Off Label

https://www.ncbi.nlm.nih.gov/pubmed/26024432 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665872/ To the OP, there is some evidence that challenges the directives you posted. Here are just two, the first being just an abstract, sorry. You very well may have a point in the extremely conservative use of the drug in the pre-hospital setting. People are prescribed NTG and walk around with it in their pockets every day. The problem is that when an agency writes a policy or directive, they own the problems with it and must justify the difficulties with it. I'm with you in principle. At the very least, as an antihypertensive in the setting of subendocardial ischemia, NTG, if it is all there is, is pretty valuable.

Since you put it that way, NTG should be used in appropriate patients in the appropriate setting by the appropriate personnel. It doesn't matter what anecdotal evidence anyone can offer...all anyone is able to go on are randomized controlled studies and meta-analyses that control for very specific variables so that some sort of coherent conclusion can be made. Even then, great caution has to be taken with the conclusions.

Understand that this is a very superficial context in which to view the use of NTG. Pre-hospital care is a microcosm and an entire universe of care exists beyond the ER. In a world of tight protocol and directives where one size must fit all, as is totally appropriate for the setting, NTG apparently cannot not be used to it's full potential (see my post above). Just know that it's use in the same patients that you transport for care in the ER for myocardial ischemia is far more multidimensional once that patient gets upstairs.

No, he's not.

Well even if it were just for pain, why is that not of therapeutic value? Pain causes distress which causes sympathetic discharge which causes, among other things hypertension and tachycardia which increases O2 demand and consumption in the circumstance of a pathologically impaired blood supply. Beyond that, say for example, the NTG unloads the heart and causes a diastolic pressure of 100 to become 88. That is a direct positive effect on LV subendocardial perfusion. Will it be enough? Who knows? But that by definition is therapeutic. I'm sure you could think of other examples as well. Do you really hear that all of the time? You gotta pick different people to hang around!

Good advice about getting into the multiple choice question frame of mind... taking these tests is a skill over and above mastering the subject matter. I do feel the OP's pain though... if a question like that were a deliberate curve ball and not just an error (they do happen), you'd really have to question the quality of the question writers. Can't have a pulse pressure of 40 without a pulse. Questions that contradict themselves don't muster a lot of confidence in the rest of the exam. I suspect, though, it was a typo...

I'm amazed at how articulate and seemingly intelligent some folks are that are not able to pass these exams after two or three times despite intense and diligent study. My advice as a next step would be to be assessed for an occult learning disability. Plenty of very intelligent adults suffer from these but never have them assessed. Go here for a start: https://ldaamerica.org/

The SF Bay Area has several cities that have that set up. Marin and San Francisco are two exceptions but San Mateo, Alameda and Contra Costa, to name 3 have non fire EMS agencies. Google them.

As a new member on this forum, I'm pretty reticent to give advice of this magnitude to someone I don't know. But from what I've read of your posts, you seem to be a pretty experienced dude that has some respectable chops. And a stand up dude to boot. So take this with a grain of salt and an open mind. 5 years is a really long time. It's only my opinion, Ruff, but were I you I'd seek a precepted couple of months with a busy service before going back. I say this for a couple of reasons. Firstly, it's a PRN spot where your exposure to bona fide emergencies is limited. They don't know you and credibility is a big deal. Nothing you don't already know, I get that. Second, as you kind of implied, stuff changes so quickly in medicine. What might be second nature to you now has been old news for a while in some services. Lastly, when folks in my business leave for that long and come back, they are welcomed with open arms as they do a precepted stretch on the job. These are people that have intubated thousands and thousands of time in the operating room under ideal conditions, let alone on a rainy highway in the dark. If I take two weeks off, I'm all thumbs when I get back. It's just a safe way to go and make a good impression. It would make for a really smooth transition back, IMHO. Best of luck.

So you do your due diligence and find exactly what the OP describes....a disoriented 18 year old with a bike and some scrapes that wants to refuse care. And a normal blood sugar. The real danger here is making it way more complicated than it is. Given this set of circumstances, she can't be left alone. So, finding a responsible next of kin/party (roommate, boyfriend, parent etc) can ensure she gets potentially life saving care by familiar and friendly encouragement to seek attention. At the very least, she might go to the hospital with that person. It would also avoid getting the cops involved. Based solely on what the information given is, leaving her alone is the wrong answer.

Did you not post this identical question in another forum on this site and get at least one answer?

Have cops find next of kin or responsible party while I check a blood sugar.

...where to begin? Don't know what the ratio of deaths to active shooter events is, but there is no way it is high enough to justify what the author is proposing. If there were demonstrable data that showed somehow that a significant number would be saved relative to the number of events, I'd say don't even do it then. Not so some medics could go on suicide missions. The cops weren't even going in at Orlando. Also, if he thinks a ballistic helmet and vest is any kind of protection, I question what if any expertise he actually possesses in terms of this topic. Hero complex indeed... I will say that it wouldn't be unreasonable to expect the ratio of LODD to active shooter to rise if that is something that is tracked.

I think there might be other factors in play as well....

This is a really good question. I think the answer lies in the increased alveolar ventilation relative to oxygen uptake at the alveoli. If a patient is hyperventilating, by definition it is not for the purposes of increasing oxygen delivery because there isn't an increase in demand. So instead of exhaling the usual (about) 16 % oxygen, he is exhaling something closer to the inhaled 21%. While more oxygen per minute is reaching the alveoli because of the hyper ventilation, there isn't an increased demand and uptake so there is more left over to be exhaled.

Negative...she came to us in full arrest.

Well, devil's advocate here, wouldn't that just cause a large increase in the number of medics and drive down salaries? More medics would probably mean less quality as schools had to re-tool and turn out more medics to stay open. Less experienced would be more likely to settle for lowered wages in the circumstance of more competition for a single job. A narrow gate isn't always a bad thing, IMO....I have no idea what the thread is about, just responding to you, Ruff...

Also at issue are high stakes, high skills burden procedures. For real proficiency in procedures like advanced airway security, there is just no substitute for doing it a lot. Just how that happens is another question.

ECMO is a game changer. Time was that it was only really practical in the pediatric/ neonate population, but with technological advances adults now benefit as well. I've participated in two quite thrilling saves of patients who wouldn't have had a chance of survival at all. One was a young lady in her late 20's with a PE and the other was a 50 yo sudden death/ occult severe left coronary artery dz.

Well, I think the comment brings up an interesting point and that is why do we do what we do in the first place. People usually come up with lofty answers like "to serve humanity" or "make the world a better place", but ultimately we all do what we do to restore our patients to the level of functioning that existed just prior to the event that got us involved. That is how we should measure what we do, I think, and that is all patient's can expect of us, given the circumstances. The bar is set pretty high in some cases and not so much in others but at the end of the day, if someone can go back to school or a job or being a parent intact, it was a three point landing.

Her co-workers are d***heads too. Unless that's the way she treated them and couldn't get anyone to cover. It'd be odd for such a "star" employee, but there are two sides to every story.

I don't disagree here at all. But I think the term "diagnostic" is a misnomer in this regard. Before the days of finger stick glucose, the above described patients would get a stick of D50, not for diagnostic reasons but for therapeutic ones, in the event the altered patient were suffering from you-know-what. Not too many downsides of doing that either. A little narcan isn't going to make matters worse. The fact of the matter is that there is a wide disparity of skill and experience among providers and this type of protocol is a low stakes way of mitigating that situation and making sure something isn't missed.

The reality that 3rd party payers, ie Medicare, are looking for any excuse no matter how trivial, to not pay you for the care that you've provided. If that means simply not including non-pertinent information, then don't. You should know what Medicare et Al will flag for non reimbursement and that should come from the employer. This is not falsifying anything... it's not recording unneeded information.

Oops...ya got me! Good job!

They're not dead until they're warmed after their therapeutic hypothermia!