p3medic

The research using swine suggest that crytalloid infusion didn't significantly worsen pre-existing bleeding, and transiently increased perfussion. All animals were uthanized at the end of the study, none were resusitated, so the degree of acidosis, coagulopathy and hypothermia were not addressed or studied. In humans, our goal is to restore hemodynamic stability, normothermia and prevent worsening of the patients condition. Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothemia, coagulopathy, SIRS, MOF, etc... I'm not saying giving a small bolus of crystalloid is wrong, however replacing blood with salt water doesn't work. Without the benefit of lab work that the hospital has access to, the hypovolemia is most likely secondary to an acute hemmorhagic process, and as long as he awake and appopriate, pouring large volumes of salt water in him would be unwise.

3"

You'd be surprised... :oops:

Salt water doesn't carry oxygen, it isn't a substitute for blood, has no clotting factors, and is very likely cold. This patient needed blood/blood products, and perhaps a little crystaloid for good measure. 2 liters of room temp saline is not going to improve this patients outcome. Cold, acidotic, and coagulopathic is one sure way to end up dead. Now, same patient, atensive, altered mental status, yeah, some wide open saline would be ok, at that point you need to do something, but short of that, pouring in saline seems like a bad idea. As for his hemoglobin, you don't have that luxury in the field, so the fact that his GI bleed has been progressing for some time is purely one based on HPI. Giving volume to a patient with bleeding that you cannot control is a whole lot different than a patient with bleeding you can control. Example, hypotensive patient with GSW to the abd = permissive hypotension, hypotensive pt with GSW to femoral artery, controlled with TQ, volume expansion to a reasonable MAP. Both will need blood/blood products, however one is in need of a rapid trip to the OR for surgical control of hemmorhage, the other can recieve blood products/saline, be normothermic and normotensive prior to the OR. At least thats how I see it.

I don't think it would be the determining factor, just another finding consistant with the dx. If someone is in hemodynamic collapse, air hungry with absent breath sounds, the presumptive dx of tension ptx is made and a needle thoracostomy is performed. There are many patients with simple pneumo/hemothorax who are not on the verge of hemodynamic collapse who end up with an unnecessary needle in their chest because of an overzealous paramedic. They like to use the arguement that the patient is going to recieve a cx tube anyway, so whats the problem? There are risks involved in the procedure, laceration of lung, intercostal vessels, the heart and the vasculature associated with it, etc...It is not a benign procedure. Now, with the patient in extremis, the benefit starts to outweigh the risk. Patients in hemodynamic collapse with decreased/absent breath sounds will likely recieve a needle as it is one quick procedure that can truly be life saving. The patient about to die is going to do so quickly.

You should drive to Ohio via Massachusetts....

Hyperesonance to percussion is consistant with tension ptx, although in the loud out of hospital world may be difficult to appreciate. There are things other than tension ptx that could lead to decreased or absent breath sounds and cardiovascular collapse, however they don't present with hyperesonance. So, if you can percuss, it is a valuable finding, in my opinion. Needlessly sticking needles in someones chest is generally frowned upon.

Unfortunately he is the one that holds the medical licence, so wading into a pissing contest with him would be unwise. He asked you about your protocol, and according to what you said, this woman would not have qualified for NTG. As far as the MS v.s fentanyl, both relieve pain, fentanyl has less affect on hemodynamics and no histamine release (or minimal) as opposed to MS. What your pt needed was a rapid and safe transport to a cath lab, with IV fluids prn, ASA, pain management and o2. It sounds like you provided all of the above.

And thats why the fire department should stick to fire fighting..... :oops:

At my station I have several mounted deer heads on the wall. One of the female medics hates them, feels hunting is wrong, PETA card carrying member. She complained about the heads, I listened, and then went back to posting on EMTcity.com.

I don't need the PC police to dictate what I may or may not watch at my station with my partner. If someone wants to visit, I'll turn it off untill they leave, otherwise I fail to see a problem. Comparing IBM or another business workplace to an EMS or Fire station is silly. One is a business were you are actively working except for scheduled breaks, the other is on break until called upon, assuming the station duties are completed.

Position of comfort in the awake breathing patient. The patient will generally find a position that allows for the least work of breathing, not unlike the COPD/asthma pt assuming a "tripod" position. If the patient is unconscious secondary to the penetrating chest injury, they are intubated and transported supine. If the patient is unconscious they are likely severely hypovolemic, have tension ptx or tamponade. Placing them supine may improve cerebral perfusion, and allows for repeat assessment of the airway, trachea, anterior neck and chest.

MFD has done a good job in ensuring fire department jobs, not providing the best delivery of emergency medical services in my opinion. One of the problems is requiring every new hire to be a paramedic. Think about it, you are a kid who grew up dreaming of being a Memphis firefighter. Now, to live the dream you have to go to Paramedic school. Well, putting out fires and providing advanced medical care in the streets are two entirely different jobs. The kid who wants to fight fires is now required to learn medicine too. Remember the subjects in school you disliked? You did enough to pass, but nothing more. The same can be said for the firefighter "required" to learn paramedicine in order to secure his dream job. He will learn enough to pass, will provide care as required hating every minute of it, and do his best to "promote" to suppression and get away from the ambulance. Your best and brightest medics will also advance in rank, and leave the medicine to the new kids, the ones who don't want to do it, and have minimal experience. You will never have a core of well educated, experienced paramedics in this system. I realize there will be exceptions. Some of your firefighters will enjoy the medical calls, and excell, however I'm afraid to majority will flee the ambulance as soon as allowed.

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Just because a town can convince the powers that be they need a SWAT team, or ALS doesn't make it so. There is a HUGE difference between training and doing. I think it the case of small towns, a regional approach to ALS (and SWAT) is the way to go. The providers would be responding to a greater volume of calls and gaining real life experience as opposed to sitting around the firehouse hoping for something to catch fire, and occasionally going out on an EMS run. The problem as I see it is an overwhelming number of providers with minimal experience, as opposed to using fewer providers in a regional approach. They used to use regional systems around here, and they provided a high level of care with experienced providers, but since the explosion of ALS fire departments they have fallen by the wayside.

I don't see how Taunton can expect to make money by giving EMS to the fire department. The town will end up paying to hire more ff/medics, will pay them extra to be paramedics, will take on the liability of these medics should poor care lead to a bad outcome, will pay them for their con-ed, will pay for a medical director, will pay for the fuel, medication and ALS equipment. I think the amount of money they would collect with billing would fall far short of the money needed to fund the system. And next contract they will come back and say our call volume is increasing, we need more ff/medics, new apparatus, more money, etc...Thats my prediction. I've seen it all over Mass, no reason to think Taunton would be any different.

Oh please....a town of 30,000 needs fire based ems as much as it needs its own SWAT team...oh wait, they have that. :wink: Every little town fire department wants its own ALS, even though with the tiny call volume the experience level is almost nil. What they need is a higher volume regional ALS system, with EMS professionals responding with fire department first responders. Fire based EMS in Taunton would not make money, it would lose money, although save firefighter jobs and be in line with the IAFF's mission.

Around here, narcotic OD, heroin, oxy's etc...would be my working dx, until we learn more about the patient assessment findings. For some reason the bathroom is the most common place to shoot some H.

So, other than putting water on 99% of fires, there isn't much more you can do than lets say a gardener with a hose? If paramedics have so little to offer, why then are the taxpayers in Memphis to pay for 130 more medics? Why do you need paramedics on fire trucks if they make no difference? Hmmm....Makes me wonder.

Actually it does affect us. The IAFF and fire departments like yours is on a nation wide quest of fire based EMS for all. It is NOT the best way to deliver EMS, however it is in the fire services best interest and is the agenda of your Union.

I like grits, I went to college and AIT in Texas! I'm all about southern cooking, just not sure if I'm sold on NC bbq.....yet. Now, if y'all want to talk about New England clam chowdah, I have a recipe that will make your tongue slap your brains!

Seattle Medic One you say! You are talking about ALS engine companies and 100% firefighter medics, you would be laughed right out of Seattle! Other than Boston, Seattle has the fewest paramedics per capita of any major U.S. city and doesn't have a single Paramedic engine company. You are comparing apples to oranges my friend, you are nothing like Seattle, more like DC, LA, and San Diego perhaps.

I was under the impression Wake county was considering removing intubation from their protocols in favor of the king airway, was I mistaken? In any event, I hope I was, I like the sound of the system, and if I could get used to vinegar based barbeque and convince the boss, maybe someday.....

Sounds like you need more ambulances and less engine companies. How do you expect to run a top notch ALS service when your medics are waiting for the day to get "promoted" to suppresion? So what if you want to do EMS and firefighting, if you wanted to do firefighting/policing is that a reason for fire to do law enforcement? Its the IAFF and systems like yours who take over EMS to justify your bloated staffing/budget. Its time to remove advanced EMS from the fire service and keep it in the hands of dedicated, single function EMS professionals. What if Memphis PD wanted to start up an ALS program? Would MFD support that? Didn't think so.

I guess I'm lucky, I seem to run into them all the time. We try to avoid cutting through them, but its rediculous in my opinion to delay care to a living person for a corpse in a car.