Aussieaid

OK I've Learrrrrrned something today.

No. 1., with the exception of one person, apparently you guys'n'gals really hate scanners. Good to know, I guess.

I admit, I lack class (pass the Fritos). I don't even have the class to join the QCWA although I just recently qualified, yep the Quarter Century Wireless Association, basically it's for those who remember sweatin' out the FCC test AT the FCC field office, complete with code. What some consider fast code, yep extra class now you send in 3 box tops and Tony The Tiger sends you the ticket. When all's said and done I'd rather go out and do stuff than hide in a radio room, but a longterm interest in radio is hard to kill. Blah blah blah who cares basically while I've made my share of contacts I find the listening more interesting. I like knowing what goes on around my town! So, the plan is, this scanner and a decent communications reciever, I've had and enjoyed the Eton E5 but am actually considering the Grundig Satellit 750 the next bolus of money I come across. I just want to be able to listen, across the spectrum.

I was not asking anyone's permission to get a scanner, I was wondering how many listen to 'em here and find 'em interesting, maybe trying to see if there was a subset of scanner types in the crowd here. I guess I found one, which is neat, I even gave 'em a positive point. The rest here seem to be entranced with their own ability to fling mud, thank you very much.

Have fun. Bye.

I admit that I was fascinated by scanners and the radio traffic when I first started in this field. I ended up buying a scanner and found it invaluable when I was learning how to talk on the radio including how to give better radio reports to the hospitals. I also used it when I would hear the police helicopter over my area or even now if I think I have heard gunshots nearby I will turn it on to see what is happening. I have had the SWAT team in my backyard and was able to hear what was going on and that they had caught the subject. I then informed my very worried neighbour of that fact and reassured her.

To each his own interests. No harm in it unless you start running out to looky-loo at calls or interfere with them. It is good to be mindful that other people are listening to what we say as it helps keep us professional and aware of what we are saying. Occasionally I will turn it on at work (not often anymore) as it gives us a heads up that we might be getting a call and you can get in a bathroom visit before we are activated or grab a snack bar, etc.

Cheers all.

He/she can come visit me and I'll take them for a flight!

Found this application for iPhone users that others might find useful.

Paramedic Protocol Advisor

Cheers!

P.s. Sorry I put it in the wrong section by accident. Can someone please move it to a more appropriate section? Thanks.

It notes that left ventricular failure should be treated in-hospital with IV nitrates, duiretics and vasodialstors where feasible.

Note here its right ventricular failure or could be complete heart failure but it's not like we can do an echo or other cardiac imaging to differentiate betweeen complete heart failure and cardiogenic shock caused by right ventricular failure.

It is pretty clear by the symptoms without an echo that he has complete heart failure and is already going into cardiogenic shock as evidenced by the peripheral edema, JVD, (right sided failure) pulmonary edema and hypotension. (left sided failure and shock). What we can't tell prehospital is the exact cause although the temperature, history of being sick for a few days, cardiac irritability without obvious ST changes narrows down our differentials.

Before it gets taken wrong I completely agree (as previously stated) that this patient was stable enough to not mess with him and the treatments I suggested are treatments that would be implemented in the hospital unless he deteriorated before we could get him there.

The patient had a cardiomyopathy from the myocarditis and it presents as complete heart failure (Both right and left sided failure). The note about treating myocarditis like left ventricular failure is after initial stabilization where they go to ACEI. The treatment for CHF and cardiomyopathy with or without cardiogenic shock which presents as both right and left sided failure is slightly different to just right sided failure which is totally preload dependent.

Supportive care is the first line of treatment. A minority of patients who present with fulminant or acute myocarditis will require an intensive level of hemodynamic support and aggressive pharmacological intervention, including vasopressors and positive inotropic agents, similar to other patients with advanced heart failure due to profound left ventricular dysfunction. Elevated ventricular filling pressures should be treated with intravenous diuretics and vasodilators (when feasible) such as nitroprusside or intravenous nitroglycerin. A ventricular assist device or extracorporeal membrane oxygenation may rarely be required to sustain patients with refractory cardiogenic shock.108 These devices favorably alter ventricular geometry, reduce wall stress, decrease cytokine activation, and improve myocyte contractile function. Although the data on survival after ventricular assist device or extracorporeal membrane oxygenation implantation are largely observational, the high likelihood of spontaneous recovery of ventricular function argues for aggressive short-term hemodynamic support

Good discussion and case study,

Thanks and Cheers!

Dave;

I don't have blood work sorry; don't have an iSTAT machine on the truck just yet

The problem was myocarditis however it presents in such a way that one could take it as "chest pain" and load the patient up on morphine and GTN, or "pulmonary edema" and go with GTN, lasix and morphine. The low BP might be in the minds of some, an indicator for IV fluids, when in reality none of these are clinically appropriate in my mind.

Wouldn't suprise me if some out there looked right past the obvious signs of a cardiac infection and RVF e.g. fever, pedal edema, JVD etc and just saw a person with "chest pain" or "pulmonary edema" or maybe even "short of breath" and went down the respective recipe for each. My ALS textbook mentions RVF in one paragraph and doesn't mention anything about withholding nitrates or fluid, it even states to establish an IV at KVO rate!

Note the treatment section.

Ok, so with a slightly clearer picture here and looking at his vital signs my prehospital plan would be 2 IV's one with fluids TKO (ready for a bolus if needed) and one TKO, O2, HOB elevated and boogie to the ER. In the hospital the previous treatment plan is what I would be looking at as the goals remain the same. Also in the hospital you have a few more drug choices that would be better for this patient. (i.e. milrinone verus dopamine but still may need some dobutamine or dopamine to support the BP so you can give the afterload and preload reducers). This pt still needs GTN but prefer to have a higher BP before using it. If he starts to deteriorate then inotropes, fluid, CPAP/BiPAP and possibly fluid bolus are what he needs.

Lasix is pretty much on the way out as most of these patients are actually dehydrated and since this guy has been sick with a fever for a few days he most likely needs fluid but first his heart needs help moving the fluid in the right direction. If you gave too much fluid right now he would probably deteriorate pretty rapidly.

And leave Stanley in the pasture as this guy most likely has a horse (or zebra) galloping around in his chest rather than an elephant sitting on it! If Stanley develops pachydermitis let me know as I know a few people who know a few people...if you know what I mean! (nudge, nudge, wink, wink!)

Actually we really need a few more assessment points here. Not convinced that it is a tamponade without more answers.

What is his SpO2? (Pre and post albuterol if that was actually given).

You said you didn't listen to heart sounds? At all? So we don't know if they were muffled or if there was a gallop or rub?

Were there signs of pulsus paradoxus? (eg. pulse weakening when the pt breaths in)

Did he have hepatomegaly?

What is his medical history and what medications is he on?

I had a few more but I will have to come back to it later.

So after surgery for pectus excavatum (which was not the original question) then CPR may require more force but still in the same position. The pads should be place anterior/posterior if the bar is still in situ. Ideally the patient should wear a medic alert bracelet if they have any kind of procedure that would require CPR modifications such as this surgery. (Not that people always do what they should do....)

This is definitely a tricky one and treatment is kind of a tight rope walk.

This guy has more of a cardiomyopathy picture versus septic shock and whether it is from a virus, an infection or some other cause the treatment pre hospital will still have the same goals.

Goals are to reduce preload, afterload, increase contractility and improve oxygenation.

This is where it gets tricky because his BP is on the lower side for the drugs that he needs so you may need to counteract the effects of some drugs with other drugs to be able to balance on the tightrope here.

He needs nitrates and CPAP or BiPAP to reduce the preload, afterload and to oxygenate. You may need to give a little fluid challenge or start an inotrope to help with his BP. If you start giving a little fluid without the CPAP/BiPAP you may just make him worse. So if you start to give some fluids and he gets worse stop the fluids and get the inotrope started.

Now he also need some inotropic support. If you have an ACE inhibitor that would be ideal but you may have to make do with dopamine if that is all you carry. The problem with the dopamine is that it could make him worse with tachycardia or cardiac irritability. He has a fairly slow heart rate at least so hopefully we have some room to move. I would be reluctant to use it but if he starts doing any worse arrhythmias I would give him amiodarone.

I would not be giving lasix. Leave that up to the hospital. He more than likely needs some fluids but we have to be cautious with them as the state his heart is in currently it cannot handle any more fluid. Sounds like he really needs an IABP at least.

Interesting case.

So you answered some questions but the one i want to know is would it change the hand placement/depth of compressions?

So this condition would change the placement of the pads?

and thanks for the help

For this condition you really don't need to change anything. You wouldn't move your hands off the sternum because you would do more damage doing compressions on the actual ribs than the sternum. The depth is still going to be the depth that gives you a palpable pulse as no one really measures it during CPR. You adjust to what works best for that particular pt.

You wouldn't need to change the pad placement for pectus excavatum. It is the same amount of bone just the anatomy is slightly different shaped and it's not really going to interfere with the electricity in this case.

So Kiwi you must have been taking Stanley to altitude too frequently since he no longer has the memory of an elephant. Getting lost in the subway, tsk, tsk!

We had a pet wallaby for a while that would grab our poodle by the ears, bite him on the nose and kick him with his back legs all at the same time. Luckily they were just playing and they were about the same size.

I'd bet on the Kanga in a match against humans!

Not sure how to get the picture on here but I attached it anyway.

I love my Casio Wave Ceptor. The features I love are the atomic time (I know it is accurate), it is analog and digital (easier to calculate my ETA on the analog but more accurate time for timekeeping with the digital), world time (can have local and home time at same time) and the feature I use on every flight is the time stamp (I can record up to 30 times with it....so when I lose my tape with times I have back up).

It has numerous other features as well but they are the ones I use the most. It runs about $50-$60.

Casio Wave Ceptor.tiff

Maybe we can't have everyone knowing how to get rid of cooties cause it might cause problems! So it is better for you if you don't dial the number!

In realm of the Paramedic there are generally 3 category's that one will be called for, respiratory, cardiovascular and sepsis/quote]

I thought they were stubbed toe, minor pain at 3am that's lasted longer than 3 weeks and "I'm in pain but allergic to anything but Opiates"!

I think you are being deliberately obtuse to play the Devil's advocate here!

Sweet ease is only used for babies up to 6 months in a controlled environment. It is administered under a Doctor's orders and not given as an arbitrary "treat" to "bribe" babies. I think this population is fairly immune to the whole idea of the reward system. All they understand is that they are hurting and if you give them something to help that pain it is not going to turn them into a obese child later in life.

Infants burn through glucose much faster than adults and they do not store it like we do so giving them very small amounts of sweet ease for the occasional painful procedure is really not going to have the major impact on them that you are inferring.

The concentration and amount that you use is so minimal it usually does not have any effect on their glucose levels that I have observed.

If you are really not interested in the looking into new methods for providing pain relief to this chronically under pain managed population that's your prerogative but the OP heard of a new method of pain control and was interested enough to look into it further. Just because you have never heard of it doesn't mean that it is not a valid treatment option. I have changed my views on traditional treatments and techniques when I have researched new ideas and concepts and feel that it benefits my practice and my patients to have an open mind to new ideas. I may not agree with all of them but I try not to make up my mind until I have done a fair amount of research into it. Even then sometimes there are controversial ideas and often two opposing views on just about everything related to medicine, so I read and decide what I feel is the best evidence based practice and adjust my own practice accordingly or not.

Cheers

I advocate using EMLA and sucrose if possible. Sometimes you don't have the time required for the EMLA to work. Sometimes topical anesthetics are not appropriate for some procedures. There are situations where sucrose is appropriate and some where EMLA is appropriate or both. If it works I will use it and I have found that sucrose works. Sometimes EMLA makes the IV start harder and you end up taking longer to establish an IV therefore causing more pain to the infant.

One more study to look at comparing sucrose and EMLA and it appears sucrose is actually more effective. I still recommend giving both if feasible.

In the prehospital environment you don't have time to wait for the EMLA to work so sucrose is a valid alternative and if it works for the infant why would you not use it? Anything that helps the infants pain is preferable to nothing in my opinion.

Good discussion,

Thanks and Happy Holidays to all.

I am signed up for both days but have to book my flights yet. I am planning on arriving on the 8th and departing morning of the 11th.

Squint, the sucrose is only for mildly painful procedures such as lab draw or an IV start where you would not be giving an opioid anyway. I agree that infants especially in the NICUs are not adequately pain managed and I advocate giving appropriate pain medication when required. I think infants and children are grossly undermanaged for pain in all environments including prehospital as well as ICUs. On the other hand there is no need to use a bandage when a bandaid will do. I also use tylenol but it doesn't give the immediate effect that sucrose does for mild procedures.

I also don't care exactly how it works but I have seen it work and will continue to use it when appropriate.

Cheers.

We used to use Sweet Ease (a form of sucrose) for the babies in our PICU when we were going to do minor procedures such as line placements or IV starts.

Here is one study done on the topic.

Sweet Ease is what we used.

This study mentions sucrose for pain management in infants.

I wonder if it would be an option in the prehospital setting since you can actually buy it for infants at home (I think).

Cheers

Wow, that is really scary!

I am sorry for your and your wife's loss Mobey.

I apologize for oversimplifying the explanation. I was simply trying to answer the OP's original question about Cushing's Triad and instead of getting sidetracked into all the different types of herniation I mentioned the type I have seen most commonly. The Cushing's triad can occur in the late phases of both the Central and Uncal herniation syndromes as well as other types of herniation so the point is kind of moot.

Sorry I am too tired to think clearly to explain my thought so will check back tomorrow!

Good night and keep safe!

Oops! I changed it. I had just never really changed it from the default settings in my profile. I am female.

I haven't had a chance to do the research but the first thing I thought of with this case was inhalant abuse. It is really a big problem with the preteen and early adolescent age group. Most of the parents have no idea their kids are doing it unless something bad happens. The same as they have no idea when their kids are playing the choking game. There are often few obvious signs unless you have a really strong suspicion and actually know what to look for. A lot of the mood alterations/moodiness associated with the abuse is probably put down to the phase of preteens and teenagers which is why it is really hard to monitor and prevent it.

There is a very high risk of encephalitis and brain damage from "huffing". I don't have the profile of abusers in front of me but the fact that he is a loner and doesn't have many friends puts him at risk of depression and inhalant abuse. You don't need friends or company to do it and it seems to be a less social form of abuse although they do do it with friends as well.

Does anybody want to try to do a meet up somewhere one of the nights (perhaps the night of the first day ?) to go hang out or whatever. I'll be driving up that afternoon as I have to work until that morning, so I'd like to know if anything's in the works. If something does emerge or someone wants to take the reins let me know 'cause I'd like to meet up !

I will be happy to meet up sometime. I am just not 100% sure I am going to make it yet. I've booked a room at the Red Roof Inn if anyone (female please- I am a little shy like that!) would like to share. I will wait until I get back from my vacation to book my flight. Hopefully something cheaper (flight) turns up or else I may have to bow out. PM me if you want to arrange anything.

Cheers,