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systemet

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systemet last won the day on March 16 2015

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    trunkmonkey
  1. Sorry, I realised after posting that my comments came across as rude. I'm sure you guys act professionally, and in the best interests of the patient. But, still jealous. My hope is that one day we might treat the UTI in the field. This is already happening in some of the assisted living / long-term care centers locally.
  2. I was expecting something more tricky. It would be quite embarrassing to come into the ER with the blood glucose still so low. Do we have a reason why she became hypoglycemic? She doesn't have a history of DM, Is this just some physiologic stress coupled with beta-blockade and some low glycogen stores? Do you know if there's a name for neurological deficit in the setting of hypoglycemia? I've seen this a lot -- usually it's obvious that they're hypoglycemic because you see a lot of sympathetic response (in this situation elderly + beta-blockade this is blunted). While I would
  3. I don't think it works. http://www.ncbi.nlm.nih.gov/pubmed/21879897 [Link to free .pdf on page] N Engl J Med. 2011 Sep 1;365(9):798-806. doi: 10.1056/NEJMoa1010821. A trial of an impedance threshold device in out-of-hospital cardiac arrest. Aufderheide TP1, Nichol G, Rea TD, Brown SP, Leroux BG, Pepe PE, Kudenchuk PJ, Christenson J, Daya MR, Dorian P, Callaway CW, Idris AH, Andrusiek D, Stephens SW, Hostler D, Davis DP, Dunford JV, Pirrallo RG, Stiell IG, Clement CM, Craig A, Van Ottingham L, Schmidt TA, Wang HE, Weisfeldt ML, Ornato JP, Sopko G; Resuscitation Outcomes Consort
  4. I think this is it. When I look at my peers who have developed PTSD, it's hard to discount their experiences and say, "This couldn't have been me". I think we all have our breaking point. I think that our abilities to cope with the traumatic events we experience are often related to how well our personal lives are. It's easier for me to deal with difficult calls when things are good at home. When they're not, I'm simply more vulnerable. It's easy to judge someone else for having PTSD. If you judge that individual, you don't have to accept that that could have been you. These attit
  5. Thanks for posting the scenario, by the way. Sorry, 23 mg/dl (US units - hypoglycemic) or 23 mmol/L (International units - hyperglycemic)? If she is hypoglycemic, we should give 12.5 g of dextrose and reassess (a lower dose, d/t the association with badness in neurological injury, and likeliness of intracranial ungoodness). . If she is hypoglycemic, this might explain the right-sided neuro deficits (is there a fancy medical name for this? I know Todd's paresis is focal deficit following seizure? I like to advertise this as much as possible so that I can pretend to be more intelligent than
  6. Well, it's beginning to sound like maybe she should have got a CT last night. It sounds like the family has a pretty good explanation for the fall, it's probably a simple trip and fall. This may be partly a result of all the infirmities of age, a prior ortho' injury, and possibly a bit of Parkinson's developing ("shuffling gate"). I think for confounders, any suspicion of elder abuse? Any recent med changes? Any suspicion of sepsis? While we may have other more pressing issues to deal with, it would be nice to point out to the ER if there are any issues in the home to be aware of, e.g.
  7. First thoughts: * This person is very old. Do they have any documentation limiting what care we can provide? * That looks like a hematoma, not a clear depressed skull fracture. * I like that my fire department uses words like "depressed skull fracture", and am impressed that they're not hitting on the patient's granddaughter. (1) I would like more information about the patient's history, and events surrounding the injury, e.g. fall vs syncope, prodrome, seizure-like activiity, pacemaker / AICD,. anticoagulation (riding the old dagatrabin train?), etc. Are there any bystanders, or ob
  8. I think this depends a bit on what sort of facility you're transporting to. If I'm 10 minutes from a trauma center, they'll only get intubated if they have no gag or I can't keep their sats > 90%, and they'll end up with an IV or IO. If I'm 10 minutes from a rural ER without EM coverage, I'm probably just going to stop and RSI them now, and either bypass to a bigger ER, or call for a helicopter.
  9. I'm not great at reading labs, but his CO2 is 20, so his HCO3- is probably around 18 mM, right? So, is the metabolic acidosis here just lactic acidosis? Also, why the hypokalemia / hyponatermia? Is there some SIADH here too? On one hand, his crit's 48, but his calculated osmolarity looks to be around 275? Just wondering. I'm trying to get better with this sort of thing since I got access to an iSTAT and started working in the ER a little on the side.
  10. The problem with these case presentations, is we each imagine a slightly different patient. I look at this and see someone hypertensive, with some mildly concerning symptoms; headache, dizziness, proteinuria, and you see the beginnings of hypertensive encephalopathy. We may both be right, but we're just visualising different patients. It's really hard to talk in hypotheticals. I think the analgesia for the headache is a little problematic here, and the best agent probably depends on the severity of the pain. If it is severe and debilitating, some morphine might be a reasonable choice, bu
  11. So, based on the initial description, I wouldn't treat this. Yes, she's hypertensive, and she has a headache and some dizziness, which could be the beginning of a CVA. That being said, she doesn't have any altered mental status, any focal neuro deficitis, any slurred speech, photophobia, nuchal rigidity, ataxia, vertigo, etc. Even if she is having a CVA, this may be the MAP she needs to autoregulate. If, and it's a big if, she's having a CVA, then our target MAP is going to be different based on etiology. I would sit on the patient, reassess, and let the ER work her up. http://www.cf
  12. The largest employer in my region has moved to this design, for all operations; urban / suburban / rural / ALS / BLS / IFT. We are told they are safer, which they probably are, if staff wear the seatbelt as much as possible. Personally, I'm still not convinced that they're much safer --- most ambulance models haven't been crash-tested, and many have hard corners on the cabinetry that are essentially plywood edges covered with a quarter-inch of foam. On the other hand, any move in the direction of safety is long overdue. I fear the bench seat is an endangered species, and will soon be ex
  13. Hypothesis: "Things I write while mildly intoxicated are not as funny the next day".
  14. I think you're all wrong. Discuss...
  15. So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit. * It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk. * Traditional spinal restriction results in a 20% decrease
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