Kiwiology

I do believe they are up to twelve weeks now.

I frequent the nickel slots at the Bellagio whenever possible but heck I much perfer the Circus in Reno. I'm just a sucker for an arch. Stay away fron NCTI like you'd stay away from the strip north of Freemont Street. my ear to the ground tells me it's a cookbook whacker mill. CSNV has a good program and it's accredited by CoAEMSP. Take A&P, patho, pharm, English and scientific reasearch methods before EMT and you will be 1000% more prepared than the North Las Vegas firemonkeys who everything will be watered down to accomidate. MedicWest is owned by AMR or the other way around anyway.

Hey baby, you got girlfriend Vietanm? Best bit ever, makes a really good ringtone when on jobs ....

The TSA is a joke and a farce. I have caught TSA agents alseep at the x-ray machine and alseep on seats at Logan, SFO and Dallas-Ft Worth. I have had bags put through for search not searched and have been told that I do not need to be searched because the same guy searched me yesterday. I've gone through with some nitrate gloves stuffed in my back pocket no problem.

I wonder how many TVs were destroyed at stations around the country when Trauma made its debut here on Sunday Well Anthony if you ever want to get into acting I know some actors in LA, heck, he's even in the same SAG getup as Randy Mantooth; reckons he's an ass

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Yeah if this guy started to crash I'd get into the drug roll otherwise the agreeable consensus is on supportive care. I was more interested to see how many would dip into the tacklebox without considering that it can do more harm than good in a case like this. The way various standing orders are written and ambo's are taught leaves something to be desired here too, ours for example make no mention of it. I know it SHOULD be known by virtue of education, but well, so much for education in some cases. Now it may be implied that out there in the periphery ambos should spot the larger clinical signs and not load our man up on GTN, fluids, morphine and frusemide but we both know there are ambos out there who have no peripheral vision whatsoever! Me however, I'm just a blind bastard plain and simple!

It notes that left ventricular failure should be treated in-hospital with IV nitrates, duiretics and vasodialstors where feasible. Note here its right ventricular failure or could be complete heart failure but it's not like we can do an echo or other cardiac imaging to differentiate betweeen complete heart failure and cardiogenic shock caused by right ventricular failure.

Dave; I don't have blood work sorry; don't have an iSTAT machine on the truck just yet The problem was myocarditis however it presents in such a way that one could take it as "chest pain" and load the patient up on morphine and GTN, or "pulmonary edema" and go with GTN, lasix and morphine. The low BP might be in the minds of some, an indicator for IV fluids, when in reality none of these are clinically appropriate in my mind. Wouldn't suprise me if some out there looked right past the obvious signs of a cardiac infection and RVF e.g. fever, pedal edema, JVD etc and just saw a person with "chest pain" or "pulmonary edema" or maybe even "short of breath" and went down the respective recipe for each. My ALS textbook mentions RVF in one paragraph and doesn't mention anything about withholding nitrates or fluid, it even states to establish an IV at KVO rate!

Now now why must we make Los Angeles look bad again? I didn't mean to stur up the pot (jurisdictional differences aside) it however would seem it's kind of black and white to me; somebody doesn't want something done, OK, fine, I'm not gonna do it!

Are you not allowed to think for yourself? While laws may vary by jurisdiction I think that this is totally unnecessary. I am a very strong advocate for patient rights, if somebody does not want something done then they do not have to be subject to it; whether its taking a blood pressure or resuscitation from cardiac arrest. Whilst our legal system is more flexible and we have no "online medical command" to speak of, let alone call up, here is how we are directed

Doesn't suprise me; the TSA is a joke, a farce and a waste of money. I have caught TSA employees at San Francisco, Boston-Logan and Oakland asleep on the job; I've had bags put through for search ignored and in one case was told I did not need to be searched because I had been searched the previous day by the same guy.

During the campaign, I really like Obama. Now I have discovered he is a lair, a hoax, a fraud and a puppet to the criminal elite who run the world. Before you dismiss me as a nutter like the TV has trained you to; I encourage you to watch this

Perhaps we should go with some dopamine then

A few I know (myself included) who operate at less than ALS level have consistently scored 80-90+ percent on practice National Registry Paramedic written tests. Our new assessment format here for all Officers not just Intensive Care (ALS) includes written, practical, simulation and viva-voce assessments

I thought isuprel had less chronotropic effect than dopamine? Perhaps I am wrong. So can I however I am just not convinced it's of a great deal of benefit when given to the masses of ambo's.

I am not in favour of GTN because it will reduce cardiac output and worsen fluid mismatch/cardiogenic shock. Having said that GTN may have a role in reducing myocardial workload and demand which may benefit his knackered conduction system. Hence why I don't think fluid or frusemide will be of benefit here. What he needs is, as you say, help to shift the fluid out of the interstitium and into the intravascular space which should fix up his edema and shortness of breath. If we can move the fluid into the arterial circulation by way of pumping it out of the left ventricle then this will help. Now, not being an Intensivist and having not stayed at a Holiday Inn last night (Hostel California $29 a night FTW!), I would immagine some sort of vasopressor and inotropic support is in order. He's out in the front yard at the moment and it's raining again, blast, I wish summer were not bipolar. I couldn't find a big enough tarp at Home Depot or Bunnings to cover him. I may have to build a barn or something. Hmm I am not either. ACE inhibitors lower blood pressure through preventing angiotensin 1 being converted to angiotensin 2 by blocking angiotensin converting enzyme (gosh whodathunkit?) which lowers Na/H2O rebsorption, sympathetic vascular tone and the release of ADH/aldosterone. If anything I would think that ACE inhibitors would have a negative inotropic effect! Isuprel rather How often do you have the quiet to listen to heart tones? What do you do with the findings once you have them; do we introduce a new treatment based upon them or just write them down in a purely extrinsic exercise that will be repeated 20 minutes later in the ER? Somebody, somewhere would find a way to screw up spending a lot of time on scene with a time critical cardiac patient trying to listen to heart sounds; I almost guarentee it. It could be useful but IMHO it has limited benefit in the out of hospital setting with the current state of the system. It's kind of like saying well we want to measure if the patient hears better in one ear than the other.

No it's not tamponade This patient never got salbutamol; his SPO2 was ~92% on O2 Heart sounds should have been taken but here at least they are not taught and while I agree it might be useful some sparky ambo would find some way to screw it up, kill somebody by blowing out thier scene time and it'd be taken away agian. I am an elephant keeper not a horse whisperer; I dont think Stanley will be galloping anything he is much to large I mean when is the last time you saw an elephant running? That's like tubbo infront of you at McDonalds ordering a salad then going for a jog! No No He has no history to speak of except has been feeling sick and fluey for the past 5 days. I'm more interested in seeing how we would manage this patient than a concrete diagnosis because most of what he presents with would catch a few ambo's I know off gaurd and they might do silly things like GTN and frusemide and end up on the fast track to a lawsuit without much support!

Dopamine could be out because of its chronotropic effect perhaps isporel or something else might do the trick however I think we are starting to get into tunnel vision of over-treating the patient. I think the best thing we can do here is oxygen and transport.

I would be dubious about nitrates in his present state or really at all as it'll just make his cardiogenic shock worse. Agree he needs an inotrope rather than a chronotrope so some dopamine should be in order here. My treatment plan would be a dopamine and CPAP with no GTN or frusemide.

OK, so .... to ask a conspiciously leading question (yes I have an alterior motive here) Simply put this guy has classic "chest pain and short of breath with rales" what do we not want to give him and why?

There is noticable JVD, but unsure of heart sounds sorry Nothing else remarkable

No 15 lead and PVCs are unifocal. Pedal edema and mid/basalar crackles.

1° AVB (new onset) and bigeminy PVCs with no specific ST segment changes

LOL Looks like I was wrong, my bad. A lot of my classmates have gone over (or back) to Dubai they seem to like it.