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-Trying to give Activated Charcoal IV The above actually happened in a neighbor province. Don't worry Mobey, it wasn't your province.

I'd like to see a copy of the ECG as well, but even without it we can form a differential of three possibilities (assuming widened QRS): VT SVT with aberrant conduction due to bundle branch block SVT with aberrant conduction due to the Wolff-Parkinson-White syndrome

If the patient is mentating well with a good pressure, I/O him and set up an Amiodarone infusion, 150mg over ten. I've performed an I/O to a cx pt. before, didn't seem to be a problem with the EZ-IO anyway.

I prefer stale starbursts

I really liked the book Enroute by Kelly 'Steven' Grayson. He's a really good story teller and doesn't selectively share the stories that just make him look good. Just finished the book 'Cheating Death' by Dr. Sanjay Gupta and currently working on one called 'The Night Shift.'

Thanks Mike, I'll do that!

I have a question regarding Ketamine use in medicated facilitated intubation along with the use of Fentanyl/Midaz for post intubation analgesia/sedation. In my province in Canada, we just got the green light to use any combination of Etomidate, Ketamine, Midazolam, and Fentanyl depending on our regional directors. In school, we weren't actually taught which regimen or combination, it was just expected that we would be with a service who would inform us of the way they prefer to anesthetize and sedate their patients prior/post intubation. Unfortunately, during practicum I was in a service who hadn't yet implemented an MFI protocol, so I've done a fair amount of research on the best practices and doses to use, as well as picking at the ER/OR docs on their preferences. The one I've compiled based on what other services are using, and from what some of the docs have told me is to start with Ketamine 1.0-1.5mg/kg, Intubate, Fentanyl 2.5mg/kg max of 250mcg and then maintain sedation with Fentanyl 25-50mcg PRN and Ketamine 0.5mg/kg. One of the OR Anesthesiologists suggested a Fentanyl drip, because I would most likely be tied up physically bagging the pt if I didn't have an extra set of hands. Any thoughts on a Fentanyl drip instead of administering PRN?

I guess we're safe to assume that the dx is high pressure pulmonary edema. CPAP, GTN q 5, IV access and if we're pretty confident in our dx of high pressure pulmonary edema and confirm this with scattered/diffuse crackles along with the wheezes on auscultation, 40mg Lasix SIVP. I think that Ventolin/Atrovent 2.5mg/250mcg has its place in this tx plan to maximize oxygenation and ventilation. My only concern with providing a bronchodilator was not so much the irritation of the heart, but rather the possible complication of additional fluid to enter the bronchioles because we've now dilated them. Interesting, I didn't consider Ativan in my tx plan.. We don't carry S/L Ativan on car. The reason I'm cautious about the nebs is because I had a patient with the classic "cardiac wheeze" as the doctor called it, and I treated with nebs and it worsened my patient's condition, and I couldn't hear crackles before, but I sure could after the nebs.

and thennnnn?

Good story! Thanks for sharing.

I'd like to hold off on the nebs, continue the high flow 02 until we can be sure this is not a case of Cardiac Asthma. If our assessment suggests Cardiac Asthma, neb tx's may worsen the condition. Trepopnea present? Any pedal edema? How is her mental status, any dizziness/fatigue? Has she recently been experiencing increased SOB on exertion? Cough? s1, s2 audible? Let's continue high flow 02 as stated above, get a set of vitals including temp, get a 3 lead than 12 lead looking for signs of recent infarct/ischemia or hypertrophy. Is her breathing worse off when laying down? Has she been taking her meds regularly?

Accessory muscle use? Perioral cyanosis? Hx of asthma or CHF? Let's get our partner to get a r/a 02 sat as we're auscaltating lung sounds down the back, what do we hear? Any associated tightness to the chest, or pain on inspiration? Lets get ETC02 reading, get her on an NRB 15 lpm, switch the reservoir for a combivent neb canister and continually monitor how she responds.

I might take you up on that offer Captain. I'll be applying for ACP jobs myself in the next month or so, and I feel as though my resume could use atleast a look from an experienced eye.

You bet! That'd be great!

I have to head west sometime and do some ride alongs to see how different things are out there.. I'd be interested to see how some of the integrated systems work for you. Will you be attending the GlobalMedic cross country training session when it passes through Calgary?

I try to use the KED as much as possible for patients with a longer transport or in situations where offload delay is expected. Still considered full SMR, easier to pad and make them more comfortable, and patients I've had in a KED for 3 hours have far fewer complaints of SMR induced back pain than those restrained to the backboard for that amount of time.

According to the book "The Trauma Manual," cloudy urine in trauma situations where patients suffer sustaining crush injuries, severe extremity injuries (# ankle?), or vascular injuries are at risk for myoglobinuric ARF. It says these patients may have Rhabdomyolysis, and that the urine will present with a tea color when CPK is high. It goes on to say that "Cloudy urine that is dipstick positive for protein or blood, but without RBCs on microscopic examination, suggests Rhabdomyolysis." http://books.google.ca/books?id=_Ik-V7DwCd8C&pg=PA365&lpg=PA365&dq=cloudy+urine+in+trauma&source=bl&ots=jXlIggWv2W&sig=GQIahvZexJIDsLABdWBswQJ0IWM&hl=en&sa=X&ei=7CBdUtfvCqSayQGCoIDwDw&ved=0CDYQ6AEwAg#v=onepage&q=cloudy%20urine%20in%20trauma&f=false

You don't need med control for an apneic patient, but sask protocol indicates you need orders to maintain the tube with a sedative. If the patient begins to buck the tube and still has little respiratory effort, it could be helpful to have orders already even if you never end up using them.

Set second line to TKO to be sure not to fluid overload, reassess pupils, Glucose spike could be due to stress response. I would like to have this pt. intubated, however, under the new MFI protocol, I'd like to call med control first for orders to maintain sedation if needed, 25-50 mcg fentanyl PRN, and lets hook the tube up to your portable ventilator that you have in your ALS unit for the trip to the hospital.

Establish a second line, get a glucose reading off of the IV stick, check lung sounds for any signs of aspiration or flash pulmonary edema. With no respiratory effort, intubation could be considered.

I'm alive! I just watched that movie called "Bringing out the dead" with Nicolas Cage, and I have to say that it was one of the most depressing films I've ever seen.

Hey team it has been a while since I've posted on here, but I've been checking the forums weekly. I passed my final semester of ACP school with flying colours and managed to get the highest mark on the 200 question comprehensive exam at the end scoring 93%! For the summer break, I decided to volunteer to teach first aid at a summer wilderness camp I've been involved with for the past 4 years and then I travelled to Thailand with a couple good friends on a shoestring budget and made it back in time for my Labour and Delivery shifts at the hospital. Delivering babies was definitely a fun way to get back into the groove of things after a month and a half break! I was able to do some reading while I was gone, but nowhere near the amount I needed or wanted to in order to maintain my knowledge base that I had worked so hard to build while in school. I start my first shift of my final ambulance practicum tomorrow morning, and I have to admit that I'm a bit nervous after taking such a long time off. I am also in the process of starting a strict study schedule for my upcoming licencing exam in November. I plan to do about 2-3 hours a day at home, and to review my study notes in between calls at work. One of my most important resources though will be the City. When I first started here and school I was pleased to find such a supportive group of people with input from all over the world. The place where I'll be doing my practicum has recently had a new owner and my last experience was a good one because of the calls and learning, but the work environment was quite negative and the morale fairly low. I want to start sharing the calls and the things I've learned from them throughout this final 8 tours. I want to get to the point where I feel confident behind each and every one of my treatment plans and when asked about them I can calmly and confidently defend my position. I look forward to becoming an active citizen again in the city.

Welcome to the city neighbour! I'm an ACP student from Saskatchewan.

Hey cool! I used to work with both of them.

To the 'untrained' eye it may appear that way.