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

- Rogue Medic

Examples of Ventricular Tachycardia Caused by Amiodarone – Part I

ResearchBlogging.org
 

How much worse could the patient get if we give amiodarone?

But amiodarone doesn’t cause V Tach (Ventricular Tachycardia). Amiodarone stops V Tach.

Right?

If amiodarone can cause V Tach, shouldn’t someone have told us?
 


Click on image to make it larger.
 

This is a wide complex tachycardia, which should be presumed to be V Tach. The diagnosis of the rhythm as V Tach is supported by the P-wave dissociation and by the history of a heart attack a couple of weeks before. 19 QRS complexes in 5 seconds (multiply by 12 to get the rate for 60 seconds) = 228.

According to ACLS (Advanced Cardiac Life Support) what drug would be indicated for the above rhythm?

For the old timers, let’s throw in a bit of information that is supposed to be important in deciding among the various antiarrhythmics –
 

Transthoracic echocardiography was performed, and the ejection fraction was 34% based on the modified Simpson method.[1]

 

Does the ejection fraction matter in treating wide-complex tachycardia?
 

Note that amiodarone becomes the antiarrhythmic of choice (after failure of adenosine) if the patient’s cardiac function is impaired and the ejection fraction is <40% or there are signs of congestive heart failure.[2]

 

That was only mentioned in the 2000 ACLS guidelines. The 2005 ACLS guidelines and the 2010 ACLS guidelines do not mention ejection fraction in the treatment of V Tach.
 

Do we have good evidence that amiodarone is effective for stable V Tach?
 

Amiodarone has not been studied specifically for the pharmacological termination of hemodynamically stable VT, but it is effective in treating hemodynamically unstable VT and VF.78 81 82 83 84 85 86 87 88 89 90 91 [2]

 

That was written in 2000 and the answer was NO.

Now we have evidence that amiodarone may be effective in about one out of four patients – if we are prepared to wait a half hour, or more. In other words, it is rare for amiodarone to work and rarer still for amiodarone to work before we can get the patient to the hospital.[3],[4],[5]

We do have evidence that amiodarone may be a part of the long-term treatment of unstable V Tach. On the other hand, maybe not.

I do mean long-term treatment, even though these are unstable patients.
 

Twenty-seven (58.5%) of the 46 patients responded to intravenous amiodarone, and an additional 6 patients (13%) showed a late response to amiodarone (Fig. I). Fifteen of the 27 responders (33% of all patients) responded immediately (0 to 2 h), and 26 responded within 72 h . The other patient responded within 84 h (Fig. 2).[6]

 
Up to 84 hours to take effect.

Not exactly an emergency drug.

I have worked some very long shifts. I have never worked an 84 hour shift.

If amiodarone can take 84 hours to work, and the patient is receiving a variety of other treatments during those 84 hours, is it really the amiodarone that is working?

Compared with 84 hours, a less than two hour time to response seems almost instantaneous, but it is not fast for EMS.
 

This patient was treated with oral amiodarone for sustained V Tach during his previous hospital admission for an acute anterior MI (Myocardial Infarction) treated with a stent in the LAD (Left Anterior Descending) coronary artery.

This time he was treated with IV (IntraVenous) amiodarone. The problems began on the first day of IV amiodarone treatment.
 

On the first day of hospitalization, the patients had 10 attacks of pulseless VT treated with successful DC shocks. Occasionally, VT attacks degenerated to ventricular fibrillation.[1]

 

And continued –
 

On the second day of hospitalization, the patient had 14 pulseless VT attacks with successful DC shocks.[1]

 

But the V Tach stopped after the amiodarone was stopped and antithyroid therapy was begun.
 

Thyroid gland toxicity is one of the most important adverse effects of amiodarone and is called amiodarone-induced thyrotoxicosis. Thyrotoxicosis may alter arrhythmia and lead to frequent ventricular tachycardia attacks.[1]

 

All things are poison, and nothing is without poison; only the dose permits something not to be poisonous. – Paracelsus (1493-1541)
 

We do not seem to explain that well in EMS, or even in emergency medicine.
 

All antiarrhythmic agents have some degree of proarrhythmic effects.[7]

 

Amiodarone is one of the most dangerous drugs we carry in EMS.

How much thought do we give to the problems we can cause for our patients with this drug?

How much do we understand about the problems we could be causing when we push medications, such as amiodarone?

-

Footnotes:

-

[1] Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm.
Erdogan HI, Gul EE, Gok H, Nikus KC.
Am J Emerg Med. 2012 Nov;30(9):2092.e5-7. doi: 10.1016/j.ajem.2011.12.035. Epub 2012 Mar 3.
PMID: 22386340 [PubMed - indexed for MEDLINE]

-

[2] Amiodarone
2000 ECC Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 5: Pharmacology I: Agents for Arrhythmias
Arrhythmias and the Drugs Used to Treat Them
Hemodynamically Stable Wide-/Broad-Complex Tachycardias
Treatment of Wide-Complex Tachycardias
Free Full Text from Circulation.

-

[3] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed - indexed for MEDLINE]

-

[4] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306. doi: 10.1111/j.1553-2712.2010.00680.x.
PMID: 20370763 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

-

[5] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed - indexed for MEDLINE]

-

[6] Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias.
Helmy I, Herre JM, Gee G, Sharkey H, Malone P, Sauve MJ, Griffin JC, Scheinman MM.
J Am Coll Cardiol. 1988 Oct;12(4):1015-22.
PMID: 3417974 [PubMed - indexed for MEDLINE]

Page with link to Free Full Text Download in PDF format from J Am Coll Cardiol.

This is footnote 84 from the second 2000 ACLS quote.

-

[7] New Concerns From the International Guidelines 2000 Conference: Impaired Hearts and “Proarrhythmic Antiarrhythmics”
2000 ECC Guidelines
Part 6: Advanced Cardiovascular Life Support
Section 5: Pharmacology I: Agents for Arrhythmias
Arrhythmias and the Drugs Used to Treat Them
Hemodynamically Stable Wide-/Broad-Complex Tachycardias
Free Full Text from Circulation.

-

Erdogan, H., Gul, E., Gok, H., & Nikus, K. (2012). Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm The American Journal of Emergency Medicine, 30 (9), 209200000-2147483647 DOI: 10.1016/j.ajem.2011.12.035

-

Marill, K., deSouza, I., Nishijima, D., Stair, T., Setnik, G., & Ruskin, J. (2006). Amiodarone Is Poorly Effective for the Acute Termination of Ventricular Tachycardia Annals of Emergency Medicine, 47 (3), 217-224 DOI: 10.1016/j.annemergmed.2005.08.022

-

Marill, K., deSouza, I., Nishijima, D., Senecal, E., Setnik, G., Stair, T., Ruskin, J., & Ellinor, P. (2010). Amiodarone or Procainamide for the Termination of Sustained Stable Ventricular Tachycardia: An Historical Multicenter Comparison Academic Emergency Medicine, 17 (3), 297-306 DOI: 10.1111/j.1553-2712.2010.00680.x

-

Tomlinson, D., Cherian, P., Betts, T., & Bashir, Y. (2008). Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment? Emergency Medicine Journal, 25 (1), 15-18 DOI: 10.1136/emj.2007.051086

-

Helmy, I., Herre, J., Gee, G., Sharkey, H., Malone, P., Sauve, M., Griffin, J., & Scheinman, M. (1988). Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias Journal of the American College of Cardiology, 12 (4), 1015-1022 DOI: 10.1016/0735-1097(88)90470-6

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Bad Recipe for EMS Event Laughter


 

EduMedic has a post about making public relations more entertaining, but he seems to be entertaining his crews and only scaring the children.

He creates a game of Russian Roulette with each child holding a wire connected to the defibrillator and the appearance of the defibrillator delivering a shock through only one of the wires.

No shock will be delivered to anyone, but the children do not know this. The children are told the opposite.

The defibrillator is charged. Capacitor whining until it stops. Dramatic tension for the children.

The defibrillator is discharged. Since everyone is only ECG leads, nobody is shocked, but the presenter is supposed to give the appearance of having been shocked.
 

9. Immediately scream in agony, drop your limb lead, and run/jump/cry as you feel is appropriate to convey that you were “shocked.”

10. After catching your breath, thank them for being brave and invite them to bring their friends back for additional demonstrations on the half-hour for the duration of the event. With their full attention at your disposal, it is also the ideal time to discuss relevant public safety messages for your organization.

11. Repeat procedure for the rest of the day, or as long as you can keep a straight face.[1]

 

Look at the picture that accompanies this. The medics are laughing, but the children are not.

This could be a set up for explaining to children the dangers of playing with a defibrillator/AED (Automated External Defibrillator), or any other electrical device.

This could be justified as a way of teaching children about the dangers of electric current, or the benefits of electricity when used appropriately. This could be used for explaining that everything has risks, no matter how beneficial it might be.

I do not see any reason for not explaining that nobody was shocked, but nowhere is that suggested. Nowhere in the responses to my comments is that suggested.

What is provided is a series of logical fallacies.

 

Ahh, mounting opposition for anything in EMS that isn’t evidenced-based. True to form for you, Rogue![1]

 

Nowhere did I criticize this for not being evidence-based.

Logical fallacies have to do with confusion, misdirection, deceit, . . . , but not with anything good.[2] This is just one of many logical fallacies that will be used by EduMedic in his responses to my comments.
 

“You do not appear to have provided them with any education to justify this.”

1. Re-read the title post. It’s a recipe for laughter. The kids laugh, parents laugh, we laugh. Laughter needs no justification.

2. After this demonstration, I have their undivided attention because they had fun. This is when we talk about what EMS personnel do for the sick & injured and when to call 911.[1]

The bold type is EduMedic’s.
 


Download Video from YouTube | Convert YouTube to MP3
 

We have laughter.

The video shows a way to produce laughter. Nobody really had their fingers cut off. Should we be teaching children to laugh at the misfortune of others?

Laughter needs no justification, because nervous laughter is the same as amusement?

 

Nervous laughter is a physical reaction to stress, tension, confusion, or anxiety. Neuroscientist Vilayanur S. Ramachandran states “We have nervous laughter because we want to make ourselves think what horrible thing we encountered isn’t really as horrible as it appears, something we want to believe.”[3]

 

Having the opportunity to talk to the children afterward is important.

Explaining the difference between a real danger and this fake electrocution is more important. Where does he explain, or even suggest explaining that the electrocution was not real?
 

“You do appear to have taught them that EMS encourages taking unreasonable risks.”

1. At no time is there any risk to anyone involved, only the suggestion of it for the sake of teaching. The same thing is done routinely in HazMat Technician classes with adult students when jars of colored water are presented to the students as something highly toxic. Suddenly the presenter has their full attention.

2. The teachable moment occurs when they quickly realize that there really was no shock. I have yet to see a group of children fail to realize it was purely theatrical. It is at THAT moment when they smile, they laugh, and their minds are open to a new idea… that ambulances and the paramedics on them are not scary after all.[1]

 

Nowhere did I suggest that there was a real risk of shock. My objection has been to the lack of explanation to the children.

Even in adult education, we should tell the students that there was no actual dangerous chemical in the container. Otherwise, we are suggesting that the chemicals are safe enough to keep in a classroom.
 

Where is there any suggestion that it should be made clear to the children that there was no real risk at any time?

I’m really trying to understand your preoccupation with the disclosure of an imaginary risk. Remember the context of most any public safety PR event. Law enforcement typically comes with a buckle-up “convincer” or a talking DARE car. However, there are no multi-page waivers to sign prior to riding the convincer, nor are there counselors on hand to debrief children who may have been frightened by an unoccupied vehicle that suddenly comes to life.[1]

 

Even more logical fallacies, but they don’t end there.

EduMedic provides clear statement that he does not understand that children do not look at the world the same way adults do.

Should we teach children to take risks, but not teach them the difference between real risk and pretend risk?

By the way, the D.A.R.E. program is an example of a myth. D.A.R.E. has been shown to have the opposite effect of what is intended. I would provide evidence, but EduMedic might claim that by citing research I was justifying some of his use of logical fallacies.
 

A large part of education is about perception.

We are trying to change the way students perceive the world.

Being vague, or omitting information, is not good education. These may be good reasons there are so many myths for me to debunk.

-

Footnotes:

-

[1] Photo Phriday: Recipe for PR Event Laughter
May 3, 2013 9:00 am
Brian Lilley
Article and comments

-

[2] Fallacy
Wikipedia
Article

-

[3] Nervous laughter
Wikipedia
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

.

Free Transport Ventilator Class from CentreLearn and Jim Hoffman This Thursday

 

Is this important if we do not do interfacility transport?

Yes.

Eventually, we will be using ventilators for almost everything where we currently use a BVM (Bag Valve Mask).

Why?

Because we humans are pathetic at bagging patients.

If you have not seen a doctor/nurse/respiratory therapist/paramedic/EMT basic bagging a patient at 60 breaths per minute, you have not been paying attention.

Since we seem to be resistant to education, the protocol writers are starting to make this something that is not corrected by education, but is prevented from happening by putting it in the hands of machines.

Needless to write, but this will have plenty of unintended consequences. The best way to avoid these unintended consequences (assuming that we do not magically develop excellent BVM skills, which would be the subject of other posts) is to be as familiar as possible with the use of transport ventilators and the kinds of problems that we can cause.
 

Original image credit.
 

The goal of medical care is to make things better, or to not make things worse.

The three most basic points, that apply just as much to BVM use as to ventilator use.

1. How to assess the patient for the cause of a sudden deterioration of the intubated patient. Everyone should know this. It is a part of every PALS/NRP class. If it is not, it was supposed to be. It should also be a part of every ACLS class, since these are some of the preventable causes of cardiac arrest.

DOPE – DOPE (or POET for the more politically correct) stands for Dislodged, Obstructed, Pneumothorax, Equipment failure. I have discussed these elsewhere.[1]

2. Hypotension – Even in a trauma patient, hypotension is often resolved by correcting the ventilation, rather than by adding fluid to the blood vessels.

3. Waveform Capnography – Continuous waveform capnography should be mandatory for the movement of all intubated patients anywhere. The same is true for extraglottic devices (LMAs, CombiTubes, King Airways, et cetera).

This is from CentreLearn and Jim Hoffman.
 

CentreLearn Webinar: Automatic Transport Ventilators in EMS
Thursday, April 25, 2013 8:30 PM – 9:30 PM EDT
 

Registrater here.
 

You will be connected to audio using your computer’s microphone and speakers (VoIP). A headset is recommended.

Or, you may select Use Telephone after joining the Webinar.
Toll: +1 (914) 339-0030
Access Code: 677-535-345
Audio PIN: Shown after joining the Webinar
Webinar ID: 799-127-985

System Requirements
PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees
Required: Mac OS® X 10.6 or newer

Mobile attendees
Required: iPhone®, iPad®, Android™ phone or Android tablet

Read our Audio Checklist for tips on using your computer’s microphone and speakers with GoToWebinar.

 

Registrater here.
 

-

Footnotes:

-

[1] Origins of the Dope Mnemonic
Wed, 26 Jan 2011
Rogue Medic
Article

-

[2] Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
Aufderheide TP, Lurie KG.
Crit Care Med. 2004 Sep;32(9 Suppl):S345-51.
PMID: 15508657 [PubMed - indexed for MEDLINE]

Free Full Text Download in PDF format from burndoc.net.

-

[3] Capnography Use Saves Lives AND Money
Rogue Medic

Part I
Fri, 10 Dec 2010

Part II
Mon, 13 Dec 2010

Part III
Thu, 16 Dec 2010

Part IV
Thu, 16 Dec 2010

Part V
Tue, 04 Jan 2011

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Paramedic School Accreditation – Advanced Airways vs. BVM

-
 

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, John Broyles, and I discuss a few topics. National Registry of EMTs accreditation of paramedic schools.

Paramedic School Accreditation | Advanced Airways vs. BVM

If we are going to have standards, they should be based on some evidence that they work.

Is something better than nothing?

Something is only better than nothing if the something is something good.

Is a grade better than 80% good for bragging rights?

What does the grade mean? Does the exam demonstrate that the person understands good patient care? I do not see evidence that this initial exam does that.

The NR exam is just an initial exam, but some benighted people think that there should be higher pay for people who have passed this particular brand of entrance exam. Are they supposed to remain beginners forever?

Is a structured way of doing things a good way to evaluate people for the unstructured, or minimally structured, job of paramedic.

-

We also discuss what I wrote in Advanced Airway vs. BVM During CPR – Which is Worse?

There is no evidence that ventilations improve outcomes.

I was at Dr. Banerjee’s presentation on cardiac arrest and how their treatment protocol produces better outcomes than the rest of the country. One person in the audience kept complaining that he is wrong to not follow the ACLS guidelines because he will be sued. Dr. Banerjee’s response should be obvious – You need to show evidence of harm to win a law suit. I produce better outcomes than the rest of the country.

-

John Broyles brought up the way we educate badly with our focus on verbalizing Gloves on – Scene safe! and not thinking about what we are doing as far as using gloves and continually assessing scene safety.

Gloves are often inadequate BSI (Body Substance Isolation), but we act as if wearing gloves will protect against everything; as if wearing gloves somehow produces a force field around the body that protects parts of the body not covered by the gloves; as if gloves do not tear or break down and need to be replaced on the job; as if gloves make up for not cleaning our hands; as if touching clipboards and other equipment with gloves on is doing anything other than spreading germs all over the equipment that we will later pick up without gloves on; as if gloves need to be worn for every patient.
 


Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings
CDC (Centers for Disease Control and Prevention)
 

According to the CDC – Not every patient.

According to the CDC – Not every time.
 

Go listen to the podcast.

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Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians

 

 

Jamie Davis (the man behind the camera for this show and the man behind the MedicCast), Chris Montera (the man behind the EMS Garage), Kyle David Bates (Pedi-U and First Few Moments), Kelly Grayson (A Day in the Life of an Ambulance Driver and Confessions of an EMS Newbie) and I were on a video podcast from the 2012 EMS Expo in New Orleans.

None of the participants seem to feel that this discussion topic is a form of personal attack and the discussion is calm and thoughtful.
 

Chris Montera Assembles a Crew of EMS Leaders at EMS World Expo
November 19th, 2012

You can watch the video podcast at the ProMed Network page here.

Advance the video to the 10 minute mark for the beginning of the discussion.
 


 

Before the podcast I was at David Page’s presentation on how we educate EMTs and medics to kill. I had been trying to hear Dr. Keith Wesley’s presentation on the harms of oxygen, but the room was overcrowded, the crowd was spilling out into the hallway, and the microphone was not working. Why was Dr. Wesley put in a small room? I don’t know, but I could not hear, so I left.

I was very disappointed – until I saw the title of David Page’s presentation. That is a great topic. When I heard his presentation, I was even happier.

If you are an educator and you get a chance to attend this presentation – do not miss it.[1]

In our talk, we discussed the one thing on which I did disagree with David Page – the value of multiple choice test questions on a certification exam.

Multiple choice questions provide the person taking the test with limited information and no opportunity to obtain further information. Then the examinee is supposed to choose, from among several selections, the one best answer.

The idea of one best answer is a fraud.

Limited information.

No opportunity to gather more information.

Must choose one of the selections.

This just teaches bad decision making skills.

The multiple choice question on a certification exam is an excellent example of Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians.[1]

That was the only disagreement I had with David’s presentation.

We come up with ridiculous ways to artificially limit the learning of our students. For example – why not have the students create their own scenarios after reading the material for the class? No lecture. No guidance from the instructors. The students run it with only occasional feedback from the instructors.

The objections came from the instructors –

What do you mean, we are not necessary?!?!?

They were not thinking of the students and how this may be better for the students. They were only thinking of how this devalued their input and overturned their dogma.

If you are big on dogma, you are probably more harmful than beneficial.

This is another excellent example of Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians.[1]

We discuss several problems with education.

Why do we assume that the amount of time we spend on education is just right?

If our certification exams are any good at assessing for adequate education, why do we have any kind of classroom attendance requirements to get in?

I think that we just figure the completion of the class means that it doesn’t matter who passes the test, since the certification test is not a valid assessment.

Here is an example of the problem with multiple choice questions -

Worst test question ever! – Maybe
 

You can watch the video podcast at the ProMed Network page here.
 

The first 10 minutes is an advertisement, but it is for an interesting product that looks as if it can dramatically cut down on the risk of needlestick injuries and cut down on the cost of disposal of needles.

If you regularly have problems getting needles into the sharps container, because people who inexplicably passed a multiple choice exam esteemed colleagues have stuffed bandages and other non-sharps into the sharps container, the Sharps Terminator by Medical Safety Solutions should prevent that dangerous situation. I do not receive anything from the company.

-

Footnotes:

-

[1] Educated to Kill: How EMS Education Preprograms Medical Errors in Future Clinicians
Nov 1 2012 11:00AM
David Page, MS, NREMT-P
Thursday Schedule

This controversial look at safety and medical errors in EMS explores the role of education in preprogramming future clinicians to make deadly mistakes. Is it time for EMS education to embrace its role in creating cultures of safety? Or is it all up to the employers?

.

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.

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Footnotes:

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[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

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What can I give you as a present for 2012? FOAM

 

 

This is a time when many of us are giving gifts to others.

This is not my gift, it comes from Life in the Fast Lane. I am only letting you know about it.
 

This is FREE.
 

F – Free
O – Open
A – Access
M – Meducation

Meducation is Medical Education. There was Guinness involved. The quantity of Guinness was not specified.
 

Then he got an idea. An awful idea. The Grinch got a wonderful, *awful* idea![1]

 

Is this awful?

No, but I am not fond of the term meducation. ;-)
 

 

What is the most important part of medical education?

Medical education is expensive!

FOAM is –

Free.

No cost to us.

Open Access.

We do not have to subscribe to anything.

Medical education.

Better understanding of medicine.
 

We have access to free, up to date, medical education anywhere we have internet access, or we can download it for later use.
 

If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.
— from International EM Education Efforts & E-Learning by Joe Lex 2012[2]

 

Dr. Joe Lex of Temple University Hospital has had the Free Emergency Medicine Talks web site for years. There are over 2,000 free mp3 downloads of presentations from many of the top medical conferences. These are usually without the slides, but some do include the slides.

I disagree with What Dr. Cadogan says about anonymity. My identity is no secret. If you don’y know who I am, you either don’t care or you don’t know how to use a search engine.

Would knowledge of my identity change anything about what I write?

No.

Would I need to pretend that bad ideas deserve more respect?

Not even a little bit. Bad ideas do not deserve respect.

We need to be able to determine whether information is valid without having to rely on the authority of the name attached to the information. If we need names, then we do not know enough for people to put their lives in our hands.[3]

Some people may need to maintain anonymity because of the archaic rules of their employers, so anonymity can be important, but anonymity is not bad.
 

Check out FOAM.

Check out GMEP.org

Check out Free Emergency Medicine Talks

We can learn from people we may never have heard of, speaking/writing in places we would never be able to travel to.

We can give ourselves the vital gifts of education and understanding.

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Footnotes:

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[1] Grinch (1966) quotes
IMDb.com
Quote page

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[2] International EM Education Efforts & E-Learning
Dr. Joe Lex
Free Emergency Medicine Talks
Web page with link to mp3 download

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[3] Blogging and Anonymity
Rogue Medic
Sun, 07 Oct 2012
Article

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