ERDoc

I gotta say, the comparison to an AED is foolish. AEDs were created so that people with no medical training can use them. It takes all of the thought process away from the user. The glucometer is a completely different beast. As others have said, it gives you a number. It does not diagnose and it does not treat. It depends on the user to have an adequate knowledge of what the number means, why it is what it is and what needs to be done about it. You cannot compare the two. The AED is made so that a monkey can use it and it will do what it is supposed to. You can teach a monkey to use a glucometer, but you cannot teach him how to respond to the results. I have been going back and forth with this. I can see BLS providers using it as long as there is a good protocol written to cover what happens when they get their result or required medical control contact prior to using it. It is far from an ideal situation which leads us back to the whole, "Do we really need BLS," debate. I have a feeling it will become one of those situations where there is a new toy, everyone will use it, usually inappropriately.

When you get multiple articles from emedicine the best thing to do is just look through all of them. Their quality is based on the authors so there is no way to tell you which section has the best articles. For specific prehospital treatment, you will find that in the EM section. Some of the best EM texts include Tintinalli (the full verion) and Harwood-Nuss. These cover most of what I want to know. There is no one comprehensive text for any field. Each book will be better on one topic than another book.

Pneumothorax and PE are very real possibilities in this case. She can have a small pneumo that may not cause much change in her lung sounds. You do not have to be in significant distress to have a PE. No, it is not retarted for NJ to disallow BLS from using glucose machines. Is the pain still present? Has she ever had anything like this before? I might have missed it but were pulses equal? What was the BP in each arm? Were there any carotid bruits or heart murmurs? PS-you can throw an embolus or have an embolism or you can throw emboli (plural)

If it wasn't going to be the Dolphins (though they were close) I am happy with the Giants.

Another great place for info is emedicine.com

What day of the week is it?

Good case JP.

From emedicinehealth.com: Components of Informed Consent There are 4 components of informed consent: You must have the capacity (or ability) to make the decision. The medical provider must disclose information on the treatment, test, or procedure in question, including the expected benefits and risks, and the likelihood (or probability) that the benefits and risks will occur. You must comprehend the relevant information. You must voluntarily grant consent, without coercion or duress. Decision-Making Capacity Decision-making capacity is often referred to by the legal term competency. It is one of the most important components of informed consent. Decision-making capacity is not black and white. You may have the capacity to make some decisions, but not others. The components of decision-making capacity are as follows: The ability to understand the options The ability to understand the consequences of choosing each of the options The ability to evaluate the personal cost and benefit of each of the consequences and relate them to your own set of values and priorities If you are not able to do all of the components, family members, court-appointed guardians, or others (as determined by state law) may act as "surrogate decision-makers" and make decisions for you. To have decision-making capacity does not mean that you, as the patient, will always make "good" decisions, or decisions that your doctor agrees with. Likewise, making a "bad" decision does not mean that you, as patient, are "incompetent" or do not have decision-making capacity. Decision-making capacity, or competency, simply means that you can understand and explain the options, their implications, and give a rational reason why you would decide on a particular option instead of the others Informed Consent, The Right to Refuse Treatment Except for legally authorized involuntary treatment, patients who are legally competent to make medical decisions and who are judged by health care providers to have decision-making capacity have the legal and moral right to refuse any or all treatment. This is true even if the patient chooses to make a "bad decision" that may result in serious disability or even death. To document that you have been given the option of obtaining a recommended treatment or test and have chosen not to, you may be asked to sign an Against Medical Advice (AMA) form to protect the health care provider from legal liability for not providing the disputed treatment. Refusing a test, treatment, or procedure does not necessarily mean that you are refusing all care. The next best treatment should always be offered to anyone who refuses the recommended care. If, because of intoxication, injury, illness, emotional stress, or other reason, a health care provider decides that a patient does not have decision-making capacity, the patient may not be able to refuse treatment. The law presumes that the average reasonable person would consent to treatment in most emergencies to prevent permanent disability or death. Advance directives and living wills are documents that you can complete before an emergency occurs. These legal documents direct doctors and other health care providers as to what specific treatments you want, or do not want, should illness or injury prevent you from having decision-making capacity. With all due respect Eyedawn, your significant other may want to review the law before he gets himself into a sticky legal situation.

I'd like to see the legal cases, because I respectfully disagree with you. The person has to be able to make an informed decision and if they cannot understand the ramifications they cannot consent or refuse. Edit: Here is the law from Louisiana: 1299.58. Consent to surgical or medical treatment for mentally retarded or developmentally disabled persons and residents of state-operated nursing homes - [top] A. Upon the written recommendation of the treating physician, the following persons may consent to any surgical or medical treatment on behalf of any mentally retarded or developmentally disabled person who is a recipient of service from a state-operated supported living or supervised independent living program, or personal care attendant program for the mentally retarded or developmentally disabled, or who is a resident of a state school or community home for the mentally retarded or developmentally disabled, state- supervised extended family living program, or a nonstate-operated residential facility, community, or group home for the mentally retarded or developmentally disabled or who is a resident of a state-operated nursing home: (1) For a resident of a state school or a state-operated community home for the mentally retarded, the superintendent of the state school. (2) For a resident of a state-supervised extended family living program, or a recipient of service from a state-operated supported living or supervised independent living program, or personal care attendant program for the mentally retarded or developmentally disabled, the office for citizens with developmental disabilities administrator or manager with administrative authority over the extended family living program, supported living or supervised independent living program, or personal care attendant program for the region where the home is located or the program is being provided. (3) For a resident of a nonstate-operated residential facility, community, or group home for the mentally retarded, the chief executive officer of the provider organization which administers or operates the facility or home. (4) For a resident of a state-operated nursing home, the administrator of the home or facility. B. Consent for any surgical or medical treatment on behalf of a mentally retarded person or a resident in a facility, home, or program as described in R.S. 40:1299.58(A) is authorized under the following circumstances: (1) When all reasonable efforts to contact the parent, family, or guardian of the resident have failed or (2) When the resident's record does not contain the name of the parent, family member, or guardian. C. Consent given pursuant to this Section shall be in writing and shall comply with the provisions of R.S. 40:1299.40(A). A copy of the signed written consent form and of the physician's written recommendation shall be placed in the resident's permanent record. D. Nothing contained in this Section shall be construed to authorize consent to surgical or medical treatment for a resident if the parent, family member, or guardian of the resident has been contacted and has refused to consent to medical treatment for the resident. E. Consent to surgical or medical treatment for residents will be implied where an emergency, as defined in R.S. 40:1299.54, exists. F. As used in this Section, mentally retarded includes the developmentally disabled. Added by Acts 1978, No. 607,§ 2; Acts 1990, No. 177,§ 1; Acts 2001, No. 519,§ 1.

Does the baby seem to have increased saliva?

That is not exactly true. The person has to have the ability to understand the consequences of their refusal of care. This is part of having the capacity to refuse. A mentally retarted person can be all of the above but may not be able to understand the consequences of refusing a procedure so they cannot make an informed refusal of care.

Does anyone think MAST pants might be a good idea in this situation? :shock: :shock: :shock:

ATLS preaches the rectal exam and the old surgical mantra "a tube or finger in every hole." Multiple studies have shown that the rectal may be a relatively useless test. I'm not a big fan of it in most cases as I feel it doesn't change the management or provide any additional information. Again, it is taught in ATLS so you have to keep in mind that it is part of the surgical mentality. A pt that is competent has the right to refuse anything they want, including a rectal exam. Just because it is part of the workup does not mean you can force it on the pt. If they say no (and have the capacity to do so) then it is no. Period. There are a few things about this case that just do not make sense. It is probably from the uneducated media trying to report the facts. If this guy got RSI'd, then a rectal exam is useless except to look for blood (no likely to find it in a head injury). I also heard that the doctor filed a case against the guy. So, the doctor thinks the guy is competent enough to be responsible for his actions but no competent to make the decision not to have a rectal exam. You can't have it both ways. He either had the capacity or not, which is it doc? I think there are too many facts left out for us Monday morning quarterbacks to make a real decision. I also think the pt is a tool. He now has PTSD? WTF? If he was RSI's he is not going to remember the rectal. Maybe his rights were violated, but come on, get a life. Pretty messed up situation all around, but hard to draw a true conclusions due to the lack of facts from the media. Thread Hijack: The assault thing brings up another interesting discussion for those of us in medicine. If a cop is assaulted in the line of duty the person will go to jail. If one of us is assaulted, the courts will shrug it off saying it is part of the job. I think that pretty much sucks. If it is someone who has been injured or is sick and not ini their right mental state then I would agree. However, if someone is drunk or high then no, it should not be part of the job. They should be prosecuted just like they would if they did it to a cop. I'll step off my soapbox now and return you to your regularly scheduled thread.

How much water has the baby been given? How was it prepared?

What do the loose stools look like?

:cheers:

I think you mean PERRL or PERRLA. Pupils Equal, Round, Reactive to Light (and Accomodation, few people truly know what accomodation means).

:lol:/ Go me!!! Seriously though. It is very important to look, listen and feel (ok, maybe in this case it is not important to listen). You physical exam can uncover some subtle findings. The main differential in a case like this is torsion, epididymitis, hernia, orchitis and a few other things. If one testicle is riding higher and possibly rotated you can be more concerned about torsion. If the pain feel better by elevating the testicle you should think epididymitis. That being said, you will be hard pressed to find an ER doc that will base their treatment on their physicial exam. There are just too many bad consequences if you miss a torsion, so more than likely most patients are going to get an US.

OK, now I feel violated. I'm not sure I am comfortable with someone talking about my equipment. :wink: There must be something in the TOS about sexual harassment. Eyedawn, you'll be hearing from my lawyer and the ACLU.

All of these "recommendations" just plug the holes in the dyke. We need to fix the real problem. We need to re-educate people about what an emergency room is. Hospital administration loves high volumes because they love the money. We need to be allowed to turn people away when it is inappropraite for them to be here. Until adminstration backs off on money and Press-Ganey our hands are tied. Since I can't make them go away, the thing I try to do is make them uncomfortable with their decision to come in. "So, you've had this pain for 2 weeks. Have you called your doctor yet? No? Why not? What about it made it so bad that you need to be seen tonight."

They usually use condoms. So I hear.

I'd like to palpate and see if this really is testicle, intestine or something else.

Who are we to judge? Maybe this guy really was probed by aliens. Maybe they really did tell him to come here. Maybe he listened because he was afraid of getting probed again if he didn't listen. Maybe he was hoping to get probed again.

The first one that calls the administrator is getting their Dilaudid drip cut off. Blowing chunks in the waiting room? Looks like you need an NG tube.

I doubt this is PMS, she's pregnant. Everyone is jumping to physical exam. I would focus on the history a little more. You can make 90% of your diagnoses on the history and then confirm it with the physical exam.