triemal04

You wouldn't be studying medchem for pharmacists would you? If that's the case the only advice I can give comes from the Pharm.D students I knew; "medchem...what the hell was THAT all about!?"

Smart ass or not, it would be a good idea to pay attention to what's being said. (I'm not saying that any of your comments were out of line ruff) In all seriousness, why do you think this place is so dead? Part of it has to do with people posting on social media sites (facebook, g+ and such) instead of forums, part probably has to do with how high this place pops up on a search engine, but I'd bet a lot has to do with the reception that people get when they first post, or when they see what that reception will be. Take a look at how many new posters are treated when they ask a question; they get some high and mighty response that probably has nothing to do with the question, and then someone pops off about how they need to stay in their place. Great reception, huh? Can't imagine why people aren't flocking here.

Really? Allow me to be the first to say shut the hell up. You wonder why this forum is so dead? It's because of bullshit responses like this one. YOU didn't hand out "thereal truth" all YOU did was make a statement that had nothing to do with the question that was asked, and in all reality, doesn't really even matter. And now you seem to be hopping on a high horse as is your standard procedure here. Yippy ki yay there buddy. In fact, nobody handed out "thereal truth;" chbare was nice enough to point out that, given the terminolgy the OP used, the expectations from that course might be different than the reality. That was appropriate, and nice to do. MP-EMT22, I can't give you any first hand info on this course right now; if you haven't taken it by then, check back in 6-8 months or so. I've been looking into this one for awhile and will either end up taking the course that starts next month, or the one after that.

You do realize that the reasoning behind the current trend of titrating the delivery of oxygen has nothing to do with the hypoxic drive, right?

Man I really can't tell if you're being serious, or just trolling to try and stir people up. I'm leaning towards the latter. So for now I'm just going to sit back and enjoy the show.

Some medical directors can respond on some calls, though it's not on a regular basis. In St. Louis (I think) one of the EM residency programs lets third year residents fly on their helicopter. That's really going to be about all you'll find here. Beyond asking what you really want to do with your life, a better question that you need to ask is, "how effectively could you work as a doctor in a prehospital setting in todays environment?" Beyond doctors themselves, the equipment that they would need (ultrasound, possibly echo, lab capabilties [i-stats and the various cartridges aren't cheap when used all the time] plus a larger and more comprehensive stock of medications and routine equipment) isn't cheap. When you add in the fact that some patients need at least a couple hours of observation for repeat labs before discharge, and that many things would still require a visit to the ER (fractures, anything that needed a CT, anything that requires cultures, anything that needs more than a brief workup, anything that requires an x-ray and so forth)...and you further add in the nature of our legal system and how people will sue at the drop of a hat...what doctor do you think would be willing to spend all their time seeing patients in a setting where they would only be able to take care of the most minimal problems without a massive potential for a lawsuit if anything went wrong? Add that to the question of, what department would be willing to spend all that money on equipment and supplies, wages for the doctor, a large and robust malpractise insurance plan for them, and then get very minimal return; how many people do you think could see on a daily basis in that role? How many could you really keep from going to the ER, bearing in mind that YOU are doing all the work that is usually done by ancillary staff? How many people do you think you could see and effectively treat in the field with limited equipment in a way that was safe for both the patient, and for YOUR continued practice? Whenever some bozo brings up the fact that other countries use doctors as field providers, you have to keep in mind that those doctors are not being used in the same role as the average paramedic or even EMT; they are more limited in supply and don't respond to every call. They are paid very differently than doctors in the US (and due to differences in schooling often have different financial needs) with some of them still being residents. Those countries also have a very different legal setup when it comes to tort law and malpractice. Food for thought.

The lack of people here may have something to do with the reception that all new posters seem to get...

Have you got your anxiety disorder and OCD under control yet? Yes or no.

Piss actually serves a purpose... Of course I freely admit to being biased about beer given my location...though in this case it's such a good bias...

Trollin' trollin' trollin' Keep trollin', trollin', trollin', Though they're disapprovin' Keep them trolls movin'...Trollin'! Don't try to understand 'em Soon we'll be laughing in disgust. Boy my heart's calculatin' My detestation will be waitin', be waiting at the end of the thread. Move 'em on, head 'em up, Head 'em up, move 'em out, Move 'em on, head 'em out...Trollin'! Set 'em out, ride 'em in Ride 'em in, let 'em out, Cut 'em out, ride 'em in...Trollin'! I missed the last blatant troll thread, but this should be fun. If the next few verses are needed, I've got 'em...

Fix the things that you have to fix the facilitate transport and prevent further harm; ie decrease the tidal volume, seal the puncture in the chest, and adjust the sedatives and pressors as needed. Does this lady need more than what was done? Sure...but at a certain point you need to weigh the cost of staying, potentially getting into a pissing match with the transferring facility (and potentially the receiving facility) and actually getting the patient to the care they need in a timely manner and in as appropriate a condition as possible. Some things can be done on the road...some must be done before leaving...some things are "nice to do"....some things must be done...knowing the difference and how to pick and choose your battles can be difficult, but can be a big part of doing transfers. And I'd just like to give a shout out to ventmedic...good to see it back...again...

Don't use propofol; either versed or your choice of benzo's. The fixed gaze and decerebrate posturing could easily be missed seizure activity. While a deviated gaze can happen for other reasons, in this unresponsive patient, with everything else in his presentation, treating for a potential seizure is appropriate. To recap: Intubate; use etomidate (or versed) and succynocholine to faciliate that. DO NOT use a long term paralytic unless the patients innate respiratory drive interfers with your ventilations. Sedate with versed initially, think about adding in some fentanyl down the road. Set your initial ventilations at 8ml/kg and 12/min. This is likely a patient that you will want to hyperventilate and drive down the CO2 but that can wait for a minute or two. Reassess the BP, pulse, rhythm, 12lead, SpO2 and ETCO2, pupillary response and any response to painful stimuli after a couple minutes. Elevating the head of the bed is a great (and often forgotten) idea. Before you leave have someone get a better and more accurate history of the events leading up to the collapse, including the last several days, what actually happened at the start of the event, patients normal mentation, previous history, and how long was the delay between collapse and activation of 911. This could go either way; either a primary neurologic event, probably a hemmorhagic stroke, or a very prolonged downtime with hypoxia.

Early administration of Epi-pens in kids....public access AED programs...citizen CPR programs...and now narcan....hmmm....I'm sensing a trend here... (the trend being these are all things are potentially life-saving with very few true drawbacks, and all are...you know...actually working when implemented) I'm reminded of chicken little whenever this bullshit comes up...as it always does...

I would have cut back the propofol and versed for fentanyl, but that's me. As long as the patient stays deeply sedated enough that she doesn't interfere with the vent settings the nimbex can be stopped; if her own respiratory drive starts to cause problems I'd restart her on it before upping the dose of fentanyl (or whatever sedative is being used). The vent volume needs to be cut way back. 550ml for someone who's only 5 feet or so tall, and has a pneumo, and probably ARDS is far to much. Her ideal bodyweight should be somewhere between 45 and 55 kilo's, depending on exactly how tall she is. Drop it to 440ml and reassess. Are you able to tell how long her PEEP has been at 22? No transfusion, it can wait. What do you mean by a "red dot?" Just a small puncture mark, or something bigger?

Oops. Cardiogenic shock from an MI most likely (still won't fully rule out other causes but's start with that). Start a levophed drip. I think even if dopamine was available I'd still start with that; levophed will make it more difficult for the heart to pump blood, but it won't increase the myocardial demand as much, and as the right side of the heart is likely involved a pressor will be beneficial. Start at 8mcg/min, titrate up/down as needed and aim for a MAP of 65. Continue to reassess BP, lung sounds, SpO2, mental status, etc. Then continue as before. Why a trauma team activation?

The patient goes to the level one. It is in no way the mommies decision and she shouldn't be in the back of the ambulance at this point anyway. If the patient himself is hesitant be very blunt in explaining what may be happening to him and why he needs to go to that specific hospital. While you should (and I would) call in and activate the cath-lab, there is the possibility that this isn't a MI. Two things in particular pop to mind. You've got what looks to be an anterolateral MI with inferior involvement; almost global ST-elevation; only 4 leads don't have any. And a narrower pulse-pressure. And hypoxia from an undetermined cause. And an elevated respiratory rate. Cardiac tamponade comes to mind. Was any JVD noted on the physical? Appropriate hearttones? Pulsus paradoxus? You've also got a patient with a diminished level of consciousness and abnormal respiratory pattern from an undetermined cause. 72/54 isn't THAT low of a blood pressure, though he may live at a higher BP which could explain it. But the rapid, irregular respirations don't fit. Neither does a 90 second seizure; a hypoxic seizure or one due to a low-flow state wouldn't likely last that long. While not that common, it isn't unheard of for a head bleed to mimic a STEMI, not just ST-depression. So. Activate the cath-lab, but give the recieving doc a heads up that not everything fits. It most likely is a MI, but be considering those other things. Give 500ml of fluid Place on O2 Start a second line Reassess BP, mental status, respiratory rate/pattern and lung sounds. Be prepared to intubate if the mental status declines, and be ready to more aggresively support the BP prior to, during, and after if you do.

I haven't read the whole thread (for some reason I'm now only seeing 5 posts/page which is highly annoying) so this is more of a general statement. With higher risk patients who need some type of venous access, either because they need a treatement, they need a treatement that can only be provided at the hospital, or have a high potential of decompensating with or without treatement, starting an IV, or in this case an IO, even though it may not be used in the field isn't always wrong. Speaking specifically of an IO in a situation where an IV is unobtainable, there isn't anything wrong with placing it while enroute to the ER so that it can be used as a bridge, if needed, until better access is obtained. This is really where knowing the capabilities of the hospitals you transport to comes into play. Ignoring any childish debates on whether or not a paramedic is better than a nurse at starting an IV and visa versa, just figure that if you can't, and have explored all options (feet, inner wrist, EJ) that they won't be able to either. So where does that leave you? If the patient really is that high risk, they're either getting a central line, an unltrasound guided line (deep brachial), or maybe an IO (that that's less likely). Neither of the first two are fast; to do a full sterile prep and drape for a central line (and I think the last time I saw a non-sterile central line started, even in an emergent situation, was over 10 years ago) takes time. To grab the ultrasound and find a suitable vein and access it takes time (less than a CVC if the operator is good). So...taking 5-6 minutes while transporting to start an IO in a comfortable manner may be more than appropriate. When done on appropriate patients and at appropriate times. I'd say if individual paramedics can't figure out who and when that is they should quit...but then there would be far, far, far farfarfar fewer paramedics out there. Wait...that's a good thing...

Talk to, or have your partner talk to the mother. What were the events leading up to the collapse? Was it just a complaint of dizziness? For how long? How has he been for the last several days? Sick? Compliant with his meds? Eating/drinking normally? Any abnormal events or complaints before today? Tell me more about the collapse and seizure. Did he immediately seize? If so for how long? If there was a gap between falling and the seizure, how long, and what was the patient's status during that gap? What is the patient's normal mental state? Talk to the patient. Does he remember the episode? Any previous episodes, or similar episodes? Does dizzy mean the room is spinning, or he feels like he's going to pass out? And all of the questions asked of the mom. Tell me more about the lethargy. Is he fully lucid? Coherent? How responsive to verbal is he? (responds to a normal speaking voice, a loud voice, needs to have his name called to respond, needs to have questions repeated) What happens when you stop talking/stimulating him? How irregular are his respirations? Are there periods of apnea? Are they all equal in depth? Physical exam Neuro exam 12-lead Lung sounds If the distance between hospitals is equal then he's going to the level 1 regardless.

Chest x-ray Lung sounds Current chem-7 Current CBC Current ABG Initial chem-7, CBC, and ABG How much fluid did she initially recieve, and how much was she given over the last 3 days? What is the levophed running at, for how long, and has the rate had to be adjusted? When and why were the chest tubes inserted (symptomatic or did they find the pneumo on x-ray? What are the vent settings, and have they been adjusted? What are the drip rates for her sedatives? Any urine output? If so, how much per day since admission? What type of venous access is there? Home medications? Medical history? There are things that need to be done and/or changed, but I'd like that info first.

Probably junctional. It'd be a stretch but maaaybe it could be argued that it's a WAP but that'd be a stretch I think,

It's good that you are willing and capable of standing up for yourself. You'll need that working in EMS, more so or less so depending on the type of environment that you find yourself working in. If you haven't already figured it out, the MIP really shouldn't be a concern for you. If you have several that is a red flag and a different story, but one...not so much. If your state allows the expungement of juvenile records, if it really continues to bother you, look into that. Otherwise, keep being up front and honest about it, like you were. The problem with your driving record is a little more of a gray area, and will also vary with different EMS agencies. In all reality you won't know for certain until it comes up. If it does keep you from getting this job that doesn't mean that it will always do so, just that you may need more than 5 months of a clean record. If you can't get a job on an ambulance there are other options for EMT's, though this also depends on your location. Look into those if this is something that you want to do as a career. If you can sift through the bullshit and are really willing to listen sites like this can be educational...or not unfortunately. I can't resist... That is patently absurd, based on anecdotal experience only, and highly, HIGHLY situational. There are many places that are quite strict about MIP's, just as there are many that are not. While I've lived and worked in both, I'm not going to suggest that "most" do it one way or another based on that.

Agreed. The problem with protocols is when they are no longer looked at as guidelines of what should be considered, but rather as a concrete set of rules that you will follow...or else. I think when that happens not only are people less likely to take the risk of going against them (especially when there is some evidence that the protocol works) but that the protocol starts to be seen as the only way to do things...so nobody takes a deeper look at it and really questions how appropriate it is. If you look at how many studies have been published in the last couple years that directly refute previous ones and the current way of treating people (and many of these studies have a larger enrollment and better analysis than the previous ones), it's rather amazing. EGDT...tPA...beta-blockers in STEMI...hypothermia post ROSC...field hypothermia...concussion guidelines (probably)...it's just another reminder that, as we better understand the body, and better understand what the treatments actually do, medicine will change. I still think that the take home message from all this is that early recognition, aggressive treatment individualized to the patient, and actually treating the pathology behind the illness and symptoms will be what makes a difference. I can't take credit for this quote, but it sums it up rather nicely. Simply switch EGDT with another protocol, and sepsis with another problem.

I hate that line of thinking, although their medical director is partially right and taking the least harmful path. If something isn't good for a patient on a transfer, it's not good for a patient picked up from the field, especially when you consider that patient may be even less well managed and in potentially in worse shape. Spend the money...take the time to teach people...and get something that is acceptable for both. Unfortunately it really is the easiest choice, and to some degree the only choice without overcoming some potentially large obstacles. Why wouldn't they? And really, it's not even a lie. Why couldn't it be used for an interfacility transfer? (I mean if the patient is completely paralyzed and has no extra requirements for ventilation beyond rate and volume...) They don't advertise it as an ICU ventilator; that leaves a lot of room for advertising that is...open to interpretation.

Unless the ground is rough or unstable or it's an...exceptionally...large...person I keep the gurney fully raised all the time. It really isn't the safest and is more dangerous, but it's also the easiest and safest way for the people pushing/pulling it. Like I said, while catastrophic failures of the gurney do happen, most likely it'll be operator error. The problem is there isn't a great solution; while the gurney should be keep low if the ground isn't smooth, pushing or pulling while bent over is much worse for the back...so....damned if you do, damned if you don't. Which is why not getting complacent is so important.

I watched the lecture from Dr. Marik and the response from Dr. Weingart when they first came out; absolutely worth listening to, and if you have the time to read through the discussion that followed (and even if you don't; it's that worth it) do so. What they are both advocating really isn't that different; massive volume infusions in septic patients are bad, causing pulmonary edema in sepsis is bad, and patient's should be fluid resuscitated only as much as each individual requires. If you've been following any of the FOAMED websites this has been the line of thinking for quite some time, and from talking with a couple of local ER docs it's how many have been practicing locally. http://resus.me/no-benefit-from-early-goal-directed-therapy/ The results of the ProCESS trial are now out (I think there's 2 more similar studies that are still finishing up) and the results aren't neccasarily that surprising; EGDT really doesn't make a difference in patient outcomes. (granted I haven't looked at the who study, so why mortality wasn't different, I don't know if there were differences in ICU time, intubation rates, etc) Like the recent study on in-hospital hypothermia post cardiac arrest, I think what people are starting to realize is that if you have a semi-standardized approach and then actually PAY CLOSE ATTENTION to the patient, the outcomes are better.