ERDoc

This pt is even more hypokalemic than it appears. Acidosis brings the K out of the intracellular space. As you correct the acidosis you will drive the K back into the cells making the pt more hypokalemic. LR would not be a good choice because of the lactate. It has the potential to worsen the acidosis. Rehydrate with NS and we will take care of the electrolyte problems in the ER.

FF523 as is typical of you, you come out with some of the most absurd posts. As I and others have said in the past, your arrogance and ignorance are going to get you and your pts killed. Your post shows why protocol monkeys should be outlawed. Chest pain does not equal aspirin. You are OK giving a medication that will make bleeding worse to someone with a potential fatal bleed? It is a good thing that you don't carry heparin or even worse thrombolytics. I am afraid to think of the number of people you would send to an early grave. If you can't differentiate ACS from disection in the field, you don't belong there. No, you cannot make a definitive diagnosis but you can make an educated decision. Spend a few minutes talking to your patients and less time trying to see how many skills you can use and you can pull apart the story and possibly do the right thing for the pt. Try asking more about the pain than just where it is and when it started. The pain from a dissection is usually a ripping or tearing that is greatest at onset and gets better. There are several other differneces but I will let you look them up for yourself (consider it a test to see how truly professional you are). I do not have xray vision, but I know how to take a good history and decide that it may be wise to hold on the aspirin until I know there is no disection. You should be doing this also. No one is going to knock you if you withold aspirin and can justify it. Document your reason and tell the ER staff, "I didn't give him any aspirin because I was concerned for a dissection because of XYZ." You should also be careful giving nitro to a pt with a possible dissection. Can you tell me why?

I see you guys are all haters. Don't be too jealous of the Yankees. It is getting harder and harder to make ends meet these days. Maybe if the other teams paid a living wage like the Yankees they could get better players. You can't expect the players to support their families on the low wages they make.

So, now that the Yankees have been knocked out, the rest of the playoffs are pretty much irrelevant. :wink: So, what does everyone think of Joe Torre's future?

I have never seen the angered mentation, but you have probably been using it longer than I have (no offense). I have a personal bias against compazine as I have seen a family member develop torticolis from it. It is one of the most excrutiating things I Have ever seen. It's like watching some have an appendectomy without anesthesia.

I use Reglan all the time with no problems. All meds are going to have their side effects. With Droperidol you have to worry about the THEORETIC cardiac issues and sedation. Phenergan is bad for reasons that have been discussed ad nauseum (pun intended) on other threads. Reglan is the least sedating (based on personal experience) and works pretty well.

It looks as if a lot of people are thinking DVT. It should be on your differential, but keep in mind that it is very uncommon to have bilateral DVTs in healthy people (as Brain said). It is also unusual to have episodic exacerbations of the pain. The pain from DVTs is pretty constant and usually gets worse if you touch the painful area. However, DVT is one of those dx where if you consider it you need to rule it out. This is easily done with ultrasound. Has this patient done anything strenuous recently? Any recent medication changes? Any fevers or URI symptoms? Any h/o trauma? Any numbness or tingling? Any pain in the perineal area? Any problems with bowel or bladder incontinence?

There have been a lot of issues brought up and it is good that we have opinions from people outside the US to give their feelings on their current systems. Universal health care does not equal communism. In a first world country we should be able to provide all citizens with basics such as food, education and healthcare. Yes, here in the US we have Medicare which covers the elderly and Medicaid which covers the poor. However, there is a large portion of the population that is not insured because they make too much money to be able to afford medicare, but don't make enough to be able to pay for their coverage. It is the people in this group that are at the center of the current SCHIP debate. I usually agree with Dust on most points, but Darwin will not work this one out. One of the greatest forves fighting survival of the fittest is Emergency Medicine. Without insurance people have no primary care provider, so what do they do? They go to the ER for their primary care. The last person you want providing primary care is an ER doctor (Doczilla can back me up here). I am not trained in primary care and I do not have the time to get deep into your history (like a good PCP should). I have about 10 minutes tops to figure out which one of your many complaints I need to work up to make sure it won't kill you and then move on to the next person. It is these people who use the ER for primary care that are putting such a burden on the system. These people also affect you in the field. You are the ones that they are calling to get to the ER. They are the ones that are taking up the bed that you are waiting 60 mintues for to unload your chest pain patient. Give these people insurance and they will have someone that they can see instead of jamming up the ERs and EMS crews. I support a universal health plan, but not one run by the government. I think it will take a program that is developed by collaboration between the government and the private sector to be effective. I also support a system where people are penalized for inappropriate use of services. There should be significant copays for using the ER/EMS for a cold. I think this would help control the increasing health care costs because people would not be so quick to run to the ER for every little thing. The population that is being hit the most by the rising costs are the blue collar, working people. They generally tend to be the ones who cannot afford insurance but feel the right thing to do is to pay the bills anyway. Hospitals (and EMS for that matter) will never collect what they bill from insurance companies/medicare/medicaid. I beleive medicaid pays about 30% of what is billed. You also have the population that gives a fake name and address who get their care and can never be collected from. The losses that the health care system takes from the insured and the scammers are passed along to those who are willing to pay for their own care. These people are unable to negotiate fees like the insurance companies can so the burden of the costs get passed on to them and they get shafted. Scaramedic, you said, "Also, no hospital in the U.S. can turn away an emergency patient, they have to treat them. We take care of our own believe it or not we just do it in a different way." This sounds all good and dandy, but let me put it in a different light for you. As I said previously, going to the ER is not a good form of primary care. Also consider this. As you said, we in the ER cannot turn away any patient. The ER doc is the only physician in the country that is forced to see any patient. All others (surgeons, pediatricians, internists) can select who they see. We are forced to see these people whether they can pay or not. This is going to sound greedy, but stay with me for a second. I am being forced by the government to see any and all patients reguardless of their ability to pay. While I am doing this I am also taking on the liability of seeing these patients (there is no Good Sam laws or anything to protect me). So I am now being forced by the government to put my career, license and family on the line and will get nothing in return. Would you be interested in a job where they told you that you will not be paid for the time you spend doing transports that do not pay their bills, but should you end up in court you are responsible for the outcome? I can't see too many people taking this position. Outside of academia there are many ER doc who are paid based on what they are able to collect. If 50% of your pts don't pay (a very real figure in some areas) you are volunteering your time for half the time you work. Again, would you be willing to take a job like this? I'm sorry for any rambling but I am working on a few hours of sleep over the last few days and it makes sense in my foggy state. If it doesn't make sense, let me know and I will clarify. PS- most politicians aren't saying that the government should control the healthcare system like a classic medicare/caid system, but are promoting a combined govt/private sector run program that gives people choice while keeping premiums low and guaranteeing coverage even to those with preexisting conditions. Some on the other hand have talked about giving tax credits to those that pay for thier own coverage (this is good only for those that can afford it and does absolutely nothing for those most in need). I actually took a look through several of the candidates websites and checked out their plans. Some interesting stuff that I still haven't had enough time to form an opinion over. Here is a link to the ED forum on SDN with a similar discussion.

Many classics from the original American Pie: "Oh and this one time at band camp..." "Say my name b!tch!" "God bless the Internet!" "Suck me, beautiful." "I was used??? I WAS USED!!!!!!! Cool! " and a few others that are probably too explicit to put here. Dr. Hill in Malice: The question is, 'Do I have a God complex?' which makes me wonder if this... lawyer... has any idea as to the kind of grades one has to receive in college to be accepted at a top medical school. If you have the vaguest clue as to how talented someone has to be to lead a surgical team. I have an M.D. from Harvard. I am board certified in cardio-thoracic medicine and trauma surgery. I have been awarded citations from seven different medical boards in New England, and I am never, ever, sick at sea. So I ask you, when someone goes in to that chapel and they fall on their knees and they pray to God that their wife doesn't miscarry, or that their daughter doesn't bleed to death, or that their mother doesn't suffer acute neural trauma from post-operative shock, who do you think they're praying to? You go ahead and read your Bible... Dennis, and you go to your church, and with any luck you might win the annual raffle, but if you're looking for God, He was in operating room number two on November 17th, and He doesn't like to be second guessed. You ask me if I have a God complex? Let me tell you something. I AM God.

Dwayne, I will agree with you that continual bashing for something that could have been found with the search funtion is a waste of time, so we should end it here. It is good that the OP is questioning things and looking for more answers and info, but part of being a good student is using all of your resources, including the search. As for my opinion on the original topic, I do not feel that ntg should be given without an IV line. As others have said, if things go south you need to have an out. You also should not be blindly giving ntg because someone says the magic words, "chest pain." This is where I'm afraid that the "because I have it, I should use it," mentality will come out. Ntg should be given after a good H&P have been done. There are a lot of other things that cause chest pain and do not need ntg. I hate to bring out the old cliche, but 110 hours does not cover all of the things on the differential.

Haven't we beaten this dead horse several times already? :banghead: :director: The search function is your friend

Core Concepts in Anatomy by Stern. Not a great book for learning basic anatomy, but once you have learned anatomy it will help you tie in everything that you have learned to your clinical practice.

Are you going to give aspirin to a patient with a disection?

This is a real nit-picky (-5 for making up my own word). In a tension pneumo you can see deviation of the trachea to the side opposite of the pneumo. The trapped air in the chest is pushing the mediastinal contents to the other side, pulling the trach with it. In a large simple pneumothorax I imagine you would see the trach tug to the collapsed side during inspiration. The reason being that the good lung is inflating while the pneumo side is not so you would see the trach get "tugged" to the collapsed side during inspiration. Just a thought.

No pun intended (or was it)!

While I respect you for giving your time, are you really a volunteer if you are being paid (though not very much)?

Guess someone needs to let my hospital know this. We keep getting happy grams reminding us not to use IV Zofran due to the costs. Guess that's what happens when beancounters are allowed to get involved with pt care. Either that or maybe we are finishing up our supply of brand name Zofran and the hospital doesn't want to lose the money.

Phenergan is not as evil as it is made out to be. It has gotten a bad rap, just like droperidol. Sure it can cause problems but I think it has been overhyped. Zofran may be last resort because of the cost. IV Zofran can be pretty expensive.

There is no need for a board. A long board is only for transport purposes. Walking may not have been the best idea, but a long board is not needed.

One thing that is not taught in any school is tact. There is a tactful way to approach a situation like this that will ususally not offend anyone. The best way to do it is to make it look like you are trying to do some of the work for the medic so that he can do more important things. Try something like, "Do you want me to bag him so that you can take care of the family/start an IV/etc." You are not questioning their ability and pointing out their deficiencies, but kindly taking over a menial task so that they can move on to bigger and better things.

Every pt that goes by ambulance needs a certificate of medical necessity filled out by an MD (mostly for Medicare and caid). This form can be quite a pain in the ass because there are very strict guidelines that we have to meet. There have been a few pts that I have transferred to another facility that were borderline on these criteria. A problem we have in the ER at night is there is no one but ambulances to take people home, so we are stuck calling one (and trying to justify it). As someone else said there are ambulettes but they often do not run at night. I have even seen an ambulette with a strecher and a 2 man crew (great idea to take the burden off of the EMS crews). Again, these are not available at night. Renal roundup is such a waste of ambulance resources also. A better system needs to be developed, until then you guys are gonna get stuck with inappropriate transfers (sorry).

I think if we can correct the education the rest will quickly fall into place.

I don't get why? Should I have to go through PA school or nursing school before I become a doctor? This is where real education comes into play. Making medic school a 4 year program would allow enough basic sciences and clinicals that you could turn out a decent medic who didn't go through EMT school and could function in the street without calling medical control for every little thing.

For high school students the policy should be ABSOLUTELY NO PAGERS. You are there to learn, not wait for the next big trauma. Get your education done and then go out and play. As for the college services they should not have their pagers on (unless they have a vibrate only mode). When I was in college I was at a big premed university that had an EMS corps. Talk about a bunch of wackers. They would sit in a group in class, each one in uniform with their pagers on monitor. Whenever someones tones would go off (even if it wasn't theirs) they would start talking. It got to the point that the professor had to yell at them. Very distracting and disrespectful. Bottom line, if you are in class (of any kind) turn off the pager. If you feel the need to be on duty 24/7, do it from your house/dorm and don't bother those that want to learn.

Sounds to me like this pt is becoming combative. Maybe a little etomide and sux are in order. :wink: