Doczilla

Garmin seems to be the most popular (according to the guy I spoke with at Cabela's when researching the topic), though both Garmin and Magellan have been around for a long time and are known to make good units. On the handheld side, Magellan has a new line coming out, Triton, which looks pretty darn cool. I am, however, somewhat hesitant to buy version 1.0 of anything. You'll have to decide if you want a handheld model or a car mounted one. Car mounted ones have larger screens, but the handheld one gives you added functionality since it's portable and you can take it into the back woods. Color will cost you more. High sensitivity, which gets a signal more easily in heavy treecover and natural depressions in the land, will cost you more. Optional features include barometer and compass. You'll have to ask yourself if you really need either of these. One thing to look for is the expandability. Some GPS units allow you to download various maps to the memory chip, while others only provide them preloaded on chips that they sell. Consider also whether or not you will need topomaps. If driving, no. If hiking or doing SAR, yes. One thing that a lot of folks don't know is that helicopters can navigate to coordinates. We do some fairly rural operations with our SWAT team here, and having coordinates means I can land a medevac in the backcountry pretty easily. Even in suburban ops, having coordinates can reduce confusion. When I was a medic, we had GPS on the truck, and that info would often be provided by dispatch to the responding helicopter (our GPS units were part of a system-wide vehicle locator and system status management program). A basic handheld GPS that will just give you coordinates will run you about $100. 'zilla

Inexcusable. 'zilla

Holy crap. Dust, you better stay close to Chuck Norris. 'zilla

(after giving them the results, follow-up plan, instructions, etc., and telling them that the nurse will be in with their prescriptions and discharge paperwork) Q: Is someone going to take the IV out? A: No. It should rot and fall off in a couple of weeks. I swear I get asked that EVERY shift. 'zilla

Your translator looks like he could make you his be-yoch. And I KNOW Chuck Norris could make you his be-yoch. 'zilla

Where the &%$# have you been the last few months? I thought there was an uprising against the medical director and you were burned at the stake or something. 'zilla

Damn skippy. Hoping to make some contacts along those lines and sit down and talk with some folks in Tampa in December. 'zilla

I have seen a more recent study done by the Navy. Good info, well done study. Go to http://www.handhfirstaid.com/ and click on the NAVSEA tourniquet study on the home page. Yes, they are touting the results because their products did well, but don't let that throw you on the objectivity of the study. They combined objective data along with subjective reviews and comments from the users (which are included) in the study. 'zilla

I also fail to see how this diagnosis was made in the ER unless the kid was sneaking insulin. Untreated diabetes is marked by hypERglycemia, not hypOglycemia. He may very well be diabetic, but that's not what is causing this kid's problem. Fever with altered LOC in a child is a big red flag for badness. He needs a spinal tap. The hypoglycemia is interesting as well. Now, 75mg/dL is not all that low. This could be a simple thing, like the kid really didn't eat all he said he did. If it was lower, I'd be more inclined to be worried. Sepsis, meningitis, adrenal crisis can all lead to this. I suppose this could be simple heat illness with hypotonic rehydration resulting in hyponatremia, but I would look to see that the fever resolves quickly with treatment. If not, then infection must be ruled out. He's been drinking water and not eating, so he hasn't been taking in any sodium. If he's drinking a whole lot of water without sodium intake, then hyponatremia is on the list. I agree with not waiting for ALS. You can be at the hospital faster, and he's not so unstable that you can't move him. If you were ALS, you could start an IV and give him a bolus of NS, which would help the heat illness and possible hyponatremia, but if you transport to the ER, he'll be on the road to recovery much faster. 'zilla

Initially, rapid hydration to the tune of 2-3 liters or so of isotonic crystalloid. You will not "shock the kidneys" by doing this. He needs aggressive fluid resuscitation. After that, fluid deficits should be corrected more slowly with IVF, usually over the course of 48 hours or so. Calculate it as follows: Assume 15% dehydration based on signs and symptoms, which you have described. Take 15% of his body weight in kg, that's how many liters he's dry. Let's use round numbers for this example. Say that he weighed 220 pounds at the start of his trip, or 100 kg. Thus he is now 15kg dry, at around 190 lbs or 85 kg. So he needs 15 L of fluids total (1L of water=1kg. Thank God for the metric system). You wouldn't want to give him that amount IV as a bolus over a few hours, because you want to allow time for the fluid to shift. Subtract the bolus you gave initially, and let's argue that you gave 2L as an initial bolus. He therefore needs 13L more slowly. Take 13 L, or 13,000cc, and divide by 48 hours. This works out to 270cc/hour. You have to account for maintenance fluid as well, so don't forget that. He's 100 kg, or at least he's using fluid like a person who is 100 kg. For any person with body weight above 20kg, you take their weight in kg and add 40. This is the number of cc's per hour of IVF they should receive. This means that your patient should get 140cc/hr as maintenance. So 140cc/hr (maint) plus 270cc/hr (rehydration) gives you at total fluid rate of 410cc/hr. That's if he's doing IVF only. Account for anything he's taking in by mouth and subtract that from your IVF rate. We're also not accounting for anything he'll lose through diarrhea from drinking stream water. Crypto shouldn't set in for another week or so, but giardia or E. coli may start hitting him now. 'zilla

Here we go... :laughing3:

Central lines can be a pain in the arse. The "central lines" that most prehospital providers use (if they use them) is a large bore catheter to the IJ between the sternal and clavicular heads of the sternocleidomastoid muscle (commonly referred to as a "pocket shot" among drug addicts) or to the femoral vein. True "central lines" are done with seldinger technique (with a guidewire). Even when done emergently with minimal attention to sterile technique, it takes a few minutes to set up and complete. That's not accounting for difficulty placing it due to anatomy and body habitus. The IO is faster. If you're having trouble putting fluid through the EZ-IO, flush it with a 3cc syringe. A 10cc syringe cannot generate as high a pressure as the 3cc syringe can (think, same pressure on the plunger, but a smaller surface area, so more pounds per square inch), so you can dislodge any material more easily. 'zilla

As far as traumatic aortic rupture goes, nothing done in the prehospital environment will help, other than rapid transport. Position doesn't matter. Movement doesn't matter. Give oxygen, and if able, obtain IV access and treat for shock. If your patient crashes, you can consider pericardiocentesis, though it's unlikely to be helpful. 'zilla

Riblett, personal experience with the device does not constitute "doing your research". 'zilla

It goes into some detail about the EMS, hospitals, and tactical medics who were involved in the incident. Some good lessons learned all the way around. http://www.governor.virginia.gov/TempConte...PanelReport.cfm 'zilla

Antidepressants of various kinds are proven to help the clinical manifestations of depression. Despite what the Law Offices of Dewey Cheatem and Howe would have you believe, the risk of suicide with antidepressants is overstated. The media hype over them and subsequent black box warning and giant jury awards have resulted in fewer candidates taking SSRIs, and a resulting increase in suicides among at-risk groups. Antidepressants in appropriate doses are very well tolerated and have side effects that are rarely anything but annoying. That includes SSRIs, TCPs, other cyclics, and MAOIs. Professionals of all types take them for treating diseases that move far past just depression and anxiety. Chronic pain, muscle spasm, smoking, and irritable bowel syndrome to name a few. I don't think that they should be taken to "prevent burnout". They are medications to treat a disease, and nobody should be taking them if they don't manifest the symptoms of the disease. 'zilla

I was on the squad at Carnegie Mellon what seems like a very long time ago. The National Collegiate EMS Foundation (www.ncemsf.org) is a great way to look up where these squads are and what kind of system they are in. 'zilla

Some people will list an "allergy" to any medicine to which they feel they have had any side effect or adverse reaction. They may list a penicillin allergy when really they had mild nausea when they took it. Or they will list a phenergan allergy because it made them sleepy. I would swear that some people take pride in the number of allergies they list, or maybe just in being a PITA patient in general. Others list and allergy because they read on the internet that one of their medicines will interact with another medicine (like the ASA/plavix thing or phenergan and levaquin), but don't really have any concept of the importance or lack thereof of the specific interaction. For this reason, it's always important to ask them to characterize the symptoms that they have with each of their allergies. Unless you have rash or full-blown anaphylaxis to aspirin, or have a specific platelet disorder, everyone with suspected ACS gets aspirin. More than 5 listed allergies = borderline personality disorder (BPD). 'zilla

Don't know what's going on with the patient, but now I'm hungry as hell. 'zilla

Take this opportunity to hit the books. Perhaps it's time to pick up some new skills? - Try an ACLS class (you won't be able to intubate, but at least this may help give you a good grounding in it). - Take AMLS or APLS. Even if you're not an ALS provider, the classes give you a good "general approach" to really sick folks, and reinforce the assessment skills on these patients. - Spend some time observing in an ER or hospital. Seek out some of the areas that might scare you, like pediatrics or OB. If you have a children's specialty hospital nearby, spend time shadowing one of the peds ED docs. - Start studying EKGs. I'd recommend Garcia and Holz's book 12 Lead ECG: The Art of Interpretation. - Try your local community college or other school for some classes on anatomy and physiology. You can never study too much of this. Too bad you're not in paramedic school. This physical downtime would be a great opportunity to be in class. Make sure that your physical skills are up to the task before you go back. Have someone at your agency run you through scenarios with backboarding, AED, oxygen application, etc. Common sense may be permanent, but physical skills are perishable. Since you are a volunteer at an ambulance squad, there is probably no shortage of projects to be done. What about writing some scenarios for practice? Classroom training? I find that preparing a lecture on a topic forces me to read a lot about it and distill it into useful info. Maybe your squad could use some prepared lectures like this to use during your convalescence or give at a later date. 'zilla

Here the ER docs seem to gravitate toward a scrub shirt with khakis. I suppose this started out as a shirt and tie and khakis, then polo and khakis, now a scrub top and khakis. There are some folks of the surgical ilk that think it's ridiculous. We ignore them and increase the haldol we're slipping into their coffee. The scrub tops are nice ones of good quality and embroidered. I've moved to 5.11 pants since they offer more storage and are a bit thicker (double layer through the knees) and more durable than my dockers. I don't think this is a bad way to go. The scrub top, as people have said, is distinctly medical. The khakis are practical but still look decent. Neither makes you look like a cop or fireman. As far as outerwear goes, the service I work with has moved to the ANSI coats in the bright fluorescent yellow with reflective striping. I don't care what anyone says about the looks. It's very visible and it helps me avoid getting schmucked by some idiot driving by who's entranced by the bright flashing lights. I don't know why they've known about this in Europe for so long and yet it's just catching on now in the US. 'zilla

As a general rule, the method of applying painful stimuli to assess responsiveness is left up to the caregiver, but probably shouldn't include slapping, punching, kicking, nipple-biting, nose-pulling, noogies, or an "atomic wedgie". Slapping the patient to make them come around is only acceptable if you do it while shouting "Live, damn you, LIVE!!" 'zilla

Experience, judgement, and knowledge of the medical literature. Apart from that, I haven't heard of any condensed objective-based courses that mimic the course content. There is Advanced Medical Life Support class, but this is more like the "general approach to sick patients" class rather than the "how to run a code" class that ACLS has become. 'zilla

Metoclopramide is sold under the brand name Reglan. It's for nausea, gastroesophageal reflux, diabetic gastroparesis, migraines, or other problems. AK, I'm assuming that some knucklehead got hold of your login information, and you are, as we speak, pummeling him with a brick. You too, Terri. There are several potentially disastrous causes that have to be considered. Infection. First on my list. All elderly people in my ER get a urinalysis no matter what they came in for. Metabolic derangement. Sodium problems (hypo or hypernatremia) can present this way. You were correct to check the blood sugar. He's on lasix, so electrolyte disturbances are possible. MI. Global weakness is not an uncommon presentation of MI in the elderly. Worsening CHF will also do this. Hypoxia. Must be ruled out with a pulse ox, preferrably on room air and watched over time. Renal failure from any number of causes. Azotemia will cause the symptoms you describe. You know he's at risk for this because he has hypertension. Drug overdose. Elderly folks with questionable renal function can easily accumulate toxic doses of several medications, so it can be more of a chronic thing. Also, slight decline in neuro function can lead to a medication mix-up, either taking too few, too many, or the wrong ones. Intracranial problem. Smouldering subdurals can present as your patient did. Liver failure is somewhere on this list. Elevated ammonia level will cause somnolence and ataxia. Anemia. A slow steady GI bleed from a cancer or ulcer could deplete the RBC count without notice. Anemia is common in the elderly also from poor dietary iron intake, stomach or intestinal problems, or poor RBC production in the bone marrow. Bottom line: subtle signs and symptoms in the elderly can herald a potentially life-threatening problem. It should be worked up. I would NEVER encourage this patient to refuse transport, and would allow him to do so only if he flatly refuses while knowing all the risks. And if he's somnolent, I am invoking implied consent and transporting him against his will. 'zilla

Before we crucify these physicians and this hospital, remember that we are hearing only one side of this whole argument. And it's the side constructed by the attorneys to make the defendants (respondents) sound as guilty as possible. It is best for the plaintiff if everyone sees the doctors and hospital as selfish, unfeeling, inconsiderate, incompetent, or frankly mean. Initial claims in a lawsuit are always written this way, no matter how much or little merit there is. The same applies to criminal charges. If you were wondering, benzos like ativan are administered to prevent myoclonus which occurs in patients on morphine drips. I have found that nurses and physicians frequently have very differing opinions on orders given when it comes to end-of-life care. I have given orders for horrifyingly large doses of narcotics and benzos at EOL which a few nurses have been frankly uncomfortable with. The intent is not to end life (and it's suprising how much of these meds someone can take before they have a really detrimental effect) but to ease pain and suffering. As a matter of course, morphine drips are mixed with 100mg in a bag and the administration rate is set based on the order or condition. 5 or 10mg/hour would not be unusual. Ativan drips are also mixed up this way, and 40mg would not be unusual for a drip that was intended to be administered at appropriate rates, which could be 1-4mg/hr. The prosecuting or plaintiff's attorney will be happy for you to believe that they ordered a monster whopping dose of drugs to be administered as a lethal shot. This is why I pay very little attention to articles like this. 'zilla