BLS Shock

[alphatrauma]

...This from the same state the requires that your shotguns to be blessed in a Christian church and has regions where playing the violin outside is illegal.

Whilst we cannot choose where we are born, we most certainly can decide where we live

 

[usafmedic45]

This from the same state the requires that your shotguns to be blessed in a Christian church and has regions where playing the violin outside is illegal.

We also used to have a law banning the song 'Louie, Louie' from the radio as 'obscene'. Your point other than a failed attempt to discredit me after I pointed out your errors?

 

[Veneficus]

I try to enable students, but in US EMS there is a huge problem.

An instructor meets that qualification by years in service. Not by knowledge or any special education. Students expect a teacher is knowledgable, some form of social contract actually.

Personally I can never find fault with a student who doesn't know something that is beyond their level and the legal aspects of EMS are probably completely beyond Basic EMT class anyway as it is set up to be do as I say, do not ask questions.

No instructor should ever be teaching local protocols in the original EMS education. Many protocols do not meet the modern standards of care and teaching them confuses the hell out of students because verified and credentialed tests are based on the EMS curriculum, not on local practice.

In this particular case I think the failure is on the agency and the instructor.

While the instructor may have been sarcastic or joking, teachers have to be very aware that some jokes interefere with education.

As advice to the OP, I would seriously hold in question the ability of your instructors and school. Get a copy of your state or national curriculum. Read the book very carefully, always go with the book answer. If a teacher fails you, you can argue a published source. They cannot do the same with their anecdotes.

I would still demand my money back. Even if you are dropped from the program, you are now armed with the knowledge of what makes a program and instructor substandard so you can better evaluate your next school.

 

[Veneficus]

I think of it as the same kind of professionalism that USMC DIs adhere to when dealing with recruits...minus the screaming.

While I recognize the effectiveness and value of the drill instructor method, it is simply not my way.

I like the senpai/kohai method.

 

[AMF]

I try to enable students, but in US EMS there is a huge problem...

As advice to the OP, I would seriously hold in question the ability of your instructors and school. Get a copy of your state or national curriculum. Read the book very carefully, always go with the book answer. If a teacher fails you, you can argue a published source. They cannot do the same with their anecdotes.

I would still demand my money back. Even if you are dropped from the program, you are now armed with the knowledge of what makes a program and instructor substandard so you can better evaluate your next school.

To be clear, what are you contesting? That legs should be raised or that raising them shouldn't be malpractice? If it's the former, that seems very similar to immediate release of a tk.

 

[usafmedic45]

If it's the former, that seems very similar to immediate release of a tk.

How so? I want to hear your reasoning on that one.

 

[AMF]

We also used to have a law banning the song 'Louie, Louie' from the radio as 'obscene'. Your point other than a failed attempt to discredit me after I pointed out your errors?

I'm saying that just because a law sounds crazy doesn't mean it isn't legit, especially since I assume legislation for public servant operation licensure is more lax than more traditional criminal/civil law.

I didn't mean to offend you or compare ME to wherever you're from.

 

[usafmedic45]

I'm saying that just because a law sounds crazy doesn't mean it isn't legit, especially since I assume legislation for public servant operation licensure is more lax than more traditional criminal/civil law.

Yeah, but EMS related legislation are generally not spelled out that specifically. They are written in pretty broad strokes by the state legislature and the specifics are worked out by the EMS cronies (usually docs and senior EMS personnel) at the state EMS agency. It's not a matter of the "lawmakers" not knowing what they are talking about. That's what we have been trying to get across and why we have been asking you to point us to the particular source of this information since it seems so exceptional and outlandish.

 

[Veneficus]

To be clear, what are you contesting? That legs should be raised or that raising them shouldn't be malpractice? If it's the former, that seems very similar to immediate release of a tk.

All of the research I have seen demonstrates that there is no benefit to raising the legs. There is no mention of demonstratable harm either.

In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.

I would also like to point out from one of the most widely used EMT texts.

Step 2 of managing shock. "If there is no serious injury," (referring to the spine) "elevate the feet 8-12 inches."

I have not found any reference in any law on google or yahoo that states it is illegal or improper treatment anywhere.

All I did find about the legality of it was that it is not permitted during the interrogation of a prisoner in several states in laws referring to "aggresive interrogation techniques."

Some local protocols I have seen have removed trendelenburg position from their standing orders because of its lack of demonstratable effect in shock, but that doesn't make it illegal.

I doubt very much that there is any law on any book that states specifically legs may be elevated during surgical procedures where there is demonstratable benefit like moving anatomy to a more technically efficent position but not in the course of EMS treatment of shock.

Even saying it sounds stupid.

Not to mention every surgeon who performed a laproscopic procedure of the lower GI would be in violation. (along with some other specific procedures)

as for the tk, is there another way to release it I am unaware of?

 

[AMF]

How so? I want to hear your reasoning on that one.

Sudden return of vascular volume. Wouldn't you worry about de-oxygenation in the blood vessels? Obviously the vascular volume is different and the return methods have different flow time-derivatives, which is why I asked. From what I understand, extracorporeal oxygenation works similarly with refractory cardiogenic shock in acute MIs, specifically in reversing circulatory collapse without compromising (or maybe even improving) hemodynamic stability. However, Linuss and another early commenter informed me that the reason this procedure fell out of practice was not because it did the wrong thing but because it didn't do enough of the right thing.

 

[AMF]

All of the research I have seen demonstrates that there is no benefit to raising the legs. There is no mention of demonstratable harm either.

In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.

I would also like to point out from one of the most widely used EMT texts.

Step 2 of managing shock. "If there is no serious injury," (referring to the spine) "elevate the feet 8-12 inches."

I have not found any reference in any law on google or yahoo that states it is illegal or improper treatment anywhere.

All I did find about the legality of it was that it is not permitted during the interrogation of a prisoner in several states in laws referring to "aggresive interrogation techniques."

Some local protocols I have seen have removed trendelenburg position from their standing orders because of its lack of demonstratable effect in shock, but that doesn't make it illegal.

I doubt very much that there is any law on any book that states specifically legs may be elevated during surgical procedures where there is demonstratable benefit like moving anatomy to a more technically efficent position but not in the course of EMS treatment of shock.

Even saying it sounds stupid.

Not to mention every surgeon who performed a laproscopic procedure of the lower GI would be in violation. (along with some other specific procedures)

as for the tk, is there another way to release it I am unaware of?

EMTs (to my knowledge) do not remove tourniquets. It's not so much criminally offensive as outside our scope of practice. But it seems that the collective opinion is that it doesn't matter either way.

 

[Veneficus]

Sudden return of vascular volume. Wouldn't you worry about de-oxygenation in the blood vessels? Obviously the vascular volume is different and the return methods have different flow time-derivatives, which is why I asked. From what I understand, extracorporeal oxygenation works similarly with refractory cardiogenic shock in acute MIs, specifically in reversing circulatory collapse without compromising (or maybe even improving) hemodynamic stability. However, Linuss and another early commenter informed me that the reason this procedure fell out of practice was not because it did the wrong thing but because it didn't do enough of the right thing.

What the hell are they teaching you?

You are comparing ECMO to trendelenburg based on deoxyhemaglobin?

My head hurts now.

 

[Veneficus]

EMTs (to my knowledge) do not remove tourniquets. It's not so much criminally offensive as outside our scope of practice. But it seems that the collective opinion is that it doesn't matter either way.

Performing procedures outside of your scope constitutes the practice of medicine without a license. In every country I know of it is a felony offense. That makes it against the law.

 

[AMF]

What the hell are they teaching you?

You are comparing ECMO to trendelenburg based on deoxyhemaglobin?

My head hurts now.

The motivation is the same (AMI vs idiopathic, but really...) and the end result is the same, only the mechanism differs.

My question now is why would surgeons (I presume you at least work with them) use a procedure that EMS personel found ineffective (See the first couple of responses)?

 

[AMF]

Performing procedures outside of your scope constitutes the practice of medicine without a license. In every country I know of it is a felony offense. That makes it against the law.

I know you people love citations, so I'm sorry I can't provide any, but somewhat famously some european dude performed cardioversion on a police officer without a certification. I'm just saying that good samaritan can make some legal gray areas.

 

[Veneficus]

The motivation is the same (AMI vs idiopathic, but really...) and the end result is the same, only the mechanism differs.

My question now is why would surgeons (I presume you at least work with them) use a procedure that EMS personel found ineffective (See the first couple of responses)?

Because EMS providers know more about medicine than surgeons? (pay no attention to the sarcasm)

In surgery it is not used for shock, it is used for the optimal placement of anatomy as well as things like aiding in the reduction of indirect inginal hernias or to increase vascular volume in the neck and thorax for the placement of invasive catheters.

Trendelenburg as a treatment of shock is based off of venous compliance and volume in regards to CVP, not oxyhemaglobin concentration.

 

[AMF]

Because EMS providers know more about medicine than surgeons? (pay no attention to the sarcasm)

In surgery it is not used for shock, it is used for the optimal placement of anatomy as well as things like aiding in the reduction of indirect inginal hernias or to increase vascular volume in the neck and thorax for the placement of invasive catheters.

Trendelenburg as a treatment of shock is based off of venous compliance and volume in regards to CVP, not oxyhemaglobin concentration.

I was indicating that maybe said EMS providers were wrong. So now I really don't know if your "pay no attention to the sarcasm" was sarcastic or not.

But apparently (^) it doesn't matter anyways.

 

[Veneficus]

I was indicating that maybe said EMS providers were wrong. So now I really don't know if your "pay no attention to the sarcasm" was sarcastic or not.

But apparently (^) it doesn't matter anyways.

It looked to me like you were accusing surgeons of using an ineffective practice that EMS providers discovered the truth about.

 

[cw15321]

In Surgery we put people in trendelenburg quite often. I have never witnessed some type of rebound hypotension upon righting them.

I would also like to point out from one of the most widely used EMT texts.

Step 2 of managing shock. "If there is no serious injury," (referring to the spine) "elevate the feet 8-12 inches."

If you read Prehospital Emergency Care, 9th edition by Joseph Mistovich, in Chapter 6 on Lifting and Moving Patients, it does mention that Trendelenburg is no longer a treatment for shock due the fact that it causes abdomen organs to compress the diaphram and increase the pt's difficulty breathing. In addition for pt's with head bleeds it makes the situation worse for them.

 

[usalsfyre]

I'm gonna take a stab here and say the fact that any CHI patient your thinking about trendelenburging likely has no CPP is a FAR, FAR bigger issue than any harmful effects of the position itself...