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Doczilla

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Posts posted by Doczilla

  1. Over the past few years the Special Operations Medical Association has been expanding offerings of interest to civilian and government tactical medical support providers. The ultimate mission of this organization is to arm medical providers with the knowledge and skills to care for the warfighter and tactical operator in any setting.

    Continuing with this tradition, we are putting out a call for presentations specific to the civilian TEMS environment. We are especially interested in presentations from medics with field experience that can share that experience in terms of lessons learned. Attendees of the conference are physicians, PAs, nurses, and medics, from US and foreign military, government organizations (FBI, Marshals, ICE, etc.), and civilian law enforcement and rescue organizations. Over 2000 people came to last year's conference, which is nearly double the number that came in 2008.

    It's also the cheapest 28 hours of category 1 CME you'll get anywhere.

    December 15-18

    Tampa Convention Center

    Tampa, FL

    The first 2 days of the conference are mostly presentations from SOF medics and docs, with emphasis on the military special operations medic. Great information in these sessions last year, which included combat vignettes, an 18D discussing firebase medicine in Afghanistan, a member of a female engagement team in Afghanistan, an in-depth presentation on the Tucson mass shooting (that involved Rep Guiffords), and talks on evolving medications and techniques for the SOF medical provider.

    The last 2 days of the conference are breakout sessions tailored to one's specific environment. There is a military track as well as a civilian TEMS track. Presentations in the TEMS track last year included terrific talks on high rise casualty evacuation, rapid breaching for active shooter incidents, and the CoTECC update.

    These are the kinds of things we are looking for:

    After action reviews or lessons learned from tactical or mass casualty events

    Hands on training in the form of skills training or simulations (VERY popular)

    Training programs to sustain and improve medical skills among TEMS providers

    Presentations of original research

    Innovative problem solving for the tactical medic

    Topics of importance to TEMS program administration (liability, training, selection, funding)

    We have a HUGE amount of space at our disposal at the Tampa Convention Center. The exhibit floor can support heavy equipment and vehicles (up to an Abrams tank. Anything heavier, we'll have to ask), and we have plenty of breakout space for hands on sessions. If you can think of a great training exercise, we'd love to do it.

    If you would like to teach a topic, or can suggest a speaker or topic you think would be of interest to the TEMS community, please drop me an email.

    If you know of an organization that would like to have a meeting or luncheon at the conference, please let me know as well.

    The website: www.specialoperationsmedicine.org

    V/R,

    j.r.

    SOMA 2012 Co-Chair

  2. I don't understand those numbers ("to Treat", "to Harm"), can you please explain what you tried to extract there?

    The "number needed to treat" reflects the number of patients that will receive a treatment in order to create one good outcome. Few treatments benefit every patient who receives them. For example, cholesterol lowering drugs are known to help prevent heart attacks, but not 100% of the time. You will have to give hundreds of people the drug before you can say you have prevented one heart attack. A NNT of 1 means that everyone who receives the treatment lives, and everyone who doesn't (the controls) dies. For the spinal study, you have to immobilize over 1000 patients before you could theoretically prevent one bad outcome (doubtful that backboarding would even do so).

    The "number needed to harm" is the same concept, only looking at bad outcomes. Say a treatment is very toxic, and there is a 5% mortality rate caused by the drug. For every 20 patients who receive the drug, one will die, therefore the NNH is 20. In the spinal immobilization study, you would only immobilize 66 people before you caused a bad outcome.

    Taking the above numbers into account, if you immobilized 1032 patients with penetrating trauma, you might prevent 1 bad outcome, but cause bad outcomes in 15 others.

    More on this calculation: http://en.wikipedia.org/wiki/Number_needed_to_treat

    This I don't understand. When there ARE 87% of distracting injuries, why are they a myth?

    A "distracting injury" is theoretical. The idea is that if you have a painful enough injury, such as a femur fracture or rib fracture, it may focus your mind so that you do not feel the pain in your neck from a spinal fracture, and you should therefore be immobilized until x-rays are performed. What the study showed was that of these patients with confirmed spinal injuries, 87% of them had other injuries that would meet their definition of potentially distracting. What they found was that even with these other injuries, all but 4 of the patients still had pain and tenderness in their neck. Of the 4 that did not, all 4 had tenderness and bruising of the anterior chest. It calls into question the theory of a distracting injury that would require x-rays of the neck on a patient who has no neck pain, or perhaps we should better define a distracting injury to include anterior chest tenderness.

    'zilla

    • Like 1
  3. Octreotide causes vasoconstriction of the splanchnic bed (mesenteric circulation), and in theory decreases rate of GI bleeding. Not sure it would do anything for nose cancer, but if there is bleeding further down in the GI tract, it might help.

    'zilla

    • Like 1
  4. To the original post, immobilization of patients with penetrating trauma doubles their mortality rate. Even with penetrating injury of the spinal cord itself or supporting structures, the damage is done. Don't immobilize them.

    To the question about penetrating trauma arrest, transport is not indicated unless the patient can be in the trauma bay within 5 minutes of the arrest. This only applies to penetrating trauma of the trunk, not the head. All we can do is a thoracotomy in the trauma bay, and survival rates are abysmal. Shot in the head + no pulse = dead.

    'Zilla

    (null)

    • Like 1
  5. Holy crap, just saw the thread. Sorry about that, BEorP! Did you at least get to tour the facility? We would have hooked you up with some clinical experiences, as well as beer! Wait, are you old enough to drink?

    I will monkey stomp you at the next CAP Lab for breezing through Dayton without dropping me a line.

  6. Ketamine is probably better than versed for cardioversion or pacing because of minimal effects on BP or HR. Since any patient you are cardioverting in the field is likely unstable or hypotensive, ketamine makes more sense than a drug that will drop BP.

    '

    (null)

  7. I was once told regarding malpractice, kill them, don't maim them. Malpractice judgments are higher when the patient survives and is crippled than when they die outright.

    The move for ETCO2 monitoring/detection became standard in EMS only a few years ago, so while the colormetric devices were available, they weren't necessarily in widespread use. The question is, was the tube dislodged, or misplaced in the first place? That's why waveform capnography is so helpful in cases like this; it's written proof of proper placement, and warns you of dislodgement or other problems.

    There are other issues here which are not clear. Remember that the lawyer will paint everything in the worst light possible. It helps their case to paint the responders as complete idiots to generate negative sentiment against those who don't know them (as this article has done here). Remember that juries generally LIKE EMS providers and firefighters. In order to overcome their generally positive regard, the lawyer has to make them look like complete buffoons. They also (in many states, not sure if IL is one of them) have to overcome a standard of "willful or wanton neglect".

    It is entirely possible that this patient was already very unstable. An asthmatic who has to be intubated has a very high likelihood of death. Intubation is not particularly helpful unless you can paralyze them, extend the i:e ratio, and maybe give Heliox. The medics were already dealing with a critically ill patient for whom they had few remedies beyond IM epi.

    Never hang anyone out to dry just based on what's said by the plaintiff's attorney.

    'zilla

  8. Children, particularly infants much younger than this child, have a harder time reclaiming sodium from the urine than adults do. A higher intravascular sodium level will draw water from the cells, shrinking the cells down, but infants can't get as hypernatremic as an adult. If hyponatremic, those signs of cell shrinkage and dehydration will be absent as well. A dehydrated infant or child may therefore not show some of the cardinal signs of dehydration, such as sunken eyes, poor skin turgor, and dry mucous membranes. The take home point is that if the clinical situation suggests it, consider giving the child some IV fluid in a typical dose of 20 cc/kg.

    Hyponatremia can be seen with extreme exercise with inadequate sodium replenishment, such as military recruits who PT to death and drink liters of water without taking in enough sodium by eating well. We typically only see this with intake of >8 L of water per day. They will typically be resuscitated with normal saline initially.

    Even with profound hyponatremia, you can't go wrong with 0.9% saline as a resuscitation fluid. It will get them on the right track, but not too quickly to where they will have complications. Hypertonic (3%) saline is reserved for very unique circumstances, and honestly isn't given very much for hyponatremia.

    Bottom line: there is no need for a specific hyponatremia protocol. Resuscitate with the usual isotonic crystalloid, treat seizures with benzodiazepines, and keep a broad differential in mind such as hypoglycemia or other medical problems.

    'zilla

  9. Kiwi, you're starting to get cynical in your old age Brother. We'd not forget you, we'd honor you with the "The Thorny Fucker Finally Dropped Dead Anual EMTCity CAP Lap Scholarship."

    I'm a little bit hurt that you believe us so calous as to just walk away from your dead body...

    We'd waive the tuition fee.

    'zilla

    It sounds like she was full of ideas as to what she thought they should be doing, and based on her complaint, probably not too quiet about it. If she was being such a massive PITA, I'd drop her ass by the side of the road too.

    They cynical part of me knows from prior experience with virtually any healthcare provider is that everyone seems to think they know better than the medics, and that they have the right to tell them what to do, being that EMS is apparently at the bottom of the medical food chain.

    'zilla

  10. I've heard a lot of people are doing this, but have no direct experience myself. Is there any concern that we're taking a potentially aggressive patient, and giving them a close chemical cousin of PCP? It just seems a little counter-intuitive. Is there a risk of taking someone violent and making them fairly immune to pain, more disoriented, and more difficult to handle?

    I've not seen anyone get agitated with the administration of proper doses of ketamine. They can get agitated as it wears off, however, which is why a benzo should be given.

  11. I wonder who might have put that idea in your head? :ph34r:

    ¡Davis, et al: retrospective study of 32,117 trauma patients

    §2.3% with c-spine injury

    §10 patients with delayed dx of spinal injury AND permanent neurological sequelae

    ¡Gerrelts, et al: Review of 1331 trauma patients

    §5 patients with delayed dx of cervical injury

    §None with permanent deficit

    ¡Platzer et al: 347 with c-spine injuries

    §Of the 18 with delayed dx, 2 had permanent deficit

    ¡Hauswald: 5 year retrospective review

    §NM vs. Malaya

    §The difference: Malayan patients had less frequent deterioration and less overall neuro disability

    §Small numbers, different mechanisms

    ¡Neuro decompensation occurs in 5% anyway

    ¡Spinal immobilization raises ICP 4.5 mmHg

    ¡MILS led to failed airway in 50% after 30 seconds vs. 5.7% without

    ¡Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64.

    §Failure to secure an airway in 16% of those

    ¡Santoni: MILS doubles force necessary for intubation

    ¡Totten, et al: LBB or vacuum mattress restricted respiration by 15%

    ¡Bauer, et al: LBB limits respiratory function

    ¡Respiratory failure is COD in 6% of trauma patients

    ¡Hauswald: Substantial force required to injure spinal cord

    §Post-injury movement probably not sufficient

    ¡Pain scale: 9.7 vs. 3.7cm on pain scale with LBB vs. LBB with air mattress

    ¡76% reporting pain after 60 min

    ¡15% with point tenderness of spine after 30 min, 25% after 60 min

    ¡18/20 reported increasing pain and discomfort

    Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6.

    Lerner EB, Billittier AJ 4th, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects.

    March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002 Oct-Dec;6(4):421-4.

    ¡3 times more likely to develop pain with LBB than vacuum mattress

    ¡Trunk movement still significant; no method with a LBB eliminates motion

    Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8.

    Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44.

    ¡101 blunt trauma patients with c-spine injuries

    ¡87% had “distracting” injuries

    §rib fractures, lower and upper extremity fractures

    ¡4% had no tenderness on c-spine

    §All 4% had bruising and tenderness of anterior chest

    Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, Bukur M, Branco BC, Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32.

    ¡Log roll creates unacceptable motion

    ¡Lift and slide technique creates less motion

    ¡Scoop stretcher may be better as well

    Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285.

    Del Rossi G, Horodyski M, Heffernan TP, Powers ME, Siders R, Brunt D, Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8.

    Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25.

    ¡Twice the mortality rate if immobilized (14.7 vs. 7.2%)

    ¡0.01% had incomplete neurological injury and underwent fixation

    ¡NNT: 1032

    ¡NNH: 66

    Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.

    ¡18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD

    ¡Additional 4/30 immobilized unless cleared radiographically

    ¡No services moved pts to softer surface if known to have injury

    ¡

    ¡51% reported no neck or back pain at scene

    ¡13% not even asked about neck or back pain before FSI

    Hauswald M, McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7.

    McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80.

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