AnthonyM83

So left side positioning it wouldn't help them days out, but would it help them in the short-term if they did throw up and aspirate large amounts? Not talking infection-wise, rather physical fluid covering alveoli bronchioles impeding air flow and gas exchange. Is this LEFT lateral thing as common in other places as it is in California? Perhaps, because there's so many different unique cases where left would be good (pregnancy, facing toward bench seat in most ambulances, cardiac output problems) that they just started saying left lateral for everyone instead of explaining specifics? Or is there an actual reason why this term came about? I really want to know. If there's no good reason, I'm going to start contesting it everytime I hear it...

An uneducated question, I suppose, but how does the score change your actions? Every action I can think of, is something that would be done/prepared anyway, with a "non-difficult" airway.

That's reason 5. Most recent one I've heard, but couldn't recall it earlier. Right lung has 3 lobes and is larger, so in case of respiratory distress or regurgitation, it would make sense to keep the "most useful" lung on top with least amount of pressure on it. If patient aspirates, at least it'll be "less useful" lung. That one actually kind of makes sense, actually...

You hear it a lot to put altered patient "left lateral" or in "recovery position" but on their left side (even if NOT pregnant). Is there scientific reason for the LEFT side, specifically? I was originally told it was to prevent aspiration, but no one can really explain why the LEFT side. I've heard: - Stomach curves to the left, so vomit would have an extra curve to overcome - Stomach curves to left, so contents won't be pushing against sphincter. - In the ambulance, attendant can watch him better facing toward him. - It helps pre-load by not having thoracic pressure on inferior vena cava The first two don't quite sound legitimate enough. The third isn't great, because it only applies once patient is on gurney. Fourth does make sense, but it has nothing to do with aspiration and it assumes that all patients are in some kind of blood pressure / preload distress. It would make sense as a position for a post-arrest patient who is now breathing or shock patients, perhaps. But why is it this big rule I seem to hear all over? Why must it be to the left side?

How do you know he didn't have a 12-lead? How do you know it would have shown something? How do you know that if it was done and it did show something non-specific that the death could have been prevented for sure? You're making it seem like if it had been a top notch doctor, he would have lived for sure. How the heck do you keep someone salvageable if they go into asystole? His body either has the ability to survive if all medical interventions are done perfectly or it doesn't (and no matter what is done, he would have died)? Seriously, do you understand medicine? Medicine is crude science, not magic... Nature doesn't go "oh, they did all their procedures right, so I'll go ahead and let this guy survive". In the end nature wins, regardless of what we do, even at 50 and "not obese" (as if that were the determining fact - eye roll - )

Get it down to 10 seconds from last ventilation pre-intubation to the first ventilation post-intubation without assistance. (Basically, whatever time you posted, I probably still would have told you to better it.) If you're getting too nervous about the stakes, pretend you're just doing another practice scenario in class (even though you're doing the real thing with a live patient). Detach....

The Miami one actually looks like it might end up as a decent show. The San Francisco one seems like it's trying to show off paramedics. You're going to run out things to show off pretty quickly, whereas the Miami is more of an ER setting and you can get into a lot of topics and interpersonal relations and dramas. Both shows have consultations with competent EMS/trauma personnel, but reality often gets thrown out because the non-real way looks better. Gotta find a right balance...which I think the Miami show has a bit more of.

Make best friends with the nurses at the ER. Have them teach you everything they know about IVs. Watch them closely, have them watch you. See how they try to salvage yours when you can't get a flash. Ask them what you think went wrong with each one. Start an IV on every single patient that comes into the ER. Don't be tentative. Not pushing the cuff past cords makes me think you're tentative, since you should know to push it past, hold it hard, don't let a single mm of it come out, and inflate the cuff all the way. Other than talking through it with the ER doctors and instructors and reviewing your intubation chapters, I might recommend practicing on the dummies several dozen times (50-100). Get extremely confident with the dummies. Know that if you can't visualize cuff going completely past cords, then don't even try it. Confidence with the dummies will (to an extent) translate to confidence with a real patient. I also used to miss IV's because I was tentative when advancing the catheter, either because I thought I was being too rough or because the patient winced in pain when I started advancing. Now, I don't hesitate and I find there's less resistance to advancing and usually no wincing.

You'd expect a better outcome? So, the fact that he had a personal doctor and he was (possibly) present over overrules biology and nature? Nature should yield simply because you feel having a doctor in his presence should mean he lives? Yes, the doctor MAY have been incompetent, but there's no way to arrive at that conclusion based on the statements you've made. So if he had daily 12-leads, they would have caught everything and he would have lived? You know this?

You can have MI with CVA and you CVA can also show signs in 12-leads. MI's may also appear when one thought the patient was having a CVA, but really just an MI. I'm sure others might have more stats and details, but yes, I would do 12-leads on CVA's if I had the same protocol (duh...) But even if I didn't, I would still do it if I had the time. They're pretty fast to do..

Not sure what that has to do with anything? The influence has been done. The culture has already been affected. Lack of anything new doesn't change the past or how people grew up listening to his music.

Who said anything about a free pass? We're talking about the hype after death. Honestly, I don't even watch TV, but I'm already tired of seeing him on the tube when the TV's on at the dinner table at work. I've gone off on the pedophile aspect a number of times. BUT that doesn't change the fact that he as a single person has been EXTREMELY influential to modern day society. He IS part of our culture and there was a sudden loss of it, so it makes sense people will be shocked and pay attention to how their lives were influenced by that culture and his music. Doesn't mean I wouldn't find him as guilty as the next, though. Edit: Grammar

Could have. Maybe could have asked to be put on one of the RA's assigned to the event if I really really wanted to be around that. But instead, I slept

Got another save last night, though she didn't regain consciousness like in our previous examples. I believe it was respiratory related and the intubation/oxygenation is what really brought pulses back. Was doing a lot better when we left ER.... I never get to find out ultimate outcome, though (discharge and such).

Had a similar rapid return of pulse and consciousness with extreme confusion and some violence after defibrillation (from Torsades). Had projectile vomiting, possibly from the bagging. After finally calming him down, did a 12-lead, which revealed an AMI. Found out he had been doing coke.

Well if it's not a drug interaction (including home medications, eg anticonvulsants) and it's not caused by his injuries, then it has to do with drug itself (OD, wrong drug, faulty drug) or something metabolic (distribution, elimination, etc) Several disorders/conditions can put one at risk for prolonged effect. How are his electrolytes? pH levels? Signs of conditions like neuromuscular disorders, hepatic or renal failure, porphyria? Something that would decrease plasma cholinesterase activity. Try to get medical history from family. Don't try to counteract with neostigmine, though!

What was his monitor / 12-lead? Fentanyl with the head injury? Edit: This is the only one I haven't seen given with head injury, rather only told it can be given, despite head injury being listed as a contraindication in many sources.

Hmmm. You're describing a paralytic, but I have max duration of sux listed at 10 minutes. (Fentanyl at 2 hours, etomidate at 5 min, propofol at 10 min) Is this a drug interaction with something else he was taking....or do I just have incomplete/incorrect info on the drugs I gave him?

"Do you have a copy of my run patient care report? I'll look it over with you, just so I can be exact and give you doses." But really, I'd ask him why he thinks it was something we gave. He got O2, D50, Fentanyl/Succ/Etomidate/Propofol (since scenario said we went ahead with RSI). Don't think any of those medications should be causing unresponsiveness 24 hours later. There may be concerns about use with head trauma with some of them, but they were either necessary or literature supports shows acceptable outcomes despite concerns. Any kidney injuries that could affect drug excretion? Maybe get an MRI? Not all head trauma patients recover?

Classic signs of posterior dislocation. Prop some pillows under the leg to maintain position. Otherwise not going to intervene on it.

If he's bleeding internally, there's likely a lack of perfusion to the area (which is why I wanted to get perfusion and whatever neuro status I could on all extremities). As it relates to RSI, not much, except maybe only getting partial paralysis due to poor extremity perfusion. As far as the lower area itself, I think I get ya. Signs of hip dislocation. I'm going to let that be, as there's not much I can do. If it were a pelvic fracture, I would consider binding it with sheets, but seems like a hip dislocation...

I'm considering RSI, but I won't do it until I have more information if I'm getting good compliance and sats continue to improve with BLS airway. Want things like pupils, full GCS, signs of herniation, trends in VS. If I do decide he needs RSI, I'm okay with using sux despite the ICP consideration, as it's short-acting and the patient outcome studies on using sux with head injuries have been variable. I'll use Fentanyl to premedicate and Etomidate to sedate. Maybe some propofol after if I have it. I'm also considering internal bleeding from the pelvic/hip injury. Confirm the rotation is of the entire leg, not just the foot (aka not an ankle fx). And I might just be foggy on this or the terminology, but what do you mean by flexion with adduction? Aren't they synonyms in this case? You flex the hip, so it's going to adduct (flex)?

Assessments: Can I have condition of pupils? Any signs of seizure activity (per witnesses or oral trauma)? What is his GCS score? Neurovascular status of each extremity (pulses and withdrawal x4) ? Breathing was irregular. Did it fit any common respiratory pattern, such as Cheyne-Stokes? Interventions: I want to keep this patient warm with blankets. We should be en-route to the trauma center. Considerations: Herniation. Though still possible, pulse is not pointing it at this time. Other underlying medical conditions. RSI, though will hold off until I get more information. Nasal intubation, though I want to see what his trend is. So far trend seems to be improvement after interventions, but still critical. Will wait to hear more.

When it comes down to it, I haven't reviewed the entirety to court evidence and procedures. That doesn't preclude me from having an opinion on the matter (I'm not handing him a verdict or sentence). But many times in my jobs, I've found that if it walks and talks like a duck, it is. Maybe it's me becoming cynical, but in a previous job I can't count the number of times people were accused of crimes, but they had very good explanations, were supported by friends/family, and I'd say almost every single time they were guilty. Yes, it's possible for him to be completely innocent, but realistically the combination of previous allegations, the ranch, calling things Jesus Juice, weirdness (not the best term, but there is association with SUCH eccentricness and other deviant behavior), not learning from previous accusations, points to improper stuff going on. In the end, I wasn't judging in court, but can't preclude me from my opinion.

We had a nurse order it over the phone once. Also had a friend do it under physician's direction in the ER upon her recommending it (pads weren't on yet). Converted the guy.