ERDoc

Keep in mind that cimetidine is the only one that has been shown to be beneficial (the others just haven't been studied).

Wow, don't want to make that mistake, especially around you people. Conisder it corrected.

Damn, guess I made this one too easy. Yes, any beta blocker can blunt the effect of epi and glucagon would be the appropriate treatment. Guess I'll have to make it a little harder next time.

Read all about it: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_DocSum Those are just a few. I'm sure there are many more out there, but I'm too lazy to find them.

I'm all for it, lessens my workload. My point is that there is really nothing a medic is going to do for a simple injury or someone with a cold that an EMT can't do. Why not keep the additional education for those that need it (MI, CHF, etc).

Check with any VAC or FD on Long Island. They could use a few good people that have the time to donate. Hope the comedians pay well though.

Dust, do you feel it is a waste of resources using an ALS unit to transport an ankle injury or a wrist injury? Why not keep the ALS units for the ALS calls and let the EMTs transport the pts that don't need the higher level of care? How about in rural areas where there may not be medics? To play devil's advocate, would it not be better to have an EMT, who can contact medical control and be overseen by an MD/DO, give IM glucagon to someone with hypoglycemic seizures with a long transport time than it would for that pt to be seizing for 30-45 minutes? I agree that every area should be covered by ALS, but we have to be realistic and accept that utilization of resources dictates that this is not always possible.

This is an issue that really grinds my beans. I really bothers me when field crews give D50 for a hypoglycemic while in the house and then wait for the pt to come around and then call for an RMA. Don't give the D50 in the house, wait till you are in the ambulance. The few minutes that it takes to get the pt out of the house. The pt will need to be observed for a while and I just don't trust family members to do it. If they are hypoglycemic due to sulfonylurea use they will need to be admitted for observation at least overnight. Please do your friendly medical control doc a favor and don't give the D50 until you are in the ambulance (unless you can do the RMA without him/her). I will now step off of my soapbox

A couple of things I was thinking while reading the scenario (not being there, this is all Monday Morning Quarterbacking). I don't think I would have so quick to intubate. All of the bad things in this scenario could be rate related. I would try to get the rate down first. Had I needed to intubate, I would have chosen a different choice of meds (but this is more personal preference) and a bigger tube. Synchronized cardioversion was the way to go here, I would not have done an unsynchronized shock. I also would have given adenosine a try and not jumped to amiodarone first. I think the cardizem was a good idea, though the sphincter would have been tight. I think the BP was low due to the heart rate. Slow down the heart and allow a little more filling time and up your BP will come. Boluses were a good idea. NO beta blockers for this guy. Maybe some more haldol. In the end the guy survived, so I guess the ends justify the means, but it seems like this guy was committed to a tube a little early.

Putting aside the battling going on (I'll let you guys finish that one), is everyone here against EMTs giving meds period? Or are we talking about EMTs giving IM glucagon as standing orders? Are you more experienced guys okay with EMTs giving IM if they have medical control approval for it? People have said that skills can be taught to a monkey. Do you feel that EMTs can be taught how to give IM meds as long as they have been given approval by online medical control, especially in a case like this where you have very objective info (you know what the FS is)? How about with more subjective things (ie steroids for asthma/COPD)? Has anyone ever seen a bad reaction to glucagon (personally I have used it quite a few times both in the ER and as the medical control doc and have never had a problem with it)? If so, what did you do about it? Would it not be more beneficial to the pt to have some form of treatment instead of killing brain cells? What do you think?

Here in the US, we have perfected it and now are apparently encouraging it. Most of the Italians here seem to know what is and what is not appropriate. We do have a few groups that seem to think we are here solely for them whenever they need something.

OK, this guy is the Chief of Emergency Medicine at one of the hospitals in NYC. What is he thinking? I'm guessing he does not work too many clinical shifts any more.

AHHHHHHHHHH!!!!!!! (Doc prepares for the onslaught of stupidity that is about to hit his doors). Why would anyone, especially a doctor say something like this. This is why we have PMDs. People (apparently including other doctors) don't understand what the word EMERGENCY means. Don't come to my ER for a sunburn. I will be as sweet as pie and tell you what to do, but you won't be getting any scripts from me and you will get a several hundred dollar bill. This is why our health care system is in such chaos. People (and physicians) utilizing the limited resources inappropriately wastes money. I can't count the number of times I got a bad burn when I was a kid (I'm a fair skinned guy with ancestry from northern Europe). Never once did I got to the ER. Had I even thought about it, my mother would have laughed at me and given me some over the counter cream that worked just fine. You guys in the field are going to feel the effects too. People are going to want to go to the ER and will forget how to drive the 3 cars in their driveway. This reminds me of a pateint from my EMS days. It was around 3am and we brought in a lady with chest pain. Behind us in triage comes an ambulance with a 20-something years old woman who had sunburn on the top of her feet. The doc told them not to take her off the strecher. He examined her, wrote the note, gave her the discharge instructions and told them to take her out to the waiting room for her family to pick her up. Sorry to ramble, but stupidity makes me angry and I needed to vent.

Some swelling of the uvula. No noticeable stridor. Do you want to give the epi? What's the deal with the glucagon?

PMH as stated, only htn. Known hx of allergy to peanuts. Pt takes atenolol. Those dogs behind the store are for security and have nothing to do with the food. Ignore that furball in your wonton soup.

Meds as ordered. EKG shows stach at 118. Pt states he is not feeling better.

You know, sometimes when you make pts feel like they are going to die, it stops them from being repeat customers. Just a thought .

You are called to a 59 y/o male with a h/o htn who "started to feel itchy," after he ate some Chinese food. He has a known allergy to peanuts and thinks he may have tasted one in the food he ate. He compalins of a mild scratching in his throat and a little sob. He also c/o full body pruritis.

A great deal is how organized you are. If you sound like you are stumbling to get the story across it does not instill the gratest confidence. I think I discussed this a long time ago about giving hospital presentations. Try going something like this, "65 y/o male with h/o CAD, MIX2, 3VCABG c/o substernal chest pain going to left arm for 1 hr. Started while shoveling snow." Give pertinent PE info or say PE unremarkable. Give any pertinent EKG/rhythm strip info. Tell what you've done and the response to it. Finally give ETA to hospital. Obviously there are exceptions. If you have a trauma that needs to be RSI'd, keep it quick. "Unrestrained driver in head on MVA. GCS=3, would like to RSI." Keep it simple and too the point. As long as you sound competent, you will be treated as competent and usually get what you want (just be prepared to justify it if needed). Obviously this is just my opinion and everyone is different. Hope this helps.

OK, so let's take that first ABG and assume that it is not from hyperventilation. It means that we are looking at a chronic, compensated respiratory alkalosis. What sort of things can cause this? Well, chronic anemia (he's got it), hyperthyroid (he's got it, could be thyrotoxicosis), interstitial lung disease (sounds like he might have it), hepatic failure (sounds like a possibility), sepsis (he's got a white count). A resp alkalosis is usually a sign of something ominous going on, be very careful, the only thing more scary is metabolic alkalosis. I would like to see some more of his labs. chbare, I know it doesn't give you the answer, but I hope it helps.

That first ABG may be from hyperventilating while intubating. Or could it be from something more sinister???

I'm having trouble believing that at 160 the rhythm was sinus tach. If I had to be I would either say it was RAF or SVT, either of which could explain the possible chest discomfort and syncope.

When did we lose Reagan?????? Seriously, want to know why Medical Control thinks the way they do? Check out this thread. I have many more stories. To be fair I also have many stories of things going the right way and field crews performing above and beyond. http://www.emtcity.com/phpBB2/viewtopic.php?t=4723

Racemic epi does not equal an automatic admission. It means at least a 2-4 hours observation in the ER, although some will automatically admit. My concern with giving it in the field is that I will not be able to fully evaluate the pt and make the best decision. That field provider has committed the pt to at minimum a 2hr ER visit.

I'm not a big fan of glucagon for hypoglycemia. I'll take an amp of D50 anyday. If you can't get an IV, then I guess go for the glucagon. For EMTs I guess it depends on distance to hospital and resources. If you are in an area where you are only a few minutes from the hospital then package and go. If you have a longer ride, get ALS involved. The patient may need for than a shot of glucagon. What is your issue with racemic epi?