tniuqs

Green Dude:

Nope VORTAN is "NOT' goof proof...no alarms, and best use an ETCO2 to monitor efficacy of ventilations, a bit of a different way of thinking when it comes to ventilation fer sure, (a Pressure Controller) but no worries about calculating ideal body weight...tee hee.

http://www.floteco2.com/htm/Products/B-VOR...esuscitator.htm

But never the less, one can ventilate a hamster to a moose, it is really light, and one can scab off darn near any source of O2 delivery system.

They look pretty cheezy, but Dr. Birds ideas still live on...hey maybe we could find one in Camo for you :shock:

Dust:

Just an idea here, if you have a need to ventilate patient and need to free up a spare hand, the VAR (pressure controller) Ventilator is a real work saver (Bird -in-a- Bag coined by RRTs.) it was a developed for SARs epidemic in T.O. if you want one pm me I will send one to you, they weigh about 4 ozs. and one can drive it with a 50 psi wall outlet, or use a regular flowmeter..

cheers

Quote:

"Michael"]To those who took the original poster to task for having asked, I would cut him some slack.

Michael: I can't see where anyone here has been too harse at all, I think that you may be a bit over sensitive to the comments provided. I think Holocene got exactly what he asked for..... education and in-sight, dare to ask hard questions dare to receive hard answers, in fact he apologized for asking because the realizing that this can be a very sensitive topic for some that in itself speaks volumes, I don't believe that he needs someone to defend him at all. A lot of these posts really spoke from their hearts and please don't think of it as easy but in fact it could be very therapeutic for some to get it out, put it on paper, and hit SEND.

Just a premature conclusion by myself but the "gross" things persay are not really the most difficult situations for EMS providers. In fact its the humanity side of things that is the real trend here..... quite reveling....... hey EMS workers are actually humans too! WOW!

Quote:

quoting Micheal:I don't sense that morbid curiosity drove the question here, though outside this context it certainly could, and I'm sure y'all would handle that occurence gracefully and redemptively. The tone of Holocene's several posts at this site suggests something other than ghoulishness, so I wouldn't want to tar him with the same brush.

Just to be crystal clear here:

Quoting myself: I believe its blatant morbid curiosity, edit (its a human trait) but agreed totally it is annoying and quite rude to my way of thinking. edit (the point here) I have often been at a social gathering when someone asks the standard question.

I think R/r and hammerpcp summed this up nicely. I too have had some nightmares "that wake me up in a cold sweat" that I (can't remember) when I do wake. How about 8 arrests in one shift and not one survived....hmm.....I was the last person to ever talk to those good folks........ How about 16 burned to death in a train wreck, then 96 more to give care too with some being the living relative's....don't think that haunts me? I rarely get into this type of topic because one just can't explain this to the lay person, or even an ex wife :roll: Then someone decide's to post their religious values or beliefs believing that their way is the only way, now that does frost me to be certian.

... so like I was saying back to the free shrimp and doubles.....cheers.

Hammerpcp you hit the nail right on the head.

Hey that IS funny! hit the nail....on the head....lmfao.

hammerpcp :I will never understand why this is one of the first questions people not involved in EMS ask. In fact, I put that to you, the original poster, what motivates you to ask such a question?

I believe its blatant morbid curiosity, but agreed totally it is annoying and quite rude to my way of thinking.

I have often been at a social gathering when someone asks the standard question "hey whats the grossest thing you have ever seen.....my short answer is.......... a Surgeon making his first incision.....odd thing that this never is asked of an MD?

That's the part that I go looking for more free shrimp, and order a double.

cheers

Ahh... the force is strong with this one. Wouldn't mind chatting with you some time.

Ok first off where did that Lithum hide :twisted: ....he started this synapse challenging thread.

Secondly medic-ruth.......come to the DARK SIDE

Personally would like to hear what other enlighghted folk have to say.....testing testing come in DUST, or AK... ++++++

You you out there?

cheers

Good post!

I forgot to mention teachers......like again... :oops:

Always wondered how to spell rote... ty

Ok North you have my "somewhat" undivided attention.....Just HOW does one go about this? Frequently the heads are too full on absolute gibberish some folks do get the global picture from the onset were as others get tottally snarled up in the sequenses and or details of a senario or in fact in real life this is quite common. I guess I mean is there a established theory in education to address this as the teacher must be already be a critical thinker themselves....dont take this personal at your old age but so many of the educators focus on the cirriculem content as opposed to the I quote R/r "INTENT".

We see this so much in law, the interpretation of the law can become quite squewred with prescedent being set, I am beginning to believe that emergency medicine somewhat follows this concept sadly. :roll:

Question is: What guidelines as a mentor can be used to teach critical thinking?

I suspect the adage "when your up to your ass in alligators it is difficult to remember the the intent was to drain the swamp".

Minus egotism (take my advice, I'm not using it).

Correction;

Common sense + education + experience + (good observational skills) + situational awareness + Prioritizing - ego = the Critical Thinker

I believe in this so much, I wish there were practical scenarios on the NREMT exam, using critical thinking skills. As well, should be part of the clinical objectives for field, ICU, ER , etc.. clinical sites.

R/r 911

I can't disagree but as you stated the "Grey" areas become very fuzzy at the best of times. Presently in "my hood" the scenario testing has come under serious scrutiny as well.... just how would you propose an evaluation of ones critical thinking skills? OMG....this would open up one serious can of worms, as we all do not think alike. (nor should we)

I will disagree with the theorists that the level of intelligence one is born with can be seriously modified or even think in a different manner, granted "some modification" can be accomplished if there is the desire....as Carl Jung stated (loosely) "one is a product of one's enviroment" you can't easily change the spots on a career truck driver. I have worked with very competent First Aiders but asking them to do multiple triage at a disaster is just not possible..... given the weight of outcomes. I think that's just a fact of life, spending inordinate amounts of effort to do this is a may be lesson absolute futility for some.

Question is: Just when is the end point in an evaluation do you fail someone as not all will pass? Personally through my experience it has been some folks are leaders some are not, is not so much a "tangable value" that can one can put a finger on. Besides the criteria and goals would be extremely difficult to conceive from the get go, I would like to be the fly on the wall in that regard in those meetings :shock: .......but I am open to new ideas.

cheers

Another fine example in educating the ADULT......repetition....

EDIT and admitting misteakes right away.....lol.

While I wouldn't agree the patients in need of critical thinking are "critical" patients, I do think more paramedics need to understand critical thinking. A great book to challenge the way you think is Morgan Jones' "The Thinker's Toolkit." It explains why we think the way we do and challenges the reader to look at many of the fallacies that we use in everyday decision making.

The patients most in need of critical thinking would be those patients that we automatically assume we know what the problem is. 1+1 doesn't always equal 2 in EMS. Ever been completely blindsided during a call? If you look back at the circumstances surrounding the call, you'll probably pick up on something you might have missed because you were lulled into thinking you knew exactly what the problem was. Usually this occurs with the patients who are complaining of the same routine complaints we always see and we've been prejudiced into thinking X complaints = Y diagnosis.

Interesting topic. I would definitely suggest picking up Jones' book! And since you're on Amazon anyway, click over and pick up my books too!

Devin

Very interesting topic here Lithium:

So here is my .0181 (USD) cents.....Critical Thinking can not be taught persay but protocol medical treatment can as this a matter of wrote memory skills and is sequential in nature compiled by..... Critical thinkers. The protocols are just guidelines and not a cook book recipe book but in saying so they are the foundation for the educational process(s). In fact in services that I work for it is essential to myself that a "deviation from protocol" is included in the guidelines, bit of irony? You say but protocols cannot ever include all of the variables that we observe in the field, we are applied sciences not TECHs. Don't get me going here..... At the present time it is the only means to train an individual, and the bar in which to judge as well. This is an attempt taking the good with the bad to teach with a common sense approach to emergency medical care.

A perfect example would be life threating haemorrhage of lower extremity in a entrapped patient......a critical thinker may go straight to a tourniquet because if one applies direct pressure, the helper is in the damn way and delaying extrication (maybe not the best example but it is all I can think of before coffee is brewed)

I have spent many a day or rotation with students EMTs, Paramedics, RRTs and Residents in clinical critical care settings and have come to the conclusion that "Common Sense" cannot be taught, one either HAS IT or DOES NOT.... seriously.....so in following those that do not possess common sense will never ever become Critical Thinkers.

Common sense + education + experience + (good observational skills) + situational awareness + Prioritizing - ego = the Critical Thinker

[hr:8781938448]

A perfect example here is Medic2588 taking a prime opportunity to use a topic to blatantly sell his books LMFAO!

Devin shoot me the link, you have spiked my interest.....

EDITED Re Micheal-----good advice all.

Just an idea here but a set of "scrubs" made out of Protex or Nomex may be a good joke gift for your MD.... sometimes a reward from like minded professionals goes way further than a an award from a government official.

If you need a lead to where to get some of this kind of "stuff" I have link (contact pm) my contact just shakes his head when I ask for "special requests" like this, and I love the look on his face when I ask for specialty items..... like 5 bars on eplilets....te he.

You know MDs and RNs get a bad rep for attempting to assist at "outside" calls, I can honestly say that I have never had a negative interaction, in fact most cases the good samaritans walk away with an improved understanding of what it is like in the field....

Kudos Doc, and welcome to the "Glad to be Alive Crowd"

My god, I'm such a geek --I actually UNDERSTOOD the above --and I found it funny!

Best,

--Coop

Your not a geek you just like stuff...

Hey did you hear the one about the di-sulfide bond that walks into a bar?

Yah you probably did.

cheers

Interesting and terrific methodology here..... knock out perfusing ectopics to determine an underlying rhythum?.....just what heck was this ER MD thinking? Certianly looks as if the pacemaker needs a bit of maintnence now. I bet the Patients Cardiologist is suitably impressed.

Question so just how did the arrest work out?

I highly suspect that the next thing you observed is tombstone "T" waves.

I agree NREMT-Basic, start with this post right here...

:wink:

:oops:

Again guessing and "not to treat the strip but the patient"...if the ICD is in a non operative mode and the history preceding may be a hint..

A question would be are these beats perfusing?...I suspect so if his LOC remains a GCS of 15??

If this fellow is paced previously, as I am seeing zip for spikes...perhaps off to cardiology to tweek up the rate a bit... perhaps check the implant leads as well, I am confused as to your statement the data was removed?

A rate increase "may" reduce the break thru ectopics, the rational would be that hypoxia could be part of this? dunno.

Your senario did not include Sao2? how come?

If they did an ABG and stat electrolytes that would be helpful as well, mag and ionised calcium would be nice, you are in the ER?

cheers an interesting strip.

Is it just me or is the speling cow not working AGAIN......la la la.

:twisted: :twisted: :twisted: :twisted: :twisted:

For all the Canadians :knob:

Ok so Brokeback Mountian WAS filmed here....will we ever live it down? :oops:

Good god, what the hell are these two smiley faces doing to the one in the center????

:3some:

Someone get them a room!

Sorry for the outbust, I'm a little sleep deprived and I just noticed these three.

Doc we just have to talk.....LMFAO..... do need some educational links?

Kyle: Yes thats right... bellys, your way too young for THIS tread...lmao.

ml/kg?

Usually 5-7ml/kg is what is cited. I have seen 7-10ml/kg as well...

Since tidal volume is almost always quoted at 500ml for an adult (70kg?) it would appear to be 6-8ml/kg.

EDIT - Just looked in the Walls book, and he quotes 10-15ml/kg...Meh...

GENTS:

The 5 to 7 ml/kg. based on ideal body weight is now the accepted NORM, a very large study worldwide found (NEJM Sept. 14, 2000 Vol. 343, No, 11) That "VOLUTRAUMA" was indeed a large factor contributing to ARDs, in fact prior to end of the study (approximately 75% of results in) was so conclusive that the study was concluded....oh.... I "MUST" add that the baseline PEEP level of + 5 cmh20 was used in this study as it it is a protective mechanism to prevent (micro) atelectasis.....EVEN in those in the "head injury" category. OMG, totally radical eh what? this does not inadvertently affect ICP which was a thoroughly evaluated in an other study (can't find that one, oops)

As a rule of thumb, the concept is: Keep plateau pressures (static compliance) less than 32 cmh20, this can be difficult to calculate on most transport ventilators. This based on the assumption that (on average) 8 cmh2o pressures is the result of (dynamic compliance) on a clean # 8 mm ETT with flows in average 40 t0 60 lpm. hope you are following so far.

Soooo in the back of the truck/bird....if one eyeball's the PIP (Peak Inspiratory Pressures) try to keep PIP less than 40 cmH2o then this can be accomplished without too much difficulty. If one encounters ETCO2 levels rising then pick up the rates not the Vt's. Targets shoud be ETCO2 of around 35 to 38....this accounts for "Norms" granted the pathophyiology of the acute lung injury can be affect these reading but lets keep it as simple as possible.

The concept of ventilation is that CO2 is dependant on Minute Volumes Rate x Vts....lets stay away from VD/VT for now...k?

It is also mentioned that in the asthmatic patient or the very difficult to ventilate crowd that 3 to 5 mls per kg is acceptable, note these values and suggested guidelines are buried somewhere in the guidelines of the "OLD" 2000 American Heart Foundation International Consensus on Science #239 Part 8 Advanced Challenges in Resus: page #239 as is permissive hypocapnic ventilation... in fact if PH of less than 7.25 then bicarb can be added, numerous on going studies are pointing towards acidosis at the cellular level 'could be" protective homeostatic mechanism yet to be determined.

While your at it a great brief on Auto PEEP as well, not really indepth but and just my 2 cents would be that this unrecognized condition if far more prevalent than first believed in EMS.... a relative mechanical hypovolemia...leading to PEA. A very common point observed when a rookie is told to squeese the BVM.....slow down dude, its not a ballon! I digress...sorry got on a roll there, look back in the SOB OBS thread (or something like) a GUEST? made a post there that was quite interesting a "medics" explanation of Auto PEEP.

General rule is that Hypoxia kills yah way quicker than Acid base imbalances.

Oxygenation as stated by "ERDOC" when a patient is this acute ABGs should be used as the "Golden Standard" as the evaluation tool.

Oh Dust...if my SATS were less than 85% I would call it "STATS" too.....LMFAO.

Do I get points deducted for rambling?

cheers

oxygen boy...... aka squint.

The improvised chairs mentioned in one of the previous post are called rehab chairs distributed through Morning Pride. The concept of forearm immersion has been around for a while, I believe the military has been using it for some time. Studies have shown that immersion of the forearm in cool or tepid water can drop the body temp by approximately 4 degrees F in about 10 minutes. We are waiting for some grant money to purchase them for each of our transport vehicles. I will update when they arrive.

Resqdivemedic: Thank you eh, I was hoping that someone had seen these device besides myself, was beginning to think I saw them in a Hollywood movie or something..... Were you in involved in the studies in New York or the Windy City or did you use them in the military?

Thanks for the heads up, the link is http://www.morningpride.com/products/default.asp?p=5 if anyone wishes to check it out appears that one could improvise with a plastic bag or 2 if one had a boy scout knot "how to tie knots badge"

cheers

Question would be the time frame from ingestion, to nausea....good old natures way.

Tylenol has a nasty habit of prolonging peak onset for up to 24 hours, somethimes longer.

Really rough on the liver and kidneys as well.

I suspect that the hospital initiated N-acetylcysteine (Mucomist)?

cheers

When blood pressure starts to decline, if you grab pressors in a hypovolemic patient you have just vasoconstricted the vessels to the kidneys and bowel to raise the number (BP) you are actively causing organ death. Organs are like dominoes, when one falls more often follow.

Just a question here (at this part of movie I usually eat popcorn)

If one is hypotensive, even from hypovolemia and not trying to put words in ones mouth here.... BUT would it not be logical that they are already hypotensive (not producing pee pee) therefore the kidneys are already hypo-perfused?

I was always under the impression that Dopamine (#1 trope on the hit parade) improves renal and mesentaric artery dilation? Dopamine can (defendant on dose delivery) affect the drain size as well, (in reference to your analogy).

So just for argument sake, why not start with Dopamine?..... after the Dr. Placebo and Oxygenation concerns are resolved, whatever way one wishes to deal in that regard.

Fact of the matter may be that a trope may be more beneficial in the decompensated (circling the drain crowd) whether it be from septic shock OR cardiogenic....just thought I would throw that out there. Perhaps a study even, could put a mark on the wall for EMS practitioners? :wink:

As for the reference to percentile in correct Dx of experienced, well trained Medics out there, by your own admission as well 90% is pretty good odds I'd say?

Quoting Asysin2leads: Okay, playing devil's advocate here, what is the worse that could happen if you gave a patient who had rales from pneumatic sepsis rather than CHF?

First off no point in even trying to answer this Asysin2leads.....you are playing the village idiots helper their and I won't bite at that hook...I do read YOUR posts....lol.

The confusion some time exists as "rales"......Rales are wet, crackly lung noises heard on inspiration which indicate fluid in the air sacs of the lungs. Rales are often indicative of pneumonia. See also rhonchi, wheezing. rales is a 'very old term'

and sounds are more indicative of course secretions ......if the rattle improves with cough and have the patient "hork"(an approved medical term :twisted: ) in a K basin the picture this can become quite a bit more clear.

"Creps" are far more indicative of pulmonary oedema, (sometimes the give away is pink frothy sputum!)

bit of an D.G.A. (dead give away)

cheers

note: edited due to sub therapeutic caffeine level on initial posting.

[

tniuqs,

THANKS for all of your trouble! Please thank your aussie and "hikers" Friends as well.

I don't know, people PAY to get to this place and survivers even say they had a great time.

"SNOW"? I have heard of that phenomenon. They say Inuit has more than a 100 words for it, don't they? Hebrew has 1.

asy gee I am blushing!

Odd you refer to the Inuit, as I too "personally" have more than one word for Snow.

@#$$!^@ !!!!

#@$% ^"@#$ it is cold.

and last but not least $#@&%%@@$&**( in my boot)

I seriously doubt there is a Translation in Hebrew.

#$@% is falling in the mountains as we talk....it is 7 degrees Celsius outside today.

Time to find something warm for my sleeping bag...te he.

cheers

Just a curious here:

What setting (s) do you initially start the with on your patients with CPAP or BIPAP?

And (in your respective areas) do you have criteria established that excludes the use of CPAP or BIPAP, especially in Hypotensive states.

Just a personal comment here: I have found that most ventilators can be used for NON Invasive Positive Pressure Ventilation usually those that are more expensive, the criteria being those that have adjustable PEEP settings, and Pressure Support Mode, and Peak Inspiratory Flow rates exceed 50 lpm. Adjustable "slope" or "% rise time" are superior in regards to "titration" to patient comfort levels and tolerance in my experience.

NEJM Jan. 14, 1999-- Vol. 340, No 2.

Question posed would be what types of Machines are being implemented in the Pre-Hospital Care World?

EDIT

Rereading the prior discuss:

You nor I give Pulmicort or any of the inhaled steroids as they do not help in the decompensated asthmatic, they are intended to control the asthma to avoid an attack

There is some evidence that early administration may be beneficial in the asthmatic patient and on spec. it has been used here, the actions of steroids an not fully understood as of yet, but does stabilize cell membranes.

Granted Asthma is not the topic here (although stimulation of key receptors in the airways may be triggered with a flash PE) Beta 2 adrenergics as well are used to improve oxygenation, but caution should be excersised in regards to the degee of distress (heart rate commonly can be a used as a guideline) although in passing: MOST of these patients are on Beta Blockers these days further complicating this pathphysiology.

Evidence does exist to support this theorem in a similar related topic NEJ MED 1994:331:286-9

cheers

These comments forward from another listserver from another experianced desert "Hiker"

Hey squint, as she probably knows she in a bad spot without much help. We found here in the Iraq desert that prevention is key. So we hammer it in at every morning meeting and pay attention to the weather. For us we usually have problems early in the summer and when it grows hotter then 110 F. We were able to obtain a small freezer which is loaded only with water bottles which of course freeze over night. We then load the portable ice chest with these bottles and on most days we maintain a decent supply all day even when we hit 130F. If we need the ice the we either use them as is or crush them and put the remains in plastic bags. You can also wrap the IV line around the bottle and it will cool the fluids as they flow from the bag. But prevention is key

Patrick C.