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I've always thought that after the initial and secondary patient assessment, we followed up with what's known as a 'continuing assessment' to provide the results of our treatments and to trend the patients condition. It is during these 'ongoing assessments' that the modality of our treatments may or may not change.

I haven't seen a posting to this thread that advocates the "Let's try this and see what happens!" mentality. The responses that disprove Crotchity's premise of "I know everything NOT in the book!" seem to be based on solid evidence, rather than conjecture.

Crotchity,

Since you know 'everything NOT in the book", why haven't you followed through with your responsibility to furthering the field of pre-hospital care, and begun to publish what the rest of us obvious idiots don't know?

While I've got some experience in a really major EMS system (I think metro Detroit qualifies as 'really major EMS system') I'm far from ever being confused with any MENSA members, (past or present); but I would be willing to follow the teachings/orders/directions/ advice of the respected physicians that are assoiciated with this forum (i.e.: Dr. Bledsoe, ERDoc, Doc 'Zilla, et al) and the guidance of the 'rock star members' that obviously know more than this mere 'medic student' will ever know.

Sure, equipment fails, it has its limitations, but given that we mere mortals do not have xray vision, clairvoyance and the God like power to heal by touch, I'm going to have to rely on those electronic devices to help guide me in the treatment of my patients. They are not the sole source I base my treatments on, (thats where education comes into play),but they ARE developed and used to help diagnose whats wrong with our patients.

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How do you do this? How many TAAs have you seen? In what percentage of the times that you thought you saw a TAA were you right? In what percentage were you wrong? How many patients have you evalua

Aside from what has already been stated, you might want to do some reading on “stress hyperglycemia”. This is relatively common with cardiac failure/AIM, or any other acute injury/stress state for tha

I totally understand crotchity's point... when your not sure, just give drugs until something happens Good lessen for the younger generation eh?

Sure, equipment fails, it has its limitations, but given that we mere mortals do not have xray vision, clairvoyance and the God like power to heal by touch, I'm going to have to rely on those electronic devices to help guide me in the treatment of my patients

But that's what set's our good friend Crotchity apart from us. He has x-ray vision, clairvoyance and is the right hand of God. He has the power to heal by touch but also the power to smite thee in your boots if you disagree with what he knows.

Thou has a feeble understanding of what's not in the books yet thou understanding of book learning is well renowned. Get back to thee tiny hovel and begin to pray at the altar of Crotchity "all knowing of things not in the book". We should not be worthy to even read the book LoneStar suggested that he write. The book may just strike us dead where we sit.

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WOW I AM AMAZED ! Thank you for making my point, the younger generation is apparently all about the equipment.

And is your point that because you have a lot of EMS experience you're excused from having to make logical and coherrent arguments?

A half amp of D50 is hardly similar to pushing cardiac drugs.

I will agree that TNK and D50W are different drugs, with different indications / contraindications / safety profiles / spellings / pronounciations / scrabble triple-word-score values.

Of course there's a world of difference. The point is, I give medications because there's an indication, not because I have a paranoid fantasy that my glucometer is inaccurate. If we just give D50W to patients that are unconscious and sweaty, should I even bother checking the blood sugar in unconscious patients any more?

Are we saving the glucometer for identifying HHNC / DKA now? And if I see a high value, am I now going to worry that I'm inappropriately treating the patient because the glucometer was actually inaccurate?

The likelihood of the patient being unresponsive due to another etiology seems greater than the probability that today is the day that my glucometer has decided not only not to work, but to report a falsely high value.

So then let me see if you are willing to kill any other patients besides diabetics ? You have a 40 year old male with crushing chest pain, SOB, pain radiating down left arm, but your 12Lead says NSR (no infarct). Are you going to withhold ASA and NTG (NTG is far more dangerous than 1/2 amp of D50)?

No, because the sensitivity of the 12-lead ECG for myocardial infarction is approximately 40%, therefore the absence of ST changes has a low negative predicitive value.

The patient gets both ASA and NTG. But I'm not going to assume that the 12-lead is giving me a false-negative, push a bunch of enoxaparin and tNK and give the patient plavix.

He could be having an embolus, a AAA, it could just be gas, or pneumonia/pleurisy. Or do you give the ASA and NTG and see if it improves the patient ? Now explain to me how the diabetic scenario is different.

My glucometer is sensitive for hypoglycemia, my 12-lead is relatively insensitive for myocardial infarction. Both machines are quite reliable.

The ECG has a low negative-predicitive value, and therefore can't be used to rule out infarction. The glucometer has a high negative predictive value. It's a useful rule-out tool.

I hear crickets ! Did it click yet ? Treat the patient, not the equipment.

Sounds like a medication noncompliance issue.

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[Edit]

On a different point, cardiac biomarkers are probably an awesome tool to have for identifying NSTEMI patients who could benefit from transport to a facility capable of PCI, but they have no role in deciding whether a patient is eligible for thrombolysis.

Edited by systemet
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Dang Systemet, another great response. WE need to have a beer summit.

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I did not say I was giving asa for pain, I said i was giving asa and NTg because it is a possible MI (I would then move to Morphine if Ntg didnt work). Someone then wrote back that ASA does nothing for chest pain, so I answered as I did to be fecicious. Wow DOC you never had your Chem-7 contradict your ER glucometer ? I can not believe you would let a known unconscious diaphortic diabetic patient die because you needed to do a head CT to rule out a CVA.

So following all of you guys line of thinking, we should not push Narcan for unconscious patients when we have no evidence of an overdose ? Why would we ever push thiamine, what test do you have to prove the patient is an alcoholic, versus just being drunk today ? Same thing. And I guess we should never backboard an unconscious patient lying on the side of the road, if there is no bleeding or fractures ?

Wow, did you seriously just advocate for pushing narcan just because someone is unconscious? You just lost any thread of credibility you ever had right there. The coma cocktail when out of style with Johnny and Roy. Seriously, when I started EMS in 1992 in a far from progressive system they were talking about the coma cocktail as, "That crazy stuff we did years ago." If I was your medical director, I would pull your card right there if you ever gave a coma cocktail.

No, I have never had a significant discrepancy between my glucometer and my labs, when they were used properly. A few points here and there, but nothing that would change management. I've seen a few operator errors that have caused a discrepancy, but the values they obtained did not make sense so a repeat was always done. When something doesn't make sense, you need to recheck.

You can do harm in stroke pts by putting them into a hyperglycemic state. http://stroke.ahajournals.org/content/35/2/363.full

As for your ASA agruement, have you ever heard of a NSTEMI? systemet has addressed this pretty well, so I won't do it again. Keep in mind that ASA is not without it's complications. Do you think it would be a good idea to give a drug to someone that prevents platelet aggregation who has a dissection? I'll let you think it through.

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"Do you think it would be a good idea to give a drug to someone that prevents platelet aggregation who has a dissection? I'll let you think it through."

oooooooh!!!!!!!!!!!! I know this one but I won't spoil Crotchities thunder.

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No, but I can spot a dissection from a mile away (either through my xray vision, or God tells me according to you guys). That is the whole point, I have seen too many medics treat the equipment instead of the patient. The overuse of technology has made you guys weak in assessment. I can tell the difference between Dyspnea that is caused by left sided heart failure, early COPD, or Pnuemonia, or pleurisy in a patient with no history of any respiratory ailments . Most Docs can't without a chest xray and a BNP (lab test). And I can tell you most of you miss it when it is left sided heart failure, and you end of giving an albuterol/atrovent treatment, and atrovent is contraindicated in CHF. So who is practicing bad medicine now ?

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Thanks man! I've no idea what a beer summit is, but as long it involves beer, I'm in.

A beer summit is a meeting where beer is consumed to give the appearance that the participants are friends and that the host hasn't caused a monumental idiotic blunder he wants to give the impression he really didn’t intend harm.

The term became popular after President Obama called a US policeman stupid and implied he was a racist. Then forced him to drink a beer with the guy he arrested in an effort to play like things were on the level. Why beer? I would conclude he either was further denigrating the policeman by implying he was common or trying to imply that he (the prez) is a regular guy.

You probably want to use another term for an intellectual meeting among friends, even if beer is involved.

Salud,

http://www.huffingtonpost.com/2009/07/30/beer-summit-begins-obama-_n_248254.html

Edited by DFIB
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No, but I can spot a dissection from a mile away (either through my xray vision, or God tells me according to you guys). That is the whole point, I have seen too many medics treat the equipment instead of the patient. The overuse of technology has made you guys weak in assessment. I can tell the difference between Dyspnea that is caused by left sided heart failure, early COPD, or Pnuemonia, or pleurisy in a patient with no history of any respiratory ailments . Most Docs can't without a chest xray and a BNP (lab test). And I can tell you most of you miss it when it is left sided heart failure, and you end of giving an albuterol/atrovent treatment, and atrovent is contraindicated in CHF. So who is practicing bad medicine now ?

Ah, here is the problem. You don't think you are an awesome medic nor hear the voice of god. You truly think you are god. Explains alot. Thanks for playing, your tin foil hat is waiting.

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