Ridryder 911

Curious on how you .........accidentally give anything I.V. ?.. Not to be an ass but that is what the attorney will ask as well. Actually, 0.3 mg of 1: 1,000 is not WAY out there but, definitely enough to light her lights if not needed. Every one makes mistakes, you did the proper paperwork ? The Dr. checked her out.. that's the best you can do The headache is suspicious ... I suppose a CT, MRI etc. was performed afterwords? I have a hard time believing continuous H/A ... remember epi is the same as adrenalin.. smell like someone wants money... I would check into an attorney for myself, I definitely would not trust my boss if he is known not to be responsible pay premiums from time to time. Good luck, R/R 911

Kyphosis (abnormal spinal curvature) can complicate things if you don't think "outside the box". Remember immobilization can occur with the patient laying lateral, prone and if they are well padded. You do the best you can to prevent further injuries. Again remembering spinal immobilization is not really a treatment, but a preventative measure. As far as the oxygen, why ? .. If she is not S.O.B. and appears to non-hypoxic, no nuero deficit.. the why even consider oxygen ?.. R/R 911

I seen some cases while I worked at the burn center, I to worked in the HBO unit and most of "bad skin" problems was punted to the burn center. It is not frequently, but not unusual. R/R 911

Can you say BLEB ?! R/R 911

The problem is taking care of them and then being able to stabilize. Can every hospital afford a vascular neurosurgeon and his/her team ?..no... can every facility afford a cath team with a chest-cutter present 24 hr a day ? In which you have to have... most of EMS only sees the back doors of the hospital... there is a lot more that is required than an ER. So yes specialties are going to increase as competition and to decrease services that are able to make the hospital grow. There is no reason to have multiple specialties... that is why 40% of Trauma Centers goes out of business within 5 years.. Trauma does not pay..(most GSW does not have Blue Cross & Blue Shield in their pocket) R/R 911

Trauma team for a burn... WOW! .. Actually burns are not really classified as trauma. Lets not make a mountain out of a molehill. 1'st & 2 second degree burns are usually easily managed... No burns are NOT impaled objects.... C'mon folks let's use some common sense.... Even Boy Scouts are taught how to treat burns. R/R 911

You shopuld be confirming ETI with capnography... this is the only legal true documentation. Otherwise there is no verification of displacement and continous ventillation. R/R 911

Worked at a couple... lot of band-aids and dehydration... R/R 911

The reason you feel better is because you are increasing your ICP slightly. Remember syncope usually caused by the dilatation of vasculature lumen, (vasovagal syncope). Most current studies show positioning has very little effect, in this case. Peripheral vascular resistance is related to the vagal sympathetic response.. so actually, laying the patient in a supine position has the same effect. Allowing the body to auto-regulate itself and regain its tone is the main goal. Usually this is transient. That is why when people have simple syncope (fainting) episode, the usual treatment is no treatment other than placing them in a coma position to prevent airway obstruction. Mother nature will usually take care of itself. I would never to suggest trendlenburg position for anyone with a headache, raising the ICP increases pain. Remember all etiology of hypotensive episode is either related to volume, vessel, or pump problems. Either low on fluids (volume), dilation from either nor epi or medications or loss of neuro (vessel) or poor perfusion problems ( AMI poor cardiac output) all providing circulation to the brain. If you have poor cardiac output (<Pl/Al) , you will not have good cerebral blood flow. R/R 911

So Dust are you going to the ELVIS chapel ?.. maybe we get the Elvis team to attend

I disagree... if you were to do USS etc .. on every abdominal pain because the rate is just 150 I would have to have 5 U/S machines in my little ER. Treat the patient not the numbers.. and after a detailed examination then to rule out (if needed) then do aggressive work up. Why run up a ER bill into the thousands of dollars..? I would had suggested a green lizard or GI cocktail prior to the Demerol... with epigastric pain, run a liter of fluid in and see if her rate goes down and allow the analgesics to work. Get a better H & P then go from there. You probably just scared the hell out of the girl...and running hot didn't help. R/R 911

Hmm.. that is the Trendelenburg position most people use. As the studies shows it DOES NOT WORK. when you are alive, why would it work you are dead ?... The most you could get is some venous pooling... c'mon this is basic pathophysiology. Without a circulating and brain function (thus no autonomic function.. no release of alpha stimulation then decreasing angiotension I and II) pre & post sphincters dilate causing massive pooling in the central pool ... thus pale, cold skin... Raising the feet 6 - 10 inches is not going to cause nothing except more pale toes... It does not cause any change in pre-load and after load short and simple. This is just one of the studies that was performed. At one time Emergency Cardiac Committee had considered placing trendlenburg into the standards and found out it was just a myth R/R 911

I think I described yes.. leave it on, let them clean it off in ER... R/R 911

Okay kymedic2007.. after reviewing some of the web sites that was given it has some nice diagrams and simplistic information on the Fick principle. Maybe you can enlighten us on the problems you are having understanding it ? Or you have a comment etc.. Questions such as this might get a better response...Apparently we have been getting a lot of students lately wanting people to do their homework or research for them. I suggest reading your text, then reviewing some of the web sites then come back with specific questions that you have about the theory. I am sure there will be plenty of medics to assist you then... who knows you might even teach us a thing or two... R/R 911

First do the patient no harm... if it is not harming them, then I would leave it on. If it is 1'st degree, it won't really matter. The chances of you causing the more pain, and contaminating is greater. After the patient arrives in ER they will cleanse the area, and probably do some debridement as well as some SSD and tetanus, dressings. Why temporary attempt to cleanse the area and cause pain to have it redone in a few minutes?... Be safe, R/R 911

I guess you can say they had a successful save... :wink: LOL

Nate, this is the accepted layman CPR method from AHA... yeah, it is hard to kill a dead man... R/R 911

Because most education that teaches cardiac care knows that trendlenburg is a myth... Without perfusion all that would occur is slight venous pooling. ....short and simple. R/R 911

Very Good indeed!...... R/R 911

This is why .. The Trendelenburg Position: Another EMS Myth By Bryan E. Bledsoe, DO, FACEP MERGINET—One of my most-requested conference talks is entitled Myths of Modern EMS. It also corresponds to a series that I wrote for EMS Magazine in 2003. In that lecture, I review numerous EMS practices and the science, or lack thereof, behind them. It stimulates discussion and, as I had hoped, has stimulated some research. Now, I have another EMS myth I can add to my repertoire: the Trendelenburg position improves circulation in cases of shock. Researchers at the University of Southern California Keck School of Medicine performed a retrospective review of the literature pertaining to use of the Trendelenburg position in shock. They found several studies on the maneuver. One compared six hypotensive patients in clinical shock to five normotensive patients. In nine of the 11 patients, the Trendelenburg position was ineffective, causing reductions in systolic, diastolic and mean arterial pressure. They also found that the abdominal viscera moved up onto the diaphragm, restricting respiratory volumes when patients were placed in the Trendelenburg position. Another study looked at oxygen transport in eight hypovolemic postoperative patients placed into the Trendelenburg position. While the position seemed to increase blood pressure, it did not increase cardiac output. Another researcher studied the effect of the Trendelenburg position on blood distribution and found that only 1.8 percent of the total blood volume was displaced centrally. In a relatively large study of 76 critically ill patients (61 normotensive and 15 hypotensive), they found no change in pre-load or mean arterial pressure for normotensive patients. In normotensive patients, they found a slight increase in cardiac output. However, for hypotensive patients, there was no increase in pre-load or mean arterial pressure. In these patients they found that cardiac output actually diminished—a detrimental effect. In summary, the Trendelenburg offers no benefit to hypotensive patients. Like the MAST/PASG, another long-held belief can be abandoned as EMS becomes more evidence based. ****************** *************** ******************* *********

Should Heart Attack Care be More Like Trauma Care? Courtesy the EMS House of DeFrance http://www.defrance.org In a heart attack, every minute counts. But should patients spend a few more of those minutes getting to a hospital that can provide the most advanced treatment, rather than just the closest hospital? That question is at the heart of a current debate among heart specialists: whether to make heart attack care more like trauma care, with ambulance crews taking certain patients to specialized hospitals that can perform emergency heart procedures, rather than stopping at the closest hospital. A new study looks at a crucial issue in that debate: how close Americans live to hospitals that can perform angioplasty, which is considered the best treatment for the form of heart attack called STEMI, if it’s done quickly. Only a fraction of American hospitals perform angioplasties, which re-open blocked blood vessels in the heart and can be done electively to prevent a heart attack or urgently to treat one. The new research shows that nearly 80 percent of Americans live within an hour’s ambulance trip of an angioplasty-performing hospital. The University of Michigan and Yale University research team made the finding by combining and analyzing census data, hospital locations, driving distances and estimated driving times. The researchers also found that the closest hospital to about 58 percent of Americans doesn’t do angioplasty. But the extra drive time to an angioplasty hospital would be less than 30 minutes for most of them, though many patients in rural areas would have farther to go. The research will be published March 8 in the journal Circulation, and will also be presented March 13 at the annual meeting of the American College of Cardiology. “There are many more issues involved in regionalizing heart attack care, with proximity to specialized hospitals being necessary, but not sufficient, for making such a system feasible,” says lead author Brahmajee Nallamothu, M.D., MPH. an assistant professor of internal medicine at the U-M Medical School, researcher at the VA Ann Arbor Healthcare System and member of the U-M Cardiovascular Center. “This study puts in perspective what it would mean for patients to be diverted from the closest hospital to one that performs angioplasty.” Says Harlan Krumholz, M.D., senior author and professor at the Yale School of Medicine. “For some patients the difference in time is trivial, for others it may add a potentially dangerous delay to their treatment. It suggests that a national policy needs to take into account local geography.” Adds co-author Eric Bates, M.D., a U-M professor of cardiovascular medicine who has studied emergency heart attack care for years, “This analysis is a first step. It shows that the majority of patients don’t have geographic limitations that would obstruct the concept of regionalization, but it doesn’t address implementation and economic issues.” One of the major issues in the regionalization debate is the ability of ambulance crews to distinguish STEMI heart attacks from other problems using portable electrocardiogram equipment, since only STEMI patients have been shown to derive more benefit from emergency angioplasty than from fibrinolytic (clot-busting) drugs that can be given at most hospitals. Research by the new paper’s authors and others also continues to show that emergency angioplasty holds the most benefit for patients when it’s performed by experienced doctors at hospitals where it is the “default” STEMI treatment and when it can be performed in a timely way. For these reasons and more, Nallamothu notes that the regionalization of heart attack care will probably have to happen on a local and state basis, rather than nationally. Already, he says, several cities such as Boston and states such as Maryland have started to implement new protocols for ambulances and hospitals that allow quick diagnosis of STEMI and immediate transport of STEMI patients to hospitals that can perform emergency angioplasty. The new study is based on data from the 2000 U.S. Census broken down by individual tracts, the American Hospital Association’s database of hospitals’ locations and the services they provide, Medicare data on angioplasty billing by hospitals, and driving times, distances and road routes derived from commercial geographical mapping software. The researchers added in time for the dispatching of an ambulance and the assessment and loading of a patient at the scene by the emergency medical personnel. In all, 1,176 hospitals provided angioplasty, about 25 percent of all acute-care hospitals at the time. The number and percentage have almost certainly grown since 2001, as more states allow hospitals to perform angioplasty even if they don’t have open-heart surgery capability in case of a complication. The median driving time to an angioplasty hospital was calculated to be 11.3 minutes, or a distance of 7.9 miles. Driving times and distances were calculated using road routes, not “as the crow flies.” The researchers also calculated the “bypass delay” – the additional minutes an ambulance would have to drive to get to an angioplasty hospital if it wasn’t the closest hospital. The median was 10.6 minutes, and 9.7 miles. A total of 73.8 percent of adults whose ambulances would have to bypass another hospital to get to an angioplasty hospital would be able to get there within 30 minutes, and 90 percent would get there within 60 minutes of additional driving time. While 79 percent of American adults lived within a 60 minute ambulance trip of an angioplasty hospital, there was tremendous variation across the nation. In the mid-Atlantic states, New England, and West Coast states, more than 82 percent of adults were within an hour of such a hospital, while in the plains states and desert Southwest, the percentage was in the 60s. No matter what state they lived in, only 47 percent of rural adults were within an hour’s drive of an angioplasty hospital. And rural adults also faced longer “bypass delays” than adults in suburban and urban areas. In addition to Nallamothu, Krumholz and Bates, the study’s authors are Yongfei Wang, M.S. and Elizabeth Bradley, Ph.D. of Yale.

Actually, this is a prime example why our EMS is considered training like in 1'st Aid. Excuses and laziness of EMS and their by-products. Even nursing homes nurses aides get clinical time....Wow that says a lot about our profession! R/R 911

It is not an unusual order.. I do not like administering Phenergran to anyone over 65 because of the side effects I have seen, If I have to administer it I too prefer 6.25 to 12.5mg (diluted IV). In our ER our Doc's no longer will prescribe Phenergran sue to the caustic effects on the veins. even after explaining we will dilute it down... they prefer Zofran. Although Zofran is a very good antiemtic the costs is about $350.00 a pop in comparison of Phenergran at $15.00... be safe, R/R 011

As a program coordinator I always had 3 forms for the evaluation. One for the preceptor to fill out for the student to fill out daily, what they seen, whom they worked with etc. with some brief lines that the preceptor could fill out to give the student some ideas, suggestions or even kudos. The grade form was given to the preceptor and was was placed in a lock box for me or other instructors to pick up. The student was allowed as well to evaluate the preceptor and the clinical site. This definitely helped identifying helpful preceptors and better clinical sites. I believe honest student eval's was given do to privacy of the eval.'s.... I know it more time consuming, but worth it... Be safe, R/R 911

Thanks Tinman.. I did spell check I must have accidently over corrected it... R/R 911