Doczilla

I would not use the wound tract from the bullet. The fact is that you just don't know what tract the bullet took. Travel in a straight line should not be assumed, since bullets almost never do once they start traveling through human tissue of varying densities. If you stick the tube through that, you can't be sure where you are ending up. The bullet may have just nicked the trachea, and the dark space you see may or may not be the trachea. You could penetrate the trachea completely and end up on the other side. You are also putting a tube right into the part of the trachea which is least stable and least able to tolerate the force you will apply when sticking the tube in. There is also the caliber issue that p3 medic mentioned. I have not seen a bullet entrance wound large enough to squeeze an ET tube through without forcing it or widening the hole. Even high-velocity rifles will leave a relatively small entrance wound. Early definitive airway control is indicated to prevent occlusion by a hematoma, which will make later attempts at airway control (surgical or otherwise) difficult by distortion of anatomy. Thus the patient needs an airway as soon as possible, BEFORE they are in distress. If someone successfully intubated this patient by nasal intubation or regular orotracheal intubation, they had better give thanks in prayer every day of the week and twice on Sunday. There is the very real danger of completing the transection of the trachea by regular intubation. Once this happens, the trachea can retract into the chest where it is not accessible by anyone. For this reason, you may consider surgical cricothyroidotomy without attempting oral intubation first. If the wound is too low to go through the cricothyroid membrane, then we will do an emergent tracheostomy. The next question you have to answer: c-spine the patient or not? 'zilla

ER Doc's point is a good one. Backup airways, such as LMA, Combitube, King-LT-D, depend on some semblance of normal anatomy to work. With a penetrating injury to the neck, you've got tracts that shouldn't be there.... Here's another question: Do you attempt to intubate him, or go first and immediately to cric? And why am I asking that? 'zilla

"Down Under" Men at Work

Need for a Blakemore tube is virtually a death sentence. 'zilla

Paradoxical emboli are rarely diagnosed and rarely suspected. There are plenty of folks with silent asymptomatic septal defects. Paradoxical embolus requires not only a septal defect, such as a PFO, but also requires right-to-left shunting in the heart. 'zilla Edited for clarity.

The study is not referring to thrombolytics (tPA, streptokinase, tenecteplase). It is referring to antithrombotics (heparin, low molecular weight heparin, or bivalirudin) along with mechanical sequential compression dressings. Thrombolytics dissolve clots such as those in acute stroke, MI, or massive hemodynamically unstable PE. Antithrombotics and sequential compression dressings prevent clot formation and propagation. They can be used to treat DVT and PE by preventing clot propagation, and the body's natural thrombolytic mechanisms dissolve the clot. And Eyedawn, DVTs don't lodge in the heart unless there is a septal defect. 'zilla

"Patients who have bled once from esophageal varices have a 70% chance of rebleeding, and approximately one third of further bleeding episodes are fatal. The risk of death is maximal during the first few days after the bleeding episode and decreases slowly over the first 6 weeks. Mortality rates in the setting of surgical intervention for acute variceal bleeding are high. Associated abnormalities in the renal, pulmonary, cardiovascular, and immune systems in patients with esophageal varices contribute to 20-65% of mortality... ...High morbidity and mortality (30-40% of the group with severe persistent GI hemorrhage) - Factors such as underlying liver disease and associated abnormalities of the renal, cardiovascular, and immune systems contribute to the high morbidity and mortality." -eMedicine In my experience, they don't USUALLY die, but certainly can. And I have seen plenty of patients in my ER who have a ruptured esophageal varix in their medical history, so most do actually survive. 'zilla

No. The ultrasound can detect intraperitoneal blood, but not hemorrhage into the GI tract. 'zilla

There is no utility in saving the emesis in upper GI bleed. With a ruptured varix, bleeding ulcer, or hemorrhagic gastritis, there will be an uncertain volume of blood in the intestine that is moving through the digestive tract. Emesis is therefore an inaccurate way to estimate blood loss. Vital signs, physical exam, and to some extent lab values will determine the need for blood transfusion. Complicating things is that the patient's varices most often result from liver damage. Since the liver makes clotting factors, liver damage will also produce a coagulopathy, which makes the bleeding much more difficult to control. Continued bleeding can be assumed. 'zilla

I just threw up in my mouth a little. That's an image that will be with me for a while. 'zilla

Have the officer search him for weapons. 'zilla

Rather than just altered LOC, it's altered LOC with inability to protect airway. It's obviously open to some interpretation. 'zilla

Unbreakable by Fireflight Slow Turning by John Hiatt Lost Highway by Bon Jovi Learning to Fly by Tom Petty Battleflag by Lo Fidelity Allstars Dirty Little Secret by The All-American Rejects Army running cadences 'zilla

I tend to agree with MSDelta. This has very little to do with the care provided by the parents. The state has a responsibility to ensure the safety and welfare of children despite idiocy on the parents' part. When concerns arise over the condition, treatment, or care of a child, the state has a responsibility to investigate. What appears to have happened here is that the parents would not permit evaluation of the child. The EMTs who responded initially did not have the opportunity to examine the child and verify that. Their suspicions were aroused not by the condition of the child but by the behavior of the father. Neither laypeople nor medical providers need evidence to report their suspicions. Following proper channels, Child Services became involved, and requested to examine the child. The father again refused to let them see the child, then threatened them. This did not help him appear to be a reasonable person raising a child in the manner which he has chosen. This makes him look volatile, and a possible danger to the child and to officers who came to enforce the judge's decision. Is the father simply indignant about his parental right to determine, to some extent, the destiny of the child, or is he attempting to cover up a crime of child abuse or neglect? Without examining the child, nobody knows. The child was not taken in order to terminate parental rights; he was taken to allow lawful examination in an effort to protect the child's rights. Once it was determined that there was no abuse or neglect involved, the child was returned immediately to the family. It's easy for a parent to say how fit a parent they are, how well they care for their child, etc. If you know the parent and the child, it may be easy to agree. What we have here is a great unknown: a child with a suspicious and possibly serious injury based on extremely limited information, and a parent who refuses to interact with the agencies charged with protecting children from bad parents. What are they supposed to do? Leave the child there and say, "it's probably okay because he said so"? If that were the case, what parent would ever go to jail for abusing a child? 'zilla

The tactical problem here: 1) Observed injury to child, possibly serious. More detailed medical assessment refused. EMS unable to tell if the injury was inflicted or occurred as a result of neglect. 2) Father makes threats of harm against those who would come to evaluate said child. 3) Father is ex-military, known to be armed, possibly trained in use of firearms. I wouldn't send regular street cops to that. That's a SWAT response. On another note, this father is an idiot. He was a medic in Vietnam during the Tet Offensive? Good thing for him medical care hasn't changed in 40 freakin' years. And that the typical army medic spends so much time with pediatric training. :roll: 'zilla

I don't mean to say that NPs are less competent or poorly suited for the profession. As I said in my post, I have worked with many very competent NPs, and continue to do so on an ongoing basis. I respect their input and experience. What I meant to say was that the individual who has completed nursing school and gained valuable experience as a nurse must be trained in a different role, one not germane to the formative years of nursing education. This requires the change in mindset I was referring to. Dustdevil, as always, is quite eloquent in his reply. NP training is designed to build on the medical foundations of nursing education and utilize the experience of the practiced nurse to bridge the gap to a physician extender. Physician Assistant training trains the practitioner in the physician extender role from the ground up. If you want to be a physician, go to medical school. If that's really what you want to be, then you will never feel fulfilled by any other profession. If you want to be a physician extender, go to PA school. Why go through all the nursing school, master's degree, clinical practice, and NP school if you just want to be a physician extender? If you're already a nurse, then NP school is a viable option. I can't think of anything more boring than being a CRNA. Yeah, they bank, but they sit for HOURS ON END doing nothing but checking little boxes. The difficult airways are managed by the anesthesiologist. And I don't know too many CRNA's who started out as nurses to be CRNA's. They become CRNA's because they like the money and the easy hours and it represents a slowed pace from most other nursing practices. I say that with respect, owing much of my initial airway training to CRNA's. 'zilla

What kind of fracture was it? We don't really use "compound fracture" as a term anymore, largely because it means different things to different people. Open? Closed? Comminuted? Intraarticular? Which bone? 'zilla

I made the decision to go to med school right around the end of my paramedic training (though I spent another few years in the field before making the leap). I knew that medicine was what I liked to do. I wanted to understand more, do more, and accomplish more than I could as a medic. I like seeing the "big picture" from the seat as the MD. I also felt I needed to cut my teeth in the field before moving up. I had been in EMS for a total of 7 years (2 basic, 5 medic) when I entered med school. One day, after a night shift, I was getting a bite of breakfast at a diner by myself, and I had an epiphany: I had come as far as I wanted to come as a medic, and it was time to move on. I largely changed over because the field is hugely fragmented, mostly unstructured, and lacks little-if-any upward mobility. Plus the pay generally sucks. :wink: Becoming a physician is a long and difficult road, but each step is another step. If you don't keep telling yourself that you could do something else easier, then it's easy enough. Good family support is crucial; if your spouse doesn't believe completely in what you are doing, then it will be an unhappy ride at home, and one of two things will end: your marriage or your medical education. It is an adjustment to go back to being a poor student after you've stretched your wings a little bit and earned a salary. If you have a REALISTIC picture of what awaits you at the other end, you can endure this bit of difficulty. None of my med school classmates dropped out for financial reasons. Though the numbers are frightening, none have any worries about being able to pay off their financial aid (barring unforseen catastrophe). Most I know have it paid off within 5 years of finishing residency, and not by starving. I hear plenty of folks say, "I thought about being a doctor, but the schooling was too expensive/hard/long/trying on the family for me to do it." I have never heard any of my colleagues say, "I should have stayed a medic/RN/PA because this was a waste of time." Physicians who are flirting with burnout occasionally do say that they regret going into medicine. A lot of that has to do with recent changes in the work environment for physicians, who remember easier times with less liability and lower insurance and better call days and higher salaries. It's still the best job anywhere. NPs and PAs, though they often fill similar roles, come up in vastly different training environments. PA school is essentially an abbreviated, intense version of MD training. The mindset is the same, and they generally do well in physician-extender roles. NPs come up through the nursing ranks, so the mindset needs to switch. I work with several extremely smart and competent NPs who do a fine job as physician extenders, but I don't imagine it's something that all NPs are able to do. Since Rid has been borne up the ranks of EMS, and is used to a certain amount of autonomy, it is probably easier for him. There is nothing wrong with being a medic for a while, but to avoid losing too much ground, start working toward med school or nursing school immediately. Finish your prerequisites, explore financial aid, start looking at programs to see what you like. Visit some schools, talk to the students, get the guides to med school (AAMC and AAOMC put out publications yearly with profiles of MD and DO schools, and there are many others available at Barnes and Noble) and imagine what it would be like to be there. 'zilla

Except that febrile seizures aren't really an emergency. 'zilla

That would be acetaminophen (Tylenol) for those of us on this side of the pond. I haven't heard of an IV preparation of acetaminophen before. I don't see a huge drawback to it, except that it is not yet in wide use, and therefore there may be issues with the drug itself that only become apparent with adverse event monitoring. 'zilla

We looked into it for employee health. We figured if we could do the TdAP, hep B, and flu shot in house, it would increase compliance with vaccination, and also be viewed as a benefit by the employees. The state Board of EMS replied that paramedics can only do it in declared emergencies (actually, any EMT can do it in those circumstances). For services that operate in really rural environments, where transport is very long and very expensive, they may be suturing and doing other wound care in the field. In this setting, giving the TdAP makes sense and might help save a patient a 2 hour trip each way to the hospital. 'zilla

We're only going to see more of this. We are the YouTube generation. Everyone has a cell phone with a camera, and more and more idiots are going to be taking pictures and film of stupid stuff like this so they can get their 15 seconds of fame. Everyone thinks that they could be filming the next Rodney King beating. 'zilla

In Ohio, EMS personnel may administer vaccines in a declared emergency but not under routine operations. The particular vaccines are intentionally not specified, so the disaster plan may remain flexible. 'zilla

I don't see a dilemma here. Unless you have an undeniable urge to suffocate him with a pillow. 'zilla

I don't see a dilemma here. Unless you have an undeniable urge to suffocate him with a pillow. 'zilla