Re: 8-ball

[Guest guest]

OUCH, CHARLES!!!

I've got to jump in here and say something about professionalism.

Professionalism involves having an open mind and the curiosity to explore

other ideas. While I teach ACLS, know ACLS, and understand it, it is also

true that ACLS is only a guideline. It can be a mistake to rigidly follow

ACLS protocols. Knowledge is a moveable feast. What I know today won't be

exactly what I know tomorrow. But if I don't listen to what others say and

consider their thoughts and ideas, I'll never make progress. So it is in

science. The questioning mind is the one that finds the answers, and they're

not always in the " recipes " we have been following.

So let's please be tolerant of the ideas and thoughts of others. We might

actually learn new things. Be grateful when others challenge your ideas.

They're doing you the ultimate favor. And don't hesitate to challenge the

ideas of others but be kind, please. We all want to do our best here, and

hopefully we'll all learn lots from the experience of going back and forth

with each other. There's no need to put anyone down. Be as sharp as you

want, probe and demand justification for positions taken, but keep an open

mind. Things are not always what the seem.

Gene

In a message dated 3/3/2001 17:37:22 Central Standard Time,

CBlum26666@... writes:

> Subj: Re: 8-ball

> Date: 3/3/2001 17:37:22 Central Standard Time

> From: CBlum26666@...

> Reply-to: <A

HREF= " mailto: " > </A>

> To:

>

>

>

>

> I am glad to hear that at least one person on here knows the correct way to

> manage these patients. I have seen alot of nothing but absurd comments and

> statements by people who " think " they know what they are talking about, but

> the fact remains what ACLS teaches regarding these " special situations " is

> the correct way to manage these patients. Thanks to Petty, EMT-P,

> ACLS-I for being the true professional in the bunch. As for Mike. I don't

> know you, but for an LP, you are pretty lacking in the basic knowledge you

> need to be familiar with regarding toxicological emergencies. I suggest

> you

> read up.

>

> Blum, EMT-P

>

>

>

>

[Guest guest]

Dr. Bledsoe has put it better than I ever could. Hence my admonitions about

rigid adherence to " protocols. "

To do something to a patient to " teach her a lesson " or " punish him " for

calling us out in the middle of the night is beneath contempt, and it shows a

failure of character in the medic who would do so.

No matter how bizarre the behaviour of the patient has been, no matter how

offensive to us, no matter how disruptive of our routines, the fact remains

that THEY ARE PATIENTS! Not CLIENTS, as the nurses have come to say,

PATIENTS. The definition of PATIENT is one who is awaiting or under medical

care and treatment. Medical care does not involve punishment nor lesson

teaching. It involves CARE and HEALING. Care implies knowledge of the

conditions requiring care. Care requires compassion. Knowledge plus

compassion may equal care, under the right circumstances.

Those who ridicule patients who overdose or commit other self-destructive

acts for " attention " are ignorant of science and medicine. Until you've been

in the mind of a depressed patient, you can't understand the pain that can

push one to consider suicide as an answer. Unless you've heard the

unrelenting voices that torment you, you can't understand the motivations of

the schizophrenic. Most of us, happily, won't be able to experience those

feelings, but if we can't emphathize with those patients and approach them as

friends and helpers, then we have no place in medicine.

As 21st Century Paramedics, we must progress past the constraints of the

past. We must become true professionals. That requires us all to

continually learn, relearn, practice, and readjust to the improvements in

understanding and education that are available to us.

Once a Red Patch, Always a Red Patch, has no more validity than once an ER

physician, always an ER physician has. Board certified ACEP or AAEMP doctors

still have to recertify and constantly learn and relearn their craft.

All professionals must continually learn and update their knowledge and

skills. So must we.

Gene

E. Gandy, JD, LP

EMS Professions Program

Tyler Junior College

Tyler, TX

[Guest guest]

Please forgive the origial post. and My comment on Narcan. I was kidding at

the time and was requesting treatment methods. I got a few and for those

thank you. Our transport time is 25 to 40 minutes bepending on traffic, to

the nearest hospital fit to handle the pt. during which we may or may not

have access to a PD or SO officer. To those who decided to turn on each

other. Grow UP! This list is for education purposes. So when a question is

asked don't trash other opionions. If you don't agree give your opinion and

show that your is better. When I went to school they called that research

data.

Thanks,

CLinton Browning

Lockhart Fire / Rescue

[Guest guest]

" If the blood pressure is sufficient " Ouch. Had a guy in our ED the other

night with a BP of 142/90 with CP (a sufficient BP in my book). Thank god

the ER doc noted the ST depression and wanted a right sided 12-lead. Good

thing too, the guy was having a right sided MI. Be careful with the

sufficient BP thing. If the diastolic is high, they might be maintaining

through afterload only. You dump the afterload with ntg and you gots a dead

patient.

Interesting side note, patient with CP whose pain radiates to the right

shoulder/arm seem to have a higher morbidity rate than those with pain

radiating to the left shoulder/arm. Any idea why? (I had to leave due to a

call at that point and never got an answer)

Webb, LP

_________________________________________________________________

Get your FREE download of MSN Explorer at http://explorer.msn.com

[Guest guest]

Sigh. Again I presuppose a certain level of assumed understanding. So,

again, let me clarify.

A certain percentage of inferior-wall MI patients will also be having a

RVMI. These patients are at risk for developing significant hypotension.

The definitive prehospital treatment for these patients is judicious fluid

loading (500mL or so) providing the lung sounds are clear. Some warning

signs that a patient is having a RVMI include jugular venous distension and

varying degrees of hypotension associated with the chest pain. Obviously,

if the patient is hypotensive or even normotensive and the clinical

indicators of RVMI are present, then sublingual NTG should not be given.

Intravenous NTG is another story, although generally not in the prehospital

field.

However, RVMI may also be present as part of a larger inferior LVMI or

anterior MI. These patients may benefit from the NTG, again, if the BP is

sufficient. We routinely use 12-lead EKG including V4R if RVMI is

suspected. When I revised our system protocols in 99, we had a big

controversy about the use of NTG. I was against allowing basics to

administer NTG because of this very issue (I was overruled). I much prefer

the initiation of IV lines prior to NTG being administered.

I would agree that in the instance of isolated RVMI, with the patient

presenting as hypotensive or normotensive, that the administration of any

vasodilator without adequate fluid loading is contraindicated. I do not

agree with the blanket statement that NTG is universally contraindicated in

RVMI.

Petty, EMT-P

Re: 8-ball

> To clarify myself to Christy & , ..... why else would you use Narcan

except if extreme conditions are present?? I did not mean to imply so, if I

did. And as for RVMI not being a contraindication for NTG, you are wrong.

If you give NTG, or Morphine, you will most likely kill the patient, unless

you FLUID LOAD the patient, sometimes with several liters of fluid, before

administering the drug. It takes out what little ability the heart has left

to maintain it's own pressure. RVMI is highly understood by most, and is

very touchy. The definitive treatment for RVMI in the pre-hospital setting

is fluid, and lots of it, unless they present in failure (CHF). Careful

monitoring will not help as the effect is almost instantaneous....the blood

pressure will cease to exist. The only thing you can hope for is that if

you do give it with findings of RVMI, is that it is in fact actually

Prinzmetal's Angina. If it is, it can present with findings on the 12-lead

that mimic an RVMI!

> , but without the side effects i

> f NTG or MS is administered. Any finding indicating possible Inferior MI

should be suspect for RVMI, and V4R should be checked to confirm before NTG

or MS administration. Hence, why this is such a big topic right now with

basics and intermediates giving NTG. The current school of thought is

swinging towards teaching them to read a 12lead so they can rule it out

before they give NTG.

>

> Blum, EMT-P

>

>

>

>

[Guest guest]

This is my last response to ........as others have said much of what I

already wanted to say. I worked with a cardiology group for quite a while,

and have extensive experience in the hospital setting dealing with cardiac

patients........not to mention my field experience. Every case of RVMI I

have seen....and I do mean EVERY.....the physicians and the consulting

cardiologists firmly stood by the decision not to give NTG or MS to treat the

MI.......even in normotensive and hypertensive patients. They continued to

withhold NTG, IV and PO, and rather opted to go to the cath

lab............the risk is too great. Today I called one of the

cardiologists that I use to work with......he is one of the most experienced

interventional cardiologist in this area, and he confirmed what i already

said. He stated that you should fluid load with at least 2 liters of NS

prior to any attempt to give NTG or MS in RVMI, and sometimes may have to

give in excess of 4 or 5 liters.......the management in these patients is to

maintain fluid volume.....Dopamine, Epi, and Levophed usually don't work for

these patients when hypotensive, and once again, fluid is the key. Of

course, you must monitor these patients for overload. You give NTG or MS,

you remove any compensatory support that the patient has, and hey.....you

have a dead patient.

Several services here in TX are carying Tridil on the rigs as well, hence IV

NTG is being used in the field.

And this is also a little politically incorrect, but I don't see why a

paramedic who has less than a year of certification has any business being

allowed to revise their EMS protocols....they lack the knowledge and

experience to make valid judgements. Not that I think you are stupid or

anything, just stating my opinion in general. I wouldn't feel comfortable

with anyone with that little experience at patch level re-writing protocols

for my system....not even myself (if I were that new).

Until Later,

Blum, EMT-P

[Guest guest]

Way to go . Does anybody remember a young gentleman by the name of

Len Bias. Cocaine is a patent vasoconstrictor. Pts can die of an acute MI

that is no more than a coronary artery spasm. If you recall your coronary

anatomy, you only have three main coronary arteries. If a spasm occurs in

your left main, you are toast, because it supplies two of your coronaries

with blood flow, thereby eliminating blood flow to 2/3 of your heart muscle.

If your Right coronary artery spasms, you have a high likelihood of going

into a life threatening arrhythmia, as the Right coronary artery supplies

oxygenated blood to the electrical system of your heart. (SA node, AV node,

Bundle of HIS)

So if any of you guys out there do not want to give ntg for your cocaine

induced chest pain with a viable blood pressure... go ahead.

btw, one of the cardiologists I work with is also a plaintiff's lawyer, look

out for him!

Rodney Fuller, LP, CVT, ACLS coordinator

Baylor University Medical Center

Dallas, TX

[Guest guest]

Christy,

I hope I didn't anger you by asking. It's just the only way I've found of

learning. If I don't ask, then I never learn! Thanks for the explanation,

though.

Take care and go safely!

Jana

Re: 8-ball

> > >

> > >

> > > > Current street value about $200 - $350. What other than the obvious

> > ABC's

> > > do

> > > > you do for that. Is there enough Narcan on the truck or do you

devirt

> to

> > > the

> > > > morgue?

> > > >

> > > > Clinton Browning

> > > > Lockhart Fire / Rescue

> > > >

> > > >

> > > >

> > > >

> > > >

[Guest guest]

Mike:

While I agree with you that we shouldn't automatically treat something just

because we can, you must remember that discussion of how it should be done

is important because sometimes the patient is bad enough that we must

intervene. I have dealt with numerous cocaine and other stimulant drugs in

my career and, while most were managed well by TLC and basic support, a few

were suffering from what has been described as sympathomimetic toxic

syndrome, which does often require field intervention. This is where the

stimulus effect is so severe that it causes lifethreatening bodily

responses. You are correct that there is no drug (that I know of) that fully

antagonizes cocaine. There is no narcan for coke or crack. However, we have

a host of drugs on board our ambulances that do functionally antagonize some

of the specific adverse effects this drug causes in severe ODs If any of

those effects are lifethreatening or moving in that direction, we have to

act and we have to know how to act. In addition, you are also correct that

the toxicology texts don't cover specific treatment of mixtures of drugs.

This is where being street-saavy enough to know what the common mixtures

(and their street names) are, having a good knowledge of basic

pharmacodynamics and human physiology, and haveing good critical thinking

skills come in. You have to reason out what aspects of mixed drugs are

antagonistic to each other and what are additive or synergistic, and then

treat accordingly if the patient's overall condition warrants it. Judgement

and understanding is the key. It is good that the folks on here are debating

treatment options. Some of them will need to use those options sooner or

later. Your recommendations of restraint are also good since we should try

to avoid overtreating, if possible.

Those are just my 2 sesterces

Dave

Re: 8-ball

>

>

> I am glad to hear that at least one person on here knows the correct way

to

> manage these patients. I have seen alot of nothing but absurd comments

and

> statements by people who " think " they know what they are talking about,

but

> the fact remains what ACLS teaches regarding these " special situations "

is

> the correct way to manage these patients. Thanks to Petty,

EMT-P,

> ACLS-I for being the true professional in the bunch. As for Mike. I

don't

> know you, but for an LP, you are pretty lacking in the basic knowledge

you

> need to be familiar with regarding toxicological emergencies. I suggest

you

> read up.

>

> Blum, EMT-P

>

>

>

>

[Guest guest]

Gene & Co.

I think you hit a critical point right on the head. While someone is a

patient, its all about healing and helping. Only after a person ceases to be

a patient should society ask for punishment and retribution. Our role is in

the first realm. It is someone else's charge to hand the P & R part. I know A

LOT of medics out there have at one time, or still routinely do, carry out

some procedures in a way that is meant to be as unpleasant as possible to

" show " the patient the price for his or her behavior. In my younger, more

stupid days, I did it myself. Eventually, wisdom replaces youthful excess

and one begins to look at the world through more reasoned, mature eyes.

Black and white blur into countless shades of grey and you begin to realize

you don't have enough of the big picture to pass judgement on the other guy.

That is why we have codes of conduct and oaths to follow, to help us keep to

our professionalism when our ability to see the shades of grey is

temporarily lost and we revert to black and white vision again. We need to

take stock of why we do things the way we do. Ask yourself these questions:

Do you start IVs with large bore needles on rude patients or patients whose

behavior you don't like when a small-bore would do just as well or where an

IV is purely elective?

Do you drop NG tubes on OD patients as much for retribution as for the

purpose of evacuating their stomachs? (the staffs of some overburdened

county hospitals oughta ask themselves this one, too)

Do you use narcotic antagonists to excess and relish the agony of withdrawl

the patient then suffers? (if you do, has a job for you, the duties of

which he has already described)

Do you speak in a disdainful or disrespectful manner to the patient who is

found soaked with cheap hootch (and other even worse liquids) under a

bridge, somehow seeing him as a lesser being. Do you treat him roughly or go

out of your way to insult what little dignity he may have left to punish him

for allowing himself to decline to this state?

Do you speak harshly to the attempted suicide patient, maybe even suggesting

better ways to " do it right next time? " (If you do, I suggest you get on one

of those pre-paid legal plans, you're eventually going to need it)

Do you quietly look the other way while your partner or other medics in your

service treat patients in any of the ways I have mentioned above, figuring

it is none of your business how other medics do things?

If you answered yes to any of these and are fairly new at this profession.

It's time to grow up and realize that this isn't the way to do it. If your

an old salt and you still think this is appropriate behavior for a medic,

it's time for you to go...far, far away.

I do hereby endeth the rant

Dave

Re: 8-ball

> Dr. Bledsoe has put it better than I ever could. Hence my admonitions

about

> rigid adherence to " protocols. "

>

> To do something to a patient to " teach her a lesson " or " punish him " for

> calling us out in the middle of the night is beneath contempt, and it

shows a

> failure of character in the medic who would do so.

>

> No matter how bizarre the behaviour of the patient has been, no matter how

> offensive to us, no matter how disruptive of our routines, the fact

remains

> that THEY ARE PATIENTS! Not CLIENTS, as the nurses have come to say,

> PATIENTS. The definition of PATIENT is one who is awaiting or under

medical

> care and treatment. Medical care does not involve punishment nor lesson

> teaching. It involves CARE and HEALING. Care implies knowledge of the

> conditions requiring care. Care requires compassion. Knowledge plus

> compassion may equal care, under the right circumstances.

>

> Those who ridicule patients who overdose or commit other self-destructive

> acts for " attention " are ignorant of science and medicine. Until you've

been

> in the mind of a depressed patient, you can't understand the pain that can

> push one to consider suicide as an answer. Unless you've heard the

> unrelenting voices that torment you, you can't understand the motivations

of

> the schizophrenic. Most of us, happily, won't be able to experience those

> feelings, but if we can't emphathize with those patients and approach them

as

> friends and helpers, then we have no place in medicine.

>

> As 21st Century Paramedics, we must progress past the constraints of the

> past. We must become true professionals. That requires us all to

> continually learn, relearn, practice, and readjust to the improvements in

> understanding and education that are available to us.

>

> Once a Red Patch, Always a Red Patch, has no more validity than once an ER

> physician, always an ER physician has. Board certified ACEP or AAEMP

doctors

> still have to recertify and constantly learn and relearn their craft.

>

> All professionals must continually learn and update their knowledge and

> skills. So must we.

>

> Gene

> E. Gandy, JD, LP

> EMS Professions Program

> Tyler Junior College

> Tyler, TX

>

>

>