ERDoc

I totally agree with you Dust, but in the part of my post you quoted, I was actually referring to where I said, "It is the inability to think past what has been taught to you that makes it hard for someone, like a certain firefighter on this thread, to accept that soomething that we do is not the best medicine." It's late and I may be rambling a little, so I appologize if it doesn't make sense.

It is issues like this (using ntg in MI) that show why we do studies. Things may seem intuitive to one person and not to another. As someone said, ntg is used to vasodilate the coronary arteries to allow blood to flow past the blockage thus perfusing the tissue beyond the block. This seems to make sense, but one could also argue the following. Ntg causes vasodilation such that there is a decrease in forward flow from the reduced coronary perfusion pressure leading to local hypoxia and worsening ischemia/infarction. This seems to make sense too. So, now we have a conundrum. We have two opposing theories that make sense but lead to opposite outcomes. What do we do? We do a study and compare the two. The problem here is that ntg has been so ingrained in cardiac care that you will never get an IRB approval to do a study without it (short of conducting unapproved studies on unwelcomed family members and nosy neighbors in your basement). It is the inability to think past what has been taught to you that makes it hard for someone, like a certain firefighter on this thread, to accept that soomething that we do is not the best medicine. But, that is just my hypothesis and I have no intention of conducting any double blinded, placebo-controlled trials to prove it.

:laughing3:

Insults are the weapon of the weak, incompetent and uneducated. Once again, you have shown your true colors. My residency days are long behind me. I was not picking a fight, but your insecurity may have taken it that way and I am sorry you feel that way. An experienced doc would question someone making such a blanket statement to provide the evidence to backup their arguement, which is exactly what I did. It appears from your comments that you need a little education in cardiology. Not all MIs are rushed to the cath lab. STEMIs are the ones that every gets all hot and bothered over. They are the ones that get rushed for a cath as soon as they walk in the door. NSTEMIs do not always end up with stents. Some are treated with medical therapy, some just receive angioplasty. I'm assuming that in your vast experience (which I have to assume since you have NEVER bothered to answer anyone's question about your experience) you have seen a pt or two who have had MIs and not been stented. As others have said, there is current literature which has been saying that we are stenting people too quickly in angina and NSTEMI. There are also other causes of MI such as coronary vasospams, Prinzmetal angina, etc. They people generally are not stented. Sometimes the vessels can be too clogged for a stent and people end up having CABGs. As I have told you in the past, study and read up on a topic before you shoot your mouth off with incorrect information.

Why?

Yeah, but I'm an MD! :wink:

It is not really different levels as it is different philosophies. An MD is your traditional doctor. A DO (Doctor of osteopathic medicine) goes through the same schooling as an MD, except that in addition to what the MDs take, they also take courses in OMT (osteopathic manipulative therapy or whatever your local verbiage is). So they are in effect getting the same education and then some compared to MDs. Here is a little more info. The thing about DOs not being able to work in an ER 20 years ago stems from the ego of MDs who felt if you weren't an MD you weren't really a doctor. Things have changed now days and you find DOs in every specialty, including the surgical specialties.

Yeah, there are a few things that shouldn't be learned online, one of them being a medical degree. My residency director was a DO (we were a predominantly MD program). He was a real bright guy and there didn't seem to be anything he didn't know about. One of my co-residents asked him why he chose to go to DO school and his reply was that he didn't choose it. He partied a little too much as an undergrad and the DO stood for Do Over. This is in no way meant to put down DOs. Some people that make great doctors have their priorities slightly off as undergrads and luckily have an alternative path to take (DO, Carribean school, etc).

That is the number of overall applicants. All med students apply through a centralized system (AMCAS-American Medical College Appliation Service).

You should checkout studentdoctor.net They have lots of good info that may help. Be sure to check out the EM forum (one of the best). You can also try scutwork.com, but I don't know if they have info on foreign med schools.

No one with a possible stroke should be getting ASA until a CT has been done. This means no ASA in the ER, the ambualnce or over the phone.

AZCEP, do you have the journals and years that those studies were published. I admit, I'm too lazy to look for it myself right now.

And your evidence to support this statement is?

Yeah, that study (or a similar one) also found that mothers are actually quite accurate. I will look on pubmed and see if I can find it when I have some free time.

As much of a proponent of rectal temps as I am, I don't know if it needs to be done in the field. It isn't going to change your treatment really and there isn't the most privacy. I would never fault any crew for coming in without a temp. Where is trained and where I currently work, no one in the field checks a temp.

I love it when you talk dirty, Dust. I should have clarified that. Anything other than rectal is inaccurate. I have seen people with up to 5 degree difference between rectal and other methods. If you get a non-rectal temp that is above 100.4, great, it's a fever. If it is a pt where a temp is going to sway my workup and I get a normal non-rectal temp, better believe we are getting a rectal temp. I used to have great hope for temporal artery temps, but after working with them for over a year I have been sorely let down. They are about as useful as ear temps. The only true temp is a rectal temp!

There are no set standards for temperatures. It has been widely accepted that 100.4 and above constitutes a fever. Any fever in an elderly person should be concerning. They can be severely septic and not manifest many outward signs until they are already going down. Their immune systems also aren't are efficient so infections are more worrisome. Fevers as high as 104.5 in kids are not concerning, assuming they look ok. Generally above 105 you start to get breakdown in metabolism. Infection will generally not cause a fever over 105. Neurologic injuries can cause problems with temperature regulation. I have seen stroke pts with temps in the 107-108 range. There is not much you can do at this point other than colling blankets, etc. Tylenol and Motrin will not do anything to help as their regualtory mechanisms are shot. Again, any fever can be concerning. Any infant under 2 months will get a full septic workup (including spinal tap) if their temp is 100.4 or greater. They cannot localize an infection and it is very easy for them to develop meningitis and sepsis as a result.

AZCEP, I think you hit on something big right there. Part of the problem with EMS is knowing who sets the standards and rules. EMS is like the red headed step child that no body wants, but everyone keeps yelling at. Personally (I admit I have some bias), I think EMS would be best served (in the short term at least) if it came under the umbrella of an EM organization such as ABEM. You would then have doctors, and not politicians, who could set the standards based on the best evidence (though this is sorely lacking in EMS). I think EMS would also gain more respect at the street level from hospital staff if they knew that EMS was being guided by the EM people. I think this would also help to raise the level of education as anyone in medicine respects and understands the need for education vesus training. I think you would see a move towards a college level program (for medics at least). Who knows, maybe down the line we could see the birth of the ABEPM (American Board of Emergency Prehospital Medicine)?

In order to keep my state license I need to complete 50 hours of CME per year. To keep my board certification I need to complete an additional 150 hours of CME in 3 years. I cannot speak for any other level of provider. I also don't have protocols, we have clinical judgement and EBM.

With the many different ways that ACS can present I wouldn't fault anyone for giving ASA. There have been plenty of pts where I have thought, "well, I guess it could be an atypical presentation, let's just give the ASA so that we are ahead of the game." The only time you shouldn't give ASA is if you are thinking disection or aneurysm. ACS is a scary thing because of the varied and vauge ways it can present. Even with a 12 lead you can't definitely rule out ACS.

The delta waves are pretty clear on the EKG where she is in a NSR. The best leads to see it are V2 and V3. See the gentle upsloping at the beginning of the R wave. That is a delta wave. This is a great EKG for educational purposes.

That's affirmative, roger and wilco.

I think it is safe to assume that this genius nurse didn't even check a pulse.

Innocent people are not going to lose out. I have a low threshold for meds. Again, with enough experience you know what is real pain and what is not. I'm not being selective about who gets meds, I am making sure that a pt is being treated properly. Medicine is about clinical judgement and that includes making sure you are treating pain, or the lack there of, properly. Narcotics are not without some nasty side effects. So why do I want to take the risk of exposing a person to these when clinically I do not feel the treatment is warranted? This include getting a person addicted to a medication. Do you want to be responsible for adding to someones addiction? There are numerous other ways to treat pain beside narcotics. You are either very niave or have a very different pt population than we have here in the US. The are always drug seekers using an ambulance to get in the door. It gets them into a room quicker and they think they will be taken more seriously. There are few chronic conditions that we are able to stabilize in an ambulance or in the ER. What am I going to give to a person who is already on methadone, oxycontin, fentanyl patches and oral dilaudid? The only thing I can do is just dope you up to the point of unconsciousness. What pts with chronic pain need is a pain clinic who can manage their pain appropriately and not just throw narcotics at them. Before they get any narcs, their pain doc should be called so that you can develop an appropriate plan for the pt. There are also two different kinds of pt we are talking about and I think you are getting them confused. There are people with chronic pain and then there are drug seekers. I have no problem giving meds to people with chronic pain. When you come in and tell me you are allergic to motrin, toradol, tylenol, morphine, benadryl, phenergan, reglan, compazine and droperidol, complain of a migraine that is 20 out of 10 (despite the fact that you are sitting there watching TV and laughing with your friends) and the only thing that works for your migraine is 2mg IV of dilaudid then yes, you will be labeled as a seeker. When you ask me for a script for vicodin or percocet for a .5cm superficial lac from a cat scratch to your cuticle and tell me that you will go to XY hospital because they will give you the script, then yes I will label you. If you do not let the big picture influence how you treat a pt then you truly do not grasp or keep in mind the bigger picture. We are talking about more than just what happens when you hand the pt over. We are talking about the impact on society as a whole. It may not seem like a big deal, but you are missing so much.

Yeah, it was the broken neck that took 5 days to kill this guy. It had nothing to do with the ESRD, scleroderma, multiple amputations or GI bleed because other than those few small problems he was an otherwise healthy guy.