chbare

If you are going with a fluoroquinolone and have to choose one, why not go with Levaquin?

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned.

Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

If available, yes. EEG monitoring post arrest with ROSC in unresponsive patients is a class I intervention (*However, it is supported by class C evidence), therefore, if available, I would absolutely use it. (Emphasis on "if" however.)

Judgement call on the hypothermia, but unless compelling evidence is discovered, I am not keen to deviate significantly, particularly when seizures are not an uncommon occurrence post arrest.

Generally agree with labs and a chest X-ray; however, if we are considering a Chem-7, we may as well go all the way and look at a CMP/Chem 12. Additionally, I would look at cardiac enzymes if ordered in addition to coagulation studies, and I would also like a urine tox screen and a draw for ASA & APAP levels. The known electrolyte abnormalities are curious to say the least and warrant further investigation. Agree with Potassium supplementation.

We need an ABG and I would correlate to quantitative capnography monitoring if able. If we have a central line in place, what is her CVP? What was the CVP prior to the norepinephrine infusion?

Review the ventilator settings as well and make sure the pressure problem is not related to auto PEEP, air trapping, pneumothorax or high airway pressures.

Regarding hypothermia, if there is no history of trauma, I would not recommend stopping and re-warming without significant history or findings. At this point, she had ROSC status post defibrillation with a history (presumably) of a non-traumatic arrest. Additionally, the patient remains comatose and hypothermia has already been initiated. I am not compelled to make significant changes without markedly more compelling information. Additionally, EEG monitoring if available, may be of benefit, particularly if we administer neuromuscular blockers, so we can monitor for seizure activity.

Just wanted to add that if you transport a patient, make sure you transport all of the equipment for the VAD including the power base unit (PBU).

There's also a big difference between what one plans on doing and what one ends up doing.

Depends on the state. New Mexico for example has a state scope of practice. The right to practice as a EMS provider in New Mexico is called a license. While medical directors can limit the scope, providers cannot exceed the scope set by the state unless a service goes through a special skills application. The way in which license and certification is interpreted will vary significantly and may even be a function of situational context.

The last time I said this I was tore up a bit, but it looks like atrial fibrillation to me.

I strongly suggest you go to the website and do some research. It actually contains good information and may answer many of your questions. Good luck.

http://www.nremt.org/

I honestly do not think any of us can say with any certainty exactly how things went down. It is pretty easy for us to arm chair quarter back this to death, but what a tough job the jury must have had. I am not really all that keen on the speculation and baiting that can be derived from this situation and I cannot think of an outcome where all involved including the nation in general would feel as though the justice system provided optimal results (With the exception of the confrontation not occurring in the first place.). This is the problem with humanity, the ambiguities and imperfections lead to imperfect systems. I hope that the national dialogue that results is productive and it clearly illustrates that we have much work to do as a nation.

I'm really not keen to do so. As stated I'm not a Rolling Stone fan in general but I wholeheartedly support their right to publish this article and have the picture they used on the front page.

I would take it even further. I think the magazine has every right to publish their story, front page. It is up to the reader to decide if the story is worthwhile. I would not feel comfortable regulating a magazine publisher even if they publish ideas and conclusions that run contrary to my world view.

I cannot say what I think. I'm not much of a fan of Rolling Stone so I've yet to read the article. I assume the article's conclusions are likely to be overly simple and myopic as we've yet to really have this situation play out in the courts, but that is simply a guess.

Yes, supraglottic airways can be used as a rescue. I'm still not convinced that vecuronium is an optimal agent, but there are probably worse ways to do it.

Vecuronium is a competitive agent in that it must compete with acetylcholine at the receptor site. This means that it's onset can take minutes at standard doses.

When used as a paralytic agent for the RSI procedure, I can see a few pitfalls:

1) Intubating conditions will take longer to develop

2) The duration is longer than the duration of many commonly used induction agents

3) There is no chance of a salvage after a few minutes if a failed airway situation develops

Personally, I'd say it's a suboptimal agent for facilitating RSI. I've used other competitive agents such as rocuronium but at relatively large doses to produce a relatively rapid onset. I also worked at a facility where vecuronium was used with varying degrees of success.

Unfortunately, some concepts simply lack human intuition. As humans we are biologically wired to understand a macroscopic world and thus develop intuitive heuristics to learn and function in this world. At some point, simple analogies break down and completely fail to explain some of the deepest concepts that underlie the universe.

"It is a different concept I mentioned. It is a type of spin that very small objects such as electrons have" E.g. quantum spin states. Were you teaching MRI theory?

I was doing a fairly standard lecture on general chemistry and quantum numbers. However, there are always students who ask the tough questions and I have yet to really find a good, intuitive answer. I know many people use a planet orbiting with a certain spin about it's axis analogy, but this fails when people start pushing for better answers. Likewise, saying spin is an intrinsic type of angular momentum due to anti-symmetric wave functions, the Pauli exclusion principle and so on does little to help.

Spin is simply something so bizarre and outside of the human experience, there are no good classical analogies that I can think of to describe it.

I am not sure. It is a tough situation for sure and I think the jury has their work cut out for them. I do not envy the task that they face. Regarding rioting, I cannot say. There may be some unrest but I try to remain optimistic about humanity.

That is exactly how it works. There is a passage that allows the cuff to communicate with the ventilation port. I'm not throwing in with the idea, but it's novel and is at least as effective as the LMA when looking at the limited evidence.

While I agree with the other posts about the NRB I am going to play devils advocate here for the sake of discussion. I find it doubtful that the CC is incompetent and would do anything to harm the patient (maybe they are, I don't know). So this leads me to question your facts and whether you have the knowledge to treat the patient or if your using textbook medicine.

The patient was apparently having an Asthma attack and had an SpO2 of 89%. What were the kids vitals? Did you auscultate the lungs? Did the patient have a hx of asthma? Skin condition? Hot to touch? Audible sounds?

I could be wrong but it sounds to me like you focused strictly on the SpO2 reading and not the entire condition of the patient. In my system we don't use SpO2 for this reason, we give oxygen only when medically necessary and to be honest when I first started I hated not having Spo2 readings though I find we have better care and better outcome when not relying on SpO2 reading.

The other thing is maybe the CC was angry because he was testing you. Maybe he wanted to see if you could defend your actions. I have rolled into an ER numerous times only to be yelled at by doctors and nurses for either doing something or not doing something.

One of the lessons you will learn is regardless of what your protocol or book says, you need to be able to back up and defend your actions. Maybe, the attitude of the CC wasn't to come down on you but to see if you could defend yourself. I have not heard anything from you that supports your actions except for the SpO2 reading.

You do not monitor pulse oximetry at all? I can think of several situations where pulse oximetry is indicated and even what may be considered a standard of care such as during intubation or when attempting to decide if you want to intubate. For example, if you are not able to effectively bag the patient to saturations above 90%, you would have a difficult time justifying the intubation/RSI.

This is an interesting and novel design. It looks to be very much like the love child of an LMA and an iGel. However, the interesting thing is the self pressurizing component where the cuff inflates and deflates in response to how you ventilate the patient.

The studies seem to place it's effectiveness as a primary airway as being on par with other types of supraglottic airways. Does anybody have any experience with these airways?

http://mercurymed.com/catalog2/index.php?type=85

Evidence is a funny thing prone to errors, misinterpretation and bias. If the evidence is strong, reproducible and generally accepted then I'm quite willing to change. Unfortunately, the strength of evidence is quite debatable and sometimes to the neglect of progress, we must reject alternatives that may be better until additional data is available.

The most productive thing to discuss is what are you proposing to change and what evidence are you using to base your conclusions on?

Wow, what a rambling post. Sorry all. I think I went bug nutty after spend most of last night doing chi squared calculations for a homework assignment and took my craziness out on the city.

Off topic, but cheating is an interesting thing. The last time I cheated, I was in middle school and rather than memorise the periodic table, I drew it on my hand and cheated. Unfortunately, my "friend" who also cheated was caught and ratted me out before I had the chance to wash my hand. I think the only lesson I learned at that point was one about snitching and trust.

Anyway, I have never cheated or considered cheating on these types of exams and all of the security made no difference. It's hard to explain, but I'd rather fail than know I didn't really pass. Knowing that I did something on my own is simply more gratifying. I am a type A person and I am absolutely terrified by failure, but I'd rather fail honestly. The thought of being so incompetent that I have to cheat is a greater failure IMHO.

With that said, I'm a pretty mediocre guy in the overall intelligence and humanity department, therefore I cannot assume that I have a better ethical code or moral compass than most everybody else. I have to assume most people are honest? It's too bad we all are inconvenienced because of a presumably small number of people?

With all that said, the NREMT testing process does seem to be well organised and administered in a self consistent manner that delivers reliable results when compared to many of the other alternatives such as filling in scantron bubbles and looking at a recycled paper booklet exam where you can see the erased marks of the candidates past in addition to the occasional missed scribble and call this # for a good time comments found within said state EMS exam booklet.

Not saying I had this experience when I had to take the state EMT-Intermediate exam before we transitioned to national registry...

There is a difference between monitoring another country and doing so with citizens in our own country. In addition, a dark period in American history occurred during this time. The Japanese-American experience during WWII should be just the thing we fear today. This occurrd in part due to similar excuses (safety, preventing attacks, fear mongering and so on) that are being used today.

Job well done.