Arrest

[mycrofft]

Pareto Principle At Work

As well as Heinsenberg's, and the Principle of Four.

Mycrofft, Dark Overlord of the Universe.

 

[Smash]

Smash, if you would quit dodging, and just ANSWER the questions, then there wouldnt really be much of a problem.

I work for the Olomouc Ambulance Service in the Czech republic

Now, can you answer a question of mine? In what way does knowing the above information change the question of how other people would have treated this patient?

The only question that I "dodge" are the ones that make no difference to the discussion. The case was laid out, what was done was laid out, what happened was laid out, and all that I ask is then what would others have done in such a situation. If someone wants to know why something was done, that is fine, I will answer it. If someone wants to know specifics of what drugs were used I will answer that. Fortunately some such as MelClin are able to answer that question and contribute from an Australian perspective, however others are clearly too tied up in where I am from and what training I have. I can only speculate as to why this is so important to some, and I've addressed this already; it quickly becomes tiresome when an interesting clinical discussion could be had and instead we get bogged down in such ridiculous irrelevancies. You may as well ask what kind of ambulance was driven to the case for all the difference it makes to the clinical discussion(Mercedes Sprinter van by the way <_< )

 

[akflightmedic]

I am with you...at no point does your level of training nor your location have impact on the discussion. You asked people what they would do and those responses should be based around what they do or know in their area of operation.

Obviously by your discussion you do indeed have some knowledge, training and experience other than google, which is commendable.

I think a few people need to reexamine their selves and get on board with the discussion points which are relevant.

 

[VentMedic]

MelClin, we too do not use IV beta-agonists if there is adequate air-movement to have an effect with inhaled agonists. However we do not currently have the option of including nebulized medications through a ventilation circuit. We are also very, very wary of using IV beta-agonists in the chronic obstructive patient.

And now, as I am no longer on the beach in Thailand, but rather in the hill country in the north, I am going to lie beside the pool for the rest of the day.

I am with you...at no point does your level of training nor your location have impact on the discussion. You asked people what they would do and those responses should be based around what they do or know in their area of operation.

Obviously by your discussion you do indeed have some knowledge, training and experience other than google, which is commendable.

I think a few people need to reexamine their selves and get on board with the discussion points which are relevant.

Then why didn't Smash want to answer a few simple questions like what country he is from and what beta agonists he is using IV?

This has been the subject of lengthy discussions in the U.S. and it wouild be nice to know what others are doing if it could be beneficially implimented into their own protocols. Why do some have to be so closed minded and not look outside of their own recipe book? Is that what a scenario is for? To also share ideas? Or, has this forum become so rigidly idiotic that even asking a question about a medical practice in another area is ridiculous?

Is it really too much to ask? He brings things up but can not or won't give any further information. What's the point of doing a scenario if he can not even answer what country he are from and a few, very few, simple questions? Was he ashamed of being from the Czech Republic?

Do some not even understand the differences in medication approval as it varies from country to country? Do you not see the revelance of being curious as to what is approved in another country that will later affect protocols in the U.S. Are some really that closed minded to learning something different or is it the fear of the moderators slapping you with a violation for asking a medical question that they may not know enough about to even see the revelance of it?

Just being a smart arse when asked questions does little for one's credibility. If you don't know something, just say so. Someone else might have the answer to the question for that area and their scope of practice.

This forum has really gotten to a low level when questions about medicine and level of care are not or should not be asked because it might hurt an EMt-B or FR's feelings.

akflightmedic, I am surprised at you for criticizing those of us who want a little more information on issues that are also controversial in this area. Have you also become so complacent to things that could impact protocols in the U.S.? Medicine is constantly changing and even though EMS is reluctant to change, you should close off your mind to where you next set of protocols come from be it next week or 10 years from now. Please don't close off you mind completely to alternative ways of doing things even if they are not currently in your own protocol book.

 

[akflightmedic]

Not closed off at all but am dismayed at the attack bandwagon which occurred.

The few little snips here and there/badgering was unwarranted. If one chooses not to answer, it is their thread to not do so, especially if it is not entirely relevant to the scenario being presented.

While yes there is/was a learning opportunity there, maybe it was not the time to receive it. I think he did a nice job trying to steer his thread and his scenario to garner different approaches to this situation. However, one person made a few questions and then others jumped on board with nothing more to add constructively other than to try and call out or discredit...who knows.

So in short, maybe it was the "tone" of gathering more information as opposed to the simple request for curiosity and improvement.

 

[VentMedic]

Not closed off at all but am dismayed at the attack bandwagon which occurred.

The few little snips here and there/badgering was unwarranted. If one chooses not to answer, it is their thread to not do so, especially if it is not entirely relevant to the scenario being presented.

While yes there is/was a learning opportunity there, maybe it was not the time to receive it. I think he did a nice job trying to steer his thread and his scenario to garner different approaches to this situation. However, one person made a few questions and then others jumped on board with nothing more to add constructively other than to try and call out or discredit...who knows.

So in short, maybe it was the "tone" of gathering more information as opposed to the simple request for curiosity and improvement.

Maybe if he hadn't been so evasive when asked simple questions it would not have lead down that path.

When there truly is an exchange of ideas within the scenario and discussion is allowed, you tend to get a better response. Just reading a recipe is not very interesting nor is the fear of being reprimanded each time you stray from that recipe. There should be encouragement, especially to those just starting, that medicine should be about learning and not just memorization of a feel notecards and a recipe book. It is a shame that this is the way EMS has gone and it also looks like the Czech Republic has similar attitudes toward education if Smash is the star example.

Those who also tend to read "tone" into messages on an anonymous forum are also dealing with their own insecurities and issues. A web page will not hurt you. You just don't read what or who you don't like. There is nothing to be afraid of except the moderators who have their own issues.

 

[akflightmedic]

Those who also tend to read "tone" into messages on an anonymous forum are also dealing with their own insecurities and issues. A web page will not hurt you. You just don't read what or who you don't like. There is nothing to be afraid of except the moderators who have their own issues.

Are you really starting into me now as well? Because I infer "tone" in people's postings and call it out you insinuate I am dealing with issues and insecurity?

Tone and context while sometimes missed is easily identified other times. There are no issues with my reading comprehension and I do not think I inferred incorrectly.

Thank you for the free psychoanalysis and please move along now cause I think all my issues have now been identified, so there is nothing more here for you to do.

 

[MrBrown]

A web page will not hurt you...

Have you checked your security software lately? :lol:

Seriously tho a very interesting discussion. Interestingly one service here uses IV salbutamol and mag while the rest don't citing lack of evidence of effectiveness.

 

[Smash]

And still no-one has answered my question: In what way does knowing the above information change the question of how other people would have treated this patient?

This has been the subject of lengthy discussions in the U.S. and it wouild be nice to know what others are doing if it could be beneficially implimented into their own protocols. Why do some have to be so closed minded and not look outside of their own recipe book? Is that what a scenario is for? To also share ideas? Or, has this forum become so rigidly idiotic that even asking a question about a medical practice in another area is ridiculous?

I am worried about reading comprehension on these boards sometimes. The reason I posted this scenario was to find out what other people would have done. Not a difficult question, but apparently beyond many. The medical practice was clearly laid out.

Just a quick recap: Here were some clinical questions:

Size 9 tube?

What was the PetCO2 during the cardiac arrest?

Where was the pulse ox placed?

These questions were answered on Page 3, post number 28.

The following however, is not a clinical question:

What country are you working in?

Thus I am not interested, as it has no bearing on the clinical scenario.

If you wanted to know what IV beta-agonist was used and on what basis, the ay to ask that would be: "What beta-agonist do you use intravenously? What is the rationale?"

However, all we get instead are incessant abusive, belittling and worthless personal attacks apparently without any critical thinking or analysis being able to be undertaken. It reminds me a a quote by the great Peter Medawar: "The spread of secondary, and latterly of tertiary education has created a large population of people, often with well developed scholarly and literary tastes, who have been educated far beyond their capacity to undertake analytical thought"

 

[Melclin]

For god sakes, why is this such an issue.

I was just curious about what level you were at primarily just as an aside, because I was wondering why you called yourself an EMT-B when you clearly were practicing at a higher level.

The difference in approach is not simply a matter appraising the evidence. It should be, but it isn't. Where you're from comes into it, and when you've having discussion with people about certain topics then it nice to know their background.

If we were having a discussion about a hypotensive trauma pt and someone came along and said well I would pump them full of Aramine, then it might be interesting to see what factors influenced that decision, considering that it is not the paradigm where I come from. You would probably find that the person had a background as a trauma or theatre nurse. If I said something about using IV salbutamol, the instant way of qualifying that, would be to refer to my geographical location and that would clear up any misunderstandings.

It's not a crucial part of the discussion, but its a simple and interesting question. Apart from the fact that people may just be interested in you, it does have some relevance to the discussion.

As Vent points out the subject of levels of education is something that comes up a lot and, again as an aside, I at least, was just curious to see what education you had to be practicing at the level you were. It wasn't so I could then criticize you, I was just curious.

Bloody hell mate, we we're just asking. I can't help but think that you saw in the question the suggestion that vent was ganna rip you a new one for being un-educated and you responded by being argumentative.

Mostly when people ask irrelevant questions they get answers unless the answer is somehow sensitive in which case they get blown off with the pseudo answer that question is irrelevant. Either you are carrying a grudge about the re-current "training levels" debate here and felt like having it out, or you are in some way ashamed of the answer to the question.

If you didn't have some issue with it, you would simply have said something like, "Oh well I don't see how its relevant, but I'm and EMT-B and medic student on my clinicals".

 

[Melclin]

The following however, is not a clinical question:
Quote:
What country are you working in?

Well it is if you are interested in the differences in standards of care in different locations. You might not be interested in that, but others might be. I certainly am.

The differences in care across different locations are often not just to do with empirical evidence published in journals. It has to do with all kinds of factors (usually to do with politics, personal grudges and the personal experience of the higher ups invovled) that are also interesting to discuss. Because of this geographical location is important.

 

[VentMedic]

Are you really starting into me now as well? Because I infer "tone" in people's postings and call it out you insinuate I am dealing with issues and insecurity?

Tone and context while sometimes missed is easily identified other times. There are no issues with my reading comprehension and I do not think I inferred incorrectly.

Thank you for the free psychoanalysis and please move along now cause I think all my issues have now been identified, so there is nothing more here for you to do.

Wow! Such sensitive types!


Again, don't be afraid of the big words or the medical tone and language in my posts. If you are, just put me on you ignore list as I really don't care to argue with someone who sees not relevance to any of my medical questions.

 

[akflightmedic]

Sensitive, no. Irritated, yes. It was you who called me out and stated I had issues.

At no time have I ever been afraid of your big words, medical knowledge or anything else. I do enjoy reading your posts and have learned lots. However, a slight disagreement and you are now the one over reacting, insulting (again) and basically saying stay away if you have a different opinion.

I stated why I felt it was irrelevant, you stated why you felt it was relevant. I still do not agree, however you going off and insulting me twice indicates possibly the issue does not lie with me...just sayin.

Ego check...aisle 3 please.

 

[DigitalSoCal]

I know I'm a newb on this board and my opinion likely means nil to anyone else, but my god what a way to take an interesting and informative discussion and send it right down the drain.

 

[VentMedic]

Sensitive, no. Irritated, yes. It was you who called me out and stated I had issues.

At no time have I ever been afraid of your big words, medical knowledge or anything else. I do enjoy reading your posts and have learned lots. However, a slight disagreement and you are now the one over reacting, insulting (again) and basically saying stay away if you have a different opinion.

I stated why I felt it was irrelevant, you stated why you felt it was relevant. I still do not agree, however you going off and insulting me twice indicates possibly the issue does not lie with me...just sayin.

Ego check...aisle 3 please.

Over reacting? Why are you stuck on this person's EMT-B status?

My questions were concerning what country and what protocols for IV beta agonsts. Why are you taking such an issue with that? Do you not realize that medications vary from country to country and that the U.S. is also conducting research in these areas for their usefulness? Why are you being so closed minded to think everyone is just picking on EMT-Bs?

Why are you continuing to bash me for ask pertinent medical questions? If you can not answer my questions, don't respond. You have offered nothing in the line of medical information. Get over that EMT-B thing. The country and the medications were the issue. If you didn't understand the IV beta agonst question, you didn't have to respond by attacking me.

Again, just put me on your ignore list because it is obvious you have nothing I want to read any longer. It is a shame your attitude has gone by the way of the rest of this forum when it comes to discussing medical issues.

 

[akflightmedic]

Yes, over reacting...just read your previous posts for clarification.

Not once did I say I am stuck or indicate concern about his status. I conveyed the message that his status and location is irrelevant for what he (the original poster) wanted out of you (the responders to his scenario).

Do I realize medications vary country to country...let's see, I have worked in Iraq, Afghanistan and the Philippines...nope I never knew that. Never mind that I work at a very large NATO base and interact with multiple providers on a recurring basis including the Dutch, French, Germans, Canadians, Bulgarians, Poles, Aussies, Kiwis, and the UK to name a few. We conduct joint training exercises/discussions, etc...

Close minded? I am one of the most liberal guys I know who constantly reminds himself to not be close minded, to explore other perspectives and encourage personal development and growth through such exercises. I have taken multiple beatings on other forums because of my views. At what point did I say you were picking on an EMT B? Please quote for effect, but I doubt you will find it.

To reiterate I said it had no relevance to the way the discussion was supposed to go.

Bashing you? Umm, I just responded to YOU insulting me twice and now three times for simply having an opinion which differed from yours. Where is the open mindedness?

No, I have not offered anything medical in this thread but as I said earlier I have enjoyed reading the posts, including yours and benefiting from them. However when the topic went on a tangent as they often do, it was then that I felt the need to offer my opinion which clearly everyone else had a right to do so as well. Sadly, mine was the minority and not in tune with yours, so I am just bad, bad, bad.

You then make the statement that I did not understand something (indicating ignorance or stupidity, your pick) as a reason for attacking you. Yet again, YOU are the one who threw the gauntlet down and my response about the line of questioning had nothing to do with my understanding or "not understanding" as you assume about the IV beta agonists. When have I ever responded in a malicious way because of my own lack of knowledge. Get over yourself and stop insulting me (yet again).

I do not use ignore lists as I read everything possible. To do so is to be close minded and petty but you seem to enjoy that as you have offered it twice thus far. That is not my solution to the issue at hand.

In closing, your closing to be exact...you insult me yet again.

 

[boingo]

Interesting case. Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min. In addition to in-line albuterol, I'd hang a Mg drip, IV epi and if the patient had any respiratory effort, I'd sedate and paralyze to take the patients diaphragm and intercostals out of the equation. I'd also give a fluid bolus as these patients tend to be on the dry side, and with the hyperinflation venous return is decreased, more so once the patient goes from negative pressure to positive. If after this I still had an arrested pt w/very poor compliance, I think a needle thoracostomy would be appropriate, and with the improved compliance and ROSC, a dx of tension PTX would be assumed. This patient would also get hypothermic therapy, assuming she/he remained obtunded after ROSC.

 

[Smash]

Interesting case. Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min. In addition to in-line albuterol, I'd hang a Mg drip, IV epi and if the patient had any respiratory effort, I'd sedate and paralyze to take the patients diaphragm and intercostals out of the equation. I'd also give a fluid bolus as these patients tend to be on the dry side, and with the hyperinflation venous return is decreased, more so once the patient goes from negative pressure to positive. If after this I still had an arrested pt w/very poor compliance, I think a needle thoracostomy would be appropriate, and with the improved compliance and ROSC, a dx of tension PTX would be assumed. This patient would also get hypothermic therapy, assuming she/he remained obtunded after ROSC.

Thanks boingo, good post. We don't have the option for Mg at this stage. IV epi was considered over the IV albuterol, however following decompression and ROSC the patient was actually hypertensive (not sure if I put that in initially) ICU also had a lot of trouble keeping BP down. I'm so much more used to patients having poor BPs post ROSC, particularly when on positive pressure ventilation as you mention, so I had to keep double checking Ultimately we opted for albuterol to have the beta effects without too much alpha.

To be honest we did not initially give a fluid bolus, although we had a couple of 16g cannula running wide open to flush drugs, so I guess the same effect would also have been achieved to a point. It's a good point though. Our hypothermia protocol also calls for the rapid infusion of a reasonably large volume of cold crystalloids. We also sedate and paralyze during cooling, however even if we had not cooled I agree with your decision to sedate and paralyze anyway. This patient was difficult enough to ventilate without having to fight his own drive, and he doesn't need to have any increase in O2 demand either.

Thanks for your post.

 

[VentMedic]

Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min. In addition to in-line albuterol,

ETT? Inline neb? Low rate? Standard acorn neb?

What do you think your extra tidal volume will be with the additional flow of the nebulizer and what will actually be the particle depostion of the albuterol with a low rate? How must will be uselessly deposited within the circuit and tube? Continuos flow vent? Some questions to ponder as many others have already studied these situations to decide the benefits vs the consequences if one does not have to proper medication delivery devices.

Thanks boingo, good post. We don't have the option for Mg at this stage. IV epi was considered over the IV albuterol, however following decompression and ROSC the patient was actually hypertensive (not sure if I put that in initially) ICU also had a lot of trouble keeping BP down. I'm so much more used to patients having poor BPs post ROSC, particularly when on positive pressure ventilation as you mention, so I had to keep double checking Ultimately we opted for albuterol to have the beta effects without too much alpha.

Do you understand what shifts IV albuterol can cause which is why it has been reconsidered in many situations in the countries that have been using it? Especially in a hemodynamically unstable post arrest patient whose BP can be easily influenced?

Now if either of you find any of those MEDICAL questions offensive, I will have to say this forum has lost hope of ever carrying out a MEDICAL discussion in fear that someone will get offended if they have to think a little about the questions that have been raised about certain treatments.

 

[boingo]

In-line neb was up to recently our only option, we have since changed that to an MDI administered through a port on the circuit. I don't know how much would actually be delivered to the target tissues, I have no way of measuring that. As I believe someone mentioned earlier in the thread, Heliox would assist in delivering medication to the more distal airways, however pre-hospitally, the world I live in this in not an option. My plan would be to deliver this patient in better shape than I found him to a facility equipped to manage the patient better than I.

Do you feel an in-line nebulizer would do more harm than good in a very tight asthma pt? I know anecdotally that in-line nebulized albuterol has improved compliance in similar patients in my experience in the past, although other medications were also in use.