Leaderboard

Regarding the OP's question, a single amp of D50 in a nondiabetic will do no appreciable harm. You cannot compare patients with impaired glucose tolerance, as the studies cited here did, with a nondiabetic patient with a functioning insulin axis getting a single 100 KCal challenge. Regarding whether or not this was an error, the patient was exhibiting altered mental status as part of the picture. So it would seem that they took the reading, interpreted it in the setting of the patient's condition, and gave the drug. And it sounds appropriate. Third, hypoglycemia causes adrenergic output, and may cause the patient to feel a lot of things that we don't expect: nauseated, short of breath, anxious. So someone who presents as an apparent MI can in fact have hypoglycemia. I had a 31 yo in thyroid storm code in front of me from hypoglycemia and catecholamine depletion, so essentially a cardiac problem begat by a glucose problem. Therein is another problem with asking the lab tech what they think of the tests being ordered. Ask the doctor WHY he is doing the test, and the answer may not stick with what the lab tech thinks. It may not be needed to make the diagnosis, but for other reasons: - to rule out the less likely but possible diagnosis that may be more life-threatening, i.e., the PE that lurks, masked by symptoms that just sound cardiac - to establish a baseline in a patient for later comparison to monitor response to therapy, i.e., getting lfts in a known hepatitis patient - to establish nutritional status, i.e., the CBC in the chronic alcoholic who can't make a RBC MCV above 60 or get the albumin above 2 - to help interpret other labs, i.r., using albumin to estimate the real calcium level when it comes back low on the BMP - to seek extra-organ sequelae of a disease process, i.e., the renal failure that accompanies a pneumonia, liver failure that accompanies septic shock. - to seek extra-organ causes of the primary problem, i.e., the PE or electrolyte disturbance that led to the a-fib - to establish the safety of doing another test, i.e., checking the renal function before doing a CT - to hone in on a diagnosis among 2 or 3 that are not as likely. Is the pain from appendicitis, an ectopic pregnancy, PID, UTI, or a kidney stone? - to get a prognosis on a disease process. LFTs may tell us how irritated the liver is, but coags will tell us if it is truly working or not. Elevated PT or PTT in a liver patient is a bad sign. Or elevated cardiac enzymes that portend a poor prognosis in PE. Or the various labs needed for Ranson's criteria in acute pancreatitis. - getting to a prognosis for discharge home. The elderly guy with weakness, no sign of infection, a normal chest xray, and a WBC of 23K doesn't go home. The middle aged gal with single lobe community acquired pneumonia and acute renal failure doesn't either. The vag bleeder with dizziness and SOB on standing and a hemoglobin of 11 can go. - getting to the bottom of a vague complaint, i.e., the COPD/CHF patient who is short of breath and coughing up greenish sputum but doesn't have a fever, and maybe has some wheezes, and has a bilateral vaguely interstitial pattern on chest xray that could be pneumonia or pulmonary edema or fibrosis. - to get a sample prior to treatment in case the patient worsens, i.e., the urine cultures on the somewhat puny looking little old lady with a UTI that I'm sending home with antibiotics and outpatient follow-up. If she crumps and comes back, that culture data may be useful. You don't want to order labs on just anyone. It's like picking your nose; you can do it, but you better know what you're going to do with it. The more tests you order, the greater the chances are that one or more will be abnormal. Shotgunning the labs will leave you scratching your head with a completely-unrelated-to-the-chief-complaint sodium level of 125 that you don't know what to do with. That said, in the prehospital setting, BGL is a lab that will never hurt you. The fact is, the patients don't read the book, and a good doctor (and medic) knows this. Some patients show up looking like one disease process, but turn out to be another. At best, a patient fits "many aspects of a pattern of a disease process", essentially, connects most of the dots but never all. Exam findings can be unreliable, and a good doctor knows not to trust all of them. An objective lab value may help sort out the weirdness. There are a few diagnoses I make each day on sight with no testing required, but most patients come with some amount of diagnostic mystery. Even if it's not a mystery, there are so many reasons above why lab tests are useful. We understand that the human body is not a series of organs in isolation, but interconnected, and true badness can lurk unseen in cases which seem straightforward. Don't think only one organ system can bite you. 'zilla

Does Russia even have an organized EMS System?

No, I was just replying to what the CehNehDeh dude posted. But, thank you for taking the time to tell us that. What would we do with out you?

Get one of those Vietnam era choppers from federal surplus and run a dustoff service.. using old, retired, corpsmen and combat medics, with no modern training. Say that you choose not to recognize the fact that it's 2010, rather than 1968.

Paramedics Investigated After Boy Handed Emergency Radio I can see where this would cause some un-needed confusion with dispatch and other people listening. Would you do the same thing? Would the 11 year old even be in the front with you?

http://www.msnbc.msn.com/id/36077879/ns/world_news-europe/ Take a look at the pictures they've released so far... how the hell do you respond to something like this? I know we all have policies and procedures that tell us what to do... but I can't imagine actually being there and responding to it. Looks like they were just doing the best they could. I wonder what Russian EMS is normally like? My thoughts go out to all the victims and their families... Wendy CO EMT-B

Thanx Don. Feels good to be back.

Hyperglycemia itself is not immediately hazardous, but as Kiwi said, it's the dehydration that accompanies it from increased renal output that is problematic. Even DKA would fail to be that problematic if it weren't for the renal insufficiency that results from the severe dehydration (healthy, hydrated kidneys are very good at handling excess acids as well as excess glucose). For this reason, the first measure of treatment in DKA is always volume resuscitation. Insulin is a secondary concern, and I will usually wait until I have a potassium level back before starting the insulin drip in DKA. Asymptomatic hyperglycemia does not require any prehospital treatment, but anyone showing signs of dehydration (tachycardia, dry mucous membranes, nausea, poor urine output, sunken eyes) should be hydrated with IV fluid. This applies for the Type 1 diabetics in DKA as well as type 2 diabetics in a hyperosmolar nonketotic state. NS at KVO rate really won't help in any way, as it is a negligible amount of fluid. I start with fluid boluses, dose dependent on other comorbidities. If they have renal failure and are on dialysis, or are known brittle CHF patients, I'm pretty careful with the fluid, going 250-500cc at a time with reassessment each time. If not, I'll hit them with a liter of fluid. In children with DKA, overly aggressive fluid resuscitation is a risk factor for cerebral edema, so I'll hit them with 20cc/kg of NS IV bolus, followed by a maintenance rate + rehydration rate, which requires a bit of calculation. Remember that the dehydrated hyperglycemic patient didn't get that way overnight, so you shouldn't expect to fix it in a short period of time. Most people I plan to rehydrate over 48 hours. The initial bolus is helpful, but they will continue getting hydrated in the hospital over that time, or if sent home, will have instructions regarding aggressive hydration with PO fluids. 'zilla

Are you drunk? What pictures? And who is y'all?

Well, I guess everyone here is actually enjoying the show. I mean I have read a ton of medics complaining about minutia and yet a few who notice that hey, we are being shown in a positive light including all of the Medic types. Sure the medicine sucks, but these are script writers. Hell one of my favorite things on Third Watch was when Kim went Christmas Shopping in the Ambulance. Let's face it, we are all EMS personnel and are master complainers. You know a Medic needs help when they stop complaining. My first post on here and a new member. I sold out and went offshore, but I rediscovered my love for EMS by doing it. Seriously, try to see the good in this, instead of worrying about if it is proper lighting on the ambulances. I know I will be there screaming they're not doing it right next week right along with you, but at least this isn't a bunch of idiots with a keyboard horn.

So basically the higher powers to be gave this guys death a Muligan on the 18th hole.

If you've ever been around the people who smoke a pack or so a day, they always have that smell on them, though gum may mask the breath, you cant mask the smell all over your clothes. I would think in the pt with minor illness or injury, they would rather have someone who doesn't smell like a ashtray

Dwayne, You are correct, and no I am not offended. The first one went well (First Aid) I knew that I was doing that and was able to prepare for a week or more and borrowed some props. It went great. The second got sprung on me with about 3 days notice. I did not have the time to do a good presentation and worked with what little I had. Yes it could have been better and yes I have wondered if "I" failed them... As the old saying goes, If you are not a part of the solution then you are part of the problem. I totally believe it. I know a little more about the subject and if need be with a little more notice I can get the necessary props to do the class. The general attitude of the kids was more of what I was commenting on. Unfortunately some of them have no interest in putting forth the effort to achieve anything. They believe it should just be handed to them. Some of the requirements like the 5 mile hike we try to make a little more intersting. We include other requirements like identifying wildlife and trees and stop along the way to do this as well as just talking to the kids about what is going on with school and family and life in general. Anything to get there mind off the fact that it is 5 miles. It is inevitable that about 1/2 way into the hike or whatever I hear the complaining about stopping and just saying that we did it. I guess my observation is more from a lack of integrity, honor, or commitment. But we will keep plugging away and working with them. We can't give up on them. We have to keep working with them and trying to teach the values or we have failed. If we give up on them, then they have no positive reinforcement and will give up on themselves. Failure is not an option. Thanks for the feed back. I am always open to criticism and new ideas. Trust me I do not have all the answers.

I am actually myself seeing more and more of that "entitlement" among people of my age. I am not sure if I am just now open about it, or its just becoming more common? What I am noticing with younger kids and teenagers is a lack of patients. With the INTERNET, I'M, texting, etc. they don't have to wait for anything anymore. Its now now now. So maybe, you can somehow bridge cheating with the thought process of instead of waiting to learn, just taking right then and there? Also, kids are treated with kid gloves and have been for a generation now. I am very militant with my kids (Army brat here) . When they mess up, it's usually a harsh punishment. I let them know that they chose the action that chose the consequence. I make them think twice about doing something stupid again, or even for the first time. I have not spanked them, I usually make them give up something or do something physical. They know they are loved, and that their father and I are doing what we need to to ensure that they are smart, grounded, productive, active, and healthy members of society when they become adults. They know that to get something you have to work for it. Nothing is handed to them, except at Christmas and birthdays and honor roll. The rest of the time, if they want something, the first thing they do is come up to me or their dad and say, "I want ______, what do I need to do to work for it?" and we set up a plan for them to get _________. They know about dishonesty, and what it can do them as a person, and how even one little lie can haunt them for a long time.

As stated at 1:28...

Dart, Here is the REAL, NO BULLSHIT deal answers to your questions... FIRST AND FOREMOST...... 1. You and Your Friend need to write a BUSINESS PLAN for your future Helicopter Service.... For Example I am currently in the process of starting a fixed wing operation with a friend of mine, and the business plan we wrote was 35 pages, with 15 of those pages being nothing but FINANCIAL INDICATORS. This will be the HEART and SOUL of the operation and not something that can be thrown together quickly or done mediocre. For example, 1. Personnel Plan 2. Profitability % 3. Activity Ratios 4. Leverage Ratios 5. Liquidity Ratios 6. EBITDA 7. Debt to Asset Ratios 8. Revenue Forecast - Broken down monthly 9. Revenue Forecast - yearly 10. Break Even Analysis for 1st year 11. Pro Forma P&L ( Profit and Loss) Statements, Must Pro Forma out 5 years 12. Gross Margin & Monthly Profit 13. Pro Forma Cash Flow - 5 years Projected 14. Pro Forma Balance Sheet - 5 years = Assets & Liabilities / Shareholders Equity 15. Sensitivity Analysis The above was just my financial section alone, and it took us months just to write the plan, revise, revise, revise, etc......We are now in the process of dealing with Angel Investors for our initial startup funds..... With your limited experience in the air-medical industry and limited formal business education, I would say you have your work cut out for you indeed, not impossible, but, you're going to need the right help from the right people.... Once, you get this done and perfected, you then need to decide if you are going with a specific Vendor, and whose Part 135 certificate you will be using. This is also something that must be planned for, as the FAA just doesnt give these out like candy....They are VERY EXPENSIVE and time consuming to get one....and without one, you do not fly anywhere..... Now, after those things are done, you must think about aircraft type, Single vs Twin, VFR vs IFR, Single Pilot vs Dual Pilot, Medical Crew Configuration, training, continuing education, maintenance, Night Vision Goggles..., etc..... Where are you going to base the helicopter, Hospital, airport, or some other option? Medical Director....You must have a medical director for the program. These are just some of the very basic things you must have done to even remotely have a chance to get this thing off the ground......again, Not impossible, but highly improbable with what I have read so far..... Let us know more. John Wade, MBA, CCEMT-P, FP-C

Side note: That word is really falling out of favor in a big way, it is offensive to those with disabilities and the ones who care about them. I realize it is still pretty widely used (especially outside Canada) but being in healthcare I just wanted to note it.

What?

If the person is holding c-spine, then I want a direct, face to face communication and in depth report on what they have. I don't care if they're a boy scout first aid instructor or a trauma surgeon, they're in control of the most important (at the moment) function. The first thing they may say, is "don't get too close, he'll hit ya". I would want to know what. I'd take their report, then do my own size up of the victim.

In my opinion, and I really don't want to dig deep or speculate with out more information; but I foresee it being bad for smaller services. Small, one town companies, "mom and pop" services, possibly voluntary services that do bill. I don't support EMS that doesn't bill the patient for costs. We're a "rural" service, so we get more reimbursed. Medicare is definitely in the red, as far as what they owe us. I see more bills going to collections. I don't like to see a monopoly of ambulance companies. But I do think that Obamacare, with bundled costs, will have less of that money going to the EMS end of health care. Thus, the loss of services that are fighting to hang on, tooth and nail as it is.

I've noticed, randomly, that images posted on the forums, just pop up in the chat room. test

Your ambulance is a Cadillac high-top?

Weird.. When u posted that space suit thing, the picture showed up in the chat room.

It really seems that all three of us were pretty much saying the same thing. ERDoc's example was excellent. The glucometer showed a seriously low BGL. Yet, rather than go, "Oh boy! That's another 'skill' I get to perform on this patient!", the time was taken to both confirm the reading multiple times AND to analyse the patient's overall clinical picture before precipitously implementing a plan. I believe that is exactly what Crotch was originally suggesting, as it is certainly what I was suggesting.

On the original topic, if you run many cardiac emergencies, it doesn't take you long to realise that a pretty significant portion of acute cardiac patients are mildly, but noticeably hypoglycaemic. And if you're well educated in physiology, it's not any big surprise when you realise it. I agree with Crotch to a degree. You cannot just go blindly "treating" signs and symptoms without any intelligent regard for the total clinical picture. That is an extremely valid and important concept in medicine. However, in order to make that intelligent decision, you do first need all the facts, which means getting all those tests and exams done before jumping in feet first with potentially contraindicated interventions, i.e. D50. It does appear, from the story presented here, that the crew did make an uneducated mistake by jumping at the chance to pop the top on another drug vial without any clinical indication, and without sufficient knowledge of the potential consequences. Education FTW. If your agency doesn't make a major learning issue out of this incident, your agency sucks.

Oh I can't disagree more. I am so sick of this treating the patient not the machine thing that everyone is so hung up on. How bout an UnCx diabetic??... just intubate & transport? What about perfusing V-Tach? What about silent STEMI? How many diabetics have you seen that can go as low as 1 mmol without having any read symptoms? Your saying just wait till they become altered?? To be honest I think the crap that is spewed in this "treat the symptoms" is a catch-all for those who can't critically think for themselves. The machines are an assessment tool, they should be used to guide Tx. Reactive medicine treats symptoms. Proactive medicine treats signs. You decide. As for the bold text above; I would be interested to know if these same Dr's could diagnose without the "fancy tests". I gotta tell you though...... feel free to ultrasound, draw blood, or CT me anyday to ward off "exploratory surgery". Each to thier own though.

Actually hyperglycemia has been shown to contribute to morbidity and mortality in many acute conditions, MI and CVAs being 2 of them. Multiple studies have shown that it can reduce hospital survival rates and glucose levels are often looked at as predictors of outcomes. Pt's are started on insulin drips to strictly control the glucose levels even when they are only slightly elevated no matter what the cause of the hyperglycemia. There are plenty of studies out there and it the adverse effects of hyperglycemia with head injuries and sepsis is also well documented. Here are just a couple of article to get you started: Controlling hyperglycemia in the hospital. hyperglycemia and MI Just learn from this mistake and remember that none of the treatments we administer are completely benign and all have some degree of risk associated with them. Cheers!

http://www.canada.com/news/national/Dying+officer+thanked+paramedic+rescuers/2426743/story.html

The backboard makes absolutely no difference whatsoever. It's not going to keep somebody's arms or fat arse from hanging over onto the side rails, which is really your only concern. With almost all defibrillation going to pads these days, accidental shock of EMS personnel is an increasingly rare probability. Of bigger concern now is that a patient grounded out on metal cot rails will dissipate some of the energy that was meant for the heart, rendering the conversion ineffective. On the old thin Ferno cot mattresses, a backboard didn't even make that much difference on CPR. But with the newer, thicker mattresses, it is definitely an asset.

No sense in making it harder than it has to be. Lock the darn doors.

What is a RCMP officer? Was that someone he was working with? How sad, just sad. Last February I had a tonsilectomy that put me in the ER about a week later with massive hemorrhaging. The blood was puring out my nose, and my mouth, but I still did the best I could to thank the medics who rushed me to the ER...

One thing I hate about EMS forums and really EMS in general is that everyone is a know-it-all. And thanks Dart

CNN is a good news channel but frankly I don't care for that channel cause unlike Fox News (who ask the actual tough questions) all they ask (and this is just in general, i do not know if it was an actual question) "so how about them RedSox?" But I also agree that are former health care industry did need a change just not one that was jammed down our throats like this was. In my opinion Pelosi, Obama, DNC pretty much said sit down, shut up and just take it. Trust us we know whats good for you. If they do then how come they are not subject to the bills they sign into law...huh. In my opinion we should elect a whole new group or ppl in both the Senate and House. Keep those who have had only 1 term (if there is any) but everyone else just vote out. that way it will also show the DNC that WE THE PEOPLE want OUR ELECTED OFFICIALS to do what we want and not what they want. Yes the GOP all voted against the bill, Great they did what we wanted along with the hand full of Dems. Speaking of compromise, there willing to sit down with Iran but not a group of TEA Party members or 9/12ers. Whats wrong with that picture....just food for thought the last part was.

boeingb13 Group: EMT City Sponsor Posts: 99 Joined: 27-August 06 Gender:Male Location:Jacksonville Florida Interests:surfing,music Reputation: -7Neutral Sent Today, 07:00 PM That was cute, my info I believe is in my profile, if not i'll post it. Whats the last name, since were not hiding. The tone of your messages is beginning to get really, really unfunny. All future messages will be posted publicly and forwarded to Admin. Any with a threatening tone will be forwarded to law enforcement. You need to think very carefully before you start playing the, "Fuck with me and I'll hunt you down" game shithead. You think I'm froggy online? Give me some reason to think that you're actually stupid enough to show up on my family's doorstep... Fair warning. Dwayne

^ Seriously not recommended.

Answer 1 - We are already in debt so why not put us more into debt. So no I personally do not think it will work out Answer 2 - that happens to the best of us.

most of my training is self taught or I picked up from various places. Now with swords and knife and the like I train at least 4hrs a day. so which do you want

all I have to say...and even then I can't take credit for it...so as Glenn Beck says "Game on progressives, we'll see you at the polls this November."

This is an interesting view point and I did consider it. However, people go to the ER for non-emergent issues because they are ignorant. This is my view point formed by working in a high call volume system and also working in a trauma center ER in an inner city ghetto. I have for the most part stopped trying to educate people, as I see it as a lost cause and a waste of my breath. Most of these people will never get it and don't care to. You stubbed your toe 2 days ago? Ok lets go and get this run over with....

We had better stay vigilant about terrorism because they are still out there and they have been studying us the whole time and when the are ready they will definitely attack.

The thing that caught my ear was at the beginning where the newbie says "I didn't go to medic school to be treated like an EMT". Now before all the EMT's burn me.. I give it a point for that because maybe the public will figure out that there is a difference.

let it be noted the pt. had a smell of etoh. i don't know most of the details as i was not there thanks for the feedback You act like you were there? Was this you on the call? I did not provide much details....and there is more to the story. You guys got way off topic and started spouting off your mouths without knowing the full story. This topic was meant to discuss what I had posted about it...no to bash the crew based on the little information I gave. From what I understand the pt. had smelled of ETOH and was acting intoxicated, but was AAO X 3 With that being said thanks for the inoformative stuff that was posted by you and others on this topic.

yup I chew and we all quit chewing or smoking eventually.

Tom is right, just because you don't like the bill that was passed does not mean go and throw actual rocks and that persons office or even send mail with baby powder in it. What that does mean is that in November when some of those ppl who voted for the bill are up for re-election you vote them out of office. Like Glenn Beck said in one of his shows this week "Game On Progressives, we will see you at the polls this November." So don't stoop to the level of actually throwing stuff or sending death threats cause if you do then your only proving that the left is right. that the TEA Party goers and 9/12ers are nothing than a bunch of vigilanties out for revenge just cause there representative did not vote how they want. Ghandi once said (and forgive me if I misquote) "Use truth as your anvil, and peace as your hammer." That is what you do, you hold to your beliefs and do so in a peaceful way.