tniuqs

Firstly what's "job status" employed, non employed, air, ground, rural, urban, suburban, turban, remote, sandbox ???

We have many countries in here, varied levels of education / training should we be talking down to "I am just an EMT" (I hate that personally) ... I think not, posts should be judged on merit.

For example the "Country" of British Columbia where everyone is a called "Paramedic" even the P1 P2 P3 ?

Then OZ and who the hell knows what that's called, well besides tossers.

Then the Germans a rechesstalage ? WTF over, it sure sounds that these guys are advanced practioners no doubt in my mind.

Even this AAS title used on your tagline Dwayne and for the life or goggle of me I have no idea what it means.

Shouldn't the context / content of the post be judged on that alone ? We have so many "variations" of titles is not realistic in my view, so I will remain a lazy band aid, if I put all my crap letters up any anonymity would be lost.

cheers

Your asking many questions .. in one sentence.

1- Ok so just how in an arrest with no forward blood flow could blood glucose levels be raised ?

Prior to an arrest in CVA MI or trauma the human body will in compensate for the increased physiological requirements, (cortisol and gluconeogenesis) but is that measurable in the field on the dip stick ...hmmm, not likely.

2- If it were a respiratory failure and typically extremely high metabolic demands due to WOB "work of breathing" and depleted glucose stores the reading would be lower, this makes logical sense, does it not ?

3- 30 mmol/L (that's 545.454 mg/ dl would be rather high, did the supervisors patient arrest due to a Hyperosmolar Hyperglycemia and buddy supervisor is basing his "observation" on that anecdotal finding alone ?

Here is some links for your reading pleasure and further educational needs:

http://emedicine.med...914705-overview

http://en.wikipedia....aboratory_tests

<edit spelling again>

10 months of winter and 2 months of "poor" skiing ... but hey come on up lots to do lots to see in the National Parks.

I came across this while reading news article about a record breaking rescue ...

http://www.edmontonj...8966/story.html

LOL in the vid no spine board was used ... due to terrian .. no shit batman, and puts a new spin on giving report on the FLY !

Ah the good old days, I sure miss em.

Do you know anything about whether blood sugar levels rise shortly after respiratory & circulatory failure?

Yesterday one of my supervisors said he once measured the blood sugar of a patient to 30 shortly after he went into cardiac arrest, how could this be?

Marc

Well just me but when working in a remote clinic setting, the couple minutes of extra time spent to evaluate is very positive for patient contact, in fact I did it yesterday on a "I have a HA, dizzy" and a resultant negative finding ... the worker was bragging to the bosses how great a paramedic they had, the treatment plan was 500 ml of H2O and a tylenol, it was a magical fix and no lost time on the job.

Not that he was wrong mind you about the great part LOL ...

Would a positive finding of orthostatic hypotension result in a different treatment plan, in a non acute patient, well not really, but I would have a tendency to "flip" to a higher level of care to investigate in far more depth just to be on the safe side for the patient.

The skin turger or tenting can be a bit misleading as well, and in a geriatric with PMHX of HTN and on meds I look more towards end organ perfusion LOC and urine output, if in an acute care setting.

Yes ERDoc those dang snot spewing, toddling virus packing alien life forms called children never follow the rule books !

cheers

LOL BushyFromOz!!!! Funny story

NOT if it was your nipple ! OUCH !

and how long do you have your patient in sat or laid before starting your series of blood pressure recordings ...

personally unless you are working as an advanced practitioner in a system which might divert certain classes of calls away from transport to the ED , Orthostatic hypotension screening by EMS personnel is a waste of time for the following reasons

1. if you do it properly you drastically increase your scene time

2. it has no value as a screening tool to decide if ALS is needed ( see 1 above) and it is of little value in making decisions regarding which facility to transport to if thechoice is different EDs

however it has it's place in Acute and emergency medicine ...

Interesting opinion, so its useful in some areas restricted to Acute Care Medicine ?

I do not see in the thread any suggestion that this could be used as a method for triaging a patient or choice of destination facilities nor in fact delaying transport in those vital seconds for the trip from Nursing home to ER .

Frankly this would help me guide care for a suspect geriatric and assit to decide to pop a line in for systemic re hydration problem, for those that deal with this routinely the geriatric population is notorious for forgetting to drink fluids.

also a finding of postural hypotension without all the other tests examination and the like is only a small part of the picture.

Agreed is just part of the picture but is a 5 minute evaluation something that is frowned upon in your service, that to be dilegent in a "field" work-up ? I believe that Robert C. Knies, RN MSN CEN just may disagree with your opinion.

http://www.youtube.com/watch?v=z0rt9BB0FoU&feature=related

You be the judge .

here is another pic.

It's been a while since I studied pulmonary contusions, but I would think that watching the trending in sPO2 and CO2 would tell us more about gas exchange condition. With adding artificial O2 to the mix, it would be difficult to tell if this guy was having issues at the gas level?

Shallow breathing, re chest wall pain, RR of 26 its kinda curious that ETCO2 was low 30s but trending was more of a priority to me, VQ match would have been a consideration but I would have expected norm or higher than norms. As I have said frequently maybe the patient didnt read the "Normal Lung" LOL.

Is it safe enough to guess that the guys only issue in the end was the arm? I'm still curious about abdominal/pelvic injury.

Honest injun I would have mentioned that in my presentation of History.

Just don't try and mount a 50" flat screen by yourself when you're in your 70's and you'll be good

You mean I should get one before my next birthday ?

I didn't see any rib fx immediately on the shoulder xray, but pulmonary contusion could be a huge factor for this guy... the arm was clearly forced into the ribs and that could have been enough to cause a pulmonary contusion...cardiac also....maybe.

And Kate goes to top of the class !

PULMONARY CONTUSION ...so any shots at the possible sequela of that with high concentrations of O2 ?

Also from the amount of facial trauma seen on the first photo, I would be for sure interested in what a facial series looked like as well as a face/brain CT.

Yup no argument from me but no signs of head injury, just plastics work in the end.

Since he claims to have been seat-belted at the time, any signs of a lap belt injury? Would have really liked to see pictures of this accident to have an idea of the forces involved, but from the one xray you showed, must have been a good amount of force.

Yup good catch wearing a seatbelt "was a pt states thingy" I could not see any signs of belt marks. I did not see the intrusion into the wreck (I wasn't on scene and it occured at - 36 C, blizzard the Paramedic was a good one on the scene but I suspect when patient walked to truck bleeding, looking at a 3/4 ton crew cab rolled in the ditch against a pole/ tree was last of his priorities. I do highly suspect some a cya company policy was being covered for and driver was arrested at the scene for DUI.

Side note...we once had a mid-shaft femur fracture come into us, and he was sitting up and talking completely fine.... Dropped a flat-screen tv on his thigh and snapped it in two. No other trauma occurred. Made me realize that not everything that you would think is a huge trauma, there can be freak isolated injuries that we would normally associate with more complex issues.

Ah yet another reason I should not buy a flat screen TV ... dang you Kate !

And summer T storms are not expected in North America ?

Absolutely no excuse for poor engineering, it wasn't tornadoes or hurricanes that brought these down .. like I said my tent stood up to it in you know were.

DFIB ... as you wish.

Mass and Temperature (remaining constant) the volume of a gas is directly proportional. That stated: with the pressure decreases there is also shift of the ODC, (the oxygen dissociation curve) which in this case presentation, So if the curve shifts with a decrease .. what happens to the affinity of the haemoglobin for oxygen ?

Hence my question for pressurised vs non pressurized, you can be in a typical helo at just 5000 ft agl but in fixed wing you can have a cabin pressure of 3000 ft agl and actually be at 25,000 ft agl and "over the weather in calm air" ... now look back at the patient picture, is the musculoskeletal injury life threatening or is something else you may wish to make note in clinical observation ???? must have been one hell of a high impact to bust buddy's arm this bad, any other concerns for going flying ?

Ah Bushy, just wake up mate ?

Agreed. Im tired of seeing people jam 15 L/min on everybody, even when they know the patient isn't aneamic! Twisted ankle = 02, paper cut = 02, boggles the mind (and the 02 cylinder rental costs im told )

I am not a fan of the toxic effects of O2 ... te he, (a high potential for ARDS) but my reasoning was, with the rather liberal amounts of analgesia that I was using to control pain, was that oximetry changes could indicate a hypoventilation state (late).. but was relying on ETCO2 as primary tool for hypoventilation, for a near conscious sedation.

I really did not want to push Narcan or have to ETI on board but with the "yet to be identified" life threatening issue, sorry no AP CXR available. (hint with the good clinical observation skills applied) and no pneumo but we are getting closer close (ps) vascular lines to periphery was the hint that no pneumo present initially although that can change when Boyle puts his physics to work , a small closed pneumo becomes a lot bigger with increase in altitude.

Probably myoglobin, i dont know the normal values though.

That is one .. myglobinuria better, any others ?

Its "poikilothermia" a failure to thermoregulate.

Ah the presenter becomes the student .. you sheep shagger !

Ill see if i can find it, but there was retrospective analysis done here on tension pneumo's that were missed in the field, led to an education pack coming out where they got us to be more aggressive in identifying and manageing, there was a good stretch in it about trending ETCo2 and the missed pneumo.

Ah send it to me svp, that svp is french btw and good thing you don't have to deal with those spy talkers like we do.

Let me get back to you boke, i dont understand ETCo2 or fully remember treatment for hyperkalaemia due to my lazyness (i used to). I went to some joint once and learned some stuff then got a job and forgot most of the stuff that i learn't

I wasn't concerned about hi K+, could give ventolin while on board, but not going the glucagon and insulin because we don't carry insulin and this was a stable no CP distress, no big ass T waves and K excelate was out definatly of the question, but we are getting a bit off topic direction.

rhabdo treatment was where I was headed ... any ideas ?

hint TVI flight time was 1.5 hours, then add 40 mins for ground transport both ends.

I was curious about the 30 to 32 ETCO2 although .. I think I can explain it but one can not be 100% why he was hyperventilating just a tad any comments ?

cheers

You really spiked my interest in this area ERDoc ... it will be my "safety talk topic" early dark wake up on a project I am deployed, Its really hot here and the workers are not conditioned to this heat nor are the providers for EMS in evaluation.

btw I peeked at the american journal of nursing, no link provided to their suggestion's, just to keep this excellent teaching tread going.

cheers

Dear Members:

Well with now another G Damn stage has happened now in Indiana, count 5 dead 40 injured .. One in Ottawa this year and one near Edmonton 2009...one dead, 23 injured.

I am pretty certain why that one went down, I have pictures of the failure of I beam where a reinforced gusset would have "likely" at least helped prevent a catastrophic failure and I am no rocket surgeon, note balliest block placement ... a boy scout knows better !

Fact remains that until the engineers to "get it right". Stop the shows, I will be writing a letter to my government officials that my fn'ing tent is bloody stronger that and these so called Stages, the engineers responsible should be in jail waiting for results of the investigation as these are no longer rare fluke events.

I would like to encourage all of you to do the same, as we are the ones that end up dealing with these very "preventable" wrecks, deaths and subject we the EMS and Fire Rescue in serious jeopardy crawling around in the mud, debris and crushed bodies.

EMS across borders for safer communities.

the end

Well we do not have any volly EMS in AB that I am aware ..and thank you very much for that.

LOL Richard... or maybe Kelly Grayson .. he is known to have a few knee slappers "his own self' that (self acclaimed coon ass Louisiana good ole boy.

ER doc I woulds say an increase of 10 % in pulse rate and changes of 20/10 ... time would be more of a consern if pulse did not return to base line (say 5 minutes) .. i know this is controversial.

Personally a one beer infusion makes me dizzy when standing up too quickly, that when I realize its empty and need another, its sounds like a good justification to me re: "orthostatic hypotension" so I am going with that, as an answer for door number one.

Not exactly certain of what your asking for pulse, resps , BP, colouration, skin turger.

I would expect, say if I observe a relative tachcardia and change in BP correspondingly (sp) that dehydration or a low volume may be a culprit but if I observe no response in pulse rate or borderline brady I would be asking if patient is beta blocked, doing any labs in field for say hypothyroidism is not available or in the case of a "blue hair" my favourite demographic actually, ask for the chart .. but maybe I should stand down and let someone further up the Darwinian ladder have a crack at the answer. before I completely make a fool of myself in reading comprehension.

Thanks .. We too have "laws" permitting running of red lights and over the posted speed limits, the previso being only when safe to do so ... one wreck and the legal domino's fall squarely in the operators lap.

Kind of a hollow promise really.

Got a link to a pic or do want all readers to goggle of what you speak ?

OR are you selling something ?

In Alberta Canada :

Green for vollie FF was allowed here but under very serious legislative review now as a Volly FF smoked a family and killed 2 in an intersection when he was responding to the fire hall, for a grass fire.

BLUE here is strictly verbotten POLICE ONLY.

I so wish that when on scene at say major MVC with extraction that ALL emergency viehles could have a "select" switch for just protect a scene from behind or in "front" all these flashing things make me blind when your working on a patient that is trapped, most times these lights are way overkill.

ps Edit .. whats a VAC ?

ER doc ... are you asking about orthostatic hypotension ? As Kate is suggesting as a positive finding, as in a change in 10 to 20 mmHg from lying to sitting position ?

OR is this just another EMS myth ? I am sensing an ass kicking here is forthcoming LOL ----- >

Unabashedly I "have" been under the impression that this is an indication the "tank" may be low, due dehydration or a hypovolemic component (dependant on underlying pathology) although I believe in some endocrine disorders its a more than common finding .. argh back to goggle and studies AGAIN !

Good topic

LS ... I spit coffee on me screen Damn YOU !

ROFLMFAO !

Here I thought packing a magnetic cheezy $30.00 ... so I don't get smoked on the Highway when I come across a wreck was whackerism ?

Isn't their any LAW about this in the USA ?

My baby rotating red beacon is stretching the law here to the very limit, even on an industrial ECALUBMA . I have never been charged for "impersonating" an ambulance a hose monkeys school bus or LEO vehicle, in fact thanked for protecting a scene but this Christmas tree stuff would NEVER be tolerated .. SD would have his nisson towed to impound yard if he ever switched them on even parked at the side of the road .. if moving he would likely be arrested.

Dear ADMIN: PLEASE change forum to "Funny Stuff"

Way outside my league turnip.

No way mate this is a stable patient transfer, keep in mind that this was my first kick at the roo agreed "my presentation" is a bit a rough,

D for the first one,

D is correct

not that that they arn't all relevent but im a bit suspect you might by the attending and answer A eems unlikely and i dont understandb answer B

Ok now teach me ... what is eems ?

But yes to A its a teaser .... Why did you not give O2 ? This is a trauma patient ? Was the first thing I was asked giving report to the RN staff ! It was my glib answer to a ... does this patient need O2 when you have HGB and Pulse Oximetry ? Yup it sounds like a dumb ass answer but it is really not ...

Pressurised for the second, though its a guess as i dont know anything about aeromed.

Ah bless you my son, an opening for an introduction to Boyles Law ... I will get into it later if their is any interest in the thread.

rhabdo is a consideration.

Oh yes it is ... I did not include another lab value that I was presented .. next question what "lab" value could point that direction ?

There's damage to a large muscles group along with the fracture and possibly reduced pefusion distally, possible compartment syndrom. Either one could have similar Signs/Symptoms, severe pain, perfsuions compromise and those

Ah compartment syndrome .. this was a rather large wound, and open ps the dressing was removed for the pic, as was the "splints" used in transport ... I thought some one was going to rip me a "new" one for that ! Quite amazingly NO loss of distal perfusion, no neuro isues, this patient could actually squeeze my fingers, my initial thought was "buddy" was looking at a prosthetic device down the road ! Apparently he's back on his drilling rig AND was the son of a very good Parameduck Friend's who lived next door "neighbour" his MOM asked for the "before pictures" ... just weird how that stuff goes down EH ?

Counter question .. is compartment syndrome something we can treat or even can be diagnosed in the inter-facility transport ?

5 P's, (Pallor, parasthesia, paralysis another one which i cant remember and the poliko-whatever it is where they cant regulate temp (looks a bit like polkadot with a thermia on the end))

Fist bump ! ... but whats this polka dot of which you speak ?

Supine on a spine baord for how long compressing muscle groups could do the same.

Ok salient point, C spine was cleared in sending facility BUT recieving Facility is really "touchy" about that as it was a GP sending ... ah the joy of it all ! LOL.

Could also see peaked T waves.

Nice ... but seeing as its your "catch" could you go into some detail to explain to the First Responders that have monitors ? This patient was NSR .. I would have mentioned any "irregularities" but good point never the less.

No idea what a flight paramedic would do? Manage for pain, fluids and ECG with some bicarb ready?

Its just a different (can I say bus ride here) Pain was managed and the whole point of this presentation ... did I need to tube this brute, Did I even need O2 ? .. this was done in 2007 when very few used ETCO2 for anything other than Tube conformation or trending on ventilated patients that has changed, sure hope mobey sees this one.

Why would you need Bicarb .. on a spontaneous breathing patient and with ETCO2 a bit lower than expected ?

like i said, way out of my pay grade

Disagree !

Wow, just came back to this thread. Didn't think anyone had posted in it. I appreciate the bits of input from some of you, thanks. And wow, crotchity, I am really glad I don't know you in person because I'm pretty sure I wouldn't be able to keep myself from kicking your ass. I can't help but wonder, do you just get a kick out of stirring shit up and pissing people off online? Or are you actually that ignorant? If so, man, I feel sorry for you. "PSTD is weaklings who are looking for a way out." Wow, just wow. I don't even know how to respond to that. Actually, I don't think it's really worth responding to.

You do have a very point about ignorance