DartmouthDave

Hello, If the leg was red as described I would be keen to get the I/O pulled as well. A bit slow with the line. But, they were able to get one. Was the infant transfer from that ED or did the hospital have a NICU?? David

LOL..... ATTORNEY: Doctor, before you performed the autopsy, did you check for a pulse? WITNESS: No. ATTORNEY: Did you check for blood pressure? WITNESS: No. ATTORNEY: Did you check for breathing? WITNESS: No. ATTORNEY: So, then it is possible that the patient was alive when you began the autopsy? WITNESS: No. ATTORNEY: How can you be so sure, Doctor? WITNESS: Because his brain was sitting on my desk in a jar. ATTORNEY: I see, but could the patient have still been alive, nevertheless? WITNESS: Yes, it is possible that he could have been alive and practising law. A few more........ ATTORNEY: What gear were you in at the moment of the impact? WITNESS: Gucci sweats and Reeboks. ______________________________________ ATTORNEY: This myasthenia gravis, does it affect your memory at all? WITNESS: Yes. ATTORNEY: And in what ways does it affect your memory? WITNESS: I forget. ATTORNEY: You forget? Can you give us an example of something you forgot? _____________________________________ ATTORNEY: What was the first thing your husband said to you that morning? WITNESS: He said, “Where am I, Cathy?” ATTORNEY: And why did that upset you? WITNESS: My name is Susan! ______________________________________ ATTORNEY: Do you know if your daughter has ever been involved in voodoo? WITNESS: We both do. ATTORNEY: Voodoo? WITNESS: We do. ATTORNEY: You do? WITNESS: Yes, voodoo. ______________________________________ ATTORNEY: Now doctor, isn’t it true that when a person dies in his sleep, he doesn’t know about it until the next morning? WITNESS: Did you actually pass the bar exam? ____________________________________ ATTORNEY: The youngest son, the twenty-year-old, how old is he? WITNESS: Uh, he’s twenty-one. ________________________________________ ATTORNEY: Were you present when your picture was taken? WITNESS: Are you shittin’ me? ______________________________________ ATTORNEY: So the date of conception (of the baby) was August 8th? WITNESS: Yes. ATTORNEY: And what were you doing at that time? WITNESS: Uh…. I was gettin’ laid! ______________________________________ ATTORNEY: She had three children, right? WITNESS: Yes. ATTORNEY: How many were boys? WITNESS: None. ATTORNEY: Were there any girls? WITNESS: Are you shittin’ me? Your Honour, I think I need a different attorney. Can I get a new attorney? ______________________________________ ATTORNEY: How was your first marriage terminated? WITNESS: By death. ATTORNEY: And by whose death was it terminated? WITNESS: Now whose death do you suppose terminated it? ______________________________________ ATTORNEY: Can you describe the individual? WITNESS: He was about medium height and had a beard. ATTORNEY: Was this a male or a female? WITNESS: Guess. _____________________________________ ATTORNEY: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney? WITNESS: No, this is how I dress when I go to work. ______________________________________ ATTORNEY: Doctor, how many of your autopsies have you performed on dead people? WITNESS: All my autopsies are performed on dead people. Would you like to rephrase that? ______________________________________ ATTORNEY: ALL your responses MUST be oral, OK? What school did you go to? WITNESS: Oral. ______________________________________ ATTORNEY: Do you recall the time that you examined the body? WITNESS: The autopsy started around 8:30 p.m. ATTORNEY: And Mr. Denton was dead at the time? WITNESS: No, he was sitting on the table wondering why I was doing an autopsy on him! ____________________________________________ ATTORNEY: Are you qualified to give a urine sample? WITNESS: Huh….are you qualified to ask that question? ______________________________________

Hello, I agree as well. This sounds like an odd situation that could lead to a big problem for the RN as well as the Paramedics. Not to get off topic too much. E/C <-----Is that short hand for ectomy? I have nver seen it used before. Cheers

Hello, "Seizures started E/C appendix post 7 months with some sort of complication peri surgery." Just a quick question. What dose 'E/C' mean? Is 'peri surgery'? Endoscopic surgery? Difficult situation for EMS. Did the nurse have any patient records from the consulted hospital that may help illuminate the situation? Cheers, D

Hello, Here is an other interesting one; Clumsy Hand Syndrome. Clumsy hand syndrome Dysarthria-clumsy hand syndrome is characterized by the combination of facial weakness, severe dysarthria, and dysphagia, with mild hand weakness and clumsiness (Fisher, 1967, 1982). Occasionally, some weakness of the arm or leg is present (Mohr, 1998; Tuhrim, 1982). Fisher described dysarthria-clumsy hand syndrome as a variant of ataxic hemiparesis, with the same localizing import. Dysarthria-clumsy hand syndrome is found in 2-16% of all lacunar syndromes (Donnan, 1982). In Fisher's initial pathologic description, a lacuna was found in the upper paramedian base of the pons (Fisher, 1967). In CT-based reports, lesions have been found in the internal capsule and in the junction between the capsule and corona radiata (Donnan, 1982). Other etiologies causing this syndrome include pontine (Tuhrim, 1982) and putaminal hemorrhage (Mori, 1985). Overall, the prognosis is favorable (Mohr, 1998). Saw this my last block with a dementia/lacunar stroke patient. Some reading for those interested; http://emedicine.medscape.com/article/1163029-overview Also, saw this syndrome with a 3rd years nursing student working on her IV skills. =) DD

Hello, I thought that we could start a thread talking about various medical syndromes. I was planning to write about Dressler's syndrome or Restless Leg syndrome. But, I came across this; http://en.wikipedia.org/wiki/Foreign_accent_syndrome I couldn't restrain myself! DD

Hello, I though this was an interesting idea. A unique was to prevent ED crowding and free up ambulances. http://www.winnipegfreepress.com/breakingn...n-41015477.html Cheers, D

Hello, SIAT's program is CMA approved. So SAIT's EMT (PCP) is the same as the JI's PCP (EMT). No problem. The question I would ask is, "Can you get a job with BCAS in Kamloops?" From talking to different BCAS paramedics I have found that they have some odd rules about were you can work for senority reasons. D

Hello, A coagulopathy is the main problem here I think. The family has not had any prenatal care/screening done....so there could be an ABO issue here. Has RhoGam been given at 7 months and after the birth?? Here is my guess; Neonatal alloimmune thrombocytopenia — Neonatal alloimmune thrombocytopenia (NAIT) occurs when fetal platelets contain an antigen inherited from the father that the mother lacks. The mother forms IgG class antiplatelet antibodies against the "foreign" antigen; these cross the placenta and destroy fetal platelets, resulting in fetal and neonatal thrombocytopenia [10]. Plasma levels of thrombopoietin in these patients are normal because the megakaryocytes and platelets that are produced bind to this growth factor [11]. In contrast to Rh sensitization, NAIT often develops in the first pregnancy of an at-risk couple. NAIT can result in severe thrombocytopenia in the fetus because platelet antigens form early in gestation and maternal antibodies cross the placenta in early midtrimester. The most serious complication is intracranial hemorrhage, which occurs in approximately 10 to 20 percent of affected newborns; one-quarter to one-half of these occur in utero [12]. The risk of severe thrombocytopenia and intracranial hemorrhage is greater in alloimmune than in autoimmune thrombocytopenia [13]. (See "Autoimmune thrombocytopenia" below). The extent and severity of NAIT was documented in 107 fetuses identified because of an affected older sibling [12]. The initial platelet count obtained by fetal blood sampling (mostly between 20 and 32 weeks gestation) was ≤20,000/microL in 50 percent, including 46 percent of the 46 fetuses studied before 24 weeks gestation. Send of a PKU as well...... David

Hello, A PPT and an INR would be nice. Also, platelets (if not a part of the CBC) would be nice as well. As for the infant rapid transport a NeuroSx facility. The little one needs an EVD and an evacuation of the SDH. The infant has an IO so let’s get some sedation (Fentanyl/Versed gtts) and an other line. If we are still bagging I would connect to a ventilator and vent to a low normal PaCo2. Mannitol20% as per the Broselow tape. Dilantin loading dose as per Broselow. Foley cath OG as well Then, send a lackey to the library to search PubMed and the data bases for other consideration. Let’s just say we were budget friendly. When we did the head CT a chest and abd was done as well. Anything? ETA for transport? Or, would it be faster to do a ground run?

Hello, Off topic a little. But, it is good to see early abx and aggressive IV therapy for septic patients. On occassion I still see septic patients transfer in with no abx give and little IV fluids given. =( As for the Brudzinskis signs I have never seen it myself. Cheers

Hello, Poor AMR....lol Tell them that you are a people person. That you like to organize group activities (union) and love reading CT labour law. Plus, you look great on hidden cameras. =)

Hello, It sounds like you are working hard at becoming a well rounded ACP. Hit the library as well. The more you know the more comfortable you will feel. If possible, try to following up at the ED to see how things went with your patient (if possible). The ED I am working in now I see some of the newer ACP pop by all the time to see what is going on with a patient they borough in. Cheers

Hello, I have work in the hospital setting and with EMS. Diversions are needed sometimes when the ER is too full with ER patients as well as admitted patients waiting for a ward or ICU bed. Also, diversion only applies to EMS. People still walk in to be seen while on diversion. Some of whom may be quite sick. Cancelling all elective surgeries isn't an option as well. Elective surgeries can be quite serious and urgently needed, say you AAA needs repair? Or, somebody needs a new hip so she can get up and around again. The answer is simple, more beds are needed for long term care and skilled nursing care (i.e. chronic vent units). More medical, surgical and geriatric wards are needed. So, that you do not have a log jam of patients effecting EMS. DD

Hello, I have heard that this spring ACP program at the JI is mostly made up of RN's and RT's. I hope this new programs goes well. Cheers DD

Hello, It is my understanding that RN/RT education should cover the electives (i.e. Bio...ect...) and the prehospital care foundation modules cover areas of weakness before the ACP program starts (i.e. Introduction to Paramedic Practice 111). That way, for example, a RT who has never seen that back of an ambulance won't be too lost on clinicals. Personally, I am pleased with the science courses needed. Plus, the option for allied health professionals. It is an option I am planning to do. However, I do feel bad for people who have spent a great deal of time and money to become a PCP when in hind sight taking an EMR course and some university credits would have been better. =( For what it is worth, I feel that ACP should be the gold standard in most urban/suburban and rural areas. With a decent 3 year college/university level training program you should have professional ACP by the end of it all. Heck, you can take a zero-to-hero for a RT or a RN. Why not for a ACP? David

Hello, Most that I can think off were bacterial pneumonias. As for the lasix, in most setting, it isn't required. Now for those poor folks with longer transport times I think it has a role. As for not being able to dx pneumonia, CHF or both at the same time as an argument against CPAP...I do not get it....I think that may be some sandbagging due to the costs. From my point of view, anytime EMS can prevent a tube thereby allowing time to flog the patient...I say great. For us and the patient. I will float this one by the RT at work tonight. D

[/font:258d3c7e55]Hello, Taking a reasonable amount of time to assess and start treating most patients is a good idea. Considering, despite being sick, their acuity is relatively low and odds are you will spend time waiting at the triage desk. It is nice to see a correctly dx patient with a decent history and physical done who appears better than they did when EMS arrived. As opposed to a c/c, with no hx, no IV and a NRB jammed on the patient's face. However, I have seen CPAP used for patients with pneumonia before. In fact, I have seen it work well and prevent the need for intubation for some frail patients that would be next to impossible to wean. Cheers, D

Hello, Fentanyl patches are in mcg/hr. The ratio for MSO4:Fentanyl is 1:10 in general. Cheers D

Hello, In most urban and suburban setting treating HTN is problematic. Really, there are many reason for HTN and in some cases it may be essential. Recently, I saw a Lt. MCA who had their BP dropped in to the mid 140's from 200 or so. Bad idea. I know many will disagree with me. Or, see my example as self serving. But, the point remains that treating HTN outside the hospital in most cases strikes me as a bad idea. Cheers

Hello, We have velcro strips. We attach them to the cords (just like belts on a stretcher or scoop) through a hole in one end. Then the over priced and delicate cables a coiled in a loop and held together with the velcro. This made thing easier as opposed to fighting through a rats nest in a situation. Of course, this was a small service (3 ambulances and two planes) so they were easy to keep track off. David

Hello, Is a power-port a PICC line? Or, is it a Portacath? At my old job we were setting things up for PCP and ACP to be able to use PICC lines and Portacath (with gripper needles) if patients had them. Saves digging around for an IV when odds are the central line would be used once the patient arrives at the hospital. Cheers

Hello, Nice protocols. Rate control, from my experience, (for what it is worth) usually isn't a treatment option for many EMS services. Just cardioversion if the patient is unstable. In regards to the main body of your post Mateo_1387 I have seen CCB, beta blockers.....ect...used in the ED and ICU to slow things down while anticoagulation is acheived. However, I can not recall seeing steroids used for pneumonias. Unless, there was a hx of COPD for example. Again, not a bad protcol to have if one has longer transport times. Medic 112. Did you have a chance to see what happened at the local ED? Cheers

Hello, I agree with a fluids and see what happens. As for the Afib. One doesn't know how long she has been in Afib (whatever the rate). If she converts she mat stoke on you and as noted above (for now) she is stable. Like noted above, the pt was stable. As for the steroids. What is the theory there? Cheers, David

Hello, I have never seen or heard of Atropine SL before but I have seen it give IM before. Not so much for coughing but if the palliative patient has excessive oral secretion and wet lungs. In theory, the Anti-Ach effects should dry things out some and make it less unpleasant for the patient (if still aware) and equally as important, the family. Near the end MOS4 is added to surpress and smooth over unpleasant respiratory patterns for the family (if done right). I have also seen Scopolamine used as a patch, IV and IM. For similar effects.....dry out secretions. For excessive coughing the only thing I have seen used is Codeine Elixir or IM/PO. Cheers