36 ABC or CAB

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(36:10) “Which will kill you faster? And which should you treat first?” Ron had his first test of the semester in trauma and we talk about a couple of questions that annoyed him. One involved and airway problem and a lacerated femoral artery. Was this a case of the book vs the street?

Speaking of the real world, we also talk about taking off helmets, using a PASG, and one of the alternative uses of a KED – pelvis fractures.

Listener Questions

Answers about Boston EMT from Ep 32 from Matt: “NREMT-B vs. MA EMT-B…
a bit of a difference. NR generally comes with Epi and Glucometry skills. MA EMT-B must be tested and individually get permission from the service for such skills. MA EMT-B per diem runs $9.50 – $12.00”

Stomach inflation when using BVM from the video. from Timothy

Simon –
More questions, sorry if there are too many for the show, feel free to make them more succinct, and dont feel you need to use them all:
1. The dreaded BP. Lately I do a BP on a patient either by auscultation and/or palpation (no machines ever), I instantly do it again to confirm it, I get repeatable results all the way to hospital…and the hospital gets something way different to me with the machine. Like 50mmHg higher different. And they confirm it with auscultation. Someone told me I might be aligning the cuff in the wrong spot or on the wrong way, but changing its position doesnt seem to help. Any ideas?
2. Another BP question. I remember reading that if you let the cuff deflate too slowly, you are creating a back pressure of blood that will give you an artificially high reading. This makes some sense to me, is it correct?

Mentions:

Videos on airways, and tourniquets. In the tourniquets video at 20 min what femoral artery bleed looks like (animal). At 23:15 what radial arterial bleed looks like and a tourniquet stopping the bleeding (human).

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  • Anonymous

    I have a story with poor airway training. I am in my last semester of my paramedic and we are required only ONE live ET. We have ONE OR that will let us do intubations. We have a large number of paramedic students fighting for time. I arrived for my 8 hour rotation and found one of the doctors. She started a rant about how she hates our school for sending students at 3pm, the time I was told to show up, because they don’t have any scheduled operations past that time, and they have already decided who intubates who. She told me to go sit on the couch for the next 8 hours because they had only one case who was runing late, and she was getting an LMA. Well lucky for me they decided seconds before taking her back they would do an ET. So I got to attempt intubation on a 300+ lbs woman with no neck, and less than 10, very lose teeth. I was unable to see the chords so the CNRA grabed the laryngescope and opened her air way. She pointed the chords out to me and helped me pass the tube…. The school said, thats good enough, and no I can’t have another OR rotation. My feild time has given new meaning to “white cloud” and I have had ONE attempt in over a year at a live intubation. She was post arrest (and home with her family now and since learned CPR at my rescue squad) however she was eating oatmeal when she went down. Any advice on suctioning oatmeal? Because we couldn’t get that mess out of her air way. At the time I went looking for the chords I could see she had regained her gag reflex and we transported her with a BLS air way at 100% O2. (BLS WORKS WHEN DONE RIGHT!) I hate that I am so under-trained with airway and wish there was a way to get more training. The ER’s don’t let students, or even their own nurses intubate, our only chance is on the ambulance, or our ONE OR shift. It’s pretty scary! I guess if I had a question, it would be any idea how I can get some more practice, with out digging up fresh cadavers at the grave yard in the middle of the night?

  • VinceD

    A couple tips of my own for Simon.
    1) Make sure you’re listening at the correct point in the AC. Lots of folks just slap the stethoscope in the crook of the elbow without first checking the location of the brachial artery, which is what you’re trying to listen to. If you’re not listening close enough to it, your readings will come up low, so first feel that pulse and then put the scope right on top of it. As a bonus, you’ll also get good at finding brachial pulses in an instant. It also helps to make sure your cuff is sufficiently high on the arm so that you can fit the scope between the elbow crease and the bottom of the cuff without overlapping.
    2) If you look at the AHA’s guidelines on how to properly take a blood pressue (if I remember correctly), they recommend first obtaining a BP by palpation, deflating and waiting around 30 seconds, and then inflating the cuff 20-40 mmHg or so past the palpated BP and auscultating. This allows you to have a rough idea of where you need to listen so you can really scrutinize what you’re hearing for that first sound. It also decreases the likelihood of you beginning your auscultation in the middle of an auscultatory gap and missing the true systolic pressure. From one experience, it can mean the difference between obtaining a systolic of 170 or 240 in a patient.

  • Ross

    No linkey for the videos you were discussing. I’m pretty sure that you were talking about the King County EMS Tuesday Lectures at Harborview from Feb. 2011. Those can be found at http://www.emsonline.net/ts/tuesday_2010.asp.

  • I don’t know what happen to that HTML, thanks for the direct link.

  • Ross

    Actually http://www.emsonline.net/ts/tuesday_2010.asp?date=0211should be a permalink

    There is surely some decent blog fodder in the documemnts posted there. I was just looking at the protocols at http://www.emsonline.net/assets/2010PCP-021910Online.pdf and was surprised to see some interesting things including alternate destinations and an option to coordinate with physicians from the dominant local HMO (actually a cooperative) when treating its members/subscribers.

  • Mike

    Thanks for the answer to the MA vs. NR Question guys!

  • Mike

    I might be getting annoying with all the questions that I’m asking, but…..

    If an NPA or an OPA is inserted into a patient, is a head tilt chin lift or a jaw thrust still neccessary? It’s one of those questions that has been nagging around in my head, and I’m curious about it.

    And I’ll add another airway training horror story. My EMT class hasn’t even done practicals on inserting an NPA, and we’re past Airway Management in our studies. Why? Our dummies can’t take an NPA, but they can take an OPA.

  • So… PHTLS has some sort of evidence that spinal immobilization decreases secondary spinal injury? 😀

    To throw some more fuel on the fire, Dalhousie University up in Canada has a database of evidence based medicine for EMS and, while listing 10 studies for spinal immobilization, currently gives spinal immobilization a “C, There is an insufficient amount of evidence available to determine if this intervention should be used or not.”

    http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal%20Immobilization

    Meanwhile, “C-spine clearance” (side note: Do you need to “clear” c-spine if immobilization isn’t really indicated?”) has more studies and a higher rating of evidence.
    http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#C-Spine%20Clearance

    Finally, NREMT-B (National Standard Curriculum style) vs MAEMT

    MA has aspirin and EPI-pens as a standing order instead of patient assist. There is a very interesting (and, in my opinion stupid) nebulized albuterol protocol (requires support of the service’s medical director and can only be administered to patients who have been preprescribed beta agonists, but the albuterol comes from the ambulance’s supply). Then there’s glucometry and pulse oxymetry which also requires endorsement of the service’s medical director. There may be a few more that I can’t remember, but I only worked for about 6 months for a tiny IFT company.