Arizonaffcep

You can also download Dr. Guy's podcasts free from iTunes. The most interesting podcast is called ICU Rounds. Much of it is directed at residents, therefore I suggest you have a good foundation of A&P along with a working knowledge of how studies and EBM applies to clinical practice. Definitely not like picking up your favorite copy of "JEMS."

The truth about all this permissive hypotension is that we are not quite sure of the optimal resuscitation modality. There are many new studies in the pipe line and the next decade will most likely be exciting. Anybody go to the SATNET conference this year in Tucson Arizona? I am just back from this conference, and there were several physicians commenting on resuscitation, EBM, and head injury treatment modalities. Much of it is a crap shoot.

If anybody knows a Dr. Peter Rhee, you are most likely aware of his "suspended animation" research on pigs. In addition, a large multi centre study is in the works. So, we will see how things pan out.

Take care,

chbare.

And he's a hell of a nice guy. He will always stop to talk/discuss questions/etc (provided the timing is correct and he's not busy with a Pt). First time I met him when he started at UMC in Tucson, he introduced himself as "Peter." How many well known trauma surgons do that? He's great!

Out of curiosity, I know this thread is a few months from the last post, but I just wrote a paper on permissive hypotension for Lifeline, and was wondering if anyone had any interest in reading it. It deals with a bunch of different aspects all involved with blood pressure and trauma care. Including cited references to the thought that a systolic of 80mmHg will "pop clots"...

I would agree I have never seen a bulge in the abdomen except for a herina however in many people who have a relatively flat abdomen while supine you can often see the pulsation of the abdominal aorta. Give a try and look for it and you may be surprised.

Well hell, I can see that on myself and I'm about 20 lbs overweight . That being said, it's the pressure wave is what you are seeing affecting the surrounding tissues, and NOT the actual outline of the aorta itself. That'd be really impressive. Maybe in Ethiopia?

Posting from work so I must be brief. More info on request.

To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable.

This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube.

I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

As I was reading the posts for this, I don't remember seeing anyone say the science behind the "new" ACLS changes (they are also coming out with new guidelines this year as well folks), for the AHA. It was the largest study done, certainly by the AHA (possibly ever) and encompassed medicine from literally all over the world. What was discovered was that because the coronary arteries are "filled" on the "back pressure" from the aorta, it does take a significant amount of time and energy (in this case energy=compressions) to bring the perfusion of the myocardium to a state where the muscle is more "accepting" of an electrical charge. Another reason that they are saying "don't stop compressions for LONGER than 10 SECONDS" is because they found that the cardiac output during compressions is at BEST 1/3 of a normal contraction, and the assumption was that it was higher than that prior to the release of the studies. That being said, there really is no reason that you should stop compressions for longer than 10 seconds, especially with the availability of alternative airways. I would prefer the combi-tube or something similar instead of an LMA, but the reality is either will work.

As an addendum to the AHA studies, they found that for every 10 second stop (2 minutes or 5 cycles of 30 compressions and 1 breath-BVM, non-secured airway) it takes about 15-20 compressions to bring that perfusion level in the myocardium back up to the point where it was before the 10 second stop. So, in essence, even with only a 10 second stop, at least 1/2 of the compressions of the next "round" are just used to bring the perfusion back up and not a maintenance.

OK you give 5mg of salbutamol, patient says its now harder to breathe and his resp rate has gone thru the roof

What's his 12 lead look like?

I agree with the additional history and assessment considerations. For example, sudden onset stridor is going to have different pathology considerations.

I would most likely not go with salbutamol for an upper airway obstruction problem such as this kiddo. I would want to consider something like racemic epinephrine and ensure we are nebulising this medication properly, because unlike salbutamol, we want inertial impaction and deposition of the aerosol in the upper airway.

I would agree, that at least a loading dose of a steriod will be indicated in this patient.

While not an EMS consideration, this patient may benefit from Heliox therapy.

If we are still looking at croup, I would not consider antimicrobial therapy unless we have other indications of a bacterial infection. We must remember, croup is typically a viral infection.

Take care,

chbare.

Good call!

From the founds of it,I would think infection moving along to sepsis. Pneumonia? For me, continue any meds that need to be continued (ie abx), other than that, supportive measures. Give him as much O2 as they can tolerate, possibly fluid challenge for decreased B/P. Reason for possible fluid challenge with wet lungs-infection causing wet lungs vs CHF/ARDS, etc. In my eyes, this seems to be a fairly obvious infection-hence the temp.

Sorry for the development of a typing lisp...not sure what happened. In reading over this again, would probably go with a breathing treatment as well.

Additionally, I would like to emphasize that yes etomidate is well known to cause transient adrenal suppression after one dose. However, I am unaware of any evidence that definitively says etomidate leads to poor outcomes in patients where this may be a problem. There are studies and allot of talk; however, the fact remains that etomidate is still a viable agent...

Take care,

chbare.

CH, from the research I've done in the past year (first partner on the helicopter was really into this etomidate stuff) it's not a single does that does the bad, as levels will return to normal and if you look at the output for 24 hours, there is little difference between those that didn't get it and those that got a single dose. However, the continued use (ie etomidate drip) is what all the commotion is about. I would quote the studies, but taking a break from chart writing and don't have the time to re-research them.

Does any department have an operational procedure/sop/etc for "kidnapped/missing" crew? I work in a major urban system that has directives, procedures, etc for basically every situation including civil unrest/abandoning a fire station. We also have the typical "police assist" for situations when your in danger but does anyone have any expierence with this type of situation?

My company doesn't have any policy for kidnapped crew...but don't think that'd be even a small potential (possible, just extrodiarily improbable), as we are a crew of 3 (pilot, medic, RN) and either respond to a scene that's full of personnel already along with PD-typically to shut down a road for landing-or to a facility (rural hospital/clinic)-so the potential is VERY low. But...we do have a PAIP (post accident/incident plan) in place for missing aircraft.

-How long would it take within your local to find an ambulance, then the crew if it was seperated from the truck?

The last drill we did, our dispatch took 7 minutes from when we had an unscheduled landing to our pagers going off that they had our GPS location, had notified the program manager and initiated the PAIP. Seems like a good time frame to me, as in talking with other flight crews, they've done the same and sat for over 45 minutes...

-How long would it take depending on your status (on a run, at a hosp, etc) would it take for your communications center to determine something was wrong?

See question above.

-Does your truck, radio, etc have gps or some other type of tracking system to find you?

Yes, while we don't have handhelds, our aircraft are equipted with the lattest radio/gps safety stuff. Infact, it's the newest dual band thingy.

I guess this is sort of a rare and unlikely event but it would be worth talking about.

You're sent two suburbs over to pick up Charlie fron a walk in medical centre and take him to the hospital.

a) BP is 96/86, how do you treat?

a) If BP was 136/96, how would that alter your treatment?

From the founds of it,I would think infection moving along to sepsis. Pneumonia? For me, continue any meds that need to be continued (ie abx), other than that, supportive measures. Give him as much O2 as they can tolerate, possibly fluid challenge for decreased B/P. Reason for possible fluid challenge with wet lungs-infection causing wet lungs vs CHF/ARDS, etc. In my eyes, this seems to be a fairly obvious infection-hence the temp.

But it's got 'lectrolytes!

Makes me think of the hospital I visited that had a McDonalds in the cafeteria about two halls down from the cath lab.

Quite the clever marketing scheme...

Patient had not eaten lunch yet and tells us the pain feels as if something is "pulling apart" in his belly and lifts up his shirt to reveal an vertical 5-8cm oval lump in his abdomen just off the mid line.

On scene the patient was outwardly stable. From the history, visualization of the abdomen and vital signs this pt was potentially unstable 2 large bore were started in route, and run kvo, on arrival I advised the ER staff I was treating a rule out AAA and they confirmed it by a sono. Patient was taken to the O.R. he burst on the table but was saved.

How thin was this patient? Seriously...on an "regular sized" adult, you shouldn't be able to see that. I just did a paper on permissive hypotension, and came across a quote (although for the life of me I can't find it again). However, it did say something along the line of a patient can bleed in the realm of 2L into the abdomen without it being noticed visually (distending). This being said...I would find the whole sitution implausable.

During transport I looked at my partner, and said, want to give her some fluids as well? He asked a great question, why? My only answer was, I remember someone(I don't remember who) saying to do so, but the physiology behind it was a mystery, so we skipped the fluids.

Ok...so I haven't posted on here in like...a year or more shame on me. Do damned busy. Only words of wisdom I might have regarding fluids bolus with suspected CVA is an OBVIOUS Cushings Triad, where their MAP would need to be adjusted. But...that's rare and WAY late in the bleed. Only time I can think of.

On an obvious note...the N95 masks should have been stocked at the begining of shift, and when out, get more. That being said...I would doubt the "they can't test for anything anymore," especially if it's a true exposure. However, even at that, for an HIV/AIDS test, they still would need Pt consent OR family OR, if it's resonable, a 2 doctor consent signed. But...if for some reason it is true, then I'm sure it's a local issue only, as things haven't changed in AZ regarding it.

Without a chem anda mental status this could not be a refusal. Their parents are not the ones making the decision in this case. I hope it doesn't come back to bite your ass. The doc on scene is not your medical director and his input about transport is meaningless.

I disagree. While certainly not the end all, taken in consideration with consultation with YOUR medical director, then it is a good consideration. After all, from all the practictioners who are tending to this patient, they are the most knowlegable about the Pt.

hate to tell you this.. but there are tons of them

No pun intended, right?

This study blows, I don't care just as long as fat people don't become paramedics.

Are you being facetious or serious?

If you could, I'd love a copy as well!

Dust, you had me all excited! When I was in high school and part of the debate team, one of the arguments in the global warming "venue" was that more fast food restaurants=more need for beef=greater number of cows. Cow farts are methane and contribute to global warming. I was kinda initially thinking that the article was going somewhere along those lines....

There are several things that I don't like about this...first, if his forehead required 11 stiches, where are they? I didn't see any bloody matted hair either. How did he get that, without getting beat up? Broken glass doesn't attack people in that fashion. The other is, if the dog alerted, that's enough PC (cop talk-probable cause) to search and detain (not arrest). They are NOT required by any law to "show the alert," nor are they required to show a speeder (PD-not B/P) a radar gun with the reading on it. My BS meter is pegged. He's full of it. Besides, did any catch the date this happened? No month associated, but he said "today's the 15, so on the 14th" yet at the end...his arraignment was on the 10th? WTF? No. And besides...doing a records search under Arizona Supreme Courts, shows that all the "Steven Anderson" people's who had court in Yuma, none had corresponding addresses in the Phoenix area. Here's the website for verification if ya'll are interested...http://apps.supremecourt.az.gov/publicaccess/caselookup.aspx. Yes, I know. I'm bored at work...

Ok...I had to re-read the initial post before I felt ok to comment. That being said, most of what I have to say has already been said about POA/HC, etc, parents can't legally sign for him blah blah blah. So here's my question...why is his liver chirrotic? I would assume ETOH abuse? If that's the case, is the HX of SZ from DT's from past attempts at quitting? If that's the case, and the bleed is from a head bonk, and this SZ is from DT's, then it was a definate medical emergency that was abandoned. If not...still should have been transported, parent's wishes be damned-cause they can't sign (he's a big boy, no matter what mommy wants to think). Just my thoughts and/or questions.

I would assume that it's company wide...but in AZ, R/M does have a "you will have all doors locked at all time" policy...but I always wondered how you would be able to get in and out if all the doors were locked at all times...

I try to adapt myself to the patients needs, be it someone to hold hands with, a shoulder to cry on, or if they need it, "tough love," and the occasional taxi attendant. I agree that there is a lot of immaturity in a "spiteful" provider, and or burn out. Once this happens, it is very important to remove yourself from the field at this point. Not forever, but enough that it's a "vacation," which allows you to reset and recenter yourself. All I can say about the Adam Henry that pushes 2mg narcan at the hospital doors had better not show up on one of my scenes. If you push that all at once, wow...not only painful for the ED folks, but what about SEIZURES?!?!?!

Never been offered monitary stuffs, but I have accepted food stuffs, home made cookies and the likes. Thankfully, when they dropped it off, I was usually on a call, so it was outside my control. Good cookies though...

Terr, I'll have to ask my wife (or you can... ) if she's got a pic...

Lol, nice.... Your probably right. Oh well, a girl can dream!

You do know they drive the big trucks as compensation, right?