jinx1764

I'd read this before I'd run off to North American Spine http://www.complaintsboard.com/complaints/north-american-spine-c384876.html

And don't forget the other issue floating around the States right now which would directly impact this patient. Drug shortages. My service is already ouf of Mag and Dopamine and we're borderline on Valium and Etomidate (have one box of each in storage left, we're up to using expired Etomidate) The hospitals are in the same boat, so the question becomes: even if you take this patient to the closes ER for medication stabiization, will they have enough of the right meds on hand? Can they do (well) and emergency c-section meds don't work (meds aren't always successful) and can they care for a preemie long enough to transfer out? The specility hospital will at least have the knowledge on hand and will likely have first dibs on the necessary meds for those specialty cases. One hopes. Got the word today, in fact, that some meds might take up to 3 years before the shortage is eased because of some drug companies (like Lilly) having gone of out biz.

I agree with flightmedic. As long as ET is considered the definitive airway, I will always attempt it first and foremost. We have protocols for our ALS fire depts to use king airways in cardiac arrests as their first line airway, but only during cardiac arrest. Meanwhile, our MICU units (just another fancy name for ALS dual paramedic units in Texas) carry kings but consdier them secondary if ET is unable to be obtained. The main problem I've been seeing (and other veterans too) is the tendancy for new medics to skip harder to master skills like ET and IV (compared to IO drills) especially EJ's in favor of these 'easier' skills. Then these medics go years without masatering the essentials and when they're leads and the shit hits the fan they and their newbie have a very small tool box. I've been in this biz 19+years and I don't allow any medic I FTO to skip an EJ or an ET attempt, ever. Even if it ends up FPO, they're still getting that attempt under they're belt before I allow them to try secondary adjuncts. All the fancy tools and such in the world will never take the place of a seasoned medic with an ET tube or an IV cath. with a critical pt. They're all tools and they have they're place and they all need to be mastered.

I'd say it's a definite crossroads. IMO the mother takes priority. Not because the baby is worth less, but because in this limited scenario, she's the one I can do the most for and the better she fares, the more likely her baby will fare better as well. No guarantees but you've got to make a choice because making no choice is always wrong. You have to understand too, just because you're giving high risk meds, you don't have to max the doses. Give the minimums to get the job done; you can always give a bit more if needed within your dosage range. No need to max her and the baby out just because you can. Less is more and if you can give her less and still manage her condition, thereby managing the baby's condition. Maybe everybody might end up having a good day. You've just got to get them to the womens center in stable condition. You don't have to over think this too much within good decisions of meds vs airway vs sz etc. There's so much going wrong, you've just got to balance her on the razor's edge for enough time until the docs can save the baby then effectively manage her condition without the risk to the fetus. Plus, after the delivery, many of the symptoms will begin to resolve themselves with advanced care.

Based on the above question, I'd say it really comes down to the medic's experience running the call. I would not allow an inexperienced medic to attempt one of their first RSI's on this patient if I were their FTO. No arrogance intended, but I have top notch intubation skills (years of practice) and even I'd been hesitant to intubate this patient unless it were absolutely necessary. However, if you're going to protect the airway, if she's that critical, it's best to go all the way and get it right the first time. Secondary airway adjundants (even with NG tubes) increase aspiration risk when they're removed and they will be once you hit the ER. If diazepam doesn't stop her seizures and her bp keeps raising (whether or not your service can effectively treat it) her neurological functions need to protected, thereby hopefully protecting the fetus. Any medication cross over to the fetus is secondary at this point because they're dying and in the box our options are limited. This is kitchen sink time; you save the mother life/quailty as best as you can and hope to hell saving her saves her baby.

Well that just sucks. She's moved from pre-eclampsic to eclampsic and previous measures have failed. It's time to give diazepam or whatever anti-seizure medication your service uses such as Ativan, (we carry diazepam only) and shit and get. She's going to need advance material care and emergency C-section (assuming the baby can even be saved at this point). While the community hospital is a few minutes closer, I wouldn't place bets on the staff doing a bang up job with this case. Between 22 and 35 mins and the difference in care, I'd say the dash for the womens center is worth it, but you'd better have a helluva driver who knows what they're doing. I'd also get my intubation and RSI medications prepped, depending on if she needs it and depending on which way she goes. Total crap out or if I need to knock her down. Either way her brain functions need to be aggressively protected. FYI- I used to work part-time for a neuropsychologist and once of his jobs was to rehab pts. One lady was a eclampsia survivor - baby didn't survive and her IQ dropped from being a lawyer to a data entry clerk. Seriously, she experienced that much neurological damage from the event.

Is it Dr. Pauza in Tyler, Texas? I know he and two other docs have jointly applied for a patent like the one you're talking about. Though I don't know more about the success of the procedure, etc. I live in the Houston area and try to keep an ear out for things.

Diagnosed with L4/L5 herniated disc in Dec with 8/10 pain radiating to right buttocks and thigh. Today I stay pain free after an initial round of steriods and tramadol to get me moving again. As soon as I was mobile I started advanced core strength training (because I was in great shape already and the low level exerces did nothing for me even at 40+) Within the first day my back felt better and within two weeks my pain was 2/10. But I have to do 2-3 hours of appropriate strength training every week. If I skip workouts or sit too long on hard surfaces I feel it stiffen up and pain sets in. You have to stay on top of staying loose, strong, flexible and ambulatory. Can't be a couch potato or it'll get worse.

I just joined and am coming late to this discussion but I had a similar injury Dec'11 L4/L5 herniated disc due to 19 yrs on the box. Joy. Anyhow the pain in my lower back, radiating to my right buttock and thigh was excuciating for weeks, worsening the longer I sat. Only lying supine helped. First doc tells me it's trochanter bursitus which I knew was wrong, wrong, wrong. MRI showed the herniated discs with mild nerve impingement on the right side which radiated to my right siactic nerve, blah, blah. Today I'm 95% pain free on a dailiy basis and I don't take pain meds and I'm still working full-time. Two things which did are the short run steriods to calm the injury and serious (I really mean serious) core strengthening exercises. I've always had a strong core, have been foil fencing up until my injury and many other core exercies but that won't keep you from injurying your back. What needs to happen is advanced core strengthening. I currently do 2-3 hours of advanced yoga weekly. The strengthening, stretching and relaxing of my back, hips and hamstrings (low back issuese will tighten your hamstrings) ease the nerve impingement and immediately cease all pain for hours to days. Find a good instructor and learn the correct positions to challenge your core, you should feel immediate relief as it realigns and opens your spine. I felt better within the first day. And within the first two weeks my pain went from 8/10 to 2/10.

Awesome, CE is always appreciated! I was talking mainly systolic but MAP is higher (since our system doesn't focus on MAP which is ironic - we're 30-60 from the Houston medical center but overall our standing orders are conservative which has been a long term compliant with us older medics. Our available meds to admin. are limited. No labetol or verapamil. Which is the main reason I suggested the low stress transport. When your tool box is limited, you get very creative on treating your patients to gain a physical benefit/reaction. It's not always about giving meds, sometimes altering the physical environment goes a long way for pre-hospital treatment, especially when diagnoses are in doubt.

What a great idea, both the scenarios and possible CEU's. Would take advantage of both. As for this scenario - possible diagnoses: pre-eclampsia/eclampsia is the obvious starting point, but pregnant women have been known to suffer HTN and CVA without eclampsia. even pre-hospital treatment is the soon except for magnesium. Treatment: I would start with basic supportive care: O2, large bore IV, EKG with Mag for eclampsia and be prepared for treating further HTN. Though protocols differ on when to treat HTN do to collateral circulation. Usually it doesn't start until BP goes over 200 diastolic. Some protocols may also be willing to treat with pain meds for HA which will likely lower BP as a side effect. Transport- immediate transport. Personally I would attempt transport to the woman's hospital at 'fast non emergency depending on traffic condition etc" as long as pt's condition remains stable or improves enroute. I say this because emergency rarely saves much time, is dangerous and with pt's BP and HA, the noise and stress of emerg. traffic will likely worsen pt's condition. However, if pt's condition worsens, upgrading to emergency and/or changing transport to closer facility if distance allows for pt stabilization and tier up transfer.