If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

NYPD Officer Stuck in Tree Trying to Rescue Cat is Rescued by NYFD


Image credit.
 

What were you thinking?

That is the obvious question to ask this police officer.

That is after asking is the story true. It was reported by NBC with no author listed.

Do cats die if not rescued from trees?

I wonder if PETA has a page on this. They do not appear to, but it could have been amusing.

However –
 

When a Tennessee woman’s cat was stuck in a pine tree, firefighters gave her two options: they could blast it out with a hose or shake the tree until the cat fell out. When asked how option B was any different from the cat’s just falling out on its own, one firefighter answered, “Neither is real different, ma’am. Just quicker.”[1]

 

Things could have turned out worse for the officer. they could have used the hose or shaken the tree until the officer fell to the ground. Humans have not evolved the ability land as gracefully as other species do.

Still, this rescue may end up being a fate worse than death for this NYPD officer.
 

The officer had lit a flare and set up cones on the ground underneath the tree before going up but onlookers ignored them as they gathered and gawked from the ground, said Yu.[2]

 

Flares and trees and children are not a good combination. Fortunately, it is Spring and there is no drought.

When going to so much trouble to be a hazard to one’s self, protecting others is probably not one of this officer’s strong points.

Nothing says come hither like cones, flares, and treeful stupidity.

Perhaps cats in trees should have a time limit before someone responds with a hose to dislodge them from the trees. If the cat doesn’t come down on its own in 48 hours, then someone might respond.
 


 

This image accompanied the article.

Maybe this is a mug shot of the tree that abducted the officer.

-

Footnotes:

-

[1] Do fire departments actually rescue cats from trees?
Straight Dope
January 8, 2010
Article

-

[2]
FDNY Rescues Cop Stuck in Tree Trying to Rescue Cat
NBCNewYork.com
updated 5/13/2013 10:47:22 PM ET
Article

.

The Art of Critical Thinking at The EMS Roundtable


 

Last night I called in to the EMS Roundtable because the topic was one of the most important in EMS – critical thinking.[1]
 

Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.[2]

 

More simply, in EMS critical thinking is how we make good decisions based on the limited information available in the emergency setting.

In EMS we definitely can be too safe.

Not applying a tourniquet, because What if the tourniquet causes a problem?

That is being too safe.

Not giving large doses of NTG to a hypertensive CHF patient, because What if the NTG causes the pressure to bottom?

That is being too safe.

Strapping someone to a backboard with straps and a collar, Just to be safe.

How is that not being too safe?

Where is there any evidence that spinal immobilization is safe?

Not sedating (or not adequately sedating) an excited delirium patient, because What if he stops hyperventilating?

That is being too safe.

These are some of the things that need to be considered when we engage in critical thinking.
 

Go listen to the podcast.
 

Show Notes:

Guest Dan Limmer: http://limmercreative.com

Live Call-in Tim Noonan: http://roguemedic.com

Chat Room:

Jim Hoffman: http://emsofficehours.com

Tom Bouthillet: http://EMS12Lead.com

 

Go listen to the podcast.
 

-

Footnotes:

-

[1] The Art of Critical Thinking
The EMS Roundtable
Wed, April 24, 2013 07:00 pm
Podcast page.

-

[2] Defining Critical Thinking
Criticalthinking.org
Web page

.

Another Sinus Tachycardia that F&B Medics Want to Shock

 

In Worst test question ever! – Maybe, I pointed out some of the problems with the way we “educate” people in EMS. The following question was provided with the rhythm above.
 

You are dispatched emergency traffic to the scene of a 24 yo F with “palpitations.” You arrive to find her pale, sweaty and lethargic. You palpate a radial pulse with an extreme rate. You hook her up to the monitor and find the following rhythm? You have a 45 minute transport time. Which of the following is the most appropriate initial treatment for this condition?

1.) Nitroglycerin 0.4mg SL
2.) Immediate synchronized cardioversion
3.) Adenosine 12mg Rapid IV push followed by 20cc NS bolus
4.) Epinephrine 1mg 1:10000 q-3-5m IVP

 

If a test question is so poorly written that there is no justifiable answer, why would anyone competent defend the question?

The answer is that we have dangerous people as “educators” and no really good method of eliminating them from EMS classrooms.

If there are no correct answers, can there be one best answer?

If there are no correct answers, can the most deadly answer possibly be the best answer?

We are supposed to be providing patient care, not making “educators” feel good about being dangerous.

Could the rhythm be atrial flutter?

It is not a bad idea to suspect flutter when the ECG rate is an even fraction of the ≈300 rate that is typical of flutter waves e.g. ≈75, ≈100, and ≈150)?

Is there another wave half way between the P waves seen in this rhythm, which would make both waves F waves?

I do not see any Flutter waves.
 

 

That is the same rhythm. Do you see any F waves?

If the rhythm is sinus, then cardioversion/defibrillation is not going to help, but can make things a lot worse.

We can produce anything from pain to death by shocking this rhythm.

Why would we do that to satisfy an incompetent “educator”?

This might be a good question to identify people who should not be trusted to care for patients. If we are willing to make a choice that is the equivalent of harming patients in order to come up with the one best answer right answer in a testing environment, what might we do when faced with a real patient, but a protocol that we think needs to be followed?

Is cardioversion the way to avoid the QA/QI/CYA spanking?

Should we be trying to figure out how to intervene?

Should we be trying to figure out when to intervene?

If the intervention is a heart-stopping dose of electricity (cardioversion), should we be looking for excuses to shock, or should we be trying to figure out if the patient is likely to benefit from that treatment?

-

What about this 80+ year old patient, who is pale, and lethargic, but is not confused?
 

 

 
 

Here is a different EMS 12 Lead Facebook post.
 

More ACLS…
Your pt is a 54 yo male found in bed, with AMS. He looks pale, has BP of 84/52 with the rhythm below. No other hx is available right now. What’s the treatment?

 

The earlier post looked like a sinus tachycardia from a rhythm generator. With the HeartSim, to get a good fast narrow complex rhythm use atrial tachycardia and hit the faster button once or twice – that produces a rhythm that is not obviously sinus. There were 25 comments choosing from among the choices given, before there was a comment from someone smart enough to recognize that all of the choices were wrong.

Yes, the National Registry does encourage the fraud of one best answer. Why do medics choose a dangerous treatment, when we know it is dangerous?

We have been taught to choose try to figure out what would be most pleasing to the instructor/evaluator – not to do what is best for the patient.

Why aren’t the instructors/evaluators looking for what is best for the patient?

 
One of the reasons for fewer indefensible answers at EMS 12 Lead is that many of the people following EMS 12 Lead are already medics, nurses, and/or doctors, rather than students looking to please an instructor/evaluator.

This time, there were four good answers before anyone suggested cardioversion, but why are so many of us looking for excuses to use electricity to stop the hearts of patients?

.

Destroying a car to pretend to protect against spinal cord injury

 

 

This car was not damaged in the original collision.

This car was not even involved in the original collision.

This car was destroyed by fire and EMS in order to pretend to protect the spines of the people who had walked to the car.
 

Firefighters cut the roof off a woman’s undamaged car to rescue two people she gave shelter to following an accident.[1]

 

Yes, the patients did develop neck pain while sitting in the car waiting for police/fire/EMS to arrive, but would getting out of the car, without cutting the roof off, have increased the likelihood of a spinal injury becoming worse?

We don’t know. there is no evidence, but the lawyers tell us that they are afraid of that risk.

Why are we taking medical advice from lawyers?

Because we do not know what we are doing.
 

Injured people with pain from their injuries probably do a much better job of protecting their own injuries than by allowing a bunch of people playing with various implements of destruction to move them.
 

A spokesman for the South East Coast Ambulance Service said: “While the pair were sheltering in the car they developed neck pain.

“Paramedics explored every opportunity to get them out of the vehicle. However, in the end they had to get the fire service to cut the roof off and take them out on back boards.

“We can only apologise to Mrs Dunlop for the inconvenience of that.”[1]

 

No. You can pay her for the damage you did to her car. This was damage done to protect the agency from liability. They should be held accountable for the damage.
 

We act as if the patients’ reactions to cutting the car apart around them will not be putting as much strain on any potentially unstable neck injuries as having the patients get out of the car on their own.

People, who have no experience being in cars being cut apart around them, will probably flinch at the sounds of extrication equipment tearing apart a car around them.

People, who do have experience being in cars being cut apart around them, will also probably flinch at the sounds of extrication equipment tearing apart a car around them.

Why pretend that there is reason to believe otherwise?

Why pretend that muscular movement from flinching is any less significant than what the patients would cause by getting out of the car on their own?

Any movement of the car is also going to result in movement of the necks of the occupants.

Is there any evidence that self-extrication causes damage to an unstable spinal cord?

Is there any evidence that we provide any protection to patients by extricating them our way?

This is another example of how far we will go to protect a traditional treatment with no known benefit.
 

We don’t know and we don’t want to know.
 

At Street Watch: Notes of a Paramedic, there is a description of the continuing fall from grace of “spinal immobilization” – Another Nail in the Board. Go read it.

At Mill Hill Ave Command, there is a review of a recent study of the methods of extrication from vehicles and the amount of movement of the cervical spine – In order to protect the c-spine, should we stop helping?. Go read it.

-

Footnotes:

-

[1] Good Samaritan’s car destroyed after pair given shelter
8 January 2013 Last updated at 08:22 ET
BBC News Sussex
Article

.

Pulse Oximetry vs. Waveform Capnography – Which is better?

 

 

Pulse Oximetry vs. Waveform Capnography – Which is better?

Choose only one?
 

No.
 

Why would I?

In a situation where I had to choose only one, I would pinch myself to awaken from this National Registry nightmare of artificial choices. There is no one best choice.
 

The best choice depends on what we are trying to do.

If the patient is receiving paralytics during an intubation attempt, does waveform capnography matter?

No, but the pulse oximetry is important in determining how long it is safe to continue to attempt to intubate before ventilating the patient again (whether with a BVM or a crichothyrotomy).

With use of preoxygenation and passive apneic oxygenation, patients may tolerate apnea for extended periods without desaturation. Apneic oxygenation dramatically changes the way we approach airway management.

Does it matter if the patient is not breathing, if the patient’s oxygen saturation is in the high 90s?

Yes, because ventilation is the removal of CO2 (Carbon DiOxide). If the patient is already acidotic, even a brief period of apnea may kill the patient.

Does it matter if the cardiac arrest patient is receiving ventilation?

No.

Chest compressions appear to provide adequate ventilation without any use of the usual means of ventilation.

Does pulse oximetry have a place in the assessment of endotracheal tube placement?

Yes, but waveform capnography, while not 100% accurate maybe 99 44100%, is almost always the best means of tube confirmation.
 

 

The numbers do not match the waveforms. There are four pulses for three breaths. A heart rate of 79 and a respiratory rate of 12 are indicated on the screen.

For a heart rate of 79, the respiratory rate would be 60. For a respiratory rate of 12, the heart rate would be 15. A respiratory rate of 60 could be to compensate for a metabolic acidosis or many other medical conditions, but these would not be expected to produce an accurate reading of 35 mm/Hg.

A heart rate of 15 is kind of slow for a human and should get our attention, but the context is important. What is going on with the patient?

It could be that the display presents the waveform at different rates, so that there is more of the capnograph to see.
 

 

Is this a problem?

The answer depends on knowing what is going on with the patient.

An oxygen saturation of 98% may drop pretty quickly, if the patient has not been preoxygenated. Is this following a paralytic during an intubation attempt? Is the patient being ventilated with a BVM after being disconnected from a ventilator for suctioning, or bronchoscopy, or . . . ? If the patient has sleep apnea the display would look different, but that is another form of intermittent apnea that does not necessarily require any emergency medical intervention.
 

 

We generally want to maintain an oxygen saturation of 94% or better. Is 93% a problem?

 

 

 

 

 

 

 

Is 83% a problem?

 

 

 

 

 

 

 

Is 58% a problem?

83% is looking a lot better.

Again, the answers depend on context.

Isolated hypoxia is not a problem, but the patients we assess tend not to have isolated hypoxia. what is normal oxygenation for the patient? The hypoxia is generally an indicator that something else is wrong – something that is probably not going to be made all better just because we turn up the oxygen and make the numbers pretty. 100% does not mean all better.
 

 

Is 55 mm/Hg a problem?

 

 

 

 

 

 

 

Is 85 mm/Hg a problem?

Why is the CO2 elevated?

Treating the numbers is not the same as treating the patient.

-

Added 01/16/2013 @ 12:00 There is an interesting Facebook post on a patient with an oxygen saturation of 58% here. Thanks to Vince DiGiulio for the link.

.

Worst test question ever! – Maybe

 

Thank you to David Baumrind of EMS 12 Lead for linking to this here. It probably is not the worst test question ever, but it is very bad.

Read the question, figure out what your response would be, then scroll down for my explanation.
 

You are dispatched emergency traffic to the scene of a 24 yo F with “palpitations.” You arrive to find her pale, sweaty and lethargic. You palpate a radial pulse with an extreme rate. You hook her up to the monitor and find the following rhythm? You have a 45 minute transport time. Which of the following is the most appropriate initial treatment for this condition?

1.) Nitroglycerin 0.4mg SL
2.) Immediate synchronized cardioversion
3.) Adenosine 12mg Rapid IV push followed by 20cc NS bolus
4.) Epinephrine 1mg 1:10000 q-3-5m IVP

-Admin Paul

The original posting was from Exhausted Medic Students ‘R’ Us here.

Go read the original with its hundreds of comments.

 

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All of the answers are completely wrong.
 

ST (Sinus Tachycardia) is the rhythm.

There are clear P waves with consistent PR intervals. It is faster than what some people expect to see from ST, but that is because many of us do not think about what we are learning in EMS.

It is true that the cardiology part of paramedic school is probably the toughest for most people, and we are overwhelmed with new information, but we should be very familiar with this rhythm.

Carry a patient up/down a flight of steps and you may have significant ST – maybe even faster than what is on this strip. If your heart rate is over 150, so what?

Before you have a chance to recover, use the pulse oximeter to measure your heart rate after carrying a patient. You are just checking the accuracy of the machine before applying it to the patient, or before reconnecting it to the patient.
 

1. Nitroglycerin is NOT indicated for palpitations.

NTG is not indicated even for a lot of palpitations. Do you have a protocol for NTG for palpitations?

Ask your medical director how much NTG should be given for palpitations, but don’t be surprised if you are expected to go through some scenarios to demonstrate that you would not really give NTG for palpitations.
 

2. Cardioversion is NOT indicated for sinus tachycardia.

Cardioversion is supposed to cause asystole. During that asystole, it is hoped that the sinus node will become the pacemaker for the patient’s rhythm.

SINUS tachycardia means that the sinus node is already the pacemaker.
 

Cardioversion of sinus tachycardia can only make things worse.
 

Cardioversion of sinus bradycardia can only make things worse.

Cardioversion of any sinus rhythm can only make things worse.
 

3. Adenosine is NOT indicated for sinus tachycardia.

The dose does not matter. The drug is not indicated.

No matter how wrong NTG is for palpitations, adenosine is worse.
 

4. Epinephrine is NOT indicated for sinus tachycardia with a pulse.

How much faster do we want this ST to be? Epinephrine can make it faster.
 

Maybe some people think that the choices should include a vagal maneuver.

No. That would also be wrong.

Calcium channel blocker?

Another wrong.

Beta blocker?

Wrong again.
 

No competent paramedic should attempt to justify any of these answers.

Maybe this is a question to find out just how incompetent people will be to satisfy an authority figure.

One horrible answer is –
 

As a paramedic instructor and a evaluator for National Registry…if my student didn’t cardiovert…I’m failing them.

 

Does the National Registry hire people this ignorant as evaluators?

Yes, but so does every other testing organization. Maybe this guy is lying about being an instructor and evaluator, but this is EMS and we like low standards.

A defender of cardioversion posted the ACLS tachycardia cheat sheet.
 

Click on image to make it larger.

 

Unfortunately, the cheat sheet does not state that we should not shock sinus tachycardia.

If all we know is the cheat sheet, we should consider a career change to explore the exciting world of fast food order fulfillment.

The text of the 2010 ACLS guidelines states –
 

ACLS professionals should be able to recognize and differentiate between sinus tachycardia, narrow-complex supraventricular tachycardia (SVT), and wide-complex tachycardia.[1]

 

A lot of people could not recognize an obvious sinus tachycardia.

Is that the fault of their instructors?

Yes and No.
 

Sinus tachycardia is among the rhythms listed that we are expected to be able to identify.
 

Synchronized cardioversion is recommended to treat (1) unstable SVT, (2) unstable atrial fibrillation, (3) unstable atrial flutter, and (4) unstable monomorphic (regular) VT. Shock can terminate these tachyarrhythmias by interrupting the underlying reentrant pathway that is responsible for them.[1]

 

Sinus tachycardia is not listed among the rhythms that should be shocked.

Here is the important part –
 

If judged to be sinus tachycardia, no specific drug treatment is required. Instead, therapy is directed toward identification and treatment of the underlying cause. When cardiac function is poor, cardiac output can be dependent on a rapid heart rate. In such compensatory tachycardias, stroke volume is limited, so “normalizing” the heart rate can be detrimental.[1]

 

We treat sinus tachycardia by treating the cause.

The cause of sinus tachycardia is never lack of cardioversion.
 

A good test near the end of the cardiology section of paramedic school might include this question to find out if the students have learned anything.

All of the choices are wrong.
 

In medicine, there is not one best answer for all patients.
 

Anyone who says differently is selling something.

-

Footnotes:

-

[1] Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Cardioversion and Regular Narrow-Complex Tachycardia

.

Ambulance Debate

 

There is a surprisingly intelligent discussion of the bidding for an ambulance contract in St. George, Utah.

None of the usual hyperbole by people who are not in EMS and don’t know better.

None of the usual hyperbole by people who are in EMS and should know better.
 

Image credit.

 

Hundreds of residents showed up at hearings last week to show support for Dixie Ambulance. They made impassioned pleas to maintain the local provider. Gold Cross supporters were just as impassioned about how they believed a change was necessary.[1]

 

The author goes on to ask those making the decision to ignore the emotions and to go with the ambulance company that provides the best care.

Very refreshing. Very smart.
 

Quite simply, please ignore the emotion on both sides in this issue. Instead, focus solely on the quality of care. It is that factor, and that factor alone, that the vast majority of residents in St. George want considered when making this choice.[1]

 

This is not a matter of watching some reality TV show and being persuaded by the person who puts on the most emotional show. those are scripted dramas, written to appeal to emotion.

Smart decisions are only rarely emotional. Emotional decisions tend to be the ones where we later ask, What was I thinking?
 

If Dixie Ambulance is the best choice — or at least equal to Gold Cross — then by all means, keep the local company as the service provider. If Gold Cross is markedly better with caring for patients, then make the switch for the betterment of residents.[1]

 

Yes, the tie should go to the incumbent. There needs to be a good enough reason to go through all of the head aches associated with changing out an ambulance service.

I could not find the name of the author, so I would guess that this is from the editorial staff. I hope the rest of their coverage of EMS is as well done.

-

Footnotes:

-

[1] Ambulance Debate
TheSpectrum.com
Opinion
Article

.

Advertising unapproved uses of drugs is free speech, which is what the FDA has been trying to say

 

Off-label drug use is very common.

This is a ruling a ruling that only affects New York, Connecticut, and Vermont,[1] but may be reviewed by the full Second Circuit Court and by the Supreme Court. That won’t stop it from having an effect nationally. What power does the FDA (Food and Drug Administration) have to regulate what drug representatives may say about uses of drugs that are not FDA approved uses, but are completely legal uses for the doctors they are talking to?

The FDA rules do prohibit drug representatives from discussing uses of drugs that are not FDA approved.

The FDA rules do not doctors from prescribing drugs for uses that are not FDA approved.

This is off-label drug use.

The NAEMSP (National Association of EMS Physicians) has a position paper on off-label drug use.
 

If EMS medical directors use a product for an indication not in the approved or cleared labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain awareness of the product’s use and effects[2]

 

This should be true for any medical treatment.

The most important part of the article on the ruling is this quote -
 

Gerald Masoudi, a former chief counsel of the F.D.A., said the ruling made a distinction between truthful discussion of off-label uses of drugs, many of which are considered legitimate by the medical community, and those that are misleading or false. He noted that “anyone on the planet” could discuss off-label uses of drugs, except for pharmaceutical companies.

“It’s very significant,” he said, “because it’s going to make F.D.A., in its promotion cases, focus on the kinds of speech that are more likely to harm consumers, such as false or misleading marketing versus something that is not approved.”[3]

 

Will that be the case?

That is the way it should work, but the politics of regulation may not be ready for such a reasonable approach.

The FDA should focus on whether the communication is honest and complete, rather than whether taboo topics are mentioned.

 

Then there are the several different flavors of off-label.

1. The label does not mention the particular use, or dose, or population as being approved. Intranasal and intraosseous medication administration are just some of the reasons that EMS drug use can be off-label drug use.

2. The label mentions the use, but points out problems with the use. Haloperidol given intravenously, or in larger doses, is an example.[4]

3. The label has a black box warning. Droperidol is an example.[5]

There are FDA approved drugs that have the same problems, but without the formal warnings. According to the small print of the FDA label, amiodarone has greater problems with QT prolongation and torsades than haloperidol or droperidol, but there is no warning.[6]

While amiodarone does not have any of these warnings, the documented rates of QT prolongation and torsades appear to be greater with amiodarone than with droperidol. Droperidol receives the kiss of death, while amiodarone receives recommendations from the AHA (American Heart Association).[7]

In what way does such an inconsistent approach benefit patients?

Off-label use has also led to many problems, but that is more than can be covered today.
 

Image credit.[8]
 

This decision has not yet been covered on The Volokh Conspiracy, which can be expected to provide excellent insight to the way the law works and what decisions mean for everyone else.

-

Footnotes:

-

[1] United States Court of Appeals
Wikipedia
Article

-

[2] Off-Label Use of Medical Products
NAEMSP Position Statement
Position Statement in PDF format at NAEMSP.org

-

[3] Ruling Is Victory for Drug Companies in Promoting Medicine for Other Uses
By Katie Thomas
Published: December 3, 2012
NY Times
Article

-

[4] Information for Healthcare Professionals: Haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate)
Postmarket Drug Safety Information for Patients and Providers
Page Last Updated: 09/29/2009
FDA letter

There is a black box warning for haloperidol, but there is no mention of this in the black box warning. This is mentioned elsewhere in all capital letters.

FDA ALERT [9/2007]: This Alert highlights revisions to the labeling for haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate). The updated labeling includes WARNINGS stating that Torsades de Pointes and QT prolongation have been observed in patients receiving haloperidol, especially when the drug is administered intravenously or in higher doses than recommended. Haloperidol is not approved for intravenous use.

-

[5] DROPERIDOL injection, solution
[Hospira, Inc.]

DailyMed
FDA label

Here is the first paragraph of the black box warning on the label.

WARNING
Cases of QT prolongation and/or torsade de pointes have been reported in patients receiving droperidol at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.

-

[6] AMIODARONE HYDROCHLORIDE injection, solution
[Hospira, Inc.]

DailyMed
FDA label

-

[7] Where are the Black Box Warnings on These Drugs – II
Rogue Medic
Sun, 11 Dec 2011
Article

-

[8] Boost for Off-Label Drug Use – FDA Would Let Firms Keep Doctors Informed On Unapproved Methods
By Anna Wilde Mathews and Avery Johnson
Wall Street Journal
Article

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