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zmedic last won the day on February 13 2012

zmedic had the most liked content!

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    New York

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    Emergency Medicine Resident
  1. Rattle snake bites

    The most important part of treating a snake bite is to bite the snake back. Otherwise, they never learn how it feels and will keep biting people. (To the idiots of the world, don't do this)
  2. Intubation woes

    My advice is to say out loud what you are doing and seeing. This is helpful for a few reasons 1: It calms you down 2: It reminds you what you are doing (by saying what you are supposed to be doing at that point in the intubation it reminds you to do it. 3: You get more time to try the intubation if the person supervising hears that you know what you are doing, and if things are going well, they know what you are doing to correct the situation and are not just staring and the esophagus. Example: "I'm opening the mouth wide, inserting the blade to the right and sweeping the tongue. I'm clearing the lips, I'm lifting to the opposite corner of the room. I see the epiglottis, I'm advancing into the valecula and pulling up. I see the cords, tube please. I have a grade 1 view (if you do), I see the tube passing through the cords. (hook up bag) I see chest rise, I have tube fogging, I have good C02 capnography. Equal breath sounds over the lungs and nothing over the belly." Sounds dumb but that's what I was doing in anesthesia and I wasn't having people bump me out of the way after 5 seconds like some were.
  3. why was atropine removed from acls?

    I think EMS research is valuable, but it's worth remembering that the that big thing in research is having enough of whatever event you are studying to be able to detect a difference between the study group and the control group. Take cardiac arrest as an example. If you want to know if a certain drug has an effect of cardiac arrest survival it is much easier to study in a hospital than in the field. For one thing it is easier to train one or two people who sit in the hospital all day and go to every cardiac arrest than it is to train 50 paramedics in a study protocol knowing that most of them will not have a cardiac arrest in a given shift. It is also easier to record data in a hospital because there are so many people there (ie it is hard to have a medic record information for a study while also providing patient care). Finally, in a hospital there are less variables. Again take cardiac arrest. When someone arrests in a witnessed setting there is often immediate CPR, and rapid ALS. In the field you have more variables (dispatch time, arrival time, ALS v BLS v first responder first on scene, transport time to ER etc). Furthermore, since so many prehospital patients aren't going to survive their cardiac arrest no matter what because of no bystander CPR, no early defib etc, it is harder to see the difference in outcomes between say two drugs. I guess as far as ACLS goes I feel like "if it doesn't work in the hospital, where the patient has the best chance of getting lots of help from highly trained people, there is no way it is going to work in the field." I think show that something works in the hospital, then test it to see if it makes sense to have in the field. If it doesn't work in the hospital, don't even bother studying it in the ambulance. I'd also mention that one reason it is so hard to change things in EMS is that once something becomes standard of care, it is very very hard to test, because it could be considered unethical to withhold standard treatment from a patient. I'd love to randomize people who have been in low speed MVCs to backboard or no backboard, but I don't see that happening any time soon.
  4. DIlaudid

    In this case the issue with methadone wasn't so much the side effects. It's that (and this is my understanding, don't quote me) since the methedone is still stimulating some of the opioid receptors the patent still has those receptors active, so they still have high tolerance to opioid medications. (More receptors=you need more receptors activated to have the same effect). That and/or the methadone may be competing with the morphine for the receptors, reducing the morphines effect. Not sure exactly but the issue were were having was reduced response to the morphine rather than side effects. It's like when a cancer patient who is getting 10mg of morphine an hour for their pain comes in with a broken hip. You better not be staring with a 2mg of morphine dose in the ER.
  5. DIlaudid

    As others have mentioned, high addiction potential. That alone makes me wary of giving it. I don't think addicts are inherently bad people, I think genetically there are many people who have genetic predispositions for addiction. Given that, I'd rather not expose people to addictive substances if I have a choice. I'm sure that there are many cocaine users, meth heads etc who wish they had never tried the stuff. That being said it seems to work very well on sickle cell pain. Also for some reason maybe some better effect than morphine in those with high morphine tolerances. Had a burn patient the other night who was on methadone at home, morphine wasn't really touching her pain but 2mg dilauded x 2 over 3 hours did well.
  6. Benzo Overdose

    The benefit is that nebulized (or more commonly intra nasal spray with an atomizer) gives you the ability to have people like EMTs or bystanders who don't have the ability to give IM/IV drugs to give Narcan. There are a lot of rural places that don't have medics and have a big problem with opiods. Narcan is a pretty safe med and narcan up the nose sure beats bagging the patient for an hour.
  7. Prehospital RSI

    New York City, manhattan.
  8. Severe pelvic pain, post-partum

    Not sure I'd start antibiotics. Especially since 1) she had similar symtoms before delivering (thereby less likely that it's a new problem) 2) The uterus is usually examined after the delivery, so less likely that the has a big retained piece. 3) A quick ultrasound can rule out retained products. Before you start thinking she's septic from retained products, does she have a fever? Sounds like no. vaginal discharge? Is she writhing around? More typical for kidney stones. Does the pain radiate to the right shoulder or get worse with food? More likely gallstones (especially since she's had them. Appendicitis, round ligament pain are also on my differential. Truth it it doesn't really matter. She needs rapid transport, an OB/GYN consult, ultrasound, maybe a CT. And ideally pain control, but if she wants to suffer that's her choice.
  9. Patient Advocate

    Yeah. At the end of the day it is the responsibility of the person doing the transport to decide if they feel comfortable with the transfer. Whether it is an EMT being asked to do a transfer that is clearly ALS, a medic being asked to titrate a medication they don't feel comfortable with, or a situation like this. I personally think I would have called the supervisor back and had them come to the scene, show them the size of the ambulance etc. If they still want to do the transfer let them take responsibility for the call. I'll drive their truck and they can sit in the back.
  10. Prehospital RSI

    The problem with kiwi's data is what do you do with that in the US? It's apples and oranges. I think it's great that down there they have a great success rate, but like he said, they have medics with 6+ years of training and lots of experience. So I don't know what to do with that data when deciding if my medics (when I'm a med director) who have a year of training and 6 months of experience should be able to RSI. I also think the need for RSI is going to go way down as more ambulances get BiPAP. It's reducing the number of tubes we're doing in the ER. And I think RSI is sorta an all or nothing thing. Either you are doing it all the time (like at least monthly) or you shouldn't get to do it. I don't want my medics trying to do RSI once a year.
  11. Four Loko

    The reason to use narcan is because the patient has depressed respiratory drive, not decreased mental status. The indication for narcan is respirations less than 12 a minute. The risk of narcan is taking a patient who is just chilling after an opiate OD and putting them into frank withdrawal. It may have some use in diagnosis but if you have to give it I think you should be giving dosages of 0.2-0.4 mg at a time. 2mg is too much unless you are about to intubate the patient. I second no using flumazinil. Most benzo ODs aren't so bad that they can't control their airway. And the benzos may be keeping other withdrawal, like from alcohol, under control. Then when they seize giving more benzos doesn't work.
  12. Where I used to work we covered a bunch of long canyons. Not a bad idea to be able to handle N/V when you are stuck with an ALS patient who has to stare out the back window at twisting road for 45min
  13. ALS using Lights and Sirens back to the hospital

    Not to start a fight with Dust, who'd win, but I'd like to talk about the idea of not having BLS rigs. I worked in a county where we were contractually obligated to have a medic on every rig, and that seemed really wasteful. A large percentage of our patients, like 80%, could have been managed on the BLS level. They were stable, didn't need drugs/pain control. It costs the system a whole lot more to have a medic on every truck. A well trained EMT should be able to handle a lot and get ALS backup when they are in over their head. (Clearly ALS should be dispatched immediately to certain calls, like chest pain, SOB, etc.) Thoughts?
  14. ALS using Lights and Sirens back to the hospital

    One big reason for the discrepancies between places is policies. I worked for a private company that said statistically only about 5% of our patients should be brought in L/S. Every emergent run was QA/QI, and while that was mainly to check medical care, if you were running hot when the patient didn't have any idications you would hear about it. So most patients didn't get run LS, and those that did were the really sick ones who needed it. I thought it worked well.
  15. ALS using Lights and Sirens back to the hospital

    I think emergent response is still indicated for events such as suspected stroke or MI, where even a five minute difference can be a big difference (MI you lose 1% of infarcted area per minute) I’ve also had patients that in the course of the ten minute ambulance ride went from being awake and alert to unconscious. In most urban situations emergent driving saves very little time, though on long transports the savings in time may be more dramatic (I’ve had 45min emergency transports where I probably saved ten minutes from slower traffic pulling over for me.) But I will agree with you that 90% of emergent transports are unnecessary. They put our lives at risk and risk the live of our patients and people on the road. I also think it's sorta funny that a lot of these patients who come in emergent then sit on the pram for 15min while the nurse triages and looks for a bed.