DwayneEMTP

Thanks guys. It's been a while since I've been involved in a thread where I thought, "Holy shit. I've been doing this, and thinking in this way for a while now...and I may in fact be off in the ditch." I'm sure there have been many threads here where that has been the case but I just didn't recognize them as I have here. What a gift it is to see that my friends an fellow providers will be kind enough and brave enough to intervene and help me be better today than yesterday. I would be curious to see if anyone else has like experiences or if you all stumble across any research covering my perceived phenomenon. You have made me rethink these cases, and that is awesome, but now, I truly have no idea what I would do if faced with the exact same situation again. Though I've been, and continue to be a rabid advocate for pain management I think that I've not been as rabid as possible and it irks the shit out of me to think that others are doing a better and more compassionate job than I am...And that's even better I think. Less comfortable, but more productive. Thanks again for participating. Dwayne

Hey can you post the reference and their justification here? Truly curious, not busting your chops brother. Dwayne

Auscultation is all audio. Following the bouncing needle will put you off into the ditch. I absolutely get where you're coming from though. Intuitively it seems that the bounce of the needle should have some correspondence to the reading of the systolic b/p, and it probably does, just not in any way that is useful to you. Good question. Dwayne

Yeah, again as Chris says, it's anecdotal though. I've seen a lot of patients in pain. Many of them seemed to be able to focus and manage that pain to a considerable level. Not all, but most, including children, have some level of natural mental (guessing) pain management abilities. In these patients it 'appears' to me to be not uncommon that when given low doses of anagesia that it snows them enough to interrupt their natural ability to somewhat manage their pain and their response to pain seems to become magnified when compared to what it was before 'touching' them with some pain meds. For example, and I have no idea if this is valid or not. When Babs was giving birth to Dylan they had the little monitor doodad that measured her contractions. As the contraction would increase, along with her pain, the numbers on the monitor would climb. She had chosen to deliver naturally. After about 10 hrs her contractions were a few mins apart, the monitor would show in the teens between contractions and would climb up to about 120-130 at their peak, at which point she was in terrible pain and would cry out. Finally she asked for "something for the pain." I can't remember what they gave her now. It made her sleepy and she would start to doze between contractions, she had no amnesia afterwards. When she was awakened by the beginning of a contraction she was perfectly lucid and able to carry on a conversation with only a slightly distracted, dazed manner added by the meds. But what really changed was that when the monitor hit about 35-40 she would now cry out in pain and continue to do so throughout the entire contraction instead of just at it's peak as she'd done before. It appeared to me that she was now much less able to cope with the pain than she had been before. When I asked her about it later she told me that it was a huge mistake to ask to be medication because though it did little for the pain it made it impossible for her to concentrate enough to 'deal with it' on her own. Of course it's possible that I misunderstood what I saw 15 years ago, but I do believe that I see this same thing often with patients in significant pain. If I, for whatever reason, chose (often, but of course not always. And this has been my belief for so long that I don't have any recent patients to relate it to) to 'touch' them with Morphine or Fentanyl often they would become more agitated and appear to be in more pain than before I did so. If I'd 'smack' them (Don't try to keep up. I know these terms are way to sophisticated for the average provider) hard enough so that I can be confident that I'll create a significant effect very quickly I not only seem to miss the previously mentioned phase, but the second group 'seems' to take smaller doses than the previous. All anecdotal, and I know that I now look to be the biggest moronic asshole on the City, but that has seemed to have been my experience and it's that experience that shaped my treatment of the patients mentioned above. So there you have it. I have absolutely no idea what I would even begin to search for to try and validate my theories with research, but I would certainly be interested in those data. Dwayne

I think I would like to play with Ketamine a bit. If it's all Magic says it is then it sounds very appropriate for this situation. I still maintain that a tiny dose of Fentanyl is as bad, or maybe worse than nothing when real pain is involved. Sprained ankle, a bit of road rash, minor trauma, that's ok maybe, but for any real pain, stand alone Fentanyl just hasn't shown itself to me to have any real claws. I think most services keep it at the dosages we use more for placebo than for true pain management. It makes the medics feel better regardless of it's effect on patients. Dwayne

Yeah Beiber, I hear you. I knew she has something going on in the pelvic region that was causing her pain and had suspicions that it was also responsible for her hypertension, but didn't know exactly what until after she was diagnosed in the ER. Her legs were together when I arrived, no shortening or rotation. I simply tied them together and tented them over pillows on the cot. I chose not to use spinal precautions simply because any touch or movement of the area seemed to cause great pain and I couldn't fathom laying her on a spine board, even with a quartered blanket on it. Yeah, I know, I'm a bad medic as I couldn't clear her via NEXUS but her writhing on the floor convinced me that there was little likelihood of gross damage...Probably the wrong path, but it was the one I chose. I think you guys are just braver than I am maybe. Her perfusion pressures are already obviously in the toilet, my priority at this point, and bringing them up with fluids is, in my opinion, very dangerous due to her current assessment combined with her medical history. I guess the issue that I'm having is with the term 'titrate' in this situation. It's going to take several minutes minimum to get even a micro trend of her condition and titrating fluids takes time, relatively speaking. The term titrate seems to be being used as if it's a predefined delivered volume, when in fact the fluids need to be delivered slowly, over time, and and reassessments conducted. The reassessments in this case revolve around physiological markers that can be tough to precisely quantify, lung sounds, B/P, pulse quality and mentation levels. I guess my point is that it seems that to risk retarding her pulmonary/cardiac/hemodynamic status further, to any degree, would be irresponsible, yet to verify that you are not retarding those values takes more time than available before hand off at the ER. Unless you might choose to stay on scene to provide these interventions? Thanks for the discussion. You guys are awesome. Dwayne

I agree that sitting patients with pulmonary edema up is normally a good option, but would you sit her up on her damaged pelvis?

On the first patient how minor of a depression would you consider acceptable? Even had her pit bull eaten my B/P cuff, I'm confident from her altered mentation, pulse quality, (What I know it must have been. Not pretending to remember now) that perfusion pressure is already critical, how much more critical is acceptable in order to manage her pain? What will you do to correct the current issues as well as overcome the minor depression? Ok, to both of you, do me this favor. And this is in the spirit of learning not a "So you think so, do you!!" moment. You've convinced me that I 'may' be off in the ditch on this issue. I'm hoping you can convince me that I am... Define the first patients injuries, her presentation and history and then your treatment to include all interventions, drugs, dosages. This will assume, as in reality, a 15 minute transport time to a level 3 trauma center. And for the record, I didn't know exactly what the injury was when I treated her. I followed up on her at the ER and was informed there. Only that she was altered, seemed in terrible pain from an undiagnosed pelvic injury after falling from her bed, and that I was confident by her physiological markers that she was losing, if not into her pelvic cavity as I believed, a bunch of blood somewhere internally. I didn't medicate her pain, and still feel that that was the prudent decision, but I'm miles away from knowing even what I'd like to, much less knowing everything...give 'er hell! Dwayne

Yeah, you could be right, but I've never been a fan of small doses of any type of pain management, and in fact believe that in doses small enough not to mask physiological markers often removes their natural ability to mentally manage the pain and seems to make it worse. I've no experience with Ketamine though. I believe that my experience with dealing with pain is not insignificant, yet find that if I lead a patient with significant pain into analgesia/sedation inch by inch it often seems to kill their faith in it and it takes much more to manage them than those that I started off with a good shove. I'd be curious of the opinions of others, but I believe low doses often to be worse than nothing. Of course because of this I have rarely used it. 25mcgs Fent in an 'average' sized patient? Yeah, more likely to make things worse instead of better in my experience. Dwayne

70 y/o F, normally bedridden, open book pelvic fracture from fall. Initial B/P 78/44, altered, screaming in pain. History of dementia/COPD/CHF, course crackles to lower lobes bilat. 30 y/o F, c/c of "my head is splitting apart! If feels just like the last time I had a stroke!" PERRL, all physiological markers acceptable for situation. The problem was, according to her parents she had had several strokes in the past two years, each leaving a deficit, and in this case her behavior screamed of bullshit to me. But I had nothing but her behavior, speech patterns/diction/facial movement/extremity movement etc to monitor her current status and track it during transport. I chose not to medicate based on the fact that I was unable to establish a reasonable baseline and couldn't risk losing my markers under the narcs. These patients suffered short term but I believe benefited long term. Of course my goal is to always manage both. But forced to choose, I have to choose 'life over limb' and attempt to mitigate long term morbidity even at the expense of short term suffering. Or at least that is my belief. I was in no way questioning the spirit of your comment Brother, as I love the spirit. What I was questioning was the reliability of the 'absolute' statement. I've found nothing in life, and particularly EMS to be absolute. Dwayne

A couple of thoughts.... First is that you can spend some of that time reviewing the history with the parents. Normal birth? Any issues since? Any meds? What happened step by step leading up to this? They gave some of this information to the arriving crew, but it was probably disorganized in their heads and and was focused more on getting the crews to do the 'important' stuff instead of talking. You can find a lot of new and valuable information at this time as well as give the parents something productive to do while they watch the code. Second, parents, even in this situation, can smell bullshit a mile away. You need to be focused on them. Not on whether or not you're going to do or say the wrong things. If you're worried about you they will see that in a second and it will make them really mad...understandably, right? To this day my favorite call was helping an attack victim during my clinicals. I could hear my preceptors and the cops laughing and making fun of me from the doorway for 'being such a pussy.' But man, that is one of the calls that changed me as a medic forever. She was better for it (I like to believe) I certainly was better for it, an neither of us was the worse because a bunch of assholes thought that I should have been able to see that she was just a whore that didn't deserve consideration. Everyone counts or no one does. There are very few people that are good in this situation and most of them have done it a ton or gone to school for years to know how to deal with mentally/emotionally damaged people. Most of us are neither of those, so we have to do the best that we can. Also, I can tell you with nearly 100% accuracy that those that I've been around that brag about being 'really good at it?' They're not. They are bullshitting themselves. And don't have a strong need to fill the silence with mindless chatter. Watch their faces. What are they focused on? Ask if they need it explained. Mom looks faint? Get her a chair. Offer both a drink of water as the catecholemines are going to cause their mouths to be dry early on. Simply never forget that these are not people that you are sharing this experience with, from a professional point of view, they are your patients. Love them, and take care of them, but do so from a reasonable, professional distance. Dwayne

He's more or less saying that the only reason to look through a persons' personal space is to steal from them... Why be indignant Ruffster? If that's the only reason he can see for doing so, that speaks to him, not you, right? I don't know any decent EMS providers at any level that don't do the same, and the better docs and nurses I've been fortunate to work with will assume that I've done so with a certain type of patient and ask for my findings. Just bring in an unclean, under nourished, 'failure to thrive' geriatric with bed sores, have the ER ask what the environment looked like, say, "I didn't really notice...." and see how much respect you get. That's just Crotch poking the bear man...Most every provider I know would consider investigating the environment the standard of care on a subclass of apparently high risk patients. Deep breath Brother... Dwayne

Really?

Heh..Yeah, I hear ya Doc. First, I get your point, though unfortunately there's currently no state of education for paramedics. When you can spend from 4 months to 3 years becoming a medic we can't ever really compare apples to apples. But as Chris and Mike said, I do believe that there is a lot we could do. Most of the education that folks need at home is Basic level stuff. Anyone that's ever childproofed their home has a decent idea of many of the needs of the infirm elderly. And I too, when I have reason to believe that someone is at unusual risk take a look in the bedroom, bathroom, and kitchen for clues to how they are living. Often times it's simply a matter of reminding them that their meds are important that gets them to become compliant again. I've used the phrase, "Do you have anyone that cares about you? Anyone at all that cares if you live or die?" To which the answer is almost always, though not always, "Yeah...my son, daughter, grandkids, etc.." "Then you have no right to treat yourself like this, right? If they were here would you feel ok telling them, 'kids, I'm sorry, but I've chosen to be sick/die because being with you isn't worth the bother of taking a couple of pills every day." The upside is that I've seen significant change in a few patients following this simple intervention (Of course I can't verify that I had anything to do with it, but there appeared to be a connection). The down side is getting a call from a patients doc saying, "Bob said that you told him he would die if he missed a dose of his medicine...What's wrong with you?!?!" "Ummmm....that's not exactly what I said..." Should cops be teaching kids how to stay off of drugs? Probably not. Should priests be conducting marriage counseling? Almost certainly not. Should medics spend their spare time teaching the elderly and infirm how to live safer and healthier lives? God no.... But sometimes making really inefficient use of the resources we've got may be better than doing nothing at all. And most of the medics that I know are not putting their down time to any kind of good use...so maybe this is one of those times? (Assuming an acceptable scope of education and proper oversight of course.) (No, I know that sounds like I'm kidding, but I'm trying to be serious.) (Yeah, on second though, if proper oversight needs be a requirement then it's simply not worth the risk.) (Why did I write that last part in ()s? I'm not exactly sure...) Dwayne

Remote paramedics deal constantly with preventative medicine...As it should be on the streets, right? Don't you council your elderly patients on staying compliant with their meds, eliminating throw rugs in the house, making sure their phone is within reach of their bed? If you don't, you should. I rarely have a black patient when I work remote that I don't take a B/P, (often finding undiagnosed hypertension), council them on the risks of vascular/heart disease/diabetes in the black population, etc. Council the kids on their drinking and smoking habits...quiz the muscleheads on their supplement use. Now that I think of it, the same stuff I did on the streets as well. Good article, and I absolutely see a need for it. But I also see the best medics I know teaching these things, call to call, every day. Thanks for posting. Dwayne

Chris posted this a while back, and I can't even tell you what an amazing resource it is for me, as well as my whole family. Do yourself a favor and read the back story...It's pretty incredible. Want to quite pissing away your down time? Visit this site... http://www.khanacademy.org/ Dwayne

Admin, I tried to 'like' medicgirl05's post above and got the following error. Hope it helps... An error occurred There was a problem storing your reputation vote. Dwayne

Though this article is hospital based and refers to nurses instead of pre hospital EMS, I see no reason why it doesn't still apply to the latter group as well. I think that such thinking is long overdue...thoughts? http://ht.ly/6xpnb Dwayne

Hey Kyle...Welcome to the City. I'm guessing that you're not being purposely ignored here, but that we just don't have any providers with good information for that area... It's a fair question and I didn't want to let you think that there was something wrong with it because of the lack of responses. Dwayne

I'm not aware of the research, but I can't see why pain management in multisystem trauma would be significantly different than in any other setting other than the increased difficulty of determining exactly where the patient is at hemodynamically/physiologically. I've medicated many multisystem traumas and the only one I really remember being criticized for is head on collision with a telephone pole. Bilat femur fractures, significant bruising from the seatbelt with abd distention, though for all intents an purposes the patient was perfectly lucid and in amazing pain. The doc didn't bag on me, but a couple of nurses did because "You just don't medicate abdominal pain!" If they need pain management and I don't believe that I'll lose important physiological markers under the medication, or compromise their hemo/pulmonary dynamics beyond my ability to manage, then they get it. If they're altered beyond what I believe is their ability to suffer, or I believe that I can't track or manage their condition properly if I medicate them, then they have to wait until one of those things change. See...same as everyone else, right? Now, of course, on the flip side the majority of medics I know can come up with an amazing matrix of excuses that are 'common sense' for not medicating simply because they are afraid of managing medicated patients. I friggin' hate them. Good question man...I look forward to the responses.

Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Holy crap...Sorry all. When I posted I got a blank page with an error. I kept hitting it to see if it would go through, but evidently it went through every time. Certainly wasn't such a funny/intelligent post that it needed to be posted once, much less a gazillion times... Sheesh... Dwayne

Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne Just for the record... I still think you're mentally retarded....Just sayin'... But if given the opportunity to medicate you, I wouldn't even consider it. Watching you travel the path from where you were, to where you are? Amazing. B. F. Skinner once took a beating, (one of hundreds) when a popular study came out that studied the levels of some cerebral chemical or another in those incarcerated for violent crimes. (taken from memory so I don't know the chemical or the level of crime). They 'proved' that an increase in this chemical would cause a person to be more likely to commit these types of crimes. Skinner posed the challenge, "Show me how you know that the chemical cause the behavior instead of the behavior causing the production of the chemical." (paraphrasing, as explained above.) I see this the same way. We can medicate these children for behavior that we find unacceptable based on neural chemistry that we believe to be responsible, but did the brain cause the behavior or did the environment cause the creation of the pathology? I don't know of anyone qualified to answer this question to date. Unfortunately human nature is most motivated to simply choose an answer most likely to support our personal needs/beliefs...so it remains a mystery I believe... Dwayne

Jan, 2006. I came here to try and be part of something. I was getting ready to register for a 6 month medic school...And then the City changed everything... It makes me a little bit nauseous when I think of the direction I would have taken had I not had the advice of all of you here. Thanks for everything... Dwayne

Last point, just to be clear, and then I'll leave you be in this thread, I promise. I didn't make my point very well before. At no point did I believe that you were, or would, attack these folks. I was speaking of those that do, and are. Not only violently, but in trying to take away their legally purchased property. I'm grateful you stayed to participate. Being wrong occupies nearly as much time for me as my full time job. I'm always grateful for a contrary opinion as it allows/forces me to more thoroughly think through the opinions that I hold now. And If I'm proved wrong...what a gift. Someone has then allowed me to move forward tomorrow more intelligent than I was today..not that that takes any great doing... I have nothing but respect for each of your opinions, the way you chose to present them, and the honesty in explaining that you weren't mentally/emotionally invested enough in the topic to want to continue to participate, instead of just disappearing. Each of those things, in my opinion, represent the best of what we do here at the City. Dwayne

Fair enough Brother... For me it's an important topic not only because of my feelings developed while living in Afg, but more so because I see people attacking my friends and neighbors. It's not so much political as social. I won't allow people to attack my gay, lesbian, black, Chinese, fat, mentally challenged neighbors, and so it goes with our religious neighbors as well. It's been a good conversation and I'm completely on board with the failed cost/benefit analysis. Thanks for participating...I'll see you in the medical threads.. Dwayne