triemal04

The newer (2nd generation) LVAD's aren't pulsatile; they operate on a continuous flow basis. So the pressure that you start hearing the blood flow at (the "whoosh" sound") is the MAP, not the diastolic or systolic. You'll stop hearing it very rapidly as well. Depending on how much work the LVAD is doing compared to the patient's own heart, you might be able to feel a radial pulse. I think if this is the case you should be able to take a normal BP, but the times I've dealt with this type of patient's there's been no palpable radial pulses and a regular BP was unobtainable.

Personal comfort; I'm more familiar with cipro than I am levaquin.

With just saying "austere" that's a hard question to answer. Even at the most basic level, different areas will have different requirements for medications, depending on local conditions. Is it a tropical region? Mountainous? Arctic? Desert? Are you in a populated area and it's "austere" due to other causes (war, earthquake, floods, etc)? Will you be relying on locals/the local environment for sustenance and shelter? Interacting with the locals? Will you be mobile or in a fixed location? Need a lot of info before you can really plan for even the smallest needs. Buuuut...if I had to choose 5 all purpose meds... Epi 1:1000 (as said, for anaphylaxis/severe allergic reactions, asthma/COPD exacerbation, pressor, etc) Phenergan (anti-emetic, sedative, and a H1 blocker) Loperamide (anti-diarrheal) Cipro (ok all round antibiotic, and will help with some gastritis and diarrhea, depending on the cause) Lactated Ringer's Ibuprofen is OTC so it doesn't count (tylenol might actually be better, but I'm not a fan)

It is. It might be worth a discussion with the receiving doctor either way; if you have the ability to communicate while in flight then there is plenty of time. If not, then yeah, judgement call. But either way, if the patient becomes even more unstable, I know what the first thing I'm stopping will be... With the EEG what I'm getting at isn't that it wouldn't at some point be beneficial, but how beneficial would it be RIGHT NOW, and do you think it would a- be worth waiting for it to be performed and read, and b- can you interpret it yourself? I know I can't. Which rules out continous monitoring for me, which I don't think would work so well in a moving vehicle or plane anyway.

I think most of them. While it may be hard to say for certain that some are the specific problem (and most will require extra tests that are not commonly available prehospital to be certain) with a good history and physical a competent provider should be know enough, and be able to figure out enough based on the questioning/exam to have them in their differential. While it leaves out a lot, if you're teaching paramedic students the mnemonic AEIOU-TIPSS is pretty easy to remember, and covers a lot of issues that can cause changes in mental status. Alcohol Epilepsy (or seizure disorder, though that ruins the mnemonic) Insulin Overdose (very broad, but should start people thinking) Uremia Trauma Infection Psychosis Stroke Sepsis

You are absolutely right. You don't get it at all.

This is just going to go around in circles, so I'll ask one more time and then throw in the towel. In your day to day life, do you glove up before you shake hands or otherwise touch someone else's skin? Or before you pick up an object that someone else was touching just prior to you and may have left...something...on?

Aw shucks... I'm not trying to win anything though. If someone makes a personal decision that they will wear gloves on every call, or there are extenuating circumstances (like your constantly cracked skin or other damage to their hands) that is one thing. My only point is that there is no legitimate NEED for gloves on EVERY call.

Ruff- As far as fluids then I think we are on the same page. Where we differ is that you have made it sound very much like you should have gloves on for every call, and every time you touch a patient...no matter what. That is what I take issue with because...to be blunt...it's bullshit. It's just another one of those things that get's beaten (as someone else put it, which is a very accurate term for it) into everyone's head until nobody actually stops and THINKS about it. And then when some heretic dares to <gasp> question the gospel, they are immediately reviled and get the equivalent of being burned at the stake. No, I'm not. I'm argueing because you very clearly don't understand what you are talking about. Do you really actually think that every patient knows what is wrong with them and tells the facility they are at? Do you really think that every facility tests every patient for every possible infectious disease? Do you really think that every facility actually knows what is wrong with every patient they send out? Fuckin' A...

So you're playing the odds then? Assuming that someone will let you know if something is wrong...or that they will have noticed... And, for the record, if you are examining someone with no fluids leaking out or other issues, do you put gloves on each and every single time? Not being a dick, but trying to make it clear. I agree. For the given situation the OP should have had gloves on, and should have reported it, minimal risk or not. The "but" comes in because people are freaking out and losing it because apparently you must always wear gloves in EMS...NO MATTER WHAT AND FOR EVERY SINGLE PATIENT YOU SEE. That is not accurate. I'm sorry, but that is not an excuse, or a reason. And not accurate. While you should have gloves on in the first situation (blood present), it takes a second to put a pair on. If you don't need them...why? Not knowing what you are about to see as the only reason...naw. Stop being so hypocritical. A patient on an interfacility transfer that is not feeling well may also "just had the mrsa scrapped from their knee yesterday" and you just don't know about it. So why would you treat a transfer patient different than a 911 patient? Unless it's because you don't understand what you are dealing with. Edit: Hell, depending on where that transfer patient is coming from, they may have a much higher risk of having an infectious disease THAT THEY DON'T KNOW ABOUT than the average person off the street. So why is ok to not wear gloves on a transfer, but wrong for 911? Diseases don't just decide to act different due to the location or type of responce. If it's safe in one situation, it's safe in the other.

I don't know. I'd agree in a little different situation but I'm not so sure here. If there was some type of anoxic injury to the brain (or other type of insult to the brain) the hypothermia would probably be beneficial, but I'd still be hesitant here. This is pretty unstable patient with an unknown problem; there is the possibility that she has in issue that will be made worse by cooling. I don't think that the hypothermia is going to help with her management as it is either, just make it more difficult. As it stands she has only been cooled to 35.5C; letting her rewarm from that won't be an issue. Could even avoid the warmed fluids if concerned. Out of curiosity, for the situation (a fixed-wing transfer from low care to high care) would you really ask (if it was even available, which I doubt) for an EEG prior to leaving?

Technically no, there wasn't an exposure. It still should have been reported to your infection control officer to let them make the decision on what needed to be done next though; you may not have touched the dried blood to your scrapes but I'd say it was close enough. Basically, follow your procedures for what to do in the case of an exposure. It's a very low risk situation anyway, but you should've still gone through the hoops. Now, I don't know if you were asking a real question or looking to stir discussion, but nicely done either way. I would not listen to the people who are screaming about how you need to have full PPE on every call or you'll automatically catch the herpegonohepahiv virus. This is one of those sacred cows of EMS that get's beaten into people and taken as gospel...but isn't fully accurate. If you are dealing with bodily fluids or there would seem to be a high likelihood of those being present...put some gloves on. If you are performing an invasive procedure...put some gloves on. If the patient is a known infectious risk...you'll probably feel better if you put some gloves on, but just touching someone with hepatitis/hiv won't cause you to become infected. If you are going to be touching a patient who's personal hygiene gives you the shivers...you'll feel better with gloves on. Wash your hands after every patient contact and use some common sense. You should do fine with that. Now on to the rest. You don't really know what you may find in the ER either. Or are you saying you've never been surprised or had a patient suddenly decompensate in the hospital? It doesn't take more than a second to put a pair of gloves on and you should always have a (fresh, new) pair with you, so what's the issue? What is the difference between a patient in the ER and one in the field? Do they somehow magically get cured of whatever you are afraid they have once they set foot in the hospital? Somehow become less infectious (if that is what you are worried about)? Hell, what is the difference between the random person you are introduced to and shake hands with and someone in the ER or field? Or any object that you touch that some filthy infected stranger may have been holding 30 seconds before? So what is the difference between a transfer patient and a 911 patient? Both will have the same potential for disease transmission. Both will have the same potential to have an unknown disease. If you won't wear them for certain situations with a transfer, why not leave them off for the same situation with a 911 call? They also drill into your head that every patient get's high-flow O2 and a backboard and c-collar should be used for just about every type of traumatic or potentially traumatic injury. Just because something is a sacred cow doesn't mean it's right or should not be questioned. I hope you wear gloves, eye protection, and a gown 24/7 in your daily life then. Because there is no way you can look at someone and tell if they have something. That buddy from work who's hand you shake...that friend of your wife's who you give a hug and kiss on the cheek...might pick up a deadly virus from them. And let's not forget all the inanimate objects that could be contaminated... I agree, he should have had gloves on for the given situation, and should have followed his infectious policy (even though the risk was minimal). But... It is the same. You don't know the status of the people or things you touch on a daily basis. It is no different. Use common sense, use proper protection when the risks are there, but when the risk isn't there...what is the point? I agree with assuming that the patient may have...something...that you might catch, but simply putting gloves on isn't the end all/be all cure for that. Take out bodily fluids, and how are gloves going to fully protect you and better than washing your hands after a contact? If I put a 12-lead on the 60 year old man with chest pain, what am I at risk for by not wearing gloves and simply washing my hands a few minutes later? Who cares? It is (or could anyway) generate discussion and maybe people could learn something. Or you either apparently. Since you have allready said you don't wear gloves all the time in the ER. Wait...so has this changed from an "OMG! YOU TOUCHED SOMEONE WITHOUT A GLOVE YOU ARE GOING TO DIE OH GOD YOU ARE INFECTED" conversation to a, "you should not touch bodily fluids without gloves" conversation?

^^^^^That. An EEG wouldn't be done that early, but there are other ways of checking for brain death/damage. But again, to early to be sure at this point. Should also add in that knowing the time of the arrest and ROSC and total downtime are very important. If it's been awhile and the patient isn't currently sedated (and possible never was) the odds of there being an anoxic brain injury are going up; no movement and apparently no respiratory drive well after the fact plus no sedation is a bad thing. Depending on how long it would take the family to drive to the next hospital, and depending on how the father was acting I'd be inclined to bring him with me. Someone from the patient's family who can make medical decisions for her needs to be there.

Well... Done. You aren't worth wasting time on.

Start with the investigation: Current chem7/BMP ABG CBC Foley content (if one isn't placed, do so) Ideal body weight? Lungs sounds and chest xray? What, if any meds have been given by the ER? You said no meds at home, but she is obsessed with body image; any supplements, OTC vitamins? What exactly has she been eating? What is her daily routine; extreme exercising, couch potato? Any clinical signs of dehydration? Any known blood loss or GI bleeding at home? History of anemia? Treatements: I don't think this is someone I'd cool. It was apparently a vf arrest, so it's the right situation...but there's more going on here and she's to unstable for me to want to risk it. Remove the ice packs, let her rewarm passively and with some warmed fluid. Start correcting the hypokalemia and hypomagnesemia. She's on a lot of levo without a lot of result; how much if any fluid has she gotten? My guess is none, so start some (warmed) fluid boluses and titrate the levo down as needed. Might think about switching to dopamine. Her hemoglobin is low, guessing her hematocrit is also low, think about a transfusion but that is probably going to be done by the recieving hospital. If she starts to wake up then sedate with fentanyl and versed. Carefully. She's anemic, and malnourished. That's probably the root cause of everything.

Yeah...that was pretty pathetic. Try again. Here's the thing...all the posts that have suggested you think twice about getting into EMS, not get into it, or that there will be huge difficulties for you...they've all given some very clear reasons why someone with your problem wouldn't be a good fit. The fact that you refuse to listen means that, yes, you are cherry-picking the answers you want to hear and ignoring everything else. Whether you like it or not, you have been given several things you need to think very hard about before you try and get involved in EMS, or any other kind of medicine. For everyone it's not as simple as "I'm gonna do this no matter what and downsides be damned," and doubly so for you. Until you get your meds worked out and your condition under control you shouldn't even be considering this. Once it is and you've figured out how you well you will function, then you should take an honest look at what has been said and make a decision. But you obviously aren't capable of doing that. For some reason I highly, highly doubt that will ever happen.

Yeah...thought you were one of the sponsors and could go back and delete your posts...my bad.

Actually, I think I do. Funny how your post is gone now...did you delete it, or did admin?

Certainly. Feel free to correct any and all spelling, punctuation and grammar errors you find. Or you can accuse me and other posters of being high. Or you can actually contribute something.

Because being told something that you don't want to hear doesn't mean you were given incorrect information. Just because you don't like the answer doesn't make it wrong. Now, you again have made it clear that you don't want any real advice and will only listen to things that confirm what you want to do, but hey, maybe somebody else will get something out of this. No, you aren't. You may have a very general idea, but until you have done either for quite awhile you don't have a clue. You don't know what your responsibilities will be, what your reactions will be, how your body will react to different types of stress, how your mind and emotions will react to different types of stress, you don't know what your real role will be in various situations and how that will effect you, you don't know what you will see doing this, what you WON'T see doing this, you don't know how your view of all of these things may change over time, you don't know how your view of regular life may change over time, and so on and so forth. It should be. You don't have any abilities yet. You may have been through an EMT class before, but that is not the same as actually practicing in the field. Perhaps before you go any further you need to get your medications sorted out. Forget EMS, isn't this something that you should do so that you can improve your daily quality of life? Get that taken care of first, until it is everything else is moot. There are lots and lots of "insignificant" things that you will come across that will have bearing on your patient care. There are lots of "significant" things that you will come across that will have bearing on your patient care. I'll ask again, if you are constantly worrying about these things and are unable to seperate what you should actually be concerned about from what doesn't matter, how will you be able to effectively treat your patient? It's great you are worried about the cumulative build up of stress; that is something that everyone should worry about, but your bigger concern should be your other problems. As you describe them, and since you are currently not able to control these problems with medicine, you have issues that make you a poor fit for medicine. Get them under control, and maybe that will change. Or just continue blithely down your road of only hearing what you want and pretending that nothing else matters.

And when the wife changes her mind? Or says she just wanted him checked out? It's a very realistic situation; what are you going to do when she says to get your hands off him? There are no papers there; but there are some. Should you ask if she knows what is in them? I guess what I'm getting at is that there is more than should go into this situaion that just a blanket "he can't talk so I'm gonna do what I want." The final outcome very well may be that you start providing all the care you can, but there is more that should go into making that decision.

Most of the constructive advice had more to do with his meds or how to deal with stress, and less with what he would actually be facing by working in EMS. If he is not being given enough information to make an informed decision, then how can he be expected to make the right choice? Sure there are. And some should be practising and some shouldn't. That's a different topic for discussion. This is a person who has has mental health problems, who'es meds are apparently not working, and is trying to enter a stressful and ambigous field, where their described problems may create serious problems. Shouldn't they be told about how their issues may adversly affect them? And as far as the passive agressiveness...why not? The OP made it clear that he won't listen to advice, so scew it.

Yes, and correcting it is what I did. If you choose to take offence then that is not my concern. And the posted link and what is says about a scope of practise has no bearing on your comment about it. You said, "There is no legal scope defined for EMS providers, just that of what the medical director approves under their license." My point being that is incorrect, and each state DOES have a legal scope of practise for EMT's and Paramedics. Of course they still may not function under it without the authorization of a doctor, who may in turn restrict what they can do, but that scope of practise is still there, as it is for most providers. Like I said before. Now, there is no NATIONAL scope of practise for EMT's or Paramedic's, that would be correct.

Of course you can; this is a public forum as you said. But when you post incorrect information...it may be corrected. To be honest I was more concerned with the comment about scopes of practice; that matters just a bit more than if someone holds a license or certification in their various states. And I don't care what you are or aren't in the mood for.