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Spock last won the day on June 2

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About Spock

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    CRNA, Medic, Hazmat Tech

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  1. Upgraded Software

    OMG, Calvin and Hobbes! My all time favorite comic stopped and I went into a six month funk. How about a Spaceman Spiff Club? This made my day! Spock
  2. Medical conditions causing crush syndrome

    Off Label has a great post. I really do believe that obese patients that fall and can't get up for an extended period of time will exhibit signs and symptoms of crush injury. How long does that take is unknown but I suspect it depends upon BMI and the amount of tissue compressed. I've had patients with crush injuries from traditional causes (building collapse) and medical causes and they are very challenging. Prehospital concerns are acidosis, hyperkalemia, low BP, and pain. A crushed extremity that does not hurt is a very bad sign and will result in amputation and possibly death. Saw far to much of that in Haiti. May the tube be with you. Spock
  3. Medical conditions causing crush syndrome

    Crush injuries are well documented in the literature. They are usually caused by trauma but can be from medical conditions such as the diabetic patient that passes out and lays on the floor for days before being found. Glucose levels are through the roof and the patient is in DKA. We saw a lot of crush injuries in Haiti after the 2010 earthquake and amputated many limbs. Biggest concern for crush injuries is the sudden release of toxins when the offending structure is removed from the patient. They become acidotic and will crash as fast as you can say boo. Have the bicarb and calcium ready along with plenty of fluid. The PA Department of Health has a decent crush injury protocol but I am biased because I wrote it. Most of my references were from the Israeli military since they have more experience than most. Actually, the first SAR teams to arrive in Haiti were from Mexico, Israel, and Turkey. Compartment syndrome, renal failure, and gangrene are some of the more dire results of crush injuries. If this helps to lead you on the correct path for writing a paper then I hope it helps. There are many good search engines for medical conditions and you should avail yourself of all except Wikipedia which can be written by any knuckle head. Spock May the tube be with you.
  4. CHF & Low BP

    Low dose dopamine is notorious for causing tachycardia and it has been seen in higher doses also. CPAP can drop the BP because of the increased inter-thoracic pressure causing a drop in preload. Let's face it, this patient scenario is a nightmare for ANY health care provider and if you get your patient to the hospital or to the end of your shift with a pulse, then you did a great job. A puzzlement to be sure. May the tube be with you. Spock
  5. Books Every Paramedic Student Should Read

    I would recommend "Anybody can intubate" if it is still in print. Good luck with school. Spock May the tube be with you.
  6. CHF & Low BP

    Pump failure requires an inotrope and epinephrine is your friend. A great heart surgeon I worked with (he usually just yelled at me) had a prescient saying: "Dobutamine is a great inotrope when you don't need one". Dopamine is a possibility if an epi drip is not possible. My service used to carry dobuatmine and dopamine but discontinued the dobutamine because it was never used and now the docs are always ordering epi drips or epi bolus if the transport time is short. We dilute epi into a 10 cc syringe (10 mcg/cc) and use that to bump up the pressure until arrival. Our transport times are rarely over 20 minutes so longer transports would benefit from a drip. Complex problem and all have suggested excellent interventions but I would have used a steel vasopressor (laryngoscope) to help the pressure. OK, as a CRNA, I'm biased. Clearly BiPap or CPAP is preferable to intubation when considering mortality and morbidity. Spock May the tube be with you.
  7. Pathophysiology of cyanide poisioning

    Cyanide poisoning is hypoxia at the cellular level. Hydroxocobalamin is the best treatment since it is a precursor to vitamin B-12 and combines with cyanide to form B-12. The other treatments try to eliminate cyanide by other mechanisms but less effectively. Hydroxocobalamin is expensive and not always readily available for prehospital services. The Paris Fire Brigade did some of the early work on its use for patients with altered LOC after smoke inhalation and also with patients pulled from a fire scene in cardiac arrest. The Advanced Hazmat Life Support text book is a fantastic reference for hazmat medicine although it is expensive. Hazmat medicine has moved into the Hot Zone and should not remain in the cold zone. Early treatment is essential for survival and the attitude of my hazmat medical team is to enter the hot zone and apply airway, antidotes and tourniquets to the injured. Airway is the King LTD (although we may switch to the i_Gel), antidotes are the Duo Dotes, and tourniquets are the CATS. We have a process for transitioning the airway from the hot to the cold zone and have a variety of difficult airway devices available not to mention the appropriate drugs. Our medical team also can serve as the RIT for the regular hazmat teams. Hazmat isn't for everybody and only those with specialized training should get into the mix. My days as a fire fighter are long past and I wouldn't think of entering a burning building now but suiting up in level A hazmat is second nature. To each his or her own. Spock May the tube be with you. Sorry chbare, I didn't see your excellent post before I chimed in. My humble apologies. Spock
  8. Afib RVR

    I can think of any number of drugs to give this patient and none of them include NTG or ASA. ERDoc is certainly correct in that this is rate related and with the a SBP of 110, the patient leans toward stable rather than unstable although that may not be the case for very long. Diltiazem is the drug of choice here followed by beta blockers, amiodarone, and perhaps verapamil. My service carries diltiazem and amiodarone but not beta blockers or verapamil. I wish we carried a beta blocker such as esmolol, lopressor, or labatelol. The last patient I had go into AFIB with RVR was under general anesthetic and already in a lateral position for a video assisted thoracoscopy. When prepping the patient, I had placed the defib pads on him because he was sicker than crap. Just before incision, the rate took off into the stratosphere and the BP as measured by my arterial line dropped like a rock. The last numbers I saw was a rate of 180 and a SBP of 50. I sync cardioverted with 200j and knocked him into sinus rhythm. The surgeon was quite happy and we finished the case after cleaning the infection out of his chest. He had a rocky ICU course but survived. The risk of cardioversion is dropping a clot into the brain and stroking out but there really was no choice here. May the Tube be with you Spock
  9. Spinal Restriction

    Agree with the transected cords and I've seen two in my career. The first was when I worked as an athletic trainer and a defensive back ducked his head when he made a tackle. The second was in the trauma bay at the level one trauma center where I worked for 16 years and the city medics brought in a guy that had been robbed in a downtown parking garage and even though he willing gave up every thing he had, the knuckleheads shot him in the neck. He was conscious and alert when they moved him over onto the hospital cot. The medics gave a report and finished up by stating almost incidentally that the patient couldn't move his arms and legs. You could have heard a pin drop in the room. Spock
  10. Spinal Restriction

    Glad to see humor has not disappeared from the City. I did not intend to imply that c-collars would or should go away, only that they really do not restrict very much motion. Collars will always be used as long as lawyers chase ambulances. Spock
  11. Spinal Restriction

    I certainly remember teaching and using the standing board take down but it is gone. The new Pennsylvania (July 2015) spine injury care protocol specifically states the standing take down should not be used. We also used to put the MAST trousers on every trauma patient although actually inflating them was rare. Finished my Doctor of Nursing Practice (DNP) degree from Carlow University in May 2016. It is my fifth college degree and I think I can safely say it will be my last. The negative outcomes from LSB use was a given based upon the literature. The question is: Will a change to spinal motion restriction cause injury by missing significant spinal injuries and causing more harm by movement? Morrissey et al. (2014) found only two missed spinal injuries after switching to SMR from using the board in a patient population of 5800 in a service area population of 1.5 million. Both of these "missed" spinal injuries were insignificant (spinal process fractures). My work looked at three services in suburban Pittsburgh and had no missed injuries in patient population of 543 and a service area population of 143,000. Since Eyre (2006) reported an estimated 13 million people seek care in emergency departments each year with an incidence of significant spinal injure of 0.3%, one would need a very large patient population in order to achieve power when looking for spinal injuries made worse by SMR. Getting follow up information from hospitals is very difficult as both the Morrissey and my study found. So the jury is still out on SMR and it is interesting that spinal immobilization was instituted by consensus and not evidence just as SMR is being instituted by consensus. Ten years from now we may look back and say how stupid we were to use SMR and cervical collars but only time will tell. Considering we used the LSB for almost 50 years before moving away from it, if we recognize problems with SMR in only ten years we have learned something. Don't get me started on the effectiveness of cervical collars. I bet ERDoc will agree with my next statement. Ask any ED physician about the worst spinal injury they ever saw and they will probably tell you the patient walked into the hospital under their own power and not on an ambulance stretcher. Bottom line is that changing to SMR from SI resulted in an initial decrease in the use of the LSB by about 60%, Unpublished data indicates use of the LSB has dropped almost 95% since changing protocols. Are there still times when a LSB should be used? Yes, but as I mentioned previously, it should be the exception and not the rule. Never say never! Spock
  12. Spinal Restriction

    It just so happens my doctoral dissertation was on this exact subject. The literature since the early 1980s demonstrated that the LSB increases pain, causes respiratory compromise, leads to tissue breakdown, and is ineffective. Yet, the practice continued until 2013 when the NAEMSP released a position paper that called for the limited use of the LSB. ACEP followed in 2015. Using it as an extrication device is warranted and the services in my area have stopped using it except for the entrapped patient with multi system injuries (multiple fractures) but we have transport times to the trauma center of less than 10 minutes. My dissertation showed a 60% decrease in the use of the LSB in the first six months after implementing a spinal motion restriction protocol by the state. Additional service QA indicates the decrease continued the next year to the point use of the LSB is the exception and not the rule. If anybody wants a copy of my references, let me know and I would be happy to send them. They date to 1966. Spock
  13. Sugamadex is not the answer to a failed intubation. While it will reverse neuromuscular blockade from a non-depolariizing agent such as rocuronium, it does not reverse the induction agents administered such as versed, fentanyl, etomidate, propofol, or any combination of those medications. I've used sugamadex several times when a surgical case ended much sooner than expected and it reverses the blockade in about 30 seconds. The best approach for prehospital RSI should include video laryngoscopy along with the usual induction agents including succinylcholine which is safe in the vast majority of patients. Solid QA medical oversight along with operating room time to maintain skills are also required for good RSI outcomes. As I cited before, versed alone as an induction agent for RSI is not supported in the literature and the drop in BP can be lethal. That does not negate the anecdotal experiences of many folks including myself, but it is not a good option. Spock
  14. Capnography

    These comments are great and prove that the folks that post on the City are really smart. Off label may not realize the difference in the types of capnography and may not have the advantage of the sophisticated technology available today. If I do a sedation case in the operating room, I have the patient on oxygen via a simple face mask and attach my ETCO2 tubing to the mask. This gives me an indication of the patients respiratory pattern but the number is always low and has no real value other than tell me a quick glance that the patient is breathing. You may ask why I don't just look at the patient and that is a good question. I am frequently distracted by other things in the OR (the surgeon wants the table moved or some other BS) or the lights have been dimmed because of the procedure and I can't see the patient. The capnography we use in our ambulances around here use micro stream technology and the quantitative values given have true meaning. Capnography is one more tool in your tool box and is just as important as your BP cuff, pulse oximeter and EKG monitor. Tube or not, ETCO2 is important for every patient with respiratory compromise. May the tube be with you. Spock
  15. These are nice comments, all based upon clinical experience which should never be minimized. That said, if you look at the literature, versed as a sole induction agent is not supported and has been associated with increased mortality and morbidity. There is no substitute for true RSI (induction agent and paralytic) when faced with an emergent airway crisis. I have used versed and fentanyl for intubation in the ambulance and etomidate or propofol alone in the hospital with good success but that is only because I have around 10,000 intubations under my belt. Give me enough time to anesthetize an airway, I can intubate an awake patient. Prehospital staff are being dealt a raw deal when it comes to intubating a patient not in cardiac arrest but you must remember that if you have poor first pass intubation success rates, RSI is not the answer. May the tube be with you. Spock