tniuqs

No worries mate ... good convo.

Well lookie what I found in old files and permission to reprint (as I am the author) and signed release form in hand ... well in a manner of speaking the Mother signed as PT was right handed.

Case History:

Dispatch info;

Called for 26yo Male Pt. involved in M.V.C. with multiple #, received from P.F.C.C.

Upon arrival to Hospital Facility:

A 26 y/o male patient lying supine in ER, Pt found supine on backboard, without straps, C-collar on, two large bore IV’s in situ L arm, not on O2, Awake and Alert but appears restless.

Hx of C/C;

Was involved in MVC, Single vehicle, Crew Cab truck that at high speed departed from pavement and impacted a tree. Pt was a passenger, back seat, impact side, states was wearing seatbelt. The pt. was removed from truck by friends? And passersby’s. No report of loss of consciousness and pt. walked with assistance to passerby vehicle.

Patient was intercepted by A.L.S. unit. Advanced Care Paramedics took spinal precautions and initiated IV therapy and gave 100 mics of Fentanyl in total. Damage to Truck not observed due to logistics, too bad no one had a digital camera on scene, as this could have provided valuable info to receiving M.D.s.

PmHx;

Of: HTN? States no follow up, of smoker presently on Zyban, states H.B.D. x 1 beer this am. NKA.

C/C;

Pain moderate? To R shoulder, to Chest, to Face.

Focused assessment; No obvious signs of Respiratory Distress Sao2= 98% on R.A. RR=26 bpm. No c/o Dyspnea, Resps, Shallow, with increase in pain upon deep breath.

Rapid pre-transport assessment;

Obvious Lac to R face nasty poss. Plastics consult with 1. # to Zygomatic arch reported, 2. CXR shows # 2+3+4 Ribs anterior mid-clavicular line, no obvious air in thorax. 3 # compounded proximal end of humerous, with GROSS misplacement and dislocation of A.C. process. Rather large LAC. As observed on picture.

CNS: Alert + oriented, moves all extremities, a bit anxious and restless due to lack of padding on spine board.

CVS: Good end organ perfusion, cap refill less than 2 sec. producing urine cloudy, and a bit pinkish in color. B/P acceptable a hair on the low side but no tachycardia NSR in lead 2

Pulm: A/E decreased to bases bilaterally, no obvious adventica, auscultation over site of injury ant/post

Some crepitus noted but air entry present.

CXR: vascular lines noted to periphery no obvious pneumo/hemo present, at this time. Sao2 = 94 % on R.A. ETCO2 sidestream applied to pt. via nasal cannula, with trends around 30 to 32, even with ++ Morphine analgesia.

Abdo: soft, no c/o pain upon palpation. No obvious signs of internal hemorrhage.

GI/GU: urine as above, bowel sound present.

Labs: hgb= 15.8, increased leucocytes, ABG n/a,

Treatment: T.L.C., Hx, V/S q 15 min. by automated device, Sao2 continuous, ETCO2 side stream continuous, Monitor Lead 2, Pt. flipped, assessed, and spine board padded with flannel, fully resecured to board, also used ½ full mini-bag to occipital area secured firmly, to improve comfort level and hopefully decrease amount of analgesia required. Morphine used liberally, for movement during assessment and prior to medivac, during transport fluid bolus given due to transient drop in B/P, T.V.I = 1700 cc. N/S

Questions:

1-Why was Oxygen not used on this patient ?

Any Questions about abbreviations ?

I like your attitude PCP .. don't let the "girl's" talk get to you.

Seriously WHY in this profession do we throw an noob into the fray, without "modelling" first a good FTO or Preceptor WILL lead by example, that is what mentoring is all about.

Hmmm ... well LS as usual is most correct.

Without getting into a huge post, respectfully, perhaps do a bit of review control of homoeostasis, including pulses paradoxus.

http://en.wikipedia.org/wiki/Pulsus_paradoxus

If I remember correctly systolic pressure is "driven" by cardiac output and diastolic pressure by norepinefrin.

Not really, its not quite as simple as that as baroreceptors, chemo receptors, and then the adrenergic and sypmathetic responses come into play as well as underlying pathology's which make my head explode some days.

In a hypovolemic patient the sympathetic system is hyperactive.

In a manner of speaking "kinda" to a point, when you state hyper active that could indicate an endocrine system involvement, hormonal or adreanal insufficency.

Systolic pressure is down because the volume is low but the diastolic is high because of the sympathetic is crazy trying to vaso constrict.

Nope: The adrenegic system is attempting to "compensate" but with more than 40% circulating volume loss (more or less) the venous return is compromised as a result, therefore the hypovolemic hypotension is a direct result of not enough blood returning to the heart, both systiolic and diastolic will be down.

I remember 3 things in shock the 1-PUMP the 2-FLUID and the 3-CONTAINER.

So it would be just the opposite of your post, a narrow pulse pressure would be hypovolemia and a wide pulse pressure would indicate shock by vasodilatation such as anaphylaxis or septic shock.

Narrowing pulse pressures are a result of (most typically) mechanical in nature as in a pericardial tamponade, or "Obstructive Shock"

Wide pulse pressures is typically observed in head injuries called the Cushing Response although epinephrine is a mediator, in part.

http://en.wikipedia.org/wiki/Cushing_reflex

Anaphylactic Shock and Septic/ Warm Shock are forms of "Distributive Shock" although the mechanisms quite different, histamine in anaphalaxis + SRSA or in septic a "histotoxic" response when pre and post capillary's sphincter fail due to toxins. The C.O in sepsis is very high or "pumping wide open into blood into space" but delivery of O2 to the tissue is the problem.

http://en.wikipedia.org/wiki/Cushing_reflex

I hope that helps

I disagree. The more proximal the better. It's closer to where the fluids and drugs need to go (adenocard, anyone?), and the closer your IV is to the trunk of the body the less the catheter moves around when the patient flails. There is no such thing as the "vein of shame" in an emergency.

Fiz I have to agree with you if you really need a line then AC is way closer to the heart for meds, starting lines in feet is not good for any med delivery and plus patients kick, my personal experience is a PITA line especially with decreased perfusion pathology or the blue hair crowd. Again, personally I believe this gas passer was just a tosser s/he had 2 lines and push come to shove could infuse blood (not positive of underlying pathology here but circling the drain is something I understand ) and with an introducer could have rethreaded a larger bore if needed in OR or get a shlep Resident MD to do it for him.

On the other side of the fence if Timmy did not have 2 patient lines this primadona gas passer would have been pissed off more.

cheers

(Sounds strange but humor me).

Elderly Females are a higher risk for Silent MI, but with the very limited PmHx, its anyone's guess.

Any "does it ache anywhere else" i.e. referred pain queries.

No left shoulder pain ? or a back ache ?

BGL is that scope for basics ?

And is anyone doing bedside troponins down south ? just one drop of blood from iv start and no brainer.

Dwayne to answer your query of Bilateral BP in the geriatric HTN patient:

http://www.medscape.com/viewarticle/436713

http://journals.lww.com/cardiologyinreview/Abstract/2004/09000/Simultaneous_Measurements_of_Blood_Pressures_in.6.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120993/

Gee I got to try this sleep deprivation thing sounds awesome, and a much lower cost than my present medications

Seriously if your that wasted best book off duty, you could be a hazard to yourself and patients, chronic sleep deprivation can lead to psychosis.

Not to forget to mention my call yesterday "buddy" rolling a car after falling sleeping at the wheel just a good thing he didn't paste anyone head on, on my "Death Highway" 63.

Ok I will bite what is dilordan is that spelt correctly because Google can't locate it.

25 mgs of benadyl is not going to knock you out ... just dozzy is all.

whats a clamshell ?

Its a BC thing, like a patient on a half shell only no oysters.

Yes this weather has been absolutely crazy, I was at huge forest fires, (burned 500 homes) then monsoon rains .... then I personally got hailed on 2 weeks ago, not a pea sized but ping pong to bigger, pock marked my relatively new truck, new roof needed now, shingles are beat to rat shit, even blew holes in the "frames" of my windows, siding shredded this in just 15 minutes ... my garden was looking so good too, but not a stalk left now.

I guess I am lucky I still have a pot to piss in and no twister in that storm... all the best and keep a wee dram of Glenfiddich on hand for me.

cheers

Get this Girl on America Has TALENT .. because she DOES !

This has only been posted on utube for one day and 33000 hits ... you go girl whoever you are !

Another 1000 hits in 20 minutes . WOW this is going viral in a huge hurry.

Actually, I was wondering about putting about 10mg of Fentanyl in a syringe with a nasal atomizer and just make a cloud of it around his head?

Of course we're really off into 'what if' land now...but I wonder if it would work?

Dwayne

That's actually not that far fetched the Russians have used it:

Unexpected "gas" casualties in Moscow:

a medical toxicology perspective

by

Wax PM, Becker CE, Curry SC.

Department of Medical Toxicology,

Good Samaritan Regional Medical Center,

Phoenix, AZ, USA.

paul.wax@bannerhealth.com

Ann Emerg Med. 2003 May;41(5):700-5

ABSTRACT

In October 2002, the Russian military used a mysterious "gas" to incapacitate Chechen rebels at a Moscow theater. Despite increased interest in the potential use of lethal chemical weapons in recent years, the medical community has paid little attention to the development of incapacitating, calmative, and "less than lethal" technologies. In this analysis, we review the events surrounding the use of a calmative "gas" during the Russian military action and discuss what is currently known about fentanyl derivatives, their aerosolization, and the rationale for their use as incapacitating agents. Collectively, the available evidence strongly suggests that a combination of a potent aerosolized fentanyl derivative, such as carfentanil, and an inhalational anesthetic, such as halothane, was used. The paper also assesses potential errors leading to the loss of a substantial number of hostages. Several lessons can be learned from this surprising and novel use of an incapacitating gas.

http://opioids.com/carfentanil/gas.html

After our debrief with RCMP on the real life scenario this was discussed, as was pygmy blowguns.

But in that scenario would anyone be glad I was there with my gear?

Nope don't think I would want you anywhere near me, yet once again you missed the part where any goal focused animal, whether it be 4 legged or 2 legged. the OC just has unpredictable results, the risk assessment to yourself and a partner is increased ten fold in the event of 'side stream over spray" in a confined area.

You just don't get it, that you some day, will be in real deep ca ca if you continue to pack this crap on your bat belt. My bet is someone (if you get lippy) is going to disarm you, yes with all your martial arts ninja training, then you and your partner will pay the price.

First off, your paramedic was a bitch.

Dwayne

PCP

Ha,Ha, sounds like the paramedic deserved to be puked on!

Agreed .. a puke covered bitch is always looking to blame someone for their mistakes.

Ouch Dwayne .. I like Texas !

There is no such thing as PTSD, just as there is no such thing as ADD. It is all a figment of the pharmaceutical industrys imagination to sell you drugs.

Yet another reason to bring back the reputation thing, so that when a visitor drops in for a look to this site, the clear understanding that the poser routinely spews dung and is not respected.

It is all a figment of the pharmaceutical industrys imagination to sell you drugs.

Following the Crotch Logic: all of the other drugs we use in daily practice must be in our imagination as well ?

You know like vaccines, chemotherapy drugs, antibiotics, adrenaline and pain medication, yup it's all government conspiracy.

<edited to remove rude language and not bring myself down to the crotch level of ignorance and stupidity>

As a dog owner and with a wife knowing everything about dogs plus having multiple scary calls with dogs involved and survived all of them (plus keeping the dogs alive) I would say the following: Dogs are pretty predictable and are very bad poker players. Usually they simply want to keep control over the house if the owner can't do it, that's why they're scared like hell with a lot of unknown people coming to the door. Just keep cool and assume control, use a clear body language and a strict & deep voice, if needed escalate to shouting to the dog all the way long (imagine a Marine drill instructor). instantly be the most respectable beeing on scene (if random firefighters salute to you, you're on the right way). Give the dog clear commands with voice and hand signals (point to indicate direction or flat hand to indicate "to the ground"), the dog will understand them when given with clear intention even if never learned. Try to move the dog into an unused room or hook a leash on them (only if the dog already has a collar on). Be sure to have no distraction nearby, noone should do something out of your control (i.e. start to care for the patient in view of the dog, break a window in the back of the dog or else). To control this may be the hardest thing on such a scene, someone seems to always knows it better and does something silly...with you beeing the nearest one to the dog. That would be my greatest worry. Most dogs and especially the random big dogs soon will be glad to have someone in charge on scene. Their social behaviour is based on a very strict hierarchy, and you have to show you're on the upper side. For a human and especially a medic this should be easy, even when you're not belonging to the pack. Dogs know the difference between other dogs and humans very well, the latter are trusted "in charge" even as a stranger. The trick is to not show any uncertainness - act quick!

That's great advice BUT NOT A HOPE IN HELL, that this would have worked, and I even tried my best German too

No way am I going to try being the Dog Whisperer this was a "RED ZONE" assault dog, hitting the door with enough force to knock it out of the frame. Most seriously, I would rather deal with Bears because they will 95.00 % run away. One foot into that home would have resulted in immediate attack, no de-escalation attempts would have been successful, the lead injection was the only possible solution to neutralize.

Diversion: #1-We played "chase the medic" from front door to back door to another, epic fail.

Another fail with humour attempt, we tried to isolate the dog in another room, but knowing that it was way faster, even letting it get outside and we go in would have put the community at risk to a serious safety issue. I did not go into it, but the Dog was known to the RCMP and had already terrified people in the neighbourhood, the "patient" was on the to solve issue RCMP list, for other reasons unknow to us at the time.

But from the "KEEP OUT MEAN DOG sign's" the "grow op deco" with a bent 8 ft chain-link fence surrounding the property, deer skeletal remains and a huge spiked collar it was a bit of a "tell". I did not want to get into this on first post but this was NOT just someone's pet.

sure wish we had 10 smokies on that call as bait.

Some language barrier here Smokies = Fire Fighters, disposable, multi purpose, bunker gear would have reduced the risk assessment to myself and partner (again attempt at humour).. any attempt trying to blanket a 170 lbs rotty would be just simply a suicide attempt.

Bottom Line: If one has a 4 legged weapon on a premises, a rational owner has to factor in if they ever need Emergency Services they may just SOL. Review of the 911 recorded call (their was a fatalities inquiry because autopsy relieved questionable non prescription medications in bloodstream) the owner cautioned responders that he was putting the dog away in a bathroom but he did not make it, he collapsed before he could isolate the "weapon" the caller even stated "do not send" Police.

cheers

Dwayne have had that "real life" with a huge Rottweiler standing over his master with more saliva than a komodo dragon.

Diversion: #1-We played "chase the medic" from front door to back door to another, epic fail.

Pharmo: #2 try- 4mgs /kg of Anectine (the whole 400 bottle) in a 20 cc syringe, biggest short 14 ga we could find, with plunger taped with duct tape and a old shovel handle. That didn't work the dawg shredded it, it work's well for bears in a culvert trap because they can't turn fast enough, they can be tubed blind, surprisingly easy (the animal lab is a well worthwhile Con Ed).

Restraint: #3 try rope lasso (sp) on a stick, dawg won again ...

Non Lethal: #4: RCMP showed up tries pepper now (as stated in prior threads goal focused critters it just doesn't phase them)

Lethal: .40 cal to the bean, problem solved.

The patients down time was just way too long (35 minutes from his 911 call phone in hand) we worked him for 30 minutes then called him .. sure wish we had 10 smokies on that call as bait.

Your all crazy for not using all the Fire Monkeys ... they are like the Borg use all resources available.

1-Dude then they get the wrap for B and E, if no patient located.

2- get a rookie (look for cleanest Bunker Gear) pumped up franticly yelling (waiving hand in air helps)

"OMG someone is dying in there, WHAT should we DO" at this juncture point to a crash axe.

3- Then tell the other 5 goofs stinking of smoke to go get the cot and gear

"don't just stand there" "do something" ! again animated hand waving in air wildly helps.

Clear language is required ... The .... RED bag and the .... BLUE bag and that ......TV looking thing, speak slowly.

Directed adrenaline workers every time"

1- you cancel if no patient located,

2- go for strudel,

3- the police show up to take pictures of damage.

Mission Accomplished

No ethical/moral/legal conundrum here when EMS is not any breaking glass, doors and wrecking the place.

Do you mean TGV Transposition of Great Vessels or TGA ?

Did you have any surgeries as a Child ?

Do you have any Murmurs and what grade ? and quieter is worse (more volume) than louder and any regurgitation or gallop ?

Has your cardiologist ever said anything about WPW thats Wolfe Parkinsons White ?

That's an "extra" conductive pathway ? many WPW require either medications or abligation surgery ... see link.

http://www.mayoclinic.com/health/wolff-parkinson-white-syndrome/DS00923/DSECTION=treatments-and-drugs

Any other PMHX your missing ? Are you on ANY prescribed meds or taking OTC for something ?

Yup NO Caffeine at all, stay away from any soda/ pop, chocolate and any "Power Drinks" .

Don't use a Pulse Ox to check pulse rate when you are in warp drive ... use a cardiac monitor 3 lead is fine to get an accurate rate.

Who ever cleared back to work is a fool / tool, and doesn't BCAS do a in depth physical before hiring ?

You should not be working on a truck till the cardiologist gets a handle on this ... most seriously contact your CUPE rep too.

cheers

sorry for short note I have very limited Internet out here in the toolies.

Or a Jamaican Martial Artist and received a knock out punch ?

see link provided earlier.

cheers

Have you spent much time around pregnant women? Mean as snakes I tell you!, and twice as tough! Why...I....once saw a pregger chick get hit by a truck! She flipped it over, ate the drivers sack lunch, and went about her way, all the time mumbling that she was pissed that the truck pushed her belly and made her have to pee...again....Just sayin'...

Dwayne

ROFLMAO ! How true, took my ex carrying #2 on a Zodiac, in the open pacific, in rough seas (gale warning) from Ucluelet to broken group islands (pacific rim national park) I needed dental work after to put the fillings back in my teeth. Her complaint WHAT no bathrooms !

Point being that we should not consider "pregnancy" as a disease and often we do. I would use the v/s and s/s and clinical observation, and the history. If we are having contractions well that's a different picture.

How about the pregnant chick that cuts off the end of her finger while making dinner? (Yeah, so it's sexist..)

Dwayne its only sexist if she is making YOUR dinner and is wearing white to match the kitchen appliances.

cheers

I thought this is applicable for those highly trained martial artists out there.

CapoeiraFighter.wmv

cheers may the luck of the Irish be with yee.

My first aid manual claims that for treatment of internal bleeding I should lay the patient and raise the legs or bend the knees. Is that because that way the circulation that way is slower and therefor let blood is injected by the ruptured vein/artery into the body?

Your "last aid" Manuel is old as dirt, read the thread http://www.emtcity.com/index.php/topic/20453-did-you-ever-use-a-tourniquet/page__st__20

page 3.

No movie star here, have been known to break lenses with my ugly gob.

A simple firm "NO COMMENT" and refer to Police PR guy, I am a dumb Paradork and don't know a THING.

It is just human nature to be curious, I feel an intrusion into the patients privacy and mine.

The cell phone types encouraged by media and with cash rewards for "hot shots" are a PITA, without shadow of doubt.

Biggest problem in my mind is the sensationalism and get the story at all costs, as that is the prime directive of mainstream media.

cheers

Just found this thread .. bit tired right now but a good topic to bring up.

cheers

After careful review, and seeing that my original post was quite brief, I apologize if I came across harsh.

Sometimes the thoughts we are trying to convey come across our brain but seldom make it past the keyboard.

No worries I am happy you added the "edit" as my head was going to implode or explode not really sure which and croaker the in comments highlighted, welcome to the club will you support me in my bid for president ?

Now these interesting bovine-hormone saturated exotic dancers I saw afterward...but that is another story ..... please feel free to share your insights PLEASE and Bless You.