DwayneEMTP

Man, I have entonox here again! I'm a very happy camper! I've had nothing but really good luck (relatively speaking) with morphine, but because of that I've no comparable experience with Fentanyl. When I first started using it Fentanyl just seemed to be such a lightweight in the pain management ring that I didn't play with it much. I know many worry about the hemodynamic effects, but I've not encountered them to any degree that has cause me much concern. And I've pushed it quite a bit. The exception, as stated above, would be if I was concerned about compromising his hemodynamic status, even by a little bit, then certainly Fentanyl would be the better option. I've never worked with Ketamine. But the patient description so far, his vitals, nor the injury as described give me any concern really that he's compensating, so morphine would still be my choice for the reasons mentioned previously. CYA statement: As this wasn't answered before...Does this guy have anything on board that could be controlling his rate and pressure chemically? Because if so, then I'm going to have to step back and reconsider... Dwayne

First off, good on you. I think few realize that it takes balls to post scenarios, to try and come up with something that you're confident that you can recall, or create every conceivable sign or symptom. I've been at the City for a few weeks now and I still get nervous every time I do so. What angle did the post go in at? How did he end up on it? Trip while playing grab ass? Get thrown from a horse? Fall while standing on his truck driving it in? In most scenarios that I'd imagine it most likely went in at a shallow angle, sounds like it pierced his Lat which is a pretty big muscle that bled for a bit but then spasm'd around the post making the external bleeding self limiting. And his vitals seem to support this assuming his rate and pressure are not chemically controlled. My treatment will depend in a very large part on the angle of entry. Though with his vitals and exam (as above) I'm confident that this will not be a terribly significant wound from an EMS point of view, unless we change it during transport and make it so. I'm surprised, (genuinely, not in a 'what a bunch of idiots' way) that so many would choose Fentanyl for this guy. Particularly, depending somewhat on size, at 100mcgs. It's possible that he's shocky in the area of injury and in very little pain. But if he's screaming I'd expect Fentanyl to be about as effective as spitting on the wound, at those doses, with this injury. But, experiences differ, as seen in other threads. I would choose morphine not only because in my experience it would kick him much harder, but it would also last longer, and will likely, again in my experience, be what they continue him on at the ER. Interesting scenario. I look forward to your updates! Dwayne

Can't help much on this one, I think I was, like, 6 or so in 1990. I'll have to leave this one to you oldsters...

As chbare said...

Kiwi, I'd jump all over that BBQ brother. It'd probably do you good to see how real men drink. I had a sitdown with some Aussies that were bragging yet had them flopping on the ground like fish trying to find their center of gravity before I'd even gotten a proper buzzz. And they claim that the Kiwi's are even more delicate still? Pitiful. System, thanks for the above. That's awesome. I think that many forget, or don't realize that the relative effectiveness of narcan alone, and/or over time can't be completely understood in a vacuum, but must be compared to what it's antagonizing as well. Allow it to compete with Heroine and it looks pretty good, Methodone, and not so much when the single dose 24 hr picture is considered. Great post.. Dwayne

I have a feeling Kiwi that you think that med control is called here regularly. Actually, I don't think that, as we've talked about it a gazillion times, I think you're really just being an asshole...which is why we love you best. I don't disagree with calling medical control here, though I think that I've only contacted medical control 3-4 times in my short career. Not because you need their advice on what to do, though they may bring a perspective that you've not considered, but so as to be able to document on your PCR that 'you've done everything possible' to convince them to make a better decision. Wake up an overdose and allow them to refuse without having them talk to the police, your partner, their mom, the hosemonkeys, the neighbor, and yeah, possibly med con, and it could be an issue. The main point here is that you have to do all that you can to disallow anyone in the future that may be reviewing/judging your decisions from being able to make the statement, "So, you gave them some narcan and then just walked away?" when referring to your now dead, relapsed patient that competently refused care. Dwayne

We have a member here that sells such things, and has been known to take care of members here... Try this... AnnieMedic10@gmail.com And she's a peach to boot.... Dwayne

My favorite redneck joke, "You might be a redneck if your dad walks you to school because you're both in the same grade."

This is where, in my opinion, you begin to go off into the ditch. First, and foremost, we're patient advocates, right? Why would you want to make even more rules, that will be abused even more than the ones that we have, that would remove more of a patients rights? We sometimes get caught up in, "But I knew how to help them! I could have made them better!" Making them better is your second priority, the first is making sure that you give them the respect that they deserve for being a human being. I have the right to make self destructive decisions. I have a right to ride motorcycles, jump our of airplanes, drink too much, and yeah, choose a medical course of action that might cause me damage or death. (The exception being my claim that I've put myself there with the intention of purposely hurting or killing myself. For some reason choosing pain and dismemberment on purpose is illegal, doing something that has a high probability of causing the same results, fine.) If they are awake, and made aware of the dangers, and they had every reason to believe that they were mentating effectively enough to understand those dangers, then there were no legal tools available for forcing them. And there were absolutely no moral tools there, not if your morality is based on patient advocacy. Having said that, I want them at the hospital, right? I want them monitored so that they will be safe. I personally, as with hypoglycemics, don't believe that they are going to be competent after a few minutes of alertness to make such decisions. So I just don't wake them up. I have a moral and ethical obligation to rescue them from danger, but not one, that I am aware of, to wake them to the point of being able to make self destructive decisions. So I choose to put them in a place where they will have a few hours to make those decisions. Instead of ending up in this situation, life would have been better for all concerned if they'd just pushed 0.2 of narcan times, however much was necessary, until the patients breathing was adequate and their airway protected and then taken them to the hospital asleep, right? Even here though, I've taken them without their permission. Saddled them with thousands of dollars in hospital bills. The difference for me is patient advocacy. If I believe that they will wake up and run into traffic, then I'm obligated not to wake them up. If I believe that they will wake up and make alert, though ill conceived decisions, then, in my opinion I'm not obligated to wake them up. But should I wake them up, and put them into a situation where they have moral/ethical/legal rights regarding their own care, then I am forced to comply with those decisions. See? Clear as mud, right? The highlight of this story for me is that an EMT was fighting management and higher levels of care for a patients right not to be mugged by those that often feel that they don't have to follow the rules because they don't apply when 'you're helping.' Tell that dude that I want to ride with him for a while...for what that's worth.. Excellent thread man.... Dwayne +3 Edit: I often hear people say that 'they did a refusal because they were lazy.' Has anyone ever worked at a place where a refusal was easier than a transport? Any place that I've worked needed a PCR to explain what you were refusing as well as the refusal documentation. In nearly ever instance I could have transported and been done with my PCR in a shorter period of time. Is this the experience of others? (The exception being multiple car fender benders where one service only required a name, address, "I've been asked but refused a full exam" kind of statement and a signature.)

Just a heads up that this thread is pretty old...It's still good information though. Dwayne

Ahhhh....there's the petty, deflecting, Siffalis that we've come to know, if not love. I knew you were in there girl!!! I might believe more of that crap if we didn't know many people in common.... And I notice that you continue to fail to answer the questions about school? How's that going again? Perhaps we can explore that before you get all excited about how jealous I am of your life, your scope of practice, your opportunities over mine? Again, some of us have actually done and completed things, you need to really questions the reasons that you believe people to be jealous of you as the only reason to criticize you....You've not really done so much Babe....Perhaps there's other reasons that people might bring shit to your attention other than wishing they were you? Yeah, I didn't think that you'd be able to see any other options... But whatever....good luck. Dwayne

As I mentioned before about testing responsiveness being more often about punishing people, as well, the majority of the time that I've seen the arm drop test has been more in the spirit of "Look everyone! See how clever I am?" instead of a search for data. But perhaps my experiences or my perceptions of them are different than others... Dwayne

But he didn't receive a thank you note from the son, the airlines did, to the 'passengers and crew', it was the reporter that named him specifically, not the note. And he shouldn't have been there to be interviewed. He should have been to hell and gone from baggage claim.... Of course it doesn't matter, but it's fun to dissect.

You'll want to be a little careful here. Though Kiwi is relatively well spoken for an Underworlder, his jump bag does still contain rattles, blood letting equipment, and protocols for 'vagina blowing' to help resolve fertility issues. Should you encourage him too much, or two often, your next thread will likely be titled, "Brain bleach. Can it really remove complete bullshit that I've seen and heard?" Just a heads up is all.....for perspective. Dwayne

In response to chbare... I think that in the truly physically damaged patient that sorting the fakers from the non's isn't really very important. A couple of exceptions of course being a CVA or head injury. And perhaps my perspective is queered as I've spent very little time with the option of relatively short transport times..But I see two reasons.. The first is that fakers, in my unscientific opinion, are often emotionally damaged. There is much good that we can do for these folks by speaking with them as opposed to spending the entire transport with them listening to us speak about them, or being ignored. I think that fakers are often silently screaming because they've run out of other options to solve their problems. If we do nothing else but make sure that they feel 'seen' and explain what will happen next at the hospital and mention their options for receiving additional help, then I think that we've made a difference. And secondly, there are issues that may be discovered with reported symptoms that are relevant that won't be immediately noticeable by survivable breathing and pulse quality/rate. A well patient now is not necessarily a well patient later. Of course, I'm aware that I'm preaching to the choir, and don't mean to imply that these things would escape your assessment, but only trying to be clear for those that may be reading this thread but not have the history with you to understand the direction that you're attempting to teach, that it's not your feeling that LOC is irrelevant. (Of course, arrogantly assuming that I understand what's going on in the big, fat brain of yours.) Of course, if I'm wrong, and that is your feeling, then above are the reasons that I disagree with you. :-) Dwayne

+5. That gets my vote for post of the year so far... What a perfect picture it draws of the dangers when a providers ambition is combined with mental/experiential frailty...Not that most of us would know anything about that... Of course the opposite is just as often, or perhaps even more so true in my experience. Providers paralyzed from the 'what if I can't' toxins coursing through their veins. Not just in intubations, but in pushing any new med, starting IVs, using CPAP....What a challenge it can be to plan the multifront assault of attacking with confidence while defending your flanks against ill preparation. Excellent thread! Dwayne

(Psssst. When she says, 'imaging', that's code for 'strip club.') We wish you all the best Toni, in your new 'imaging' endeavors! (Truly am excited to hear how it goes...The ()? That's me whispering...see? Clever, right?) Dwayne

Hey Brother, I deleted your other thread for posting to more than one forum. No offense intended, it was placed properly in both places, but only allowed in one or the other. This is an excellent topic...Thanks for posting. I think that most career prehospital professionals would, and have, supported standardization in EMS. The problem that arises is with the vollies and fire services. A huge percentage of vollies want radios and tshirts, but have no desire to truly learn how to provide real prehospital care. The fire services want the EMS budget, but have no desire to do anything really, that isn't likely to get them on the news. (Speaking in VERY broad strokes to address the national issue. Not meaning to imply that there isn't a minority that is excellent in each category.) The standard of care would have to be raised if it was to be national, to something realistic, but any time the attempt has been made the vollies claim poverty and abuse of their generous hearts and the fire services claim that we're we're incarcerating their heroes in class rooms instead of allowing them to be on the street saving a gazillion babies from a gazillion burning buildings every day, where they belong. If you want to drop the national standard lower, so that even more bozos will get in than do now, then perhaps... So, the answer to your question, in my opinion, is until you solve those two issues that there is no chance of a realistically professional EMS standard being implemented nationally. Welcome to the City! Dwayne

Yeah, it also mentions that the flight crew plus a nurse were 'gathered around.'

Asking around to the Docs, that is about the only thing that they seem to agree on, that it is a decent vasodilator. I guess it was taken IV prior to workouts by body builders for many years. I think for the most part it's a, "We know what it is, and it seems to do that but we really don't understand it yet' kind of substance. It's my sincerest hope to never have any useful anecdotal evidence to offer on the herpes issues...

As if there's a snowballs chance in hell of your ever being sensitive to anything....

DFIB, I got that from three places... First, he's the only one that even mentioned that he was involved. The airline completely ignored his heroic contribution. Secondly, they thank their crews for doing their jobs really well. No mention of heroes. I would appear that the airlines expect their people to be able to do simple first aid/patient care without news photos or having their names on some holy wall or plaque. Third, the sentence, "Everyone on the plane was, like, "he's a hero!" . Do you think that 'everyone' was? And if that was the case, don't you think that they could have gotten a quote from someone besides him? And even if people on the plane were saying that, according to his own replaying of events, he did nothing really but hold her hair when she puked, and her hand after. There is only one reason that I can see to repeat it...because he wanted the words linked to his name in the paper. You could be right Brother, but I'm still calling douchebag...It's just too huge of a coincidence that a fireman and the word hero would be in the same sentence...Though of course no surprise that he's the only one that recognized his heroism. And, this just occurring to me, why was he even still there instead of through baggage claim and on his way to...the hero convention or wherever the hell he was going? This was for the airlines to comment on, not the bystanders. Dwayne

Speaking of which, I have to go to cultural awareness training!! Can you believe that?? I was addressing the fact that most of the patients here, Papuans/Morobians/Islanders, are relatively hypertensive. I said, "I have a feeling that the cause of this is going to turn out to be relative dehydration, but we should try and identify it as hypertension is a more significant risk factor in the black population." My supervisor said, "Ohhhh....we don't use 'black' here, we say 'locals'." I said, "But I wasn't referring to the local population, but the the global population of blacks that share this trait. What term should I use when race specific issues need to be addressed?" He said, "I don't know, but just don't say black." and then friggin' scheduled me for cultural sensitivity training.... I don't know who is more sensitive than I am.. I go barefoot and talk about 'energy' and crap like that...that should speak for itself I think....

I'd never heard of it for migraine, but I used it on myself when I used to get them, but only because 12.5mg would completely snow me. Babs would pull my IV, and I'd wake up in the morning feeling fine. I've also, and this may get me a bashing, used it a lot for pain in patients. In Afg where we only had morphine I'd push 12.5mg prior and very often people wouldn't need narcs. I'm sure that's bad, as I don't think that I've ever had a protocol indicating it for pain, but it seemed to work really well, seemed to give them a decent buzz without losing them beneath it if careful, (For the students: You won't get into 'decent buzz' or 'losing them under it' until way, way advanced learning.) and I don't recall any adverse reactions. Though of course I'm not discounting chbare's reports of distonic reactions, it's just not been my experience. I guess I'm wondering, if we asked the people that created the U.S. protocols that say Phen = N/V, Ben = Allergy, how would they defend that decision over the reverse? And the same question to the upside down people... Why need we carry both? It seems that Phenergan (fin- Errrrrrrrrrrr-gin) for the Aussies, doesn't have the pregnancy warnings of Benadryl, and would realistically do both jobs, wouldn't it? I'm guessing that the question is rhetorical, as the whole world seems to carry them both, I'm just not sure when I would use one that the other would be contraindicated, absolute or relatively? Dwayne

No offense to anyone that can understand what he's actually saying....I didn't think to take that into account...