DFIB

Don't snort the water!

I thought the policeman did good. He wasn't in the blast radius. I remembered that video from training and decided I would share.

Cover this with your thumb.

Corpus Christi has been doing this for some time now, I think.

Welcome!

The more you participate the greater the opportunity to reinforce your knowledge. Enjoy the forum.

The only time I use the EMS title for a discount is when crossing military checkpoints and when LE try to shake me down. Being an EMT is really useful and will usually get me a free pass. I just make sure that some company ID is visible. I don't know if that is in any way related to this thread, but in that sense it does save me money.

I have had people make gifts kinda like Island EMT. It is usually something simple but very sincere and always appreciated.

Can you imagine the recruitment slogan for the human testing phase?

Ok, thanks.

This is just cool.

What is that big circle of dots?

I have found myself counting on the NIBP, until all of a sudden the battery was dead. What a rude awakening!! I had to do bp manually and was tough to do in the back of the rig while rolling.

Stick to manual every so often, if for nothing else than to keep up the skills or to "check" the NIBP.

I get my first manual before the truck starts rolling. On our roads additional BP checks are tricky. Manual is all we have.

Mike,

Experience interacting with the New generation?!? You mean old geezers putting up with young whippersnappers and upstarts perhaps! It is really neat to be able to interact with "experience" minus the fear of being treated as dumb and in the ditch as I feel.

You have had an interesting run at EMS to say the least. For me as a relatively new EMT, I find it a honor and frankly, pretty cool, to be able to interact with seasoned providers. I am glad you found us.

Pretty much everything you have done are areas that I have at least thought about as possibilities in the future. Well, I have never thought about working the Bering sea, except for when I am watching "The Deadliest Catch" and get that 10 foot tall and bullet proof feeling

In a lot of ways EMTCity forms a sense of community beyond the casual internet chat room or forum. Many of the members know each other personally and a lot of us interact outside of the forum. I think you will enjoy the forum. I know I do.

Welcome

Additionally I am a little surprised at the percentages of men with spinal cord injury that are capable of sexual activity.

"In 200 male paraplegics, 36.5% were unable to have erections; 42.5% were able to have erections on local stimulation; 21% were able to have erections on psychic stimulation. Of the 200 paraplegics 46 have had intercourse with intromission; 20 of these had ejaculations and 12 more reported gratification without ejaculation. Since two-thirds of these 200 patients are capable of at least a reflex erectile response, they should not be dismissed as permanently impotent. The author closes with a discussion of the relation of this response to the level and completeness of the spinal cord lesion." (A report on sexual function in paraplegics, Talbot, Herbert S., Journal of Urology (Baltimore), Vol 61, 1949, 265-270.)

This scenario was a lot if fun. Thank you everyone for participating.

Do you mean that one? Should he have said in in Spanish or something?

Oh that one. Thanks.

The most common cause of this condition is urinary due to bladder distention and/or bladder spasms. It can also be caused by the inserting of a catheter. It was first observed in 1890 by Anthony Bowlby during the cauterization of a patient with spinal cord injury.

The second most common cause is bowel related due to rectal distention. This destention can be due to constipation, edema, rectal exams, suppository insertion, impaction, enemas, or any other mechanical or physiological force that can cause distention. (Spinal Cord Injury Information Network, Autonomic Dysreflexia, Fact sheet # 25,)

The immediate pre-hospital management is the elimination of the cause. Since Autonomic Dysreflexia can be caused by a host of reasons immediately begin by placing the patient in a sitting position with their feed dangling, loosen their clothing while looking for any obvious source of noxious stimuli starting with the urinary system followed by checking the bowels. An quick acting, short action antihypertensive should be administered while looking for the root cause if the blood pressure is above 150mmHg systolic.

If the patient does not have a catheter in place one should be inserted immediately. If a catheter is in place check the catheter for correct placement and obstructions such as kinks, folds, or constrictions.

If the catheter seems to be blocked gentle irrigation should be initiated with warm saline. Palpation or tapping of the bladder should be avoided.

If the catheter is properly placed and is draining and hypertension persists, we should be suspect of fecal impaction and check the rectum for feces using Xilocaine jelly as a lubricant. This will lubricate the finger and anus while diminishing further stimuli. (Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury.)

A quick acting short duration anti-hypertensive can be administered if necessary. “The most commonly used agents are nifedipine and nitrates (eg, nitroglycerine paste). Nifedipine 10mg should be in the immediate release form; bite and swallow is the preferred method of administering the drug, not sublingual administration. Other agents used are mecamylamine, diazoxide, and phenoxybenzamine. Use antihypertensives with extreme caution in older persons or in people with coronary artery disease.” (Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury)

If the blood pressure remains high Nifedipine 10mg can be repeated in 30-60 minutes.

Patients who suffer from Autonomic Dysreflexia should be monitored for 2 hours after the cause is resolved. If the cause of Autonomic Dysreflexia cannot be identified the patient should be admitted into the Emergency Department for observation and management.

Conclusion: Autonomic Dysreflexia is a life threatening condition and it’s understanding extremely important to pre-hospital providers. A misdiagnosed or mismanaged Autonomic Dysreflexia incident can deteriorate very quickly causing permanent neurological, cardiac or vascular damage. A provider must not only understand the contradictory physiological findings but have the skills so search out and resolve the origin of the offending stimuli.

Autonomic Dysreflexia is the nervous system reaction to overstimulation of the autonomic nervous system when there is an interrupted flow of stimulation at the level of the injury. The mechanism of this condition begins in patients that have a spinal cord injury above the splanchnic outflow, generally above the 6^th thoracic vertebrae. The development of this mechanism is described below.

1) Below the injury, the intact peripheral nerves transmit strong nervous stimuli into the spinal cord and stimulate the sympathetic neurons located in the intermediolateral gray matter of the spinal cord. This stimuli does not have to be a painful stimuli as even pleasurable stimuli such as sexual intercourse can trigger this condition.

2) The sensory input or stimuli travels up the spinal cord and provokes a huge sympathetic surge from the thoracolumbar sympathetic nerves, resulting in peripheral hypertension, caused by widespread vasoconstriction primarily in the subdiagfragmatic vasculature.

3) The surge in the sympathetic reaction releases an entire gamma of neurotransmitters , norepinephrine, dopamine-b-hydroxylase, dopamine, that result in vasodilation above the level of injury but that is blocked from traveling to the subdiagfragmatic vessels. This explains symptoms such as piloerection, skin parlor and sudation above the injury.

4) Baroreceptors in the neck detect the increase in pressure and respond to the hypertension by provoking bradicardia and vasodilation above the level of injury. This can be explained by Poiseuille formula that basically states the variables that affect pressure in a controlled environment taking into account viscosity, vessel lumen radius, fluid velocity and length of the pipe length of the pipe.

5) The brain attempts to shut down the sympathetic surge by sending inhibitory impulses that are blocked at the level of the spinal cord injury. At the same time there is a vagal parasympathetic stimuli that produces bradicardia that cannot compensate so the hypertension continues.( Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury)

In conclusion the essence of the effects of Autonomic Dysreflexia is that the upper half of the body is under parasympathetic control and the lower half of the body is under sympathetic control where the hypertension is caused by sympathetic vasoconstriction and the headache, by parasympathetic vasodilation. The solution is to remove the stimulus so that the reflex hypertension can resolve.

OK Wendy here's a challenge for you. Why don't you give a short lecture /training on Autonomic dysreflexia.

Defib that was a pretty good scenario to make folks think.

I am already on it. To follow shortly but if Wendy wants to beat me to it she is welcome.

AUTONOMIC DYSREFLEXIA

Autonomic Dysreflexia is an important imbalanced reflex sympathetic discharge that is common in patients with spinal cord injury above T-6 vertebrae. Statistically Autonomic Dysreflexia can occur in 49%-90% of all persons with spinal cord injury above the splanchnic sympathetic outflow[1] although there are reports of patients presenting Autonomic Dysreflexia with spinal cord injuries as low as T-10.

The rate of occurrence can vary greatly from several incidents per day in some patients to an occasional presentation or none in others. The first presentation is usually 4-6 months after injury but can present as early as two months or even after years, Since males are 4 times more likely to suffer spinal cord injury, Autonomic Dysreflexia is almost an exclusive male condition although approximately 66% of pregnant women develop Autonomic Dysreflexia during labor.[2]

Since Autonomic Dysreflexia seems to be a condition that is exclusive to patients with spinal cord injury above the T-6 vertebrae, and generally occurs in an out-of-hospital setting many physicians have never seen this condition and would not recognize it when presented. This scenario also amplifies the importance that pre-hospital providers be familiar with the presentation and treatment of Autonomic Dysreflexia in the field.[3]

More to follow.

[1] Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury http://emedicine.med...rview#aw2aab6b4

[2] Medscape Reference, Autonomic Dysreflexia in Spinal Cord Injury, IBID

[3] Spinal Cord Injury Information Network, Autonomic Dysreflexia, Fact sheet # 25, http://www.spinalcor...asp?durki=21542

Absolutely

Our protocols are approved by the Saskatchewan College of Physicians and Surgeons and the Saskatchewan Medical Association. In 2009 we obtained self regulation and licensure, which means that we act under our own licence, not as an extension of a Medical Director. No one, absolutely no one, can give us provisional permission to exceed our scope of practice or protocols. Anyone accused of exceeding their Scope is investigated byt the college and if warranted summoned before the professional conduct committee. The sentences to date have included fines and suspensions, never revocation. Their decisions are published online:

http://www.collegeof...nduct/index.php

I like that, operating under your own license that is.

Would a action guided by online medical direction be considered a breach. Wouldn't they in essence be authorizing you as an extension of their practice and taking ultimate responsibility for the action?

If they are not taking responsibility I would like to know the difference of one exsists.

Agnostic was basically a PC term developed by Darwin's pit bull that essentially means atheist. Personally, I don't think there exist many atheists and prefer the term agnostic. AK, finish reading before commenting. Most rational people who are skeptical and believe in the scientific method would agree that they would believe in a conscious, divine mechanism if good, reproducible, peer reviewed evidence existed. This way of believing epitomises the contemporary understanding of the term agnostic. Therefore, there really is little difference between the terms agnostic and atheist other that an interpretation bias. In fact, the terms skeptic and humanist may better describe what people believe.

Bottom line: There is little to no fundamental difference between a contemporary agnostic and a contemporary atheist.

Dwayne, Khan academy will be your best bet. Download his free videos for all your learning needs. Edit: Download when you get home or find somebody who can provide you with decent Internet access.

In a practical sense Agnostic and Atheist may have the same end result, but agnostics do not deny the existence of deity, but hold to the position that said deity cannot be understood or known. I think you said that but am not sure.

I was overlooking all the widow dressing such as barking dog ,newly mowed lawn hedges need trimming, etc.

The weapons out in plain view are still a red flag to me.

You don't forget the sound of high velocity lead hitting the walls a foot over your head , EVER.

The redneck riviera scenario re-enforced the perception of possible dangers on entering the scene.

It wasn't until the end that you gave the thoracic spinal injury and cause.

Good on you Wendy!

It did go kinda fast after that! All of you guys are great! I love bouncing ideas around with all of you.

I'll bet there was a second half to what the medic said. "I'm probably going to lose my licence for this," "but the love I have for my friend and her family trumps that."

Like a mentioned in my first post. For such a heavy handed reaction from the state he must have been disciplined before.

Love is a very powerful motivator, one of the most powerful motivators. I think one of the big questions he will have to answer is, Did he act in a manner that other medics would have acted in the same situation.

I absolutely believe in second chances in some instances. I don't know if the second chance should be immediate. There are some things we do we just cannot make repair for and should not get a second chance.

Does this case qualify for a second chance? It is not for me to decide, I simply do not know.

That we should have the balls to do whatever is necessary no matter the cost. To be totally blunt and to the point - that is a bunch of horseshit.

Anyone can have the balls to freelance, the question is, do we have the brains not to.

I have transported patients with medications drawn that I know I am not authorized to give, praying to God that I don't have to. Until now I never have. A lot of our job is about calculated restraint.

I think the state did the right thing. I feel compassion for the offending medic (what a horrible experience and aftermath) but not much mercy. He knew what he was doing, was aware of the consecuences, rolled the dice, a human being died, and he is left to pay the piper. It stinks but, what other conclusion could he have possibly expected.

In Mexico EMT-Bs are allowed training in advanced airway skills that are way outside their scope of practice. If one of our EMTs tries to run an ETT they are gone. Their training is irrelevant.

All off us should know procedures that are outside our scope. We also refrain from using them because we are bound by rules.

In some instances life is really simple.

Well hell. Foley? Removed? Sweating? High pressure?

Autonomic dysreflexia. Sit his ass upright!

Wendy

CO EMT-B

RN-ADN Student

You are just way too good Wendy!

Actually it is not any patient I have personally attended. I just thought Autonomic Dysreflexia was an interesting case study in the prehospital setting so I set up the obvious path to a relatively straightforward discover. It interested me that sex could trigger this condition and bladder distention is the number one cause so u decided to use them both. I pitched in a couple of drugs to to cover the scent and had a lot of fun with the assumptions I thought participants would make.

All the added drama was just for fun.

I am curious, would you try to medicate this patient's hypertension or just fix the origin of the stimuli?

Anyone care to mention the second most common cause of this condition?