p3medic

They exist believe it or not. Our city is similar in size to DC, and has a very active Medical Director, along with several other active physicians as Associate Medical Directors. I wonder if those paramedics that get demoted will have their pay adjusted as well, I can see the Union giving them hell on that one.

I used to like the term "wall to wall counseling", we used that on occasion back in my Army days...

No video, no witness, didn't happen.

I would agree completely Dust, if the patient weren't restrained. He broke the 11th Commandment, "Thou shall not get caught."

Sounds like a bad idea all around. I personally don't think a 911 provider for a city should be taken away from the taxpayers to do an IFT run. IFT jobs should be handled by a private provider, or a IFT branch of a municipal service, IMHO. If you need to do them for whatever reason, you should be afforded the same ability to administer medication as the place your tranfering them from. A patient on a NTG infusion shouldn't be d/c'd and started on sl NTG. I realize things are different in the Great White North, but it seems to be a huge liability from were I sit.

Refered BLS, see BLS report for futher.

There have been several studies showing that sitting around in an idleing truck leads to long term issues with back pain. Google whole body vibration, you'll see what I mean. No one should have to spend 8-12 hrs or more sitting on a street corner in a vehicle, its not good for anyone. As for my IMSERT question, NREMT-B mentioned training with a fire department, I was curious if it was task specific training to your IMSERT volunteer work. I see now your training to be a firefighter, so that answered my question.

Slows down fire response....interesting. Bet there are a lot more medical emergencies needing responding to anyhow. What are they training you to do? Is it an IMSERT thing?

I've had hemostats come in quite handy, and never for field surgery if you can believe that.

I'm a bit confused, you say that not all providers want to become medics, but you want them to perform LIKE medics, by administering medication and performing invasive procedures? So, they want to use the toys, but don't want the hassle of going to school? Sounds good to me. :roll: You might get to respond to a disaster yet! Sorry, couldn't help myself....back on topic.

I love for EMT's to ask me questions about a case after the call, it shows they have a real interest, and are not just bidding time until they get called for a police or fire job. We all learn in this line of work by asking questions of others, be they nurses, docs other emt's and medics. Questions are good.

I have a union sticker on my car, to help with not getting a speeding ticket. I'm happy to say this has worked on numerous occasions, well worth the 5$ investment.

Without actually seeing this injury, I would reserve the surgical option as a last resort. You are looking at distorted anatomy already, we know there is a perf of the upper airway by the presence of an air leak. Cutting into a neck with a vascular injury, expanding hematoma and a damaged trachea is a bad idea. There is little downside to attempting to secure the airway from above, if the trachea is so unstable from the initial injury that it might drop into the chest, manipulation of it during a surgical procedure is going to be no less dangerous. This patient is unconsious, so in all likelyhood we can perform a gentle laryngoscopy and get an idea of what we are dealing with. I'm leary of using a paralytic in this patient who is still breathing, if meds are needed I think a topical anesthetic and some sedation with versed/fentanyl, or etomidate might give us enough relaxation without stopping this patients own breathing. Another important question that hasn't been answered is what is the level of the injury? Is it at the larynx, or well below? If we intubate the patient, how deep to we need to place the ett? As for the doc's question regarding c-spine, I say no. I have no issue securing his head to the board, but I have no intention of covering his neck with a collar.

First, do no harm. Easier said than done. BLS the airway for a short rapid transport, and you have done no harm, per se, however with the above potential problems, all resulting in an unmanageable airway, early control is paramount, not unlike the airway burn patient. There have been several papers and retrospective studies on this very topic, and the consensus was that nasotracheal intubation had a high degree of success (Denver prehospital study) and RSI was highly successful, from several places, most recently Los Angeles(in hospital). Surgical airway, if it becomes necessary is an option, but one of last resort. Intubation through the wound tract is possible, if large enough, but with most GSW's in the US, its a small caliber wound. I have tubed a patient through a neck wound once, but it was a huge lac from a knife, and the anatomy was so blatantly obvious a firefighter could have done it. Now, me personally? I guess it would depend on his LOC. Unresponsive, as in this senario, careful laryngoscopy and attempt to intubate, if too much muscle tone, or patient to light, perhaps some topical anesthesia and versed/fentanyl or etomidate, with sux drawn if needed. At the end of the day, this is a horrible airway problem, and despite all we do, things can go very, very, bad.

Look up whole body vibration, and you'll see why idleing on a street corner is a bad idea.

Pipebomb on Lansdowne st. Dropkick Murphy's

So in your opinion, a blood glucose would be of no use to you if provided by a BLS crew transporting this patient? I realize that different stroke etiologies require different intervention, but as part of any stroke workup a blood glucose needs to be assessed. Hypoglycemia is one of, if not the number one mimic of CVA, ruling it in or out seems to me to be of great benefit, with little risk. I won't beat this issue to death, (unless I've already done that) buy I see no down side to having that information at your disposal when the patient hits your ED, not 20 minutes later. The BLS crew doesn't need to be an expert on the Kreb's cylce to perform this minimally invasive test, IMHO.

I understand your point, however in a busy ER, a patient with slurred speach and an unsteady gait may not get the attention they deserve. On the other hand, same patient with a documented normal blood sugar, no etoh on board would highten your suspicion, no? Thrombolytics can be given in any ER with a competent ER doc with a set of balls, but in my experience, this is the world of neurologists, who in addition to thrombolytics have other tx modalities such as angioplasty, coiling, and surgery at their disposal. All I'm saying is that the extremely low risk of the procedure of checking a blood sugar by BLS could expedite the care at the recieving facility, which is in the patients best interest. Its so simple a firefighter could do it. I agree that education is a requirement, and that not any EMT straight out of school should be doing it, but with good medical ovesight and a dedicated physician led training department, it isn't rocket science.

How about as part of a stroke assessment? Given a variety of points of entry, some with the status of "stroke center" some without, wouldn't determining that a patients neuro sx's were not related to something as simple as hypoglycemia be important? Regardless of what level of care the patient should be recieving, were talking about a BLS crew with pts presenting with CVA symptoms, and the ability to rule out a very common and easily corrected cause of AMS. Thoughts?

In systems that utilize a tiered response, and with several potential recieving facilities, some of which are classified as stroke centers, some that are not having the BLS crew obtain a prehospital blood glucose could make a difference in the cva patient. For example, patient with confusion and slurred speach is followed at facility A, family requests transport there, however facility A is not a stroke center, BLS crew do a quick finger stick and determine that pt has a blood glucose of 152mg/dl. With that information, a transport to facility B may be indicated. Now we can debate BLS vs ALS, tiered vs ALS, fire vs 3rd service, but thats not the question. Can BLS safely obtain a blood glucose as part of a prehospital stroke assessment? Absolutely. IMHO.

Our medical director doesn't answer to fire chiefs, they answer to him. A physician in charge of an EMS system wouldn't dictate how a fire chief fights fire, why would he dictate anything that has to do with the delivery of medicine? I realize not all medical directors are physicians although they should be.

This is NOT a STEMI. This IS Brugada syndrome. There is abnormal repolarization, its type 1 and the tx is ICD. This patient in the mean time would get an antiarrythmic, fluid, and have a brief neuro exam, hopefully he will wake up in the next minute or two, and all the other heroics won't need to take place.

Spontaneous resp effort? can I get that in 12lds? What is his BP?

around here the patient would get 2 minutes of good cpr prior to defib, assuming I didn't witness the arrest. With that said, after shock, immediately return to good cpr, and gain IV access. Epinephrine 1mg ivp followed by another shock if still in vf...