ERDoc

AHHHHHHHHHH!!!!!!! (Doc prepares for the onslaught of stupidity that is about to hit his doors). Why would anyone, especially a doctor say something like this. This is why we have PMDs. People (apparently including other doctors) don't understand what the word EMERGENCY means. Don't come to my ER for a sunburn. I will be as sweet as pie and tell you what to do, but you won't be getting any scripts from me and you will get a several hundred dollar bill. This is why our health care system is in such chaos. People (and physicians) utilizing the limited resources inappropriately wastes money. I can't count the number of times I got a bad burn when I was a kid (I'm a fair skinned guy with ancestry from northern Europe). Never once did I got to the ER. Had I even thought about it, my mother would have laughed at me and given me some over the counter cream that worked just fine. You guys in the field are going to feel the effects too. People are going to want to go to the ER and will forget how to drive the 3 cars in their driveway.

This reminds me of a pateint from my EMS days. It was around 3am and we brought in a lady with chest pain. Behind us in triage comes an ambulance with a 20-something years old woman who had sunburn on the top of her feet. The doc told them not to take her off the strecher. He examined her, wrote the note, gave her the discharge instructions and told them to take her out to the waiting room for her family to pick her up.

Sorry to ramble, but stupidity makes me angry and I needed to vent.

I certainly hope whit72 is reading this

Angioedema? Stridor?

If so, epi 0.3 mg IM and get the glucagon out

Some swelling of the uvula. No noticeable stridor. Do you want to give the epi? What's the deal with the glucagon?

PMH as stated, only htn. Known hx of allergy to peanuts. Pt takes atenolol. Those dogs behind the store are for security and have nothing to do with the food. Ignore that furball in your wonton soup.

Meds as ordered. EKG shows stach at 118. Pt states he is not feeling better.

We could try adenosizing his ass but its not going to do anything except make him think he's dying for a few seconds, and we could find other ways to entertain ourselves.

You know, sometimes when you make pts feel like they are going to die, it stops them from being repeat customers. Just a thought .

You are called to a 59 y/o male with a h/o htn who "started to feel itchy," after he ate some Chinese food. He has a known allergy to peanuts and thinks he may have tasted one in the food he ate. He compalins of a mild scratching in his throat and a little sob. He also c/o full body pruritis.

"ERDoc,"

I'd like to try to help some of the people here who may be new, and have never utilized medical control before. Do you have any advice for Basics who maybe requesting-recieving Medical control for the first time? Any hints, do's, don't etc... Next for the Paramedics, step it up a notch, what are your minimum expectations with a 'presentation' from a medic? What may or may not dictate sucess (menaing approval and ultimately agreement with their request)?

Thanks,

ACE844

A great deal is how organized you are. If you sound like you are stumbling to get the story across it does not instill the gratest confidence. I think I discussed this a long time ago about giving hospital presentations. Try going something like this, "65 y/o male with h/o CAD, MIX2, 3VCABG c/o substernal chest pain going to left arm for 1 hr. Started while shoveling snow." Give pertinent PE info or say PE unremarkable. Give any pertinent EKG/rhythm strip info. Tell what you've done and the response to it. Finally give ETA to hospital. Obviously there are exceptions. If you have a trauma that needs to be RSI'd, keep it quick. "Unrestrained driver in head on MVA. GCS=3, would like to RSI." Keep it simple and too the point. As long as you sound competent, you will be treated as competent and usually get what you want (just be prepared to justify it if needed). Obviously this is just my opinion and everyone is different.

Hope this helps.

OK, so let's take that first ABG and assume that it is not from hyperventilation. It means that we are looking at a chronic, compensated respiratory alkalosis. What sort of things can cause this? Well, chronic anemia (he's got it), hyperthyroid (he's got it, could be thyrotoxicosis), interstitial lung disease (sounds like he might have it), hepatic failure (sounds like a possibility), sepsis (he's got a white count). A resp alkalosis is usually a sign of something ominous going on, be very careful, the only thing more scary is metabolic alkalosis. I would like to see some more of his labs. chbare, I know it doesn't give you the answer, but I hope it helps.

That first ABG may be from hyperventilating while intubating. Or could it be from something more sinister???

I'm having trouble believing that at 160 the rhythm was sinus tach. If I had to be I would either say it was RAF or SVT, either of which could explain the possible chest discomfort and syncope.

When did we lose Reagan??????

Seriously, want to know why Medical Control thinks the way they do? Check out this thread. I have many more stories. To be fair I also have many stories of things going the right way and field crews performing above and beyond.

http://www.emtcity.com/phpBB2/viewtopic.php?t=4723

JPINFV: Does it matter if I know.

What I do know. Is that it has no business being in any prehospital protocols.

Can you say things like automatic indicator for admittence to hospital for severe rebound effects.

And possible link with Miocardial Infarction

I dont want to turn this into a pissing contest. If you dont have anything to add, please dont clutter the thread.

Racemic epi does not equal an automatic admission. It means at least a 2-4 hours observation in the ER, although some will automatically admit. My concern with giving it in the field is that I will not be able to fully evaluate the pt and make the best decision. That field provider has committed the pt to at minimum a 2hr ER visit.

Now that we have you here DOC what do you think about EMT administering Glucagon IM?

I'm not a big fan of glucagon for hypoglycemia. I'll take an amp of D50 anyday. If you can't get an IV, then I guess go for the glucagon. For EMTs I guess it depends on distance to hospital and resources. If you are in an area where you are only a few minutes from the hospital then package and go. If you have a longer ride, get ALS involved. The patient may need for than a shot of glucagon.

What is your issue with racemic epi?

OK, it says for a febrile seizure to give tylenol. That makes sense now. I thought we had a new form of coma cocktail, guess we could have called it the pediatric fever cocktail.

hope ERDOC has an enema.......cause he will have to float his way to the top cause i am here

Eww. Nope, no enemas here. That's what nurses are for (just kidding Rid). But hey, I'm back on top for a few secs.

It's my turn on top.

I've been staying out of this, but Tylenol supp for a pediatric seizure?

Did I miss that day of med school?

But that is your classic crush injury. The Pt's death is not caused only by bleeding out but by electrolyte displacement (K+ in the blood stream) and other cellular waste products.

Sorry Hammer, I'm going to have to disagree with you. The death is probably the result of severe internal blood loss. This guy probably has a liver and spleen the thickness of pancakes which just let loose once the pressure on them is removed. The aorta and illiacs have probably also seen better days. You are not going to get a build up of toxic products that quickly. Even electrolyte shifts should not happen that quickly.

An abscess looks like the opposite of a mass. The center is dark and there is a white ring around it. Here is what it looks like:

She has 2 brain lesions (most likely mets from the breast ca) and 2 bone lesions. The black surrounding those masses is edema. That "bump" she got on her head was actually a lytic lesion in her skull. While she contributed all of her symptoms to the two accidents, they were red herings. Her chest xray that was done in the ER also showed a few masses. CT scan of the chest the next day did not look good at all. She has a pretty poor prognosis.

That emergontologist comment was a joke. I hate the term, I am but a simple ERDoc.

To stop Punisher from whining, I have finally included the CT.

Man, Doc, you're taking longer to get our CT than any radiology department I've ever seen.....

Hey, cut me some slack. I'm an emergontologist , not a radiologist. You've obviously never worked at my hospital.

Arteries are covered in smooth muscle that spasm whenever there is an injury (just ask anyone who has ever missed an ABG, the second time is even harder). If the pressure coming down the pipe is higher than the spasm force then you will get bleeding. Veins don't have this compensation mechanism so they tend to bleed more. Luckily they are such low pressure vessels that it doesn't take much to stop them from bleeding. Organ injry such as splenic and liver tends to lead to massive blood loss because they don't have such mechanisms.

I think I found the ambulance your looking for Doc.

Peace,

Marty

:joker:

Now that's what I'm talkin' about. I will have the CT up for you soon.