Doczilla

You need therapy. 'zilla

You wouldn't include it in the traditional G#P#A#, but if using G#P####, you do. I don't know why. It doesn't seem to be all that relevant for birth hx unless the baby died of neonatal sepsis or congenital anomaly. 'zilla

Any problems with previous pregnancies? (Hypertension, prematurity, seizures...) Any heart problems after your last pregnancy? (I have now seen 3 cases of peripartum cardiomyopathy, and it scares the crap out of me) Did you have to have antibiotics with any of your previous deliveries, or were you told that you need antibiotics near this delivery? (Indicates colonization with group B strep, a risk factor for neonatal sepsis). If there was a previous c-section, was it transverse or vertical? Vertical incisions are much more likely to lead to uterine rupture with subsequent deliveries, and usually dictate that all deliveries after that will be by c-section. Most c-sections are a low transverse incision, which may be okay with a trial of vaginal birth. Vertical incisions are done for emergent c-sections when mother or baby is really in trouble. Is the pain constant or intermittent? Uterine tetany is seen with abruption or infection. Any recent illnesses, fevers, chills, etc.? This may indicate chorioamnioitis, a serious infection of the amniotic fluid. When was the last time you felt the baby move? Any urinary symptoms? UTI in pregnant women frequently leads to pyelonephritis. Even bacteria in the urine without symptoms will lead to treatment. The typical Gravida/Para/Aborta question is broken down further by OB/Gyns. They'll still understand you just fine, but you'll sound like you know what you're talking about if you use their system. Instead of G5P3A1, it's broken down like this: G (# of pregnancies, including the current one) P (# of term deliveries) (# of preterm deliveries) (# of abortions/miscarriages) (# of living children) Therefore, a woman who is pregnant for the 5th time, delivered 1 full term infant, 2 preterm infants (before 36 weeks), had one miscarriage, and has 2 living children after one died in a car accident, would be noted like this: G5P1212 And Scara, you're a sick dude. 'zilla

I thought this 60 Min bit on sleep was particularly applicable to emergency work, and fairly enlightening. At least, I think it's enlightening, since I just got off an overnight and was up for 24 straight. 60 Minutes: The Science of Sleep 'zilla

10-8, no pt found. Call us back if you find him. Police can chase him down if they like, but I see no reason to tie up the ambulance. 'zilla

BVESBC- You have f#$ked up a perfectly good thread with your drivel. And you have demonstrated a complete lack of situational awareness by taking this tack with the veteran providers represented in this thread. Go away. 'zilla

EMS research is something that is fairly difficult to do because of the nature of the environment. That said, there are several docs in the EMS Section of the American College of Emergency Physicians (ACEP) as well as the National Association of EMS Physicians (NAEMSP) that would love to talk to you more about it. ACEP has grants each year for exactly this sort of thing at the state as well as national level, and they can help explain their requirements to you for these. State governments also have grants for this sort of research. Contact ACEP and NAEMSP, and they can point you in the right direction. 'zilla

Ruling out an acute MI with a normal 12 lead is a terrible idea. Only 30%-50% of acute MI's show acute EKG changes. I'm not sure what "assessments" your friend used, but unless they included serial cardiac enzymes over several hours and a stress test/echo, he was incorrect. 'zilla

No protocol can cover every conceivable situation that a paramedic will encounter. Some amount of independent thought is required. As a medical director, I leave this type of decision up to the medics. They have standing orders for vascular access to employ as they see fit. I have to depend on their good judgment. 'zilla

WTF, over?

Unless they need a bolus, I say lock. As Fallout suggested, there is the potential for a problem if a line is started, and the patient gets a bolus when they didn't need one. And there's less to get tangled up when you move the patient. You can always connect a line to the lock if you decide they need a bolus. I really don't believe in maintenance fluid in the emergency setting unless the patient is boarding in the ED for a long time before going upstairs. 'zilla

I agree with many of the posters here. It is correct to refuse, but impolite and sometimes offensive to refuse it repeatedly when the giver insists. You could alleviate some of the moral ambiguity of this by taking the tip, adding it to whatever charity fund or community donation fund your company has (or this hospital's, if your company doesn't have one), and recording it properly as a donation in that patient's name. Then the patient feels good for giving it to you, you've remained polite and appropriately grateful to them, and you are not lining your own pockets but improving the service that your EMS provides, which is what they wanted to acknowledge in the first place. 'zilla

The short answer is, no, I don't think that everyone should be playing with the same deck of cards, for the following reasons: 1) Differential levels of medical director involvement. Some medical directors are cut out for close EMS oversight, others not. In addition, close oversight can be damn near a full time job. If the MD has several squads, this can be prohibitive. 2) Different levels of quality assurance between services. Some do this really well, some not. 3) Different levels of experience between services. Some run the complex critical patient call all the time, others get it only rarely. Some medics get the chance to intubate weekly, others only once a year. 4) Different cultures among the services. Some embrace aggressive protocols and the training that it takes to sustain them, others see it as an impingement on their time and unnecessary when they can just "take someone to the hospital". I don't think it makes one whit of difference to know if another service has permission to do something prior to your arrival. It doesn't mean that it got done, and doesn't mean that it was done right, and doesn't mean that it worked, so you've still got to bring all of your equipment. 'zilla

It's called persevorating, and it is not limited to trauma. Altered mental status from any cause can lead to this. I don't know if there is any relationship between severity of the brain insult and length of the loop. 'zilla

ALF is an assisted living facility. If the trach is not fresh (i.e., <1 week old) the you absolutely should pull the tube and replace it with a new one if the patient does not respond to aggressive suctioning. This patient is not in the immediate post-op period, and therefore changing the trach tube does not pose the same hazards as doing it in the ICU the day after the surgery was done. The important thing here is that any trach patient in distress should be immediately removed from vent (if on one), suctioned aggressively, and bagged. If they don't turn right around, replace the tube. If you don't know how to work a trach tube, then you can use an appropriately sized ET tube through the tracheostomy hole. This patient has a pulse ox of 70%, tachycardia and tachypnea. He is critically ill at this point. The more you fiddle-fart around doing things like IVs that won't really help, the worse the patient will get. Replacement of a tracheostomy tube is well within the scope of practice for a paramedic. If you are a BLS provider, then ask the nurse to do it. It is part of their routine training for care of these patients and well within their scope of practice to perform, even without a direct physician order. If you replace the tube, and he still doesn't turn around, then you can explore everything else. Several good ideas along this line such as sepsis, pulmonary embolism, and dysrhythmia have already been mentioned. 'zilla

Stop screwing around with the history. Suction aggressively, with a squirt of saline into the trach if needed, and if he doesn't get instantly better, replace the trach with a new tube now. This is your first and only priority right now. Get the full history afterwards or broaden your differential diagnosis after you have done this. 'zilla

There was a review of this topic on EM:RAP a couple of years ago which was excellent. Medical equipment carried varies by airline. Some are very comprehensive, while others meet the minimum standards. The airlines tend to guard this information for security or other reasons. As several physicians pointed out, they may or may not be asked to show credentials (another reason the state medical board issues wallet-size cards, and I always carry mine), again varying by airline policy. In the absence of credentials you can give them your identifying information and the state licensing agency. The pilot has control of all decisions regarding aircraft control, whether or not they land or divert the aircraft for the medical emergency. The best thing that you can do (other than snatch the passenger from the hungry jaws of death) is advise them whether or not to divert or land early. The ground-based medical control doc has control over what medical care is provided in the air, and they can and will tell the flight attendants to tell you to piss off if you're obviously clueless. These are usually aerospace medicine or emergency medicine trained physicians who are contracted by the airlines for this service. They will also provide advice to the pilot on whether or not to land or divert. No matter who you are, they will be talking to this physician, so deal with it and talk to them over the radio. Likely your assessment will be better than the one provided by the flight attendant or non-medically trained passenger and will be helpful to the medical control physician. You do not necessarily need an active license to perform interventions under direction of this physician. Diverting an aircraft or landing early presents significant challenges. Airplanes are always full; if they don't have a full complement of passengers, they make up for it in cargo. The landing gear are generally not designed to land with a full plane and a full fuel tank. If you divert, you have to burn off that fuel or dump it. The first takes time, the second, well, sucks for the environment. It therefore would behoove you to make this decision wisely. Keep in mind that once the pilot gets clearance to land, burns off the fuel, makes approach, etc, you may not be saving much time with most domestic flights. You can't really pronounce a patient in the air, because the coroner that has jurisdiction is the one for the county you are flying over at that point. There is nothing to say you can't discontinue futile resuscitation efforts (or not initiate resusc on someone who is obviously dead), but the patient will not be declared dead until landing. In this case, it would be advisable not to divert the plane, since doing so would not help anyone. On the oxygen issue, there is a specific FAA guideline on permitting transport of medical oxygen cylinders. You can't SHIP them by air, but they may be carried for emergency or routine passenger use. 'zilla

Scara, if that's what you consider fun, you need to get out more. And it would be far more fun if you did it at the FBI or something. Reasons that we've s#it canned applicants for medic positions as well as residency positions: - Obvious adrenaline junkie - Had no real idea of what the job was about - Had no enthusiasm for the job - Failed to engage during the interview (i.e., a dud in a conversation). - Could not verbalize why they wanted to do this job in anything but the most broad and generic terms (I like to help people....I like the variety of emergency medicine....). - Lied or exaggerated on their resume or in the interview. - Failed to learn anything from failures (one question I like to ask is "Tell me about something you failed at". If they start going on about why this or that was someone else's fault, bye bye.) - Failed to provide a realistic view of their own limitations. - Lied or downplayed shortcomings in their background when asked about them. Everyone has something, whether it was a failed course or poor exam showing or getting fired from a job, that they would rather we not know about. We expect candid answers with an honest assessment of how it could have been approached differently in the future. - Could not say anything about why they wanted to come to THIS program/agency over others. Those are the ones that made it to the interview. Those that didn't were canned for most of what others have listed here, i.e., criminal record, adverse actions on their license, etc. Serial job hopping is also a red flag. If you haven't spent more than 3 months in any one job, prepare to explain it. 'zilla

No, I don't see any real problems with this, apart from the fact that your agency is getting fewer calls and less experience. The NPS, like other federal agencies that operate on federal land, do not need to seek local/state certification for their EMTs. Our military medics that operate ambulances on military bases follow similar rules. The same thing for federal law enforcement officers, with a few exceptions. I don't see a problem with them billing for it, either. Any EMS service, whether fire based, government 3rd service, or private, has the right to bill for the medical services it provides. The Center for Medicare and Medicaid services has a universal fee schedule for ambulance services for just this reason. I don't know why an ambulance run by the federal government should be any different. Because of this set fee schedule, reimbursement from emergency runs will almost never equal expenditures for proper staffing and short response times. There is nothing that says the government can't run its own ambulance service, even if there is another service nearby, particularly when it operates on federal land. Local governments can do this, state governments can do this, so its logical that the federal government can too. Local governments have started taking back their territory from private ambulance companies because of response times and other issues, and the private services have essentially no recourse. Local governments have handed over EMS from private agencies as well as government run 3rd services to the fire department, and that's again their prerogative. 'zilla

Just to clarify, we're talking about 2 different things here: nitRIC oxide, which is an endogenous chemical that causes localized vasodilation, and nitROUS oxide, which we commonly know as laughing gas and may use for prehospital pain control. Wanted to make sure we're all staying on the same page. 'zilla

With one of my teams, yes, with the other one, no. j.r.

"It's gonorrhea."

In a single dose, no. 'zilla

Tylenol dose in children is 10-15 mg/kg body weight q4h. For the average 10 year old, that runs about 400-600 mg. A single toxic dose would be on the order of 140 mg/kg, or 5600 mg. 'zilla

Review of systems is a brief run-down of pertinent positives and negatives that may or may not be germane to the chief complaint. I usually put this at the end of the "Subjective" portion of the SOAP note. You can go by area of body or body systems. For example, by body area: Constitutional: No fever, chills, or malaise. HEENT: No HA, rhinorrhea, ear pain, sore throat, neck pain or stiffness, or visual disturbance. Chest: No CP, SOB, palpitations Abd: No Abd pain, n/v/d/constipation, hematochezia or melena. GU: No vaginal bleeding or d/c. LNMP 1/22/08. No dysuria, frequency, or urgency. Extrem: No edema, focal weakness, cyanosis, or rash. By body system: Constitutional: No fever, chills, or myalgias. No recent illness. HEENT: no rhinorrhea, ear pain, sore throat, neck pain or stiffness, Cardio: No CP, palpitations, edema, or syncope Pulm: No cough, wheezing, or dyspnea. No recent increases in oxygen use. GI: No n/v/d/c, hematochezia, or melena. GU: No dysuria, frequency, or urgency. No testicular pain or penile discharge. Neuro: No HA, focal neuro deficits, weakness, or visual disturbance. Endocrine: No heat/cold intolerance, weight gain or loss, or hair loss. Skin: No rash or skin lesions. This is a bit more detailed than your typical EMS run sheet, but you get the idea. It can be modified, and certain areas expanded or contracted as relates to the chief complaint. 'zilla