ERDoc

So, here is a brief synopsis for the treatment of myxedema from Emedicine (with some highlights based on the discussion here). If you want to read the full story, here is the link: http://www.emedicine.com/emerg/topic280.htm Prehospital Care: Stabilize acute life-threatening conditions, and initiate supportive therapy (that helps clear it up, doesn't it). Emergency Department Care: Patients with myxedema coma may present in extremis; implement initial resuscitative measures, including intravenous (IV) access, cardiac monitoring, and oxygen therapy, as indicated. Mechanical ventilation is indicated for patients with diminished respiratory drive or obtundation. Evaluate for life-threatening causes of altered mental status (eg, bedside glucose, pulse oximetry). If myxedema coma is suspected on clinical impression, start IV thyroid hormone treatment. Confirmatory tests often are not available to an ED physician. With a diagnosis of myxedema coma, initiate hormonal therapy. Investigate immediately for inciting events such as infection. Treat respiratory failure with appropriate ventilatory support. The condition often requires mechanical ventilation. Treat underlying pulmonary infection. Hypotension may respond to crystalloid infusion. Occasionally, vasopressive agents are required. In refractory cases, hypotension may resolve with thyroid hormone replacement. Treat hypothermia. Most patients with myxedema coma respond to passive rewarming measures such as blankets and removal of cold or wet clothing; aggressive rewarming may lead to peripheral vasodilatation and hypotension. However, hemodynamically unstable patients with profound hypothermia require active rewarming measures. Treat hyponatremia initially with water restriction; however, if sodium levels are less than 120 mEq/L or any seizures occur, hypertonic saline is indicated. Avoid medications such as sedatives, narcotics, and anesthetics. Metabolism of these agents may be slowed significantly, causing prolonged effects.

Yeah, we use steroids. I don't know about the studies, but the steroids take as long as 4 hours to work, so you may not be covered. Also in the letiginous world called the United States, you need to CYA and standard of care at this point is observation.

You'd be surprised how well people do with RE. People can make a full 180 turn and are able to walk out of the ER with close followup.

The effects of racemic epi last about two hours. You are going to keep the pt in the ER at least that long to make sure they don't have any rebound. The pediatric literature recommends four hours of observation, giving you 2 hours after the epi has worn off to look for worsening. EM literature says two hours is fine. FP splits the difference and says three hours. It's really up to the treating physician and their comfort level. Here are a few references for your review. Hope it helps. http://www.fpnotebook.com/LUN125.htm http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

Speaking for the ER docs that will be taking care of your pts after you drop them off, please don't give racemic epi unless you absolutely have to. You are committing them to at least a four hour ER stay. Let the ER doc make that decision if you can avoid not giving it. I'll get off my soap box now.

Also try pubmed.com but you must know how to read true research papers.

Good god, what the hell are these two smiley faces doing to the one in the center???? :3some: Someone get them a room! Sorry for the outbust, I'm a little sleep deprived and I just noticed these three.

Don't know about his O2 stats, but Jeeter is batting .339, go Yankees! :occasion5:

Hey UM, did you guys call the helicopter for the ant, or are you lucky enough to work in one of those systems where you can pronounce on the scene?

Whatever rate and TV I need to keep the ABG lookin' good, but I genrally start 8-10cc/kg.

Just a little update. I just did a medline search and as expected there were no articles about ants impaled in the tonsil of a transexual. Sorry, you will have to come up with your own plans. On the otherhand, I have a great idea for a new study.

Alright, I have been asked to come out of troll-mode after several months. Here's my take on it. First, I am going to make a few assumptions. I am going to assume that the laryngoscope was used for lighting purposes. I am going to assume that this pt was not placed supine and had true direct laryngoscopy or anything close to it (if so, please leave your card at the door on your way out). There is always more than one solution to a problem, especially when it comes to medicine. Some people may prefer one method over another. If I were presented with this pt in the ER, I would grab a pair of forceps and pull the ant out. Other docs may handle it differently, but I am a "get the job done" kind of guy. Nothing in medicine is clear-cut and I can almost guanantee that you will not find any text book chapter or randomized, double-blinded, placebo controlled study to determine the best way to get an ant off of a tonsil (you probably won't even find a case study in the literature). Just because someone does something differently than you doesn't necessarily make it the wrong thing to do. Sorry for rambling on for so long, it's just been a while since I have do so. Sorry vs.

Wow, tough case. While you cannot force someone who has the capacity to make their own decisions to go, you can try really hard to convince them (I think this is what the medic meant by coersion). From the medical control standpoint, there is no way I would allow an RMA. The pt in the original scenario clearly does not have the capacity to make an informed decision. The key here is to document everything. I would document the way the pt presented, what we saw. I would document the pt mental status. I would document the fact the law enforcement was asked to intervene and refused. I would document the refusal by medical control. I would also document that the pt was getting combative with the crew and they you felt it was a risk to the crew to take the pt without law enforcement assistance. You've used all of your possible resources at that point. It is doubtful that a case like this will make it to court, but if it does you stand a good chance of getting cleared, the officers may not be so lucky. Where I did my residency, the EMS crews called us to determine whether the pt had the capacity to refuse treatment. That was our only purpose, but most of us would also try to convince the pt to go if we felt they needed to go. Once we felt that the pt could not make that decision, it was up to the crew to get the job done. They had the option of asking the police to give assistance. The was not a problem when I was in the field, but the county PD had seen one too many unlawful imprisonment cases and decided that it was not their responsibility to take these people anymore. This left the field crews in pretty much the same position as this crew. My only advice would be document, document, document.

The lab test is a prolactin level, which is usually elevated for a short period after a seizure (about 15 minutes or so). Does it really matter is someone gets one over on you? It doesn't make you any less of a provider. As long as you are doing the right thing, then no big deal. So what if you just gave some junkie their fix. It happens to everyone at some point, reguardless of how much experience you have. Just be alert to it so you don't become their supplier.

I was once asked by a pts daughter, "Are you a resident or a real doctor?" To which I replied "Yes." They seemed satisfied with that and we moved on.

"I need to have my ovaries washed out." "My penis is red and itchy and swollen." 4am "I was in an accident 10 hours ago and now my neck is hurting. I don't want to go to the hospital, but was hoping you could give me one of those collars." 4am volley call "I've had this belly pain for 15 years. I saw a 3 GI guys who said it was GERD and started me on a pill that I have to take once a day. I don't want to take the pill anymore, so what can you do for me?" Me: "I can have you sign your discharge papers and have you follow up with one of your GI guys in 2-4 weeks."

Decreased sounds on the left with good sats, let's pull the tube back a little, and shoot a cxr. How 'bout digital intubation in the truck prior to extrication? Let's pan scan him and find out what's broke so that the surgeons can fix it.

Sinus node dysfunction/sick sinus syndrome. Check out below: http://www.emedicine.com/med/topic2132.htm

The important thing is that the person who identifies themself as a medic/EMT/MD/RN/etc be able to provide proof. You would be justified in turning someone away if they were unable to produce ID. We used to have a guy who would run around in one of those generic EMS jackets you can get from Galls and tell everyone he was an EMT. Happened one too many times and he got himself in over his head with a sick pt. Ended up getting a pair of shiny silver bracelettes courtesy of county PD.

One more just to post pad.

Hey, I now have over 400 posts!

How did this thread go from a discussion of glucose/glucgon to a talk about overly aggressive intubations?

12cm????? :shock: That's no small tear (it's about half the length of the tube) and that takes quite a bit of force. This guy needs a little remediation to say the least.

The rules vary by state, but in general once you have made patient contact and identified yourself you have established your duty to act. It does not matter if you are paid, oncall or whatever. You as an EMT are the highest medically trained person on the scene and you have properly identified yourself. Should something happen to this person once she has left the scene you will be held resposible and considered negligent. There are some states, such as Vermont that say that your duty to act begins once you know that there is a problem, even before you have made pt contact. This means that if you are driving by an MVA you have to stop. If you don't and someone recognises you, you may be held responsible in a court of law. Isn't the US legal system great? As far as Whit's comment about not identifying yourself, this too could lead to legal problems should someone recognise you and things go bad, not to mention that ethically you should not be lying to your patients.

Medical cases are 90% history and 10% PE. You should be able to narrow down your differential from the history and help to confirm it with your physical exam. CHF will also cause dyspnea on exertion, paroxysmal nocturnal dyspnea and othropnea. Ask them how many pillows they sleep on. Ask if they able to walk as far as they used to with getting sob. Ask if there has been any weight gain. They are just a few examples. If you have one of those really cool ambulances with a full stocked lab you can order up a BNP.