What are you allowed to do?

Veneficus said:
Patient is part of modern society?
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AND has good health insurance or a large bank account....


I was under the impression that there was only a benefit to plavix in the highest risk group of patients, and that troponins were needed to determine that risk stratification. Has it become common practice to hand it out more liberally?
 
MrBrown said:
Sorry mate, Brown forget to mention it takes four years to become a Paramedic here and six or seven to become an Intensive Care Paramedic.

No disrespect intended.
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So, does that mean the pay is decent, if you don't mind me asking?
 
jrm818 said:
AND has good health insurance or a large bank account....


I was under the impression that there was only a benefit to plavix in the highest risk group of patients, and that troponins were needed to determine that risk stratification. Has it become common practice to hand it out more liberally?
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Given the rate at which it is prescribed and the amount of self referral I see among cardiologists for a prescription, I can't imagine that it wasn't always handed out rather liberally.
 
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Veneficus said:
Given the rate at which it is prescribed and the amount of self referral I see among cardiologists for a prescription, I can't imagine that it wasn't always handed out rather liberally.
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It is one of the top selling drugs in the US, so I suppose that I shouldn't really be surprised. Of course I really have no real exposure to this medication other than the small bit that I've read, but what I've seen doesn't seem to me to demonstrate enough benefit to make this a "super drug." I'm sure marketing has nothing to do with it of course.....

I don't know really anything about long term prophylaxis (which I imagine is a lot of what you see), but in terms of acute administration for ACS, I was pretty sure that only a rather limited cohort of patients would benefit.

I just looked at the big CURE trial published in the NEJM, and I did misremember the criteria for inclusion, expanding a bit the population in which some benefit may have been demonstrated.

I had remembered that in addition to ECG changes there must be elevated troponin for inclusion (thus my surprise that it was being given prehospitally, when troponin presumably could not be determined), but it turns out that the presence of either was sufficient. I'm still curious about the criteria Brownland ambulances are using.

Apparently with a less rigorous screening scheme only harm was found. I didn't think there had been a subsequent expansion of the population in which benefit was found, but I wouldn't be at all surprised to be proven wrong.


Is anyone else giving plavix in the prehospital arena?
 
over in ireland we have no med control.
i have my own licence to practice which currently sits at emt level.
and i can decide what route of care i need to take, we have clinical practice guidelines to follow set out by our national ems regulator.

i can admin 10 drugs (oxygen, salbutamol, asprin, gtn, glucose gel, glucogon im, entanox, paracetamol, epi pens) and then since were trianed to do i.m injections a doctor or someone higher qualified then us e.g paramedic or advanced paramedic can tell us to admin any other i.m drug.

I can do 3 lead ecg monitoring and rythm recognition, semi auto defib and all the usual bls stuff like bvm's and opa's. etc
emergency child birth and neonatal resus/care,
then the usual things like spinal immoblisation, wound care and fracture care etc etc
we also do an emergency driving standard course, a radio opperations course and mass casuality training using the triage sort using cruciforms or coloured tape.

thats all i can think of off the top of my head, the rest that i cant think of is stuff we'd never realisticially use.
 
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jrm818 said:
Is anyone else giving plavix in the prehospital arena?
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Yes. Several counties in Washington State have now added Plavix (along with Heparin, Nitro drips and Tenecteplase) to the STEMI protocol.
 
Pittma said:
So, does that mean the pay is decent, if you don't mind me asking?
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Nah the pay is not that good .... $50k NZ for a Paramedic and $60k for an Intensive Care Paramedic is about right .... tax is 21.9c on the dolllar
 
n7lxi said:
Yes. Several counties in Washington State have now added Plavix (along with Heparin, Nitro drips and Tenecteplase) to the STEMI protocol.
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Interesting. If you happen to know, are these mostly outlying areas with extremly long time to ED? Are they transporting direct to PCI capable facilities?

I guess maybe I need to do some more plavix reading...
 
jrm818 said:
Interesting. If you happen to know, are these mostly outlying areas with extremly long time to ED? Are they transporting direct to PCI capable facilities?

I guess maybe I need to do some more plavix reading...
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Yes. One agency I work for has a routine transport time of at least 45 minutes to a cath lab. Here, after a consult with OLMC, we can open the "Stemi Kit" and get at all of the above mentioned items. I was hoping I could find a copy of the protocols online to post here... but no luck yet.
 
usalsfyre said:
Considering most of my past experinces with narcan, I disagree with how "freaking sweet" administering it is...
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Ironic as I was thinking the same exact thing. I was even talking to a medic recently who starts pushing at just 0.4 to avoid vagal stimulation affecting the puke reflex, if still no luck, 1mg thereafter. One of the smartest things I heard in a while.
 
Jay said:
pushing at just 0.4 to avoid vagal stimulation affecting the puke reflex,
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Errr.... what?


It's more to prevent the sudden and violent withdrawal symptoms, such as seizures and combativeness.
 
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I haven't used narcan in literally years. Part of it is the area (more meth and mixed ODs rather than just straight narcotics) and some of it is the nasitness associated with Narcan. Most of the time an NPA, a little suction, some O2 and the occasional gentle stimulation to breathe is all that's needed. No puking, combativness, seizures, pulmonary edema, ect with this method.
 
usalsfyre said:
I haven't used narcan in literally years. Part of it is the area (more meth and mixed ODs rather than just straight narcotics) and some of it is the nasitness associated with Narcan. Most of the time an NPA, a little suction, some O2 and the occasional gentle stimulation to breathe is all that's needed. No puking, combativness, seizures, pulmonary edema, ect with this method.
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Do we have much PCP out here too, or is that more of a Dallas thing?
 
Linuss said:
Do we have much PCP out here too, or is that more of a Dallas thing?
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You see a smidgen of it in the area your going to but it's really spillover from the metroplex. East Texas is mostly meth, crack, benzos, "hillbilly heroin" (perscription opiates) and good old fashioned ethyl alcohol.
 
usalsfyre said:
You see a smidgen of it in the area your going to but it's really spillover from the metroplex. East Texas is mostly meth, crack, benzos, "hillbilly heroin" (perscription opiates) and good old fashioned ethyl alcohol.
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Funny, here in W. TX we have all of that except meth... Lots and lots of Benzo ODs though.
 
We carry naloxone but Brown would not say its popular per-se and has never seen it used.

In Browns mind there is more benefit in focusing on adequate support of oxygenation and circulation rather than waking people up, having them spew up on you and then have a seizure.

Perhaps naloxone is the next frusemide?
 
pushing just enough narcan is freaking sweet...just enough to bring back respitory function. I think breathing is freaking sweet. Anything more than that, narcan isn't needed.
 
MrBrown said:
Perhaps naloxone is the next frusemide?
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Nah, it will stick around. Medics can titrate to get respiration back without waking pts up, and I don't think I'm the biggest fan of leaving someone in respiratory arrest just to avoid waking them. Sure, you can breathe for them, but I feel like that's just bad medicine.
 
We give Narcan by the bucket full. We don't see any meth, mostly heroin, crack and alcohol.
 
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