kristo

Sounds like it'll be easier and cheaper to go accross the border, buy a degree and license. Then open a wonderful clinic that promises to cure all the uncurable USA patients that have lots of cash. They come pay, die or if lucky live but I don't know how but I'll take credit, no law suits. Ah my dream job. 8) :wink: :roll:

I wish they had had that when I was choosing a med school! Why do I study research methods in molecular biology from 7 am to 10 pm every day when I could be doing that???

If you're decided upon practicing in the US when you graduate, you should do your MD there. American residency programs frown upon IMGs. We can spend all day arguing about why, but that's how it is. You will have to do extremely well in med school to get into a decent US residency if you're an IMG. Your degree will be recognized, even in states like California, but you'll get a shitty residency.

If you still want to do it, you basically have two types to choose from. You can go take a four year "US-style" degree, available in the Caribbean, basically made for American medschool-rejects, spoonfed material, often run by shady guys.

You could also take the European route and do it like we do, six years in medical school. We have different focuses, though, for example, European medical schools tend to focus more on academia and theoretical background than their American counterparts. European doctors tend to score very well on part 1 of the USMLE and perhaps step 2 CK, but suck at 2 CS (clinical skills), as treatment approaches seem to be pretty different over there (in the US).

Both of those options will have significantly lower tuition fees than your average US medical school. Most European schools are state-run.

All in all, if you want to practice in the states, study in the states. Same goes for Europe. If you want to practice here, study here (at least where I come from, US medical degrees are not valid for getting a license to practice medicine). If your grades aren't good enough, go back to college and take a few more courses, retake the MCATs...

That said, I believe any of the three options (US, Caribbean, Europe) is likely to make you as good a doctor as you are material to be. No more, no less.

In Europe, we have such a thing as a bachelors degree in medicine. It's a three year university degree (here, by university, I mean what comes after college at age about 20). This degree is pretty much, as far as I can tell, the same first 2 years as in general medicine, then a similar 3rd year, but a little bit more research-oriented and a BS paper/study to write and defend. In some schools, all medical students have to complete their BS in their 3rd year, but most medical students who go the BS route go straight into some sort of research assignments and end up with PhD's and DSc's, teaching and doing research.

So, maybe EMS providers could do an BS in medicine and then proceed to a masters in EMS. The extra two years could be more hands-on, practical training, similar to masters (or magisters) in psychiatry, engineering, law, etc, where the BS is more theoretical, but the MS degree gives them the more practical education.

This could even be an alternative for those interested in being semi-autonomous health-professionals, but don't want to do the whole doctor thing. Not everbody is so keen on doing 4 years of college + 6 years medicine in university + (in some countries) 0,5 - 1 year internship + 5 years of specialty training to become a family physician.

Another unusual condition, and this time one that I did encounter in the field.

A 17 y/o female complaining of mild respiratory distress, getting SOB while walking up stairs, things like that. No history of respitatory diseases in her or her family.

She'd been drinking pretty much non-stop for about 36 hours, then stopped, and after a few hours, she felt SOB, nothing in particular made it better or worse. She preferred to sit in an upright position and lean forwards, no surprises there.

No extra sounds in her lungs or airway (according to the *bad* cheapo stethoscope I had there). We took her to the sick bay of a ferry this happened in, where I started administering high flow oxygen. There was no pulse oximeter available, although there should have, according to laws on ships that size, so I couldn't get O2 saturation levels.

Upon oxygen administration, her fingers became numb. We tried withholding oxygen and have her breathe in a plastic bag instead. That worked better. We gave her an antacid tablet, and after a few minutes of breathing into the bag, she was fine. Apparently, she was suffering from hyperventilation secondary to heart burn caused by all the drinking.

You encountered this in the field? And I know this isn't the misdiagnosis thread, but what was your working diagnosis before getting the labs?

Heh, heh, no. I've never seen a patient with this condition in my whole life. It's just an example of a rare disease. The original poster did state that "any interesting condition is fine" and also said "I kind of have a curiousity for illnesses and conditions that aren't very common."

This disease won't be diagnosed without extensive lab work, working diagnosis would be diabetus mellitus, type II, or polycystic ovarian syndrome (PCOS), or just unexplained, unusually high testosterone levels. The connection to EMS would mainly be the insulin resistance thing, this might be something EMS would have to respond to...

For the ones that do seek medical help (probably more because of the insulin resistance than the other symptoms), I believe that the connection is not always made by the practitioner. The increased testosterone levels cause problems like unwanted facial hair in women, which is usually managed cosmetically. A lot of endocrine things can cause high testosterone levels. The infertility can also be caused by a number of things, for example PCOS, which is, in that aspect, and in testosterone levels, similar to cortisone reductase deficiency.

As a student, and (mostly former nowadays) SAR/W-EMT, most of what I can contribute to conversations like this is theoretical. I do hope that some will find the cortisone reductase deficiency thing interesting. Maybe it's just me being a geek. :wink:

Edit: One thing you *can* do to test a patient for this disease is to administer cortisone and check before and after ratios of cortisone vs. cortisol in a blood sample. There are some baseline numbers on how fast a person should reduce cortisone to cortisol, if your patient is way off, and shows the symptoms, you might have your diagnosis.

Just to get this thread on the original track, how about cortisone reductase deficiency? Basically, it's a mutation in a gene that codes for an enzyme, cortisone reductase, which reduces cortisone to cortisol. This leads to a lack of cortisol. Since cortisol is an antagonist to insulin, this causes insulin resistance (diabetes type 2)

As if that's not enough, cortisol also regulates the secretion of adrenocorticotropic hormone, which makes the body create testosterone. In the absence of cortisol, the body makes too much testosterone, which makes women infertile...

The disease also causes abdominal obesity, high cholesterol levels, high blood pressure, the list goes on and on. This is one golden zebra, though.

In 2003, my EMT-B was $1600 dollars, including room and half board, it included the Brady book and a wilderness EMT certification, but I had to pay additional testing fees (Washington state (or was that free?) and NREMT).

I had to travel from Iceland and take 6 weeks off work, so yes, that part was expensive (around $1100 for the flight).

I thought that was expensive until I went to medical school (which I also relocated for)...

PS: Wouldn't it be better if the spell checker at this site recognized "EMT-B" and "NREMT"?

A slight correction: WE will provide (emergency assistance). The fact that we have found it convenient to have a common body for certain services and for enforcing the rules doesn't make it a third party. That body, the government, is us. We re-hire or fire OUR employees there every four years.

Our employees have a simple task: day-to-day operations we (the public) feel we should unite on, such as healthcare, maintaining roads, law enforcement, etc. We aren't just a bunch of pigeons waiting for some big guy to throw bread crumbs our way.

The European mindset, since you brought that up, on this issue, is that we do not want the general public settling their disputes with firearms, nor do we feel that our society would benefit from having people shooting at each other in our cities. This is why we have decided to have law enforcement, usually (in most of Europe), armed police. We have, conveniently, entrusted the task of handling that matter to that common body of ours that I mentioned earlier. If our staff doesn't seem to be up to the job, we won't extend their contract in four years, or even demand their resignation immediately, if that suits us better.

Another option; at least where I come from. In Iceland, doctors very often ride with ambulances for the most serious cases. In the capital, Reykjavík, there's a special ambulance staffed 24/7 with a doctor, that one is always sent along with a regular one if the case warrants it (respitory distress, young children, anything cardiac related, etc.). Also, all coast guard helicopters always have a doctor on board in all SAR / med-evac trips.

So, for those doctors, they have all the "good" parts of EMS, only go to the "popular" calls, don't have to do the grunt work (they have paramedics with them on the ambulance and at least one EMT on the helicopters), a pretty much unlimited scope of practice and complete autonomy - and a very decent paycheck.

To our Icelandic brother, I'm glad your country is the way it is. I'm sad we have to be this way but we do. I'm not going to let the criminals win and if I just leave it to law enforcement they will.

So, maybe the problem is that you guys don't trust your law enforcement agencies? Maybe they're not trust-worthy?

Bare with me here, I'm trying to get in to this mindset. 8)

Maybe the reason why so many Americans feel that they have to carry arms in their society is the fact that so many others do, and not all of them do it for defensive purposes. To most other countries, having the general public armed is something we see in old westerns, not in reality.

If people the large cities in Europe can survive without firearms in their homes, so should Americans, right? Or maybe not, for the reasons stated above.

Not everything on this side of the ocean is that great, though. For example, we had an incident in Iceland a few months ago, where police officers were arresting a man whose job was to collect debts for drug dealers. If the one owing the money couldn't pay, he would go after his parents, grandparents, siblings, whatever, using brutal violence if "necessary". Those debts carried interests in the vicinity of 100% per day, so we're talking about a lot of money here.

Anyway, during the arrest, the man threatened one of the officers, he actually threatened to attack the officer's wife and/or small child. He could name the wife, the child and he even knew which kindergarten the child was in.

The response of the judiciary system? A small fine and a probation. That's including several assaults/batteries in his "job". I'm curious as to what that would have gotten him in the US? :roll:

A sidenote; Right now, the government is pushing laws through our parliament that are supposed to increase penalties for assaulting/threatening law enforcement officers, giving them a little more job security. This is largely because of an uproar in the police officer's union.

Well, let's see. I used to do volunteer SAR, back then I carried a lot of useless junk.

Now, well, as in right now; lab coats don't have that many pockets, so, the upper, left one, a clip-on photo ID (required) and a pen. Lower, right pocket, a small leather case with a scalpel and forceps. Lower, left pocket, a couple of pairs latex gloves.

Of course, right now, my only "human" contact (except to teachers and other students) is to the cadavers we dissect in anatomy and the blood samples we do lab rat stuff on in cell biology or genetics...

-Kristo

Kristo, no offense taken. In fact, it is actually nice to have a cordial conversation with somebody that has a different view. One of the issues that must be considered is that the United States is a huge country with millions of citizens,

Duly noted. The Icelandic approach does not scale.

and unfortunately a large population of criminals. In a situation like this, we cannot expect the law enforcement resources to be readily available. I think it is reasonable to allow the citizens to protect themselves, keeping in mind the concept of accountability.

Be that as it may, but wouldn't more guns in the community mean more illegal use of them? I actually do believe that gun's don't kill people, people kill people, but I am much more comfortable with a fist fight than a shoot-out...

Is lack of available law enforcement a part of the problem, in your opinion?

This is obviously debatable. As I understand, and as you pointed out, there is also a debate within the US on interpretation of the amendment, eg. when is it legal to shoot someone, and what kind of guns can which people have...

This might not be something that I, as a foreigner, can really understand or even discuss, as it is your community, not mine (I've only once even been to the US).

As I understand, Jón Sigurðsson was a well know scholar and played a crucial role in the development of Iceland's constitution.

+5 - wasn't there a ranking system on this site at one point? What happened to that system?

one question kristo if some one was breaking into your home and they were going to harm you or one of your family member would you not want the right to defend yourself and how would you choose to do this? if this said criminal had a gun or a knife

I'm not sure sure if I'm hi-jacking the thread and starting a flame war (OP, was this kind of discussion the intended usage of the thread?), but I'll answer the question.

First of all, I like to think that, in my society, this is extremely unlikely to happen, especially with firearms (I don't personally know of any case in Iceland where a firearm has been used to rob anyone or to attack anyone in their home), but if it would, I do not believe I would have what it takes to point a gun at another human being and squeeze the trigger unless under extremely exceptional conditions. I see a weapon in my home as an increased risk for me or my family, either by accident or if a potential attacker (if one would come) would somehow get the weapon (maybe through my inability to use it against him?).

I realize this is a difference in cultures and not all of my arguments are applicable in the US. Since you asked about me and my home, however, I find them valid.

I'm sure there are some situations where I would feel forced to exercise lethal force, eg. someone harming members of my family. However, I think the risk of accidents and "the bad guys" getting weapons significantly outweighs any benefits of arming the general public. Again, I realize that in the US, the "bad guys" already have guns, so this partly does not apply for you.

For self-defense, I like to call 112 (the European version of 911). That makes me a dot on a digital map for a dispatcher that can send me police, EMS, FD, coast guard, SAR, the Icelandic Red Rross, Icelandic Road Administration, even child protection services with a push of a button...

chbare,

Thanks for the clarification - I had some idea about this, but it's good to get a "general view" from a normal person on it.

I must stress that it neither was, nor is, my intention to bash your culture, especially not here, in an American forum. That would be like for you guys to come to Iceland and spit on Jón Sigurðsson's grave...(plus 5 for anyone who knows who he was ).

We should probably just put this on cultural differences and move on...sorry if I offended anyone.

Ours is a small society (the total population of the country is about 300 thousand) and since we do not have a history of public gun ownership, we have no "tradition" of armed criminals, hence very limited need for armed police (SWAT only, maybe 1-2 calls a year in the whole country).

For those reasons, I do understand how our model would not work everywhere.

However, I still think law enforcement should be left to the police (that includes any protection/defense needed), judging and sentencing should be left to courts and the aftermath to the correction system. Letting any member of the general public buy a gun and be all of those in one person...well, obviously, I must say it wouldn't make me feel any safer.

I see I'm in a minority here, and I probably won't convince anyone, especially given the cultural difference, but I still wanted to put in my 2 cents.

This has a faint start of reminding me of a thread on allowing the general public to listen in on police/FD/EMS radio communications, which we discussed for 5-6 pages on EMT city about 3-4 years ago. Don't see many of the same people here anymore, though. Just RichardB, the EMT and Medic2588 (Devlin, the book promoter )...and now me again... :wink:

Edit: Removed a potentially "flammable" comment about the jury system.

Of course, a thread like this is something that makes a foreigner like myself jump.

I'm really not that familiar with the American mentality towards guns, except from what I've read and seen on TV, but really, do you really, honestly think that the general public should be given the authority to use lethal force? I can see how self-defense can be a valid excuse for accidentally harming your attacker, but to allow people to shoot someone for entering their property or "Unlawfully attempting to enter a protected place"?

Here's where I start babbling about how it is in my country. Please feel free to skip over the rest of the post... 8)

Where I'm from, self-defense is when you use minimum-needed force to defend yourself - if you use a weapon, you better be ready to prove in court that it was bona fide self defense and you did not use excessive force.

...and, for the guns: if the police find a handgun on your person or in your house, you're facing jail time. There are some rare exceptions where individuals have been allowed to possess small handguns, but only long-time active (and must stay active) members of recognized clubs for sport shooting (marksmanship). In those cases, they have to keep their handguns at the club at all times.

Hunting rifles...if you have a license, sure, but there are very strict rules on those - can't even be loaded within city limits. Have to be kept in special gun cabinets.

Automatic or semi-automatic weapons: I believe the police and the coast guard have some, but I don't know anybody who has seen them. An individual possessing those kind of weapons would obviously have to face legal repercussions.

End result: We don't have a military, nor do we need it. Our police do not carry anything stronger than mace and a club (except for the SWAT team, which has firearms), nor do they need it.

In Reykjavik, Iceland, there's something of the kind that (I think) you're looking for.

So, basically, they have six ambulance/fire stations spread around the city. In each, two staffed ambulances with a minimum of one EMT-B and one EMT-I (since all employees are required to get their EMT-I after 36 months as EMT-B's, they're mostly EMT-I's). They also have an increasing amount of paramedics.

In one of these stations, another ambulance, so called "emergency truck" is stationed, which is staffed by two ALS providers (usually two paramedics, but sometimes EMT-I's, I believe) plus a doctor who has received some out-of-hospital training, provided by the ER. This ambulance is equipped just like the other ones, except a few more meds and a heatbox for newborns.

Now, the way things work there, for all calls that are potentially cardiac, respitory distress, very young children, severe trauma, etc, they dispatch one or more ambulances from the nearest stations (sometimes from two directions to get them there sooner) plus the "emergency truck" from the main station.

The "emergency truck" almost never transports. Sometimes the doctor rides with the other ambulance to the hospital, if needed, but they try to have him/her free for other calls that might come up, also the doctor carries a cell phone and acts as online medical command, which is able to come to the scene if needed. So they will sometimes travel from one scene to another, if there's more need somewhere else.

The EMD's will usually err on the side of caution, if the "emergency truck" is not busy, they will send them if they think they might be needed. If there's a student ride-along (which there usually is), it's usually on that one, as that one is guaranteed to get all the "student-friendly" stuff. That'll be medical students, nursing students, EMT-B/I students (don't have EMT-P training in Iceland yet) or EMT's from rural parts of the country, with low call volume, they often come to Reykjavik a couple of times a year to brush up on their skills.

Actually, the O2 would probably lose heat upon depressurization, ie. it would be colder when it would come out of the pressurized tank.

I've wondered about this for a large snow mobile ("cat") my volunteer SAR squad recently purchased and I haven't really come up with a solution. The cat would primarily be transporting patients in the wilderness where no other option exists (if the weather would permit a helicopter, the patient would be in it), since the cat can only do 20-30 mph. Therefore, in the rare cases a patient would be transported in the cat, we would probably be looking at long transport times. I was wondering about placing a 25L O2 tank on the top of it (that would give us about 5 and a half hour at 100% FiO2) and connect to an internal delivery system of some kind, so there would be an "O2 tap" inside.

Here's a picture of the cat before they made a bigger passenger compartment:

http://www.bjorgunarsveit.is/index.php?opt...;g2_itemId=2305

I've seen someone defibrillated while conscious - by an implanted defibrillator. We had a monitor on him, we saw him go into v-tach and his defibrillator shocked him. A number of times. Always set the rhythm straight immediately, but in a few minutes, he would go back into v-tach. Never lost consciousness.

Asside from being able to point and say "Hey, look, it's an xray!", I really know nothing of xrays.

Pretty simple technology, just place something that emits a known dose of radiation that can penetrate a human (x- or gamma rays) on one end, a radiation meter (probably a simple Geiger-Muller counter) on the other end and see how much gets through at different places - then you get the density of the specimen (patient) in between. Where a lot gets through, it's just air. If a little less goes through, it's soft tissue. Where very little goes through, it's a bone. If a bone looks non-continous or malformed where it shouldn't be, it's broken.

On the topic, ultrasound would probably be easiest, not to mention safest, imaging technique for use in EMS. That just means sending sound (in a higher frequency than the human ear can detect) through tissues and assessing what's in it's way by the frequency and latency of the echo (simplified). When the frequency of the echo is taken into account, it can also assess things like blood flow, which is pretty cool. This is the only imaging technique that's not using ionizing radiation, that I see fit for EMS use (MRI uses magnet fields and radiowaves, but we won't ever see that or even need it in EMS). I can totally see a small screen next to the cardiac monitor in an ambulance with a small pad attached, which can be used to take a peak into someone's lungs or whatever. It's not perfect, but it would probably give us something to go by.

I'd check her blood glucose levels myself - I wouldn't trust a patient with an altered mental status to do that themselves. This patient is showing some symptoms of low glucose levels.

The recent surgery (or any implications with it, such as an infection) might be affecting the diabetes. Check the glucose, be prepared to do ALS on her airway (just in case) and get en route to the hospital ASAP - don't need to run hot, but at least get moving.

This is an extremely interesting thread. I couldn't agree more with what Steve posted. War and terrorism is the exactly same thing. The ONLY difference between the USA and Al Queada is PR. The USA have the media on their side. The methods are exactly the same.

As for international trials, it is clearly illegal for anyone to invade another country and judge the people there. Period. It would always be an illegal court.

There are international courts, made for situations like this - only, the USA has specifically stated that they will not recognise them unless the rules will be changed so US citizens are not subject to those courts. So, not going to happen.