DwayneEMTP

Maybe this will help??What is the likely diagnosis? Hint: Consider the history of fever; weakness; and tender, painful nodules on each thumb.Secondary syphilisInfectious endocarditisHistoplasmosisSystemic lupus erythematosus

What is the location of the body? The position that you found him in? Before touching him, what is you initial impression of the person and the scene? Going slow so that many can participate... Dwayne

Welcome man! What is someone with a BS doing working as an EMT? Not criticizing, I'm happy to have you and your knowledge! Just curious... :-) Dwayne

Done. But without qualifying respondents I don't see how it can really be a significant part of any study so much as a possible catalyst for developing the study mentioned. See? Dwayne

I get your point, certainly, but you still kind of freak me out when you go into these types of explanations... Just sayin.. :-) Dwayne

Yeah, screw you.... I think they're coming back. We seem to go through waves of crazy stuff, but ultimately the folks like you, or Wendy, or Herbie get folks refocused and back on the right track.... But we do need folks creating more interesting thread topics I think. I've been racking my brain for the last few weeks and still can't come up with much that gets the blood flowing. But if we all focus, all will once again be right with the world. Dwayne Edit. I have noticed that we have some newer BLS and medic student members that have cast iron balls/ovaries and jump in no matter the bullshit comments! They have come to learn and they will not be denied...Man, I love that a lot. These folks to me, are at least as important as our members that are able to teach...God bless em.

Man, Lone Star just killed your thread brother, as that is nearly a perfect post in my experience. There is no way to describe here what the job means and entails to everyone, but if you choose this path you will instantly recognize each and every point that he made. I'm going to highlight a few simply so that I can feel superior and believe if I've added something pertinent to the conversation... I never get tired of pts.in general. There are moments, but they are incredibly rare. My coworkers sometimes make fun of me, mostly in a good way, because I tell them that my theory is to 'love all of my patients. If I love them then I talk to them right and all of the other decisions become easy.' And I believe this, that I share my life with each and every pt that I encounter. (Understand that I have never worked a high volume system with the exception of being overseas, so others may feel differently, and justifiably so) I forget most of them almost immediately when I leave the ER, or in my current gig send them off to the hospital or clinic. But for the few minutes/hours/days that I am with them I try and open myself up and truly see them... I love that. Some here will tell you that that is just a bunch of wanker bullshit. And they will also be right..for them. But sometimes we all get tired of the bullshit we work around. I recently came into contact with a medic that was telling me that the only use he had for Hydrogen Peroxide in his ambulance was convincing the drug addicts that it is an HIV/AIDS test. You bring it into contact with blood, and if it foams, that that is a positive test. I completely destroyed him in front of God and everyone. I forced him to try and explain in front of about 15 people how convincing someone that has almost nothing to live for that they now have absolutely nothing to live for was proper care? I asked him to define the role of a paramedic in healthcare, to define the word compassion. It's wasn't pretty, but I'll bet he's more careful about talking idiotic macho TV crap around people he doesn't know in the future. He doesn't like me much now, and that's ok, because I don't like him at all. Unfortunately he will tell that story to many, many of his coworkers that will think that it's hilarious and will use it on their trucks. Of course the flip side is that you will also run with many providers that will almost take your breath away with their kindness and competence. And for me, that keeps me working, and thinking and studying every day, so that I can try and throw my hat into their ring. But the truth is, if you truly want to be a rockstar provider you will always be in the minority. You will always make others at least a little bit uncomfortable. But fuck em...This isn't a popularity contest. Akflightmedic, chbare, billygoatpete, Mobey, hell...there are probably 30 more here that I could name if I took the time..Being in a profession that allows me the priveledge of having folks like that to council and guide me? Priceless. Yeah, I'm not sure where you're at, but these wages sound well above the national average. I do pretty well now, by my standards, but I work a min of 14/12s in a row in some pretty cool, but weird places. Yeah, this is the down side of having a career that is dominated mostly by kids. They are willing to go crazy, burning themselves out working a gazillion shifts a week. It's not healthy, but it pays the bills they would say. I'm thinking that if you have a family, a house, a boat, a motorcycle and a jetski, that you need to redefine your priorities and what it actually means to pay the bills. Another great point. Plus, if you have a hard time keeping your dick in your pants there is plenty of opportunity to cheat on your spouse or sleep with someone else's. Judging from the quality of your first post though, you don't strike me as someone that has trouble with logic and focus. As far as stories...yeah, mostly they are best left at work unless you have something that hurt your heart, and then of course you should share that with your mate. My wife could not possibly care less about EMS. She's proud of me for being a medic but has no interested in the blood and gore stories, etc. Once, early on I had 6 patients in one day and three of them died. After the last pt was delivered dead to the ER (two were end stage pathologies that died during transit and one arrest.) I swore I was going to duck calls for the rest of the day. As I was walking back to my ambulance, another pulled in so I reached out and opened the doors for them and they had a pt in arrest. My partner was waiting at the truck and saw me riding in on the cot doing compression and almost died laughing at the coincidence of me getting stuck on another dead person. I was laughing my ass off telling this story to my wife who said, "Honey, that story is very funny, I'm sure it is, but please don't tell that to any of our friends or family." Heh.. It's a crazy world... I wish if firemen really needed to get whacker hero tattoos that they would replace the 911 nonsense, (unless of course you were actually there) with some of the words in bold. Ok, not the IFT part, but you know what I mean. Lone Star has pretty much created an EMS primer for you as it relates to your questions. I've got almost nothing to do in the clinic at my current job, which is why I feel the need to chime in and give long winded answers where there often weren't really any questions. But you know what? One of the things I love about being a paramedic? Is that those here get that I'm bored out of my mind, they will allow me my drivel, even support me if I need it, until enough is enough, and then one will be kind enough to say, "Ok man, it's way past time to stop being an asshole. you've had your time, now suck it up princess and go do something productive!" Heh...I love my job.... Dwayne

You will think about getting nervous on your first ALS calls, just remember though, you have given up your right to freak out. Nerves and good decision making rarely go hand in hand. I taught myself early on that when I felt my nerves start to kick in to make that a marker to slow down, and then slow down some more. You were called because at this time, at this place, you are the highest level of care available. You were called to help. You get paid to be calm and do things that make other people afraid, right? I was afraid every time I pushed a new drug for the first time. I wanted to do as I see many medics do, come up with an excuse not to do it. "The hospital is right around the corner, there's better lights/more people/different options/yadda yadda there!" You've studied, sweated, worried, neglected your friends and family for this education...when the time comes choose to use it instead of run away from it. And when you feel the nerves? Slow down. As far as practicals, I give everyone that's asked the same advice, though I don't believe any have listened. The thing that will kill you during practicals is fear. You'll get your brain all bunched up with anxiety, rush, and do foolish things. There truly is a simple solution to this. Assume going in that you are going to do every single thing wrong. Assume that you will fail so badly that having to retake the entire test is already a given. Assuming that, what could there possibly be to be afraid of? The mistake people make in my opinion when taking tests is that they worry that they might not do well. Then, each time you run into something that you're not sure of, it reinforces your idea that you will fail, ultimately leading you down a path to a self fulfilled prophecy. Instead, assume from the beginning, and you have to really focus on this until you believe it, that you won't possibly know the answer to anything. Then what happens is, immediately you see that the test is not that difficult and you know something, and....wait....you know something else! Holy shit, this is easy! So instead of positively reinforcing your idea/fear that you will fail, you are constantly proving to yourself that you know more than you thought. See? One leads to fear, the other to calmness. When I took my first practical I had a friggin' awesome day! It was one of the calmest days I'd had in medic school. Others were literally vomiting before going into certain stations. I could give a shit...I'd already failed, all I had to do now was play the game and go home.. I flew through, didn't miss a station, and went home while some others retested late into the evening, yet I never broke a sweat. Fear and anxiety are your enemies when you need to focus. At every turn find a way to defeat them and you will truly stand out in intense situations. Good luck..you're going to suck! (Do fine) Dwayne

That's always a good thing... Have you seen these without a significant cardiac/pulmonary issue? Intuitively it seems that the force necessary to create this type of injury would be pretty severe, to the point that soft tissues would not likely escape unscathed. Though we know how well intuition and medicine go together sometimes... And it seems that your pain management and weaned tidal volume (making up terms now) would be dependent on the stabilization of the chest segment, wouldn't it? Again, intuitively it seems that this would be a terribly painful injury with significant co-morbidities so stabilization would be necessary to facilitate pain management. It also seems intuitive that a person injured this severely would need all of the tidal volume with the least effort possible, again mandating immediate/early stabilization. But I don't know... As above Great points! But I don't think we got terribly tunnel visioned here, I think in most cases it was an over estimation of ventilatory/respiratory compromise as well as possibly an over estimation of likely co-morbidities that sent most to intubation. I would have been happy to answer your silly little question but I just saw a study on the internet that says that physics is a myth...Just thought you should know before you waste any more time dinking around with it... :-) Dwayne Sometimes I hate this fucking editor...Edited to reformat.

I just checked my watch as I was winding it...where do I find the multiple vibrating alarm function?? Dwayne

Actually Wendy, you'd be a better one to run this little shindig. I don't have the education to taunt you with s/s, but you might be able to lead some other folks on an interesting journey. Whatcha think? Dwayne Actually, I think your logic is really strong, but would it be likely that he would have been bitten in nearly the same location bilat? Dwayne

Man Mobey, I'm really sorry to hear that. I can't think of anything more worrisome or frustrating than having to send your baby out into the world with a challenge when you can't be there to watch over them.... If none of the options on Wendy's link works out shoot me a note and I will put Babs on it. From finding freakish things for Dylan she can find just about anything... (For those not familiar with my family, my son Dylan is autistic, so when I say freakish it's only in the sense of things you might look for for a normally developing child...just sayin'. Didn't want imaginations to wander... :-) ) Good luck brother. If you need help beating up any bratty eight year olds, give me a call, I've got a few weeks off coming up... Dwayne

I hear you girl...but not to worry, certainly within the next decade BC will have cell phones and you'll understand them better. It can't be long after that that you'll get cable TV, and then, well, the world is your oyster... :-) Dwayne

Laboratory analysis reveals a hemoglobin level of 12.2 g/dL (122 g/L), hematocrit of 37.0% (0.37), a white blood cell count of 6.7 × 103/μL (6.7 × 109/L), a platelet count of 150 × 103/μL (150 × 109/L), a creatinine level of 1.15 mg/dL (101.66 μmol/L), a blood urea nitrogen (BUN) level of 13 mg/dL (4.64 mmol/L), and an erythrocyte sedimentation rate of 47 mm/hr. Electrocardiography reveals a normal sinus rhythm, with no ST- or T-wave abnormalities. The patient is given a normal saline bolus, ibuprofen, and morphine sulfate in the ED. The nodules on the patient's hands are pictured here (

Actually, this is a great post. I'm glad you gave a hint as to the multisystem issues involved. Dwayne

Man, great question! But I don't have the answer. As well, they don't present race, which at first I thought might be relevant, but as I don't see it I'm guessing it's not. I've not read the answer to this scenario by the way. But I'm going to take a stab based on experience...Above the knee amputation, hypertension, regular weed, alcohol, cigarette use, left one hospital AMA and went to another mid treatment (Guessing no narcs for pain at first hospital)....I'm going with homeless or home bound. Dwayne Edit. Also I only posted one picture, but both hands have near identical issues.

This scenario delivered to my email from Medscape.com. If you aren't familiar with them, I think you should be. Pretty interesting stuff on their site, plus they have a really good smart phone med app, as well as sending these cool scenarios to my email. Note to new users and those with unusually small penises. The purpose of the scenarios is to walk through anatomy and physiology from the information that you already have in your head. This is not a test, it is a learning exercise. Googling your the answers prior to answering not only cheats you out of developing vital context links to this information in your head for use on scene, where Goggle can most times be scarce, but makes you look like a coward and cheater when you post your carefully edited, though dishonest response. Also, people can spot a Googled answer a mile away. I'm not saying that you shouldn't use Google to help in your investigation if you MUST, but don't post your findings unless you can explain them in your own words and justify them. Just saying. (Edit: for the record, I couldn't have diagnosed this in a million years. I just thought that the s/s were such that with the help of those here we would take a long and enjoyable walk through the body trying to tie them together.) To those of you that choose to answer, please don't just list the name of a disorder in your post. Give those of us that might not be as smart as you the benefit of the logic tree that you followed to come to your diagnosis. Know what I mean? Thanks a bunch... http://cme.medscape...._0&uac=150988SZ "A 48-year-old man presents to the emergency department (ED) with a 10-day history of intermittent subjective fever and pain in his hands. He has also noticed 2 swollen and painful areas on his thumbs. Concurrently with the fever, he reports weakness, malaise, watery diarrhea, weight loss, anorexia, and intermittent vomiting. He denies having any cough, dyspnea, headache, chest pain, abdominal pain, hematemesis, or hematochezia. His medical history includes hypertension, deep venous thrombosis without a known coagulation disorder, nephrolithiasis, peptic ulcer disease, and a methicillin-resistant Staphylococcus aureus cellulitis. His surgical history includes a right leg above-the-knee amputation resulting from a gangrenous infection acquired during a natural disaster years ago. The leg healed well and without complications. He has no medical or seasonal allergies. The patient takes lisinopril, 20 mg daily; amlodipine, 5 mg daily; carvedilol, 25 mg daily; and ibuprofen as needed for pain. He is not currently taking any blood-thinning agents. The patient admits to occasional tobacco, cannabis, and alcohol use but denies injection drug use. He reports no remarkable family history. The patient had recently been admitted to another hospital, but he left before completing treatment and does not know his diagnosis." On physical examination, his oral temperature is 97.8°F (36.6°C), pulse is regular and with a rate of 74 bpm, blood pressure is 151/90 mm Hg, and respiratory rate is 16 breaths/min. The patient is in mild distress due to pain from his hands. His sclerae are anicteric. The lungs are clear to auscultation, and the heart sounds are normal and without murmur, rub, or gallop. His abdomen is soft, nontender, and nondistended, with normal active bowel sounds and no hepatosplenomegaly. Examination of the hands reveals 2 discrete, tender nodules over the palmar aspect of the thumbs at the metacarpal-phalangeal joints bilaterally. The nail beds of both hands are pale, but his radial pulses are normal bilaterally. His right leg has a well-healed knee amputation site, with no signs of erythema or induration.

Yeah, what UE said pretty much sums it up. Assuming that you aren't going to take a college level A&P course you might want to focus on respiratory and circulatory anatomy, that will narrow it down a bit. Welcome to the City! As you go through class, make sure to participate in the forums instead of simply reading, OK? It will make all the difference. Dwayne Edited to change 'should' to 'might want to', no other changes made.

Yeah, alright, point taken. I tend to like the racial discussions as as a kid I didn't grow up around much racial diversity. Whites, mexicans, indians, that was pretty much it. But you're right. Trying to have that discussion with Crotchity would be an exercise in futility. As often is the case, thanks for saving me from myslef... :-) Dwayne

Thanks for that link! Though I was afraid it was going to show the opposite. Intuitively I've always felt that pts rested more comfortably, and squirmed less on a scoop than on a traditional long board and that seems to be of significant benefit in these pts. It seems like, though I could be wrong, that someone posted a study here a few years back that showed that the traditional LBB not only could, but does cause addl/increased injury to those with certain types of spinal compromise by forcing the injured area up against a hard surface, limiting circulation to the effected area as well as causing pts to struggle to remove contact with that area from the hard surface for comfort. It was that that actually caused me to become a bigger Scoop fan than I had in the past. If I have to us a LBB now, I never use it if I can help it without folding a blanket in quarters and placing it on the board first. Protocol? Not sure exactly, but I've never been called on the carpet for it and it seems to make a big difference as to how my patients accept and cooperate with the board. Dwayne Edited to reformat only.

Hey Rinnie, Welcome! You just finished your state testing for what? Psychology? You should stick with that, you can get paid... Being shy as a paramedic isn't a strength, that's for sure, but I've know medics that aren't exactly type A, in your face folks but I consider to be really good medics! And a few medics I've known that couldn't stand to have a round table call review debate become Godzilla on scene..most won't know until they try I think. The bigger issue is the "being afraid to mess up" thing..Because you will, at least I believe most of us have. And when you do it can suck. But hopefully by the time you make medic you will come to understand that everyone screws up sometimes and most often someone suffers for it, accountant, judge,  cop, hooker, everyone. People tend to work from the point of view that "if a paramedic screws up, somebody dies!" yet that is very rarely the case. When I was a little bit younger medic I once bagged a pt into the ER, he had all of the s/s of hypoglycemia but I'd checked and his BGL was fine, followed up and it was still fine...I watched him degrade until I had to assist with vents, finally convincing myself that he was having a stroke. The doc ordered an amp of glucose and he woke up wondering what all of the fuss was about. :-) Asshat moment? Oh yeah, but it taught me to never again trust my machines over my instincts and nothing like that has ever happened again. Have I ever made the dreaded 'life ending' mistake? I'm not sure, but I believe that I have. I don't believe that I've ever killed anyone that would have ultimately lived, but I believe that I've made mistakes in judgement that caused people to die sooner than they might have. And I have mixed feelings about that. The people involved need quick, aggressive treatment, which I delivered in the best, most responsible manner that I was able to at that time. But I don't know everything, though I try and know as much as I can, and I can't see everything, though I try and gather every piece of information that I can before deciding on a course of treatment, but in a few cases I believe that I tried my best, yet failed. It's going to happen to most, if not all providers I believe. At least those with the balls to try and make a difference. At 23 you're looking at your career choices from the point of view of self fulfillment, and I think that that's ok, 'specially seeing as how you were smart enough to get your education out of the way early. Most medics I know wish that they had made different career choices, mainly wishing they had chose something that allowed them to be better paid. So this may be something to consider... Good questions. I'm glad to see you here, and to see you posting! Dwayne Edited as the City editor put the text in one big block....again. No contextual changes made.

I thought the CPAP/splinting from within was intriguing, though it might never have occurred to me...I don't really know the answer, but as the pt isn't really going to live or die on my intuitive medicine today, I'm going to take a shot. I'm no CPAP expert as I'm not really an expert on anything I guess, but I'm going to go with no on CPAP in the short term on this guy. It would depend on a lot of factor, BP/ECG/Pulse quality, etc. Intuitively it seems that the splint from within is a decent idea, but the splinting comes with the significant side effect of increased ITP (IntraThoracic Pressurebrev.Completely unsure if that is even a real abrev.) that could significantly complicate the other injuries and/or their side effects that are at least halfway likely with this guy. Pneumo/Pneumo-Hemothorax, increase ITP certainly isn't going to do this guy any favors if they are present, and it's difficult to believe that they won't be present in some form. Ditto pericardial tamponade (When blood begins to leak into the sack around the heart). On the flip side, if I don't see the electrical changes expected for tamponade, nor s/s of Hemo/Pneumo, and my b/p seems to be holding it's own, then it seems like it might be a good intervention? I'm not sure. The little angel on my shoulder says that this makes since, the little devil on the other is laughing his ass off knowing that I just stepped on my weenie.. Man, it's been a long time since I've posted here and though, "Holy shit..I hope I don't look like a complete idiot.." I like it! I look forward to further conversation. Dwayne