EMT Foose

Lets say a fluid bolus is out of the question. Only thing available is 10cc flushes. On an AC, it's pretty difficult if not impossible to note any edema from 10-20cc of saline, especially on large patients. What's the best option at that point? There's a reason I'm asking these questions..

With algebra not being a strong point, I had a little trouble at first too. What I did is simple repetition. I took 2 of every homework assignment, then looked up some more on the internet. Practice practice practice...the more the merrier. Then make up some problems and try to do them in your head, it'll help it sink in. Also, the first 2 equations have one thing in common.. The only thing on the bottom is the concentration (dose on hand). All other variables go on top. Try to keep it simple, eliminate any other numbers they throw in a question to mess you up, and stick with the equations. Plug in your variables, and you're golden. These are the formats I used. Dd= Desired dose, Dh= Dose on hand (the vial/amp etc) Dd/kg/gtts ---------- Dh Dd/gtts ------- Dh Whatever number you end up with is the gtts/min.

Something I've really been debating a lot.. What is the general consensus of pushing D50 through a line that will not aspirate? Also taking into consideration the common D50 patient- long term diabetic with crappy veins, or veins that are near impossible to cannulate. Personally I would prefer to utilize glucagon and hunt for a better IV site rather than take a gamble...but I'm just a para-maybe. What does everyone think?

Good call on the right side ekg. Looks like RVI to me. Good thing she's not in pain, because NTG and morphine wouldn't be good things to give her.

You fully grasped the point I was alluding to, and illustrated it quite nicely. Basically, I've seen some shoddy paramedicine....and I hate it. Even with the amount of hoops to jump through, it's still not enough to weed out the types that shouldn't be paramedics. I won't even go into detail about some people that have their path to a P-card facilitated in ways that either make my jaw drop, or shake my head in shame...or both. You said testees. haha

I've been told by several military buddies their system is basically CBA rather than ABC. It makes sense when traumatic amputations are commonplace, like in a warzone. Realistically, as a paramedic or lead EMT in charge of the scene, aren't you going to order another responder to address a major hemorrhage as you assess airway/breathing? At least by direct pressure with a gloved hand while dressings/tourniquets are opened up. PHTLS stresses that every RBC is precious in major trauma, and ideally major hemorrhage is controlled while A and B are assessed. That's assuming you have the manpower, otherwise it's still ABC outright in the primary survey. I can see the MARCH system creating problems if street medics start focusing on controlling minor to moderate bleeds prior to airway/breathing control...which is a definitely a possibility.

Hey, you gotta get on the same level as the patient somehow, right? :shock:

Seeing as how a patient in the scenario would probably be well known to EMS, I would have informed him long ago to move closer to a good hospital. :? I've come across that heart condition once in my short EMS career, in a transport from an airport to childrens hospital. They had the little guy on medical air (would've been nice if someone had informed us of that ahead of time), and the isolette ran out halfway through ground transport. Seeing as how we don't carry it, the RT had to bag him (on RA) for about 20 mins. That was the first time I'd seen an ekg of a heart rate greater than 220.

I hate when I show up late! I was reading through scubamedics posts thinking: She's high on something! Just find the source. Next time

I was thinking about possible hyperkalemia until I got to the ekg, and would r/o depending on: Did the family or BLS crews move the pt at all? Any bruising or anything on the body parts she was laying on? What type of floor surface? Any other new onset neuro besides decreased LOC and dysphasia? Gotta keep TIA and syncope in mind, but otherwise usual c-spine stuff, O2, warm blankets, and 250-500 bolus depending on her size. I'm concerned about being too aggressive with anything because of the a-fib, high cholesterol, and possibility of laying still for 24 hours. If she hasn't thrown a clot already, I don't want to cause it.

Since you said anything could be asked.. Ever had wheezes/sob before? Does (and how much) activity make him SOB and/or dizzy? Headache? Anxious? Family history? What does the patient do for work? I'm leaning toward COPD (although that BP and possibility of masked rales bothers me), but want to know a bit more history. Good LOC/skins with sats of 88% suggest chronically low PaO2. Initial Tx: O2, IV TKO, Albuterol (wary of BP and want to know more history) Standing by with nitro and getting answers to questions.. Reassess lungs throughout treatment looking for anything besides wheezes. I would kinda go from there after reassessment..

Very true. I haven't been exposed to helicopters a whole lot, but Air 5 seems to be a bit more violent than others on its take-offs and landings. It would be fun to stand in the wash and fight the winds if it weren't for the peppering of shrapnel you'd get.

While not being much fun to watch, these videos are excellent from an educational standpoint.

It's the one that has you running to get behind the ambulance as it's landing/taking off so the gale force winds don't impale you with random objects. Even around a frequently used helipad, it kicks up quite a bit of debris. Pretty awesome!

An old partner and I had a chance to chat with one of the crew of L.A. County Sheriff's Air 5 after a drop off at an L.A. trauma center a while back. That thing is huge! The average time put in trying to get on that chopper is about 15 years. There's quite a bit of additional training they require, and they are very experienced paramedics.

Sometimes, observing quietly is the best thing to do.. Only sometimes, though. :D/

Argh! That one definitely made me think in order to narrow it down. Good scenario.

This just screams of nerve damage, only trouble is finding the mechanism. I'm not betting on an obscure medical condition just yet, still thinking trauma.. The defecit is local, so the mechanism must be as well. Perhaps some type of ischemic damage to the nerve running through the knee..? How long does he typically sit with his weight on the sling? How long was he in that position today? Has he ever experienced ANYTHING similar or heard of something like this from his colleagues?

I'm going to throw out a guess, mainly because I have to go to school now and won't be able to read this for a while.. The area of deficit follows the dermatome route for L5, so I'm guessing a herniated disk pressing on the nerve root around L5. Either that, or a complete tear of the anterior tibialis muscle from climbing trees. Those are the 2 avenues I would pursue, anyway.. Hopefully I'm not waaay off...

Any more history? Drug use, ETOH, recent illness, unusual activities, etc.. Definitely get the pads and IV TKO on that guy. I would call it a recurrent accelerated IVR, so Lidocaine is contraindicated. I'm going out on a limb and considering an Amiodarone infusion, but would of course be looking for medical consult. I would follow the standard chest pain protocols and see if that provided enough relief of the s/s prior to initiating any antidysrhythmics. I don't know which cardiac drug would be most appropriate, if it's even carried in the field that is.. My differentials include MI, pericarditis, acute metabolic condition leading to acidosis, and keep an eye on his sats for possible PE. Beyond that, I dunno.. Get him in for blood tests and get as much history as possible.

Great description. Not that I know much at all, but I agree with holding off on ASA. There's no telling what her warfarin levels are like and it's impossible to know exactly the cause of the event. The things swirling around in my head- She had a pretty good amount of O2 administration before the 12 lead was done, and you did mention some slight ST abnormality. Possibly the O2 altered the 12 lead..? Did you ever see a follow up ekg? With exception to ASA and keeping her home meds in mind, she got the full MONA treatment for MI when you gave nitro.. Or maybe it was TIA and the nitro vasodilated enough for a clot to head on down the highway..? It's hard to rule out psych on this one too, I think. Schizophrenia and/or Bipolar in the geriatric brain (especially with benzos/narcs) can be pretty unpredictable. I assume the daughter handles the meds.. Was she compliant with all meds? Good food for thought. Any chance of a follow up?

Those will work if need be, but I'd like to find an even more detailed image. Thanks

I'm trying to hunt down an actual picture or a very detailed (color) diagram of the airway. An ideal example is something similar to the link, but not under copywrite (or this costly anyway). High quality is the key, so I don't want to scan, edit, and then print anything out of my texts. Any help is much appreciated by myself and the other poor souls in class with me. Scroll to the 3rd down from the top http://images.google.com/imgres?imgurl=htt...ficial%26sa%3DG I've searched google quite a bit, and looked at most of the downloads available on this website..

Oh I will be a reading fool, don't worry! I actually like a good medical call just as much as a good trauma, so I'll definitely be paying attention to the details of all that. Thanks for the replies!

School starts tomorrow! I'm a pretty laid back guy, always able to keep my cool...but I'm pretty nervous about this! It's a very reputable school (AMA accreditation #001), tough selection process, and they expect a lot out of their students. I hope my best is enough to make it through! I've pre-read the entire A&P book, know my 3-lead ekg's pretty well, and have a good idea about ACLS. Any advice from students or from you old-timers would be greatly appreciated!