Doczilla

Any recent viral illness? 'zilla

I agree that this looks like a SLUDGE presentation. Agree with all the treatment recommendations regarding atropine and 2Pam. Because of the contamination, I would not try to fly the guy. Most flight services will balk at flying a hazmat victim, even if decontaminated in the field, and for good reason. The helicopter can't pull over and stop if the pilot's eyes start watering. As I found out last week on an unfortunate patient with a pesticide mishap, atropine works wonders for this presentation. I don't think we need to break out all the Mark 1 kits. 1 or two should suffice, supplemented by the atropine in the drug box. 2 Pam is pretty expensive, as are the autoinjector kits, and he's unlikely to benefit beyond a couple of doses. If we're running out of atropine and he still needs more, then yeah, he gets all the Mark 1 kits. If the dog was my own dog or a military or police K9, and there were no human patients, I would treat him. Otherwise agree that the dog is DOA. Probably some runoff from a field that was sprayed for pests. Great case! 'zilla

Why would you choose a secret, unproven material for your armor when there are plenty of choices of armor materials that are extensively and independently tested and proven to be consistently reliable to defeat rated threat levels? Bullet resistant panels, in both soft and rigid materials, can be obtained at a fraction of this price and sewn into any garment. And Uzis fire 9mm rounds, hardly the "assault rifle" caliber that the manufacturer is claiming. This threat is defeated by level IIA armor, the lowest level of body armor rated by the NIJ. This guy's business is obviously aimed at those with more money than sense. 'zilla

He was discharged "a fortnight later"? People really talk like that? ("Nurse, please change admission status from 23 hour observation to full fortnight admission") 'zilla

I haven't heard this before. I polled several of the other faculty, and they haven't either. One is very well acquainted with the PE literature, having reviewed and edited articles on the subject, and had never seen it. The best anyone could come up with is that it indicates central cyanosis, which fits with a large PE, particularly if the cyanosis didn't clear with appropriate resuscitation. It would be consistent with a thoracic aortic dissection with occlusion of the brachiocephalics and carotids, but not pathognomonic for PE. This would also fit with SVC syndrome or ventricular rupture. 'zilla

I could tell you how to percuss, but you are probably better off having one of the docs at the hospital quickly show you the technique. Percussion allows you to hear the relative density of what is directly underneath the skin. It is most useful in the abdomen and chest. Percussion of the abdomen can tell you if there is dilation of the bowel or a large amount of free air. Percussion of the chest can detect large pneumothorax or pleural effusions or consolidation. For different percussion densities, practice first on yourself. Percuss your thigh. This gives you an idea of what a pleural effusion will sound like. If you percuss the right upper quadrant of the abdomen, you will get a similar sound over the liver. You can percuss down the anterior liver until the sound changes. This point is the liver edge, so it gives you an idea of the size of the liver. You can do the same with the spleen in the left flank. You can use this to detect hepatomegaly or splenomegaly. Next percuss your upper chest. This sounds a little less dense, more of a "thump" than the "thwack" like you get percussing the thigh. This is normal lung tissue. You can do this on someone's back and measure the movement of the diaphragm as the patient breathes. Next percuss the abdomen in the various quadrants. You should at some point run into a pocket of gas, which will sound like a tiny drum. This hollow sound is what a pneumothorax might sound like. Large pockets of gas, such as those with ileus or bowel obstruction, will sound even more pronounced and hollow. Percussion can be used to elicit pain to diagnose certain conditions as well. Percussion tenderness is more sensitive and specific for peritoneal irritation than rebound tenderness. You can elicit rebound tenderness on just about everyone, whether they have peritonitis or not, but percussion will not generally hurt those who don't (granted, some emotional stuff plays in, and some patients will complain of tenderness with percussion anyway. For a good exam, watch their face as you do it). For the patient with suspected peritonitis from appendicitis, percussion tenderness may help give clues to who really has it and who might not. Percussion of the costovertebral angle can elicit pain from obstructive uropathies (like a kidney stone) or pyelonephritis. Percussion of the maxillary or frontal sinuses can indicate acute bacterial sinusitis. 'zilla

So, let me get this straight. The Fire Marshal, who is off duty, ARRESTS a woman for using the F word in a public place, handcuffing her after she tells him where to go. I guess there is a shortage of arsons and malfunctioning sprinklers in La Marque that this idiot feels it necessary to wander around the Wal Mart looking for people swearing. Oh, but it's a CRIME. One that demands immediate intervention from an off duty peace officer. The arrest of an individual is tantamount to the government taking away your freedom (life, liberty, etc.), and the law is fairly stringent regarding the conditions under which this can be done. It doesn't sound like the Fire Marshal here is in a very good position to defend the arrest. It sounds like he stuck his nose in, and when she wouldn't give him the answer he wanted, he had a choice; defuse the situation, or escalate it. Good cops know when to choose one over the other. Looks like we know which one he chose. This is so incredibly stupid, I can see why the town didn't want to release a copy of the summons. 'zilla

FLK- Funny Lookin' Kid (usually describes physical traits thought to be associated with nonspecific congenital anomaly) 'zilla

It was, until Bob Dole f&%*ed that up with his Viagra commercials. 'zilla

Generally, yes. 'zilla

Contrast agents for xray, CT scan, and angiography contain iodine, and this is the issue with this allergy and is usually how people find out that they are allergic to it. MRI contrast is gadollinium, and does not contain iodine, and is therefore safe for these patients. For this and other reasons, noncontrast CT is gaining wide use, even for intra-abdominal pathology. MRI is a reasonable alternative, though not typically available during off-hours. On the OP's note, if a patient has more than 5 drug allergies, they have a high likelihood of having borderline personality disorder. There is a study out there to prove it, only I'm too lazy right now to look it up. 'zilla

Thanks to everyone for the great ideas. Obviously, if we want to get the attention of EMS, it helps to have an idea of what EMS providers are looking for. The relationship between the hospital and EMS is professional but not that personal. I don't hear about animosity of EMS crews toward the hospital (and the EMS agencies I work with would quickly bring that to my attention if there was), and though there is the occasional dust-up (every workplace has its problem children and occasional snafu), the EMS providers seem to like us fine. The hospital does celebrate EMS week in the usual ways, but I think the powers that be want a more significant and consistent contribution to the EMS community. Thanks again for the thoughts. 'zilla

I remember something like this from anatomy class: 80-90% of men are found to have a prostate cancer on autopsy. The vast majority (obviously) never metastasize or become clinically relevant. Treatment for this condition is not fun. For that matter, diagnosis isn't a laughing matter either (let's make dozens of tiny holes through your rectum into your prostate. No thanks.). Trouble is, right now we have a hard time telling the difference between those that will remain harmless and those that will become deadly, so each patient has a difficult decision to make. 'zilla

It was recently asked of me to come up with some ideas to improve our hospital's relationship with EMS. I'm fairly sure that printed coffee mugs don't quite cut it. I was hoping that the learned folks here would have some good thoughts on this. Currently our flight service here does training sessions "on the road" in some of the surrounding areas. They offer great classes by solid instructors. The hospital takes paramedic students for clinical time but does not have its own paramedic program. We have a full time EMS coordinator who is very proactive. We'd like to offer something that has some actual value, not something like the usual junk handed out on EMS Week. One idea that has been floated is creating a mobile training center with high fidelity patient simulators that can be taken to various squads for offering continuing ed. Another is to offer clinical time (which is available for EMS students but not to EMTs/medics who are not in a training program. This can be done on an individual basis with physicians, but there is no real "system" to do it.). Anyone care to share some ideas? 'zilla

I don't see anywhere in my post where I said that they were uneducated, ill-educated, or picking up the scraps left over from nurses. I also don't see where you get that I think so little of these specialized techs, this so called "crappy attitude I have toward radiology professionals." I also mentioned nothing regarding licensure. But by all means, rant on. 'zilla

Rid- I think you're talking about 2 different things here. Triage is not necessarily considered a "medical screening exam" to satisfy the EMTALA requirements. Per EMTALA, the MSE and stabilization is all that is REQUIRED of the hospital for any patient who comes through the door, and this has generally been held that it must be performed by a physician or representative (PA, NP, APN). After this screening exam, if it is found that no further stabilization is necessary, the patient can legally be discharged from the ER. While it is true that paramedics are not generally considered trained or qualified to do this MSE, triage is not an MSE, since the patient is not being sent home from there. Rule 482.55 sets forth the requirements of what personnel may perform the MSE, though it is vague and subject to interpretation. The upshot is that the hospital bylaws determine who meets this criteria. The CMS position on this is that it does not need to be a physician who performs the MSE, but may be a non-physician member of the hospital staff. They specifically cited an ER nurse as an example of a non-physician staff member that can perform an MSE. RNs are frequently used to perform MSEs in Labor & Delivery. Most hospitals interpret this to mean MDs, DOs, PAs, NPs, or APNs. Again, triage doesn't necessarily qualify as an MSE. If the person at triage looks you over and says, "you don't need anything more in the ER, go see your doctor", then it is an MSE, and that person who said it has to be identified in the hospital by-laws. State law may determine who does triage, but EMTALA does not. The next few comments are not directed at you, Rid.

Did you get a CO level in the home? 'zilla

Some of us do this stuff for free. 'zilla

Get a Mac. 'zilla :headbang:

Yes, as it also alarms with awake patients on the ventilator who are "fighting" the vent because it is uncomfortable, which he appeared to be doing. One of the chest tubes clogged. It had been in place for over a week, so there was no reason to suspect that he would get a pneumo at that point. Oddly, the initial presenting issue was paroxysmal SVT. He didn't develop ventilation issues for a good 30 min after that. Clots can form in chest tubes, preventing them from doing what they need to do (chest tubes have multiple ports in the chest, so it is usually a clot in the tube proximal to the last hole or the tube is wrapped in fibrin). For future reference, I know much better now how to evaluate and test chest tube function. 'zilla

"We'll be enroute from 48 and ...[air horn] (partner in background: YOU STUPID MOTHERF*****)" "Can you repeat that last traffic?" 'zilla

I have had highly combative, initially thought to be psychiatric patients, with the following final diagnoses: Spontaneous intracranial hemorrhage Occult head trauma Meningitis/encephalitis Pulmonary embolism Acute ST elevation MI Hypoglycemia Pneumonia Hyponatremia Uremia Sepsis That doesn't count the folks with known issues (GSW, stab wounds, hemorrhagic shock, pneumonia, CVA) whom I have seen highly combative and required restraint. Always let these things go through your mind as you are applying the restraints and the meds. Again, it is still medically appropriate to use medication to treat their behavioral emergency (and to allow a complete exam), but never chalk it up to behavior alone without a very thorough eval. 'zilla

+1 on the Afrin. Epi will also work. We still do quite a few nasal intubations in this area, as damn few of the ground services are utilizing RSI. 'zilla

My feelings on drugs down the ET tube: not adequately studied, and largely moot now that we have easy to use IO devices. A tool for the tool bag if you left the IOs back at the station accidentally, but otherwise of historical interest only. 'zilla