HERBIE1

I was never actually officially taught how to to an EJ either- I was shown that method years ago by a mentor. As for the tape, a clear op-site is almost mandatory if you have them available. It's really difficult to adequately secure an EJ with tape alone.

No problem. This is one of the reasons I suggested a longer catheter. After you advance the catheter(and retract the needle), and believe you are in the vein's lumen, you gently wiggle the catheter to see if it is indeed inside the vein and not under, over, or through it. Just a secondary- and certainly not perfect- method to help confirm patency.

The vast majority of these tests are written at the level of an average newspaper- around 6th grade. The claim in most of these cases is that the test itself is racially biased somehow. In the case of the listed lawsuit, the test was made race neutral and they still did not get the results they wanted. Short of throwing out the results and simply picking the numbers that make everyone happy, I don't see what else should be done. What many cities are doing- in ours as well- is that they require 60 hours of college credit(not even necessarily a degree) to even apply for the job in law enforcement. At that point, if a person is able to complete 2 years of college course work, I guess the assumption is the applicants must have at least a minimum level of intelligence, competence, and diligence.

Sounds like you have a pretty good technique. Problem is, because of the variations of anatomy, thick necks, short necks, etc, the angle of entry will vary quite a bit. Sometimes you get a pretty good flash, other times you get nothing. Depends on the patient's underlying condition-ie a person in fluid overload will give you quite a big flow. A dehydrated little old lady in a nursing home will probably take some work to confirm your IV. Wiggle the catheter to see if it's in the vein, and hook up your IV. To secure the catheter, use an op-site membrane, loop the tubing over the ear and tape it down securely. They can be good places to have IV access because the arms and chest area tend to get crowded- cables from Pulse OX, EKG, Defib pads, CPR, etc, so an EJ can be useful. To confirm a patent line, you can also always drop the IV bag, or even aspirate a bit of blood with a syringe, but sometimes the only way you'll know for sure if it infiltrates. Also, don't use a short catheter-I'd suggest at least 1.5 inches and the largest bore you think the vein can handle- the sturdier the better.

Great story. doc. Glad to see your grandfather is doing well. Personally, I think the thank you's from families like that make all the other BS we deal with worthwhile. Far more satisfying than a bonus, but I'd never turn that down, either. LOL

Interesting theories. I'm assuming the problem was due to a hyperflexion type injury. Twisting, torquing- gawd only knows what position he was in at impact? He was struck from behind, spun out, and then hit the guardrail.

Intuitively Thanks. I will read these in detail. Based on his loss of function, the problem was probably in the lower thoracic/upper lumbar area. I'm also thinking his HIV may have something to do with this, but I'm at a loss to explain how. Based on anecdotal evidence, what outcomes have you seen with cases such as these?

No visible injuries at all- chest or otherwise except for the slightly bloody gums from the airbag deployment, and he was still restrained when we arrived. Even at the hospital, he still didn't have a mark on his body. The state police officer found him in the same position and didn't touch him because the victim told the trooper the same thing he told us- he couldn't move his legs. The belts appeared to be correctly applied when we found him.

Thanks for the info. I had no idea this was common enough to have a syndrome. Obviously there was some type of cord disruption- a small tear in a single fiber, swelling- whatever. I've seen a fair number of cases attributed to cord shock but generally the deficits began to subside fairly quickly after steroids. I want to follow up to see what happened in this case. What is the prognosis of such cases- SCIWORA? I was asking about similar cases- unsuspected spinal injuries, not if the person needed to be immobilized. Agreed. It obviously depends on where the airbags are deployed from, and when the bags are located on top of the dash, the compartment doors usually crack the windshield when they open. Since airbags are deployed at well over 100MPH, damage to the windshield is logical. The damage in these cases is located at the level of those doors- the bottom portion of the windshield.

I see the same flaws in this study as are mentioned above. In a stable ER setting, an automatic cuff is perfectly acceptable, although there have been many times when I questioned the readings and performed a manual BP to verify what the machine tells me. Sometimes they are right, and sometimes they are dead wrong. Personally, I trust my ears before a machine, and in the back of a rough riding ambulance, I question the accuracy of a machine. I think the bottom line here with either method is to chart a trend. Is the BP going up, down, or all over the place? The numbers are important, but I think the more important issue is what those numbers are doing and what does that tell you. Is the patient responding to treatment, are they decompensating, is the pulse pressure changing, are the numbers remaining the same? Obviously you need to correlate the readings- however they are obtained- with the patient's condition. Just like we generally do not treat an EKG rhythm without checking the patient, if you get a BP that says the patient is not perfusing and is ready to code, and the person is busy telling you a joke, you might double check that BP reading. Bottom line- like any of the toys we have, nothing can replace your skills, training, and experience. An automatic BP cuff can be a useful tool in the proper setting.

Depends heavily on which group you pose that question to. City managers look at the bottom line. Does it generate money for us? Does it make the voters happy and gets us reelected? Tax paying citizens generally support EMS but are probably ambivalent and/or ignorant about the details of how their service operates until they need it. They certainly do not know about the problems the system may have in providing EMS care. Frequent flyers simply look at it as a taxi to bail them out of their latest self induced tragedy. Abusers- those who do NOT need an ambulance, much less an ER visit- look at it simply as another service they "deserve"- regardless of it's original intent. Fire service looks at it as a necessary evil/red-headed step child which generates revenue for them and saves FF jobs.

Agreed about someone whose ideas of right and wrong is governed by the current political wind. Like I said though, these days, it is tough to find a candidate who agrees with your own ideas- ESPECIALLY if you are not a dyed in the wool republican or democrat. Personally, I have mostly conservative ideas-along with a couple that definitely do NOT align with a Republican ideology. As such, presidential campaigns are tough for me. Thus, my perpetual candidate always seems to be named "None of the above". LOL

Apolitical or not, my reasons stand. The pendulum will be stuck on the left for quite some time to come, and in cases such as this, "right and wrong" is completely dependent on your political and social ideology. As for John McCain, I could not get past some of his ideas like Immigration reform. Problem is, a pure liberal or conservative is hard to come by these days. Politicians hate to alienate even one voting bloc for fear of losing their chance to get elected. In many ways, this blended politician can be a good thing, but some of the hot button issues like abortion, immigration, and affirmative action are deal breakers for many people. They have such a strong opinion, they simply cannot get past that one issue.

Don't count on that-at least not for a long time. We have a Democratic president, a majority democratic Congresss, and Sotomayor will soon be confirmed as a new justice. This will be the last ruling of this kind for quite some time.

LMAO Very clever, Lone Star.

OK, because the prior string has gotten pretty long, I decided to break out with a new one- with a different spin. Describe a case that involved a spinal injury- suspected or not and we can discuss. Here we go- Recently I had a relatively minor crash- although it was at highway speed. A 21 year old man was clipped in his left rear and spun out, striking a guardrail head on. No different from thousands of similar scenarios I've seen. Damage to the car was minimal to the L rear, the front end damage was moderate. No intrusion, windshield was broken from the airbag deployment and he never lost consciousness. The driver was restrained, airbags were deployed. We encountered the victim sitting behind the wheel alert, with a bit of blood at his mouth- from the airbag deployment and this was the only visible injury. His initial complaint was he could not feel his legs- he had no other complaints. Based on the MOI and the condition of the car, his complaint seemed suspect- I've had hundreds of people with the same complaint and it turned out to be initial hysteria or panic. Looking at this guy and the look on his face- the look of absolute terror. It was clear this guy was legit. We did an initial survey and he indeed had NO feeling from the waist down. Strangely, he also had point tenderness at the base of his skull. Of course an injury at this level would make you suspect deficits higher up than his waist, this could have also been a muscular/tendon injury- but nevertheless, this was his presentation. Obviously we proceeded very carefully, his vitals were rock solid and steady, and we transported him to a Level 1. Later, I learned they could not find any physical damage via Xrays, MRI, or CT or an explanation for his paralysis, but they immediately started him on steroids and transferred him to a spinal cord center. Cord shock, a missed injury- who knows. The hospital could not provide an explanation for his problems. His only PMH was HIV(not AIDS yet) and I have no idea how that condition may figure in this. I will be following up to see what has happened to him. So, I was thinking-of all the cord injuries that we see, how many occurred BEFORE we encountered them, and how many were the result of a missed vertebral injury that is made worse by handling or improper or a lack of immobilization? What say you folks?

There was a local radio show here that had a guy who was a frequent guest and he played the part of Jefferson. Heard it a few times- the guy is very knowledgeable about Jefferson and even takes calls from listeners about Jefferson's opinions on current events, staying in character. The bit started out on radio but the guy actually does public appearances as well. Fascinating stuff.

5 years isn't very long- even in a busy area. Are you just a restless spirit? In the business- teacher. Have a Degree? What about transferring to a slower area if possible? Another provider in a slower area? What about the Allied Professions- Xray tech, MRI tech, ultrasound, Respiratory tech? Out of the business? What are your interests? Pick a hobby or interest and expand on it.

The jails are full of innocent people- just ask them. How about the countless interviews of moms when they cry and complain that their gang bangin child, full of tatoos and an arrest record as long as their arm claim their cherub is not involved in gangs, they are a good boy? Should we believe them at face value? The man has admitted to "sleeping" in the same bed with children, had countless private encounters with kids at his ranch, yet we're supposed to believe he was just some pathetic, innocent "man-child"? Were some of the accusations money grabs- I'm sure. Problem is, a couple hundred grand easily could make them go away if he was truly innocent and only worried about bad PR. Tens of millions of dollars AND a confidentiality agreement means he was buying his freedom. I was born at night, but not last night. I call BULLSH*T. If someone wants to give him the benefit of the doubt- be my guest, but we're talking about children here. I truly hope he was innocent or there are some really screwed up kids in the world because of him.

Add my thoughts, prayers, and best wishes to Dale and his friends and family.

Done it a couple times- before the days of snazzy plastic ET holders and we only used copious amounts of tape to secure the tube. If the patient needed to be moved alot- carried around corners, tight spaces, etc, the collar came in handy. Was never told not to or even discouraged. If it prevented a tube from slipping out, it was worth it.

Not responding to this string specifically, but the idea of an ALS "flying squad" that evaluates patients so that an appropriate response is made_ALS or BLS- sounds good on the surface. Problem is, like all stop gap measures, the bottom line is you still need a transport of some type. It's always the limiting factor. You can have fire based EMS that relies on a private transport or even an EMS unit within the department, but there are never enough ambulances. Where ALS resources are limited, an initial ALS responder is better than nothing.

I agree, but in this venue, I'm thinking people are more apt to want to learn/refresh their knowledge. Ahhh- memories. I honestly never thought I would hear anyone talking about that stuff anymore. I need to break out my old physiology books. Been too long. My pleasure. I was doing this job for years before I learned about the jaw thing. A coworker who went back to school to be a funeral director told me about how rigor starts and progresses. Many times a body may remain under a blanket so the limbs may be still warm and supple, but the head/jaw is exposed. Checking the jaw on a suspected DOA accomplishes 2 things immediately and takes no extra time-it confirms the rigor, and whether or not an airway/ventilations are even possible. Obviously you confirm in the usual manner,pulses, EKG, lividity, pupils, etc.

Well, I think that in a forum such as this, the level of education is generally higher than other forums. In this case, a "technical" description seems perfectly appropriate to me- context.

ANy trauma center worth it's salt needs volume- both critical and not- in order to stay sharp. They also need a certain patient volume in order to receive certain state and federal funds and to keep their trauma status. Does this wide net mean some paitents are brought to Level ones unnecessarily? Yep, but a quick look by the trauma team should be enough to "deescalate" the trauma activation and keep costs down.