3 ms·

An 'airway' doesn't necessarily mean an ET tube. A simple airway adjunct (NPA, OPA, LMA, etc) would go a long way towards keeping an unresponsive pt's airway op

An 'airway' doesn't necessarily mean an ET tube. A simple airway adjunct (NPA, OPA, LMA, etc) would go a long way towards keeping an unresponsive pt's airway open without having to dedicate someone to monitoring it. IV access is useful for administration of several drugs that airlines (in the US anyway) are required to carry. While lots of docs haven't placed an IV since residency, it's not _that_ hard a skill, and it's more than just nurses who start a lot of IVs... A nurse wouldn't even be my first choice in that situation. I'd hope there was a paramedic (or ER nurse) aboard. As far as IV fluids go... There are plenty of situations where a 250-500mL bolus can make a significant difference. Given the limited diagnostic tools available, I'd give fluids to anything that smelled like an MI (barring any contraindications). For all you know it's an inferior wall MI, and that boost to their preload will help tremendously.

paviva 10y ago
HN is not a place to argue medicine, but given that you're an EMT, I'll comment a little further. 1. Placing an IV in a sick, clamped patient IS difficult, even for experienced ER nurses. If the patient is not sick, he doesn't need an IV. Its way easier to give drugs directly with a syringe than setting up an IV first. 2. In those situations, I'll just lift the patients legs up to give him that 500 mL bolus, which will take exactly 10 seconds, and not require any skills at all. Bonus points, if I realize he's not fluid-depleted, I'll just them back on floor -- et voilà!.
- JshWright 10y ago
  I'm a paramedic. I place IVs in "sick, clamped patients" all the time, often in a moving vehicle... I still maintain it's not that hard (the doc in the article managed it twice). You're not going to buy 500 mLs by raising someone's legs... 250, maybe. And if they _do_ have a positive response, you'd still hold off on fluids? I see it as more of a friendly discussion than an argument, but I'll certainly respect your wishes if you'd rather not...
  - paviva 10y ago
    It was in the sense of that kind of discussion probably not interesting to most people on HN. I don't doubt you place IVs in sick patients, I only doubt those IVs make any difference. I am not very familiar with prehospital/EMT literature, and I don't know if any studies have been done, and I certainly don't have any hard data, but I do prefer when paramedics give aspirin, stick in a combi-tube, do basic stuff, and just rush the patient to the hospital instead of wasted time installing and IV on-site, giving fluids and what not. I've seen a great many "heart attacks" treated with fluids in full-blown congestive heart failure. This is anecdotal of course. Again, for the 500 bolus, I am not aware of any literature to support it as a life-saving measure, and I do believe that if the patient is gonna code without a 500 bolus, he will code with a 500 bolus, too. We're talking of a previously healthy person suddenly dying here -- in those scenario fluid rarely makes a different unless its profuse bleeding, in which case 500 mL is not enough anyways. The big problem I see with fluids, stethoscopes, IV benadryl, and the like, is that these things are DISTRACTIONS that make people waste their time trying to get a blood pressure when its obvious the patient's in shock (or equally obvious he isn't). A quick, focused history and exam + Epi + AED + Albuterol are the real life-savers and where the emphasis should be on.
    - JshWright 10y ago
      If EMS in your area is starting IVs and pushing fluids on scene, then yeah, that's an issue. Plenty of time to do that in the truck. My primary goal is to gather all clinically relevant information I can, establish any needed access (airway, IV, or otherwise), and stabilize any life threats. In short, to set up the ED doc with the best chance of success (a patient with all the 'prep' taken care of, and a good, clear picture of what's going on. I do think you're focusing too much on the dying/not dying distinction. There is a pretty wide range in the middle, and much can be done to help those patients (even if it's only to improve their comfort and reduce anxiety). There are a lot of patients who aren't going to die in the next couple hours who would still benefit from one or more of the interventions available on an aircraft (including a 500cc bolus). "Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore. 500 mL may indeed be enough (if it's not enough, they're gonna bleed out anyway). I agree 100% that any provider dealing with a medical emergency on an aircraft (or anywhere else) should be looking at the patient, first and foremost, and not rummaging through a medical kit...

paviva 10y ago

HN is not a place to argue medicine, but given that you're an EMT, I'll comment a little further. 1. Placing an IV in a sick, clamped patient IS difficult, even for experienced ER nurses. If the patient is not sick, he doesn't need an IV. Its way easier to give drugs directly with a syringe than setting up an IV first. 2. In those situations, I'll just lift the patients legs up to give him that 500 mL bolus, which will take exactly 10 seconds, and not require any skills at all. Bonus points, if I realize he's not fluid-depleted, I'll just them back on floor -- et voilà!.

JshWright 10y ago
I'm a paramedic. I place IVs in "sick, clamped patients" all the time, often in a moving vehicle... I still maintain it's not that hard (the doc in the article managed it twice). You're not going to buy 500 mLs by raising someone's legs... 250, maybe. And if they _do_ have a positive response, you'd still hold off on fluids? I see it as more of a friendly discussion than an argument, but I'll certainly respect your wishes if you'd rather not...
- paviva 10y ago
  It was in the sense of that kind of discussion probably not interesting to most people on HN. I don't doubt you place IVs in sick patients, I only doubt those IVs make any difference. I am not very familiar with prehospital/EMT literature, and I don't know if any studies have been done, and I certainly don't have any hard data, but I do prefer when paramedics give aspirin, stick in a combi-tube, do basic stuff, and just rush the patient to the hospital instead of wasted time installing and IV on-site, giving fluids and what not. I've seen a great many "heart attacks" treated with fluids in full-blown congestive heart failure. This is anecdotal of course. Again, for the 500 bolus, I am not aware of any literature to support it as a life-saving measure, and I do believe that if the patient is gonna code without a 500 bolus, he will code with a 500 bolus, too. We're talking of a previously healthy person suddenly dying here -- in those scenario fluid rarely makes a different unless its profuse bleeding, in which case 500 mL is not enough anyways. The big problem I see with fluids, stethoscopes, IV benadryl, and the like, is that these things are DISTRACTIONS that make people waste their time trying to get a blood pressure when its obvious the patient's in shock (or equally obvious he isn't). A quick, focused history and exam + Epi + AED + Albuterol are the real life-savers and where the emphasis should be on.
  - JshWright 10y ago
    If EMS in your area is starting IVs and pushing fluids on scene, then yeah, that's an issue. Plenty of time to do that in the truck. My primary goal is to gather all clinically relevant information I can, establish any needed access (airway, IV, or otherwise), and stabilize any life threats. In short, to set up the ED doc with the best chance of success (a patient with all the 'prep' taken care of, and a good, clear picture of what's going on. I do think you're focusing too much on the dying/not dying distinction. There is a pretty wide range in the middle, and much can be done to help those patients (even if it's only to improve their comfort and reduce anxiety). There are a lot of patients who aren't going to die in the next couple hours who would still benefit from one or more of the interventions available on an aircraft (including a 500cc bolus). "Lots of fluid" really isn't generally the standard of care for severe hemorrhage anymore. 500 mL may indeed be enough (if it's not enough, they're gonna bleed out anyway). I agree 100% that any provider dealing with a medical emergency on an aircraft (or anywhere else) should be looking at the patient, first and foremost, and not rummaging through a medical kit...