Re: 8-ball

[Guest guest]

Comments inline...

Mike

----- Original Message -----

From: CBlum26666@...

I assume when talking about

these things (maybe wrongly so), that people on here realize the importance

of pre-hospital 12-leads prior to giving NTG in CP patients.

M> Except that there are still those out there who do not realize the

importance of pre-hospital 12-leads, or teach how to obtain them but not how to

read them. While you and I understand that, there are lots of folks that don't

meet your assumption. And I think we both agree that's not something that helps

paramedicine state-wide.

Acute Coronary Syndromes is still a

relatively new phrase to most people in EMS. I also understand that ACLS is

just a guideline to follow, but it also sets a " standard of care " for us to

follow.

M> I disagree, but semantically. ACLS sets a standard of care for us to

compare our own treatments, protocols and guidelines against considering the

factors our service(s) work with (financial, geographical, experience, service

level (ALS, ILS, BLS, intercept, etc.)).

Changes take place all of the time, and there is always room for

discussion on new ideas. ACLS changes every few years and the newest changes

made in mid 2000 are possibly the most drastic ever.

M> And quite possibly the changes in which the least actual medical

research has been considered prior to. There is considerable discussion

surrounding the financing that went into the recent ACLS changes. That's

another thread for people far more versed in the specifics of cardiology

research than I, though.

I am a

very open minded person and always listen to what people have to say,

however, what was being said by Mike was essentially that time would fix the

problems associated with these patient's illegal drug use, or overdose, and

that we should just let the ER handle it.

M> In the absence of life-threatening complications, this is in fact

true. The patient simply needs to " come down, " and monitoring this process is

often the only component of care given to these patients presenting in the ED

without complication.

He also said that if they were

going die, it's because they would have died anyway.

M> I don't remember saying that. It may have been mis-interpreted. Can

you cut-and-paste what you're referring to?

I dissagree, and

beleive that definitive care begins in the field. If a patient warrants

care, they should receive it. Even if it is " preventive " care to keep them

from developing more serious complications. You can always pick up a phone

and run it by your Doc if you want, and I have rarely had one question my

reasoning when asking to do something that will bennefit the patient.

M> For the first time, I'm in a system that requires such overhead - my

prior experience is mainly in a system with no online medical control and open

protocols. But I'll agree, I've never had my treatment decisions questioned or

denied by my online medical control physician. And we both agree that

definitive care begins in the field. I'm *not* for witholding care, but I am

for evaluating the risk of providing a particular intervention in the

prehospital arena vs the the reward, and understanding if that risk is less in

the ED. For something like intubation, with a clear intention of securing an

airway, the choice is almost always to intubate in the field (airways with a

high degree of difficulty may require additional consideration, including other

treatment options). For something like sedating a " high " cocaine addict with

Valium, in my mind, the benefit in the short term doesn't outweigh the

limitations an ED physician may find himself up against, now dealing with a

patient on two different drugs. Your mileage may vary.

A

short ambulance ride doesn't mean we don't need to treat these patients the

same as someone who would require a longer transport.

M> Sure it does. I've had MANY nursing home (911) patients whom I'm

declined IV attempts on because they present as incredibly hard sticks because

we're only 3-5 minutes from the ER and there is *no immediate need for

life-saving care via IV drugs*. For a longer transport I would most assuredly

have placed a precautionary IV in these patients (the correct thing to do, both

per protocol and for the eventually that the patient gets worse). But knowing I

was close, and knowing that the situation would be more controlled, the better

option for the patient was to have the catheterization performed in the ED.

Bottom line: I have more options for controlling bad outcomes in the short term

than I do managing a crashing patient for a longer term. Time does matter, and

it does influence treatment decisions.

The standard of care

should apply to ALL patients. And by standard of care, I don't mean formulas

in a protocol book, or pages from ACLS, etc. I mean the most appropriate

care for the patient should be rendered according to CURRENT accepted

practices in medicine.

M> Accepted by whom? The only acceptance that *really* matters is what

your medical director accepts. If your medical director decides that NTG is the

worst drug on the planet and you can't carry it, and that Morphine is a useless

drug, how are you going to work your MI patient up to the " standard of care "

provided in ACLS? If you're limited in your system, does that make *you*

responsible for not following the standard of care? Of course not. But

" accepted practices " is a very, very vague, general term that has no real

meaning, because many things in medicine are not accepted by *someone*.

Deviation is a must in some cases, and in those

services where the MD allows his medics to deviate from protocol without

consult, it means we need to know when it is right to do so, and be prepared

to back our thoughts with solid medical reasoning, and that we use proper

judgement.

M> And in those cases where there isn't time to gain consult and

concurrence, a medic must be of sound thought to deviate (correctly) from

protocol in the best interest of the patient on his/her own, within reason

(which varies per medic and per situation). Any medical director worth their

smelling salts will realize that occasion comes when consult just isn't

possible, and the medic *must* be able to appropriately describe, rationalize

and apply treatment and explain it to the medical director afterwards. Another

reason for a solid QA/QI process. An agreement must be had beforehand on what

how much deviation is " allowable " based on circumstances, and what constitutes

outright protocol violation. Often, the standard of care makes the difference,

but it's still ultimately the medical director's opinion that matters. Like I

said earlier, I've never had a decision questioned by my medical director, but I

think it's because I have a different mentality. When I pick up the phone to

call for a consult on treatment, I have already decided that the patient needs

that treatment and understand why. I'm not calling to ask for something, I'm

calling to gain concurrence. To some it may be a difference of words, but I'm

calling because my protocol says " when you get to this point in a decision tree,

you need to call " not " call if you think this treatment might help. " I have

full faith that if for some reason my cell phone and radio went out and I

couldn't ask for something, I would be right to continue with a treatment that

requires authorization. Now, I might very well find myself in a QA review, but

if you (the medic) have done the right thing, and adhered to your standard of

care (as provided by your protocols), what do you really have to fear? We must

get past the idea that QA/QI is a punitive process and come to understand that

in many cases it may be the only way for management and medical directors to

understand many of the nuances that field care provides.

Mike

[Guest guest]

What research backs up this claim? Please cite specific studies from medical

journals or texts. I'm not saying you're wrong, I'd just like proof.

What I've been able to find is this

(http://medicine.ucsf.edu/housestaff/handbook/toxicology.shtml):

1. ABCs, vital signs and ECG monitor.

2. For tachyarrhythmias, give ß-blocker (propranolol 0.5-3 mg iv, may repeat

after 5-10 min, or esmolol 500 mcg/kg i.v. loading dose, then 50-100 mcg/kg/min)

3. For HTN, give ß-blocker plus phentolamine (to prevent paradoxic HTN via ß2

blockade) 1-5 mg iv bolus, may repeat in 5-10 min or as drip at 0.1-2 mg/min;

aim for DBP<100-110.

4. For agitation and psychosis, use Haldol, chlorpromazine, or droperidol prn

5. For seizures, give diazepam (0.1-0.2 mg/kg iv q10-15 min for a total of 30

mg), but if status epilepticus, consider other causes such as continued drug

absorption from broken bag of cocaine in GI tract

6. Decontamination via gastric lavage, charcoal and cathartic if indicated.

Mike

Re: 8-ball

The use of benzodiazepines in tachycardia associated with cocaine

intoxication is not new science. It has been proven time and again

[Guest guest]

not at all ,that's how we all learn

Christy

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

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >