Cardiac Arrest

[whit72]

OK rid here is one for you where did the medic come from?

[JPINFV]

Well, according to your article, the medic and the basic were developed at the same time and evolved out of intern doctors (which would be Post Graduate Year 1 following medical school). These doctors (they finished medical school and had earned the right to place an MD behind their names) are ALS providers. The ALS provider came before the BLS provider. Paramedics are the current ALS provider. Therefore, the history of the medic starts earlier then the history of the basic.

[Ridryder 911]

Actually, the article is half right.. what do you expect form a fire web site... lol

Ambulance services such as ones in Florida, Washington State, Wishard in Indianapolis, instituted training programs for ambulance services. Remember, most ambulance services were funeral home, hospital, and some fire departments. The National Registry was formed to keep a "Registrar" hence the name national registry for trained medics in case of war time events. hmmm.. didn't see that in the article. Remember this was in 1968-69... and Vietnam was still going on strong. Johnny & Roy was not even a thought yet.. until mid 1972-73. The infamous late James Page ( hence a play on the name Johny Gage) was a technical consultant, and provided insight. The rest is history on promoting EMS advancement.

Pioneer physicians that this article did not include or I did not see one was Nancy Caroline. I believe she was Chicago EMS medical director. She was one of the authors of the DOT curriculum and the produced it in bound copies called Emergency Care in the Streets.for easier distribution and $$. Yes, there many states that had variable training of Paramedic. Later when the D.O.T. did come up with the 15 modules for the EMT Paramedic curriculum there was at least a national standard. One needs to remember that courses like ACLS, PHTLS etc.. has not been invented yet, into mid 70's.

The NREMT did not have Paramedic level until late 79 to 80's. Until then most states had their own testing and certification. Most allowed one to be a Paramedic if you had completed the program and pass ACLS ( it was a lot different then.. most Paramedics these days would never pass the physiology questions) There was no formal intrastate recognition.

R/r 911

[Asysin2leads]

I don't by the whole keeping up the skills thing as a reason to have less medics on the street. That's like saying having less cops on the street is better for crime rates because the ones who are the street will be able to handcuff faster and shoot straighter. Maybe Boston's EMS system is good, but then again, who the hell wants to be an EMT for 4 years? Christ man, in that time, I could graduate as a PA and not have to put up with an obnoxious partner. Any system that puts unneeded restrictions on getting paramedics to the calls they can be useful on is not a good system. The reason BLS flourishes in urban areas is two fold, one, that there are the higher proportion of BS taxi runs, which sucks up time and energy from units, and two, and if my cynicism is too apparent, I apologize, I think that EMS is very much litigation driven. In other words, members of the lower economic class are less likely to sue when provided with substandard care then those of the a higher economic class. A kid in the ghetto emergency medical treatment is simply not as important as a kid from the suburbs when it comes to the funding of EMS. That's what I truly believe.

[Punisher]

Whit, no offense, but you seem very aggressive but your stances are not back up with much in the way of hard scientific evidence. You believe in flogging corpses basically because you think it is right. Every study I've seen has suggested that asystole is not a rhythm to be treated in 99.9% of the cases, but rather just an indicator that the patient is beyond help. No ALS level intervention has been proven to be effective in cardiac arrest resuscitation in the prehospital setting- only CPR and defibrillation have been proven to improve survival to hospital discharge. Personally I'm an advocate of on-scene attempts at resuscitation followed by either transport for those patients with ROSC or field pronouncement for those who do not respond to treatment.

The argument that ALS level airway management prevents brain death isn't supported by much evidence either. In fact, quite the opposite....most studies have shown that we well, for lack of a better term, suck at intubations when taken as a group. Now I'm quite sure we all think we are sharp and at the top of our game, but remember that you don't put together protocols for the sharp troops....you write them for the ones you only allow to practice because you don't have grounds to revoke their certification just yet.

By the way, given the fishy nature of the situation described, I would have ordered the crew to transport because of the shoddy nature of their work. Any more information on the case?

[whit72]

I am sick of hearing about studies WHAT DO YOUR PROTOCOLS STATE.I am saying my protocols state you work arrest pt's, without obvious signs of injuries non compatible with life. Why is this such a big problem for people to understand it has nothing to do with being aggressive. It has nothing to do with my emotions. Until the protocols change thats how they are handled regardless of my own personal opinions. The facts about intubation are true medics suck at it because they never perform the skill. If the rate for intubation was higher you would have more succesful tubes. I had to take and intubation class in a another state that I worked in, lets face it its not rocket science. But wouldnt you be more proficent at it if you did three a day rather then one a month.

[Ridryder 911]

I am sick of hearing about studies WHAT DO YOUR PROTOCOLS STATE.I am saying my protocols state you work arrest pt's, without obvious signs of injuries non compatible with life. Why is this such a big problem for people to understand it has nothing to do with being aggressive. It has nothing to do with my emotions. Until the protocols change thats how they are handled regardless of my own personal opinions. The facts about intubation are true medics suck at it because they never perform the skill. If the rate for intubation was higher you would have more succesful tubes. I had to take and intubation class in a another state that I worked in, lets face it its not rocket science. But wouldnt you be more proficent at it if you did three a day rather then one a month.

Appearantly not. If you did read the studies, you would find out this was not the case. Appearantly poor confirmation of assessing the tube plaement was the main key factors as well as displacement during movement. These studies were performed in high volume areas, so intubations occured often and routine.

The purpose of reading studies is see the weaknesses and possibility of changing to correct the problems. You are endorsing protocols so much, this is a good example. I read the four studies of poor intubation ratios studies and the protocol committee along with our medical director, administrator decided to avoid having such incidence changed the protocols to have EtCo2 wave form on all intubated patients and as well show run a strip of such just prior to movement of patient onto ER stretcher. With this information, we will always have 100% intubation ratio.. other wise the patient will either have alternative airway, crich or basic BVM. But no patient will present with an ETT in wrong placement.

How does one think protocols would ever change, or physcian becomes aware of new methods, better treatment regime, without reading studies and research ? Do you not have inter action with your medical control and re-evaluation of outcomes, and treatments? Just because the protocols are written does not mean they have to stay the same again they should be used as guidelines not direct "what to do" in every case. They need to be evalualted at least twice a year and have revisions made as necessary.

R/r 911

[JPINFV]

I am sick of hearing about studies WHAT DO YOUR PROTOCOLS STATE.I am saying my protocols state you work arrest pt's, without obvious signs of injuries non compatible with life. Why is this such a big problem for people to understand it has nothing to do with being aggressive. It has nothing to do with my emotions. Until the protocols change thats how they are handled regardless of my own personal opinions. The facts about intubation are true medics suck at it because they never perform the skill. If the rate for intubation was higher you would have more succesful tubes. I had to take and intubation class in a another state that I worked in, lets face it its not rocket science. But wouldnt you be more proficent at it if you did three a day rather then one a month.

ok, I'll give int. Its not technically my protocol, but its the ALS protocol in my county.

Medical arrests:

Consider field pronouncement by Base MD if no return of spontaneous pulse and respiration after

resuscitative efforts.

http://www.ochealthinfo.com/docs/medical/e...delines/c05.pdf

Trauma arrests:

If no signs of life, consider prehospital determination of death.

Contact BH as soon as possible for disposition. Paramedics may factor in proximity of trauma center

or PRC in determining indication of resuscitation attempt.

http://www.ochealthinfo.com/docs/medical/e...delines/t10.pdf

[Punisher]

I am sick of hearing about studies WHAT DO YOUR PROTOCOLS STATE.I am saying my protocols state you work arrest pt's, without obvious signs of injuries non compatible with life.

What my protocols say, is based 100%, totally, completely and entirely upon what research advocates to be the best course of action for a given situation. That is what my protocols say since you are so focused on them. That is why my protocols say that if you don't have a treatable rhythm (VF, VT, EMD) then the decision to resusciate is left to the crew on the scene. Research and protocol development in most places are inseperably linked and are not seperate issues as you would like to think them to be.

Why is this such a big problem for people to understand it has nothing to do with being aggressive. It has nothing to do with my emotions. Until the protocols change thats how they are handled regardless of my own personal opinions.

Actually it does have a lot to do with being overly aggressive- because even though you say that it is not, you still speak volumes by your contentious approach to evidence to the contrary even in the form of the very thing and hold in such high regard as you ask about what they say: protocols. If you don't want to hear that your service's protocols are rapidly becoming the minority in this country and that many of us support this change, then please either don't ask the question or at very least learn the time-honored tradition of putting one's fingers into your ears and repeating after me: "LALALALALALALALALALA! I can't hear you!!!! LALALALALALALALALALALALALALA!!!! (repeat ad nauseum)

As Rid said, how do you expect anything to be improved in regards to protocols if there are not studies done. It really speaks to your ignorance of how medicine works that you assume that protocols are just pulled out of the air or that the ACLS guidelines are just randomly thrown together without evidence to back them up. It is exactly this type of attitude that is holding EMS back and will continue to do so until we begin to act more like professionals guided by what is best for our patients and less like small children desperately clinging to whatever will give us the most pleasure. If you don't understand the research that backs up what we do, and stay up to date on it, how will you be able to understand to work towards improvement in your system.

By the way, what are your PERSONAL opinions of this (since you brought it up)? Regardless of what your protocols recommend, what do you feel is correct?

The facts about intubation are true medics suck at it because they never perform the skill. If the rate for intubation was higher you would have more succesful tubes. I had to take and intubation class in a another state that I worked in, lets face it its not rocket science. But wouldnt you be more proficent at it if you did three a day rather then one a month.

Once again as Rid pointed out, the problem is not a lack of practice- since one of the larger studies was done in LA County, and I'm sure they see more tubes that you. The problem (at least as most people see it) is the fact that there is an excessively nonchalant approach to it- mainly because it isn't rocket science as you put it. People become comfortable, people become complacent, and mistakes happen. Yes, one would assume that increased volume would lead to increased success rates, but this is simply not represented in most systems that have been properly evaluated.

By the way, what seperates a "true medic" from everyone else? Is it one that simply blindly follows protocol and hasn't given any thought that maybe what they were taught in class a few months ago (given the tone of your posts I'm assuming you are either a student or haven't been out more than a couple of years) is not necessarily proper, correct or accurate?

[Ace844]

I am sick of hearing about studies WHAT DO YOUR PROTOCOLS STATE.I am saying my protocols state you work arrest pt's, without obvious signs of injuries non compatible with life. Why is this such a big problem for people to understand it has nothing to do with being aggressive. It has nothing to do with my emotions. Until the protocols change thats how they are handled regardless of my own personal opinions. The facts about intubation are true medics suck at it because they never perform the skill. If the rate for intubation was higher you would have more succesful tubes. I had to take and intubation class in a another state that I worked in, lets face it its not rocket science. But wouldnt you be more proficent at it if you did three a day rather then one a month.

Kindly At least read the following texts, then come back here and post.

1.) Titenalli and or Rosens Series of Emergency Medicine Books

2.) The Art and Science of Bed Side PE, Sapira

3.) Pathophysiology of Heart Disease

4.) Emergency Airway Management, Walls, and take the course

There are about 30 more I would recommend as well as the various journals you can get the links to by doing a search here. When your done and you understand and are proficent with the material then come back here and try to 'defend' your current position...

A protocol is not an END ALL BE ALL. It is a guideline. ALWAYS has been and always WILL BE. If you believe your protocols are your '10 Commandments etched in Stone' than I doubt you are as educated or as able a clinician as you purport. Often times pt's fit into 'Multiple protocols' at once, by simple matter of their 'presentation, symptomatology, and or DDX'. If your rigid and you don't recognize this, then you are no better than a trained monkey providing negligent care to your pts...

Hope this helps,

ACE844