another thing, lets not confuse why the new cardiac arrest guidelines are putting less emphasis (lower in the protocol list) on intubation. It's not because they are suddenly discovering intubation to be less effective than they once thought. It's because we suck at it so much and thus are taking too much time trying to intubate while neglecting other essential stuff. If educators were doing their job, I wouldn't be writing this right now.
Aaa?
- Thread starter MedicPrincess
- Start date
always remeber BLS before ALS yeah if your pt is not getting better by just ventilating move to et tube, did the fire medic ride in also if so two medics on board 1 for iv 1 for et dont ever worry about b/p cant feel radial most likely not going to get a b/p airway should have been first concern with ivs en route to hosp and or et tube placement en route also I always do codes with bvm monitor and backboard till loaded, because you can ventilate compressions and defib if necessary why drag drop bag and drug box out and have more to carry back to the truck, ivs meds and et tubes can be done en route, and i agree pt's that arrive in er with ivs and or ets benefit, while it does take more time for er to reassess problem and begin their tx, that call seemed to be handle well and everyone of us would have done it differently.
Ridryder911
EMS Guru
- 5,923
- 40
- 48
Wow ! That was one long sentence.
First our job is to stabilize the patient for transport. I have found much easier to establish an IV and intubate in a large room than going down a bumpy road. Why the hurry on a full arrest?.. their dead, they can't get worse! Again it depends on the situation, but stabilize enough to be able to provide care enroute.
What good is a monitor, if you don't have an IV line to push med through? Even ACLS recommends 1-2 minutes of CPR before defibrillating on a unwitnessed arrest, surely you can establish a line and intubate if someone is able to perform CPR. Like Guardian stated, intubation has not been removed it is just emphasized not to stop compressions very long to perform an airway. I agree, the reason they no longer push intubation is because many medics suck at it.. because they were trained at lower levels and received inadequate education, poor TQI and no proficiency intubation requirements. Airway devices such as LMA does not prevent aspiration which occurs very frequently in cardiac arrest and has a near fatal outcome.
Sometimes, I won't even respond back with L & S .. if it is a short distance....why ? Many services are now responding back without such.
The reason ER may "take longer" is because the physician is now responsible and has to make another assessment. Treatment should not be any different except possibly checking with U/S for mechanical movement of the heart in a , determining tamponade, etc.. in a PEA situation.
First our job is to stabilize the patient for transport. I have found much easier to establish an IV and intubate in a large room than going down a bumpy road. Why the hurry on a full arrest?.. their dead, they can't get worse! Again it depends on the situation, but stabilize enough to be able to provide care enroute.
What good is a monitor, if you don't have an IV line to push med through? Even ACLS recommends 1-2 minutes of CPR before defibrillating on a unwitnessed arrest, surely you can establish a line and intubate if someone is able to perform CPR. Like Guardian stated, intubation has not been removed it is just emphasized not to stop compressions very long to perform an airway. I agree, the reason they no longer push intubation is because many medics suck at it.. because they were trained at lower levels and received inadequate education, poor TQI and no proficiency intubation requirements. Airway devices such as LMA does not prevent aspiration which occurs very frequently in cardiac arrest and has a near fatal outcome.
Sometimes, I won't even respond back with L & S .. if it is a short distance....why ? Many services are now responding back without such.
The reason ER may "take longer" is because the physician is now responsible and has to make another assessment. Treatment should not be any different except possibly checking with U/S for mechanical movement of the heart in a , determining tamponade, etc.. in a PEA situation.
Last edited by a moderator:
Pablo the Pirate
Forum Crew Member
- 44
- 0
- 0
please understand that i was by no means sayin we shouldnt intubate. i was just repeating what the new guidelines are saying. I do think we should intubate! there are too many reasons why we should. as for why i rarely start IV's on scene there is a very good reason behind it. Namely longer transport times. It's not uncomman to have 15 to 20 min in the back of the truck. I just dont think sitting on scene to start an IV is a good idea when i can do it bouncing down the road.
Ridryder911
EMS Guru
- 5,923
- 40
- 48
!5 -20 minutes is not a bad return response time.. try 1 hour +.. Again, it is one of those situtaion and scenarios, I do not believe should be written in stone. Like all protocols, they should be left under the discretion of the medic.. and used as general guidelines.. not thou shall or not..
R/r 911
R/r 911
firemedic1563
Forum Probie
- 29
- 0
- 0
OK, maybe it is just me, but I have to disagree with Guardian that this one should not have been a load and go. AAA or not, she presented as being in some sort of shock. She was pale, cool, had no peripheral circulation, probably had a sudden onset as she was found in a busy intersection. Sounds like she is bleeding out somewhere. What are we going to do in the field to save her? Nothing. A rapid load, quick IV, get her on monitor and go!
Manage her airway enroute, and intubate if necessary. She needed surgery and needed it fast. Chances are in this particular case, she would not have made it to the OR regardless, but we can't determine that in the field. Ever hear of the golden hour? It applies to more than trauma. We are not definitive care. Sometimes we can be, but overall we have neither the equipment nor the training of a Hospital. We cannot treat this patients underlying problem. We can manage some problems from it, and provide advanced life "support". But only surgery can correct the condition and treat her.
Manage her airway enroute, and intubate if necessary. She needed surgery and needed it fast. Chances are in this particular case, she would not have made it to the OR regardless, but we can't determine that in the field. Ever hear of the golden hour? It applies to more than trauma. We are not definitive care. Sometimes we can be, but overall we have neither the equipment nor the training of a Hospital. We cannot treat this patients underlying problem. We can manage some problems from it, and provide advanced life "support". But only surgery can correct the condition and treat her.
Firemedic1563, I believe in taking a systematic approach to pt assessment. If you don't learn to do this, you will jump to conclusions (diagnosis) and kill people. There are many many many types of disease, illness, and trauma that will present with the symptoms that were given in the first post. When I see a 45 y/o middle aged women with "pale, cool, had no peripheral circulation", I don't jump to conclusions and decide she is having a AAA.
Let me give you a hypothetical example of why good paramedics don't jump to conclusions, stay calm, and do what they are trained to do. Same scenario, 45 y/o women in an intersection with the same s/s that were given in first post. Firemedic1563 pulls up on scene and prematurely decides she's having a AAA. They load and go with the pt. Halfway to the hospital, the pt vomits and aspirates and the abdomen is now distended because firemedic1563 couldn't get the tube on the bumpy road. No IV was attained either. Nevertheless, firemedic is proud of her/himself for at least getting the pt to the hospital fast because time is critical in AAA. Then the doctor comes over and asks firemedic why he/she didn't secure a proper airway, give medications, and do a 12 lead and alert the surgical team that a major MI was coming in. It now takes an extra 45 mins for the pt to get to surgery. Because of this, the pt dies.
Let me give you a hypothetical example of why good paramedics don't jump to conclusions, stay calm, and do what they are trained to do. Same scenario, 45 y/o women in an intersection with the same s/s that were given in first post. Firemedic1563 pulls up on scene and prematurely decides she's having a AAA. They load and go with the pt. Halfway to the hospital, the pt vomits and aspirates and the abdomen is now distended because firemedic1563 couldn't get the tube on the bumpy road. No IV was attained either. Nevertheless, firemedic is proud of her/himself for at least getting the pt to the hospital fast because time is critical in AAA. Then the doctor comes over and asks firemedic why he/she didn't secure a proper airway, give medications, and do a 12 lead and alert the surgical team that a major MI was coming in. It now takes an extra 45 mins for the pt to get to surgery. Because of this, the pt dies.
Ridryder911
EMS Guru
- 5,923
- 40
- 48
Ever hear how the "golden hour" is Bull Sh*t ? Read a little more than the novel of R.A. Conley (inventor of shock trauma) Trauma Center, where he declared the Golden Hour .. yes, myth!
There has been no scientific findings after years and years of research that proves there has ever or ever will be such things. The same as the magical 8 minute response time.. all made up stuff, that has been handed down for generation and generations without any substance to it.
Trauma Surgeons as Dr. Don Trunkey, etc.. all original shock trauma surgeons will agree delayed care is not good, but in reality there is little we can do in the field and with the extent of injuries, really not much can be done at all. Many die after 2-3 days with complications of shock syndrome with organ failures. This is those that you blame on the ICU or hospital for "letting them die", in reality most medics know very little about shock, even though we should be the best educated in it. Since that is job !
I was fortunate to meet Dr. Trunkey and he definitely will tell you they way it truly is !..
For more information on this look in this months JEMS in which Dr. Bledsoe has written an article Have We Set the Bar Too High? .. I suggested to him, maybe we need a "Myth Busters for EMS"...
One needs to understand cellular level of lactic acid and metabolism as well deluge of acidotic blood kept in the capillary system when released causes major problem (diluted down version).
Ever wondered why person become pale in shock state? Where did all the blood supply feeding tissue go ?
So yes, we need to be concerned with delayed scene times, but we need to perform a thorough assessment and history.
R/r 911
Last edited by a moderator:
firemedic1563, In most cases, and a 12 lead, IV, ETT could be done in 10 mins. I'm not talking about taking my good old time. Heck, I usually shoot for a less than 15 min cardiac arrest scene time.
"definitive care" doesn't mean crap if the pt's dead because something critical like intubation wasn't done. The term "definitive care" could be argued but all I know is most if not all of what we do is just as important as "definitive care" and sometimes more so.
"definitive care" doesn't mean crap if the pt's dead because something critical like intubation wasn't done. The term "definitive care" could be argued but all I know is most if not all of what we do is just as important as "definitive care" and sometimes more so.
Last edited by a moderator:
firemedic1563
Forum Probie
- 29
- 0
- 0
Good points and all well taken. I am not arguing that we need to diagnose anything, rather that a quick, yet thorough assesment be done and the need for rapid transport be decided based on the finding of the need for critical interventions that we cannot perform. I have seen firsthand patients saved via surgical and/or invasive procedures in the very trauma center named after R. A Cowley. Many of them would not had survived a few more minutes.
I do agree that an arrest is workable in the field, and the few minutes should be taken to intubate, and attempt to get a line. But problems arise, and transport should not be delayed. if you are having problems with a line, either try enroute, or maybe start thinking IO if there are no other options. On that note, do any of you use the IO guns?
I do agree that an arrest is workable in the field, and the few minutes should be taken to intubate, and attempt to get a line. But problems arise, and transport should not be delayed. if you are having problems with a line, either try enroute, or maybe start thinking IO if there are no other options. On that note, do any of you use the IO guns?