Canadian Caesar

100% certain that my shower is cleaner than the public pool or hotel hotub, those of which many people gladly jump into while cringing at the though of me peeing in my shower.

I had to use a separate Medical Journal search engine than PubMed. It's called Medline, one of the searchable databases via the University of Alberta website. I couldn't figure out how to make a hotlink work since the whole thing is password protected. :? But I did manage to save the whole thing in PDF form so if you want it i would be happy to send it via E-mail. I have a link if you have a system that gives you journal access like a University. http://www.springerlink.com/content/t9w42636x03w77v7/ Just click the full PDF at the top of the abstract. The info you are looking for is in the description for Fig. 13 on page 6. It describes the force required for a Hangman's Type I fracture.

I am very glad you found such an interesting and valuable subject for discussion. According to the following Medical journal article (The European Spine Journal) Eur Spine J (1995) 4:126-132: Kinematics of cervical spine injury: A functional radiological hypothesis L. Penning Departments of Diagnostic Radiology and Neurosurgery, University Hospital of Groningen AZG, Groningen, The Netherlands It only requires 8kg of Axial Traction on the cervical spine to cause a "Hangman's Fracture." To put that force into terms you may have felt yourself, the relatively mild maximum 15lbs of force you use in the application of a traction splint to a femur fracture is enough to cause this type of fracture. I myself have had 15lbs a la Sager splint to my bare ankle and had no ligature marks with that amount of force. I would also hazard to guess that even with his knees on the ground, his total supported body weight results in more than a paltry 8kg of axial traction. So unless the practitioner can somehow determine that this force was never applied, I would be uncomfortable ruling out C-spine involvement. Who is to say that the patient did not slip and fall to his knees? Or thrash about as his brain was slowly starved for oxygen? Perhaps the noose was a half inch too short to allow his knees to rest on the floor, and the fact that they are now touching means he now has a half in gap in his vertebrate somewhere? So with the best that my personal experience can offer me, as well as the information gleaned from various medical journals, I stand by my original position. This particular scenario presents a realistic chance of spinal injuries, and proper precautions are warranted.

VSA = Vital signs absent??? Of course I would suspect potential c-spine injury. You are talking about the application of significant forces in a manner that the spine was not meant to tolerate. Even the gradual application of a few dozen pounds of force is more than enough to separate, twist, dislocate or otherwise injure the fragile cervical vertebrate.

Barak Hussein Obama is a Long-legged Mac-Daddy! http://www.veoh.com/videos/v15997742JGzPAAqB This guy kills me. This guy is the most racist black man I have ever heard speak. lol He reminds me of the Chappelle Show skit about the blind african-american white supremacist.

I have almost hit that mark in 18 months of EMS training... I can't imagine being a 30 year veteran and only being as educated as I am right now. Isn't publishing those numbers kind of like saying "Yesiree, we are undereducated! Here is an exact number to show just how undereducated even our 30 year veterans (We have a few!) are!!" I wonder if the great citizens of the Superior Area might actually do the math and figure out they spend more than 1300 hours over 30 years wiping their asscrack. Actually... :shock: Those numbers terrify me...

Isn't that a BIG no-no in Alberta? EMR's CANNOT work with medics I thought...

This "non-American" EMS professional says NO to alcohol in the nose. The fact is: not only are there many professionals here telling you that the practice might be unacceptable, many of them thought your suggestion was so ridiculous that initially it was regarded as a joke. Got that? Not an unusual approach, not a questionable procedure, A JOKE! If that doesn't ring any alarm bells in your head I don't know what should. "Do not use internally" means "do not use internally" whether in Dutch or English doesn't matter. Perhaps after centuries of exposure, the Dutch people have developed some sort of tolerance for nasal exposure to alcohol that makes it acceptable. :roll: I strongly feel that there are far more effective and less "potentially" harmful ways to ascertain true unconsciousness, some of which have already been discussed here. It seems to be that your procedure would be right at home in your idea of overreacting to a situation. Talk about using a sledgehammer on a thumbtack... Alcohol in the nose?!?! I guess the trait of overreacting is not so distinctly an American trait as you so brilliantly hypothesized.

Same as above and also query any history of thyroid problems?

You mean with the camels?

^^LOL, So did you two go grab beers or what? Maybe know we will find out what you REALLY look like AK...

Skin colour? Specifically, are his cheeks a little red, or his toes or fingers? Any skin peeling anywhere on his body? Any edema anywhere? What HAS his diet been then? If he hasn't eaten much poultry? Any fish in his diet?

Just wanted to say great job guys. I don't see much more reason to carry on any further with this scenario. I am very pleased with the way it turned out and I hope everyone had the chance to learn (or at least remember) something new. Somebody mentioned running out of atropine. Another option would be calling for an intercept from the closest ALS unit for no other reason than to borrow their extra atropine. Even if you don't need the hands, they can certainly bring you drugs. Another point that has been brought to my attention (rather vehemently) is that some people would feel entirely uncomfortable even assessing this patient until they have been decontaminated by Fire, regardless of the wait time until Fire Services arrival. Others are willing to risk decontamination themselves and feel that they would be able to do so with their own PPE at minimal risk to themselves. There are experienced and respected practitioners on both sides of the issue and I think the topic could warrant further discussion if the forum wishes. I must stress that I am interested in BOTH sides of the issue. The questions I would pose are: In your opinion, what would constitute acceptable risk in this case? What would be your deciding factors in risking the decontamination process yourselves? Do you feel adequately trained and equipped to manage a specific case like the one that has been presented? Would you even attempt it regardless of the patients condition and wait time? There certainly comes a time when your safety and that of your partner becomes priority? Is this one of those times?

The Pt has JUST stopped tolerating the NRB and removed it after your partner secured the line. He has been compliant with it thus far, but now is in too much distress and spitting and vomiting too much.

(The scenario is being based on the majority rule as far as treatment decisions, so do not think I am ignoring your idea if I do not use it. I am simply waiting for more people to back up your position so that the most people can get the most out of this scenario.) Since all of you seem to be moving in a similar direction I will continue the scenario as follows: While there is no farming taking place in the sub-division itself, the area surrounding it is popular for cattle ranching and various forms of agriculture. Although your patient does not remember any equipment or tankers, he admits that his walking route did take him outside the subdivision a fair distance and out among the more agricultural land. He is coughing more and more often now and is slurring his speech more pronouncedly. Due to his coughing and spitting he is having to remove the NRB more and more often. - Thinking chemical exposure, you activate the local fire service. A Pump crew and 2 recue trucks with hazmat equipment are enroute. ETA 15 min. - Based on the ETA of resources and your patient’s rapidly deteriorating condition you know you must act yourself. If he has been exposed to chemicals, you cannot risk contaminating yourself, your unit or the receiving facility. Once the patient has been decontaminated, then you will be able to safely asses and treat the patient. Taking appropriate measures and PPE to protect yourself, you decide to attempt decontamination yourself, you remove the patient’s clothing and double-bag it in plastic bags. You notice that the skin on his lower legs and buttocks appears slightly reddened and splotchy without true urticaria. - You and your partner assist him to the shower where you proceed to decontaminate him with water so that you can continue your treatment. - You leave your male partner to perform the decontamination while you go to set up the equipment in the unit and prepare for transport. On the way out you recall that you have yet to hear the dog bark even once since your arrival. Your curiosity gets the best of you and you decide to take a look in the pen on your way out the door. A quick glance confirms your suspicions; the dog is lying motionless with no movement as you approach. There are several puddles of vomit and urine combined with a single large loose bowel movement on the floor of the pen. The dog no longer appears to be breathing and its legs appear to be positioned rather stiffly. - Your partner calls for you loudly to return to the shower. Upon entering you find the patient collapsed in your partner`s arms still semi-standing. The patient is complaining in 2 word sentences that it has become suddenly very hard to breath. He is consistently spitting and is unwilling to tolerate the NRB in this state. The patient has defecated himself (narrowly missing your nimble partner), and is now writhing in pain at the severity of the cramps. A quick pulse check reveals a now irregular pulse at approx. 100 bpm. Your partner states that he had just finished decon when the patient grabbed him and collapsed in his arms. The Pt vomits a small amount of bile on the floor as you and your partner hurry him onto the cot and into the back of the unit just as fire arrives on scene. -Your partner initiates an 18g IV in the patients right forearm on the second attempt. He also re-connects the patient to the monitor via a quick 3-lead. The patients most recent set of vitals is as follows: HR: 112 with a few intermittent runs of V-tach every minute or so. BP: 82/ 56 Resp: 28 and frequently interrupted by bouts of coughing, spitting and gasping to catch his breath. Upon reconnecting the SpO2 machine after the shower, you see sats have fallen to 81% The patient is now having difficulty with instruction as he begins to panic. He removes the NRB to spit and the mask slips from his trembling grasp. He dry-heaves a few times and tries to catch his breath. As the senior crew member, you have time for a few actions before getting the heck out of dodge. A few things are demanding your attention: The fire crew is on-scene and requesting information on the potential chemical and exposure, they are also offering their single most experienced EMT to assist you. The rest are trained as First Responders. The airway management of the patient has been left up to you and your partner is beginning to show signs that he is overwhelmed by the sudden deterioration and in need of your guidance of what to do next. It has also begun to pour... again... with lightning. :wink:

As you begin your assessment, the patient answers your questions, tears streaming down his face and frequently coughing. You also notice he has begun to slur as he talks. He says he is from the city and is here house-sitting for his brother who is out of town. He works as a lawyer and decided to take a few days off for some R&R at his brother’s country home. He said he has been in the house for a few days now and was feeling fine until about an hour ago. The acreage is not a farm, and neither he nor his brother does any sort of gardening. It had been raining all day yesterday and he was anxious to take advantage of the break in the clouds to get in some physical activity. He decided to take his dog for a jog on the roads around the area at about 13:30. At one point his dog slipped away from him and chased a squirrel and ran down the road. After giving chase to his dog, the patient slipped and slid on his butt into the ditch were his dog soon followed him down. The ground was still quite muddy from the rain. This explains the soiled condition of the dog and clothes. He denies any injuries form the fall and says that he simply fell to his butt and slid down the embankment into the ditch. He climbed out and decided to return home for lunch and to clean up. He had just begun to make himself a sandwich when he began to sweat profusely and get cramps. Your initial assessment reveals the following: HR: 50 Regular, No Murmur, Good perfusion BP: 92/60 Resps: 20 with intermittent coughing. Stats at 83% RA and 94% on RNB which he is constantly removing to cough and spit then replacing the mask in between coughing fits. The spit seems to be only saliva, clear in appearance. Temp: 98.6* F 37* C BGL: 88 mg/dl or about 4.3 mmol/L CNS: GCS=15 A/Ox4 CVS: Radial Pulses Strong and Regular, Skin slightly pale and Very Sweaty. His clothing is quite damp. HEENT: Bilateral Miosis and Sluggish response. Chest: Scattered wheezing with equal air entry. ECG: Sinus Brad with a prolonged Q-Tc interval. Abdomen: Soft, non-tender. No rigidity, guarding or masses. Pt complains of cramps unaffected by palpation. Bowel sounds are present. He denies vomiting, hemoptysis, hematuria, bright red blood per rectum (BRBPR), chills, fever, headache, myalgia, arthralgia, or diarrhea. Pelvis: During your exam, the patient becomes incontinent of urine, this upsets him greatly and he tells you that he already been to the bathroom twice since he got back from his walk Extremities: A slight tremor is noticed in the patients left arm which he states has only just begun, transient fasciculations in both upper extremities. The only medical history that the Pt can think of is that both his father and grandfather died of Heat-attacks in their early fifties. The patient states that he goes for annual check-up's with his doctor and has had no other medical problems or reason to see him. The Pt denies any allergies or meds and states that he has been in good health and the last pill he took was some Tum’s antacid after he had taco’s for dinner the night before and got a little heartburn. He had cheerios this morning at about 10:00.

Dispatch Info: You are dispatched at 16:00 to the home of a 38 year old male complaining of sudden onset nausea, cramps, coughing and sweating. He walked his dog at noon and returned home for lunch. Shortly after eating his sandwich he began to suffer severe nausea, sweating and coughing fits. Concerned about the sudden onset of the symptoms, his first thought is that he might be having a heart attack. He calls 9-1-1 and begins to suffer some moderate SOB and cramps while talking to the dispatcher. Your response time is 20 min. Location: He lives on a small acreage in a upper-middle class subdivision of about 20 houses approx. 35 minutes from a large urban center. Patient Approach: You enter the house to find it spotlessly clean except for the muddy paw prints of a large dog on the carpet. You enter the kitchen to find your patient sitting on a stool still on the phone with dispatch. He is approx. 6”1’ and 175lbs. He is dressed in a mud-covered Nike jogging outfit and appears fit and healthy for a man his age. He appears to be in pain and short of breath due to coughing. “Don’t worry about the... *cough cough*... dog. The lady on the phone told me to...*cough*... put him away before you guys got here, so I did. He doesn`t really... *cough*... like strangers and normally goes crazy with his barking.” The patient raises a trembling arm to point to a mud covered dog laying quietly in a large pen in the corner of the kitchen. The patient seems very worried and is coughing uncontrollably every few words when he talks to you. Without crying out, his eyes begin to well up with tears as he talks to you. “I would normally have just seen a doctor... *cough* myself. But my dad died of a heart attack 3 years ago and I’m so worried... *cough cough* I have to piss so bad, but the cramps make it hard to stand and walk... *cough cough* You may begin your assessment. There is plenty of additional history and details available for the asking. Treatment Centers/ Backup: There is a modest community hospital in a town approx. 20 min East, while the large city hospitals are approx 45 min. West of your location. Air Rescue is occupied with a multi-vehicle collision on a highway and will not be available for at least an hour. A mixed volunteer/paid fire department is available from a nearby town. Another EMS unit is available and will take 20 min to respond.

Things to check IMMEDIATELY after collision: - Myself (Injuries, etc.) - My Partner - My Patient (The little guy WAS restrained... right?) - The Mother (Even if she wasn't in the passenger seat where we were hit, she still needs to be checked.) - THE DRIVER OF THE CAR THAT HIT ME! (Nobody else thought about this?)

To me it seems the answer is this: - In a traditional witnessed arrest, you know there is a chance that the heart is still being supplied with enough oxygen and nutrients to favor a positive response to immediate defibrillation. - In a witnessed arrest that is due to asphyxia, you know that most likely the heart has a lack of oxygen, so the odds of electricity helping are very slim until you correct that problem. The 2 min. of CPR is meant to supply the heart with enough oxygen and nutrients so that the muscle is at least capable of sustaining a heartbeat after AED use. So in other words, arrest due to asphyxia presents the same situation as an unwitnessed arrest for the EMS provider. In both cases, there is a great possibility that the heart muscle is chemically unable to beat in a hypoxic state and AED use will be largely unsuccessful until the heart is re-oxygenated by CPR. Does this answer your question? Does anyone have anything else to add?

Well ruff, if you have to get a line, you have to get a line. The books say that the IV through the burn drastically increases the risk of infection, but no line at all drastically increases the chance of DYING! Just find the least burned site that you have a chance with a large bore and go for it. (Was the Jugular a possibility for this one?) I definitely think the crew member with the best track record for IV's should take the shot, there's no time to be practicing on this patient. Although I have read that IV sites distal to severe burns can be poor choices because deep tissue swelling with soon cause a compartments syndrome that will keep fluids from making it to the body effectively. Maybe the nurse could be so kind as to recommend a better site when she critiques... In the interest of professional development and all... That is unless the Nurse is recommending fluid resuscitation via ET tube... :roll:

And if you were one of those 100k a year EMT's , that bet would be much, much more exciting... :wink:

DAI = Drug Assisted Intubation? Just my best guess, I don't know for sure.

Barring RSI, a King LT could also work here :wink: Just an example of a challenging intubation where even a Medic might want to pull one out. - So I bag her, and what are the Lung sounds? Any obvious Aspiration of Emesis? - Any signs that she seized prior to us getting our eyes on her? - Is there a patient in the room next to hers that can tell us anything about how the patient has been feeling or behaving lately? Unreliable info is better than none at all at this point I think. But the answers I am most interested in at this point are: - Did we have any Pill bottles present in her room? Possible overdose on meds? - How is the rest of her body behaving? Does it seem appropriately limp? Or does the clenching of her Vocal Chords also extend to other muscle groups in her body?

I think I would go the route of Saline Neb and Gargling water first, then move to possible Albuterol if there is no relief. One thing that I think is important to remember is that she is still in this level of distress after at LEAST 20 min. probably closer to 30min. (with the time it would take her to call and dispatch to come down the line.) So basic measures might not work at this point and more aggressive treatment might be warranted.

Check the date there Arky BEFORE you reignite a 2-year old argument... :wink: