AZCEP

Well said by someone doing the flights. I have a hard time buying the "helicopter EMS is a higher level of care" mantra, simply due to the experiences that I've had with several flight services. Knuckleheads in all groups, I guess. Get them off my scene and to definitive care faster.

As Ace brought up, wouldn't BiPAP be a better choice for COPD? Don't CPAP generators carry the ability to use BiPAP, or would this be an entirely separate piece of equipment? I ask because we are looking at the Boussignac device, which is reasonably priced and doesn't require any other system mods.

Watch closely, at least one IV, consider a second, hope the ALS tricks don't have to appear.

Actually, the TRISS, APACHE, and ISS all have their own issues. Most common is the depth of the score, and the ability to remember what each section is for. The one I've found to be the easiest is the F-O-U-R score. When using the FOUR Score, evaluators assign a score of zero to fourin each of four categories, including eye, motor, brain stem andrespiratory function. A score of four represents normal functioning ineach category, while a score of zero indicates nonfunctioning. Comatose patients remain fully testable even if a tube is inserted to enable breathing, which applies to almost half of all comatose patients Brain stem reflexes, indicators of the entire brain's health emanating from the underside portion of the brain that controls breathing and consciousness, are tested, providing information for immediate intervention and prognosis More precise measurements and higher agreement between evaluators than the Glasgow Coma Scale Recognition of a locked-in syndrome Attention to stages of brain herniation and breathing as indicators of coma depth Scores have better correlation with outcomes, e.g., in the comatose patients with lower scores on the FOUR Score and the Glasgow Coma Scale, more patients with low FOUR Score ratings died www.sciencedaily.com/releases/2005/09/050908080323.htm

How much does she weigh? Knowing this will allow us to determine which stage of shock we are dealing with. Guessing the standard 70 kg for weight, I'm figuring ~20% blood loss. This amount is the dividing point between class 1 and class 2. The lack of tachycardia is a bit concerning. Why is she unable to compensate? Definitely ALS.

The increase could be related to the pulmonary infiltrate that was discussed, but somehow I'm thinking you didn't make it that easy

Sit this individual down, and lay it out for them. No one likes confrontation, but if you don't do it then you are propagating the problem. Whether it is a supervisor, or just a group of peers, reality needs to be snapped into view. Until then, all the coaching will be for naught. Tough situation, but how you handle this determines what kind of professional you are. Good luck.

The WBC is very low. Would lead you to think a viral cause. I'd still like to get a picture of the liver and gall bladder, for kicks.

I can think of a couple of questions regarding this study. If the occasional "overtriage" of a patient that doesn't need air transport is okay, then how often would "undertriage" be acceptable? When helicopters are used, is it solely based on the level of injury, or are there other factors involved? In my own experience, any time a helicopter is requested it is a mix of both factors. The area I work in is 40+ minutes from a receiving facility by ground, and there is one ALS unit for the response area. If we didn't use air resources when they were needed, we would be extremely limited in our ability to provide service, just based on turn around times. When we respond to reported trauma, we launch the aircraft, which will get them to us in 20-25 minutes. Just long enough to, maybe, arrive on scene and do a quick assessment. If we do in fact need them, we will land them, and turn the patient over. If we don't, we cancel them before they get too close. We've never had any problems with the 4 different air providers cancelling without landing. I will admit that we are probably very guilty of the "overtriage", but at the same time, much can change in 40 minutes worth of transport time, so it will probably continue.

Let's check the Liver function while we a sending things to the lab. A CBC would also be in order. While we're at it, how about an abdominal CT with and without contrast.

Doesn't the traction splint sit in the bottom of a compartment on top of the MAST suit? Wait I think I know where to find it. Either would be a reasonable option for splinting, though neither would be considered by most.

The hypoglycemia could very well have been a response to the infection. Hyperdynamic-->hypodynamic state progression. As the body uses up it's fuel, sugar, the temp will progressively lessen. Very bad when it happens, but I've seen septic patients with all color of oozing substances without fever. Excuse me while I go shower. I suddenly feel very dirty. :oops:

Done

There are some alternatives out there, but you really are pinned to what your local protocol wants you to use. The motor response has been studied to be the most important of the three sections of the GCS. Like most other assessment tools, if your receiving facility doesn't understand the scale you use, you can bet you won't be getting the attention that you need.

Blast! Where was that link 4 months ago when I had to sit through the BLEEPITY, BLEEP, BLEEPING course? Good alternative source. Thanks Mike.

So I guess we skipped right past Ace, eh? The bear in the Studebaker is from "The Muppet Movie" " I think three old ladies with brooms could sweep us off of there."

No, no, no, my comment was directed at the "no signs of infection, body is hot." Temp means infection until proven otherwise.

It can make it more challenging to get into position, but it will make the turn much better. I think my new favorite back up device is the King-LT. It is much cheaper than the Combi-tube, doesn't have the latex cuffs, and is placed almost as easily as an OPA. The full kit from narrescue.com is $55. For just the tube, it is only $15. Then you just have to find a 60 mL syringe to fill the cuffs. My favorite feature of this device is the ramp in the distal port that allows you to use a bougie through it, and replace it with an ETT. Pure genius, I tell you. Practicing on manikins, I've had EMT partners place the King, then ventilate for a bit, then place an ETT later. Haven't had any opportunities with actual patients yet, but we are prepared for the first one.

How exactly are you "leading"? You find a pet cause, bluster about it for a bit, allow someone to offer an opposing view, then ignore the responses? How is this leadership? It smells distinctly of Captain Bligh. Saying and doing are significantly different things. You want to discuss improvements, no matter how small? Then listen to some of the responses that are given to you. You want to "challenge" people and agencies you have never seen or met? How can you possibly make any value judgement for or against them? My point was, no one, and EMS personnel in particular, want to hear from a cheerleader with no earthly idea what will need to happen to effect a change. So, I suggested a small change, dosed with heavy sarcasm. How is professionalism a small change? Keep your answer to yourself, because I'm willing to bet most here do not need your view of it shoved down their throat. Is it realistic? Of course not. Neither is expecting anyone to make a grand, sweeping change in the next month. I suggested making a small change to the professionalism of one's appearance. Sarcasm aside, this is about all that an individual will be able to accomplish in this ridiculous timeframe. Take as many reputation points as you feel you need to. My point is made.

The most significant change from the Incident Command System to NIMS is the name. You still have the issues of which system every department is following. Now they have included receiving facilities in the educational process, which is long overdue, but they are going about it a bit sideways. Administrators with little time/experience with these kinds of incidents are being set up to fail at the worst possible time. These facilities will be calling for help from local fire/EMS departments because that is where the people who know how to manage the incident will be. In time it will get better, but until then let's hope we don't need it.

GA, Be careful you don't hurt yourself with all the soapbox jumping. My suggestion for improvement will be an elimination of all calls within 24 hours of polishing my boots. How are we supposed to present a professional image if we are forced to run into all manner of terrain and soil our footwear. Well, no more. There, done, what do I win?

One of my co-workers made the mistake of asking where the MAST suit was located, and if I had ever actually used it. What followed was pretty entertaining. We pulled it out, attached the pump, inflated the compartments--no pop-off valves to open--listened closely, and discovered the air bladders had dry rotted. We basically had a nylon encased, rubber swiss cheese. As we are getting this mess taken care of, we respond to an elderly fall victim. When we arrive on scene we find our patient lying flat on her back on the floor, with her left femoral head obviously dislocated from the socket. IV/Pain meds later, patient moved to LSB with MAST in place. Took a few minutes to explain how to properly secure the velcro, inflated to just enough pressure to splint, and off to the hospital we go. Arrive at the ER, and no one is able to understand why I didn't mention the patient had no blood pressure. I told them her pressure is fine, and the response was, "Why did you use the MAST suit?" A quick inservice later, the staff shaking their heads agreed that was probably the best way to immobilize this patient's injury.

That is a pretty good book Ace. I do wish I could find it in hardcover though. I just keep stealing it from the medical library. It doesn't seem to be having much influence with the residents, so they don't miss it much. My suggestions: Title:Pathophysiology: The Biologic Basis for Disease in Adults and Children Author: McCance and Huether Hardcover: 1616 pages Publisher: Mosby ISBN: 0-323-01438-0 Copyright: 2002 This is a good text for anyone interested in the way things work. It does a good job incorporating the A&P that is so important to understanding why things happen the way they do. It also discusses how the physiology changes with age, and highlights the differences that can occur in kids. Like most of the Elsevier books, it also has an accompanying website with more images and quizzes to further understand how things work. I give this a 9/10. My second suggestion: Trauma Management: An Emergency Medicine Approach Author: Ferrera, et al Hardcover: 760 pages Publisher: Mosby ISBN:0-323-00210-2 Copyright: 2001 This book has been the base of knowledge for the last 2 paramedic classes that I've taught. It greatly expands on what is available in a standard issue paramedic text, and doesn't go so deep that the students get lost. It is written in a format for ER doctors, instead of the trauma surgeon, so much of the suggested treatments are available to prehospital providers. It also discusses some of the issues in dealing with EMS. My only complaint has been it is getting close to time to buy another edition, that has not been updated yet. If you like trauma, and want to better understand what your treatment will mean to your patients, this is the best book available. Take the PHTLS or BTLS textbooks and toss them. This one will easily replace both without burying you in minutiae. 8/10 stars.

I'll take a shot with no possibility of being correct, but is it SWINGERS?

Come on now Whit, answer the first one before throwing out another one. Chvostek's sign is facial muscle spasm related to hypocalcemia. It is created by the increased muscle tetany from the facial nerve. Trousseau's sign, good combination by the way Ace, is a spasm of the flexor muscles of the upper arm when pressure is applied for a period of time. It is also associated with hypocalcemia, and is easily elicited by inflating the blood pressure cuff, waiting a moment, and watching the flexor response. Kernig's sign is a symptom of meningitis evidenced by reflex contraction and pain in the hamstring muscles when attempting to extend the leg after flexing the thigh upon the body. Now for something a bit more challenging. What are the vital sign changes associated with the four stages of shock?