Doczilla

Congrats Ruff! And about the boys who come calling for her in a few years, I borrow a line from Charles Barkley when his daughter got to dating age: "I figure I just have to kill one and word will get around." 'zilla

'zilla

If it makes you feel better, I didn't either. 'zilla

They don't really know just yet if it's a migrating granule or a systemic effect of the coagulation cascade. They studied it on pigs, and found clots in the lungs distant from the site of application. Whether that was an errant granule that gets into the bloodstream or if it triggers clotting in the bloodstream by some other means is unknown. The fact that granules were found in the lungs may implicate this as the mechanism. Whether or not other hemostatic agents do the same is not quite known, but being studied. Quikclot is spending a good bit of money convincing joggers and campers that they need a hemostatic agent. I disagree, for reasons that I have posted elsewhere. Unless you are hiking through zones of active hostile fire, weight, cube, and training time is better spent elsewhere. 'zilla

UPDATE: Woundstat is being permanently pulled from Army use. 'zilla PERMANENT SUSPENSION OF WOUNDSTAT USE WHO: DA WASHINGTON DC//DASG WHAT: PERMANENT SUSPENSION OF WOUNDSTAT USE WHEN: N/A WHERE: N/A WHY: THIS ALARACT DIRECTS PERMANENT SUSPENSION OF WOUNDSTAT (WS) USE BY MEDICAL PERSONNEL DUE TO SAFETY CONCERNS CONFIRMED BY THE US ARMY INSTITUTE OF SURGICAL RESEARCH (USAISR). THIS IS A FOLLOW-UP TO ALARACT 313/2008 (24 DEC 08) ENTITLED "SUSPENSION OF THE USE OF WOUNDSTAT". REF/A/ALARACT 185/2005/INDIVIDUAL SOLDIER HEMOSTATIC DRESSING/SEP 05// REF/B/ALARACT 239/2008/NEW SOLDIER HEMOSTATIC DRESSINGS/SEP 08// REF/C/ALARACT 313/2008/SUSPENSION OF USE OF WOUNDSTAT/DEC 08// 1. (U) THIS ALARACT DIRECTS PERMANENT SUSPENSION OF WOUNDSTAT (WS) USE BY MEDICAL PERSONNEL DUE TO SAFETY CONCERNS CONFIRMED BY THE US ARMY INSTITUTE OF SURGICAL RESEARCH (USAISR). THIS IS A FOLLOW-UP TO ALARACT 313/2008 (24 DEC 08) ENTITLED "SUSPENSION OF THE USE OF WOUNDSTAT". 2. (U) THE USAISR HAS COMPLETED THREE SAFETY STUDIES AND ONE COAGULOPATHY (LOW LEVELS OF CLOTTING FACTORS) STUDY OF WS. WS MAY INJURE THE LINING AND WALL OF BLOOD VESSELS IN COMBAT WOUNDS, POTENTIALLY LEADING TO THE NEED FOR SURGICAL REPLACEMENT OF THE BLOOD VESSEL. BECAUSE WS IS A FREE GRANULE, IT MAY TRAVEL TO OTHER PARTS OF THE BODY (E.G., WS WAS FOUND IN THE LUNG OF TWO TEST ANIMALS) AND CAUSE INJURY. FINALLY, A STUDY SHOWED THAT WS WAS NO MORE EFFECTIVE THAN PLAIN GAUZE FOR TREATING COAGULOPATHIC BLEEDING. 3. (U) THE RISK INHERENT IN WS USE OUTWEIGHS ITS BENEFIT AS A BACK-UP HEMOSTATIC AGENT TO COMBAT GAUZE (CG) FOR 68W COMBAT MEDICS. CG REMAINS THE RECOMMENDED HEMOSTATIC AGENT FOR CURRENT COMBAT OPERATIONS. UNIT COMMANDERS MAY REPLACE THE TWO WS ISSUED TO 68W COMBAT MEDICS WITH CG, BASED ON MISSION REQUIREMENTS, IN ADDITION TO THE THREE CG ALREADY ISSUED TO 68W COMBAT MEDICS. 4. (U) UNITS WILL CONTINUE TO TURN IN WS TO THEIR SUPPORTING MEDICAL SUPPLY SUPPORT ACTIVITY (SSA). MEDICAL SSAS WILL COMPLETE 100% CONTACT WITH UNITS ISSUED WS TO ENSURE TURN-IN OF PRODUCT IS COMPLETE. MEDICAL SSAS WILL HOLD WS IN SUSPENDED STOCK STATUS UNTIL DISPOSITION INSTRUCTIONS ARE RECEIVED FROM THE OFFICE OF THE SURGEON GENERAL (OTSG). OTSG WILL PUBLISH DISPOSITION INSTRUCTIONS AT A FUTURE DATE.

Whine me a freakin' river. First, I wasn't there, so I can't speak to what really happened. I'm going off what this guy is saying as true, and while I understand he feels wronged, I don't see any inappropriate behavior on the officers' part. In fact, it sounds like they were quite tolerant and accommodating. 1) The stop was lawful. No law prohibits LEO from asking your identification. 2) Drug dogs don't bark when they hit on a scent. They are trained to sit down. 3) A warrant is not needed when there is probable cause. 4) He was given a lawful direct order by an officer, and not an unreasonable one. This was based on evidence from a trained dog that indicated the possibility of drugs. They are not arresting him for anything, simply taking a look. The probable cause would not extend to his house, but the dog indicated on the car. 5) By his own admission they sat there with him for an hour to let him think about it, call his lawyer, whatever. 6) They informed him that if he did not comply, they would force him to comply. 7) They were considerate enough to tell him to cover his eyes because they were about to break out the glass. 8) They tazered him to gain physical control. Here I don't know if he was still refusing to get out of the car, or resisting, or what, but application of tazer is quite safe, moreso than wrestling with him. They didn't beat him with sticks or do other, less pleasant things that they could have done. 9) After it is obvious that he needs medical attention, they take him to the doctor. It sounds like, from the tape here, that he refused to comply with a lawful (and not difficult) order and forced the police to resort to physical means to enforce that order. The use of force was escalated and proportional to the resistance presented. Once in custody, they addressed his need for medical attention. 'zilla

It's usually more difficult to fire an employee than a volunteer, or at least, you're more likely to be sued. It's hard to be sued for firing someone from a job that pays no money, unless the volunteer contends that they have been harassed or a hostile work environment was created, or some lasting disability from their time as a volly. I am also in the US, and I know absolutely nothing of Aussie law. (Since the colony was founded by criminals, maybe it's not so bad..... ) 1) Discipline, except for egregious infractions, usually has to be progressive. For repeated violations of policy, disciplinary measures should be increased with each subsequent one. First offense, a written reprimand with verbal counseling. Second, a suspension. Third, termination. Certain infractions can go right to suspension or termination. Any criminal offense committed on duty, for example. Any violent or sexual crime committed at any time is another. Gross insubordination, threatening or harassing a coworker are others. 2) Document the hell out of it. Make sure you document where expectations have been failed and what measures are to be taken to rectify it. Establish a time line for completion of whatever the task is, be it remedial training, improvement of a tangible physical fitness standard, or a counseling regimen. 3) Add testing to continuing education (which should be done anyway). If you can't pass, you gotta go through again before you get the hours. 4) Basic hygiene should be a company policy. Grooming and bathing standards should be clear. Make this a written policy. 5) Any incident of non-performance of duty must be documented. If he freaks out on every call, then this should not be difficult to establish a pattern. He must be immediately counseled, and this documented. 6) You may mandate him to see the counselor through your agency's Employee Assistance Program as well. He may claim mental disability from his years of emergency medical care, and you may just have to deal with that through whatever disability compensation system you have. 7) In the US, some states and municipalities have specific requirements on what steps must be taken to release a volunteer ambulance attendant or volunteer firefighter from service. Research this in your area. 8) Simulation based or scenario based testing is another way to show competence. 9) The medical director may pull an employee's right to practice, and there is usually little recourse (an appeals process usually involves other physicians not connected with the organization). This should be done only in cases where medical care has suffered, and will usually only result in termination of privileges for repeated gross violations of the standard of care. Do not use the MD as a blunt instrument to get rid of a problem employee because you're too chickenshit to fire them yourself. Remember also that in most systems, the MD cannot "fire" them, i.e., terminate their employment, but can simply limit their right to practice in that system. Do NOT allow a problem employee to continue to work simply because you are afraid of litigation. That said, it sometimes takes some time to get all your ducks in a row to make sure that the employee, and the agency's, rights are protected. This chucklehead is a clown, and you should probably get rid of him. The best way for you to ensure that all is done correctly is to consult a lawyer. Many municipalities have an arrangement with their prosecutor's office to look this stuff over. Otherwise, go through your usual counsel. 'zilla

I think your nurse friend is mistaken. I don't recall hypokalemia as a side effect of CCBs, and I couldn't find any reference that mentioned it. Did you find any reference material that said so? 'zilla

The bone scan is looking for increased cortical activity that would indicate bone remodeling from stress fractures that otherwise might not show up on xray, CT, or MRI. Certain types of arthritis will show up as well. As far as the B12 shots go, it's hard to say. B12 deficiency has been implicated in causing fatigue, and B12 shots are not uncommonly given for chronic fatigue when another cause cannot be determined. B12 deficiency will lead to (macrocytic) anemia and a neuropathy, which presents as pain in the extremities (called pernicious anemia). B12 requires a functioning stomach and functioning ilium to be absorbed (stomach makes intrinsic factor necessary for absorption, ilium absorbs the vitamin), so any defect in this system will necessitate parenteral B12 administration. B12 injections are quite safe, so many PCPs do it for fatigue, peripheral neuropathy, pain syndromes, and other reasons. 'zilla

This is, without a doubt, the most retarded thread I've seen on this board. 'zilla

I agree with other posts on this. She's mentating fine, so I wouldn't get too worked up to give fluid just because of a number. Her history suggests some relative hypotension, with the recent starting of a CCB (and dizziness is a frequent side effect). Her symptoms may respond favorably to IV fluid. Probably won't hurt, unless her dizziness is the result of a cardiomyopathy, in which case the IV fluid could push her into acute CHF. No. You're thinking of diuretics. Mean Arterial Pressure = systolic BP + (2 x diastolic BP). Divide the entire result by 3. I don't get too bent out of shape about the use of "within normal limits". Shorthand is commonly used to represent portions of the usual and customary exam. While this book may say one range, and that book might say another, there is no need to split hairs over these numbers. You can write down the exact number if it makes you feel better. Slick lawyers will find a way to make you look like an idiot no matter what you do. If you use "WNL" to describe part of the exam, you'll have to explain what parts of the exam you did. 'zilla

With multiple empty water bottles on the counter, dilutional hyponatremia is a possibility. We see this in soldiers who overhydrate with water without taking in enough sodium through meals or their MREs. And it's not that rare. This kind of electrolyte imbalance is not evident on the EKG. Hydration with NS is indicated. The other concern would be rhabdomyolysis after extreme exercise leading to hyperkalemia, but a 3 lead EKG would not typically show this unless the potassium level was extremely high and the patient near death with a sinusoidal EKG trace. What I can say about this is the FIRST thing I would do is hydrate him with NS. Not because he asked for it, but because it's indicated. Re: the patient's right to refuse, it is difficult to put an exact line at where this kid is able to legally refuse. He doesn't meet the emancipation clauses that permit him to make his own decisions regarding treatment for STD, pregnancy, or drug abuse. At the same time, his decision making capacity is roughly that of an adult. This puts the medic in a difficult place. The second issue is whether or not the medic had any indication of altered mental status. We don't REALLY know what the medics saw and interacted with on scene, so we can't say that from the invariably wrong news report. 'zilla

Prescription drug abuse is an exploding problem nationwide. The safety, purity, and predictability of prescription meds is an attractive option for the junkie who knows full well what can happen to you when you OD on heroin. While many police departments handled few of these cases a few years ago, now many have detectives assigned solely to combat prescription fraud. Dealing with this issue on a nearly daily basis now, there are a few possibilities here: 1) The patient has a problem with chronic pain, and the multiple pain medications are part of a comprehensive pain control strategy. Many of these patients will have one medication for a chronic "base" level of pain control, other narcotics for breakthrough pain, and others to complement their base pain control medication. They may be trying out different medications to see what works for control of the patient's pain. 2) The patient has chronic pain and an unpredictable income, so they "hoard" pain control meds when they can afford them. Hoarding can also be seen in patients with chronic pain that is undertreated. 3) The doctor is unaware that the patient has multiple scripts with multiple refills, and is prescribing what he feels is appropriate based on the patient's complaint without having access to the record or knowing that the patient should be GTG on refills for now. 4) The doctor is well aware that the patient has multiple scripts, and doesn't care or makes his living scripting these chuckleheads for narcs. Some drug pushers have an MD license. 5) The patient or someone the patient knows is forging scripts. One recent antidrug operation I did with involved someone who was filching DEA numbers from his girlfriend at an insurance company, then writing scripts for people under a physician's license. Pay $40 and get yourself a script for some vikes or perkies. Obviously that only got him so far, since the SWAT team was breaking down the door. The best course of action is to notify the ER nurse/doctor. Bring the meds to the ER with the patient if able. If your state has a prescription registry, they can look the patient up and figure out how legit those scripts are. We'll contact the PCP is able and see if we can verify the scripts are right. We also can tell if a pattern of narcotic prescription is legit or not. Social Services does not handle this sort of thing in my area. Obviously there are certain tricks to this trade that I would prefer not to discuss on an open forum, since many drug seekers work to avoid the methods we use to detect them. 'zilla

Keep them for your disaster kit. Kept in a cool dark place they will be good for many years. Just make sure they are locked up where the kids can't "experiment" with them. 'zilla

Would you administer activated charcoal to this patient? Would it be helpful if you did? If this is a magnesium product she ingested, what sort of signs, symptoms, and EKG manifestations would you expect? How would you treat them? Besides the heavy metals, what is another major type of rat poison? 'zilla

Every patient without an airway dies. All other considerations are secondary to this. The concern over placing an NPA in a patient with a possible basilar skull fracture are based on the theoretical danger that you could poke the NPA into the cranial vault. Everyone has seen the x-ray of an NG tube curled up in the head after being placed on someone with a BSF. NPAs are much larger diameter than NG tubes, and if the patient has such a large BSF as to admit one of these into the brain, the patient has much bigger problems than you can fix. At the BLS level, you have no other options at this point but an NPA with a hypoxic head trauma patient with a clenched jaw. At the ALS level, you have to consider the possible risks of RSI in this patient, which are not insignificant. If they need an airway, give them one. 'zilla

The BIG is a single use disposable unit. The EZIO driver can be cleaned with disinfectant wipes like any other equipment. The needles are disposable. 'zilla

Etomidate 0.3 mg/kg IV up to 40mg. Wait 60 seconds, and if insufficient, give the rest of the 40 mg you didn't use with the first dose. Combining agents will get you good results. 0.3 mg/kg of etomidate along with 10 mg of versed or 200 mcg of fentanyl will do quite well. If you don't carry etomidate, 10 mg versed and 200 of fentanyl. If you don't carry fentanyl, versed 10mg and 5mg of morphine. Haldol is another one to consider as an adjunct, particularly if the patient is hypotensive and you don't have a lot to work with for drugs. The above combinations are likely to result in an inability to protect the airway. That's good for tubing, but not good if you can't get the tube. But I've been able to tube a lot of folks with just 40 mg of Etomidate. The above does not include adjuncts such as atropine, lidocaine, or LTA lidocaine. And it's assuming you don't have ketamine, propofol, or methohexital. And the doses mentioned are for adults. 'zilla

EZIO will run you about $300+ for the driver, and $80 each for needles. BIG is self-contained and I get them for around $60 each. The medic services I work for use EZIO for ease of use and general reliability. We carry the BIG on the SWAT team, partly for cost, partly for size and weight. A local service here was having trouble with their BIGs. WAISMed sent a rep out and retrained them on its use, and they've enjoyed very good success with them. For the EZIOs, we almost never have a problem with them when we use them. Overall, I like the EZIO better, but BIG has a role. 'zilla

Not necessarily. If you have the time, you can, but many folks do not. Pain control can take the form of an IV narcotic, such as fentanyl (which I usually do) to help blunt some of the ICP rise with intubation. Others prefer tracheal lidocaine, squirted down the hole before the tube goes in. Since I'm doing more difficult airways now, usually with the glidescope, I've done the lido less often and fentanyl more often. For my crash tubes, you get Etomidate and Succ, and usually the first is being pushed as the second is being drawn up. I don't feel that strongly about it. I don't routinely push fentanyl with fracture reductions or dislocation reductions (usually just propofol or etomidate/versed). The patient has had some pain control by this point usually, but not enough to offset the pulling on the broken bone ends. So on the principle of the thing, giving fentanyl or morphine for the "pain" of intubation with adequate sedation, I don't feel that it's an absolute necessity. With regards to your scenario with the doc, I am NOT a fan of benzos like Versed as a sole agent for intubation. Too many people who take them daily for medical reasons or for fun. If pushing the paralytics at the same time you push the sedative, you have no opportunity to judge if the sedative has worked or not. With experience with procedural sedations, I get much more reliable results with etomidate. If unable to use that (though I can't think of a good reason why other than breaking the vial accidentally), I would definitely add some analgesic if using a benzo as a primary sedative agent. 'zilla

The push away from pediatric intubation comes from a couple of recent studies showing that, controlling for injury severity and other factors, kids who are intubated in the prehospital setting have worse outcomes that kids who aren't. Before you say "it's a skill or practice thing", I don't think we've locked in on exactly why. 'zilla

I'm sorry, what was your question? 'zilla

I don't think Nifty is too far off the mark here proposing that the medic contact medical control and not have this on standing order. This would be an extremely rare event for a medic to witness. I don't know that I've seen medics bring someone like this in to my hospital in the last 4 years. The disease may affect 5% of all pregnancies, but it creates a medical emergency necessitating prehospital intervention in far fewer. When adding a drug to a protocol/standing order, you've got to think about the cost in terms of medication, training, and possible errors. Can the paramedics adequately draw the line in preeclampsia between the patient who needs mag now, and the patient who can wait for it? It's not just a question of BP, but other findings as well. And unlike other disease processes, like respiratory distress, where the medic gets to build his clinical decision making skills over and over, this is an occasion that will happen very few times in his career. I'm not saying not to have a protocol. I'm saying don't reject the idea of not having a protocol. Just because we can doesn't necessarily mean we should. 'zilla providing your zen moment for the day

Then I'm charging a copay and your insurance company for reading every one of my posts. 'zilla