captainstandup

Diastolic pressure is very important in cardiac patients and those suspected of having stroke. As you are aware the disatolic number is at least partially representative of just how well the heart is resting. In trauma patients, pulse pressure is very important as an early indicator of tamponade.

Stay out of North Carolina, neither your paycheck nor the virtue of your wife, girfriend, or if you are considering Asheville, your son or barnyard animals are safe! That place is a cesspool and worth avoiding!

I spend way too much time complaining about what I don't like, and this thread gave me a much needed reality check! There are so many things I like about having the opportunity to care for the sick and injured. I am the first in my family to work in health care and have had opportunity to serve in such a broad range of roles from EMT-Basic to Paramedic then Training Officer and finally EMS Director. Now I'm in Critical Care and the learning has begun anew.

There have been so many patients helped and unfortunately a great number that could not be helped. Education came from local colleges, training from my mentors, clinical judgment has been and is now being provided by each patient I care for. I owe all of these folks immensely as they have provided a man of average background and culture the opportunity to be successful in a very challenging environment. To those who allow us to invade their most sacred personal space, we owe a huge debt of gratitude!

I'm not much for the "touchy feely stuff" but here goes, Some of my favorite things are:

A sunrise while on the way back to base after a rare opportunity to make a difference, especially on cold mountain mornings in the early spring.

A parent in the ER with a teenage son who has just destroyed their new car, that while the son is saying "mom I'm so sorry about the car", interrupts her son by saying "it's just a car son, it's just a car" and ask how he feels.

Really good physicians and nurses that value our contribution to patient care and show us respect, there aren't many but, those who do are incredible and provide another valuable learning opportunity We are responsible for being humble enough to ask questions of these folks.

Partners that understand that when driving emergency or not you should always "drive only as fast as you are willing to wreck"

As patronizing as it may seem, EMT City. In the history of our industry there has never been a "vehicle" for transmission of information, thoughts, emotions, data (good & bad) as valuable as this. Where else on earth can you find virtually instant feedback from some of the brightest, most educated and experienced minds in worldwide EMS? I've learned to tame my tongue and think before "speaking" these folks will call us on silliness or bad information and rightfully so.

Quit working for them. It's very hard, if not impossible, to outlive management and work culture such as you have described. The county where I served as EMS Director was essentially run by a bunch of illiterate redneck's and especially a Fire Chief's organization that couldn't formulate an educated opinion and certainly did not have the capacity for abstract thought. They were, and are to this date, a bunch of idiots with political influence. These guys buy $260,000.00 trucks and compete with each other in opulent buildings instead of providing high quality services and training to their personnel. These guys were my nemesis and gave us a great deal of difficulty. I finally gave up and took a much higher paying job with much less responsibility and a great deal of opportunity to expand my knowledge and perhaps venture in another direction.

It's really important to know when to cut your losses, and it certainly sounds like they (the powers that be) have pretty much sewed this thing up

Medtronic and Guidant have experienced some really serious issues with their implanted devices lately. Perhaps the device failed or for whatever reason the patient has "lost mechanical capture" and was at that point not truly being paced by the device. This could easily result in low cardiac output, confusion and lethargy. Of course we are going to consider the other disease processes and fully assess the patient. In my opinion a Medic that fails to FULLY assess and gather information utilizing a combination of education, training and clinical judgment all supported by some really expensive electronics is dangerous.

Expert consultant = Idiot from out of town (>30 miles) with a suit, attitude and he must have a credit card to get lunch with, she better be really pretty and have a credit card to get lunch with.

As elementary as it may seem, that is giving the patient advice on eating protein, in reality the patient would be better served by a complete workup in the ER and a really specific assessment of their health from an endocrinology perspective.

Even the best equipped pre-hospital providers should, in my opinion, not be giving nutritional advice to a diabetic patient. Lab studies including fasting blood glucose and later on an A1-C would be a great addition to this discussion. You didn't mention whether this was in treatment of a known diabetic or not, furthermore I've never seen a symptomatic patient with a BG of 65, most are much lower.

If this patient, hypothetical or real, is not a known diabetic, they simply must be transferred to the hospital. There is a myriad of conditions other than diabetes that can result in hypoglycemia. Hypoglycemia may actually be a "symptom" rather than a condition, as it were, and must be investigated by folks such as JPINFV who understand the krebs cycle and associated processes.

Most physicians will, after a great deal of lab work and fasting / non-fasting studies either consult with or refer a diabetic patient to a registered dietician for nutritional advice.

I would spend $900K EDUCATING our staff. $100K would be used to purchase wooden stakes to be driven into the heart of the redneck training system in our state and hopefully have a few left over to take care of the AHA. (Now thats what I call remediation to success!)

Enough is enough! It is time to train and arm paramedics. Societal decay and liberal politics have conditioned losers to have no respect for Law Enforcement, EMS and Fire. Cities overrun with gangs, nasty assed housing projects, drugs, prostitution, and organized crime. It’s insane to enter these types of environments without defensive weapons. I prefer to be armed with a conventional handgun, but at a very minimum we should be allowed to carry police issue tazers

Please save yourself from a really bad decision. Go to nursing school or med school If you choose nursing do what it takes to become an ER or critical care nurse then get your CRNA and make a decent living. I'll concede to Dust that at least you are in the UK, but in the US we are less than pond scum. You may also want to take a look into sonography. If sonography interests you please follow a course that educate you in cardiovascular and OB sonography

If we are going to do this crap i want an MP5 K and four mags with me on every call.

I recommend taking care of his airway first. 24, shallow and labored with this MOI is a really strong indicator that a tension pneumo or hemo may exist. Unless I missed it in the thread, there was no mention of BBS.

With airway issues you simply must take a look at the patients back to ensure you aren't missing / ignoring an occult insult to the chest wall, lungs, etc. The airway issues alone are indication enough to immediately stabilize to the best of your ability and roll this patient to perform a proper airway / spinal assessment.

Sounds like Canadia needs to pass more gun laws!

Maybe talk to New York City or Washington, DC. They both passed more gun laws, and I'm pretty sure they completely eliminated murder from their cities. As much as they whine about what is going on in Iraq, obviously they have nothing to worry about in their cities anymore.

People of honor and standup don’t need the gun thing explained to them Dust. Fools that believe gun laws help anything except the criminals deserve to be shot in the face by a thug in the mall parking lot. Perhaps their straight democrat voting family members can then find this poor misguided soul and minister to their damaged inner child.

You guys doing the hard stuff in the sand box shithole have my total respect, we desperately need men and women of honor to lead this country instead of the nauseating limpwristed, helpless, hapless, dishonorable, liberal, take no responsibility for your actions, Godforsaken, fraudulent charlatans running for office in the US now.

We don’t need more gun laws; we need more armed citizens with enough honor to stand up when others run away. Just imagine if a couple of kids at Virginia Tech had been trained, armed and standup they could have killed that bastard before he killed 32 precious souls. The liberals can’t protect us, yet want to disarm us.

Just remember, an armed society is a polite society.

Dobutamine is less cardiotoxic than dopamine, especially in the setting of CHF (assuming the problem is not rate related) where the desired effect is inotropic rather than chronotropic. The obvious risk is increasing myocardial Oxygen demand and worsening an already decompensated patients condition.

Surely you dont think I was saying not to provide high flow oxygen, comfort and transport to a patient in this condition? I was referring to the posts that listed ONLY these three thing, which is completely inapproprate.

Which MAOI was he taking?

Have you seen any penetrating injuries in the sandbox Dust? I'll bet you see more in six months that I have seen in 16 years of EMS.

What percentage of GSW injuries you see involve spinal trauma?

Everything about nursing homes, all of them, no matter how opulent or meager the surroundings. I hate going to them, the smell, the idiot staff that always say" i jus come on shift and don't know nuthang" the hopelessness and the mortality check it gives me.

You asked what I hate and I was honest, bear in mind i am always, 100% professional, compassionate and focused on caring for the patients, but I really really hate going to these places.

The other thing I hate is mutt, non-standup partners that never pick up a book or trade manual, attend the minimum training and watch that dumbass Jerry Springer or Maury Povich with the exciting DNA results identifying the baby daddy every shift!

I suffer fools, poorly....................................

Sorry I have been away for a few days, family calamity. In any event I was referring to a fluid challenge in CHF patients being necessary to improve preload and subsequently cardiac output to a point that would allow treatment of the CHF with nitrates an other therapies. Ideally we would consider dopamine or dobutrex to accomplish this but it may be worth trying a small fluid challenge 200 to 300 ml. Perhaps this will accomplish the task and permit instant treatment without the toxic effects of the pressors including the risk of tissue necrosis with extravasation and of course the potential for increased myocardial oxygen demand with the pressors.

This was merely intended to draw a similarity between the benefit versus risk of treating chf with fluid and treating Acute asthma with bronchodialators such as albuterol while weighing the risk of hypertensive crisis and risk of death from the status asthmaticus.

Oxygen, comfort, transport for a status asthmaticus patient when you are 24 miles from the ER = Take them around back to the morgue entrance when you get there.

This statement was unrelated to the asthma / MAOI discussion. I was trying to make a comparison between patients in congestive failure who are marginally hypotensive preventing nitrate administration. These patients can benefit from a small fluid challenge which temporarily improves their overall hemodynamic state to a point allowing other therapies without causing harm.

With this said I understand that we do not rely on BP alone in determining a course of action There are several additional considerations including determining whether the overall problem is related to rate, pump, container or "relative container" problems.

Due to the "fact" there seems to be few meds a person taking MOAI's can utilized in treating acute asthma attacks, I was wondering of this isn't simply an issue where the potential for gain outweighs the risk.

Perhaps this is more a function of risk vs. benefit than just straight up pharmacology. In theory we can treat hypertension, even hypertensive crisis, if absolutely necessary. Untreated or improperly treated status asthmaticus can kill our patient before we can deliver them to definitive care.

How many of you, when treating hypostensive CHF patients, administer a small fluid bolus to increase the BP to a level which permits treatment of the underlying CHF? This is illustrative of a therapy that runs the risk of at least temporarily worsening the patient’s condition in order to treat a more life threatening condition

Wow that’s a relief, I just knew you would be busting my chops over this one Dust! I really don’t mind four years of living hell, I do mind being so discriminated against in this godforsaken redneck state that it isn’t even worth applying unless you are female, gay male or a minority. This isn’t a sexist, racist or homophobic statement, just an irrefutable fact.

Hospice simply flushed the meds my Grandmother was on, down the toilet. It is inconceivable to me there would ever be enough home administered medications or even hospital administered medications entrained, via the waste stream, into the public sewer system to cause any problems.

In large metropolitan areas such as New York which processes roughly 1.5 BILLION gallons of water per day, it would require almost 3 MILLION gallons of a liquid substance (or solution when tablets or capsules dissolve in water) to contaminate the total daily sewer volume with only .25 ounces/gallon of an offending substance .

Did I in any manner imply that we should not treat an acute asthmatic? Hell no!! The point of this discussion is to; discuss what, if any, other therapies and medications are used by other providers in these situations and not a the ridiculous notion of not treating the patient.

OK I haven't been around EMT City long enough to understand the hieroglyphics, just slam me in a PM or on the thread and get it over with. I was on a rant about this ridiculous local nursing school. I just haven't figured out who to bribe to get in yet. Considering that everyone who applies has a 4.0 and they already hate Paramedics, they can discriminate at will and routinely do.

It's my understanding that administration of Albuterol and like preparations to patients taking MAOI's may induce hypertensive crisis. I haven't fully researched the subject and honestly beginning this thread is part of that research. I called one of our pharmacists and am awaiting her return call.