ERDoc

I can respect that, but you will find there are many more that feel the same way. There is not much you can learn about doing an assessment in a 120 hours course. In medical school we spend over 50 hours learning to take proper history and over 100 hours learning how to do a proper physical exam.

Assessment is not a BLS skill. The subject of real assesment just skims the surface in EMT classes. I would argue that assessment is an ALS skill. The whole thing of BLS before ALS is just bull.

Maybe this would help.

When I used to do EMS on Long Island I'd usually just shut off the lights and sirens. On most of the roadways if you were doing 70mph you were getting passed. It seemed a little rediculous to be doing lights and sirens in the right lane with people speeding past you.

I can't say much about the oxygen but I am curious about the possible AED. We are hearing the family's opinion that it was not working. Was it truly defective or was it just that no shock was indicated? I think we need to hear a lot more about this before making any judgements. Even if there were oxygen in the tanks, would it have made a difference? I would be willing to be a large sum of money that the outcome would have been the same. I don't know if I would be willing to pronounce someone on a plane. I'd much rather run the code til we get on the ground (realizing it was futile)and allow the locals to take care of the paperwork. I also would not want to be sitting with a corpse, even if it was covered.

ABSOLUTELY NOT. The two should be practiced together. As I have said in the past, in the real world of medicine there are no such things as ALS and BLS. There is patient care. The mantra you bring up is what is used by people that try to make themselves feel better about their position. BLS really is nothing more than first aid practiced in the back of an ambulance. As for your story about the medic who went to the hospital without "lights and whistles," I'm not sure what the point was. Are you being critical of his decision not to use lights and whistles? If you consider that decision poor patient care you might want to review some of the literature on the use of lights and sirens. I am not sure if there is any literature to support the use of whistles in an ambulance but I would guess that they would not be very effective since traffic may not be able to hear them. I don't know if there is any state that recognizes the use of whistles as an emergency device either.

Dwayne, I have to admit that I have not read any of her other posts. I think it is the arrogance and attitude that is taken which is causing to jump on the OP. Asking if EMTs should babysit medics starts the flame war before you have even opened the thread. Maybe the OPs other posts have been worthwhile, but I think starting this one in this manner was just a set up for trouble. Keep in mind that experience without education just means you keep making the same mistakes and don't know that you are doing it.

As always it is a risk vs benefit situation. Allergy is a definite contraindication. I don't have a problem giving it to someone who is anticoagulated. As far as the GI bleed, it depends on the severity. I would be more concerned with giving heparin than asa. As far as trauma and surgery it depends on the situation. Pregnant pts are often given ASA during their pregnancies if they have a hypercoagulable issue.

OK, we can try to make this educational (and I might win the MegaMillions jackpot on Friday). Not all that wheezes is asthma. The guy with the wheezes and resp distress can be in CHF. Just because you have NSR on a rhythm strip does not mean that the issue is not cardiac. Even pts with MIs can have a normal EKG, called a nonST elevation MI (NSTEMI). Giving a CHF pt ASA and nitro is a great idea. I don't see an issue with the treatment of this pt without having more details. I hope I have been able to start the education process and others will help add to it.

:shock: :shock: :shock: :shock: :shock: Duck, cause it's about to hit the fan.

Here is a clip from Micromedix. If your pt is hypoglycemic and having a seizure, I think we could all agree that the benefits outweight the risks. I also can't imagine a one time dose would be a problem. Chronic hyperglycemia during pregnancy can be a bad thing though. If mom can tolerate PO, give her PO. REPROTOX® GLUCOSE Quick take: Abnormally high blood glucose may cause abnormal embryo development in diabetic pregnancies. * * * Glucose (dextrose) is a hexose found as an energy source in many biologic systems. Concern about the effects of glucose on embryonic development are based on the finding that infants of diabetic women have an increased incidence of congenital anomalies (see below). Experiments with early (2 and 8 cell) hamster embryos in vitro have shown that the presence of small amounts of glucose in the medium inhibits development (1,2). Culture of rat embryos with glucose concentrations many times those achieved even in diabetic women results in the production of anomalies, particularly involving the central nervous system (3-5). Animal experiments using l-glucose, the nonmetabolizable isomer of naturally occurring d-glucose, suggest that osmotic effects may play a role in producing some of the defects associated with elevated serum glucose (16). Pregnancies in diabetic women carry an increased rate of congenital anomalies, with estimates ranging from 6 to 13% (6-8). The most common abnormalities are cardiac and neural tube defects. With more strict metabolic control of diabetes using insulin (#1095) and close monitoring of glucose or glycosylated macromolecules, the congenital anomaly rate appears to be decreased, provided such control is instituted very early in the pregnancy (9-11). These findings suggest but do not prove that an elevated glucose level in maternal blood is the teratogenic principle in diabetic pregnancies. Mothers who develop gestational diabetes in mid or late pregnancy also have an increased risk of pregnancy complications. Tight glucose control in these patients can also improve perinatal outcome (15). Intravenous solutions containing glucose may be administered during labor; however, if the rate of administration is too rapid, maternal hyperglycemia may lead to reactive neonatal hypoglycemia. Other metabolic abnormalities described in neonates after maternal intravenous glucose during labor include hyponatremia and metabolic acidosis (12,13). However, another study did not find acidosis to be a problem after use of large amounts of intravenous glucose during labor (14). Selected References 1. Seshagiri PB, Bavister BD: Glucose inhibits development of hamster 8-cell embryos in vitro. Biol Reprod 40:599-606, 1989. 2. Schini SA, Bavister BD: Two-cell block to development of cultured hamster embryos is caused by phosphate and glucose. Biol Reprod 39:1183-92, 1988. 3. Garnham EA et al: Effects of glucose on rat embryos in culture. Diabetologia 25:291-5, 1983. 4. Cockroft DL, Coppola PT: Teratogenic effects of excess glucose on head-fold rat embryos in culture. Teratology 16:141-6, 1977. 5. Sadler TW: Effects of maternal diabetes on early rat embryo-genesis. 2. Hyperglycemia-induced exencephaly. Teratology 21:349-56, 1980. 6. Molsted-Pederson L et al: Congenital malformations in newborn infants of diabetic women. Lancet 1:1124-6, 1964. 7. Soler NG et al: Congenital malformations in infants of diabetic mothers. QJ Med 178:303-13, 1976. 8. Mills JL: Malformations in infants of diabetic mothers. Teratology 25:385-94, 1982. 9. Fuhrmann K et al: The effect of intensified conventional insulin therapy before and during pregnancy on the malformation rate in offspring of diabetic mothers. Exp Clin Endocrinol 83:173-7, 1984. 10. Molsted-Pederson L, Pederson JF: Congenital malformations in diabetic pregnancies. Acta Paediatr Scand 320(Suppl):79-84, 1985. 11. Damm P, Molsted-Pederson L: Significant decrease in congenital malformations in newborn infants of an unselected population of diabetic women. Am J Obstet Gynecol 161:1163-7, 1989. 12. Philipson EH et al: Effects of maternal glucose infusion on fetal acid-base status in human pregnancy. Am J Obstet Gynecol 157:866-73, 1987. 13. Singhi S et al: Iatrogenic neonatal and maternal hyponatraemia following oxytocin and aqueous glucose infusion during labour. Br J Obstet Gynaecol 91:1014-8, 1984. 14. Piquard F et al: Does fetal acidosis develop with maternal glucose infusion during normal labor? Obstet Gynecol 74:909-14, 1989. 15. Thompson DM, Dansereau J, Creed M, Ridell L: Tight glucose control results in normal perinatal outcome in 150 patients with gestational diabetes. Obstet Gynecol 83:362- 6, 1994. 16. Gale TF: Effects of in vivo exposure of pregnant hamsters to glucose. 1. Abnormalities in LVG strain fetuses following intermittent multiple treatments with two isomers. Teratology 1991;44:193-202. © 1974-2008 Thomson Healthcare. All rights reserved.

Doh!!!!!!!

So what do you give your hypoglycemia pregnant women?

I'd have to agree that the issue here is going to be airway control. This is a very tenuous airway from the sound of it. If you don't secure it at the scene, will he make it to the hospital? You might want to be careful how much pressure you put on the throat. The bullet may have damaged some of the supporting structure of the trachea/larynx and you may make it worse. The next question is, do you RSI this guy? Will your backup airways be adequate (think an LMA is going to be a good idea in this guys throat)?

OK, points well taken. Continue you equine flogging.

Keep in mind that not all pain requires narcotics. There are plenty of nonnarcotic pain relievers out there (though I realize that on the ambulance you are limited). There is no real way to test for fibromyalgia. It is basically a diagnosis of exclusion. These pts are fully worked up and have no real cause for the pain. They must have 12 pain points (I believe). This means that they have to hurt when you push on 12 spots on their body. There is a huge debate over whether fibromyalgia is real. Even the physician who first coined the phrase says that he was wrong and there is no such thing as fibromyalgia. Many people feel that fibromyaglia is just the physical manifestations of an underlying psychiatric illness such as depression. Giving pain meds to treat fibromyalgia is probably not the best method to treat these pts. They need the psychiatric support such as SSRIs, therapy, behavior modification, biofeedback etc. Fibromyalgia has almost become the medical code word for a difficult pt. I think it is applied to way too many pts (assuming it is even real). That being said, in this case pain control is appropriate. She might have a legitimate injury. Does she need narcotics? No, not necessarily, but if it is all you have then you do what you have to do. Just watch out for the ones that say they have end-stage fibromyalgia. NO ONE has ever died from fibromyalgia.

11 pages already.

I liked the comment about EMS absorbing fire since 90% of the volume is medical. Sign me up for that job. Can you imagine firefighters taking orders from a doctor on how to fight a fire? "OK, get a hose and put some water over there!!!! Get that big silver tool and break some of those windows!!! What do you mean venting???? There is no one intubated yet!!!!!" It's probably much funnier picturing it in my head. Why do these fire chiefs think they can appropriately run EMS?

I don't think any pt with slurred speech and trouble walking is going to get lost in a busy ER. These pts usually get shuffled to the front of the line (of course everyone has their story about this one pt that did). Many of the things you mention would not be used in a case like this. A pt who has had lytics is not going to to OR any time soon. Coiling is done in a bleed, not ischemic stroke. Some stroke centers (like the large academic type) can you intraarterial lytics, but most community hospitals that have been able to get the stroke center designation do not have this capability. Personally, I think more research needs to be done on the topic of stroke centers. Until then I am not a big fan of them as I see no advantage.

This is where I am a small problem with "stroke centers." Any ER can get a CT scan and push lytics. I've done it several times in non-stroke center designated hospitals. It's nice to have all of those other people who can take the pressure off of you having to make the decision to push lytics or not but it is not necessary. Get the CT, push the lytics and arrange for transfer. There is not much else that a stroke center is going to do in the early phases.

Since when do bad asses from Texas speak English and not American?

With a thorough H&P you can usually differentiate between a stroke and hypoglycemia. I don't think anyone would fault a BLS crew for giving oral glucose to someone with a stroke. It may not be an idea situation but it is easily corrected in the ER.

I've had a few Nurses Aides bring family members into the ER who had just enough knowledge to be dangerous. I had one bring in her father, "I was practicing taking his blood pressure at home. It was 142/86. I knew that it was dangerous and I should bring him right in." I also got into a debate on the benefits/risk and pathophysiology on coumadin with one who brought in her father with an ulnar artery occlusion.

We can all make up some scenario when you could justify the use of just about any medical procedure. I was working in Koldknutz, Canada in the middle on Jan. There was a massive snow storm and no helicopter was flying. Koldknutz is a small town that is 250 miles down a dirt road. The closest hospital is 300 miles away and the closest trauma center is in another country. The only 2 cars in the town managed to collide. One driver hit the steering wheel and was in pretty bad shape. We start the 3 day transport to the local trauma center. About a day and a half into it the pt loses his vitals. It was a good thing we were allowed to do thoracotomies because the guy never would have made it. PatrickW, in the scenario you gave, why would you not just give the oral glucose? You said that the pt was a known diabetic and presenting with hypoglycemic symptoms. Why not just give the oral stuff? Another option is to have the pt or the family check it with their machine. I know I said previously that I was going back an forth with the issue, but I just can't see why BLS would need a glucometer.