First time CPR

[mycrofft]

Would an emergency spinal tap with manometry help?

Or even just opthalmoscoping the fundus of the eyes for flattening...probably too late a finding, like waiting for Battle marks.

I tell you, emergency services needs to be folded into the mainstream of the hospital and not made to be a keyhole to try to resist the tide, with appropriate imaging and surgical resources on hand and not competing for other departments' use for them.

 

[Veneficus]

Or even just opthalmoscoping the fundus of the eyes for flattening...probably too late a finding, like waiting for Battle marks.

I tell you, emergency services needs to be folded into the mainstream of the hospital and not made to be a keyhole to try to resist the tide, with appropriate imaging and surgical resources on hand and not competing for other departments' use for them.

Better late then never, but it might work if you actually know what you are looking at. (considering the lack of opthalmoscopy here, I'm betting its even less in the US)

If you were really desperate you could continue CPR with a repeat head scan.

But no matter what you find, you would still have to do something about it.

What really is the icing on the cake here I thought was the use of epi. Shutting off the afferent arterioles sounds like it would reduce bleeding in the brain. But only because you were shutting off the blood supply to it.

Slight flaw in the logic if you ask me.


As for intergration of emergency services, I am seriously wondering if perhaps Emergency Medicine as a medical specialty is really useful.

 

[boingo]

As for intergration of emergency services, I am seriously wondering if perhaps Emergency Medicine as a medical specialty is really useful.

Dr. Copass in Seattle would say no, hell, he's a neurologist and runs an ED like a champ, and runs an EMS system on top of that. He don't need no stinkin EM doctors.

 

[mycrofft]

We're off topic, but yes!

ER's are separate because of history and politics, not pragmatic realities.

As for epinephrine...why not just have a carotid tourniquet? Or that cute judo lapel choke where you curl your knuckles into the carotid valleys alongside the trachea?

OP, you guys did the best you can, sometimes you find yourself playing for points 'cause the win just isn't coming.

 

[yotam]

Hello,

So, I am a EMT student about to be completed with the course, however last night I was doing one of my ER clinical rotations when something occured. A 40 yr old came in for bumping his head. Ran him through the CT and nothing showed on the scan. He had no complaints and was in the ER going on three hours. Then he started to having respiratory problems and boom he went into serious brachycardia and unresponsive. I went in and began chest compressions, while they began to bag him with the bvm. Anyways, it went on for awhile and he got itubuated, push meds, etc, but they ended up calling it. It didn't hit me at the time but when I drove home it hit me and that's is all i've been thinking about. Has this happened to you guys/ladies your first time on losing a patient that was tagged "green"?

oh god, another emt with "a soul"...

seeing to my virtual peers and raise; the main "shock" you're experiencing stems from cognitive dissonanse of "we're trained to save lives but fail to do so...". The correct fraising should be "we're trained to do our very best with the knowledge and training we possess". Seemingly, realizing that should resolve this dissonance, and eventualy it does, to some extent (in some more that others), but it does takes time and some extra layers of dermis.


And i'm in for smallpox... it fits nothing of the symptoms and highly unlikely- a perfect candidate.

 

[zmedic]

Dr. Copass in Seattle would say no, hell, he's a neurologist and runs an ED like a champ, and runs an EMS system on top of that. He don't need no stinkin EM doctors.

Yeah, he ran it so well he got his emergency residency de-accredited. Now that he's gone the residency is coming back.

I think emergency medicine is totally justified as a specialty, especially as we are starting to try and contain medical costs. It isn't efficient to CT and have a neurosurgical consult for every patient who hits their head. OB/GYN doesn't need to see every patient with pelvic pain. Etc etc.

Emergency physicians are experts at the evaluation and stabilization of the undifferentiated patient.

As to this case, emergency physicians used to be trained to do burr holes. I don't think that's super useful at most places because you have a few minutes to get a patient with a head bleed to surgery or get neurosurg down to do a burr hole. A patient in cardiac arrest from penetrating trauma doesn't really have any time to wait. I think it's more likely this patient went into cardiac arrest from whatever underlying medical problem rather than crashed from a huge head bleed.

 

[Veneficus]

Emergency physicians are experts at the evaluation and stabilization of the undifferentiated patient.

Unfortunately, the more I learn, the less convinced I am.

From my current endevors in researching identification and treatments for vital organs involved in shock pathology, the "stabilizing" treatments of the ED look more like glorified paramedicine.

In the seriously injured patients, fewer and fewer these days, surgery whisks these people away almost instantly. At the larger academic centers they are often in the ED on patient arrival. What is the point of having an EM in the trauma bay then? None that I can think of. None that I have seen spending years in a major trauma center in the US.

In a seriously ill medical patient, in that same center and I am guessing many other larger centers, shipping the patient off to the ICU ASAP is the goal. Where an intensivist will start looking for, measuring, and treating the specific parameters of disease with treatments not even in the ED.

The need for the emergency specialist is really because of the system as far as I can tell, not the medical necessity, and every one of my recommendations for school were written by EMs. My bosses where I teach are EMs. Many of my friends are as well. It just seems to me that the EM is what is needed outside of the major academic medical centers, not in the place where a host of experts are available 24/7.

All it does is add another level.

Really does it take an emergency doc and an interventional cardiologist to treat ACS? No. But that IC would have to walk a few feet from his lab.

Does the PID patient at 3am need an OB/GYN? No, but she doesn't need anything other than a proficent GP either.

It just seems to me that what the EM is really doing is just functioning as an emergency admitting specialist rather than actual medical treatment.

Some of the arguments for are actually as pathetic as the EMT vs. Medic ones. "An intensivist needs all kinds of special tests and gadgets." Yea, because they wouldn't know how to hang a bag of fluid otherwise in a timely manner right?

As to this case, emergency physicians used to be trained to do burr holes. I don't think that's super useful at most places because you have a few minutes to get a patient with a head bleed to surgery or get neurosurg down to do a burr hole. A patient in cardiac arrest from penetrating trauma doesn't really have any time to wait.

Like I said, in those large facilities, the EM is really superfluous. In the smaller facilities, which may or may not have a surgeon available. Probably don't have a highly advanced ICU and lots of experienced staff on life threatening trauma, once you open a chest and "stop the bleeding," Which I have only seen a survivor 1 time in dozens of cracked chests, what then?

Planning to call people from home so they can formulate a plan or call an expert? Plan to ship this person with an open chest to a bigger center? Maybe close the chest and ship it out so it can be reopened?

I would really like to see some numbers showing the effectiveness and benefit of that in the civillian world.

It would be great if EMs could triage people accordingly and not simply run every test available to them because of defensive medical practices. But from what I see today, you could set up a "run all tests" protocol, describing a variety of presentations and have a tech initiate it while the expert who will eventually care for the patient walks down stairs.

I acknowledge the systemic need, but I cannot find actual medical justification for it.

 

[usafmedic45]

Probably don't have a highly advanced ICU and lots of experienced staff on life threatening trauma, once you open a chest and "stop the bleeding," Which I have only seen a survivor 1 time in dozens of cracked chests, what then?

One of the surgeons I used to work with had a saying: "Never ask a question you don't want the honest answer to. Never open a chest unless you really want to deal with what is broken in there."

Plan to ship this person with an open chest to a bigger center? Maybe close the chest and ship it out so it can be reopened?

I hate to advocate for that idea, but the military does it all the time with abdomens. God bless damage control surgery.

 

[Veneficus]

I hate to advocate for that idea, but the military does it all the time with abdomens. God bless damage control surgery.

Abdomens are left open regularly for a variety of reasons.

But things like peritonitis is considerably more managable than an osteomyelitis of the sternum. Among a host of other complications.

Just as we critisize EMS for considering survival to the ED a save, medical professionals cannot claim survival to the ultimate care destination as a save if they die in it. No matter what skills are utilized.

 

[usafmedic45]

But things like peritonitis is considerably more managable than an osteomyelitis of the sternum. Among a host of other complications.

Very true, but then again, I very seldom if ever saw a midline sternotomy in the ER. Usually it was just a right or left anterolateral approach.

Just as we critisize EMS for considering survival to the ED a save, medical professionals cannot claim survival to the ultimate care destination as a save if they die in it. No matter what skills are utilized

Very true, but if it takes a thoracotomy to get the patient to care that can save them, isn't that justifiable even given the chance of giving the patient osteomyelitis, mediastinitis, etc? (BTW, I see your point....just wanting to play devil's advocate here).

 

[mycrofft]

One reason for dedicated receiving (if not officially named "Emergency") staff

They can (potentially) know the most common presentations and the stopgap measures occasionally needed to get them into more-definitve care still with vital signs. Where newbies will be using an otoscope while the pt is bleeding out of a posterior thorax wound, the seasoned pro will have the subject flipped and evaluated when (s)he suspects a GSW, as a loose but quick example.
As for having to move patients after procedures are started, move the "emergency" section closer to the OR, or vice versa.
And get rid of that expensive landscaping and executive furniture! That'll pay for it.

 

[zmedic]

The hard part of emergency medicine isn't the really sick patients, but rather deciding who is potentially sick. You can't CT every patient with chest pain because they might have a PE. You have to have some data and training to decide who needs a work up for mesenteric ischemia and who can be discharged. That is what an emergency residency teaches you. The work up of acute abdominal pain in the ED is different from how a GP approaches abdomnial pain in their office. Could FM docs or GPs muddle through emergency care? Yeah, but not nearly as efficiently as an EM doc, nor with as much data to back up their decisions on who is safe to be discharged and who needs to be admitted.

Maybe your problem is that you've been working at a hospital where people are being sent to the ED as direct admits or from their docs with a diagnosis already in place. But where I work it's a lot more than just triaging people or being an admit monkey.

What did you match into by the way, since you don't really see the value in EM?

 

[Veneficus]

Very true, but then again, I very seldom if ever saw a midline sternotomy in the ER. Usually it was just a right and left anterolateral approach.

fixed it for you.

Very true, but if it takes a thoracotomy to get the patient to care that can save them, isn't that justifiable even given the chance of giving the patient osteomyelitis, mediastinitis, etc? (BTW, I see your point....just wanting to play devil's advocate here).

It's like all the life saving arrest care.

If they die in the ICU, it is not life saving.

 

[Veneficus]

The hard part of emergency medicine isn't the really sick patients, but rather deciding who is potentially sick. You can't CT every patient with chest pain because they might have a PE.

It really seems to me like they do. Along with every abd pain and everyone who hits their head on a headboard of a bed.

Maybe your problem is that you've been working at a hospital where people are being sent to the ED as direct admits or from their docs with a diagnosis already in place. But where I work it's a lot more than just triaging people or being an admit monkey.

"The hard part of emergency medicine isn't the really sick patients, but rather deciding who is potentially sick."

Forgive me, but isn't that triage?

What did you match into by the way, since you don't really see the value in EM?

I have not yet reached the point of applying for match. I haven't decided if I am even going to return to the US, and if I do, it will only be because they are making a better offer for what I want. (Which is not, and never has been EM)

But my opinion is formed from working in both systems, EM as a specialty and ones where the ED is staffed by other specialists. Have you had the opportunity to compare both systems first hand for any length of time?

My observation as I stated earlier, is that EM is required by system set up in the US.

There seems to be no trouble with the cardiologists, anesthesiologists, trauma surgeons(who are orthopods first), and pathologists I have seen here working in the ED as the primary provider. The triage doesn't seem much different and the treatments available are more comprehensive than in any US ED I ever saw. Follow up can also be accomplished in the ED. Which does seem to better benefit patients in regards to access and scheduling.

 

[usafmedic45]

fixed it for you.

It's been a while since I've seen them "clamshell" someone like you're describing.

It's like all the life saving arrest care.

If they die in the ICU, it is not life saving.

Statistically, if they present to hospital with vitals or have been down less than ten minutes, they have a decent chance to survive to hospital discharge (see Moore et al: J Trauma. 2011 Feb;70(2):334-9 and Kalina et al: Del Med J. 2009 May;81(5):195-8.).

 

[Veneficus]

It's been a while since I've seen them "clamshell" someone like you're describing.

In my experience that is not the initial intent, but once they get one side open they decide access is bad and then "extend the field" which basically becomes partial or eventually total.

I have seen both EMs and surgeons do this so I think it is more the problem of the procedure than the actual person performing it. But as I said, EM lacks the capability to go to OR and clean up after themselves and if yo suggested they start, you'd hear all kinds of crying about resource utilization. AKA, maintaining that 32 hour work week and billing by volume.

Statistically, if they present to hospital with vitals or have been down less than ten minutes, they have a decent chance to survive to hospital discharge (see Moore et al: J Trauma. 2011 Feb;70(2):334-9 and Kalina et al: Del Med J. 2009 May;81(5):195-8.).

How often does that happen?

That is like saying if you die outside the door and the triage nurse notices.

 

[boingo]

In a large urban center? More than you think. The survival rates for ED thoracotomy are not great, but there are certain patients likely to benefit. Obviously if you crack every traumatic arrest your numbers would be terrible, but if you select patient based on certain criteria survival rates (to discharge, not from the ED) are pretty good.

I know of one local trauma center that uses strict criteria for ED thoracotomy. Pt needs to present to the ED w/vital signs or a narrow complex rhythm at a rate >40, penetrating trauma only.

Another hospital in the same city will do ED thoracotomy on blunt trauma as well assuming loss of v/s of less than 5 minutes, penetrating trauma with loss of vitals of less than 15 minutes, obviously their results are different.

 

[zmedic]

"The hard part of emergency medicine isn't the really sick patients, but rather deciding who is potentially sick."

Forgive me, but isn't that triage?
.

By that argument a good chunk of medicine is "triage." IM on the floor deciding who should go to the ICU and who should be watched, surgery deciding who should be operated upon, GPs deciding who need follow up with them for chest pain versus who needs to be referred to a cardiologist.

 

[Veneficus]

By that argument a good chunk of medicine is "triage." IM on the floor deciding who should go to the ICU and who should be watched, surgery deciding who should be operated upon, GPs deciding who need follow up with them for chest pain versus who needs to be referred to a cardiologist.

So help me out.

Aside from the system benefit of deciding who needs a bed and who can be sent home, what is the medical benefit to EM?

(I will also put this to my friends who are already EMs as well in the search for answers, but I would like to hear your take on it)

 

[zmedic]

The medical benefit is for those patients who we can either cure ourselves (like a simple UTI, sent home with antibiotics) or patients who that initial management is going to make a difference in outcome (early goal directed therapy for sepsis, correcting a potassium of 8.0 etc)

How much EM docs do depends a lot on where they work. Plenty of places we will evaluate fractures, do the pain control, and splint for out patient follow up. We are generalists, trained to work in the emergency department. It's like being a pediatrician or GP, there are things you can handle, things you need a specialist. Nobody tells GPs they are worthless because they could just send all diabetics to an endocrinologist, all hypertensives to a cardiologist etc.

You were asking if I've seen both systems, EM trained and general. I have. And I've seen what it looks like when residents from other fields are staffing the ED. They are slower, order more un-needed tests, and tend not to think in terms of worst case scenario.

I would point out that it matters what you mean by "other fields" running the ED. There were places where someone had done a residency in IM, but they only worked in the ED. After a few years of experience that person is a lot more like an emergency physician than having random IM docs in the ED once a month.