Doczilla

We generally account for an additional 10 deg F added to the WBGT for body armor. Laminate vest materials (Spectra, GoldFlex) have greater evaporative resistance and are perceived subjectively as hotter by wearers than the woven kevlar or twaron vests. I would recommend against soft laminate body armor for a number of reasons. Plate armor is probably unnecessary for the type of threats you will typically face. I agree that there is no reason to pay $1000 for body armor unless you are on a SWAT team and are wearing a vest rated for those types of threats. A concealable level II or IIIa vest will run you no more than $500US, and usually is considerably less. And it's a lot less conspicuous to the viewer than one of these "EMS vests". The EMS vests add some functionality in that they can carry gear in all the little pouches, but with the difference in price, you have to wonder if you're paying an additional $500 on top of what you'd spend for body armor to carry stuff that you could carry in a $100 load bearing vest. Your local police department likely has a contract with a uniform shop for their vests. Go there and get fitted, as they will have the knowledge to fit you properly and will have mock-up vests for you to try on. They may honor the negotiated price that they charge the police. My recommendation is to buy your own and buy it brand new. That way you know how it has been treated and cared for and how much use it's had. I realize this is difficult on an EMT-B salary, and would require a substantial amount of savings. A false sense of security is really no security at all. 'zilla

An eccentric pupil may be congenital or the result of previous eye trauma. Either way, it does not represent a neurological injury. This is why one shouldn't run with sticks. 'zilla

Wear the vest until it is habit, until it no longer chafes you or bothers you, and until putting it on is unconscious thought like putting on socks. I'm with Dust; the scenes that make you think of wearing the vest are not the ones you should worry about. A vest in the truck does you no good whatsoever. Don't buy into the "comfort" BS of vests. A level IIa vest is not any more comfortable than a level II or IIIa. Go with the threat protection for threats faced in your area. If you go armed, then have something that covers at least the weapon that you carry. Stab protection may not be necessary. For corrections officers, defending against an ice pick with 80 lbs of force is a real concern. Many stab vests intended for COs have no protection from bullets. For most of us, your standard ballistic vest will supply adequate protection from knives. No, it's not rated, but yes, it will provide some protection. To size a concealable vest properly: It should cover from the manubrium of the sternum to just above the belt line. Side coverage may vary based on your comfort level. I would highly recommend full side coverage. When donning, take a deep breath in and hold it, and affix the velcro straps so they are not slack but not stretched. Care and feeding of a soft ballistic vest: Wear a moisture-wicking shirt under it such as UnderArmour or CoolMax. Always allow to dry flat on a rack after each time you wear it, whether you clean it or not. Remove panels from carrier Wash carrier separately, by hand or in machine. Wipe panels with a damp cloth and allow to dry flat on a rack. If necessary, wipe with cloth dampened with a very mild soap solution, then with a clean damp cloth. No bleach, deodorants, chemical cleaners or sterilizers. Protect from extremes of heat. This includes in the trunk of your car. Keep out of sunlight. Never ever fold or crease a vest panel, particularly laminate vests (Spectra, GoldFlex) Do not soak in water. Inspect for damage and wear frequently. Things to watch out for: Delamination or peeling at the edges Creases Frayed carrier, worn elastic straps A vest, when properly cared for, will last many years beyond it's "expiration date", particularly if woven Kevlar and not laminate. 'zilla

Provide reassurance. Tell them what they can exect when they get around to treating her. Tell her about what to expect in the ambulance and upon arrival at the ER. Much of the anxiety that they feel is not knowing what to expect, and by demystifying this for her, you are alleviating a lot of that. Tell her how lucky she it that it appears she is not badly hurt. Then, talk about whatever. You can only talk medical stuff with them for so long before you start repeating yourself, boring them, or scaring them. Most patients appreciate you talking to them like a human being. If nothing occurs to you, then talk about everyday things. Ask if she has any children, brothers or sisters, etc. Ask where she grew up, what she does for a living. Ask her how she likes living in the area, etc. This will help to keep her mind off the medical, which is probably weighing heavily on her. It sounds like you did a fine job with helping to keep her calm and reassured. 'zilla

It sounds like you came here with an axe to grind. I have never seen any disparity in care between the payers and non-payers who show up at the ERs that I work in. They are treated the same by the staff regardless of insurance status. 'zilla

Not going to happen. This concept does not account for acute life-threatening blood loss which must be immediately corrected. This comprises the majority of blood transfusions that I order in the ED and ICU. Until we have a workable blood substitute, there will always be a need for this kind of emergent transfusion. I admire the attempt to reduce need for blood transfusions by reclaimation of blood during surgery (the "Cell Saver"), increased attention paid to surgical bleeding control, and use of erythropoetin to increase red cell production in the bone marrow. 'zilla

Hextend (hetastarch in balanced electrolyte solution) and Hespan (hetastarch in normal saline) are used by forces far removed into the field from medical support. Crystalloid fluids rapidly redistribute into tissues, so of each L of saline infused, only about 1/3 will stay in the vascular container. This means that you have to give 3 L of saline or LR for every 1L of blood loss. The colloids hold fluid longer in the vascular space, and can replace blood loss 1:1. The medics, who may have to hump long distances with their medical load on their back, have to carry less fluid into the field for the same net effect. Hypertonic saline is sometimes used for the same reason. Colloids haven't been shown to improve mortality over crystalloid when compared side-by-side in traditional medical environments. The starch solutions are >10x more expensive than crystalloids, and have not shown any other real advantage when compared to crystalloids. That's why it hasn't replaced saline on the ambulance and in the trauma bay. Polyheme is disappearing after the initial results of the big trauma study. Other similar products (Bioheme) are waiting in the wings to become more widely used, but more testing is needed, particularly in light of the Polyheme study results. Forces deployed far afield are also performing blood transfusions. The "walking blood donor" concept is not that new but is gaining some acceptance. The idea is that if you have a guy with serious blood loss who needs a transfusion, his buddies might give up some blood for him. There are kits to do this. The blood is crossmatched in the field using very rudimentary means, and if compatible, the transfusion can be undertaken while awaiting transport to definitive care. 'zilla

Prehospital Emergency Care. http://www.tandf.co.uk/journals/titles/10903127.asp 'zilla

According to the literature, they handle 60-80% of airways without them. Sorry. Couldn't resist. And Akroeze: My mistake. I thought you were trying to pick a fight. Or had been talking with an anesthesiologist or CRNA who was shooting his mouth off. 'zilla

*dander up* I think that the anesthesiologists who feel this way should keep in mind that ER docs handle 99% of the airways in the emergency department without any help from them. This kind of thinking is nothing but territorial garbage. They will get all hot and bothered right up until the point that we ask them to come down to the ED for every emergent or semi-emergent tube that comes along. When we were doing this, they felt that we had developed sufficient expertise not to keep bothering them. Now stop trolling. 'zilla

Do no harm. Do know harm. (credit to Dr Brown from GMRS) This might hurt a little... Next to killing people for money, this is the best job anywhere. Lack of a will to live on your part is no excuse for making me work. Don't worry, this won't hurt any worse than being shot. Molon Labe 'zilla

no

Dust: Vivi is a lucky woman. Dwayne: If you knew how to sort out the horses from the zebras, then you could teach at the medical school. This is a skill that is virtually impossible to teach. Medical intuition comes, as others have said, from experience. There are subconscious cues that we pick up on that tell us someone is sick. Most of those cues we haven't yet identified. Some folks approach it one way, by treating the most likely cause of the patient's illness, leaving the zebras to settle out once intitial treatment has failed. Others shotgun lab everyone and admit everything because they lack confidence in their ability to sort these out. Some folks decide on a diagnosis, then continue to believe in that diagnosis despite emerging evidence from the patient that it might be wrong. This is where people run into real trouble. The correct diagnosis may become clear to the outside observer as the patient condition changes (and would have been clear to the provider had he seen the patient this way initially), but because the provider has essentially settled the question in his mind, the right answer eludes him. Zebras are just that: rare. Most of the patients which make us scratch our heads are uncommon presentations of common illnesses, rather than presentations of obscure illnesses. I agree completely with Dust on doing a thorough assessment. A good rule for your medical practice as well as for testing: if anything changes, if something isn't working, if you still don't know, then reassess. Until you have your own jedi sense of sick people, you have to be more conservative in your approach, i.e., overtreat and overmanage. Treat what is most likely, but always keep the zebras in the back of your mind and have a tactical plan to deal with them. If the patient isn't quite what you expect, or if he isn't responding the way you think he should, then reexamine your initial impression and consider other possibilities. Don't get locked in by your preliminary diagnosis. Folks who never think of zebras will get blindsided by them on a regular basis. The above is why PAs and NPs will never truly take the place of physicians. Their training is in the "most common" and "most likely", whereas the physician also has training in those obscure diagnoses that elude most midlevel providers. And Dust, you must have had a good run of bad luck, because I've had plenty of female preceptors- medics, nurses, and physicians- who were excellent teachers and helped me develop skills (MEDICAL skills, you pervert) that I will keep for the rest of my life. Come up this way and I will introduce you to some of them. 'zilla

The exact mechanisms by which people (mostly kids) get cerebral edema in DKA are not exactly known. There is an association with bicarb administration. Even if the serum potassium is relatively high, the patient will still need potassium supplementation. The serum potassium is elevated because K+ shifts out of the cells in response to the acidosis. The H+/K+ antiporter, a cell surface protein which exchanges hydrogen ions for potassium ions, pulls H+ ions into the cell, giving up potassium into the serum. The kidneys, however, have been trying to shed the excess potassium into the urine, so the total body stores of potassium are low. As soon as the insulin drip starts, the potassium will shift rapidly back into the cells and serum potassium will drop precipitously. Correction of the acidosis with bicarb will do the same thing by reversing the H+/K+ antiporter. Also, once the patient is hydrated by your fluid bolus, the kidneys will start shedding more of the excess serum potassium. The hyperkalemia and much of the acidosis is more an issue of renal insufficiency brought on by dehydration (if you were perfusing your kidneys adequately, they could deal with much of the excess acid). 'zilla

Your post here indicates that you really don't know what each of these different teams does. First responders, USAR, DMAT, and MRC are not all doing the same thing. Effectively they represent different eschelons of care. While there is some overlap, there is a substantial amount of equipment that is unique to each eschelon of care and therefore inappropriate to be in the hands of a first responder agency. By having mobile push-packs of drugs warehoused at strategic locations, they are able to be mobilized to areas needing them quickly. Rather than having them stored under questionable conditions at every hoopdie jolly volly station in the state, they can be monitored, tracked, and accessed in short order when needed. You could train thousands upon thousands of basic EMTs for weeks on end to provide the kind of extended care that an ACC would provide, and they still would be inadequately prepared. Since we have a hard enough time training paramedics on an ongoing basis in the basic functions of the job that they do every day, I think that this would be a tall order. Again, think mobile, scalable, and flexible. The system actually saves money. 'zilla

The different resources have different capabilities. The ones that you mentioned all fill a certain niche. Local/county resources must generally be available instantly. State teams will be up and running in a few hours (USAR, NEHC, ACC). Federal resources (DMAT) will generally not arrive until 72 hours after a major incident occurs/is declared. Others, such as the medical reserve corps, fill healthcare gaps over longer periods, such as when an area's medical infrastructure is so devastated that it takes months to get back up and running. Each team is trained and equipped to meet these various needs. They plan for utilization of the resources without need for further direction or resupply for the prescribed period of time. When federal resources are inbound, it makes sense for the state resources to have sufficient equipment until they arrive, so they use that 72 hours as a goal. This ensures that response is mobile, scalable, and flexible. Local resources are not carrying cots, state resources carry medications but only certain ones. NIMS dictates interaction of the various agencies. Communication difficulties always abound, but they all have to have the same understanding of NIMS and their role within it. This ensures that the various agencies interact appropriately and can function independently within the greater disaster system, particularly when communication breakdown occurs. Here's the spin: we're preparing for terrorist attack that might happen. Al Qaida is out there, planning. This spin gets a lot of attention and a lot of dollars for this kind of preparation. Here's the reality: natural disasters will continue to occur, frequently, at all different levels of impact, from tornadoes that level towns to tsunamis that level ecosystems. Pandemics will occur as they have throughout history (and the impact is even greater, with a highly mobile and interactive population). This is where our disaster preparation will really pay off. Al Qaida may or may not ever get a nuke into downtown LA, but hurricanes are happening every year. The disaster preparation we are doing is shifting from preparation for "terrorism" to an "all-hazards" approach, where the disaster resources are scalable and flexible to mitigate an incident of any kind that would overwhelm the healthcare infrastructure. 'zilla

Missing the point. The point here is not if tattoos are right or wrong, if people are right or wrong for judging people who wear them, or whether or not they have any bearing on one's skills as an EMT. So before this deteriorates into mindless rants about how people who judge others should get a life, read the OP's original question. 'zilla

I wasn't pimping YOU, ERDoc. Just gotta answer all the questions, don't ya? Gunner. 'zilla

Okay, I'll throw down the next pimp question here (tag team!). How much fluid do you want to give to her total. Do you want to push bicarb? Do you want to paralyze and intubate? 'zilla

Nerve gas. 'zilla

I would recommend against it, no matter how many services do or do not have written policy on the matter. Someday, you may not want to be a paramedic, or your career may move you to look at services that frown on tattoos which are not covered by the uniform. The military bans such tattoos, (the Army has this year reversed its decision on this, now allowing them. This might have to do more with missed recruiting goals.), and military standards of dress and grooming are frequently used as models for governmental services such as police, fire, and EMS. Despite growing acceptance of tattoos in our society, there is still a significant portion of our population which views them as unprofessional. There is no argument that tattoos are often meaningful tributes to friends and family or reminders of inspirations in the wearer's life. To many people, they still suggest many of the things that make tattoos attractive: a sense of counterculture, a frowning on societal norms, and an independence for those who don't quite "fit in". That's part of what makes a tattoo "cool". Many of my female friends with tattoos thought that getting some "small of the back" design, as has become popular, was a pretty cool thing to do. They didn't anticipate the cultural shift which accompanied the popularity of the practice, and now feel a little sheepish when they hear the tattoos referred to as a "tramp stamp". In a few years, a tattoo around the wrist may become a subject of ridicule, much as tribal armbands have now. You don't know where your career will take you. At one point a long time ago, I considered getting a tattoo on my face. I had no idea then that there would be such a shift in my career. Doubtful that anyone would smile on their doctor if they saw him walk into the room with tattoos showing. Does that make me less of a doctor? No, but in many people's eyes, it would make me look like less of one. Someday you may be trying to climb the ladder at a company that requires you to wear suits, or wanting to work for an EMS where the higher ups frown on the practice, no matter how trendy it is. Even if you wear long sleeves all the time, there are times when you are working that the sleeve will ride up and show the tattoo. Imagine the little old lady patient's opinion of you and how it will change. Knowing that they come to depend on them at very vulnerable and critical times, the public has a certain image of EMTs and firefighters. (I mean the ones that care). They see them as professional, and to some extent expect them to be clean cut, with a uniform that is clean and kempt. That image usually doesn't include tattoos. My advice is to get the tattoos that you like, but as a favor to your older self, get one that remains covered by clothing when in uniform. You never know when you might regret this decision. 'zilla

Classic carpopedal spasm associated with hyperventilation. 'zilla

There are plenty of people who do both and do them both well. Because of the cost of living and relatively low salary, you are hard pressed to find a medic or a police officer that doesn't have a part time job on the side. 'zilla

Whether formulary or not, the generic injectable form is just under $2 per 4mg vial retail. The oral dissolving tablets are still pretty pricey, even generic. 'zilla

IV Zofran is now generic, and is as cheap as Phenergan. We are replacing Phenergan entirely with Zofran in our drug bags. 'zilla