BLS scenerio time

[certguy]

It's a beautiful sunday afternoon and you're on duty at your mostly vollie FD . Your dept. covers 12 square miles , rough population of 2800 to 3000 , with 2 additional auto - aid areas . You have a single station with 2 engines , a brush rig that doubles as a rescue , and a utility rig . Your dept. self dispatches for all but multiple alarms . It's just you and the duty LT. watching the chargers kick butt when suddenly you hear a burst of automatic fire , a couple of stray shots , then another long burst . About a minute later , all 3 of your emergency phone lines light up with reports of a shooting in the south end of town . SDSO calls and confirms the reports , states they and CHP are responding , but ETA is at least 15 min. Number of victims is unknown . The LT sends out the dispatch while you're still handling phone traffic , then as a dispatcher arrives , he says to load up , we're heading for staging . In your mind , you remember the responding LE units have to pass your station to get to the scene and there are automatic weapons out there . As you're about to roll out of station , a pickup skids to a stop , blocking you in , and the driver runs up to you screaming he's got a victim in his truck . It's a female in her early 20's and amazingly , she's walking behind the driver despite taking 5 hits . You assess the victim and find 2 shoulder wounds , 1 on each side , both with exit wounds , 1 wound right upper thigh no exit , 1 wound right lower jaw ( graze ) with an amputation of the earlobe , and amazingly , a wound left side of the neck , no exit , and the slug is easily palpated near the c - spine . Somehow , this slug has apparently missed the carotid and jugular , but there is signifigent blood loss in all areas , no airway comprimise , but pts LOC is rapidly decreasing . Vitals are ; b/p 90/p , pulse 130 , resp . 40 shallow , skins pale , cool , very diaphoretic . Nearest hospital 10 min. , medivac 25 min. , the county is just starting it's trauma system and ETA to trauma center is 30 min. READY , SET , GO .

[certguy]

Sorry guys ,
I forgot to tell you you have a BLS ambulance also .

Craig

[Paramajik]

Throw her in the most pt friendly vehicle. Administer oxygen NRB - dont gotta bag quite yet, but its comin. control all areas of hemorrhage, fer cuz she needs every little RBC that she has. Oh yeah, and haul ass.

[Topher38]

Remove the bullet from her neck with tweezers. j/k

IS THE SCENE SAFE!? Are any of them carrying a gun? Who are they and what happened?! Who was shooting? Where are the shooters? WHAT HAPPENED?

After all this is answered then:


Altered mental status?


Airway - O2 via non-rebreather
-Prepare for suction
-Have BVM ready
-Any blood in airway?
-What color is the blood coming from her neck?

Control the bleeding

-SKIN COLOR, TEMP, and CONDITION?
-Direct pressure, elevate
-Treat for shock

S ?
A ?
M ?
P ?
L ?
E ?

Is ALS available? How many more people are injured/shot?

[certguy]

Nobody has addressed how they're going to transport to the trauma center . A little hint ; She's obviously very unstable and you can get her to the closest ER even before a medivac can get to you . ALS eta is longer than transport also . This pt. amazes you , there's no airway comprimise and amazingly , no neuro deficit despite the proximity of the slug to the c - spine . There's an important concern with her that has yet to be addressed . Niether of the individuals in the pickup were armed , the hysterical driver is hard to get info from but you do find out there were 3 people in the mercedes that got shot at by a wild - eyed biker looking psycho with an M - 16 . No word on the other 2 pts. or any bystanders . Vollies are pouring into the station , nearly your whole dept. is there . As one of them is arriving , a van comes tearing by the station at a high rate of speed and nearly head - on 's him . It's coming from the area of the incident and the driver matches the description . An alert vollie got the license no. You've seen no LE units pass the station yet . You realize you have a potential MCI .


Welcome to my first shooting .

[rescuepoppy]

First thing notify dispatch an d incoming units that victims are at your base. If they can find you then so can the shooter. Dont do anything fancy load into the nearest rig and apply diesel treatment towaard nearest hospital. Stabilize c spine assess airway and work on bleeding control enroute. Notify hospital LEO an ALS unit of where you are going. The most important thing you need to do is to get yourself out of a possible deadly situation. I want LEO at the hospital for security and information and ALS will probably have to transport to a trauma center,

[Topher38]

First let me say, nice scenario ^_^ makes me think

[Code 3]

1. C-Spine precautions

2. Assess LOC

3. C/C and apparent life threats are diminishing LOC, major bleeding and shock. I'm going to get this PT supine, legs elevated 8-12", and toss a blanket on her.

A - Airway is patent for now and there's no airway compromise. I'm going to get an OPA and NPA on standby if she goes unresponsive.

B - Breathing rate is 40 pm with shallow chest rise. Due to the fact that this PT presents with both an inadequate rate and volume, I'm going to initiate PPV with a BVM @ 15 lpm. Suction unit on stanby.

C - Control any major bleeds that are found, assess pulse for rhythm and quality, and lastly check skins.

4. Conduct a rapid trauma assessment; looking for DCAP-BTLS and all that good stuff. I'm also going to take this time to get a C-Collar on the PT so we can log roll her on a board. During the log roll, I'm going to palpate the vertebrae and auscultate lung sounds on the back. In addition, I would check for S/S of a pneumothorax from the GSW's to the shoulders. I would also check for tracheal deviation as well before applying the collar.

5. Grab a set of vitals (PRBELLS)

6. Get a SAMPLE from the person that brought her in

7. Transport whether it be meeting with ALS or flight crew.

[certguy]

Rescuepoppy - puha ????? what's that ? You get the prize . You picked up on the c - spine issue the others before you missed . Code 3 did a good workup too . Topher , this was my first shooting pt. What a concept ! they come to you . It scares the ____ out of you though because you don't know what's coming next .


The pt. we had was quickly loaded into the rig , assessed , stripped - n - flipped , c - spined , NPA inserted , ventilations assisted , bleeding control , and treatment for shock . Lifeflight was requested before we even left the station to meet us at the hosp. ER staff was notified and worked to stabilize her prior to the flight . I'm glad to report she made it . Heck of a save for all involved .


When the scene was finally secured , we were notified by SO of 2 additional victims at the scene . Mutual aid ALS was requested , and our 2 engines and chief responded . We found 1 DOA ( the driver ) , and 1 shook up backseat passenger , shocky but otherwise unhurt . ( he must've become one with the floorboards ) No bystanders hit miraculously , though a couple houses took rounds from ricochets . Our pt. was the front seat passenger . It's amazing the backseat guy didn't get hit considering the stories you hear of M 16 rounds passing completely through cars .


According to witnesses , this was a drug deal gone bad . The folks in the car pulled up looking for drugs . The perp calmly goes in the house , comes out with the weapon , and opens up from the porch first , then the hood of the car . He then loads a small arsenal into the van along with his drugs and takes off . 2 hours later , he's involved in an MVA in a town about 100 miles away , but due to a glich in communications CHP has no idea he's wanted , so they let him go . He's apprehended 6 months later .

[certguy]

This was the LAST thing I'd ever have expected to respond to in our normally quiet rural area .


Craig

[certguy]

Okay , who's next , let's keep it going . Remember to keep it BLS .

Craig

[certguy]

Okay , who else has a good BLS scenerio ? Let's keep it going .

[Topher38]

You are dispatched to a home on the southern part of town for a "dyspnea". You and your partner hop in the rig, and within 7 min arrive on scene to find lights on in the home and door unlocked. You knock on the door and there is no answer, You radio dispatch to assure you have the right address, "address is correct. You look in the window and see a older man, not exactly elderly but older (45-50) sitting in a chair with his back to you, he appears to be watching TV.....go.....

[lcbjr3000]

That could be a scary situation. I would speak or yell from the door outside and see for a response. If i get none i go back to rig and get pd there stat. He could easily have a weapon in his hand and just waiting to kill someone. Until i know scene safe im not going near him

[certguy]

Gee , thanks topher . I'm 48 and I don't consider myself THAT old ! My first thought would be to find out from dispatch who the RP was - the pt. or someone else . If it was a second party and they're nowhere to be found , pull out and stage till LE clears the scene , this may be a crime scene . I would request LE code 3 JIC ( just in case ) . I would get a REAL good look at what I could see of the scene looking for anything that could indicate danger . If the scene looks safe , the RP was the pt. and we have additional eyes on scene ( engine or LE ) , we would cautiously enter keeping in mind the type of call and pt. may have passed out or coded . If anything at all looks hinky , we back out till LE clears . For all we know , pt. may be deaf and doesn't realize we're here . Once pt. contact made , check ABC's and go from there .

[Topher38]

That could be a scary situation. I would speak or yell from the door outside and see for a response. If i get none i go back to rig and get pd there stat. He could easily have a weapon in his hand and just waiting to kill someone. Until i know scene safe im not going near him


Good job you both didnt die. Originally if you didnt check with PD or check for scene safety which most people on these scenarios ignore, you would have been dead.

You go back to your rig and soon PD arrives, they sweep in and find the man with a loaded shotgun, the man fires at the officers shot dead center in the chest and grazing another officer in the arm, the "older" man in the wheel chair is killed by the 3rd officer entering. More PD arrives on scene. And declares the scene safe but now it is being turned into a crime scene, You hurry in to help to injured/dieing officers and "older" fella. Another ambulance has been dispatched to your location.

You walk in. And.............Ill tell you what you see shortly I gotta go to school, The scenario is far from over. be back soon.

[Code 3]

You walk in. And.............Ill tell you what you see shortly I gotta go to school, The scenario is far from over. be back soon.

The suspense is killing me :lol:

[certguy]

Topher , hate to say it , but you've been watching too many movies . When did the "older " guy ( about my age ) go from sitting in a chair to a wheelchair ? Good imagination though . Don't get into the trap of thinking every call the pt. can't get to the door and is quiet on could be an ambush . There are a lot of " older " and elderly folks out there living alone and the type of scenerio you laid out could also be a very routine call , up until the shootout that is . It's always good to get PD cover if in doubt . Saves time if you wind up having a DOA .

[Topher38]

I never said he was in a wheel chair. I said he was in a chair.

I made this scenario to be a fun one, not an "everyday call".

Now I have lost my traine of thought :huh:

[Topher38]

Wow wait I did say wheel chair. I have no idea I did, I musta been zoning out. My bad ^_^

[certguy]

Don't you just hate it when your train of thought jumps the tracks??? What were we talking about ??? Oh yeh , the scenerio , okay , perp's dead , 2 officers down . Does the officer hit in the chest have his vest on ? Did he get hit with buckshot , a rifled slug , or maybe he got real lucky and it was birdshot . A dead center hit , even if it didn't get through , could produce internal trauma . We triage both officers , check ABC's , and go from there with appropriate treatment .


Hey Topher , sorry I gave you a bad time ( just in fun ) . It's good you're getting into the scenerios . They're good practice for your thought processes . What I was trying to tell you earlier and probably did a lousy job of it , was that sometimes new people can get too concerned with thier safety and go overboard . Don't fall into that trap . You can't always have PD with you and if you call them too often when they're not really needed , they could become complacent , think it's just another pain in the backside call and take thier time , which would be a really bad thing if you really need them . Over time , you'll develop your personal spidey - sense . That sixth sense that tells you something's not right here . If that happens listen to it , but be aware that sometimes you can't always tell a dangerous scene before you go in . Pts. can and will surprize you at times .

[gcfd_rez31]

Call time: 2245

ALS rig dispatched to approx 55 y/o female, welfare check. Pt hadn't been heard from in days, and neighbors were getting worried.

Crew is thinking that pt isn't going to be doing so well when they arrive on scene. [OBVIOUSLY...]

Crew arrives on scene to find pt laying in her bedroom (unattended). There is urine, pecies, vomit, and blood on the floor. Pt not moving.

BP = 100/P
SpO2 = 88
RR = 12 shallow
HR = 72 tacky


any questions??? lemme know..... GO!

[certguy]

Okay , first things first . Is the scene safe ? Is there any evidence of a possible crime scene ? Is the pt. conscious ?What am I looking at on assessment ? Where's the blood coming from ? Does she have a medic alert tag / vial of life ?

[BossyCow]

She's breathing, but not well, hearts beating, but not effectively...

What's her general appearance, skin color, visible injuries? What is going on around her.. sign of struggle, fall, gun? Where's the blood coming from?

While I'm waiting for your answers on this, I would have her on O2, NRB cranked up.. I'd have ALS on the way, and be hooking up the monitor. I'd be checking a temp, doing a Blood glucose check. At this point.. just trying to get as much infomation as possible... I'd have someone looking for pill bottles.. to see what meds she's taking for an indication of possible med hx. I'd want her in the rig moving towards ALS as fast as possible.

Without knowing the location of the bleeding or volume. is it from a rectal bleed? Trauma? Vomiting? Stoma issues?

Oh wait.. are the body fluids hers??? lol

[skyemt]

HR= 72 TACKY


what does that mean?

[AZFF/EMT]

72 tachy? Maybe means thready/weak? Don't know but 72 is not tach.

[AZFF/EMT]

I would assure my own safety/BSI.
Unknown reason the patient is on the ground so C-spine precautions at least to start. Is she supine or prone?
I would move her on to a backboard(support for cpr if needed, she sounds like a pre-coder to me.

A-Check her airway, prepare to suction if any vomit remains inside.
B-High flow o2, consider dropping an OPA if she'll take it, if not NPA.
C-If pulse is weak and thready(not tachy at 72?) Hope o2 helps and monitor her.

Obtain as much info from the scene as possible, meds, alert tags, family if around(someone called 911)

I would want a blood sugar.

If your medics can start lines I would set-up for an IV.

What other finding are there?

[wolfwyndd]

I THINK HR = 72 TACKY Means Heart Rate is 72 and tachycardic.
HOWEVER, I'm not sure how someone could consider a heart rate of 72 as tachycardic. Generally tachycardic isn't considered till it gets to about 100 beats per minute. I'd consider 72 closer to bradycardic, which is about 60 beats per minute or less.

[skyemt]

I THINK HR = 72 TACKY Means Heart Rate is 72 and tachycardic.
HOWEVER, I'm not sure how someone could consider a heart rate of 72 as tachycardic. Generally tachycardic isn't considered till it gets to about 100 beats per minute. I'd consider 72 closer to bradycardic, which is about 60 beats per minute or less.

72 is not bradycardic, nor tachycardic...

i don't think in adults tachycardia is a relative term... i think it is HR above 100...

did the poster mean thready?

[gcfd_rez31]

sorry everybody on the tacky. i meant thready... (someone around me said tacky and i typed it lol)

anyways...

scene IS safe.

skin color = pale
no visible injuries.
no gun or weapon.
blood came from vomit.

BGL = 76

caller was concerned neighbors that hadn't heard from pt for a day or two.
unknown if pt is normally living independently or not.

unknown hx.

meds = hypertension medication bottle on kitchen counter
[remember, pt located in bedroom]

this crew is als... but medic wants emt-b to assess and decide on course of action [to the best of his scope] -- besides just turning it over to als.

***FORGOT TO MENTION PT IS APPROX 350 LBS. - SRY LOL***

[BossyCow]

Is it bright red blood or coffee ground emesis?

[Topher38]

Is it bright red blood or coffee ground emesis?

How about AVPU?

Is this patient responsive at all?


A Oxygen via nonrebreather 15L / min
-N.P.A. (12 and shallow)
B Hows the breathing? (any snoring? gurgling?)
-Suction. If the pt vomited.
C Any Obvious bleeding on the pt?

What does the patients mouth smell like? (any vomit around the corners?) Funny sounding, i know but that vomit may not be from this paticular episode.

Skin is pale
pulse is still 72 thready
B/p ???? What is it with ascultation?
Respirations 12
Pupils?

ALS (moniter)

[gcfd_rez31]

pt is slightly responsive.

pt is having snoring resperations.

no obvious bleeding. just the blood in vomit.

pt's mouth smells like vomit.

[JPINFV]

Examine mouth for anything less to suction and suction PRN.

Temp?
Edema?
JVD?
Indications of hx of EtOH abuse?
Color/consistency of vomit?
Incontinence?
Name of HTN medication?

[certguy]

Are there any indicators of CVA or fall ? Something nobody's mentioned also is that a pt. down for extended periods on a tile floor in there own urine/feces will most probably be hypothermic also in addtion to the other problems . What is the volume of blood loss ?

[sabbymedic]

Ok well now you have to hold the loose bowel feeling in and get to work. Activate any and all resouses available including air ambulance. If scene is secured get more resources out there to act as triage set up. Two or three individuals need to stay with this victim the rest need to go to a secure scene to set up triage as mentioned above. ABC's good. Prior to PHTLS survey someone should be doing very careful C- spine maintenance. Next PHTLS survey to look for any life threatening wounds and control any and all serious bleeds. O2 Blanket and vitals if you have time, remember this pt needs a surgeon. If you are not too worried about ICP elevate the legs to maintain BP or if you are able to establish IV start large bore IV with an infusion of 20ml/Kg 0.9% NACL remember to evaluate lung sounds prior to fluid administration and check after every 250cc infusion. This pt also needs to be boarded due to gun shots and possible spinal injuries. If this pt is able to be transported directed to a trauma facility right away by land transport and waiting for air evac would take too long send by land. This pt would be part of your triage system that will be taking place at the original scene something to remember as all your resources will be heading that way so you will need to notify dispatch of this. Can't really think of much else other than monitor vitals every 5 min if No IV then use Mast Trousers if available our service does not use them we have to elevate legs, oh yeah drive fast.

[JPINFV]

Just wondering, does anyone have any evidence that trendelenburg actually works? The closest I've seen to validation of that position is a "it might have increased blood pressure in 1 subject with no increase of cardiac output." Besides that, every single study failed to come close to rejecting the null hypothesis.

[skyemt]

Just wondering, does anyone have any evidence that trendelenburg actually works? The closest I've seen to validation of that position is a "it might have increased blood pressure in 1 subject with no increase of cardiac output." Besides that, every single study failed to come close to rejecting the null hypothesis.

i attended a class at the JEMS conference that referenced this... they cited a study (don't know which one), the results were only a minimal difference in preload, and no real measurable increase in CO.

one of those things that's in all the protocols (at least in NY), but i, like you, have not been able to find any reference to a real improvement with this position.

[sabbymedic]

Ok. There may not be a big increase in cardiac output but if I read correctly the pt has a BP of 80 palp. The BLS patient care standards says to use this position to help eleviate the effects of hypotension which in this case if you do not have IV access at least you are doing something other than watching the pt die. That was the point I was trying to make doing something is better than nothing.

[JPINFV]

Doing something with no scienfitically measurable effect is better than doing nothing?

[sabbymedic]

I am not sure what your standards are but over here in Canada and in Ontario we follow the BLS patient care standards. Trendellenburg does work I am not sure what studies say it does not but it does work to bring up a pt's BP. When you have a hypovelimic pt it is one of the only things you can do to elevate BP. This procedure has been around for years and would not have been if it did not work to some degree. I agree it is not the best method but if you don't have any other options you need to do something. The pt does not always read the book. Scientifically proven or not proven studies are not always right that is why medicine is called a practice.

[skyemt]

I am not sure what your standards are but over here in Canada and in Ontario we follow the BLS patient care standards. Trendellenburg does work I am not sure what studies say it does not but it does work to bring up a pt's BP. When you have a hypovelimic pt it is one of the only things you can do to elevate BP. This procedure has been around for years and would not have been if it did not work to some degree. I agree it is not the best method but if you don't have any other options you need to do something. The pt does not always read the book. Scientifically proven or not proven studies are not always right that is why medicine is called a practice.

if you like, you can go to the website of Dr. Bryan Bledsoe... he opines that it is something in EMS that was anecdotally based, and he cites studies showing no improvement in the position.

so to say it "does work"... what is that based on?

[sabbymedic]

That would be based on experience. I have used it on pt's and it does have positive effects. Hospital beds, ambulance stretchers all have Trendelumburg positions and have for years but what you are saying is that all that is there for the heck of it. Our doctors that run our base hospitals still say that it can be used if you are not worried about ICP. I personally have used it several times and have go an increase in BP which is what you want to keep oxygenated blood going to the heart and lungs and brain. Not trying to argue but saving a pt's life is not based on case studies it is doing what you can to save a life.

[JPINFV]

Link to Bledsoe's reveiw
http://www.merginet.com/index.cfm?pg=trauma&fn=TrendelenburgPosition


WISE-2005: orthostatic tolerance is poorly predicted by acute changes in cardiovascular variables.
Twenty-four (24) healthy women from 25-40 years of age underwent orthostatic tolerance tests consisting of passive tilt and lower body negative pressure before and after completing 60-days of continuous -6 degree head down tilt bed rest (HDBR). Prior to HDBR, participants were assigned to one of three groups: control, exercise or nutrition. We aimed to identify any acute head up tilt changes in mean arterial pressure, pulse pressure, total peripheral resistance, cardiac output, stroke volume, or heart rate, which might predict tolerance or changes in tolerance with HDBR. Generally, these attempts were largely unsuccessful. The results indicate that the mechanisms of orthostatic failure are not strongly related to the way in which the body responds to the initial challenge. Additionally, the observation that some variables were predictive of tolerance before and not after tilt may indicate a change in the strategies used to maintain blood pressure, or differential adaptations to HDBR.
http://www.ncbi.nlm.nih.gov/pubmed/18372701?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum

Myth: The Trendelenburg position improves circulation in cases of shock

Conclusion

The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicine.

http://www.caep.ca/template.asp?id=DF61785B363D4460835A593243E70058

to note, that last one is from Canada.

Not trying to argue but saving a pt's life is not based on case studies it is doing what you can to save a life.
How is your anecdotal evidence any different than a case study? Do you still use massive amounts of fluids, or are they practicing permissive hypotension in trauma patients in Canada? I bet there are plenty of medics who have seen patients walk out of a hospital after maintaining a blood pressure in the 120s due to fluids alone. That doesn't mean that fluid resuscitation is still the standard of care. Personally, I prefer to practice evidence based medicine as much as possible instead of emotion based medicine.

Protip: Most BP cuffs have a standard of error of +/-3 mmHg. Therefore, any true change has to be at least 6 mmHg difference. (100+3= 103 106-3=103. Hence the BP could have been both 103 both times.

[sabbymedic]

Like I said before I was not trying to start an argument. I mentioned that there were potential risks in the use of this position especially in ICP. If you don't use it, well that is up to you. I have used it in pt's with low BP due to blood loss and it has worked. I am not talking about huge leg elevation here I am only talking about 6-8 inches with pt laying flat. This job is teaches you a lot about what you learn by experience and what you learn in class and out of books. If something works for you and helps the pt then at the end of the day as long as you are not breaking any of your Base Hospitals rules then we are doing our jobs as medics. That is my opinion anyway.

[JPINFV]

Psuedotreatments (treatments that have failed to prove effect despite clinical trials) have no place on an ambulance.


Just for kicks, another review article (not case study, not anecdotal evidence)
Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T?
American Journal of Critical Care. 2005;14: 364-368
• Conclusion The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

So, I ask again, does anyone have any evidence, scientific evidence, that shows that Trendelenburg is useful for combating hypotension? Especially the foot lift/non-body tilt one that is used on prehospital stretchers?

[Arkymedic]

Psuedotreatments (treatments that have failed to prove effect despite clinical trials) have no place on an ambulance.


Just for kicks, another review article (not case study, not anecdotal evidence)
Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T?
American Journal of Critical Care. 2005;14: 364-368


So, I ask again, does anyone have any evidence, scientific evidence, that shows that Trendelenburg is useful for combating hypotension? Especially the foot lift/non-body tilt one that is used on prehospital stretchers?

What does your protocol say to do? If it says to use then its in your best interest to do so, despite your personal feeling. Your personal feeling and research does not stand up in court like a protocol book does.

[JPINFV]

Well, to be purely technical, the only written protocol for the basic level is to achieve rapid advanced care for critical patients, including transport if paramedic ETA is longer than transport time. Crazy, I know, but that's the system. As far as paramedic protocols are concerned, trendelenburg is not addressed in either the trauma (http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/t05.pdf) or non-traumatic (http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/m45.pdf) shock protocols. Mind you, this is the same system that feels that a written protocol is needed for paramedics to use a pulse ox (http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/pr65.pdf) and that the paramedics are too stupid to interpret a 12-lead. (http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/pr105.pdf) So I'm sure if the medical director thought that the trendelenburg position was worthy of pursuing then it would be included.

Your also assuming that all systems require cookbook style systems. Some systems treat their protocols as guidelines, not an automatic treatment. (http://www.rivcoems.org/downloads/downloads_documents/Protocol102904/7000.pdf) So 'deviating' is not always a bad thing guaranteed to get a provider in trouble.

*note: All links lead to a .pdf file.

[sabbymedic]

In Ottawa were I work we have protocals that we follow set out by a Base Hospital. We are trained to be clinitians not technitions. Can we deviate from our protocols? You better be sure that you can cover yourself before doing so because you are betting your mortgage if you do. As Paramedics we practice under a doctors lisence and I don't know too many doctors that would be willing to lose it because of Paramedics who don't know how to work in their scope of practice. Yesterday I referred to the BLS Patient care standards and those are set out in Ontario Canada by the Ministry of Health. If we do not practice within those guidelines this is where we will lose in court. As far as Trendelenburg I read some of the studies you spoke of or read some of it I did not have time to finish all and I find it very interesting. Our Base Hospital states that the use of raising the legs should be used at the Paramedics discretion but use carefully due to possible complications with SOB and ICP this I already knew and have for years. After all do we take respiratory pt's and lift their legs above the heart? No!! Why because it makes it harder to breath common sense. Same applies for persons with a head injury raise the legs increase blood flow to the head possibly causing further increase in ICP then we get into the old seizure coma death scenario. You asked if people had scientific evidence and a couple of times I mentioned that I have used the position with persons with low BP and had a successful outcome an increase in BP. Not scientific in a book but real life. I may not be a medical student or have a university degree but I am also not stupid. I have been a medic for a while now and have to rely on my training and my experience. That was the point I was trying to make. The whole scenario that was on here was fantastic that is why I replied to it because that is what I thought the point was, for people to reply to it giving their view on what they would do. So once again if I offended I am sorry.