Subarachnoid bleed and hyperventilation

[TatuICU]

Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit. Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.

They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT. Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it. If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.

Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.

I would re-evaluate the education you received regarding ABGs. It certainly doesn't tell the whole story but it can sure tell you alot. And who said anything about throwing bicarb at people? Not sure where that's coming from.

 

[jwk]

I would re-evaluate the education you received regarding ABGs. It certainly doesn't tell the whole story but it can sure tell you alot. And who said anything about throwing bicarb at people? Not sure where that's coming from.

Ditto - ABG's can tell you a ton.

Hopefully nobody is throwing bicarb at anyone anymore without an ABG.

 

[JakeEMTP]

Your ETCO2 may be 35 with a PaCO2 of 80, you won't know till you have an ABG in hand.

I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for. The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field. Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation. Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.

To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.

 

[TatuICU]

I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for. The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field. Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation. Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.

To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.

can i ask how long you've been in actual critical care settings?

 

[usalsfyre]

I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital.

Or by iStat. That said, CCT is not about speed. I've run two hour scene times on CCT IFTs before, it took that much to be able to move safely.

You mention PaCO2. That value is from the artery. That is what the a stands for.

Got that, I've looked at ABGs once or twice .

The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number.

Unless there is a change in hemodynamics or alveolar status, the PaCO2 to ETCO2 remains the same. So if there's a PaCO2 of 60 and an ETCO2 of 55, it will be 40 and 35 respectively after changes.

I also can not think of one state that allows Paramedics to stick arteries in the field.

Not all of us are bound by what a state EMS administrator thinks we need to be doing. You can also draw off an a-line.

Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care.

Sometimes your giving your patient a death sentence by not optimizing them for transport. There is a time to fish or cut bait. However, taking a truly mismanaged CCM patient (and it happens more often than you think) and throwing them in the truck where you don't have the help, equipment or room to work without trying to at least start correcting the issues is negligent.

The heart and brain are not that forgiving.

Hence why CCT is a distinct discipline.

Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation.

The training needs to. Furthermore, ALS crews don't need to be doing ICU to ICU trips.

Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.

You lost me here. The will work short-term with a vent as well as an Ambu bag. Maybe better, because the breath is delivered in a far more controlled manner.

To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.

Knowing is sometimes half the battle. Some of us also carry the pharmacology to correct a lot of this.

I'm not sure where you took CCEMT-P. It doesn't sound like you were taught by true subject matter experts though, rather by someone who had a tenuous grasp of the material.

 

[Handsome Robb]

Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.

We use vents on KING tubes all the time without any problems. Sure they get swapped to an ETT when we get to the hospital. The KING and Combi by definition are rescue airways. Not definitive airways.

Is an ETT better? Yes. But our doc wants a KING during arrests, any other time it's an ETT.

 

[TatuICU]

I won't beat a dead horse as usalfyre has touched on most everything.

However, just to kind of expound on his final point, there is no real standardization when it comes to "CC"EMT-P. There are many "CC"EMT-Ps out there who got the designation after a laughable two week course taught by other "CC"EMT-Ps who think they have critical care experience because they transport vents and *gasp* more than 3 gtts.

Conversely, I've had the pleasure of having paramedics during an in hospital 6 month CCEMT-P program who have gotten to come recover CABGs with us, really learn about hemodynamics, really learn about ventilation, and in general get some actual critical care experience in dealing with a variety of situations. Those are people where there is actual continuity of care and I wish there was a different way to recognize them instead of lumping them in with the two-weeker wannabes.

In any case Jake, I would look into a different program.

You talk about "sticking" arteries and not being allowed to. How many critical care transports have you actually done? i ask because most critical care transports deemed critical enough to be called "critical care" transports usually have an art line to monitor BP which is very easy to draw off of. And as far as the "vents with fancy knobs" comment, I have to ask how you transport critical pts that are in APRV mode or other non-CMV/SIMV settings? If the critical care truck does not have critical care equipment, then it is not a critical care truck and should not bill as such.

 

[hyperlyeman1]

I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for. The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field. Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation. Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.

To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.

When did medics get labs?:glare:

 

[usalsfyre]

When did medics get labs?:glare:

On every CCT I do.

 

[hyperlyeman1]

What is the purpose of labs in the field, I get their importance in the hospital setting and their use as a diagnostic tool. But unless you have an extremely long transport time or are on an ift (in which case labs most likely have been done already), why waste the time to do them? In the event of a true emergency that would warrant their use, wouldn't our time be better served treating the patient instead of screwing around with labs? Just my .02

 

[JakeEMTP]

You talk about "sticking" arteries and not being allowed to. How many critical care transports have you actually done? i ask because most critical care transports deemed critical enough to be called "critical care" transports usually have an art line to monitor BP which is very easy to draw off of. .

You wanted iStats and ABGs in the field.

Correct. iSTATs would be useful in the field for a long list of reasons.

Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be.

A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.

I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.

You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment.

You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down you should be doing.

Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.

 

[hyperlyeman1]

You wanted iStats and ABGs in the field.



Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be.

A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.

I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.

You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment.

You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down you should be doing.

Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.

I likes new toys labs would be great as a diagnostic tool. As are blood pressures, rhythms, 12 leads and the 50 other things we have to worry about while upside down under a car. If we spent another 10 minutes obtaining blood and doing labs, we may be doing CPR instead of just using cpap. Our job is to get them to the hospital as fast as safely possible. Anything that delays that process can cause a negative outcome in our patients

 

[JakeEMTP]

I don't think any ER doctor is going to call an ICU doc just to put an art line in before they transfer a Subarachnoid bleed to another hospital either.

I have seen nurses telling the doc they need to order bicarb stat because of the ABG result and to be told how stupid they were by the doctor since they didn't have a clue about the rest of the labs such as anion gap or the medical condition. You can easily over treat the wrong thing by putting all your focus on just a handful of labs and knowing only the stuff from Paramedic school which alot of us should know that is only a small part of medicine knowledge. All the toys might sound great but if you aren't going to treat any of the lab values whats the point. You can really :censored::censored::censored::censored: up a patient by thinking you know it all from a few number on an iStat when your education does not support it. Try being a Paramedic first and getting that stuff right. The field isn't the same as an ICU so those who think they need all the toys to assess a patient are going to be disappointed as Paramedics.

 

[usalsfyre]

You wanted iStats and ABGs in the field.

They are indeed useful for both field and IFT calls.

Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be.

You want to talk about CCEMT-P class and critical care medicine? Welcome to the deep end of the pool. Your going to end up looking and feeling like an idiot a lot at first. I've been doing CCT a little while, and I still regularly feel like one. Coming in with a chip on your shoulder will make it worse.

A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.

We've moved well beyond the context of the field setting here. Not to mention there are some "field" paramedics who do do things like arterial sticks, ultrasounds, ect. Just because its not done at your shop doesn't mean it doesn't exist.

I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.

Yet you threw it out there as a qualifier.

You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment.

You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down you should be doing.

I'm rather fond of saying CCM could probably be done in a mud hut if the provider is good. I never questioned your physical exam skills, yet you seem to feel the need to question mine. I assure you I'm up to snuff in that area. I've worked with providers who peruse these forums. That said all of the things above make life easier.

Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.

Perhaps a commentary on your own inadequacies? The equipment mentioned is nothing about ego. CCT is based around one thing. Bringing an ICU level of care to transport the patient. If you can't provide that level because of your own knowledge gap you should not be doing CCT. Period. Full stop.

The biggest issue I see here is that your still thinking like a 911 FD medic with a 5 minute transport. CCM means thinking hours, days and even weeks down the road. That means making decisions in an informed environment with things like labs, imaging, ect available. You might be with the patient for an hour or more, seemingly small changes (that you may need to make) can have a profound effect. Its this understanding that differentiates the true CCM providers from the posers.

 

[TatuICU]

You wanted iStats and ABGs in the field.



Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be.

A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.

I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.

You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment.

You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down you should be doing.

Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.

Before I attempt to reply to the rest of this asinine babble, you do realize that in addition to working in an ICU, I'm also a practicing paramedic in a 911 system for longer than is care to admit. Also I find it mildly ironic that someone without an understanding of something like arterial blood gases, is calling other people's assessment skills into question. assessments are what lead to those things being ordered. And if you actually believe that RNs and RRTs in ICUs call physicians to order labs, diagnostics, etc in emergency situations then I would say that either A. You're angry for some reason and speaking illogically, B. you have little to no experience and thus have no frame of reference, or C. You are just completely out of touch with reality. By the time you have that physician on the phone you had better have answers and be in the process of stabilizing that patient. But then again, Ive worked with a ton of medics in my career that actually believe they are just as good as "mobile physicians" because "they don't need orders for anything" lol.

And you never answered any of my questions. Why?

 

[usalsfyre]

I likes new toys labs would be great as a diagnostic tool. As are blood pressures, rhythms, 12 leads and the 50 other things we have to worry about while upside down under a car. If we spent another 10 minutes obtaining blood and doing labs, we may be doing CPR instead of just using cpap. Our job is to get them to the hospital as fast as safely possible. Anything that delays that process can cause a negative outcome in our patients

I don't think any ER doctor is going to call an ICU doc just to put an art line in before they transfer a Subarachnoid bleed to another hospital either.

I have seen nurses telling the doc they need to order bicarb stat because of the ABG result and to be told how stupid they were by the doctor since they didn't have a clue about the rest of the labs such as anion gap or the medical condition. You can easily over treat the wrong thing by putting all your focus on just a handful of labs and knowing only the stuff from Paramedic school which alot of us should know that is only a small part of medicine knowledge. All the toys might sound great but if you aren't going to treat any of the lab values whats the point. You can really :censored::censored::censored::censored: up a patient by thinking you know it all from a few number on an iStat when your education does not support it. Try being a Paramedic first and getting that stuff right. The field isn't the same as an ICU so those who think they need all the toys to assess a patient are going to be disappointed as Paramedics.

Spare me the hyperbole. I've done a decade of 911 and can count on one hand I've been "upside down in a car". The number of truly time sensitive calls is probably <5%. A medic should be able to recognize these.

If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.

 

[JakeEMTP]

[

If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.

This was not about CCT to begin with. You and nurse Tatu wanted iSTATs in the field.

Just how many hours does your state require its Paramedics? Doesn't Texas only require 600? Others are barely at 1000. Does everyone in your 911 ALs have a bachelors degree in EMS? Everyone? You sure make your education sound superior to all of us. I bet most don't have a 2 year degree or even any college. It is usually those with the least amount of education who want to cut others down especially when they have already stated they know their deficiencies. Get over yourself and see that education for Paramedics isnt' that great so don't go preaching to me about mine. I know what I can and can not do but you don't seem to know what your limitations are.

Just how do you think all 911 EMS systems are going to provide istats on every truck? Hell most dont have 12 leads or ETCO2. Y

ou haven't said how it will make any difference for a field paramedic doing 911 calls. Are you going to expand all of the meds to be given? If you can not tell if a patient might be getting a low HCT or Hb by all of that red stuff on the ground maybe you should get an istat but I don't think that will make you a better Paramedic. Do you really need to get an ABG right after you intubate? I would rather have an ETCO2 and a stethoscope. By the time you do all of that you could be in the ER and the patient won't have to go through another poke at their artery. How many people do you need onscene while you do all of this stuff? I have been doing this a long time and have managed to get patients to the ER just find without wasting time on things that I can't treat. What next? A CT scanner on every truck.

I don't think TatuICU deserves a reply with her attitude towards Paramedics. Not all of us believe they are doctors with the exception of usalsfrye.

 

[hyperlyeman1]

Spare me the hyperbole. I've done a decade of 911 and can count on one hand I've been "upside down in a car". The number of truly time sensitive calls is probably <5%. A medic should be able to recognize these.

If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.

So are you suggesting that we draw labs on every call when you know full well the hospital will redo them and disregard ours? And those time sensitive calls... The ones where labs matter, are the ones where it would be impractical to draw. And tell me again how said labs would change our treatment? My protocols don't specify what to do for a patient who's abg is off, but they do tell me what to do when they are in respiratory distress. And I know that the patients abg will be off if they are in respiratory distress. So the abg in effort will only tellus something we already know, correct? So again why waste time?

 

[TatuICU]

[

This was not about CCT to begin with. You and nurse Tatu wanted iSTATs in the field.

Just how many hours does your state require its Paramedics? Doesn't Texas only require 600? Others are barely at 1000. Does everyone in your 911 ALs have a bachelors degree in EMS? Everyone? You sure make your education sound superior to all of us. I bet most don't have a 2 year degree or even any college. It is usually those with the least amount of education who want to cut others down especially when they have already stated they know their deficiencies. Get over yourself and see that education for Paramedics isnt' that great so don't go preaching to me about mine. I know what I can and can not do but you don't seem to know what your limitations are.

Just how do you think all 911 EMS systems are going to provide istats on every truck? Hell most dont have 12 leads or ETCO2. Y

ou haven't said how it will make any difference for a field paramedic doing 911 calls. Are you going to expand all of the meds to be given? If you can not tell if a patient might be getting a low HCT or Hb by all of that red stuff on the ground maybe you should get an istat but I don't think that will make you a better Paramedic. Do you really need to get an ABG right after you intubate? I would rather have an ETCO2 and a stethoscope. By the time you do all of that you could be in the ER and the patient won't have to go through another poke at their artery. How many people do you need onscene while you do all of this stuff? I have been doing this a long time and have managed to get patients to the ER just find without wasting time on things that I can't treat. What next? A CT scanner on every truck.

I don't think TatuICU deserves a reply with her attitude towards Paramedics. Not all of us believe they are doctors with the exception of usalsfrye.

This post is nothing but one non-sequitur after another. Cute with the "her" comment, but if there is anyone in this thread acting like a little girl with their feelings hurt, it sure isn't me. Neither usalfyre or myself made the argument for iSTATS on every call. You're making yourself out to be some sort of "critical care" transporter which you obviously are not. An actual critical care transport can take place on the ground over the course of several hours, state to state, etc. It is in these instances where it would be useful and also prehospital when your transport times to a facility are greater than 45-60 minutes. Once again, I'd be willing to bet I've been a practicing paramedic far longer than yourself so my attitude toward paramedics is a bit more in depth than the hurt feelings assessment you're offering.

And I do believe usalfyre holds a real degree. As for myself, I received my AS as a paramedic and a BSN so I'm not sure where your rant about educational standards are coming into play?

In any case, this tread has gone way off the rails. I can't wait until paramedics are required to have Bachelor degrees or at least an AS. We need it badly.

 

[TatuICU]

So are you suggesting that we draw labs on every call when you know full well the hospital will redo them and disregard ours? And those time sensitive calls... The ones where labs matter, are the ones where it would be impractical to draw. And tell me again how said labs would change our treatment? My protocols don't specify what to do for a patient who's abg is off, but they do tell me what to do when they are in respiratory distress. And I know that the patients abg will be off if they are in respiratory distress. So the abg in effort will only tellus something we already know, correct? So again why waste time?

Once again, you are out of left field and in no way addressing the issue of CCT And again, if you're actually arguing that ABGs prehospital with transport times of greater than 45-60 minutes then I really don't see te point in even trying to discuss this subject with you