Doczilla

Because Jack Bauer wears Dustdevil pajamas. 'zilla

Thought you wanted to get into the ruckus. Gettin' soft in your old age? :wink: 'zilla

I have to respectfully disagree with Dust and SoMedic here, though I have a profound regard for their knowledge and experience in this area. The officers I have worked with have been patently uncomfortable with providing medical care. Its a paradigm shift which they don't seem prepared to make. There is 1 emt and 1 paramedic among the officers, but they are officers first. They seem to be far more comfortable when one of the docs is there. The vast majority of what I do as a SWAT medic is not trauma care, but symptomatic management, injury and disease prevention, and evaluating and treating injuries and illnesses other than those sustained in the stack. The medic is the "medical conscience" of the team, and I frequently provide input on work/rest cycles, hydration, nutrition, etc. I help them figure out work or training restrictions for the SWAT members who have injuries and illnesses. I often review medical care provided by another physician, particularly when relevant to injuries that impact mission readiness. I'm more approachable than their doc in a white coat, and can advise them about specialists to see and make relevant phone calls to arrange follow-up visits. I have never had to provide trauma care in the zone, but have had to listen to lung sounds of plenty of chuckleheads complaining of asthma after the flash-bang goes off and cuffs go on. I do "sick call" kind of stuff, and provide medical evaluation and management on minor illnesses, rashes, and injuries. And I'm the one that remembers to bring the big cooler full of ice and water bottles. This is the uncommon image of the tactical medic, but is far more accurate. Paramedic school did absolutely nothing to prepare me for it. And no amount of training for the officers would prepare them for it. 'zilla

Hey, it doesn't matter how HSLD you are. Still gotta wipe with the fluffy stuff. 'zilla

Nothing but idiotic propaganda cloaked with an air of legitimacy by attaching a couple of doctor's names to it. Notice the following: 1) No scientific evidence to support their claims 2) Written as though the fire service is and has always been the only way to provide EMS 3) No participation of any actual EMS agency in the report 4) References incidental to the argument, not integral to it This one about had me on the floor (p 11): "This type of universal coordination takes leadership, work, and the willingness to subordinate fire service prerogatives to those of the greater public need. " Fire services have difficulty subordinating fire service perogatives to EMS TRAINING. Strange, since EMS calls comprise the majority of responses in any fire-based EMS system. Let alone subordinating fire service perogatives for anything else. I have an idea about what to do with this little piece of literature, and if I can run some Charmin Ultra through the inkjet printer, I know what I'm doing on my next day off. 'zilla

:laughing3:

Purely physical diagnosis. He observed the jugular venous waves (atrial pulsations) while palpating the arterial pulse, and realized the correlation. Whenever I think my physical exam skills are up to snuff, I think of this and recognize that I pale by comparison. 'zilla

Pimp question for the day: Wenkeback identified the rhythm before EKGs were widely available or understood. How? ER Doc, Dustdevil, and Ridryder, hang back on this one. 'zilla

Wow, monster thread hijack. Back to the topic. I've got a few problems with this article. I would suggest that before this distinguished professor of neurobiology start recommending any more treatment regimens, he obtain an MD and actually see a patient. So, reviewing the quality of evidence here: 1) It's small. Tiny, in fact. 2) Tight age range. From data on 8-15 year olds, he wants to recommend global change in practice? We've universally recognized great differences in neurobiology between children under the age of 12 and adults in the ability for neuro tissue to regenerate. There are undoubtedly myriad differences that we haven't even mapped yet. 3) Healthy children, not sick adults or infants. See #2. 4) Imaging study. No attempt whatsoever is made to identify actual correlation to any function or outcome, whether neurological, cardiac, etc. Just because it's on the MRI doesn't mean it matters. 5) 5% carbon dioxide? So 10 times the normal partial pressure of CO2? 6) They do the study with 5% CO2, but recommend resuscitating with room air. That's not what they studied. 7) They only breathe the O2 or the mix for 2 minutes. I could hold my breath for that long, but it doesn't mean I should do it for a 30 minute ambulance ride (then again, there are some people who might suggest it to me). Nor does it mean that the physiological changes I undergo in that 2 minutes will have any lasting effect. WTF were they trying to prove here? I see this study making no dent whatsoever in practice. I'm not saying that there is no merit in challenging the status quo, but this study is not helpful in any way. Back to the bench, lab rats. 'zilla

Any severe physiologic stressor, such as the aforementioned near death experience, will drive up catecholamine and steroid levels and raise blood sugar. And before AZCEP lets me have it with both barrels, yes he said it first. I'll disagree though with the initial hypoglycemia. Amazing how medical knowledge drops off toward the end of the shift. 'zilla

It misses the point that nonemergent cardiac catheterizations are done not to prevent heart attacks, but to diagnose and treat lesions which lead to anginal symptoms or CHF. I would not call this monumental waste. Lesions which cause heart attacks are not the stable slow-growing 90% stenosis with a thick fibrous cap, but the unstable 10% lesion with a thin and friable cap, which Dr. Agastson alluded to. These 10% lesions are not typically stented. The statement that using thrombolytics for acute MI was ineffective is just plain untrue. In the short term, it is just as effective as emergent angioplasty. I think it brings up some very good points about dietary modification and medication. Too bad so few are listening. 'zilla

This is a topic which is badly glossed over in paramedic school, and is often not even covered in EMT school. Virtually nobody teaching these classes has ever done it before or done it more than once. Bones should never be reduced with a "jerk" like in the movies. Steady, firm traction followed by reversing the presumed mechanism of injury will suffice for most bones. For example, if an ankle was fractured and rotated outward, steady traction then rotation inward should be applied. Fingers are a different story, as there are some special considerations because of the anatomy of the lumbrical muscles and the tendons. Much of the time, you are providing traction against the muscles that are deforming the bone. Once you stretch those out, the bone will often fall back into place or close to it, then traction is all that is needed. Traction splints help overcome the very strong muscles surrounding the femur. As a general rule, hips and shoulders shouldn't be reduced without xrays, even if neurovascularly compromised. The exception is the hockey player who has dislocated his shoulder 50 times before and knows exactly how it feels and probably knows better than his orthopedic surgeon how to put it back in. There are good techniques for doing it, but I would again discourage anyone from doing it in the field. 'zilla

Yeah, yeah, but I said it with bigger words. The bigger the words you use, the fewer questions the patients ask, and the sooner you can get out of a room. My vocabulary expands exponentially in the presence of annoying family members who happen to be veterinary techs/chiropractic assistants/phlebotomists who try to ask a bunch of questions like they know what they're talking about. Perhaps it's darker than you think... 'zilla

It numbs them only when applied topically. Many anesthesiologists will squirt lido down the trachea once visualized with a laryngoscope and just before tube placement. I'm not sure how well this works, since lido needs a couple of minutes to really take full effect, and the ETT is placed only seconds after the lido goes down the tube. Another way of approaching this is to nebulize some lido for a few minutes before intubation. I have mixed feelings on this. On the one hand, it numbs the airway, and may blunt some of the reflexes that induce coughing and gagging. On the other hand, since they get numb, they can have more difficulty managing their own airway and secretions. Lido is injected IV a minute or two before intubation, and it's been found to blunt some of the rise in ICP, which is why we do it. The evidence supporting the practice really isn't great, but somehow it worked it's way into the sequence. That's incorrect. Etomidate is thought to be somewhat cerebroprotective, and therefore okay to use with elevated ICP. It's not as well-demonstrated as it is with a barbiturate, but the effect is there. Perhaps you are thinking of ketamine? Also, the etomidate dose you have there is a little light. For procedural sedation, 0.15 mg/kg is good, as the patient will stay breathing and maintain airway reflexes. 0.3mg/kg is the dose for induction/intubation. As far as the evidence goes, etomidate-only intubation hasn't been shown to improve intubation success rates in the prehospital environment. There is a big jump in success rate once they're paralyzed. A lot of docs still shudder at the thought of giving some medics the ability to paralyze patients, and this is a battle that's been fought here at the Regional Physicians Advisory Board for EMS. The best way to prevent the rise in ICP is to not screw around in the patient's airway for long periods of time. For me, this means paralyzing them. Visualization is better, the attempt is smoother, and it doesn't take so long. That, and if they vomit, they won't do so forcefully, and they won't take a deep breath in and suck that all down into the lungs. 'zilla

At the 2007 Symposium of EMT City Physicians (SECP), the resolution was drawn and passed. 2 in favor, one abstaining since he's in Australia. You don't have to genuflect, just bring us food. And coffee. Lots of coffee. 'zilla

There are several inaccuracies in your post and your assumptions about intracranial hemorrhage. It is obvious that you have seen very few, if any, of them. AZCEP is absolutely correct. a) you don't know the insulting problem, and even if you did, dropping their BP like a stone is a pi$$ poor idea. You should be extremely cautious about lowering the BP in the field, particularly without knowing the details of what's causing the patient's problem. Aggressively lowering this patient's BP, whether from SAH or uncontrolled hypertention, is potentially disastrous. There are many medical directors, including myself, who feel that this is a dangerous practice. You might ask to give some lopressor, but if I'm on the other end of that radio, it would not be a very large dose. And the order sure as s#it wouldn't be for nitroglycerine sublingual tablets. Read more and post less. 'zilla

The movement disorder that you are describing sounds more like akisthesia, which is the restless feeling that a patient gets when they feel like they "need to move". It's like restless leg syndrome, but all over the body. This is a common side effect of many antipsychotics, and can happen with one dose or after many. It is temporary and often reversible with benadryl or cogentin (benztropine: think "benadryl" and "atropine". This is essentially it's action). I agree with ERDoc that with the tachycardia and flushing, this is concerning for serotonin syndrome. Tardive dyskinesia is a movement disorder characterized by rigidity, difficulty initiating movement, and shuffling gait. It bears some similarity to some aspects of parkinsonism. It is a late effect (the "tardive" part) after years of using the typical antipsychotic drugs. It is permanent and irreversible. 'zilla

Why would you want to conceal a weapon in Texas? 'zilla

Looks like you don't have to take just narcs to land into hot water (no sh%t, Sherlock). The new "environmentally friendly" albuterol inhalers we use now run about $35/each, so $120 worth isn't that many. There but for the grace of God go many of us. A cautionary tale in case anyone looked sideways at their untracked meds. 'zilla Firefighter/paramedic loses pay pending felony theft case Dayton Daily News Staff report Saturday, April 07, 2007 MIAMISBURG (OH) — A Miamisburg firefighter/paramedic has been placed on unpaid administrative leave, after originally being placed on paid leave, pending the outcome of his criminal case. City Manager Bill Nelson issued the order for Jack Ikerd on Wednesday after a personnel hearing last week, said city spokesman Gary Giles, who explained that he could not say why Nelson switched Ikerd's leave status. Ikerd has had the full-time job since 1996. A Montgomery County grand jury in March indicted Ikerd, 38, on two felony counts of theft in office. He is accused of stealing two albuterol packages from the city valued at $12 each and $125 worth of inhalers from the city of West Carrollton, according to police reports. Ikerd remains on unpaid administrative leave from his part-time firefighter/paramedic job with the West Carrollton Fire Department. He started in West Carrollton as a volunteer firefighter in 1993, Chief Jack Keister said. Albuterol is an asthma medication that helps relax muscles that open airways and ease breathing.

Fentanyl is given in micrograms, and in pediatric dosages, it could be as little as 10mcg, or 0.01mg. 'zilla

Try this "two hands, no tube" method: When approaching the patient with the laryngoscope, place your right hand on the occiput of the patient's head. Guide the head to line up the airway as you insert the laryngoscope and visualize the cords. Once you see them, let go of the head with your right hand and pick up the tube while you maintain the visualization with your left hand. 'zilla

Can't say for sure, really. The short answer is that your department should be part of a larger regional response system. To that end, you need to figure out what your department will be doing, what the regional system will be doing, and how to better integrate into that system. Going it alone not only isolates you in the system, but guarantees that you will be marginalized when the regional resources arrive. And it's a waste of effort. Find out what the regional disaster system has in mind, and ask how your department can help. The longer answer is that the contents of the kit are based on level of care, expected injuries and illnesses, population to be served, other disaster resources in the area, distance from other resources, what will be available when (whatever the Canadian equivalent of FEMA) helps, and the time frame that you are expected to manage. WHat you want to prevent is buying a bunch of stuff for your disaster kits that wouldn't be needed, such as antibiotics, special radio systems, or other stuff that would only cost you money. These things may be needed in a disaster, but the question is whether or not it would be needed at your level. The regional system may need you to fill any number of roles, from first response to individual patients, setting up aid stations, distributing medications, securing potable water, accounting for missing persons, or other stuff. Fact is, you don't really know until you talk to them. There is no reason that you should have to go this alone or come up with it on your own. There are folks at higher levels in your (larger) area who have thought this through, and would be glad to share the overall plan and integrate your department. 'zilla

If you really want to know the subject, check out the Pulmonary Arterial Catheter Education Project (www.pacep.org). It's a series of narrated powerpoints that takes you through hemodynamic parameters, effects of different interventions like fluids and pressors, and how to use them to your advantage. The parts about how to interpret waveforms of Swan-Ganz catheters are probably of less use, but the physiology is good. 'zilla

Haldol Depo is one example of such an emulsion for deep IM injection. These types of injections are for extremely-long acting shots that are intended to work over days or weeks. With haldol, it ensures compliance with medication if the patient has demonstrated that they will stop taking oral meds if given the chance. They are required to show up once a week to get their shot, and if they don't, someone goes looking for them. Actually, haldol is the only injectable oil emulsion that I can think of right now, though I'm sure there are others. And you're right; there's no reason to use these prehospital. 'zilla

Both cardizem and lopressor will slow conduction across the AV node in a similar manner and are indicated for rapid a-fib. If she had other conditions, such as coronary artery disease, then the beta blocker may have additional benefits. In the presence of acute ischemia, the beta blocker will reduce morbidity and mortality, attenuate deleterious remodelling of the heart, and reduce the emergence of a more serious arrhythmia. Additionally, if she's already on a beta blocker, the doc may have been wary of giving a CCB, which may have deleterious adverse effects. Lopressor is a fine choice for treating the rapid a-fib. 15mg is also not that big a dose, particularly in 5mg aliquots. Considering also that her BGL has been above 500 for a few days, dehydration may have been contributing to her rapid heart rate. The elevated heart rate may not have been the cause, but the symptom, of her underlying problem. Therefore aggressive treatment with antiarrhythmics might do more harm than good. The doc was right not to get too focused on treating the number, especially since she was not symptomatic. Based on the information you've given us, this is not someone that you should push cardizem on in the field. 'zilla