Pulling the plug on EMS

[medicRob]

Jonny Rocket? I thought it was Sue Maple

Shh.. that is my drag name.

 

[JPINFV]

You don't have to call me killer, I prefer my porn name, "Johnny Rocket" !

Fine then, I'll settle for 3.

Johnny Rocket? Maybe Johnny Bottle Rocket...

 

[medicRob]

Johnny Rocket? Maybe Johnny Bottle Rocket...

If I wasn't so entertained by that comment, I might strike you.

 

[18G]

WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA. If anything typed sounds like the scribblings of a crazy person, that is why.

This entire thread has made me lol. Nothing but two sides setting up strawman after strawman against each other.

"I think Narcan is silly." "Well then maybe we should take away every drug!" "I bet you're the kind of paramedic who immobilizes everybody!" "So you're saying we should just be a taxi service?"

Quite frankly the entire thing has been nauseating. Both sides have valid points, but then again both sides have said some incredibly ludicrous things.

Firstly, just because a treatment isn't NECESSARY does not mean that it is not BENEFICIAL. If I had the choice of administering Narcan and allowing a patient to regulate their own ventilatory status or shove a tube down their nose or throat and force air into their lungs with a bag, I would choose the Narcan every time. Not because it's easier for me, but because it's better for the patient.

On the other hand, if a little old lady slips out of her chair, lands on her butt, lays down, and is not exhibiting ANY signs of potential spinal compromise (i.e. NEXUS criteria), and I have the choice of immobilizing her and protecting myself from lawsuit but risking negative effects such as pressure sores or hyperextension of the cervical spine or saying "forget the board", I will "forget the board" every time. Not because it's easier for me, but because it's better for the patient.

Sometimes less is more, and sometimes more is more. It takes clinical judgment to determine which is which. Personally, I want every cool toy in the book. I want RSI meds, I want video laryngoscopy, I want blood products, I want pre-hospital thrombolytics for MIs, I want everything! I want to start definitive care in the field, because it's better for the patient!

Are bronchodilators really necessary pre-hospital? No. But does receiving Albuterol on scene and en route rather than 15 minutes later at the hospital provide the patient with relief faster? Isn't that better for the patient?

What about CPAP? Is it really necessary pre-hospital? The part of me that's a patient advocate says yes, but an argument could be made for the opposite. That one patient on the verge of respiratory distress that breaths easier because I put that mask on his face and doesn't need to be intubated and spend days or weeks in the ICU, but instead walks out of the ED 10 hours later makes me say that CPAP in the pre-hospital environment is absolutely necessary.

Or the patient with chest pain who goes directly to the cath lab because a pre-hospital 12-lead not only DIAGNOSED a myocardial infarction, but LOCALIZED it.

Now take that same chest pain patient. Let's say the 12-lead DOESN'T diagnose an MI. Would you proceed with treatment or would you dig a little deeper and perform, say, a 15-lead? If you went with the 15-lead, you might find a right ventricular infarction, in which case you would have to be VERY careful with that Nitroglycerin. Or you may find a posterior wall MI and thus have prevented an MI from being missed (and don't give me that non-sense about ST depression in the anteroseptal leads, because that only occurs in 8% of posterior MIs). If you said you would just proceed with treatment and subsequently miss the RVI, you could very well kill your patient. This would not only hurt the very person you're supposed to be protecting, but you allow people to argue that pre-hospital Nitroglycerin is detrimental and is a practice that should be ceased (I jest).

Like I said, both sides make valid points, but both sides also make some ridiculous statements and just like with most matters with two opposing views, the truth lies somewhere in the middle. My attitude is that paramedics should be permitted a LOT more treatments and procedures than they are currently, but I realize that entails more responsibility and better clinical judgment is therefore necessary.

If you don't possess the clinical judgment necessary to make these kinds of decisions, I hear Wal-Mart is hiring.

Very well said...

 

[systemet]

WARNING: The following post was authored by an extremely sleep-deprived EMTinNEPA. If anything typed sounds like the scribblings of a crazy person, that is why.

Just wanted to address a couple of things you said. Nothing personal. I totally understand sleep deprivation.

On the other hand, if a little old lady slips out of her chair, lands on her butt, lays down, and is not exhibiting ANY signs of potential spinal compromise (i.e. NEXUS criteria), and I have the choice of immobilizing her and protecting myself from lawsuit but risking negative effects such as pressure sores or hyperextension of the cervical spine or saying "forget the board", I will "forget the board" every time. Not because it's easier for me, but because it's better for the patient.

The other major c-spine rule out protocol, the "Canadian C-spine protocol", include age of >65 years old as an exclusion criteria, so while age may not be part of NEXUS, it is commonly used in some places.

Are bronchodilators really necessary pre-hospital? No. But does receiving Albuterol on scene and en route rather than 15 minutes later at the hospital provide the patient with relief faster? Isn't that better for the patient?

This is actually one thing that does have some evidence to support it. You've probably heard about the OPALS study in Canada, where the system in Ontario (pop. ~ 12 million) moved from a primarily BLS system into an ALS system, and studied the outcome changes as they went. This is commonly cited as evidence for ALS procedures having no added benefit in cardiac arrest, and as one of the many studies suggesting an association between ALS care and increased mortality in trauma.

One of the subgroups looked at the benefit of prehospital treatment of dyspnea, using the available modalities at the time. Many of these are now a little out of favour, like lasix and morphine in acute pulmonary edema. But they did show a significant survival benefit with ALS (even though a small percentage of patients in the BLS cohort were already being treated with ventolin). Citation is:

Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, Dreyer J, Toohey LL, Campeau T, Dagnone E, Lyver M, Wells GA; OPALS Study Group.
Advanced life support for out-of-hospital respiratory distress. N Engl J Med. 2007 May 24;356(21):2156-64.

This is available as a free .pdf, if you go here:

http://www.nejm.org/doi/full/10.1056/NEJMoa060334

Or the patient with chest pain who goes directly to the cath lab because a pre-hospital 12-lead not only DIAGNOSED a myocardial infarction, but LOCALIZED it.

Perhaps I'm missing something here, but when I was working ALS, if the patient had a STEMI, it was either prehospital thrombolysis or enoxaparin + plavix, direct to cathlab.

While localisation was important in terms of identifying right ventricular infarction, it seemed like the cardiologists decision as to thrombolysis vs. PCI usually came down to the timely availability of facilities, presence of higher risk for ICH (e.g. advanced age), and cardiogenic shock, versus anatomic localisation. You could argue that identifying a left main occlusion could alter the balance of these factors. But beyond changing treatment for RVI, localisation was less important for us.

Now take that same chest pain patient. Let's say the 12-lead DOESN'T diagnose an MI. Would you proceed with treatment or would you dig a little deeper and perform, say, a 15-lead? If you went with the 15-lead, you might find a right ventricular infarction, in which case you would have to be VERY careful with that Nitroglycerin.

Absolutely. I'd withhold it unless IV nitro was available. And even if it was, the priority would be to toss in a liter of fluid and get reperfusion therapy started.

Or you may find a posterior wall MI and thus have prevented an MI from being missed (and don't give me that non-sense about ST depression in the anteroseptal leads, because that only occurs in 8% of posterior MIs).

I absolutely agree that an educated provider should perform a 15-lead if there strong suspicion of ACS. But I think your number for the incidence of ST depression in posterior wall MI might be inaccurate.

When you say 8%, this is pretty close to the number of isolated posterior wall MIs (Brady). ST depression is present in ~80% of inferior wall MIs (Brady), and a fair percentage of both inferior wall (RCA) and lateral wall (LCX) MIs have extension into the posterior wall. PWMI is thought to
complicate as many as 20% of all MIs.

The problem, as I understand it, is not that ST depression rarely happens with PWMI, more than many other things can cause anterior ST depression, e.g. reciprocal changes in inferior wall MI.

[Just in case anyone is wondering about isolated RVI, the incidence is around 2% (Porter et al.)]

Anyway, I absolutely agree that 15-lead ECG is a valuable and much underused tool. I think I also need some sleep -- before I do that, my intent here is to provide extra information for anyone who's interested, not to criticise your post, which I mostly agree with.







Porter A, Herz I, Strasberg B. Isolated right ventricular infarction presenting as anterior wall myocardial infarction on echocardiography. Clin Cardiol (1997) 20, 971-973 --- read here http://onlinelibrary.wiley.com/doi/10.1002/clc.4960201115/pdf

Brady WJ. Acute posterior wall myocardial infarction: electrocardiographic manifestations. Am J Emerg Med (1998) 16:409-413