sjslennon

SJS technically is a skin rash, but the real thing (like what you describe) is treated like a burn, often in a burn unit. Were you transporting to a burn center? It is often from a drug, sulfas and pcns being common causes, as well as some anticonvulsants. It can also be caused by an infection or simply be idiopathic. It exists as part of a spectrum. SJS is also known as erythema multiforme major. There is an erythema multiforme minor, which I see a few times per year. These we send home with close follow up. The other end of the spectrum is toxic epidermal necrolysis. You can see pictures of all of these rashes (plus some other gnarly pictures) at http://www.dermnet.com/moduleIndex.cfm?moduleID=22. Be concerned for any pt with sloughing skin. As a rough general rule, the % BSA sloughing is the mortality rate. Neat case! Thanks for sharing.

I just finished a shift so please excuse me if I am misreading your post - The crew put a tube in her airway such that the ONLY way to ventilate the pt was through this tube, but the only oxygen they gave her was supplied by a NRB placed over the tube??? The crew should be informed that it is possible to bag a pt who has spontaneous respirations. I won't criticize the decision to intubate because I don't have enough information to do so, but it is hard to imagine a scenario where this is appropriate. Was she vomiting so much that there truly was no way to suction the vomitus? Was it clearly established that there was no head injury (ie, contraindication to nasal intubation, one cause of vomiting, not surprising with obtunded drunken pt)? Most pts with a GCS less than 8 are not difficult to intubate orally, in my experience.

This is a beautiful thought. ACEP is pushing for it, so let's see if it really happens. In my ED, there are days when: Every bed is full, either with pts waiting for beds upstairs, or waiting for their workup to be complete (and these pts are too sick to sit in the lobby and wait for results). There is a 4+ hour wait to be seen. Every nurse is busy with their usual load of sick pts, plus the additional sick pts that we can't get to the wards. Paramedics line the walls that aren't taken with ED pts, because we have no beds for them to put their pts in, and their pts are too sick to sit in the lobby and wait. They sometimes wait as long as the lobby pts. Every tech is busy, either supporting the nurses or circulating in the waiting room, rechecking vitals on the crowds waiting to be seen. And I sit at my desk with NOTHING to do - because I have no space in which to see a new pt. It is frustrating for all.

Scandalous!!

In my *limited* experience with Muslims, they tend to be more concerned about the potential for pork-derived substances in medications than the route itself. I recently diagnosed a pt with strep pharyngitis, which I usually treat with a single shot of long-acting penicillin (pcn). The mother knew that there are some formulations that have porcine-derivatives, so she chose oral pcn - 4 times per day for 10 days. She also chose liquid instead of pills, because she knew the liquid was more likely to be pure. Her son drank 3 tablespoons of elixir 40 times instead of one shot. I've also had Muslims request that medications be given at a specific time during Ramadan. They are allowed (and expected) to take any medications that cannot safely be delayed until sunset.

I am a textbook junkie. How much do you want to spend? :wink: In my opinion, Garcia is the only ecg text you need. Master that and you will be interpreting at the physician level. Tintinalli is excellent. The study guide is great to keep around, but "baby Tint" is handy as well. Lange does an excellent series of texts in the basic sciences. The "----- made ridiculously simple" is a great series, explained in easier terms than Lange. Bates and/or Mosby are the standard physical exam texts in medical school. Harrison is a bit heavy; you might find Current Medical Diagnosis and Treatment a better read for general medicine, or the similar Current Diagnosis and Treatment in Emergency Medicine more readable. A differential diagnosis handbook is helpful. I like The Professional Guide to Signs & Symptoms. Two great peds books are The Pediatric Emergency Medicine Resource (the textbook for the APLS course) and Pediatric Resuscitation: A Practical Approach. If you order the second book from the ACEP.org bookstore, it includes updates reflecting the newest PALS guidelines. There is a red and black peds text that looks a lot like Tint and is from the same publisher; I don't think it will add much to your pre-hospital practice if you read Tint. Minor Emergencies: Splinters to Fractures is a quick and easy read with lots of high-yield information. If you really want to spend some money (or can find used copies at a good price), Atlas of Emergency Medicine and Atlas of Pediatric Emergency Medicine have great pictures plus useful clinical pearls. That should start you off!

May I offer a different perspective? Let me say up front, "BS dumping" does occur. And we all need a safe happy place to blow of steam. On the other hand, EMTs and paramedics often do not have the knowledge to diagnose a pt with BS. But some do, and get no feedback that they were wrong, so they assume their diagnosis was right. I saw a pt last month for "headache, resolved." The pt was triaged to fast track and waited almost 2 hours to be seen. I read the run sheet before seeing the pt (yes, we DO read them) - it started by saying the pt's doctor ordered a CT head for headaches that morning, and in the afternoon the doc called to tell the pt the CT was abnormal and to call 911. It went on for several lines about the pt having no pain, carrying own suitcase, headache resolved with Tylenol, etc. The phrase "in no distress" was written 4 times, including once in all caps and the height of three lines. Tylenol may resolve the pain of head bleeds in some cases, but doesn't fix the bleed in any case. I took it up with the crew the next time I saw them, and the cocky kids saw nothing wrong with how they managed the pt. No stroke sxs, so how were they to know? My point exactly - if you don't know, don't assume you know. My advice (for what it is worth) is to make a habit of following up on your patients. Find out who in the EDs is open to talking to you guys so you can find out if your pre-hospital hunches are correct. You'll learn from this - if you remain open to learning - and will have sharper judgment. You can also identify trends of BS dumping, substantiated by ED records, making any formal complaint you bring more likely to be taken seriously.

I'm not aware of a WD40 deficiency in females. Are women in your area especially tight and squeaky?

If he hasn't had any food in the last 48 hours, then his liver has used up the glycogen stores. The body has been turning to non-carb substances to convert to glucose (process called gluconeogenesis). EtOH impairs gluconeogenesis, leading to no glucose... ie this scenario. Treat it with oral carbs if the pt comes around enough to control his airway and can eat safely. If not oral, D50. He'll also need fluid resuscitatation. Thiamine is a great thought if you have it pre-hospital. EtOH-induced hypoglycemia does not respond to glucagon, although it wouldn't harm him either. He may have been having PACs, brought on by the caffeine in Red Bull and No-Doz. That's an arrhythmia that will "fix itself." I'm curious where the ethnicity/Muslim question came from... were you thinking G6PD deficiency?