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Everything posted by Doczilla

  1. When you look at a situation and see all that has to be done, when you are feeling overwhelmed and unprepared, just get started. Things will start to flow. Be a good EMT first. As someone else just said, seconds rarely count. If they do, it's almost always something in the BLS arena. If you handle ABC and transport, you've still done the patient a favor. Usually those who die on you in the ambulance couldn't be saved to begin with. The skein of their life was written long before you got there. So do not fear it. Drill, drill, drill. When the shit hits the fan, you do not rise to the occasion, you sink to the level of your training. 'zilla
  2. Sometimes, you get what you pay for. 'zilla
  3. I agree with anything that makes the feet happier. My personal kit always had a small bottle of gold bond, rubbing alcohol, and moleskin. Socks are really important. I am very fond of the Thorlo "combat boot" socks. Heavily cushioned, moisture wicking, worth the price ($11-13/pair at AAFES). While sending some dirt is nice as a tangible bit of home, it's generally considered restricted agricultural material, and therefore not permitted to send. I found this out when I wanted to take home some sand from Kuwait and Iraq, ala SGT Horvath in Saving Private Ryan. 'zilla
  4. Remember too that stuff you send may also be shared with his comrades, which is always a good thing. Here's a list of stuff we liked when I was in Iraq. Oreos. Couldn't get these over there, though they did have some cookies. Good shoe insoles (walking on all the gravel meant we were seeing a crapload of plantar fasciitis) If he is on land, a small dry erase board to hang on his CHU is good. BEEF JERKY. Hugely popular. Never lasted more than a day, no matter how much I got. Febreze ATT phone cards Trail mix type stuff. Nuts, dried fruit, etc. Colored chalk. A lot of the guys drew stuff on their Twalls outside their CHU Nerf guns. Which, incidentally, will fit a $1500 combat optic. Water guns Dart board Little bottles of hand sanitizer Decent razors for shaving Any toiletry stuff he is fond of, like a particular kind of soap, shampoo, having gel, whatever. Cheryl and Co cookies ships free to APO addresses. These are awesome. Whatever you ship, USPS priority flat rate box is usually the best way to go. We had plenty of books. Thanks to the Iraqis, we had lots of cheap shitty DVDs, but good quality DVDs of decent movies were not as easy to find. And for some reason, half the DVDs at AAFES on base were Dolph Lundgren straight to video crap. Drop me a PM if you have any questions. Thank you for your husband's service, and yours in support of him. 'zilla
  5. The IAFF is a labor organization. As all such unions do, they are positioning themselves politically to their own benefit. By positioning themselves with representatives on the CoAEMSP, they can ensure enough votes to pass the rules they want, and admit friendly organizations. They say as much in their resolution. Hopefully CoAEMSP sees it for what it is. I think they should be represented, as it would help to know what their reaction will be to proposed changes in training, but to give them 2 votes only gives them additional voting power, and does not serve the CoAEMSP or EMS in any way. One of the IAFF chapters I deal with argues every time there is a change in protocol. 12 lead EKG? Now we're doing more, so you have to pay us more. They take this same approach to every advancement in prehospital care. Fortunately the other chapters I deal with are not like this. Many are quite progressive and embrace more advanced protocols. It just depends on who the rep is and the culture of that organization. Most, in fact near all, of our EMS around here is fire based. There is wide variation in how they look at EMS and the responsibilities of their firefighters. 'zilla
  6. My dentist is very active with the disaster mortuary teams, helping to identify victims, and has deployed to multiple disaster sites. I think it is reasonable that they be classified as emergency responders. I have also taught ACLS to large numbers of dentists that are providing sedation for office procedures, so they do have some lifesaving skills. Of interest, a dentist aided a wounded police officer during the North Hollywood shootout. 'zilla Although in reading the article, I don't know why the author refers to dentists and MDs as "colleagues and rivals.". Colleagues? Sometimes. Rivals? Certainly not. We're not in competition any more than psychiatrists and OB/Gyns.
  7. You've got two different concepts presented here, both valid in this overdose but for different reasons. The glucagon is a positive inotrope because it activates the same cAMP G-protein mediated intracellular pathway that a beta agonist would. If the beta receptors are blocked by metoprolol or something, then the glucagon is a way to increase the inotropic effect since response to the beta agonist (like epinephrine) will be less. We use this technique with less effective result in CCB overdose, since the beta receptors aren't really the problem. The insulin therapy is part of what webrefer to as GIK, for glucose, insulin, and potassium that we sometimes use in severe myocardial depression. The insulin forces the uptake of the glucose by the cell, while the dextrose provides carbohydrate substrate. In effect, you are force-feeding energy to the cells in hopes of increasing contractility and metabolic activity. The potassium is added because the intensive insulin therapy will also force the uptake of potassium into the cells, leading to potentially significant hypokalemia. The lipid thing is something that has been getting more attention in toxicology. The idea is that you inject 200cc of intralipid (the lipid bottle you usually see hanging with tpn), and this will scavenge a lipophilic poison. There's not much harm to be done by it, and there are several case reports of lipid rescue from accidental intravascular marcaine (bupivicaine) injection during nerve blocks (very cardiotoxic if injected into a vessel, unlike lidocaine). There is thought that his may be useful for other overdoses, particularly lipophilic substances. 'zilla Lurking from his iPhone.
  8. Rumor has it that it will be December 8 & 9 this year. So I've heard. In a meeting. About the CAPLab. With other CAPLab director types. Cost looks to be $40. Registration will probably open in October. No preregistration slots, so don't email us about that. 'zilla
  9. Hyperglycemia itself is not immediately hazardous, but as Kiwi said, it's the dehydration that accompanies it from increased renal output that is problematic. Even DKA would fail to be that problematic if it weren't for the renal insufficiency that results from the severe dehydration (healthy, hydrated kidneys are very good at handling excess acids as well as excess glucose). For this reason, the first measure of treatment in DKA is always volume resuscitation. Insulin is a secondary concern, and I will usually wait until I have a potassium level back before starting the insulin drip in DKA. Asymptomatic hyperglycemia does not require any prehospital treatment, but anyone showing signs of dehydration (tachycardia, dry mucous membranes, nausea, poor urine output, sunken eyes) should be hydrated with IV fluid. This applies for the Type 1 diabetics in DKA as well as type 2 diabetics in a hyperosmolar nonketotic state. NS at KVO rate really won't help in any way, as it is a negligible amount of fluid. I start with fluid boluses, dose dependent on other comorbidities. If they have renal failure and are on dialysis, or are known brittle CHF patients, I'm pretty careful with the fluid, going 250-500cc at a time with reassessment each time. If not, I'll hit them with a liter of fluid. In children with DKA, overly aggressive fluid resuscitation is a risk factor for cerebral edema, so I'll hit them with 20cc/kg of NS IV bolus, followed by a maintenance rate + rehydration rate, which requires a bit of calculation. Remember that the dehydrated hyperglycemic patient didn't get that way overnight, so you shouldn't expect to fix it in a short period of time. Most people I plan to rehydrate over 48 hours. The initial bolus is helpful, but they will continue getting hydrated in the hospital over that time, or if sent home, will have instructions regarding aggressive hydration with PO fluids. 'zilla
  10. Regarding the OP's question, a single amp of D50 in a nondiabetic will do no appreciable harm. You cannot compare patients with impaired glucose tolerance, as the studies cited here did, with a nondiabetic patient with a functioning insulin axis getting a single 100 KCal challenge. Regarding whether or not this was an error, the patient was exhibiting altered mental status as part of the picture. So it would seem that they took the reading, interpreted it in the setting of the patient's condition, and gave the drug. And it sounds appropriate. Third, hypoglycemia causes adrenergic output, and may cause the patient to feel a lot of things that we don't expect: nauseated, short of breath, anxious. So someone who presents as an apparent MI can in fact have hypoglycemia. I had a 31 yo in thyroid storm code in front of me from hypoglycemia and catecholamine depletion, so essentially a cardiac problem begat by a glucose problem. Therein is another problem with asking the lab tech what they think of the tests being ordered. Ask the doctor WHY he is doing the test, and the answer may not stick with what the lab tech thinks. It may not be needed to make the diagnosis, but for other reasons: - to rule out the less likely but possible diagnosis that may be more life-threatening, i.e., the PE that lurks, masked by symptoms that just sound cardiac - to establish a baseline in a patient for later comparison to monitor response to therapy, i.e., getting lfts in a known hepatitis patient - to establish nutritional status, i.e., the CBC in the chronic alcoholic who can't make a RBC MCV above 60 or get the albumin above 2 - to help interpret other labs, i.r., using albumin to estimate the real calcium level when it comes back low on the BMP - to seek extra-organ sequelae of a disease process, i.e., the renal failure that accompanies a pneumonia, liver failure that accompanies septic shock. - to seek extra-organ causes of the primary problem, i.e., the PE or electrolyte disturbance that led to the a-fib - to establish the safety of doing another test, i.e., checking the renal function before doing a CT - to hone in on a diagnosis among 2 or 3 that are not as likely. Is the pain from appendicitis, an ectopic pregnancy, PID, UTI, or a kidney stone? - to get a prognosis on a disease process. LFTs may tell us how irritated the liver is, but coags will tell us if it is truly working or not. Elevated PT or PTT in a liver patient is a bad sign. Or elevated cardiac enzymes that portend a poor prognosis in PE. Or the various labs needed for Ranson's criteria in acute pancreatitis. - getting to a prognosis for discharge home. The elderly guy with weakness, no sign of infection, a normal chest xray, and a WBC of 23K doesn't go home. The middle aged gal with single lobe community acquired pneumonia and acute renal failure doesn't either. The vag bleeder with dizziness and SOB on standing and a hemoglobin of 11 can go. - getting to the bottom of a vague complaint, i.e., the COPD/CHF patient who is short of breath and coughing up greenish sputum but doesn't have a fever, and maybe has some wheezes, and has a bilateral vaguely interstitial pattern on chest xray that could be pneumonia or pulmonary edema or fibrosis. - to get a sample prior to treatment in case the patient worsens, i.e., the urine cultures on the somewhat puny looking little old lady with a UTI that I'm sending home with antibiotics and outpatient follow-up. If she crumps and comes back, that culture data may be useful. You don't want to order labs on just anyone. It's like picking your nose; you can do it, but you better know what you're going to do with it. The more tests you order, the greater the chances are that one or more will be abnormal. Shotgunning the labs will leave you scratching your head with a completely-unrelated-to-the-chief-complaint sodium level of 125 that you don't know what to do with. That said, in the prehospital setting, BGL is a lab that will never hurt you. The fact is, the patients don't read the book, and a good doctor (and medic) knows this. Some patients show up looking like one disease process, but turn out to be another. At best, a patient fits "many aspects of a pattern of a disease process", essentially, connects most of the dots but never all. Exam findings can be unreliable, and a good doctor knows not to trust all of them. An objective lab value may help sort out the weirdness. There are a few diagnoses I make each day on sight with no testing required, but most patients come with some amount of diagnostic mystery. Even if it's not a mystery, there are so many reasons above why lab tests are useful. We understand that the human body is not a series of organs in isolation, but interconnected, and true badness can lurk unseen in cases which seem straightforward. Don't think only one organ system can bite you. 'zilla
  11. It was great to have you, and I'm glad that you liked the lab. We're already coming up with ideas for next year. The weather hates the CAP Lab. Every year it's something, whether raining, snowing, sleeting, icing, or just damn cold. By comparison, it's sunny and near 60 today. Makes no sense. Dust, I'm sorry you had to miss out this year. Maybe next year we'll come to your house, throw you on a Reeve's Sleeve in handcuffs, and bring you out. 'zilla
  12. The website shuts off registration and shows a message when slots are full. And Dwayne and Mateo, what happens at CAP Lab, stays at CAP Lab. 'zilla
  13. Yes. We usually have a waiting list, so we can give away your slot with sufficient notice. 'zilla
  14. It's a one day event, repeated once. You can go twice, and we will give you double the CEUs. BTW, looks like registrants can pay through the website now. 'zilla
  15. It's so we can sequester you in a part of the lecture hall where you will not disturb the "normal" people. 'zilla
  16. Be sure to put EMT City" in the comments part, along with your username if you are comfortable doing so. 'zilla
  17. Registration is officially open. 'zilla
  18. I don't know yet when registration will open exactly, but it is usually opened about 1 month prior to the class. You will receive payment instructions when you register. Last year we had people call in their credit card payment to WSU Dept of EM or send purchase orders from their EMS agencies if the agency is paying for it. Several people sent checks. Some EMS agencies here reserved a block of seats each day, then filled them later and sent a PO. For some reason the school can't seem to get the credit card thing on the website, but Cassie and her minions did a fine job with collections these last few years. As far as hotels go, get anything that is near or at Fairfield Mall and Wright State University. WSU is on Col Glenn Highway, and there are several hotels there. The closest airport is Dayton International Airport. You could fly into Columbus (about 1.5hrs away) or Cincinnati (about 1.25hrs away) if you don't find the fare that you want at Dayton, though it shouldn't be too tough. You probably will want to rent a car (or share with someone who is). JPINFV, if you bring your white coat, the residents and attendings will pimp you in humiliating fashion as is the common practice in many medical schools. Actually, if you wear your Harry Potter Short White Cloak of Invisibility, you may be generally ignored and frequently shoved. Yes, there will be people there besides you. None of them as cool, though. We have several repeat offenders from local agencies. There are usually 100 attendees per day, and the registration is almost always maxed out (takes about a week). Make time to see the Air Force Museum (free) as well as go out to dinner a couple of nights. Sorry I haven't replied to the PMs. Internet is a little spotty out here. 'zilla
  19. It's on again... http://med.wright.edu/em/caplab/ Dayton OH at Wright State University. It is our 4th annual Cadaver, Anatomy, and Procedure Lab for EMS (CAP Lab). It is an all-day (one day) seminar on cadavers, live tissue, and simulators covering a variety of topics, held on Dec 9 and 10. We are offering it for $35 to EMS providers of all levels, and it's good for 6.5 Cat 1 CEUs. The Lab starts with a 45 minute lecture and anatomical review. The students (usually about 100 per day) are divided into groups of 10 to rotate through several stations, which are all taught by residents and faculty from the Dept. of EM as well as PAs from the EM PA Fellowship at WPAFB. Students get to practice procedures as well as get hands-on with the cadavers for close instruction. Stations include: Surgical airways Rescue airways Field amputation Tactical/battlefield medicine Neuro, with cadaver brains Cardiac, with cadaver hearts and EKG review Cadaver airway, chest decompression Vascular access Chest and abdomen anatomy Musculoskeletal anatomy Website: http://www.med.wright.edu/em/caplab/ When you register, put EMTCity and your username in the "comments" area. Registration is not open yet, and I will post here when it is. Attendees must register to receive directions and important info, including disclaimer forms. Email address is on the website if you have any questions. Slots are open until they are filled. No, you can't stay at my house. With any luck I'll be teaching it again if they let me out of Iraq in time. From last year: http://www.emtcity.com/index.php/topic/13528-cadaver-anatomy-procedure-lab-for-ems-dec-3-and-4/page__st__140 'zilla
  20. Doczilla


    Not to excuse anything here, as there are certainly several lapses in judgement and care (and I'm more than happy to beat down the neurosurgeons when opportunity presents), BUT.... This was an elective procedure. It could be that a clerical error resulted in the procedure being scheduled on the wrong day, and the operating surgeon did not realize it. He could have thought it was NEXT Monday. The Chief of Neurosurgery may have been right to refuse to operate on the patient. Think about it... operate on a patient he has never met for an elective procedure for a long-standing painful problem which his colleague has diagnosed and treated, for which his colleague has a treatment plan? I think the prudent thing here would be to NOT operate, to allow her to recover from anesthesia, and do the procedure another day. All while offering many apologies to the patient as well as wiping clean the hospital bill. 'zilla
  21. My feeling on this thread is that those of you who haven't spent 5 minutes on a SWAT team should probably keep your opinions to yourself. Just my $0.02. 'zilla
  22. M- Massive exsanguination. This is defined as heavy constant bleeding that is acutely life threatening and obvious on the most cursory inspection. Hemorrhage from an extremity is the most common cause of preventable battlefield death. Since we've debunked the myths surrounding tourniquets that have been taught in EMT school (and still are in many places by the unknowing), civilian EMTs are paying more attention to tourniquets as a method of bleeding control. The fact is that they are safe, and can more or less be applied with impunity. In the military setting, replacing lost blood is not nearly as easy as it is in the civilian setting, and since MEDEVAC may take many hours (or days), it is vital to preserve as much of the red stuff as possible since field transfusion may not be feasible. It may be easier to get a transfusion going at the trauma center, but it's much easier to save it in the first place. Bottom line is that civilian EMS should carry and be trained in proven combat tourniquet use. This goes in front of the airway because it is easily recognizable and very quick to deal with, as tourniquet application takes about 30 seconds. A- Airway. Airway compromise is the second most preventable cause of combat death. And now we're hitting the traditional ABCs. R- Respirations. This is to some extent respiratory rate, but also addressing tension pneumothorax, which is the 3rd most common cause of preventable battlefield death. For the purpose of calling the 9-line MEDEVAC request, you need to know if you need a ventilator if you are breathing for them. C- Circulation. We don't tend to do CPR for massive trauma, but here we address vascular access and fluid resuscitation. H- Hypothermia/Head injury. Hypothermic trauma patients do rather poorly compared to case matched controls. 1 degree of hypothermia will increase blood loss in surgery, so it's a very important aspect of trauma care. The providers are typically still in protective gear, not stripped naked on the cold ground, and then there's the aspect of a windy transport in a helicopter. So patient's should be warm and kept warm. Putting this in the pneumonic reminds them that they need to hood and wrap the casualty, and that addressing hypothermia is absolutely essential. These recommendations grew from combat trauma, which is mostly penetrating trauma, rather than civilian trauma which tends to be blunt trauma. Life threatening hemorrhage from an extremity is fairly rare in the civilian setting, so this is probably why it's not catching on that fast. Still, there are important lessons in it, and I think that for civilian trauma, it should still be used. The other thing is that the above is not nearly as applicable for civilian medical emergencies, which usually comprises the majority of EMS runs. 'zilla
  23. Check with AlertMedic. His info would be far more current than mine. 'zilla
  24. Little know fact: he was a Marine pilot in WW2 and Korea. He was awarded 6 Air Medals in WW2 and had something like 85 combat missions in Korea. He retired a Colonel and was then a Brigadier General in the CANG. He's in a different category from the others. 'zilla
  25. Hey Dust, is this us? 'zilla
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