post except for the statement above. Many patients for all intents and purposes do not have a "primary care physician, or only see one once or twice a year (or even less), but see their specialist every few months or even every month. To discount or assume that one has no valid input is setting your self up for a pissing match on scene/on phone and problems later in review. Additionally, a jury or Judge might take the view that you were ingoring a powerful rescource in the care fo this patient. The way to handle it is to follow your protocols for advice from a physician other than your medical control, hopefully you have a well written one. Now these ae usually written for problem docs on scene, but cover this situation as well. Simply make contact with the neurologist, and explain (tactfully) on the front end of the conversation that you certainly want his input and insight, but any medical orders or advice must be confirmed by your med control doc before you put them into place. Therefore, in this case, you speak clearly and articulate your assessments and concerns well, note his comments and reccomendations , get his phone number so your doc and he can talk if needed ..may not be...and then call your doc with this extra and vital insight in hand. If you work in a system where you have the technology to do this over a recorded line, even better, but most systems do not have that easily ascessible.

I have a ppt, older, on SOAP and everything else. Its long and could do with some updating and shortening, but its yours if you wnat it. ALso haev some other directed self study materials on the same. As a side note, with out HiJacking the thread....Documentation of mental status and cognition in refusals goes way ...WAY ....beyond CA & O x 4...But that is truely another thread.

There is a distinct difference today between MDT wich are sued in dispatch, mapping, etc and E-PCRs for clinical documentation. We have both. A laptop mounted int he rig linked to disaptch for mappng, dispatch , communication, etc. And a tough book (and a desktop too) in each station with ESO (we used to use healthware) that we can take on calls. MDTS' ...LOVE them. We use Northrup grummen software. Whole County (PD, fire, ems) on it. Had them here for over 12 years, liike everything lots of bugs initially, now partof our operations so much people panic with out them. E-PCRs: Slower than just writing charts in MS Word or PDF...but otherwise a huge bonus fro QA, better billing, etc.

one observation: Your problem is not HIM. As a supervisor , it is NEVER personal. The probelm is HIS PERFORMANCE. PERFORMANCCE IS EVALUATED AGAINST POLICIES, PROTOCOLS, AND EXPECTATIONS. WHAT ARE YOUR POLICIES, PROTOCOLS, AND EXPECTAIONS? If you dont have those in writting, build them collaboratively in your group. The question is what are your policies? I would avoid writing policies "just for him"...this will invariably come back to bite you. I would advise against insituting hoops "to wash him out" . Again, more work, may not work, etc. I would look at your policies, build them if needed then approach it OBJECTIVELY. For example, .HYGENE is not a personal issue if your policy says people must be at training and on duty with good hygene. Then have the balls to PRIVATELY (with another supervisor) coach, then counsel, then warn, etc etc then terminate. If he responds and gets clean, then your problem is still solved. Example: Radio performace: establish policies realistic policies, on how radio communications shoudl be performed. Then train , then apply. Then counsel him, etc. if he fixes it, then great. Example: Documentation. Example: Appearance Example: Conduct at standby events and staying at your post. Get the idea? I manage our reserve (Volunteer) program in a department of over 100 paid employees and up to 20 volunteers. it has been a learning experiance, but from the begining if you apply the same policies evenly accross all , and stet the standards from the begining, and work to help peopel to meet them, 90% of your problems self resolve.

I would add that med control is not the end all be all, only 1/2 of the solution...the other half is your services on duty supervisor/officer, if it is large neough to have one. Use rescources. All of them. As a sup myself I have had situations where a med control call wa smade that would have allowed something that policy or liability wouldnt. In otherwords the doc may know medical issues, but not operational or administrative or policy issues. And just because a doc gives you medical advice/orders, doesnt mean he can make you violate the law (and there are EMTALA , custody, consent, and other laws you may not be aware of or considered) and he cannot make you violate your companies policies. Therefore a two pronged approach is rare. And yes I am aware some sups are useless. So are some docs. Involving both increases your odds that your butt and the patients interest are covered. That said, in this particular situation, I see some issues: 1- Contacting the patients PMD/neurologist, etc is appropriate, but the discussion should be between the medic and the neurologist, not third hand from the parents who have a bias. Depending on your agencies policies, this would may involve a 3 way call with your med control, or at least when you call him you have more "facts" for your discussion with med control. 2- THERE IS A DISTINCT AND LEGAL DIFFERECE BETWEEN DPAHC AND POA's. POA's primarily are for financial concerns,where Durable Power of Attorny for Health Care delegate health care descison making. In addition, they may have different criteria for when they are "active". Having one availble is very useful. May or may not be mandatory ...but determining wich is important. 3- I have a hard time releasing anyone who is altered (beyond their baseline) to anything other than a medical facility. This is a Med Control issue, and a huge pitfall. I release SZ patients all the time, after they have returned to their baseline mental status, after ensuring they have some safeguards inplace, and after as full of an assessment as we can do. This is why a sup is imprortant to provide checks and balances and CYA. Now, I am sure there are two sides to the story here, and I am not an "every patient needs transported or an ER" type of medic. Im not saying it is inappropriate to relase the patient to parents...just that there sounds liek there could have been more done prior to doing so. And expressing to the parents that there were some hoops to jump through and involving them in the process on the front end of the call makes it less advasarial and more collaborative. IMHO .

Ran into the same problem after caring for my grandmother who died of CA. In the end I flushed them anyway with my brother as witness as I couldnt get any agency to take responsibility. Better than getting caught with them later.

As a forerly certed EMD and EMD-Q I can answer that. 1- because you are answering the call and they arnt. 2- Because weather you use MDs, RNs, EMTs, or medics, they all spend more time and what if and double guess the protocols because of their additional training. Give me a civilian with no medical experiance, and reinforce protocol compliance....and you will have a better dispatcher than a 20 year medic. Not saying that the 20 yer medic isnt an excellant street provider, but it is two different jobs tackinging a single commonality. The protocols are not perfect, but they work 95% of the time with out major issue, and 99% of the time with out critical issue. Dispatchers establish the priorities (Alpha , bravo, etc) and obtain vital information, then provide Dispatch Life Support (Telephonic instructions) if needed. The System administrators determine how to use those priorities in their system (example: Alpha equals cold responses, bravo equals 1 hot and 1 cold, etc) The medic/EMT on the street takes these policies and guidelines and and translate them into daily operations and make them work. Exceptions to policies should be just that...exceptions....not every day occurances. Otherwise you have 10 different medics who would respond to the same call 20 different ways...chaos. You cant run a system thaat way.

Surprisingly research shows that EMD done by nurses with out cards, just following a loose set of rules, took (IIRC) about 2.5 to 5 minutes to obtain infrmation and complete, where for EMD using MPDS it was about 1-1.5 minutes. Speaking off the op of my head here. I can tell you several years ago when I did dispatch QA for our agencies central dispatch (it was part of the sheriffs department, all EMD trained) , the average call from beginning to end was in the 45 second range, and the average time to dispatch (Tones dropping) was about 15 seconds when the dispatchers tag teamed, about 1 minute when a single dispatcher ran an entire call. Obviously when PDI/PAIs (i.e. CPR instructions) where given the total time extended a lot, but the time to initial dispatch remained pretty constant.

Back in 2002-ish we did an internal review of our MAI/RSI. We found that those tubes which were maintained post intubation with just benzos tend to have more complicatons and required more repeat administrations of the benzo than those (relatively few) tubes that were maintained with Benzos and Opiods. This was pre-vecuronium for us, and included both post-codes and post RSI's. This involved a review of about (IIRC) 120 tubes over a 6 month period. So while this is an unpublished and not peer reviewed , and a retrospective non randomized review...all of which puts it just a few steps above "This aint no sh*t" in credibility of evidence, the moral of the story is opiods are a useful adjunct in post intubation management regardless of trauma or not. That said they are a tool, and not perfect for every situation.

I would love to see the references for those two cases, as I was unwaware of ANY that werent NG tubes (wich are completely different, obviously). I assume that the OP was an EMT, simply because if I was going to insert an NPA... I would go ahead and do a Nasal ETT (I a bit old school) if for some reason RSI/MAI was not an option. Other than getting an ass chewing by the recieving doc or internist.....any clinical based reasoning behind Nasal ETT over NPA assuming both are an option and RSI/MAI isnt?

FACT: Research shows that the average time savings is approx 30 seconds per call in an urban/suburban enviroment. I am not aware of this being studied in a rural enviroment, but believe the benifit would be less than a minute. I would veneture that in 99% of EMS systems the calls that would benifit from that 30 seconds are less than 2%. Not 10%, not 30%, 2%. Even calls that are ALS and "emergent". Even STEMI's. FACT: MOST EMS RESPONDERS WHO DIE ON DUTY, IN THE LINE OF DUTY, (Excluding those heart condition deaths with in 24 hours of a call) DO SO IN THE RESPONSE OR TRANSPORT PHASE...not on scene. Air Medical, or ground, appropriate use of transport mode and safe driving (or piloting) practices is essential to our (and our patients) survival. As essential as our clinical skills. Note, I didnt say FAST NASCAR STYLE driving skills, I said SAFE DRIVING PRACTICES. EDUCATED OPINION: If Time is indeed a factor, we can save more time with good scene mamagement skills than we will EVER save driving fast. EDUCATED OPINION: Most people who are going to "die" (Defined as going into arrest, not stay dead) with in that specific 30 second window of our arrival time that we will allegedly save, are going to "die" anyway, despite our best efforts. Therefore arrving in one peice and being able to work a rescusitation is more clinically important than arriving 30 seconds earlier. ANECTDOTAL EXPERIANCE: Using traffic pre-emption (i.e. the opticom or other devices) devices both emergently and non emergently, saves more time, provides for SIGNIFICANTLY safer response and transport, and less cardiac stress on the patient than running Lights and Sirens. I work in a system with Opticoms, and I can say we run more calls, and have fewer accidents per call or per mile than the agency I ran with that didnt have opticoms and ran L & S to most everything. Now, we use an EMD system to determine mode of response. The key to our EMD systems accuracy (and it still makes mistakes) is we use an certified QA process to ensure complaince with the protocols. STrangely, even when there are mistakes (over or under response) these mistakes do not result in bad outcomes. Now in the field, the medics have the option to either upgrade or downgrade for any reason, but they have to justify it. Some Common Examples: Fall Patient that is normally a cold response. But its 110 outside and the patient is on the sidewalk. In our area this can lead to asphalt burns. Call is upgraded by the medic depending on distance. The same is true for a ptaient who falls outside in winter. Battery victim/shooting/etc where we stage for PD. Typically it makes no sense to run L & S for 3 minutes to stage for 5. Depending on distance, we will run cold to the staging point. If PD secures the scene prior to our arriving at the staging area (rare), then we upgrade. Typically only a small delay (read non clinically significant) in total response time. Weather: Snow, Ice, poor visibility, we encourage downgrading for safety. And this is in IDAHO where we deal with snow, Ice and fog all the time. Simply put we recognize the risk and while we mitigate it (snow tires, winter driving training, etc), we take a thought out approach to it and try to mitigate it too by downgrading. .

http://www.adaweb.net/LinkClick.aspx?filet...d&tabid=798