Leaderboard

This might not go anywhere, but I see that alot of members in this forum have trouble with grammer and spelling, so I thought it might be good to have a "word(s) of the day posted on here, as an educational tool. I am thinking we take turns, and add: 1 medical word that we would use in our work-life. 1 word that you have probably never heard of. So here goes day 1, someone else find something for tomorrow please, who knows, we might actually learn something: PANEGYRIC = Elaborate praise. DIARRHEA = Watery feces

You know, Im not saying its ligit (who buys Zoll charging stations?),but it has a ring of some truth to it. My bigger question, Have you talked to your counseler about " I want to get rid of the reminders"? I am just sensing that there may be more to this descision...and while I am not a counseler I generally go with my guton things. If your story is true, I hope you tlk to someone about this to be sure its a healthy expresson of your therapy, and not an unhealthy one. Eitherway.best of luck. ALso, for what its worth, my department trialed those griffin vests for TAC-MED...too bulky, heay as crap, and not modular enough for their needs. They went with a traditional ERT MOLLE type vest that our local swat wears.

Take a listen to an interview with the NREMT Assoc Director on the CBT exam. I think it may help clarify some of the misconceptions on how the exam is scored. http://emsseo.com/2011/02/interview-with-nremt/

VERY IMPORTANT POINT: Absense of fever does not preclude an infectious process or septicemia. Now I am going to ramble. If you want to skip ahead to treatment, feel fee to do so. If this was without the precceding history and if her mentation was more altered with neuropathic-encephalopathic s/s ...... I would think septic shock secondary to meningitis. She is the right age for that kind of silliness... HOWEVER, Since there is no suppotive history for meningitis, and SHE DOES HAVE the history of abdominal injury, miscariage, presumptively for a D&C, and abd rigidty, I am assuming probably some adverse sequala from the abrupted placenta/D&C, and related care. (I am assuming she isnt a closet alcoholic with end stage liver failure and coagulapathy, right? ) My guess is that she is currently in DIC, and probably secondary to septic shock, with exacerbating coagulopathy caused by her plavix/ASA a (distant) second in my mind. Regardless, the exact etiology is academic at this point At this point she is actively (strike that...AGRESSIVELY) dying. The cut on the arm probably saved her life because it prompted the call for help. So, to recap treatment and add some: BLS: O2, BVM, OPA, Suction PRN, Shock position, and the TQ on the arm lac is a good idea. If you are one of those agencies that carries hemostatic agents, use them. A special comment on the TQ: Use a B/P cuff not a CAT or similar TQ. In this case a narrower TQ (like the CAT) may actually precipitate severe bleeding at the site of the TQ due to micro-lacerations in an already coagulopathic patient. ALS: 1- ETT placement, va RSI/MAI if required, but do not use ETOMIDATE (mixed research on its adverse effects on adrenal response and survival in septic shock situations) 2- 2 large bore IV's, Start significant fluid resuscitation. I know there is a lot of information about permissive hypotension, but 99% of that is in traumatic cases. In SEPTIC shock, and in DIC, restoring perfusion to the gut and kidneys is paramount, and fluid resuscitation is key. Therefore, I would open the lines up and reassess Q 500-1000cc but probably wouldn’t slow down until I got past 2 liters. 3- Start the vasopressors now concurrently with your crystalloid infusions. Again I am presuming DIC secondary to septic shock, but in this case EPI drips (2-10 mcg/.min...mix 1 mg in 250 cc) is going to be a better than dopamine, though you may have to do both. if you carry levophed, that is probably your best choice. 4- When/if you get some breathing room...Since she is going to get multiple lines, start a third. YES a THIRD line. Use a twin cath (multi lumen) because many of the meds she needs to get NOW are not compatible with each other. Start it now while she has some vasculature left to hit. Yes she is probably getting a swan and a multi-lumen central line later...but only if she lives that long. Some thoughts: CHF is not an immediate concern, you have PPV in place which will stave off any pulmonary edema. In most other 20-something-year-olds their cardiovasculature can take 2-4 liters with no problem. Since we don’t have a lot of history on her non-specific cardiac issues, we cant assume that is the case with her, but we do KNOW she is dying right in front of us. If we dont start large volume resuscitation concurrently with vasopressors, she wont live long enough to die from CHF. One more thought: Yes this looks like DIC/MODS and possibly septic shock as I described above, but the only time I have seen septic shock try to kill someone this quick with (presumably) this sudden onset of DIC is bacterial meningitis, and I have heard that same thought repeated by several well respected docs in my area. THEREFORE: While none of the history points to this, It costs nothing to mask up all providers as well, and use the HEPA filters on the vent. Cover all your bases. One final thought: If she doesnt code, andshe doesnt respond to dopamine, epi, and volume rescusitation, I would get orders (or in my SWO's..invoke a clause that allows me todo this without calling due to her trying to die right in front of me... ) to increase her Dopamine beyond 20/mcg/min to about 30 mcg/kg/min...at this dose it mimics (kinda) Levophed. Unless I carry levophed, which most services do not. At this point, your pulling out all the "stops".

So to express your uniqueness and individuality, flamingemt, you adopt the speech patterns and mannerisms of others?

Myopic - 1. Ophthalmology . pertaining to or having myopia; nearsighted. 2. Unable or unwilling to act prudently; shortsighted. 3. Lacking tolerance or understanding; narrow-minded. A multipurpose word for EMS... Dwayne

Below are a couple of studies that showed there was no instability with either D5W or NS. No degradation even started until at least 18 days which is not even a consideration. http://www.ncbi.nlm.nih.gov/pubmed/3706337 http://www.ijpc.com/abstracts/abstract.cfm?ABS=1285 I think you the manufacturer's recommendations are just ultra conservative. In the end it will come down to company protocols but you can safely use either admixture.

I'm okay if it fizzled out as I am about done with the news broadcasts anyway but just as long as we do not treat our men and women who served in the same manner.

My way works on all concentrations, and yes I have a pump, if I did not I would demand dial-a-flows. We should not administer dopamine without one.

Possibility 1: The pulse ox is wrong, and the patient is acutely hypoxemic, and cyanosis is due to a unhealthy amount of deoxygenated hemoglobin. This would make so many of the people posting on recent threads ecstatic, but is probably unlikely in practice. Do we have a good pleth? Is there another pulseox we can use to verify our values? I realise that we have a venous gas, but is there the possibility to get an ABG and SaO2. How's the SvO2? Do these things support our pulse oximetry? Possibility 2: The patient's hypercapnia is baseline, because they're one of those relatively rare CO2-retaining COPDers. The pH argues for an acute change, especially if the bicarb / BE is normal. Another process is causing altered mentation, e.g. a CVA. The cyanosis is due to another cause, e.g. methemoglobinemia. If we can get an ABG with MetHb% or use a co-oximeter (as inaccurate as they are) for an SpMet this might help. There is a single case report on methemoglobinemia with cephalexin in a mixed overdose on pubmed. It's also possible that there's been another exposure, e.g. well-water, home-preserved meats, etc. http://www.ncbi.nlm....themoglobinemia Possibility 3: The patient is in acute ventilatory failure and has CO2 narcosis (supported by pH, mentation, PvCO2, past hx). However, if his CO2 is baseline high, then 80 mmHg might not be that high for him, even if it's in the danger zone for CNS / cardiac effects for most of the rest of us. Is it possible that he received a large dose of benzos, opiates or neuroleptics, or some other CNS depressant from the hospital? I've seen small facilities do this sometimes. This still doesn't explain the cyanosis, unless methemoglobinemia is also present. But then, I'd expect the saturation to be lower if there's a significant amount of MetHb present. Concommitant CO poisoning seems unlikely here. --------------------------------- I think that we have too little information here to make a dx. We might want to try a NRB if he's moving any tidal volume first, just to see if the cyanosis resolves with a higher FiO2. If that fails, Given the patient's mentation and pH, I think we can probably look at intubating. We can then ventilate with a target PETCO2 of 60 mmHg, which should bring the pH up to about 7.37, give or take a bit. Hopefully we can check that with a serial PvO2 if they have any point-of-care. This would be an excellent time to call an EM physician in the city for a little help / advice. EMS hates patching, but it's these situations where a physician's input can be really valuable. I'm curious to see how this one works out. Edit: punctuation

After 2-3 weeks the vaginal bleeding should have stopped by now. The car accident involved abdominal trauma that caused the miscarriage. What quadrant is her belly distended and rigid? Lower quadrants I would guess a perforated uterus because of the D and C. If the impact from the accident was enough to cause abruptio placentae,she could also have a ruptured uterus that they didn't catch earlier or made worse because of the D and C. I'm not sure about the TQ. I would use it as a very last resort, if additional dressings and pressure didn't get the bleeding to stop. I would also would not be hosing fluid in. Giving the 250 mL bolus should be enough to bring her pressure up but she is already starting to decompensate and ringers or saline don't carry oxygen, so I would be careful about that. It's pretty obvious that we are behind the 8 ball with her.

"Facility" can mean alot of different things. I have a hospital within 30 miles of my house that has a 3 bed ER, with no OR or ICU. Lab and xray techs have to be called in from home after 5pm. Since the patient is still cyanotic, and is being transferred out, it is apparant that they do not have the capabilities to fix this problem. It is also fairly apparent to me that a Paramedic, will probably not be able to fix his problem either, although having ALS there when he arrests might allow for ROSC, but I doubt it would be much more likely than a BLS crew with an AED. He needs rapid intervention, the sooner you get him to that intervention, the greater his chances are for survival. If the attending doctor could have fixed it he would, and in a perfect world they would use a helicopter for transport. If the patient was at home and called 911, would you wait 20 minutes for ALS, or load and go ?

With the ASA and Plavix, that explains why the cut wont top bleeding. Put another pressure dressing on it. I am also guessing that the rash is a subq bleed. Oxygen at 15 liters by NRM. Get her on the stretcher and into the ambulance. Start an IV of ringers, draw bloods (if you have it) or saline, I would also put iher in modified trendelenburg and give her a 250mL bolus, then cut it back to KVO and reassess BP. Cardiac monitor. With the ASA and Plavix, her INR may be too high.

The same reason ER doctors order a CT on every patient with a bump to the head, the LAWYERS. The public has been educated by TV and Movies that every patient magically is saved in the ER. Medics have been sued for failure to transport because the family believed they took away their only chance of survival. Is it right ? No And then occasionally you read that story where medics declare someone dead, and then have to go back and work the patient when the coroner or funeral home found a pulse or saw the patient breath.

According to the people who did the billing at one place I worked, you can't bill for the call if you don't transport. They didn't like me much. They couldn't bill for a good number of the codes I ran because I called them. Otherwise, you need to talk to your medical director.

Thanks dwayne, I say irregardless all of the time