AZCEP

Atlanto-relates to the Atlas, or first cervical vertebrae Occipital-relates to the bones over the posterior skull The Atlas is in close proximity to the occiput so they can be described together Subluxation is a specific type of movement of the joint, usually between vertebrae where shearing forces impinge on the spinal cord. Basically this patient's skull moved over the top of the Atlas(C-1 vertebrae) cutting the brain stem. Even if they hadn't cut the cardiorespiratory center, from the mechanism you describe, they probably wouldn't have lasted long anyway. The whole Traumatic Brain Injury bit.

First, welcome to the City. Second, do a search for CHF, you will find that many others have had this same question. Some recommendations: http://www.emtcity.com/phpBB2/viewtopic.php?t=2496 http://www.emtcity.com/phpBB2/viewtopic.php?t=2639 Also: http://www.emtcity.com/phpBB2/viewtopic.php?t=5195 http://www.emtcity.com/phpBB2/viewtopic.php?t=3565 http://www.emtcity.com/phpBB2/viewtopic.php?t=2021 http://www.emtcity.com/phpBB2/viewtopic.php?t=4917 If those don't answer your questions, come on back. We will be here.

Yes, we can exclude a bleed. It is a bit more detective work, but it can be done. The information you need can all be gathered from the history to be reasonably sure a bleed is not happening. More times than not it would be ruled out, instead of in, but prehospital the three hour window for ischemic CVA is much more achievable than it is for the hospital. It will never be approved for CVA, but if it is acceptable to use for AMI, one can only hope.

The drug, in and of itself, is not dangerous. I'd be willing to bet that right now there are hundreds of bottles of the stuff near your stations sitting in a cabinet minding their own business. Now, when they start plotting, we need to worry. The danger is in the mind/hands of the providers that have discovered they didn't receive enough education on how to use this wonderful medication, and have not taken it upon themselves to find out what it can/can't/should/shouldn't be expected to do. Once that is taken care of, very few medications are as effective for their intended jobs as Verapamil.

I have a feeling that we can all relate a bit to #12. I do notice that #11 indicated some CE generation, correct? And did this program work as you had planned it to? Pretty impressive list.

I'm going to suggest skipping the paramedic thing altogether. Go to MEDICAL school instead, jock-o. Just remember where you came from.

Transport times of greater than 1 hour was not where I was going, but it is a good point. The utility of the fibrinolytics for AMI, and AMI only, can be up to 6 hours from symptom onset. This usually means the patient denies the symptoms for a while, then calls for help, and arrives at a facility beyond the recommended time frame. For those that have PCI facilities available, withholding the fibrinolytic is a reasonable measure. The use in CVA, can be extended to 6 hours, but it must be given intra-arterial at the site of the occlusion. Tough to do this in the prehospital environment. Pulmonary embolus and DVT, might be reasonable opportunities to use them prehospital, but the severity of the occlusions would have to be graded beforehand, again tough to accomplish. I will agree that for some situations, there is nothing better. At the same time, for the wrong situation, there could be few things worse.

This is another case of policy makers being caught in the moment. "Bird flu" was supposed to be the next big threat, right behind smallpox, bioterror, West Nile virus, and WMD's. Makes you think that maybe they are spending too much time watching CNN for their own good. They see a story about something, then inflate the dangers to unrealistic levels. How many flu patients did you see this last year? Were any of them "Bird flu"? I didn't think so. Wash your hands, cover your cough, eat some chicken soup. The "Bird flu" is not a significant danger yet. The yet is important, because it can become one, but until it happens we all need to relax just a bit. Walking around looking for this one bug, blinds us to the possibilities of other bugs that are more of a problem.

Report: Drug Errors Injure More Than 1.5M Sign In to E-Mail This Print Save By THE ASSOCIATED PRESS Published: July 21, 2006 Filed at 1:55 a.m. ET WASHINGTON (AP) -- Medication mistakes injure well over 1.5 million Americans every year, a toll too often unrecognized and unfought, says a sobering call to action. At least a quarter of the errors are preventable, the Institute of Medicine said Thursday in urging major steps by the government, health providers and patients alike. Topping the list: All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines. Perhaps the report's most stunning finding was that, on average, a hospitalized patient is subject to at least one medication error per day. A serious drug error can add more than $8,750 to the hospital bill of a single patient. Assuming that hospitals commit 400,000 preventable drug errors each year, that's $3.5 billion -- not counting lost productivity and other costs -- from hospitals alone, the report concluded. ''I'm a patient-safety researcher (yet) I was surprised and shocked at just how common and how serious a problem this is,'' said Dr. Albert Wu of Johns Hopkins University, who co-authored Thursday's report. Worse, there's too little incentive for health providers to invest in technology that could prevent some errors today, added Dr. J. Lyle Bootman, the University of Arizona's pharmacy dean, who co-chaired the IOM probe. ''We're paid whether these errors occur or not,'' lamented Bootman, who recently experienced the threat firsthand as his son-in-law dodged some drug near-misses while in intensive care in a reputable hospital. The new probe couldn't say how many of the injuries are serious, or how many victims die. A 1999 estimate put deaths, conservatively, at 7,000 a year. Even the total injury estimate is conservative, Bootman stressed. It includes drug errors in hospitals, nursing homes and among Medicare outpatients, but it doesn't attempt to count mix-ups in most doctors' offices or by patients themselves. There have been efforts to improve patient safety in the six years since the IOM first spotlighted medical mistakes of all kinds, including recent bar-coding of drugs to minimize mix-ups in hospitals and pharmacies. But clearly more are needed, and the new report highlights how the nation's fragmented health care system is conducive to drug errors, said Dr. Donald Berwick, a Harvard professor who heads the nonprofit Institute for Healthcare Improvement. ''This isn't a matter of doctors and nurses trying harder not to harm people,'' Berwick cautioned. ''Safety isn't automatic. It has to be designed into the system.'' Medications' sheer volume and complexity illustrate the difficulty. There are more than 10,000 prescription drugs on the market, and 300,000 over-the-counter products. It's impossible to memorize their different usage and dosage instructions, which may vary according to the patient's age, weight and other risk factors, such as bad kidneys. Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take at least five. The more you use, the greater your risk of bad interactions, especially if multiple doctors prescribe different drugs without knowing what you already take. Add doctors' notoriously bad handwriting and sound-alike drug names: Was that order for 10 milligrams or 10 migrams? The hormone Premarin or the antibiotic Primaxin? Moreover, consumer instructions are woefully inadequate, the report concludes. One study found parents gave their children the wrong dose of over-the-counter fever medicines 47 percent of the time. Then there was the newly diagnosed asthmatic wondering why his inhaler didn't work. Asked how he used it, the middle-age man squirted two puffs into the air and tried to breathe the mist. His original doctor had demonstrated the inhaler without telling him to spray it inside his mouth. Among the report's recommendations: --The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible. Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient's records show use of another drug that can dangerously interact. --Patients and their families must be aggressive in questioning doctors, nurses and pharmacists about medications. Get a list of each drug you're prescribed, why and the dose from each doctor and pharmacy you use, and show it at every doctor visit. ''Take active steps to make sure you know what you're getting, and is it what you need,'' said report co-author Dr. Wilson Pace of the University of Colorado. --The nation should invest about $100 million annually on research into drug errors and how to prevent them. Among the most-needed studies is the impact of free drug samples, which often lack proper labeling, on medication safety. --The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs, but often have incomplete information or are written in consumer-confusing jargon. --The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems. The Institute of Medicine is an independent organization chartered by Congress to advise the government on health matters. So, let's take an honest look at what can be done from a prehospital view. Can you forsee any of your agencies taking the necessary steps, or will it fall back to the provider with the syringe/pill?

Where exactly did you see that I was "poo-pooing" the idea? It is great that the idea was presented. I was merely giving a warning in the execution of it. To clarify my position, there are dozens of available programs that have free CE programs already available online. Medscape and Cyberrounds are two that jump to mind. These are designed for those that want to learn something new, that is not integrated into the standard alphabet soup classes. They are significantly more difficult than most EMS specific offerings, because of a lack of an instructor to ask questions of, and they are designed for doctors and nurses. GA, you may be reading a bit much into what is being posted. I am speaking from experience when I suggest having the instructor available to the students. I have built CE programs that failed miserably, due to lack of instructor interactions. If you want to discuss it further, I would be glad to help you build your own. This forum is probably not the best place to pound out the details, but I'm willing to try.

Agree with Rid, any female of child bearing age, with abdominal pain is pregnant until proven otherwise.

The Poiseuille's law (or the Hagen-Poiseuille law also named after Gotthilf Heinrich Ludwig Hagen (1797-1884) for his experiments in 1839) is the physical law concerning the voluminal laminar stationary flow Φ of incompressible uniform viscous liquid (so called Newtonian fluid) through a cylindrical tube with the constant circular cross-section, experimentally derived in 1838, formulated and published in 1840 and 1846 by Jean Louis Marie Poiseuille (1797-1869), and defined by: where V is a volume of the liquid, poured in the time unit t, v the median fluid velocity along the length of the tube, x the direction of flow, R the internal radius of the tube, P the pressure difference between the two ends, η dynamic fluid viscosity and L the total length of the tube in the x direction. The law can be derived from the Darcy-Weisbach equation, developed in the field of hydraulics and which is otherwise valid for all types of flow, and also expressed in the form: where Re is the Reynolds number and ρ fluid density. In this form the law approximates the Darcy friction factor, the energy (head) loss factor, friction loss factor or Darcy (friction) factor Λ in the laminar flow at very low velocities in cylindrical tube. The theoretical derivation of a slightly different form of the law was made independently by Wiedman in 1856 and Neumann and E. Hagenbach in 1858 (1859, 1860). Hagenbach was the first who called this law the Poiseuille's law. The law is also very important specially in hemorheology and hemodynamics, both fields of physiology. The Poiseuilles' law was later in 1891 extended to turbulent flow by L. R. Wilberforce, based on Hagenbach's work. Viscosity Two fluids moving past each other in the x direction. The liquid on top is moving faster and will be pulled in the negative direction by the bottom liquid while the bottom liquid will be pulled in the positive direction by the top liquid.The derivation of Poiseuille's Law is surprisingly simple, but it requires an understanding of Viscosity. When two layers of liquid in contact with each other move at different speeds, there will be a force between them. This force is proportional to the area of contact A, the velocity difference in the direction of flow Δvx/Δy, and a proportionality constant η and is given by The negative sign is in there because we are concerned with the faster moving liquid (top in figure), which is being slowed by the slower liquid (bottom in figure). By Newton's third law of motion, the force on the slower liquid is equal and opposite (no negative sign) to the force on the faster liquid. This equation assumes that the area of contact is so large that we can ignore any effects from the edges and that the fluids behave as Newtonian fluids. [edit] Liquid flow through a pipe In a tube we make a basic assumption: the liquid in the center is moving fastest while the liquid touching the walls of the tube is stationary (due to friction). A cross section of a hypothetical tube shows the lamina moving at different speeds. Those closest to the edge of the tube are moving slow while those near the center are moving fastTo simplify the situation, let's assume that there are a bunch of circular layers (lamina) of liquid, each having a velocity determined only by their radial distance from the center of the tube. To figure out the motion of the liquid, we need to know all forces acting on each lamina: The force pushing the liquid through the tube is the change in pressure multiplied by the area: F = -ΔPA. This force is in the direction of the motion of the liquid - the negative sign comes from the conventional way we define ΔP. The pull from the faster lamina immediately closer to the center of the tube The drag from the slower lamina immediately closer to the walls of the tube The first of these forces comes from the definition of pressure. The other two forces require us to modify the equations above that we have for viscocity. In fact, we are not modifying the equations, instead merely plugging in values specific to our problem. Let's focus on the drag from the faster lamina (#2) first. [edit] Faster lamina Assume that we are figuring out the force on the lamina with radius s. From the equation above, we need to know the area of contact and the velocity gradient. Think of the lamina as a cylinder of radius s and thickness ds. The area of contact between the lamina and the faster one is simply the area of the inside of the cylinder: A = 2πsΔx. We don't know the exact form for the velocity of the liquid within the tube yet, but we do know (from our assumption above) that it is dependent on the radius. Therefore, the velocity gradient is the change of the velocity with respect to the change in the radius at the intersection of these two laminae. That intersection is at a radius of s. So, considering that this force will be positive with respect to the movement of the liquid, the final form of the equation becomes where the vertical bar and subscript s following the derivative indicates that it should be taken at a radius of s. [edit] Slower lamina Next let's find the force of drag from the slower lamina. We need to calculate the same values that we did for the force from the faster lamina. In this case, the area of contact is at s+ds instead of s. Also, we need to remember that this force opposes the direction of movement of the liquid and will therefore be negative. [edit] Putting it all together To find the solution for the flow of liquid through a tube, we need to make one last assumption. There is no acceleration of liquid in the pipe, and by Newton's first law, there is no net force. If there is no net force then we can add all of the forces together to get zero 0 = Fpressure + Fviscosity,fast − Fviscosity,slow or Before we move further, we need to simplify this ugly equation. First, to get everything happening at the same point, we need to do a Taylor series expansion of the velocity gradient, keeping only the linear and quadratic terms (a standard mathematical trick). Let's use this relation in our equation. Also, let's use r instead of s since the lamina we chose was arbitrary and we want our expression to be valid for all laminae. Grouping like terms and dropping the vertical bar since all derivatives are assummed to be at radius r, Finally, let's get this in the form of a differential equation, moving some terms around to make it easier to solve later, and neglecting the term quadratic in dr since this will be really small compared to the rest (another standard mathematical trick) This type of differential equation has solutions of the form v = A+Br2. To solve, we will substitute this into our equation and solve for A and B. this means that to solve for A we'll use the assumption we made at the beginning that at the wall of the tube (r = R) the velocity must be 0. or Now we have a formula for the velocity of liquid moving through the tube as a function of the distance from the center of the tube or, at the center of the tube where the liquid is moving fastest (r = 0) with R being the radius of the tube, [edit] Poiseuille's Law To get the total volume that flows through the tube, we need to add up the contributions from each lamina. To calculate the flow through each lamina, we multiply the velocity (from above) and the area of the lamina. Finally, we integrate over all lamina via the radius variable r. There are a lot of diagrams that help to explain some of this at: http://en.wikipedia.org/wiki/Poiseuille's_law Basically: Fluid flows faster through a large, short, smooth tube than it does through a small, long, rough one PIH, PreEclampsia, Eclampsia

6 pages in and there are two obvious omissions: 1) Creeping Death-Metallica 2) Ride the Lightning-Metallica For my own submissions: 1) Walk the Line-Johnny Cash, it has been remade by several other artists, but the original is still the best. 2) Sunday Mornin' Coming Down-Johnny Cash 3) Fat Bottomed Girls-Queen 4) Pressure-Billy Joel, the Queen/David Bowie version always makes me think of Vanilla Ice and some unfortunate record purchases in the past 5) Steve McQueen-Sheryl Crow, just for the irony 6) I Love This Bar-Toby Keith 7) I Ain't as Good as I Once Was-Toby Keith 8) Life is a Highway-Tom Cochrane, he released it in the mid-90's, and I think it sounds better than the newer version by Rascal Flatts 9) Crush 'Em-Megadeth, the entrance bass line is great 10) Suspicious Minds-Elvis Presley, because, well, we all have one...or do we? And finally, after a long day, with entirely too much societal refuse: 11) Happy Happy, Joy Joy-Ren and Stimpy soundtrack, kind of helps to put the mind right before you get home to people who just don't care about your work life.

Good points mdparamedic, and welcome to the City. RSI has somehow developed into a sordid "merit badge" for those that get to use it. It also has become a device to compare different systems, and how progressive/restrictive they are. I'm sure we've all seen/heard it, "We use RSI, but you don't? We must have a better system." There are many that have used medication-assisted intubation quite frequently, with great success. This same group is the most hesitant to upgrade to RSI. Let's all step back for just a moment and try to remember that RSI is a tool. That is all it is. The process for using this tool can be quite complex, but it is a tool designed to make the first intubation attempt easier. Ideally, it will make first attempt placement much easier. Hopefully success rates will bear this out. The most important tool in any intubation attempt is the one holding the laryngoscope.

Makes for a good story when you get some new guys on the squad with less experience than you have. "Back in the day, I can remember riding 4 miles uphill both ways, just so we could get in a horse-drawn wagon to respond" Wait, maybe Rid actually did that. :shock:

While it is a good idea to put these courses together, an important point is being missed. If the student is blankly reading a presentation, powerpoint or otherwise, will they be able to remember what they read when the time comes? Most EMS providers are not good at taking a concept off a page and applying it. The majority are combination learners, hear-see-do types. When we eliminate one of these modes, it becomes much more difficult for them. There are already dozens of "canned" courses out there. The benefit lies in the instructor's ability to relate the information. Knowing there is nothing worse than watching a presentation being read word-for-word from the slides, how can you possibly condone this type of CEU program? I would also direct you to the Training files. Many good presentations there to build from. The work has already been done, it would be ridiculous to duplicate efforts when you don't have to.

Can I suggest some skis? Oh, and maybe a parka.

There are already CEU programs ripe for the picking on this and many other sites. The individual putting the program together just has to see them for what they are. The scenarios forum is one place. The Students forum is another. Right now the Educational forums thread is pushing 5 pages and going strong. Pick some of those topics and run with them. Flip through a medical dictionary, and pick a problem. Use it as a basis for your CE program.

Let's see if we can right this ship before it goes under like a cargo vessel hauling import cars. Fibrinolytics for AMI have no true place in EMS. Remote rural, maybe, if times from onset of symptoms to delivery of the drug are in excess of 6 hours. For CVA, even less place for them. There are too many bad things that can happen to a CVA, and most ER's hesitate to use it without a neurosurgical consult. I can't remember the last time I spoke to a neurosurgeon on the radio, so that is out entirely.

The management concerns are not only directed toward Cardizem. Any agent that works through slowing conduction through the AV node has the possibility of worsening the tachycardia. Adenosine, Beta blockers, Calcium channel blockers, vagal maneuvers can all have negative effects on the patient. Patient tachycardic, accessory pathway noted, AV blocking agent used, tachycardia worsens. Drugs like Pronestyl and Amiodarone, that work on atrial and ventricular tissue, are the agents of choice. Amiodarone does not do a great job, but it can work. Pronestyl has been around a long time, but few EMS systems carry it.

I've got to say it again. :x You can give a monkey a hammer, but that doesn't mean he can build a house with it. Excellent points Spock. That logical Vulcan mind in action, I suppose. The well ventilated patient can still be hypoxic. The well oxygenated, can still be hypoventilating. We have to bear in mind that we treat the whole picture, so let's look at the whole picture before we pick a treatment path. Right now, EMS tends to get excited about new toys. EtCO2 is one of them, while very useful, can't replace an educated mind. Which may be in short supply in some cases.

The nice thing about Primacor/Natrecor is the lack of beta activation to get a response. Beta blocker OD's? No problem, if the patient can tolerate the vasodilation that goes with it. These are great with hypertensive left heart failure. Increase the contractility, dilate the vessels, double-edged sword, but very effective. You do not want these if you don't have pumps to control the rate. They act nothing like Dopamine/Dobutamine, and titrating to effect is a moment to moment situation. The dosing is a nightmare as well. Whoever came up with the initial dose range for these had to be a masochist. Arterial lines, and Swan-Ganz make life easier, but even with them, this class of medication is a bit challenging when you aren't bouncing down the road. Leave them for flight, or ICU.

THAT is impressive Ace. Managed a TCA OD last week with NPA's X2, no OPA due to a gag. Couldn't intubate for a number of reasons, BLS airway management with no difficulty. Got to the ER, Doc used a fiber-optic scope to get the ETT in. Patient released home after some discussion with a noodle doc. BLS maneuvers do work. They take less time in class because everyone wants to learn the invasive techniques.

EMS is entirely different from most other lines of work out there. Few, if any, can come close to comparing. EMS is not what you may think it is either. TV/movies don't show anything near real situations. Yes, occasionally, we do something heroic and save/prolong a life. Most of the time, however, we are dealing with less than ideal circumstances, and less than ideal people. To paraphrase a nursing description, "We see the absolute best and worst, in the absolute best and worst of, and with people/weather/equipment." Maybe you could do some ride-time with your local service before you decide. You will be glad you did.

I won't discuss why you should or shouldn't use an opioid narcotic to assist with intubation. That is a matter entirely for your system to deal with. A suggestion would be to try using some Morphine/Fentanyl in combination with the other agents, and you might find you get better results. The issue is one of patient comfort. Muscle groups that can't flex/extend periodically become extremely sore after a short time.