EMTs and paramedics – what do you carry?

Buff Johnson wrote:I didn't imply to start efforts with an underlying rhythm present. Although Scott's statement simply is not correct. We have more than just random outcomes if we effort from the field and all the way to the table.

From a medical perspective, however, hypothermic arrest was the topic of an emergency medicine conference I attended last week. There is no conclusive evidence, and the recent trend is away from compressions for hypothermic arrest. The prevailing attitude in my department is against it. We're in the realm of expert opinion on this, but there certainly isn't a demonstrated benefit for compressions.

random-chance -- goes to whether performing continuously versus doing nothing saw no difference in chanced outcomes. This has been incorrectly relied upon.

Obviously, our area disagrees in protocol.

Buff Johnson wrote:random-chance -- goes to whether performing continuously versus doing nothing saw no difference in chanced outcomes. This has been incorrectly relied upon.

This still makes no grammatical sense.

nevermind.

re:hypothermic cardiac arrest-not dead 'til WARM and dead. And I've seen plenty of info that says chest compressions in a severely hypothermic pt. can "do more harm than good".

Also applies in cold-water drowning, but then you have the chance of a human-mammillian response going on as well.

Buff Johnson wrote:I didn't imply to start efforts with an underlying rhythm present. Although Scott's statement simply is not correct. We have more than just random-chance outcomes if we effort from the field and all the way to the table. The question marks are rescuer safety and effectiveness while in field transport, which is just reality of the situation.

I've bolded the portion since your last edit to this post. This is flatly incorrect. The question marks extend up to the point of whether or not we should perform chest compressions while rewarming a hypothermic arrest in the emergency department, which was the subject of the most recent morbidity and mortality conference I participated in with my department. The evidence is unclear on the matter, and expert opinion is divided but probably trending against the use of compressions in hypothermic arrest.

However, since you insist there are "more than random-chance outcomes," I would be happy to appraise the studies you're referencing which show a benefit from providing compressions in hypothermic arrest.

All of that being said, I would never fault a medic, EMT or FR who started compressions on a patient who suffered cardiac arrest due to hypothermia and would be somewhat shocked if you didn't. In 99+% of pulseless patients, the most important thing is to start compressions, and I don't want a responder thinking twice about whether or not they should start compressions in a pulseless patient because of some blowhard doctor ranting about a poorly established caveat.

The evidence is unclear, and it might hurt (a little bit, not a lot), but I don't want to counsel responders to do anything but start CPR in a pulseless patient.

(after all, the question posed wasn't whether or not you should do it, but whether or not it was useless)

Scott is right on. While "usefulness" informs the debate on "should" to some extent, there is a stark dividing line between private party in the backcountry and responder. I am speaking from my personal perspective as a fellow participant in backcountry recreation (no duty to respond). Which I believe was the spirit of the OP. Those looking at these discussions from the perspective of a responder must have a different perspective and protocol. Even if you agree you're wasting your time/effort.

Not starting CPR is a weighty decision to be sure. Having "no duty to respond" is a whole other issue. Whether on the clock or at play I think there's a moral question here.

I guess I don't see us coming together on this.

When I've got cardiothoracics and repeated cases on the military side saying this is bullshit, we've had favorable outcomes, and that they want to see a patient worked all the way to the table, I'm going with them.

Now, if it's rescuer concern, fine, life sucks.

Welcome to medicine. Things change all the time. CPR is constantly changing. Epinepherine in arrests will likely change significantly in the near future. Sometimes we just do things because that's how we've been doing them for so long it just seem right regardless of a significant lack of data to support it. But Buff, nobody is asking you to stop doing CPR on hypothermic pts.

Until there is a general agreement, I would keep on doing what you have been doing. Scott's comments are great and it's always cool to have an idea where medicine is headed. That way you can be ready when they get enough data to support change.

The positive side to a grim situation of continuing CPR is the possibility of harvesting organs.

Great thread!

Buff Johnson wrote:I guess I don't see us coming together on this. When I've got cardiothoracics and repeated cases on the military side saying this is bullshit, we've had favorable outcomes, and that they want to see a patient worked all the way to the table, I'm going with them. Now, if it's rescuer concern, fine, life sucks.

I don't think there are very many cases from the modern military of people freezing to death.

Even if there were, how would you even begin to infer from the results of a case series where only a single treatment protocol is used whether or not that treatment protocol is effective relative to another?

EMT-Advanced....will be a medic in a month.

heard lots about dealing with trauma but not too many med lists.

ill start with medical stuff then trauma stuff

meds
prescription meds
epi pen
albuterol inhaler
steroid pack like prednisone
broad spectrum antibiotic

OTC meds
25 mg diphenhydramine(benadryl) X 10
ibuprophen...lots
acetaminophen (tylenol) tablets..a couple
psudephedrine(sudafed)
some kind of GI upset med
some kind of laxative

all these meds but the first few are OTC. the prescription meds are pretty easy to come by.

all these meds fit in a fairly compact pack and dont weigh very much

a trick i use to save space is to have one pill bottle that contains all of your pills and label on the bottle the codes on each pill and what they are to keep track just in case youre worried about a mix up.

as far as trauma management in back county...well stuff gets kinda civil war era for me. duct or medical tape is your best friend and can be easily stored wrapped around water bottles, fuel bottles, anything cylindrical to save space and have lots of tape on hand.

for a splint use a stick or ski pole
a sleeping pad makes a great leg splint
for trauma dressings i plan on using clothing for immediate issues.

sterile stuff for immediate control of bleeding trauma is not THAT relevant because the wound itself is dirty. once the wound has been cleaned with soap and water you can apply cut clothing thats been boiled in water and more sterile

if you have less than a few hours to get to a hospital staying sterile wont be that big of a deal. it takes time for bacteria to take hold.

something to remember is that advanced medicine in the backcounty is fairly impractical if not impossible. it is fairly quick and easy to become medically proficient enough to solve almost any fixable issue in the backcountry. then, you evacuate your patient and get them on the way to a hospital.

Sam, glad you are working your way up the EMS ranks. Good luck on your test that I assume is coming up.

Sam Latone wrote:prescription meds epi pen albuterol inhaler steroid pack like prednisone broad spectrum antibiotic

Sam Latone wrote:something to remember is that advanced medicine in the backcounty is fairly impractical if not impossible

Seems like several of those meds would fall into the 'advanced medicine' category.
I think it's odd you carry or plan on carrying prednisone but 4x4's and some bandaging equipment are impractical. Not to mention you are incredibly out of your scope of practice giving everyone of those medications outside of medical direction. You are prepared to handle lots of medical stuff but then revert to 'civil war era' trauma care. What do you think you are more likely to face in the back country?

Sam Latone wrote:sterile stuff for immediate control of bleeding trauma is not THAT relevant because the wound itself is dirty. once the wound has been cleaned with soap and water you can apply cut clothing thats been boiled in water and more sterile

Why waste the time, fuel, and water on boiling your t-shirt? You can easily just bring clean bandaging equipment that weighs very little. To me, wound dressing seems much more practical than meds. Most of the meds expire from my FAK when very few 4x4s do.
What about irrigation of the wound? You won't really clean much with topical soap and water. If you bring some sort of wound cleaning agent and irrigation supplies you can take care of most wounds that require artificial closure without ruining your trip and having to return early.
What about actual back country? If I am less than a few hrs from definitive treatment, I'm not bringing shit. What if you're out 24+ hrs from treatment?

Sam Latone wrote:it is fairly quick and easy to become medically proficient enough to solve almost any fixable issue in the backcountry.

No. No, it isn't.

Got to open up my first aid kit for the first time last weekend. Used a little package of combo gauze and bandage. Any idea where I can get a new one?

Wal Mart any pharmacy store

My friends in the great white north (interior AK) who know a thing or two about hypothermia and cardiac arrest just updated their medic protocols this year. I've attached the flow chart, but the gist of it is if they're within 3 hours of a hospital in the absence of a cardiac monitor - they don't do CPR. If they're in the bush more than 3hrs from a doc and the patient's core temp isn't below 50*C then they do CPR.

iremsc.org/FNSB/FNSB%20SO%2…

It's on page 67.

CodyL wrote:Wal Mart any pharmacy store

Looked around, everything I found was either gauze packages or bandages. This had the bandage sewn to the gauze so it's all one piece. I found it very convenient.

Donald Kerabatsos wrote:Welcome to medicine. Things change all the time. CPR is constantly changing...

Truer words have never been spoken. I mean, it wasn't until just a few years ago that we all realized that stopping compressions to give breaths is probably the worst thing you can do – because you lose the pressure buildup necessary for perfusing the brain. Nowadays, there are TONS of hot topics still under study/debate, especially is pre-hospital care: selective spinal immobilization, permissive hypotension, the use of lights and sirens, even the need for intubation.

As for the spirit of my original post, I was definitely aiming at the off-duty crowd. When you're on duty, you're following protocols, are under medical control, and already have the whole kitchen sink with you. Here in Colorado, there is no duty to act when you're off the clock, and our Good Samaritan laws even explicitly cover SAR folks and ski patrol/rescue. However, there are definitely some states that do (Vermont is the only one that comes to mind w/ climbing areas, but there are probably others) though I imagine it's virtually impossible to enforce.

And, IANAL, but I imagine that especially if you have had formal training (WFR, EMT, whatever), even if you don't work in EMS, and you try a procedure that is outside your "scope of training," you most definitely can be held liable because "you should know better." So, yeah, I probably wouldn't encourage others to try a cricothyrotomy after watching a couple YouTube videos on it. :-P But, in that kind of situation, with a close friend or family member, and that is truly the last resort to saving their life, who knows...