AZCEP

I won't go so far as to say dismayed, but these scenarios really don't fit with what you should be focusing on. It's great that you are being challenged to differentiate between disease states that cause medical students fits, but I'm not sure that's the most useful way to spend your time. I am also curious about which textbook you are using. I fear that the lack of information that it is giving you is widespread, and not isolated to one publisher. I'm beginning to understand why some don't want EMT's handling emergency traffic. :shock:

DISCLAIMER: Only based on the information provided, and could be wildly wrong. #1: Spot on with the Tb. At least that's what it sounds like from here. #2: I'm guessing right sided heart failure. Although, why your instructor would focus on this is truly beyond me. #3: Definitely epiglottitis. Croup is caused by a bacterial infection, and epiglottitis is viral. This child had a cold, which is usually viral as well.

PnEumonia is a possibility, but there is one that accounts for all three symptoms you mentioned. Think infectious disease, and a mask (PPE) Tough to elaborate with the information that is presented. The MDI usage isn't really excessive, and we don't know how long he has been dosing that way. After a while, he will become tolerant of the dose, and become less responsive to it. The AMI is a possibility, but again, not enough information to say for sure. He has a significant history for cardiac issues, all of which could contribute. I not sure where you got the information, but a 3 year old, or a 30 year old will drool when their upper airway is inflamed. Now you just have to figure what is more likely. Your humility is refreshing, but you have no reason to think you don't know what you are talking about. Some of the best providers, with decades of experience, are known to pick up a book and re-re-re-read sections to make sure they understand it. With scenarios like these, don't read into them too much. It is very easy to trap yourself in the "...if this was happening then this..." game. Take the information, distill it to get the items that are important, and make a decision. At worst you will be wrong, and you will learn more than those that are right with their guesses.

Nocturnal dyspnea, productive cough, and sweats is not hypovolemia. Respiratory disease process...which one has all three... For #2, there is a much better explanation for the vital signs than MDI overusage. #3: With that information you can't rule out one over the other. Unless you look at the "common cold" information a bit deeper. What causes a cold? Which upper airway issue is has a similar causative factor? I do agree with Ruff, though. Your instructor needs to think about what she has taught you, since these scenarios don't fit with the standard basic curriculum.

These are the patients that alternatives need to be considered more frequently in. Thus the suggestion of using magnesium. CPAP is one option that too many providers don't have yet, while magnesium is relatively common.

Ipratropium (Atrovent)

I've got plenty. Thanks for asking. You have yet to prove your point. You say it yourself, AFTER every other treatment is tried. How is this an "early" administration? Even at that, the recommendations are for inhaled/nebulized steroids, not the commonly available IV route that most EMS providers have. Yes, we do use IV steroids for the management of reactive airway disorders. We do not see a response to that specific treatment until after the beta 2/anticholinergics are effective. The use of magnesium can supplement the other modes of management, and I doubt anyone will suggest using it to replace the beta 2s and steroids any time soon. Why would you want an ABG? Waiting the requisite time for the equipment to give you a reading that should be accomplished by observing the patient is near negligent. Use your pulse oximetry/ECG/EtCO2/hands & eyes. Listen for changes in breath sounds. Feel for changes in skin condition. These are not difficult concepts.

With the system you suggest brentoli, you end up with two bastardized systems instead of one. A field provider uses an entirely different set of processes to gather information than dispatchers do. You can't expect a dispatcher to magically understand which questions not to ask when confronted with a situation, and you can't expect a field provider to ask the right ones when you take away 80% of their observational ability. There are select few that are capable of doing both jobs well, and you should not spend time trying to find them. I would actually prefer the dispatcher not gather extraneous information. The more information I have before arriving on scene, the more errors I tend to make because I use the bad information to plan what I'm going to do. Send me an "unknown medical" every time. I know it's medical, and I know that the dispatcher honestly didn't know what the problem was. When this happens I am able to determine what is actually happening by experiencing the scene instead of forcing the situation to fit the information that was received in error.

Is there really anything that the non-medically trained bystander can do to help? I'd venture probably not. CPR is big and dramatic, but it doesn't happen all that often, statistically. Holding someone's hand, keeping them warm, staying by their side is just as important, but not as impressive.

No reason to be sorry. You have a different view of the utility of this medication. So be it. It is also adversely effected by the overuse of Albuterol MDI's for the rescue of reactive airway disease. Quite the broad brush there. Every patient is going to respond a bit differently to this and every medication. Deep Tendon reflexes are just one sign that you may have used too much magnesium. It is also a therapeutic end point. We are allowed 8 grams, and when given too fast, can cause the loss of DTR. Not common, but it is possible. There are just as many that haven't, so take it easy with the aim of your gauntlet. The typical administration of magnesium is following a number of patient administered rescue MDI treatments. The 2-3 SVN administered beta 2/anti-cholinergics are not going to magically alter the peak effect/onset times of the medications. Most often they are already in the middle of the time span for these to be happening. Unless we are doing a randomized examination of the individual treatments, why would we not administer the first line treatment and progress to an adjunctive modality? Discussing one over the other as definitive is a bit problematic, but the end result of better ventilation/oxygenation is where our concern lies. Without the studies that have been done, the mere suggestion that magnesium may be helpful could not be made. Are they directly applicable? Probably not, but they have fostered the discussion. So you are saying the use of IV Ventolin is ineffective for relaxing uterine smooth muscle? This proves what exactly? There are many beta agonists that do work for relaxing the gravid uterus that aren't especially helpful for other reasons. Terbutaline anyone? I suppose I just need what you are trying to say here clarified. The problem comes with the definition of early. Steroids help reduce morbidity/mortality in these patients, but they do not help to rescue the affected airways. These are the same questions that get in the way of every piece of research not relegated to animals or the newly deceased. Because the treatments in question have been used for such a long period of time, and have gathered support from those that have used them, we get the ethical dilemma of not giving a medication that we THINK works, without KNOWING it does.

Whoa there speedy. Let's not get the nursing crowd wound up just yet, okay? Congratulations on the job. You will gather a significantly different view of how to manage a patient in an ER than you will get in the street. Not better/worse, just different. You are closer to the end points of treatment, so your exposure will be geared more to the eventuality that the patient will experience. The labs/blood draws and any other procedure that you are allowed to help with will also help you down the road. The ability of paramedics to work in hospitals, and other facilities is based on the willingness of the facility to allow them. The different things that they are allowed to do will be monitored by RN's/MD's/RT's, and they are all going to be a bit different in each facility. Some will follow state regulations to the letter, while some will be a bit more lax in their interpretation of the rules. For the most part, they can and do function in a similar capacity to RN's, but they generally are not given the ultimate responsibility for the care a patient receives.

The fact that this patient had a neuro-muscular disorder gives here the predisposition you are looking for. A bit generalized, but it is there. How was she positioned following the lasix? Was she on one side? Your description raises some questions as well. Did you have an ECG? It might show something also. If in fact this was an aspiration pneumonia, your treatment was not going to change things much. NTG/Lasix might dilate the vessels a bit, but the aspirated material would, typically, have a tough time moving into the vascular space. CPAP might have been quite useful, or some tracheal suctioning. On a side note, this is pretty common in some assisted living facilities. The nursing assistants know they need to provide nutrition, and will do so when the patient should not be given anything by mouth.

Overactive, this is but one way to use a bougie, or flexible tube introducer. You can also use it by itself, through your ET tube, or with a number of other airway devices. There are verisions available with an O2 port built into them to allow continuous oxygen delivery, but you are unable to truly ventilate with the device. Nasal intubation can be done on an apneic patient as well. I've done a couple where access was quite limited due to manpower or obstructions, while the chest was being compressed, I dropped the tube. No, I don't recommend this, but it can be done. I recall seeing a description for a visualized nasal intubation in a textbook some time ago also.

How to get to the end point? Quite simple in realization, quite difficult in practice. We stop allowing the special interest groups that want to take part in the provision of medical care from influencing the decisions that are made. Fire chiefs want to be heard, volunteers want to be coddled, the public is completely in the dark about what type of service they will actually receive. Let the public in on some of the decisions. Get more of your colleagues to realize that a volunteer system will soon be unable to cover the call volume that is in the future. Voice your concerns to your representatives. You are but one voice, and that one voice can be muted. Everyone that is willing to take a few minutes to bring light to the situation can affect a change. We are working toward getting this realized, and if you would like to know more drop me a PM, or visit the sites in my signature. It can be done.

Not to belabor the point, as it looks you've thought about the response RichardB, but if memory serves, the Passover feast was in memory of the saving of the Jewish first born while they were still in Egypt.

Sorry, but I have to get in here. There is a definite possibility that the individual service would not be able to survive. Just as likely, this would become a regional issue. So instead of eliminating service to the entire region, combine services. Regionalize the providers so that the call volume would increase enough to support the newly formed agencies. Just one idea that has met with some success already. For a period, there may need to be a reduction in service. Until the bugs in the system are worked out, but in the end it would be vastly improved over the current state of affairs. Even if it means maintaining a number of volunteers on call to serve a more remote area until others can arrive. Reducing response times would be one of several benefits, eventually. As broke as the system currently is, moving to change the way things are done should not be viewed as a bad thing. Ideas abound as to how to best alter the status quo. The problem with implementation lies with a lack of vision, or fear of change from providers that don't see the need.

Amazing what one will try when pushed far enough.

If she got dizzy when she stood up, her orthostatic vital signs were positive. There was no need to take a full set to figure this out. With the age alone, she should have been "exhaustively encouraged" to seek medical assistance. (Nice one there ERDoc, ) Alert and oriented, but can't stand up? She needs evaluated further. I'd venture hypovolemia, simply because it is very common. 81 y/o and on no medications? Everyone starts sometime, and this patient may be telling you from her presentation that it is time for her. Very easy to become complacent with this one. Fear the female over 45.

The evidence is still being gathered as to how effective it actually is. By itself, it's not going to do much for the problem. In concert with the beta-2s and steroids, it is great stuff. It works particularly well for the exacerbation that has tried to get relief with multiple MDI doses and can't. The biggest risk of mag toxicity is sedation/apnea. Mind you it takes a metric @$$load to get that far, but it is a risk. 1-2 grams over 2-5 minutes, repeating as needed is not going to be a huge problem. In the event it doesn't work, you will probably end up ventilating/intubating anyway.

There's a lot of variables that your question doesn't account for. Is the patient dead? Can you access the patient safely? Does law enforcement need to be notified before you enter the scene? Car on it's side and patients still in their original positions? Stabilize the vehicle and work from there. Here again too many variables. What type of injury? Where on the back is it located? Is it a life threat? You've got some decent questions, and with a little clarification you'll get good answers.

Good lord man, that's Dean Martin. Such a sad, sad, state of affairs when people forget the "Rat Pack" :roll:

Using terms like "verapakill" shows a misunderstanding of the utility of the drug. Yes, it is not quite as good as Cardizem for the rate control of AF/Aflutter. It is however very effective when it is used. As I already mentioned, a little pre-dosing with some calcium chloride would limit some of it's vasoactive effects for the patient that is significantly dehydrated. I don't blame you for coming up with the term, but the educational system that you are working in. I've used Calan numerous times, and have never been anywhere near experiencing this, ahem, side effect. It works great, and you don't have to worry about re-dosing if you are within 30 minutes of a facility. Most beta blockers are "kinder/gentler" rate control agents. The trouble with most is they are not as rapid in their onset as the calcium channel blockers. Perhaps more correctly, the effects of the drug aren't as obvious to the provider that is using them. I think I may be missing something in the translation of this: There isn't a beta channel on the myocardial cell wall. It is a beta receptor. It's activation allows the cell to break down stored energy and release it through contraction, and/or electrical stimulation. The calcium channel, in this instance the slow calcium channel, slows the inward flow of the calcium cation into and out of the cell. This inhibition prolongs phase 2 of the action potential. Lengthen the AP, slow the heart rate. The slower the rate, the greater the amount of fiber stretch, leading to a greater force related to Starling's law. The calcium channel blockers do reduce contractility, but some of this effect is balanced with the slower rate.

Ask him to clarify this. I've never heard anything like this one. Ventilate, stop for the intubation, begin ventilations. It is possible to intubate during compressions, but it can make things more challenging. If someone is providing cricoid pressure the movement is reduced, but sometimes it makes tube placement exceedingly difficult. Check www.theairwaysite.com and www.airwayeducation.com They both offer programs about nothing but airway management and are well worth the expense. Youtube also has some videos that show the airway anatomy. Just use "intubation" as your search term.

Unless you study every provider, from every service, everywhere, you will never have a truly accurate picture of how each individual system works. My assertion is, quite simply, if the dedicated volunteer is able to perform at the highest level without the support of a paycheck from a dedicated service, why would they be any less so from a career department that would allow them to have some off time? Many volunteers a quite capable, and I won't argue that point. The suggestion that it is the best method to provide the service is where my question lies. If it is good to have providers that will respond from home or work in 5-10(or more) minutes, how would it be worse to have them within 1-2 minutes of a response unit?

It would seem the problem is one of generalizing the information to fit everyone with a title. Some volunteer services are quite valuable, some are a significant drain of resources. The same can obviously be said of career departments as well. I doubt this is the direction you might be looking, but why should your county government pursue the securing of a career department for the provision of EMS while there is still the view that volunteers can mangage the situation? I'm sure they are quite capable, but wouldn't a paid department be able to better support their employees? This discussion turns quite emotional very quickly. This is not my intention with my questions. I just want to look at the situation as objectively as possible.