dgmedic

How funny ruff - perhaps we have crossed paths before and didn’t know it. I was a medic at St. John’s (now called Mercy). I worked on the ground and flew for Life Line. I am back there now and yeah both Mercy and Cox are Level 1....and they are only about 1 mile from one another. Both places are still ridiculously busy. Go figure- build it and they will come. We do get a lot of area referrals though. Bob Page, the 12 lead master - you know i still read 12 leads as a physician the same way he taught me as a medic....it works. And my god the good ol lake of the ozarks. LOL that place is wild. My fiancé is from there. I remember back in the day when MEMSA would hold the combined clinical conference there at tan tar a. What a party. LOL. Crap I think I posted in the wrong thread....oh well. Freaking mobile phones.

Just finished residency this last year....graduated in June. I am now an EM doc at a level 1 trauma center in Southwest MO. It is actually the same place I was a ground medic and flight medic. It was like a homecoming of sorts. Every time I have interactions with the EMS crews here it is like we fall back into our old routines, ribbing each other in some sophomoric banter, etc. But better yet, I am yet another EMS advocating physician for our area. Would trust our medics with my life. -dg

How weird that this is an ongoing topic and I ran across it; although it was started back in 2015 lol. I was active about 10 years ago - dgmedic. I had also ran another site medictutor.com. Stopped that a long time ago too. I ended up going to medical school, EM residency, and am now an emergency medicine doc! It is good to see the site still up and going. And paramedicmike.......good to see you are still here too. Wasn’t there a RichmondMedic or something like that too? ~dg

Voted for 2 yr if that's as high as it will go. The most interesting post I read was regarding a 2 yr degree pre-requisite to entering training. At least one would have a handle on grammar and spelling (aside from the occasional missed key-stroke - and not trying to start an argument...I realize forum informality...but damn, seriously). Oh, and for those that are concerned about folks not going into EMS because of additional personal and familial pressures that would be imposed....could you see about winning over some medical school admissions committees for me? It would be great if I could go ahead and have a few move to my city so I don't have to move my family, sell my house, or go into further debt. That would be super!! Oh, and if you get ahold of Wash U....please have them lower their GPA requirements.....DAMN!! Thanks! Dissuading a few folks away from entering EMS may not be such a bad idea. I am more concerned about having dedicated, competent medics than....well, you get the idea. -dg

Potassium and sodium are the main cations in cellular electropotentiation...so..it basically runs the electrical system of the heart. Look up the sodium-potassium pump and you should get something. You can also look for hyperkalemia (and its effects on cardiac depolarization/repolarization "hyperkalemic T-waves"), hypokalemia (less problematic than having too much). Sodium applies above as well, but not to the extent of potassium. Search for the term hyponatremia (low sodium). Typically happens to kiddos that have been fluid overloaded or with excessive diarrhea. Either way, their sodium is getting washed out. Sorry I don't have too much time to go into the specifics...I'm sure someone around has time to explain further....I will check back in a few days to make sure you have been fully answered (although the above should get you pretty close to an adequate explanation from the internet). - in short, if k or na is too outta wack...you are screwed if not corrected and will die. that should make the parent's ear perk up. -dg

Agreed. Although being well versed in traditional research and statistical methods still will not get to the bottom line. The problem is (and you all know), that trying to control (for the purpose of research) such an uncontrollable environment, poor data is recorded. Although many good studies have come from the military theater, this complication is seen. If you structure a prehospital study as an inhospital.....it just doesn't work well.... To the original poster...look at the domier paper on EMS vs. walk ins and then look at the importance (difficulty and introduction of bias) of appropriate matching. It is important for us to be active in voicing views on data and the interpretation of that data. Just because someone publishes results does not mean that they have interpreted those results correctly. Just remember that correlation does not define causation..... You can see many of these attempted jumps in logic from many authors....look up many of the recent RSI studies (wang's early papers and situational issues...TBI vs. medical vs. pediatric), and many of the obviously biased (even through the peer-review process) papers on steriods in SCI. The big issue is that: once we find out that a treatment/procedure is not beneficial...we as EMS providers need to willingly stop the procedure and not bitch and whine about "removal of procedure" .....my part....I typically am very reluctant to intubate small kiddo's anymore....if I don't need to have the kid on the vent and just need to bag...I just bag. There is enough data for me to alter this part of my EMS treatments. -dg

Oh, Rid...you hurt me man!! No worldly experience? okay...... Dust? stick to you aid station then....keep crackin' them chests boy!! you keep on a practicing!! Don't know many nurses that independently open up their own clinics and practice medicine. Yes Rid...I know NP - I was speaking of nurses in general. Your argument is similar to saying that a physician which happens to be a medic too. They are practicing under the advanced degree.... Rid...exactly - you consult physicians - that's what I am saying....don't call 'em...don't work from protocols...just do it - then you are practicing. As far as incompetent physicians in the ED, directing vs. asking, bla, bla, bla. Well, I have gone from a brand new medic in a small rural town in missouri where the ED physician was my family physician, to the streets of Denver working with actual ED docs, and now to springfield missouri. I work both on the ground and fly for the Level I here...so I still see both small and large facilities...see both competent and incompetent physicians, nurses, medics, humans, monkeys. Yes there are folks out there that have no business being where they are......like me right? I work (as we all do) from protocols (guidelines...whatever you want to call them to make you feel fuzzy)...I deviate from the protocols when it will benefit the patient....whether I discuss it with a physician or not...but when I do, I make sure to discuss the case with my medical director. If anyone else has a problem with it, they can pull it to M&M, and I present the case, the research, and my line of thinking on my decision (ops...yup rid...I am somewhat current on "medical stuff"). If I am wrong, the physicians educate me on why I am wrong...otherwise, it's good. Looks as if I stepped on some toes....sorry to hurt some feelings. I know some folks really hang their hat on certain things........ I guess I could have just quoted the best line of this thread........ -dg

YEAH!!! my semester is over so mom said I can come out and play!! Been a while - hello all... Yup, tapy tapy - I would. It is in our guidelines though. If you screw it up and pop a lung...just say you were decompressing the chest and hit a bump or something. It is a simple procedure and medically acceptable, it is all good. My feelings on this is not the procedure itself, but whom is the directing physician on the other end. Are you speaking to a family physician that just happens to be picking up an ED shift at a small hospital, are you speaking to a board certified or trauma surgeon? And, at that point, to whom are you responsible? On the basis of medical acceptability, the procedure is appropriate, but at what point does the blind-leading-the-blind fall into the "paramedic PRACTICING medicine?" A competent physician DIRECTING the procedure to a medic is completely different than a physician (ill-wittingly in the ED) practicing medicine over the phone. Although it is cute to say and makes us feel like big boys, we do not practice medicine, nurses do not practice medicine, no one "practices" medicine other than a physician. So, if you are being "directed"....do it. If you are being "asked"....don't do it. If you are comfortable with the procedure, can explain physiologically why that procedure would be life-saving, and based on the risk vs. benefit of the outcome and made best decision possible for the patient.....do it (or not). If you feel that you are not able to follow directions...don't do it. If you can...do it. If you feel that your job is at risk and purely have linear thinking abilities, constantly referring to page 154 of "your protocols" - good use of those opposable thumbs that have been bestowed upon you through evolution.........I turn crying.......dubya, dubya, dubya, dot emedicine dot COME ON!!! Think about it...they're DYING...not dead....do the damn procedure. Street lights are starting to come on....gotta get home - my mom is calling - damn...no it is dispatch...gotta go!! -dg

I agree with the doc and AZ. Temp and EtCO2? Pale and mottled but how about super sweaty? This presentation without initial labs I would also be going down the road of E too - Due to the diminished lung sounds, I would have them listen again for some edema....my index would be pretty high for potential cocaine/amphet induced APE. I would have definately given some benzos.....lean more toward benzos rather than haldol even for calming them down if I was strongly thinking cocaine - potential for QTc prolongation.....probably doesn't matter though. I think benzos would have fixed a majority of issues. hhhmmmm, if I did RSI 'em I would go with the biggest tube possible....if 7.5 is adequate, go with it - and give a little bit o' fentanyl with it - just in case you pinch a lip, pop a tooth, or use a really long straight blade I would go with etomidate for induction just b/c of the pressure. After the labs, I would go with cocaine induce APE (have them listen to the lungs again or get a chest film)....with the labs you stated, I would go without rhabdo.... maybe wrong - but that is the first thing that came to mind.... -dg

hhhhmmmmm, wouldn't water classify as the "most simple" alcohol? H-OH -> an alcohol.....sorry, just finished up my orgo final yesterday..... -dg

Ken Mattox has put together a great reference page over at trauma.org. No one is talking about it b/c it goes against the traditional EMS dogma....a continuation of the many dumbass things blind faith dogma will get you. Before you talk to your medical director, head of trauma, or whatever, jog on over to trauma.org: the link is http://www.trauma.org/resus/permissivehypotension.html Ask your trauma director why, in the face of all this evidence he/she is wanting to change? Everyone that has protocols that default to that "2 large bore, 3:1" crap needs to print and pass along. 2 big IV's prepares the patient to get blood, 3:1 on the other hand prepares the patient to die. How about 2 large bore saline locks? That sounds more appropriate. -dg

da-tah'da! -d

Yup, it fixes it...by blowing the other pupil!! -dg

List of studies which do not back up my point? I'm disappointed you didn't take time to read the studies. So, this post was a little more clear on what you needed.....So I will point out once again the Burton study...and R-E-A-D the study...the entire study. If you have trouble interpreting the results, find a statistician. The results of the study show: "Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients" (that addresses your first "requirement"). You will also notice (again...you have to read the study...that would mean more than just the abstract just in case I'm not being clear) that all of the patients that were not immobilized...NONE OF THEM HAD SPINAL FRACTURES (that would hit your second "requirement"). So, there ya go....you were clear on what you wanted, I provided it. So now you can say that there is a valid study, conducted in the prehospital environment, published in a reputable journal which was peer-reviewed, that showed a reduction in unnecessary spinal immobilization with a protocol that identified all the fractures. Scientific validation...at least for the rest of the medical community. - quality - not quantity Read a bit -dg

I'm actually surprised that this is a subject of such debate - Well, that’s odd, not to be argumentitive, but that would mean that all that disagree are not intelligent (or something other than intelligent) and you are able to accurately predict their intentions every time. When you read the studies, you do know one is to look for validity right? And you do know what the term validity means right? I ask because your above interpretation of the discussion up to this point. Perhaps you are just not communicating well. If you could point us in the direction of studies that show that field medics are unable to clear the spine or why the studies that have shown we are able to selectively immobilize, be invalid studies. Now let me say that I completely agree with you that studies that are conducted in hospital should not be extrapolated to the out-of-hospital setting (though this is no-brainer logic). But with this said, it is completely appropriate to implement procedures in the prehospital environment from the hospital setting that have been studied (and resulted in favorable, valid results) in the prehospital setting. This has been done with spine clearance…in the prehospital setting…with valid prehospital studies. Perhaps you can differentiate between field and clinical practice for me? These are quite subjective terms; with your definition perhaps we may be able to address your concern. Also, I don’t understand what you mean by the “discount[ing of] asymptomatic spinal injuries as insignificant.†Do you mean in reporting methods, evaluation methods, or inclusion for statistical analysis? Or just point me to the study and I can read it for myself. I agree on suspect injury, but according to your above logic, you should “expect†every person that has upper right injury automatically has a liver injury. I would say no if a 3 year old hit his father in the gut, I would say yes if the 3 year old shot the father there. But if this is your argument for spinal immobilization I would suggest you look at the study by Domeier et. al (PEC 1999 Oct-Dec; 3(4):332-7) regarding MOI – MOI has no reliability regarding prehospital clinical evaluation for spinal injury – ie it’s not predictive - doesn’t really matter. If you need more valid studies, I can give them. Also, if you suggest that even the suspicion of injury we should board, even if there is no injury, even with the documented drawbacks of spinal immobilization – I would suggest that we should start defibrillating every one of our patients because early defibrillation is key. So, we defib all, no matter what their complaint or status. I know it’s asinine, but it is parallel reasoning. Scientific validation? In the American medical community, peer-reviewed studies are the essence of scientific validation. I will amend that the studies need to be published in reputable journals, but…well, I guess I just don’t know where you get “your†scientific validation if not from valid studies or by conducting your own valid (and peer-reviewed) research. As for a “5 question†cookbook style: hhhhmmmm, how about the thrombolytic screening list? I would like to see you make a decision purely based on your “practice†for the administration of thrombolytics. I can say that you probably wouldn’t be in medicine for very long. I do believe that this screening everyone does – even those stupid, monkey cardiologists – those idiots, freaking cookbook cardiologists! Yeah, considering all the other evidence, we do need to see those pressure ulcers don’t we? Come on, be serious man, that truly is not your sole evidence for selective immobilization is it? How about evaluation purposes (even for the physician)? And down to the last point, if everyone is still stuck on godsend of immobilization, let me ask you this – where are the studies that show that immobilization prevents FURTHER neurological damage (although there are studies that show that they do not…just want a few that show that they do). And lastly….for a bit of trivia…can anyone tell us how the use of the LSB came into use in the prehospital setting? What was the LSB designed for…what was it’s original purpose? I think that would answer a lot too. If you really haven't found valid prehospital studies on this subject, let me know and I will post...but I'm a little tired now. I would suggest looking a little harder. -dg