DwayneEMTP

Mari, not a loser until you spoil the thread. It makes me a little bit crazy that we almost always have someone that Googles the answer and then acts like it's common knowledge for a "good" provider..., "Ahh...Yeah, I've seen this, it's a Ukrainian rhythmic butt slug larva infestation. Let's see...Thinking here...Hmmm...thinking...thinking....If I remember correctly it's only seen in teenage Ukrainian trensvestite strippers exposed over long periods to drums made from the combined hides of baby seals and American Bald Eagles...Treated with PO tears of virgins, womb infused steroids and antibiotics and the drawing of a pumpkin face on each breast. Though, I could be wrong...that's just from memory." I just want to beat the shit out of them... Doc, Chris, would you have picked it up from the history? Or through some other means? Could you have named it? (Again, not a challenge, but as I mention, I'm shocked to find that it seems many people are familiar with this (in this environment), though I've never heard of, or could have imagined it.)

I'm curious, as I'd not heard of it, if others have. Please, please don't Google it before answering. It's not about being the macho diagnostician, but just a curiosity of mine to see if others have heard of it, as I'm told that it's not terribly uncommon. If you recognize it, please just post a "yes", or if not, a "no" and anything else of course, but I'd be grateful if you'd not give it away to others. This isn't really a "who'dun'it" as I think that those that have seen it will recognize it, and those that haven't, won't intuitively find their way there. I know that I could have never thought my way to a diagnosis on this, not in a hundred years. 38 y/0/m presents to you with a swollen right ankle. Swelling is uniform, no discoloration. Atraumatic per assessment and history, slightly febrile to touch locally, patient is afebrile per temporal thermometer generally (tried to get a local temp, but temporal therm wouldn't read his ankle.). No s/s (signs/symptoms) cellulitis, proximal/distal anatomy uneffected. No other relevant s/s. No relevant meds, no known allergies. Pt reports that he had diarrhea for about 4 days that ended three or four days ago, (patients may also present with current or recently resolve STD), that he now feels awesome except for this swollen joint which is painful 8/10. Ankle is not specific to this issue. It's sometimes (Or so I'm told.) in the toes, and knees, and more rarely in the hips. Usually effects one joint only instead of being a bilat issue. It's not gout. It pisses me off that now that I've been exposed/educated on this that I'm confident that I've seen it dozens of times, didn't recognize it, and mistreated it. But...we do the best we can I guess..when we know better, we do better. (hopefully.) So what do you think? Does it ring any bells? If this thread gets any action, I'll try and come back to it in the next 24 hours or so, but I fly tomorrow morning so sometimes go a long time without internet access.

Hey Irish, welcome Brother... Jump in my friend...it's good to wrap your head around some new thoughts and perspectives...

Yeah, man, it was so exciting! Trials going awesome, a new factory built for production, 50 person staff in place for when trials are completed, and Pfffftttt....Dead. Whoever does figure it out, yeah man, they will be sipping margueritas on a beach somewhere...

They didn't dodge any bullets, or pull any kids out of a burning house, but in my mind, this is truly heroic. I can't imagine losing your child and still being strong enough to bring such a chilling image to the public view hoping to do some good... http://www.ems1.com/ems-news/1431222-parents-release-unfinished-text-message-of-son-killed-in-crash/

Katie, you really get an anaphylaxis reaction to latex? Does this come from simply being touched by a providers latex gloves? I'd not heard of such a sever reaction before... And is a, significant in this case though not huge, drop in blood pressure without other factors involved really an anaphylaxis reaction? Certainly not claiming that it's not, but I can easily imagine that drop in B/P with an uncomplicated, simple (?) alergic reaction creating symptoms based on the Vinca's normally low B/P without it being an actual anaphylaxis reaction? Does it matter really? Just curious. It sounds like a person categorizing their issue into the most extreme category that they've heard of instead of it being completely accurate. I would think in this patient, altered/unresponsive with a systolic near 60, no n/v, clear lungs/airway, lack of erythema, that I'm going to try a fluid challenge long before Epi. Certainly anaphylaxis isn't going to be at the top of my list of differentials early on. Sort of like everyone that gets a bad headache now has a migraine. It's not accurate necessarily, but just the most extreme thing that they've heard of so they use that instead.

I'm not sure if this is in the spirit of what you're asking, and if not, then my apologies...not trying to be a dork and derail your thread.. But one thing that makes me a bit crazy trying to explain, even though it seems to me that it should be intuitively obvious to everyone, is using a patients movements, postures, facial expressions, and how they relate to each other as an assessment tool. I used to write it off to laziness, but now thing that maybe my history as an animal trainer made me a little more sensitive to it (see 'Clever Hans'). Even something so simple as a call that I was the second ambulance on scene. First ambulance had mom in the rig, minor trauma if I remember right, fire was cutting two kids out of another car that would come with me. (Yeah, I know, not the way it's supposed to work, but first medic in was already off in the ditch mentally, no one served by schooling him on triage/MCI management) I asked the first medic about dad, "He's fine, I've already talked to him" yet dad is running around trying to keep track of his whole family and it's as if his entire upper body is made out of cement. Nothing moves in relation to each other...legs and hips shift to shift dad's line of sight. I called dad into my ambulance and took him and his two kids...he ended up with some flavor of spinal fracture despite insisting that he was fine (and yeah, he rode in sitting up wearing a collar. Two kids pretty damaged, next ambulance in would have been 30 mins or more..so there you have it). I asked the medic later, "Couldn't you tell by looking at him that he was injured?" He said, "He looked ok, he said he was fine." I said, "What did you expect him to say when he saw one medic and he had three injured family members?? Screw them, take care of me first! Don't most people that you see normally move their upper body part somewhat independent of each other?" Anyway, probably most providers of any level have a million stories just like that, the uncoordinated patient that swears they're "tired" with a bgl of 25, stroke patient that's jolly and laughing, no issues on the stroke scale but can't seem to button their shirt or shows uncharacteristic repetitive movement or tics...just strange stuff that doesn't seem catastrophic but should be explained before a description of "fine" is accepted by any provider... Maybe it's just a matter of really caring whether or not they are in fact fine or not that makes the difference? Anyway, I've had almost zero success trying to pass this assessment value on despite trying to explain it while the behavior is occurring and able to be observed...Grrrrrr

Man, I've never heard of that, but if it's closely monitored to prevent people having their plumber dad let them sit home on the couch, I like it a lot...

You know, kind of a funny story on this. This was one of the few things that caught my interest during a time when I was all excited about investing... I'd just gotten back from Afg, or wasn't back yet, I can't remember, but started thinking of the massive market such a product would have just with the military. Researched the bejeezus out of it...Man, they were building new factories for it's production after completion of clinic trials! I called everyone I knew, "Oh my God! You need to buy this stuff!! Trust me on this!!" Being the poorest member of the family no one listened of course...I was so disappointed in them all...then read that the trials had been discontinued...I immediately though, "Oh man...I think I don't know all that I need to know to get rich in the investement world..." Whew. Good thing I didn't have any money to invest...

Remember to verify, reverify PMS...the rest is cake... :-)

1. What sort of education do you have? AAS Paramedic Medicine, assorted separate certifications (ACLS, PHTLS, etc) 2. What was your career path from college to present? Why did you decide to follow this career path? I went directly into remote medicine after school. Not recommended, nor possible in most cases.I got lucky and had some hardcore EMTCity friends that made it happen. Have since worked the streets in the U.S. as an ALS medic in a progressive system, but am back to remote work again. 3. What are your basic duties performed during a typical day? Week? Month? Do you have a set routine? What are the major job responsibilities? I do clinical and emergent care for expats and the local national populations that I serve. Lots of over the counter meds with some narcotics and antibiotics sprinkled in. 4. How much variety is there on a day-to-day basis? Very, though most often boredom is the rule. Study, write, eat, treat a patient or two or three (Diarrhea, minor trauma, headaches, malaria) eat, go on the City, sleep, do it again. 5. How many hours do you work? I work a min of 42 12hr days in a row and then have about 38 days off. (6wk/6wk rotation) 6. Does the typical EMT have a set schedule or are the hours flexible? When I worked the streets they had a set schedule where I worked with lots of opportunities for OT. 7. Which skills do you feel are most important to acquire? Adult life experience, compassion, a desire to care for people instead of simply treat them. (Sounds like a bunch of rah rah bullshit, I know, but I truly believe that decent paramedic medicine arrises from these.) 8. What types of technology are used and how are they used? How often are changes made when it comes to new technologies? Varies greatly here, but with my company usually the current equipment accepted as standard of care in most 1st world countries. (Monitors, SPO2, etc) 9. What educational program do you recommend as preparation? What kinds of courses are most valuable in order to gain skills necessary for success in this occupation? In my opinion should you choose this carreer path without college level anatomy and physiology then you're just playing and not really wanting to be a provider. You can't assess a patient based on protocols. Assessment takes more of an understanding of how the body works than the few hours of "This is how you breath" that you'll get in EMT school. 10. What degree or certificate do employers look for? What kind of work/internship experience would employers look for in a job applicant? Employers of remote medics nearly universally want NREMTP, PHTLS, ACLS, and sometimes some specific stuff, like BOISET, Deep water/cold water survival. But usually you won't worry about such things. 11. How can a person obtain this work experience? Make friends and earn the respect of people that are already doing it making it worth taking the risk to refer you. 12. What entry level positions are there? Many. Most times your willingness to fly on short notice will trump any extraordinary qualties that you may bring to the job. 13. What steps besides meeting educational and experiential requirements are necessary to "break into" this occupation? As above. Without knowing someone getting hired is akin to hitting a pretty liberal lottery. You can play, but it's best not to hold your breath. 14. What are opportunities for advancement? To what position? Is an advanced degree needed? (If so, in what discipline?) Unsure. I avoid anything and anyone that interacts with offices or white shirts. 15. Is there a typical chain of command in the field? Typically, but it rarely works. Radio and phone communication unreliability can make it difficult when your medical director is in a different country many time zones away. Most often chain of command comes into play long after the dust has settled. 16. What are the different salary ranges? From $50k/yr to $250k/year for medics carrying weapons in the war zones. 17. What other kinds of workers frequently interact with this position? Sometimes local national medical staff, employees of the client, OSHA safety divisions. 18. What are the main or most important personal characteristics for success in the field? Unfortunately you can make it as a remote medic with almost no morals or ethics if you're willing to stay in some pretty shitty places withoug quitting. If you want to be a decent medic you need to be able to do your best medicine, to provide your most compassionate care, even after discovering that most of the people that you serve can't complain or sue you. In my opinion, nearly no one can manage this... 19. What are the satisfying aspects of your work? Bringing paramedic level first world medicine to people that are considered by many, if not most, to be beneath human dignity. Truly, the less society cares for someone the more joy I find in doing my very best for them. In trying to convince them that society's percieved value of them is bullshit. Other than getting well layed, nothing brings a bigger smile to my spirit than that. 20. What are the dissatisfying aspects of the work? Is this typical of the field? Watching shitheads that have never done anything, or been anywhere strutting around like heroes simply because they got on a plane that flew a long ways from home. One medic that I'm aware of spends his whole day in quarters. He has the staff deliver his custom made meals to his room, sleeps with a couple of the women in camp to pass the time, and then goes on Facebook talking about what a studd he is. He's not treated a patient in months. Makes me want to spit... Frustration with the sometimes uncertain nature of contract work. But you have to accept that as part of the gig. 21. How would you describe the atmosphere/culture of the work place? Very emotionally challenging. It can be tough to live in an environment where you share almost nothing culturally with those that you live with. Rewarding, but exhausting too. 22. Is there evidence of differential treatment between men and women EMTs with respect to job duties, pay, and opportunities for advancement? For the women that work in the field there is no difference in compensation. For example everyone in PNG, where I work doing a single medic gig makes the same amount of money. I believe, and for good reason, that a woman working in this environment often have better paths for advancement. But they've also paid their dues to get hired. Many places won't allow women. PNG is a good example. The culture has women far down on the food chain compared to men or and even pigs in some provices (Don't think of pigs in the American sense, but instead as you might, say, a rare and expensive horse. Better, right?). There are many clinics that employ expat women, but none, that I'm aware of in the bush. Also, because of the freedom that some of your sisters enjoy when playing the sexual harrassment card, many places where women would rock wont' accept them because of the carreer ending/sometimes company ending devistation caused simply by the accusation, without it being proved. But, I also know of many, many women in this field...it can be done, and as a woman you can see many advantages and increased career opportunities, in my opinion, once people come to respect you and cease being afraid of you. The field would certainly benefit from more women. 23. What do you feel are the toughest types of problems and decisions that you must make? Whether to follow the rules, or follow my heart, morals and ethics. For example I recently went into one of the local villages to assess the dying son of the lady that cleans the clinic. Because of the violent nature of this area we're not allowed out of secured areas without security present, and there was no way that security was going to waste their time on this person. Others would make a different, and likely more carreer savy decisions, but mine seem best for me. 24. What are the demands and frustrations that typically accompany this type of work? What are the greatest pressures, strains or anxieties in the work? Being away from my family weeks at a time. There can be a gazillion others, lack of necessary supplies, etc, but you have to choose to compartmentalize those as part of the gig and try to slowly improve them, or you need to stay home. If you get frustrated over bad food, being sweaty all the time, bugs, spending your day with people that dont' bath or brush their teeth...You could be frustrated all the time. I'm almost never unhappy... 25. What do you know now which would have been helpful to know when you were a student? I don't understand. 26. Any other important questions that I have not asked that would be helpful in learning about the job or occupation? I don't think so, not at this level of inquiry.

Yeah, well, I paid $200+ just because I thought that it looked cool...And it friggin' did! Don't you judge me! I still have it, it still looks brand new, weighs about 6lbs, so if you give me trouble I'll bludgeon you to death with it...I am convinced that my stethoscope allows me to hear things that non other does...but it's possible, if only slightly, that that's bullshit. http://www.littmann.com/wps/portal/3M/en_US/3M-Littmann/stethoscope/stethoscope-catalog/catalog/~/3M-Littmann-Cardiology-S-T-C-soft-touch-chestpiece-Stethoscope-Navy-Blue-Tube-27-inch-4473?N=5002728+5932256+4294958406&rt=d But, for the record, that's the one that I have...

Man, since you turned us on to it I've spent hundreds of hours at the Khan Academy....

Ahhh....gotcha...

What did happen with that Christopher? (Maybe you can paraphrase and save me hours of waiting for pages to download to search?)

Chin up Babe... Any changes?

Inappropriate? That's the most awesome friggin' post that I've seen in the last year!! +2 I believe that it's way past time to cardiovert this patient. I'm not confident that it's going to stick, but perhaps we can temporarily salvage some perfusion value? Doc, you say that you would want more info before doing so...what info might you get that would likely change your mind?

OP appears to be history...

MAST isn't a station, nor an option for a random at NR skills stations, at least for paramedic. I've proctored several of them, so I'm pretty confident about this...

Ahhh...gotcha

So you're saying that in all of your years on an ambulance that no one has ever died in your ambulance? That you've never continued CPR on a patient because they were in your ambulance, despite it being way past any possiblility of a resuscitation? Never had a DNR code in your ambulance, etc? C'mon...how is that possible? And it's not really laziness if you're 30 mins into a resusc transport, it's time to discontinue, but "no one dies in my ambulance" right? Does it make more sense to continue compressions and pushing drugs the other 20 mins to the hospital?

And yet, it appears that Toni gave him exactly what he was looking for?