Doczilla

The longtime providers of emergency medical service, a company based out of Palestine, can no longer cover the costs after years of service in the Buffalo-Flo-Oakwood area. Their deal -- one that was essentially a free service to the area -- ends Tuesday.

You get what you pay for.

'zilla

Oxygen thieves.

'zilla

WANTED

One Tennisball ...

Will exchange for MRE .. (Lung in a Bag aka Scrambled Egg with veggies) puke.

Those are the WORST. Not enough Tabasco in the bottle to cover it up. Just gotta choke it down, telling myself, "it's protein, it's calories, it keeps the body going..."

Trade ya a cheese spread for a chocolate peanut butter?

'zilla

Doczilla

Query 2: I see this is your light kit ... but wtf is the tennis ball for ? I dont have a pistol, just reach out and touch (someone/ moose) rifle and a 12ga cannon ... why fool around ?

If you would not mind some positive input ... Get a Sigg bottle for water ... dump the nalgene because one cant boil water in it, don't need iodine based water purification then.

My fire starters are Flint, (same one Bear Gillis uses) plus Zippo.

I agree that a rifle is preferable. The pistol is for sudden close encounters while moving among other people, as we may have to travel around a crowd. I may not want to travel as conspicuously with my M4 unless the zombies come.

I like my old Zippo for style points, but it dries out every couple of months, requiring me to have a handy bottle of lighter fluid. The flint is okay, but to me, more work than just using a disposable Bic. The lighter holds its fuel forever. And at 3/$1, I can have several.

Appreciate the recommendation on the bottle. Good idea. I'll look into adding that. Right now the Nalgene (actually, polycarbonate) bottle also doubles as storage for the duct tape, a few turns of which are wrapped around it and holds many of the smaller items in my kit.

Tennis ball can serve multiple purposes. Chief among them is fighting off boredom and maintaining morale, which is extremely important in a bad situation. Good for not just us, but the dogs too. Other purposes:

Bleeding control. Put it in the armpit and tie the arm against the body, and it will put pressure on the axillary artery and vein. The same can be done in the groin. The ball can be placed directly over gauze on a wound and tied tightly, maintaining direct pressure.

Storing small items. Cut a slit in it and you can store small things you don't want lost. As an added benefit, it floats and is brightly colored.

Securing impaled objects. Cut it in half, then cut a slit halfway through it. No need to waste bulky rolls of precious gauze or other bandage material.

Cut into strips for finger splints.

Drinking cup (insulated!)

Makeshift clothes pin. Cut a slit in the ball. Squeeze the two ends of the cut together to open the "mouth", then release and it closes.

One thing I forgot to mention. The meds I keep are in a small plastic divided box, a "bead box" that I bought at a craft store for storing small items. As my injectable meds expire from my regular kits, I add them to this one.

Also forgot to mention the space blanket. Good for emergency warmth, a fire reflector, and signaling.

Never forget that you will not rise to the occasion, but sink to the level of your training: http://www.zombietargets.net/

'zilla

Packed on my back:

Water purification tablets

Fish hooks and line

Several disposable lighters

Vaseline soaked cotton balls (firestarter)

550 cord

Duct tape

LED microlight flashlights, several

LED flashlight, 90 lumens

LED headlamp

1qt nalgene bottle

Powerbars

Tennis ball

MRE, broken down into its individual components

3 pairs of socks and underwear

One pair pants

2 T shirts

Thermal base layer

Glock, 3 magazines

Knife, folding (Benchmade Griptillian)

Knife, fixed blade (Fallkniven S1, good for splitting small branches, digging, etc.)

Small bar soap

Toothbrush and toothpaste

Body powder

Baby wipes

Medications:

Antibiotics

Pain meds

NSAIDS

Antihistamines

Antinausea

Antidiarrheal

When traveling by vehicle:

5 gal water jug

Dog food

MREs

Rifle, 4 mags

'zilla

More paying full time jobs for doctors.

'zilla

Ohio has been hit pretty hard by the recession, with a strong manufacturing base in the domestic automotive industry. I am not surprised that they are looking to cut back every way they can. I even applaud their creative thinking, such as it is without understanding one whit of what they are talking about.

I don't see this getting that far before the docs from OSU climb all over these idiots.

'zilla

Talk and Die Syndrome? For $%# sake. Lucid interval after epidural hematoma is well documented in the medical literature, but nobody calls it "talk and die syndrome".

Because of this, now every patient and parent of a child who has had a minor head trauma in the last week is coming to the ER demanding a head CT. This one incident is going to cause more cancer than asbestos.

Clinical decision rules (specifically, the Canadian Head CT rule, which is somewhat ironic given that she was injured in Canada) dictates that even with LOC up to 30min, if she has a normal neuro exam, normal mental status, no intoxication, etc., the chances of her having a clinically significant intracranial injury is extremely rare. We get a large number of minor head traumas that we don't scan because of clinical decision rules like this and the New Orleans Criteria, saving time, expense, and radiation. As long as they can be watched by a sober reasonable person, we send them home, with instructions to return if things worsen. Her case is a rare one, but unless there is something we're not being told, I wouldn't have insisted on scanning her immediately until she started complaining of the severe headache.

'zilla

Thread must die.

Sniper team, weapons free.

'zilla

The police "choke" (an incorrect term), otherwise known as a Lateral Vascular Neck Restraint, is often applied to interrupt blood flow to the brain and end a fight with a suspect. It's not a true "choke" since the airway is ideally not compromised during application (though it can be if the officer has to convert to a lethal technique based on suspect actions). When properly applied, bloodflow to the brain is interrupted and the patient briefly loses consciousness. The patient should return to a normal level of consciousness shortly thereafter, hopefully in handcuffs.

Check for signs of serious vascular injury to the neck (extremely rare). Listen for carotid bruits or stridor, check for bruising or swelling to the anterior neck, and assess respiratory effort (granted, the suspect will probably be winded from the physical confrontation). If none are present, you may safely discharge the patient into police custody.

'zilla

There are many folks who do quite well on Xanax are are capable of performing their job functions despite the effect of the medication. In order to determine this, I recommend a driving test, skills test in a simulated environment with scenarios, and quiz the employee after on aspects of the scenario (Xanax affects short term memory). If they pass, they should be allowed to continue their job functions. It's important to understand under what circumstances they take the Xanax. At night to prevent insomnia? Twice or 3 times daily for anxiety on a schedule regimen, or as needed anytime when they feel stressed ("I'm stressed. *pops pill*). I list these from least to most worrisome from an employer's perspective.

As far as the Nyquil goes, there is the alcohol and the benadryl, either of which render a team member unfit to continue the mission on my SWAT team by policy. That employee should be educated on this and sent home.

'zilla

I thought that "Emergency Medicine" was ALREADY considered a medical specialty amongst the MDs and DOs?

It is. We have a national organization (ACEP, AAEM, SAEM) and our own specialty boards. (ABEM)

Emergency Medicine is an established specialty. What they are looking for is to make EMS (wouldn't "prehospital medicine" be a better name?) a subspecialty of EMS. Kinda of like how cardiology is a subspecialty of internal medicine.

Also correct.

'zilla

The reason behind this push is to get more physicians into EMS fellowships. It's a difficult argument to make to a resident just completing residency that they should do an EMS fellowship, when there is no recognized subspecialty exam, no pay differential, and no additional recognition. This push is really more about the physicians than EMS as a whole. There are other potential benefits, though, including a larger base for EMS research.

I tend to take the view that this further cements the relationship between doctors and EMS which shouldn't have to be there in the first place. This will make it even harder to become an independent profession with our own scope of practice if we have a group who has their own agenda for keeping it under their domain.

I'm going to ask that you clarify this statement. Are you proposing that EMS providers have their own prescribing privileges? And are you saying that EMS medical directors have a reason behind this agenda?

It is interesting; however, physicians in the United States are not as involved in EMS as many other countries. In countries such as South Africa and Australia, physicians work extensively in the pre-hospital environment and are quite involved with the pre-hospital providers. This is something that is unique in the United States. So, I see this as a potentially good move for physicians in the United States.

In many other countries, physicians do work in the prehospital environment, but a lot of that is a cultural thing that comes from EMS's origins in those countries. In the US, EMS was born from public safety and from funeral homes. It's hard to argue now to pay someone $150K+/year when they can get a paramedic for $40K (or less). If communities or hospitals decided to pay a physician a proper physician's wage for working prehospital, you'd have more of them doing it. This becomes harder to justify in this day and age of evidence-based medicine, when it is difficult to demonstrate the benefit of prehospital ALS, particularly showing the difference between outcomes with a paramedic providing the prehospital care or a physician (which I don't think there is any reproducible objective data to support). We may know it's a good idea, but we've got to be able to prove it to the bean counters.

'zilla

[iam sorry but I had to jump here on th one comment that was made about who would you rather have put a tube in?

Well I was in he hosp for the past two weeks and the so called peope standing around that hae just ONE job to do intead of 5 different skills, well they messed up big time. I was getting a line in the neck and they totally blew it and sent a bleed into my neck and what the docs no thought to be a bleed into my chest. So whom is ready for what want to know?

Stop posting.

'zilla

After a fast Google, Douglas Adams is only known for Hitchhikers Guide to the Universe. Have not read book or seen movie yet.

Am I getting warm?

Yes, quite. While the movie is entertaining, I recommend reading the books.

'zilla

A standard that many departments use is .42

Of course it is. Douglas Adams fans know why.

'zilla

Can you really be so sure it WILL help? After a quick check there are quite a few reports of atropine being ineffective in the setting of digoxin overdose. I am happy to be proven wrong but it was this unknown quantity that provided my main justification for advocating cardiac pacing if I had to only choose ONE treatment - as per your question.

I would be keen hear your answer and justification to your question Doczilla on which ONE you would choose in the scenario - drugs or pacing?

Stay safe,

Curse

a) Dial back the attitude.

The reasons for choosing atropine over pacing were covered in my previous post. That's not to say you would never pace someone who is possibly dig toxic.

c) I phrased the question this way because I didn't want the dogmatic answer that anyone would come up with who has taken ACLS of "atropine, pacing" or "pacing, because atropine never works on heart blocks". This is one of those cases where not all bradycardias are the same, and it's important not to do something simply because the algorithm says so. It's not enough to know to do it; you should know why you are doing it. By putting someone to a choice, and having them justify it, you see who really knows why one is appropriate over another.

'zilla

I've heard that Glucagon is a safe treatment for Dig toxicity as well as beta-blocker OD

For Beta blocker OD, yes. Calcium channel blocker OD, possibly. For dig toxicity, no. Glucagon is not indicated here.

Sounds like the classic dementia where patients do normal tasks repeatly to act like they are ok.

Dementia is a slow, progressive, irreversible decline in mental function. Acute changes in behavior or fluctuating symptoms suggest delirium, which is usually secondary to an acute and often reversible cause.

Atropine can be used to prevent heart block.

Atropine can be used to TREAT heart block, but is not usually used to prevent it except under limited circumstances, like intubation in pediatrics. Don't throw atropine at someone unless you have a good reason.

I believe the chance that atropine may have little effect is too high due to the fact that the rhythm is not primarily vagally mediated.

Actually, in the setting of dig toxicity, heart block IS parasympathetically mediated, through 3 mechanisms:

1) direct vagal stimulation

2) increased parasympathetic transmission at the AV node

3) increased sensitivity of baroreceptors in the aortic arch (which in turn leads to vagal stimulation)

Atropine is therefore DOC in heart block caused by dig toxicity. Don't let some ACLS instructor tell you never to bother with atropine in heart block. In this situation, it will help.

Pacing has to be done with caution in the setting of dig toxicity. It will lower fibrillatory threshold and should be avoided if at all possible. Pharmacological treatment is preferred.

I don't know of any prehospital system that carries digibind. It takes 45 minutes to get it from the pharmacy at my hospital. The cost/benefit ratio would be extremely high, particularly when dig toxicity is difficult to diagnose without a dig level. Digibind would be the DOC if you had all of the info and the ability to give it.

'zilla

I recommend that we have a separate forum for this called "Morbidity and Mortality Conference" where each case can have its own thread.

'zilla

Then let's up the stakes.

Same patient, same presentation, different vitals.

Alert, disoriented.

Multifocal Atrial tachycardia with superimposed 3rd degree block (pathognomonic for dig toxicity)

Ventricular rate (and pulse) 30

BP 70/40

What do you want to do?

You get one choice. Pace, or drug. Don't just guess; justify your answer as to why one is better than the other.

'zilla

Of course, her dig toxicity may be due to sepsis, dehydration, potassium deficiency, or other factors. The scrubbing may be simply delirium due to sepsis, UTI, dehydration, dig toxicity, or her other medications.

The question is, do you want to treat presumptively for dig toxicity in the field with her vitals in the absence of definitive diagnostic information?

'zilla

Does she say it's dirty because it looks yellow to her from her dig toxicity?

'zilla

Chronic cocaine use leads to accelerated atherosclerosis and hypertension, and acute use can lead to rhabdo and hypercoagulability. Cocaine users can have thrombotic events, just like everyone else, and at young ages. It's generally a bad idea to dismiss cocaine-associated ST elevation as "just vasospasm". They should go to cath like everyone else.

'zilla

I won't beat the paramedics up. I choke them using the Force.

'zilla

Double tap.