Posts filed under 'Audio Podcast'
Dr. Ross Judice recently attended EMT Basic classes to get a better understanding of the curriculum and skills training that the students undergo. Dr. Judice surprised us all by attending National Registry testing! He passed his written and all of his skills tests on the first try. To help others going through the program, here are audio recordings of Dr. Judice taking you through the steps of each skill station.
Bleeding Control – Shock Management:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Bleeding Control – Shock Management.mp3 (1.0 MB)
Cardiac Arrest – AED:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Cardiac Arrest – AED.mp3 (2.6 MB)
Combitube:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Combitube.mp3 (2.6 MB)
Immobilization of Joint Injury:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Immobilization of Joint Injury.mp3 (0.7 MB)
Immobilization of Long Bone Injury:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Immobilization of Long Bone Injury.mp3 (1.0 MB)
Patient Assessment – Medical:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Patient Assessment – Medical.mp3 (5.2 MB)
Patient Assessment – Trauma:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Patient Assessment – Trauma.mp3 (6.7 MB)
Seated -KED – Spinal Immobilization:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Seated -KED – Spinal Immobilization.mp3 (2.8 MB)
Supine Spinal Immobilization:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Supine Spinal Immobilization.mp3 (1.6 MB)
Traction Splint:
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
>>> Download File: Traction Splint.mp3 (3.2 MB)
November 30th, 2009
Hey Dr. J,
Recently I responded to a call with a female in her early forty’s complaining of chest pain. In my 12 lead ECG assessment, STEMI was revealed in multiple leads. I administered sublingual nitroglycerin twice on scene and once en route. The patient’s systolic BP never dropped below 200 systolic. I was not able to start an IV due to poor veins. I was also less than one mile from the hospital. After documenting this call, it was audited. Though mostly positive feedback was given, one of the things i was criticized on was the administration of more than one nitroglycerin prior to having IV access. I was hoping you could give me your opinion if I should have withheld the much needed Nitroglycerin?
Stem E.
Dear Stem E.,
It is ideal to have an IV while administering nitroglycerin in the event that the patient’s blood pressure drops and needs fluids. I would not withhold NTG from this patient because of the absence of an IV. Why? Because nitroglycerin’s benefits outweigh the IV issue. Our protocols DO encourage an IV prior to the second NTG so that medics are reminded about the importance of IV access.
I would, however, be very vigilant about monitoring the blood pressure and would be ready to put in an IO quickly if the pressure drops.
Dr. J
Ross Judice, MD, MPH
Chief Medical Officer
Acadian Ambulance Service, Inc.
October 25th, 2009
Dr. J,
I just ran an emergency on a patient with advanced directives. It stated “I do not want CPR, mechanical ventalations, peg tube, and emergency medicines.” The patient was a CHF patient so I only increased her oxygen from 2 L by nasal cannula to 15 L by non-rebreather because her oxygen saturations were in the 80′s. I withheld the drugs in our protocols due the my interpretation of the advanced directives. My opinion is every drug in my ALS bag is considered “emergency medicines”. I was wondering if I was right or wrong in my decision to withhold drugs. What is your take on this?
Thanks, Endov Life
Dear Endov,
I agree with your decision.
As you did, I would interpret the advanced directive to mean that the patient does not want any extraordinary means (in this case – medications, CPR, or nutrition) in order to reverse the dying process. I would say that certain medications might offer comfort without reversing the dying process, like oxygen for shortness of breath. In addition, it would be OK to give morphine for pain relief (with cancer patients, for instance) since it does not reverse the dying process and it offers some comfort.
Dr. J
Ross Judice, MD, MPH
Chief Medical Officer
Acadian Ambulance Service, Inc.
October 16th, 2009
Dr. J–
I recently had a patient who was not feeling well. She was a former nurse and had over 100 different medications at her house (pictures attached). Most of these medications were decades old, and obviously expired. I found a list of the current meds she was supposed to be taking, but could not find the actual medication to go with it. The patient stated that she was currently taking the expired medications (which may explain why she was not feeling well).
So here’s my question– We transported her to the hospital, but I left the medications at the house. I informed the ER of the medications and showed them these same pics. Since I did not feel comfortable with the patient having the medications around I also called Adult Protective Services. Should I have taken the medications with me to the ER? Would that have been theft?
Sincerely,
Concerned Medic
Dear Concerned,
I am sorry that I am just getting back to you on your e-mail. I’ve been out on vacation and I am just catching up.
You handled the situation perfectly. Adult protective services should be involved and have this patient on their radar. Even if you had removed the medications, the problem would only return over time. Hopefully, protective services will be able to assess the underlying issues with this patient and help her long-term.
If you had removed the medications and brought them to the emergency department, that would NOT be theft. That would be the efforts of a conscientious medic acting on behalf of her patients.
Thanks for the opportunity to address your question
Dr. J
Ross Judice, MD, MPH
Chief Medical Officer
Acadian Ambulance Service, Inc.
October 15th, 2009
Dr. Judice,
I am assigned as a swing medic and had not done a Critical Care Transport (CCT) for some time. I believe our transport ventilator and infusion pump should be paramedic level skill requirements for all paramedics (and not just a special group of CCT medics). Within a defined period following your employ you should be required to be proficient on the vent and pump and then you may perform these transports. I realize this is contradictory to your ideal but I will always believe our skills and service should be standardized.
Sincerely,
N. Swing
Dear N.,
Thanks for the email.
I respectfully disagree with the idea that all paramedics can maintain proficiency on ventilators. I tried that for several years and it is not possible. Like all medical care, we’re only as good as the frequency with which we perform a skill. Cardiologist that perform lots of caths are proficient – same is true with paramedics that perform lots of vent transports, especially with the type of vents we use.
The current CCT program is FAR BETTER than when we trained all the medics.
Regards,
Ross Judice, MD
Chief Medical Officer
October 1st, 2009
Dear Dr. J,
I have picked up several high school players at football games and am wondering why we do not carry ammonia capsules on the ambulance. If a player gets knocked out, this would be a great tool for the medic to have at his disposal.
Signed, Smelly Salts
Dear Smelly,
Thanks for the question.
Ammonia is a direct respiratory irritant to the nasal mucosa that produces a violent avoidance response, sometimes causing the patient to thrash about uncontrollably. If the patient has a potential spinal injury, this could be a problem. Also, even small amounts of ammonia inhaled is not a good thing for patients with respiratory distress or airway compromise due to edema. Ammonia use may also produce coughing, nausea and vomiting, which can increase the risk of aspiration in unresponsive patients. Frankly, ammonia capsules have been considered inappropriate in the prehospital setting for quite some time.
We definitely want to assess the mental status of our patients. I prefer to use the Glasgow coma score (GCS) since it’s a common medical standard. A sharp pinch of an extremity or sternal rub is the preferable way to elicit a response.
Hope this helps.
Ross Judice, MD, MPH
Chief Medical Officer
Acadian Ambulance Service, Inc.
September 18th, 2009
I would like to thank you for the memo that you posted in regards to publishing the statistics for survival rates of cardiac arrest patients. I feel that it was patient orientated. I would like to make a few suggestions, that might improve patient outcomes. I agree with the idea that we need to prioritize our actions – as with medication administration before intubation – because AHA is trying to teach us the importance of more effective chest compressions than what is being done now. It may be the idea of some paramedics that ALS intervention is far superior and more important than something we learn as a first responder – chest compressions. Paramedics may be so focused on the many other things that we need to do that quality chest compressions take a back seat. The first suggestion I have is to purchase a device that performs chest compressions. This would ensure continuous, quality compressions. The other idea that I have is to use capnography to measure cardiac output (quality of chest compressions) and a tool to teach us the specific areas we need to improve. Some may think that capnography is only used to confirm proper tracheal intubation, but I believe capnography should help us determine quality chest compression and help determine H’s and T’s. Studies show that if end-tidal CO2 is above 14 during resuscitative efforts of patient with little down time, that chances of ROSC are much higher. Is it possible for us to purchase these devices that preform chest compressions or at least promote a standard for the use of capnography during a cardiac arrest to measure all resuscitative efforts. As a medic, I understand that another “thing to do” during a code is inconvenient, but if chest compressions are so important than we should be doing what we need to perform effective compressions for the patient’s sake. Medications are of no use if there is no perfusing cardiac output. I wanted to bring a few more ideas to the table since patient outcome is our goal. Thanks again.
Michael
Dear Michael,
First, let me thank you for taking the time to write. It shows that you are thinking about how we can improve patient care.
I’m glad to hear a paramedic speak to the importance of the BLS portion of the resuscitation effort. A study out of Toronto surprised many in EMS when it showed that BLS units were having the same success at resuscitations as ALS units, and a lot of us think it’s because the paramedics were fiddling around with intubation while the basics were focusing on shock and compressions.
I especially like your compassion about uninterrupted chest compressions. I’m very excited about the compression devices, and if they weren’t $17,000 per unit, we might already have them on the ambulances. Deploying them today would cost a fortune. I’m keeping a close eye on them. Based on some recent QI research, we can stand to improve our scene management and priorities. Some video analysis of simulated resuscitations show we could stand some improvement in terms of continuous, uninterrupted compressions.
I also like your thoughts about the use of capnography to assess cardiac output and ROSC. We’re promoting the use of capnography for these purposes in our training. Feel free to use the ETCO2 device on your monitor for this purpose.
Regarding capnography’s predicting our chances of success – while this is talked about a lot – this really isn’t the standard of care today. I’m a little hesitant to formalize a number, say below 10, to quit resuscitation. That’s not to say more evidence won’t promote this practice down the road.
You’ll find it interesting to know that I’ve assigned one of our staff to work on a plan to improve cardiac survival at Acadian. Casey, our Air Med FTO, started this special project this week and is working on it full-time through the end of the year when she’ll resume her regular duties. She’ll be evaluating the first responders, dispatch, and our ambulance crews in order to find opportunities for improvement. She’s looking at everything across the board, including therapeutic hypothermia, impedance threshold devices (IDTs), and early bicarbonate administration. She and I discussed the compression devices this morning.
We have made contact with the King County (Seattle) Fire Department and one of my instructors will be meeting with them in two weeks during his personal vacation to Seattle. We’re hoping to pick up some best practices. They have the best resuscitation rates in the U.S. While our latest cardiac resuscitation rate is 20.3% for out-of-hospital survival, Seattle’s is over twice that. They appear to address every link on the Chain of Survival.
As you can see, we’re going “back to the basics” and trying to get CPR right for the sake of our patients.
Sincerely,
Ross Judice, MD, MPH
Chief Medical Officer
September 11th, 2009
Dear Dr.J,
Your case of the week this week was on dystonic reactions. Interesting timing on that case, I had one just last week. Same basic scenario, young girl out drinking all night comes home acting very strange with jerky movements of her head and arms that she can’t seem to control. Now, my patient’s VS were stable and she was alert and orientated so I did not treat with medications. Upon arrival at the ED, the ER physician said he believed this to be a dystonic reaction due to an antipsychotic medication – most likely Haldol. He did give her Benadryl with a favorable outcome. He stated that he would rather we not use such treatment action in the field so that the ER physician could see the pt in their symptomatic state. He also told me that Haldol would not show up on a tox screen. I was wondering how you feel about this. If the pt’s VS are stable yet we suspect a dystonic reaction should we treat with Benadryl or simply monitor and transport? In addition, all the cases I have ever heard of like this seem to involve alcohol. Is this type of reaction caused by the mixture of the alcohol with the antipsychotic medications?
Thank you, Eddie
Dear Eddie,
You pose a very good question. The dystonic reactions related to the use of antipsychotic medications can come on for no reason at all. I am not aware of a common correlation with alcohol. If you have a patient who is suffering from a dystonic reaction, the most appropriate step would be to contact online medical control and request an order for Benadryl. I don’t agree with the doctor’s suggestion that we refrain from treating so that he can see the condition in its “symptomatic state”. That’s like refraining from treating cardiac ischemia with nitrates so that the doctor can see the ST elevation better in the ED, or refraining from treating pain so that he can assess the patient’s “symptomatic state”.
Stay vigilant for a serious condition called Neuroleptic Malignant Syndrome seen with chronic use of antipsychotic medications. It generally presents with muscle rigidity, fever, autonomic instability, and delirium.
Ross Judice, MD, MPH
Chief Medical Officer
September 10th, 2009
Previous Posts
