Arizonaffcep

True, and I will say the guidelines are focused on an MD level for in hospital treatment, not prehospital. What was in the references and a key point is that 80% of Gi bleeds stop spontaneously. With that in mind, 100-200ml's of blood is needed to create melena. But, if it bled more than that, it can stop, and melena can still be excreted until it has cleared the system. Taken a step further, the presence of melena DOES NOT ALWAYS MEAN CURRENT BLEED. That's the point I was getting at. Keep in mind that melena TAKES TIME to create, as it must be DIGESTED...if it was an uncontrolled large hemorrhage, then it would present as lots of frank blood from the rectum or hematemisis (WITHOUT coffee ground emesis).

At that point, why would you? He's not in shock....In THIS scenario, permissive hypotension is not called for. So, here's another question for you...as you stated (please see the underlined sentence above), if you don't have an IV warmer, it sounds like you wouldn't treat sock with fluid replacement, which is called for (except in the instance of applicable permissive hypotension). As a courtesy, can you site the "Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothermia, coagulopathy, SIRS, MOF, etc..." reference? Point me in a direction where I can verify that statement for PREHOSPITAL treatment? And if you could also qualify it, are you talking PREHOSPTIAL or IN HOSPITAL? Big difference. It's an issue IN HOSPITAL. Reason I ask...the FD I used to work for was about 30-40 minutes from the area level 1 trauma center, "flying-low." I can tell you...I've only been able to get in about 3 almost 4 liters (pressurized) on trauma patients who were hypovolemic and shocky during transport. 3-4 liters is NOTHING fluid wise for a severe trauma. But, it's all we have to work with. Now...once the patient is turned over to the ED, it becomes a VERY different story. Then, you can get the luxury of lab work, blood, "hot-admix" if need be. I am taking this stance from a PREHOSPITAL point of view. With this in mind, you have a limited time with the patient before transferring to the ED, and limited resources.

Sure it is, if you have narcolepssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss

And what if this GI bleed was not a surgical bleed? What then? Withhold fluids? We all agree that he needs a transfusion...one unit of blood will have more effect on his B/P than NS or LR! So what then, no blood either? He needs fluid. Preferably blood. But we don't carry blood, so that rules that out. Next best thing... So, in the tradition of the City, here's a study on fluid resuscitation. Please, keep in mind I am not trying to disprove permissive hypotension, just show that this is NOT a case for it. http://cat.inist.fr/?aModele=afficheN&cpsidt=13745104 To quote from it, "Conclusion: Fluid resuscitation with either large-volume LR solution or small-volume HSD, during uncontrolled hemorrhage from intra-abdominal vascular injury, produced hemodynamic and metabolic benefits, without additional blood loss, whereas no fluid resuscitation was associated with sustained low cardiac output and hypotension." Here's another: http://pdm.medicine.wisc.edu/Volume14/riddez.htm "Conclusion: Short-term crystalloid fluid therapy in uncontrolled aortic hemorrhage transiently improved the hemodynamic status and the oxygen consumption following the initial bleeding. Furthermore, the infusion did not cause re-bleeding of more than 100 ml, which occurred in previously conducted experiments when the infusion was continued for more than 20 minutes." Here's from the Merk Manual: http://www.merck.com/mmpe/sec02/ch010/ch010a.html This also goes on to say that 80% of GI bleeds stop spontaneously. "Fluid resuscitation: IV fluids are initiated as for any patient with hypovolemia or hemorrhagic shock (see Shock and Fluid Resuscitation: Intravenous Fluid Resuscitation): healthy adults are given normal saline IV in 500- to 1000-mL aliquots until signs of hypovolemia remit—up to a maximum of 2 L (for children, 20 mL/kg, that may be repeated once). Patients requiring further resuscitation should receive transfusion with packed RBCs. Transfusions continue until intravascular volume is restored and then are given as needed to replace ongoing blood loss. Transfusions in older patients or those with coronary artery disease may be stopped when Hct is stable at 30 unless the patient is symptomatic. Younger patients or those with chronic bleeding are usually not transfused unless Hct is < 23 or they have symptoms such as dyspnea or coronary ischemia." Heres the guidelines from the American Journal of Gastroenterology: http://www.acg.gi.org/physicians/guideline...inginAdults.pdf

I'll step out on a limb here and assume that they didn't JUST unionise, since the last contract was signed. That being said, if there was a question as to who was the union, look at the last contract, no?

Here's the thing though...even if the tarry stool started 30 seconds ago, its been sitting in his gut for a while digesting. Hence the dark tarry stool vs. frank blood. Even with hematoemesis, coffee ground emesis is indicative of a chronic GI bleed as well...other wise the blood would be undigested and unchanged. This means it's a small, steady bleed.

I would guess that this pt is probably on HTN meds, and probably beta blockers at that. He's a truck driver (not ment to be profiling) but how many truck drivers do you know that eat well, get good exercise and don't have HTN?

It would seem to me though, that the bleed in question, while maybe not BAD itself, it has just been going a while, as is evidenced by the dark tarry stools, vs frank blood (and the low hemoglobin). It just seems to me that this has been going on for maybe at least a day or two. Besides, we know the Pt died, but HOW did he die? Was he taken to surgery and died as a result of a complication? I just DON'T think permissive hypotension is appropriate here. 'Zilla or ERDoc, you guys wanna weigh in on this? Any opinions/pointers?

Sounds like they could use a new medical director...like the Dr. from Florida... :twisted:

I don't know anything about this. But I do know that both Clark County and LVFD are able to transport pts, and do. AMR seems to be there as a "3rd wheel" so to speak. Not making a judgement call on it either way, just saying that AMR doesn't have exclusive rights to transport there.

True, but it sounded like ALS was transfering care to a BLS only service/truck. Totally inappropriate, IMHO. Femur's are big and strong, lots of force to break them.

I really don't understand how a femur fx can be BLS'd. A closed fx can still loose 1500ml/femur...not a small amount!

Gettin' kinda personal, ain't ya?

Ok, I can see the whole labeling thing, but not EMS wise...you typically have only 1 patient, and draw blood from them. The blood stays with them in the same room. No real chance for mixing it up that way.

Wow...I want what you are smoking!

Happens all the time in Southern AZ. I can tell you in a period of a year and a half my wife worked for an Ambo Company out of Douglas AZ (on the boarder of AZ/Mex), she delivered at least 12 children to women who crossed the border just to have their kids.

That's not true. HIPAA says that, for one if it's YOUR patient, you are etitled to the information. Second, if it's for educational endevors, such as CME, you can share the information as is prudent to the lesson. Whomever told you that about HIPAA is wrong. Now, on the flip side, it might be hospital policy, but get in contact with your prehospital coordinator. He/she might be able to find out what happened.

The guy in question has been "cured" as the articles have put it for over 20 months with a totally undetectable virus level. The marrow transplant get got was due to leukemia, unrelated to the virus. And for the record, there have been at least 2 other cases similar to his in the past 20 years or so.

We carry light blue, light green, gold, lavender and a tiger top. However, these are only good for a couple of hospitals around town, most don't like prehospital to draw labs for them...for whatever reason.

Wow...talk about bad aim.

Both.

It's meant as a secondary airway, if the standard direct laryngoscopy doesn't work.

The hospital I work at uses these a lot. They are VERY nice, but are a RESCUE airway. What this means is...they should not be used front line, in theory. Most of the residents use them anyway as front line. The lense doesn't readily fog when compared to other rescue airways, and I've seen it provides a really good view of everything. It is a fairly rugged design, which is nice. The only thing is, I'm not sure how bleach as a cleaner would work with the blade and wire (wire is NOT detachable from the Ranger blade). I would think over time the rubber coating on the wires would be worn down and degrated by the bleach (used most commonly pre-hospital).

I would say permissive hypotension is not called for here. It is geared more towards acute bleeds that are traumatic in origin, although there are other applications. I would guess that as a truck driver, he's probably on HTN meds, which is why his HR is only high 90's. I'm thinking he's probably pale, cool, and possibly diaphoretic. This type of GI bleed is more chronic than acute...as it's digested, meaning it's been in his guts for a while. I would treat with NS and LR, with at least a litter bolus (or w/o and get in as much as you can without pressure bag by the time you get to the hospital). Remember, with a hemoglobin like that, he's got perfusion issues...1 because there are not the normal amount of RBC's to take the O2 around, and 2 is because of lack of fluid, which we CAN replace. Hope this helps!

Actually, at the FD I worked at, our EMS collection rate was right around 80%.