mobey

So this scenario was more of a "Would you leave this kid at home" poll than an actual scenario in EMTCity terms. In that case, no. If a child is at all unwell I always transport or have the parent transport.

In Canada we cannot force patients against their alone will under any circumstances. If they are unconscious that is "Implied consent" If they are refusing but deemed a danger to themselves or others we call police to 'Form 10' them. (Under protective arrest) Then police accompany us to the hospital. If they are competent, sober and refusing but not a danger - we leave them at home. Nice part about this system is all the liability lies with the Police (RCMP) and not the EMS crew. To take a competent sober person against their will here would be kidnapping.

Yeah..... we have that system in Canada. Trouble is no one ever looks at it. You have to login and look up the patient then read the prescription history. Takes time. But to keep it secure it has to be a secure server that each person must log in too each time, otherwise privacy issues come up.

This is a great point. As we all know, some people are searching for a reaction, and are going to get offended and dramatic no matter what.

Check lists for what?? Online like on a private server?

OK here is your scenario,...... you are me. 2nd scenario: You call for orders: "Hello Dr, I have a 22 year old bla bla bla....." Dr asks the gender, *you look like an idiot. Scenario 3: Abd pain at or below the level of the navel.

Gotta chime in on the Ketamine discussion. In my opinion I think using Ketamine routinely in the prehospital setting is a little narrow minded. The problem being: most ER's are not going to continue use of Ketamine after EMS leaves. What that means for the patient is at some point (quite quickly) the ketamine will wear off and they will be left writhing in pain until they get assessed by an ER doc and get new orders for a narcotic.... then the loading dose must be administered to reach therapeutic effect- which we all know with personal bias involved, or a really busy ER, can take a long long long time... Then finally at some point they will have pain relief achieved while awaiting further treatment. This just seems like a poor approach to pain control, where on that same patient we could have used the 25mg of morphine to reach the therapeutic effect prior to entering the ER leaving them to just top up on a simple narcotic as the patient needed. Instead too many give 10mg of morphine, call the pain 'refractory' and switch drugs so the patient has quicker pain control while in the ambulance without considering the tertiary care. This theme is also becoming common with RSI's in this area. People are using Ketamine for the RSI, then followup sedation/analgesia with Fentanyl/Versed. But they wait for the patient to begin waking up so they know most of the ketamine has been used up prior to administering the benzo's and narcotics. Yaya... we can debate neuroprotection, and blood pressure with ketamine all night, but the point i'm making is that every case should be individualized for that specific patient and the health care collaboration they are involved in, not just rubber stamped. Now don't get me wrong: I do think ketamine has a place for true refractory pain, or opioid sensitivity, but in those cases I DO suspect the ER will continue with it's use. The reality is, prehospitally we kinda suck at pain relief with narcotics. We tend to stay away from true therapeutic doses either because of protocol, or fear of resp depression or mental status change.

oh good one! Also I ask the spelling of your full name. 'Sam - Samantha' 'Pat - Patrick' Another is to ask if they have kids, and if so get a few details that may lead to some indicators. I have also asked about any recent genital infections or STD's..... A lot of times - if female they will report a yeast infection within the last year. One of the areas I cover has a population of transvestites living there, I just flat out ask the guy-looking person who is wearing a dress and a 5o'clock shadow "Do you have a penis?" It's akward for them.... but it passes. Other than that just wait till your at the hospital and let them sort it out lol.

Yes, Sorry. Should just speak in generic names. ....Links to a few studies for those who are not familiar. Exact mechanism is unknown, but results are statistically significant to support it's use. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341930/ http://www.bmj.com/content/329/7479/1369

How about Maxeran? That's what we are doing 2nd line prehospitally.

Lately I have noticed on a lot of forums, that usernames are nothing more than a collage of letters and numbers. Efssg348, SSSkk123, etc. Thought it might be fun to come up with some clever usernames for those with no imagination to draw from. WailYelp99 Criticare11

Yes I have had it (see my old post in burnout & stress forum), and here is my take: I can tell from the tone of your post that you are defensive about linking psychological factors to the variant angina. Set that aside for a moment and look at it this way: IF you are in an existing anxiety state (which you may not know btw) you may be prone to vaso spasm due to increased release of stress hormones. Stay with me here..... If you are secreting higher than normal stress hormones, simply adding a little more stress, whether it be psychological, smoking a cigarette, or physical exertion, may trigger an angina attack. Now this may not be what is occurring, but as a diagnostician you should do a thorough job of ruling out whatever you can. My suggestion to you is to entertain the idea that perhaps without knowing it you may be in an "anxious state" and secreting extra catecholamine's that is putting you on the verge of vasospasm, and take some action. You may be surprised what a massage, meditation, or even a cleanout of your psychological closet can reward you with physically. If you find my old post about longevity in EMS you will see the steps I took. I am happy to report I am 6mos without angina, horrible nightmares, and have a lower resting heart rate. No drugs, no exercise change, just a change in mentality. I'm not saying it's all in your head....... I'm just saying some of it may be buried deep within your brain.

Hey I recognize those posts! Welcome back "iStater"! RRT hey?

Okay: I'm on the "High pressure Pulmonary edema" train. Just want a HR and BP and temp to solidify my assessment. Either way, CPAP goes on now. Get a line in her and once the pressure comes back hypertensive give her a Nitro (OK that was a little arrogant) In the mean time, squirt the Salbutamol MDI in the cpap a few times. There is a balance between relieving spasm to maximize ventilation/oxygenation, and irritating the heart with excess salbutamol. I'll also give her 1.0mg Ativan SL if that BP comes back high. I like to treat the intrinsic catecholamine dump from the source. of course all this is based on vitals = tachycardia with hypertension and afebrile. Ya kiwi that is correct. The problem is, sometimes you cant hear the crackles through the wheezes, or differentiate good enough until it is too late. With a RR of 60 and signs of fatigue I am as aggressive as they come if I suspect flash edema. I have had 3 people die in my ambulance ever...... and they were all high pressure pulmonary edema patients. All the ECG's are important, if this is an acute MI, we may thrombolize it. If the A-Fib is gotten out of control again, she may need rate control, but if we don't get her resp status temporized none of that would matter.

First off.... Welcome to the city! Regarding your post - your grammar is so terrible I can't really make out what your trying to say. You have had 12 continuous patients at all levels?? Then you went on to tell me to get a history?? Or maybe you are saying you don't miss pulses because you get a history before treating suspected cardiac arrests? I dunno.... The point I was making is that this patient obviously DID have a pulse, one which I was unable to detect after 10years of detecting pulses on all types of patients. I was simply acknowledging that the science has now aligned with my experience.

Sweet! Thanks for all your effort doc!!

Well here I am..... after nearly 10 years of continuous patient interaction at some level it finally happened. I went to a call for a 60y/o choking (didn't know he was choking), and I couldn't feel a pulse. No carotid No radial No nothing. I looked at him when I entered the room, and was thought "yup.... he's dead" then confirmed it when I couldn't find a pulse. I moved his arm off his chest as to start compressions, and noticed it was rigid. Then the unthinkable happened.... he put his arm back to his chest! I redirected my focus and started bagging his stoma, and my partner snapped on an Sp02 monitor to find a waveform and a readout. couple breaths in he started getting some colour back and somewhere over the next while we pulled out an obstruction. Full recovery No CPR Ain't that some shit. Guess I'm human too?

Top sample all the way! was flowing clear.... then suddenly, bam..... turned to photo #1

Nice find. Thanks

The 70 year old kyphosis patients will be so happy!

Am I too sensitive? Why do I seem to be the only one with a moral problem having a 15 year old on an ambulance watching?

Hooch is crazy... Anyway... Man this is a really legitimate, but tough question.. How to teach critical thinking. You know I think the problem is that we teach EMT's flowcharts and acronyms. Then in scenario's we try to test them on concepts which involves critical thinking. I really think critical thinking has to be taught on the street. I just keep asking "Why", until they cant stand me anymore. I think it is a little unfair to expect critical thinking in the classroom unless they are taught pathophysiology.

Due to a few recent personal attacks I have stated carrying a self defence pen, and am acquiring an ATAC L2 flashlight (Small blinding strobe feature). Other than that, just my stethoscope, narc pouch, and safety glasses. By the way: Page 9, shockdoctor states Oh My Gawd..... Sooooo funny. I am definatly using that line more often.

Could also be just as simple as motion sickness form traveling backwards! This is one of the reasons I consider antiemetic use in spinaled patients to be basic airway protection regardless of nausea. From a BLS perspective, 02 may help the nausea as well. http://www.ncbi.nlm.nih.gov/pubmed/11794455 Reported pain remained greater in the oxygen group. However, those given oxygen had less nausea (22 +/- 29 vs 54 +/- 38 mm; P<.001) and vomiting (4 vs 19 episodes; P<.001),

Since there is a lack of threads to search on this topic, i'll add that here in Canada there are circumstances where EMS may assist in transport of a short duration. I'll give a few examples of when I have done it: Pt codes in the ambulance and is pronounced in the unit. Funeral attendant/Coroner is going to be delayed Particularly 'messy' patient We would never deplete a community of it's only ambulance for something like this, but usually the funeral home comes with a minivan and 1 person to recover the body. Fire could be called to assist, but most are volley services in the rural setting, so we will step up and help out as long as the transport is short. For the record: I know New York is not in Canada