Guest guest Posted April 20, 2004 Report Share Posted April 20, 2004 , You are not trashing the list. CCT issues are extremely important. I realize that there are many medics who cannot see themselves in the role of a CCT medic, but here in the wilds of West Texas we do transfers all the time with patients on vents, pumps with multiple drips running, and so forth. We do NOT do critical neonatal transports nor would we even think of doing a balloon pump transfer. There IS a role for the critical care nurse in that setting, but most of the transfers can be done by medics with advanced training and experience. It would be a great waste of resources to send a CCRN on these. Some time ago I wrote a series of posts on the EMS of the future in which I predicted that EMTs and EMT-Is with enhanced skills (Paramedic Junior) would be used more and more in urban settings where advanced pharmacology and cardiac skills are seldom used. And I'm not talking about Codes. I'm talking about the cardiac patient like this one I had yesterday. Elderly patient with CP and SOB x 20 hours, post 3 previous MIs and post right carotid endarterectomy two weeks. Has a DDDRD pacer. Patient is in a wide complex (188 ms) sinus tach at 120 and no pacer spikes visible. There is ST elevation in II and III, and big time ST elevation in MCL1 and 2. Right MCL leads 3-6 show large ST elevation also. He has a LBBB and left axis deviation. Guy's blood pressure is 90/68 and he has fine crackles at the bases posteriorly. He also looks very, very dehydrated. He's on furosemide and says he has been urinating 15 times a day for the past several days. His skin turgor looks like a prune. Even on his forehead. He describes the pain as intense. Problem: Possible MI with right ventricular involvement so use NTG with caution, but what to do about the pain? Wet lungs but dehydrated. 40 minute transport. What to do? We did a Spectral 3 way test (Troponin I, CKMB, myoglobin), started a Tridil drip, gave a 500 ml fluid bolus, and MS 2 mg. . BP came up to 100, pain went away, and things got better. Rate came down, pacer started working again, breathing got better. That's routine for us. That's not exactly a CCT type thing, but it's the sort of thing we deal with all the time. If I worked in Abilene rather than Albany, I would probably never do any of those things because txp time to hospital is 4-5 minutes from anywhere. So there's a place for advanced training and knowledge, but it's not everywhere. In my evaluation of the situation, I suggested that a few well-trained and well educated medics be deployed as needed, but not routinely. That's where I see the big cities going. Rural will go the other way. Agree? Disagree? GG Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 20, 2004 Report Share Posted April 20, 2004 , You are not trashing the list. CCT issues are extremely important. I realize that there are many medics who cannot see themselves in the role of a CCT medic, but here in the wilds of West Texas we do transfers all the time with patients on vents, pumps with multiple drips running, and so forth. We do NOT do critical neonatal transports nor would we even think of doing a balloon pump transfer. There IS a role for the critical care nurse in that setting, but most of the transfers can be done by medics with advanced training and experience. It would be a great waste of resources to send a CCRN on these. Some time ago I wrote a series of posts on the EMS of the future in which I predicted that EMTs and EMT-Is with enhanced skills (Paramedic Junior) would be used more and more in urban settings where advanced pharmacology and cardiac skills are seldom used. And I'm not talking about Codes. I'm talking about the cardiac patient like this one I had yesterday. Elderly patient with CP and SOB x 20 hours, post 3 previous MIs and post right carotid endarterectomy two weeks. Has a DDDRD pacer. Patient is in a wide complex (188 ms) sinus tach at 120 and no pacer spikes visible. There is ST elevation in II and III, and big time ST elevation in MCL1 and 2. Right MCL leads 3-6 show large ST elevation also. He has a LBBB and left axis deviation. Guy's blood pressure is 90/68 and he has fine crackles at the bases posteriorly. He also looks very, very dehydrated. He's on furosemide and says he has been urinating 15 times a day for the past several days. His skin turgor looks like a prune. Even on his forehead. He describes the pain as intense. Problem: Possible MI with right ventricular involvement so use NTG with caution, but what to do about the pain? Wet lungs but dehydrated. 40 minute transport. What to do? We did a Spectral 3 way test (Troponin I, CKMB, myoglobin), started a Tridil drip, gave a 500 ml fluid bolus, and MS 2 mg. . BP came up to 100, pain went away, and things got better. Rate came down, pacer started working again, breathing got better. That's routine for us. That's not exactly a CCT type thing, but it's the sort of thing we deal with all the time. If I worked in Abilene rather than Albany, I would probably never do any of those things because txp time to hospital is 4-5 minutes from anywhere. So there's a place for advanced training and knowledge, but it's not everywhere. In my evaluation of the situation, I suggested that a few well-trained and well educated medics be deployed as needed, but not routinely. That's where I see the big cities going. Rural will go the other way. Agree? Disagree? GG Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 21, 2004 Report Share Posted April 21, 2004 I asked about that particular portion of their website a while ago and was told it was obsolete and was never removed from their website. Jim B. , LP Baylor Regional Medical Center at Grapevine EMS Educator Baylor EMS Medical Control 400 N. Main St. #104 Grapevine, Tx 76051-3300 Office Fax Cell Cell e-mail 8179925662@... Hospital Pager Personal Pager pager e-mail 8174342094@... Re: RE: The Debate TDH has something on their website for EMT's working in ER's. It's something of a guideline/scope of practice. Anyway, basically it states that the EMT reports directly to the doc and does what they tell them to do. Unfortunately, we most often end up as bed changers, etc., because the HOSPITAL mandates we report directly to the nurse. Any idea from anyone as to why TDH's guideline is not followed? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 21, 2004 Report Share Posted April 21, 2004 I asked about that particular portion of their website a while ago and was told it was obsolete and was never removed from their website. Jim B. , LP Baylor Regional Medical Center at Grapevine EMS Educator Baylor EMS Medical Control 400 N. Main St. #104 Grapevine, Tx 76051-3300 Office Fax Cell Cell e-mail 8179925662@... Hospital Pager Personal Pager pager e-mail 8174342094@... Re: RE: The Debate TDH has something on their website for EMT's working in ER's. It's something of a guideline/scope of practice. Anyway, basically it states that the EMT reports directly to the doc and does what they tell them to do. Unfortunately, we most often end up as bed changers, etc., because the HOSPITAL mandates we report directly to the nurse. Any idea from anyone as to why TDH's guideline is not followed? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 23, 2004 Report Share Posted April 23, 2004 Keep it coming Doc. I find it very interesting. FF/Lic-P Vernon College FIRE/EMS Training Program 4105 Maplewood Wichita Falls, Texas 76308 Office ext. 3233 Fax agarcia@... Re: The Debate > Please don't stop with posting CCT material on this list server - as one > who has worked most EMS jobs (field EMT/Paramedic, off-shore here and in > the middle east, public and private ED and now education), I find the > debate interesting. What I find most interesting is that the arguments > for and against paramedics in critical care roles haven't changed since > I first worked in an ED (15 years ago). > > > > Rick LaChance, EMT-LP > Web/Streaming CE Developer > Emergency Medicine Education > UT Southwestern Medical Center > Dallas, TX 75390-9134 > > > >>> bbledsoe@... 4/20/2004 9:16:51 AM >>> > > I just received an email asking me not to " trash the list " with > information > about the CCT debate on the NAEMSP list. I thought paramedics and > others on > these lists would find it of interest. I have taken the physician's > names > off the emails as I do not have their express permission to forward > (although I know them all and none will mind). If I am " trashing the > list " > let me know and I will cease and desist. > > BEB > > > Bledsoe, DO, FACEP > > Midlothian, TX > > > > " Faith is believing what you know ain't so. " > > Mark Twain > > Following the Equator > > > > > Don't miss EMStock 2004!http://www.emstock.com > <http://www.emstock.com/> > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 23, 2004 Report Share Posted April 23, 2004 Keep it coming Doc. I find it very interesting. FF/Lic-P Vernon College FIRE/EMS Training Program 4105 Maplewood Wichita Falls, Texas 76308 Office ext. 3233 Fax agarcia@... Re: The Debate > Please don't stop with posting CCT material on this list server - as one > who has worked most EMS jobs (field EMT/Paramedic, off-shore here and in > the middle east, public and private ED and now education), I find the > debate interesting. What I find most interesting is that the arguments > for and against paramedics in critical care roles haven't changed since > I first worked in an ED (15 years ago). > > > > Rick LaChance, EMT-LP > Web/Streaming CE Developer > Emergency Medicine Education > UT Southwestern Medical Center > Dallas, TX 75390-9134 > > > >>> bbledsoe@... 4/20/2004 9:16:51 AM >>> > > I just received an email asking me not to " trash the list " with > information > about the CCT debate on the NAEMSP list. I thought paramedics and > others on > these lists would find it of interest. I have taken the physician's > names > off the emails as I do not have their express permission to forward > (although I know them all and none will mind). If I am " trashing the > list " > let me know and I will cease and desist. > > BEB > > > Bledsoe, DO, FACEP > > Midlothian, TX > > > > " Faith is believing what you know ain't so. " > > Mark Twain > > Following the Equator > > > > > Don't miss EMStock 2004!http://www.emstock.com > <http://www.emstock.com/> > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 23, 2004 Report Share Posted April 23, 2004 Doc, We will do a lot of talking on this subject at EMStock. I have my bags packed and the travel trailer ready to go. See ya there. FF/Lic-P Vernon College FIRE/EMS Training Program 4105 Maplewood Wichita Falls, Texas 76308 Office ext. 3233 Fax agarcia@... Re: The Debate > > brian what about Introducing more critical care ICU or making a mandatory > ICU rotation every year per so many hours just to gain training and expense > > > Quote Link to comment Share on other sites More sharing options...
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